frequency of dialysis

By Guest on Tuesday, 20 November 2012

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Dear Experts ,

a patient of 50 years old started hemodialysis since 6 months came to our unit 2 days ago to have his sessions . he was discovered to be hypertensive one year ago and was kept on CCB ( ADALAT 30 ) ONCE DAILY . BB ( LOPRESSOR 50 ) ONCE DAILY . BP = 160/110

The patient did not have dialysis for 12 days . new labs were as follows : urea 136 mg/dl , creatinine = 7.6 mg/dl , k 5.5 mmol/l

no symptoms or signs of volume overload . according to cockroft formula the GFR = 8 ML/M .

what is your advice for this patient regarding dialysis frequency and BP control ?

Hello,

This man's renal function is extremely low, in the ESRD range. Although he survived the 12 day period without dialysis, this would not reassure me that he needs infrequent dialysis. I would resume a 3x / week schedule and reassess his response. Regarding his blood pressure, I would reassess it after a period of adjustment to resuming dialysis. If still elevated, I would try to reduce his target weight slightly and then consider increasing his medication. His current dosages are quite low and he is not on an ACEi or ARB, either of which might be considered additionally.

Jordan Weinstein

11 years ago

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#236

He should have 3 x per week, but if he doesn't come to dialysis reliably do not start ace or arb, it will reduce his residual function and he may not make it next time. I would switch adalat to amlodipine for better BP lowering and longer duration of action. If he is compliant with dialysis schedule, his BP may come under control just with better volume control.

Guest

11 years ago

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#237

Hello,

If the patient is not adherent with dialysis then any regimen will be unlikely to successfully lower his blood pressure. If not using ACE or ARB, there would be many other options of course from alpha blockers, hydralazine, minoxidil, aldomet, diuretics or clonidine (though clonidine should be used with caution with a beta-blocker on board).

Jordan

Jordan Weinstein

11 years ago

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#238

Dr jordan, please let me know how will you start ACEi or ARB in a pt who is non compliant to dialysis? There is risk of Hyperkalemia in LOSS OF RESIDUAL FUNCTIONS.

Guest

11 years ago

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#240

I think that sounds like good outcome, especially if he is not adherent.

Jordan Weinstein

11 years ago

#13

Actually i am keeping the patient away from ACEI or ARBS , I increased the dose of BB to be twice daily , i changed the CCB to be amilodipin 10 mg once daily , and i added alpha methyl dopa 250 mg twice daily . Now the patient BP is controlled around 135/90

khaled

11 years ago

#12

I agree, if the patient is not adherent to dialysis, then there is a risk of hyperkalemia.

And so if the question is how to manage a non-adherent patient safely, I think there is no ideal answer here. I suppose this is why non-adherence is so difficult to manage as a clinician. I was speaking in generality, that if a patient would come for dialysis and adhere to a low potassium diet, then ACEi and ARB (like most antihypertensives) could be useful in the management of ESRD-associated hypertension.

Jordan Weinstein

11 years ago

#11