Center for Nephrology "G. Papadakis", General Hospital of Nikaia-Piraeus "Ag. Panteleimon", Nikaia, Greece.
Am J Nephrol. 2023;54(5-6):200-207. doi: 10.1159/000531047. Epub 2023 May 12.
Individuals with end-stage renal disease on chronic hemodialysis (HD) may encounter numerous HD-associated complications, including intradialytic hypertension (IDHYPER). Although blood pressure (BP) follows a predictable course in the post-HD period, BP levels during the session may vary across the individuals. Typically, a decline in BP is noted during HD, but a significant proportion of patients exhibit a paradoxical elevation.
Several studies have been conducted to understand the complexity of IDHYPER, but much remains to be elucidated in the future. This review article aimed to present the current evidence regarding the proposed definitions, the pathophysiologic background, the extent and clinical implications of IDHYPER, as well as the possible therapeutic options that have emerged from clinical studies.
IDHYPER is noted in approximately 15% of individuals undergoing HD. Several definitions have been proposed, with a systolic BP rise >10 mm Hg from pre- to post-dialysis in the hypertensive range in at least four out of six consecutive HD treatments being suggested by the latest Kidney Disease: Improving Global Outcomes. Concerning its pathophysiology, extracellular fluid overload is a crucial determinant, with endothelial dysfunction, sympathetic nervous system overdrive, renin-angiotensin-aldosterone system activation, and electrolyte alterations being important contributors. Although its association with ambulatory BP in the interdialytic period is controversial, IDHYPER is associated with adverse cardiovascular events and mortality. Moving to its management, the antihypertensive drugs of choice should ideally be nondialyzable with proven cardiovascular and mortality benefits. Finally, rigorous clinical and objective assessment of extracellular fluid volume is essential. Volume-overloaded patients should be instructed about the importance of sodium restriction, while physicians ought to alter HD settings toward a greater dry weight reduction. The use of a low-sodium dialysate and isothermic HD could also be considered on a case-by-case basis since no randomized evidence is currently available.
接受慢性血液透析（HD）的终末期肾病患者可能会遇到许多与血液透析相关的并发症，包括透析中高血压（IDHYPER）。尽管血液透析后血压（BP）呈可预测的变化，但个体透析期间的血压水平可能会有所不同。通常，在血液透析过程中会观察到血压下降，但相当一部分患者会出现反常升高。
已经进行了多项研究来了解 IDHYPER 的复杂性，但未来仍有许多需要阐明。本文旨在介绍目前关于 IDHYPER 的定义、病理生理背景、发生率及临床意义，以及从临床研究中得出的可能治疗选择的相关证据。
大约 15%接受 HD 的患者会出现 IDHYPER。最新的肾脏病：改善全球预后（Kidney Disease: Improving Global Outcomes）建议使用以下定义：在至少连续 6 次血液透析治疗中的 4 次中，透析前至透析后收缩压升高≥10mmHg，且血压处于高血压范围。关于其病理生理学，细胞外液超负荷是一个关键决定因素，内皮功能障碍、交感神经系统过度兴奋、肾素-血管紧张素-醛固酮系统激活和电解质紊乱是重要的促成因素。尽管它与透析间动态血压的关系存在争议，但 IDHYPER 与不良心血管事件和死亡率相关。在其管理方面，理想情况下应选择无透析作用且具有明确心血管和死亡率获益的降压药物。最后，需要严格评估细胞外液容量。应告知容量超负荷的患者限制钠摄入的重要性，同时医生应调整 HD 设定以实现更大的干体重减少。在没有随机证据的情况下，还可以考虑使用低钠透析液和等渗 HD。
