EJCCM 25 No.

of Pages 6
9 June 2014
The Egyptian Journal of Critical Care Medicine (2014) xxx, xxx–xxx
1

The Egyptian College of Critical Care Physicians

The Egyptian Journal of Critical Care Medicine

http://ees.elsevier.com/ejccm
www.sciencedirect.com

2 ORIGINAL ARTICLE

4 Assessment of hypotension during dialysis

5 as a manifestation of myocardial ischemia
6 Q1 in patients with chronic renal failure

a,*
7 Q2 Randa Aly Soliman , Mohamed Fawzy a, Hussein Kandil b, Alia Abd el Fattah a

a
8 The Critical Care Department, Cairo university, Egypt
b
9 Q3 The Critical Department in the National Liver Institute, Egypt

10 Received 4 September 2013; revised 3 May 2014; accepted 15 May 2014

11

13 KEYWORDS Abstract Introduction: Intradialytic hypotension (IDH) remains to be a major complication of

14
15 Intradialytic hypotension hemodialysis occurring in nearly 25% of dialysis sessions. It is a significant independent factor
16 (IDH); affecting mortality in hemodialysis patients. Autonomic nervous system dysfunction, blood seques-
17 With chronic renal failure tration in the setting of hypovolemia, cardiovascular diseases and increased plasma level of end
18 (CRF); products of nitric oxide metabolism are possible causes. In this controlled prospective study we
19 Myocardial perfusion; examined patients with chronic renal failure and intradialytic hypotension to evaluate the relation-
20 Imaging (MPI) ship between this hypotension and myocardial ischemia after controlling other possible causes.
Materials and methods: Thirty patients with chronic renal failure who are on regular dialysis
were enrolled. Before dialysis, patients were subjected to history taking and clinical examination.
Echocardiography and several lab tests were done. Glomerular filtration rate (GFR) was calculated
using Cockcroft’s and Gault formula. Autonomic dysfunction was also assessed. The dialysis ses-
sion was standardized in all patients. Intradialytic blood pressure was monitored and hypotension
was classified as mild (SBP > 100 mmHg), moderate (SBP 80–100) or severe (SBP < 80). After
dialysis, myocardial ischemia was assessed using stress myocardial perfusion imaging (MPI) (Phar-
macologic stress testing using Dipyridamole) and is further classified as mild, moderate or severe
ischemia. Patients with sepsis, hemoglobin level less than 9 g/dL, diabetes mellitus, low cardiac out-
put, coronary artery disease, significant valvular lesion or body weight below the dry weight of the
patient were excluded from the study. Bronchial asthma, emphysema and severe COPD are contra-
indications to Dipyridamole and thus were also excluded from the study.
Results: Twenty patients had no or mild intradialytic hypotension whereas ten patients had

* Corresponding author. Address: 20 Abou Hazem st., Madkour,

Haram, Giza, Egypt. Tel.: +20 1222402018.
E-mail address: randaalysoliman@hotmail.com (R.A. Soliman).
Peer review under responsibility of The Egyptian College of Critical
Care Physicians.

Production and hosting by Elsevier

2090-7303  2014 Production and hosting by Elsevier B.V. on behalf of The Egyptian College of Critical Care Physicians.
http://dx.doi.org/10.1016/j.ejccm.2014.05.001

Please cite this article in press as: Soliman RA et al. Assessment of hypotension during dialysis as a manifestation of myocardial ischemia in
Q1 patients with chronic renal failure, Egypt J Crit Care Med (2014), http://dx.doi.org/10.1016/j.ejccm.2014.05.001
 EJCCM 25 No. of Pages 6
9 June 2014
2 R.A. Soliman et al.

21 moderate or severe hypotension. Among the first group, only two patients (10%) were found to
22 have myocardial ischemia, while in the latter group, seven patients (70%) had myocardial ischemia
23 that is mostly moderate (p = 0.002). Stress induced LV dysfunction was also significantly prevalent
24 in patients with moderate or severe intradialytic hypotension as opposed to the other group
25 (p = 0.002) LVED.
26 Conclusions: Patients with CKD and regular hemodialysis who experience moderate or severe
27 intradialytic hypotension have significantly higher prevalence of myocardial ischemia and stress
28 induced myocardial dysfunction, than those who experience no or mild intradialytic hypotension.
32
29
30  2014 Production and hosting by Elsevier B.V. on behalf of The Egyptian College of Critical Care
31 Physicians.

33 1. Introduction

34 Intradialytic hypotension (IDH) remains to be a major compli- Table 1 Baseline characteristics of the study group (n = 30).
35 cation of hemodialysis. It occurs in nearly 25% of dialysis ses-
Parameter Value [N (%) or mean ± SD]
36 sions [1] and often requires aggressive resuscitative measures
37 and sometimes premature termination of hemodialysis. It is Age (years) 44 ± 13
38 also a significant independent factor affecting mortality in Weight (Kg) 66 ± 10
Male 12 (40)
39 hemodialysis patients [2].
40 Despite the advances of machines with ultrafiltration con- Clinical
41 trol devices, modifying dialysate composition, temperature Smokers 7 (23)
42 control, correction of nutritional deficiencies and treatment Hypertension 12 (40)
43 of anemia with erythropoietin therapy, many patients still have History of chest pain 6 (20)
Family history of IHD 9 (30)
44 episodes of intradialytic hypotension. Among other factors,
Autonomic neuropathy 9 (30)
45 the major pathophysiology of these episodes is the removal
AV fistula 23 (77)
46 of large volume of blood water and solutes over a short period Duration of hemodialysis (years) 3.7 ± 2.1
47 of time, overwhelming normal compensatory mechanisms,
48 which include plasma refilling and reduction of venous capac- ECG and ECHO
49 ity (due to reduction of pressure transmission to veins). Arrhythmia in ECG 4 (13)
LVH in ECG 6 (20)
50 In some patients, a seemingly paradoxical and inappropri-
RWMA 5 (17)
51 ate reduction of sympathetic tone may occur, causing reduc- LVEDD (mm) 49.7 ± 5.4
52 tion of arteriolar resistance, decreased transmission of LVESD (mm) 32.4 ± 4
53 pressure to veins with corresponding increase in venous capac- EF (%) 62.3 ± 7.6
54 ity. Increased sequestration of blood in veins under conditions
Grades of Albuminuria*
55 of hypovolemia reduces cardiac filling, cardiac output and ulti-
(+) 6 (20)
56 mately blood pressure. Hypotensive episodes during hemodial- (++) 7 (23)
57 ysis in patients with end stage renal disease in the absence of (+++) 2 (7)
58 inadequate maintenance of the plasma volume, pre-existence Urine specific gravity* 1009 ± 2.1
59 of cardiovascular disease, or autonomic nervous system dys-
Labs
60 function are accompanied by increased plasma concentrations
Hb (g/dL) 10.5 ± 0.73
61 of the end-products of nitric oxide metabolism (above the Hct (%) 32.6 ± 2.9
62 expected levels, based on the reduction of urea [3]). TLC (103 cells/cmm) 6.1 ± 2.1
63 In this controlled prospective study, patients with chronic FBS (mg/dL) 70.2 ± 11.2
64 renal failure and intradialytic hypotension episodes were thor- PPBS (mg/dL) 123.5 ± 15.2
65 oughly investigated, to evaluate the relationship between hypo- HB A1C (mg/dL) 5 ± 0.59
66 tension and myocardial ischemia after controlling other Serum Triglycerides (mg/dL) 109.7 ± 43
67 possible causes. Serum Cholesterol (mg/dL) 151 ± 60
Serum Urea (mg/dL) 129.8 ± 29.7
Serum Creatinine (mg/dL) 7.9 ± 2.1
68 2. Patients and methods
GFR (ml/min/1.73 m2) 11 ± 4.2
Serum Sodium (mEq/L) 138 ± 5.8
69 This prospective study was conducted in King Fahd Hemodi- Serum Potassium (mEq/L) 5.2 ± 0.63
70 alysis unit in Kasr Al-Aini hospital, Hemodialysis Unit in Al- IHD, ischemic heart disease; LVH, left ventricular hypertrophy;
71 Zahraa hospital and Critical Care Medicine Department in RWMA, regional wall motion abnormalities; LVEDD, left ven-
72 Kasr Al-Aini hospital over the time period from February tricle end-diastolic diameter; LVESD, left ventricle end-systolic
73 2010 to June 2011. All patients included in the study provided diameter; EF, ejection fraction Hb, hemoglobin; Hct, hematocrit;
74 informed written consent. The study includes 30 patients with TLC, total leukocytic count; FBS, fasting blood sugar; PPBS, post
75 chronic renal failure who receive regular hemodialysis sessions. prandial blood sugar; HB A1C, hemoglobin A1C; GFR, glomerular
76 Twenty patients developed hypotension during hemodialysis filtration rate.
*
77 session, and the remaining 10 patients did not develop hypo- Done only for the 15 patients who were not anuric.

Please cite this article in press as: Soliman RA et al. Assessment of hypotension during dialysis as a manifestation of myocardial ischemia in
Q1 patients with chronic renal failure, Egypt J Crit Care Med (2014), http://dx.doi.org/10.1016/j.ejccm.2014.05.001
 EJCCM 25 No. of Pages 6
9 June 2014
Q1 Assessment of hypotension during dialysis as a manifestation of myocardial ischemia 3

Figure 1 Myocardial ischemia diagnosed by MPI in patients with moderate or severe intradialytic hypotension, in comparison to those
with no or mild hypotension (p = 0.002).

78 tension during the sessions. Myocardial ischemia was assessed Patients who required vasopressors were unstable and 116
79 in all patients using stress myocardial perfusion imaging (MPI) accordingly were excluded from this study. 117
80 (Pharmacologic stress testing using Dipyridamole).
81 Patients with sepsis, hemoglobin level less than 9 g/dL, 2.3. After dialysis 118
82 diabetes mellitus, low cardiac output, acute coronary
83 syndrome, significant valvular lesion or body weight below Within 2–5 h after dialysis, patients had both trans-thoracic 119
84 the dry weight of the patient were excluded from the study. echocardiography and MPI. The echo was done using an 120
85 Bronchial Asthma, emphysema and severe COPD are ATL machine HDI 5000 with the patient lying in the left lat- 121
86 contraindications to Dipyridamole and thus were also eral decubitus using a 3.5 MHZ probe. MPI was done at the 122
87 excluded from the study. nuclear laboratory of the critical care medicine department, 123
Kasr Al-Aini hospital, Cairo University utilizing the ‘‘freeze 124
88 2.1. Before dialysis imaging protocol’’. The set of SPECT images was acquired 125
using a triple head Siemens gamma camera with high resolu- 126

89 All eligible patients were subjected to full history taking and tion collimators (model Symbia E). Pharmacological stress 127

90 clinical examination. Serum Urea and Creatinine were mea- testing using Dipyridamole was done as most patients with 128

91 sured. Glomerular filtration rate (GFR) was calculated using CKD could not achieve target HR during treadmill stress test- 129

92 Cockcroft’s and Gault equation. Autonomic dysfunction was ing due to marked physical limitations. 130

93 assessed using at least 2 of the following tests; blood pressure Patients were instructed to fast for at least 6–8 h, stop the- 131

94 (BP) response to standing, BP response to sustained handgrip, ophylline medications for at least 24 h and not to have any caf- 132

95 Heart Rate (HR) response to standing, HR response to deep feinated drinks or beverages for at least 24 h prior to the study. 133

96 breathing and HR response to valsalva. Positive result of Dipyridamole 0.56 mg/kg was diluted with 40 cc normal saline 134

97 any test indicates autonomic dysfunction [4]. and infused over 4 min. 2 min later, 20–25 mCi Tc-99 m Sestam- 135
ibi were injected intravenously through a wide bore cannula fol- 136
lowed by saline flush. Patients were monitored for at least 5 min 137
98 2.2. During dialysis
or till vital signs returned to baseline. Ambulant patients were 138
asked to walk for 4 min after Dipyridamole infusion. 139
99 Dialysis was done via AV fistula (23 patients) or dialysis cath- Twenty projections were acquired (30 s for each frame) at 140
100 eter (7 patients), using Fresenius 4008B, Nipro machine with 120 degree arc and total acquisition time of 12 min. SPECT 141
101 ultrafiltration volume control and polysulfone, Fresenius F6 images were processed using the back-projection technique to 142
102 filters. Temperature of dialysate was kept at 36 C. Blood get trans-axial images then short axis, vertical long axis and 143
103 pump was kept between 250 and 350 ml/min except during horizontal long axis cuts. The twenty-segment scoring system 144
104 the hypotensive episodes during which the blood pump was was applied to estimate the Myocardium At Risk (MAR), 145
105 decreased to only 200 ml/min and not less to insure adequate and the severity of perfusion defect was assessed for each seg- 146
106 dialysis session. Dialysate flow was 500 ml/min. All dialysis ment using a ‘‘0–4’’ scoring system with ‘‘0’’ indicating normal 147
107 sessions lasted around 4 h. perfusion and ‘‘4’’ indicating no photon activity. The sum of 148
108 BP is recorded using standard sphygmomanometer every these scores is the Summed Stress Score (SSS). 149
109 30 min in supine position. Each time the mean of 3 measure- Seventy two hours later, patients were re-injected with 20– 150
110 ments is recorded. Intradialytic hypotension is defined as a 30 mCi Tc-99 m Sestamibi intravenously to acquire the second 151
111 symptomatic decrease of more than 30 mmHg in systolic blood set of SPECT images at rest, and to estimate the left ventricu- 152
112 pressure or as an absolute systolic blood pressure under lar ejection fraction (EF) utilizing the Gated SPECT tech- 153
113 90 mmHg [5]. Hypotension is further classified as mild (Sys- nique. The severity of perfusion defects of MAR in this set 154
114 tolic Blood Pressure (SBP) > 100 mmHg), moderate (SBP of SPECT images is assessed similarly and the sum of these 155
115 80–100 mmHg) and Severe (SBP < 80 mmHg) [6]. scores is the Summed Rest Score (SRS). 156

Please cite this article in press as: Soliman RA et al. Assessment of hypotension during dialysis as a manifestation of myocardial ischemia in
Q1 patients with chronic renal failure, Egypt J Crit Care Med (2014), http://dx.doi.org/10.1016/j.ejccm.2014.05.001
 EJCCM 25 No. of Pages 6
9 June 2014
4 R.A. Soliman et al.

Table 2 Comparison of demographic, clinical, laboratory and MPI data between the 2 study groups.
Parameter Group A (n = 20) Group B (n = 10)
Age (years) 43.5 (33–54) 47.5 (28–58) 0.63
Weight (Kg) 65.5 (56–73) 67 (58–77) 0.81
Male 9 (45) 3 (30) 0.69
Clinical
Smokers 5 (25) 2 (20) 1.0
Hypertension 7 (35) 5 (50) 0.69
Family history of IHD 5 (25) 4 (20) 0.43
Autonomic neuropathy 4 (20) 5 (50) 0.115
AV fistula 16 (80) 7 (70) 0.66
Duration of hemodialysis (years) 4 (3–6) 2.5 (1–4) 0.1
ECG and ECHO
Arrhythmia in ECG 1 (5) 3 (30) 0.095
LVH in ECG 3 (15) 3 (30) 0.37
RWMA 2 (10) 3 (30) 0.30
LVEDD (mm) 52 (46.5–55) 44.5 (44–51) 0.046
LVESD (mm) 32 (30–35) 31.5 (28–34) 0.63
EF (%) 63 (56–70) 59.5 (56–62) 0.19
Grades of Albuminuria* n=8 n=7
(+) 5/8 (62.5) 1/7 (14.3) 0.092
(++) 3/8 (37.5) 4/7 (57.1)
(+++) 0/8 2/7 (28.6)
Urine specific gravity 1010 (1008–1010) 1009 (1005–1010) 0.12
Labs
Hb (g/dL) 10.4 (9.8–10.9) 10.5 (10.3–11.3) 0.15
Hct (%) 31.9 (30.3–35) 33 (32.3–37) 0.098
TLC (103 cells/cmm) 5.4 (4.8–7.6) 5.2 (4–8) 0.74
FBS (mg/dL) 71 (60–80) 69 (62–76) 0.88
PPBS (mg/dL) 123 (116–131) 119 (108–134) 0.58
HB A1C (mg/dL) 4.9 (4.6–5.5) 4.8 (4.3–5.5) 0.42
Serum Triglycerides (mg/dL) 90.5 (80–117) 97 (75–170) 0.75
Serum Cholesterol (mg/dL) 135 (113–165) 117 (109–247) 0.55
Serum Urea (mg/dL) 138 (101–151) 121 (106–144) 0.4
Serum Creatinine (mg/dL) 8.4 (6.3–9.7) 7.7 (6.5–9) 0.63
GFR (ml/min/1.73 m2) 10.2 (7.9–12.4) 9.5 (8.9–12.6) 0.55
Serum Sodium (mEq/L) 138.5 (133–144) 138.5 (133–142) 1.0
Serum Potassium (mEq/L) 5.2 (4.7–5.5) 5.3 (5–6.1) 0.094
MPI
Ischemia (total count) 2 (10) 7 (70) 0.002
Mild ischemia 1/1 (50) 1/7 (14.3) 0.417
Moderate ischemia 1/1 (50) 6/7 (85.7)
Scar 0 2 (20) 0.103
Stress induced LV dysfunction 2 (10) 7 (70) 0.002
Data are displayed as n (%) or median (inter-quartile range).
IHD, ischemic heart disease; LVH, left ventricular hypertrophy; RWMA, regional wall motion abnormalities; LVEDD, left ventricle end-
diastolic diameter; LVESD, left ventricle end-systolic diameter; EF, ejection fraction; Hb, hemoglobin; Hct, hematocrit; TLC, total leukocytic
count; FBS, fasting blood sugar; PPBS, post prandial blood sugar; HB A1C, hemoglobin A1C; GFR, glomerular filtration rate.
*
Done only for the 15 patients who were not anuric.

157 The difference between SSS and SRS is the Summed Differ- Categorical variables are described as frequency (n) and 165
158 ence Score (SDS). It is classified as follows; 0–4 indicates no percentage (%). Quantitative variables are described as 166
159 ischemia, 5–8 mild ischemia, 9–12 moderate ischemia and mean ± standard deviation (SD) whenever parametric. Non- 167
160 more than 12 is severe ischemia. parametric quantitative variables are described as median 168
and interquartile range (IQR). Bivariate analysis of categorical 169
variables was done using Chi-square test with Yates Continu- 170
161 2.4. Statistical methods
ity correction for 2 · 2 tables. Whenever cell frequency is <5, 171
Fisher’s Exact test is used. 172
162 Statistical analysis was done using Statistical Package for Comparison of two groups of quantitative variables was 173
163 Social Sciences (SPSS) software, release 16.0.0 for Windows done using Independent-Samples Student’s t test for paramet- 174
164 (SPSS Inc., Chicago, Illinois). ric data, and Mann–Whitney test for non-parametric data. 175

Please cite this article in press as: Soliman RA et al. Assessment of hypotension during dialysis as a manifestation of myocardial ischemia in
Q1 patients with chronic renal failure, Egypt J Crit Care Med (2014), http://dx.doi.org/10.1016/j.ejccm.2014.05.001
 EJCCM 25 No. of Pages 6
9 June 2014
Q1 Assessment of hypotension during dialysis as a manifestation of myocardial ischemia 5

Figure 2 Stress induced LV dysfunction diagnosed by MPI in patients with moderate or severe intradialytic hypotension in comparison
to those with no or mild hypotension (p = 0.002).

Figure 3 Left ventricular end-diastolic diameter in patients with moderate or severe intradialytic hypotension (44.5 mm [44–51]) in
comparison to those with no or mild intradialytic hypotension (52 mm [46.5–55]) (p = 0.046).

176 In all cases, the 2-sided significance was always taken as p 52 mm, IQR 46.5–55) than in Group B (44.5 mm, 44–50.75) 191
177 value. p value <0.05 is considered statistically significant. (p = 0.046) (Fig. 3). 192

178 3. Results 4. Discussion 193

179 Thirty patients were included in this study. Their baseline Intradialytic hypotension (IDH) is a major complication of 194
180 characteristics are listed in Table 1. hemodialysis. Two to four liters of fluid needs to be removed 195
181 We found that 70% (7/10) of patients who had moderate or during a regular session, equivalent to 40–80% of the blood 196
182 severe hypotension (Group B) had myocardial ischemia on volume. It is therefore not surprising that hypotension occurs 197
183 MPI, in comparison to 10% (2/20) of patients who experienced so often. Although many factors – patient or treatment related 198
184 no or mild intradialytic hypotension (Group A); a difference – play a role, a reduction of blood volume is crucial in its path- 199
185 that is statistically significant (p = 0.002) (Fig. 1). ogenesis [1]. 200
186 Several other variables were compared across both study Hypotension is one of the clinical presentations of CVD in 201
187 groups (Table 2). It is to be noted that patients of Group B patients with CKD [7]. There are a number of possible expla- 202
188 were more likely to have stress induced LV dysfunction on nations for the independent association of reduced GFR and 203
189 MPI (7/10, 70%) than patients of Group A (2/20, 10%) CVD outcomes. First, a reduced GFR may be associated with 204
190 (p = 0.002) (Fig. 2). LVED was wider in Group A (Median an increased level of nontraditional CVD risk factors that fre- 205

Please cite this article in press as: Soliman RA et al. Assessment of hypotension during dialysis as a manifestation of myocardial ischemia in
Q1 patients with chronic renal failure, Egypt J Crit Care Med (2014), http://dx.doi.org/10.1016/j.ejccm.2014.05.001
 EJCCM 25 No. of Pages 6
9 June 2014
6 R.A. Soliman et al.

206 quently are not assessed in many studies. Second, reduced In conclusion, we found that patients with CKD and regu- 267
207 GFR may be a marker of undiagnosed vascular disease or lar hemodialysis who experience moderate or severe intradia- 268
208 alternatively a marker of the severity of diagnosed vascular lytic hypotension have significantly higher prevalence of 269
209 disease, especially in high or highest risk populations. Third, myocardial ischemia and stress induced myocardial dysfunc- 270
210 reduced GFR may have had more severe hypertension or dysl- tion, than those who experience no or mild intradialytic 271
211 ipidemia and therefore have suffered more vascular damage hypotension. 272
212 secondary to hypertension or dyslipidemia. Fourth, recent
213 studies have suggested that subjects with reduced GFR are less References 273
214 likely to receive medications or therapies such as angiotensin
215 converting enzyme inhibitors, ß-blockers, aspirin, platelet [1] Ligtenberg G, Blankestijn PJ, Boomsma F, Koomans HA. No 274
216 inhibitors, thrombolytics, or percutaneous intervention than change in automatic function tests during uncomplicated hae- 275
217 patients with preserved GFR. Perhaps as important was the modialysis. Nephrol Dial Transplant 1996;11(4):651–6. 276
218 fact that in the same studies, patients with reduced GFR [2] Shoji T, Tsubakihara Y, Fujii M, Imai E. Hemodialysis-associ- 277

219 who did receive the above interventions obtained similar ben- ated hypotension as an independent risk factor for two-year 278

220 efit as patients with preserved GFR. Finally, decreased GFR mortality in hemodialysis patients. Kidney Int 279
2004;66(3):1212–20. 280
221 itself may be a risk factor for progression of ventricular remod-
[3] Madore F, Prud’homme L, Austin JS, Blaise G, Francoeur M, 281
222 eling and cardiac dysfunction [7]. Leveille M, et al. Impact of nitric oxide on blood pressure in 282
223 Different studies stated that, during hemodialysis, patients hemodialysis patients. Am J Kidney Dis 1997;30(5):665–71. 283
224 are particularly susceptible to myocardial ischemia for number [4] Ewing DJ, Campbell IW, Murray A, Neilson JM, Clarke BF. 284
225 of reasons including: LV hypertrophy [8], intradialytic hypo- Immediate heart-rate response to standing: simple test for 285
226 tension and instability [9], high prevalence of decreased coro- autonomic neuropathy in diabetes. Br Med J 1978;1(6106):145–7. 286
227 nary flow reserve even in the absence of coronary vessel [5] Straver B, Hypotension during hemodialysis. Noninvasivce mon- 287
228 stenosis [10,11]. itoring of hemodynamic variables. 2005, The Dutch Kidney 288

229 Hakeem et al. [12] reported that in patients with CKD 40% Foundation (Nierstichting Nederland, project C 94–1391). 289

230 of perfusion scans were abnormal (SSS P 4) with 20% mild [6] Hanss R, Bein B, Ledowski T, Lehmkuhl M, Ohnesorge H, 290
Scherkl W, et al. Heart rate variability predicts severe hypoten- 291
231 defects and 20% moderated to severe defects.
sion after spinal anesthesia for elective cesarean delivery. Anes- 292
232 Q4 In line with Hakeem’s result, we found that patients who thesiology 2005;102(6):1086–93. 293
233 experience moderate or severe intradialytic hypotension have [7] Sarnak MJ, Levey AS, Schoolwerth AC, Coresh J, Culleton B, 294
234 significantly higher prevalence of myocardial ischemia (70%, Hamm LL, et al. Kidney disease as a risk factor for development 295
235 7/10), in comparison to those who have no or mild intradialyt- of cardiovascular disease: a statement from the American Heart 296
236 ic hypotension (10%, 2/20) (p = 0.002). Association Councils on Kidney in Cardiovascular Disease, High 297
237 Paoletti et al. [13] stated that there is growing evidence that Blood Pressure Research, Clinical Cardiology, and Epidemiology 298
238 patients with CKD have unrecognized LV dysfunction, both and Prevention. Hypertension 2003;42(5):1050–65. 299

239 systolic and diastolic. They also pointed at the importance of [8] Silberberg JS, Barre PE, Prichard SS, Sniderman AD. Impact of 300

240 LV dysfunction (LV ejection fraction <40%) as a predictor left ventricular hypertrophy on survival in end-stage renal disease. 301
Kidney Int 1989;36(2):286–90. 302
241 of cardiac death in patients with CKD.
[9] Bos WJ, Bruin S, van Olden RW, Keur I, Wesseling KH, 303
242 We similarly found that CKD patients who develop moder- Westerhof N, et al. Cardiac and hemodynamic effects of hemod- 304
243 ate or severe intradialytic hypotension, have significantly ialysis and ultrafiltration. Am J Kidney Dis 2000;35(5):819–26. 305
244 higher prevalence of stress induced LV dysfunction (70%, 7/ [10] Ragosta M, Samady H, Isaacs RB, Gimple LW, Sarembock IJ, 306
245 10) than those who have no or mild hypotensive episodes Powers ER. Coronary flow reserve abnormalities in patients 307
246 (10%, 2/20) (p = 0.002). with diabetes mellitus who have end-stage renal disease and 308
247 Deterioration of renal function in CKD may lead to dysli- normal epicardial coronary arteries. Am Heart J 309
248 pidemia or accumulation of uremic toxins, which can stimulate 2004;147(6):1017–23. 310

249 oxidative stress and inflammation, which in turn contributes to [11] Tok D, Gullu H, Erdogan D, Topcu S, Ciftci O, Yildirim I, et al. 311

250 endothelial dysfunction and progression of atherosclerosis Impaired coronary flow reserve in hemodialysis patients: a 312
transthoracic Doppler echocardiographic study. Nephron Clin 313
251 [14]. Renal failure causes changes in plasma components and
Pract 2005;101(4):c200–6. 314
252 endothelial structure and function that favor vascular injury, [12] Hakeem A, Bhatti S, Dillie KS, Cook JR, Samad Z, Roth-Cline 315
253 which may play a role as a trigger for inflammatory response. MD, et al. Predictive value of myocardial perfusion single-photon 316
254 Dyslipidemia associated with CKD contributes to the inflam- emission computed tomography and the impact of renal function 317
255 matory response in renal failure [15]. However, in our study on cardiac death. Circulation 2008;118(24):2540–9. 318
256 we found that levels of serum cholesterol and triglycerides were [13] Paoletti E, Cannella G. Left ventricular hypertrophy in chronic 319
257 not significantly different between the two study groups, a kidney disease. G Ital Nefrol 2006;23(6):560–8. 320
258 finding probably attributed to the small number of the study [14] Kaysen GA, Eiserich JP. The role of oxidative stress-altered 321

259 group and the relatively low economic standard of those lipoprotein structure and function and microinflammation on 322

260 patients. cardiovascular risk in patients with minor renal dysfunction. J Am 323
Soc Nephrol 2004;15(3):538–48. 324
261 Patients with CKD also have a high prevalence of arterio-
[15] Mann J, Hilger KF, Veelken R, Lenhardt C, Schiffrin EL, 325
262 sclerosis and remodeling of large arteries. Remodeling may Chronic kidney disease and the cardiovascular system. Internist 326
263 be due to either pressure overload – which is distinguished (Berl) 2008;49(4): 413–414, 416–418, 420–421. 327
264 by wall hypertrophy and an increased wall-to-lumen ratio – [16] London GM, Marchais SJ, Metivier F, Guerin AP. Cardiovas- 328
265 or flow overload, which is characterized by a proportional cular risk in end-stage renal disease: vascular aspects. Nephrol 329
266 increase in arterial diameter and wall thickness [16]. Dial Transplant 2000;15(Suppl 5):97–104. 330

Please cite this article in press as: Soliman RA et al. Assessment of hypotension during dialysis as a manifestation of myocardial ischemia in
Q1 patients with chronic renal failure, Egypt J Crit Care Med (2014), http://dx.doi.org/10.1016/j.ejccm.2014.05.001