American Journal of Kidney Diseases

Midodrine and cool dialysate are effective therapies for symptomatic intradialytic hypotension


      Intradialytic hypotension (IDH) is a morbid complication of hemodialysis (HD). Both midodrine, an oral selective α1 agonist, and cool dialysate have been reported as useful therapies for this problem. We performed this prospective crossover study to compare the efficacy of these two therapies, alone and in combination, for IDH. The study consisted of a control phase and three treatment phases: midodrine phase (10 mg oral dose pre-HD), cool dialysate phase (35.5°C), and combination therapy phase (midodrine, 10 mg, and dialysate temperature, 35.5°C). Each phase consisted of nine consecutive HD treatments. Eleven patients (six men, five women; mean age, 67.5 years) with known symptomatic IDH were studied. This cohort was followed up in terms of blood pressure measurements (pre-HD blood pressure, lowest intradialytic blood pressure, post-HD blood pressure), weights, laboratory values, and interventions for IDH. The lowest intradialytic blood pressures were significantly better with midodrine and cool dialysate compared with the control phase (systolic blood pressure [SBP], 103.9 ± 4.1 [mean ± standard error of the mean] and 102.6 ± 2.9 v 90.6 ± 2.5 mm Hg, respectively; P < 0.001), as were the post-HD blood pressures (SBP, 116.9 ± 4.0 and 118.2 ± 3.5 v 109.0 ± 2.1 mm Hg; P < 0.01). In addition, the lowest intradialytic blood pressures were significantly better with the combination phase compared with the control phase (SBP, 103.7 ± 4.2 v 90.6 ± 2.5 mm Hg; P < 0.001), as were the post-HD blood pressures (SBP, 122.1 ± 4.6 v 109.0 ± 2.1 mm Hg; P < 0.01). There was a significant reduction in the number of nursing interventions performed and volume of saline infused for IDH with midodrine and cool dialysate compared with control. There was a trend toward amelioration of hypotensive symptoms with both therapies. Laboratory values, including Kt/V, did not change significantly with either midodrine or cool dialysate. This prospective study shows that both midodrine and cool dialysate are effective therapies for symptomatic IDH. There does not seem to be additional benefit when these two therapies are used in combination.


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        • Sherman RA
        The pathophysiologic basis for hemodialysis-related hypotension.
        Semin Dial. 1988; 1: 136-142
        • Daugirdas JT
        Dialysis hypotension: A hemodynamic analysis.
        Kidney Int. 1991; 39: 233-246
        • Jost CM
        • Agarwal R
        • Khaur-El-Din T
        • Grayburn PA
        • Victor RG
        • Heinrich WL
        Effects of cooler temperature dialysate on hemodynamic stability in “problem” dialysis patients.
        Kidney Int. 1993; 44: 606-612
        • Converse RL
        • Jacobsen TN
        • Jost CM
        • Toto RD
        • Grayburn PA
        • Obregon TM
        • Fouad-Tarazi F
        • Victor RG
        Paradoxical withdrawal of reflex vasoconstriction as a cause of hemodialysis-induced hypotension.
        J Clin Invest. 1992; 90: 1657-1665
        • Sherman RA
        • Faustino EF
        • Bernholc AS
        • Eisinger RD
        Effect of variations in dialysis temperature on blood pressure during hemodialysis.
        Am J Kidney Dis. 1984; 4: 66-69
        • Sherman RA
        • Rubin MP
        • Cody RP
        • Eisinger RD
        Amelioration of hemodialysis-associated hypotension by the use of cool dialysate.
        Am J Kidney Dis. 1985; 5: 124-127
        • Marcen R
        • Quereda C
        • Orofino L
        • Lamas S
        • Teruel JL
        • Matesanz R
        • Ortuno J
        Hemodialysis with low-temperature dialysate: A long-term experience.
        Nephron. 1988; 49: 29-32
        • Fine A
        • Penner B
        The protective effect of cool dialysate is dependent on patients' predialysis temperature.
        Am J Kidney Dis. 1996; 28: 262-265
        • Yu AW
        • Ing TS
        • Zabaneh RI
        • Daugirdas JT
        Effect of dialysate temperature on central hemodynamics and urea kinetics.
        Kidney Int. 1995; 48: 237-243
        • Flynn JJ
        • Mitchell MC
        • Caruso FS
        • McElligott MA
        Midodrine treatment for patients with hemodialysis hypotension.
        Clin Nephrol. 1996; 45: 261-267
        • Blowey DL
        • Balfe JW
        • Gupta I
        • Gajaria MM
        • Koren G
        Midodrine efficacy and pharmacokinetics in a patient with recurrent intradialytic hypotension.
        Am J Kidney Dis. 1996; 28: 132-136
        • Cruz DN
        • Mahnensmith RL
        • Perazella MA
        Intradialytic hypotension: Is midodrine beneficial in symptomatic hemodialysis patients?.
        Am J Kidney Dis. 1997; 30: 772-779
        • Cruz DN
        • Mahnensmith RL
        • Brickel HM
        • Perazella MA
        Midodrine is effective and safe therapy for intradialytic hypotension over 8 months of follow-up.
        Clin Nephrol. 1998; 50: 101-107
        • Fang JT
        • Huang CC
        Midodrine hydrochloride in patients on hemodialysis with chronic hypotension.
        Ren Fail. 1996; 18: 253-260
        • Lim PS
        • Yang CC
        • Li HP
        • Lim YT
        • Yeh CH
        Midodrine for the treatment of intradialytic hypotension.
        Nephron. 1997; 77: 279-283
        • Daugirdas JT
        Chronic hemodialysis prescription: A urea kinetic approach.
        in: ed 2. Handbook of Dialysis. Little, Brown, Boston, MA1994: 92-120
        • Norusis MJ
        SPSS 6.1 Base System User's Guide, Part 2.
        in: SPSS, Chicago, IL1994: 319-320
        • Kaufman AM
        • Morris AT
        • L'Avarias VA
        • Wang Y
        • Leung JF
        • Glabman MB
        • Yusuf SA
        • Levoci AL
        • Polaschegg HD
        • Levin NW
        Effects of controlled blood cooling on hemodynamic stability and urea kinetics during high-efficiency hemodialysis.
        J Am Soc Nephrol. 1998; 9: 877-883
        • Jankovic J
        • Gilden JL
        • Hiner BC
        • Kaufmann H
        • Brown DC
        • Coghlan CH
        • Rubin M
        • Fouad-Tarazi FM
        Neurogenic orthostatic hypotension: A double-blind, placebo-controlled study with midodrine.
        Am J Med. 1993; 95: 38-48
        • Fouad-Tarazi FM
        • Okabe M
        • Goren H
        Alpha sympa-thomimetic treatment of autonomic insufficiency with orthostatic hypotension.
        Am J Med. 1995; 99: 604-610
        • Marini U
        • Cecchi A
        • Venturini M
        Controlled clinical investigation of dimetophrine versus midodrine in the management of moderately decreased arterial blood pressure.
        Curr Med Res Opin. 1984; 9: 265-274
        • McTavish D
        • Goa KL
        Midodrine: A review of its pharmacologic properties and therapeutic use in orthostatic hypotension and secondary hypotensive disorders.
        Drugs. 1989; 38: 757-777