Efecto de la midodrina en la hipotensión sintomática en hemodiálisis

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Background: Hypotension occurs in 20% of hemodialysis procedures. Aim: To study the effects of midodrine on hypotension during hemodialysis. Patients and methods: Ten patients on chronic hemodialysis and with a history of hypotension during the procedure, were studied. They received midodrine 10 mg per os or placebo during 5 dialytic procedures each, in a double blind cross over design. Results: Blood pressure levels prior to dialysis were similar during the midodrine or placebo administration periods. During dialysis, systolic blood pressure fell 19.3±28 mmHg with midodrine and 23.4±28 mmHg with placebo. Diastolic blood pressure fell 7.3±11.5 mmHg with midodrine and 11.1±12 mmHg with placebo. The reduction in median arterial pressure was also less pronounced with midodrine. Conclusions: Midodrine lessens the fall in arterial pressure during hemodialysis, in patients with symptomatic hypotension (Rev Méd Chile 2002; 130: 1009-13)

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Pathophysiology of dialysis hypotension: an update.

J Daugirdas (2001)

Dialysis hypotension occurs because a large volume of blood water and solutes are removed over a short period of time, overwhelming normal compensatory mechanisms, including plasma refilling and reduction of venous capacity, due to reduction of pressure transmission to veins. In some patients, seemingly paradoxical and inappropriate reduction of sympathetic tone may occur, causing reduction of arteriolar resistance, increased transmission of pressure to veins, and corresponding increase in venous capacity. Increased sequestration of blood in veins under conditions of hypovolemia reduces cardiac filling, cardiac output, and, ultimately, blood pressure. Adenosine release due to tissue ischemia may participate in reducing norepinephrine release locally, and activation of the Bezold-Jarisch reflex, perhaps in patients with certain but as yet undefined cardiac pathology, may be responsible for sudden dialysis hypotension. Patients with diastolic dysfunction may be more sensitive to the effects of reduced cardiac filling. The ultimate solution is reducing the ultrafiltration rate by use of longer dialysis sessions, more frequent dialysis, or reduction in salt intake. Increasing dialysis solution sodium chloride levels helps maintain blood volume and refilling but ultimately increases thirst and interdialytic weight gain, with a possible adverse effect on hypertension. Blood volume monitoring with ultrafiltration or dialysis solution sodium feedback loops are promising new strategies. Maintaining tissue oxygenation via an adequate blood hemoglobin level seems to be important. Use of adenosine antagonists remains experimental. Given the importance of sympathetic withdrawal, the use of pharmacologic sympathetic agonists is theoretically an attractive therapeutic strategy.

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Reversal of type 1 hepatorenal syndrome with the administration of midodrine and octreotide.

P Roner, Jonathan A. Sticca, L Caregaro … (1999)

The aim of the study was to verify the effects of the administration of an inhibitor of the release of endogenous vasodilators together with a vasoconstrictor agent in patients with hepatorenal syndrome (HRS). This new medical perspective was compared with a traditional medical approach for HRS, such as the infusion of nonpressor doses of dopamine to produce renal vasodilation. Thirteen patients with type 1 HRS were enrolled in the study. Five of them were treated with the oral administration of midodrine and the parenteral administration of octreotide. In addition, the patients received 50 to 100 mL of 20% human albumin solution daily for 20 days. Midodrine and octreotide were dosed to obtain a stable increase of at least 15 mm Hg of mean arterial pressure. Eight patients were treated with the intravenous administration of nonpressor doses of dopamine (2-4 micrograms/kg/min) and the same daily amount of albumin. After 20 days of treatment with midodrine and octreotide, an impressive improvement in renal plasma flow (RPF), glomerular filtration rate, and urinary sodium excretion was observed in patients. This was accompanied by a significant reduction in plasma renin activity, plasma vasopressin, and plasma glucagon. No side effects were observed. Three patients were discharged from the hospital. One of them successfully underwent liver transplantation. One of the two remaining patients is still alive after 472 days with a preserved renal function, and the other died from terminal liver failure after 76 days. One of the two patients who were not discharged from the hospital successfully underwent liver transplantation, and the other died from pneumonia after 29 days. Seven out of eight patients who were treated with dopamine experienced a progressive deterioration in renal function and died during the first 12 days. Only one patient recovered renal function and underwent liver transplantation. In conclusion, the long-term administration of midodrine and octreotide seems to be an effective and safe treatment of type 1 HRS in patients with cirrhosis.

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Efficacy of midodrine vs placebo in neurogenic orthostatic hypotension. A randomized, double-blind multicenter study. Midodrine Study Group.

Michael R. Freeman, David Low, A McElligott … (1997)

To evaluate the efficacy of a 10-mg dose of midodrine 3 times per day in improving blood pressure (BP) and ameliorating symptoms of orthostatic hypotension in patients with neurogenic orthostatic hypotension. Midodrine hydrochloride, an alpha-agonist, could improve orthostatic BP by increasing vasomotor and venomotor tone. A total of 171 patients with orthostatic hypotension participated in a multicenter, randomized, placebo-controlled study. They were randomized to a 10-mg dose of midodrine or placebo 3 times per day in a 6-week study, comprising single-blind run-in (at week 1) and washout at weeks 5 and 6, with an intervening double-blind period (weeks 2 to 4). Twenty-five centers, with most patients evaluated in referral centers. The primary end points were improvement in standing systolic BP, symptoms of lightheadedness, and a global symptom relief score (by the investigator and patient separately). Nine patients were not evaluable because of noncompliance or taking concomitant vasoactive medications (3 in the midodrine group, 6 in the placebo group). In the evaluable patients, midodrine resulted in improvements in standing systolic BP at all time points (P<.001 at visits 2, 3, 4, and 5), in reported symptoms by the end of the second week of treatment (P=.001), and in the global symptom relief score rated by both the patient (P=.03) and the investigator (P<.001). There was no effect by center, severity of orthostatic hypotension, use of fludrocortisone or compression garments, or diagnosis. The main adverse effects were those of pilomotor reactions, urinary retention, and supine hypertension. Midodrine is efficacious and safe in the treatment of neurogenic orthostatic hypotension.

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Author and article information

Journal

Journal ID (publisher-id): rmc

Title: Revista médica de Chile

Abbreviated Title: Rev. méd. Chile

Publisher: Sociedad Médica de Santiago (Santiago, , Chile )

ISSN (Print): 0034-9887

Publication date (Print and electronic): September 2002

Volume: 130

Issue: 9

Pages: 1009-1013

Affiliations

[01] orgnameHospital Clínico Universidad de Chile orgdiv1Departamento de Medicina orgdiv2Sección de Nefrología

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Publisher ID: S0034-98872002000900007 Publisher ID: S0034-9887(02)13000907

DOI: 10.4067/S0034-98872002000900007

SO-VID: ac715c97-76da-4b47-b548-4675756f0ff4

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This work is licensed under a Creative Commons Attribution 4.0 International License.

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Date accepted : 08 July 2002

Date received : 02 January 2002

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Figures: 0, Tables: 0, Equations: 0, References: 15, Pages: 5

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Efecto de la midodrina en la hipotensión sintomática en hemodiálisis Translated title: Effects of midodrine on orthostatic hypotension during hemodialysis

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Most cited references 23

Pathophysiology of dialysis hypotension: an update.

Reversal of type 1 hepatorenal syndrome with the administration of midodrine and octreotide.

Efficacy of midodrine vs placebo in neurogenic orthostatic hypotension. A randomized, double-blind multicenter study. Midodrine Study Group.

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