Hemofiltration as a Treatment for “Dialysis-Resistant” Hypertension and Hypotensive Hyperhydration

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Abstract
Normalization of blood pressure cannot be achieved in about 5% of patients with chronic renal insufficiency by fluid and sodium extraction on dialysis. An accompanying high plasma renin activity has, until now, been an indication for bilateral nephrectomy. In a group of 8 patients, treated since 1974 by hemofiltration, 3 had been originally considered for bilateral nephrectomy. However, through this treatment their blood pressure was normalized. The extraction of large quantities of fluid was tolerated by the patients; they did not have side effects such as muscle cramps or vascular collapse. Large quantities of fluid can also be removed by hemofiltration from hyperhydrated normotensive patients without hypotensive reactions. The present results show that the response of blood pressure to the extraction of a definite amount of fluid by hemofiltration is dependent upon the starting blood pressure: the higher the blood pressure value at the start of hemofiltration, the greater is the effect of dehydration on blood pressure. Observations on the pathogenesis of hypertension in patients with terminal renal insufficiency leave no doubt as to the importance of salt and water retention. It has been found that approximately 95% of hypertension in dialysis patients is controlled by hemodialysis. The remaining, so-called “dialysis-resistant” forms are, as a rule, controlled after bilateral nephrectomy. Investigations of blood pressure response during dialysis against high sodium concentrations have shown that isotonic dehydration is the critical factor for lowering blood pressure, and not the rapid decrease in exchangeable sodium (3, 4). It is therefore to be expected that hypertension in terminal renal Insufficiency can be more effectively controlled by hemofiltration, a dialysis form with isotonic fluid reduction of the extracellular space, than by other forms of dialysis treatment. The object of our investigation was to determine how well dialysis resistant hypertension could be regulated during both a single dialysis, and over a period of long-term treatment.

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