Elsevier

Kidney International

Volume 61, Issue 2, February 2002, Pages 697-704
Kidney International

Dialysis – Transplantation
Hemodynamic changes during hemodialysis: Role of nitric oxide and endothelin

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Hemodynamic changes during hemodialysis: Role of nitric oxide and endothelin.

Background

Etiology of dialysis induced hypotension and hypertension remains speculative. There is mounting evidence that nitric oxide (NO) and endothelin (ET-1) may play a vital role in these hemodynamic changes. We examined the intradialytic dynamic changes in NO and ET-1 levels and their role in the pathogenesis of hypotension and rebound hypertension during hemodialysis (HD).

Methods

The serum nitrate + nitrite (NT), fractional exhaled NO concentration (FENO), L-arginine (L-Arg), NGNG-dimethyl-L-arginine (ADMA) and endothelin (ET-1) profiles were studied in 27 end-stage renal disease (ESRD) patients on HD and 6 matched controls. The ESRD patients were grouped according to their hemodynamic profile; Group I patients had stable BP throughout HD, Group II had dialysis-induced hypotension, and Group III had intradialytic rebound hypertension.

Results

Pre-dialysis FENO was significantly lower in the dialysis patients compared to controls (19.3 ± 6.3 vs. 28.6 ± 3.4 ppb, P < 0.002). Between the experimental groups, pre-dialysis FENO was significantly higher in Group II (24.1 ± 6.7 ppb) compared to Group I (17.8 ± 5.6 ppb) and Group III (16.1 ± 4.2 ppb; P < 0.05). Post-dialysis, FENO increased significantly from the pre-dialysis values (19.3 ± 6.3 vs. 22.6 ± 7.9 ppb; P = 0.001). Pre-dialysis NT (34.4 ± 28.2 μmol/L/L) level was not significantly different from that of controls (30.2 ± 12.3 μmol/L/L). Serum NT decreased from 34.4 ± 28.2 μmol/L/L at initiation of dialysis to 10.0 ± 7.4 μmol/L/L at end of dialysis (P < 0.001). NT concentration was comparable in all the three groups at all time points. Pre-dialysis L-Arg (105.3 ± 25.2 vs. 93.7 ± 6.0 μmol/L/L; P < 0.05) and ADMA levels were significantly higher in ESRD patients (4.0 ± 1.8 vs. 0.9 ± 0.2 μmol/L/L; P < 0.001) compared to controls. Dialysis resulted in significant reduction in L-Arg (105.3 ± 25.2 vs. 86.8 ± 19.8 μmol/L/L; P < 0.005) and ADMA (4.0 ± 1.8 vs. 1.6 ± 0.7 μmol/L/L; P < 0.001) concentrations. Pre-dialysis ET-1 levels were significantly higher in ESRD patients compared to the controls (8.0 ± 1.9 vs. 12.7 ± 4.1 pg/mL; P < 0.002), but were comparable in the three study groups. Post-dialysis ET-1 levels did not change significantly in Group I compared to pre-dialysis values (14.3 ± 4.3 vs.15.0 ± 2.4 pg/mL, P = NS). However, while the ET-1 concentration decreased significantly in Group II (12.0 ± 4.0 vs. 8.7 ± 1.8 pg/mL, P < 0.05), it increased in Group III from pre-dialysis levels (12.8 ± 3.8 vs. 16.7 ± 4.5 pg/mL, P = 0.06).

Conclusion

Pre-dialysis FENO is elevated in patients with dialysis-induced hypotension and may be a more reliable than NT as a marker for endogenous NO activity in dialysis patients. Altered NO/ET-1 balance may be involved in the pathogenesis of rebound hypertension and hypotension during dialysis.

Keywords

dialysis
hypotension
hypertension
cytokines
asymmetric dimethyl arginine
L-arginine
fractional exhaled nitric oxide

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