Clinical Investigation

Kidney International (1977) 12, 294–302; doi:10.1038/ki.1977.114

Autonomic blockade and the Valsalva maneuver in patients on maintenance hemodialysis: A hemodynamic study

Barry P McGrath1, David J Tiller1, Alex Bune1, John P Chalmers1, Paul I Korner1 and John B Uther1

1The Renal Unit and Hallstrom Institute of Cardiology, Royal Prince Alfred Hospital, Camperdown, Sydney, Australia

Correspondence: Dr D J Tiller, Renal Unit, Royal Prince Alfred Hospital, Camperdown, Sydney 2050, Australia.

Received 8 November 1976; Revised 10 March 1977.

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Abstract

Autonomic blockade and the Valsalva maneuver in patients on maintenance hemodialysis: A hemodynamic study. Hemodynamic studies were performed at two levels of dietary sodium intake (10 mmoles/day and 100 mmoles/day for 14 days) in a group of patients (with retained kidneys) on chronic hemodialysis. Plasma renin activity and aldosterone, plasma, and extracellular fluid (ECF) volumes were measured while the patients were at rest. Cardiac output, mean intraarterial pressure, and the calculated total peripheral resistance index were recorded while the patients were at rest and during acute "total" autonomic blockade. On the sodium diet of 10 mmoles/day, normotensive and hypertensive patients had similarly low total blood volumes, low-normal ECF volumes, and similar levels of plasma renin and aldosterone. The resting cardiac output was increased in both groups, but the total peripheral resistance was increased only in the patients with hypertension, in whom peripheral resistance was inappropriately high for the degree of anemia. Six hypertensive patients were studied on both diets. The resting mean arterial pressure was greater on the sodium diet of 100 mmoles/day than on the 10 mmoles/day diet, accompanied by increases in plasma volume, extracellular fluid volume, and cardiac output, but no change in peripheral resistance. During autonomic blockade on either diet, there was a marked fall in blood pressure in the patients with hypertension. This was mainly due to a fall in peripheral resistance which reached levels similar to those seen in the normotensive patients whose resistance was unaltered by blockade. Autonomic factors appear to contribute to the elevated peripheral resistance of hypertensive dialysis patients. In these patients, the effect of a high sodium diet, at least over the time-scale studied here, is to increase blood pressure and cardiac output, without the change in peripheral resistance expected from autoregulation.

Blocage du système nerveux autonome et manoeuvre de Valsalva chez des malades en hèmodialyse itérative: Etude hémodynamique. Des études hémodynamiques ont été réalisées à deux niveaux d'apport alimentaire de sodium (10 mmoles/jour et 100 mmoles/jour) dans un groupe de malades possédant leurs reins soumis à l'hémodiayse itérative. L'activité renine et l'aldostérone plasmatiques, le volume plasmatique et le volume des liquides extracellulaires ont été mesurés au repos. Le débit cardiaque, la pression artérielle moyenne et la résistance périphérique totale calculée ont été obtenus au repos et pendant le blocage "total" aigu du système nerveux autonome. Au cours de l'ingestion du régime à 10 mmoles/jour de sodium les malades à pression artérielle normale ou à pression artérielle élevée ont de façon semblable des volumes sanguins totaux bas, des volumes extra-cellulaires bas ou normaux et des valeurs voisines d'activité rénine et d'aldostérone plasmatiques. Le débit cardiaque au repos est augmenté dans les deux groupes mais la résistance périphérique totale n'est augmentée que dans le groupe atteint d'hypertension, dans lequel la résistance périphérique est plus grande que ne le voudrait le degré d'anémie. Six malades atteints d'hypertension ont été étudiés au cours de l'ingestion des deux régimes. La pression artérielle au repos est plus élevée avec 100 mmoles de sodium qu'avec 10, en même temps que sont augmentés le volume plasmatique, le volume extra-cellulaire et le débit cardiaque, mais sans changement des résistances périphériques. Au cours du blocage du système autonome, et quel que soit le régime, une baisse de pression artérielle importante est observée dans le groupe avec hypertension. Cela est dû essentiellement à une chute de la résistance périphérique qui atteint des valeurs semblables à celles observées chez les malades exempts d'hypertension, dont la résistance périphérique n'est pas modifiée par le blocage. Les facteurs autonomes paraissent contribuer à l'augmentation de la résistance périphérique des malades dialysés atteints d'hypertension. Chez ces malades l'effet d'une alimentation riche en sodium est, au moins dans l'intervalle de temps étudié ici, l'augmentation de la pression artérielle et du débit cardiaque sans la modification de la résistance périphérique que l'on pourrait attendre de l'autorégulation.

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