Exaggerated blood pressure response to dynamic exercise despite chronic refractory hypotension: Results of a human case study

Alice Rogan, Gordon McGregor, Charles Weston, Nithya Krishnan, Robert Higgins, Daniel Zehnder, Stephen M S Ting

Research output: Contribution to journalArticle

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Abstract

BACKGROUND: Chronic refractory hypotension is a rare but significant mortality risk in renal failure patients. Such aberrant physiology usually deems patient unfit for renal transplant surgery. Exercise stimulates the mechano-chemoreceptors in the skeletal muscle thereby modulating the sympathetic effects on blood pressure regulation. The haemodynamic response to dynamic exercise in such patients has not been previously investigated. We present a case with severe chronic hypotension who underwent exercise testing before and after renal transplantation, with marked differences in blood pressure response to exercise.

CASE PRESENTATION: A 40-year old haemodialysis-dependent patient with a 2 year history of refractory hypotension (≤80/50 mmHg) was referred for living donor renal transplantation at our tertiary centre. Each dialysis session was often less than 2 h and 30 min due to symptomatic hypotension. As part of the cardiovascular assessment, she underwent haemodynamic evaluation with cardiopulmonary exercise testing. Blood pressure normalized during unloaded pedalling but was exaggerated at maximal workload whereby it rose from 82/50 mmHg to a peak of 201/120 mmHg. Transthoracic echocardiography, tonometric measure of central vascular compliance and myocardial perfusion scan were normal. She subsequently underwent an antibody-incompatible renal transplantation and was vasopressor reliant for 14 days during the post-operative period. Eight weeks following transplant, resting blood pressure was normal and a physiological exercise-haemodynamic response was observed during a repeat cardiopulmonary exercise testing.

CONCLUSION: This case highlights the potential therapeutic role of unloaded leg cycling exercise during dialysis session to correct chronic hypotension, allowing patients to have greater tolerance to fluid shift. It also adds to existing evidence that sympathetic dysfunction is reversible with renal transplant. Furthermore chronic hypotension with preserved exercise-haemodynamic response and cardiovascular reserve should not preclude these patients from renal transplant surgery.

Original languageEnglish
Article number81
JournalBMC Nephrology
Volume16
Early online date21 May 2015
DOIs
Publication statusPublished - 9 Jun 2015
Externally publishedYes

Fingerprint

Hypotension
Exercise
Blood Pressure
Hemodynamics
Kidney Transplantation
Transplants
Kidney
Dialysis
Fluid Shifts
Living Donors
Workload
Compliance
Renal Insufficiency
Blood Vessels
Echocardiography
Renal Dialysis
Foot
Leg
Skeletal Muscle
Perfusion

Keywords

  • Adult
  • Autonomic Nervous System Diseases
  • Blood Pressure
  • Exercise
  • Exercise Test
  • Exercise Therapy
  • Female
  • Fluid Shifts
  • Humans
  • Hypotension
  • Kidney Failure, Chronic
  • Kidney Transplantation
  • Renal Dialysis
  • Treatment Outcome
  • Vascular Resistance
  • Case Reports
  • Journal Article
  • Research Support, Non-U.S. Gov't

Cite this

Exaggerated blood pressure response to dynamic exercise despite chronic refractory hypotension : Results of a human case study. / Rogan, Alice; McGregor, Gordon; Weston, Charles; Krishnan, Nithya; Higgins, Robert; Zehnder, Daniel; Ting, Stephen M S.

In: BMC Nephrology, Vol. 16, 81, 09.06.2015.

Research output: Contribution to journalArticle

Rogan, Alice ; McGregor, Gordon ; Weston, Charles ; Krishnan, Nithya ; Higgins, Robert ; Zehnder, Daniel ; Ting, Stephen M S. / Exaggerated blood pressure response to dynamic exercise despite chronic refractory hypotension : Results of a human case study. In: BMC Nephrology. 2015 ; Vol. 16.
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AU - Rogan, Alice

AU - McGregor, Gordon

AU - Weston, Charles

AU - Krishnan, Nithya

AU - Higgins, Robert

AU - Zehnder, Daniel

AU - Ting, Stephen M S

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AB - BACKGROUND: Chronic refractory hypotension is a rare but significant mortality risk in renal failure patients. Such aberrant physiology usually deems patient unfit for renal transplant surgery. Exercise stimulates the mechano-chemoreceptors in the skeletal muscle thereby modulating the sympathetic effects on blood pressure regulation. The haemodynamic response to dynamic exercise in such patients has not been previously investigated. We present a case with severe chronic hypotension who underwent exercise testing before and after renal transplantation, with marked differences in blood pressure response to exercise.CASE PRESENTATION: A 40-year old haemodialysis-dependent patient with a 2 year history of refractory hypotension (≤80/50 mmHg) was referred for living donor renal transplantation at our tertiary centre. Each dialysis session was often less than 2 h and 30 min due to symptomatic hypotension. As part of the cardiovascular assessment, she underwent haemodynamic evaluation with cardiopulmonary exercise testing. Blood pressure normalized during unloaded pedalling but was exaggerated at maximal workload whereby it rose from 82/50 mmHg to a peak of 201/120 mmHg. Transthoracic echocardiography, tonometric measure of central vascular compliance and myocardial perfusion scan were normal. She subsequently underwent an antibody-incompatible renal transplantation and was vasopressor reliant for 14 days during the post-operative period. Eight weeks following transplant, resting blood pressure was normal and a physiological exercise-haemodynamic response was observed during a repeat cardiopulmonary exercise testing.CONCLUSION: This case highlights the potential therapeutic role of unloaded leg cycling exercise during dialysis session to correct chronic hypotension, allowing patients to have greater tolerance to fluid shift. It also adds to existing evidence that sympathetic dysfunction is reversible with renal transplant. Furthermore chronic hypotension with preserved exercise-haemodynamic response and cardiovascular reserve should not preclude these patients from renal transplant surgery.

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KW - Exercise Test

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KW - Fluid Shifts

KW - Humans

KW - Hypotension

KW - Kidney Failure, Chronic

KW - Kidney Transplantation

KW - Renal Dialysis

KW - Treatment Outcome

KW - Vascular Resistance

KW - Case Reports

KW - Journal Article

KW - Research Support, Non-U.S. Gov't

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DO - 10.1186/s12882-015-0076-7

M3 - Article

VL - 16

JO - BMC Nephrology

JF - BMC Nephrology

SN - 1471-2369

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ER -