Symptomatic
hypotension during
hemodialysis is a disabling complication in
end-stage renal disease (
ESRD) patients, especially in certain groups of patients who are at higher risk for this problem. Autonomic dysfunction is thought to play a significant role. We evaluated the efficacy of
midodrine, an oral agent with selective
alpha-adrenergic agonist activity used in the treatment of neurogenic
orthostatic hypotension, on 10
hemodialysis patients with persistent intradialytic
hypotension. The patients were given a dose of
midodrine (mean dose, 5.5 mg; range, 5 to 10 mg) 30 minutes before each
hemodialysis session. We compared blood pressure, pulse,
body weight, and laboratory values for 10 consecutive dialysis sessions off and on
midodrine therapy. There was a statistically significant improvement in lowest intradialytic systolic blood pressure (from 96.6 to 114.7 mm Hg; P < 0.001), lowest intradialytic diastolic blood pressure (from 53.2 to 59.0 mm Hg; P = 0.002), lowest intradialytic mean arterial pressure (from 67.7 to 77.6 mm Hg; P < 0.001), posthemodialysis systolic blood pressure (from 116.5 to 127.1 mm Hg; P < 0.001), posthemodialysis diastolic blood pressure (from 66.6 to 69.7 mm Hg; P = 0.040), and posthemodialysis mean arterial pressure (from 83.2 to 88.8 mm Hg; P = 0.001) after patients were placed on
midodrine. There also was a small but statistically significant decrease in intradialytic pulse rate (from 86.3 to 81 beats/min; P = 0.021) and posthemodialysis pulse rate (from 87.4 to 81.7 beats/min; P = 0.024) after initiation of
midodrine therapy. There was no significant difference in any of the prehemodialysis blood pressure measurements or pulse rate off or on
midodrine therapy. The improvements in intradialytic and posthemodialysis blood pressure were associated with a uniform subjective improvement in symptoms associated with dialysis
hypotension, such as
cramps,
fatigue,
dizziness, and weakness. Other than scalp
paresthesia in one patient, no adverse effects were noted. Our results suggest that the administration of a single dose of
midodrine before
hemodialysis is an effective
therapy for intradialytic
hypotension. A prospective trial with adequate patient numbers and long-term follow-up would be useful to evaluate this
drug's efficacy and safety profile in patients with
ESRD.