710 - Successful Rehabilitation of a Hemodialysis Patient with Extremely High and Extremely Labile Blood Pressure on Acute Inpatient Rehabilitation Following a Stroke

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

MC

Michelle Cho, MD

Resident Physician
Metropolitan Hospital
New York, New York, United States
NM

Nathan Michalak, MD

Resident Physician
Metropolitan Hospital
New York, New York, United States
JK

Jun Beom Ku, MD

Resident Physician
Metropolitan Hospital
New York, New York, United States
SL

Schan Lartigue, BS

Medical Student
New York Medical College
Valhalla, New York, United States
AA

Arjun Ashok, BS

Medical Student
New York Medical College
Valhalla, New York, United States

Co-Author(s)

MA

Mawerdi Abdulkadir, MA, BS

Medical Student
New York Medical College
Valhalla, New York, United States
NS

Nathan Schanzer, MS, BA

Medical Student
New York Medical College
Valhalla, New York, United States
AR

Ashley Rosenberg, BA

MS2
New York Medical College
Valhalla, New York, United States

Corresponding Author(s)

EA

Eric Altschuler, MD, PhD

Associate Chief
Metropolitan Hospital
New York, New York, United States

Case Diagnosis: ESRD on HD, multiple CVAs

Case Description: 63-year-old female with type 2 diabetes, hypertension, and end-stage renal disease (ESRD) presented with unresponsiveness following hemodialysis (HD). Patient was found to have multi-territorial cortical infarcts. During handoff to Acute Inpatient Rehab (AIR), SBP was noted to be ~190 but would decrease to ~90 after morning medications. Anti-hypertensive regimen was carvedilol 25 mg BID, hydralazine 25 mg TID, losartan 25 mg QD, and nifedipine extended-release (ER) 60 mg QD. On arrival at AIR, BP was 208/73 without symptoms or neurologic deficits. Patient developed symptomatic orthostatic hypotension during physical therapy and persistently labile blood pressures throughout AIR admission, preventing participation in 23% of physical and occupational therapy sessions. Nephrology and internal medicine were consulted, and the dosage of nifedipine ER was increased from 90 mg QD to 60 mg BID, with consistent reduction of the daily maximum SBP to < 190, though daily minimum SBP was still ~90.

Discussions: During her AIR stay, patient improved from ambulating 70’ with minimum assistance to 150’ with supervision upon discharge, and improved from minimum to moderate assistance with transfers to supervision or touching assistance. High and/or labile blood pressure in the AIR setting may result in limited participation in therapy. Patients with ESRD on dialysis are at higher risk for blood pressure fluctuations from fluid shifts. Nifedipine inhibits entry of calcium ions by blocking voltage-gated L-type calcium channels, reducing systemic blood pressure and increasing myocardial oxygen delivery. Increasing the dosage of nifedipine ER from once to twice daily stabilized this patient's blood pressure, permitting participation in therapy.

Conclusions: ESRD patients on AIR may have extremely high and extremely labile blood pressure. Nifedipine ER seemed necessary to control blood pressure in this case, as was coordination of care among the rehabilitation team to allow for a successful AIR course.