Prevention of Intradialytic Hypotension in Hemodialysis Patients: Current Challenges and Future Prospects

Abstract

Intradialytic hypotension, defined as rapid decrease in systolic blood pressure of greater than or equal to 20 mmHg or in mean arterial pressure of greater than or equal to 10 mmHg that results in end-organ ischemia and requires countermeasures such as ultrafiltration reduction or saline infusion to increase blood pressure to improve patient’s symptoms, is a known complication of hemodialysis and is associated with several potential adverse outcomes. Its pathogenesis is complex and involves both patient-related factors such as age and comorbidities, as well as factors related to the dialysis prescription itself. Key factors include the need for volume removal during hemodialysis and a suboptimal vascular response which compromises the ability to compensate for acute intravascular volume loss. Inadequate vascular refill, incorrect assessment or unaccounted changes of target weight, acute illnesses and medication interference are further potential contributors. Intradialytic hypotension can lead to compromised tissue perfusion and end-organ damage, both acutely and over time, resulting in repetitive injuries. To address these problems, a careful assessment of subjective symptoms, minimizing interdialytic weight gains, individualizing dialysis prescription and adjusting the dialysis procedure based on patients’ risk factors can mitigate negative outcomes.

Keywords:

• end-stage renal disease
• dialysis
• hemodialysis
• hypotension
• ultrafiltration

Disclosure

Drs. Herberth and Fülöp are current employees of the United States Veterans Health Administration. However, the opinions and views expressed in this paper are the Authors’ own and do not represent the official views or policies of the United States Veteran Health Administrations. Dr. Salem Vilayet is a current Fellow at the Department of Medicine - Division of Nephrology, Medical University of South Carolina (Class of 2024). The authors alone are responsible for the content and writing of the paper. The authors report no other conflicts of interest in this work.