Intradialytic hypotension

Abstract

Intradialytic hypotension (IDH) is common in children during conventional, 4 hour haemodialysis (HD) sessions. The declining blood pressure (BP) was originally believed to be caused by ultrafiltration (UF) and priming of the HD circuit, however emerging data now supports a multifactorial aetiology. Therefore strategies to improve haemodynamic stability need to be diverse and address specific patient requirements or risks. In the treatment of IDH immediate action is required to stop or reduce the severity of symptoms that may precede or follow. Typically UF is slowed or stopped, a fluid bolus is given and in resistant cases the HD session is prematurely discontinued. Patients complete their treatment under-dialysed and volume expanded. Chronically, repeated episodes of IDH cause devastating, multi-system morbidity with an increased risk of mortality. This had provided the impetus for more haemodynamically friendly dialysis prescriptions that attenuate the risk of IDH. During pediatric HD several preventative strategies have been tested but with variable success. Of these, dialysate sodium profiling, UF guided by relative blood volume (RBV) algorithms, cooling and intradialytic mannitol appear to be the most effective. However in refractory cases one may be left with no option but to switch dialysis modality to haemodiafiltration (HDF) or more frequent or prolonged HD regimens.

Lower Dialysate Temperature in Hemodialysis

“…In addition, repeated episodes of IDH are uncomfortable for the patient and may cause multisystem morbidity and increased risk of mortality (3). These adverse health outcomes are thought to result from recurrent and cumulative ischemic insults to multiple organs, such as the brain (4), heart, skin vessels, and native kidneys.…”

“…Various hemodynamically friendly hemodialysis (HD) prescriptions to address IDH have previously been tested with variable success (3). In previous work, lowering the dialysate temperature (cool dialysis) has been advocated as a simple, useful, universally applicable, and economic procedure, especially for highly symptomatic patients (6)(7)(8).…”

“…Vascular instability and severe episodes of intradialytic hypotension (IDH) represent the most frequent (up to 20%) (1) and challenging complications of conventional dialysis regimens (2), resulting in underdialysis and volume expansion (3). In addition, repeated episodes of IDH are uncomfortable for the patient and may cause multisystem morbidity and increased risk of mortality (3).…”

Shenfu Injection for Intradialytic Hypotension: A Systematic Review and Meta‐Analysis

“…IDH occurs as a consequence of a mismatch between ultrafiltration and plasma refilling rates, coupled with a decline in cardiac function, changes in serum electrolyte concentrations, autonomic dysfunction, imbalance of vasoactive agents, dialysate temperature, and an immune response to dialysis [3]. IDH is independently associated with higher mortality in hemodialysis patients, contributes to a variety of clinical events such as stroke [4], mesenteric ischemia [5], cardiac infarction, and arrhythmias [6], and impairs the ability to reach the required dry weight, which will lead to fluid overload, hypertension, and left ventricular hypertrophy [7].…”

Complications During Continuous Renal Replacement Therapy in Critically Ill Neonates

“…There is no uniform definition of IDH in adults, children [8,15,16], and neonates [10,11]. In adults, IDH was often observed at the end of the session due to hypovolemia from the removal of excessive ultrafiltration.…”