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 endorgan 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.

Hemodialysis Procedures for Stable Incident and Prevalent Patients Optimize Hemodynamic Stability, Dialysis Dose, Electrolytes, and Fluid Balance

“…DBW represents the patient’s most accurate weight without the extra fluid accumulating between dialysis sessions. Post-dialysis target weight should be regularly assessed because an inappropriately low target increases the risk of IDH [ 29 , 120 , 121 ]. DBW overestimation will increase the size of the interstitial space, minimizing the reduction of plasma volume during HD with elevated UF, but this may cause adverse effects related to an interstitial volume overload.…”

Hemodialysis Procedures for Stable Incident and Prevalent Patients to Optimize Hemodynamic Stability, Dialysis Dose, Electrolytes, and Fluid Balance

“…DBW represents the patientʹs most accurate weight without the extra fluid accumulating between dialysis sessions. Post-dialysis target weight should be regularly assessed because an inappropriately low target increases the risk of IDH [26,117,118]. DBW overestimation will increase the size of the interstitial space, minimizing the reduction of plasma volume during HD with elevated UF, but this may cause adverse effects related to an interstitial volume overload.…”

Unveiling the Clinical Benefits of High-Volume Hemodiafiltration: Optimizing the Removal of Medium-Weight Uremic Toxins and Beyond

“…Risk factors associated with hemodynamic intolerance on HD include diabetes mellitus; cardiovascular disease with systolic and diastolic dysfunction, ischemic heart disease, arrhythmias, and severe vascular calcification; autonomic dysfunction; poor nutritional status; hypoalbuminemia; female sex; age > 65 years; predialysis SBP < 100 mmHg; high body mass index; and severe anemia [ 107 , 108 ].…”