How to manage intradialytic hypotension?

Management of Intradialytic Hypotension

The most effective approach to managing intradialytic hypotension involves optimizing ultrafiltration parameters, modifying dialysate composition, and using pharmacological interventions when necessary. 1

Initial Assessment and Immediate Management

When intradialytic hypotension occurs:

1. Slow or temporarily pause ultrafiltration 1
2. Place patient in Trendelenburg position 2
3. Administer fluid bolus (100-200 mL normal saline) if hypotension persists 2
4. Monitor vital signs continuously until stabilized 2

Preventive Strategies

Ultrafiltration Optimization

• Avoid excessive ultrafiltration - reassess estimated dry weight 1
• Slow the ultrafiltration rate - limit to <3% of body weight per session 3
• Consider isolated ultrafiltration (separate from diffusive clearance) 1
• Extend dialysis time to allow for more gradual fluid removal 1, 2
• Consider more frequent dialysis sessions if appropriate 2

Dialysate Modifications

• Increase dialysate sodium concentration to 148 mEq/L 1, 2
• Switch from acetate to bicarbonate-buffered dialysate 1, 4
• Reduce dialysate temperature to 34-35°C 1, 2
• Use higher dialysate calcium (≥1.50 mmol/L) to improve vascular stability 2

Pharmacological Interventions

• Administer midodrine 5-10 mg orally 30 minutes before dialysis 1, 5
  • Monitor for supine hypertension
  • Avoid in patients with urinary retention
  • Use cautiously with cardiac glycosides or beta-blockers
• Consider L-carnitine for persistent hypotension unresponsive to other measures 2
• Reserve norepinephrine (2-4 mcg/min IV) for severe, refractory cases only 6
  • Requires careful monitoring due to risk of tissue ischemia
  • Should be administered through a central venous catheter

Patient Education and Interdialytic Management

• Counsel on sodium restriction (2-3 g/day) to reduce interdialytic weight gain 2
• Advise fluid restriction to limit weight gain between sessions 2
• Review timing of antihypertensive medications - consider administering at night rather than before dialysis 1, 2
• Correct anemia to target hemoglobin of 11 g/dL 1, 2
• Consider supplemental oxygen during dialysis, particularly for patients with cardiovascular disease 1, 2

Special Considerations

• Patients with diabetes or cardiomyopathy may require more gradual approaches to fluid removal 2
• Avoid eating immediately before or during dialysis as this can exacerbate hypotension 2
• Higher dialysis dose at constrained treatment times may increase risk of hypotension 7
• Albumin infusion has limited evidence supporting its use and is costly (approximately $20,000/year for thrice-weekly administration) 1
• Vasopressin deficiency may contribute to intradialytic hypotension; research on vasopressin administration is ongoing but not yet standard practice 8

Common Pitfalls to Avoid

• Incorrect dry weight assessment - regularly reassess based on clinical parameters, not just hypotension 1
• Excessive ultrafiltration rates - can lead to inadequate plasma refilling and vascular collapse 9, 3
• Overlooking sodium intake - high sodium drives thirst and fluid consumption between sessions 2
• Ignoring medication timing - antihypertensive medications taken shortly before dialysis can exacerbate hypotension 1, 2
• Rapid correction of hypotension with excessive fluid boluses can lead to pulmonary edema and inadequate fluid removal 2

By implementing these strategies systematically, the frequency and severity of intradialytic hypotension can be significantly reduced, improving patient comfort, dialysis adequacy, and long-term outcomes.