How to manage hypotension and prevent falls in patients after dialysis?

Management of Post-Dialysis Hypotension and Fall Prevention

The most effective strategy to prevent post-dialysis hypotension and falls is to reassess and potentially increase the dry weight target, switch antihypertensive medications to nighttime dosing (avoiding morning pre-dialysis administration), and implement strict sodium restriction (2-3 g/day) with extended dialysis sessions to allow slower ultrafiltration rates. 1

Immediate Assessment of Hypotension

Measure Blood Pressure Properly

• Have the patient sit quietly for 5 minutes with feet flat on the floor and arm supported at heart level before measurement 1
• Check for orthostatic hypotension by measuring blood pressure after standing for 2 minutes—a drop of ≥15 mmHg systolic or ≥10 mmHg diastolic indicates orthostatic hypotension and significantly increases fall risk 2, 1
• Blood pressure typically reaches its lowest point during and immediately after dialysis sessions 1

Assess for Symptoms Indicating Fall Risk

• Evaluate for dizziness, weakness, fatigue, syncope, confusion, or prior falls—these symptoms indicate the patient is at high risk for falling 1
• Note that some patients may remain asymptomatic despite significant blood pressure drops, while others become symptomatic with lesser decreases 2

Critical Dry Weight Evaluation

Determine if Dry Weight is Set Too Low

• The most common cause of persistent post-dialysis hypotension is that the patient's dry weight target is set below their true dry weight 1
• Signs suggesting dry weight is too low include: persistent hypotension despite adequate nutrition, increasing serum albumin and creatinine levels, improved appetite, and recurrent symptomatic hypotension 1
• Paradoxically, excessive interdialytic weight gains may indicate the dry weight is set too low, as patients drink more to compensate for chronic hypovolemia 1

Adjust Dry Weight Target

• Increase the target dry weight by 0.5-1.0 kg if the patient cannot tolerate current ultrafiltration goals 3
• Reassess dry weight if the patient has been gaining muscle mass or improving nutritionally 1
• A dry weight that is too low can lead to faster loss of residual kidney function 3

Medication Management to Prevent Hypotension

Review and Adjust Antihypertensive Medications

• Antihypertensive medications taken in the morning before dialysis are a common culprit and frequently cause intradialytic and post-dialysis hypotension 1
• Switch all antihypertensive drugs to nighttime dosing to reduce nocturnal blood pressure surge and minimize intradialytic hypotension 2, 1
• If blood pressure is consistently low at home (systolic <100 mmHg), reduce or stop antihypertensive medications, particularly if volume status is optimized 1

Consider Medication Dialyzability

• Review whether medications are removed during dialysis—for example, metoprolol is dialyzable and may cause rebound effects 1
• Switch to non-dialyzable alternatives when appropriate 1
• Discontinue or hold carvedilol on dialysis days due to its nondialyzable properties, which increase hypotension risk 3

Pharmacologic Support for Refractory Hypotension

• Consider midodrine, a selective alpha-1 adrenergic pressor agent, for patients with severe refractory hypotension 4, 5
• Midodrine significantly increases systolic blood pressure from 93 mmHg to 107 mmHg during hemodialysis and from 116 mmHg to 130 mmHg post-dialysis 5
• Start with 2.5 mg in patients with renal impairment, with typical maintenance doses of 8 mg (range 2.5-25 mg) 4, 5
• Critical caveat: Patients should avoid taking midodrine if they will be supine for any length of time, and should take their last daily dose 3-4 hours before bedtime to minimize supine hypertension 4

Dietary and Fluid Management

Sodium and Fluid Restriction

• Maintain sodium intake at 2-3 g/day with regular dietitian counseling every 3 months 2, 1
• Limit interdialytic weight gain to <3 kg between sessions to reduce ultrafiltration requirements 1
• Avoid eating during or immediately before dialysis, as this causes splanchnic vasodilation and worsens hypotension 1

Dialysis Prescription Modifications

Extend Treatment Time and Frequency

• Extend treatment time to >4 hours to allow slower ultrafiltration rates and better hemodynamic stability 1
• Increase treatment frequency to >3 times per week to reduce per-session ultrafiltration requirements 1
• Limit ultrafiltration rate to <6-10 mL/h/kg to reduce mortality risk and prevent end-organ ischemia 3

Adjust Dialysate Parameters

• Lower dialysate temperature to 35-36°C (instead of 37°C) to increase peripheral vasoconstriction and reduce hypotensive episodes 1, 3
• Consider sodium profiling by increasing dialysate sodium concentration early in the session to improve hemodynamic stability 3
• Implement ultrafiltration profiling to remove more fluid early in the session when hemodynamic tolerance is better 6

Fall Prevention Strategies

Target Blood Pressure Goals

• Target predialysis blood pressure of 110-140 mmHg systolic for most patients, as both very low (<110 mmHg) and very high blood pressure are associated with increased mortality 1
• Maintain mean arterial pressure (MAP) ≥65 mmHg during dialysis to ensure adequate tissue perfusion and prevent end-organ ischemia 3

Home Blood Pressure Monitoring

• Implement home blood pressure monitoring, as it provides more accurate assessment of true blood pressure burden than pre- or post-dialysis measurements 1
• Use out-of-unit blood pressure measurements to guide management decisions 3

Common Pitfalls to Avoid

• Do not continue aggressive ultrafiltration in a hypotensive patient, as this causes end-organ ischemia and increases mortality risk 3
• Do not assume all hypotension requires more aggressive ultrafiltration—excessive ultrafiltration may be causing the hypotension 3
• Avoid administering normal saline to treat hypotension, as this expands extracellular volume further and perpetuates the problem 2
• Do not overlook that the first dialysis session of the week carries a 60% higher risk of hypotension compared to the third session 7

Multidisciplinary Approach for High-Risk Patients

• Establish systematic interdisciplinary team meetings involving nephrology, cardiology, neurology, pharmacy, nutrition, and nursing for patients with recurrent hypotension and falls 3
• Recognize that hypotensive episodes can cause myocardial ischemia, ischemic cerebrovascular accidents, vascular access thrombosis, and intestinal ischemia 8
• Pre-dialysis hypotension is associated with increased mortality rates in the long-term 8