What is the management for a dialysis patient with hypotension (blood pressure below 90/60 mmHg)?

Management of Dialysis Patient with BP Below 90/60

The most critical first step is to reassess and likely increase the dry weight target by 0.5-1.0 kg, as setting the dry weight below the patient's true dry weight is the most common cause of persistent hypotension in dialysis patients. 1, 2

Immediate Assessment

Confirm Hypotension and Assess Severity

• Measure blood pressure properly with the patient sitting quietly for 5 minutes, feet flat on floor, arm supported at heart level 1, 2
• Check for orthostatic hypotension by measuring BP after standing for 2 minutes—a drop of ≥15 mmHg systolic or ≥10 mmHg diastolic indicates orthostatic hypotension and significantly increases fall risk 1
• Assess for symptoms: dizziness, weakness, fatigue, falls, syncope, chest pain, or confusion 2
• Maintain mean arterial pressure (MAP) ≥65 mmHg to ensure adequate tissue perfusion and prevent end-organ ischemia 1, 3

Timing Considerations

• Blood pressure typically reaches its lowest point during and immediately after dialysis sessions 1, 2
• Distinguish between intradialytic hypotension (occurring during treatment) versus persistent post-dialysis or interdialytic hypotension 4

Critical Dry Weight Evaluation (Primary Intervention)

Signs That Dry Weight Is Set Too Low

• Persistent hypotension despite adequate nutrition 1, 2
• Increasing serum albumin and creatinine levels 1, 2
• Improved appetite 1, 2
• Recurrent symptomatic hypotension 1, 2
• Paradoxically excessive interdialytic weight gains (patient drinking more to compensate for chronic hypovolemia) 2

Action Steps

• Increase target dry weight by 0.5-1.0 kg as the primary intervention 2
• Reassess if patient has been gaining muscle mass or improving nutritionally, as dry weight target needs adjustment 2
• A dry weight set too low leads to hypotension and faster loss of residual kidney function 2

Medication Review and Adjustment

Antihypertensive Medications

• Switch ALL antihypertensive drugs to nighttime dosing to reduce nocturnal BP surge and minimize intradialytic hypotension 4, 1, 2
• If BP is consistently low at home (systolic <100 mmHg), reduce or stop antihypertensive medications, particularly if volume status is optimized 1, 2
• Consider dialyzability of medications—metoprolol is highly dialyzable and may be removed during dialysis, causing rebound effects; switch to non-dialyzable alternatives 2

Pharmacological Treatment for Persistent Hypotension

• Midodrine (selective alpha-1 adrenergic agonist) is the primary pharmacological option for refractory hypotension 5, 6
• Midodrine increases standing systolic BP by approximately 15-30 mmHg at 1 hour after a 10 mg dose, with effects persisting 2-3 hours 5
• Typical dosing: 2.5-10 mg given before dialysis sessions, titrated to effect (mean effective dose 8 mg in clinical studies) 6
• Midodrine is removed by dialysis, so timing of administration is important 5
• Significantly increases minimal systolic pressure during hemodialysis from 93 to 107 mmHg and post-dialysis BP from 116/62 to 130/68 mmHg 6

Dietary and Fluid Management

Sodium and Fluid Restrictions

• Maintain sodium intake at 2-3 g/day with regular dietitian counseling every 3 months 4, 1, 2
• Limit interdialytic weight gain to <3 kg between sessions to reduce ultrafiltration requirements 1, 2
• Avoid eating during or immediately before dialysis, as this causes splanchnic vasodilation and worsens hypotension 1, 2

Dialysis Prescription Modifications

Treatment Time and Frequency

• Extend treatment time to >4 hours to allow slower ultrafiltration rates and better hemodynamic stability 1, 2
• Increase treatment frequency to >3 times per week to reduce per-session ultrafiltration requirements 1, 2
• Limit ultrafiltration rate to <6-10 mL/h/kg to reduce mortality risk and prevent end-organ ischemia 1, 2

Dialysate Modifications

• Lower dialysate temperature to 35-36°C (instead of 37°C) to increase peripheral vasoconstriction and reduce hypotensive episodes 2, 7
• Consider using relative blood volume monitoring and biofeedback systems to adjust ultrafiltration rate according to plasma volume changes 7

Blood Pressure Targets

Optimal Ranges

• Target predialysis BP of 110-140 mmHg systolic for most patients, as both very low (<110 mmHg) and very high BP are associated with increased mortality 1, 3
• Maintain MAP ≥65 mmHg during dialysis sessions 1, 3
• Post-dialytic drops in systolic BP up to 30 mmHg are associated with improved survival, but greater decreases correlate with higher mortality 3

Critical Pitfalls to Avoid

What NOT to Do

• Do NOT continue aggressive ultrafiltration in a hypotensive patient—this causes end-organ ischemia and increases mortality risk 1, 2
• Do NOT administer normal saline to treat hypotension—this expands extracellular volume further and perpetuates the problem 1
• Do NOT assume all hypotension requires more aggressive ultrafiltration—excessive ultrafiltration may be causing the hypotension 2
• Do NOT rely solely on predialysis or postdialysis BP measurements—home BP monitoring provides more accurate assessment 2, 3

Monitoring Strategy

Home Blood Pressure Monitoring

• Home BP monitoring provides more accurate assessment of true BP burden than pre- or post-dialysis measurements 2, 3
• This helps distinguish true hypotension from measurement artifact related to dialysis timing 3