Can excessive fluid removal during hemodialysis (HD) cause lethargy and weakness in patients with end-stage renal disease (ESRD)?

Excessive Fluid Removal During Hemodialysis and Post-Dialysis Symptoms

Yes, removing more fluid than necessary during hemodialysis directly causes lethargy and weakness post-dialysis by inducing hypovolemia and end-organ ischemia, with recovery time extending from 2-6 hours in 41% of patients and exceeding 6 hours in 27% of patients when ultrafiltration is excessive. 1, 2

Physiological Mechanism of Post-Dialysis Fatigue

When ultrafiltration depletes intravascular volume faster than plasma refilling can compensate from interstitial spaces, patients develop hypovolemia that triggers both immediate hemodynamic instability and prolonged recovery symptoms. 1 The critical issue is that excessive fluid removal—particularly at ultrafiltration rates exceeding 10 ml/h/kg—causes:

• End-organ ischemic injury affecting the heart, brain, liver, gut, and kidneys, which manifests clinically as profound fatigue and weakness 1
• Cardiovascular collapse requiring premature termination of ultrafiltration, often with normal saline administration that paradoxically worsens volume status 1
• Accelerated loss of residual kidney function from recurrent ischemic insults 1

Clinical Evidence for Post-Dialysis Lethargy

The relationship between excessive ultrafiltration and feeling "washed out or drained" is well-established:

• Recovery time after dialysis sessions was 2-6 hours for 41% of hemodialysis patients and longer than 6 hours for 27% in the DOPPS study, with recovery time linearly associated with increased risks for death and hospitalization 2
• Patients identify feeling washed out or drained as more important outcomes than death or hospitalization, underscoring the clinical significance of this symptom 2
• Fatigue is a common symptom with mean Fatigue Assessment Scale scores of 24.99, where 47.3% of hemodialysis patients were fatigued and 13.7% were extremely fatigued 3

The Critical Distinction: Rate Versus Total Volume

The ultrafiltration rate matters as much as total volume removed—observational data consistently show that higher ultrafiltration rates correlate with increased mortality risk even at rates as low as 6 ml/h/kg. 1 This means:

• Attempting to remove appropriate total fluid volume too rapidly causes the lethargy and weakness, not necessarily the achievement of euvolemia itself 1
• Lengthening dialysis sessions or adding additional treatments can lower ultrafiltration rates below 10 ml/h/kg while achieving the same total volume removal, which is the most effective strategy to prevent post-dialysis symptoms 1

Recognizing When You've Gone Too Far

Hypotension during dialysis signals that ultrafiltration has depleted intravascular volume faster than plasma refilling can compensate, meaning the patient has likely reached or gone below their actual dry weight. 1 When this occurs:

• Immediately increase the dry weight target by 0.3-0.5 kg 1
• Reduce the ultrafiltration rate for the remainder of the current session to allow plasma refilling to catch up 1
• Reassess volume status between sessions looking for clinical signs of fluid overload (edema, hypertension, elevated jugular venous pressure) 1

Evidence from Intensive Hemodialysis Regimens

The Frequent Hemodialysis Network trial provides compelling evidence that slower, more frequent dialysis reduces post-dialysis symptoms:

• Short daily and nocturnal schedules reduced the per-session probability of intradialytic hypotension by 20% and 68%, respectively, relative to 3 sessions per week 2
• Recovery time after nocturnal hemodialysis may be minutes, compared to hours with conventional schedules 2
• In the FREEDOM study, recovery time was reduced after 12 months from 8 hours to 1 hour with short daily hemodialysis 2

Common Clinical Pitfall

Conventional dialysis time is too short for patients with large interdialytic weight gains to achieve adequate ultrafiltration without exceeding safe ultrafiltration rates, and attempts to accelerate ultrafiltration to compensate for limited time precipitate hypovolemia and the resulting lethargy and weakness. 1 The solution is not to abandon volume removal goals but rather to:

• Extend dialysis time rather than increasing ultrafiltration rate 1
• Implement strict dietary sodium restriction to <2 g/day to reduce interdialytic weight gains 1, 4
• Consider more frequent dialysis sessions to distribute fluid removal over more treatments 2

The Gradual Approach to Dry Weight Achievement

True dry weight reduction must be accomplished gradually over 4-12 weeks (or even 6-12 months in some patients), not in a single session. 1 The recommended approach is:

• Reduce dry weight by 0.1 kg per 10 kg body weight per dialysis session when attempting to achieve euvolemia 1
• Patients with diabetes mellitus (autonomic dysfunction) or cardiomyopathy require even slower dry weight reduction due to impaired compensatory mechanisms 1
• Rapid dry weight reduction with frequent hypotensive episodes causes adverse events, including seizures 1