In a hemodialysis patient who develops shortness of breath and a rise in blood pressure during treatment, and point‑of‑care ultrasound shows a kissing left ventricle (markedly reduced preload) without right‑ventricular distension, how should the intradialytic hypertension and fluid management be addressed?

Management of Intradialytic Hypertension with POCUS Evidence of Hypovolemia

Critical Clinical Interpretation

When POCUS demonstrates a "kissing" left ventricle (markedly reduced preload) without right ventricular distension in a hemodialysis patient with intradialytic hypertension and dyspnea, this represents a paradoxical hypertensive response to volume depletion—you must immediately stop ultrafiltration, reassess dry weight upward, and address the underlying vascular resistance surge rather than continuing fluid removal. 1, 2

Immediate Intradialytic Management

Stop or dramatically reduce ultrafiltration immediately when POCUS shows kissing LV, as this indicates you have already exceeded true dry weight and further volume removal will worsen the paradoxical hypertensive response through increased vascular resistance. 1, 3

• Continue the dialysis session for solute clearance but with minimal or zero ultrafiltration to avoid further hemodynamic compromise. 1
• Monitor blood pressure every 5 minutes during this adjustment period to detect any improvement as vascular resistance mechanisms stabilize. 3
• The dyspnea in this context likely reflects acute cardiac dysfunction from excessive preload reduction rather than volume overload, despite the elevated blood pressure. 3

Understanding the Paradoxical Physiology

The blood pressure rise during dialysis in the setting of hypovolemia (kissing LV) occurs through acute vascular resistance surges mediated by:

• Sympathetic nervous system activation triggered by excessive volume removal. 2, 4
• Renin-angiotensin-aldosterone system activation in response to perceived hypovolemia. 2, 5
• Endothelial cell dysfunction causing vasoconstriction, possibly mediated by endothelin-1. 2, 4

This represents intradialytic hypertension driven by excessive ultrafiltration rather than volume overload—the opposite of the typical mechanism. 2, 6

Post-Session Dry Weight Reassessment

Increase the target dry weight by 0.5-1.0 kg at the next session based on the POCUS findings of severe preload reduction. 1, 3

• The kissing LV pattern definitively demonstrates you have surpassed euvolemia and entered a hypovolemic state. 3
• Reassess dry weight upward over 2-4 weeks, using serial POCUS examinations to guide adjustments until LV cavity size normalizes. 1
• Avoid the common pitfall of aggressively pursuing lower dry weights in response to the elevated blood pressure, as this will worsen the paradoxical hypertensive response. 1, 3

Medication Management Strategy

Prioritize nondialyzable antihypertensive agents with vasodilatory properties to counteract the vascular resistance surge:

• Carvedilol (beta-blocker with vasodilatory properties) demonstrated lower cardiovascular mortality in hemodialysis patients and is poorly dialyzed, making it ideal for this scenario. 7, 1
• Amlodipine (long-acting calcium channel blocker) reduced cardiovascular events in hypertensive hemodialysis patients and provides sustained vasodilation. 7, 1
• Withhold dialyzable antihypertensives (short-acting ACE inhibitors, atenolol) before sessions as their removal during dialysis can precipitate rebound hypertension. 3
• Administer antihypertensives at night rather than pre-dialysis to reduce nocturnal blood pressure surge while minimizing intradialytic effects. 1

Dialysate Prescription Modifications

Maintain dialysate sodium concentration at ≤140 mmol/L to avoid exacerbating the hypertensive response through osmolar shifts. 3

• Higher dialysate sodium concentrations can trigger endothelial cell dysfunction and worsen vascular resistance surges in patients with intradialytic hypertension. 2
• Avoid sodium profiling protocols, which increase interdialytic weight gain and complicate volume assessment. 3

Critical Pitfalls to Avoid

Do not continue aggressive ultrafiltration simply because blood pressure is elevated—the POCUS findings override the blood pressure measurement in determining volume status. 1, 3

• The elevated blood pressure in this scenario is a compensatory response to hypovolemia, not an indication for more fluid removal. 2, 6
• Administering saline boluses to treat symptoms would be appropriate if the patient develops cramping or symptomatic hypotension, despite the elevated blood pressure reading. 3
• Do not mistake this presentation for typical intradialytic hypertension from volume overload, which would show normal or dilated cardiac chambers on POCUS. 1, 2

Monitoring and Follow-Up

Repeat POCUS at subsequent sessions to confirm normalization of LV cavity size and guide further dry weight adjustments. 1

• Reassess blood pressure response after each dry weight modification, expecting gradual improvement over 4-8 weeks as vascular resistance mechanisms normalize. 1, 8
• The "lag phenomenon" means blood pressure may continue to improve for 8 months after achieving appropriate volume status, so avoid premature medication intensification. 8, 3
• Consider extending dialysis treatment time (5+ hours per session) if ultrafiltration requirements remain high, as longer sessions reduce ultrafiltration rates and hemodynamic stress. 7