Managing Hypotension During Hemodialysis: A Comprehensive Clinical Guide

Understanding and Addressing Intradialytic Hypotension

Hypotension during hemodialysis—commonly referred to as intradialytic hypotension (IDH)—is one of the most frequent acute complications encountered in outpatient dialysis units worldwide. Affecting up to 20–30% of hemodialysis sessions, IDH not only disrupts treatment efficacy but also increases the risk of cardiovascular stress, end-organ hypoperfusion, and long-term morbidity. Early recognition and evidence-based intervention are essential for maintaining patient safety, treatment adherence, and overall quality of care.

Immediate Non-Pharmacologic Interventions

When systolic blood pressure drops below 90 mmHg—or when patients exhibit symptoms such as dizziness, nausea, diaphoresis, or altered mental status—the first step is rapid, non-invasive stabilization. Repositioning the patient supine with legs slightly elevated (Trendelenburg or modified Trendelenburg position) helps optimize venous return and cerebral perfusion. Avoid semi-recumbent or upright positions, which can exacerbate orthostatic stress and reduce cardiac preload.

Fluid Resuscitation Strategies

Volume expansion remains a cornerstone of acute IDH management. Administering isotonic crystalloids like 0.9% sodium chloride (normal saline)—typically 100–250 mL boluses—is both safe and effective for restoring intravascular volume. In cases where rapid osmotic shift is indicated (e.g., suspected hyponatremia or hypoosmolality), cautious use of hypertonic solutions—including 50% dextrose (25 g IV) or 20% mannitol (0.25–0.5 g/kg)—may be considered. However, these should be used judiciously due to potential metabolic side effects and contraindications in heart failure or severe renal impairment.

Optimizing Dialysis Machine Parameters

Real-time adjustment of dialysis settings significantly improves hemodynamic stability:

Suspend ultrafiltration immediately—halting fluid removal prevents further intravascular depletion;
Lower dialysate temperature to 35.5–36.5°C—cooler dialysate reduces systemic vasodilation and enhances peripheral vascular resistance;
Increase dialysate sodium concentration (e.g., from 138 to 145 mEq/L)—this promotes sodium-driven fluid shift into the intravascular space and supports blood pressure via osmotic and neurohormonal mechanisms;
Consider individualized sodium profiling or ultrafiltration profiling for recurrent IDH, especially in frail, elderly, or autonomic-dysfunctional patients.

Pharmacologic Support When Conservative Measures Fail

If hypotension persists despite repositioning, fluid resuscitation, and dialysis parameter adjustments, timely pharmacologic support is warranted. First-line agents include:

IV midodrine (2.5–5 mg)—a selective α1-adrenergic agonist that increases systemic vascular resistance;
IV phenylephrine (40–100 mcg bolus, titrated as needed)—fast-acting and ideal for acute refractory episodes;
IV norepinephrine (in ICU or high-acuity settings)—reserved for profound, shock-like hypotension unresponsive to other interventions.

Always document response time, dosage, and adverse effects—and integrate findings into future session planning.

Prevention Is Key: Proactive Strategies Beyond Acute Management

While prompt treatment is vital, preventing IDH is far more impactful. Clinicians should routinely assess dry weight accuracy, review antihypertensive timing (avoid administering ACE inhibitors or ARBs pre-dialysis), screen for autonomic neuropathy, and encourage dietary sodium moderation. Emerging tools—including bioimpedance spectroscopy (BIS), continuous blood volume monitoring, and machine learning–driven hemodynamic prediction models—are transforming IDH from a reactive challenge into a predictable, preventable condition.

By combining real-time clinical judgment with personalized dialysis prescription and patient-centered education, healthcare teams can dramatically reduce IDH incidence—and improve both survival rates and quality of life for individuals living with end-stage kidney disease.