Updates in the management of intradialytic hypotension: Emerging strategies and innovations

Abstract

Intradialytic hypotension (IDH) is a prevalent and critical complication of haemodialysis associated with significant morbidity, mortality, and reduced quality of life in end-stage renal disease patients. IDH results from multifactorial interactions, including excessive ultrafiltration rates (UFR), rapid osmotic shifts, impaired vascular resistance, and comorbidities such as diabetes and cardiovascular disease. It triggers hypovolemic stress, leading to myocardial stunning, cerebral ischemia, and organ dysfunction. Non-modifiable risk factors, including age and preexisting conditions, exacerbate susceptibility, while modifiable elements such as high interdialytic weight gain and improper dialysis prescriptions worsen outcomes. In this review, we aim to conduct an in-depth analysis of IDH, exploring its clinical relevance, underlying mechanisms, risk factors, and management approaches. Additionally, we advocate for a standardised definition and propose a strategic framework to guide future research efforts. Effective management requires individualised approaches, including optimised UFR, cooled dialysate, and nutritional adjustments, alongside emerging technologies like bio-impedance spectroscopy and artificial intelligence for real-time risk prediction. A multidisciplinary team approach, incorporating nephrologists, nurses, and dietitians, is essential for holistic patient care. Future research and technological advancements hold promise for mitigating IDH’s clinical and systemic impact, ultimately improving patient outcomes and survival.

Keywords: Intradialytic hypotension; Haemodialysis; Ultrafiltration rates; Osmotic shifts; Management strategies

Core Tip: Intradialytic hypotension remains a critical complication in haemodialysis, lacking a universal definition and significantly impacting patient morbidity and mortality. This comprehensive review elucidates the complex interplay of its pathophysiology, diverse risk factors, and severe consequences. It critically evaluates current management strategies, highlighting the limitations of existing definitions and the need for individualised approaches. The review underscores the promise of emerging technologies like artificial intelligence for prediction and the importance of multidisciplinary care and patient education. Ultimately, it advocates for a unified definition and strategically directs future research to optimize prevention and treatment, thereby improving outcomes for this vulnerable population.