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

Table 1 Risk factors of intradialytic hypotension

Risk factors	IDH risk profile
Patient-related risk factors	Comorbidities: Diabetes mellitus; cardiovascular diseases (heart failure, ischemic heart disease, diastolic dysfunction, arrhythmias); autonomic dysfunction, often linked to diabetes or advanced kidney disease; vascular calcification leading to arterial stiffness
	Demographics: Age > 65 years; female sex; high body mass index or sarcopenia
	Nutritional and metabolic factors: Poor nutritional status (e.g., hypoalbuminemia); severe anemia; high IDWG, requiring higher UFR; electrolyte disturbances, particularly rapid bicarbonate influx and calcium shifts
Dialysis-related risk factors	Dialysis prescription: High UFR (> 10-13 mL/kg/hour); short treatment time with rapid fluid removal; use of dialysate with high temperature or inappropriate sodium concentrations
	Hemodynamic challenges: Failure of compensatory mechanisms, including impaired vascular tone and cardiac output; inadequate plasma refill rate during ultrafiltration
	Procedural issues: Food intake during dialysis sessions leading to splanchnic blood flow shifts
Pathophysiological factors	Cardiac dysfunction: Reduced cardiac contractility or preload dependency during dialysis; recurrent myocardial stunning from repeated IDH episodes
	Neurohumoral dysregulation: Blunted sympathetic nervous system response; loss of autonomic regulation, especially in diabetes
	Osmotic and fluid dynamics: Rapid shifts in serum osmolality due to urea clearance; poor vascular refill rates from interstitial to intravascular compartments
Modifiable risk factors	IDWG: Control fluid and sodium intake to limit IDWG
	Dialysis adjustments: Adjusting UFR, temperature, and sodium concentrations

IDH: Intradialytic hypotension; IDWG: Interdialytic weight changes; UFR: Ultrafiltration rates.