Management of Hypotension During Hemodialysis
Initial Interventions for Acute Hypotension
- The American Journal of Kidney Diseases recommends reducing or temporarily stopping ultrafiltration to prevent further blood pressure drop in patients experiencing hypotension during hemodialysis 1
- Administering intravenous normal saline bolus can rapidly expand plasma volume and improve blood pressure in patients with hypotension during hemodialysis 1
- Placing the patient in Trendelenburg position (head down, legs elevated) can improve venous return and increase blood pressure in patients with hypotension during hemodialysis 2
- Supplemental oxygen can improve tissue oxygenation and reduce symptoms in patients with hypotension during hemodialysis 1
Pharmacological Management
- The American Journal of Kidney Diseases recommends administering midodrine (an oral selective α1-adrenergic agonist) within 30 minutes before dialysis initiation to prevent hypotension in patients undergoing hemodialysis 1
Dialysate Modifications
- Increasing dialysate sodium concentration to 148 mEq/L can prevent hypotension in patients undergoing hemodialysis, especially early in the dialysis session 1
- Sodium profiling (starting with higher sodium concentration and gradually decreasing it) can maintain vascular stability and prevent hypotension in patients undergoing hemodialysis 1, 3
- Switching from acetate-containing dialysate to bicarbonate-containing dialysate can minimize hypotension by preventing inappropriate decreases in total vascular resistance in patients undergoing hemodialysis 1
- Reducing dialysate temperature from 37°C to 34-35°C can increase peripheral vasoconstriction and cardiac output, and prevent hypotension in patients undergoing hemodialysis 1
Ultrafiltration Strategies
- Slowing the ultrafiltration rate by extending treatment time when possible can prevent hypotension in patients undergoing hemodialysis 1, 2
- Reevaluating the patient's estimated dry weight can help identify and prevent hypotension in patients undergoing hemodialysis, as hypotension may indicate that it is set too low 4
Prevention Strategies for Recurrent Hypotension
- Limiting fluid intake between dialysis sessions can reduce interdialytic weight gain and prevent hypotension in patients undergoing hemodialysis 2, 4
- Avoiding food intake immediately before or during hemodialysis can prevent decreased peripheral vascular resistance and hypotension in patients undergoing hemodialysis 1
- Raising hemoglobin to 11 g/L can improve oxygen-carrying capacity and prevent hypotension in patients undergoing hemodialysis 1
- Reviewing and potentially adjusting antihypertensive medications can help prevent intradialytic hypotension in patients undergoing hemodialysis, as these may contribute to hypotension 1, 2