Clinical case-based approach to understanding intradialytic hypotension.

The approach to end-stage renal disease (ESRD) patients who develop intradialytic hypotension (IDH) encompasses an understanding of the pathophysiology, appropriate dialysis prescription modification, application of newer pharmacologic therapies, and development of strategies for prevention. Patients should have a "minimal data set" as part of their predialysis assessment. This information is critical to prescription modifications that may help decrease the risk for IDH. Individuals at "high risk" for IDH should be kept to a "safe zone" for dialysis ultrafiltration (</=3% of body weight). Specific maneuvers that may decrease the risk for IDH include adjustment of the dialysate sodium or calcium concentration and dialysate temperature. The first priority for patients developing IDH should be the stabilization of the blood pressure and improvement in the patient's symptomology. Pharmacologic intervention should be considered for patients who require repeat interventions for IDH. "At-risk" patients with a strong cardiac history should undergo an assessment of their cardiovascular status if IDH episodes occur. The use of pharmacologic therapy, ie, midodrine, alone or in combination with prescription modification, can be helpful in decreasing interventions required for IDH. Noncompliance and high interdialytic weight gain in the setting of left ventricular hypertrophy (LVH) and diastolic dysfunction can increase the risk of IDH. Assessment of antihypertensive medications should be performed on a regular basis to determine the correct dosing schedule for patients with hypertension who develop IDH. Coronary flow reserve may be compromised in patients with LVH, adding to the risk for perfusion injury with low blood pressure. Increasing the dialysate calcium concentration may decrease the incidence of arrhythmogenicity in certain patients. Patients with low body temperature may benefit most from cool dialysate. Unit personnel should be aware of the potential link between hypotension and the increased relative risk for death in ESRD patients. Clinical training sessions on IDH risk recognition and appropriate treatment should be implemented within the dialysis unit. Because repeated bouts of IDH can be disruptive to the smooth efficiency of unit operations, attention to prevention as well as acute intervention of IDH is important. Preventive strategies can be developed in each unit to decrease the number of future IDH events. Considering the importance of hypotension in overall patient survival, attention to identifying the percentage of patients in each unit who experience IDH and/or who present with low blood pressure (systolic <110 mm Hg) should be tracked as a quality assurance initiative.