How can we prevent intradialytic hypotension?

PURPOSE OF REVIEW: Intradialytic hypotension (IDH) produces uncomfortable symptoms for the patient and reduces the efficiency of dialysis. RECENT
FINDINGS: IDH may be an important cause of vascular access thrombosis. Automatic biofeedback-controlled dialysis changes dialysate conductivity and ultrafiltration during dialysis. A number of trials suggest that automatic feedback-controlled dialysis improves IDH in part by improvement in myocardial stunning and preservation of cardiac function. However, the effects of automatic biofeedback dialysis are inconsistent between studies and sample sizes are small. Acetate even in small amounts may trigger IDH especially in predisposed patients. Cool temperature dialysate causes vasoconstriction, activates the sympathetic nervous system, preserves central blood volume, and mitigates IDH. Increasing the treatment time to at least 4 h three times a week and limiting dialysate and dietary sodium intake are effective ways to reduce IDH. Ultrafiltration profiling needs further work, but it appears that removing more fluid during the first hour of dialysis and reducing the rate later on may also reduce IDH.
SUMMARY: Adequate prescription and frequency of dialysis treatments, limiting dietary and dialysate sodium, ultrafiltration profiling, automatic biofeedback-controlled dialysis, avoidance of acetate, and cool temperature dialysate may be effective strategies to reduce IDH.