Clinical Implications of Intradialytic Hypotension: Impact on Morbidity and Mortality in Dialysis Patients

Naema Liaqat Khan; Kulsoom Ilyas; Muhammed Zubair; Fayaz Khan; Faizan Banaras

doi:10.70749/ijbr.v3i09.2255

Authors

Naema Liaqat Khan Department of Nephrology, Emirates Health Services, UAE.
Kulsoom Ilyas Department of Nephrology, Emirates Health Services, UAE.
Muhammed Zubair Department of Nephrology, Dubai Health Authority, UAE.
Fayaz Khan Department of Nephrology, Rehman Medical Institute, Peshawar, KP, Pakistan.
Faizan Banaras Department of Nephrology, Khyber Teaching Hospital, Peshawar, KP, Pakistan.

DOI:

https://doi.org/10.70749/ijbr.v3i09.2255

Keywords:

Hemodialysis, Intradialytic Hypotension, Morbidity, Mortality, Ultrafiltration, Vascular Access

Abstract

Background: Intradialytic hypotension (IDH) is the most frequent acute complication during hemodialysis (HD), associated with reduced treatment adequacy, recurrent hospitalizations, and increased mortality. Despite guidelinse-directed preventive measures, IDH remains highly prevalent in resource-limited settings. This study aimed to determine the frequency, clinical predictors, and outcomes of IDH among HD patients in a tertiary care center in Peshawar, Pakistan. Methods: A descriptive cross-sectional study was conducted at Khyber Teaching Hospital, Peshawar, from January to June 2025. A total of 240 adult patients undergoing maintenance HD were enrolled. Data on demographics, comorbidities, dialysis vintage, interdialytic weight gain, ultrafiltration volume, and antihypertensive medication use were collected. IDH was defined as a fall in systolic blood pressure ≥20 mmHg or mean arterial pressure ≥10 mmHg during dialysis accompanied by symptoms requiring nursing intervention. Associations with morbidity (hospitalizations, vascular access dysfunction, dialysis discontinuation) and mortality were assessed using Chi-square tests. Results: A total of 240 maintenance hemodialysis patients were enrolled, with a mean age of 53.1 ± 12.8 years and male predominance (58.3%). Intradialytic hypotension (IDH) was observed in 94 patients (39.2%). Patients with IDH had significantly higher interdialytic weight gain >3 kg (65.0% vs. 37.5%, p<0.01) and more frequent ultrafiltration rates >10 ml/kg/hr (68.3% vs. 35.0%, p<0.001). Use of antihypertensive medications was also greater in the IDH group (79.2% vs. 58.3%, p=0.02). Clinical outcomes revealed higher hospitalization rates in patients with IDH (40.0% vs. 18.3%, p<0.01), alongside increased vascular access complications (20.8% vs. 8.3%, p=0.01) and premature session discontinuation (25.0% vs. 11.7%, p=0.02). Importantly, six-month mortality was significantly higher among IDH patients (16.7% vs. 6.7%, p=0.03). These findings highlight the high burden of IDH and its strong association with morbidity and mortality in dialysis patients. Conclusion: IDH was highly prevalent among HD patients and was linked to greater morbidity and mortality. Optimization of fluid management, individualized ultrafiltration targets, and avoidance of intradialytic antihypertensive use may reduce its burden. Early identification of high-risk patients and structured preventive strategies are urgently needed in resource-limited settings.

Downloads

Download data is not yet available.

References

1. Cockwell, P., & Fisher, L. (2020). The global burden of chronic kidney disease. The Lancet, 395(10225), 662-664.

https://doi.org/10.1016/s0140-6736(19)32977-0

2. Francis, A., Harhay, M. N., Ong, A. C. M., Tummalapalli, S. L., Ortiz, A., Fogo, A. B., Fliser, D., Roy-Chaudhury, P., Fontana, M., Nangaku, M., Wanner, C., Malik, C., Hradsky, A., Adu, D., Bavanandan, S., Cusumano, A., Sola, L., Ulasi, I., & Jha, V. (2024). Chronic kidney disease and the global public health agenda: an international consensus. Nature Reviews Nephrology, 20(20), 1–13.

https://doi.org/10.1038/s41581-024-00820-6

3. Kuipers, J., Oosterhuis, J. K., Krijnen, W. P., Dasselaar, J. J., Gaillard, C. A., Westerhuis, R., & Franssen, C. F. (2016). Prevalence of intradialytic hypotension, clinical symptoms and nursing interventions - a three-months, prospective study of 3818 haemodialysis sessions. BMC Nephrology, 17(1).

https://doi.org/10.1186/s12882-016-0231-9

4. Kuipers, J., Verboom, L. M., Ipema, K. J., Paans, W., Krijnen, W. P., Gaillard, C. A., ... & Franssen, C. F. (2019). The prevalence of intradialytic hypotension in patients on conventional hemodialysis: a systematic review with meta-analysis. American journal of nephrology, 49(6), 497-506.

https://doi.org/10.1159/000500877

5. Hamrahian, S. M., Vilayet, S., Herberth, J., & Fülöp, T. (2023). Prevention of Intradialytic hypotension in hemodialysis patients: Current challenges and future prospects. International Journal of Nephrology and Renovascular Disease, 16, 173-181.

https://doi.org/10.2147/ijnrd.s245621

6. Davenport, A. (2023). Why is intradialytic hypotension the commonest complication of outpatient dialysis treatments?. Kidney international reports, 8(3), 405-418.

https://doi.org/10.1016/j.ekir.2022.10.031

7. Habas, E., Rayani, A., Habas, A., Farfar, K., Habas, E., Alarbi, K., Habas, A., Errayes, E., & Alfitori, G. (2025). Intradialytic Hypotension Pathophysiology and Therapy Update: Review and Update. Blood Pressure, 1–18.

https://doi.org/10.1080/08037051.2025.2469260

8. Ozen, N., & Cepken, T. (2020). Intradialytic hypotension prevalence, influencing factors, and nursing interventions: prospective results of 744 hemodialysis sessions. Irish Journal of Medical Science (1971 -).

https://doi.org/10.1007/s11845-020-02249-9

9. Zhi, M., Zeng, Y., Chen, C., Deng, S., Liu, Y., Huang, Y., Chu, B., & Hu, H. (2025). The relationship between intradialytic hypotension and health-related quality of life in patients undergoing hemodialysis: A cross-sectional study. Scientific Reports, 15(1).

https://doi.org/10.1038/s41598-025-96286-y

10. Deng, Y., Li, N., Wu, Y., Wang, M., Yang, S., Zheng, Y., Deng, X., Xiang, D., Zhu, Y., Xu, P., Zhai, Z., Zhang, D., Dai, Z., & Gao, J. (2021). Global, Regional, and National Burden of Diabetes-Related Chronic Kidney Disease From 1990 to 2019. Frontiers in Endocrinology, 12.

https://doi.org/10.3389/fendo.2021.672350

11. Pourhoseingholi, M. A., Vahedi, M., & Rahimzadeh, M. (2013). Sample size calculation in medical studies. Gastroenterology and Hepatology from bed to bench, 6(1), 14.

https://pmc.ncbi.nlm.nih.gov/articles/PMC4017493/

12. Nanjundeswaraswamy, T. S., & Divakar, S. (2021). Determination of sample size and sampling methods in applied research. Proceedings on engineering sciences, 3(1), 25-32.

https://doi.org/10.24874/PES03.01.003

13. Yin LK. How to analyze your research data? SPSS and common statistical tests explained. J Clin Epidemiol. 2006;59(4):353–501. (Describes Chi-square usage in SPSS) doi: 10.1016/j.jclinepi.2005.03.015

14. Flythe, J. E., Kimmel, S. E., & Brunelli, S. M. (2011). Rapid fluid removal during dialysis is associated with cardiovascular morbidity and mortality. Kidney international, 79(2), 250-257.

https://doi.org/10.1038/ki.2010.383

15. Sands, J. J., Usvyat, L. A., Sullivan, T., Segal, J. H., Zabetakis, P., Kotanko, P., Maddux, F. W., & Diaz-Buxo, J. A. (2014). Intradialytic hypotension: Frequency, sources of variation and correlation with clinical outcome. Hemodialysis International, 18(2), 415–422.

https://doi.org/10.1111/hdi.12138

16. Silversides, J. A., Pinto, R., Kuint, R., Wald, R., Hladunewich, M. A., Lapinsky, S. E., & Adhikari, N. K. (2014). Fluid balance, intradialytic hypotension, and outcomes in critically ill patients undergoing renal replacement therapy: a cohort study. Critical Care, 18(6).

https://doi.org/10.1186/s13054-014-0624-8

17. McIntyre, C. W., & Goldsmith, D. J. (2015). Ischemic brain injury in hemodialysis patients: which is more dangerous, hypertension or intradialytic hypotension? Kidney International, 87(6), 1109–1115.

https://doi.org/10.1038/ki.2015.62

18. Brunelli SM, Cohen DE, Marlowe G, Van Wyck D. The impact of intradialytic hypotension on quality of life outcomes in dialysis patients. Semin Dial. 2018;31(6):551–6.

19. Shoji, T., Tsubakihara, Y., Fujii, M., & Imai, E. (2004). Hemodialysis-associated hypotension as an independent risk factor for two-year mortality in hemodialysis patients. Kidney International, 66(3), 1212–1220.

https://doi.org/10.1111/j.1523-1755.2004.00812.x

20. Basile C, Lomonte C. A new approach to hemodialysis hypotension: biofeedback systems. J Nephrol. 2015;28(3):289–99.

21. Kuipers, J., Verboom, Loes M., Ipema, Karin J. R., Paans, W., Krijnen, Wim P., Gaillard, Carlo A. J. M., Westerhuis, R., & Franssen, Casper F. M. (2019). The Prevalence of Intradialytic Hypotension in Patients on Conventional Hemodialysis: A Systematic Review with Meta-Analysis. American Journal of Nephrology, 49(6), 497–506.

https://doi.org/10.1159/000500877

22. Abe M, Kalantar-Zadeh K. Haemodialysis-induced hypoxaemia and hypotension: mechanisms and management. Nephrol Dial Transplant. 2019;34(12):2030–6.