10 tips how to prevent and treat hemodynamic instability during hemodialysis

Abstract Intradialytic hypotension (IDH) is a frequent complication of hemodialysis that may occur with symptoms and often requires interventions to restore hemodynamic stability and end-organ perfusion. In the absence of large trials with IDH as the primary endpoint, guidelines recommending specific management protocols are not available, but hemodynamic instability is a daily clinical reality, nevertheless. First, we suggest to (i) define and monitor IDH, by adopting a uniform IDH definition such as the Nadir90 criteria and document symptoms, and regularly measuring intradialytic as well as ambulatory blood pressure. Next, we give recommendations on how to (ii) treat IDH, by developing a standard operating procedure for acute events, and increasing dialysate sodium, and decreasing ultrafiltration rates and dialysate temperature. Finally, the majority of our tips are dedicated to (iii) preventing IDH, by regularly assessing fluid status, reviewing antihypertensive drugs, considering more frequent, longer or nocturnal dialysis, potentially considering hemodiafiltration, avoiding food and consider exercise, and trying automatic feedback algorithms. No single measure consistently prevents IDH, and each tip should be viewed as one lever among many. In practice, IDH is best managed by a layered, individualized approach that combines rigorous documentation, structured follow-up, and a willingness to revisit the prescription each time hemodynamic instability recurs.