Dialysis-associated hypotension

Background

• Most frequent complication of hemodialysis (20%-30% of tx)
• Timing of intradialytic hypotension is helpful in formulating DDX:
  • Hypotension early in session usually due to preexisting hypovolemia
  • Hypotension during the session is often due to blood loss (from tubing or filter leak)
  • Hypotension near the end usually result of excessive ultrafiltration
    • Underestimation of pt's ideal blood volume (dry weight)
    • Also consider pericardial or cardiac disease

Clinical Features

• N/V
• Anxiety
• Dizziness
• Orthostatic hypotension
• Syncope

Diagnosis

1. Assess:
   1. Volume status (US)
   2. Cardiac function
   3. Pericardial disease
   4. Infection
   5. GI bleeding

Differential Diagnosis

1. Excessive ultrafiltration
2. Predialytic volume loss
   1. GI losses
   2. Decreased oral intake
3. Intradialytic volume loss
   1. Tube and hemodialyzer blood losses
4. Postdialytic volume loss
   1. Vascular access blood loss
5. Medication effects
   1. Antihypertensives
   2. Opiates
6. Decreased vascular tone (sepsis)
7. Cardiac dysfunction
   1. LVH, ischemia, hypoxia, arrhythmia, pericardial tamponade
8. Pericardial disease
   1. Effusion
   2. Tamponade

Dialysis Complications

• Dialysis-associated hypotension
• Dialysis disequilibrium syndrome
• Air embolism
• Missed dialysis (pulmonary edema)

See Also

• Dialysis complications