Clinical dilemmas in dialysis: Managing the hypotensive patient - Setting the stage

Intradialytic hypotension (IDH) occurs during 25% to 50% of end-stage renal disease (ESRD) hemodialysis (HD) treatments. The development of IDH signal s both technology- and patient-dependent limitations expressed across a bro ad range of symptoms, from nausea and muscle cramps to ischemic injury. Whi le traditional thinking has emphasized the link between hypertension and ca rdio-cerebrovascular injury, more recent studies of ESRD patients have stim ulated significant interest in hypotension and poor outcomes. Theoretically , hypotension can contribute to the increased relative risk of death in ESR D by several mechanisms, which include acute coronary syndrome, autoregulat ion dysfunction, ischemia, and arrhythmogenicity. Endothelial abnormalities (increased procoagulation, thrombogenecity risk, and alterations in corona ry flow reserve) and altered vascular distribution within the myocardium pr ovide an environment for vascular injury. The current symposia will examine the pathophysiology of IDH, the specific HD prescription modifications to prevent IDH, and newer pharmacologic interventions to treat IDH and will hi ghlight the approach to several clinical cases based on the information pre sented. It is becoming increasingly important to identify patients at "high risk" for IDH, to customize the HD prescription to the individual patient, to use drug therapy to prevent IDH events, and to track the prevalence of chronic hypotension and the incidence of IDH complications in the dialysis unit. (C) 2001 by the National Kidney Foundation, Inc.