Abstract
Intradialytic hypotension (IDH) is a common complication of hemodialysis, but there is no data about the time of onset during treatment. Here we describe the incidence of IDH throughout hemodialysis and associations of time of hypotension with clinical parameters and survival by analyzing data from 21 dialysis clinics in the United States to include 785682 treatments from 4348 patients. IDH was defined as a systolic blood pressure of 90 mmHg or under while IDH incidence was calculated in 30-minute intervals throughout the hemodialysis session. Associations of time of IDH with clinical and treatment parameters were explored using logistic regression and with survival using Cox-regression. Sensitivity analysis considered further IDH definitions. IDH occurred in 12% of sessions at a median time interval of 120-149 minutes. There was no notable change in IDH incidence across hemodialysis intervals (range: 2.6-3.2 episodes per 100 session-intervals). Relative blood volume and ultrafiltration volume did not notably associate with IDH in the first 90 minutes but did thereafter. Associations between central venous but not arterial oxygen saturation and IDH were present throughout hemodialysis. Patients prone to IDH early as compared to late in a session had worse survival. Sensitivity analyses suggested IDH definition affects time of onset but other analyses were comparable. Thus, our study highlights the incidence of IDH during the early part of hemodialysis which, when compared to later episodes, associates with clinical parameters and mortality.
Highlights
Intradialytic hypotension (IDH) associates with adverse outcomes in hemodialysis (HD) patients, including patient self-reported symptom burden, access failure, cardiovascular events, and mortality.[1,2,3] Despite being one of the most common complications associated with HD, there is no consensus on the definition, means to prevention, and management of IDH
Time of IDH onset Using our primary definition of IDH, the median session-interval for first IDH in a session was 120 to 149 minutes
Intradialytic measurements Intradialytic relative blood volume (RBV), ultrafiltration volume (UFV), SO2, and estimated upper-body blood flow (eUBBF) results are plotted in Figure 4, separated based on whether IDH occurs in the subsequent 30 minutes or not
Summary
Intradialytic hypotension (IDH) associates with adverse outcomes in hemodialysis (HD) patients, including patient self-reported symptom burden, access failure, cardiovascular events, and mortality.[1,2,3] Despite being one of the most common complications associated with HD, there is no consensus on the definition, means to prevention, and management of IDH. Other interventions, including use of relative blood volume (RBV),[8] biofeedback-controlled ultrafiltration rate (UFR), and/or dialysate sodium[9] and pharmacological management,[10] all lack a sufficient evidence base for widespread acceptance. Numerous factors have been shown to associate with IDH occurrence These include demographic factors, comorbidities, treatment prescriptions, serum osmolality, antihypertensive medications, and anemia.[11,12,13] RBV at the time of IDH has been shown to have significant intersubject variability, but for a given individual, there appears to be a relatively stable critical RBV preceding IDH.[14] There are some data to suggest that central venous oxygen saturation (ScvO2) decreases more in sessions where IDH occurs.[15]. Studies investigating IDH frequently define sessions based on whether an IDH event occurs, or define patients as being prone to IDH or not, but little attention has been given to how the incidence of IDH onset varies within the HD session
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