Updates in the management of intradialytic hypotension: Emerging strategies and innovations

Intradialytic hypotension (IDH) is a prevalent and critical complication of haemodialysis associated with significant morbidity, mortality, and reduced quality of life in end-stage renal disease patients. IDH results from multifactorial interactions, including excessive ultrafiltration rates (UFR), rapid osmotic shifts, impaired vascular resistance, and comorbidities such as diabetes and cardiovascular disease. It triggers hypovolemic stress, leading to myocardial stunning, cerebral ischemia, and organ dysfunction. Non-modifiable risk factors, including age and preexisting conditions, exacerbate susceptibility, while modifiable elements such as high interdialytic weight gain and improper dialysis prescriptions worsen outcomes. In this review, we aim to conduct an in-depth analysis of IDH, exploring its clinical relevance, underlying mechanisms, risk factors, and management approaches. Additionally, we advocate for a standardised definition and propose a strategic framework to guide future research efforts. Effective management requires individualised approaches, including optimised UFR, cooled dialysate, and nutritional adjustments, alongside emerging technologies like bio-impedance spectroscopy and artificial intelligence for real-time risk prediction. A multidisciplinary team approach, incorporating nephrologists, nurses, and dietitians, is essential for holistic patient care. Future research and technological advancements hold promise for mitigating IDH's clinical and systemic impact, ultimately improving patient outcomes and survival.