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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2010  |  Volume : 21  |  Issue : 4  |  Page : 756-761
Characteristics of intradialytic hypotension: Experience of agadir center-morocco

1 Department of Nephrology, 1st Medical and Chirurgical Center, Agadir, Morocco
2 Department of Nephrology, Hemodialysis and Transplantation, Military Hospital, Rabat, Morocco
3 Department of Hemodialysis, and Cardiology, 1st Medical and Chirurgical Center, Agadir, Morocco

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Date of Web Publication26-Jun-2010


We report in this retrospective study the experience of our hemodialysis (HD) center in the incidence of intradialytic hypotension (IDH) over 18 months. We first studied the de­mographic, clinical, biological and morphological data of our 52 HD patients and compared the characteristics of patients with frequent IDH and those without. We found that factors signi­ficantly associated with IDH include diabetes, left ventricular hypertrophy, impaired diastolic function, weight gain and high ultrafiltration rates. Despite these results, further larger studies are required to confirm them.

How to cite this article:
Akhmouch I, Bahadi A, Zajjari Y, Bouzerda A, Asserraji M, Alayoud A, Montasser D, Moujoud O, Aattif T, Kadiri M, Zemraoui N, Elkabbaj D, Hassani M, El Allam M, Benyahia M, Oualim Z. Characteristics of intradialytic hypotension: Experience of agadir center-morocco. Saudi J Kidney Dis Transpl 2010;21:756-61

How to cite this URL:
Akhmouch I, Bahadi A, Zajjari Y, Bouzerda A, Asserraji M, Alayoud A, Montasser D, Moujoud O, Aattif T, Kadiri M, Zemraoui N, Elkabbaj D, Hassani M, El Allam M, Benyahia M, Oualim Z. Characteristics of intradialytic hypotension: Experience of agadir center-morocco. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2022 Aug 19];21:756-61. Available from: https://www.sjkdt.org/text.asp?2010/21/4/756/64673

   Introduction Top

Symptomatic intradialytic hypotension (IDH) is a common complication of hemodialysis (HD). Despite significant improvements of HD techniques in the recent years, the frequency of recurrent IDH episodes has remained nearly unchanged with the incidence of 20 to 30% of treatments. [1],[2] It is a major complication of HD and has a negative impact on health-related quality of life in HD patients. [3]

IDH is the clinical manifestation of an imba­lance between the decrease in plasma volume during dialysis and the counter-regulatory car­diovascular hemodynamic and neurohormonal mechanisms. [4],[5],[6],[7] Besides factors directly related to the dialysis procedure itself, several patient related characteristics and comorbidities in­crease the risk of IDH, mainly through im­pairment of the above compensatory mecha­nisms, such as age, diabetes, ischemic heart disease, left ventricular hypertrophy and auto­nomic neuropathy. [8],[9],[10],[11] In this study, we report our experience with the IDH and the risk factors that may precipitate this event in HD patients.

   Patients and Methods Top

This is a retrospective study conducted at the Military center of hemodialysis in Agadir, Mo­rocco from 14/05/2007 to 31/12/2008.

We defined IDH as that proposed by the K/ DOQI guidelines and approved by the Euro­pean renal best practice (ERBP) of hemody­namic instability (IDH by a decrease in sys­tolic blood pressure ≥ 20 mmHg or a decrease in the mean arterial pressure (MAP) by 10 mmHg associated with clinical events and need for nur­sing interventions). [12]

We excluded all patients who had one of the following criteria: Age less than 18 years, length of hemodialysis less than 3 months, and dura­tion of hemodialysis session under 3 hours.

We screened the patients for demographic characteristics: age, sex; clinical data: nephro­pathy, length of hemodialysis, dry weight, blood pressure before and after dialysis, ultrafil­tration rate, hours of intradialytic hypotension, interdialytic weight gain, and anti-hypertensive treatment; laboratory data: hemoglobin, CRP, albumin, intact parathyroid hormone 1-84; mor­phological data: left ventricular hypertrophy, systolic function and diastolic heart.

We defined frequent IDH patients by those who have had more than ten episodes during the time of screening and more than 5% of the number of sessions conducted at the center.

   Statistical Analysis Top

We performed analysis of data by the "SPSS" in order to select of patients with frequent IDH, and compared with the Student "t" test the de­mographic, clinical, biological, and morpholo­gical data of patients with frequent IDH those with rare IDH. P value <0.05 was considered significant.

   Results Top

We have included in our study 54 patients. Their demographics are shown in [Table 1].

During the study period, IDH occurred more than 500 times with an average of 9.72 IDH per patient and range from 0 to 54 episodes. Nephropathies, time of the IDH and the intake anti-hypertensive treatment are shown in [Table 2].

Of the 54 patients we have included, 18 pa­tients met these criteria. The comparison of the demographic and clinical data of both groups showed that the factors predisposing to IDH in the population studied are: diabetes, hemodia­lysis in the recent two years, left ventricular hypertrophy, especially concentric and impaired diastolic function [Table 3].

The comparison of laboratory data between the two groups revealed that the average he­moglobin in patients with frequent IDH was lower than the rare IDH but the difference was not significant [Table 4].

The comparison of conditions of HD sessions revealed that the incidence of IDH increased significantly with increasing interdialytic weight gain, ultrafiltration rate, especially if it was greater than 800 mL/h and with hypertension before the hemodialysis session [Table 5].

   Discussion Top

The incidence of IDH is estimated at 20%. [13],[14] More recent papers estimated the incidence from 6 to 27%. [15],[16] In our study, IDH occurred in less than 5% of all HD sessions done at our center.

It is now clear that the IDH significantly in­creases the morbidity and mortality in chronic HD, [17] in particular cardiac, mesenteric, cerebral ischemia, and atrophy of brain frontal lobe. [18],[19],[20],[21],[22] The frequency of IDH episodes also influences negatively the life span of arteriovenous fis­tulas. [23]

IDH is the result of a decrease in blood vo­lume and an inadequate cardiovascular response to this situation. It depends on the patient and the parameters of the hemodialysis session and its prevention is the action on one or more of these factors.

Only a few studies have investigated the po­tential factors for the IDH. Tisler et al [24] found that age, female sex, diabetes, hyperphosphate­mia, and presence of ischemic heart disease are encountered in patients with frequent IDH. In our study, the presence of diabetes and du­ration of HD for less than two years signi­ficantly correlated with frequent IDH, while the serum phosphorus levels did not.

The alteration of cardiac function increases the risk of IDH. Similarly to ours, observatio­nal studies have found that the IDH was more common in patients with impaired diastolic cardiac function and concentric left ventricular hypertrophy. [25],[26] In addition, we found that the systolic function, long blamed in hypotension, [27] did not influence the frequency of IDH, [28] and arterial blood pressure was higher in the IDH susceptible IDH patients.

On the laboratory level, although hypoalbu­minemia has recently been reported as a risk factor for IDH, [29] we did not find a significant correlation of IDH with low serum albumin levels due to its good levels in our patients. Furthermore, in our study, the hemoglobin in levels did not correlate with the frequent IDH.

Several factors that affect the course of the HD session influence the frequency of IDH. The increased ultarfiltration rate, especially when it exceeds 800 mL/h, is an important de­terminant of IDH. [20],[31] Moreover, interdialytic weight gain increases the sensitivity to hypo­tension because the ultrafiltration rate increases with weight gain, especially when the duration of the HD session remains unchanged. Inter­dialytic weight gain may be aggravated by many factors such as dry mouth, non-com­pliance with the prescribed diet, [21],[22],[23],[24] or uncon­trolled diabetes. [32],[36]

Finally, food intake during dialysis may re­sult in IDH linked to splanchnic vasodila­ tion. [37],[38] However, a recent study in Canada has found no link between food intake and hypotension. [39]

We conclude that IDH is a common compli­cation during HD sessions, and our study found that the factors predisposing to the IDH included diabetes, recent entry into HD, left ventricular hypertrophy, alteration of cardiac diastolic function, excessive interdialytic weight gain, and high ultrafiltration rate.

   References Top

1.Bregman H, Daugirdas JT, Ing TS. Compli­cations during hemodialysis. In: Handbook of Dialysis, 3rd Ed., edited by Daugirdas JT, Blake PG, Ing TS, Philadelphia, Lippincott Williams & Wilkins, 2001:148-68.  Back to cited text no. 1      
2.Zuchell P, Santoro A. Dialysis-induced hypo­tension: A fresh look at pathohysiology. Blood Purif 1993;11:85-98.  Back to cited text no. 2      
3.Laupacis A, Muirhead N, Keown P, Wong C. A diseasespecific questionnaire for assessing quality of life in patients on hemodialysis. Nephron 1992;60:302-6.  Back to cited text no. 3      
4.Daugirdas JT. Pathophysiology of dialysis hypotension: an update. Am J Kidney Dis 2001;38(Suppl4):S11-7.  Back to cited text no. 4      
5.Passauer J, Bussemaker E, Gross P. Dialysis hypotension: do we see the end of tunnel? Nephrol Dial Transplant 1998;13:3024-9.  Back to cited text no. 5      
6.Sherman RA. Intradialytic hypotension: an over-view of recent, unresolved and over­looked issues. Semin Dial 2002;15:141-3.  Back to cited text no. 6      
7.Andrulli S, Colzani S, Mascia F, et al. The role of blood volume reduction in the genesis of intradialytic hypotension. Am J Kidney Dis 2002;40:1244-54.  Back to cited text no. 7      
8.Raine AE. The susceptible patient. Nephrol Dial Transplant 1996;11(Suppl2):6-10.  Back to cited text no. 8      
9.Heinrich WL. Dialysis consideration in the elderly patient. Am J Kidney Dis 1990;16:339-­41.  Back to cited text no. 9      
10.Leunissen KM, Kooman JP, van Kuijk W, van der Sande F, Luik AJ, van Hooff JP. Pre­venting haemodynamic instability in patients at risk for intradialytic hypotension. Nephrol Dial Transplant 1996;11[Suppl 2]:11-5.  Back to cited text no. 10      
11.Sato M, Horigome I, Chiba S, et al. Autonomic insufficiency as a factor contributing to dialysis-induced hypotension. Nephrol Dial Transplant 2001;16:1657-62.  Back to cited text no. 11      
12.Kooman J, Basci A, Pizzarelli F. EBPG guide­line on haemodynamic instability. Nephrol Dial Transplant 2007;22(suppl 2);ii22-44.  Back to cited text no. 12      
13.Daugirdas JT. Dialysis hypotension: a hemo­dynamic analysis. Kidney Int 1991;39:233-46.  Back to cited text no. 13      
14.Degoulet P, Reach I, Di Giulio S, et al. Epidemiology of dialysis induced hypotension. Proc Eur Dial Transplant Assoc 1981;18:133-­8.  Back to cited text no. 14      
15.Civati G, Guastoni C, Teatini U, et al. High­flux acetate haemodialysis: a single center experience. Nephrol Dial Transplant 1991;6 (suppl 2):75-81.  Back to cited text no. 15      
16.Al Muhanna FA, Saeed I, AlMuelo S, Larbi E, Rubaish A. Disease profile, complications and outcome in patients on maintenance haemo­dynamic at King Faisal University Hospital, Saudi Arabia. E Afr Med J 1999;76:664-7.  Back to cited text no. 16      
17.Kovesdy CP, Trivedi BK, Kalantar-Zadeh K, Anderson JE. Association of low blood pre­ssure with increased mortality in patients with moderate to severe chronic kidney disease. Nephrol Dial Transplant 2006;21:1257-62  Back to cited text no. 17      
18.Tisler A, Akocsi K, Borbas B, et al. The effect of frequent or occasional dialysis associated hypotension on survival of patients on main­tenance haemodialysis. Nephrol Dial Transplant 2003;18:2601-5.  Back to cited text no. 18      
19.Shoji T, Tsubakihara Y, Fujii M, Imai E. Hemodialysis associated hypotension as an independent risk factor for two year mortality in hemodialysis patients. Kidney Int 2004;66: 1212-20.  Back to cited text no. 19      
20.Hung SY, Hung YM, Fang HC, et al. Cardiac troponin I and creatine kinase isoenzyme MB in patients with intradialytic hypotension. Blood Purif 2004;22:338-43.  Back to cited text no. 20      
21.Ori Y, Chagnac A, Schwartz A, et al. Non­occlusive mesenteric ischemia in chronically dialyzed patients: a disease with multiple risk Factors. Nephron Clin Pract 2005;101:c87-93.  Back to cited text no. 21      
22.Mizumasa T, Hirakata H, Yoshimitsu T, et al. Dialysis related hypotension as a cause of progressive frontal lobe atrophy in chronic hemodialysis patients: a 3 year prospective study. Nephron Clin Pract 2004;97:c23-30.  Back to cited text no. 22      
23.Puskar D, Pasini J, Savic I, Bedalov G, Sonicki Z. Survival of primary arteriovenous fistula in 463 patients on chronic hemodialysis. Croat Med J 2002;43:306-11.  Back to cited text no. 23      
24.Tisler A, Akocsi K, Harshegyi I, et al. Com­parison of dialysis and clinical characteristics of patients with frequent and occasional hemo­dialysis-associated hypotension. Kidney Blood Press Res 2002;25:97-102.  Back to cited text no. 24      
25.van der Sande FM, Mulder AW, Hoorntje SJ, et al. The hemodynamic effect of different ultrafiltration rates in patients with cardiac failure and patients without cardiac failure: comparison between isolated ultra filtration and ultra filtration with dialysis. Clin Nephrol 1998;50:301-8.  Back to cited text no. 25      
26.Ritz E, Rambausek K, Mall G, Ruffmann K, Mandelbaum A. Cardiac changes in uraemia and their possible relationship to cardiovascular instability on dialysis. Nephrol Dial Transplant 1990;5(suppl 1):93-7.  Back to cited text no. 26      
27.Henrich WL. Principles and Practice of Dialysis. Lippincott Williams and Wilkins, Philadelphia, PA:2004;284.  Back to cited text no. 27      
28.Ie EH, Krams R, Vletter WB, Nette RW, Weimar W, Zietse R. Myocardial contractility does not determine the haemodynamic res­ponse during dialysis. Nephrol Dial Transplant 2005;20:2465-71.  Back to cited text no. 28      
29.Nakamoto H, Honda N, Mimura T, Suzuki H. Hypoalbuminemia is an important risk factor of hypotension during hemodialysis. Hemodial Inter 2006;10(suppl2):s10-5.  Back to cited text no. 29      
30.Henderson LW. Symptomatic hypotension during hemodialysis. Kidney Int 1980;17:51-6.  Back to cited text no. 30      
31.Mitra S, Chamney PW, Greenwood R, et al. Characterising blood volume changes during ultrafiltration: can hypotension on haemodia­lysis be predicted? J Am Soc Nephrol 1999; A1493(abstract):95A.  Back to cited text no. 31      
32.Sung JM, Kuo SC, Guo HR, Chuang SF, Lee SY, Huang JJ. Decreased salivary flow rate as a dipsogenic factor in hemodialysis patients: evidence from an observational study and a pilocarpine clinical trial. J Am Soc Nephrol 2005;16:3418-29.  Back to cited text no. 32      
33.Ramdeen G, Tzamaloukas AH, Malhotra D, Leger A, Murata GH. Estimates of interdialytic sodium and water intake based on the balance principle: differences between non diabetic and diabetic subjects on hemodialysis. ASAIO J 1998;44:812-7.  Back to cited text no. 33      
34.Ozkahya M, Ok E, Cirit M, et al. Regression of left ventricular hypertrophy in haemodialysis patients by ultra filtration and reduced salt intake without antihypertensive drugs. Nephrol Dial Transplant 1998;13:1489-93.  Back to cited text no. 34      
35.Maduell F, Navarro V. Assessment of salt intake in hemodialysis. Nefrologia 2001;21:71-­7.  Back to cited text no. 35      
36.Sung JM, Kuo SC, Guo HR, Chuang SF, Lee SY, Huang JJ. The role of oral dryness in interdialytic weight gain by diabetic and non­diabetic haemodialysis patients. Nephrol Dial Transplant 2006;21:2521-8.  Back to cited text no. 36      
37.Sherman RA, Torres F, Cody RP. Postprandial blood pressure changes during hemodialysis. Am J Kidney Dis 1988;12:37-9.  Back to cited text no. 37      
38.Strong J, Burgett M, Buss ML, Carver M, Kwankin S, Walker D. Effects of calorie and fluid intake on adverse events during hemo­dialysis. J Ren Nutr 2001;11:97-100.  Back to cited text no. 38      
39.Benaroia M, Iliescu EA. Oral intake during ha­emodialysis: Is there an association with intra­dialytic hypotension? Hemodial Int 2008;12: 62-5.  Back to cited text no. 39      

Correspondence Address:
I Akhmouch
Service de Nephro-Hemodialyse Etat Major General, Agadir
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Source of Support: None, Conflict of Interest: None

PMID: 20587892

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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