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The Pathophysiologic Basis for Hemodialysis‐Related Hypotension

Hypotension complicates hemodialysis in 20 ( 1, 2) to 50% (3) of treatments. Dialysis-related hypotension may be accompanied by neurologic complications (seizures, cerebral infarction), cardiac ischemia (angina, myocardial infarction, arrhythmias), aspiration pneumonia, vascular access closure (4) as well as considerable discomfort (nausea, vomiting, diaphoresis, cramps). To understand the pathophysiologic basis for hypotension it is of value to examine the determinants of blood pressure (Fig. 1). Mean arterial pressure is determined solely by peripheral vascular resistance (PVR) and cardiac output. Cardiac output is a function of heart rate and stroke volume, with stroke volume, in turn, depending upon intrinsic myocardial contractility and plasma volume. Ultrafiltration of blood during hemodialysis will lead to a reduction in plasma volume and will result in hypotension unless compensatory changes occur in PVR, heart rate, or myocardial contractility.