Approach to intradialytic hypotension in intensive care unit patients with acute renal failure

The increasing prevalence of acute renal failure (ARF) patients with hemodynamic intolerance of intermittent hemodialysis (HD), generally because of septic vasoparesis or severe cardiac dysfunction, has led to the development of several strategies to improve the delivery of renal replacement therapy (RRT) in ARF patients. Intradialytic hypotension (IDH) is caused by the interaction of dialysis-dependent and dialysis-independent factors. Dialysis-dependent factors include the prescriptions for fluid removal, solute removal, and dialysate components such as sodium, buffer, and calcium. Dialysis-independent factors include hemodynamic compromise caused by hypovolemic, cardiogenic, vasodilatory, and mixed mechanisms. We propose an approach to the prevention and management of IDH in critically ill ARF patients, which minimizes hypovolemic, cardiogenic, and vasodilatory insults by optimizing fluid removal, cardiac function, and vascular contractility.