Dialysis dose and intradialytic hypotension: results from the HEMO study

Intradialytic hypotension (IDH) is common and is associated with increased morbidity and mortality in chronic hemodialysis patients. A higher dialysis 'dose' may generate transient intradialytic osmotic gradients, predisposing to intracellular fluid shifts and resulting in hypotension.

We performed a post hoc analysis of the HEMO study, a multicenter trial that randomized chronic hemodialysis patients to high versus standard Kt/V and higher versus lower membrane flux. In order to achieve dose targets, per protocol, adjustments were made in membrane efficiency, blood flow or dialysate flow before changing session length. Detailed hemodynamic and urea kinetic modeling data were abstracted from 1,825 individuals. The primary outcome was the occurrence of hypotensive events necessitating clinical intervention (saline infusion, lowering of ultrafiltration rate or reduced blood flow).

Intradialytic hypotensive events occurred more frequently in the higher-Kt/V group (18.3 vs. 16.8%; p < 0.001). Participants randomized to higher-target Kt/V had a greater adjusted risk of IDH than those randomized to standard Kt/V [odds ratio (OR) 1.12; 95% confidence interval (CI) 1.01-1.25]. Higher vs. lower dialyzer mass transfer-area coefficient for urea and rate of urea removal were associated with greater adjusted odds of IDH (OR 1.15; 95% CI 1.04-1.27 and OR 1.05; 95% CI 1.04-1.06 per mg/dl/h, respectively).

Higher dialysis dose, at relatively constrained treatment times, may associate with an increased risk of IDH. These findings support the possibility that rapidity of intradialytic reductions in plasma osmolality may play an important role in mediating hemodynamic instability during dialysis.