Complications at Hemodialysis: Low Blood Pressure

Blood pressure drops can happen at dialysis and interfere with well being

Blood pressure drops are a common issue during dialysis. Getty Images/Eric O'Connell

This article is part of a series covering the common complications seen during hemodialysis. I have talked about cramps and other associated subjective symptoms including nausea, headache, back pain, etc which can occur in conjunction in patients on hemodialysis, here

Blood pressure drop is not an uncommon complication during hemodialysis. In medical jargon, we guys call it intra-dialytic hypotension. It can be a debilitating problem which often leads to kidney failure patients not getting enough dialysis because of abrupt cessation of treatments.

 It can also lead to excess fluid being left on patients, which we know is associated with a higher risk of death. Let's try and understand why this happens and what can be done about it.


As a practicing nephrologist, it didn't take too long for me to realize that certain patients were more likely to see debilitating drops in their blood pressure during dialysis. While my observations do not suffice as acceptable medical evidence, a quick review of literature reveals that certain patients are more likely to see blood pressure drops:

  • Older patients
  • Patients who have been on dialysis for a longer duration of time
  • Diabetics tend to be higher risk
  • Female patients
  • Obese patients
  • Patients requiring excessively high amount of fluid removal, or ultrafiltration, because of high amount of inter-dialytic weight gain
  • Patients with too low dry weight. To understand the concept of dry weight, click here
  • Taking blood pressure medications just prior to dialysis will increase the risk
  • Meals during dialysis are a known risk factor

The discussion regarding why these patients are necessarily high-risk is beyond the scope of this article. The reasons could vary from nerve disease in diabetics (autonomic neuropathy), to rapid fluid removal during dialysis (that might be done in patients with high inter-dialytic weight gain).

 I have also not mentioned the less common but more serious causes of drop in blood pressure that can occur during dialysis, which include things like infections, and problems with the heart like abnormal rhythm or even heart attacks.


The obvious part is that intradialytic hypotension will manifest as a rapid drop in blood pressure.  However patients will often complain of cramps, back pain or chest pain, headaches, lightheadedness, etc.  Signs of the vagal nerve stimulation can often be seen and will usually present as yawning


Intradialytic hypotension can be pretty challenging to treat, especially in patients with multiple risk factors mentioned above. It therefore goes without saying that all the underlying risk factors will need to be individually addressed.  Some suggestions that might work are:

  • Avoid meals during dialysis
  • Avoid taking blood pressure medications just prior to dialysis, or consider switching times
  • It helps to not gain too much weight between successive dialysis treatments; therefore a low inter-dialytic weight gain is helpful.  The less fluid that needs removal from you, the easier it is for your circulatory system to maintain blood pressure.
  • Your nephrologist might prescribe dialysis differently, with a higher amount of sodium.  The details of this are beyond the scope of this article.
  • If these measures fail, talk to your nephrologist about possibly increasing your dry weight

If it looks like the patient is being reasonably compliant with the prescribed fluid regimen, and no other risk factors mentioned above are present, it might be worthwhile to check the patient's heart.  Problems with the heart function aren't an uncommon cause of drops in blood pressure, and the patient might benefit from getting an echocardiogram.  In this situation, seeing a cardiologist would be a good idea.

A medication called midodrine is often used as a last resort. And if nothing else works and the problem is recurrent, consider a switch to peritoneal dialysis or home hemodialysis


Usually, small amounts of intravenous fluids will be given to you in this situation.  This could include a common fluid like normal saline given in a small bolus of 250 ml or so.  Typically, the dialysis staff will reduce or even stop fluid removal from you completely during this period, and you might also be reclined in a specific position to increase the blood flow to the brain, called the Trendelenburg position (the use of which is debatable).

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