Clinical Implications of Intradialytic Hypotension: Impact on Morbidity and Mortality in Dialysis Patients

Background: Intradialytic hypotension (IDH) is the most frequent acute complication during hemodialysis (HD), associated with reduced treatment adequacy, recurrent hospitalizations, and increased mortality. Despite guidelinse-directed preventive measures, IDH remains highly prevalent in resource-limited settings. This study aimed to determine the frequency, clinical predictors, and outcomes of IDH among HD patients in a tertiary care center in Peshawar, Pakistan. Methods: A descriptive cross-sectional study was conducted at Khyber Teaching Hospital, Peshawar, from January to June 2025. A total of 240 adult patients undergoing maintenance HD were enrolled. Data on demographics, comorbidities, dialysis vintage, interdialytic weight gain, ultrafiltration volume, and antihypertensive medication use were collected. IDH was defined as a fall in systolic blood pressure ≥20 mmHg or mean arterial pressure ≥10 mmHg during dialysis accompanied by symptoms requiring nursing intervention. Associations with morbidity (hospitalizations, vascular access dysfunction, dialysis discontinuation) and mortality were assessed using Chi-square tests. Results: A total of 240 maintenance hemodialysis patients were enrolled, with a mean age of 53.1 ± 12.8 years and male predominance (58.3%). Intradialytic hypotension (IDH) was observed in 94 patients (39.2%). Patients with IDH had significantly higher interdialytic weight gain >3 kg (65.0% vs. 37.5%, p<0.01) and more frequent ultrafiltration rates >10 ml/kg/hr (68.3% vs. 35.0%, p<0.001). Use of antihypertensive medications was also greater in the IDH group (79.2% vs. 58.3%, p=0.02). Clinical outcomes revealed higher hospitalization rates in patients with IDH (40.0% vs. 18.3%, p<0.01), alongside increased vascular access complications (20.8% vs. 8.3%, p=0.01) and premature session discontinuation (25.0% vs. 11.7%, p=0.02). Importantly, six-month mortality was significantly higher among IDH patients (16.7% vs. 6.7%, p=0.03). These findings highlight the high burden of IDH and its strong association with morbidity and mortality in dialysis patients. Conclusion: IDH was highly prevalent among HD patients and was linked to greater morbidity and mortality. Optimization of fluid management, individualized ultrafiltration targets, and avoidance of intradialytic antihypertensive use may reduce its burden. Early identification of high-risk patients and structured preventive strategies are urgently needed in resource-limited settings.