The hemodynamic cost of intermittent hemodialysis and systemic organ stunning

Despite advancements in solute clearance technologies, cardiovascular mortality in maintenance intermittent hemodialysis (IHD) patients remains disproportionately high. The traditional clearance-based paradigm fails to fully explain this survival gap. Here, we propose conceptualizing IHD as a repetitive iatrogenic stressor and introduce the framework of Repetitive Dialytic Stress Syndrome (RDSS). We postulate that rapid fluctuations in intravascular volume and osmolarity impose a cyclical hemodynamic burden, inducing subclinical microcirculatory shock. Current evidence demonstrates how this recurrent perfusion deficit triggers systemic ischemia-reperfusion injury. This cascade manifests as synchronous organ stunning, driving myocardial fibrosis, cerebral white matter injury, gut endotoxemia, and residual kidney function loss. By redefining dialysis adequacy to include hemodynamic stability, we highlight how therapeutic strategies optimizing physiological stability can mitigate RDSS and improve long-term outcomes.