Chronic kidney disease (CKD) is a heterogeneous disorder affecting kidney structure and function and represents a major public-health problem. Progressive loss of renal function may culminate in end-stage renal disease (ESRD), in which renal replacement therapy, including haemodialysis or kidney transplantation, is required to maintain life ⁽¹⁾. Haemodialysis removes accumulated metabolic waste and excess fluid when renal function is no longer adequate.⁽²⁾

Although haemodialysis is an established and generally safe renal-replacement modality, patients may develop complications during treatment, including vomiting,

hypoglycaemia, hypertension, muscle cramps and intradialytic hypotension.⁽³⁾ The dissertation notes that IDH is among the most frequent complications of haemodialysis, with reported prevalence in the literature of approximately 20%–50%. Excessive ultrafiltration, pre-dialysis antihypertensive medication, sepsis, obstructive nephropathy, poor nutrition, autonomic dysfunction, cardiovascular disease and older age have been described as potential risk factors.⁽⁴⁾

IDH is clinically important because recurrent falls in blood pressure may be associated with myocardial or cerebral ischaemia, vascular-access thrombosis, arrhythmias, fluid overload due to limited ultrafiltration, interdialytic hypertension and increased mortality.⁽⁵⁾ Despite improvements in dialysis technology, ultrafiltration control, dialysate composition and temperature management, episodes of IDH continue to occur.⁽⁶⁾

Previous studies cited in the dissertation reported an IDH frequency of 45.7% in a Nigerian study and 37.5% in a tertiary-care hospital in Pakistan. The present study was undertaken to determine the frequency of IDH in an ESRD haemodialysis population and to examine its relationship with selected factors including age, sex, BMI, diabetes and hypertension^.(7)

Objective

To determine the frequency of intradialytic hypotension in ESRD patients on haemodialysis and to assess its association with selected demographic and clinical characteristics.

Study design and setting: This was a cross-sectional study conducted in the Department of Nephrology of various hospitals in Abbottabad including Pakistan kidney center Abbottabad, Abbottabad International medical institute, Jinnah Hospital women medical college Abbottabad , from 26 November 2025 to 25 May 2026. Sample size and sampling: The dissertation reports a sample size of 141, calculated using WHO software with a 95% confidence level, an anticipated IDH frequency of 37.5%, and absolute precision of 8%. Consecutive non-probability sampling was used. Eligibility: Patients of either sex, aged 20–65 years, on regular haemodialysis for more than two months, and undergoing haemodialysis twice weekly for at least three hours were eligible. Patients with fever, gross ascites due to liver cirrhosis, dialysis duration of less than two months, previous myocardial infarction with ischaemic dilated cardiomyopathy, or inability to provide consent were excluded.Data collection: Ethical and research committee approval was obtained and written consent was taken. Baseline blood pressure was recorded immediately before dialysis. Intradialytic blood pressure was measured every 30 minutes for three hours using an automatic cuff attached to the dialysis machine. IDH was defined as a decrease in systolic blood pressure of ≥20 mmHg or a decrease in mean arterial pressure of 10 mmHg compared with the pre-dialysis baseline. Age, sex, height, weight, BMI, diabetes and hypertension history were recorded on a structured proforma. Statistical analysis: Data were analyzed with SPSS version 23. Quantitative variables, including age and BMI, were summarized as mean ± standard deviation, while categorical variables were summarized as frequencies and percentages. IDH was stratified by age, sex, BMI, diabetes and hypertension. Chi-square testing was used after stratification, with p≤0.05 considered statistically significant.

A total of 141 dialysis-dependent patients were included. The mean age was 38.4 ± 12.2 years and the mean BMI was 23.1 ± 2.7 kg/m². Sixty-one participants (43.2%) were male and 80 (56.8%) were female. Ninety-two patients (65.2%) had a previous history of hypertension and 78 (55.3%) had diabetes. Ninety-six patients (68.0%) had BMI <25 kg/m², while 45 (32.0%) had BMI >25 kg/m².

IDH was documented in 79 of the 141 patients (56.0%), while 62 (44.0%) did not meet the study definition. The frequency was therefore greater than half of the study population.

The principal finding of this study was that IDH occurred in 56% of patients receiving maintenance haemophilia. This indicates that IDH was a frequent event in the studied population and is consistent with the dissertation's emphasis on its clinical importance. The reported frequency was higher than the 37.5% frequency previously reported from a tertiary-care hospital in Pakistan and the 45.7% frequency cited from a Nigerian study.(9) A strong association was observed between IDH and previous hypertension. In the present study, 78.2% of patients with a history of hypertension experienced IDH compared with 14.2% among those without such a history (p<0.00001). The dissertation discusses possible contributions from anti-hypertensive therapy and altered haemodynamic responses during dialysis. These observations support careful assessment of blood pressure and antihypertensive medication use before and during dialysis.(10) Male sex was also strongly associated with IDH. IDH occurred in 64.5% of male participants compared with 16.1% of female participants (p<0.00001). The dissertation notes that this differs from reports in which IDH occurs with similar frequency in both sexes. A possible explanation proposed in the dissertation is the influence of lower BMI or target weight and ultra filtration, although the exact mechanism could not be established. Low BMI was significantly associated with IDH. Among patients with BMI <25 kg/m², 66.6% developed IDH compared with 33.3% of those with BMI >25 kg/m² (p=0.000201). The dissertation suggests that low body weight may make patients more susceptible to haemodynamic changes even with relatively small volumes of ultra-filtration. It also discusses possible contributions from hypoalbuminaemia, nutritional status, volume overload and ultrafiltration.(11) Diabetes was significantly associated with IDH (p=0.03246), with 51.2% of patients with diabetes experiencing IDH compared with 33.3% of those without diabetes. The dissertation attributes this possible relationship to diabetes-related vascular changes, including atherosclerosis and reduced vascular compliance. The study also reported a strong association with the younger age group. This finding is noteworthy because older age has commonly been considered a risk factor for haemodynamic instability during dialysis; the dissertation therefore recommends further investigation of this unexpected association.(12) Clinical Implications The frequency observed in this study highlights the need for structured surveillance for IDH during haemodialysis. Particular attention may be warranted for patients with a history of hypertension or diabetes, low BMI, and the demographic characteristics identified in this study. Regular pre-dialysis and intradialytic blood-pressure measurement, careful assessment of fluid status and ultrafiltration requirements, and review of relevant medications may help dialysis teams recognize patients at increased risk. The dissertation also emphasizes staff education and appropriate management of episodes of hypotension. Because IDH may compromise ultrafiltration and is associated in the dissertation with adverse clinical outcomes, preventing recurrent episodes is an important component of dialysis quality improvement. However, the observed associations should be interpreted as associations from a cross-sectional study and should not be taken as proof of causality. Limitations The study was conducted at tertiary-care nephrology departments of Private institutes and used consecutive non-probability sampling, which may limit generalizability. Its cross-sectional design prevents assessment of temporal relationships or causality. The dissertation focused on selected variables and did not establish independent predictors through multivariable analysis. The findings concerning younger age and male sex are particularly in need of confirmation in larger, multicentre prospective studies.

Intradialytic hypotension was frequent among ESRD patients receiving haemodialysis in the Department of Nephrology, Khyber Teaching Hospital, Peshawar, with 56% of the 141 participants meeting the study definition. Significant associations were observed with lower age group, male sex, low BMI, previous hypertension and diabetes. The findings reinforce the importance of vigilant intradialytic blood-pressure monitoring and identification of patients at increased risk. Further studies are needed to validate the associations, particularly those involving younger age and male sex, and to determine modifiable predictors and effective preventive interventions.

Recommendations

• Implement consistent pre-dialysis and intradialytic blood-pressure monitoring and document episodes of IDH systematically.
• Identify patients with hypertension, diabetes and low BMI as potentially higher-risk groups and assess them carefully before each dialysis session.
• Review fluid status, target/dry weight and ultrafiltration requirements to reduce avoidable Haemodynamic instability.
• Review relevant Antihypertensive medication timing and other potentially modifiable contributors in accordance with the treating Nephrologist's plan.
• Provide regular education and competency-based training for dialysis staff in recognition and management of IDH.
• Conduct larger multicentre prospective studies to validate the observed associations and investigate independent risk factors and outcomes.

1. Razmaria AA. Chronic kidney disease. JAMA. 2016;315(20):2248.
2. Hill NR, Fatoba ST, Oke JL, et al. Global prevalence of chronic kidney disease—a systematic review and meta-analysis. PLoS One. 2016;11(7):e0158765.
3. Brunet P. Treatment of chronic kidney failure by haemodialysis. Soins. 2018;63(826):21-23.
4. Kuipers J, Oosterhuis JK, Krijnen WP, et al. Prevalence of intradialytic hypotension, clinical symptoms and nursing interventions—a three-month prospective study of 3818 haemodialysis sessions. BMC Nephrol. 2016;17:21.
5. Harshman LA, Alexander SR, Brophy PD. Intradialytic hypotension: potential causes and mediating factors. In: Warady B, Schaefer F, Alexander editors. Pediatric Dialysis Case Studies. Cham: Springer; 2017. p.141-148.
6. Stefánsson BV, Brunelli SM, Cabrera C, et al. [Reference as cited in the dissertation].
7. Okoye OC, Slater HE, Rajora N. Prevalence and risk factors of intradialytic hypotension: a 5-year retrospective report from a single Nigerian Centre. Pan Afr Med J. 2017;28(1).
8. Neves PL, Camacho A, Bernardo I, et al. Chronic hemodialysis: risk factors for intradialytic hypotension. Acta Med Port. 1990;3(4):205-207.
9. Tian M, Zha Y, Qie S, Lin X, Yuan J. Association of body composition and intradialytic hypotension in hemodialysis patients. Blood Purif. 2020;49(3):334-340.
10. Bossola M, Laudisio A, Antocicco M, et al. Intradialytic hypotension is associated with dialytic age in patients on chronic hemodialysis. Ren Fail. 2013;35(9):1260-1263.
11. Agrawal, R. K., et al. (2012). "Acute intradialytic complications in end stage renal disease on maintenance hemodialysis." Journal of the Nepal Medical Association 52(187): 118.