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Introduction <p>Hemodialysis is often used to enhance the clearance of dialyzable poisons, but intradialytic hypotension (IDH) can impede timely toxin removal and impact clinical outcomes. We summarize mechanisms and evidence-based strategies to prevent or treat IDH during toxicology-directed hemodialysis.</p> Methods <p>We searched PubMed (via MEDLINE), Embase and Web of Science from January 1980 to July 2025 for English language studies addressing IDH during hemodialysis, toxicology-related extracorporeal treatments, or pharmacologic adjuncts (“intradialytic hypotension,” “hemodialysis,” “hypertonic saline,” “albumin,” “vasopressin,” “methylene blue,” “carnitine,” “dialysate calcium,” “dialysate magnesium,” and “toxicology”). We performed snowballing of references from retrieved articles and included both randomized and observational studies without restriction.</p> Discussion <p>IDH results from the interaction of hypovolemia with inadequate plasma refilling, myocardial stunning, and vasoplegia due to blunted vasopressin release or nitric oxide-mediated vasodilation. Interventions with supportive evidence include albumin to augment oncotic pressure; hypertonic agents to preserve plasma osmolality; methylene blue to inhibit soluble guanylate cyclase; cooled dialysate to blunt vasodilation; optimization of dialysate calcium and magnesium to improve vascular tone and contractility; levocarnitine for myocardial metabolism; and vasopressors for persistent instability. When fluid removal is required, minimizing ultrafiltration or sequencing continuous therapies can improve hemodynamic tolerance. Extracorporeal membrane oxygenation permits simultaneous support and solute clearance in refractory shock.</p> Conclusion <p>Selective use of hyperoncotic albumin or crystalloids, methylene blue, cooled dialysate, tailored dialysate composition, levocarnitine, delayed ultrafiltration, vasopressors/inotropes and extracorporeal membrane oxygenation offers an array of approaches to preserve perfusion, enable adequate toxin clearance, reduce interruptions to therapy, and improve clinical outcomes in poisoned patients requiring extracorporeal toxin clearance.</p>

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A Narrative Summary of Strategies to Mitigate Intradialytic Hypotension in Poisoned Patients Requiring Extracorporeal Toxin Elimination

  • 期刊论文

  • 发表日期：

    2026年4月9日

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  • David K. Carroll,
  • Andrew M. King,
  • Andrew Isaacson,
  • Brandtly Yakey,
  • Aria Darling,
  • Varun Vohra,
  • Josh D. King

摘要

Introduction

Hemodialysis is often used to enhance the clearance of dialyzable poisons, but intradialytic hypotension (IDH) can impede timely toxin removal and impact clinical outcomes. We summarize mechanisms and evidence-based strategies to prevent or treat IDH during toxicology-directed hemodialysis.

Methods

We searched PubMed (via MEDLINE), Embase and Web of Science from January 1980 to July 2025 for English language studies addressing IDH during hemodialysis, toxicology-related extracorporeal treatments, or pharmacologic adjuncts (“intradialytic hypotension,” “hemodialysis,” “hypertonic saline,” “albumin,” “vasopressin,” “methylene blue,” “carnitine,” “dialysate calcium,” “dialysate magnesium,” and “toxicology”). We performed snowballing of references from retrieved articles and included both randomized and observational studies without restriction.

Discussion

IDH results from the interaction of hypovolemia with inadequate plasma refilling, myocardial stunning, and vasoplegia due to blunted vasopressin release or nitric oxide-mediated vasodilation. Interventions with supportive evidence include albumin to augment oncotic pressure; hypertonic agents to preserve plasma osmolality; methylene blue to inhibit soluble guanylate cyclase; cooled dialysate to blunt vasodilation; optimization of dialysate calcium and magnesium to improve vascular tone and contractility; levocarnitine for myocardial metabolism; and vasopressors for persistent instability. When fluid removal is required, minimizing ultrafiltration or sequencing continuous therapies can improve hemodynamic tolerance. Extracorporeal membrane oxygenation permits simultaneous support and solute clearance in refractory shock.

Conclusion

Selective use of hyperoncotic albumin or crystalloids, methylene blue, cooled dialysate, tailored dialysate composition, levocarnitine, delayed ultrafiltration, vasopressors/inotropes and extracorporeal membrane oxygenation offers an array of approaches to preserve perfusion, enable adequate toxin clearance, reduce interruptions to therapy, and improve clinical outcomes in poisoned patients requiring extracorporeal toxin clearance.