Intradialytic Hypertension


Intradialytic hypertension is defined as an increase in blood pressure during or immediately after hemodialysis, yet no standard definition of intradialytic hypertension exists. Some of the definitions used in clinical practice and clinical studies are as follows1:

  1. Increase in mean arterial blood pressure (MAP) ≥ 15 mm Hg during or immediately after hemodialysis2
  2. Increase in systolic blood pressure (SBP) > 10 mm Hg from pre- to post-dialysis3,4
  3. Hypertension during the second or third hour of hemodialysis after significant ultrafiltration has taken place5
  4. Increase in blood pressure that is resistant to ultrafiltration6
  5. Aggravation of preexisting hypertension or the development of de novo hypertension with erythropoietin-stimulating agents (ESAs)7


Although the causative mechanisms of intradialytic hypotension have been widely investigated, the pathogenesis of intradialytic hypertension remains unknown. Available data on this aspect are inconclusive, however, numerous potential factors have been suggested to contribute the development of hypertensive episodes during hemodialysis.

Potential pathophysiologic mechanisms of intradialytic hypertension1

  • Volume overload
  • Sympathetic over-activity
  • Activation of the renin-angiotensin-aldosterone system
  • Endothelial cell dysfunction
  • Dialysis-specific factors
    • Net sodium gain
    • High ionized calcium
    • Hypokalemia
  • Medications
    • Erythropoietin-stimulating agents
    • Removal of antihypertensive medications
  • Vascular stiffness


  • Lifestyle modifications such as weight reduction, dietary modification, sodium restriction, physical activity and moderation of alcohol consumption can reduce systolic blood pressure from 2-14 mm Hg8
  • Adjustment of target weight on a regular basis. Gradual reduction of interdialytic weight gain over a few weeks using zero sodium balance, salt restriction, longer dialysis or extra dialysis sessions may yield a significant benefit9
  • Reducing erythropoietin dose in patients with severe hypertension Nephrectomy in rare cases of resistant hypertension

Therapeutic options1

  • Volume management
    • Lowering dry weight, minimizing salt and fluid intake
  • Inhibition of the sympathetic nervous system
    • Adrenergic blockers
  • Inhibition of the renin-angiotensin-aldosterone system
    • ACE inhibitors and angiotensin receptor blockers
  • Pharmacologic inhibition of endothelin-1
    • Endothelin-1 antagonists
  • Antihypertensive regimen
    • Revision of antihypertensive agents, timing and dosing
  • Erythropoietin stimulating agents
    • Switching from intravenous to subcutaneous ESA
  • Adjustment of the dialysis prescription


  1. Inrig JK. Intradialytic hypertension: a less-recognized cardiovascular complication of hemodialysis. Am J Kidney Dis. 2010;55(3):580-589. Available from:
  2. Amerling R, Cu GA, Dubrow A, Levin NW, Osheroff RJ. Complications during hemodialysis. Clin Dial. 1995;3:235-267.
  3. Inrig JK, Oddone EZ, Hasselblad V, et al. Association of intradialytic blood pressure changes with hospitalization and mortality rates in prevalent ESRD patients. Kidney Int. 2007;71(5):454-461.
  4. Inrig JK, Patel UD, Toto RD, Szczech LA. Association of blood pressure increases during hemodialysis with 2-year mortality in incident hemodialysis patients: a secondary analysis of the Dialysis Morbidity and Mortality Wave 2 Study. Am J kidney Dis  Off J Natl Kidney  Found. 2009;54(5):881-890.
  5. Fellner SK. Intradialytic hypertension: II. In: Seminars in Dialysis. Vol 6. Wiley Online Library; 1993:371-373.
  6. Levin NW. Intradialytic hypertension: I. In: Seminars in Dialysis. Vol 6. Wiley Online Library; 1993:370-371.
  7. Krapf R, Hulter HN. Arterial hypertension induced by erythropoietin and erythropoiesis-stimulating agents (ESA). Clin J Am Soc Nephrol. 2009;4(2):470-480.
  8. Chobanian A V, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289(19):2560-2572. Available from:
  9. Charra B. “Dry weight” in dialysis: the history of a concept. Nephrol Dial Transplant. 1998;13(7):1882-1885. Available from:

P/N 103060-01 Rev A 02/2021