Beyond Fluid Overload: Reassessing the Role of Interdialytic Weight Gain in Intradialytic Blood Pressure Dynamics
DOI:
https://doi.org/10.62255/mjhp.v4i1.287Abstract
Background: Interdialytic weight gain (IDWG) is hypothesized to drive intradialytic blood pressure instability in hemodialysis patients, yet evidence remains contradictory, particularly in low-income and middle-income countries (LMICs) bearing the highest end-stage renal disease (ESRD) burden. We evaluated the association between IDWG and intradialytic blood pressure changes in an Indonesian cohort.
Methods: In this cross-sectional study at Lavalette Hospital, Indonesia (May 2025), we enrolled 83 ESRD patients undergoing maintenance hemodialysis. IDWG was calculated as the percentage weight gain between consecutive sessions. Intradialytic blood pressure change was defined as the difference in systolic blood pressure pre- and post-dialysis. Associations were analyzed using Pearson correlation and stratified analyses.
Results: The mean age was 52·4 years (SD 12·3), with 43 (52%) women. Most participants (62 [75%]) achieved mild IDWG (<4%), while 37 (45%) maintained stable intradialytic blood pressure, 31 (37%) experienced hypertension, and 15 (18%) hypotension. Despite progressive increases in ultrafiltration rates across IDWG categories (245 to 578 mL/h; p<0·0001), mean blood pressure changes did not differ significantly (p=0·89). Crucially, Pearson analysis revealed no significant linear association between IDWG and intradialytic blood pressure changes (r=–0·209; p=0·057), with IDWG explaining only 4·4% of hemodynamic variance.
Conclusion: IDWG alone is an insufficient predictor of intradialytic hemodynamic instability. These findings challenge weight-centric monitoring paradigms, advocating for multifactorial management incorporating ultrafiltration optimization and dialysate profiling. This underscores the urgent need for context-specific, comprehensive hemodialysis quality indicators to advance Sustainable Development Goal targets in resource-constrained settings.
Downloads
Keywords:
Interdialytic Weight Gain, Intradialytic Blood Pressure, ESRD, HemodialysisReferences
Abdulaziz, H.M.M., Gomaa, H. and El-Said, G. (2026) “Improvement of visit-to-visit SBP variability with lowering dialysate sodium concentration in patients undergoing hemodialysis: a randomized controlled trial.,” Journal of hypertension, 44(4), pp. 629–635. Available at: https://doi.org/10.1097/HJH.0000000000004243.
Al Barbandi, M. et al. (2025) “Reducing Excessive Interdialytic Weight Gain in Young Hemodialysis Patients: A Quality Improvement Initiative.,” Kidney medicine, 7(11), p. 101109. Available at: https://doi.org/10.1016/j.xkme.2025.101109.
Borzych-Duzalka, D. et al. (2024) “Prospective Study of Modifiable Risk Factors of Arterial Hypertension and Left Ventricular Hypertrophy in Pediatric Patients on Hemodialysis.,” Kidney international reports, 9(6), pp. 1694–1704. Available at: https://doi.org/10.1016/j.ekir.2024.03.016.
Bossola, M. et al. (2025) “How to Limit Interdialytic Weight Gain in Patients on Maintenance Hemodialysis: State of the Art and Perspectives.,” Journal of clinical medicine, 14(6). Available at: https://doi.org/10.3390/jcm14061846.
Van Buren, P.N. (2017) “Pathophysiology and implications of intradialytic hypertension.,” Current opinion in nephrology and hypertension, 26(4), pp. 303–310. Available at: https://doi.org/10.1097/MNH.0000000000000334.
Van Buren, P.N. and Inrig, J.K. (2017) “Special situations: Intradialytic hypertension/chronic hypertension and intradialytic hypotension.,” Seminars in dialysis, 30(6), pp. 545–552. Available at: https://doi.org/10.1111/sdi.12631.
Chou, J.A., Kalantar-Zadeh, K. and Mathew, A.T. (2017) “A brief review of intradialytic hypotension with a focus on survival.,” Seminars in dialysis, 30(6), pp. 473–480. Available at: https://doi.org/10.1111/sdi.12627.
Colson, A. et al. (2018) “Impact of salt reduction in meals consumed during hemodialysis sessions on interdialytic weight gain and hemodynamic stability.,” Hemodialysis international. International Symposium on Home Hemodialysis, 22(4), pp. 501–506. Available at: https://doi.org/10.1111/hdi.12655.
Curtis, K.A., Waikar, S.S. and Mc Causland, F.R. (2024) “Higher NT-proBNP levels and the risk of intradialytic hypotension at hemodialysis initiation.,” Hemodialysis international. International Symposium on Home Hemodialysis, 28(1), pp. 77–84. Available at: https://doi.org/10.1111/hdi.13125.
Delma, S. et al. (2022) “[Prevalence and risk factors associated with intradialytic hypotension in Sub-Saharan Africa: The case of Burkina Faso].,” Annales de cardiologie et d’angeiologie, 71(1), pp. 27–31. Available at: https://doi.org/10.1016/j.ancard.2021.01.002.
Eftimovska-Otovic, N. et al. (2016) “Clinical Effects of Standard and Individualized Dialysate Sodium in Patients on Maintenance Hemodialysis.,” Open access Macedonian journal of medical sciences, 4(2), pp. 248–252. Available at: https://doi.org/10.3889/oamjms.2016.056.
Ertuglu, L.A. et al. (2021) “Sodium and ultrafiltration profiling in hemodialysis: A long-forgotten issue revisited.,” Hemodialysis international. International Symposium on Home Hemodialysis, 25(4), pp. 433–446. Available at: https://doi.org/10.1111/hdi.12952.
Geng, X. et al. (2020) “The efficacy and safety of low dialysate sodium levels for patients with maintenance haemodialysis: A systematic review and meta-analysis.,” International journal of surgery (London, England), 79, pp. 332–339. Available at: https://doi.org/10.1016/j.ijsu.2020.05.027.
Gul, A. et al. (2016) “Intradialytic hypotension.,” Current opinion in nephrology and hypertension, 25(6), pp. 545–550. Available at: https://doi.org/10.1097/MNH.0000000000000271.
Hamrahian, S.M. et al. (2023) “Prevention of Intradialytic Hypotension in Hemodialysis Patients: Current Challenges and Future Prospects.,” International journal of nephrology and renovascular disease, 16, pp. 173–181. Available at: https://doi.org/10.2147/IJNRD.S245621.
Hanafusa, N., Tsuchiya, K. and Nitta, K. (2018) “Dialysate sodium concentration: The forgotten salt shaker.,” Seminars in dialysis, 31(6), pp. 563–568. Available at: https://doi.org/10.1111/sdi.12749.
Hussein, W.F. and Schiller, B. (2017) “Dialysate sodium and intradialytic hypotension.,” Seminars in dialysis, 30(6), pp. 492–500. Available at: https://doi.org/10.1111/sdi.12634.
Iatridi, F. et al. (2024) “Low dialysate sodium and 48-h ambulatory blood pressure in patients with intradialytic hypertension: a randomized crossover study.,” Nephrology, dialysis, transplantation?: official publication of the European Dialysis and Transplant Association - European Renal Association, 39(11), pp. 1900–1910. Available at: https://doi.org/10.1093/ndt/gfae104.
Jalalzadeh, M. et al. (2021) “Consequences of Interdialytic Weight Gain Among Hemodialysis Patients.,” Cureus, 13(5), p. e15013. Available at: https://doi.org/10.7759/cureus.15013.
Koda, Y. et al. (2017) “Feasibility of intermittent back-filtrate infusion hemodiafiltration to reduce intradialytic hypotension in patients with cardiovascular instability: a pilot study.,” Clinical and experimental nephrology, 21(2), pp. 324–332. Available at: https://doi.org/10.1007/s10157-016-1270-z.
Koda, Y. and Aoike, I. (2019) “Prevention of Intradialytic Hypotension with Intermittent Back-Filtrate Infusion Haemodiafiltration: Insights into the Underlying Mechanism.,” Blood purification, 48 Suppl 1, pp. 1–6. Available at: https://doi.org/10.1159/000503878.
Krishnan, N. and Peixoto, A.J. (2016) “We Hold Antihypertensives Prior To Dialysis.,” Seminars in dialysis, 29(4), pp. 323–325. Available at: https://doi.org/10.1111/sdi.12498.
Lew, S.Q. et al. (2023) “The role of intra- and interdialytic sodium balance and restriction in dialysis therapies.,” Frontiers in medicine, 10, p. 1268319. Available at: https://doi.org/10.3389/fmed.2023.1268319.
Mora-Bravo, F. et al. (2026) “Weekly Liraglutide for the Management of Intractable Polydipsia and Interdialytic Weight Gain in a Patient on Hemodialysis: A Case Report.,” Cureus, 18(1), p. e102197. Available at: https://doi.org/10.7759/cureus.102197.
Paglialonga, F. et al. (2018) “Blood pressure management in children on dialysis.,” Pediatric nephrology (Berlin, Germany), 33(2), pp. 239–250. Available at: https://doi.org/10.1007/s00467-017-3666-8.
Ramaswamy, K. et al. (2020) “Individualized dialysate sodium prescriptions using sodium gradients for high-risk hemodialysis patients lowered interdialytic weight gain and achieved target weights.,” Hemodialysis international. International Symposium on Home Hemodialysis, 24(3), pp. 406–413. Available at: https://doi.org/10.1111/hdi.12830.
Tangvoraphonkchai, K. and Davenport, A. (2018) “Why does the choice of dialysate sodium concentration remain controversial?,” Hemodialysis international. International Symposium on Home Hemodialysis, 22(4), pp. 435–444. Available at: https://doi.org/10.1111/hdi.12645.
Yu, J. et al. (2021) “Paradoxical Association Between Intradialytic Blood Pressure Change and Long-Term Mortality with Different Levels of Interdialytic Weight Gain.,” International journal of general medicine, 14, pp. 211–220. Available at: https://doi.org/10.2147/IJGM.S288038.
Zhi, M. et al. (2025) “The relationship between intradialytic hypotension and health-related quality of life in patients undergoing hemodialysis: a cross-sectional study.,” Scientific reports, 15(1), p. 11532. Available at: https://doi.org/10.1038/s41598-025-96286-y.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Reny Nur Indah Firdaus , Maria Diah Ciptaningtyas , Supono Supono, Joko Wiyono
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
