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Intradialytic hypotension (IDH) is one of the most common reasons for modification of the dialysis prescription and remains a significant clinical barrier for effective treatment [1, 2]. The differential diagnosis is broad and may differ between hospitalized inpatients and outpatients, or patients with acute versus chronic renal failure. There are cases to be made for all three major categories of hypotension: hypovolemia, distributive shock and pump failure. In this issue of Nephrology Dialysis Transplantation, du Cheyron reports on the use of two commercially available technologies to control IDH in hospitalized patients with acute renal failure by controlling hypovolemia and core temperature, a putative culprit in distributive shock during dialysis. Rather than using hematocrit change for end-point detection and dry weight estimation, a closed-loop negative feedback control system continuously adjusts ultrafiltration rates based on relative blood volume (RBV) changes during the dialysis session. In addition, the impact of isothermal dialysis, in which the dialysate temperature was continuously controlled to hold the patient’s body temperature constant, was tested. The authors report on 572 treatments in 74 acute kidney injury patients where each treatment session was randomized to standard therapy with cooled and high-sodium dialysate (n = 188) or blood volume controlled (n = 190) or blood volume and temperature controlled (n = 194) dialysis. No differences were observed in the incidence of IDH or the need for intervention between the control group and the intervention groups. Du Cheyron’s report is an important contribution to our understanding of how technologies developed for the outpatient setting may not yield clinical benefit in the inpatient setting. Critically ill patients who are mechanically ventilated and receiving vasoactive amines are physiologically quite different from ambulatory outpatients. The factors that impact applicability of this report to general practice are worthy of discussion.

Intradialytic hypotension: a case for going slow and looking carefully