Prevalence of cardiovascular instability during hemodialysis therapy in hospitalized patients: A systematic review and meta-analysis

Abstract

Background: Intradialytic hypotension (IDH) is a common and serious complication in renal replacement therapy, especially in hospitalized patients. The absence of a standardized definition complicates data synthesis and the development of evidence-based guidelines. Current definitions vary, including different blood pressure thresholds, clinical symptoms, and the need for medical intervention during dialysis. IDH is linked to increased mortality and cardiovascular morbidity and may impede renal recovery in patients with acute kidney injury and chronic kidney disease.

Methods: A systematic review was conducted using MEDLINE via PubMed, Embase, and Web of Science to identify studies reporting IDH prevalence. A meta-analysis of proportions was performed to determine the global prevalence of IDH, with subgroup analyses to explore heterogeneity. The Joanna Briggs Institute's checklist was used to assess the risk of bias in prevalence studies. The PRISMA guidelines were followed to report the results of this study, PROSPERO registration number CRD42024500622.

Results: The meta-analysis found a global IDH prevalence of 31% (95% CI 0.18-0.44) across nine studies. Significant heterogeneity was observed (I²: 97.87%; p < 0.01), with prevalence rates ranging from 10.7% to 64% based on patient demographics and session characteristics. Sensitivity analysis suggested prevalence could range between 27% and 33% depending on study criteria.

Conclusions: IDH is a significant complication during hospital-based renal replacement therapy, with a global prevalence of 31%. These findings highlight the need for a standardized, evidence-based definition of IDH to improve diagnostic consistency and clinical outcomes through more accurate diagnosis, better treatment strategies, and tailored patient management.

Keywords: Dialysis; cardiovascular instability; intradialytic hypotension; proportions meta-analysis; systematic review.

Figure 1.

PRISMA flow diagram for studies selection.

Figure 2.

World map with the origin countries of the included studies.

Figure 3.

Risk of bias across studies through the Joanna Briggs Institute's critical appraisal checklist for studies reporting prevalence data.

Figure 4.

Risk of bias across the domains of the Joanna Briggs Institute's critical appraisal checklist for studies reporting prevalence data.

Figure 5.

Forest plot for the prevalence of IDH divided by risk of bias.

Figure 6.

Forest plot for the prevalence of IDH divided by the number of participants or sessions.

Figure 7.

Forest plot for the prevalence of IDH in critical patients divided by the measures adopted to prevent IDH.

Figure 8.

Funnel plot with asymmetric distribution of studies.