Midodrine Intradialytic Hypotension — ESENeph MCQ

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ModerateHaemodialysisMidodrine Intradialytic HypotensionESENeph

A 65-year-old man with CKD G5D on haemodialysis develops hypotension during every dialysis session despite cool dialysate (35°C), sodium profiling, and UF rate <13 mL/kg/hr. His dry weight has been reassessed. What additional pharmacological option can be tried?

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Correct answer: A — Oral Midodrine 5-10 mg given 30-60 minutes before dialysis – an alpha-1 agonist that causes vasoconstriction to prevent intradialytic hypotension

Midodrine is an oral selective alpha-1 adrenergic agonist that causes peripheral vasoconstriction. Given 30-60 minutes pre-dialysis, it helps maintain BP during ultrafiltration. Multiple RCTs have shown benefit for intradialytic hypotension when non-pharmacological measures (cool dialysate, reduced UF rate, sodium profiling, avoiding food during dialysis, dry weight reassessment) have been optimised. It should be used cautiously in patients with significant cardiac disease. Other pharmacological options include Droxidopa and L-carnitine supplementation (limited evidence).

Reference: ERA-EDTA 2019 – Intradialytic Hypotension; Prakash et al 2004 – Midodrine in HD