Intradialytic hypotension hits 75% of patients, causes organ damage

75% of hemodialysis patients experience at least one episode of intradialytic hypotension (IDH) -- a sudden blood pressure crash during treatment -- and it occurs in 20-30% of all dialysis sessions. During IDH, patients experience dizziness, nausea, vomiting, muscle cramps, abdominal pain, and sometimes loss of consciousness. But the invisible damage is worse: each IDH episode causes transient ischemia to the heart, brain, and gut. Repeated episodes over months and years lead to cumulative cardiac stunning (myocardial injury), white matter brain lesions, and mesenteric ischemia. IDH is independently associated with higher cardiovascular mortality. Patients dread it -- many describe the 'post-dialysis crash' where they are wiped out for 6-8 hours after treatment, unable to work, parent, or function. The structural reason this persists is that conventional 3x/week, 4-hour hemodialysis requires removing 2-4 liters of fluid in each session (the fluid that accumulated between treatments), which is a physiologically violent process. More frequent or longer dialysis (daily short HD, nocturnal HD) dramatically reduces IDH by removing smaller volumes, but the Medicare bundled payment pays the same per-treatment regardless of frequency, and clinics maximize revenue with 3 shifts of 4-hour treatments per day.