Dynamic changes in right ventricular free wall strain during hemodialysis identify patients at risk for intradialytic hypotension.

Background: Intradialytic hypotension (IDH) is a frequent complication of hemodialysis that is associated with adverse cardiovascular consequences. The contribution of right ventricular (RV) functional reserve to hemodynamic stability during dialysis remains unclear. We investigated whether dynamic changes in RV strain are associated with IDH. Methods: In this prospective single-center study, 50 patients with end-stage renal disease undergoing maintenance hemodialysis underwent comprehensive echocardiography with speckle-tracking analysis immediately before and after dialysis. IDH was defined as a decrease in systolic blood pressure (SBP) of ≥ 20 mmHg from pre- to post-dialysis. Right ventricular free wall strain (RVFWS) was analyzed offline by a blinded specialist. Changes in RVFWS were compared between patients with and without IDH, and correlations between SBP change and RVFWS change were assessed. Results: In the analyzed 33 patients, 15 patients (45%) developed IDH. Baseline clinical characteristics, ultrafiltration volume (mean, 2.9 L), and pre-dialysis SBP were comparable between groups. Left ventricular ejection fraction was preserved in most patients, and baseline RVFWS did not differ significantly. However, the IDH group showed a significantly greater post-dialysis reduction in RVFWS than the non-IDH group (-7.0 ± 7.2% vs. -1.7 ± 4.6%, Conclusions: IDH was associated with a greater dialysis-induced decline in RVFWS despite similar baseline RV function, suggesting that acute volume unloading may unmask impaired RV contractile reserve. These findings provide preliminary evidence that dynamic RV strain assessment could help identify patients vulnerable to intradialytic hemodynamic instability, warranting further validation in larger studies.