Methylene Blue and Dialysis-Related Hypotension

End stage renal disease (ESRD) affects over 400,000 Americans, and over 8 million have chronic renal insufficiency [1]. Chronic renal insufficiency (CRI) describes a continuum of impaired renal function based on several parameters including glomerular filtration rate and serum creatinine. As renal function deteriorates, the risk of all-cause mortality increases [1]. The most prevalent form of renal replacement therapy is hemodialysis (HD), with over 75% of ESRD patients being treated with this modality [2, 3]. Patients requiring chronic HD have been noted to experience an increase in cardiovascular morbidity and mortality [4]. In fact, between 10-20% of patients who require HD die each year and approximately 45% of these deaths are attributable to cardiovascular causes [2, 3]. Hemodialysis itself is associated with substantial morbidity, including complications related to vascular access and those inherent to the HD procedure itself. One of the most common complications of hemodialysis is intradialytic hypotension (IDH), which occurs in approximately 25% of HD sessions [5]. There are several therapeutic options available for the treatment of IDH. However, “resistant” forms of IDH do occur and a multimodality approach is usually necessary in such cases. The aim of this chapter is to discuss IDH and outline existing clinical approaches to IDH. Specifically, we will focus on the use of methylene blue (MB) in the treatment of IDH. Methylene blue, a nitric oxide pathway mediator, has shown promise in prevention or treatment of IDH in difficult-totreat cases [6, 7].