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However, this efficiency also induces significant hemodynamic, thermal, and respiratory stressors. These have parallels with the extreme physiologic demands which are normally mainly experienced by healthy subjects under adverse environmental conditions, with the difference that they must be endured by a vulnerable patient population. <jats:italic>Hemodynamic stress<\/jats:italic> induced by ultrafiltration leads to a decline in circulating blood volume, which may result in intradialytic hypotension (<jats:styled-content style=\"fixed-case\">IDH<\/jats:styled-content>) and changes in tissue perfusion, which may have long\u2010term consequences for the function of vital organs such as the brain and the heart. Pronounced declines in central venous oxygen saturation have been observed during routine <jats:styled-content style=\"fixed-case\">HD<\/jats:styled-content>, which are related to the circulatory stress imposed upon the patient. Apart from patient\u2010related factors, <jats:italic>thermal stress<\/jats:italic> induced by <jats:styled-content style=\"fixed-case\">HD<\/jats:styled-content> may lead to skin vasodilation, counteracting the normal hemodynamic response to hypovolemia, which has important pathophysiologic correlates in heat syncope. Lastly, <jats:italic>respiratory stress<\/jats:italic> is reflected by prolonged arterial hypoxemia during <jats:styled-content style=\"fixed-case\">HD<\/jats:styled-content>, which is both related to patient\u2010related factors, but may also be partly because of the treatment itself, especially during the first 30\u201060\u00a0minutes. Whereas hypoxemia during <jats:styled-content style=\"fixed-case\">HD<\/jats:styled-content> is related to increased mortality, its role in the reduced tissue oxygen delivery during <jats:styled-content style=\"fixed-case\">HD<\/jats:styled-content> should be further defined. Treatment modifications, such as cool or temperature\u2010controlled <jats:styled-content style=\"fixed-case\">HD<\/jats:styled-content>, may reduce circulatory and thermal stress, which also may translate into a reduced risk of long\u2010term cardiac or cerebral damage. However, as circulatory stress is mainly time\u2010dependent, prolonged, or more dialysis treatment may reduce the homeostatic burden on the patient.<\/jats:p>","DOI":"10.1111\/sdi.12704","type":"journal-article","created":{"date-parts":[[2018,4,20]],"date-time":"2018-04-20T02:05:05Z","timestamp":1524189905000},"page":"500-506","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":32,"title":["Hemodialysis: A model for extreme physiology in a vulnerable patient population"],"prefix":"10.1111","volume":"31","author":[{"given":"Jeroen P.","family":"Kooman","sequence":"first","affiliation":[{"name":"Division of Nephrology Department of Internal Medicine Maastricht University Medical Center Maastricht The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Krassimir","family":"Katzarski","sequence":"additional","affiliation":[{"name":"Dialysis Unit Solna Gate Diaverum AB and Division of Renal Medicine Department 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