The Effects of Sertraline on Dialysis-Induced Hypotension: A Systematic Review and Meta-Analysis

Figures

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  Figure 1. Pathophysiology of dialysis-induced hypotension and mechanism of sertraline. During hemodialysis, ultrafiltration leads to intravascular volume depletion, triggering three interacting pathways: (A) cardiac underfilling with reduced venous return and cardiac output; (B) impaired autonomic compensation due to uremic neuropathy; and (C) the Bezold–Jarisch reflex, a paradoxical vagal response mediated by central serotonin release. Sertraline (SSRI) attenuates the Bezold–Jarisch reflex by increasing central serotonin levels, thereby restoring appropriate sympathetic responses to hypovolemia. DIH, dialysis-induced hypotension; 5-HT, serotonin; LV, left ventricle; SVR, systemic vascular resistance; UFR, ultrafiltration rate.

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  Figure 2. PRISMA 2020 flow diagram showing study selection process (revised).

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  Figure 3. Forest plot of the effect of sertraline on mean arterial pressure. Blue squares indicate individual study effects (size proportional to weight); the red diamond represents the pooled effect estimate. CI, confidence interval; SMD, standardized mean difference. Blue squares indicate individual study effects (size proportional to study weight); the red diamond represents the pooled effect estimate [20,21,22,23,24,25,26,27,28].

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  Figure 4. Subgroup analysis by study design and sertraline dose (revised) [20,21,22,23,24,25,26,27,28]. Each square represents the standardized mean difference (SMD) for an individual study, with square size proportional to study weight. Horizontal lines represent 95% confidence intervals. Diamonds represent the pooled effect estimate for each subgroup and the overall effect, with diamond width corresponding to the 95% confidence interval. The vertical dashed line indicates the null effect (SMD = 0). Values to the right of the null line favor sertraline.

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  Figure 5. Risk of bias summary using Cochrane RoB 2 tool for RCTs and Newcastle–Ottawa Scale for observational studies [20,21,22,23,24,25,26,27,28].

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  Figure 6. Funnel plot for assessment of publication bias (revised). Egger’s test p = 0.21.