Do you use mannitol when initiating patients on intermittent hemodialysis?

This is a very good question. Mannitol has been used for decades to try and reduce disequilibrium, cramping and intradialytic hypotension. Most of the studies are small and were not placebo controlled and were performed in prevalent patients. In 2019, a randomized controlled trial was done that did not show any significant difference in decline in intradialytic SBP between mannitol and placebo but there was lower frequency of intradialytic hypotension episodes with the use of mannitol. There is concern about causing hypervolemia with mannitol. Thus there are no firm recommendations for routine use of mannitol when initiating HD.