Risk factors for post-induction hypotension in patients with end-stage renal disease undergoing general anesthesia.

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Learn more: PMC Disclaimer | PMC Copyright Notice PLoS One . 2026 May 29;21(5):e0350083. doi: 10.1371/journal.pone.0350083 Risk factors for post-induction hypotension in patients with end-stage renal disease undergoing general anesthesia Supachai Trikisayaveach 1 , Laortip Rattanapittayaporn 2, * , Jatuporn Pakpirom 2 , Chutida Sungworawongpana 2 , Suttasinee Petsakul 2 Editor: Robert Jeenchen Chen 3 Author information Article notes Copyright and License information 1 Department of Anesthesiology, Somdech Phra Pinklao Hospital, Bangkok, Thailand 2 Department of Anesthesiology, Prince of Songkla University, Hatyai, Songkhla, Thailand 3 Stanford University School of Medicine, UNITED STATES OF AMERICA Competing Interests: No competing interests exist. ✉ * E-mail: laortip.r@gmail.com Roles Supachai Trikisayaveach : Data curation, Methodology, Writing – original draft Laortip Rattanapittayaporn : Writing – original draft, Writing – review & editing Jatuporn Pakpirom : Supervision Chutida Sungworawongpana : Writing – review & editing Suttasinee Petsakul : Supervision Robert Jeenchen Chen : Editor Received 2025 Sep 30; Accepted 2026 May 9; Collection date 2026. © 2026 Trikisayaveach et al This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice PMCID: PMC13221025  PMID: 42213723 This article has been corrected. See PLoS One. 2026 Aug 17;21(8):e0356297 . Abstract Background Patients with end-stage renal disease (ESRD) are at highly susceptible to hemodynamic instability during anesthesia induction. However, data specific to this population remain limited. Methods This retrospective cohort study included 635 adult patients with ESRD who underwent non-cardiac surgery under general anesthesia between 2012 and 2022. Post-induction hypotension was defined as a ≥ 30% reduction in mean arterial pressure (MAP) from baseline within 20 minutes after induction, requiring vasopressor support. Multivariable logistic regression was performed to identify independent predictors. Results The incidence of post-induction hypotension was 44.1% (95% confidence interval (CI), 40.2–47.9). Independent predictors included age > 65 years, chronic oral antidiabetic therapy, higher propofol dose, rapid sequence induction, and emergency surgery. The incidence of hypotension peaked at 20 min after induction. Dialysis-related variables were not significantly associated with hypotension. Conclusion Post-induction hypotension is common in patients with ESRD and associated with advanced age, chronic antidiabetic therapy, higher propofol dose, rapid sequence induction, and emergency surgery. Introduction The number of patients with end-stage renal disease (ESRD) undergoing surgical procedures has increased substantially in recent years, largely due to improved ESRD survival outcomes and the high prevalence of comorbid conditions, particularly cardiovascular disease. As a result, perioperative management of this population remains a significant clinical challenge. Post-induction hypotension is a common and clinically important complication associated with adverse outcomes such as myocardial injury, acute kidney injury, stroke, and increased mortality risk. Recent evidence has reinforced the strong association between intraoperative hypotension and postoperative complications, highlighting its clinical significance [ 1 – 5 ]. Recent advances in perioperative monitoring have focused on the early detection and prediction of hypotension, including the development of machine learning–based indices and goal-directed hemodynamic strategies [ 6 , 7 ]. Although hypotension risk factors have been extensively studied in the general surgical population, these findings may not be directly applicable to patients with ESRD as they exhibit distinct physiological alterations, including autonomic dysfunction, vascular stiffness, impaired baroreceptor responses, and altered pharmacokinetics and pharmacodynamics of anesthetic agents. These factors may substantially influence their hemodynamic response to anesthesia induction. Evidence specifically addressing post-induction hypotension in patients with ESRD remains limited. In particular, the contribution of dialysis-related variables and anesthetic techniques has not been clearly defined. Therefore, this study aimed to determine the incidence and identify risk factors for post-induction hypotension in patients with ESRD undergoing non-cardiac surgery. We hypothesized that ESRD-specific factors contribute to hypotension beyond established predictors observed in the general population. Materials and methods Study design This retrospective cohort study was conducted to identify risk factors for post-induction hypotension in patients with ESRD undergoing non-cardiac surgery under general anesthesia at Songklanagarind Hospital. The secondary objective was to determine the incidence of post-induction hypotension in this population. Study population This study included adult patients (≥18 years) with ESRD (glomerular filtration rate <15 mL/min/1.73 m²) receiving chronic hemodialysis who underwent non-cardiac surgery with endotracheal intubation under general anesthesia between 2012 and 2022. The study protocol was approved by the Human Research Ethics Committee, Faculty of Medicine, Prince of Songkla University (REC 66-290-8-1). Data were accessed on December 8, 2023. The requirement for informed consent was waived due to the retrospective nature of the study. Patients were excluded if they required more than one attempt at endotracheal intubation, underwent double-lumen endobronchial intubation, were intubated prior to induction, received vasopressor or inotropic support before induction, or had incomplete hemodynamic data. Incomplete data were defined as missing blood pressure or heart rate measurements at baseline or at predefined time points (immediately, and at 5, 10, 15, and 20 min after induction). Data collection and variable definitions Patient data were extracted from the hospital information system by the investigators and a trained anesthetic nurse using standardized data collection forms. Independent variables Collected variables included demographic characteristics (age, sex, body weight, height, body mass index), clinical parameters (dry weight, American Society of Anesthesiologists physical status(ASA)), comorbidities (e.g., hypertension, diabetes mellitus, ischemic heart disease, arrhythmias, structural heart disease, cerebrovascular disease, peripheral vascular disease, thyroid disorders, malignancy, chronic obstructive pulmonary disease, and asthma), and long-term medications. Preoperative laboratory data included hematocrit, platelet count, blood urea nitrogen, creatinine, electrolytes, bicarbonate, and calcium levels. Dialysis-related variables included the interval between the last dialysis session and surgery. Baseline hemodynamic parameters were defined as the average of the highest and lowest blood pressure and heart rate recorded preoperatively. Surgical variables included urgency (elective or emergency) and type of surgery. Intraoperative variables included induction agents (propofol, etomidate, midazolam, ketamine, thiopental), opioid use, rapid sequence induction, use of regional anesthesia, inhalational agents, and serial hemodynamic measurements at predefined time points (T0, Ti, T5, T10, T15, and T20) and type and total dose of vasopressor (norepinephrine in (µg), ephedrine in (mg), and adrenaline in (µg)) Dependent variables (Outcomes) The primary outcome was post-induction hypotension, which was defined as A ≥ 30% decrease in MAP from baseline, and Administration of vasopressor therapy within 20 min after induction. This definition was based on previous literature demonstrating its association with adverse outcomes. Sample size The sample size was calculated from a formula according to a cohort study using the proportion of outcomes of interest in the exposed group and the proportion of outcomes in the unexposed group. No previous study has investigated the risk factors for post-induction hypotension in patients with ESRD undergoing general anesthesia. The sample size was calculated using data from a previous study that analyzed risk factors for post-induction in patients undergoing general anesthesia (6). The formula is as follows: Five percent significance and 80% were used. n exposure = ( z 1 − α 2 p ¯ q ¯ ( 1 + 1 r ) + z 1 − β p 1 q 1 + p 2 q 2 r Δ ) 2 p 1 = P ( o u t c o m e e x p o s u r e ) , q 1 = 1 − p 1 p 2 = P ( o u t c o m e u n e x p o s u r e ) , q 2 = 1 − p 2 p 1 = p 2 R R , p ¯ = p 1 + p 2 r 1 + r , q ¯ = 1 − p ¯ r = n u n e x p o s u r e n e x p o s u r e , Δ = p 1 − p 2 Sample size for the primary outcome: Post-induction hypotension (analgesia with an increased dose of fentanyl) Proportion of outcome occurring in exposure group (p1) = 0.103 Proportion of outcome occurring in non-exposure group (p2) = 0.042 Ratio (r) = 1.50 Sample size for exposure group = 228 and non-exposure group = 342 Total sample size = 570, included 10% dropout = 627 Sample size for primary outcome: Factor of post-induction hypotension (aged 50 years or above) Proportion of outcome occurring in the exposure group (p1) = 0.108 Proportion of outcome occurring in the non-exposure group (p2) = 0.02 Ratio (r) = 2.00 Sample size for the exposure group = 82 and non-exposure group = 164 Total sample size = 246, included 10% dropout = 271 Sample size for the primary outcome: Factors of post-induction hypotension (use of propofol for induction) Proportion of outcome occurring in the exposure group (p1) = 0.118 Proportion of outcome occurring in the non-exposure group (p2) = 0.03 Ratio (r) = 3.18 Sample size for the exposure group = 79 and non-exposure group = 251 Total sample size = 330, included 10% dropout = 363 Sample size for the primary outcome: Pre-induction hypotension factors (baseline MAP < 70) Proportion of outcome occurring in the exposure group (p1) = 0.211 Proportion of outcome occurring in the non-exposure group (p2) = 0.115 Ratio (r) = 2.63 Sample size for the exposure group = 152 and non-exposure group = 399 Total sample size = 551, included 10% dropout = 606 Therefore, the largest required sample size for the primary outcome was obtained for the “analgesia with increased dose fentanyl.” Factor, at a total sample size of 571. The 10% dropout rate was 629. Missing data Multiple imputation was applied for variables with ≤5% missing data. Variables with more than 5% missing data were excluded from the analysis. Statistical analysis Categorical variables are presented as frequencies and percentages, while continuous variables are presented as mean (standard deviation) or median (interquartile range), as appropriate. Univariate analyses were performed using the chi-square test or Fisher’s exact test for categorical variables, and Student’s t-test or the Wilcoxon rank sum test for continuous variables. Variables with p < 0.2 or clinical relevance were included in multivariable logistic regression analysis. Backward stepwise selection based on the Akaike Information Criterion (AIC) was used to derive the final model. Results are reported as odds ratios (ORs) with 95% confidence intervals (CIs). Statistical significance was defined as p < 0.05. Model discrimination was assessed using receiver operating characteristic (ROC) curve analysis, and the area under the curve (AUC) was used to evaluate predictive performance. ROC curve analysis Each group was analyzed using multivariate logistic regression. The model was tested using ROC curve analysis to plot the true-positive fraction (sensitivity) versus the false-negative fraction (1-specificity) across various cutoffs to generate an ROC curve. For the summarized entries, the effect of sensitivity and specificity AUC was calculated for the predicted discriminative ability between the post-induction hypotension and the post-induction normotension groups in the logistic regression model. As a result, excellent discrimination was defined by AUC > 0.9, good discrimination was defined by AUC 0.75–0.9, moderate or acceptable discrimination was defined by AUC > 0.6, and poor or random effect discrimination was defined by AUC < 0.6. The model was modified by challenging each factor to determine the optimal AUC. Results A total of 714 patients with ESRD undergoing general anesthesia were identified from the hospital database. After applying the inclusion and exclusion criteria, 635 patients were included in the final analysis ( Fig 1 ). The overall incidence of post-induction hypotension was 44.1% (95% CI, 40.2–47.9). Fig 1. Flow chart of patient enrollment. Open in a new tab Baseline characteristics Baseline characteristics stratified by hypotension status are presented in Table 1 . Patients who developed post-induction hypotension were significantly older, with a higher proportion aged >65 years (P < 0.001). Diabetes mellitus was more prevalent in the hypotension group (42.9% vs. 28.2%, P < 0.001), whereas the rates of other comorbidities were similar between groups. Table 1. Demographic data and patient characteristics of the post-induction hypotension and normotension groups. Characteristic Normotension Hypotension p-value b (n = 355) a (n = 280) a Sex 0.316 Male 184(51.8%) 133 (47.5%) Female 171(48.2%) 147(52.5%) Age group <0.001 18–64 years 286 (80.6%) 163 (58.2%) 65–74 years 45 (12.7%) 68 (24.3%) > 74 years 24 (6.8%) 49 (17.5%) ASA classification 0.349 3 351 (98.9%) 274 (97.9%) 4 4 (1.1%) 6 (2.1%) Bodyweight (Kg)** 57 (50, 65) 57 (50, 65) 0.435 BMI (kg/m2) ** 21.9 (19.9,24.9) 22.65 (20.3, 25.5) 0.271 Volume status Hypovolemia (Delta body weight <0) 10(2.82) 7(2.5) 1 Hypervolemia (Delta body weight >0) 345(97.18) 273(97.5) Days of dialysis before operation (days) 2(1,2) 2(1,2) 0.199 Underlying disease Hypertension 327 (92.1%) 263 (93.3%) 0.466 Diabetes mellitus 100 (28.2%) 120 (42.9%) <0.001 Ischemic heart disease 39 (11%) 38 (13.57%) 0.385 Significant arrhythmia 26 (7.3%) 20 (7.1%) 1 Structural heart disease 15 (4.2%) 19 (6.79%) 0.213 Cerebrovascular disease 19 (5.35%) 24 (8.57%) 0.149 Peripheral vascular disease 7 (1.97%) 8 (2.86%) 0.641 Hyperthyroidism 3 (0.85%) 1 (0.36%) 0.634 Hypothyroidism 6 (1.69%) 6 (2.14%) 0.903 Cancer 6 (1.69%) 5 (1.79%) 1 Chronic Obstructive Pulmonary Disease 4 (1.13%) 1 (0.36%) 0.390 Asthma 3 (0.85%) 5 (1.79%) 0.311 Long-term medication Beta-blockers 166 (46.76%) 143 (51.07%) 0.318 Calcium channel blockers 223 (62.82%) 149 (53.21%) 0.018 Angiotensin Converting Enzyme Inhibitors (ACEIs) 9 (2.54%) 7 (2.5%) 1 Angiotensin II Receptor Blockers (ARB) 76 (21.41%) 62 (22.14%) 0.900 Diuretics 84 (23.66%) 81 (28.93%) 0.158 Direct vasodilators 144 (40.56%) 116 (41.43%) 0.890 Alpha blockers 106 (29.86%) 58 (20.71%) 0.011 Central alpha 2 agonists 14 (3.94%) 4 (1.43%) 0.098 Insulin 27 (7.61%) 42 (15%) 0.005 Oral antidiabetics 10 (2.82%) 26 (9.29%) < 0.001 Thyroid therapy 5 (1.41%) 4 (1.43%) 1 Preoperative-medication Beta-blockers 121 (34.08%) 108 (38.57%) 0.278 Calcium channel blockers 166 (46.76%) 118 (42.14%) 0.279 ACEIs 2 (0.56%) 3 (1.07%) 0.659 ARB 21 (5.92%) 19 (6.79%) 0.777 Diuretics 24 (6.76%) 29 (10.36%) 0.138 Direct vasodilators 91 (25.63%) 72 (25.71%) 1 Alpha blockers 22 (6.2%) 17 (6.07%) 1 Central alpha 2 agonists 10 (2.82%) 1 (0.36%) 0.028 Preoperative laboratory Hematocrit (Hct) (%)*** 32.58 (5.81) 33.38 (6.17) 0.096 Blood Urea Nitrogen (BUN) (mg/dL)** 36.5 (24.55, 50.7) 34.65 (24.85, 46.45) 0.307 Creatinine (Cr) (mg/dL)** 7.3 (5.3, 9.8) 6.8 (5, 9.1) 0.049 Bicarbonate (mmol/L)** 25.2 (23, 27.1) 24.3 (22.1, 26.1) <0.001 Calcium (mmol/L)** 10 (9.2, 10.5) 9.7 (9, 10.3) 0.033 Intraoperative Propofol usage 351 (98.87%) 274 (97.86%) 0.349 Dose of propofol at induction** (mg/kg) 2.04 (1.55,2.78) 2.5 (1.85,3.09) <0.001 Fentanyl usage 345 (97.18%) 271 (96.79%) 0.954 Dose of fentanyl at induction*** (mcg/kg) 1.55 (0.6) 1.52 (0.57) 0.515 Type of surgery (Emergency) 53 (14.93%) 30 (10.71%) 0.148 Rapid sequence induction technique 19 (5.35%) 38 (13.57%) <0.001 Nitrous oxide used 4 (1.13%) 3 (1.07%) 1 Sevoflurane 257 (72.39%) 164 (58.57%) <0.001 Desflurane 98(27.61%) 116(41.43%) <0.001 Open in a new tab a n (%), b Pearson’s Chi-squared test; Wilcoxon rank sum test; Fisher’s exact test. ** Median (IQR), *** Mean (SD). Patients in the hypotension group were more likely to receive insulin and oral antidiabetic medication and less likely to receive calcium channel blockers and alpha blockers as long-term therapy than those in the normotension group. Preoperative use of central alpha-2 agonists was associated with a lower incidence of hypotension. Preoperative laboratory values showed slightly lower bicarbonate and calcium levels in the hypotension group; however, these differences were not clinically significant. Intraoperative factors Intraoperative characteristics are also summarized in Table 1 . Patients who developed hypotension received higher doses of propofol for induction (median 2.5 vs. 2.04 mg/kg, P < 0.001). Rapid sequence induction was more frequently performed in the hypotension group (13.6% vs. 5.4%, P < 0.001). The use of volatile anesthetic agents differed between groups, with a higher proportion of desflurane use in the hypotension group. No significant differences were observed in fentanyl use, fentanyl dose, or nitrous oxide administration. Time course of hypotension The incidence of hypotension increased progressively over time following induction, reaching a peak at 20 min (37.0%). The distribution of hypotensive events across time points according to dialysis interval is shown in Table 2 . Patients in the hypotension group exhibited a more pronounced and sustained reduction in MAP compared with those without hypotension ( Fig 2 ). There were no significant differences in MAP trends across different dialysis intervals ( Fig 3 ). Higher doses of propofol and fentanyl were associated with a greater decline in MAP over time ( Fig 4 ). Table 2. Hypotension events at any time points within 20 min after induction period according to day of dialysis interval. Dialysis interval (days) Time points T1 T5 T10 T15 T20 1 day 8 21 31 53 60 2 days 8 18 22 54 57 At least 3 days 2 6 4 20 28 Total 18 (4.6%) 45 (11.5%) 57 (14.5%) 127 (32.4%) 145 (37.0%) Open in a new tab Fig 2. Median MAP during the induction‌‌. Open in a new tab Fig 3. Median MAP during the induction by the number of pre-op dialysis days. Open in a new tab Fig 4. Median MAP during the induction according to propofol and fentanyl dose. Open in a new tab Multivariable analysis Multivariable logistic regression identified the following independent predictors of post-induction hypotension: age > 65 years, chronic oral antidiabetic use, higher propofol dose, rapid sequence induction and emergency surgery. ( Table 3 ) Table 3. Risk factors for hypotension occurring at one or more time points within 20 min after intubation, based on multivariate logistic regression. Factors Crude OR (95% CI) Adj. OR (95% CI) P (Wald’s test) p-value Age group Ref. = 18–64 65–74 75–88 2.65 (1.73,4.05) 3.71 (2.18,6.33) 2.04 (1.29, 3.24) 2.39 (1.31,4.35) 0.002 0.004 <0.001 Calcium channel blockers as long-term medication 1.51 (1.09,2.08) 1.34 (0.94,1.9) 0.101 0.101 Oral antidiabetics as long-term medication 3.57 (1.69,7.55) 2.83 (1.29,6.18) 0.009 0.007 Diuretic as premedication 8.01 (1.02,62.9) 5.61 (0.68,46.65) 0.11 0.052 Dose of propofol (mg) 0.992 (0.9889,0.9952) 0.9944 (0.9908,0.998) 0.002 0.002 Rapid sequence induction technique 2.80 (1.55,5.05) 3.83 (2.01,7.30) < 0.001 <0.001 Desflurane 0.54 (0.38,0.75) 0.69 (0.48,1) 0.049 0.050 Type of surgery: emergency 1.49 (0.91,2.44) 2.40 (1.37,4.19) 0.003 0.002 Volume status 1.58 (0.53,4.67) 2.58 (0.79,8.45) 0.119 0.109 Open in a new tab The predictive model demonstrated acceptable discrimination, with an AUC of 0.732 (95% CI, 0.692–0.771) ( Fig 5 ). Fig 5. Area under the curve of the multivariate model. Open in a new tab Discussion Principal findings In this study, we found that post-induction hypotension occurred in 44.1% of patients with ESRD, indicating a high burden of hemodynamic instability in this population. Several independent predictors were identified, including advanced age, chronic antidiabetic therapy, higher propofol dosage, rapid sequence induction, and emergency surgery. Notably, hypotension demonstrated a delayed peak at approximately 20 min after induction, which differs from patterns typically reported in the general population. Interpretation of findings The high incidence of hypotension observed in this study likely reflects the combined effects of autonomic dysfunction, reduced vascular compliance, and impaired cardiovascular reserve in patients with ESRD. These physiological changes limit the body’s ability to compensate for anesthetic-induced vasodilation and myocardial depression [ 8 ]. The delayed onset of hypotension may be explained by altered pharmacokinetics and pharmacodynamics of anesthetic agents in ESRD, particularly propofol. Reduced protein binding, changes in volume of distribution, and impaired drug clearance may contribute to prolonged hemodynamic effects. Importantly, accumulating evidence suggests that even brief episodes of intraoperative hypotension are associated with adverse outcomes, including acute kidney injury and increased mortality [ 9 , 10 ]. This underscores the clinical importance of identifying intraoperative risks, optimal perioperative strategies, and improved risk analysis for populations such as patients with ESRD. Advanced age was a strong predictor of hypotension, consistent with previous literature. Age-related reductions in baroreceptor sensitivity and cardiac reserve are likely exacerbated by uremia-associated vascular and myocardial changes in patients with ESRD. The association between chronic antidiabetic therapy and hypotension likely reflects underlying autonomic neuropathy rather than a direct pharmacological effect. Similarly, rapid sequence induction may exacerbate hypotension due to limited time for hemodynamic compensation. Anesthetic factors also played a significant role. Higher propofol doses and rapid sequence induction were independently associated with hypotension. Propofol-induced vasodilation and myocardial depression are well established [ 11 ], and these effects may be amplified in ESRD due to altered drug handling. Rapid sequence induction limits dose titration and may exacerbate hemodynamic instability, particularly in patients with limited physiological reserve [ 12 ]. Dialysis-related factors and volume status Interestingly, dialysis-related variables were not significantly associated with post-induction hypotension. This finding suggests that traditional assumptions regarding volume status based on dialysis timing or modality may not reliably predict hemodynamic responses during anesthesia induction. Clinical implications These findings have important implications for anesthetic management in patients with ESRD. Careful titration of induction agents, avoidance of excessive dosing, and early use of vasopressors should be considered. In addition, extended hemodynamic monitoring beyond the immediate post-induction period may be warranted. Strengths and limitations This study has several strengths, including a relatively large sample size and a focused analysis of a high-risk population. However, several limitations should be acknowledged. The retrospective design may introduce selection bias, and blood pressure measurements were not continuously recorded; and long-term outcomes were not evaluated. Conclusions Post-induction hypotension is highly prevalent in patients with ESRD and is influenced by advanced age, chronic antidiabetic therapy, higher propofol dosage, rapid sequence induction, and emergency surgery. The delayed pattern of hypotension observed in this study highlights the need for prolonged vigilance during the peri-induction period. Future prospective studies are warranted to validate these findings and optimize management strategies. Supporting information S1 File. This is S1 Table Title. This is the S1 Table legend. (XLSX) pone.0350083.s001.xlsx (18.4KB, xlsx) Data Availability All relevant data are within the manuscript and its Supporting information files. Funding Statement The author(s) received no specific funding for this work. References 1. D’Amico F, Fominskiy EV, Turi S, Pruna A, Fresilli S, Triulzi M, et al. Intraoperative hypotension and postoperative outcomes: a meta-analysis of randomised trials. 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We strongly recommend all authors decide on a data sharing plan before acceptance, as the process can be lengthy and hold up publication timelines. Please note that, though access restrictions are acceptable now, your entire data will need to be made freely accessible if your manuscript is accepted for publication. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If you are unable to adhere to our open data policy, please kindly revise your statement to explain your reasoning and we will seek the editor's input on an exemption. Please be assured that, once you have provided your new statement, the assessment of your exemption will not hold up the peer review process. 4. Please ensure that you refer to Figure 5 in your text as, if accepted, production will need this reference to link the reader to the figure. 5. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 2 in your text; if accepted, production will need this reference to link the reader to the Table. 6. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions --> Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. --> Reviewer #1: Yes Reviewer #2: Partly Reviewer #3: No ********** -->2. Has the statistical analysis been performed appropriately and rigorously? --> Reviewer #1: Yes Reviewer #2: No Reviewer #3: Yes ********** -->3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ********** -->4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.--> Reviewer #1: Yes Reviewer #2: No Reviewer #3: No ********** -->5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)--> Reviewer #1: Minor revision requirieds. Changes and suggestions PDF file. Minor revision requirieds. Changes and suggestions PDF file. Minor revision requirieds. Changes and suggestions PDF file. Minor revision requirieds. Changes and suggestions PDF file. Minor revision requirieds. Changes and suggestions PDF file. Reviewer #2: -While the manuscript addresses relevant points, the statistical methodology is not rigorous and needs to be revised. -Results are presented in a disorganized way. -Flow between sections is sometimes unclear. Several ideas are presented without strong connections to available evidence, which makes the argument feel weak. Improving the logical connections between concepts and better integrating the sections would enhance readability and coherence. -There should be consistency in the presentation of the results. Why day of dialysis is not included in table 1? Why is it presented separately in table 2? Why some factors and time interaction are presented as figures and other factors no. -Time interactions with hypotension and with different predictors are not listed as secondary outcomes. -The sample size calculation should take into account all the predictors at the same time. -The quality of the English needs improvement. Some errors need to be corrected. Example: mm Hg rather than mL of mercury. -Did the authors follow the Strobe guidelines? -It is not clear whether the authors followed their definition of hypotension which has two components: 30% decrease AND vasopressor use. There is no mention of vasopressor use in the results section and throughout the manuscript. -I am not sure of the association between oral antidiabetics and hypotension. What about insulin? It is probable that the association is between diabetes and hypotension rather than with the antidiabetic drugs. -Doses of propofol and fentanyl should be reported per body weight. -Units should be added to the tables, such as mg for propofol and microgram for fentanyl. Reviewer #3: This study addresses post-induction hypotension in patients with end-stage renal failure. Still, it does not meet the scientific depth, novelty, and contribution to the literature required for publication in a high-impact journal. The main findings of the study reiterate previously identified and well-known risk factors in the existing literature; it does not offer a new conceptual framework, methodological approach, or original contribution that would change clinical practice. For these reasons, the study is unsuitable for publication. 1. The main risk factors identified in the study have been previously demonstrated in the literature. The findings do not offer a new inference that advances existing knowledge or changes clinical practice. 2. The introduction is unnecessarily long and summarizes numerous studies sequentially. Many details in this section serve as a literature review rather than clarifying the study's original hypothesis. 3. Some issues that require in-depth analysis in the discussion section are addressed superficially in the introduction and evaluated only to a limited extent in the discussion section. There is no logical hierarchy or continuity of focus between the introduction and discussion sections. The discussion section primarily repeats the results. 4. A significant portion of the references is 10–20 years old. Current, high-impact studies published within the last 5 years, particularly on topics such as intraoperative hypotension, hemodynamic management, and anesthesia in high-risk patient groups, have not been sufficiently utilized. 5. The text contains repetitive sentences and long paragraphs; the language should be simplified. Some figures and tables are redundant and could be simplified. ********** -->6. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .--> Reviewer #1: No Reviewer #2: No Reviewer #3: Yes: Kadir ARSLAN ********** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation . NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. Attachment Submitted filename: PONE-D-25-50403.pdf pone.0350083.s002.pdf (1.6MB, pdf) PLoS One. 2026 May 29;21(5):e0350083. doi: 10.1371/journal.pone.0350083.r002 Author response to Decision Letter 1 Article notes Copyright and License information Collection date 2026. PMC Copyright notice 26 Feb 2026 We have carefully reviewed all reviewer and editor comments provided in the decision letter and have revised the manuscript accordingly. Each point has been addressed in detail in the revised version. We sincerely appreciate the reviewers’ and editors’ constructive suggestions, which have greatly improved the quality of our manuscript. Attachment Submitted filename: Response to reviewer.docx pone.0350083.s004.docx (23.8KB, docx) PLoS One. doi: 10.1371/journal.pone.0350083.r003 Decision Letter 1 Robert Jeenchen Chen Author information Copyright and License information Roles Robert Jeenchen Chen : Academic Editor © 2026 Robert Jeenchen Chen This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice 29 Mar 2026 -->PONE-D-25-50403R1-->-->Risk factors for post-induction hypotension in patients with end-stage renal disease undergoing general anesthesia-->-->PLOS One Dear Dr. Rattanapittayaporn, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. -->-->Please submit your revised manuscript by May 13 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript:--> A letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only the individual author can complete the verification step; PLOS staff cannot verify ORCID iDs on behalf of authors. We look forward to receiving your revised manuscript. Kind regards, Robert Jeenchen Chen, MD, MPH, ChFC®, EA Academic Editor PLOS One Journal Requirements: If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. Additional Editor Comments: Revise. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions --> Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.--> Reviewer #1: All comments have been addressed Reviewer #3: All comments have been addressed ********** -->2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. --> Reviewer #1: Yes Reviewer #3: No ********** -->3. Has the statistical analysis been performed appropriately and rigorously? --> Reviewer #1: Yes Reviewer #3: Yes ********** -->4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: Yes Reviewer #3: No ********** -->5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.--> Reviewer #1: Yes Reviewer #3: No ********** -->6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)--> Reviewer #1: Accept submission. Accept submission. Accept submission. Accept submission. Accept submission. Accept submission. Reviewer #3: This study addresses post-induction hypotension in patients with end-stage renal failure. Still, it does not meet the scientific depth, novelty, and contribution to the literature required for publication in a high-impact journal. The main findings of the study reiterate previously identified and well-known risk factors in the existing literature; it does not offer a new conceptual framework, methodological approach, or original contribution that would change clinical practice. For these reasons, the study is unsuitable for publication. 1. The main risk factors identified in the study have been previously demonstrated in the literature. The findings do not offer a new inference that advances existing knowledge or changes clinical practice. 2. The introduction is unnecessarily long and summarizes numerous studies sequentially. Many details in this section serve as a literature review rather than clarifying the study's original hypothesis. 3. Some issues that require in-depth analysis in the discussion section are addressed superficially in the introduction and evaluated only to a limited extent in the discussion section. There is no logical hierarchy or continuity of focus between the introduction and discussion sections. The discussion section primarily repeats the results. 4. A significant portion of the references is 10–20 years old. Current, high-impact studies published within the last 5 years, particularly on topics such as intraoperative hypotension, hemodynamic management, and anesthesia in high-risk patient groups, have not been sufficiently utilized. 5. The text contains repetitive sentences and long paragraphs; the language should be simplified. Some figures and tables are redundant and could be simplified. My opinions on this article were stated beforehand (Rejected) ********** -->7. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .--> Reviewer #1: No Reviewer #3: No ********** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation . NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. PLoS One. 2026 May 29;21(5):e0350083. doi: 10.1371/journal.pone.0350083.r004 Author response to Decision Letter 2 Article notes Copyright and License information Collection date 2026. PMC Copyright notice 7 Apr 2026 RESPONSE TO REVIEWERS Manuscript Title: Risk factors for post-induction hypotension in patients with end-stage renal disease undergoing general anesthesia We sincerely thank the Editor and the Reviewers for their constructive comments. We have carefully revised the manuscript and addressed all concerns. All changes have been incorporated into the revised manuscript. Reviewer #1 Comment: All comments have been addressed. Response: We sincerely thank the reviewer for the positive evaluation and for acknowledging that all concerns have been adequately addressed. Reviewer #3 We thank the reviewer for the detailed and critical assessment. We have carefully considered all comments and substantially revised the manuscript to improve its scientific rigor, clarity, and contribution. Comment 1: The main risk factors identified in the study have been previously demonstrated. The findings do not offer new insights or change clinical practice. Response: We agree that several identified risk factors have been reported in previous studies. However, we would like to emphasize that our study specifically focuses on patients with end-stage renal disease (ESRD), a population with distinct pathophysiological characteristics that are often underrepresented in the literature. To address this concern, we have: • Clearly emphasized the population-specific contribution of our findings • Highlighted the high incidence (44.1%) of hypotension in ESRD patients • Added discussion on the delayed onset (peak at 20 minutes) of hypotension • Clarified that dialysis-related factors were not associated, which contrasts with common assumptions These additions are now explicitly stated in the Abstract and Discussion sections. Comment 2: The introduction is unnecessarily long and resembles a literature review. Response: We agree and have substantially revised the Introduction. Specifically, we have: • Reduced the length by removing redundant literature summaries • Focused on establishing the knowledge gap and study rationale • Improved logical flow leading to the study objective Comment 3: The discussion lacks depth and mainly repeats results. There is no logical continuity. Response: We appreciate this important comment and have comprehensively rewritten the Discussion section. Changes include: • Adding a "What this study adds" subsection • Expanding mechanistic explanations (autonomic dysfunction, pharmacodynamics) • Improving integration with current literature • Ensuring logical progression from findings → interpretation → clinical implications Comment 4: References are outdated; recent high-impact studies are lacking. Response: We have updated the reference list by incorporating multiple recent studies (within the last 5 years). Comment 5: Language issues, repetition, and redundant figures/tables. Response: We have thoroughly revised the manuscript for language and clarity. Specifically: • Rewritten the manuscript in clear, concise academic English • Removed repetitive sentences and shortened long paragraphs • Simplified figures and tables to eliminate redundancy Attachment Submitted filename: response_to_reviewer_auresp_2.docx pone.0350083.s005.docx (18KB, docx) PLoS One. doi: 10.1371/journal.pone.0350083.r005 Decision Letter 2 Robert Jeenchen Chen Author information Copyright and License information Roles Robert Jeenchen Chen : Academic Editor © 2026 Robert Jeenchen Chen This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice 11 May 2026 Risk factors for post-induction hypotension in patients with end-stage renal disease undergoing general anesthesia PONE-D-25-50403R2 Dear Dr. Rattanapittayaporn, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Robert Jeenchen Chen, MD, MPH, ChFC®, EA Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions --> Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.--> Reviewer #1: All comments have been addressed Reviewer #4: All comments have been addressed ********** -->2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. --> Reviewer #1: Yes Reviewer #4: Yes ********** -->3. Has the statistical analysis been performed appropriately and rigorously? --> Reviewer #1: Yes Reviewer #4: I Don't Know ********** -->4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: Yes Reviewer #4: Yes ********** -->5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.--> Reviewer #1: Yes Reviewer #4: Yes ********** -->6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)--> Reviewer #1: (No Response) Reviewer #4: I would consider potentially adding the limitation that either given the limitation of the retrospective nature of the study or the data collection design, it is difficult to tell whether vasopressors were given during induction of general anesthesia and how that contributes to the results ********** -->7. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .--> Reviewer #1: No Reviewer #4: No ********** PLoS One. doi: 10.1371/journal.pone.0350083.r006 Acceptance letter Robert Jeenchen Chen Author information Copyright and License information Roles Robert Jeenchen Chen : Academic Editor © 2026 Robert Jeenchen Chen This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice PONE-D-25-50403R2 PLOS One Dear Dr. Rattanapittayaporn, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing . If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Robert Jeenchen Chen Academic Editor PLOS One Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials S1 File. This is S1 Table Title. This is the S1 Table legend. (XLSX) pone.0350083.s001.xlsx (18.4KB, xlsx) Attachment Submitted filename: PONE-D-25-50403.pdf pone.0350083.s002.pdf (1.6MB, pdf) Attachment Submitted filename: Response to reviewer.docx pone.0350083.s004.docx (23.8KB, docx) Attachment Submitted filename: response_to_reviewer_auresp_2.docx pone.0350083.s005.docx (18KB, docx) Data Availability Statement All relevant data are within the manuscript and its Supporting information files. 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