1. Work out the type and cause first

• Presyncope or lightheadedness is the most common type here. Causes are hypotension, volume shifts, anemia, arrhythmia and drugs.
• Vertigo points to a vestibular cause (BPPV, vestibular neuritis, ototoxicity) or, less often, a central cause.
• Disequilibrium or confusion points to metabolic causes: uremia, hepatic encephalopathy, hypoglycemia, hyponatremia and hypocapnia.

• Lying and standing BP.
• Fingerstick glucose.
• ECG.
• Hemoglobin.
• Electrolytes (Na, K, Ca), urea, ammonia and a mental status exam.
• Medication review.

2. CKD

• Immediate treatment:
  • Place the patient in the Trendelenburg position.
  • Reduce or stop ultrafiltration.
  • Give 0.9% saline boluses of 100 mL or more.
  • Do not routinely cut the blood flow rate.
  • If there is chest pain or dyspnea, get an ECG and troponin.
• Prevention:
  • Correct anemia.
  • Treat heart failure and arrhythmias.
  • Hold antihypertensives on the morning of dialysis.
  • Avoid eating during dialysis.
  • Restrict salt to limit weight gain between sessions.
  • Reassess dry weight carefully.
• If those fail: midodrine 5 to 10 mg before dialysis. Other options are bicarbonate dialysate, a lower ultrafiltration rate with longer or more frequent sessions, and online blood volume monitoring.
• Higher dialysate sodium: this may raise BP but increases weight gain and volume overload.

• Anemia: treat iron deficiency, then consider an ESA.
• Orthostatic hypotension:
  • Often from antihypertensives, diuretics, autonomic neuropathy (diabetes) or over-diuresis. Adjust the drugs first.
  • Add non-drug measures such as slow standing and compression stockings.
  • Midodrine is a later option, and only if the patient is not supine hypertensive.
• Electrolytes and metabolic: correct hyponatremia, hyperkalemia with bradyarrhythmia, hypoglycemia, acidosis and uremia. Uremia is treated by starting or optimizing dialysis.
• Drug accumulation: gabapentin and pregabalin are classic causes. Dose them by eGFR, for example gabapentin about 100 to 300 mg after dialysis in HD patients. Also review opioids, benzodiazepines and antihistamines.

3. Cirrhosis

• Circulatory dysfunction: cirrhosis causes peripheral vasodilation and low BP even with ascites (Miller's Anesthesia, 10e). Low BP, orthostasis and presyncope are therefore common.
• Large-volume paracentesis: this can cause hypotension and hepatorenal syndrome. For taps above 5 L, give albumin (about 6 to 8 g per litre removed), and use it in cirrhotic patients with hypoalbuminemia.
• Medications:
  • Over-diuresis from spironolactone or furosemide.
  • Non-selective beta-blockers. Reduce the dose or hold them if systolic BP is below 90, there is refractory ascites, or AKI develops. A 2024 meta-analysis linked them to renal dysfunction in cirrhosis.
  • Avoid NSAIDs, which cause AKI and also cause dizziness.
• Hepatic encephalopathy: dizziness, confusion or unsteadiness may be early signs. Look for and treat precipitants (infection, GI bleed, constipation, electrolytes, sedatives). Give lactulose with or without rifaximin.
• Other causes to exclude:
  • Hyponatremia.
  • Hypoglycemia (impaired gluconeogenesis).
  • GI bleeding or anemia.
  • Spontaneous bacterial peritonitis.
  • Hepatorenal syndrome, treated with a vasoconstrictor plus albumin.

4. Treating vertigo in CKD or cirrhosis

• BPPV: the Epley maneuver. It needs no drugs and is safe in both diseases.
• Vestibular rehabilitation: safe in both diseases.
• Antivertiginous drugs: keep them to a few days.
  • Meclizine and dimenhydrinate: cause sedation, which can worsen or mask encephalopathy. Use the lowest dose with caution in both diseases.
  • Betahistine: has limited evidence, and CKD dosing data are poor. Use caution with advanced disease.
  • Benzodiazepines: avoid. They can precipitate hepatic encephalopathy and accumulate in CKD.
  • Promethazine or prochlorperazine: sedating and risky in cirrhosis.
• Ototoxic drugs: avoid aminoglycosides, high-dose loop diuretics (especially IV boluses in CKD) and vancomycin where possible. Check the doses.

5. Red flags needing urgent workup

• Focal neurologic signs, new severe headache, or inability to walk. These suggest a central cause such as stroke.
• Syncope, chest pain, or arrhythmia on ECG.
• GI bleeding or melena.
• Fever with ascites.
• Falling urine output or a sudden creatinine rise.
• Severe hyponatremia or hyperkalemia.

Caveats

• The textbook sections I found support the dialysis and cirrhosis hemodynamics. The drug choices for vertigo and the specific doses in section 4 come from general clinical knowledge, not the library. Check them against local renal and hepatic dosing references.
• A quick PubMed check of the last 2 years turned up no new systematic reviews on dizziness treatment in this population that would change the above.