Intradialytic hypotension (IDH) is a critical complication in patients with chronic kidney disease undergoing dialysis, affecting both patient safety and treatment efficacy. This study examines the application of advanced machine learning techniques, combined with metaheuristic optimization methods, to improve predictive models for intradialytic hypotension (IDH) in hemodialysis patients. Given the critical nature of IDH, which can lead to significant complications during dialysis, the development of effective predictive tools is vital for improving patient safety and outcomes. Dialysis session data from 758 patients collected between January 2016 and October 2019 were analyzed. Particle Swarm Optimization, Grey Wolf Optimizer, Pendulum Search Algorithm, and Whale Optimization Algorithm were employed to reduce the feature space, removing approximately 45% of clinical and analytical variables while maintaining high recall for the minority class of patients experiencing hypotension. Among the evaluated models, the XGBoost classifier showed superior performance, achieving a macro F-score of 0.745 with a recall of 0.756 and a precision of 0.718. These results highlight the effectiveness of the combined approach for early identification of patients at risk for IDH, minimizing false negatives, and improving clinical decision-making in nephrology.