Haemodiafiltration Does Not Reduce the Frequency of Intradialytic Hypotensive Episodes when Compared to Cooled High-Flux Haemodialysis

Abstract

Introduction: Intradialytic hypotension remains the commonest complication of outpatient haemodialysis (HD) treatments. On-line haemodiafiltration (HDF) has been reported to reduce the frequency of intradialytic hypotension. We introduced on-line HDF into our satellite dialysis program, and prospectively audited the effect of HDF on cardiovascular stability. Methods: 34 patients’ dialysis schedules (Tuesday/Thursday/Saturday) were converted to online post-dilutional HDF, and 44 patients’ dialysis schedules (Monday/Wednesday/Friday) remained on high-flux HD. Blood pressure and intra-treatment complications were monitored prospectively for 12 months. Results: There was no significant change in pre-treatment mean arterial blood pressure in the HDF group during the 12 months of the study (pre-treatment 113.7 ± 0.7 mm Hg vs. 109.3 ± 2.8 after 12 months), or for the HD cohort (113.9 ± 2.7 vs. 117.9 ± 2.6). However, the frequency of intradialytic hypotensive episodes was greater for the HDF cohort: 25.9 versus 16.5% in the HD cohort, p = 0.0116. During HDF, on average >16 litres of substitution fluid was used and the median temperature was 36°C (35°C–36°C), higher than the dialysate in the HD cohort which was 35°C (35°C–36°C), p < 0.05. Conclusion: In this study, HDF did not improve blood pressure control or reduce the frequency of intradialytic hypotensive episodes compared to high-flux HD using cooled dialysate.

Does Online Haemodiafiltration Reduce Intra-Dialytic Patient Symptoms?

“…Patients treated with HDF reported fewer symptoms than those on HD, apart from hypotension and the time to recover after the treatment. Previous reports have shown an advantage of HDF in reducing intra-dialytic hypotension [10], although later studies have shown no benefit when using cooled dialysate [22], as with our cohort. However, as most of our centres predominantly used one dialysis modality, our findings could be affected by centre effects.…”

“…We have traditionally used cooled dialysate to reduce the frequency of intra-dialytic hypotension [22]. Although very few patients actively complained to supervising nursing or medical staff about feeling cold, most patients reported feeling cold during treatment, and there has been a debate regarding the benefits of isothermic compared to cooled dialysate in terms of reducing intra-dialytic hypotension.…”

Haemodiafiltration Results in Similar Changes in Intracellular Water and Extracellular Water Compared to Cooled Haemodialysis

“…Similarly on-line HDF has been reported to lead to greater cardiovascular stability and reduced intradialytic hypotension compared to standard HD [4], although other smaller studies did not find a difference in intradialytic hypotension and dialysis mode [15], particularly when comparing HDF with HD using cooled dialysate [16]. …”

Measuring Intradialytic Hypotension to Improve Quality of Care

“…2 Some, if not all, of the increased tolerability of hemodiafiltration may be due to thermal effects. 9 Use of lower-temperature dialysate has been associated with reduced cardiovascular mortality, 10 and it is possible that some of the "hard outcomes" benefits of high-volume hemodiafiltration in terms of fewer cardiovascular events may be due to slight cooling associated with this therapy. Use of pharmacologic aids to maintain BP during dialysis, such as midodrine or sertraline, have no additive benefit if given to patients being dialyzed with cool-temperature dialysate.…”