To cool, or too cool: Is reducing dialysate temperature the optimal approach to preventing intradialytic hypotension?

Abstract

Abnormal decreases in blood pressure during hemodialysis are frequent in end stage renal disease (ESRD) patients treated with hemodialysis, and thought to be largely due to an inadequate cardiovascular response to the rapid blood volume decline. Intradialytic hypotension (IDH) and cardiac instability during dialysis can increase risks for negative health consequences and is possibly preventable though several types of interventions. One intervention that holds promise for prevention of IDH in hemodialysis patients is to reduce the temperature of the dialysate to or below the patient's core temperature. A considerable number of randomized studies have demonstrated a short term benefit of using a cooler dialysate temperature for the prevention of IDH and improved cardiac stability. Despite this, a key observational study was not able to show long term improvements with lower dialysate temperatures utilized in routine clinical practice, albeit possibly confounded by indication. It appears that cooling the dialysate may be reasonable to consider on an individual basis for patients who suffer from persistent IDH if they can tolerate the adjustment and it is effective. However, careful assessment of the etiology of IDH should be performed when considering treatment options. In this review, we detail the current body of evidence on the effectiveness of using low dialysate temperatures for prevention of IDH in ESRD patients, and suggest areas where further research is needed.

Effects of sertraline in the prevention of low blood pressure in patients undergoing hemodialysis

“…In the present study, there was a relatively high prevalence of patients with IDH (32%) compared to the findings of several studies, in which the prevalence was approximately 20% 2,10,13,15,16,18,20,32 . The high prevalence of IDH may be due to their selection during the summer in the southern hemisphere (January through March 2017), a season in which the patients ingest larger amounts of liquids, leading to an increase of the dry weight and IDWG, thus contributing to an eventual higher need for UF during the HD process.…”

“…Intradialytic hypotension (IDH) is the most frequent complication among hemodialysis patients [10][11][12][13][14] . Estimates suggest that up to 75% of patients suffering from ESRD experience one or more episodes of hypotension during hemodialysis within 6 months from initiation, with a prevalence of about 25% during hemodialysis sessions, depending on the definition used to describe IDH 13 .…”

“…The prompt recognition by the hemodialysis team, associated with modifications in the patients' dialysis therapy, has been adopted for the management and prevention of hypotensive episodes. However, despite these measures, IDH prevalence remains high 13,14,17,18 .…”

Hemodynamic Instability during Dialysis: The Potential Role of Intradialytic Exercise

“…Dialysate fluid typically comprises sodium, potassium, calcium, magnesium, bicarbonate, and glucose which interact with blood flow via a semipermeable membrane. With controlled cooling of dialysate, the associated increase in sympathetic drive has been shown to positively influence MAP and reduce IDH [ 32 , 47 ]. However, urea compartmentalization may occur when dialysate is cooled, due to increased vasoconstriction of vascular beds [ 32 ].…”

“…Conversely, the same vasoconstriction of systemic vasculature may aid MAP and prevent dialysis induced vasodilation [ 32 ]. Nevertheless, there is the potential for significant patient discomfort, a theoretical risk of hypothermia, and reduced adequacy of dialysis [ 32 , 47 ]. Despite evidence suggesting a positive therapeutic effect of cooling dialysate, this procedure is not universally adopted [ 47 ].…”