Dialysate temperature reduction for intradialytic hypotension for people with chronic kidney disease requiring haemodialysis

Monitoring for intradialytic hypotension: An audit of nursing practice

BACKGROUND

Intradialytic hypotension (IDH) is one of the most common complications associated with haemodialysis (HD), yet the frequency of patient assessment by nurses varies in practice. We sought to measure the frequency of nursing assessments before, during and after HD and to identify any predictors of IDH.

OBJECTIVES

To audit the frequency, nursing management and contributing factors of IDH.

DESIGN

A prospective clinical audit was undertaken over 4 weeks.

PARTICIPANTS

Nurses completed audit sheets on 132 patients at three chronic HD units.

MEASUREMENTS

The audit tool consisted of 34 questions related to demographics, HD prescription, frequency of monitoring and nursing interventions.

RESULTS

A total of 1584 sessions were performed with 876 (55.3%) audits returned, of which 452 were useable. There were 74 actual episodes of IDH, and a further 72 potential episodes may have been prevented due to nursing intervention. Most nurses reported assessing patients before starting HD and as required before an actual or potential IDH event (n = 85; 63%); few hourly assessments were performed. Predictors of IDH were systolic blood pressure ≤140 mmHg, having more than four comorbidities, dialysate temperature > 36°C, calcium < 1.3 mmol/L and a shorter dialysis session (3.0-4.5 h). These predictors explained 14.1% of the variance in hypotensive episodes during HD.

CONCLUSION

This clinical audit highlighted the importance of assessing blood pressure trends during HD to preemptively intervene before IDH developing. The audit has resulted in a practice change to hourly assessments. Follow-up audits of practice should occur.

Improved Outcomes in Hemodialysis/Hemodiafiltration Treatments Applying Exercise and Physiological Monitoring Techniques: Preliminary Results

End-stage renal disease affects millions of people worldwide, and the only definitive solutions are renal transplants that are not widely available. Temporary solutions are renal replacement therapies such as peritoneal dialysis, hemodialysis and hemodiafiltration. These therapies as they are applied today are just partial measures and have many drawbacks and complications such as high mortality rates and high costs due to the use of supplemental drugs and emergency room visits. Many enhancements to the therapies have been published, but they are not applied consistently in real world practice. Our work presents the results from the systematic application of several techniques to provide individualized therapies that can minimize the drawbacks and improve patient outcomes. This approach is based on the use of exercise, analysis of cardiovascular parameters, such as heart-rate variability, body composition and dry weight measurements through the use of bioimpedance and real-time monitoring of energy expenditure and nutrition intradialytically in order to provide individualized and dynamically variable therapies. Results show that patients can lead long, productive lives while maintaining a quality of life equivalent to that of a renal transplant.

Dialysate temperature reduction for intradialytic hypotension for people with chronic kidney disease requiring haemodialysis

BACKGROUND

Intradialytic hypotension (IDH) is a common complication of haemodialysis (HD), and a risk factor of cardiovascular morbidity and death. Several clinical studies suggested that reduction of dialysate temperature, such as fixed reduction of dialysate temperature or isothermal dialysate using a biofeedback system, might improve the IDH rate.

OBJECTIVES

This review aimed to evaluate the benefits and harms of dialysate temperature reduction for IDH among patients with chronic kidney disease requiring HD, compared with standard dialysate temperature.

SEARCH METHODS

We searched Cochrane Kidney and Transplant's Specialised Register up to 14 May 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

All randomised controlled trials (RCTs), cross-over RCTs, cluster RCTs and quasi-RCTs were included in the review.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted information including participants, interventions, outcomes, methods of the study, and risks of bias. We used a random-effects model to perform quantitative synthesis of the evidence. We assessed the risks of bias for each study using the Cochrane 'Risk of bias' tool. We assessed the certainty of evidence using Grades of Recommendation, Assessment, Development and Evaluation (GRADE).

MAIN RESULTS

We included 25 studies (712 participants). Three studies were parallel RCTs and the others were cross-over RCTs. Nineteen studies compared fixed reduction of dialysate temperature (below 36°C) and standard dialysate temperature (37°C to 37.5°C). Most studies were of unclear or high risk of bias. Compared with standard dialysate, it is uncertain whether fixed reduction of dialysate temperature improves IDH rate (8 studies, 153 participants: rate ratio 0.52, 95% CI 0.34 to 0.80; very low certainty evidence); however, it might increase the discomfort rate compared with standard dialysate (4 studies, 161 participants: rate ratio 8.31, 95% CI 1.86 to 37.12; very low certainty evidence). There were no reported dropouts due to adverse events. No study reported death, acute coronary syndrome or stroke.Three studies compared isothermal dialysate and thermoneutral dialysate. Isothermal dialysate might improve the IDH rate compared with thermoneutral dialysate (2 studies, 133 participants: rate ratio 0.68, 95% CI 0.60 to 0.76; I² = 0%; very low certainty evidence). There were no reports of discomfort rate (1 study) or dropouts due to adverse events (2 studies). No study reported death, acute coronary syndrome or stroke.

AUTHORS' CONCLUSIONS

Reduction of dialysate temperature may prevent IDH, but the conclusion is uncertain. Larger studies that measure important outcomes for HD patients are required to assess the effect of reduction of dialysate temperature. Six ongoing studies may provide much-needed high quality evidence in the future.