Effectiveness of cold HD for the prevention of HD hypotension and mortality in the general HD population

Abstract

Background Cold hemodialysis (HD) prevented intra dialysis hypotension (IDH) in small, short term, randomized trials in selected patients with IDH. Whether this treatments prevents IDH and mortality in the HD population at large is unknown. Methods We investigated the relationship between dialysate temperature and the risk of IDH, i.e. nadir BP <90 mmHg, (GEE model) and all cause mortality (Cox's regression) in an incident cohort of hemodialysis patients (n = 8071). To control for confounding by bias by indication and other factors we applied instrumental variables adjusting for case mix at facility level. Results The twenty-seven % of patients in the study cohort were systematically treated with a dialysate temperature ≤ 35.5°. Over a median follow-up of 13.6 months (IQR: 5.2–26.1 months), a 0.5°C reduction of the dialysate temperature was associated with a small (-2.4%) reduction of the risk of IDH [OR: 0.976, 95% CI: 0.957–0.995, P = 0.013]. In case-mix, facility level adjusted analysis, the association became much stronger [OR: 0.67, 95% CI: 0.63–0.72, Risk reduction = 33%), P < 0.001]. In contrast, colder dialysate temperature had no effect on mortality both in the unadjusted [hazard ratio (HR) (0.5°C decrease): 1.074, 95%: 0.972–1.187, P = 0.16] and case-mix adjusted analysis at facility level [HR: 1.01, 95% CI: 0.88–1.16, P = 0.84]. Similar results were registered in additional analyses by instrumental variables applying the median dialysate temperature or the facility percentage of patients prescribed a dialysate temperature < 36°C. Further analyses restricted to patients with recurrent IDH fully confirmed these findings. Conclusions Cold HD was associated with IDH in the hemodialysis population but had no association with all-cause mortality.

Physical intradialytic patient‐reported outcome measures in haemodialysis and haemodiafiltration: A cross‐over study

“…As for the second and third finding, our study confirms and extends previous data on T b and thermal perception 11,13,19 . Both the recently published MyTemp study on the use of personalized cooler dialysate 11 and a lately published large retrospective analysis, 12 demonstrated comparable results in terms of cold sensations, but differed methodologically from the present investigation. In these studies, the difference in dialysate temperature between cool and standard HD(F) was 0.6 and 0.5°C, respectively, versus 1.0°C in our study.…”

“…8 An observational study even suggested that cHD is not only associated with a lower mortality risk than sHD, but also with promising effects on physical functioning and general health. 9,10 Yet, as neither a recent cluster-randomized trial nor a lately published retrospective analysis in >8000 patients could confirm this finding, 11,12 and cHD has been associated with burdensome cold sensations, 13 the combination of uncertain health effects and adverse symptoms may constrain health-care workers from advising cHD as dialysis modality of first choice.…”

Does cooled dialysate still have a role in reducing intradialytic stress? Implications of the MyTEMP trial

“…Therefore, it is possible the absence of effectiveness in the MyTEMP study may relate to the sample population under investigation (prevalent patients) rather than the intervention in question. In a large observational study of over 8000 incident dialysis patients, Zoccali et al found a 0.5°C reduction in dialysate temperature was associated with a 33% reduction ( P < 0.001) in the risk of IDH when utilizing a case-mix, facility-level adjusted analysis [36 ▪▪ ]. There was no impact on all-cause mortality [36 ▪▪ ].…”

“…In a large observational study of over 8000 incident dialysis patients, Zoccali et al found a 0.5°C reduction in dialysate temperature was associated with a 33% reduction ( P < 0.001) in the risk of IDH when utilizing a case-mix, facility-level adjusted analysis [36 ▪▪ ]. There was no impact on all-cause mortality [36 ▪▪ ]. Personalizing cooled dialysate to the individual clinical need, rather than just to degree of temperature reduction in relation to predialysis body temperature as with the MyTEMP study, offers an effective and easy-to-implement management strategy for confirmed IDH and symptomatic haemodynamic instability during haemodialysis.…”

Cooler dialysate temperature for the prevention of intradialytic hypotension: Is it time for a shift in our practice?

“…Much more robust data became available after the publication of a recent observational study that included 8071 patients receiving maintenance dialysis in 103 clinics in Portugal and Spain. 10 In unadjusted models, over a median observational period of 13.6 months, a decrement of 0.5°C in the dialysate temperature was associated with a small decrease of 2.4% in the risk of intradialytic hypotension (odds ratio [OR]: 0.976; 95% CI: 0.957-0.995). In case-mix, facility-level adjusted analysis, the use of cooler dialysate temperature was associated with a substantially higher reduction of 33% in the risk of intradialytic hypotension (OR: 0.67; 95% CI: 0.63-0.72).…”