Intermittent pneumatic compression in patients with ESRD. A systematic review

Abstract

Introduction: Patients with end‐stage renal disease (ESRD) experience frequent hemodialysis (HD) complications. Intradialytic hypotension (IDH) is a common complication presenting in approximately between 20 and 50% of HD sessions. Available interventions such as volume replacement or vasoactive medications are associated with significant side effects. Intermittent pneumatic compression (IPC) has been proposed as a feasible intervention for the prevention of IDH, treatment of peripheral arterial disease and venous ulcers. These devices apply intermittent pressure to the legs improving arterial blood flow, mobilization of pooled blood with an increase in venous return increasing the effective circulatory volume. Our goal was to identify the published clinical evidence on whether IPC has a circulatory benefit and is it well‐tolerated among patients receiving HD. Methods: We conducted a systematic review to identify studies assessing the efficacy and safety of IPC in patients with ESRD. Our primary outcome was IDH. Secondary outcomes such as HD comfort, ultrafiltration volume, and physical activity were collected. No restrictions where used and we included all observational and interventional studies. Two reviewers performed screening and study quality assessment. Findings: We included seven studies. Out of the seven studies, five addressed IDH, and the rest were included for secondary outcomes such as physical capacity and HD comfort. In one randomized crossover trial comparing exercise against IPC, 21 patients were randomized to 3 different arms (no intervention, cycling, IPC) a decrease in the rates of IDH with IPC was described (43%, 38%, and 24% respectively P = 0.014). The smaller studies corroborated these results. All studies where at high risk of bias. Discussion: IPC might offer significant benefits for patients undergoing HD not limited to prevention of IDH but also improvement of hemodialysis comfort and physical capacity. However, our results should be interpreted in the context of its limitations.

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“…The use of compression stockings in patients with renal dysfunction was well-tolerated 79 but with different hemodynamic outcomes if renal failure is present. Also, pneumatic compression was found to be useful 80 and associated with good tolerance, with a positive impact on, for example, DIH (Dialysis-Induced Hypotension). Pneumatic compression during the first hour of dialysis was associated with less DIH with no effect on fluid parameters.…”

Clinical practice guideline exercise and lifestyle in chronic kidney disease

“…Unfortunately, there is no RCT data on the effect of increasing physical activity levels and the association with mortality in the haemodialysis population. Although, as recommended by the most recent Kidney Disease Improving Global Outcomes (KDIGO) guidelines [ 88 ] and the UK Chief Medical Officers’ Guideline [ 89 ] increasing physical activity levels should be encouraged (aiming for at least 30 min of moderate intensity activity, 5 times per week). It is also important to highlight that even small increases in physical activity levels is likely to provide some benefit.…”

Intermittent pneumatic compression in patients with ESRD

“…We read with unadulterated excitement, the recent systematic review by Torres et al assessing the efficacy and safety of intermittent pneumatic compression (IPC) in the management of intradialytic hypotension (IDH) in patients with ESRD undergoing hemodialysis . We were the first to report on the application of the principle of enhanced external counter pulsation (EECP) in this regard .…”

“…This systematic review concluded that IPC might offer significant benefits for patients undergoing hemodialysis not limited to prevention of IDH but also improvement of hemodialysis comfort and physical capacity …”