Pneumatic Compression, But Not Exercise, Can Avoid Intradialytic Hypotension: A Randomized Trial

Abstract

Background: Conventional hemodialysis (HD) is associated with dialysis-induced hypotension (DIH) and ineffective phosphate removal. As the main source of extracellular fluid removed during HD are the legs, we sought to reduce DIH and increase phosphate removal by using cycling and pneumatic compression, which would potentially provide higher venous return, preserving central blood flow and also offering more phosphate to the dialyzer. Methods: We evaluated 21 patients in a randomized crossover fashion in which each patient underwent 3 different HD: control; cycling exercise during the first 60 min; and pneumatic compression during the first 60 min. Data obtained included bioelectrical impedance, hourly blood pressure measurement, biochemical parameters, and direct quantification of phosphate through the dialysate. DIH was defined as a drop in mean arterial pressure (MAP) ≥20 mm Hg. Results: There was no difference in the ultrafiltration rate (p = 0.628), delta weight (p = 0.415), delta of total, intra and extracellular body water among the control, cycling, and pneumatic compression (p = 0.209, p = 0.348, and p = 0.467 respectively). Delta MAP was less changed by pneumatic compression when compared to control, cycling, and pneumatic compression respectively (-4.7 [-17.2, 8.2], -4.7 [-20.5, -0.2], and -2.3 [-8.1, 9.0] mm Hg; p = 0.021). DIH occurred in 43, 38, and 24% of patients in control, cycling, and pneumatic compression respectively (p = 0.014). Phosphate removal did not increase in any intervention (p = 0.486). Higher phosphate removal was dependent on ultrafiltration, pre dialysis serum phosphate, and higher parathyroid hormone. Conclusion: Pneumatic compression during the first hour of dialysis was associated with less DIH, albeit there was no effect on fluid parameters. Neither exercise nor pneumatic compression increased phosphate removal.

Intermittent pneumatic compression in patients with ESRD. A systematic review

“…Four studies reported data on ultrafiltration (Table ). There were no major differences in the UF that was archived in the control group compared to IPC in two crossover trials and also on the mean UF filtration from a case series study of four patients . Lastly on the study performed by Macaulay et al results were reported as UF tolerability, in which three patients were able to achieve significantly higher UF rates after IPC was started …”

“…Alvarez et al described changes in body water, differences between water composition were analyzed pre and post‐intervention with IPC, a value defined as delta total body water was reported, no significant difference was found between groups . On a different study performed by Tai et al, a significant increase in fluid removal after HD using IPC was reported (−2.6 L versus −2.3 L, P = 0.05) (Table ).…”

“…Five of the included studies, with 62 patients, reported outcomes on IDH; the other studies reported secondary outcomes related to IPC . HD was done three times a week in 5 out of the seven studies and not reported on the remaining ones . Several IPC device models where used, Kendall 7325, Flowtron, Bio arterial Plus, Jobst 69‐00, unknown .…”

“…HD was done three times a week in 5 out of the seven studies and not reported on the remaining ones . Several IPC device models where used, Kendall 7325, Flowtron, Bio arterial Plus, Jobst 69‐00, unknown . Pressure applied by IPC ranged from 40 to 60 mmHg.…”

“…Results on intradialytic hypotension were reported in five studies (Table ). Out of these five studies, two RCTs and one nRCT were included.…”