Effects of controlled blood cooling on hemodynamic stability and urea kinetics during high-efficiency hemodialysis.

Abstract

Although the use of cooled dialysate during hemodialysis is associated with stabilization of intradialytic BP, the effects of blood cooling on hemodynamics and urea kinetics in high-efficiency hemodialysis have not been completely studied. In particular, the effects of blood cooling have not been elucidated in very short-time, high K/V dialysis treatments, in which postdialysis urea rebound is maximized. In theory, blood cooling could increase urea compartmentalization during treatment and decrease dialysis efficacy. Measurements of cardiovascular hemodynamics and urea kinetics were performed in 15 patients (56 studies) during dialysis, using a blood temperature monitor with control of dialysate temperature. Dialysate temperature was adjusted to either lower the core temperature or raise the core temperature by, respectively, producing negative heat-energy exchange (cooled dialysis) or keeping heat-energy exchange in the extracorporeal circuit neutral (thermoneutral dialysis) so that energy was not transferred to or from the patient. Each subject was studied on both protocols, thereby allowing each individual to act as his own control. In cooled dialysis, heat-energy exchange in the extracorporeal circuit was -266+/-15 kJ per treatment, and dialysate temperature averaged 35.7+/-0.02 degrees C. In thermoneutral dialysis, heat-energy exchange in the extracorporeal circuit averaged 5+/-31 kJ per treatment, and dialysate temperature averaged 37.1+/-0.02 degrees C. Dialysate cooling resulted in a reduction in mean body temperature compared with thermoneutral therapy (-0.22+/-0.04 versus +0.31+/-0.05 degrees C). Cooling resulted in a greater increase in peripheral vascular resistance index (+515+/-160 versus + 114+/-92 dyn.sec/cm5 per m2), an increase in mean arterial pressure (+4+/-3 versus -4+/-4 mmHg), a reduction in the maximum intradialytic fall in mean arterial pressure (-10+/-2 versus -18+/-3, mmHg), and a reduction in staff interventions for hypotension or dialytic symptoms (6 of 28 versus 12 of 28 studies). These differences occurred without differences in the change in blood volume (-14.3+/-1.8% versus -13.9+/-2.2%) or cardiac index (-0.4+/-0.1 versus -0.4+/-0.2, L/min per m2). Urea rebound (37+/-4% versus 38+/-3%) and effective Kt/V (1.29+/-0.05 versus 1.32+/-0.06) were not different between groups. Thus, body temperature cooling can be used to stabilize BP and reduce intradialytic events requiring staff intervention without compromising the efficacy of treatment in high-efficiency dialysis.