Thermal balance in convective therapies.
Among the factors causing intradialytic haemodynamic instability, dialysate temperature has been shown to play a relevant role. An improved cardiovascular response during isolated ultrafiltration or with cooled dialysate has been described in the past. Cold dialysate may increase the external heat loss compensating for the increase in core temperature, thus avoiding vasodilatation, but it also increases myocardial contractility. However, a better haemodynamic response to dialysis treatment has long been known in convective therapies as well, and the hypothesis of a leading role for thermal balance is under discussion. In conventional haemofiltration (HF), venous blood cooling is expected, on the basis of the infusate temperature and the filtration fraction. In on-line HF, the infusate temperature and its volume may have a different impact on thermal balance depending on the site of infusion (pre- or post-dialyser). In an in vitro study comparing haemodialysis (HD) (conventional HD, dialysate 37 degrees C; and cold HD, dialysate 35.5 degrees C) with HF (pre- and post-dilution, 37 degrees C), we observed a more negative thermal balance with cold HD (-130 kJ/h) and with post-dilution HF (-75 kJ/h). The beneficial pressor effects of HF have been confirmed even in on-line HF, which actually has very few differences in the thermal balance compared with conventional HD (dialysate 37 degrees C). In on-line HF, the amount of warm infusion, often exceeding the blood flow, makes the achievement of a negative thermal balance highly unlikely. Thus, there is not sufficient evidence that vascular stability in on-line HF is solely related to different thermal energy balances. Other factors playing a relevant role in the cardiocirculatory response to convective dialysis should thus be considered.