Key messages
- In haemodialysis patients, sodium modelling compared to slow dialysis may result in little to no difference in dialysis disequilibrium syndrome and death. The evidence is very uncertain about the effect of these interventions on adverse events.
- The evidence is very uncertain about the effect of high-sodium dialysate and standard sodium dialysate on dialysis disequilibrium syndrome, death and adverse events.
What did we want to find out?
Haemodialysis is a medical treatment that helps remove waste and excess fluids from the blood when a person's kidneys are not working properly. It is a process that uses a machine to filter the blood. Dialysis disequilibrium syndrome is a condition where patients experience neurological symptoms during or after their dialysis treatment. It often happens to those who are new to dialysis or have missed multiple sessions before restarting. Since dialysis dysequilibrium syndrome can be serious and lead to harmful effects, it is important to study different ways to prevent it and make sure they are safe and effective.
What did we do?
We searched for all trials that assessed the benefits and harms of randomly allocated interventions to prevent dialysis dysequilibrium syndrome in people with kidney failure initiated on haemodialysis. We compared and summarised the trials' results and rated our confidence in the information based on factors such as trial methods and sizes.
What did we find?
We included two studies involving 32 participants. The studies used four main types of interventions: sodium modelling, slow dialysis, standard sodium dialysate, and high sodium dialysate.
What are the limitations of the evidence?
The small number and size of the studies were limitations in this review. Not all the studies provided data about the outcomes we were interested in, and we are unsure about the results.
How up-to-date is the evidence?
The evidence is current to May 2024.
In HD patients, sodium modelling, compared to slow dialysis, may result in little to no difference in DDS and death (low certainty evidence) and has uncertain effects on adverse events (very low certainty evidence).
The evidence is very uncertain for the effect of high-sodium dialysate and standard sodium dialysate on DDS, death and adverse events (very low certainty evidence).
Dialysis dysequilibrium syndrome (DDS) refers to neurological symptoms usually seen during or after new initiation or following reinitiation of haemodialysis (HD) after missing multiple sessions. DDS is associated with death and morbidity. We studied interventions aimed at preventing DDS.
To evaluate the benefits and harms of different types of interventions for preventing DDS.
We contacted the information specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 8 May 2024 using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov.
We included randomised controlled trials (RCTs) that compared any intervention against standard care, including individuals initiated on HD, regardless of age.
Two authors independently determined study eligibility, assessed quality and extracted data. Data were collected on methods, interventions, participants, and outcomes (DDS incidence, severe DDS, death, adverse events). Risk ratios (RR) and confidence intervals (CI) were calculated. Study quality was assessed using the Cochrane Risk of Bias 2 (ROB2) tool. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
We included two RCTs, enrolling 32 adult participants. Interventions included were slow dialysis, sodium modelling, standard sodium dialysate, and high sodium dialysate. The risk of bias was of some concern to high risk of bias in both studies.
Slow dialysis compared to sodium modelling (1 study, 15 participants) may result in little to no difference in DDS, severe DDS, and death (low certainty evidence) and has uncertain effects on adverse events (RR 1.33, 95% CI 0.15 to 11.64; very low certainty evidence).
Standard sodium dialysate compared to high sodium dialysate (1 study, 17 participants) has uncertain effects on the incidence of DDS (RR 0.07, 95% CI 0.00 to 1.12), severe DDS (RR 0.47, 95% CI 0.02 to 10.32), and adverse events (RR 0.29, 95% CI 0.08 to 1.02) (very low certainty evidence).