Enhanced external counter pulsation as a novel therapy to maintain cardiac output during hemodialysis: a preliminary randomized controlled study

Intradialytic cardiac output (CO) decline normally occurs during hemodialysis (HD) and results in short-term intradialytic hypotension to longer-term increased cardiovascular morbidity and mortality in chronic HD patients. Enhanced external counter pulsation (EECP) is a novel non-invasive device that has been demonstrated to improve coronary blood flow and maintain systemic hemodynamics in patients without kidney dysfunction. This study is the first to explore the efficacy and safety of EECP application during HD on intradialytic changes of CO and other hemodynamic parameters. Stable chronic HD patients without recent cardiovascular events were randomly allocated to the EECP group (n = 7) receiving a single session of 60-min EECP therapy at the early period of 4-h online hemodiafiltration (HDF), and the control group (n = 7) obtaining standard 4-h online HDF without EECP. Interval measurements of intradialytic CO by Transonic HD03 device, intradialytic central aortic blood pressure (BP) by AtCor Medical SphygmoCor-XCEL device, and heart rate (HR) in the mid-week HD sessions were conducted. Changes in these parameters were compared with a linear mixed model. CO of the patients in the EECP group was maintained throughout the HDF session compared to a significant CO decline of 2.4 L/min after 4-h HDF in the control group (p-value 0.007). Cardiac index (CI) also changed in the same direction as CO. Central systolic BP, central diastolic BP, central mean arterial pressure, and HR were indifferent between the two groups. In 9 patients continuing the study in the subsequent 36 HDF sessions, there was a trend to prevent the increase in high-sensitivity cardiac troponin I by long-term EECP treatment. No intolerable adverse events related to EECP were reported. EECP application during online HDF could maintain CO, CI, and might reduce the risk of HD-related myocardial ischemia through various proposed mechanisms, including promoting coronary perfusion. However, larger studies on other cardiovascular outcomes are warranted.