Biofeedback dialysis for hypotension and hypervolemia: a systematic review and meta-analysis

Nephrol Dial Transplant. 2013 Jan;28(1):182-91. doi: 10.1093/ndt/gfs389. Epub 2012 Nov 29.


Background: Intradialytic hypotension (IDH) is associated with morbidity and mortality. We conducted a systematic review to determine whether biofeedback hemodialysis (HD) can improve IDH and other outcomes, compared with HD without biofeedback.

Methods: Data sources included the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and ISI Web of Science. We included randomized trials that enrolled adult patients (>18 years) with IDH or extracellular fluid expansion and that used biofeedback to guide ultrafiltration and/or dialysate conductivity. Two authors assessed trial quality and independently extracted data in duplicate. We assessed heterogeneity using I(2). We applied the GRADE framework for rating the quality of evidence.

Results: We found two parallel-arm randomized controlled clinical trials and six randomized crossover trials meeting inclusion criteria. All trials were open-label and at least four were industry-sponsored. Studies were small (median n = 27). No study evaluated hospitalization and the evidence for effect on mortality was of very low quality. Three studies assessed quality of life (QoL); none demonstrated benefit or harm, and quality of evidence was very low. Biofeedback significantly reduced IDH (risk ratio 0.61, 95% confidence interval 0.44-0.86; I(2)= 0%). Quality of evidence for this outcome was low due to risk of bias and potential publication bias.

Conclusions: Biofeedback dialysis significantly reduces the frequency of IDH. Large and well-designed randomized trials are needed to assess the effects on survival, hospitalization and QoL.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Adult
  • Blood Volume / physiology*
  • Fluid Shifts / physiology*
  • Hospitalization
  • Humans
  • Hypotension / therapy*
  • Quality of Life
  • Randomized Controlled Trials as Topic
  • Renal Dialysis / adverse effects
  • Renal Dialysis / methods*
  • Renal Dialysis / mortality
  • Treatment Outcome