Journal Article

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

Gihad E. Nesrallah, Rita S. Suri, Gordon Guyatt, Reem A. Mustafa, Stephen D. Walter, Robert M. Lindsay and Elie A. Akl

in Nephrology Dialysis Transplantation

Published on behalf of European Renal Association - European Dialysis and Transplant Assoc

Volume 28, issue 1, pages 182-191
Published in print January 2013 | ISSN: 0931-0509
Published online November 2012 | e-ISSN: 1460-2385 | DOI:
Biofeedback dialysis for hypotension and hypervolemia: a systematic review and meta-analysis

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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.


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 I2. We applied the GRADE framework for rating the quality of evidence.


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; I2= 0%). Quality of evidence for this outcome was low due to risk of bias and potential publication bias.


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.

Keywords: biofeedback dialysis; clinical trials; intradialytic hypotension; meta-analysis; systematic review

Journal Article.  4533 words.  Illustrated.

Subjects: Nephrology

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