Skip to main content

Could cooling dialysate improve inflammatory and nutritional status of hemodialysis patients?



It has been shown that dialysate cooling (lowering the dialysate temperature to 0.5 °C below central body temperature) reduces the incidence of intradialytic hypotension. Other influences on hemodialysis patients, however, have not been adequately investigated. The purpose of this study was to determine the impact of individualized dialysate cooling on nutritional and inflammatory parameters in chronic hemodialysis (HD) patients.


Seventy HD patients were separated into two groups: group A: (control group) standard dialysate temperature was 37 °C, and group B: (intervention group) dialysate temperature was 0.5 °C below core body temperature. In addition to routine laboratory tests, blood pressure, anthropometric measurements, inflammatory markers, and the malnutrition inflammation score (MIS) were calculated.


After six months of dialysate cooling, intradialytic hypotension episodes were much less prevalent in the intervention group (p = 0.001). Serum ferritin, transferrin saturation (TSAT), high sensitive C-reactive protein (HS-CRP), and Interleukin-6 (IL-6) reduced following dialysate cooling, whereas serum albumin rose. In the control group, IL-6 dropped but serum ferritin, TSAT, albumin, and HS-CRP rose. In both groups, hemoglobin levels dropped, and erythrocyte sedimentation rate (ESR) rose, both groups’ midarm muscle circumference and MIS worsened.


Cold dialysate decreased intradialytic hypotension with no significant improvement of the nutritional and inflammatory surrogates. However, more studies including larger number of patients with longer duration of follow up are required to adequately assess its effect on inflammation and nutrition in chronic hemodialysis patients.

Peer Review reports


Chronic kidney disease (CKD) is a worldwide public health issue [1, 2]. Dialysis patients have a tenfold greater relative risk of cardiovascular death than the general population [3]. Patients undergoing hemodialysis (HD) often have inflammation [4]. Malnutrition is a frequent finding in patients with CKD, affecting 18–75% of HD patients and 10–50% of peritoneal dialysis patients [5]. Chronic inflammation and malnutrition are well-known risk factors for cardiovascular diseases in HD patients [4, 6]. Inflammatory markers, such as C-reactive protein (CRP) and interleukin 6 (IL-6), are associated with protein-energy wasting [7] and cardiovascular morbidity and mortality in dialysis patients [8].

Cold dialysis uses dialysate 0.5 °C below core body temperature [9]. Dialysate cooling prevents intradialytic hypotension (IDH) [10, 11]. This is achieved by inducing vasoconstriction and activating the sympathetic nervous and therefore improving hemodynamic stability [12]. Cold dialysis reduces HD-induced brain damage by protecting the cerebral vascular beds from harmful perfusion [9]. In the heart, long-term cold dialysis improved resting ejection fraction and reduced left ventricular mass and end-diastolic volumes while preserving aortic distensibility, decreasing the risk for future cardiovascular events [13]. On the contrary, a recent multi-center, two-arm, open-label, cluster-randomized trial in Canada concluded that personalized cool dialysate has no effect on cardiovascular health when compared to standard dialysate temperature of 365 °C [14].

It is anticipated that cooling the dialysate will prevent IDH and contribute to hemodynamic stability during the course of dialysis sessions, thereby facilitating the extension of HD sessions for sufficient time to allow for improved dialysis quality, as frequent IDH was found to be associated with reduced uremic solutes clearance [15]. This improved hemodynamic stability may have an effect on inflammation and malnutrition, as the reduced dialysis adequacy with frequent IDH has been found to result in uremia and metabolic acidosis, which promotes inflammation and tissue resistance to multiple anabolic hormones and simultaneously increases the activity of catabolic corticosteroids [16].

It would be fascinating to study the influence of cooled dialysate dialysis on such dreadful conditions as inflammation and malnutrition. Unfortunately, there is a paucity of literature on this topic, with the majority of research focusing on the association between cooled dialysate and its impact on blood pressure [10, 11] and cardiovascular complications [13] .



In this open-label, randomized, controlled interventional study, seventy adult (age > 18) ESRD patients undergoing regular hemodialysis for more than six months in the Dialysis Unit of Mansoura University Hospitals, Egypt were recruited. Patients who had a recent active infection or hospitalization, an underlying malignancy, sever disability, amputated arms or legs, were over the age of 75 years or had decompensated organ failure, other than renal failure (e.g. decompensated hepatic or heart failure), were excluded. The enrolled patients were divided into two groups; intervention group (group A) (n = 30) were subjected to individualized cool dialysate (dialysate temperature 0.5 °C lower than core body temperature) and control group (group B) (n = 40) were subjected to standard dialysate temperature (dialysate temperature of 37 °C). The dialysis techniques used in the study were conventional hemodialysis and ultrafiltration guided by the clinical condition of the patient. The time and frequency of hemodialysis sessions were four hours per session and three sessions per week, and the type of dialysis membranes were Fresenius FX filters with surface area 1.8 m2 with semisynthetic membrane helixone and Allmed filters with semisynthetic polysulfone membrane with surface area ranging from 1.8 to 2.2 m2.

The enrolled patients were allocated to their groups by simple randomization technique without knowing their characteristics. The patients who were scheduled for dialysis on the weekdays Saturday, Monday and Wednesday were allocated to be the intervention group, while those who were scheduled on the weekdays Sunday, Tuesday and Thursday were allocated to be the control group. This method of randomization helped the attending staff of a certain day to stick to one method every time they look after the recruited patients of that day. The Institutional Research Board of the Faculty of Medicine, Mansoura University, approved the study protocol (code: MS.19.04.592). The study was explained to all patients and informed written consent was obtained from all of them before starting the study.

Patients’ demographic data, such as age and gender, were collected. In addition, clinical characteristics such as hemodialysis duration, original kidney disease, and the presence of diabetes and hypertension were recorded. Both systolic and diastolic blood pressure were measured and averaged for four random dialysis sessions at the beginning of the study, every two months then at the end of the study (baseline, 2nd month, 4th and 6th month). Intradialytic hypotension was defined according to Kidney Disease Outcomes Quality Initiative (KDOQI) as a decrease in systolic blood pressure (SBP) by ≥ 20 mmHg or a decrease in mean arterial pressure (MAP) by 10 mmHg from the predialysis value, accompanied by symptoms including abdominal discomfort, yawning, sighing, nausea, vomiting, muscle cramps, restlessness, dizziness, fainting, and anxiety [17]. The intradialytic hypotensive episodes were recorded during the whole duration of the study (6 months). The subsequent assessments were done twice (at the beginning of study (Baseline) and six months following randomization).

Blood sampling and laboratory tests

Before the first HD session of the week, blood samples were collected from the arteriovenous fistula. All patients were subjected to pre-dialysis basic laboratory investigations (complete blood count (CBC), serum iron, total iron binding capacity (TIBC), transferrin saturation (TSAT), serum ferritin, serum calcium, phosphorus, parathyroid hormone (PTH), serum albumin, cholesterol) on the first session of the week in addition to erythrocyte sedimentation rate (ESR), IL-6 and high sensitive C-reactive protein (HS-CRP). The IL-6 was measured by the commercial kit IL-6 ELISA kit, catalogue number is E0079h, Wuhan EIAab Science Co., Ltd, Wuhan, China.

Anthropometric measurements

After measuring body weight (kg) and height (m) after dialysis, the body mass index (BMI) was determined. Mid upper arm circumference (MAC) was measured twice, two weeks apart, using a flexible, inelastic measuring tape in the non-arteriovenous fistula arm, just at the midpoint of upper arm (i.e. between the acromion process of scapula and the olecranon process of ulna), in sitting position, with the average being recorded [18]. Twice, two weeks apart, the Triceps skin fold (TSF) thickness was measured in millimetres. It was measured at the midway between the scapular acromion process and the ulnar olecranon process [18]. Mid arm muscle circumference (MAMC) was estimated in centimeters using the following formula: MAMC = MAC– (3.14 x TSF thickness) [19].

Malnutrition inflammation score

Malnutrition inflammation score (MIS) is comprised of ten elements, including weight change, dietary intake, gastrointestinal symptoms, functional ability, comorbidity, subcutaneous fat, and signs of muscle wasting, BMI, serum albumin, and TIBC. Each component receives a score between 0 (normal) and 3 (very severe). It is anticipated that the total of all 10 compartments will fall between 0 (well-nourished) and 30 (severely malnourished) [20].

Both anthropometric measurements and MIS assessments were done by the same observer.

Sample size and statistical analysis

According to the study hypothesis, comparing the change in inflammatory and nutritional parameters, using the MIS which is considered as a valuable indicator of nutritional and inflammatory status in hemodialysis patients [20], in group A (cooling dialysate) vs. group B (control) would have a large effect size (Cohen’s d = 0.8). A large effect size means that research finding has practical significance [21]. Group sample sizes of 30 group A cases and 40 group B cases achieve 90.41% power to reject the null hypothesis of zero effect size when the population effect size is 0.80 and the significance level (α) is 0.050 using a two-sided two-sample equal-variance t-test. Sample size was calculated by using G*Power software (version

SPSS (Statistical Package of Social Sciences) version 21 for Windows (SPSS, Inc) was used to conduct the statistical analysis. Number and percent were used to describe qualitative data (n, %). When applicable, the data was first evaluated for normality using the Shapiro-Wilk test or the Kolmogorov-Smirnov test. For normally distributed data, mean ± SD (standard deviation) was used, and for non-normally distributed data, median (interquartile range) was used. When comparing two groups with quantitative normally distributed data, the Independent-Samples T test and Paired-Samples T test were used, whereas when comparing two groups with quantitative non- normally distributed data, the Mann-Whitney test and Wilcoxon test were employed. When comparing qualitative data with a 2 × 2 table, the chi-square or Fisher’s exact test was applied. Univariate correlation analysis was carried out with the Pearson test for normally distributed data and the Spearman test for non-normally distributed variables. A statistically significant P value was less than 0.05.


The baseline demographic and clinical data, as well as the anthropometric measurements, revealed no statistically significant differences between the two research groups. Except for serum ferritin, which was considerably greater in group A, there were no other significant differences in the measured laboratory tests between the two groups (Table 1).

Table 1 comparison of baseline demographic and clinical data, anthropometric measurements and laboratory data between cooling and non-cooling groups

Regarding blood pressure measurements, there was no statistically significant difference between the two groups for measurements at baseline and the sixth month, nor for bouts of intradialytic hypotension at baseline. At the end of the study, however, more patients in the intervention group had no IDH events, and the overall number of episodes each month was lower in this group (Table 2).

Table 2 Serial pre dialytic blood pressure comparison (average measurements of 4 occasion per month) and IDH between the baseline and 6-month data between the two groups:

In the group receiving cooled dialysate (group A), there was a statistically significant drop in serum ferritin, TSAT, HS-CRP, and Interleukin-6 after 6 months of cooling, but serum albumin rose, relative to the baseline values. The 6-months assessments of the group of patients who were not subjected to dialysate cooling (group B) revealed a substantial drop in IL-6, but no significant change in serum ferritin and TSAT, and a significant rise in serum albumin and HS-CRP, relative to their baseline values. Hemoglobin level decreased significantly and ESR increased significantly after 6 months of observation in both group A and group B patients. Unfortunately, both MAMC and MIS worsened after 6 months in both groups of patients (Table 3).

Table 3 Anthropometric measurements and laboratory data comparison between baseline and 6 months measures for the two groups:

Regarding the adverse effects of cooling, more patients in the intervention group experienced shivering and discomfort as a result of cooling. However, the clinical impact of these side effects was minor, and no patient withdrew from the study (Table 4).

Table 4 cooling side effects in both groups


In the current study, some inflammatory markers and the prevalence of intradialytic hypotensive episodes decreased after six months of dialysate cooling, although midarm circumference decreased and MIS deteriorated.

Using the Malnutrition-Inflammation Score to examine inflammation and malnutrition is commonly practiced [22]. More than 90% of patients in the current study had a relatively mild degree of malnutrition and inflammation (MIS score < 9) at baseline. As its data did not demonstrate regression after the intervention, MIS did not improve after dialysate cooling; in fact, more than 25% of patients in the current research who were treated to dialysate cooling obtained a MIS below 9, indicating a worsening of their malnutrition/inflammation status. Similarly, the control group’s MIS rose in follow-up observations. These findings indicate that cooling of dialysate does not affect the nutritional and inflammatory status of the patients. During the longitudinal part of their study, Beberashvili and colleagues found that MIS exhibited a decreasing trend over time [23]. In a 12-month Chinese study involving 59 peritoneal dialysis patients, only one-third of the patients exhibited worsening MIS [24]. These contradictory results can be explained by the shorter duration of follow-up in the current study, the different dialysis modality in the Chinese study and the different patient population, as our patients were younger and of a different ethnic group. Probably the patient in the present study could have been exposed to different perpetuating factors that we were not controlled for in the study and might have an impact on different studies value independently. In both the cooling and non-cooling groups, anemia and iron status worsened, which may have led to an increase in 6-month MIS levels.

Serum albumin level, a commonly used marker of nutritional status in ESRD patients [25, 26] that has been shown to be a strong predictor of morbidity and mortality in dialysis patients [26,27,28], showed a statistically significant improvement after 6 months of observation in the present study. The fact that both groups improved in albumin prevents a conclusive conclusion concerning dialysate cooling’s influence on plasma albumin. Albumin improvement can’t be firmly linked to dialysate cooling. The patients may have felt like they were the center of medical care, which may have improved their nutrition.

Inflammatory markers are the product of interaction between noxious agents and the immune system. They could include, among others, granulocytic reaction, increased ESR, CRP and ferritin, and certain interleukins [29]. Serum ferritin, a marker originally used to reflect body iron storage [30, 31] and to monitor iron therapy in CKD patients [32], has been identified as a surrogate marker of inflammation. In the current work, it was markedly elevated at the baseline in the intervention group relative to its reference range, reflecting a degree of inflammation in these patients, having observed that the median TSAT value was below the limit diagnosing iron overload states. Despite the significant decrease in the intervention group, there was no significant difference between the two groups in serum ferritin levels at the end of the study. Parallel to the change of serum ferritin, HS-CRP showed the same tendency of being significantly decreased after the observed duration of dialysate cooling, while it did not show the same tendency following the observation period without application of the same intervention. Even though the difference was statistically significant, it was not numerically significant.

Interleukin-6 is an important cytokine that has been increasingly recognized as a central regulator of the inflammatory process and is known to play a key role in the induction of the immune effector mechanisms and acute-phase responses. Unlike other cytokines, IL-6 encompasses both endocrine and paracrine effects [33]. In the current study, interleukin − 6 was observed to be statistically significantly decreased following the studied period of dialysate cooling. The control group showed similar or even greater IL-6 improvement. These findings hamper the inflammatory suppressive role of individualized dialysate cooling. Other studies involving hemodialysis [34] and peritoneal dialysis [35] patients found a tendency for IL-6 levels to remain stable over 3 and 1 years of follow-up, respectively. The shorter duration of follow-up in the present study, as well as the distinct dialysis modalities of extended hemodialysis and peritoneal dialysis, may account for these contradictory findings. The discrepant changes of IL-6 and CRP, as well as of MIS and IL-6 can be explained as IL-6 is believed to be a vulnerable molecule and is subjected to change by multitude of various trivial factors like intercurrent infection, allergic reaction during dialysis, intake of non-steroidal anti-inflammatory drugs and others, many of these were not controlled in the present study. Moreover, the decrease in IL-6 measurements could be a regression to the mean and not a true decrease. This must be confirmed by serial cytokine measurements over an extended period of follow-up.

As stated previously, it has been seen frequently that dialysate cooling inhibits IDH [10, 11, 36]. In accordance with this, the current study showed improvement in IDH during dialysate cooling. Similarly, a meta-analysis of 26 randomized controlled trials with 484 patients indicated that reducing dialysate temperature reduced IDH by 70% and elevated intradialytic MAP by 12 mmHg [37]. Recently [38], a study tested 62 dialysis patients and found that cold dialysate stabilized blood pressure and reduced IDH. The latter authors concluded that reducing dialysate temperature from 36.5 to 35 °C leads to hemodynamic stability. In contrast to these results, the recent multicenter open-label MYTEMP study involving 15,413 hemodialysis patients found no significant between-group differences in the risk of intradialytic hypotension [14]. This discrepancy can be explained by the larger number of patients in the latter study and the distinct definitions used to define intradialytic hypotension. The main measure for definition of intradialytic hypotension in this study was (i) nadir systolic blood pressure < 90 mm Hg anytime during a hemodialysis treatment when the value prior to starting the treatment was ≥ 90 mm Hg, or (ii) drop in systolic blood pressure ≥ 30 mm Hg anytime during a hemodialysis treatment from the value before starting the treatment [14].

However, dialysis based on cooled dialysate is not totally devoid of some side effects; the most commonly reported side effects are related to cold sensation, while some studies have also reported incidences of shivering [39]. In the current study, cooled dialysate infrequently induced discomfort and shivering; a finding that was previously described in previous studies [13, 40,41,42]. No other serious disadvantages of cold dialysis have been reported in the literature; even in the long-term MyTEMP study in which more patients in the cooler dialysate group reported feeling uncomfortably chilled during dialysis than those in the standard temperature dialysate group [14].

This study had limitations. First, a relatively small number of patients were studied. Second, the short duration of the study. Third, failure to control the trivial events that can affect the levels of inflammatory markers and the malnutrition inflammation score such as like intercurrent infection, allergic reaction during dialysis, intake of non-steroidal anti-inflammatory drugs. However, assessing the effect of cooled dialysis on inflammation and nutritional status in this specific group of patients is considered as a strength point in the current study.


Cool dialysate for HD patients is safe and feasible. It also protected the patient from intra-dialytic hypotension, although it was not associated with better nutrition or inflammation. Further research with more patients and longer durations is needed to fully elucidate this issue.

Data Availability

All data analyzed during the current study available from the corresponding author on reasonable request.



Chronic kidney disease


End-stage renal disease




C-reactive protein


Interleukin 6


Intradialytic hypotension


Complete blood count


Total iron binding capacity


Transferrin saturation


Parathyroid hormone


Erythrocyte sedimentation rate


High sensitive C-reactive protein


Body mass index


Mid upper arm circumference


Triceps skin fold


Mid arm muscle circumference


Malnutrition inflammation score


  1. Eckardt K-U, Coresh J, Devuyst O, Johnson RJ, Köttgen A, Levey AS, Levin A. Evolving importance of kidney disease: from subspecialty to global health burden. The Lancet. 2013;382(9887):158–69.

    Article  Google Scholar 

  2. Mills KT, Xu Y, Zhang W, Bundy JD, Chen C-S, Kelly TN, Chen J, He J. A systematic analysis of worldwide population-based data on the global burden of chronic kidney disease in 2010. Kidney Int. 2015;88(5):950–7.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Foley RN, Parfrey PS, Harnett JD, Kent GM, Martin CJ, Murray DC, Barre PE. Clinical and echocardiographic disease in patients starting end-stage renal disease therapy. Kidney Int. 1995;47(1):186–92.

    Article  CAS  PubMed  Google Scholar 

  4. Stenvinkel P. Malnutrition and chronic inflammation as risk factors for cardiovascular disease in chronic renal failure. Blood Purif. 2001;19(2):143–51.

    Article  CAS  PubMed  Google Scholar 

  5. Caimi G, Carollo C, Presti RL. Pathophysiological and clinical aspects of malnutrition in chronic renal failure. Nutr Res Rev. 2005;18(1):89–97.

    Article  CAS  PubMed  Google Scholar 

  6. Enia G, Sicuso C, Alati G, Zoccali C, Pustorino D, Biondo A. Subjective global assessment of nutrition in dialysis patients. Nephrol Dialysis Transplantation. 1993;8(10):1094–8.

    CAS  Google Scholar 

  7. Carrero JJ, Stenvinkel P, Cuppari L, Ikizler TA, Kalantar-Zadeh K, Kaysen G, Mitch WE, Price SR, Wanner C, Wang AYM, et al. Etiology of the protein-energy wasting syndrome in chronic kidney disease: a Consensus Statement from the International Society of Renal Nutrition and Metabolism (ISRNM). J Ren Nutr. 2013;23(2):77–90.

    Article  PubMed  Google Scholar 

  8. Honda H, Qureshi AR, Heimbürger O, Barany P, Wang K, Pecoits-Filho R, Stenvinkel P, Lindholm B. Serum albumin, C-Reactive protein, interleukin 6, and Fetuin A as Predictors of Malnutrition, Cardiovascular Disease, and mortality in patients with ESRD. Am J Kidney Dis. 2006;47(1):139–48.

    Article  CAS  PubMed  Google Scholar 

  9. Eldehni MT, Odudu A, McIntyre CW. Randomized clinical trial of dialysate cooling and effects on brain white matter. J Am Soc Nephrol. 2015;26(4):957–65.

    Article  CAS  PubMed  Google Scholar 

  10. Dheenan S, Henrich WL. Preventing dialysis hypotension: a comparison of usual protective maneuvers. Kidney Int. 2001;59(3):1175–81.

    Article  CAS  PubMed  Google Scholar 

  11. van der Sande FM, Wystrychowski G, Kooman JP, Rosales L, Raimann J, Kotanko P, Carter M, Chan CT, Leunissen KML, Levin NW. Control of core temperature and blood pressure stability during hemodialysis. Clin J Am Soc Nephrol. 2009;4(1):93–8.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Toth-Manikowski SM, Sozio SM. Cooling dialysate during in-center hemodialysis: Beneficial and deleterious effects. World J Nephrol. 2016;5(2):166.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Odudu A, Eldehni MT, McCann GP, McIntyre CW. Randomized Controlled Trial of Individualized Dialysate cooling for Cardiac Protection in Hemodialysis Patients. Clin J Am Soc Nephrol. 2015;10(8):1408–17.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Garg AX, Al-Jaishi AA, Dixon SN, Sontrop JM, Anderson SJ, Bagga A, Benjamin DS, Berry WA, Blake PG, Chambers LC. Personalised cooler dialysate for patients receiving maintenance haemodialysis (MyTEMP): a pragmatic, cluster-randomised trial. The Lancet. 2022;400(10364):1693–703.

    Article  Google Scholar 

  15. Gul A, Miskulin D, Harford A, Zager P. Intradialytic hypotension. Curr Opin Nephrol Hypertens. 2016;25(6):545–50.

    Article  PubMed  Google Scholar 

  16. Zha Y, Qian Q, Nutrients. 2017, 9(3):208.

  17. KD W. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis. 2005;45:1–S153.

    Google Scholar 

  18. de Brito-Ashurst I, Varagunam M, Raftery MJ, Yaqoob MM. Bicarbonate supplementation slows progression of CKD and improves nutritional status. J Am Soc Nephrol. 2009;20(9):2075–84.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Lohman T, Roche AF, Martorell R. Anthropometric standardization reference manual. ed. Champaign IL: Human Kinetics Books; 1988.

    Google Scholar 

  20. Kalantar-Zadeh K, Kopple JD, Block G, Humphreys MH. A malnutrition-inflammation score is correlated with morbidity and mortality in maintenance hemodialysis patients. Am J Kidney Dis. 2001;38(6):1251–63.

    Article  CAS  PubMed  Google Scholar 

  21. Cohen J. Statistical power analysis for the behavioural sciences. Volume 56. Hillsdale, New Jersey: L. Lea; 1988. p. 102.

    Google Scholar 

  22. Kalantar-Zadeh K, Block G, Kelly MP, Schroepfer C, Rodriguez RA, Humphreys MH. Near Infra-Red Interactance for Longitudinal Assessment of Nutrition in Dialysis Patients. J Ren Nutr. 2001;11(1):23–31.

    Article  CAS  PubMed  Google Scholar 

  23. Beberashvili I, Azar A, Sinuani I, Kadoshi H, Shapiro G, Feldman L, Averbukh Z, Weissgarten J. Comparison analysis of nutritional scores for serial monitoring of nutritional status in hemodialysis patients. Clin J Am Soc Nephrology: CJASN. 2013;8(3):443.

    Article  CAS  Google Scholar 

  24. Cheng THT, Lam DHH, Ting SKL, Wong CLY, Kwan BCH, Chow KM, Law MC, Li PKT, Szeto CC. Serial monitoring of nutritional status in chinese peritoneal dialysis patients by Subjective Global Assessment and comprehensive malnutrition inflammation score. Nephrology. 2009;14(2):143–7.

    Article  PubMed  Google Scholar 

  25. Blumenkrantz M, Ings TS. In.: Boston, Little, Brown and Company; 1994.

  26. Ikizler TA, Wingard RL, Harvell J, Shyr Y, Hakim RM. Association of morbidity with markers of nutrition and inflammation in chronic hemodialysis patients: a prospective study. Kidney Int. 1999;55(5):1945–51.

    Article  CAS  PubMed  Google Scholar 

  27. Owen WF. C-reactive protein as an outcome predictor for maintenance hemodialysis patients. Kidney Int. 1998;54(2):627–36.

    Article  CAS  PubMed  Google Scholar 

  28. Cooper BA, Penne EL, Bartlett LH, Pollock CA. Protein malnutrition and hypoalbuminemia as predictors of vascular events and mortality in ESRD. Am J Kidney Dis. 2004;43(1):61–6.

    Article  PubMed  Google Scholar 

  29. Luster AD. Chemokines — chemotactic cytokines that mediate inflammation. N Engl J Med. 1998;338(7):436–45.

    Article  CAS  PubMed  Google Scholar 

  30. Jacobs A, Miller F, Worwood M, Beamish MR, Wardrop CA. Ferritin in the serum of normal subjects and patients with iron deficiency and iron overload. Br Med J. 1972;4(5834):206–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Lipschitz DA, Cook JD, Finch CA. A clinical evaluation of serum ferritin as an index of Iron Stores. N Engl J Med. 1974;290(22):1213–6.

    Article  CAS  PubMed  Google Scholar 

  32. Kliger AS, Foley RN, Goldfarb DS, Goldstein SL, Johansen K, Singh A, Szczech L. KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for Anemia in CKD. Am J Kidney Dis. 2013;62(5):849–59.

    Article  PubMed  Google Scholar 

  33. Pecoits-Filho R, Heimbürger O, Bárány P, Suliman M, Fehrman-Ekholm I, Lindholm B, Stenvinkel P. Associations between circulating inflammatory markers and residual renal function in CRF patients. Am J Kidney Dis. 2003;41(6):1212–8.

    Article  PubMed  Google Scholar 

  34. Cho N-J, Jeong S-H, Lee KY, Yu JY, Park S, Lee EY, Gil H-W. Clinical safety of expanded hemodialysis compared with Hemodialysis using high-flux dialyzer during a three-year cohort. J Clin Med. 2022;11(8):2261.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Fung WW-S, Poon PY-K, Ng JK-C, Kwong VW-K, Pang W-F, Kwan BC-H, Cheng PM-S, Li PK-T, Szeto C-C. Longitudinal changes of NF-κB downstream mediators and peritoneal transport characteristics in incident peritoneal dialysis patients. Sci Rep. 2020;10(1):6440.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Maggiore Q. Effect of extracoporeal blood cooling on dialytic arterial hypotension. In: Proc EDTA: 1981; 1981: 597–602.

  37. Mustafa RA, Bdair F, Akl EA, Garg AX, Thiessen-Philbrook H, Salameh H, Kisra S, Nesrallah G, Al-Jaishi A, Patel P, et al. Effect of lowering the Dialysate temperature in chronic hemodialysis: a systematic review and Meta-analysis. Clin J Am Soc Nephrol. 2016;11(3):442–57.

    Article  PubMed  Google Scholar 

  38. Ahmadi F, Toulabi T, Ebrahimzadeh F, Sajadi M. The effects of cool dialysate on vital signs, adequacy and complications during hemodialysis. Iran J Nurs Midwifery Res 2021.

  39. Ayoub A, Finlayson M. Effect of cool temperature dialysate on the quality and patients’ perception of haemodialysis. Nephrol Dialysis Transplantation. 2004;19(1):190–4.

    Article  Google Scholar 

  40. Jefferies HJ, Burton JO, McIntyre CW. Individualised Dialysate temperature improves intradialytic haemodynamics and abrogates Haemodialysis-Induced Myocardial Stunning, without compromising tolerability. Blood Purif. 2011;32(1):63–8.

    Article  PubMed  Google Scholar 

  41. Ebrahimi H, Safavi M, Saeidi MH, Emamian MH. Effects of Sodium concentration and dialysate temperature changes on blood pressure in hemodialysis patients: a randomized, triple-blind crossover clinical trial. Therapeutic Apheresis and Dialysis. 2017;21(2):117–25.

    Article  CAS  PubMed  Google Scholar 

  42. Tsujimoto Y, Tsujimoto H, Nakata Y, Kataoka Y, Kimachi M, Shimizu S, Ikenoue T, Fukuma S, Yamamoto Y, Fukuhara S. Dialysate temperature reduction for intradialytic hypotension for people with chronic kidney disease requiring haemodialysis. Cochrane Database Syst Rev. 2019;7(7):CD012598–8.

    PubMed  Google Scholar 

Download references


The authors acknowledge the great efforts and contributions of all staff members of MNDU and all participants in this study since without them, this study would have never been accomplished.


There are currently no funding sources in the list.

Open access funding provided by The Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB).

Author information

Authors and Affiliations



M.K.N. and A.E. wrote the main manuscript, N.S.A. edited the manuscript, A.M. performed the necessary laboratory investigations, and all authors reviewed the manuscript.

Corresponding author

Correspondence to Mohammed Kamal Nassar.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Institutional Review Board (IRB) of Mansoura Faculty of Medicine, Mansoura University (Code: MS.19.04.592) in accordance with the Declaration of Helsinki. A written informed consent was obtained from all subjects and/ or their legal guardians before the start of the study. All methods were carried out by relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Elemshaty, A., Sayed-Ahmed, N., Mesbah, A. et al. Could cooling dialysate improve inflammatory and nutritional status of hemodialysis patients?. BMC Nephrol 24, 255 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: