Enhanced external counterpulsation, focusing on its effect on kidney function, and utilization in patients with kidney diseases: a systematic review

Thongsricome, Thana; Kositanurit, Weerapat; Siwamogsatham, Sarawut; Tiranathanagul, Khajohn

doi:10.2478/abm-2023-0062

Figures & Tables

Application of EECP in King Chulalongkorn Memorial Hospital. Each arrow represents the cuff component in a 3-cuff EECP system (with consent from the patient for publication). This is a novel utilization of the device during the hemodialysis session to improve intradialytic hemodynamics. EECP is traditionally applied in subjects not receiving dialysis. EECP, enhanced external counterpulsation.

Duplex sonography of the renal artery without EECP (A), compared with with EECP treatment (B) demonstrating augmented diastolic flow velocity (arrow), and finger pulse wave pattern without EECP (C), compared with with EECP treatment (D) systolic blood pressure (Ps), diastolic blood pressure (Pd), and augmented diastolic blood pressure (Pda). Systolic pressure reduces after EECP treatment and results in decreased cardiac oxygen demand. The FVI measured from duplex sonography also increases upon EECP therapy, reflecting increased blood flow to the artery. The finger plethysmography waveform during the therapy is similar to that from pulse wave analysis. The figure is based on results demonstrated by Applebaum et al. [17]. EECP, enhanced external counterpulsation; FVI, flow velocity integral.

MINORS quality assessment of the included studies Enhanced external counterpulsation and kidney

	Applebaum 1997	Werner 1999	Werner 2005	Onuigbo 2013	Ruangkanchanasetr 2013	Wu 2014	Zeng 2022
A stated aim of the study	2	2	2	2	2	2	2
Inclusion of consecutive patients	1	1	1	0	2	2	2
Prospective collection of data	2	2	2	2	2	2	0
Endpoint appropriate to the study aim	2	2	2	2	2	2	2
Unbiased assessment of endpoints	1	1	1	0	1	1	2
Follow-up period appropriate to the major endpoint	2	2	1	2	2	2	1
Loss to follow-up not exceeding 5%	2	2	2	2	2	0	2
Prospective calculation of the study size	0	0	0	0	2	0	1
Total	12	12	11	10	15	11	12

Characteristics of the included studies

Study	Country	Design	Included patients	Sample size (n)	EECP therapy	Contraindication for EECP or exclusion criteria	Outcome and measurement
Applebaum et al. [17]	United States and India	Pre- and post-procedure comparison (no control group)	Atherosclerotic heart disease, age 55 ± 8 years	18 (male, 78%)	- Machine: Cardiomedics, Inc., Irvine, California - 2 flexible cuffs - Cuff pressure up to a point at which the peak diastolic pressure wave reached the height of the systolic pressure wave on the finger plethysmography (150–180 mmHg for most patients) - 1 session, duration 30 min	- History of recent lower extremity thrombophlebitis, severe ischemia, or trauma including surgical incision and amputation - Moderate to severe aortic regurgitation - Severe congestive heart failure - Uncontrolled hypertension - Uncontrolled arrhythmia - Thrombolytic or anticoagulation agents use	Renal artery blood flow, measured every 5 minutes during and immediately after the counterpulsation with duplex ultrasonography (angle correction of ≤60°)
Werner et al. [18]	Germany	Pre- and post-procedure comparison (no control group)	Healthy volunteers, age 28 ± 4 years	16	- Machine: Vasomedical Inc., Westbury, New York, and Cardiomedics Inc., Irvine, California - 2 cuffs (calves and thighs) - Cuff pressure of 200 mmHg - 1 session, duration 1 h	No available data	Changes in flow volume in carotid, vertebral, hepatic, renal, and internal iliac arteries, measured by duplex ultrasonography
Werner et al. [19]	Germany	Pre- and post-procedure comparison in (1) cirrhotic patients and (2) healthy subjects	- Cirrhotic patients diagnosed by hepatologists, age 54.4 ± 10.5 years - Healthy subjects, age 23.7 ± 2.5 years	16 cirrhotic patients and 12 healthy subjects (male, 50%)	- Machine: Vasomedical Inc., Westbury, New York - 2 cuffs (calves and upper thighs) - Cuff pressure of 250–300 mmHg - 1 session (performed in the early afternoon), duration 2 h	- Aortic regurgitation - Aortic aneurysm - Atrial fibrillation - Deep venous thrombosis, leg ulcer, marked peripheral edema - INR >2 (Screened by electrocardiogram, echocardiogram, and duplex sonography of the lower extremities)	- GFR by inulin clearance (continuous infusion) - Renal plasma flow by aminohippurate sodium clearance (continuous infusion) - Continuous radial artery blood pressure, monitored by vascular unloading technique - Plasma concentrations of endothelin-1, measured by ELISA kit - Plasma concentrations of renin, ANP, ADH, epinephrine and N-epinephrine, measured by radioimmunoassay - Urinary volume determined every 30 min - Urinary excretion rates of sodium and chloride, measured by flame photometry - Urinary osmolality, measured by freezing point depression
Onuigbo [20]	United States	Case series	Hemodialysis patients with IDH and hypoalbuminemia refractory to conventional treatments	3	Using sequential compression device as a mini-EECP - Machine: Flowtron Excel deep venous thrombosis prophylaxis system (Huntleigh Healthcare, Poland) - Cuff pressures of 40 mmHg - The cuff is applied to the calves throughout the hemodialysis session, and inflation of the cuffs is alternated between both calves every other minute.	Not stated	- Achieved ultrafiltration volume in the dialysis sessions - Patient tolerability and IDH episodes
Ruangkanchanasetr et al. [21]	Thailand	Longitudinal pre- and post-procedure comparison (no control group)	Age ≥18 years with chronic stable angina and/or heart failure	30 (male, 76.7%, chronic angina 76.7%, heart failure 23.3%)	- Machine: Vasomedical Inc., Westbury, New York - 35 sessions of 1-h daily EECP treatment over a period of 7–8 weeks - Cuff pressure and amount: not specify	- Unstable angina, acute myocardial Infarction, decompensated heart failure in the preceding one month - Undergoing coronary angiography or coronary artery bypass grafting in the preceding 1 month - Blood pressure >180/110 mmHg - Severe symptomatic peripheral vascular disease - GFR <15 mL/min/1.73 m²	- Serum creatinine, measured by enzymatic methods - Serum cystatin C, measured by particle-enhanced immunonephelometric assay - Estimated GFR using combination of serum creatinine and cystatin C - NT-proBNP, measured by a sandwich immunoassay - Non-invasive blood pressure measurement (The median follow-up time after starting EECP treatment was 16 months)
Wu et al. [22]	Taiwan	Longitudinal pre- and post-procedure comparison (no control group)	Hemodialysis patients with coronary artery disease and angina refractory to medical treatment and unable or unwilling for revascularization	36 (male, 61.3%)	- Machine: Vasomedical Inc., Westbury, New York - Duration of 1- or 2-h daily EECP treatment for 5 days per week to reach total of 35 h - Cuff pressures of 260–300 mmHg to achieve mean peak diastolic augmentation of 1.6	- Significant aortic regurgitation - Abdominal aortic aneurysm (Screened by echocardiography and abdominal sonography)	- Angina symptom, measured by Canadian Cardiovascular Society Angina Grading scale - Angina medications - Myocardial perfusion, assessed by Thallium-201 imaging with pharmacological stress - Cardiovascular events (Assess immediately after complete 35 h of EECP and 1 year after complete the therapy)
Zhang et al. [23]	China	Randomized, non-sham-controlled	Age >18 years undergoing a diagnostic contrast-enhanced computed tomography with estimated GFR using CKD-EPI of 60–89 mL/min/1.73 m²	121 (male, 62%, hypertension 56%, diabetes 27%)	- A 1-h session of EECP therapy at 2 h after exposure to the contrast media - Target diastolic/systolic augmentation ratio of 1.0–1.2	- Blood pressure >180/100 mmHg - Hemorrhagic disease or bleeding tendency including INR >2 - Uncontrolled tachyarrhythmia - Severe aortic insufficiency - Acute heart failure - Arterial dissection or aneurysm - Lower-extremityvenous thrombosis - Infection, pregnancy, thyroid disease, tumor - Recent exposure to contrast media or nephrotoxic drugs	- Increase of serum cystatin C ≥10% at 24^th h after contrast exposure - Iopromide contrast clearance measurement using plasma concentration of iopromide at 2^nd, and 3^rd h - Conventional diagnosis of contrast-induced kidney injury using serum creatinine concentration at 48^th h - Adverse clinical events
Zeng et al. [24]	China	Prospective cohort, compared with active comparator (standard dose of 0.9% NaCl hydration)	Age ≥18 years with estimated GFR <60 mL/min/1.73 m² not on dialysis; Receiving coronary angiography and percutaneous intervention	230 (male, 76%, diabetes 36.1%, hypertension 77%, mean estimated GFR 42 mL/min/1.73 m²)	A once daily 1-h session of EECP therapy at 24 h before and 48–72 h after the intervention	(1) patients who had used iodinated contrast medium 30 d before inclusion, (2) patients with AKI due to other clear causes, (3) patients requesting withdrawal, (4) patients who failed to receive the re-examination of renal function indicators on time after surgery, (5) patients who underwent hemodialysis within 48 h after surgery, and (6) patients with uremia who received long-term hemodialysis.	Serum creatinine increase ≥0.3, ≥0.5 mg/dL or ≥25% relative to baseline value within 48–72 h after iodinated contrast exposure

Enhanced external counterpulsation, focusing on its effect on kidney function, and utilization in patients with kidney diseases: a systematic review

Figures & Tables

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MINORS quality assessment of the included studies Enhanced external counterpulsation and kidney

Characteristics of the included studies

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