Can hydrocortisone (corticosteroid) 100mg IV be given to a patient with chronic kidney disease (CKD) undergoing hemodialysis who experiences chills?

Hydrocortisone for Chills During Hemodialysis in CKD

No, hydrocortisone 100mg IV should not be given for chills during hemodialysis in CKD patients, as chills are typically a symptom of intradialytic temperature changes or infection, not an indication for corticosteroid therapy.

Understanding Chills During Hemodialysis

Chills during hemodialysis most commonly result from:

• Temperature-related mechanisms: Standard dialysis increases core body temperature, and when dialysate temperature is lowered to prevent intradialytic hypotension, patients may experience rigors and shivering 1
• Infection: Chills may signal catheter-related bacteremia, particularly from Staphylococcus aureus, which is the leading cause of catheter exit site infection and bacteremia in hemodialysis patients 1

Appropriate Management of Chills

First-Line Temperature Management

• Adjust dialysate temperature: Use isothermic dialysis (maintaining predialysis body temperature unchanged) rather than simple low-temperature dialysis to prevent rigors and shivering while maintaining hemodynamic stability 1
• Avoid excessive cooling: While low-temperature dialysate (lower than core temperature) decreases symptomatic hypotension, it can lead to rigors if not carefully monitored 1

Rule Out Infection Immediately

• Assess for bacteremia: Evaluate for fever, catheter site infection, tunnel tract infection, or other signs of systemic infection, as these are leading causes of catheter loss 1
• Obtain cultures: If infection is suspected, blood cultures should be drawn before any intervention 1

Why Hydrocortisone 100mg IV Is Not Indicated

Approved Indications for Hydrocortisone

Hydrocortisone at 100mg doses is specifically indicated for:

• Acute severe ulcerative colitis: 100mg every 6 hours (400mg daily) 2
• Septic shock: 200mg daily total dose when unresponsive to fluids and vasopressors 2

No Evidence for Chills Management

• There is no guideline or FDA-approved indication for using hydrocortisone to treat chills during hemodialysis 2, 3
• The only relevant study on hydrocortisone in hemodialysis examined its use for intradialytic hypotension prevention, not chills, using stress doses prior to dialysis 4

Potential Risks in CKD Patients

Endogenous Cortisol Dysregulation

• CKD patients already exhibit subclinical hypercortisolism with blunted diurnal decline, impaired negative feedback regulation, and reduced cortisol clearance 5
• Adding exogenous hydrocortisone may worsen this dysregulation 5

Monitoring Burden

• Hydrocortisone requires monitoring for hyperglycemia, hypernatremia, secondary infections, and gastrointestinal bleeding 2
• Regular blood pressure and serum electrolyte monitoring would be necessary 2

Infection Risk

• If chills are due to unrecognized bacteremia, corticosteroids could mask symptoms and worsen outcomes 1

Correct Approach Algorithm

1. Assess vital signs and infection markers immediately when chills occur 1
2. If fever or signs of infection present: Obtain blood cultures, assess catheter site, consider empiric antibiotics 1
3. If no infection and chills related to temperature: Adjust dialysate temperature to isothermic settings (maintaining predialysis body temperature) 1
4. Provide symptomatic comfort: Warm blankets, adjust room temperature 1
5. Monitor for intradialytic hypotension: Chills may accompany hemodynamic instability requiring Trendelenburg position or saline boluses 1

Common Pitfall to Avoid

• Never use corticosteroids empirically for non-specific symptoms like chills without a clear indication such as septic shock, ARDS, or inflammatory bowel disease 2
• The stress dose of hydrocortisone studied for intradialytic hypotension prevention was given prior to dialysis, not during episodes of chills, and requires further prospective validation 4