Hydrocortisone Has No Role in Managing Chills During Dialysis
Hydrocortisone should not be used to treat chills during dialysis—this symptom requires immediate evaluation for infection, not corticosteroid therapy. The evidence is clear that chills during dialysis indicate potential bacterial infection requiring prompt investigation and possible antibiotic treatment, not immunosuppression.
Why Chills During Dialysis Occur and What They Mean
Chills during hemodialysis represent a serious warning sign with high infection rates:
- 60% of hemodialysis patients presenting with chills have a documented infection, and 33.5% have bacteremia 1
- The primary causes are endotoxin contamination from dialyzer reuse or water treatment systems, and catheter-related bloodstream infections 2
- Pyrogenic reactions occur when bacterial endotoxins (>6 ng/mL) contaminate dialysis water or inadequately disinfected dialyzers 2
When Antibiotics Are Immediately Required
Most patients with chills during dialysis need prompt antibiotic coverage following blood cultures 1. The high-risk features requiring immediate antibiotics include:
- Vascular catheter as dialysis access (odds ratio 6.2 for bacteremia) 1
- Fever accompanying the chills (odds ratio 1.6 for bacteremia) 1
- Leukocytosis (odds ratio 1.265 for any infection) 1
- Hypoalbuminemia 1
- Any obvious source of infection 1
The Only Low-Risk Scenario
A very narrow subset of patients may be observed without immediate antibiotics 1:
- Arteriovenous fistula or graft access (not catheter)
- No fever
- Normal white blood cell count
- Normal albumin level
- No obvious infection source
Even in this low-risk group, only 6% had bacteremia, meaning infection cannot be excluded 1.
Why Hydrocortisone Would Be Harmful
Corticosteroids are contraindicated in this clinical scenario for multiple reasons:
- Corticosteroids should not be used for sepsis without shock 3
- Hydrocortisone is reserved exclusively for septic shock unresponsive to adequate fluid resuscitation and moderate-to-high dose vasopressors 3, 4
- The dose for septic shock is 200 mg/day IV for ≥3 days, not a single dose for symptom management 4
- Corticosteroids blunt the febrile response and mask infection, making diagnosis more difficult 4
- Immunosuppression from corticosteroids increases secondary infection risk 4
Correct Management Algorithm
Step 1: Immediately stop dialysis if severe reaction occurs (hypotension, respiratory distress, altered mental status) 5
Step 2: Obtain blood cultures from both the dialysis access and peripheral site before antibiotics 1
Step 3: Assess for high-risk features:
- Catheter access? → Immediate broad-spectrum antibiotics
- Fever present? → Immediate antibiotics
- Leukocytosis or hypoalbuminemia? → Immediate antibiotics
- Obvious infection source? → Immediate antibiotics 1
Step 4: For the rare low-risk patient (fistula/graft, afebrile, normal labs, no source), close observation with repeat cultures is acceptable 1
Step 5: Investigate dialysis equipment and water treatment systems for endotoxin contamination if multiple patients affected 2
Common Pitfalls to Avoid
- Never use procalcitonin to rule out infection in dialysis patients—it has only 59% specificity and cannot reliably identify bacterial infection in this population 6
- Do not confuse allergic reactions to dialyzer materials (ethylene oxide, cuprammonium cellulose) with infectious chills—allergic reactions occur within minutes of starting dialysis with urticaria, bronchospasm, and hypotension 5
- Avoid NSAIDs for symptomatic treatment as they are nephrotoxic and may harm residual kidney function 3
- Never delay antibiotics to wait for culture results in high-risk patients 1
The single case report of corticosteroid use in a dialysis patient 7 involved sclerosing peritonitis from peritoneal dialysis—an entirely different condition unrelated to chills during hemodialysis and not applicable to this clinical question.