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Unraveling the relationship between mortality, hyponatremia, inflammation and malnutrition in hemodialysis patients: results from the international MONDO initiative. Eur J Clin Nutr 2016; 70:779-84. [DOI: 10.1038/ejcn.2016.49] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 01/23/2016] [Accepted: 02/17/2016] [Indexed: 12/12/2022]
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102
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Demirci C, Aşcı G, Demirci MS, Özkahya M, Töz H, Duman S, Sipahi S, Erten S, Tanrısev M, Ok E. Impedance ratio: a novel marker and a powerful predictor of mortality in hemodialysis patients. Int Urol Nephrol 2016; 48:1155-62. [PMID: 27093965 DOI: 10.1007/s11255-016-1292-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 04/11/2016] [Indexed: 12/12/2022]
Abstract
PURPOSE Impedance ratio (Imp-R) obtained by multifrequency bioimpedance analysis (BIA) has been shown to be associated with volume and nutrition status. In this prospective study, the predictive role of Imp-R for mortality in hemodialysis (HD) patients was investigated. METHODS Multifrequency (5-50-100-200 kHz) BIA was applied to 493 prevalent HD patients in March-April 2006. Imp-R was defined as the ratio of 200-5 kHz impedance values. Demographical, clinical and laboratory data at the time of the analysis were recorded. All-cause and cardiovascular (CV) mortality were assessed during 3 years of follow-up. RESULTS Mean age was 57.7 ± 13.9 years, HD duration 52.1 ± 42.6 months and prevalence of diabetes 21.7 %. Imp-R was negatively correlated with nutritional markers including albumin, creatinine and hemoglobin levels. In addition, there was a positive correlation between Imp-R and age, ratio of extracellular water to total body water and high-sensitive C-reactive protein. Over a mean follow-up period of 27.9 ± 11.1 months, 93 deaths (52 from CV reasons) were observed. In the multivariate analysis, Imp-R was significantly associated with all-cause and CV mortality after adjustments [HR 1.13, 95 % CI (1.04-1.23); p = 0.004 and HR 1.15, 95 % CI (1.03-1.27); p = 0.01, respectively]. The risk of all-cause mortality was 3.4 times higher in the fourth quartile of Imp-R (>83.5 %) compared to the first Imp-R quartile (<78.8 %) as reference. Cutoff value of Imp-R for all-cause mortality was 82.0 % with a sensitivity of 65.5 % and specificity of 64 %. CONCLUSION Impedance ratio measured by multifrequency in standardized conditions BIA is an independent and powerful predictor of both all-cause and CV mortality in hemodialysis patients.
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Affiliation(s)
| | - G Aşcı
- Division of Nephrology, Ege University School of Medicine, Izmir, Turkey
| | - M S Demirci
- Division of Nephrology, Ege University School of Medicine, Izmir, Turkey
| | - M Özkahya
- Division of Nephrology, Ege University School of Medicine, Izmir, Turkey
| | - H Töz
- Division of Nephrology, Ege University School of Medicine, Izmir, Turkey
| | - S Duman
- Division of Nephrology, Ege University School of Medicine, Izmir, Turkey
| | - S Sipahi
- Sakarya University Training and Research Hospital, Sakarya, Turkey
| | - S Erten
- FMC Turkey Clinics, Izmir, Turkey
| | - M Tanrısev
- Tepecik Training and Research Hospital, Izmir, Turkey
| | - E Ok
- Division of Nephrology, Ege University School of Medicine, Izmir, Turkey
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103
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Rincón Bello A, Bucalo L, Abad Estébanez S, Vega Martínez A, Barraca Núñez D, Yuste Lozano C, Pérez de José A, López-Gómez JM. Fat tissue and inflammation in patients undergoing peritoneal dialysis. Clin Kidney J 2016; 9:374-80. [PMID: 27274820 PMCID: PMC4886903 DOI: 10.1093/ckj/sfw007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 01/19/2016] [Indexed: 01/10/2023] Open
Abstract
Background Body weight has been increasing in the general population and is an established risk factor for hypertension, diabetes, and all-cause and cardiovascular mortality. Patients undergoing peritoneal dialysis (PD) gain weight, mainly during the first months of treatment. The aim of this study was to assess the relationship between body composition and metabolic and inflammatory status in patients undergoing PD. Methods This was a prospective, non-interventional study of prevalent patients receiving PD. Body composition was studied every 3 months using bioelectrical impedance (BCM®). We performed linear regression for each patient, including all BCM® measurements, to calculate annual changes in body composition. Thirty-one patients in our PD unit met the inclusion criteria. Results Median follow-up was 26 (range 17–27) months. Mean increase in weight was 1.8 ± 2.8 kg/year. However, BCM® analysis revealed a mean increase in fat mass of 3.0 ± 3.2 kg/year with a loss of lean mass of 2.3 ± 4.1 kg/year during follow-up. The increase in fat mass was associated with the conicity index, suggesting that increases in fat mass are based mainly on abdominal adipose tissue. Changes in fat mass were directly associated with inflammation parameters such as C-reactive protein (r = 0.382, P = 0.045) and inversely associated with high-density lipoprotein cholesterol (r=−0.50, P = 0.008). Conclusions Follow-up of weight and body mass index can underestimate the fat mass increase and miss lean mass loss. The increase in fat mass is associated with proinflammatory state and alteration in lipid profile.
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Affiliation(s)
- Abraham Rincón Bello
- Department of Nephrology, Rey Juan Carlos Hospital, Móstoles, Madrid, Spain; Department of Nephrology, Gregorio Marañón Hospital, Madrid, Spain
| | - Laura Bucalo
- Department of Nephrology , Gregorio Marañón Hospital , Madrid , Spain
| | | | | | | | | | - Ana Pérez de José
- Department of Nephrology , Gregorio Marañón Hospital , Madrid , Spain
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Fluid volume expansion and depletion in hemodialysis patients lack association with clinical parameters. Can J Kidney Health Dis 2015; 2:54. [PMID: 26702360 PMCID: PMC4689039 DOI: 10.1186/s40697-015-0090-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 11/19/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Achievement of normal volume status is crucial in hemodialysis (HD), since both volume expansion and volume contraction have been associated with adverse outcome and events. OBJECTIVES The objectives of this study are to assess the prevalence of fluid volume expansion and depletion and to identify the best clinical parameter or set of parameters that can predict fluid volume expansion in HD patients. DESIGN This study is cross-sectional. SETTING This study was conducted in three hemodialysis units. PATIENTS In this study, there are 194 HD patients. METHODS Volume status was assessed by multifrequency bio-impedance spectroscopy (The Body Composition Monitor, Fresenius) prior to the mid-week HD session. RESULTS Of all patients, 48 % (n = 94) were volume-expanded and 9 % of patients were volume-depleted (n = 17). Interdialytic weight gain was not different between hypovolemic, normovolemic, and hypervolemic patients. Fifty percent of the volume-expanded patients were hypertensive. Paradoxical hypertension was very common (31 % of all patients); its incidence was not different between patient groups. Intradialytic hypotension was relatively common and was more frequent among hypovolemic patients. Multivariate regression analysis identified only four predictors for volume expansion (edema, lower BMI, higher SBP, and smoking). None of these parameters displayed both a good sensitivity and specificity. LIMITATIONS The volume assessment was performed once. CONCLUSIONS The study indicates that volume expansion is highly prevalent in HD population and could not be identified using clinical parameters alone. No clinical parameters were identified that could reliably predict volume status. This study shows that bio-impedance can assist to determine volume status. Volume status, in turn, is not related to intradialytic weight gain and is unable to explain the high incidence of paradoxical hypertension.
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105
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Bioimpedance analysis versus lung ultrasonography for optimal risk prediction in hemodialysis patients. Int J Cardiovasc Imaging 2015; 32:263-270. [DOI: 10.1007/s10554-015-0768-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 09/14/2015] [Indexed: 01/22/2023]
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106
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Overhydration, Cardiac Function and Survival in Hemodialysis Patients. PLoS One 2015; 10:e0135691. [PMID: 26274811 PMCID: PMC4537261 DOI: 10.1371/journal.pone.0135691] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 07/25/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Chronic subclinical volume overload occurs very frequently and may be ubiquitous in hemodialysis (HD) patients receiving the standard thrice-weekly treatment. It is directly associated with hypertension, increased arterial stiffness, left ventricular hipertrophy, heart failure, and eventually, higher mortality and morbidity. We aimed to assess for the first time if the relationship between bioimpedance assessed overhydration and survival is maintained when adjustments for echocardiographic parameters are considered. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS A prospective cohort trial was conducted to investigate the impact of overhydration on all cause mortality and cardiovascular events (CVE), by using a previously reported cut-off value for overhydration and also investigating a new cut-off value derived from our analysis of this specific cohort. The body composition of 221 HD patients from a single center was assessed at baseline using bioimpedance. In 157 patients supplemental echocardiography was performed (echocardiography subgroup). Comparative survival analysis was performed using two cut-off points for relative fluid overload (RFO): 15% and 17.4% (a value determined by statistical analysis to have the best predictive value for mortality in our cohort). RESULTS In the entire study population, patients considered overhydrated (using both cut-offs) had a significant increased risk for all-cause mortality in both univariate (HR = 2.12, 95%CI = 1.30-3.47 for RFO>15% and HR = 2.86, 95%CI = 1.72-4.78 for RFO>17.4%, respectively) and multivariate (HR = 1.87, 95%CI = 1.12-3.13 for RFO>15% and HR = 2.72, 95%CI = 1.60-4.63 for RFO>17.4%, respectively) Cox survival analysis. In the echocardiography subgroup, only the 17.4% cut-off remained associated with the outcome after adjustment for different echocardiographic parameters in the multivariate survival analysis. The number of CVE was significantly higher in overhydrated patients in both univariate (HR = 2.46, 95%CI = 1.56-3.87 for RFO >15% and HR = 3.67, 95%CI = 2.29-5.89 for RFO >17.4%) and multivariate (HR = 2.31, 95%CI = 1.42-3.77 for RFO >15% and HR = 4.17, 95%CI = 2.48-7.02 for RFO >17.4%) Cox regression analysis. CONCLUSIONS The study shows that the hydration status is associated with the mortality risk in a HD population, independently of cardiac morphology and function. We also describe and propose a new cut-off for RFO, in order to better define the relationship between overhydration and mortality risk. Further studies are needed to properly validate this new cut-off in other HD populations.
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107
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Stenberg J, Lindberg M, Furuland H. Clinical praxis for assessment of dry weight in Sweden and Denmark: A mixed-methods study. Hemodial Int 2015; 20:111-9. [PMID: 26264888 DOI: 10.1111/hdi.12336] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Overhydration is an independent predictor of mortality in hemodialysis (HD) patients. More than 30% of HD patients are overhydrated, motivating the development of new methods for assessing hydration status. This study surveyed clinical praxis and local guidelines for dry weight (DW) assessment in Swedish and Danish HD units, and examined if differences in routines and utilization of bioimpedance spectroscopy (BIS) and other assistive technology affected frequency of DW adjustments and blood pressure (BP) levels. Cross-sectional information on praxis, guidelines and routines, plus treatment-related data from 99 stratified patients were collected. Qualitative data were analyzed with content analysis and interpreted in convergence with statistical analysis of quantitative data in a mixed-methods design. Local guidelines concerning DW existed in 54% of the units. A BIS device was present in 52%, but only half of those units used it regularly, and no correlations to frequency of DW adjustments or BP were found. HD nurses were authorized to adjust DW in 60% of the units; in these units, the frequency of DW adjustments was 1.6 times higher and systolic BP pre-HD 8 mmHg lower. There is a wide variation in routines for DW determination, and there are indications that authorization of HD nurses to adjust DW may improve DW assessment. BIS is sparsely used; its implementation may have been delayed by uncertainty over how to manage the device and interpret measurements. Hence, better methods and guidelines for assessing DW and using BIS need to be developed.
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Affiliation(s)
- Jenny Stenberg
- Department of Medical Sciences, University Hospital, Uppsala, Sweden
| | - Magnus Lindberg
- Department of Health and Caring Sciences, University of Gävle, Gävle, Sweden.,Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Hans Furuland
- Department of Medical Sciences, University Hospital, Uppsala, Sweden
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108
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Oshima N, Onimaru H, Matsubara H, Uchida T, Watanabe A, Takechi H, Nishida Y, Kumagai H. Uric acid, indoxyl sulfate, and methylguanidine activate bulbospinal neurons in the RVLM via their specific transporters and by producing oxidative stress. Neuroscience 2015. [PMID: 26208844 DOI: 10.1016/j.neuroscience.2015.07.055] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Patients with chronic renal failure often have hypertension, but the cause of hypertension, other than an excess of body fluid, is not well known. We hypothesized that the bulbospinal neurons in the rostral ventrolateral medulla (RVLM) are stimulated by uremic toxins in patients with chronic renal failure. To investigate whether RVLM neurons are sensitive to uremic toxins, such as uric acid, indoxyl sulfate, or methylguanidine, we examined changes in the membrane potentials (MPs) of bulbospinal RVLM neurons of Wister rats using the whole-cell patch-clamp technique during superfusion with these toxins. A brainstem-spinal cord preparation that preserved the sympathetic nervous system was used for the experiments. During uric acid, indoxyl sulfate, or methylguanidine superfusion, almost all the RVLM neurons were depolarized. To examine the transporters for these toxins on RVLM neurons, histological examinations were performed. The uric acid-, indoxyl sulfate-, and methylguanidine-depolarized RVLM neurons showed the presence of urate transporter 1 (URAT 1), organic anion transporter (OAT)1 or OAT3, and organic cation transporter (OCT)3, respectively. Furthermore, the toxin-induced activities of the RVLM neurons were suppressed by the addition of an anti-oxidation drug (VAS2870, an NAD(P)H oxidase inhibitor), and a histological examination revealed the presence of NAD(P)H oxidase (nox)2 and nox4 in these RVLM neurons. The present results show that uric acid, indoxyl sulfate, and methylguanidine directly stimulate bulbospinal RVLM neurons via specific transporters on these neurons and by producing oxidative stress. These uremic toxins may cause hypertension by activating RVLM neurons.
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Affiliation(s)
- N Oshima
- Department of Nephrology and Endocrinology, National Defense Medical College, Tokorozawa, Saitama, Japan.
| | - H Onimaru
- Department of Physiology, Showa University School of Medicine, Tokyo, Japan
| | - H Matsubara
- Department of Nephrology and Endocrinology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - T Uchida
- Department of Nephrology and Endocrinology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - A Watanabe
- Department of Nephrology and Endocrinology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - H Takechi
- Department of Nephrology and Endocrinology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Y Nishida
- Department of Physiology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - H Kumagai
- Department of Nephrology and Endocrinology, National Defense Medical College, Tokorozawa, Saitama, Japan
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109
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Daugirdas JT. Kt/V (and especially its modifications) remains a useful measure of hemodialysis dose. Kidney Int 2015; 88:466-73. [PMID: 26176827 DOI: 10.1038/ki.2015.204] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 05/15/2015] [Accepted: 05/20/2015] [Indexed: 11/09/2022]
Abstract
Removal of small molecular weight solutes shows a strong relationship to hemodialysis outcomes. In contrast, survival with high-flux dialysis or hemodiafiltration is only slightly better than with low-flux hemodialysis. Despite laboratory evidence regarding toxicity of protein-bound uremic solutes, few data exist showing that increased removal of this class of molecules impacts outcomes. In the FHN trials, there was no effect of frequent dialysis, including frequent and long dialysis, on nutrition or control of anemia, outcomes expected to be sensitive to uremic toxin removal; the main benefit appeared to be better volume control. Scaling of hemodialysis dose to total body water may not be optimal. Kt/V scaling to body surface area and use of a continuous measure such as standard Kt/V reduces the likelihood of underdialysis of small patients, including children, and women. Minimum hemodialysis time may best be considered in respect to ultrafiltration rate, and a maximum target ultrafiltration rate unscaled to body size may be optimal. Intensive, extended dialysis may cause adverse effects to residual kidney function, and more information needs to be collected to better understand how urine volume modifies dose requirements, and how to maximize the chances of preserving residual kidney function.
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Affiliation(s)
- John T Daugirdas
- University of Illinois College of Medicine, Chicago, Illinois, USA
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110
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Hydration Status Is Associated with Aortic Stiffness, but Not with Peripheral Arterial Stiffness, in Chronically Hemodialysed Patients. Int J Nephrol 2015; 2015:628654. [PMID: 26167301 PMCID: PMC4488172 DOI: 10.1155/2015/628654] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 06/02/2015] [Accepted: 06/03/2015] [Indexed: 12/04/2022] Open
Abstract
Background. Adequate fluid management could be essential to minimize high arterial stiffness observed in chronically hemodialyzed patients (CHP). Aim. To determine the association between body fluid status and central and peripheral arterial stiffness levels. Methods. Arterial stiffness was assessed in 65 CHP by measuring the pulse wave velocity (PWV) in a central arterial pathway (carotid-femoral) and in a peripheral pathway (carotid-brachial). A blood pressure-independent regional arterial stiffness index was calculated using PWV. Volume status was assessed by whole-body multiple-frequency bioimpedance. Patients were first observed as an entire group and then divided into three different fluid status-related groups: normal, overhydration, and dehydration groups. Results. Only carotid-femoral stiffness was positively associated (P < 0.05) with the hydration status evaluated through extracellular/intracellular fluid, extracellular/Total Body Fluid, and absolute and relative overhydration. Conclusion. Volume status and overload are associated with central, but not peripheral, arterial stiffness levels with independence of the blood pressure level, in CHP.
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111
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Jeong H, Lim CW, Choi HM, Oh DJ. The source of net ultrafiltration during hemodialysis is mostly the extracellular space regardless of hydration status. Hemodial Int 2015; 20:129-33. [PMID: 26046949 DOI: 10.1111/hdi.12323] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Fluid shifts are common in patients undergoing chronic hemodialysis (HD) during the intradialytic periods, as several liters of fluid are removed during ultrafiltration (UF). Some patients have experienced frequent intradialytic hypotension (IDH). However, the characteristics of fluid shifts and which fluid space is affected remain controversial. Therefore, we designed this study to evaluate the fluid spaces most affected by UF and to determine whether hydration status influences the fluid shifts during HD. This was a prospective cohort study of 40 patients undergoing HD. We measured the patient's fluid spaces using a whole-body bioimpedance apparatus to evaluate the changes in the fluid spaces before HD and 1-4 hours of HD and 30 minutes after HD. UF achieved during HD by the 40 patients (age, 60.0 ± 5.2 years; 50% men; 50% of patients with diabetes; body weight, 61.3 ± 10.5 kg) was 2.18 ± 0.78 L (measured fluid overload, 2.15 ± 1.24 L). 1) Mean relative reduction of total body water and extracellular water was reduced from the start to the end of HD. 2) However, mean relative reduction of intracellular water was not reduced from the start to the end of HD. 3) No significant differences in fluid shifts were observed according to hydration status. The source of net UF during HD is mostly the extracellular space regardless of hydration status. Thus, IDH may be related to differences in the interstitial fluid shift to the vascular space.
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Affiliation(s)
- Hyeonju Jeong
- Department of Internal Medicine, Myongji Hospital, Goyang, Korea
| | - Chae-Wan Lim
- Department of Internal Medicine, Myongji Hospital, Goyang, Korea
| | - Hye-Min Choi
- Department of Internal Medicine, Myongji Hospital, Goyang, Korea
| | - Dong-Jin Oh
- Department of Internal Medicine, Myongji Hospital, Goyang, Korea
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112
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Fischbach M, Zaloszyc A, Shroff R. The interdialytic weight gain: a simple marker of left ventricular hypertrophy in children on chronic haemodialysis. Pediatr Nephrol 2015; 30:859-63. [PMID: 25797887 DOI: 10.1007/s00467-015-3086-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 02/25/2015] [Accepted: 03/03/2015] [Indexed: 11/29/2022]
Abstract
Despite multiple advances in haemodialysis (HD) technology over the years, the morbidity and mortality of HD patients remain unacceptably high. Cardiovascular disease is the most common cause of death, and left ventricular hypertrophy (LVH), seen in two-thirds of children on dialysis, is a significant contributor. The importance of volume control is increasingly recognized by nephrologists and now considered to be as important as urea kinetics, both in the day-to-day management and the long-term outcome of dialysis patients. The results published by Paglialonga et al. ( 10.1007/s00467-014-3005-2 ) in this issue of Pediatric Nephrology clearly demonstrate that there is a significant correlation between interdialytic weight gain (IDWG) and LVH in oligoanuric children on chronic HD and that children with an IDWG of >4 % are at high risk of LVH. One common practice to achieve euvolaemia is to prescribe very high ultrafiltration rates. However, both volume overload and aggressive fluid removal can induce circulatory stress and multi-organ injury. In adults, ultrafiltration rates of >1.24 % body weight per hour, even if well tolerated, are associated with a significant increase in mortality. Nephrologists should be aware of the risk of a high ultrafiltration rate, especially if tolerance is obtained by a positive dialysate-to-plasma sodium gradient. Haemodiafiltration, which allows for higher ultrafiltration rates with greater intradialytic haemodynamic stability, or more frequent and longer dialysis sessions allow for safe and effective fluid removal.
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Affiliation(s)
- Michael Fischbach
- Children's Dialysis Unit, University Hospital Strasbourg, CHU Hautepierre, 67098, Strasbourg, France,
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113
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de Louw EJ, Sun PO, Lee J, Feng M, Mark RG, Celi LA, Mukamal KJ, Danziger J. Increased incidence of diuretic use in critically ill obese patients. J Crit Care 2015; 30:619-23. [PMID: 25721030 PMCID: PMC4626009 DOI: 10.1016/j.jcrc.2015.01.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 01/08/2015] [Accepted: 01/30/2015] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Sodium retention occurs commonly in cardiac and liver disease, requiring the administration of diuretics to restore fluid balance. Whether obesity is associated with sodium retention has not been fully evaluated. METHODS In a large single-center cohort of critically ill patients, we evaluated whether admission body mass index was associated with the administration of either oral or intravenous diuretics during the intensive care unit (ICU) stay. MAIN RESULTS Of 7724 critically ill patients, 3946 (51.1%) were prescribed diuretics during the ICU stay. Overweight, class I obesity, and class II/III obesity were associated with a 1.35 (95% confidence interval [CI], 1.20-1.53; P < .001), 1.56 (95% CI, 1.35-1.80; P < .001), and 1.91 (95% CI, 1.61-2.26; P < .001) adjusted risk of receiving diuretics within the ICU, respectively. In adjusted analysis, a 5-kg/m(2) increment of body mass index was associated with a 1.19 (95% CI, 1.14-1.23; P < .001) increased adjusted risk of within-ICU diuretics. Among those patients receiving loop diuretics, obese patients received significantly larger daily diuretic doses. CONCLUSION Critically ill obese patients are more likely to receive diuretics during their stay in the ICU and to receive higher dosages of diuretics. Our data suggest that obesity is an independent risk factor for sodium retention.
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Affiliation(s)
- Emma J de Louw
- Beth Israel Deaconess Medical Center, Department of Medicine
| | - Pepijn O Sun
- Beth Israel Deaconess Medical Center, Department of Medicine
| | - Joon Lee
- Harvard-MIT Division of Health Sciences and Technology; School of Public Health and Health Systems, University of Waterloo
| | - Mengling Feng
- Harvard-MIT Division of Health Sciences and Technology; Institute for Infocomm Research, A*STAR, Singapore
| | - Roger G Mark
- Harvard-MIT Division of Health Sciences and Technology
| | - Leo Anthony Celi
- Beth Israel Deaconess Medical Center, Department of Medicine; Harvard-MIT Division of Health Sciences and Technology
| | | | - John Danziger
- Beth Israel Deaconess Medical Center, Department of Medicine.
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114
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Graft Function and Arterial Stiffness: Can Bioimpedance Analysis Be Useful in Renal Transplant Recipients? Transplant Proc 2015; 47:1182-5. [DOI: 10.1016/j.transproceed.2014.10.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 10/28/2014] [Indexed: 11/21/2022]
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115
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Lee J, de Louw E, Niemi M, Nelson R, Mark RG, Celi LA, Mukamal KJ, Danziger J. Association between fluid balance and survival in critically ill patients. J Intern Med 2015; 277:468-77. [PMID: 24931482 PMCID: PMC4265574 DOI: 10.1111/joim.12274] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Although the consequences of chronic fluid retention are well known, those of iatrogenic fluid retention that occurs during critical illness have not been fully determined. Therefore, we investigated the association between fluid balance and survival in a cohort of almost 16,000 individuals who survived an intensive care unit (ICU) stay in a large, urban, tertiary medical centre. DESIGN Longitudinal analysis of fluid balance at ICU discharge and 90-day post-ICU survival. MEASUREMENTS Associations between fluid balance during the ICU stay, determined from the electronic bedside record, and survival were tested using Cox proportional hazard models adjusted for severity of critical illness. RESULTS There were 1827 deaths in the first 90 days after ICU discharge. Compared with the lowest quartile of discharge fluid balance [median (interquartile range) -1.5 (-3.1, -0.7) L], the highest quartile [7.6 (5.7, 10.8) L] was associated with a 35% [95% confidence interval (CI) 1.13-1.61)] higher adjusted risk of death. Fluid balance was not associated with outcome amongst individuals without congestive heart failure or renal dysfunction. Amongst patients with either comorbidity, however, fluid balance was strongly associated with outcome, with the highest quartile having a 55% (95% CI 1.24-1.95) higher adjusted risk of death than the lowest quartile. Isotonic fluid balance, defined as the difference between intravenous isotonic fluid administration and urine output, was similarly associated with 90-day outcomes. CONCLUSION Positive fluid balance at the time of ICU discharge is associated with increased risk of death, after adjusting for markers of illness severity and chronic medical conditions, particularly in patients with underlying heart or kidney disease. Restoration of euvolaemia prior to discharge may improve survival after acute illness.
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Affiliation(s)
- J Lee
- Lab of Computational Physiology, Division of Health, Sciences and Technology, Harvard-Massachusetts Institute of Technology, Cambridge, MA, USA; School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
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Ronco C, Verger C, Crepaldi C, Pham J, De Los Ríos T, Gauly A, Wabel P, Van Biesen W. Baseline hydration status in incident peritoneal dialysis patients: the initiative of patient outcomes in dialysis (IPOD-PD study)†. Nephrol Dial Transplant 2015; 30:849-58. [PMID: 25762355 PMCID: PMC4425480 DOI: 10.1093/ndt/gfv013] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 01/07/2015] [Indexed: 12/30/2022] Open
Abstract
Background Non-euvolaemia in peritoneal dialysis (PD) patients is associated with elevated mortality risk. There is an urgent need to collect data to help us understand the association between clinical practices and hydration and nutritional status, and their effects on patient outcome. Methods The aim of this prospective international, longitudinal observational cohort study is to follow up the hydration and nutritional status, as measured by bioimpedance spectroscopy using the body composition monitor (BCM) of incident PD patients for up to 5 years. Measures of hydration and nutritional status and of clinical, biochemical and therapy-related data are collected directly before start of PD treatment, at 1 and 3 months, and then every 3 months. This paper presents the protocol and a pre-specified analysis of baseline data of the cohort. Results A total of 1092 patients (58.1% male, 58.0 ± 15.3 years) from 135 centres in 32 countries were included. Median fluid overload (FO) was 2.0 L (males) and 0.9 L (females). Less than half of the patients were normohydrated (38.7%), whereas FO > 1.1 L was seen in 56.5%. Systolic and diastolic blood pressure were 139.5 ± 21.8 and 80.0 ± 12.8 mmHg, respectively, and 25.1% of patients had congestive heart failure [New York Heart Association (NYHA) 1 or higher]. A substantial number of patients judged to be not overhydrated on clinical judgement appeared to be overhydrated by BCM measurement. Overhydration at baseline was independently associated with male gender and diabetic status. Conclusions The majority of patients starting on PD are overhydrated already at start of PD. This may have important consequences on clinical outcomes and preservation of residual renal function. Substantial reclassification of hydration status by BCM versus on a clinical basis was necessary, especially in patients who were not overtly overhydrated. Both clinical appreciation and bioimpedance should be combined in clinical decision-making on hydration status.
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Affiliation(s)
- Claudio Ronco
- Department of Nephrology, Ospedale S. Bortolo, Vicenza, Italy
| | | | - Carlo Crepaldi
- Department of Nephrology, Ospedale S. Bortolo, Vicenza, Italy
| | - Jenny Pham
- Clinical Research, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Tatiana De Los Ríos
- Clinical Research, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Adelheid Gauly
- Clinical Research, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Peter Wabel
- Clinical Research, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Wim Van Biesen
- Renal Division, Ghent University Hospital, Ghent, Belgium
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117
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Hecking M, Rayner H, Wabel P. What are the Consequences of Volume Expansion in Chronic Dialysis Patients? Semin Dial 2015; 28:242-7. [DOI: 10.1111/sdi.12355] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
| | - Hugh Rayner
- Heart of England; NHS Foundation Trust; Birmingham United Kingdom
| | - Peter Wabel
- Fresenius Medical Care, Research and Development; Bad Homburg Germany
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118
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Dahlmann A, Dörfelt K, Eicher F, Linz P, Kopp C, Mössinger I, Horn S, Büschges-Seraphin B, Wabel P, Hammon M, Cavallaro A, Eckardt KU, Kotanko P, Levin NW, Johannes B, Uder M, Luft FC, Müller DN, Titze JM. Magnetic resonance-determined sodium removal from tissue stores in hemodialysis patients. Kidney Int 2015; 87:434-41. [PMID: 25100048 PMCID: PMC4932096 DOI: 10.1038/ki.2014.269] [Citation(s) in RCA: 168] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 06/06/2014] [Accepted: 06/12/2014] [Indexed: 01/31/2023]
Abstract
We have previously reported that sodium is stored in skin and muscle. The amounts stored in hemodialysis (HD) patients are unknown. We determined whether (23)Na magnetic resonance imaging (sodium-MRI) allows assessment of tissue sodium and its removal in 24 HD patients and 27 age-matched healthy controls. We also studied 20 HD patients before and shortly after HD with a batch dialysis system with direct measurement of sodium in dialysate and ultrafiltrate. Age was associated with higher tissue sodium content in controls. This increase was paralleled by an age-dependent decrease of circulating levels of vascular endothelial growth factor-C (VEGF-C). Older (>60 years) HD patients showed increased sodium and water in skin and muscle and lower VEGF-C levels compared with age-matched controls. After HD, patients with low VEGF-C levels had significantly higher skin sodium content compared with patients with high VEGF-C levels (low VEGF-C: 2.3 ng/ml and skin sodium: 24.3 mmol/l; high VEGF-C: 4.1 ng/ml and skin sodium: 18.2 mmol/l). Thus, sodium-MRI quantitatively detects sodium stored in skin and muscle in humans and allows studying sodium storage reduction in ESRD patients. Age and VEGF-C-related local tissue-specific clearance mechanisms may determine the efficacy of tissue sodium removal with HD. Prospective trials on the relationship between tissue sodium content and hard end points could provide new insights into sodium homeostasis, and clarify whether increased sodium storage is a cardiovascular risk factor.
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Affiliation(s)
- Anke Dahlmann
- 1] Junior Research Group 2, Interdisciplinary Centre for Clinical Research, Nikolaus-Fiebiger-Centre for Molecular Medicine, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany [2] Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Kathrin Dörfelt
- Junior Research Group 2, Interdisciplinary Centre for Clinical Research, Nikolaus-Fiebiger-Centre for Molecular Medicine, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Florian Eicher
- Junior Research Group 2, Interdisciplinary Centre for Clinical Research, Nikolaus-Fiebiger-Centre for Molecular Medicine, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Peter Linz
- Junior Research Group 2, Interdisciplinary Centre for Clinical Research, Nikolaus-Fiebiger-Centre for Molecular Medicine, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Christoph Kopp
- 1] Junior Research Group 2, Interdisciplinary Centre for Clinical Research, Nikolaus-Fiebiger-Centre for Molecular Medicine, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany [2] Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Irina Mössinger
- Junior Research Group 2, Interdisciplinary Centre for Clinical Research, Nikolaus-Fiebiger-Centre for Molecular Medicine, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Stephan Horn
- Kuratorium für Heimdialyse und Nierentransplantation e.V., Erlangen, Germany
| | | | - Peter Wabel
- Fresenius Medical Care, Bad Homburg, Germany
| | - Matthias Hammon
- Department of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Alexander Cavallaro
- Department of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | | | | | - Bernd Johannes
- Institute of Aerospace Medicine, German Aerospace Center, Cologne, Germany
| | - Michael Uder
- Department of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Friedrich C Luft
- 1] Experimental and Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the Max-Delbrück Center for Molecular Medicine (MDC), Berlin, Germany [2] Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Dominik N Müller
- Experimental and Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the Max-Delbrück Center for Molecular Medicine (MDC), Berlin, Germany
| | - Jens M Titze
- 1] Junior Research Group 2, Interdisciplinary Centre for Clinical Research, Nikolaus-Fiebiger-Centre for Molecular Medicine, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany [2] Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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119
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Affiliation(s)
- Urvashi Mulasi
- Department of Food Science and Nutrition, University of Minnesota–Twin Cities, Saint Paul, Minnesota
| | - Adam J. Kuchnia
- Department of Food Science and Nutrition, University of Minnesota–Twin Cities, Saint Paul, Minnesota
| | - Abigail J. Cole
- Department of Food Science and Nutrition, University of Minnesota–Twin Cities, Saint Paul, Minnesota
| | - Carrie P. Earthman
- Department of Food Science and Nutrition, University of Minnesota–Twin Cities, Saint Paul, Minnesota
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Nutritional Markers and Body Composition in Hemodialysis Patients. INTERNATIONAL SCHOLARLY RESEARCH NOTICES 2015; 2015:695263. [PMID: 27347538 PMCID: PMC4897264 DOI: 10.1155/2015/695263] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 12/13/2014] [Accepted: 12/14/2014] [Indexed: 11/23/2022]
Abstract
The aims of this study were to analyse body composition, to detect the presence of undernutrition, and to establish a relationship between undernutrition and the biological markers routinely used as indicators of nutritional status in hemodialysis (HD) patients (pts). We used a body composition monitor (BCM) that expresses body weight in terms of lean tissue mass (LTM) and fat tissue mass (FTM) independent of hydration status. From nine HD units, 934 pts were included. Undernutrition was defined as having a lean tissue index (LTI = LTM/height2) below the 10th percentile of a reference population. Biochemical markers and parameters delivered by BCM were used to compare low LTI and normal LTI groups. Undernutrition prevalence was 58.8% of the population studied. Low LTI pts were older, were significantly more frequently overhydrated, and had been on HD for a longer period of time than the normal LTI group. FTI (FTI = FTM/ height2) was significantly higher in low LTI pts and increased according to BMI. LTI was not influenced by different BMI levels. Albumin and C-reactive protein correlated inversely (r = −0.28). However neither of them was statistically different when considering undernourished and normal LTI pts. Our BCM study was able to show a high prevalence of undernutrition, as expressed by low LTI. In our study, BMI and other common markers, such as albumin, failed to predict malnutrition as determined by BCM.
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121
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Balter P, Ficociello LH, Taylor PB, Usvyat L, Sawin DA, Mullon C, Diaz-Buxo J, Zabetakis P. A year-long quality improvement project on fluid management using blood volume monitoring during hemodialysis. Curr Med Res Opin 2015; 31:1323-31. [PMID: 25942380 DOI: 10.1185/03007995.2015.1047746] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Inadequate removal of extracellular volume markedly increases blood pressure and contributes to high morbidity and mortality in hemodialysis patients. Advances in fluid management are needed to improve clinical outcomes. The aim of this quality improvement project was to examine the advantages of using a hematocrit-based, blood volume monitor (Crit-Line * ) for 12 months, as part of a clinic-wide, fluid management program in one dialysis facility. METHODS Forty-five individuals were receiving hemodialysis at one facility at project initiation and are included in this analysis. Monthly averaged clinical parameters (dialysis treatment information, blood pressures, blood volume, and laboratory data) were compared from Months 1-12. Analyses were conducted overall and according to the presence/absence of hypertension at Month 1 (Baseline). Antihypertensive medication changes were assessed for patients with hypertension at Month 1. RESULTS Average hemodialysis treatment time (+10.6 minutes, p = 0.002), eKt/V (+0.25, p < 0.001) and online clearance (+0.21, p < 0.0001) increased significantly in Month 12 versus Month 1. Average albumin levels and normalized protein catabolic rate increased from Month 1 to 12. Post-dialysis systolic blood pressure (SBP) decreased by Month 12 (p = 0.003). In hypertensive patients (SBP ≥ 140 mmHg in Month 1), there were significant differences in pre- and post-dialysis SBP between Month 1 and Month 12 (pre-hemodialysis: p = 0.02; post-hemodialysis: p = 0.0003), and antihypertensive medication use decreased in 29% of patients, while only 11% increased use. Treatment time in hypertensive patients increased by 15.4 minutes (p = 0.0005). LIMITATIONS This was a single, clinic-wide, quality improvement project with no control group. All data analyzed were from existing clinical records, so only routinely measured clinical variables were available and missing data were possible. CONCLUSIONS During this year-long fluid management quality improvement project, decreases in post-dialysis SBP and increases in adequacy and treatment time were observed. Patients with hypertension at Month 1 experienced reductions in pre-dialysis SBP and antihypertensive medications.
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Affiliation(s)
- Paul Balter
- Renal Research Institute , New York, NY , USA
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122
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Abbas SR, Zhu F, Levin NW. Bioimpedance can solve problems of fluid overload. J Ren Nutr 2014; 25:234-7. [PMID: 25556307 DOI: 10.1053/j.jrn.2014.10.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 10/29/2014] [Indexed: 11/11/2022] Open
Abstract
Bioimpedance (BI) techniques for measuring normal hydration status (NHS) can be generally classified as (1) by frequency as single frequency at 50 kHz, BI analysis, and multifrequency BI spectroscopy and (2) by method as whole body (wrist to ankle) measurement and calf BI spectroscopy. The aim of this article was to review current BI methods for clinical practice in patients with end-stage of kidney disease. BI vector analysis using whole-body single-frequency BI at 50 kHz may be useful for population studies to indicate a range of degree of fluid loading and of nutritional status. Whole body multifrequency BI spectroscopy is used to estimate extracellular (ECV), intracellular fluid volume, and total body water in dialysis patients. The whole-body BI model is used in the body composition monitor (BCM). The whole-body BI model is established with ECV, intracellular fluid volume, and body weight based on parameters from regression analysis in healthy subjects to calculate fluid overload in dialysis patients. Calf BI methods have been developed to measure NHS by 2 ways: (1) continuous measurement of the intradialytic resistance curve until flattening occurs; (2) calf normalized resistivity in the range of healthy subjects (18.5 × 10(-2) Ω m(3)/kg in male and 19.1 × 10(-2) Ω m(3)/kg in female). In general, for population studies, BI vector analysis or ECV/total body water may be useful; BCM is a commercially available device that can certainly guide volume reduction safely over time. For more exact measure of fluid overload, calf BI methods appear to be most accurate, but these are at present research tools. BI techniques are not only useful in assessing NHS but also in the study of nutrition and body composition.
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Affiliation(s)
| | - Fansan Zhu
- Renal Research Institute, New York, New York.
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123
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Abushufa AM, Eldehni MT, Odudu A, Evans PD, O'Sullivan SE, McIntyre CW. Defining uremic arterial functional abnormalities in patients recently started on haemodialysis: combined in vivo and ex vivo assessment. PLoS One 2014; 9:e113462. [PMID: 25546407 PMCID: PMC4278673 DOI: 10.1371/journal.pone.0113462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 10/26/2014] [Indexed: 11/18/2022] Open
Abstract
Endothelial dysfunction is a key initiating event in vascular disease in chronic kidney disease (CKD) patients and haemodialysis (HD) patients exhibit significant vascular abnormalities. To understand this further, we examined how ex vivo intrinsic function in isolated arteries correlates with in vivo assessments of cardiovascular status in HD patients. Abdominal fat biopsies were obtained from 11 HD patients and 26 non-uremic controls. Subcutaneous arteries were dissected and mounted on a wire myograph, and cumulative concentration-response curves to noradrenalin, endothelin-1, a thromboxane A2 agonist (U46619), angiotensin II, vasopressin, bradykinin (BK), acetylcholine (ACh) and sodium nitroprusside (SNP) were constructed. Pulse wave velocity and blood pressure were measured in HD patients. Enhanced (P<0.05−0.0001) maximal contractile responses (Rmax) to all spasmogens (particularly vasopressin) were observed in arteries from HD patients compared to controls, and this effect was more pronounced in arteries with an internal diameter>600 µm. The potency (pEC50) of U46619 (P<0.01) and vasopressin (P<0.001) was also increased in arteries>600 µm of HD patients. The maximal relaxant response to the endothelium-dependent dilators ACh and BK were lower in HD patients (P<0.01-P<0.0001) (worse for ACh than BK); however the endothelium-independent dilator SNP was similar in both groups. PWV was significantly correlated with the vasoconstrictor response to vasopressin (P = 0.042) in HD patients. HD patients are primed for hypertension and end organ demand ischaemia by a highly sensitised pressor response. The failure of arterial relaxation is mediated by endothelial dysfunction. Intrinsic vascular abnormalities may be important in sensitising HD patients to recurrent cumulative ischaemic end organ injury.
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Affiliation(s)
- Adil M Abushufa
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Mohamed T Eldehni
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, United Kingdom; Department of Renal Medicine, Royal Derby Hospital, Derby, United Kingdom
| | - Aghogho Odudu
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, United Kingdom; Department of Renal Medicine, Royal Derby Hospital, Derby, United Kingdom
| | - Philip D Evans
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, United Kingdom; Department of Renal Medicine, Royal Derby Hospital, Derby, United Kingdom
| | - Saoirse E O'Sullivan
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Chris W McIntyre
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, United Kingdom; Department of Renal Medicine, Royal Derby Hospital, Derby, United Kingdom
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Voroneanu L, Siriopol D, Nistor I, Apetrii M, Hogas S, Onofriescu M, Covic A. Superior predictive value for NTproBNP compared with high sensitivity cTnT in dialysis patients: a pilot prospective observational study. Kidney Blood Press Res 2014; 39:636-47. [PMID: 25571877 DOI: 10.1159/000368452] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS The clinical utility of the new biomarker, high sensitivity cardiac T troponin (hs-cTnT) is still unclear in dialysis patients. Furthermore, the prognostic value of combining N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) and hs-cTnT has not been explored so far. The objective of this pilot study was to determine the utility of hs-cTnT alone versus hs-cTnT in combination with NT-proBNP for predicting death in a stable hemodialysis cohort. METHODS A prospective observational pilot study including 98 chronic asymptomatic hemodialysis patients with a follow up period of 24 months was designed. The cut-off values for NT-proBNP and hs-cTnT were calculated using receiver operating characteristic (ROC) analysis, using mortality as an end-point. Based on the cut-off values, the cohort was divided into four groups. Group 1--NT-proBNP < 14275 pg/ml and hs-cTnT < 69.48 ng/l; group 2--NT-proBNP < 14275 pg/ml and hs-cTnT > 69.48 ng/l; group 3--NT-proBNP > 14275 pg/ml and hs-cTnT < 69.48 ng/l; group 4--NT-proBNP > 14275 pg/ml and hs-cTnT > 69.48 ng/l. Survival for each group was determined using the Kaplan-Meier method and Cox regression analysis. RESULTS During the follow-up period 16 patients died. According to the ROC curves analysis, the cut-off point for hs-cTnT and for NT-proBNP were 69.43 ng/l (AUC = 0.618; p = 0.04) and 14275 pg/ml (AUC = 0.722; p = 0.003), respectively. In univariate Cox analysis, both hs-cTnT (HR = 3.34; p = 0.016) and NT-proBNP (HR = 5.94; p = 0.01) were predictors of death. In the multivariable Cox proportional hazards model, only NT-pro-BNP levels above the cut-off value remained an independent predictor of all-cause mortality. The combined elevation of both biomarkers did not improve significantly the prognostic value compared with NT-proBNP alone (HR = 6.15 versus HR =4 .78; p = 0.338). CONCLUSION NT-pro-BNP is a strong predictor of overall mortality in asymptomatic hemodialysis patients. The addition of hs-cTnT did not improve the prognostic accuracy compared with NT proBNP alone.
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Affiliation(s)
- Luminita Voroneanu
- Nephrology Clinic, Dialysis and Renal Transplant Center, C.I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania
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125
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Leung KCW, Quinn RR, Ravani P, MacRae JM. Ultrafiltration biofeedback guided by blood volume monitoring to reduce intradialytic hypotensive episodes in hemodialysis: study protocol for a randomized controlled trial. Trials 2014; 15:483. [PMID: 25496294 PMCID: PMC4295273 DOI: 10.1186/1745-6215-15-483] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 12/02/2014] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Fluid removal during dialysis, also known as ultrafiltration (UF), leads to intradialytic hypotension (IDH) in a significant number of patients treated with hemodialysis (HD) and is associated with an increase in morbidity and mortality. At present, there are no accepted standards of practice for the prevention or treatment of IDH. Relative blood volume monitoring (BVM) is based on the concept that the hematocrit increases with UF, relative to the patient's baseline hematocrit. The use of BVM biofeedback, whereby the HD machine automatically adjusts the rate of UF based on the relative blood volume, has been proposed for the prevention of IDH. METHODS/DESIGN This is a 22-week randomized crossover trial. Participants undergo a 4-week run-in phase to standardize medications and dialysis prescriptions. Subsequently, participants are randomized to standard HD or to BVM biofeedback for a period of 8 weeks followed by a 2-week washout phase before crossing over. The dialysis prescription remains identical for both arms. The primary outcome is the frequency of symptomatic IDH as defined by an abrupt drop in the systolic blood pressure of ≥ 20 mm Hg accompanied by headache, dizziness, loss of consciousness, thirst, dyspnea, angina, muscle cramps or vomiting. Secondary outcomes include the number of symptomatic IDH episodes and any reduction in IDH episodes, nursing interventions, dialysis adequacy, total body water, extra- and intracellular fluid volumes, brain natriuretic peptide and cardiac troponin levels, blood pressure, antihypertensive medication use, patient symptoms and quality of life. DISCUSSION Our study will determine the impact of using BVM biofeedback to prevent IDH and other serious adverse events in susceptible patients. TRIAL REGISTRATION Clinicaltrials.gov NCT01988181 (6 November 2013).
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Affiliation(s)
- Kelvin CW Leung
- />Department of Medicine, University of Calgary, Calgary, Canada
| | - Robert R Quinn
- />Department of Medicine, University of Calgary, Calgary, Canada
- />Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Pietro Ravani
- />Department of Medicine, University of Calgary, Calgary, Canada
- />Department of Community Health Sciences, University of Calgary, Calgary, Canada
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Abstract
Current views regarding hemodialysis adequacy reach beyond indices of small solute removal such as Kt/V. Nevertheless, new Kt/V-based constructs such as the standard Kt/V, which adjusts not only for dialysis frequency, but which also represents removal of sequestered solutes rather than easily removed urea, continue to be useful. The scaling of dialysis dose to measures of size other than body water results in higher recommended doses of dialysis for children, small patients, and women, compared with the current body water-based scaling approach. Aside from small solute removal, increasing weekly time on dialysis results in slower removal of fluid with better tolerance and with increased removal of phosphorus, although both salt and water and phosphorus control often respond to efforts to reduce intake. The intermediate term benefits of removing larger middle molecules such as beta-2-microglobulin appear to be modest, and the benefits of removal of protein-bound uremic toxins remain to be proved in controlled trials.
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127
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Wong MMY, Craig JC, Levin A, Strippoli GFM. Interventions for promoting adherence to fluid intake and dietary salt restriction in people with end-stage kidney disease. Hippokratia 2014. [DOI: 10.1002/14651858.cd011410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Michelle MY Wong
- Arbor Research Collaborative; 340 East Huron St, Suite 300 Ann Arbor MI USA 48104
| | - Jonathan C Craig
- The University of Sydney; Sydney School of Public Health; Edward Ford Building A27 Sydney NSW Australia 2006
- The Children's Hospital at Westmead; Cochrane Renal Group, Centre for Kidney Research; Westmead NSW Australia 2145
| | - Adeera Levin
- University of British Columbia; Division of Nephrology; 1081 Burrard St Vancouver BC Canada V6Z 1Y8
| | - Giovanni FM Strippoli
- The University of Sydney; Sydney School of Public Health; Edward Ford Building A27 Sydney NSW Australia 2006
- The Children's Hospital at Westmead; Cochrane Renal Group, Centre for Kidney Research; Westmead NSW Australia 2145
- Mario Negri Sud Consortium; Department of Clinical Pharmacology and Epidemiology; Santa Maria Imbaro Italy
- Diaverum; Medical-Scientific Office; Lund Sweden
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128
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Covic A, Voroneanu L, Goldsmith D. Routine bioimpedance-derived volume assessment for all hypertensives: a new paradigm. Am J Nephrol 2014; 40:434-40. [PMID: 25427586 DOI: 10.1159/000369218] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Hypertension is one of the most common worldwide diseases. Is linked with increased morbidity and mortality and amplified costs to society; in this context, preventing and treating hypertension is an imperative public health challenge. Unidentified, clinically unapparent volume expansion is an important cause for hypertension. Optimization of fluid status was associated with an improvement in BP control, a substantial regression of the left ventricular mass index, arterial stiffness and better survival rate in several cohorts. Clinical assessment of hydration status is an inaccurate clinical science. Bioimpedance provides a noninvasive and reliable, simple, reproducible technology for diagnosing subclinical fluid accumulation. Several small studies and a recent meta-analysis performed in patients with resistant hypertension reported an improved BP control in the impedance treated group compared with the group of patients treated as per clinical judgment alone. A combined approach (using both sphygmomanometers and bioimpedance) and individualized antihypertensive treatment in hypertensive's patients it seems probable to improve BP control and possibly end organ damage.
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Affiliation(s)
- Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, C.I. Parhon University, Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania
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Baek SH, Oh KH, Kim S, Kim DK, Joo KW, Oh YK, Han BG, Chang JH, Chung W, Kim YS, Na KY. Control of fluid balance guided by body composition monitoring in patients on peritoneal dialysis (COMPASS): study protocol for a randomized controlled trial. Trials 2014; 15:432. [PMID: 25376940 PMCID: PMC4233087 DOI: 10.1186/1745-6215-15-432] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 10/22/2014] [Indexed: 02/07/2023] Open
Abstract
Background The clinical benefits of bioimpedance spectroscopy (BIS)-guided fluid management in patients on hemodialysis have been widely demonstrated. However, no previous reports have evaluated the effect of regular and serial BIS-guided fluid management on the residual renal function (RRF) in patients on peritoneal dialysis (PD). Therefore, we will evaluate the clinical efficacy of BIS-guided fluid management for preserving RRF and protecting cardiovascular events in patients on PD. Methods/design This is a multicenter, prospective, randomized controlled trial. A total of 138 participants on PD will be enrolled and randomly assigned to receive either BIS-guided fluid management or fluid management based only on the clinical information for 1 year. The primary outcome is the change in the glomerular filtration rate (GFR) between months 0 and 12 after starting treatment. The secondary outcomes will include GFR at month 12, time to the anuric state (urine volume <100 ml/day), and fatal and nonfatal cardiovascular events during treatment. Discussion This is the first clinical trial to investigate the effect of BIS-guided fluid management on RRF and for protecting against cardiovascular events in patients on PD. Trial registration Clinical Trials.gov number NCT01887262, June 24, 2013.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Ki Young Na
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 463-707, Gyeonggi-do, South Korea.
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Weiner DE, Brunelli SM, Hunt A, Schiller B, Glassock R, Maddux FW, Johnson D, Parker T, Nissenson A. Improving Clinical Outcomes Among Hemodialysis Patients: A Proposal for a “Volume First” Approach From the Chief Medical Officers of US Dialysis Providers. Am J Kidney Dis 2014; 64:685-95. [DOI: 10.1053/j.ajkd.2014.07.003] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 07/07/2014] [Indexed: 01/03/2023]
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131
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Huang SHS, Filler G, Lindsay R, McIntyre CW. Euvolemia in hemodialysis patients: a potentially dangerous goal? Semin Dial 2014; 28:1-5. [PMID: 25348058 DOI: 10.1111/sdi.12317] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Dialysis patients have high mortality rate and the leading cause of death is cardiovascular disease. Uremic cardiomyopathy differs from that due to conventional atherosclerosis, where cardiovascular changes result in ineffective circulation and lead to tissue ischemia. Modern dialysis has significant limitations with fluid management probably the most challenging. Current evidence suggests that both volume overload and aggressive fluid removal can induce circulatory stress and multi-organ injury. Furthermore, we do not have accurate volume assessment tools. As a result, targeting euvolemia might result in more harm than benefit with conventional hemodialysis therapy. Therefore, it might be time to consider a degree of permissive over-hydration until we have better tools to both determine ideal weight and improve current renal replacement therapy so that the process of achieving it is not so fraught with the current dangers.
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Affiliation(s)
- Shih-Han S Huang
- Department of Medicine, Division of Nephrology, Western University and London Health Sciences Centre, London, Canada; Department of Medical Biophysics, Western University, London, Canada; Department of Pediatrics, Western University, London, Canada
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132
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Keane DF, Lindley E. Use of hand-to-hand measurements for body composition monitoring in patients with inaccessible or amputated feet. J Ren Care 2014; 41:28-32. [PMID: 25220681 DOI: 10.1111/jorc.12091] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The body composition monitor (BCM) provides an objective assessment of fluid status, which has been shown to improve outcomes in patients undergoing haemodialysis. The models used by the BCM were developed and validated using standard wrist-to-ankle bioimpedance measurements, made between electrodes on the hand and foot. However, in patients with inaccessible or amputated feet it is not possible to use standard electrode configurations. OBJECTIVE To compare hydration measurements made with 'hand-to-hand' (H-H) and 'hand-to-foot' (H-F) electrode configurations in patients with accessible feet or no amputations. METHODS One hundred and one consecutive patients referred for a BCM measurement were recruited to have H-H measurements at the same time as the usual H-F measurement using the same height and weight. Patients with obvious localised oedema were excluded. RESULTS Compared with H-F, H-H measurements showed a bias of -0.1 L. For 61% of patients the difference between the readings was within 0.5 L; for 81% it was within 1.0 L. CONCLUSION The agreement between H-H and H-F measurements was close enough to encourage us to use H-H measurements in patients with inaccessible or amputated feet. Prior to amputation, height and weight are recorded. Target weight (TW) reductions are made gradually when close to normal hydration. Clinically, changes based on H-H measurements appear to be as appropriate as those using H-F. The desired hydration at TW can be established and then TW adjusted to maintain this hydration as the flesh weight fluctuates.
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Affiliation(s)
- David F Keane
- Departments of Medical Physics and Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Hypervolemia for hypertension pathophysiology: a population-based study. BIOMED RESEARCH INTERNATIONAL 2014; 2014:895401. [PMID: 25177700 PMCID: PMC4142663 DOI: 10.1155/2014/895401] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 06/26/2014] [Accepted: 06/30/2014] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Hypertension and hypervolemia relationship was proven among renal disease, although it is not known in normal population. Present study determines the fluid distribution defects in relation to blood pressure. MATERIAL AND METHODS In a population-based survey in Turkey demographics, height, weight, blood pressure, urine analysis, and serum creatinine measurements were recorded. Bioimpedance measured with the Body Composition Monitor. RESULTS Total 2034 population of 71.6% male, mean age 47 ± 12.6 (18-89) years, systolic blood pressure (SBP) 134.7 ± 20, diastolic blood pressure 77.9 ± 11.6 mmHg. Body mass index (BMI) was 28.5 ± 4.5 (15.8-50.6) kg/m(2); overhydration was 0.05 ± 1.05 L. There was a correlation between extracellular water (ECW)/height and SBP (r = 0.21, P < 0.001). Receiver operating characteristic (ROC) curve with the performance of 0.60 (P < 0.001) that showed cut-off value of ECW/height was 10.06 L/m, with the 69% sensitivity and 45% specificity for SBP: 140 mmHg values. Risk factors for high SBP were increase of ECW/Height, age, BMI and presence of diabetes. ECW/height, SBP, and fat tissue index (FTI) increased in BMI categories (low, normal, and obese) and in diabetics. SBP and FTI were lower in smokers. CONCLUSIONS High blood pressure may be accompanied by increased extracellular volume indices. In the future volume status assessment could be of use in evaluating the effectiveness of pharmacological intervention in the treatment of hypertension.
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135
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Optimizing peritoneal dialysis prescription for volume control: the importance of varying dwell time and dwell volume. Pediatr Nephrol 2014; 29:1321-7. [PMID: 23903692 DOI: 10.1007/s00467-013-2573-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 07/01/2013] [Accepted: 07/09/2013] [Indexed: 01/24/2023]
Abstract
Not only adequate uremic toxin removal but also volume control is essential in peritoneal dialysis (PD) to improve patient outcome. Modification of dwell time impacts on both ultrafiltration (UF) and purification. A short dwell favors UF but preferentially removes small solutes such as urea. A long dwell favors uremic toxin removal but also peritoneal fluid reabsorption due to the time-dependent loss of the crystalloid osmotic gradient. In particular, the long daytime dwell in automated PD may result in significant water and sodium reabsorption, and in such cases icodextrin should be considered. Increasing dwell volume favors the removal of solutes such as sodium due to the increased volume of diffusion and the recruitment of peritoneal surface area. A very large fill volume with too high an intraperitoneal pressure (IPP) may, however, result in back-filtration and thus reduced UF and sodium clearance. Based on these principles and the individual transport and pressure kinetics obtained from peritoneal equilibration tests and IPP measurements, we suggest combining short dwells with a low fill volume to favor UF with long dwells and a large fill volume to favor solute removal. Results from a recent randomized cross-over trial and earlier observational data in children support this concept: the absolute UF and UF relative to the administered glucose increased and solute removal and blood pressure improved.
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Rosner MH, Ronco C. Techniques for the assessment of volume status in patients with end stage renal disease. Semin Dial 2014; 27:538-41. [PMID: 25039904 DOI: 10.1111/sdi.12273] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
While advances in assessing extracellular volume status have occurred, no methodology is sufficiently robust and accurate in all patients to recommend routine use in clinical practice. All of the methods described also perform best when measured serially in patients and when correlated with other ancillary methods of volume assessment such as body weight, physical examination and determination of vital signs and symptomatology. Perhaps, the best method for assessing and modifying dry weight is to utilize multiple complementary methods such as advocated by Ronco et in the “5B” approach (39). In this approach, the clinician utilizes data from: fluid balance (body weight changes), blood pressure, biomarkers (such as the natriuretic peptides), bioimpedance, and blood volume changes. Body (thoracic and IVC) ultrasound can also be included (Fig. 1). These combined data sources will likely lead to greater detection of subtle volume overload, a finding likely to contribute to excess mortality and morbidity. Clinical trials of such strategies are needed to better inform clinicians.
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Affiliation(s)
- Mitchell H Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia
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Crepaldi C, Rosner M, Teixeira C, Martos LB, Martino FK, Rodighiero MP, Ronco C. Is Brain Natriuretic Peptide a Reliable Biomarker of Hydration Status in All Peritoneal Dialysis Patients? Blood Purif 2014; 37:238-42. [DOI: 10.1159/000362155] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 03/11/2014] [Indexed: 11/19/2022]
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138
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Chen X, Kao TJ, Ashe JM, Boverman G, Sabatini JE, Davenport DM. Multi-channel electrical impedance tomography for regional tissue hydration monitoring. Physiol Meas 2014; 35:1137-47. [DOI: 10.1088/0967-3334/35/6/1137] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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139
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Weyer S, Zink MD, Wartzek T, Leicht L, Mischke K, Vollmer T, Leonhardt S. Bioelectrical impedance spectroscopy as a fluid management system in heart failure. Physiol Meas 2014; 35:917-30. [PMID: 24846392 DOI: 10.1088/0967-3334/35/6/917] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Episodes of hospitalization for heart failure patients are frequent and are often accompanied by fluid accumulations. The change of the body impedance, measured by bioimpendace spectroscopy, is an indicator of the water content. The hypothesis was that it is possible to detect edema from the impedance data. First, a finite integration technique was applied to test the feasibility and allowed a theoretical analysis of current flows through the body. Based on the results of the simulations, a clinical study was designed and conducted. The segmental impedances of 25 patients suffering from heart failure were monitored over their recompensation process. The mean age of the patients was 73.8 and their mean body mass index was 28.6. From these raw data the model parameters from the Cole model were deduced by an automatic fitting algorithm. These model data were used to classify the edema status of the patient. The baseline values of the regression lines of the extra- and intracellular resistance from the transthoracic measurement and the baseline value of the regression line of the extracellular resistance from the foot-to-foot measurement were identified as important parameters for the detection of peripheral edema. The rate of change of the imaginary impedance at the characteristic frequency and the mean intracellular resistance from the foot-to-foot measurement were identified as important parameters for the detection of pulmonary edema. To classify the data, two decision trees were considered: One should detect pulmonary edema (n(pulmonary) = 13, n(none) = 12) and the other peripheral edema (n(peripheral) = 12, n(none) = 13). Peripheral edema could be detected with a sensitivity of 100% and a specificity of 90%. The detection of pulmonary edema showed a sensitivity of 92.31% and a specificity of 100%. The leave-one-out cross-validation-error for the peripheral edema detection was 12% and 8% for the detection of pulmonary edema. This enables the application of BIS as an early warning system for cardiac decompensation with the potential to optimize patient care.
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Affiliation(s)
- Sören Weyer
- Philips Chair of Medical Information Technology, RWTH Aachen University, Aachen, Germany
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140
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Hyun SH, Choi JY, Cho JH, Park SH, Kim CD, Kim YL. Assessment of fluid and nutritional status using multifrequency bioelectrical impedance analysis in peritoneal dialysis patients. Blood Purif 2014; 37:152-62. [PMID: 24777057 DOI: 10.1159/000360272] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 02/02/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS The purpose of this study was to evaluate the clinical usefulness and relevance of bioelectrical impedance analysis (BIA) for assessing the fluid and nutritional status in peritoneal dialysis (PD) patients. METHODS Statistical analyses between various measures of fluid and nutritional status were performed in 106 cases of 64 patients. RESULTS Extracellular fluid/total body water (ECF/TBW) was correlated with systolic blood pressure, extremity edema, and antihypertensive medications (p = 0.042, p < 0.001, and p = 0.029, respectively). Body cell mass (BCM)/height(2) was correlated with SGA rating and PCR (p < 0.001 and p = 0.002, respectively). ECF/TBW and BCM/height(2) significantly predicted extremity edema (p < 0.001) and SGA rating (p = 0.001), respectively. ROC analysis yielded an ECF/TBW cut-off of 0.36 and a BCM/height(2) cut-off of 11.23. When the BCM/height(2) cut-off of 11.23 was applied to subclinical patients (SGA score ≥6), a significant difference in SGA rating was detected in subgroups (p = 0.010). CONCLUSION BIA yields useful and relevant information about hydration and nutritional status in PD patients.
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Affiliation(s)
- Seung-Hyea Hyun
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University School of Medicine, Clinical Research Center for End Stage Renal Disease, Daegu, Korea
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141
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van Biesen W, Claes K, Covic A, Fan S, Lichodziejewska-Niemierko M, Schoder V, Verger C, Wabel P. A multicentric, international matched pair analysis of body composition in peritoneal dialysis versus haemodialysis patients. Nephrol Dial Transplant 2014; 28:2620-8. [PMID: 24078645 DOI: 10.1093/ndt/gft296] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Volume status, lean and fat tissue are gaining interest as prognostic predictors in patients on dialysis. Comparative data in peritoneal dialysis (PD) versus haemodialysis (HD) patients are lacking. METHODS In a cohort of PD (EuroBCM) and HD (Euclid database) patients, matched for country, gender, age and dialysis vintage, body composition was assessed by bioimpedance spectroscopy (BCM, Fresenius Medical Care). Time-averaged volume overload (TAVO) was defined as the mean of pre- and post-dialysis volume overload (VO), and relative (%) (TA)VO as (TA)VO/ECV. RESULTS Four hundred and ninety-one matched pairs (55.2% males, median age 60.0 years) were included. The body mass index (BMI, PD = 26.5 ± 4.7 versus HD = 25.9 ± 4.6 kg/m(2), P = 0.18 in males and 27.4 ± 5.8 versus 27.5 ± 6.6 kg/m(2), P = 0.75 in females) and fat tissue index (males: 11.5 ± 5.3 versus 11.4 ± 5.4 kg/m(2), P = 0.90, females: 14.8 ± 6.7 versus 15.4 ± 7.2 kg/m(2), P = 0.30) were not different in PD versus HD patients, whereas the lean tissue index (LTI) was higher in PD versus HD patients (males: 14.5 ± 3.4 versus 13.7 ± 3.1 kg/m(2), P = 0.001, females: 12.6 ± 3.3 versus 11.5 ± 2.6 kg/m(2), P < 0.0001). VO/extracellular water (ECW) was not different between PD versus just before the HD treatment (males: 10.8 ± 12.1 versus 9.2 ± 10.2%, P = 0.09; females: 6.5 ± 10.8 versus 7.7 ± 9.4%, P = 0.19). The relative TAVO was higher in PD versus HD (10.8 ± 12.1% versus 3.2 ± 11.2%, and 6.5 ± 10.8% versus 1.2 ± 10.9%, both P < 0.0001). CONCLUSIONS The LTI was impaired, and this was more in males versus females, but was better preserved on PD versus HD, whereas fat tissue index (FTI) was increased, but not different between PD and HD. Volume overload was more present in PD versus HD when TAVO, but not when predialysis volume status, was used as a reference.
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Affiliation(s)
- Wim van Biesen
- Renal Division, Ghent University Hospital, Ghent, Belgium
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142
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Hung SC, Kuo KL, Peng CH, Wu CH, Lien YC, Wang YC, Tarng DC. Volume overload correlates with cardiovascular risk factors in patients with chronic kidney disease. Kidney Int 2014; 85:703-9. [DOI: 10.1038/ki.2013.336] [Citation(s) in RCA: 164] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 05/25/2013] [Accepted: 06/20/2013] [Indexed: 11/09/2022]
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143
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Onofriescu M, Hogas S, Voroneanu L, Apetrii M, Nistor I, Kanbay M, Covic AC. Bioimpedance-guided fluid management in maintenance hemodialysis: a pilot randomized controlled trial. Am J Kidney Dis 2014; 64:111-8. [PMID: 24583055 DOI: 10.1053/j.ajkd.2014.01.420] [Citation(s) in RCA: 169] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Accepted: 01/10/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Chronic subclinical volume overload happens very frequently in hemodialysis patients and is associated directly with hypertension, increased arterial stiffness, left ventricular hypertrophy, and ultimately higher mortality. STUDY DESIGN Randomized controlled parallel-group trial. SETTING & PARTICIPANTS 131 patients from one hemodialysis center, randomly assigned into 2 groups. INTERVENTION Dry weight prescription using results derived from repeated 3-month bioimpedance measurements to guide ultrafiltration for strict volume control (bioimpedance group; n=62) compared with clinical judgment without bioimpedance measures (clinical-methods group; n=69) for 2.5 years. OUTCOMES The primary outcome was all-cause mortality over 2.5 years (the duration of the intervention). Secondary outcomes were change in relative arterial stiffness, fluid overload, and blood pressure (BP) over 2.5 years. MEASUREMENTS Bioimpedance measurements were performed using a Body Composition Monitor device. Pulse wave velocity analysis was performed at baseline, 2.5 years (end of intervention), and 3.5 years (end of study). Relative fluid overload and BP were assessed at 3-month intervals. RESULTS The unadjusted HR for all-cause death in the bioimpedance group (vs the clinical-methods group) was 0.100 (95% CI, 0.013-0.805; P=0.03). After 2.5 years, we found a greater decline in arterial stiffness, relative fluid overload, and systolic BP in the bioimpedance group than the clinical-methods group. Between-group differences in change from baseline to the end of intervention were -2.78 (95% CI, -3.75 to 1.80)m/s for pulse wave velocity (P<0.001), -2.99% (95% CI, -5.00% to -0.89%) for relative fluid overload (P=0.05), and -2.43 (95% CI, -7.70 to 2.84)mmHg for systolic BP (P=0.4). LIMITATIONS Echocardiography was not performed as cardiovascular assessment and the caregivers were not masked to the intervention. CONCLUSIONS Our study showed improvement in both surrogate and hard end points after strict volume control using bioimpedance to guide dry weight adjustment. These findings need to be confirmed in a larger trial.
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Affiliation(s)
- Mihai Onofriescu
- Nephrology Department, "Dr. C.I. Parhon" University Hospital, University of Medicine and Pharmacy "Gr. T. Popa," Iasi, Romania.
| | - Simona Hogas
- Nephrology Department, "Dr. C.I. Parhon" University Hospital, University of Medicine and Pharmacy "Gr. T. Popa," Iasi, Romania
| | - Luminita Voroneanu
- Nephrology Department, "Dr. C.I. Parhon" University Hospital, University of Medicine and Pharmacy "Gr. T. Popa," Iasi, Romania
| | - Mugurel Apetrii
- Nephrology Department, "Dr. C.I. Parhon" University Hospital, University of Medicine and Pharmacy "Gr. T. Popa," Iasi, Romania
| | - Ionut Nistor
- Nephrology Department, "Dr. C.I. Parhon" University Hospital, University of Medicine and Pharmacy "Gr. T. Popa," Iasi, Romania
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Istanbul Medeniyet University School of Medicine, Istanbul, Turkey
| | - Adrian C Covic
- Nephrology Department, "Dr. C.I. Parhon" University Hospital, University of Medicine and Pharmacy "Gr. T. Popa," Iasi, Romania
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144
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[Extracellular hydration status and residual urinary sodium excretion in chronic hemodialysis patients: a cross-sectional multicenter study]. Nephrol Ther 2014; 10:94-100. [PMID: 24508000 DOI: 10.1016/j.nephro.2013.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 10/29/2013] [Accepted: 11/10/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND In dialysis patients, a misevaluation of dry weight may lead to an increased morbidity and mortality. The aim of this cross-sectional multicenter study was to evaluate the association between residual urinary sodium excretion and extracellular volume status in chronically treated hemodialysis patients. PATIENTS AND METHODS Dry weight was determined clinically and by whole-body bioimpedance spectroscopy (Body Composition Monitor, Fresenius Medical Care) prior to a mid-week session in 40 chronic hemodialysis patients with significant residual diuresis (more than 250 mL per day) and receiving treatment in four dialysis centers. Regarding their hydration status assessed by the Body Composition Monitor and in comparison to a healthy reference population, patients were assigned to 1 of the 3 categories: overhydrated, normohydrated and dehydrated. Urine output, urinary sodium excretion and residual renal function were measured for all patients within 30 days before dry weight assessment. RESULTS The median post-HD session FO was of-0.40 L (IQR: from-1.95 to+0.90) and the median residual urinary sodium excretion was of 64 mmol/L (IQR: 46-79). Among these patients, 16 were normohydated, 16 were dehydrated and 8 were overhydrated. There was a linear relationship between the hydration status after HD session and the urinary sodium excretion (estimate: 5.6±1.5; p<0.001). Compared with normohydrated patients, overhydrated patients had a higher residual urinary sodium excretion (estimate: 26±10; p<0.01). CONCLUSION In this study, urinary sodium excretion is associated with the hydration status evaluated by whole-body bioimpedance spectroscopy.
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145
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Ferrario M, Moissl U, Garzotto F, Cruz DN, Clementi A, Brendolan A, Tetta C, Gatti E, Signorini MG, Cerutti S, Ronco C. Effects of fluid overload on heart rate variability in chronic kidney disease patients on hemodialysis. BMC Nephrol 2014; 15:26. [PMID: 24490775 PMCID: PMC3916802 DOI: 10.1186/1471-2369-15-26] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 01/30/2014] [Indexed: 11/23/2022] Open
Abstract
Background While fluid overload (FO) and alterations in the autonomic nervous system (ANS) such as hypersympathetic activity, are known risk factors for cardiovascular morbidity and mortality in patients on chronic hemodialysis (HD), their relationship has not been thoroughly studied. Methods In this observational study involving 69 patients on chronic HD, FO was assessed by whole body bioimpedance measurements before the midweek HD session and ANS activity reflected by Heart Rate Variability (HRV) was measured using 24-hour Holter electrocardiogram recordings starting before the same HD treatment. In total, 13 different HRV indices were analyzed, comprising a mixture of time domain, frequency domain and complexity parameters. A correlation analysis was performed between the HRV indices and hydration status indices. Successively, patients were retrospectively assigned to a high FO (H, FO > 2.5 L) or low FO (L, FO ≤ 2.5 L) group and these were further compared also after stratification by diabetes mellitus. Finally, a small number of patients without diabetes with significant and persistent FO were followed up for 3 months post-study to investigate how normalization of fluid status affects HRV. Results SDANN, VLF, LZC and HF% parameters significantly correlate with FO (correlation coefficients were respectively r = –0.40, r = –0.37, r = –0.28 and r = 0.26, p-value < 0.05). Furthermore, LF% and LF/HF were inversely correlated with hydration status (correlation coefficients were respectively r = –0.31 and r = -0.33, p-value < 0.05). These results indicate an association between FO and reduced HRV, higher parasympathetic activation and reduced sympathetic response to the HD session. Indeed, group H tended to have lower values of SDANN, VLF and LZC, and higher values of HF% than patients in the L group. Finally, there was a trend towards lower LF% measured during the last 30 minutes of HD for the H group versus the L group. Reduction in FO achieved over 3 months by implementation of a strict fluid management plan resulted in an increase of HRV. Conclusions Our results suggest that depressed HRV is associated with fluid overload and that normalization of hydration status is accompanied by improved HRV.
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Affiliation(s)
- Manuela Ferrario
- Department of Electronics, Information and Bioengineering (DEIB), Politecnico di Milano, P,zza Leonardo da Vinci 32, Milano, Italy.
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Yilmaz Z, Yildirim Y, Oto F, Aydin FY, Aydin E, Kadiroglu AK, Yilmaz ME. Evaluation of volume overload by bioelectrical impedance analysis, NT-proBNP and inferior vena cava diameter in patients with stage 3&4 and 5 chronic kidney disease. Ren Fail 2014; 36:495-501. [PMID: 24456050 DOI: 10.3109/0886022x.2013.875815] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Determination of fluid overload is important in chronic kidney disease. Early diagnosis and treatment of volume overload may decrease morbidity and mortality. We aimed to determine body composition by using bioelectrical impedance analysis, and studying other clinical characteristics, inferior vena cava diameter, and N-terminal pro-B natriuretic peptide associated with hydration status in chronic kidney disease Stages 3&4 and 5 in patients not undergoing dialysis. METHOD We examined 62 patients with Stages 3&4 and 68 patients with Stage 5 chronic kidney disease. Plasma NT-proBNP was measured and analyzed after log transformation. Inferior vena cave diameter was measured with echocardiography and indexed for body surface area. Hydration status was assessed using multi-frequency bioelectrical impedance analysis. Overhydration was defined as overhydration/extracellular water >0.15. RESULTS Overhydration was more frequent in Stage 5 than in Stages 3&4 patients. Systolic and diastolic blood pressure, inferior vena cava index, and log NT-proBNP were higher in overhydrated compared to non-overhydrated patients. A significant positive correlation existed between overhydration/extracellular water and log NT-proBNP, systolic and diastolic blood pressures, and inferior vena cava index. In multiple linear regression analysis, the variables associated with hydration status were male sex, extracellular water/total body water, and extracellular water/intracellular water (greater overhydration), while serum albumin levels had a negative association with overhydration. CONCLUSION Overhydration is more prevalent in Stage 5 chronic kidney disease patients than in Stages 3&4 patients. Bioelectrical impedance analysis, inferior vena cava diameter, and NT-proBNP analysis in chronic kidney disease are useful methods to determine the volume overload.
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Affiliation(s)
- Zülfükar Yilmaz
- Department of Nephrology, Faculty of Medicine, Dicle University , Diyarbakir , Turkey and
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147
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Tapolyai MB, Faludi M, Fülöp T, Dossabhoy NR, Szombathelyi A, Berta K. Which fluid space is affected by ultrafiltration during hemodiafiltration? Hemodial Int 2014; 18:384-90. [DOI: 10.1111/hdi.12125] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mihály B. Tapolyai
- Fresenius Medical Care; Semmelweis University; Budapest Hungary
- Department of Medicine, Division of Nephrology; WJB Dorn VA Medical Center; Columbia South Carolina USA
| | - Mária Faludi
- Fresenius Medical Care; Semmelweis University; Budapest Hungary
| | - Tibor Fülöp
- Department of Medicine, Division of Nephrology; University of Mississippi; Jackson Mississippi USA
| | - Neville R. Dossabhoy
- Overton Brooks Veterans' Administration Medical Center; Louisiana State University Health Sciences Center; Shreveport Louisiana USA
| | - Anita Szombathelyi
- Department of Mathematics; Louisiana State University Shreveport; Shreveport Louisiana USA
| | - Klára Berta
- Fresenius Medical Care; Semmelweis University; Budapest Hungary
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148
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Abstract
Intradialytic hypotension is the most common adverse event that occurs during the hemodialysis procedure. Despite advances in machine technology, it remains a difficult management issue. The pathophysiology of intradialytic hypotension and measures to reduce its frequency are discussed. An accurate assessment of dry weight is crucial in all patients on dialysis and especially those patients prone to intradialytic hypotension. The presence of edema and hypertension has recently been shown to be a poor predictor of volume overload. Noninvasive methods to assess volume status, such as whole body and segmental bioimpedance, hold promise to more accurately assess fluid status. Reducing salt intake is key to limiting interdialytic weight gain. A common problem is that patients are often told to restrict fluid but not salt intake. Lowering the dialysate temperature, prohibiting food ingestion during hemodialysis, and midodrine administration are beneficial. Sodium modeling in the absence of ultrafiltration modeling should be abandoned. There is not enough data on the efficacy of l-carnitine to warrant its routine use.
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Affiliation(s)
- Robert F Reilly
- Division of Nephrology, Medical Service, Veterans Affairs North Texas Health Care System, Dallas, Texas
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149
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Kocyigit I, Sipahioglu MH, Orscelik O, Unal A, Celik A, Abbas SR, Zhu F, Tokgoz B, Dogan A, Oymak O, Kotanko P, Levin NW. The association between arterial stiffness and fluid status in peritoneal dialysis patients. Perit Dial Int 2014; 34:781-90. [PMID: 24385328 DOI: 10.3747/pdi.2013.00057] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES In this study our aim was to evaluate the relationship between degree of fluid status and arterial stiffness measured by pulse wave velocity (PWV) in peritoneal dialysis (PD) patients. Fluid status was determined by different methods including fluid overload measured by bioimpedance (Body Composition Monitor, BCM), calf normalized resistivity (CNR), plasma N-terminal fragment of B-type natriuretic peptide (NT-proBNP) and extracellular to intracellular water ratio (ECW/ICW). METHODS Sixty PD patients were evaluated. They were stratified into normo- and hypervolemic groups according to their fluid overload (FO). CNR was calculated from resistance at 5 kHz using calf bioimpedance spectroscopy. Arterial stiffness was assessed by PWV. Additionally, all patients underwent transthoracic echocardiography and had levels of NT-proBNP measured. RESULTS PWV was higher in the hypervolemic compared to normovolemic patients (9.99 ± 2.4 m/sec vs 7.48 ± 2.3 m/sec, p < 0.001). Hypervolemic patients had higher NT-proBNP levels (3065 ± 981 pg/mL vs 1095 ± 502 pg/mL, p < 0.001), a higher ratio of ECW/ICW; (0.93 ± 0.11 vs 0.81 ± 0.08, p < 0.001) and lower CNR (13.7 ± 2.4 vs 16.0 ± 3.3 W m(3)/kg(*)10(-2), p = 0.005). NT-pro BNP level, ECW/ICW ratio, relative FO, and left ventricular (LV) mass index were positively and CNR negatively correlated with PWV. Relative FO and CNR independently predicted PWV in multivariate analysis adjusted for age, duration of PD, body mass index and mean arterial pressure. CONCLUSIONS Arterial stiffness is increased in fluid-overloaded PD patients. Our results indicated that fluid status is an independent predictor of PWV.
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Affiliation(s)
- Ismail Kocyigit
- Erciyes University Medical Faculty, Department of Nephrology, Kayseri, Turkey; Erciyes University Medical Faculty, Department of Cardiology, Kayseri, Turkey; and Renal Research Institute, New York City, NY, USA
| | - Murat Hayri Sipahioglu
- Erciyes University Medical Faculty, Department of Nephrology, Kayseri, Turkey; Erciyes University Medical Faculty, Department of Cardiology, Kayseri, Turkey; and Renal Research Institute, New York City, NY, USA
| | - Ozcan Orscelik
- Erciyes University Medical Faculty, Department of Nephrology, Kayseri, Turkey; Erciyes University Medical Faculty, Department of Cardiology, Kayseri, Turkey; and Renal Research Institute, New York City, NY, USA
| | - Aydin Unal
- Erciyes University Medical Faculty, Department of Nephrology, Kayseri, Turkey; Erciyes University Medical Faculty, Department of Cardiology, Kayseri, Turkey; and Renal Research Institute, New York City, NY, USA
| | - Ahmet Celik
- Erciyes University Medical Faculty, Department of Nephrology, Kayseri, Turkey; Erciyes University Medical Faculty, Department of Cardiology, Kayseri, Turkey; and Renal Research Institute, New York City, NY, USA
| | - Samer R Abbas
- Erciyes University Medical Faculty, Department of Nephrology, Kayseri, Turkey; Erciyes University Medical Faculty, Department of Cardiology, Kayseri, Turkey; and Renal Research Institute, New York City, NY, USA
| | - Fansan Zhu
- Erciyes University Medical Faculty, Department of Nephrology, Kayseri, Turkey; Erciyes University Medical Faculty, Department of Cardiology, Kayseri, Turkey; and Renal Research Institute, New York City, NY, USA
| | - Bulent Tokgoz
- Erciyes University Medical Faculty, Department of Nephrology, Kayseri, Turkey; Erciyes University Medical Faculty, Department of Cardiology, Kayseri, Turkey; and Renal Research Institute, New York City, NY, USA
| | - Ali Dogan
- Erciyes University Medical Faculty, Department of Nephrology, Kayseri, Turkey; Erciyes University Medical Faculty, Department of Cardiology, Kayseri, Turkey; and Renal Research Institute, New York City, NY, USA
| | - Oktay Oymak
- Erciyes University Medical Faculty, Department of Nephrology, Kayseri, Turkey; Erciyes University Medical Faculty, Department of Cardiology, Kayseri, Turkey; and Renal Research Institute, New York City, NY, USA
| | - Peter Kotanko
- Erciyes University Medical Faculty, Department of Nephrology, Kayseri, Turkey; Erciyes University Medical Faculty, Department of Cardiology, Kayseri, Turkey; and Renal Research Institute, New York City, NY, USA
| | - Nathan W Levin
- Erciyes University Medical Faculty, Department of Nephrology, Kayseri, Turkey; Erciyes University Medical Faculty, Department of Cardiology, Kayseri, Turkey; and Renal Research Institute, New York City, NY, USA
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150
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Antlanger M, Hecking M, Haidinger M, Werzowa J, Kovarik JJ, Paul G, Eigner M, Bonderman D, Hörl WH, Säemann MD. Fluid overload in hemodialysis patients: a cross-sectional study to determine its association with cardiac biomarkers and nutritional status. BMC Nephrol 2013; 14:266. [PMID: 24295522 PMCID: PMC4219439 DOI: 10.1186/1471-2369-14-266] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Accepted: 11/26/2013] [Indexed: 12/30/2022] Open
Abstract
Background Chronic fluid overload is associated with higher mortality in dialysis patients; however, the link with cardiovascular morbidity has not formally been established and may be influenced by subclinical inflammation. We hypothesized that a relationship exists between fluid overload and [i] cardiovascular laboratory parameter as well as between fluid overload and [ii] inflammatory laboratory parameters. In addition, we aimed to confirm whether volume status correlates with nutritional status. Methods We recorded baseline characteristics of 244 hemodialysis patients at three hemodialysis facilities in Vienna (Austria) and determined associations with volume measurements using the body composition monitor (Fresenius/Germany). In one facility comprising 126 patients, we further analyzed cardiovascular, inflammatory and nutritional parameters. Results We detected predialysis fluid overload (FO) in 39% of all patients (n = 95) with FO defined as ≥15% of extracellular water (ECW). In this subgroup, the absolute FO was 4.4 +/-1.5 L or 22.9 ± 4.8% of ECW. A sub-analysis of patients from one center showed that FO was negatively associated with body mass index (r = -0.371; p = <0.001), while serum albumin was significantly lower in fluid overloaded patients (p = 0.001). FO was positively associated with D-Dimer (r = 0.316; p = 0.001), troponin T (r = 0.325; p < 0.001), and N-terminal pro-B-type natriuretic peptide (r = 0.436; p < 0.001), but not with investigated inflammatory parameters. Conclusions Fluid overload in HD patients was found to be lower in patients with high body mass index, indicating that dry weight was inadequately prescribed and/or difficult to achieve in overweight patients. The association with parameters of cardiovascular compromise and/or damage suggests that fluid overload is a biomarker for cardiovascular risk. Future studies should determine if this applies to patients prior to end-stage renal disease.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Marcus D Säemann
- Department of Internal Medicine III - Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna Austria.
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