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Abstract
The term uraemic cardiomyopathy refers to the cardiac abnormalities that are seen in patients with chronic kidney disease (CKD). Historically, this term was used to describe a severe cardiomyopathy that was associated with end-stage renal disease and characterized by severe functional abnormalities that could be reversed following renal transplantation. In a modern context, uraemic cardiomyopathy describes the clinical phenotype of cardiac disease that accompanies CKD and is perhaps best characterized as diastolic dysfunction seen in conjunction with left ventricular hypertrophy and fibrosis. A multitude of factors may contribute to the pathogenesis of uraemic cardiomyopathy, and current treatments only modestly improve outcomes. In this Review, we focus on evolving concepts regarding the roles of fibroblast growth factor 23 (FGF23), inflammation and systemic oxidant stress and their interactions with more established mechanisms such as pressure and volume overload resulting from hypertension and anaemia, respectively, activation of the renin-angiotensin and sympathetic nervous systems, activation of the transforming growth factor-β (TGFβ) pathway, abnormal mineral metabolism and increased levels of endogenous cardiotonic steroids.
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Affiliation(s)
- Xiaoliang Wang
- Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Joseph I Shapiro
- Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA.
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202
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Hong YA, Yoon HE, Choi BS, Shin SJ, Kim YS, Lee SY, Lee SH, Kim SH, Lee EY, Shin SK, Kwon YJ, Kim JH, Chang YK, Kim SY, Kim JE, Ahn SY, Ko GJ. The Effect of Strict Volume Control Assessed by Repeated Bioimpedance Spectroscopy on Cardiac Function in Peritoneal Dialysis Patients. Sci Rep 2019; 9:17679. [PMID: 31776362 PMCID: PMC6881363 DOI: 10.1038/s41598-019-53792-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 10/31/2019] [Indexed: 01/08/2023] Open
Abstract
Adequate fluid management plays an important role in decreasing cardiovascular risk in peritoneal dialysis (PD) patients. We evaluated whether strict volume control monitored by bioimpedance spectroscopy (BIS) affects cardiac function in PD patients. This study is a secondary analysis of a multicentre, prospective, randomized, controlled trial. Fluid overload was assessed by the average overhydration/extracellular water (OH/ECW) at baseline, 6 months and 12 months. Patients were categorized as time-averaged overhydrated (TA-OH/ECW ≥15%) or normohydrated (TA-OH/ECW <15%), and echocardiographic parameters were compared between groups. Among a total of 151 patients, 120 patients exhibited time-averaged normohydration. Time-averaged overhydrated patients had a significantly higher left atrial (LA) diameter and E/e′ ratio and a lower left ventricular (LV) ejection fraction at 12 months than time-averaged normohydrated patients. LA diameter, end-systolic volume and end-diastolic volume were decreased at 12 months compared to baseline in time-averaged normohydrated patients only. TA-OH/ECW was independently associated with ejection fraction at 12 months (β = −0.190; p = 0.010). TA-OH/ECW, but not OH/ECW at 12 months, was an independent risk factor for LV dysfunction (odds ratio 4.020 [95% confidence interval 1.285–12.573]). Overhydration status based on repeated BIS measurements is an independent predictor of LV systolic function in PD patients.
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Affiliation(s)
- Yu Ah Hong
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hye Eun Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Bum Soon Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok Joon Shin
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong-Soo Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - So Young Lee
- Department of Internal Medicine, Eulji University School of Medicine, Seoul, Republic of Korea
| | - Sang-Ho Lee
- Department of Internal Medicine, Kyung Hee University Medical School, Seoul, Republic of Korea
| | - Su Hyun Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Eun Young Lee
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Sug Kyun Shin
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Young Joo Kwon
- Department of Internal Medicine, Korea University School of Medicine, Seoul, Republic of Korea
| | - Jeong Ho Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoon Kyung Chang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Suk Young Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji Eun Kim
- Department of Internal Medicine, Korea University School of Medicine, Seoul, Republic of Korea
| | - Shin Young Ahn
- Department of Internal Medicine, Korea University School of Medicine, Seoul, Republic of Korea
| | - Gang Jee Ko
- Department of Internal Medicine, Korea University School of Medicine, Seoul, Republic of Korea.
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203
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Feasibility of Assessing Sodium-Associated Body Fluid Composition in End-Stage Renal Disease. Nurs Res 2019; 68:246-252. [PMID: 31033867 DOI: 10.1097/nnr.0000000000000320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Cardiovascular disease accounts for more than half of all deaths in the hemodialysis (HD) population. Although much of this mortality is associated with fluid overload (FO), FO is difficult to measure, and many HD patients have significant pulmonary congestion despite the absence of clinical presentation. Cohort studies have observed that FO, as measured by bioimpedance spectroscopy (BIS), correlates with mortality. Other studies have observed that lower sodium intake is associated with less fluid-related weight gain, improved hypertension, and survival. Whether sodium intake influences FO in HD patients as measured by BIS is not known. OBJECTIVE The aims of the study were to determine the feasibility of assessing the impact of sodium restriction on body fluid composition as measured by BIS among patients with three levels of sodium intake and to determine if there are statistical and/or clinical differences in BIS measures across sodium intake groups. METHODS We used a double-blinded randomized controlled trial design with three levels of sodium restriction, 2,400 mg per day, 1,500 mg per day, and unrestricted (control group), to test our aims. Forty-two HD patients from a tertiary acute care academic institution associated with three urban DaVita dialysis centers were enrolled. Participants remained in the inpatient center for 5 days and 4 nights and were randomly assigned to sodium intake groups. Body fluid composition was measured with BIS. RESULTS Recruitment, enrollment, and retention statistics supported the feasibility of the study design. Regression analyses showed that there were no statistically significant differences among sodium intake groups on any of the outcomes. DISCUSSION Our data suggest the need for additional research into the effects of sodium restriction on body fluid composition.
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204
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Skoumalova I, Kolarcik P, Madarasova Geckova A, Rosenberger J, Majernikova M, Klein D, van Dijk JP, Reijneveld SA. Is Health Literacy of Dialyzed Patients Related to Their Adherence to Dietary and Fluid Intake Recommendations? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E4295. [PMID: 31694265 PMCID: PMC6862452 DOI: 10.3390/ijerph16214295] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 11/16/2022]
Abstract
Non-adherence to dietary and fluid intake recommendations (NADFIR) is an important factor for the effective treatment of dialyzed patients and may be hindered by low health literacy (HL). Therefore, we assessed whether low HL of dialyzed patients is associated with their NADFIR. We performed a multicentric cross-sectional study in 20 dialysis clinics in Slovakia (n = 452; response rate: 70.1%; mean age = 63.6 years; males: 60.7%). We assessed the association between nine domains of HL and non-adherence (high serum potassium, high serum phosphate, relative overhydration, and self-reported NADFIR) using general linear models adjusted for age and gender. Moreover, we assessed the moderation by socioeconomic status (SES). We found higher NADFIR among patients with less sufficient information for health management (high serum phosphate level; odds ratio (OR): 0.77; 95% confidence interval (CI): 0.63-0.94), with a lower ability to actively manage their health (self-reported diet non-adherence; OR: 0.74; 95% CI: 0.62-0.89), and those less able to actively engage with healthcare providers (overhydrated; OR: 0.78; 95% CI: 0.65-0.94). Moreover, SES modified this relation. Low HL affects the adherence of dialyzed patients. This shows a need to support patients with low HL and to train healthcare providers to work with these patients, taking into account their SES.
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Affiliation(s)
- Ivana Skoumalova
- Department of Health Psychology, Faculty of Medicine, PJ Safarik University, Trieda SNP 1, 040 11 Kosice, Slovakia; (P.K.); (A.M.G.); (J.R.)
- Graduate School Kosice Institute for Society and Health, PJ Safarik University, Trieda SNP 1, 040 11 Kosice, Slovakia;
- Department of Community & Occupational Health, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands;
| | - Peter Kolarcik
- Department of Health Psychology, Faculty of Medicine, PJ Safarik University, Trieda SNP 1, 040 11 Kosice, Slovakia; (P.K.); (A.M.G.); (J.R.)
- Olomouc University Social Health Institute, Palacky University in Olomouc, Univerzitni 22, Olomouc 771 11, Czech Republic
| | - Andrea Madarasova Geckova
- Department of Health Psychology, Faculty of Medicine, PJ Safarik University, Trieda SNP 1, 040 11 Kosice, Slovakia; (P.K.); (A.M.G.); (J.R.)
- Department of Community & Occupational Health, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands;
- Olomouc University Social Health Institute, Palacky University in Olomouc, Univerzitni 22, Olomouc 771 11, Czech Republic
| | - Jaroslav Rosenberger
- Department of Health Psychology, Faculty of Medicine, PJ Safarik University, Trieda SNP 1, 040 11 Kosice, Slovakia; (P.K.); (A.M.G.); (J.R.)
- Graduate School Kosice Institute for Society and Health, PJ Safarik University, Trieda SNP 1, 040 11 Kosice, Slovakia;
- Olomouc University Social Health Institute, Palacky University in Olomouc, Univerzitni 22, Olomouc 771 11, Czech Republic
- II. Internal Clinic, Faculty of Medicine, P.J. Safarik University, Trieda SNP 1, 040 11 Kosice, Slovakia
- FMC-Dialysis Services Slovakia, Trieda SNP 1, 040 11 Kosice, Slovakia;
| | - Maria Majernikova
- FMC-Dialysis Services Slovakia, Trieda SNP 1, 040 11 Kosice, Slovakia;
| | - Daniel Klein
- Institute of Mathematics, Faculty of Science, P. J. Safarik University, Jesenna 5, 040 01 Kosice, Slovakia;
| | - Jitse P. van Dijk
- Graduate School Kosice Institute for Society and Health, PJ Safarik University, Trieda SNP 1, 040 11 Kosice, Slovakia;
- Department of Community & Occupational Health, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands;
- Olomouc University Social Health Institute, Palacky University in Olomouc, Univerzitni 22, Olomouc 771 11, Czech Republic
| | - Sijmen A. Reijneveld
- Department of Community & Occupational Health, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands;
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205
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Stenberg J, Keane D, Lindberg M, Furuland H. Systematic Fluid Assessment in Haemodialysis: Development and Validation of A Decision Aid. J Ren Care 2019; 46:52-61. [PMID: 31682083 PMCID: PMC7328711 DOI: 10.1111/jorc.12304] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND About a third of patients undergoing haemodialysis have poorly controlled fluid status, which may affect survival. Clinical assessment is subjective and imprecise, which has led to the increasing use of devices based on bioimpedance spectroscopy (BIS). However, BIS cannot provide a simple target applicable to all patients. Our aim was to develop and validate a decision aid combining clinical assessment of fluid status with information from BIS in target weight determination. METHODS The decision aid was based on empirical experience and a literature review identifying physiological parameters already used in the clinical assessment of fluid status. Content validity was established by patient representatives, interdisciplinary stakeholders and external experts, who assessed item relevance and comprehensiveness. Reliability was assessed by inter-rater agreement analysis between nurses assessing typical patient cases. RESULTS The decision aid for Recognition and Correction of Volume Alterations (RECOVA) consists of three parts (1) a scoring system; (2) thresholds and triggers; (3) a decision aid algorithm. Agreement between raters in the assessment of symptoms was almost perfect, with Intraclass Correlation Coefficient > 0.90. Agreement in clinical response was only fair, but increased to moderate, with training and self-reported confidence. CONCLUSION RECOVA may enable systematic clinical assessment of fluid status, facilitating early recognition of fluid alterations, and incorporation of bioimpedance into target weight management. However, implementation into clinical practice will require training of staff. Clinical intervention studies are required to evaluate if RECOVA facilitates response to and correction of recognised fluid alterations.
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Affiliation(s)
- Jenny Stenberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - David Keane
- Department of Renal Medicine, Leeds Teaching Hospitals Trust Leeds, UK
| | - 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, Uppsala University, Uppsala, Sweden
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206
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Combined Predictive Value of Extracellular Fluid/Intracellular Fluid Ratio and the Geriatric Nutritional Risk Index for Mortality in Patients Undergoing Hemodialysis. Nutrients 2019; 11:nu11112659. [PMID: 31690024 PMCID: PMC6893674 DOI: 10.3390/nu11112659] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 10/14/2019] [Accepted: 11/01/2019] [Indexed: 01/19/2023] Open
Abstract
The ratio of extracellular fluid (ECF) to intracellular fluid (ICF) may be associated with mortality in patients undergoing hemodialysis, possibly associated with protein-energy wasting. We therefore investigated the relationship of the ECF/ICF ratio and the geriatric nutritional risk index (GNRI) with the all-cause and cardiovascular-specific mortality in 234 patients undergoing hemodialysis. Bioimpedance analysis of the ECF and ICF was performed and the ECF/ICF ratio was independently associated with GNRI (β = −0.247, p < 0.0001). During a median follow-up of 2.8 years, 72 patients died, of which 29 were cardiovascular. All-cause mortality was independently associated with a lower GNRI (adjusted hazard ratio [aHR] 3.48, 95% confidence interval [CI] 2.01–6.25) and a higher ECF/ICF ratio (aHR 11.38, 95%CI 5.29–27.89). Next, we divided patients into four groups: group 1 (G1), higher GNRI and lower ECF/ICF ratio; G2, lower GNRI and lower ECF/ICF ratio; G3, higher GNRI and higher ECF/ICF ratio; and G4, lower GNRI and higher ECF/ICF ratio. Analysis of these groups revealed 10-year survival rates of 91.2%, 67.2%, 0%, and 0% in G1, G2, G3, and G4, respectively. The aHR for G4 versus G1 was 43.4 (95%CI 12.2–279.8). Adding the GNRI alone, the ECF/ICF ratio alone, or both to the established risk model improved the net reclassification improvement by 0.444, 0.793 and 0.920, respectively. Similar results were obtained for cardiovascular mortality. In conclusion, the ECF/ICF ratio was independently associated with GNRI and could predict mortality in patients undergoing hemodialysis. Combining the GNRI and ECF/ICF ratio could improve mortality predictions.
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207
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El Hussein MT, Kilfoil L. Managing End-Stage Renal Disease: An Alphabetized Mnemonic Strategy. J Nurse Pract 2019. [DOI: 10.1016/j.nurpra.2019.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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208
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Martín-Moreno A, Muñoz-Fernández MA. Dendritic Cells, the Double Agent in the War Against HIV-1. Front Immunol 2019; 10:2485. [PMID: 31708924 PMCID: PMC6820366 DOI: 10.3389/fimmu.2019.02485] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 10/04/2019] [Indexed: 12/19/2022] Open
Abstract
Human Immunodeficiency Virus (HIV) infects cells from the immune system and has thus developed tools to circumvent the host immunity and use it in its advance. Dendritic cells (DCs) are the first immune cells to encounter the HIV, and being the main antigen (Ag) presenting cells, they link the innate and the adaptive immune responses. While DCs work to promote an efficient immune response and halt the infection, HIV-1 has ways to take advantage of their role and uses DCs to gain faster and more efficient access to CD4+ T cells. Due to their ability to activate a specific immune response, DCs are promising candidates to achieve the functional cure of HIV-1 infection, but knowing the molecular partakers that determine the relationship between virus and cell is the key for the rational and successful design of a DC-based therapy. In this review, we summarize the current state of knowledge on how both DC subsets (myeloid and plasmacytoid DCs) act in presence of HIV-1, and focus on different pathways that the virus can take after binding to DC. First, we explore the consequences of HIV-1 recognition by each receptor on DCs, including CD4 and DC-SIGN. Second, we look at cellular mechanisms that prevent productive infection and weapons that turn cellular defense into a Trojan horse that hides the virus all the way to T cell. Finally, we discuss the possible outcomes of DC-T cell contact.
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Affiliation(s)
- Alba Martín-Moreno
- Sección de Inmunología, Laboratorio InmunoBiología Molecular, Hospital General Universitario Gregorio Marañón (HGUGM), Madrid, Spain.,Instituto Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Mª Angeles Muñoz-Fernández
- Sección de Inmunología, Laboratorio InmunoBiología Molecular, Hospital General Universitario Gregorio Marañón (HGUGM), Madrid, Spain.,Instituto Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain.,Spanish HIV-HGM BioBank, Madrid, Spain.,Networking Research Center on Bioengineering, Biomaterials and Nanomedicine (CIBER BBN), Madrid, Spain
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209
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Hecking M, Moissl U, Genser B, Rayner H, Dasgupta I, Stuard S, Stopper A, Chazot C, Maddux FW, Canaud B, Port FK, Zoccali C, Wabel P. Greater fluid overload and lower interdialytic weight gain are independently associated with mortality in a large international hemodialysis population. Nephrol Dial Transplant 2019; 33:1832-1842. [PMID: 29688512 PMCID: PMC6168737 DOI: 10.1093/ndt/gfy083] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/02/2018] [Indexed: 11/12/2022] Open
Abstract
Background Fluid overload and interdialytic weight gain (IDWG) are discrete components of the dynamic fluid balance in haemodialysis patients. We aimed to disentangle their relationship, and the prognostic importance of two clinically distinct, bioimpedance spectroscopy (BIS)-derived measures, pre-dialysis and post-dialysis fluid overload (FOpre and FOpost) versus IDWG. Methods We conducted a retrospective cohort study on 38 614 incident patients with one or more BIS measurement within 90 days of haemodialysis initiation (1 October 2010 through 28 February 2015). We used fractional polynomial regression to determine the association pattern between FOpre, FOpost and IDWG, and multivariate adjusted Cox models with FO and/or IDWG as longitudinal and time-varying predictors to determine all-cause mortality risk. Results In analyses using 1-month averages, patients in quartiles 3 and 4 (Q3 and Q4) of FO had an incrementally higher adjusted mortality risk compared with reference Q2, and patients in Q1 of IDWG had higher adjusted mortality compared with Q2. The highest adjusted mortality risk was observed for patients in Q4 of FOpre combined with Q1 of IDWG [hazard ratio (HR) = 2.66 (95% confidence interval 2.21-3.20), compared with FOpre-Q2/IDWG-Q2 (reference)]. Using longitudinal means of FO and IDWG only slightly altered all HRs. IDWG associated positively with FOpre, but negatively with FOpost, suggesting a link with post-dialysis extracellular volume depletion. Conclusions FOpre and FOpost were consistently positive risk factors for mortality. Low IDWG was associated with short-term mortality, suggesting perhaps an effect of protein-energy wasting. FOpost reflected the volume status without IDWG, which implies that this fluid marker is clinically most intuitive and may be best suited to guide volume management in haemodialysis patients.
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Affiliation(s)
- Manfred Hecking
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Ulrich Moissl
- Fresenius Medical Care, Research and Development, Bad Homburg, Germany
| | - Bernd Genser
- Mannheim Institute of Public Health, Social and Preventive Medicine, University of Heidelberg, Heidelberg, Germany.,BGStats Consulting, Vienna, Austria
| | - Hugh Rayner
- Heart of England, NHS Foundation Trust, Birmingham, UK
| | | | - Stefano Stuard
- Fresenius Medical Care, Research and Development, Bad Homburg, Germany
| | - Andrea Stopper
- Fresenius Medical Care, Region EMEALA, Bad Homburg, Germany
| | - Charles Chazot
- NephroCare Tassin-Charcot, Lyon, France.,F-CRIN INI-CRT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | | | - Bernard Canaud
- Fresenius Medical Care, Region EMEALA, Bad Homburg, Germany
| | | | - Carmine Zoccali
- National Research Council of Italy (CNR-IFC), Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Peter Wabel
- Fresenius Medical Care, Research and Development, Bad Homburg, Germany
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210
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Blum D, Beaubien-Souligny W, Silver SA, Wald R. Thinking Volume First: Developing a Multifaceted Systematic Approach to Volume Management in Hemodialysis. Can J Kidney Health Dis 2019; 6:2054358119879776. [PMID: 31598215 PMCID: PMC6764043 DOI: 10.1177/2054358119879776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/28/2019] [Indexed: 12/17/2022] Open
Abstract
Purpose of review: Volume overload and hypovolemia-induced symptoms are common in the
hemodialysis (HD) population and frequently result in emergency department
visits and hospitalization. A structured strategy for the reporting,
evaluation, and management of disordered volume status may improve clinical
outcomes and the patient experience. We developed a new strategy that
systematically addresses volume issues by leveraging the electronic medical
record, technological adjuncts, and multidisciplinary expertise to institute
new processes of care in our HD unit. Sources of information: This initiative was implemented in a unit located in an urban academic
hospital where 250 patients receive maintenance HD. This initiative involved
a multidisciplinary team of health professionals including physicians, nurse
practitioners, social workers, and dieticians. Methods: We generated volume metrics for HD recipients based on routinely collected
data from the unit’s electronic medical record. We then engaged stakeholders
in a root cause analysis to identify the major causes of abnormal volume
metrics locally. We subsequently developed interventions that were designed
to address each of the major causes in a pragmatic and sustainable
program. Key findings: The final product was a local volume management program with 3 components.
First, we integrated volume metric reporting into the routine surveillance
bloodwork reports across our unit. This enabled the clinical teams to more
easily target patients at risk for volume-related adverse events and provide
them with closer surveillance. Those identified with abnormal volume metrics
were then evaluated with the use of technologic adjuncts such as lung
ultrasound and bioimpedance spectroscopy to complement traditional
assessments of volume status. Finally, those with abnormal volume metrics
underwent rigorous interdisciplinary review for potential nutritional/social
interventions. Limitations: While we report the successful initial implementation of the program within a
single center, it remains unclear whether this initiative will lead to
meaningful benefits for HD recipients, be readily applicable in other
centers, or be sustainable in the long term. Implications: This volume management program will need further evaluation linked to outcome
assessment and feasibility in other centers before wider adoption is
advocated.
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Affiliation(s)
- Daniel Blum
- Jewish General Hospital, Montreal, QC, Canada
| | | | | | - Ron Wald
- St. Michael's Hospital, Toronto, ON, Canada
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211
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Dekker M, Konings C, Canaud B, Carioni P, Guinsburg A, Madero M, van der Net J, Raimann J, van der Sande F, Stuard S, Usvyat L, Wang Y, Xu X, Kotanko P, Kooman J. Pre-dialysis fluid status, pre-dialysis systolic blood pressure and outcome in prevalent haemodialysis patients: results of an international cohort study on behalf of the MONDO initiative. Nephrol Dial Transplant 2019; 33:2027-2034. [PMID: 29718469 DOI: 10.1093/ndt/gfy095] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 03/06/2018] [Indexed: 11/12/2022] Open
Abstract
Background Pre-dialysis fluid overload (FO) associates with mortality and causes elevated pre-dialysis systolic blood pressure (pre-SBP). However, low pre-SBP is associated with increased mortality in haemodialysis patients. The objective of this study was to investigate the interaction between pre-dialysis fluid status (FS) and pre-SBP in association with mortality. Methods We included all patients from the international Monitoring Dialysis Outcome Initiative (MONDO) database with a pre-dialysis multifrequency bioimpedance spectroscopy measurement in the year 2011. We used all parameters available during a 90-day baseline period. All-cause mortality was recorded during 1-year follow-up. Associations with outcome were assessed with Cox models and a smoothing spline Cox analysis. Results We included 8883 patients. In patients with pre-dialysis FO (>+1.1 to +2.5 L), pre-SBP <110 mmHg was associated with an increased risk of death {hazard ratio (HR) 1.52 [95% confidence interval (CI) 1.06-2.17]}. An increased risk of death was also associated with pre-dialysis fluid depletion (FD; <-1.1 L) combined with a pre-SBP <140 mmHg. In normovolemic (NV) patients, low pre-SBP <110 mmHg was associated with better survival [HR 0.46 (95% CI 0.23-0.91)]. Also, post-dialysis FD associated with a survival benefit. Results were similar when inflammation was present. Only high ultrafiltration rate could not explain the higher mortality rates observed. Conclusion The relation between pre-SBP and outcome is dependent on pre-dialysis FS. Low pre-SBP appears to be disadvantageous in patients with FO or FD, but not in NV patients. Post-dialysis FD was found to associate with improved survival. Therefore, we suggest interpreting pre-SBP levels in the context of FS and not as an isolated marker.
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Affiliation(s)
- Marijke Dekker
- Department of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Internal Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Constantijn Konings
- Department of Internal Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | | | | | | | - Magdalena Madero
- Department of Nephrology, National Heart Institute, Mexico City, Mexico
| | - Jeroen van der Net
- Department of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Frank van der Sande
- Department of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Len Usvyat
- Renal Research Institute, New York, NY, USA.,Fresenius Medical Care North America, Waltham, MA, USA
| | - Yuedong Wang
- Department of Statistics and Applied Probability, University of California-Santa Barbara, Santa Barbara, CA, USA
| | - Xiaoqi Xu
- Department of Nephrology, Fresenius Medical Care Asia Pacific and
| | - Peter Kotanko
- Renal Research Institute, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeroen Kooman
- Department of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
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Flythe JE, Bansal N. The relationship of volume overload and its control to hypertension in hemodialysis patients. Semin Dial 2019; 32:500-506. [PMID: 31564065 DOI: 10.1111/sdi.12838] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Hypertension is highly prevalent and associated with poor clinical outcomes among individuals receiving maintenance hemodialysis (HD). Volume overload is a key modifiable contributor to hypertension and cardiovascular disease in the HD population. Despite their importance, assessment and treatment of volume overload and hypertension remain major clinical challenges and have substantial implications for both clinical outcomes and patient experiences of care. This review will summarize current data on the diagnosis, epidemiology, pathophysiology, and clinical consequences of hypertension and volume overload in HD patients. We will also identify priorities for future research studies.
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Affiliation(s)
- Jennifer E Flythe
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Nisha Bansal
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington.,Kidney Research Institute, University of Washington, Seattle, Washington
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213
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Ratio of Early Mitral Inflow Velocity to the Global Diastolic Strain Rate and Global Left Ventricular Longitudinal Systolic Strain Predict Overall Mortality and Major Adverse Cardiovascular Events in Hemodialysis Patients. DISEASE MARKERS 2019; 2019:7512805. [PMID: 31583030 PMCID: PMC6748193 DOI: 10.1155/2019/7512805] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/18/2019] [Accepted: 07/30/2019] [Indexed: 01/15/2023]
Abstract
Background The ratio of early mitral inflow velocity to the global diastolic strain rate (E/E'sr) and global longitudinal systolic strain (GLS) of the left ventricle (LV) are emerging indices of diastolic and systolic functions, respectively, for the LV. Their prognostic significance in the prediction of mortality and cardiovascular (CV) outcomes remains underexplored in hemodialysis (HD) patients. Methods This prospective study included 190 maintenance HD patients. The E/E'sr ratio and GLS were assessed using two-dimensional speckle tracking echocardiography. The clinical outcomes included overall mortality, CV mortality, and major adverse cardiovascular events (MACE). The associations between the E/E'sr ratio, GLS, and clinical outcomes were evaluated using multivariate Cox regression analysis. The incremental values of the E/E'sr ratio and GLS in outcome prediction were assessed by χ 2 changes in Cox models. Results Over a median follow-up period of 3.7 years, there were 35 overall deaths, 16 CV deaths, and 45 MACE. Impaired diastolic function with a higher E/E'sr ratio was associated with overall mortality (HR, 1.484; 95% CI, 1.201-1.834; p < 0.001), CV mortality (HR, 1.584; 95% CI, 1.058-2.371; p = 0.025), and MACE (HR, 1.205; 95% CI, 1.040-1.397; p = 0.013) in multivariate adjusted Cox analysis. Worsening GLS was associated with overall mortality (HR, 1.276; 95% CI, 1.101-1.480; p = 0.001), CV mortality (HR, 1.513; 95% CI, 1.088-2.104; p = 0.014), and MACE (HR, 1.214; 95% CI, 1.103-1.337; p < 0.001). The E/E'sr ratio and GLS had better outcome prediction than the E to early diastolic mitral annular velocity (E/E') ratio and left ventricular ejection fraction (LVEF). Moreover, adding the E/E'sr ratio and GLS to Cox models containing relevant clinical and conventional echocardiographic parameters improved the prediction of overall mortality (p < 0.001), CV mortality (p < 0.001), and MACE (p < 0.001). Conclusion The E/E'sr ratio and GLS, as emerging indices of LV diastolic and systolic functions, significantly predict mortality and CV outcomes and outperform conventional echocardiographic parameters in outcome prediction in HD patients.
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214
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Colucci LA, Corapi KM, Li M, Parada XV, Allegretti AS, Lin HY, Ausiello DA, Rosen MS, Cima MJ. Fluid assessment in dialysis patients by point-of-care magnetic relaxometry. Sci Transl Med 2019; 11:eaau1749. [PMID: 31341060 PMCID: PMC8129985 DOI: 10.1126/scitranslmed.aau1749] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/12/2019] [Accepted: 05/23/2019] [Indexed: 01/12/2023]
Abstract
Magnetic resonance imaging (MRI) is a powerful diagnostic tool, but its use is restricted to the scanner suite. Here, we demonstrate that a bedside nuclear magnetic resonance (NMR) sensor can assess fluid status changes in individuals at a fraction of the time and cost compared to MRI. Our study recruited patients with end-stage renal disease (ESRD) who were regularly receiving hemodialysis treatments with intradialytic fluid removal as a model of volume overload and healthy controls as a model of euvolemia. Quantitative T 2 measurements of the lower leg of patients with ESRD immediately before and after dialysis were compared to those of euvolemic healthy controls using both a 0.28-T bedside single-voxel NMR sensor and a 1.5-T clinical MRI scanner. In the MRI data, we found that the first sign of fluid overload was an expanded muscle extracellular fluid (ECF) space, a finding undetectable at this stage using physical exam. A decrease in muscle ECF upon fluid removal was similarly detectable with both the bedside sensor and MRI. Bioimpedance measurements performed comparably to the bedside NMR sensor but were generally worse than MRI. These findings suggest that bedside NMR may be a useful method to identify fluid overload early in patients with ESRD and potentially other hypervolemic patient populations.
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Affiliation(s)
- Lina A Colucci
- Harvard-MIT Division of Health Sciences and Technology (HST), Cambridge, MA 02139, USA
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Kristin M Corapi
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Matthew Li
- Harvard-MIT Division of Health Sciences and Technology (HST), Cambridge, MA 02139, USA
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Xavier Vela Parada
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Herbert Y Lin
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Dennis A Ausiello
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Matthew S Rosen
- A. A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA 02129, USA
- Department of Physics, Harvard University, Cambridge, MA 02138, USA
| | - Michael J Cima
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.
- Department of Materials Science and Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
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215
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Tugman MJ, Narendra JH, Li Q, Wang Y, Hinderliter AL, Brunelli SM, Flythe JE. Ultrafiltration-profiled hemodialysis to reduce dialysis-related cardiovascular stress: Study protocol for a randomized controlled trial. Contemp Clin Trials Commun 2019; 15:100415. [PMID: 31372573 PMCID: PMC6661273 DOI: 10.1016/j.conctc.2019.100415] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/24/2019] [Accepted: 07/18/2019] [Indexed: 12/12/2022] Open
Abstract
Rapid fluid removal (ultrafiltration, UF) is associated with higher cardiovascular morbidity and mortality among individuals receiving maintenance hemodialysis (HD). Fluid removal rates that exceed vascular refill rates can result in hemodynamic instability, end-organ damage to the heart, kidneys, gut and brain, among other organs, and patient symptoms. There are no known evidence-based HD treatment strategies to reduce harm from higher UF rates. Ultrafiltration profiling, the practice of varying UF rates to maximize fluid removal during periods of greatest hydration and plasma oncotic pressure, has been proposed as an HD treatment intervention that may reduce UF rate-related complications. This study is a randomized 4-phase cross-over trial in which participants are successively alternated between study arms with intervening washout periods, and treatment order is randomized. After 4-week screening and 6-week baseline periods, participants are randomized to HD with conventional UF or HD with UF profiling for a period of 3 weeks followed by a 1-week washout period before crossing over. Participants cross into conventional UF and UF profiling phases twice (2 phases per arm). The primary outcomes of interest are intradialytic hypotension (nadir intradialytic systolic blood pressure <90 mmHg), pre-to post-HD change in troponin T (expressed as a percentage), change in left ventricular global longitudinal strain (an echocardiographic measure of left ventricular systolic function), and development of intradialytic left ventricular stunning (worsening of contractile function in ≥2 segments). This study will determine the impact of UF profiling on UF rate-related cardiovascular complications in prevalent, maintenance HD patients.
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Affiliation(s)
- Matthew J Tugman
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC, USA
| | - Julia H Narendra
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC, USA
| | - Quefeng Li
- Department of Biostatistics, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Yueting Wang
- Department of Biostatistics, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Alan L Hinderliter
- Division of Cardiology, Department of Medicine, UNC School of Medicine, Chapel Hill, NC, USA
| | | | - Jennifer E Flythe
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC, USA.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
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216
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Faucon AL, Flamant M, Metzger M, Boffa JJ, Haymann JP, Houillier P, Thervet E, Vrtovsnik F, Stengel B, Geri G, Vidal-Petiot E. Extracellular fluid volume is associated with incident end-stage kidney disease and mortality in patients with chronic kidney disease. Kidney Int 2019; 96:1020-1029. [PMID: 31477263 DOI: 10.1016/j.kint.2019.06.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/14/2019] [Accepted: 06/07/2019] [Indexed: 01/10/2023]
Abstract
Volume overload has been shown to be an independent risk factor for mortality in patients receiving chronic dialysis, but data in non-dialysis patients are scarce. Therefore we evaluated the prognostic value of extracellular fluid (ECF) volume for chronic kidney disease (CKD) progression and mortality in a prospective hospital-based cohort with CKD stage 1-4 (NephroTest Study). ECF (scaled to body surface area) and the measured glomerular filtration rate (mGFR) were determined using the distribution volume and clearance of 51Cr-EDTA, respectively. Cause-specific Cox and linear mixed-effect regression models were used to analyze the association of ECF with end-stage kidney disease (ESKD) and mortality, and with mGFR decline, respectively. The 1593 patients were mean age 58.8 years, 67% were men, mean mGFR of 43.6 mL/min/1.73m2 and mean ECF 15.1 L/1.73m2. After a median follow-up of 5.3 years, ESKD occurred in 324 patients and 185 patients died before ESKD. In multivariable analysis, ECF was significantly associated with the risk of ESKD (hazard ratio per 1L/1.73m2 increase: 1.14; 95% confidence interval [1.07; 1.21]) and with a faster GFR decline (adjusted mean difference in mGFR slope per 1L/1.73m2 increase -0.14 [-0.23; -0.05] mL/min/year). The relationship of ECF with mortality was non-linear and not significant (per 1L/1.73m2 increase 0.92, [0.73; 1.16]), below 15L/1.73m2, but significant (1.28; [1.14-1.45]) above 15L/1.73m2. Thus, in this large cohort of carefully phenotyped patients with CKD, ECF was an independent risk factor of CKD progression and mortality. Hence, close monitoring and treatment of fluid overload are important for the clinical management of patients with non-dialysis CKD.
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Affiliation(s)
- Anne-Laure Faucon
- Centre de recherche en Epidémiologie et Santé des Populations, INSERM U1018, Paris-Sud University, Villejuif, France
| | - Martin Flamant
- Université de Paris, Paris, France; Department of Physiology, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France; INSERM U1149, Centre de recherche sur l'inflammation, Paris, France
| | - Marie Metzger
- Centre de recherche en Epidémiologie et Santé des Populations, INSERM U1018, Paris-Sud University, Villejuif, France
| | - Jean-Jacques Boffa
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France; Pierre et Marie Curie University, Paris, France
| | - Jean-Philippe Haymann
- Pierre et Marie Curie University, Paris, France; Department of Physiology, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
| | - Pascal Houillier
- Université de Paris, Paris, France; Department of Physiology, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France; INSERM UMRS 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Eric Thervet
- Université de Paris, Paris, France; Department of Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - François Vrtovsnik
- Université de Paris, Paris, France; Department of Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Bénédicte Stengel
- Centre de recherche en Epidémiologie et Santé des Populations, INSERM U1018, Paris-Sud University, Villejuif, France
| | - Guillaume Geri
- Centre de recherche en Epidémiologie et Santé des Populations, INSERM U1018, Paris-Sud University, Villejuif, France; Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne-Billancourt, France; Versailles Saint Quentin University, Versailles, France
| | - Emmanuelle Vidal-Petiot
- Université de Paris, Paris, France; Department of Physiology, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France; INSERM U1149, Centre de recherche sur l'inflammation, Paris, France.
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217
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Jegatheswaran J, Hundemer GL, Massicotte-Azarniouch D, Sood MM. Anticoagulation in Patients With Advanced Chronic Kidney Disease: Walking the Fine Line Between Benefit and Harm. Can J Cardiol 2019; 35:1241-1255. [PMID: 31472820 DOI: 10.1016/j.cjca.2019.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 12/23/2022] Open
Abstract
Chronic kidney disease affects more than 3 million Canadians and is highly associated with cardiovascular diseases that require anticoagulation, such as atrial fibrillation and venous thromboembolism. Patients with chronic kidney disease are at a problematic crossroads; they are at high risk of thrombotic conditions requiring anticoagulation and bleeding complications due to anticoagulation. The limited high-quality clinical evidence to guide decision-making in this area further compounds the dilemma. In this review, we discuss the physiology and epidemiology of bleeding and thrombosis in patients with kidney disease. We specifically focus on patients with advanced kidney disease (estimated glomerular filtration rate ≤ 30 mL/min) or who are receiving dialysis and focus on the nephrologist perspective regarding these issues. We summarize the existing evidence for anticoagulation use in the prevention of stroke with atrial fibrillation and provide practical clinical recommendations for considering anticoagulation use in this population. Last, we examine specific scenarios such as the use of a glomerular filtration rate estimating equation and dosing, the use of existing prediction tools for stroke and hemorrhage risk, current patterns of anticoagulation use (including during the dialysis procedure), and vascular calcification with vitamin K antagonist use in patients with chronic kidney disease.
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Affiliation(s)
| | - Gregory L Hundemer
- Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Manish M Sood
- Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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218
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Van Biesen W, Verger C, Heaf J, Vrtovsnik F, Britto ZML, Do JY, Prieto-Velasco M, Martínez JP, Crepaldi C, De Los Ríos T, Gauly A, Ihle K, Ronco C. Evolution Over Time of Volume Status and PD-Related Practice Patterns in an Incident Peritoneal Dialysis Cohort. Clin J Am Soc Nephrol 2019; 14:882-893. [PMID: 31123180 PMCID: PMC6556715 DOI: 10.2215/cjn.11590918] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 04/10/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Volume overload is frequent in prevalent patients on kidney replacement therapies and is associated with outcome. This study was devised to follow-up volume status of an incident population on peritoneal dialysis (PD) and to relate this to patient-relevant outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This prospective cohort study was implemented in 135 study centers from 28 countries. Incident participants on PD were enrolled just before the actual PD treatment was started. Volume status was measured using bioimpedance spectroscopy before start of PD and thereafter in 3-month intervals, together with clinical and laboratory parameters, and PD prescription. The association of volume overload with time to death was tested using a competing risk Cox model. RESULTS In this population of 1054 participants incident on PD, volume overload before start of PD amounted to 1.9±2.3 L, and decreased to 1.2±1.8 L during the first year. At all time points, men and participants with diabetes were at higher risk to be volume overloaded. Dropout from PD during 3 years of observation by transfer to hemodialysis or transplantation (23% and 22%) was more prevalent than death (13%). Relative volume overload >17.3% was independently associated with higher risk of death (adjusted hazard ratio, 1.59; 95% confidence interval, 1.08 to 2.33) compared with relative volume overload ≤17.3%. Different practice patterns were observed between regions with respect to proportion of patients on PD versus hemodialysis, selection of PD modality, and prescription of hypertonic solutions. CONCLUSIONS In this large cohort of incident participants on PD, with different treatment practices across centers and regions, we found substantial volume overload already at start of dialysis. Volume overload improved over time, and was associated with survival.
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Affiliation(s)
- Wim Van Biesen
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium;
| | - Christian Verger
- Registre de dialyse péritonéale de langue Française, Pontoise, France
| | - James Heaf
- Department Medicine, Zealand University Hospital, Roskilde, Denmark
| | | | | | - Jun-Young Do
- Department of Internal Medicine, Yeungnam University Hospital, Daegu, Korea
| | | | - Juan Pérez Martínez
- Servicio de Nefrología, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Carlo Crepaldi
- Department of Nephrology Dialysis and Transplantation, International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy; and
| | - Tatiana De Los Ríos
- Clinical and Epidemiological Research, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Adelheid Gauly
- Clinical and Epidemiological Research, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Katharina Ihle
- Clinical and Epidemiological Research, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Claudio Ronco
- Department of Nephrology Dialysis and Transplantation, International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy; and
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219
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The use of bioimpedance spectroscopy to guide fluid management in patients receiving dialysis. Curr Opin Nephrol Hypertens 2019; 27:406-412. [PMID: 30063488 DOI: 10.1097/mnh.0000000000000445] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW To summarize the findings of recent trials and meta-analyses designed to determine whether bioimpedance spectroscopy adds value to the clinical assessment of fluid status in dialysis patients so as to achieve a normally hydrated weight and put these in a contemporary context. RECENT FINDINGS Eight trials (published 2010-2018) and two meta-analyses (2017) are reviewed. Both haemodialysis and peritoneal dialysis modalities are represented. Despite considerable heterogeneity in intervention, all are open-label randomized comparisons of a bioimpedance intervention with normal clinical practice in which clinicians were blinded to bioimpedance data. In a total of 1443 patients studied, no significant differences in mortality, cardiovascular or adverse events between groups were observed. Bioimpedance use was associated with a reduction in overhydration, especially when residual kidney function was not present and a greater reduction in blood pressure. A modest correlation in the change in fluid status and fall in systolic blood pressure was seen compared to baseline. A more rapid fall in urine volume was seen in the two studies with the greatest change in fluid status, with significantly higher risk of anuria in one. How bioimpedance was integrated with the complex process of decision making by clinicians was variable and not always explained. SUMMARY The usefulness of bioimpedance spectroscopy in guiding fluid management in dialysis patients is not yet clear. Bioimpedance can drive clinical decisions that lead to significant changes in fluid status but the best way to apply this in clinical practice requires further studies.
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220
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Rhodes JW, Tong O, Harman AN, Turville SG. Human Dendritic Cell Subsets, Ontogeny, and Impact on HIV Infection. Front Immunol 2019; 10:1088. [PMID: 31156637 PMCID: PMC6532592 DOI: 10.3389/fimmu.2019.01088] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 04/29/2019] [Indexed: 12/18/2022] Open
Abstract
Dendritic cells (DCs) play important roles in orchestrating host immunity against invading pathogens, representing one of the first responders to infection by mucosal invaders. From their discovery by Ralph Steinman in the 1970s followed shortly after with descriptions of their in vivo diversity and distribution by Derek Hart, we are still continuing to progressively elucidate the spectrum of DCs present in various anatomical compartments. With the power of high-dimensional approaches such as single-cell sequencing and multiparameter cytometry, recent studies have shed new light on the identities and functions of DC subtypes. Notable examples include the reclassification of plasmacytoid DCs as purely interferon-producing cells and re-evaluation of intestinal conventional DCs and macrophages as derived from monocyte precursors. Collectively, these observations have changed how we view these cells not only in steady-state immunity but also during disease and infection. In this review, we will discuss the current landscape of DCs and their ontogeny, and how this influences our understanding of their roles during HIV infection.
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Affiliation(s)
- Jake William Rhodes
- Centre for Virus Research, The Westmead Institute for Medical Research, Sydney, NSW, Australia.,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Orion Tong
- Centre for Virus Research, The Westmead Institute for Medical Research, Sydney, NSW, Australia
| | - Andrew Nicholas Harman
- Centre for Virus Research, The Westmead Institute for Medical Research, Sydney, NSW, Australia.,Discipline of Applied Medical Sciences, School of Medical Sciences, The University of Sydney, Sydney, NSW, Australia
| | - Stuart Grant Turville
- University of New South Wales, Sydney, NSW, Australia.,Kirby Institute, Kensington, NSW, Australia
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221
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Kuipers J, Oosterhuis JK, Paans W, Krijnen WP, Gaillard CAJM, Westerhuis R, Franssen CFM. Association between quality of life and various aspects of intradialytic hypotension including patient-reported intradialytic symptom score. BMC Nephrol 2019; 20:164. [PMID: 31088398 PMCID: PMC6518736 DOI: 10.1186/s12882-019-1366-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 04/30/2019] [Indexed: 12/15/2022] Open
Abstract
Background There is increasing awareness that, besides patient survival, Quality of Life (QOL) is a relevant outcome factor for patients who have a chronic disease. In haemodialysis (HD) patients, intradialytic hypotension (IDH) is considered one of the most frequent complications, and this is often accompanied by symptoms. Several studies have investigated QOL in dialysis patients, however, research on the association between intradialytic symptoms and QOL is minimal. The goal of this study was to determine whether the occurrence of IDH has an influence on the perception of QOL. Methods During 3 months, haemodynamic data, clinical events, and interventions of 2623 HD-sessions from 82 patients were prospectively collected. The patients filled out a patient-reported intradialytic symptom score (PRISS) after each HD session. IDH was defined according to the EBPG as a decrease in SBP ≥20 mmHg or in MAP ≥10 mmHg associated with a clinical event and need for nursing interventions. Patient’s self-assessment of QOL was evaluated by the 36-Item Short-Form Health Survey. Results There were no significant associations between the mental summary score or the physical summary score and the proportion of dialysis sessions that fulfilled the full EBPG definition. A lower PRISS was significantly associated with the proportion of dialysis sessions that fulfilled the full EBPG definition (R = − 0.35, P = 0.0011), the proportion of dialysis sessions with a clinical event (R = − 0.64, P = 0.001), and the proportion of dialysis sessions with nursing interventions (R = − 0.41, P = 0.0001). The physical component summary and mental component summary were significantly negatively associated with the variable diabetes and positively with PRISS (P = 0.003 and P = 0.005, respectively). UF volume was significantly negatively associated with mental health (P = 0.02) and general health (P = 0.01). Conclusions Our findings suggest that the EBPG definition of IDH does not capture aspects of intradialytic symptomatology that are relevant for the patient’s QOL. In contrast, we found a significant association between QOL and a simple patient-reported intra-dialytic symptom score, implying that how patients experience HD treatment influences their QOL. Electronic supplementary material The online version of this article (10.1186/s12882-019-1366-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Johanna Kuipers
- Dialysis Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands.
| | - Jurjen K Oosterhuis
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wolter Paans
- Hanze University Groningen, University of Applied Sciences, Groningen, The Netherlands
| | - Wim P Krijnen
- Hanze University Groningen, University of Applied Sciences, Groningen, The Netherlands
| | - Carlo A J M Gaillard
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,University of Utrecht Medical Center, University of Utrecht, Utrecht, The Netherlands
| | - Ralf Westerhuis
- Dialysis Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - Casper F M Franssen
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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222
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Ohara K, Masuda T, Murakami T, Imai T, Yoshizawa H, Nakagawa S, Okada M, Miki A, Myoga A, Sugase T, Sekiguchi C, Miyazawa Y, Maeshima A, Akimoto T, Saito O, Muto S, Nagata D. Effects of the sodium-glucose cotransporter 2 inhibitor dapagliflozin on fluid distribution: A comparison study with furosemide and tolvaptan. Nephrology (Carlton) 2019; 24:904-911. [PMID: 30578654 DOI: 10.1111/nep.13552] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2018] [Indexed: 01/08/2023]
Abstract
AIM Sodium-glucose cotransporter 2 (SGLT2) inhibitors are an antihyperglycemic drug with diuretic properties. We recently reported that an SGLT2 inhibitor ameliorated extracellular fluid expansion with a transient increase in urinary Na+ excretion. However, the effects of SGLT2 inhibitors on fluid distribution in comparison to conventional diuretics remain unclear. METHODS Forty chronic kidney disease patients with fluid retention (average estimated glomerular filtration rate 29.2 ± 3.2 mL/min per 1.73 m2 ) were divided into the SGLT2 inhibitor dapagliflozin (DAPA), loop diuretic furosemide (FR) and vasopressin V2 receptor antagonist tolvaptan (TLV). The body fluid volume was measured on days 0 and 7 using a bioimpedance analysis device. RESULTS In all three groups, body weight was significantly and similarly decreased, and urine volume numerically increased for 7 days. Bioimpedance analysis showed that the changes in intracellular water were similar, but that there were significant changes in the extracellular water (ECW) (DAPA -8.4 ± 1.7, FR -12.5 ± 1.3, TLV -7.4 ± 1.5%, P = 0.048). As a result, the change in the ratio of ECW to total body water in the DAPA group was significantly smaller than that in the FR group, but numerically larger than that in the TLV group (DAPA -1.5 ± 0.5, FR -3.6 ± 0.5, TLV -0.5 ± 0.4%, P < 0.001). CONCLUSION Sodium-glucose cotransporter 2 inhibitor DAPA predominantly decreased the ECW with a mild increase in urine volume, but the change in the ECW/total body water was smaller than that in patients treated with FR, and larger than that in patients treated with TLV, suggesting that the effects of SGLT2 inhibitors on fluid distribution may differ from those of conventional diuretics.
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Affiliation(s)
- Ken Ohara
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Takahiro Masuda
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Takuya Murakami
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Toshimi Imai
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Hiromichi Yoshizawa
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Saki Nakagawa
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Mari Okada
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Atsushi Miki
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Akihiro Myoga
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Taro Sugase
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | | | - Yasuharu Miyazawa
- Department of Internal Medicine, Nasu Minami Hospital, Tochigi, Japan
| | - Akito Maeshima
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Osamu Saito
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Shigeaki Muto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
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Ságová M, Wojke R, Maierhofer A, Gross M, Canaud B, Gauly A. Automated individualization of dialysate sodium concentration reduces intradialytic plasma sodium changes in hemodialysis. Artif Organs 2019; 43:1002-1013. [PMID: 30939213 PMCID: PMC6850400 DOI: 10.1111/aor.13463] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/20/2019] [Accepted: 03/22/2019] [Indexed: 12/15/2022]
Abstract
In standard care, hemodialysis patients are often treated with a center‐specific fixed dialysate sodium concentration, potentially resulting in diffusive sodium changes for patients with plasma sodium concentrations below or above this level. While diffusive sodium load may be associated with thirst and higher interdialytic weight gain, excessive diffusive sodium removal may cause intradialytic symptoms. In contrast, the new hemodialysis machine option “Na control” provides automated individualization of dialysate sodium during treatment with the aim to reduce such intradialytic sodium changes without the need to determine the plasma sodium concentration. This proof‐of‐principle study on sodium control was designed as a monocentric randomized controlled crossover trial: 32 patients with residual diuresis of ≤1000 mL/day were enrolled to be treated by high‐volume post‐dilution hemodiafiltration (HDF) for 2 weeks each with “Na control” (individually and automatically adjusted dialysate sodium concentration) versus “standard fixed Na” (fixed dialysate sodium 138 mmol/L), in randomized order. Pre‐ and post‐dialytic plasma sodium concentrations were determined at bedside by direct potentiometry. The study hypothesis consisted of 2 components: the mean plasma sodium change between the start and end of the treatment being within ±1.0 mmol/L for sodium‐controlled treatments, and a lower variability of the plasma sodium changes for “Na control” than for “standard fixed Na” treatments. Three hundred seventy‐two treatments of 31 adult chronic hemodialysis patients (intention‐to‐treat population) were analyzed. The estimate for the mean plasma sodium change was −0.53 mmol/L (95% confidence interval: [−1.04; −0.02] mmol/L) for “Na control” treatments and −0.95 mmol/L (95% CI: [−1.76; −0.15] mmol/L) for “standard fixed Na” treatments. The standard deviation of the plasma sodium changes was 1.39 mmol/L for “Na control” versus 2.19 mmol/L for “standard fixed Na” treatments (P = 0.0004). Whereas the 95% CI for the estimate for the mean plasma sodium change during “Na control” treatments marginally overlapped the lower border of the predefined margin ±1.0 mmol/L, the variability of intradialytic plasma sodium changes was lower during “Na control” versus “standard fixed Na” treatments. Thus, automated dialysate sodium individualization by “Na control” approaches isonatremic dialysis in the clinical setting.
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Affiliation(s)
| | - Ralf Wojke
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | | | - Malte Gross
- Faculty of Mechatronics and Medical Engineering, Ulm University of Applied Sciences, Ulm, Germany
| | - Bernard Canaud
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Adelheid Gauly
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
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224
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Abstract
In the United States, end-stage renal disease patients receiving hemodialysis have an exceedingly high risk of sudden cardiac death (SCD), accounting for 29% of death events, likely relating to their uremic milieu, recurring exposure to fluid and electrolyte fluxes, and underlying cardiovascular pathology. Furthermore, epidemiologic studies have shown that SCD events, as well as mortality and hospitalizations, occur most frequently on the first dialysis day after the long interdialytic gap, suggesting that abrupt fluctuations in the accumulation and removal of electrolytes, fluid, and uremic toxins over the dialysis cycle may be contributory. Some population-based observational studies have suggested that lower dialysate potassium concentrations appear to be associated with a heightened risk of postdialysis cardiac arrest in hemodialysis patients, although the optimal serum-to-dialysate potassium gradient remains unclear. Some observational studies have suggested that low dialysate calcium concentrations and high serum-to-dialysate calcium gradients may predispose patients to SCD. There is ongoing controversy about an association between higher dialysate bicarbonate concentrations and higher risk of cardiac arrest, likely owing to confounding by indication. Some observational studies also have shown that large interdialytic weight gains, fluid retention, and high ultrafiltration rates are linked with higher risk of SCD and mortality. However, there remains considerable controversy regarding the pros and cons of designating a specific upper ultrafiltration limit with extended treatment times as a clinical practice measure, and further studies are needed to define the optimal tools, metrics, targets, and implementation measures for volume control in the hemodialysis population. In this review, we highlight the epidemiology and pathophysiology of how specific aspects of the hemodialysis procedure may relate to the risk of SCD, as well as preventative strategies and future research directions that can address this risk.
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225
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Carvalho Fiel D, Pérez-Fontán M, López Iglesias A, Bravo González-Blas L, García Gago L, García Falcón T, Rodríguez-Carmona A. Persistent overhydration is associated with a significant risk of peritoneal infection by enteric pathogens in patients treated with peritoneal dialysis. Nefrologia 2019; 39:638-645. [PMID: 31023497 DOI: 10.1016/j.nefro.2019.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/11/2018] [Accepted: 01/14/2019] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Overhydration (OH) complicates frequently the clinical course of Peritoneal Dialysis (PD) patients, and keeps a controversial association with the risk of peritoneal infection. The main objective of this study was to disclose an association between persistent OH and the risk of enteric peritonitis in a relatively large sample of patients undergoing PD. METHOD Following a prospective design, we monitorized systematically body composition of patients treated with PD in our unit (2011-2016), searching for a correlation with the ensuing risk of peritonitis, with an emphasis on the association between persistent OH (main study variable) and the risk of infection by enteric pathogens (main outcome). Essential demographic, clinical and laboratory variables with a potential influence on the risk of peritonitis were recorded. We used multivariate survival analysis to clarify the specific effect of different body composition parameters on the main outcome. MAIN RESULTS We included 139 patients for analysis (mean follow-up 24 months). Sixty-three patients suffered at least one peritonitis, and 17 had at least one diagnosis of enteric peritonitis. Univariate analysis disclosed a general trend to an increased risk of enteric peritonitis in overhydrated patients, as evidenced by associations of this outcome with mean extracellular water/intracellular water (ECW/ICW) (p=.007), OH/ECW (p=.033) and ECW/total body water (ECW/TBW) (p=.004) ratios, but not with absolute OH values. Multivariate analysis confirmed similar associations or trends (RR: 3.48, 95% CI: 1.03-14.59; p=.046, highest versus lowest tertile of ECW/ICW, RR: 2.31, 95% CI: 0.98-6.56; p=.061, highest versus lowest tertile of OH/ECW, and RR: 6.33, 95% CI: 1.37-19.37; p=.011, highest versus lowest tertile of ECW/TBW). On the contrary, no apparent association was detected between OH and the overall risk of peritoneal infection. CONCLUSION Persistent overhydration portends a significant risk of peritoneal infection by enteric pathogens, among patients undergoing chronic PD.
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Affiliation(s)
| | - Miguel Pérez-Fontán
- Servicio de Nefrología, Hospital Universitario de A Coruña, A Coruña, España.
| | | | | | - Leticia García Gago
- Servicio de Nefrología, Hospital Universitario de A Coruña, A Coruña, España
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226
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Weinhandl ED. Piecing Together the Risk of Sudden Cardiac Death on Dialysis. J Am Soc Nephrol 2019; 30:521-523. [DOI: 10.1681/asn.2019020185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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227
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Kotanko P. The promise of bioimpedance for volume management in American dialysis patients: An unfulfilled opportunity. Semin Dial 2019; 32:223-224. [DOI: 10.1111/sdi.12790] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Peter Kotanko
- Renal Research Institute New York New York
- Icahn School of Medicine at Mount Sinai New York New York
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228
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Schotman JM, van Borren MMGJ, Wetzels JFM, Kloke HJ, Reichert LJM, de Boer H. Assessment of Plasma Resistivity as a Surrogate for Extracellular Fluid Resistivity: Analytical Performance and Impact of Fluid Composition. Ann Biomed Eng 2019; 47:1463-1469. [PMID: 30891658 DOI: 10.1007/s10439-019-02246-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 03/12/2019] [Indexed: 11/29/2022]
Abstract
Bio-electrical impedance analysis (BIA) is frequently used to assess body composition in man. Its accuracy in patients is limited, possibly because the employed algorithms are based on the assumption that total body electrical resistance (TBER) is exclusively related to body water volume, and that variation in fluid composition and its effect on fluid resistivity can be ignored. This may introduce substantial calculation errors. The aim of this study was to develop an objective method to assess plasma resistivity (ρplasma) based on measurements by a conductivity probe, as a surrogate for extracellular fluid resistivity (ρe). Sample measurements were standardized at body temperature. Analytical variation was 0.6% within runs and 0.9% between runs. The critical difference, i.e. the smallest difference needed to consider changes within individuals significant, was 1.8% for measurements within runs and 4.3% for measurements between runs. The normal range was defined by a mean ± SD of 66.9 ± 1.8 Ω cm. Multiple regression demonstrated that ρplasma was inversely related to plasma sodium and chloride concentrations, and positively related to total protein (overall R2 = 0.92, p < 0.001). In conclusion, ρplasma measurements were sufficiently robust to be useful as a tool to examine and improve the validity of BIA in clinical settings.
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Affiliation(s)
- J M Schotman
- Department of Internal Medicine, Rijnstate Hospital, Wagnerlaan 55, 6800 TA, Arnhem, The Netherlands.
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | | | - J F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - H J Kloke
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L J M Reichert
- Department of Internal Medicine, Rijnstate Hospital, Wagnerlaan 55, 6800 TA, Arnhem, The Netherlands
| | - H de Boer
- Department of Internal Medicine, Rijnstate Hospital, Wagnerlaan 55, 6800 TA, Arnhem, The Netherlands
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229
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Stenberg J, Melin J, Lindberg M, Furuland H. Brain natriuretic peptide reflects individual variation in hydration status in hemodialysis patients. Hemodial Int 2019; 23:402-413. [PMID: 30848066 PMCID: PMC6850372 DOI: 10.1111/hdi.12751] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/12/2019] [Accepted: 02/13/2019] [Indexed: 12/15/2022]
Abstract
Introduction: Fluid management in hemodialysis patients is a controversial topic. Brain natriuretic peptide (BNP) is secreted from the heart in response to volume overload, and may be a marker of overhydration in hemodialysis patients. Our aim was to investigate the correlation between BNP and overhydration in a cohort of hemodialysis patients, and to find out whether BNP and overhydration correlate in repeated measurements within individuals with elevated BNP. Methods: The study was prospective, observational, and had a cross‐sectional part and a longitudinal follow‐up. The distribution of BNP was investigated in a cohort of 64 hemodialysis patients. Blood samples and bioimpedance spectroscopy measurements were performed before midweek dialysis. Subsequently, 11 study participants with elevated BNP concentrations (>500 pg/mL) were assessed in another nine dialysis sessions each. These individuals also had their cardiac function and heart rate variability (HRV) examined. Findings: BNP was above 500 pg/mL in 38% of the participants, and correlated positively with overhydration (rs = 0.381), inflammation and malnutrition, but not with systolic blood pressure. In comparison to participants with BNP below 500 pg/mL, participants with elevated BNP were older, had lower muscle strength, lower bodyweight and lower levels of hemoglobin and albumin. Echocardiography revealed cardiac anomalies in all 11 participants in the longitudinal follow‐up, and HRV, as measured by SDNN, was pathologically low. In repeated measurements, the between‐individuals variation of BNP in relation to overhydration was greater (SD = 0.581) than the within‐person variation (SD = 0.285). Discussion: BNP correlates positively to overhydration, malnutrition, and inflammation. In a subgroup of patients with elevated BNP, who are mainly elderly and frail, BNP reflects individual variation in hydration status, and hence seems to be a modifiable marker of overhydration. These data suggest that BNP is best applied for measuring changes in hydration status within an individual over time.
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Affiliation(s)
- Jenny Stenberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Jan Melin
- Department of Medical Sciences, Uppsala University, 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, Uppsala University, Uppsala, Sweden
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230
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Dasgupta I, Thomas GN, Clarke J, Sitch A, Martin J, Bieber B, Hecking M, Karaboyas A, Pisoni R, Port F, Robinson B, Rayner H. Associations between Hemodialysis Facility Practices to Manage Fluid Volume and Intradialytic Hypotension and Patient Outcomes. Clin J Am Soc Nephrol 2019; 14:385-393. [PMID: 30723164 PMCID: PMC6419273 DOI: 10.2215/cjn.08240718] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 12/14/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND OBJECTIVES Fluid overload and intradialytic hypotension are associated with cardiovascular events and mortality in patients on hemodialysis. We investigated associations between hemodialysis facility practices related to fluid volume and intradialytic hypotension and patient outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data were analyzed from 10,250 patients in 273 facilities across 12 countries, from phase 4 of the Dialysis Outcomes and Practice Patterns Study (DOPPS; 2009-2012). Cox regression models (shared frailty) were used to estimate associations between facility practices reported by medical directors in response to the DOPPS Medical Directors Survey and all-cause and cardiovascular mortality and hospitalization, and cardiovascular events, adjusting for country, age, sex, dialysis vintage, predialysis systolic BP, cardiovascular comorbidities, diabetes, body mass index, smoking, residual kidney function, dialysis adequacy, and vascular access type. RESULTS Of ten facility practices tested (chosen a priori), having a protocol that specifies how often to assess dry weight in most patients was associated with lower all-cause (hazard ratio [HR], 0.78; 99% confidence interval [99% CI], 0.64 to 0.94) and cardiovascular mortality (HR, 0.72; 99% CI, 0.55 to 0.95). Routine orthostatic BP measurement to assess dry weight was associated with lower all-cause hospitalization (HR, 0.86; 99% CI, 0.77 to 0.97) and cardiovascular events (HR, 0.85; 99% CI, 0.73 to 0.98). Routine use of lower dialysate temperature to limit or prevent intradialytic hypotension was associated with lower cardiovascular mortality (HR, 0.76; 99% CI, 0.58 to 0.98). Routine use of an online volume indicator to assess dry weight was associated with higher all-cause hospitalization (HR, 1.19; 99% CI, 1.02 to 1.38). Routine use of sodium modeling/profiling to limit or prevent intradialytic hypotension was associated with higher all-cause mortality (HR, 1.36; 99% CI, 1.14 to 1.63), cardiovascular mortality (HR, 1.34; 99% CI, 1.04 to 1.73), and cardiovascular events (HR, 1.21; 99% CI, 1.03 to 1.43). CONCLUSIONS Hemodialysis facility practices relating to the management of fluid volume and intradialytic hypotension are associated with patient outcomes.
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Affiliation(s)
- Indranil Dasgupta
- Department of Renal Medicine, Heartlands Hospital, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - G. Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Joanne Clarke
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Alice Sitch
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- National Institute for Health Research, Birmingham Biomedical Research Centre, University Hospitals Birmingham National Health Service Foundation Trust and University of Birmingham, Birmingham, UK
| | - James Martin
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Manfred Hecking
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Angelo Karaboyas
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Ronald Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Friedrich Port
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Bruce Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Hugh Rayner
- Department of Renal Medicine, Heartlands Hospital, Birmingham, UK
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231
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Davenport A. Differences in Dialysis Center Practices in Determining Hemodialysis Patient Postdialysis Target Weight and Patient Survival and Hospitalizations. Clin J Am Soc Nephrol 2019; 14:321-323. [PMID: 30723165 PMCID: PMC6419282 DOI: 10.2215/cjn.15181218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Andrew Davenport
- University College London Department of Nephrology, University College London Centre for Dialysis and Physiology, Royal Free Hospital, London, United Kingdom
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232
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Hyponatremia in the Dialysis Population. Kidney Int Rep 2019; 4:769-780. [PMID: 31194059 PMCID: PMC6551474 DOI: 10.1016/j.ekir.2019.02.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/10/2019] [Accepted: 02/11/2019] [Indexed: 12/22/2022] Open
Abstract
Sodium derangements are among the most frequently encountered electrolyte disorders in patients with end-stage renal disease. As dialysis patients are predisposed to hyponatremia via multiple pathways, assessment of extracellular volume status is an essential first step in disentangling potential etiologic factors. In addition, multiple large population-based studies indicate that proxies of malnutrition (e.g., low body mass index, serum albumin, and serum creatinine levels) and loss of residual kidney function are important determinants of hyponatremia in dialysis patients. Among hemodialysis and peritoneal dialysis patients, evidence suggests that incrementally lower sodium levels are associated with increasingly higher death risk, highlighting the long-term risk of hyponatremia. Whereas in conventional survival models incrementally lower serum sodium concentrations are associated with worse mortality in hemodialysis patients, studies that have examined repeated measures of predialysis sodium have demonstrated mixed associations of time-varying sodium with higher mortality risk (i.e., U-shaped vs. inverse linear relationships). Although the causality of the hyponatremia-mortality association in dialysis patients remains uncertain, there are several plausible pathways by which lower sodium levels may lead to higher death risk, including central nervous system toxicity, falls and fractures, infection-related complications, and impaired cardiac function. Areas of uncertainty ripe for future studies include the following: (i) mechanistic pathways by which lower serum sodium levels are linked with higher mortality in dialysis patients, (ii) whether correction of sodium derangements improves outcomes, (iii) the optimal sodium target, and (iv) the impact of age and other sociodemographic factors on hyponatremia-outcome associations.
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233
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Pardała A, Lupa M, Chudek J, Kolonko A. Lung Ultrasound B-lines Occurrence in Relation to Left Ventricular Function and Hydration Status in Hemodialysis Patients. ACTA ACUST UNITED AC 2019; 55:medicina55020045. [PMID: 30759793 PMCID: PMC6410033 DOI: 10.3390/medicina55020045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/06/2019] [Accepted: 02/07/2019] [Indexed: 12/12/2022]
Abstract
Background and objective: Reliable assessment of the fluid status in hemodialysis (HD) patients is often difficult. A lung ultrasound with an assessment of the B-lines (“lung comets” (LCs)) number is a novel hydration status measure. However, the occurrence of left ventricular dysfunction may have a significant effect on pulmonary congestion and further modulate the LC number. The aim of this study was to analyze to what extent left ventricular dysfunction, pulmonary hypertension, and hypervolemia affect the occurrence of LC in a cohort of prevalent HD patients. Material and methods: This cross-sectional study included 108 assessments performed in 54 patients who attended thrice weekly outpatient HD. Each patient’s fluid status was evaluated twice, prior to HD sessions, using echocardiography, LC number assessment, measurement of inferior vena cava (IVC) diameters, and bioelectric impedance analysis (BIA). Patients were stratified into three subgroups according to their LC number. Results: There were 76 separate assessments with mild (<14), 16 with moderate (14–30), and 16 with severe (>30) LC occurrence. There was a negative correlation between the LC number and left ventricular ejection fraction (LVEF), and positive correlations between the LC number and mitral gradient, and the left and right atrium area and volume, but not with the BIA-derived relative fluid overload. Multivariate linear regression analysis revealed that the LC number was proportionally related to the mitral gradient (β = 0.407 (0.247–0.567), p < 0.001) and IVC max diameter (β = 0.219 (0.060–0.378), p < 0.01), and was inversely related to LVEF (β = −0.431 (−0.580 to −0.282), p < 0.001). Conclusions: The number of LCs appears to reflect both overhydration and left ventricular dysfunction in our HD patients cohort. Therefore, heart failure must be considered as an important factor limiting the usefulness of LCs number assessment in this population.
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Affiliation(s)
| | - Mariusz Lupa
- Department of Internal Medicine, District Hospital, 34-600 Limanowa, Poland.
| | - Jerzy Chudek
- Department of Internal Medicine and Oncological Chemotherapy, Medical University of Silesia, 40-027 Katowice, Poland.
| | - Aureliusz Kolonko
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, 40-027 Katowice, Poland.
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234
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Ayer A, Mills C, Donovan C, Christenson RH, Ganz P, Dubin RF. Associations of microvascular dysfunction with cardiovascular outcomes: The cardiac, endothelial function and arterial stiffness in ESRD (CERES) cohort. Hemodial Int 2019; 23:58-68. [DOI: 10.1111/hdi.12675] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 05/08/2018] [Indexed: 01/13/2023]
Affiliation(s)
- Amrita Ayer
- Division of Nephrology, San Francisco VA Medical CenterUniversity of California San Francisco California USA
| | - Claire Mills
- Division of Cardiology, Center for Vascular Excellence, Zuckerberg San Francisco General HospitalUniversity of California San Francisco California USA
| | - Catherine Donovan
- Division of Cardiology, Center for Vascular Excellence, Zuckerberg San Francisco General HospitalUniversity of California San Francisco California USA
| | - Robert H. Christenson
- Department of PathologyUniversity of Maryland School of Medicine Baltimore Maryland USA
| | - Peter Ganz
- Division of Cardiology, Center for Vascular Excellence, Zuckerberg San Francisco General HospitalUniversity of California San Francisco California USA
| | - Ruth F. Dubin
- Division of Nephrology, San Francisco VA Medical CenterUniversity of California San Francisco California USA
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235
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Fluid status assessment in hemodialysis patients and the association with outcome: review of recent literature. Curr Opin Nephrol Hypertens 2019; 27:188-193. [PMID: 29621026 DOI: 10.1097/mnh.0000000000000409] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW In this review, we will discuss the most recent literature regarding fluids status assessment in hemodialysis patients, and the associations with outcome. RECENT FINDINGS Research toward technique-assisted assessment of fluid status in hemodialysis patients has been going on for many years. However, there is no absolute agreement between techniques, such as bioimpedance, lung ultrasound, biochemical markers or vena caval diameter, likely because they reflect different fluid compartments with potentially altered distribution in hemodialysis patients. Recent studies, mostly based on bioimpedance, have shown not only an association of severe, but also of moderate predialysis fluid overload with overall survival. Also predialysis fluid depletion has been found to associate with and increased mortality risk. Interventional studies with fluid-guided management are scarce and outline the difficulties of achieving dry weight is the dialysis population. SUMMARY Optimal estimation of predialysis fluid status remains challenging and may require a combination of clinical and technical derived parameters. There appears to be a narrow window of optimal predialysis fluid status. Further clinical studies are necessary to identify strategies to improve survival in hemodialysis patients with abnormalities in fluid status.
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Abstract
Dysregulation of intravascular fluid leads to chronic volume overload in children with end-stage kidney disease (ESKD). Sequelae include left ventricular hypertrophy and remodeling and impaired cardiac function. As a result, cardiovascular complications are the commonest cause of mortality in the pediatric dialysis population. The clinical need to optimize intravascular volume in children with ESKD is clear; however, its assessment and management is the most challenging aspect of the pediatric dialysis prescription. Minimizing chronic fluid overload is a key priority; however, excessive ultrafiltration is toxic to the myocardium and can precipitate intradialytic symptoms. This review outlines emerging objective techniques to enhance the assessment of fluid overload in children on dialysis and outlines evidence for current management strategies to address this clinical problem.
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Pietribiasi M, Waniewski J, Wójcik-Załuska A, Załuska W, Lindholm B. Model of fluid and solute shifts during hemodialysis with active transport of sodium and potassium. PLoS One 2018; 13:e0209553. [PMID: 30592754 PMCID: PMC6310262 DOI: 10.1371/journal.pone.0209553] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 12/07/2018] [Indexed: 11/19/2022] Open
Abstract
Background Mathematical models are useful tools to predict fluid shifts between body compartments in patients undergoing hemodialysis (HD). The ability of a model to accurately describe the transport of water between cells and interstitium (Jv,ISIC), and the consequent changes in intracellular volume (ICV), is important for a complete assessment of fluid distribution and plasma refilling. In this study, we propose a model describing transport of fluid in the three main body compartments (intracellular, interstitial and vascular), complemented by transport mechanisms for proteins and small solutes. Methods The model was applied to data from 23 patients who underwent standard HD. The substances described in the baseline model were: water, proteins, Na, K, and urea. Small solutes were described with two-compartment kinetics between intracellular and extracellular compartments. Solute transport across the cell membrane took place via passive diffusion and, for Na and K, through the ATPase pump, characterized by the maximum transport rate, JpMAX. From the data we estimated JpMAX and two other parameters linked to transcapillary transport of fluid and protein: the capillary filtration coefficient Lp and its large pores fraction αLP. In an Expanded model one more generic solute was included to evaluate the impact of the number of substances appearing in the equation describing Jv,ISIC. Results In the baseline model, median values (interquartile range) of estimated parameters were: Lp: 11.63 (7.9, 14.2) mL/min/mmHg, αLP: 0.056 (0.050, 0.058), and JpMAX: 5.52 (3.75, 7.54) mmol/min. These values were significantly different from those obtained by the Expanded model: Lp: 8.14 (6.29, 10.01) mL/min/mmHg, αLP: 0.046 (0.038, 0.052), and JpMAX: 16.7 (11.9, 25.2) mmol/min. The relative RMSE (root mean squared error)averaged between all simulated quantities compared to data was 3.9 (3.1, 5.6) %. Conclusions The model was able to accurately reproduce most of the changes observed in HD by tuning only three parameters. While the drop in ICV was overestimated by the model, the difference between simulations and data was less than the measurement error. The biggest change in the estimated parameters in the Expanded model was a marked increase of JpMAX indicating that this parameter is highly sensitive to the number of species modeled, and that the value of JpMAX should be interpreted only in relation to this factor.
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Affiliation(s)
- Mauro Pietribiasi
- Nalecz Institute of Biocybernetics and Biomedical Engineering Polish Academy of Sciences, Warsaw, Poland
- * E-mail:
| | - Jacek Waniewski
- Nalecz Institute of Biocybernetics and Biomedical Engineering Polish Academy of Sciences, Warsaw, Poland
| | - Alicja Wójcik-Załuska
- Department of Rehabilitation and Physiotherapy, Medical University of Lublin, Lublin, Poland
| | - Wojciech Załuska
- Department of Nephrology, Medical University of Lublin, Lublin, Poland
| | - Bengt Lindholm
- Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden
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238
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Hur I, Lee Y, Kalantar-Zadeh K, Obi Y. Individualized Hemodialysis Treatment: A Perspective on Residual Kidney Function and Precision Medicine in Nephrology. Cardiorenal Med 2018; 9:69-82. [DOI: 10.1159/000494808] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/20/2018] [Indexed: 11/19/2022] Open
Abstract
Background: Residual kidney function (RKF) is often expected to inevitably and rapidly decline among hemodialysis patients and, hence, has been inadvertently ignored in clinical practice. The importance of RKF has been revisited in some recent studies. Given that patients with end-stage renal disease now tend to initiate maintenance hemodialysis therapy with higher RKF levels, there seem to be important opportunities for incremental hemodialysis by individualizing the dose and frequency according to their RKF levels. This approach is realigned with precision medicine and patient-centeredness. Summary: In this article, we first review the available methods to estimate RKF among hemodialysis patients. We then discuss the importance of maintaining and monitoring RKF levels based on a variety of clinical aspects, including volume overload, blood pressure control, mineral and bone metabolism, nutrition, and patient survival. We also review several potential measures to protect RKF: the use of high-flux and biocompatible membranes, the use of ultrapure dialysate, the incorporation of hemodiafiltration, incremental hemodialysis, and a low-protein diet, as well as general care such as avoiding nephrotoxic events, maintaining appropriate blood pressure, and better control of mineral and bone disorder parameters. Key Message: Individualized hemodialysis regimens may maintain RKF, lead to a better quality of life without compromising long-term survival, and ensure precision medicine and patient-centeredness in nephrology practice.
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Lin TY, Peng CH, Hung SC, Tarng DC. Body composition is associated with clinical outcomes in patients with non-dialysis-dependent chronic kidney disease. Kidney Int 2018; 93:733-740. [PMID: 29102374 DOI: 10.1016/j.kint.2017.08.025] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/20/2017] [Accepted: 08/24/2017] [Indexed: 10/18/2022]
Abstract
An inverse relationship between body mass index (BMI) and mortality (the obesity paradox) has been found in patients with non-dialysis-dependent chronic kidney disease (CKD). However, it is unclear whether increased muscle mass or body fat confers the survival advantage. To resolve this we investigated the impact of body makeup on a composite outcome of death or cardiovascular events in a prospective cohort of 326 patients with stage 3-5 CKD not yet on dialysis. Lean mass and body fat were determined using the Body Composition Monitor, a multifrequency bioimpedance spectroscopy device, and were expressed as the lean tissue or fat tissue index, respectively. Patients were stratified as High (above median) or Low (below median) BMI, High or Low lean tissue index, or as High or Low fat tissue index. During a median follow-up of 4.6 years, there were 40 deaths and 68 cardiovascular events. In Cox proportional hazards models, a High lean tissue index, but not High BMI or High fat tissue index, predicted a lower risk of both the composite or its component outcomes (reference: below median). When patients were further stratified into four distinct body composition groups based on both the lean and fat tissue index, only the High lean/fat tissue index group had a significantly lower risk of the composite outcome (hazard ratio 0.36, 95% confidence interval 0.14-0.87; reference: Low lean/fat tissue index group). Thus, the lean tissue index can provide better risk prediction than the BMI alone in non-dialysis-dependent patients with CKD. The High lean/fat tissue index appears to be associated with best outcomes. An optimal body composition for improving the prognosis of CKD needs to be determined.
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Affiliation(s)
- Ting-Yun Lin
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ching-Hsiu Peng
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Szu-Chun Hung
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, and School of Medicine, Tzu Chi University, Hualien, Taiwan.
| | - Der-Cherng Tarng
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institutes of Physiology and Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.
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240
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Kooman JP, van der Sande FM. Body Fluids in End-Stage Renal Disease: Statics and Dynamics. Blood Purif 2018; 47:223-229. [PMID: 30517920 DOI: 10.1159/000494583] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Abnormalities in fluid status in hemodialysis (HD) patients are highly prevalent and are related to adverse outcomes. SUMMARY The inherent discontinuity of the HD procedure in combination with an often compromised cardiovascular response is a major contributor to this phenomenon. In addition, systemic inflammation and endothelial dysfunction are related to extracellular fluid overload (FO). Underlying this relation may be factors such as hypoalbuminemia and an increased capillary permeability, leading to an altered fluid distribution between the blood volume (BV) and the interstitial fluid compartments, compromising fluid removal during dialysis. Indeed, whereas estimates of extracellular volume by bioimpedance spectroscopy are highly predictive of mortality, absolute BV assessed by the saline dilution technique was predictive of intra-dialytic morbidity. Changes in relative BV during HD are positively related to ultrafiltration rate (UFR) and, at least in some studies, negatively to FO. High UFR is also related to changes in central venous oxygen saturation (ScvO2), a marker for tissue perfusion. On the one hand, high UFR and more pronounced declines in ScvO2, but on the other hand, flat relative BV curves are also predictive of mortality; the relation between outcome which statics and dynamics of fluid status appears to be complex. Key Message: While technological developments enable the clinician to monitor statics and dynamics of fluid status and hemodynamics during HD in an accessible way, the role of technology-based interventions needs further study.
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Affiliation(s)
- Jeroen P Kooman
- Maastricht University Medical Center, Maastricht, The Netherlands,
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Hara M, Tanaka S, Taniguchi M, Fujisaki K, Torisu K, Masutani K, Hirakata H, Nakano T, Tsuruya K, Kitazono T. Prognostic value of pre-dialysis blood pressure and risk threshold on clinical outcomes in hemodialysis patients: The Q-Cohort Study. Medicine (Baltimore) 2018; 97:e13485. [PMID: 30572447 PMCID: PMC6320176 DOI: 10.1097/md.0000000000013485] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The influence of pre-dialysis blood pressure (BP) on the prognosis of hemodialysis (HD) patients is still inconclusive.A total of 3436 HD patients were prospectively followed up for 4 years. The patients were divided into quintiles of pre-dialysis systolic BP (SBP) and diastolic BP (DBP) levels [mm Hg]: Quintile 1 (Q1), SBP <134, DBP <66; Q2, SBP 134 to 147, DBP 66 to 72; Q3, SBP 148 to 158, DBP 73 to 79; Q4, SBP 159 to 171, DBP 80 to 85; Q5, SBP ≥172, DBP ≥86. The association between the pre-dialysis BP and outcomes were examined using a Cox proportional hazards model.During a 4-year follow-up period, 564 (16.4%) patients died of any cause and 590 (17.2%) developed cardiovascular (CV) events. The lowest level of pre-dialysis SBP group (Q1) showed a significantly increased risk of all-cause mortality (hazard ratio [HR] 1.83, 95% confidence interval [CI] 1.40-2.39) and the highest group (Q5) significantly increased risk of CV events (HR 1.31, 95% CI 1.02-1.68) compared with the reference group (Q3), respectively. The highest level of pre-dialysis DBP group was significantly associated with increased risk for both all-cause mortality and CV events. Restricted cubic spline analysis for BP and outcomes suggested the optimal pre-dialysis BP value associated with the lowest risk of outcomes was SBP 152 mm Hg for all-cause mortality, SBP 143 mm Hg for CV events, and DBP 68 mm Hg for all-cause mortality.Our results suggested that pre-dialysis BP was independently associated with all-cause mortality and CV events among Japanese HD patients.
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Affiliation(s)
- Masatoshi Hara
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
| | - Shigeru Tanaka
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
- Division of Internal Medicine, Fukuoka Dental College
| | | | - Kiichiro Fujisaki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
| | - Kumiko Torisu
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
| | - Kosuke Masutani
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University
| | | | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
| | - Kazuhiko Tsuruya
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
- Department of Integrated Therapy for Chronic Kidney Disease, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
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Karava V, Benzouid C, Kwon T, Macher MA, Deschênes G, Hogan J. Interdialytic weight gain and vasculopathy in children on hemodialysis: a single center study. Pediatr Nephrol 2018; 33:2329-2336. [PMID: 30178237 DOI: 10.1007/s00467-018-4026-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 06/04/2018] [Accepted: 07/16/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Increased interdialytic weight gain (IDWG) has been associated with poor outcomes in adults, but its impact on hemodialysis vasculopathy in children is unknown. METHODS Nineteen patients (age 9 to 19 years old) with a median hemodialysis duration of 10.4 months were enrolled. Cardiovascular evaluation included left ventricular mass index (LVMI), pulse wave velocity (PWV), and carotid intima-media thickness (cIMT) measurements. PWV and cIMT were expressed as z-scores based on reference values in healthy children. Blood pressure (BP) evaluation consisted in a 24-h ambulatory BP monitoring. Mean IDGW and residual urine output during the 6 months prior to cardiovascular examination were calculated. RESULTS Increased cIMT, LVMI, and PWV was observed in 11 (57.9%), 7 (36.8%), and 5 (26.3%) patients respectively, while BP was normal in all patients. Median IDWG was 3.5% (1.8-6.7). Residual urine output and BP status did not significantly differ between patients with IDWG ≥ or < 4%. After linear regression, IDWG was correlated to cIMT z-score (r2 = 0.485, p = 0.001), but not to PWV z-score (r2 = 0.04, p = 0.415) and LVMI (r2 = 0.092, p = 0.206). After univariate logistic regression, IDWG ≥ 4% was significantly associated to increased cIMT (above 1.65 SDS) (odds ratio 12.25, 95% confidence interval 1.08-138.988). The trend toward an increased cIMT with IDWG ≥ 4% was observed in both patients with short and long dialysis vintage. CONCLUSIONS High IDWG is associated with increased cIMT in hemodialyzed children independently of BP control and dialysis vintage. This observation reinforces the importance of interventions to avoid IDWG in hemodialyzed children.
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Affiliation(s)
- Vasiliki Karava
- Pediatric Nephrology Department, Robert Debré Hospital, APHP, Paris, France.
| | - Cherine Benzouid
- Pediatric Cardiology Department, Robert Debré Hospital, APHP, Paris, France
| | - Theresa Kwon
- Pediatric Nephrology Department, Robert Debré Hospital, APHP, Paris, France
| | - Marie-Alice Macher
- Pediatric Nephrology Department, Robert Debré Hospital, APHP, Paris, France
| | - Georges Deschênes
- Pediatric Nephrology Department, Robert Debré Hospital, APHP, Paris, France
| | - Julien Hogan
- Pediatric Nephrology Department, Robert Debré Hospital, APHP, Paris, France
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da Silva AT, Hauschild DB, de Almeida Oliveira LD, de Fragas Hinnig P, Franco Moreno YM, Wazlawik E. Association of hyperhydration evaluated by bioelectrical impedance analysis and mortality in patients with different medical conditions: Systematic review and meta-analyses. Clin Nutr ESPEN 2018; 28:12-20. [DOI: 10.1016/j.clnesp.2018.08.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 08/31/2018] [Indexed: 01/09/2023]
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244
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Kooman JP, Usvyat LA, Dekker MJE, Maddux DW, Raimann JG, van der Sande FM, Ye X, Wang Y, Kotanko P. Cycles, Arrows and Turbulence: Time Patterns in Renal Disease, a Path from Epidemiology to Personalized Medicine? Blood Purif 2018; 47:171-184. [PMID: 30448825 DOI: 10.1159/000494827] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 10/23/2018] [Indexed: 12/13/2022]
Abstract
Patients with end-stage renal disease (ESRD) experience unique patterns in their lifetime, such as the start of dialysis and renal transplantation. In addition, there is also an intricate link between ESRD and biological time patterns. In terms of cyclic patterns, the circadian blood pressure (BP) rhythm can be flattened, contributing to allostatic load, whereas the circadian temperature rhythm is related to the decline in BP during hemodialysis (HD). Seasonal variations in BP and interdialytic-weight gain have been observed in ESRD patients in addition to a profound relative increase in mortality during the winter period. Moreover, nonphysiological treatment patters are imposed in HD patients, leading to an excess mortality at the end of the long interdialytic interval. Recently, new evidence has emerged on the prognostic impact of trajectories of common clinical and laboratory parameters such as BP, body temperature, and serum albumin, in addition to single point in time measurements. Backward analysis of changes in cardiovascular, nutritional, and inflammatory parameters before the occurrence as hospitalization or death has shown that changes may already occur within months to even 1-2 years before the event, possibly providing a window of opportunity for earlier interventions. Disturbances in physiological variability, such as in heart rate, characterized by a loss of fractal patterns, are associated with increased mortality. In addition, an increase in random variability in different parameters such as BP and sodium is also associated with adverse outcomes. Novel techniques, based on time-dependent analysis of variability and trends and interactions of multiple physiological and laboratory parameters, for which machine-learning -approaches may be necessary, are likely of help to the clinician in the future. However, upcoming research should also evaluate whether dynamic patterns observed in large epidemiological studies have relevance for the individual risk profile of the patient.
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Affiliation(s)
- Jeroen P Kooman
- Maastricht University Medical Center, Maastricht, The Netherlands,
| | - Len A Usvyat
- Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | | | - Dugan W Maddux
- Fresenius Medical Care North America, Waltham, Massachusetts, USA
| | | | | | - Xiaoling Ye
- Renal Research Institute, New York, New York, USA
| | - Yuedong Wang
- Department of Statistics and Applied Probability, University of California-Santa Barbara, Santa Barbara, California, USA
| | - Peter Kotanko
- Renal Research Institute, New York, New York, USA.,Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
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246
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Lin TY, Liu JS, Hung SC. Obesity and risk of end-stage renal disease in patients with chronic kidney disease: a cohort study. Am J Clin Nutr 2018; 108:1145-1153. [PMID: 30321257 DOI: 10.1093/ajcn/nqy200] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 07/23/2018] [Indexed: 12/14/2022] Open
Abstract
Background Obesity is a risk factor for de novo chronic kidney disease (CKD) in the general population. Obesity has been increasingly prevalent in patients with CKD and may lead to further progression of pre-existing CKD. However, whether obesity is associated with the development of end-stage renal disease (ESRD) in patients with CKD is not well understood. Objective We investigated the impact of obesity on ESRD (needing chronic dialysis treatment or pre-emptive renal transplantation) or all-cause mortality in patients with moderate to advanced CKD. Design A total of 322 patients with stages 3-5 CKD who were not yet on dialysis were prospectively followed for a median of 4.9 y. Obesity was defined by body mass index (BMI, in kg/m2) ≥30 or body fat percentage (BF%) >25% in men and >35% in women. BF% was assessed with the use of the Body Composition Monitor, a multifrequency bioimpedance spectroscopy device. Results In total, 100 participants progressed to ESRD and 39 participants died. Obesity, whether defined by BMI or BF%, was not associated with a significantly increased risk of ESRD in Cox proportional hazards models that adjusted for age, sex, diabetes mellitus, cardiovascular disease, estimated glomerular filtration rate, urine protein:creatinine ratio, high-sensitivity C-reactive protein, and use of renin-angiotensin-aldosterone system inhibitors or statins, accounting for the competing risk for mortality (subdistribution HR: 1.15; 95% CI: 0.62, 2.14 for BMI-defined obesity and subdistribution HR: 0.84, 95% CI: 0.54, 1.29 for BF%-defined obesity, respectively). Results were similar when BMI and BF% were analyzed as continuous or time-dependent variables. Whereas higher BMI was protective, higher BF% appeared to be associated with increased all-cause mortality. Conclusions Obesity did not confer an increased risk of ESRD in patients with moderate to advanced CKD. This trial was registered at http://www.clinicaltrials.gov as NCT03285074.
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Affiliation(s)
- Ting-Yun Lin
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Jia-Sin Liu
- Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Szu-Chun Hung
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, and School of Medicine, Tzu Chi University, Hualien, Taiwan
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247
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Han YC, Tu Y, Zhou LT, Pan MM, Wang B, Liu H, Tang RN, Liu BC. Peridialysis BP levels and risk of all-cause mortality: a dose-response meta-analysis. J Hum Hypertens 2018; 33:41-49. [PMID: 30209306 DOI: 10.1038/s41371-018-0103-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 11/09/2022]
Abstract
Blood pressure (BP) management posed great challenge in hemodialysis (HD) population. We conducted a dose-response meta-analysis to investigate the quantitative features and the potential threshold effect of the associations between peridialysis BP levels and all-cause mortality risk in HD population. We searched all of the prospective cohort studies (published before 18 March 2017) on the associations between peridialysis BP levels and all-cause mortality risk. A total of 229,688 prevalent HD patients from 8 studies were included. Significant non-linear associations were noted between peridialytic BP levels and all-cause mortality risk. Significant increased risk of death was found in four peridialysis BP ranges, that is, low levels of predialysis SBP (<135 mmHg, 140 mmHg as the reference), two extremes of predialysis DBP (<55 and >95 mmHg, 90 mmHg as the reference), high levels of postdialysis SBP (>180 mmHg, 130 mmHg as the reference), and low levels of postdialysis DBP (<75 mmHg, 80 mmHg as the reference). Threshold effect was determined in the associations between peridialysis BP and all-cause mortality risk, and potential BP thresholds were identified (149 mmHg for predialysis SBP, 79 mmHg for predialysis DBP, 147 mmHg for postdialysis SBP and 76 mmHg for postdialysis DBP). In conclusion, the proposed peridialysis BP ranges and the threshold values could help clinicians identify high risk HD patients. The interpretation of the peridialysis BP mortality associations should be based on the features of HD population (especially the cardiovascular conditions, volume status and the dialysis vintage).
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Affiliation(s)
- Yu-Chen Han
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing, China
| | - Yan Tu
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing, China
| | - Le-Ting Zhou
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing, China
| | - Ming-Ming Pan
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing, China
| | - Bin Wang
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing, China
| | - Hong Liu
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing, China
| | - Ri-Ning Tang
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing, China
| | - Bi-Cheng Liu
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing, China.
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Zoccali C, Mallamaci F. Mapping Progress in Reducing Cardiovascular Risk with Kidney Disease: Managing Volume Overload. Clin J Am Soc Nephrol 2018; 13:1432-1434. [PMID: 30111588 PMCID: PMC6140577 DOI: 10.2215/cjn.01360118] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Carmine Zoccali
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases and
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases and
- Nephrology, Hypertension and Renal Transplantation Unit, Ospedali Riuniti, Reggio Calabria, Italy
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Sarafidis PA, Loutradis C, Karpetas A, Tzanis G, Bikos A, Raptis V, Syrgkanis C, Liakopoulos V, Papagianni A, Bakris G, Parati G. The association of interdialytic blood pressure variability with cardiovascular events and all-cause mortality in haemodialysis patients. Nephrol Dial Transplant 2018; 34:515-523. [DOI: 10.1093/ndt/gfy247] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 06/19/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Pantelis A Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Charalampos Loutradis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Georgios Tzanis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athanasios Bikos
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | | | - Vassilios Liakopoulos
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Bakris
- Department of Medicine, American Society of Hypertension Comprehensive Hypertension Center, The University of Chicago Medicine, Chicago, IL, USA
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS S.Luca Hospital, Istituto Auxologico Italiano, Milan, Italy
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
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Faucon AL, Flamant M, Metzger M, Boffa J, Houillier P, Thervet E, Vrtovsnik F, Stengel B, Vidal-Petiot E, Geri G. Valeur pronostique du volume extracellulaire au cours de la maladie rénale chronique. Nephrol Ther 2018. [DOI: 10.1016/j.nephro.2018.07.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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