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Liu T, Zhao D, Huang J, Gu A, Liu Q, Fang W, Gu L, Zhang H. Research hotspots and development trends in volume management of peritoneal dialysis patients: a bibliometrics and visual analysis up to 2022. Int Urol Nephrol 2024; 56:1721-1731. [PMID: 37993736 PMCID: PMC11001717 DOI: 10.1007/s11255-023-03869-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/27/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVES Among different renal replacement therapies (RRTs), peritoneal dialysis (PD) is a family based treatment method with multiple advantages, which allowing patients to maintain autonomy, avoiding frequent hospital visits, and preventing the spread of the disease virus. To visually analyze the literatures related to volume management of PD patients through bibliometric methods, to explore research hotspots and development trends in this field. METHODS The relevant literatures of PD patient volume management in the Web of Science core collection database were retrieved with the terms of peritoneal dialysis, volume management, capacity management, fluid status, and volume overload. The retrieval time was from the establishment of the database to October 2022. CiteSpace 6.1.R3 software was used to visually analyze Country, Institution, Author, Keyword, and draw keyword clusters and keyword emergence maps. RESULTS A total of 788 articles were included in the analysis, and the annual number of papers was on the rise, with the American, China, and Brirain in the top three, and Peking University and University College London in the top. Keywords cluster analysis showed 11 clusters. In the keyword emergence analysis, the keywords with higher emergence intensity rank are continuous cyclic peritoneal dialysis, ambulatory peritoneal dialysis, and icodextrin. The current research hotspots and trends are in the evaluation of peritoneal dialysis patients' volume status, the selection and adjustment of dialysis prescriptions, and adverse health outcomes. CONCLUSION The research on peritoneal dialysis volume management in China started late, but it has developed rapidly, and has a firm grasp of current research hotspots. However, there is less cooperation with other countries, so international exchanges and cooperation should be strengthened. At present, the volume assessment methods and dialysis modes are still the research hotspots, paying more attention to the adverse health outcomes of patients.
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Affiliation(s)
- Tingting Liu
- Department of Nursing, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Dan Zhao
- Department of Nursing, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Jiaying Huang
- Department of Nephrology, Ren Ji Hosptial, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Aiping Gu
- Department of Nephrology, Ren Ji Hosptial, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Qian Liu
- Department of Nephrology, Ren Ji Hosptial, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Wei Fang
- Department of Nephrology, Ren Ji Hosptial, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Leyi Gu
- Department of Nephrology, Ren Ji Hosptial, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Haifen Zhang
- Department of Nephrology, Ren Ji Hosptial, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China.
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Yang K, Pan S, Yang N, Wu J, Liu Y, He Q. Effect of bioelectrical impedance technology on the prognosis of dialysis patients: a meta-analysis of randomized controlled trials. Ren Fail 2023; 45:2203247. [PMID: 37133857 PMCID: PMC10158555 DOI: 10.1080/0886022x.2023.2203247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
Managing patient 'dry weight' according to clinical standards has deficiencies. Research has focused on the effectiveness of using bioelectrical impedance technology for fluid management in dialysis patients. Whether bioelectrical impedance monitoring can improve dialysis patients prognoses remain controversial. We performed a meta-analysis of randomized controlled trials to determine whether bioelectrical impedance was effective in improving dialysis patients prognoses. The primary outcome was all-cause mortality (13.6 ± 9.1 months). Secondary outcomes were left ventricular mass index (LVMI), arterial stiffness assessed using Pulse Wave Velocity (PWV), and N-terminal brain natriuretic peptide precursor (NT-proBNP). Of 4,641 citations retrieved, we identified 15 eligible trials involving 2763 patients divided into experimental (n = 1386) and control (n = 1377) groups. In 14 studies with mortality data, the meta-analysis showed that bioelectrical impedance intervention reduced the risk of all-cause mortality (rate ratios [RR]: 0.71; 95% confidence interval [CI]: 0.51, 0.99; p = .05; I2 = 1%). Subgroup analysis of patients on hemodialysis (RR: 0.72; 95% CI: 0.42, 1.22; p = .22) and peritoneal dialysis (RR: 0.62; 95% CI: 0.35, 1.07; p = .08) showed no significant mortality difference between intervention and control groups. It reduced the risk of all-cause mortality in the Asian population (RR: 0.52; p = .02), and reduced NT-proBNP (mean difference [MD]: -1495.73; p = 0.002; I2=0%) and PWV (MD: -1.55; p = .01; I2=89%). Bioelectrical impedance intervention reduced the LVMI in hemodialysis patients (MD: -12.69; p < .0001; I2=0%). Our analysis shows that in dialysis patients, bioelectrical impedance technology intervention could reduce, but not eliminate, the risk of all-cause mortality. Overall, this technology can improve the prognosis of dialysis patients.
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Affiliation(s)
- Kaibi Yang
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Shujun Pan
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Nan Yang
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Juan Wu
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Yueming Liu
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Qiang He
- Department of Nephrology, the First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, Zhejiang, China
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Davies SJ, Coyle D, Lindley EJ, Keane D, Belcher J, Caskey FJ, Dasgupta I, Davenport A, Farrington K, Mitra S, Ormandy P, Wilkie M, MacDonald J, Zanganeh M, Andronis L, Solis-Trapala I, Sim J. Bio-impedance spectroscopy added to a fluid management protocol does not improve preservation of residual kidney function in incident hemodialysis patients in a randomized controlled trial. Kidney Int 2023; 104:587-598. [PMID: 37263353 DOI: 10.1016/j.kint.2023.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/15/2023] [Accepted: 05/18/2023] [Indexed: 06/03/2023]
Abstract
Avoiding excessive dialysis-associated volume depletion may help preserve residual kidney function (RKF). To establish whether knowledge of the estimated normally hydrated weight from bioimpedance measurements (BI-NHW) when setting the post-hemodialysis target weight (TW) might mitigate rate of loss of RKF, we undertook an open label, randomized controlled trial in incident patients receiving HD, with clinicians and patients blinded to bioimpedance readings in controls. A total of 439 patients with over 500 ml urine/day or residual GFR exceeding 3 ml/min/1.73m2 were recruited from 34 United Kingdom centers and randomized 1:1, stratified by center. Fluid assessments were made for up to 24 months using a standardized proforma in both groups, supplemented by availability of BI-NHW in the intervention group. Primary outcome was time to anuria, analyzed using competing-risk survival models adjusted for baseline characteristics, by intention to treat. Secondary outcomes included rate of RKF decline (mean urea and creatinine clearance), blood pressure and patient-reported outcomes. There were no group differences in cause-specific hazard rates of anuria (0.751; 95% confidence interval (0.459, 1.229)) or sub-distribution hazard rates (0.742 (0.453, 1.215)). RKF decline was markedly slower than anticipated, pooled linear rates in year 1: -0.178 (-0.196, -0.159)), year 2: -0.061 (-0.086, -0.036)) ml/min/1.73m2/month. Blood pressure and patient-reported outcomes did not differ by group. The mean difference agreement between TW and BI-NHW was similar for both groups, Bioimpedance: -0.04 kg; Control: -0.25 kg. Thus, use of a standardized clinical protocol for fluid assessment when setting TW is associated with excellent preservation of RKF. Hence, bioimpedance measurements are not necessary to achieve this.
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Affiliation(s)
- Simon J Davies
- School of Medicine, Keele University, Keele, Staffordshire, UK.
| | - David Coyle
- NIHR Devices for Dignity, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - David Keane
- CÚRAM SFI Research Centre for Medical Devices, University of Galway, Galway, Ireland
| | - John Belcher
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Fergus J Caskey
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Indranil Dasgupta
- Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew Davenport
- UCL Department of Renal Medicine, Royal Free Hampstead NHS Trust, University College, London, UK
| | - Ken Farrington
- Renal Medicine, East & North Hertfordshire NHS Trust, Hertfordshire, UK
| | - Sandip Mitra
- Manchester Academic Health Sciences Centre (MAHSC), University Hospital Manchester, Manchester, UK
| | - Paula Ormandy
- School of Health and Society, University of Salford, Manchester, UK
| | - Martin Wilkie
- Renal Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jamie MacDonald
- Institute of Applied Human Physiology, Bangor University, Bangor, UK
| | - Mandana Zanganeh
- Centre for Health Economics at Warwick, University of Warwick, Coventry, UK
| | - Lazaros Andronis
- Centre for Health Economics at Warwick, University of Warwick, Coventry, UK
| | | | - Julius Sim
- School of Medicine, Keele University, Keele, Staffordshire, UK
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Horowitz L, Karadjian O, Braam B, Mavrakanas T, Weber C. Bioimpedance-Guided Monitoring of Volume Status in Patients With Kidney Disease: A Systematic Review and Meta-Analysis. Can J Kidney Health Dis 2023; 10:20543581231185433. [PMID: 37457623 PMCID: PMC10338662 DOI: 10.1177/20543581231185433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/28/2023] [Indexed: 07/18/2023] Open
Abstract
Background and Objective Bioimpedance technologies are increasingly used to determine fluid status in patients with chronic kidney disease and those with end-stage kidney disease on dialysis. We aimed to determine whether this technology improves clinical outcomes as compared with usual care. Methods We performed a systematic review and meta-analysis of trials, comparing fluid management guided by bioimpedance technologies to standard of care in patients with chronic kidney disease. Our primary outcome was all-cause mortality. Secondary outcomes included blood pressure control, all-cause hospitalization, major adverse cardiovascular events, and change in left ventricular mass index. Results Our search identified 819 citations of which 12 randomized controlled trials were included (2420 patients). No studies of non-dialysis-dependent chronic kidney disease patients met inclusion criteria. Mean age was 55 years and mean follow-up was 1 year. There was a statistically significant difference in all-cause mortality between both arms studied (risk ratio [RR] 0.64, 95% confidence interval [CI]: 0.44, 0.99). Better blood pressure control was observed in the bioimpedance arm of the included articles, weighted mean differences (WMD) -3.13 mm Hg (95% CI: -5.73, -0.53 mm Hg) for systolic blood pressure and WMD -2.50 mm Hg (95% CI: -4.36, -0.64 mm Hg) for diastolic blood pressure. No difference was observed concerning the other outcomes. Conclusions Among patients on maintenance dialysis, bioimpedance-guided volume management showed decreased all-cause mortality and blood pressure but no significant difference in all-cause hospitalization, major adverse cardiac event, or change in left ventricular mass index. This may be due to a younger population sample than previous articles. Moreover, our study identified a knowledge gap by highlighting the lack of studies evaluating this technology in non-dialysis-dependent chronic kidney disease patients.
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Affiliation(s)
- Laura Horowitz
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Oliver Karadjian
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Branko Braam
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Thomas Mavrakanas
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Catherine Weber
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
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Abstract
Peritoneal dialysis (PD) is an important home-based treatment for kidney failure and accounts for 11% of all dialysis and 9% of all kidney replacement therapy globally. Although PD is available in 81% of countries, this provision ranges from 96% in high-income countries to 32% in low-income countries. Compared with haemodialysis, PD has numerous potential advantages, including a simpler technique, greater feasibility of use in remote communities, generally lower cost, lesser need for trained staff, fewer management challenges during natural disasters, possibly better survival in the first few years, greater ability to travel, fewer dietary restrictions, better preservation of residual kidney function, greater treatment satisfaction, better quality of life, better outcomes following subsequent kidney transplantation, delayed need for vascular access (especially in small children), reduced need for erythropoiesis-stimulating agents, and lower risk of blood-borne virus infections and of SARS-CoV-2 infection. PD outcomes have been improving over time but with great variability, driven by individual and system-level inequities and by centre effects; this variation is exacerbated by a lack of standardized outcome definitions. Potential strategies for outcome improvement include enhanced standardization, monitoring and reporting of PD outcomes, and the implementation of continuous quality improvement programmes and of PD-specific interventions, such as incremental PD, the use of biocompatible PD solutions and remote PD monitoring. The use of peritoneal dialysis (PD) can be advantageous compared with haemodialysis treatment, although several barriers limit its broad implementation. This review examines the epidemiology of peritoneal dialysis (PD) outcomes, including clinical, patient-reported and surrogate PD outcomes. Peritoneal dialysis (PD) has distinct advantages compared with haemodialysis, including the convenience of home treatment, improved quality of life, technical simplicity, lesser need for trained staff, greater cost-effectiveness in most countries, improved equity of access to dialysis in resource-limited settings, and improved survival, particularly in the first few years of initiating therapy. Important barriers can hamper PD utilization in low-income settings, including the high costs of PD fluids (owing to the inability to manufacture them locally and the exorbitant costs of their import), limited workforce availability and a practice culture that limits optimal PD use, often leading to suboptimal outcomes. PD outcomes are highly variable around the world owing in part to the use of variable outcome definitions, a heterogeneous practice culture, the lack of standardized monitoring and reporting of quality indicators, and kidney failure care gaps (including health care workforce shortages, inadequate health care financing, suboptimal governance and a lack of good health care information systems). Key outcomes include not only clinical outcomes (typically defined as medical outcomes based on clinician assessment or diagnosis) — for example, PD-related infections, technique survival, mechanical complications, hospitalizations and PD-related mortality — but also patient-reported outcomes. These outcomes are directly reported by patients and focus on how they function or feel, typically in relation to quality of life or symptoms; patient-reported outcomes are used less frequently than clinical outcomes in day-to-day routine care.
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Hussein U, Cimini M, Handelman GJ, Raimann JG, Liu L, Abbas SR, Kotanko P, Levin NW, Finkelstein FO, Zhu F. Identification of fluid overload in elderly CKD Patients using bioimpedance techniques. J Appl Physiol (1985) 2022; 133:205-213. [PMID: 35652832 DOI: 10.1152/japplphysiol.00645.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Diagnosis of fluid overload (FO) in early stage is essential to manage chronic kidney disease (CKD) patients' fluid balance and to prevent cardiovascular disease (CVD). However, identification of fluid status in CKD patient is largely dependent on physician's clinical acumen. The ratio of fluid overload to extracellular volume (FO/ECV) has been used as a reference to assess fluid status. The primary aim of this study was to compare FO/ECV with other bioimpedance methods and clinical assessment in CKD patients. Whole body ECV, intracellular volume (ICV), total body water (TBW) and calf normalized resistivity (CNR) were measured (Hydra 4200). Thresholds of FO utilizing CNR and ECV/TBW were derived by receiver operator characteristic (ROC) analysis based on data from pooled CKD patients and healthy subjects (HS). Clinical assessments of FO in CKD patients were performed by nephrologists . CKD (stage 3 and stage 4) patients (n=50) and HS (n=189) were studied. The thresholds of FO were ≤ 14.3 (10-2 Ωm3/kg) for females and ≤ 13.1 (10-2 Ωm3/kg) for males using CNR and ≥ 0.445 in females and ≥ 0.434 in males using ECV/TBW. FO was diagnosed in 78%, 62% and 52% of CKD patients by CNR, FO/ECV and ECV/TBW, respectively while only 24% of CKD patients were diagnosed to be FO by clinical assessment . The proportion of FO in non-dialysis CKD patients was largely underestimated by clinical assessment compared to FO/ECV, CNR and ECV/TBW. CNR, and FO/ECV methods were more sensitive than ECV/TBW in identifying fluid overload in these CKD patients.
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Affiliation(s)
- Usama Hussein
- Renal Research Institute, New Haven, New Haven, CT, United States
| | - Monica Cimini
- Renal Research Institute, New Haven, New Haven, CT, United States
| | - Garry J Handelman
- Renal Research Institute, New York, NY, United States.,University of Massachusetts, Lowell, MA, United States
| | | | - Li Liu
- Renal Research Institute, New York, NY, United States.,Renal Division, Peking University First Hospital, Beijing, China
| | - Samer R Abbas
- Renal Research Institute, New York, NY, United States
| | - Peter Kotanko
- Renal Research Institute, New York, NY, United States.,Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Nathan W Levin
- Renal Research Institute, New York, NY, United States.,Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Fredric O Finkelstein
- Renal Research Institute, New Haven, New Haven, CT, United States.,Yale University, New Haven, CT, United States
| | - Fansan Zhu
- Renal Research Institute, New York, NY, United States
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Mohamed M, Matthie J, Fan SL. Bioimpedance spectroscopy: Is a picture worth a thousand words? Semin Dial 2022. [PMID: 35466475 DOI: 10.1111/sdi.13084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/22/2022] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Abstract
Volume status can be difficult to assess in dialysis patients. Peripheral edema, elevated venous pressure, lung crackles, and hypertension are taught as signs of fluid overload, but sensitivity and specificity are poor. Bioimpedance technology has evolved from early single frequency to multifrequency machines which apply spectroscopic analysis (BIS), modeling data to physics-based mixture theory. Bioimpedance plots can aid the evaluation of hydration status and body composition. The challenge remains how to use this information to manage dialysis populations, particularly as interventions to improve over hydration, sarcopenia, and adiposity are not without side effects. It is therefore of no surprise that validation studies for BIS use in peritoneal dialysis patients are limited, and results from clinical trials are inconsistent and conflicting. Despite these limitations, BIS has clinical utility with potential to accurately evaluate small changes in body tissue components. This article explains the information a BIS plot ("picture") can provide and how it can contribute to the overall clinical assessment of a patient. However, it remains the role of the clinician to integrate information and devise treatment strategies to optimize competing patient risks, fluid and nutrition status, effects of high glucose PD fluids on membrane function, and quality of life issues.
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Affiliation(s)
- Maha Mohamed
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK
| | | | - Stanley L Fan
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK
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Brazzelli M, Aucott L, Aceves-Martins M, Robertson C, Jacobsen E, Imamura M, Poobalan A, Manson P, Scotland G, Kaye C, Sawhney S, Boyers D. Biomarkers for assessing acute kidney injury for people who are being considered for admission to critical care: a systematic review and cost-effectiveness analysis. Health Technol Assess 2022; 26:1-286. [PMID: 35115079 PMCID: PMC8859769 DOI: 10.3310/ugez4120] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Acute kidney injury is a serious complication that occurs in the context of an acute critical illness or during a postoperative period. Earlier detection of acute kidney injury may facilitate strategies to preserve renal function, prevent further disease progression and reduce mortality. Acute kidney injury diagnosis relies on a rise in serum creatinine levels and/or fall in urine output; however, creatinine is an imperfect marker of kidney function. There is interest in the performance of novel biomarkers used in conjunction with existing clinical assessment, such as NephroCheck® (Astute Medical, Inc., San Diego, CA, USA), ARCHITECT® urine neutrophil gelatinase-associated lipocalin (NGAL) (Abbott Laboratories, Abbott Park, IL, USA), and urine and plasma BioPorto NGAL (BioPorto Diagnostics A/S, Hellerup, Denmark) immunoassays. If reliable, these biomarkers may enable earlier identification of acute kidney injury and enhance management of those with a modifiable disease course. OBJECTIVE The objective was to evaluate the role of biomarkers for assessing acute kidney injury in critically ill patients who are considered for admission to critical care. DATA SOURCES Major electronic databases, conference abstracts and ongoing studies were searched up to June 2019, with no date restrictions. MEDLINE, EMBASE, Health Technology Assessment Database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Web of Science, World Health Organization Global Index Medicus, EU Clinical Trials Register, International Clinical Trials Registry Platform and ClinicalTrials.gov were searched. REVIEW METHODS A systematic review and meta-analysis were conducted to evaluate the performance of novel biomarkers for the detection of acute kidney injury and prediction of other relevant clinical outcomes. Random-effects models were adopted to combine evidence. A decision tree was developed to evaluate costs and quality-adjusted life-years accrued as a result of changes in short-term outcomes (up to 90 days), and a Markov model was used to extrapolate results over a lifetime time horizon. RESULTS A total of 56 studies (17,967 participants), mainly prospective cohort studies, were selected for inclusion. No studies addressing the clinical impact of the use of biomarkers on patient outcomes, compared with standard care, were identified. The main sources of bias across studies were a lack of information on blinding and the optimal threshold for NGAL. For prediction studies, the reporting of statistical details was limited. Although the meta-analyses results showed the potential ability of these biomarkers to detect and predict acute kidney injury, there were limited data to establish any causal link with longer-term health outcomes and there were considerable clinical differences across studies. Cost-effectiveness results were highly uncertain, largely speculative and should be interpreted with caution in the light of the limited evidence base. To illustrate the current uncertainty, 15 scenario analyses were undertaken. Incremental quality-adjusted life-years were very low across all scenarios, ranging from positive to negative increments. Incremental costs were also small, in general, with some scenarios generating cost savings with tests dominant over standard care (cost savings with quality-adjusted life-year gains). However, other scenarios generated results whereby the candidate tests were more costly with fewer quality-adjusted life-years, and were thus dominated by standard care. Therefore, it was not possible to determine a plausible base-case incremental cost-effectiveness ratio for the tests, compared with standard care. LIMITATIONS Clinical effectiveness and cost-effectiveness results were hampered by the considerable heterogeneity across identified studies. Economic model predictions should also be interpreted cautiously because of the unknown impact of NGAL-guided treatment, and uncertain causal links between changes in acute kidney injury status and changes in health outcomes. CONCLUSIONS Current evidence is insufficient to make a full appraisal of the role and economic value of these biomarkers and to determine whether or not they provide cost-effective improvements in the clinical outcomes of acute kidney injury patients. FUTURE WORK Future studies should evaluate the targeted use of biomarkers among specific patient populations and the clinical impact of their routine use on patient outcomes and management. STUDY REGISTRATION This study is registered as PROSPERO CRD42019147039. FUNDING This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 26, No. 7. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Clare Robertson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Elisabet Jacobsen
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mari Imamura
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Amudha Poobalan
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Paul Manson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Callum Kaye
- Anaesthetics and Intensive Care Medicine, NHS Grampian, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Simon Sawhney
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
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9
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Guía de unidades de hemodiálisis 2020. Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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10
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Brimble KS, Ganame J, Margetts P, Jain A, Perl J, Walsh M, Bosch J, Yusuf S, Beshay S, Su W, Zimmerman D, Lee SF, Gangji AS. Impact of Bioelectrical Impedance-Guided Fluid Management and Vitamin D Supplementation on Left Ventricular Mass in Patients Receiving Peritoneal Dialysis: A Randomized Controlled Trial. Am J Kidney Dis 2021; 79:820-831. [PMID: 34656640 DOI: 10.1053/j.ajkd.2021.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 08/27/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVES Hypervolemia and vitamin D (Vit D) deficiency occur frequently in patients receiving peritoneal dialysis and may contribute to left ventricular hypertrophy (LVH). The effect of bioimpedance analysis-guided volume management or Vit D supplementation on LV mass among those receiving peritoneal dialysis is uncertain. STUDY DESIGN Two-by-two factorial randomized controlled trial. SETTING & PARTICIPANTS Sixty-five patients receiving chronic peritoneal dialysis. INTERVENTION BIA-guided volume management versus usual care and oral cholecalciferol 50,000u weekly for 8 weeks followed by 10,000u weekly for 44 weeks or matching placebo. OUTCOMES Change in left ventricular mass at one-year measured by cardiac magnetic resonance imaging. RESULTS Total body water decreased by 0.9L (standard deviation: 2.4) in the BIA group compared to a 1.5L (± 3.4) increase in the usual care group (adjusted between group difference: -2.4L [95% confidence interval: -4.1, -0.68], p=0.01). Left ventricular mass increased by 1.3g (± 14.3) in the BIA group and decreased by 2.4g (±37.7) in the usual care group (between group difference; +2.2g [-13.9, 18.3], p=0.78). Serum 25-OH Vit D concentration increased by a mean of 17.2 nmol/L (standard deviation: 30.8 nmol/L) in the cholecalciferol group and declined by 8.2 nmol/L (±24.3 nmol/L) in the placebo group (between group difference: 28.3 nmol/L [95% confidence interval 17.2, 39.4]; p<0.001). Left ventricular mass decreased by 3.0g (± 28.1g) in the cholecalciferol group and increased by 2.0g (±31.2g) in the placebo group (between group difference; -4.5g [-20.4, 11.5], p=0.58). LIMITATIONS Relatively small sample size with larger than expected variation in change in left ventricular mass. CONCLUSIONS BIA-guided volume management had a modest impact on volume status with no effect on the change in LV mass. Vitamin D supplementation increased serum Vit D concentration but had no effect on left ventricular mass.
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Affiliation(s)
- K Scott Brimble
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Canada.
| | - Javier Ganame
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Peter Margetts
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Arsh Jain
- Department of Medicine, Western University, London, Canada
| | - Jeffrey Perl
- Division of Nephrology, St. Michael's Hospital and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada
| | - Michael Walsh
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methodology, Evidence and Impact, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton Health Sciences / McMaster University, Canada
| | - Jackie Bosch
- Population Health Research Institute, Hamilton Health Sciences / McMaster University, Canada
| | - Salim Yusuf
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton Health Sciences / McMaster University, Canada
| | - Samy Beshay
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Winnie Su
- University of Buffalo, Buffalo, New York, United States
| | - Deborah Zimmerman
- Department of Medicine, University of Ottawa, Ottawa, Ontario Canada
| | - Shun Fu Lee
- Population Health Research Institute, Hamilton Health Sciences / McMaster University, Canada
| | - Azim S Gangji
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Canada
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11
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Tian N, Yang X, Guo Q, Zhou Q, Yi C, Lin J, Cao P, Ye H, Chen M, Yu X. Bioimpedance Guided Fluid Management in Peritoneal Dialysis: A Randomized Controlled Trial. Clin J Am Soc Nephrol 2021; 15:685-694. [PMID: 32349977 PMCID: PMC7269207 DOI: 10.2215/cjn.06480619] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 03/26/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND OBJECTIVES Bioelectrical impedance analysis (BIA) devices can help assess volume overload in patients receiving maintenance peritoneal dialysis. However, the effects of BIA on the short-term hard end points of peritoneal dialysis lack consistency. This study aimed to test whether BIA-guided fluid management could improve short-term outcomes in patients on peritoneal dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A single-center, open-labeled, randomized, controlled trial was conducted. Patients on prevalent peritoneal dialysis with volume overload were recruited from July 1, 2013 to March 30, 2014 and followed for 1 year in the initial protocol. All participants with volume overload were 1:1 randomized to the BIA-guided arm (BIA and traditional clinical methods) and control arm (only traditional clinical methods). The primary end point was all-cause mortality and secondary end points were cardiovascular disease mortality and technique survival. RESULTS A total of 240 patients (mean age, 49 years; men, 51%; diabetic, 21%, 120 per group) were enrolled. After 1-year follow-up, 11(5%) patients died (three in BIA versus eight in control) and 21 patients were permanently transferred to hemodialysis (eight in BIA versus 13 in control). The rate of extracellular water/total body water decline in the BIA group was significantly higher than that in the control group. The 1-year patient survival rates were 96% and 92% in BIA and control groups, respectively. No significant statistical differences were found between patients randomized to the BIA-guided or control arm in terms of patient survival, cardiovascular disease mortality, and technique survival (P>0.05). CONCLUSIONS Although BIA-guided fluid management improved the fluid overload status better than the traditional clinical method, no significant effect was found on 1-year patient survival and technique survival in patients on peritoneal dialysis.
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Affiliation(s)
- Na Tian
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, Guangdong, China.,Department of Nephrology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Xiao Yang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, Guangdong, China
| | - Qunying Guo
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, Guangdong, China
| | - Qian Zhou
- Department of Medical Statistics, Clinical Trials Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Chunyan Yi
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, Guangdong, China
| | - Jianxiong Lin
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, Guangdong, China
| | - Peiyi Cao
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, Guangdong, China
| | - Hongjian Ye
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, Guangdong, China
| | - Menghua Chen
- Department of Nephrology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Xueqing Yu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China .,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, Guangdong, China.,Department of Nephrology, Guangdong Provincial People's Hospital, Guangzhou, Guangdong, China
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12
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Chen W, Wang F, Zhao Y, Zhang L, Chen Z, Dai M. Efficacy and safety of furosemide for prevention of intradialytic hypotension in haemodialysis patients: protocol for a multicentre randomised controlled trial. BMJ Open 2021; 11:e048015. [PMID: 34226226 PMCID: PMC8258570 DOI: 10.1136/bmjopen-2020-048015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Intradialytic hypotension (IDH) is a frequent and serious complication of maintaining haemodialysis (HD) patients and associated with subsequent cardiovascular events and higher mortality. Furosemide is commonly used in non-dialysis chronic kidney disease patients and can effectively manage the volume and blood pressure. However, these agents are often discontinued on initiation of dialysis. Two large observational studies have demonstrated that furosemide can lower the rate of IDH episodes. However, there is still no randomised controlled trial (RCT) to investigate the efficacy and safety of furosemide for prevention of IDH in HD patients. The purpose of this study was to assess the efficacy of furosemide in reducing IDH in HD patients with residual renal function. METHODS AND ANALYSIS A two-arm, parallel, multicente RCT will be conducted at 12 hospitals in China. An estimated sample of 560 HD patients will be recruited. Eligible patients will be randomly assigned to treatment group (patients receive oral furosemide 80 mg/day; after a 2-week treatment, if their urine volume is less than 400 mL/day, the dose of furosemide is adjusted to 160 mg/day) and blank control group via a central randomisation system using 1:1 ratio. The primary outcome is the occurrence of IDH. Outcome assessors and data analysts will be blinded and participants will be asked not to reveal their allocation to assessors. The outcome analyses will be performed both on the intention-to-treat, which includes all patients randomised, and per-protocol population, which includes eligible patients who adhere to the planned treatment and follow-ups. ETHICS AND DISSEMINATION The trial protocol has been approved by the Biomedical Research Ethics Committee of West China Hospital of Sichuan University (2019.385)Results will be presented at national and international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ChiCTR2000039724.
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Affiliation(s)
- Wenwen Chen
- Division of Nephrology, Kidney Research Institute, State Key Laboratory of Biotherapy and Cancer Center, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Fang Wang
- Department of Nephrology, West China Hospital, Sichuan University/ West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
| | - Yuliang Zhao
- Department of Nephrology, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Ling Zhang
- Department of Nephrology, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Zhiwen Chen
- Department of Nephrology, West China Hospital, Sichuan University/ West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
| | - Mingjin Dai
- Department of Nephrology, West China Hospital, Sichuan University/ West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
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13
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Jacobsen E, Cruickshank M, Cooper D, Marks A, Brazzelli M, Scotland G. Cost-effectiveness and value of information analysis of multiple frequency bioimpedance devices for fluid management in people with chronic kidney disease having dialysis. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:24. [PMID: 33902602 PMCID: PMC8077940 DOI: 10.1186/s12962-021-00276-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 04/12/2021] [Indexed: 11/26/2022] Open
Abstract
Background Among people with chronic kidney disease (CKD) on dialysis, sub-optimal fluid management has been linked with hospitalisation, cardiovascular complications and death. This study assessed the cost-effectiveness using multiple-frequency bioimpedance guided fluid management versus standard fluid management based on clinical judgment. Methods A Markov model was developed to compare expected costs, outcomes and quality adjusted life years of the alternative management strategies. The relative effectiveness of the bioimpedance guided approach was informed by a systematic review of clinical trials, and focussed reviews were conducted to identify baseline event rates, costs and health state utility values for application in the model. The model was analysed probabilistically and a value of information (VOI) analysis was conducted to inform the value of conducting further research to reduce current uncertainties in the evidence base. Results For the base-case analysis, the incremental cost-effectiveness ratio (ICER) for bioimpedance guided fluid management versus standard management was £16,536 per QALY gained. There was a 59% chance of the ICER being below £20,000 per QALY. Form the VOI analysis, the theoretical upper bound on the value of further research was £53 million. The value of further research was highest for parameters relating to the relative effectiveness of bioimpedance guided management on final health outcomes. Conclusions Multiple frequency bioimpedance testing may offer a cost-effective approach to improve fluid management in patients with CKD on dialysis, but further research would be of value to reduce the current uncertainties. Supplementary Information The online version contains supplementary material available at 10.1186/s12962-021-00276-6.
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Affiliation(s)
- Elisabet Jacobsen
- Health Economics Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK.
| | | | - David Cooper
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Angharad Marks
- Chronic Disease Research Group, University of Aberdeen, Aberdeen, UK
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK.,Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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14
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La Porta E, Lanino L, Calatroni M, Caramella E, Avella A, Quinn C, Faragli A, Estienne L, Alogna A, Esposito P. Volume Balance in Chronic Kidney Disease: Evaluation Methodologies and Innovation Opportunities. Kidney Blood Press Res 2021; 46:396-410. [PMID: 34233334 DOI: 10.1159/000515172] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 02/10/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patients affected by chronic kidney disease are at a risk of cardiovascular morbidity and mortality. Body fluids unbalance is one of the main characteristics of this condition, as fluid overload is highly prevalent in patients affected by the cardiorenal syndrome. SUMMARY We describe the state of the art and new insights into body volume evaluation. The mechanisms behind fluid balance are often complex, mainly because of the interplay of multiple regulatory systems. Consequently, its management may be challenging in clinical practice and even more so out-of-hospital. Availability of novel technologies offer new opportunities to improve the quality of care and patients' outcome. Development and validation of new technologies could provide new tools to reduce costs for the healthcare system, promote personalized medicine, and boost home care. Due to the current COVID-19 pandemic, a proper monitoring of chronic patients suffering from fluid unbalances is extremely relevant. Key Message: We discuss the main mechanisms responsible for fluid overload in different clinical contexts, including hemodialysis, peritoneal dialysis, and heart failure, emphasizing the potential impact provided by the implementation of the new technologies.
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Affiliation(s)
- Edoardo La Porta
- Department of Cardionephrology, Istituto Clinico Di Alta Specialità (ICLAS), Rapallo, Italy
- Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - Luca Lanino
- Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - Marta Calatroni
- Division of Nephrology, Humanitas Clinical and Research Center, Milan, Italy
| | - Elena Caramella
- Division of Nephrology and Dialysis, Ospedale Sant'Anna, San Fermo della Battaglia, Como, Italy
| | - Alessandro Avella
- Division of Nephrology and Dialysis, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Caroline Quinn
- Department of Biological Sciences, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Alessandro Faragli
- Department of Internal Medicine and Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Luca Estienne
- Department of Nephrology and Dialysis, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Alessio Alogna
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Pasquale Esposito
- Division of Nephrology, Department of Internal Medicine, Dialysis and Transplantation, University of Genoa and IRCCS Policlinico San Martino, Genoa, Italy
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15
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Davies SJ, Zhao J, Morgenstern H, Zee J, Bieber B, Fuller DS, Sloand JA, Vychytil A, Kawanishi H, Johnson DW, Wang AYM, Kanjananbuch T, Boongird S, Moraes TP, Badve SV, Pisoni RL, Perl J. Low Serum Potassium Levels and Clinical Outcomes in Peritoneal Dialysis-International Results from PDOPPS. Kidney Int Rep 2020; 6:313-324. [PMID: 33615056 PMCID: PMC7879114 DOI: 10.1016/j.ekir.2020.11.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/26/2020] [Accepted: 11/17/2020] [Indexed: 01/15/2023] Open
Abstract
Introduction Hypokalemia, including normal range values <4 mEq/l, has been associated with increased peritonitis and mortality in patients with peritoneal dialysis. This study sought to describe international variation in hypokalemia, potential modifiable hypokalemia risk factors, and the covariate-adjusted relationship of hypokalemia with peritonitis and mortality. Methods Baseline serum potassium was determined in 7421 patients from 7 countries in the Peritoneal Dialysis Outcomes and Practice Patterns Study (2014-2017). Association of baseline patient and treatment factors with subsequent serum potassium <4 mEq/l was evaluated by logistic regression, whereas baseline serum potassium levels (4-month average and fraction of 4 months having hypokalemia) on clinical outcomes was assessed by Cox regression. Results Hypokalemia was more prevalent in Thailand and among black patients in the United States. Characteristics/treatments associated with potassium <4 mEq/l included protein-energy wasting indicators, lower urine volume, lower blood pressure, higher dialysis dose, greater diuretic use, and not being prescribed a renin-angiotensin system inhibitor. Persistent hypokalemia (all 4 months vs. 0 months over the 4-month exposure period) was associated with 80% higher subsequent peritonitis rates (at K <3.5 mEq/l) and 40% higher mortality (at K <4.0 mEq/l) after extensive case mix/potential confounding adjustments. Furthermore, adjusted peritonitis rates were higher if having mean serum K over 4 months <3.5 mEq/l versus 4.0-4.4 mEq/l (hazard ratio, 1.15 [95% confidence interval, 0.96-1.37]), largely because of Gram-positive/culture-negative infections. Conclusions Persistent hypokalemia is associated with higher mortality and peritonitis even after extensive adjustment for patient factors. Further studies are needed to elucidate mechanisms of these poorer outcomes and modifiable risk factors for persistent hypokalemia.
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Affiliation(s)
- Simon J. Davies
- Faculty of Medicine and Health Sciences, Keele University, Keele, UK
- Correspondence: Simon J. Davies, David Weatherall Building, Faculty of Medicine and Health Sciences, Keele University, Keele, UK.
| | - Junhui Zhao
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Hal Morgenstern
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
- Department of Urology, Medical School, University of Michigan, Ann Arbor, Michigan, USA
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | | | | | | | | | - David W. Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
- Translational Research Institute, Brisbane, Queensland, Australia
| | | | - Talerngsak Kanjananbuch
- Center of Excellence in Kidney Metabolic Disorders and Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok Thailand
| | - Sarinya Boongird
- Renal Unit, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Sunil V. Badve
- St. George Hospital, Sydney, New South Wales, Australia
- The George Institute for Global Health, University of New South Wales Medicine, Sydney, New South Wales, Australia
| | - Ronald L. Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Jeffrey Perl
- St. Michael’s Hospital, Toronto, Ontario, Canada
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16
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Karava V, Stabouli S, Dotis J, Liakopoulos V, Papachristou F, Printza N. Tracking hydration status changes by bioimpedance spectroscopy in children on peritoneal dialysis. Perit Dial Int 2020; 41:217-225. [PMID: 32783508 DOI: 10.1177/0896860820945813] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND This 6-month prospective longitudinal study investigates the association between hydration status changes using bioimpedance spectroscopy (BIS) and systolic blood pressure (SBP), pulse pressure (PP), and serum albumin (sAlb) changes in children on peritoneal dialysis (PD). METHODS Thirteen patients (median age: 12.58 years) were enrolled. Normal hydration, moderate hydration, severe overhydration, and dehydration were defined as -7% ≤ relative overhydration (Re-OH) < +7%, +7% ≤ Re-OH < +15%, Re-OH ≥ +15%, and Re-OH < -7%, respectively. Automated office blood pressure z-score, sAlb, and weight z-score were recorded. RESULTS Fifty-two Re-OH measurements were recorded: three in five, four in five, five in two, and seven in one patient, respectively. SBP was higher and sAlb lower in cases with severe overhydration (9 readings) (p < 0.001, p < 0.001), but distribution of these parameters did not differ between normal hydration/dehydration (28 readings) and moderate overhydration (15 readings) cases. In patients with hydration status change, SBP and PP were higher while sAlb lower in cases with higher hydration status level (p = 0.026, p = 0.05, and p = 0.109, respectively). In all patients, visit-to-visit SBP, PP, and sAlb changes were correlated to Re-OH changes (rs = 0.693, p < 0.001; rs = 0.643, p < 0.001; rs = -0.444, p = 0.008, respectively) but not to weight changes (rs = 0.052, p = 0.754; rs = 0.034, p = 0.838; rs = -0.156, p = 0.378, respectively). Visit-to-visit Re-OH changes, which were >+4% or <-4%, were linearly correlated to SBP (r = 0.858, p < 0.001), PP (r = 0.757, p < 0.001), and sAlb (r = -0.699, p = 0.002) changes. CONCLUSION In children on PD, longitudinal Re-OH changes are superior to weight changes in assessing volume-dependent variations of SBP, PP, and sAlb. Routine BIS application, rather than single BIS measurements, seems useful in the intra-patient monitoring of hydration status.
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Affiliation(s)
- Vasiliki Karava
- Pediatric Nephrology Unit, 1st Department of Pediatrics, 37782Aristotle University of Thessaloniki, Greece
| | - Stella Stabouli
- Pediatric Nephrology Unit, 1st Department of Pediatrics, 37782Aristotle University of Thessaloniki, Greece
| | - John Dotis
- Pediatric Nephrology Unit, 1st Department of Pediatrics, 37782Aristotle University of Thessaloniki, Greece
| | - Vassilios Liakopoulos
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, 37782Aristotle University of Thessaloniki, Greece
| | - Fotios Papachristou
- Pediatric Nephrology Unit, 1st Department of Pediatrics, 37782Aristotle University of Thessaloniki, Greece
| | - Nikoleta Printza
- Pediatric Nephrology Unit, 1st Department of Pediatrics, 37782Aristotle University of Thessaloniki, Greece
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17
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Alexandrou ME, Balafa O, Sarafidis P. Assessment of Hydration Status in Peritoneal Dialysis Patients: Validity, Prognostic Value, Strengths, and Limitations of Available Techniques. Am J Nephrol 2020; 51:589-612. [PMID: 32721969 DOI: 10.1159/000509115] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/25/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The majority of patients undergoing peritoneal dialysis (PD) suffer from volume overload and this overhydration is associated with increased mortality. Thus, optimal assessment of volume status in PD is an issue of paramount importance. Patient symptoms and physical signs are often unreliable indexes of true hydration status. SUMMARY Over the past decades, a quest for a valid, reproducible, and easily applicable technique to assess hydration status is taking place. Among existing techniques, inferior vena cava diameter measurements with echocardiography and natriuretic peptides such as brain natriuretic peptide and N-terminal pro-B-type natriuretic peptide were not extensively examined in PD populations; while having certain advantages, their interpretation are complicated by the underlying cardiac status and are not widely available. Bioelectrical impedance analysis (BIA) techniques are the most studied tool assessing volume overload in PD. Volume overload assessed with BIA has been associated with technique failure and increased mortality in observational studies, but the results of randomized trials on the value of BIA-based strategies to improve volume-related outcomes are contradictory. Lung ultrasound (US) is a recent technique with the ability to identify volume excess in the critical lung area. Preliminary evidence in PD showed that B-lines from lung US correlate with echocardiographic parameters but not with BIA measurements. This review presents the methods currently used to assess fluid status in PD patients and discusses existing data on their validity, applicability, limitations, and associations with intermediate and hard outcomes in this population. Key Message: No method has proved its value as an intervening tool affecting cardiovascular events, technique, and overall survival in PD patients. As BIA and lung US estimate fluid overload in different compartments of the body, they can be complementary tools for volume status assessment.
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Affiliation(s)
- Maria-Eleni Alexandrou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece,
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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18
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Davies SJ. The Elusive Promise of Bioimpedance in Fluid Management of Patients Undergoing Dialysis. Clin J Am Soc Nephrol 2020; 15:597-599. [PMID: 32381550 PMCID: PMC7269206 DOI: 10.2215/cjn.01770220] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Simon J Davies
- Institute for Applied Clinical Sciences, Keele University, Keele, Staffordshire, United Kingdom
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19
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Wang AYM, Dong J, Xu X, Davies S. Volume management as a key dimension of a high-quality PD prescription. Perit Dial Int 2020; 40:282-292. [PMID: 32063208 DOI: 10.1177/0896860819895365] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Appropriate volume control is one of the key goals in a peritoneal dialysis (PD) prescription. As such it is an important component of the International Society of Peritoneal Dialysis (ISPD) guideline for "High-quality PD prescription" necessitating a review of the literature on volume management. The workgroup recognized the importance of including within its scope measures of volume status and blood pressure in prescribing high-quality PD therapy. METHODS A Medline and PubMed search for publications addressing volume status and its management in PD since the publication of the 2015 ISPD Adult Cardiovascular and Metabolic Guidelines, from October 2014 through to July 2019, was conducted. RESULTS There were no randomized controlled trials on blood pressure intervention and six randomized trials of bioimpedance-guided volume management. Generally, all studies were of small sample size, short duration, and used surrogate markers as primary outcomes. As a consequence, only "practice points" were drawn. High-quality goal-directed PD prescription should aim to achieve and maintain clinical euvolemia taking residual kidney function and its preservation into account, so that both fluid removal from peritoneal ultrafiltration and urine output are considered and residual kidney function is not compromised. Blood pressure should be included as a key objective parameter in assessing the quality of PD prescription but there is currently no evidence for a specific target in PD. Clinical examination remains the keystone of routine clinical care. CONCLUSIONS High-quality goal-directed PD prescription should include volume management as one of the key dimensions.
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Affiliation(s)
- Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China
| | - Jie Dong
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, China
| | - Xiao Xu
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, China
| | - Simon Davies
- Faculty of Medicine and Health Sciences, Keele University and University Hospitals of North Midlands, Stoke-on-Trent, UK
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20
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Davies SJ, Finkelstein FO. Accuracy of the estimation of V and the implications this has when applying Kt/Vurea for measuring dialysis dose in peritoneal dialysis. Perit Dial Int 2020; 40:261-269. [DOI: 10.1177/0896860819893817] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background: Current guidelines for the prescription of peritoneal dialysis dose rely on a single cut-off ‘minimal’ value of K t/ V. To apply this in the clinic, this requires an accurate estimation of V, the volume of urea distribution that equates to the total body water (TBW). This analysis sought to determine the accuracy to which V can be estimated. Methods: A literature search was undertaken of studies comparing TBW estimation using two or three of the following methods: isotopic dilution (gold standard), anthropometric equations (e.g. Watson formula) and bioimpedance analysis. Studies of healthy and dialysis populations of all ages were included. Mean differences and 95% limits of agreement (LOA) were extracted and pooled. Results: In 44 studies (31 including dialysis subjects), the between-method population means were typically within 1–1.5 L of each other, although larger bias was seen when applying anthropometric equations to different racial groups. However, the 95% LOA for all comparisons were consistently wide, typically ranging ±12–18% of the TBW. For a typical individual whose TBW is 35 L with a measured K t/ V of 1.7, this translates into a range of K t/ V 1.4–2.05. Conclusions: There are limitations to the accuracy of estimation of V which call into question the validity of applying a single threshold K t/ V value as indicative of adequate dialysis. This should be taken into account in guideline development such that if a target K t/ V was deemed appropriate that this should be expressed as a range; alternatively single targets should be avoided and dialysis dose should be determined according to patient need.
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Affiliation(s)
- Simon J Davies
- Faculty of Medicine and Health Sciences, Keele University, UK
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21
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van der Sande FM, van de Wal-Visscher ER, Stuard S, Moissl U, Kooman JP. Using Bioimpedance Spectroscopy to Assess Volume Status in Dialysis Patients. Blood Purif 2019; 49:178-184. [PMID: 31851988 DOI: 10.1159/000504079] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 10/10/2019] [Indexed: 12/15/2022]
Abstract
The aim of the paper is to reflect on the current status of bioimpedance spectroscopy (BIS) in fluid management in dialysis patients. BIS identifies fluid overload (FO) as a virtual (overhydration) compartment, which is calculated from the difference between the measured extracellular volume and the predicted values based on a fixed hydration of lean and adipose tissue mass. FO is highly prevalent in both hemodialysis (HD) and peritoneal dialysis (PD) patients, while levels of FO are at a population level comparable between PD patients and HD patients when measured before the dialysis treatment. Even mild levels of FO are independently related to outcome in patients on HD, PD as well as in nondialysis patients with advanced chronic kidney disease. FO is not only related to left ventricular hypertrophy (LVH) but also forms part of a multidimensional spectrum with noncardiovascular risk factors such as malnutrition and inflammation. Even after multiple adjustments, FO remains an independent predictor of mortality. BIS-assisted adjustment of dry weight in HD patients has been shown to improve hypertension control and LVH and has resulted in a decline in intradialytic symptomatology. On the other hand, with increased fluid removal, target weight may not always be reached due to an increase in intradialytic symptomatology, and care should be applied in target weight adjustment in fluid overloaded patients with severe malnutrition and/or inflammation. Although a reduction in hospitalization rate was suggested, the effect of BIS-guided dry weight adjustment on mortality has not yet been shown, however, although available studies are underpowered. In PD patients, results have been more equivocal, which may be partly related to differences in treatment protocols or study populations. Future large-scale studies are needed to assess the full potential of BIS.
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Affiliation(s)
- Frank M van der Sande
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Esther R van de Wal-Visscher
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Stefano Stuard
- Clinical and Therapeutical Governance-Care Value Management, Fresenius Medical Care Deutschland, Bad Homburg, Germany
| | - Ulrich Moissl
- Global Research and Development, Fresenius Medical Care Deutschland, Bad Homburg, Germany
| | - Jeroen P Kooman
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands,
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22
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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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23
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Beaubien-Souligny W, Kontar L, Blum D, Bouchard J, Denault AY, Wald R. Meta-Analysis of Randomized Controlled Trials Using Tool-Assisted Target Weight Adjustments in Chronic Dialysis Patients. Kidney Int Rep 2019; 4:1426-1434. [PMID: 31701052 PMCID: PMC6829199 DOI: 10.1016/j.ekir.2019.07.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/22/2019] [Accepted: 07/01/2019] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Technological adjuncts have been developed to improve the accuracy of fluid removal goals in maintenance dialysis recipients. We aimed to determine whether the introduction of these tools has been shown to impact clinical outcomes. METHODS We performed a systematic review and meta-analysis of randomized controlled trials that compared fluid management guided by technological adjuncts to standard care in hemodialysis and peritoneal dialysis. The primary outcome was all-cause mortality. Secondary outcomes were cardiovascular events, hospitalizations, intradialytic hypotension, blood pressure, symptoms, antihypertensive medications. and left ventricular mass index. RESULTS Of the 2940 citations retrieved, we identified a total of 12 eligible trials comprising 2406 participants. In the 10 studies (n = 2111) with data on mortality, the use of adjunct technologies was not associated with a reduction of mortality (rate ratio [RR]: 0.92; confidence interval [CI]: 0.57-1.51; I2 = 36%). The intervention conferred a reduction in systolic arterial pressure (mean difference: -3.14; CI: -5.89 to -0.38; I2 = 39%) but did not affect other outcomes. In a subgroup analysis, bioimpedance was associated with a reduced risk of hospitalization (RR: 0.68; CI: 0.46-0.99; I2 = 55%). The risk of bias was high or unclear in most studies and the quality of evidence was judged to be low. CONCLUSIONS Among maintenance dialysis recipients, technological adjuncts for fluid management did not improve survival. Trials mostly investigated the use of bioimpedance, whereas the evidence for use of other technologies remain very scarce. Future adequately powered trials should assess a broader array of promising technologies using meaningful clinical outcomes over a prolonged follow-up duration.
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Affiliation(s)
- William Beaubien-Souligny
- Department of Anesthesiology and Intensive Care, Montréal Heart Institute, Montréal, Canada
- Division of Nephrology, St. Michael’s Hospital and the University of Toronto, Toronto, Canada
- Division of Nephrology, Centre Hospitalier de l’Université de Montréal, Montréal, Canada
| | - Loay Kontar
- Department of Anesthesiology and Intensive Care, Montréal Heart Institute, Montréal, Canada
| | - Daniel Blum
- Division of Nephrology, St. Michael’s Hospital and the University of Toronto, Toronto, Canada
| | - Josée Bouchard
- Department of Nephrology, Hôpital Sacré-Coeur de Montréal, Montréal, Canada
| | - André Y. Denault
- Department of Anesthesiology and Intensive Care, Montréal Heart Institute, Montréal, Canada
- Division of Intensive Care, Centre Hospitalier de l’Université de Montréal, Montréal, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital and the University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Canada
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Li Y, Ma R, Wang X, Jin J, Wang H, Liu Z, Yin T. Tissue coefficient of bioimpedance spectrometry as an index to discriminate different tissues in vivo. Biocybern Biomed Eng 2019. [DOI: 10.1016/j.bbe.2019.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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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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Yoon HE, Kwon YJ, Shin SJ, Lee SY, Lee S, Kim SH, Lee EY, Shin SK, Kim YS. Bioimpedance spectroscopy-guided fluid management in peritoneal dialysis patients with residual kidney function: A randomized controlled trial. Nephrology (Carlton) 2019; 24:1279-1289. [PMID: 30706575 DOI: 10.1111/nep.13571] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2019] [Indexed: 01/26/2023]
Abstract
AIM Bioimpedance spectroscopy (BIS) allows volume status to be assessed objectively. This study evaluated the effect of BIS-guided fluid management on residual kidney function (RKF), volume status, and cardiovascular events in peritoneal dialysis (PD) patients. METHODS A multicenter, prospective, randomized, controlled trial was conducted over 12 months in 2013-2017. Non-anuric PD patients (urine volume ≥ 500 mL/day) were randomized to clinical method-guided management (n = 98) or BIS-guided management (n = 103). The volume in the BIS group was controlled with BIS, with the aim of achieving the target overhydration (OH) goal of -2.0 to +2.0 L. The volume in the control group was controlled by clinical assessment alone. The groups were compared in terms of change in RKF and volume status at 12 months relative to baseline and in terms of cardiovascular event rates during a median follow-up period of 36 months. RESULTS Compared with the controls, the BIS group did not show a significant improvement in change in OH, after adjustments were made for covariates (P = 0.191). The two groups did not differ in terms of delta OH, renal creatinine and urea clearance, and 24 h urine volume. The control and BIS groups also did not differ significantly in terms of change in peritoneal ultrafiltration volume, blood pressure, body weight and echocardiographic variables or in cardiovascular event rates (10.2% vs 11.3%; P = 0.953). CONCLUSION Bioimpedance spectroscopy-guided fluid management did not show an additional benefit to achieve euvolemia, and did not affect the decline in RKF in non-anuric PD patients.
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Affiliation(s)
- Hye Eun Yoon
- Department of Internal Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Young Joo Kwon
- Department of Internal Medicine, Guro Hospital, Korea University, Seoul, South Korea
| | - Seok Joon Shin
- Department of Internal Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - So-Young Lee
- Department of Internal Medicine, Eulji Medical Center, Eulji University, Daejeon, South Korea
| | - Sangho Lee
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
| | - Su-Hyun Kim
- Department of Internal Medicine, Chung-Ang University Hospital, Seoul, South Korea
| | - Eun Young Lee
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, South Korea
| | - Sug Kyun Shin
- Department of Internal Medicine, National Health Insurance Serviced Ilsan Hospital, Goyang, South Korea
| | - Yong-Soo Kim
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Vaios V, Georgianos PI, Liakopoulos V, Agarwal R. Assessment and Management of Hypertension among Patients on Peritoneal Dialysis. Clin J Am Soc Nephrol 2019; 14:297-305. [PMID: 30341090 PMCID: PMC6390915 DOI: 10.2215/cjn.07480618] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Approximately 7%-10% of patients with ESKD worldwide undergo peritoneal dialysis (PD) as kidney replacement therapy. The continuous nature of this dialytic modality and the absence of acute shifts in pressure and volume parameters is an important differentiation between PD and in-center hemodialysis. However, the burden of hypertension and prognostic association of BP with mortality follow comparable patterns in both modalities. Although management of hypertension uses similar therapeutic principles, long-term preservation of residual diuresis and longevity of peritoneal membrane function require particular attention in the prescription of the appropriate dialysis regimen among those on PD. Dietary sodium restriction, appropriate use of icodextrin, and limited exposure of peritoneal membrane to bioincompatible solutions, as well as adaptation of the PD regimen to the peritoneal transport characteristics, are first-line therapeutic strategies to achieve adequate volume control with a potential long-term benefit on technique survival. Antihypertensive drug therapy is a second-line therapeutic approach, used when BP remains unresponsive to the above volume management strategies. In this article, we review the available evidence on epidemiology, diagnosis, and treatment of hypertension among patients on PD and discuss similarities and differences between PD and in-center hemodialysis. We conclude with a call for randomized trials aiming to elucidate several areas of uncertainty in management of hypertension in the PD population.
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Affiliation(s)
- Vasilios Vaios
- Peritoneal Dialysis Unit, First Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; and
| | - Panagiotis I. Georgianos
- Peritoneal Dialysis Unit, First Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; and
| | - Vassilios Liakopoulos
- Peritoneal Dialysis Unit, First Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; and
| | - Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
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Abstract
PURPOSE OF REVIEW Maintaining euvolaemia is an essential yet challenging objective in management of patients on peritoneal dialysis. Optimal method to assess volume status remains to be determined. In this review, we will discuss the risk factors and clinical outcomes of fluid overload in PD patients, and examine the role of bioimpedance study in fluid management. RECENT FINDINGS Applying bioimpedance study to measure body composition has attracted increasing attention because it is noninvasive and provides point-of-care assessment of fluid status. Observational studies suggested that presence of residual renal function did not necessarily protect peritoneal dialysis patients from developing fluid overload. This reinforces the importance of fluid restriction in peritoneal dialysis patients, in whom the thirst sensation could be exacerbated by hyperglycaemia. Notably, fluid overload is present in significant portion of asymptomatic patients. Moreover, bioimpedance-defined fluid overload is associated with increase in all-cause mortality, technique failure and possibly excess peritonitis rate. SUMMARY Although future studies should investigate the clinical benefit of bioimpedance-guided fluid management in high-risk subgroup, raising awareness among clinicians, together with structured clinical assessment and dietary counselling are the cornerstone to maintain stable fluid status.
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Tabinor M, Elphick E, Dudson M, Kwok CS, Lambie M, Davies SJ. Bioimpedance-defined overhydration predicts survival in end stage kidney failure (ESKF): systematic review and subgroup meta-analysis. Sci Rep 2018; 8:4441. [PMID: 29535377 PMCID: PMC5849723 DOI: 10.1038/s41598-018-21226-y] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 01/25/2018] [Indexed: 12/13/2022] Open
Abstract
Both overhydration and comorbidity predict mortality in end-stage kidney failure (ESKF) but it is not clear whether these are independent of one another. We undertook a systematic review of studies reporting outcomes in adult dialysis patients in which comorbidity and overhydration, quantified by whole body bioimpedance (BI), were reported. PubMed, EMBASE, PsychInfo and the Cochrane trial database were searched (1990-2017). Independent reviewers appraised studies including methodological quality (assessed using QUIPS). Primary outcome was mortality, with secondary outcomes including hospitalisation and cardiovascular events. Of 4028 citations identified, 46 matched inclusion criteria (42 cohorts; 60790 patients; 8187 deaths; 95% haemodialysis/5% peritoneal dialysis). BI measures included phase angle/BI vector (41%), overhydration index (39%) and extra:intracellular water ratio (20%). 38 of 42 cohorts had multivariable survival analyses (MVSA) adjusting for age (92%), gender (66%), diabetes (63%), albumin (58%), inflammation (CRP/IL6-37%), non-BI nutritional markers (24%) and echocardiographic data (8%). BI-defined overhydration (BI-OH) independently predicted mortality in 32 observational cohorts. Meta-analysis revealed overhydration >15% (HR 2.28, 95% CI 1.56-3.34, P < 0.001) and a 1-degree decrease in phase angle (HR 1.74, 95% CI 1.37-2.21, P < 0.001) predicted mortality. BI-OH predicts mortality in dialysis patients independent of the influence of comorbidity.
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Affiliation(s)
- Matthew Tabinor
- Institute for Applied Clinical Sciences, Keele University, Newcastle-under-Lyme, UK
| | - Emma Elphick
- Institute for Applied Clinical Sciences, Keele University, Newcastle-under-Lyme, UK
| | - Michael Dudson
- Institute for Applied Clinical Sciences, Keele University, Newcastle-under-Lyme, UK
| | - Chun Shing Kwok
- Institute for Applied Clinical Sciences, Keele University, Newcastle-under-Lyme, UK
| | - Mark Lambie
- Institute for Applied Clinical Sciences, Keele University, Newcastle-under-Lyme, UK
| | - Simon J Davies
- Institute for Applied Clinical Sciences, Keele University, Newcastle-under-Lyme, UK.
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Wilkie M, Davies S. Fluid Assessment in Peritoneal Dialysis—There is Still a Place for Clinical Acumen. Perit Dial Int 2018; 38:81-82. [DOI: 10.3747/pdi.2017.00248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Oh KH, Baek SH, Joo KW, Kim DK, Kim YS, Kim S, Oh YK, Han BG, Chang JH, Chung W, Na KY. Does Routine Bioimpedance-Guided Fluid Management Provide Additional Benefit to Non-Anuric Peritoneal Dialysis Patients? Results from COMPASS Clinical Trial. Perit Dial Int 2018; 38:131-138. [PMID: 29386302 DOI: 10.3747/pdi.2016.00241] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 10/22/2017] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION In peritoneal dialysis (PD) patients, volume overload is related to cardiac dysfunction and mortality, while intravascular volume depletion is associated with a rapid decline in the residual renal function (RRF). This study sought to determine the clinical usefulness of bioimpedance spectroscopy (BIS)-guided fluid management for preserving RRF and cardiac function in PD patients. SUBJECTS AND METHODS This is a multicenter, prospective, open-label study that was conducted over a 1-year period (NCT01887262). Non-anuric (urine volume > 500 mL/day) subjects on PD were enrolled. Subjects in the control group received fluid management based on the clinical information alone. Those in the BIS group received BIS-guided fluid management along with clinical information. RESULTS The subjects (N = 137, mean age 51.3 ± 12.8 years, 54% male) were randomly assigned to the BIS group (n = 67) or to the control group (n = 70). There were no significant differences between the 2 groups with regard to age, sex ratio, cause of kidney failure, duration of PD, baseline comorbidity, RRF, PD method, or peritoneal transport type. At baseline, the 2 groups were not different in terms of RRF (glomerular filtration rate [GFR], 5.1 ± 2.9 vs 5.5 ± 3.7 mL/min/1.73 m2). After follow-up, changes in the GFR between the 2 groups were not different (-1.5 ± 2.4 vs -1.3 ± 2.6 mL/min/1.73 m2, p = 0.593). Over the 1-year study period, both groups maintained stability of various fluid status parameters. Between the 2 groups, there were no differences in the net change of various fluid status parameters such as overhydration (OH) and extracellular water/total body water (ECW/TBW). A net change in ECW over 1 year was slightly but significantly higher in the control group (net increase, 0.57 ± 1.27 vs 0.05 ± 1.63 L, p = 0.047). However, this difference was not translated into an improvement in RRF in the BIS group. There were no differences in echocardiographic parameters or arterial stiffness at the end of follow-up. CONCLUSION Routine BIS-guided fluid management in non-anuric PD patients did not provide additional benefit in volume control, RRF preservation, or cardiovascular (CV) parameters. However, our study cannot be generalized to the whole PD population. Further research is warranted in order to investigate the subpopulation of PD patients who may benefit from routine BIS-guided fluid management.
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Affiliation(s)
- Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seon Ha Baek
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi Do, Korea
| | - Kwon-Wook Joo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi Do, Korea
| | - Yun Kyu Oh
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Byoung Geun Han
- Department of Internal Medicine, Wonju Severance Christian Hospital, Wonju, Korea
| | - Jae Hyun Chang
- Department of Internal Medicine, Gachon University Gil Hospital, Incheon, Korea
| | - Wookyung Chung
- Department of Internal Medicine, Gachon University Gil Hospital, Incheon, Korea
| | - Ki Young Na
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi Do, Korea
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Scotland G, Cruickshank M, Jacobsen E, Cooper D, Fraser C, Shimonovich M, Marks A, Brazzelli M. Multiple-frequency bioimpedance devices for fluid management in people with chronic kidney disease receiving dialysis: a systematic review and economic evaluation. Health Technol Assess 2018; 22:1-138. [PMID: 29298736 PMCID: PMC5776406 DOI: 10.3310/hta22010] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is a long-term condition requiring treatment such as conservative management, kidney transplantation or dialysis. To optimise the volume of fluid removed during dialysis (to avoid underhydration or overhydration), people are assigned a 'target weight', which is commonly assessed using clinical methods, such as weight gain between dialysis sessions, pre- and post-dialysis blood pressure and patient-reported symptoms. However, these methods are not precise, and measurement devices based on bioimpedance technology are increasingly used in dialysis centres. Current evidence on the role of bioimpedance devices for fluid management in people with CKD receiving dialysis is limited. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of multiple-frequency bioimpedance devices versus standard clinical assessment for fluid management in people with CKD receiving dialysis. DATA SOURCES We searched major electronic databases [e.g. MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Science Citation Index and Cochrane Central Register of Controlled Trials (CENTRAL)] conference abstracts and ongoing studies. There were no date restrictions. Searches were undertaken between June and October 2016. REVIEW METHODS Evidence was considered from randomised controlled trials (RCTs) comparing fluid management by multiple-frequency bioimpedance devices and standard clinical assessment in people receiving dialysis, and non-randomised studies evaluating the use of the devices for fluid management in people receiving dialysis. One reviewer extracted data and assessed the risk of bias of included studies. A second reviewer cross-checked the extracted data. Standard meta-analyses techniques were used to combine results from included studies. A Markov model was developed to assess the cost-effectiveness of the interventions. RESULTS Five RCTs (with 904 adult participants) and eight non-randomised studies (with 4915 adult participants) assessing the use of the Body Composition Monitor [(BCM) Fresenius Medical Care, Bad Homburg vor der Höhe, Germany] were included. Both absolute overhydration and relative overhydration were significantly lower in patients evaluated using BCM measurements than for those evaluated using standard clinical methods [weighted mean difference -0.44, 95% confidence interval (CI) -0.72 to -0.15, p = 0.003, I2 = 49%; and weighted mean difference -1.84, 95% CI -3.65 to -0.03; p = 0.05, I2 = 52%, respectively]. Pooled effects of bioimpedance monitoring on systolic blood pressure (SBP) (mean difference -2.46 mmHg, 95% CI -5.07 to 0.15 mmHg; p = 0.06, I2 = 0%), arterial stiffness (mean difference -1.18, 95% CI -3.14 to 0.78; p = 0.24, I2 = 92%) and mortality (hazard ratio = 0.689, 95% CI 0.23 to 2.08; p = 0.51) were not statistically significant. The economic evaluation showed that, when dialysis costs were included in the model, the probability of bioimpedance monitoring being cost-effective ranged from 13% to 26% at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year gained. With dialysis costs excluded, the corresponding probabilities of cost-effectiveness ranged from 61% to 67%. LIMITATIONS Lack of evidence on clinically relevant outcomes, children receiving dialysis, and any multifrequency bioimpedance devices, other than the BCM. CONCLUSIONS BCM used in addition to clinical assessment may lower overhydration and potentially improve intermediate outcomes, such as SBP, but effects on mortality have not been demonstrated. If dialysis costs are not considered, the incremental cost-effectiveness ratio falls below £20,000, with modest effects on mortality and/or hospitalisation rates. The current findings are not generalisable to paediatric populations nor across other multifrequency bioimpedance devices. FUTURE WORK Services that routinely use the BCM should report clinically relevant intermediate and long-term outcomes before and after introduction of the device to extend the current evidence base. STUDY REGISTRATION This study is registered as PROSPERO CRD42016041785. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Elisabet Jacobsen
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - David Cooper
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | | | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Wallace EL, Rosner MH, Alscher MD, Schmitt CP, Jain A, Tentori F, Firanek C, Rheuban KS, Florez-Arango J, Jha V, Foo M, de Blok K, Marshall MR, Sanabria M, Kudelka T, Sloand JA. Remote Patient Management for Home Dialysis Patients. Kidney Int Rep 2017; 2:1009-1017. [PMID: 29634048 PMCID: PMC5733746 DOI: 10.1016/j.ekir.2017.07.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/09/2017] [Accepted: 07/24/2017] [Indexed: 12/20/2022] Open
Abstract
Remote patient management (RPM) offers renal health care providers and patients with end-stage kidney disease opportunities to embrace home dialysis therapies with greater confidence and the potential to obtain better clinical outcomes. Barriers and evidence required to increase adoption of RPM by the nephrology community need to be clearly defined. Ten health care providers from specialties including nephrology, cardiology, pediatrics, epidemiology, nursing, and health informatics with experience in home dialysis and the use of RPM systems gathered in Vienna, Austria to discuss opportunities for, barriers to, and system requirements of RPM as it applies to the home dialysis patient. Although improved outcomes and cost-effectiveness of RPM have been demonstrated in patients with diabetes mellitus and heart disease, only observational data on RPM have been gathered in patients on dialysis. The current review focused on RPM systems currently in use, on how RPM should be integrated into future care, and on the evidence needed for optimized implementation to improve clinical and economic outcomes. Randomized controlled trials and/or large observational studies could inform the most effective and economical use of RPM in home dialysis. These studies are needed to establish the value of existing and/or future RPM models among patients, policy makers, and health care providers.
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Affiliation(s)
- Eric L. Wallace
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mitchell H. Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Mark Dominik Alscher
- Department of Internal Medicine and Nephrology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Claus Peter Schmitt
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Arsh Jain
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada, Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Institute for Clinical Evaluative Sciences, London, Ontario, Canada
| | - Francesca Tentori
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Karen S. Rheuban
- Department of Center for Telehealth, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jose Florez-Arango
- Department of Biomedical Informatics, Texas A & M University, College Station, Texas, USA
- Universidad de Pontificia Bolivariana a Escuela de Ciencias de la Salud, Medellin, Columbia
| | - Vivekanand Jha
- George Institute for Global Health, Syndey, New South Wales, Australia
| | - Marjorie Foo
- Department of Renal Medicine, Duke−National University of Singapore Graduate Medical School, Singapore
| | - Koen de Blok
- Department of Nephrology and Dialysis, Flevo Hospital, Almere, Flevoland, Netherlands
| | - Mark R. Marshall
- Baxter Healthcare (Asia) Pte Ltd, Singapore
- Counties Manukau Health, Auckland, New Zealand
| | - Mauricio Sanabria
- Baxter Healthcare Inc, Deerfield, Illinois, USA
- Renal Therapy Services, Bogota, Colombia
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Value of bioimpedance analysis estimated "dry weight" in maintenance dialysis patients: a systematic review and meta-analysis. Int Urol Nephrol 2017; 49:2231-2245. [PMID: 28965299 DOI: 10.1007/s11255-017-1698-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Volume overload is a common complication in patients with end-stage kidney disease who undergo maintenance dialysis therapy and associated with hypertension, left ventricular hypertrophy and mortality in this population. Although bioimpedance analysis (BIA), an objective method to assess overhydration, is associated with poor outcomes in observational studies, in randomized controlled trials (RCTs) the results were conflicting. We have examined the role of BIA for assessing the "dry weight" and fluid status in order to improve fluid overload in comparison with a control or clinical-based prescription in patients with ESKD receiving haemodialysis or peritoneal dialysis. METHODS All RCTs and quasi-RCTs in which BIA was used to improve fluid overload and assess the effect on all-cause mortality, cardiovascular morbidity, systolic blood pressure and volume control and arterial stiffness were included. RESULTS Seven RCTs with 1312 patients could be included in this review. In low-to-medium quality of the evidence, the use of BIA did not reduce all-cause mortality (relative risk 0.87, 95% CI 0.54-1.39) and had small to no effect on body change, but it improved systolic blood pressure control (mean difference (MD) -2.73 mmHg, 95% CI -5.00 to -0.46 mmHg) and reduce overhydration, as measured by BIA, with 0.43 L [(MD), 95% CI 0.71-0.15 L]. CONCLUSION In ESKD patients, BIA-based interventions for correction of overhydration have little to no effect on all-cause mortality, whereas BIA improved systolic blood pressure control. Our results should be interpreted with caution as the size and power of the included studies are low. Further studies, larger or with a longer follow-up period, should be performed to better describe the effect of BIA-based strategies on survival.
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Davies SJ, Caskey FJ, Coyle D, Lindley E, Macdonald J, Mitra S, Wilkie M, Davenport A, Farrington K, Dasgupta I, Ormandy P, Andronis L, Solis-Trapala I, Sim J. Rationale and design of BISTRO: a randomized controlled trial to determine whether bioimpedance spectroscopy-guided fluid management maintains residual kidney function in incident haemodialysis patients. BMC Nephrol 2017; 18:138. [PMID: 28441936 PMCID: PMC5405466 DOI: 10.1186/s12882-017-0554-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 04/13/2017] [Indexed: 12/23/2022] Open
Abstract
Background Preserved residual kidney function (RKF) and normal fluid status are associated with better patient outcomes in incident haemodialysis patients. The objective of this trial is to determine whether using bioimpedance technology in prescribing the optimal post-dialysis weight can reduce the rate of decline of RKF and potentially improve patient outcomes. Methods/Design 516 pateints commencing haemodialysis, aged >18 with RKF of > 3 ml/min/1.73 m2 or a urine volume >500 ml per day or per the shorter inter-dialytic period will be consented and enrolled into a pragmatic, open-label, randomized controlled trial. The intervention is incorporation of bioimpedance spectroscopy (BI) determination of normally hydrated weight to set a post-dialysis target weight that limits volume depletion, compared to current standard practice. Clinicians and participants will be blinded to BI measures in the control group and a standardized record capturing management of fluid status will be used in all participants. Primary outcome is preservation of residual kidney function assessed as time to anuria (≤100 ml/day or ≤200 ml urine volume in the short inter-dialytic period). A sample size of 516 was based upon a cumulative incidence of 30% anuria in the control group and 20% in the treatment group and 11% competing risks (death, transplantation) over 10 months, with up to 2 years follow-up. Secondary outcomes include rate of decline in small solute clearance, significant adverse events, hospitalization, loss of vascular access, cardiovascular events and interventions, dialysis efficacy and safety, dialysis-related symptoms and quality of life. Economic evaluation will be carried out to determine the cost-effectiveness of the intervention. Analyses will be adjusted for patient characteristics and dialysis unit practice patterns relevant to fluid management. Discussion This trial will establish the added value of undertaking BI measures to support clinical management of fluid status and establish the relationship between fluid status and preservation of residual kidney function in incident haemodialysis patients. Trial registration ISCCTN Number: 11342007, completed 26/04/2016; NIHR Portfolio number: CPMS31766; Sponsor: Keele University
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Affiliation(s)
- Simon J Davies
- Institute for Applied Clinical Sciences, Keele University, Keele, Staffordshire, UK. .,University Hospital of North Midlands, Newcastle Rd, Stoke-on-Trent, Staffordshire, ST46QG, UK.
| | - Fergus J Caskey
- UK Renal Registry and School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - David Coyle
- NIHR Devices for Dignity, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Elizabeth Lindley
- NIHR Devices for Dignity, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jamie Macdonald
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, North Wales, UK
| | - Sandip Mitra
- NIHR Devices for Dignity, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Renal Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Martin Wilkie
- Renal Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Ken Farrington
- Renal Medicine, East & North Hertfordshire NHS Trust, Hertfordshire, UK
| | - Indranil Dasgupta
- Renal Medicine, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Paula Ormandy
- School of Nursing, Midwifery, Social Work and Social Science, University of Salford, Manchester, UK
| | | | - Ivonne Solis-Trapala
- Institute for Applied Clinical Sciences, Keele University, Keele, Staffordshire, UK
| | - Julius Sim
- Institute for Applied Clinical Sciences, Keele University, Keele, Staffordshire, UK
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Abstract
Technical innovations in peritoneal dialysis (PD), now used widely for the long-term treatment of ESRD, have significantly reduced therapy-related complications, allowing patients to be maintained on PD for longer periods. Indeed, the survival rate for patients treated with PD is now equivalent to that with in-center hemodialysis. In parallel, changes in public policy have spurred an unprecedented expansion in the use of PD in many parts of the world. Meanwhile, our improved understanding of the molecular mechanisms involved in solute and water transport across the peritoneum and of the pathobiology of structural and functional changes in the peritoneum with long-term PD has provided new targets for improving efficiency and for intervention. As with hemodialysis, almost half of all deaths on PD occur because of cardiovascular events, and there is great interest in identifying modality-specific factors contributing to these events. Notably, tremendous progress has been made in developing interventions that substantially reduce the risk of PD-related peritonitis. Yet the gains have been unequal among individual centers, primarily because of unequal clinical application of knowledge gained from research. The work to date has further highlighted the areas in need of innovation as we continue to strive to improve the health and outcomes of patients treated with PD.
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Affiliation(s)
- Rajnish Mehrotra
- Kidney Research Institute and
- Harborview Medical Center, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Olivier Devuyst
- Institute of Physiology, University of Zurich, Zurich, Switzerland
- Division of Nephrology, Université Catholique de Louvain Medical School, Brussels, Belgium
| | - Simon J Davies
- Department of Nephrology, Keele University, Staffordshire, United Kingdom; and
| | - David W Johnson
- Department of Nephrology, Division of Medicine, Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
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37
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Abstract
While oral diuretics are commonly used in patients with chronic kidney disease for the management of volume and blood pressure, they are often discontinued upon initiation of dialysis. We suggest that diuretics are considerably underutilized in peritoneal dialysis and haemodialysis patients despite numerous potential benefits and few side effects. Moreover, when diuretics are used, optimal doses are not always prescribed. In peritoneal dialysis, the use of diuretics can improve volume status and minimize the need for higher glucose-containing solutions. In patients on haemodialysis, diuretics can help lessen interdialytic weight gain, resulting in decreased ultrafiltration rates and fewer episodes of intradialytic hypotension. This paper will review the mechanism of action of diuretics in patients with renal insufficiency, quantify the risk of side effects and elaborate on the potential advantages of diuretic use in peritoneal dialysis and hemodialysis patients with residual kidney function.
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Affiliation(s)
- Emilie Trinh
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Joanne M Bargman
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada.
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