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Keil N, Rathkolb V, Waller M, Krenn S, Hinterholzer G, Druml W, Hiesmayr M, Schmaldienst S, Hecking M. Challenging the common practice of intravenous fluid administration : Viewpoint on the need for an enteral fluid therapy trial in critically ill patients. Wien Klin Wochenschr 2024:10.1007/s00508-024-02335-3. [PMID: 38456939 DOI: 10.1007/s00508-024-02335-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/06/2024] [Indexed: 03/09/2024]
Affiliation(s)
- Nikolaus Keil
- First Medical Department, Klinik Favoriten, Vienna, Austria
| | | | | | - Simon Krenn
- AIT Austrian Institute of Technology GmbH, Center for Health & Bioresources, Medical Signal Analysis, Vienna, Austria
- Department of Medicine III, Division of Nephrology & Dialysis, Medical University of Vienna, Vienna, Austria
| | | | - Wilfred Druml
- Department of Medicine III, Division of Nephrology & Dialysis, Medical University of Vienna, Vienna, Austria
| | - Michael Hiesmayr
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Manfred Hecking
- Department of Medicine III, Division of Nephrology & Dialysis, Medical University of Vienna, Vienna, Austria
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Kwon YE, Choi HM, Oh DJ. Characteristics of bioimpedance-determined fluid shifts according to intradialytic blood pressure difference. Ren Fail 2021; 43:1446-1453. [PMID: 34670477 PMCID: PMC8547813 DOI: 10.1080/0886022x.2021.1988639] [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] [Indexed: 11/29/2022] Open
Abstract
This study was designed to identify the fluid spaces that are most changed during ultrafiltration (UF) according to intradialytic blood pressure (BP) difference. BP data were collected five times (before hemodialysis [HD] and 1–4 h of HD). Intradialytic BP difference was calculated as the highest minus lowest of these BP measurements. Intradialytic systolic BP (SBP) difference over 20 mm Hg and diastolic BP (DBP) difference over 10 mm Hg were defined as wide intradialytic SBP difference (SYS-W) and DBP difference (DIA-W), respectively. We measured the various fluid spaces before HD and 1–4 h of HD, and 30 min after HD using a portable, whole-body bioimpedance spectroscopy (BIS). In this study, 85 prevalent patients aged over 18 years with a fixed dry weight (65.38 ± 12.45 years, 54.18% men, 52.50% patients with diabetes), undergoing HD had participated. 1) Mean relative reduction of extracellular water (ECW) was significantly higher in SYS-W than in narrow intradialytic SBP difference (SYS-N) patients from 1 h to 30 min after HD. 2) Mean relative reduction of intracellular water (ICW) was significantly lower in DIA-W than in narrow intradialytic DBP difference (DIA-N) patients from 1 h to 30 min after HD. 3) ECW of patients with SYS-W was significantly lower than that of patients with SYS-N. Patients with SYS-W have the characteristics of fluid shifts in which reduction of ECW was steeper than patients with SYS-N whereas fluid shifts of ICW were lower in patients with DIA-W than patients with DIA-N.
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Affiliation(s)
- Young Eun Kwon
- Department of Internal Medicine, Division of Nephrology, Myongji Hospital, Hanyang University College of Medicine, Goyang, Republic of Korea
| | - Hye Min Choi
- Department of Internal Medicine, Division of Nephrology, Myongji Hospital, Hanyang University College of Medicine, Goyang, Republic of Korea
| | - Dong-Jin Oh
- Department of Internal Medicine, Division of Nephrology, Myongji Hospital, Hanyang University College of Medicine, Goyang, Republic of Korea
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Schwaiger E, Simon A, Wabel P, Schairer B, Berner C, Signorini L, Ernstbrunner M, Evstatiev R, Schwabl P, Hinterholzer G, Frommlet F, Vychytil A, Müller CJ, Hecking M. Bioimpedance spectroscopy for fluid status assessment in patients with decompensated liver cirrhosis: Implications for peritoneal dialysis. Sci Rep 2020; 10:2869. [PMID: 32071351 PMCID: PMC7028989 DOI: 10.1038/s41598-020-59817-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 01/31/2020] [Indexed: 01/08/2023] Open
Abstract
Bioimpedance spectroscopy (BIS) is routinely used in peritoneal dialysis patients and might aid fluid status assessment in patients with liver cirrhosis, but the effect of ascites volume removal on BIS-readings is unknown. Here we determined changes in BIS-derived parameters and clinical signs of fluid overload from before to after abdominal paracentesis. Per our pre-specified sample size calculation, we studied 31 cirrhotic patients, analyzing demographics, labs and clinical parameters along with BIS results. Mean volume of the abdominal paracentesis was 7.8 ± 2.6 L. From pre-to post-paracentesis, extracellular volume (ECV) decreased (20.2 ± 5.2 L to 19.0 ± 4.8 L), total body volume decreased (39.8 ± 9.8 L to 37.8 ± 8.5 L) and adipose tissue mass decreased (38.4 ± 16.0 kg to 29.9 ± 12.9 kg; all p < 0.002). Correlation of BIS-derived parameters from pre to post-paracentesis ranged from R² = 0.26 for body cell mass to R² = 0.99 for ECV. Edema did not correlate with BIS-derived fluid overload (FO ≥ 15% ECV), which occurred in 16 patients (51.6%). In conclusion, BIS-derived information on fluid status did not coincide with clinical judgement. The changes in adipose tissue mass support the BIS-model assumption that fluid in the peritoneal cavity is not detectable, suggesting that ascites (or peritoneal dialysis fluid) mass should be subtracted from adipose tissue if BIS is used in patients with a full peritoneal cavity.
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Affiliation(s)
- Elisabeth Schwaiger
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine II, Kepler University Hospital, Med Campus III, Linz, Austria
| | - Amrei Simon
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Peter Wabel
- Fresenius Medical Care, Research and Development, Bad Homburg, Germany
| | - Benjamin Schairer
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Carolin Berner
- 1st Medical Department, Division for Nephrology, Sozialmedizinisches Zentrum Süd, Vienna, Austria
| | - Lorenzo Signorini
- Dipartimento di Nefrologia e Dialis, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Matthäus Ernstbrunner
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Rayko Evstatiev
- Department of Internal Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Philipp Schwabl
- Department of Internal Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Georg Hinterholzer
- 1st Medical Department, Division for Nephrology, Sozialmedizinisches Zentrum Süd, Vienna, Austria
| | - Florian Frommlet
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Andreas Vychytil
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Christian J Müller
- Department of Internal Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Manfred Hecking
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria.
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Schwaiger E, Burghart L, Signorini L, Ristl R, Kopecky C, Tura A, Pacini G, Wrba T, Antlanger M, Schmaldienst S, Werzowa J, Säemann MD, Hecking M. Empagliflozin in posttransplantation diabetes mellitus: A prospective, interventional pilot study on glucose metabolism, fluid volume, and patient safety. Am J Transplant 2019; 19:907-919. [PMID: 30585690 PMCID: PMC6590167 DOI: 10.1111/ajt.15223] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 11/28/2018] [Accepted: 12/06/2018] [Indexed: 02/07/2023]
Abstract
The safety and efficacy of sodium-glucose cotransporter 2 inhibitors in posttransplantation diabetes mellitus is unknown. We converted stable kidney transplant patients to 10 mg empagliflozin, aiming at replacing their insulin therapy (<40 IU/d). N = 14 participants (the required sample size) completed the study visits through 4 weeks and N = 8 through 12 months. Oral glucose tolerance test (OGTT)-derived 2-hour glucose (primary end point) increased from 232 ± 82 mg/dL (baseline) to 273 ± 116 mg/dL (4 weeks, P = .06) and to 251 ± 71 mg/dL (12 months, P = .41). Self-monitored blood glucose and hemoglobin A1c were also clinically inferior with empagliflozin monotherapy, such that insulin was reinstituted in 3 of 8 remaining participants. Five participants (2 of them dropouts) vs nine of 24 matched reference patients developed bacterial urinary tract infections (P = .81). In empagliflozin-treated participants, oral glucose insulin sensitivity decreased and beta-cell glucose sensitivity increased at the 4-week and 12-month OGTTs. Estimated glomerular filtration rate and bioimpedance spectroscopy-derived extracellular and total body fluid volumes decreased by 4 weeks, but recovered. All participants lost body weight. No participant developed ketoacidosis; 1 patient developed balanitis. In conclusion, although limited by sample size and therefore preliminary, these results suggest that empagliflozin can safely be used as add-on therapy, if posttransplant diabetes patients are monitored closely (NCT03113110).
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Affiliation(s)
- Elisabeth Schwaiger
- Division of Nephrology and DialysisDepartment of Medicine IIIMedical University of ViennaViennaAustria
| | - Lukas Burghart
- Division of Nephrology and DialysisDepartment of Medicine IIIMedical University of ViennaViennaAustria
| | - Lorenzo Signorini
- Division of NephrologyOspedale Civile MaggioreBorgo TrentoVeronaItaly
| | - Robin Ristl
- Center for Medical Statistics, Informatics and Intelligent SystemsMedical University ViennaViennaAustria
| | - Chantal Kopecky
- Division of Nephrology and DialysisDepartment of Medicine IIIMedical University of ViennaViennaAustria
| | - Andrea Tura
- Metabolic UnitCNR Institute of NeuroscienceCorso Stati Uniti 4PadovaItaly
| | - Giovanni Pacini
- Metabolic UnitCNR Institute of NeuroscienceCorso Stati Uniti 4PadovaItaly
| | - Thomas Wrba
- IT4ScienceIT‐Systems & CommunicationsMedical University of ViennaViennaAustria
| | - Marlies Antlanger
- Division of Nephrology and DialysisDepartment of Medicine IIIMedical University of ViennaViennaAustria
| | | | - Johannes Werzowa
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling1st Medical DepartmentHanusch HospitalViennaAustria
| | - Marcus D. Säemann
- Division of Nephrology and DialysisDepartment of Medicine IIIMedical University of ViennaViennaAustria,6th Medical Department with Nephrology and DialysisWilhelminenspitalViennaAustria
| | - Manfred Hecking
- Division of Nephrology and DialysisDepartment of Medicine IIIMedical University of ViennaViennaAustria
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Telford T, Keane DF, Garner AE, Waller ML, Scarsbrook AF, Barnfield MC. Assessing the impact of inadequate hydration on isotope-GFR measurement. Scandinavian Journal of Clinical and Laboratory Investigation 2019; 79:86-90. [PMID: 30614738 DOI: 10.1080/00365513.2018.1555859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Guidelines state that patients undergoing isotope glomerular filtration rate (GFR) tests should maintain adequate hydration, but pragmatically these tests can coincide with procedures requiring the patient not to eat or drink ('nil-by-mouth') for up to 12 hours beforehand. This study investigated the impact of a 12-hour nil-by-mouth regime on GFR measurement. Twelve healthy volunteers were recruited from our institution. Exclusion criteria included diabetes mellitus, being under 18 years of age and pregnancy. Isotope GFR measurements were carried out on these volunteers twice. One of the tests adhered strictly to the British Nuclear Medicine Society (BNMS) guidelines for GFR measurement and the other test was carried out after the volunteers had refrained from eating or drinking anything for 12 hours. The order of these tests was randomly assigned. The results show that after a nil-by-mouth regime, participants' average absolute GFR fell from 108 ml/min to 97 ml/min (p < .01), while normalised GFR fell from 97 ml/min/1.73 m2 to 88 ml/min/1.73m2 (p < .01). Serum creatinine rose from 68 mmol/L to 73 mmol/L (p < .05). There were no changes in blood pressure, serum hydration markers or bio-impedance measured fluid status. Urine analysis showed statistically significant increases in urea, creatinine and osmolality levels after the nil-by-mouth regime. The results highlight the importance of following current guidelines recommending fluid intake during the procedure. Practitioners should consider what other outpatient appointments are being scheduled concurrently with a GFR test.
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Affiliation(s)
- Tania Telford
- a Departments of Medical Physics and Engineering, Nuclear Medicine and Blood Sciences , The Leeds Teaching Hospitals NHS Trust , Leeds , UK
| | - David F Keane
- a Departments of Medical Physics and Engineering, Nuclear Medicine and Blood Sciences , The Leeds Teaching Hospitals NHS Trust , Leeds , UK
| | - Ashley E Garner
- a Departments of Medical Physics and Engineering, Nuclear Medicine and Blood Sciences , The Leeds Teaching Hospitals NHS Trust , Leeds , UK
| | - Michael L Waller
- a Departments of Medical Physics and Engineering, Nuclear Medicine and Blood Sciences , The Leeds Teaching Hospitals NHS Trust , Leeds , UK
| | - Andrew F Scarsbrook
- a Departments of Medical Physics and Engineering, Nuclear Medicine and Blood Sciences , The Leeds Teaching Hospitals NHS Trust , Leeds , UK
| | - Mark C Barnfield
- a Departments of Medical Physics and Engineering, Nuclear Medicine and Blood Sciences , The Leeds Teaching Hospitals NHS Trust , Leeds , UK
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Microcirculation-mediated preconditioning and intracellular hypothermia. Med Hypotheses 2018; 115:8-12. [PMID: 29685204 DOI: 10.1016/j.mehy.2018.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 03/19/2018] [Indexed: 01/08/2023]
Abstract
Microcirculation is a network of perfused capillaries that connects macrocirculation with the cells. Although research has provided insight into microcirculatory blood flow, our knowledge remains limited. In this article, we propose a new role of microcirculation in physiological and shock states. In healthy individuals, microcirculation maintains cellular homeostasis via preconditioning. When blood volume decreases, the ensuing microcirculatory changes result in heterogeneity of perfusion and tissue oxygenation. Initially, this is partly compensated by the preserved autoregulation and the increase in the metabolism rate of cells, but at later stages, the loss of autoregulation activates the cascade of intracellular hypothermia.
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Kenworthy P, Phillips M, Grisbrook TL, Gibson W, Wood FM, Edgar DW. An objective measure for the assessment and management of fluid shifts in acute major burns. BURNS & TRAUMA 2018; 6:3. [PMID: 30009191 PMCID: PMC6040607 DOI: 10.1186/s41038-017-0105-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 12/19/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Major burns are life threatening. Fluid resuscitation is required for survival to maintain intravascular volumes and prevent hypovolemic shock. Bioimpedance spectroscopy (BIS) has been recognised as a potential method of monitoring fluid shifts after burn and in other disease states. The aims of this study were to examine the reliability of BIS across different dressing conditions and electrode positions, establish the influence of Acticoat™ on BIS variable measures and determine the validity of whole-body BIS to assess net fluid shift in the presence of moderate to major burns. METHODS An observational longitudinal cohort study was conducted from December 2014 to February 2016. Patients with over 15% total body surface area (TBSA) burns and injury less than 48 h were enrolled in the study. BIS triplicate measures were collected in an open wound and with an ActicoatTM dressing (at 5 half hour intervals). Standard and alternate electrode placements were utilised for the reliability analysis and standard placement only for determining the validity of BIS in moderate to major burns. The ImpediMde SFB7 was used to collect whole-body and segmental BIS measures. Stata statistical software, release 14 was utilised to analyse all results. Descriptive analyses were performed and were reported using the means and standard deviations (SD). RESULTS BIS-repeated measures established BIS raw resistance (R), and predicted volume variables were reliable in any condition (intra-class correlation coefficient (ICC) 0.996-0.999, 95% confidence intervals (CI) 0.996-0.999) without a systematic difference. Acticoat™ dressings significantly influenced all BIS-predicted volumes (p ≤ 0.01) as determined by multilevel mixed effects (MLME) linear regression analysis. Validity of BIS was demonstrated by resistance variables significantly decreasing with increasing net ionic fluid shift and increased TBSA (severity of injury) and calculated fluid volumes increasing with increasing net fluid shift and TBSA. BIS resistance also decreased with time as oedema reduced. For clinical use, a calculator was developed to adjust BIS variables when an Acticoat™ dressing is in situ, thus facilitating BIS variable change estimates in real time, with dressings intact. CONCLUSION BIS may be used clinically to monitor fluid volume change in major acute burns.
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Affiliation(s)
- Pippa Kenworthy
- Fiona Wood Foundation, Fiona Stanley Hospital, Perth, Western Australia Australia
- Burns Service of Western Australia, Fiona Stanley Hospital, Perth, Western Australia Australia
- School of Physiotherapy, Notre Dame University, Fremantle, Western Australia Australia
- Adult State Burns Service, Fiona Stanley Hospital, Murdoch Drive, Murdoch, Western Australia 6150 Australia
| | - Michael Phillips
- Harry Perkins Institute of Medical Research, The University of Western Australia, Perth, Western Australia Australia
| | - Tiffany L. Grisbrook
- Fiona Wood Foundation, Fiona Stanley Hospital, Perth, Western Australia Australia
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia Australia
| | - William Gibson
- School of Physiotherapy, Notre Dame University, Fremantle, Western Australia Australia
| | - Fiona M. Wood
- Fiona Wood Foundation, Fiona Stanley Hospital, Perth, Western Australia Australia
- Burns Service of Western Australia, Fiona Stanley Hospital, Perth, Western Australia Australia
| | - Dale W. Edgar
- Fiona Wood Foundation, Fiona Stanley Hospital, Perth, Western Australia Australia
- Burns Service of Western Australia, Fiona Stanley Hospital, Perth, Western Australia Australia
- Burn Injury Research Node, Notre Dame University, Fremantle, Western Australia Australia
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