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Motiejunaite J, Flamant M, Arnoult F, Lahens A, Tabibzadeh N, Boutten A, Rouzet F, Vrtovsnik F, Vidal-Petiot E, de Pinho NA. Predictors of daytime blood pressure, nighttime blood pressure, and nocturnal dipping in patients with chronic kidney disease. Hypertens Res 2024; 47:2511-2520. [PMID: 38969804 DOI: 10.1038/s41440-024-01778-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 04/02/2024] [Accepted: 06/04/2024] [Indexed: 07/07/2024]
Abstract
Increasing attention has recently been paid to discrepancies between office and ambulatory blood pressure (BP) control in patients with chronic kidney disease (CKD), but information on mechanisms underlying circadian BP variations in CKD remains scarce. We described circadian BP patterns and their predictors in patients with CKD stages 1 to 5 referred for kidney function testing in a French tertiary hospital: 1122 ambulatory BP measurements from 635 participants. Factors associated with daytime and nighttime systolic BP (SBP) as well as with nocturnal SBP dipping (ratio of average nighttime to daytime SBP) were analyzed with linear mixed regression models. Participants (mean age 55 ± 16 years; 36% female, mean GFR 51 ± 22 mL/min/1.73m2) had a mean daytime and nighttime SBP of 130 ± 17 and 118 ± 18 mm Hg, respectively. The prevalence of impaired dipping (nighttime over daytime SBP ratio ≥ 0.9) increased from 32% in CKD stage 1 to 68% in CKD stages 4-5. After multivariable adjustment, measured GFR, diabetes, and sub-Saharan African origin were more strongly associated with nighttime than with daytime SBP, which led to significant associations with altered nocturnal BP dipping. For a 1 SD decrease in measured GFR, nighttime BP was 2.87 mmHg (95%CI, 1.44-4.30) higher and nocturnal SBP dipping ratio was 1.55% higher (95%CI, 0.85-2.26%). In conclusion, the prevalence of impaired nocturnal BP dipping increases substantially across the spectrum of CKD. Along with sub-Saharan African origin and diabetes, lower measured GFR was a robust and specific predictor of higher nighttime BP and blunted nocturnal BP decline.
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Affiliation(s)
- Justina Motiejunaite
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
- Université Paris Cité, Paris, France
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France
| | - Martin Flamant
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
- Université Paris Cité, Paris, France
- Center for Research on Inflammation, Université de Paris, Institut National de la Santé et de la Recherche Médicale (INSERM) U1149, F-75018, Paris, France
| | - Florence Arnoult
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
| | - Alexandre Lahens
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
- Université Paris Cité, Paris, France
| | - Nahid Tabibzadeh
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
- Université Paris Cité, Paris, France
- Université de Paris, Unité Mixte de Recherche (UMR) S1138, Cordeliers Research Center, 75006, Paris, France
| | - Anne Boutten
- Departement de Biochimie, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
| | - François Rouzet
- Université Paris Cité, Paris, France
- Service de Médecine nucléaire, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, LVTS, F-75018, Paris, France
| | - François Vrtovsnik
- Université Paris Cité, Paris, France
- Center for Research on Inflammation, Université de Paris, Institut National de la Santé et de la Recherche Médicale (INSERM) U1149, F-75018, Paris, France
- Service de Néphrologie, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
| | - Emmanuelle Vidal-Petiot
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
- Université Paris Cité, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, LVTS, F-75018, Paris, France
| | - Natalia Alencar de Pinho
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France.
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Geertsema P, Koorevaar IW, Ipema KJR, Kramers BJ, Casteleijn NF, Gansevoort RT, Meijer E. Effects of salt and protein intake on polyuria in V2RA-treated ADPKD patients. Nephrol Dial Transplant 2024; 39:707-716. [PMID: 37804179 DOI: 10.1093/ndt/gfad218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Indexed: 10/09/2023] Open
Abstract
BACKGROUND The only treatment proven to be renoprotective in autosomal dominant polycystic kidney disease (ADPKD) is a vasopressin V2-receptor antagonist (V2RA). However, aquaresis-associated side effects limit tolerability. We investigated whether salt and/or protein intake influences urine volume and related endpoints in V2RA-treated ADPKD patients. METHODS In this randomized, controlled, double-blind, crossover trial, ADPKD patients treated with maximally tolerated dose of a V2RA were included. While on a low salt and low protein diet, patients were given additional salt and protein to mimic regular intake, which was subsequently replaced by placebo in random order during four 2-week periods. Primary endpoint was change in 24-h urine volume. Secondary endpoints were change in quality of life, measured glomerular filtration rate (mGFR), blood pressure and copeptin level. RESULTS Twelve patients (49 ± 8 years, 25.0% male) were included. Baseline salt and protein intake were 10.8 ± 1.3 g/24-h and 1.2 ± 0.2 g/kg/24-h, respectively. During the low salt and low protein treatment periods, intake decreased to 5.8 ± 1.6 g/24-h and 0.8 ± 0.1 g/kg/24-h, respectively. Baseline 24-h urine volume (5.9 ± 1.2 L) decreased to 5.2 ± 1.1 L (-11%, P = .004) on low salt and low protein, and to 5.4 ± 0.9 L (-8%, P = .04) on low salt. Reduction in 24-h urine volume was two times greater in patients with lower urine osmolality (-16% vs -7%). Polyuria quality of life scores improved in concordance with changes in urine volume. mGFR decreased during the low salt and low protein, while mean arterial pressure did not change during study periods. Plasma copeptin decreased significantly during low salt and low protein periods. CONCLUSION Lowering dietary salt and protein intake has a minor effect on urine volume in V2RA-treated ADPKD patients. Reduced intake of osmoles decreased copeptin concentrations and might thus increase the renoprotective effect of a V2RA in ADPKD patients.
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Affiliation(s)
- Paul Geertsema
- Departments of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Iris W Koorevaar
- Departments of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Karin J R Ipema
- Dietetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart J Kramers
- Departments of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Niek F Casteleijn
- Urology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ron T Gansevoort
- Departments of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Esther Meijer
- Departments of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Kramers BJ, Koorevaar IW, van Gastel MD, van Goor H, Hallows KR, Heerspink HL, Li H, Leonhard WN, Peters DJ, Qiu J, Touw DJ, Gansevoort RT, Meijer E. Effects of Hydrochlorothiazide and Metformin on Aquaresis and Nephroprotection by a Vasopressin V2 Receptor Antagonist in ADPKD: A Randomized Crossover Trial. Clin J Am Soc Nephrol 2022; 17:507-517. [PMID: 35314480 PMCID: PMC8993480 DOI: 10.2215/cjn.11260821] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 02/17/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES The vasopressin V2 receptor antagonist tolvaptan is the only drug that has been proven to be nephroprotective in autosomal dominant polycystic kidney disease (ADPKD). Tolvaptan also causes polyuria, limiting tolerability. We hypothesized that cotreatment with hydrochlorothiazide or metformin may ameliorate this side effect. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a clinical study and an animal study. In a randomized, controlled, double-blind, crossover trial, we included 13 tolvaptan-treated patients with ADPKD. Patients were treated for three 2-week periods with hydrochlorothiazide, metformin, or placebo in random order. Primary outcome was change in 24-hour urine volume. We also measured GFR and a range of metabolic and kidney injury markers. RESULTS Patients (age 45±8 years, 54% women, measured GFR of 55±11 ml/min per 1.73 m2) had a baseline urine volume on tolvaptan of 6.9±1.4 L/24 h. Urine volume decreased to 5.1 L/24 h (P<0.001) with hydrochlorothiazide and to 5.4 L/24 h (P<0.001) on metformin. During hydrochlorothiazide treatment, plasma copeptin (surrogate for vasopressin) decreased, quality of life improved, and several markers of kidney damage and glucose metabolism improved. Metformin did not induce changes in these markers or in quality of life. Given these results, the effect of adding hydrochlorothiazide to tolvaptan was investigated on long-term kidney outcome in an animal experiment. Water intake in tolvaptan-hydrochlorothiazide cotreated mice was 35% lower than in mice treated with tolvaptan only. Combination treatment was superior to "no treatment" on markers of disease progression (kidney weight, P=0.003 and cystic index, P=0.04) and superior or equal to tolvaptan alone. CONCLUSIONS Both metformin and hydrochlorothiazide reduced tolvaptan-caused polyuria in a short-term study. Hydrochlorothiazide also reduced polyuria in a long-term animal model without negatively affecting nephroprotection. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_03_21_CJN11260821.mp3.
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Affiliation(s)
- Bart J. Kramers
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Iris W. Koorevaar
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maatje D.A. van Gastel
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Harry van Goor
- Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Kenneth R. Hallows
- Division of Nephrology and Hypertension, Department of Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
- University of Southern California/University Kidney Research Organization Kidney Research Center, Department of Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Hiddo L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University, Hospital Groningen, Groningen, The Netherlands
| | - Hui Li
- Division of Nephrology and Hypertension, Department of Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
- University of Southern California/University Kidney Research Organization Kidney Research Center, Department of Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Wouter N. Leonhard
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dorien J.M. Peters
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jiedong Qiu
- Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Daan J. Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University, Hospital Groningen, Groningen, The Netherlands
- Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Ron T. Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Esther Meijer
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Faucon AL, Flamant M, Delanaye P, Lambert O, Essig M, Peraldi MN, Tabibzadeh N, Haymann JP, Stengel B, Geri G, Vidal-Petiot E. Estimating extracellular fluid volume in healthy individuals: evaluation of existing formulae and development of a new equation. Kidney Int Rep 2022; 7:810-822. [PMID: 35497800 PMCID: PMC9039904 DOI: 10.1016/j.ekir.2022.01.1057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/02/2022] [Accepted: 01/17/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Several clinical settings require an accurate estimation of the physiologically expected extracellular fluid volume (ECFV). We aimed to analyze the performances of existing ECFV-estimating equations and to develop a new equation. Methods The performances of 11 ECFV-estimating equations were analyzed in 228 healthy kidney donor candidates (Bichat Hospital, Paris, France) who underwent ECFV measurement using the distribution volume of 51Cr-labeled EDTA (51Cr-EDTA). An equation was developed using a penalized linear modeling approach (elastic net regression) and externally (Tenon Hospital, Paris, France, N = 142) validated. Results Participants from Bichat (mean age 45.2 ± 12.0 years, 43.0% men) and Tenon (47.8 ± 10.3 years, 29.6% men) hospitals had a mean measured ECFV of 15.4 ± 2.8 l and 15.1 ± 2.1 l, respectively. Available ECFV-estimating formulae have highly variable precision and accuracy. The new equation incorporating body weight, height, sex, and age had better precision and accuracy than all other equations in the external validation cohort, with a median bias of −0.20 (95% CI: −0.35 to −0.05) l versus −2.63 (−2.87 to −2.42) l to −0.57 (− 0.83 to −0.40) l and 0.21 (0.12 to 0.43) l to 2.89 (2.65 to 3.11) l, for underestimating and overestimating equations, respectively, an interquartile range for the bias of 0.88 (0.70 to 1.08) l versus 0.91 (0.71 to 1.20) l to 1.93 (1.67 to 2.25) l, and an accuracy within 10% of 90.9% (83.8 to 94.4) versus 88.0% (81.0 to 92.3) to 8.5% (4.2 to 13.4). These results were consistent across subgroups defined by sex, body mass index (BMI), body surface area (BSA), age, and ethnicity. Conclusion We developed and validated a new equation to estimate the individual reference value of ECFV, which is easily usable in clinical practice. Further validation in cohorts including individuals of extreme age and corpulence remains needed.
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Warwick J, Holness J. Measurement of Glomerular Filtration Rate. Semin Nucl Med 2022; 52:453-466. [DOI: 10.1053/j.semnuclmed.2021.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 12/21/2021] [Indexed: 01/21/2023]
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Abstract
This review will highlight our current understanding of the formation, circulation, and immunological role of lymphatic fluid. The formation of the extracellular fluid depends on the net balance between the hydrostatic and osmotic pressure gradients effective in the capillary beds. Lymph originates from the extracellular fluid and its composition combines the ultrafiltrated plasma proteins with the proteome generated by the metabolic activities of each parenchymal tissue. Several analyses have indicated how the lymph composition reflects the organs' physiological and pathological states. The collected lymphatic fluid moves from the capillaries into progressively larger collectors toward the draining lymph node aided by the lymphangion contractility and unidirectional valves, which prevent backflow. The proteomic composition of the lymphatic fluid is reflected in the MHC II peptidome presented by nodal antigen-presenting cells. Taken together, the past few years have generated new interest in the formation, transport, and immunological role of the lymphatic fluid.
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Roumelioti ME, Glew RH, Khitan ZJ, Rondon-Berrios H, Argyropoulos CP, Malhotra D, Raj DS, Agaba EI, Rohrscheib M, Murata GH, Shapiro JI, Tzamaloukas AH. Fluid balance concepts in medicine: Principles and practice. World J Nephrol 2018; 7:1-28. [PMID: 29359117 PMCID: PMC5760509 DOI: 10.5527/wjn.v7.i1.1] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/16/2017] [Accepted: 11/27/2017] [Indexed: 02/06/2023] Open
Abstract
The regulation of body fluid balance is a key concern in health and disease and comprises three concepts. The first concept pertains to the relationship between total body water (TBW) and total effective solute and is expressed in terms of the tonicity of the body fluids. Disturbances in tonicity are the main factor responsible for changes in cell volume, which can critically affect brain cell function and survival. Solutes distributed almost exclusively in the extracellular compartment (mainly sodium salts) and in the intracellular compartment (mainly potassium salts) contribute to tonicity, while solutes distributed in TBW have no effect on tonicity. The second body fluid balance concept relates to the regulation and measurement of abnormalities of sodium salt balance and extracellular volume. Estimation of extracellular volume is more complex and error prone than measurement of TBW. A key function of extracellular volume, which is defined as the effective arterial blood volume (EABV), is to ensure adequate perfusion of cells and organs. Other factors, including cardiac output, total and regional capacity of both arteries and veins, Starling forces in the capillaries, and gravity also affect the EABV. Collectively, these factors interact closely with extracellular volume and some of them undergo substantial changes in certain acute and chronic severe illnesses. Their changes result not only in extracellular volume expansion, but in the need for a larger extracellular volume compared with that of healthy individuals. Assessing extracellular volume in severe illness is challenging because the estimates of this volume by commonly used methods are prone to large errors in many illnesses. In addition, the optimal extracellular volume may vary from illness to illness, is only partially based on volume measurements by traditional methods, and has not been determined for each illness. Further research is needed to determine optimal extracellular volume levels in several illnesses. For these reasons, extracellular volume in severe illness merits a separate third concept of body fluid balance.
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Affiliation(s)
- Maria-Eleni Roumelioti
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Robert H Glew
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Zeid J Khitan
- Division of Nephrology, Department of Medicine, Joan Edwards School of Medicine, Marshall University, Huntington, WV 25701, United States
| | - Helbert Rondon-Berrios
- Division of Renal and Electrolyte, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, United States
| | - Christos P Argyropoulos
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Deepak Malhotra
- Division of Nephrology, Department of Medicine, University of Toledo School of Medicine, Toledo, OH 43614-5809, United States
| | - Dominic S Raj
- Division of Renal Disease and Hypertension, Department of Medicine, George Washington University, Washington, DC 20037, United States
| | - Emmanuel I Agaba
- Division of Nephology, Department of Medicine, Jos University Medical Center, Jos, Plateau State 930001, Nigeria
| | - Mark Rohrscheib
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Glen H Murata
- Research Service, Raymond G Murphy VA Medical Center and University of New Mexico School of Medicine, Albuquerque, NM 87108, United States
| | | | - Antonios H Tzamaloukas
- Research Service, Raymond G Murphy VA Medical Center and University of New Mexico School of Medicine, Albuquerque, NM 87108, United States
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Finch NC, Heiene R, Elliott J, Syme HM, Peters AM. Determination of extracellular fluid volume in healthy and azotemic cats. J Vet Intern Med 2014; 29:35-42. [PMID: 25406506 PMCID: PMC4858083 DOI: 10.1111/jvim.12506] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 07/22/2014] [Accepted: 10/21/2014] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Methods for determining extracellular fluid volume (ECFV) are important clinically for cats. Bromide dilution has been studied in cats to estimate ECFV. Markers of GFR also distribute in ECFV and can be used for its measurement. HYPOTHESIS/OBJECTIVES The primary objective was to develop a method of determining ECFV from iohexol clearance in cats and evaluate agreement with that determined using bromide dilution. Additional objectives were to compare ECFV between azotemic and nonazotemic cats and evaluate appropriate methods of standardizing ECFV. ANIMALS Client-owned cats with varying renal function. METHODS Validation of ECFV determined from slope-intercept iohexol clearance was performed in 18 healthy nonazotemic cats. ECFV was then determined using the validated method and bromide dilution and agreement assessed. Appropriateness of standardization to body weight (BW) and body surface area (BSA) was evaluated. RESULTS Extracellular fluid volume determined from slope-intercept iohexol clearance and bromide dilution was 0.84 ± 0.32 L and 0.85 ± 0.19 L (mean ± SD), respectively. There were wide limits of agreement between the methods (-0.58 to 0.54 L) and therefore, agreement was considered to be poor. ECFV did not differ significantly between azotemic and nonazotemic cats (P = .177). BSA was found to be the best method for standardizing ECFV measurement in cats. CONCLUSIONS AND CLINICAL IMPORTANCE This study developed a method for determining ECFV from slope-intercept iohexol clearance which provides simultaneous assessment of renal function and an estimate of ECFV. ECFV does not differ between azotemic and nonazotemic cats, which suggests fluid volume loss or overload is not an important clinical feature in cats with mild chronic kidney disease.
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Affiliation(s)
- N C Finch
- Royal Veterinary College, London, UK
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Finch N. Measurement of glomerular filtration rate in cats: methods and advantages over routine markers of renal function. J Feline Med Surg 2014; 16:736-48. [PMID: 25146661 PMCID: PMC11185244 DOI: 10.1177/1098612x14545274] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
PRACTICAL RELEVANCE Routinely used markers of renal function in clinical practice include urea and creatinine. However, these are insensitive markers, particularly in the early stages of kidney disease. Measurement of glomerular filtration rate (GFR) is regarded as the most sensitive index of functioning renal mass. It may be useful for feline patients in varying clinical scenarios; for example, where a more accurate measurement of renal function may aid diagnosis, to enable response to therapeutic interventions to be more closely monitored, or to evaluate renal function prior to the use of nephrotoxic or renally cleared drugs. CLINICAL CHALLENGES Traditional methods of measuring GFR, such as renal clearance or multisample plasma clearance techniques, are generally impractical for clinical use. Limited sampling and single sample plasma clearance methods using the filtration marker iohexol have been validated in cats. These have the advantages of reduced stress to cats associated with repeated sampling and reduced costs of analysis, and therefore offer greater clinical utility. Attempts to develop an estimated GFR (eGFR) formula similar to that used in human patients have been made in cats, although currently an accurate and reliable formula is not available. AUDIENCE This review presents the basis for the theoretical understanding and practical measurement of GFR for any veterinary practitioner wishing to obtain a more accurate and sensitive assessment of renal function than routinely used markers provide. EVIDENCE BASE The review draws evidence from peer-reviewed publications, the author's PhD thesis and also clinical experience.
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Affiliation(s)
- Natalie Finch
- School of Veterinary Sciences, University of Bristol, Langford, Bristol BS40 7UD, UK
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99mTc-DTPA volume of distribution, half-life and glomerular filtration rate in normal adults. Nucl Med Commun 2013; 34:1005-14. [DOI: 10.1097/mnm.0b013e328364aa12] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Peters AM, Seshadri N, Neilly MDJ, Perry L, Hooker CA, Howard B, Sobnack R, Irwin A, Dave S, Snelling H, Gruning T, Patel NH, Shabo G, Williams N, Barnfield MC, Lawson RS. Higher extracellular fluid volume in women is concealed by scaling to body surface area. Scandinavian Journal of Clinical and Laboratory Investigation 2013; 73:546-52. [PMID: 24047330 DOI: 10.3109/00365513.2013.819524] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The objective was to assess body surface area (BSA) for scaling extracellular fluid volume (ECV) in comparison with estimated lean body mass (LBM) and total body water (TBW) across a range of body mass indices (BMI). METHODS This was a multi-centre study from 15 centres that submitted raw data from routine measurement of GFR in potential kidney transplant donors. There were 819 men and 1059 women in total. ECV was calculated from slope-intercept and slope-only measurements of GFR. ECV was scaled using two methods: Firstly, division of ECV by the scaling variable (ratio method), and secondly the regression method of Turner and Reilly. Subjects were placed into five BMI groups: < 20, 20-24.9, 25-29.9, 30-34.9, and 35 + kg/m(2). LBM and TBW were estimated from previously published, gender-specific prediction equations. RESULTS Ratio and regression scaling gave almost identical results. ECV scaled to BSA by either method was higher in men in all BMI groups but ECV scaled to LBM and TBW was higher in women. There was, however, little difference between men and women in respect to ECV per unit weight in any BMI group, even though women have 10% more adipose tissue. The relations between TBW and BSA and between LBM and BSA, but not between LBM and TBW, were different between men and women. CONCLUSION Lean tissue in women contains more extracellular water than in men, a difference that is obscured by scaling to BSA. The likely problem with BSA is its insensitivity to body composition.
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Affiliation(s)
- A Michael Peters
- Department of Nuclear Medicine, Royal Sussex County Hospital , Brighton
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Simplified methods for assessment of renal function as the ratio of glomerular filtration rate to extracellular fluid volume. Nucl Med Commun 2013; 33:1243-53. [PMID: 23111354 DOI: 10.1097/mnm.0b013e3283591908] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Instead of scaling glomerular filtration rate (GFR) to a body surface area of 1.73 m(2), it has been suggested to scale GFR to extracellular fluid volume (ECV). The ratio GFR/ECV has physiological meaning in that it indicates how often 'that which is to be regulated' (i.e. ECV) comes into contact with the 'regulator' (i.e. the kidneys). AIM The aim of the present study was as follows: to analyse two published calculation methods for determining ECV and GFR/ECV; to develop a new simple and accurate formula for determining ECV; and to compare and evaluate these methods. MATERIALS AND METHODS GFR was determined as (51)Cr-EDTA clearance. The study comprised 128 individuals (35 women, 66 men and 27 children) with a full (51)Cr-EDTA plasma concentration curve, determined from injection until 4-5 h p.i. Reference values for GFR and ECV were calculated from the full curve. One-pool approximations C/(1) and V(1) were calculated using only the final-slope curve. Four calculation methods were compared: simple one-pool values; GFR/ECV according to Peters and colleagues; ECV according to Brøchner-Mortensen (BM); and ECV according to a new method (JBM): y=2x-1, where x=Cl(1)/Cl and y=V(1)/ECV. RESULTS The new JBM method is accurate and can be explained theoretically. BM has a slight bias for high renal function. The Peters method had bias in our data. GFR/ECV had better precision than ECV alone, especially for BM and JBM, which were within -4% to +7% of the reference values (95% limits of agreement in adults). CONCLUSION GFR/ECV can be precisely determined, especially with the BM and JBM methods. Expressing GFR/ECV in unit %/h gives a simple interpretation. Normal ranges for GFR/ECV need to be established.
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Finch N, Heiene R, Elliott J, Syme H, Peters A. A Single Sample Method for Estimating Glomerular Filtration Rate in Cats. J Vet Intern Med 2013; 27:782-90. [DOI: 10.1111/jvim.12089] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2011] [Revised: 02/14/2013] [Accepted: 03/11/2013] [Indexed: 11/29/2022] Open
Affiliation(s)
| | - R. Heiene
- Norwegian School of Veterinary Science; Oslo Norway
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Estimation of extracellular fluid volume in children. Pediatr Nephrol 2012; 27:1149-55. [PMID: 22422351 DOI: 10.1007/s00467-012-2117-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2011] [Revised: 12/27/2011] [Accepted: 01/02/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Many equations have been developed to estimate various body fluid volumes from height and weight, but few have been developed for children. The aim of this study was to compare four height/weight formulae for estimating extracellular fluid volume (eECV) in children against measured extracellular fluid volume (mECV). METHODS The mECV was obtained from plasma Cr-51-EDTA clearance data used for routine measurement of glomerular filtration rate (GFR) in two groups of children (n=182 and 69, respectively). eECV obtained using the formulae of Abraham et al. (Clin J Am Assoc Nephrol 6:741-747, 2011) and Friis-Hansen (Pediatrics 28:169-181, 1961) were compared with mECV in both patient groups. The formulae of Bird et al. (J Nucl Med 44:1037-1043, 2003) and of Peters (Nucl Med Commun 32:375-380, 2011) were originally based on groups 1 and 2, respectively, so the eECV from them was compared with the mECV in groups 2 and 1, respectively. RESULTS The eECV from the Friis-Hansen formula underestimated the mECV in larger children. Biases (mean differences between eECV and mECV) from the Bird (0.146 l) and Peters (0.029 l) formulae were not significantly different from zero, but those from the Abraham formula was higher than zero (0.694 and 0.588 l in groups 1 and 2; p<0.001). Precisions (standard deviations of the biases) of these three formulae were similar, ranging from 0.731 l (Peters) to 0.878 l (Abraham, group 2; p>0.1). CONCLUSION The formulae of Bird, Peters and Abraham have similar precisions. The higher bias of the Abraham formula is probably due to the higher values of mECV on which their formula was based. The Friis-Hansen formula no longer has a place.
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The reliability of glomerular filtration rate measured from plasma clearance: a multi-centre study of 1,878 healthy potential renal transplant donors. Eur J Nucl Med Mol Imaging 2012; 39:715-22. [DOI: 10.1007/s00259-011-2024-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 12/02/2011] [Indexed: 11/27/2022]
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Peters AM, Perry L, Hooker CA, Howard B, Neilly MDJ, Seshadri N, Sobnack R, Irwin A, Snelling H, Gruning T, Patel NH, Lawson RS, Shabo G, Williams N, Dave S, Barnfield MC. Extracellular fluid volume and glomerular filtration rate in 1878 healthy potential renal transplant donors: effects of age, gender, obesity and scaling. Nephrol Dial Transplant 2011; 27:1429-37. [PMID: 22076428 DOI: 10.1093/ndt/gfr479] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
UNLABELLED Aim. The aim of this study was to investigate the influence of age, gender, obesity and scaling on glomerular filtration rate (GFR) and extracellular fluid volume (ECV) in healthy subjects. METHODS This is a retrospective multi-centre study of 1878 healthy prospective kidney transplant donors (819 men) from 15 centres. Age and body mass index (BMI) were not significantly different between men and women. Slope-intercept GFR was measured (using Cr-51-EDTA in 14 centres; Tc-99m-DTPA in one) and scaled to body surface area (BSA) and lean body mass (LBM), both estimated from height and weight. GFR was also expressed as the slope rate constant, with one-compartment correction (GFR/ECV). ECV was measured as the ratio, GFR to GFR/ECV. RESULTS ECV was age independent but GFR declined with age, at a significantly faster rate in women than men. GFR/BSA was higher in men but GFR/ECV and GFR/LBM were higher in women. Young women (<30 years) had higher GFR than young men but the reverse was recorded in the elderly (>65 years). There was no difference in GFR between obese (BMI>30 kg/m2) and non-obese men. Obese women, however, had lower GFR than non-obese women and negative correlations were observed between GFR and both BMI and %fat. The decline in GFR with age was no faster in obese versus non-obese subjects. ECV/BSA was higher in men but ECV/LBM was higher in women. ECV/weight was almost gender independent, suggesting that fat-free mass in women contains more extracellular water. BSA is therefore a misleading scaling variable. CONCLUSION There are several significant differences in GFR and ECV between healthy men and women.
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Affiliation(s)
- A Michael Peters
- Department of Nuclear Medicine, Royal Sussex County Hospital, Brighton, UK.
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Peters AM, Snelling HLR, Glass DM, Bird NJ. Estimation of lean body mass in children. Br J Anaesth 2011; 106:719-23. [PMID: 21498495 DOI: 10.1093/bja/aer057] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In adults, dosages of some anaesthetic agents are based on lean body mass (LBM) rather than body weight. Our aim was to derive an equation for estimating LBM in children. METHODS Patients comprised three groups: prospective kidney transplant donors from two separate centres (centres 1 and 3) and children referred to a further centre (centre 2) for the routine clinical measurement of glomerular filtration rate (GFR). GFR and extracellular fluid volume (ECV) were measured using Cr-51-EDTA. LBM was directly estimated (eLBM) in adults using an equation based on height and weight. ECV in children was estimated (eECV) from another equation based on height and weight, converted to eLBM using the relationship between eLBM and ECV determined in the adults from centre 1 and then compared with adult data from centre 3. RESULTS In children, the ratio of eECV to ECV was 1.04 (SD 0.18). In centre 1, eLBM (kg) was 3.81 (SD 0.55) times greater than ECV (litres) in men (n=50) and 3.77 (0.77) times greater in women (n=51). eLBM in children was therefore derived by multiplying eECV by 3.8. In children, eLBM showed a close linear correlation with measured ECV (eLBM=3.50ECV+2.0; R(2)=0.857), similar to adults (eLBM=2.82ECV+14.5; R(2)=0.582). In all groups, eLBM/weight correlated inversely with weight. CONCLUSIONS In terms of the relationships between eLBM, ECV, and weight, children are similar to adults. Therefore, drug dosage in children should also be based on eLBM rather than weight.
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Affiliation(s)
- A M Peters
- Department of Nuclear Medicine, Harley St Clinic, London, UK.
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Abstract
AIMS Cancer patients may have extracellular fluid volume (ECV) abnormalities that potentially invalidate glomerular filtration rate (GFR) measured using the slope-intercept technique. The aim was to test this concern by measuring ECV in cancer patients in comparison with noncancer patients and healthy kidney donors. METHODS GFR was measured with Cr-EDTA and the slope-intercept technique in patients from two hospitals, the first using three samples (540 adults, including 382 with cancer, and 124 children, including 40 with cancer) and the second using four samples (256 adults, including 132 with cancer and 75 donors), scaled to body surface area (BSA) of 1.73 m and corrected using Brochner-Mortensen's equations (GFR/BSA). GFR/ECV was measured from the exponential rate constant with an appropriate one-compartment correction. ECV/BSA was calculated as the quotient, GFR/BSA:GFR/ECV. ECV was also expressed in adults in relation to lean body mass and in children as a fraction of ECV estimated from height and weight (eECV). RESULTS In men from both centres, neither ECV/BSA nor ECV/lean body mass showed an increase in cancer patients. In women from both centres, however, they were both significantly higher in cancer patients than in noncancer patients and, in centre 2, than in donors. In children from centre 1, ECV/BSA, but not ECV/eECV, was significantly higher in cancer patients. CONCLUSION ECV is expanded in female cancer patients but not male cancer patients. ECV may be expanded in children with cancer but the recorded difference in ECV/BSA is probably related to differences in patient size and a nonproportionate relationship between ECV and BSA.
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PETERS AMICHAEL, GLASS DAPHNEM, BIRD NICHOLASJ. Slope-only glomerular filtration rate and single-sample glomerular filtration rate as measurements of the ratio of glomerular filtration rate to extracellular fluid volume. Nephrology (Carlton) 2009; 15:281-7. [DOI: 10.1111/j.1440-1797.2009.01252.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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