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Zhang Q, Fang H, Jin L. Calculated plasma volume status in hemodialysis patients. Ren Fail 2024; 46:2322685. [PMID: 38411132 PMCID: PMC10901183 DOI: 10.1080/0886022x.2024.2322685] [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: 01/05/2024] [Accepted: 02/19/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Plasma volume (PV) calculated from hematocrit and body weight has applications in cardiovascular disease. The current study investigated the validity of the calculated PV for predicting volume overload and its prognostic utility in patients undergoing hemodialysis (HD). PATIENTS AND METHODS Fifty-four HD patients were prospectively enrolled, and their actual PV (aPV) and relative PV status (PVS) were calculated. Bioelectrical impedance analysis (BIA) with assessment of and total body water (TBW), intracellular water (ICW), extracellular water (ECW), and overhydration (OH) and routine blood examinations were performed before dialysis. A second cohort of 164 HD patients was retrospectively enrolled to evaluate the relationship between the calculated PVS and the outcome, with an endpoint of all-cause mortality. RESULTS aPV was significantly associated with TBW, ICW, ECW, OH, and ECW/TBW (all p < 0.001), and most strongly with ECW (r = 0.83). aPV predicted the extent of volume overload with an AUC of 0.770 (p < 0.001), but PVS did not (AUC = 0.617, p = 0.091). Median follow-up time was 53 months, during the course of which 60 (36.58%) patients died. Values for PVS (12.94 ± 10.87% vs. 7.45 ± 5.90%, p = 0.024) and time-averaged PVS (12.83 ± 11.20 vs. 6.78 ± 6.22%, p < 0.001) were significantly increased in patients who died relative to those who survived. A value of time-averaged PVS >8.72% was significantly associated with an increased incidence of all-cause mortality (HR = 2.48, p = 0.0023). CONCLUSIONS aPV was most strongly associated with ECW measured using BIA. HD patients with higher time-averaged PVS had a higher rate of all-cause mortality.
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Affiliation(s)
- Qiankun Zhang
- Division of Nephrology, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Central Hospital, Lishui Hospital of Zhejiang University, Lishui, China
| | - Hang Fang
- Division of Nephrology, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Central Hospital, Lishui Hospital of Zhejiang University, Lishui, China
- Division of Nephrology, Quzhou People’s Hospital, Quzhou, China
| | - Lie Jin
- Division of Nephrology, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Central Hospital, Lishui Hospital of Zhejiang University, Lishui, China
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Carmo GALD, Oliveira MP, Campos ALL, Couto BRGM, Carmo LPDFD, Cerqueira TL, Souza CAMD, Goll YL, Souza VSD, Vieira MOG, Castro PASVD, Lemos PAB, Silva ACSE. COVID-19 Computed tomography patterns in renal replacement therapy patients. J Bras Nefrol 2024; 46:e20230029. [PMID: 38502952 DOI: 10.1590/2175-8239-jbn-2023-0029en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 11/27/2023] [Indexed: 03/21/2024] Open
Abstract
INTRODUCTION Lung diseases are common in patients with end stage kidney disease (ESKD), making differential diagnosis with COVID-19 a challenge. This study describes pulmonary chest tomography (CT) findings in hospitalized ESKD patients on renal replacement therapy (RRT) with clinical suspicion of COVID-19. METHODS ESKD individuals referred to emergency department older than 18 years with clinical suspicion of COVID-19 were recruited. Epidemiological baseline clinical information was extracted from electronic health records. Pulmonary CT was classified as typical, indeterminate, atypical or negative. We then compared the CT findings of positive and negative COVID-19 patients. RESULTS We recruited 109 patients (62.3% COVID-19-positive) between March and December 2020, mean age 60 ± 12.5 years, 43% female. The most common etiology of ESKD was diabetes. Median time on dialysis was 36 months, interquartile range = 12-84. The most common pulmonary lesion on CT was ground glass opacities. Typical CT pattern was more common in COVID-19 patients (40 (61%) vs 0 (0%) in non-COVID-19 patients, p < 0.001). Sensitivity was 60.61% (40/66) and specificity was 100% (40/40). Positive predictive value and negative predictive value were 100% and 62.3%, respectively. Atypical CT pattern was more frequent in COVID-19-negative patients (9 (14%) vs 24 (56%) in COVID-19-positive, p < 0.001), while the indeterminate pattern was similar in both groups (13 (20%) vs 6 (14%), p = 0.606), and negative pattern was more common in COVID-19-negative patients (4 (6%) vs 12 (28%), p = 0.002). CONCLUSIONS In hospitalized ESKD patients on RRT, atypical chest CT pattern cannot adequately rule out the diagnosis of COVID-19.
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Affiliation(s)
- Gabriel Assis Lopes do Carmo
- Hospital Evangélico de Belo Horizonte, Belo Horizonte, MG, Brazil
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Departamento de Clínica Médica, Belo Horizonte, MG, Brazil
| | | | | | | | - Lilian Pires de Freitas do Carmo
- Hospital Evangélico de Belo Horizonte, Belo Horizonte, MG, Brazil
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Departamento de Clínica Médica, Belo Horizonte, MG, Brazil
| | | | | | - Yan Lopes Goll
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Belo Horizonte, MG, Brazil
| | - Vitor Santos de Souza
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Belo Horizonte, MG, Brazil
| | | | | | | | - Ana Cristina Simões E Silva
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Laboratório Interdisciplinar de Investigação Médica, Unidade de Nefrologia Pediátrica, Belo Horizonte, MG, Brazil
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3
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Fadel FI, Salah DM, Mawla MAA, Galal E, Sayed S. Assessment of volume status of pediatric hemodialysis patients. Pediatr Nephrol 2024:10.1007/s00467-024-06409-2. [PMID: 38839693 DOI: 10.1007/s00467-024-06409-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/08/2024] [Accepted: 05/11/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Accurate volume status assessment and dry weight achievement are the most challenging goals for a nephrologist. We aimed to evaluate the role of ultrasonographic parameters including lung ultrasound and inferior vena cava (IVC) measurements as practical methods of volume status assessment in children on hemodialysis by comparing them with established techniques, such as clinical evaluation and bioimpedance spectroscopy. METHODS A prospective cross-sectional study compared pre- and post-dialysis volume status using bioimpedance spectroscopy (BIS) parameters and clinical data with ultrasonographic lung B-lines and IVC parameters in children on regular hemodialysis. RESULTS A total 60 children (mean age 9.4 ± 2.8 years) were enrolled. Twenty patients (33.3%) were clinically overloaded to varying degrees (17 patients had mild to moderate signs of fluid overload and 3 patients had moderate to severe signs of fluid overload). All other patients (66.7%) were clinically euvolemic. Sonographic parameters were significantly lower post-dialysis than pre-dialysis, including lung B-line count and IVC diameter. IVC collapsibility index mean was significantly higher post-dialysis than pre-dialysis. There was a significant correlation between the lung B-line count, IVC parameters, and BIS-measured overhydration both before and after hemodialysis. Nine patients had ≥ 8 B-lines post-dialysis, only three of them were hypertensive. CONCLUSIONS Clinical criteria alone are not specific for determining accurate fluid status in pediatric hemodialysis patients. Lung B-line score, IVC parameters, and BIS may be complementary to each other and to clinical data. Lung B-lines outperform IVC measurements and BIS in subclinical volume overload detection in pediatric hemodialysis patients.
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Affiliation(s)
- Fatina I Fadel
- Pediatric department, Faculty of Medicine, Cairo University, 4 Extension of Nobar Street, Cairo, Egypt
| | - Doaa M Salah
- Pediatric department, Faculty of Medicine, Cairo University, 4 Extension of Nobar Street, Cairo, Egypt
| | | | - Eman Galal
- Pediatric department, Faculty of Medicine, Cairo University, 4 Extension of Nobar Street, Cairo, Egypt
| | - Shaimaa Sayed
- Pediatric department, Faculty of Medicine, Cairo University, 4 Extension of Nobar Street, Cairo, Egypt.
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4
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Stuard S, Ridel C, Cioffi M, Trost-Rupnik A, Gurevich K, Bojic M, Karibayev Y, Mohebbi N, Marcinkowski W, Kupres V, Maslovaric J, Antebi A, Ponce P, Nada M, Salvador MEB, Rosenberger J, Jirka T, Enden K, Novakivskyy V, Voiculescu D, Pachmann M, Arkossy O. Hemodialysis Procedures for Stable Incident and Prevalent Patients Optimize Hemodynamic Stability, Dialysis Dose, Electrolytes, and Fluid Balance. J Clin Med 2024; 13:3211. [PMID: 38892922 PMCID: PMC11173331 DOI: 10.3390/jcm13113211] [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: 04/13/2024] [Revised: 05/14/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
The demographic profile of patients transitioning from chronic kidney disease to kidney replacement therapy is changing, with a higher prevalence of aging patients with multiple comorbidities such as diabetes mellitus and heart failure. Cardiovascular disease remains the leading cause of mortality in this population, exacerbated by the cardiovascular stress imposed by the HD procedure. The first year after transitioning to hemodialysis is associated with increased risks of hospitalization and mortality, particularly within the first 90-120 days, with greater vulnerability observed among the elderly. Based on data from clinics in Fresenius Medical Care Europe, Middle East, and Africa NephroCare, this review aims to optimize hemodialysis procedures to reduce mortality risk in stable incident and prevalent patients. It addresses critical aspects such as treatment duration, frequency, choice of dialysis membrane, dialysate composition, blood and dialysate flow rates, electrolyte composition, temperature control, target weight management, dialysis adequacy, and additional protocols, with a focus on mitigating prevalent intradialytic complications, particularly intradialytic hypotension prevention.
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Affiliation(s)
- Stefano Stuard
- FME Global Medical Office, 61352 Bad Homburg, Germany; (M.P.); (O.A.)
| | | | | | | | | | - Marija Bojic
- FME Global Medical Office, 75400 Zvornik, Bosnia and Herzegovina;
| | | | | | | | | | | | - Alon Antebi
- FME Global Medical Office, Ra’anana 4366411, Israel;
| | - Pedro Ponce
- FME Global Medical Office, 1750-233 Lisboa, Portugal;
| | - Mamdouh Nada
- FME Global Medical Office, Riyadh 12472, Saudi Arabia;
| | | | | | - Tomas Jirka
- FME Global Medical Office, 16000 Praha, Czech Republic;
| | - Kira Enden
- FME Global Medical Office, 00380 Helsinki, Finland;
| | | | | | - Martin Pachmann
- FME Global Medical Office, 61352 Bad Homburg, Germany; (M.P.); (O.A.)
| | - Otto Arkossy
- FME Global Medical Office, 61352 Bad Homburg, Germany; (M.P.); (O.A.)
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5
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Tao J, May S, Li M, Monahan M, Phanumas D, Seelig C. A Survey for Charting Intake, Output, and Body Weight in the Electronic Medical Record. J Healthc Qual 2024:01445442-990000000-00070. [PMID: 38742984 DOI: 10.1097/jhq.0000000000000437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
BACKGROUND The accuracy of documentation of body weight and fluid balance in hospitalized patients is frequently questioned. METHODS We conducted a survey to understand provider perceptions of the accuracy of intake, output, and weight charting in the electronic medical record. We sent a six-item questionnaire to nurses and physicians who provide inpatient service in a community-based teaching hospital of the Northeastern United States. We compared the response difference between nurses and physicians by Fisher exact test. RESULTS One hundred eight nurses and 39 physicians participated in the survey. Both nurses and physicians responded that the accuracy of documentation is crucial. However, only 25.7% of participating physicians and 38.3% of participating nurses considered that documentation in the electronic medical record is reliable. Both physicians and nurses assumed that the nurses are too busy to collect and document the data, and the variability of non-patient weight and variations in body weight measurement under different conditions account for inaccuracies in the documented body weight. CONCLUSIONS Assessing the accuracy of documenting intake, output, and body weight in the electronic medical record is warranted. Providers believe that educating patients about fluid balance and volume assessment help to improve the accuracy in charting intake, output, and body weight in the electronic medical record.
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6
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Fernandes MIDCD, Tinôco JDDS, Fernandes RM, Silva JBD, Almeida ATD, Frazão CMFDQ, Lopes MVDO, Lira ALBDC. Predictors of excess fluid volume in hemodialysis patients: an observational study. Rev Bras Enferm 2024; 77:e20220816. [PMID: 38716904 PMCID: PMC11067934 DOI: 10.1590/0034-7167-2022-0816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 11/25/2023] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVES to assess risk factors for excess fluid volume in hemodialysis patients. METHODS a retrospective case-control study was conducted. A total of 392 patients (196 cases and 196 controls) from two hemodialysis centers were included. Sociodemographic data and 23 risk factors for excess fluid volume were assessed using a data collection form. Data were analyzed using a multivariate logistic regression model. RESULTS the insufficient knowledge (OR=2.06), excessive fluid intake (OR=2.33), inadequate fluid removal during hemodialysis (OR=2.62) and excessive sodium intake (OR=1.91) risk factors may increase the chance of occurrence of excess fluid volume in hemodialysis patients by approximately two times. Education level (OR=0.95) and age (OR=0.97) are protective factors for excessive fluid volume. CONCLUSIONS knowing these risk factors may help nurses with accurate and rapid diagnostic inference of the risk of excessive fluid volume.
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7
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Georgianos PI, Agarwal R. Resistant Hypertension in Dialysis: Epidemiology, Diagnosis, and Management. J Am Soc Nephrol 2024; 35:505-514. [PMID: 38227447 PMCID: PMC11000742 DOI: 10.1681/asn.0000000000000315] [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: 10/08/2023] [Accepted: 01/08/2024] [Indexed: 01/17/2024] Open
Abstract
Apparent treatment-resistant hypertension is defined as an elevated BP despite the use of ≥3 antihypertensive medications from different classes or the use of ≥4 antihypertensives regardless of BP levels. Among patients receiving maintenance hemodialysis or peritoneal dialysis, using this definition, the prevalence of apparent treatment-resistant hypertension is estimated to be between 18% and 42%. Owing to the lack of a rigorous assessment of some common causes of pseudoresistance, the burden of true resistant hypertension in the dialysis population remains unknown. What distinguishes apparent treatment-resistance from true resistance is white-coat hypertension and adherence to medications. Accordingly, the diagnostic workup of a dialysis patient with apparent treatment-resistant hypertension on dialysis includes the accurate determination of BP control status with the use of home or ambulatory BP monitoring and exclusion of nonadherence to the prescribed antihypertensive regimen. In a patient on dialysis with inadequately controlled BP, despite adherence to therapy with maximally tolerated doses of a β -blocker, a long-acting dihydropyridine calcium channel blocker, and a renin-angiotensin system inhibitor, volume-mediated hypertension is the most important treatable cause of resistance. In daily clinical practice, such patients are often managed with intensification of antihypertensive therapy. However, this therapeutic strategy is likely to fail if volume overload is not adequately recognized or treated. Instead of increasing the number of prescribed BP-lowering medications, we recommend diet and dialysate restricted in sodium to facilitate achievement of dry weight. The achievement of dry weight is facilitated by an adequate time on dialysis of at least 4 hours for delivering an adequate dialysis dose. In this article, we review the epidemiology, diagnosis, and management of resistant hypertension among patients on dialysis.
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Affiliation(s)
- Panagiotis I. Georgianos
- 2nd Department of Nephrology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana
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8
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Osborne AJ, Bierzynska A, Colby E, Andag U, Kalra PA, Radresa O, Skroblin P, Taal MW, Welsh GI, Saleem MA, Campbell C. Multivariate canonical correlation analysis identifies additional genetic variants for chronic kidney disease. NPJ Syst Biol Appl 2024; 10:28. [PMID: 38459044 PMCID: PMC10924093 DOI: 10.1038/s41540-024-00350-8] [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: 09/04/2023] [Accepted: 02/20/2024] [Indexed: 03/10/2024] Open
Abstract
Chronic kidney diseases (CKD) have genetic associations with kidney function. Univariate genome-wide association studies (GWAS) have identified single nucleotide polymorphisms (SNPs) associated with estimated glomerular filtration rate (eGFR) and blood urea nitrogen (BUN), two complementary kidney function markers. However, it is unknown whether additional SNPs for kidney function can be identified by multivariate statistical analysis. To address this, we applied canonical correlation analysis (CCA), a multivariate method, to two individual-level CKD genotype datasets, and metaCCA to two published GWAS summary statistics datasets. We identified SNPs previously associated with kidney function by published univariate GWASs with high replication rates, validating the metaCCA method. We then extended discovery and identified previously unreported lead SNPs for both kidney function markers, jointly. These showed expression quantitative trait loci (eQTL) colocalisation with genes having significant differential expression between CKD and healthy individuals. Several of these identified lead missense SNPs were predicted to have a functional impact, including in SLC14A2. We also identified previously unreported lead SNPs that showed significant correlation with both kidney function markers, jointly, in the European ancestry CKDGen, National Unified Renal Translational Research Enterprise (NURTuRE)-CKD and Salford Kidney Study (SKS) datasets. Of these, rs3094060 colocalised with FLOT1 gene expression and was significantly more common in CKD cases in both NURTURE-CKD and SKS, than in the general population. Overall, by using multivariate analysis by CCA, we identified additional SNPs and genes for both kidney function and CKD, that can be prioritised for further CKD analyses.
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Affiliation(s)
- Amy J Osborne
- Intelligent Systems Laboratory, University of Bristol, Bristol, BS8 1TW, UK.
| | - Agnieszka Bierzynska
- Bristol Renal, University of Bristol and Bristol Royal Hospital for Children, Bristol, BS1 3NY, UK
| | - Elizabeth Colby
- Bristol Renal, University of Bristol and Bristol Royal Hospital for Children, Bristol, BS1 3NY, UK
| | - Uwe Andag
- Department of Metabolic and Renal Diseases, Evotec International GmbH, Marie-Curie-Strasse 7, 37079, Göttingen, Germany
| | - Philip A Kalra
- Department of Renal Medicine, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | - Olivier Radresa
- Department of Metabolic and Renal Diseases, Evotec International GmbH, Marie-Curie-Strasse 7, 37079, Göttingen, Germany
| | - Philipp Skroblin
- Department of Metabolic and Renal Diseases, Evotec International GmbH, Marie-Curie-Strasse 7, 37079, Göttingen, Germany
| | - Maarten W Taal
- Centre for Kidney Research and Innovation, University of Nottingham, Derby, UK
| | - Gavin I Welsh
- Bristol Renal, University of Bristol and Bristol Royal Hospital for Children, Bristol, BS1 3NY, UK
| | - Moin A Saleem
- Bristol Renal, University of Bristol and Bristol Royal Hospital for Children, Bristol, BS1 3NY, UK
| | - Colin Campbell
- Intelligent Systems Laboratory, University of Bristol, Bristol, BS8 1TW, UK.
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Ito T, Akamatsu K. Echocardiographic manifestations in end-stage renal disease. Heart Fail Rev 2024; 29:465-478. [PMID: 38071738 DOI: 10.1007/s10741-023-10376-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 03/16/2024]
Abstract
End-stage renal disease (ESRD) is a common but profound clinical condition, and it is associated with extremely increased morbidity and mortality. ESRD can represent four major echocardiographic findings-myocardial hypertrophy, heart failure, valvular calcification, and pericardial effusion. Multiple factors interplay leading to these abnormalities, including pressure/volume overload, oxidative stress, and neurohormonal imbalances. Uremic cardiomyopathy is characterized by left ventricular (LV) hypertrophy and marked diastolic dysfunction. In ESRD patients on hemodialysis, LV geometry is changeable bidirectionally between concentric and eccentric hypertrophy, depending upon changes in corporal fluid volume and arterial pressure, which eventually results in a characteristic of LV systolic dysfunction. Speckle tracking echocardiography enabling to detect subclinical disease might help prevent future advancement to heart failure. Heart valve calcification also is common in ESRD, keeping in mind which progresses faster than expected. In a modern era, pericardial effusion observed in ESRD patients tends to result from volume overload, rather than pericarditis. In this review, we introduce and discuss those four echocardiography-assessed findings of ESRD, with which known and conceivable pathophysiologies for each are incorporated.
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Affiliation(s)
- Takahide Ito
- Department of Cardiology, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-Machi, Takatsuki, Osaka, 569-8686, Japan.
| | - Kanako Akamatsu
- Department of Cardiology, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-Machi, Takatsuki, Osaka, 569-8686, Japan
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Nikitiuk BE, Rydzewska-Rosołowska A, Kakareko K, Głowińska I, Hryszko T. On Whether Ca-125 Is the Answer for Diagnosing Overhydration, Particularly in End-Stage Kidney Disease Patients-A Systematic Review. Int J Mol Sci 2024; 25:2192. [PMID: 38396869 PMCID: PMC10889175 DOI: 10.3390/ijms25042192] [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: 01/15/2024] [Revised: 02/04/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Overhydration (OH) is a prevalent medical problem that occurs in patients with kidney failure, but a specific marker has still not been found. Patients requiring kidney replacement therapy suffer from a water imbalance, which is correlated with mortality rates in this population. Currently, clinicians employ techniques such as bioimpedance spectroscopy (BIS) and ultrasound (USG) markers of overhydration or markers of heart and kidney function, namely NT-pro-BNP, GFR, or creatinine levels. New serum markers, including but not limited to Ca-125, galectin-3 (Gal-3), adrenomedullin (AMD), and urocortin-2 (UCN-2), are presently under research and have displayed promising results. Ca-125, which is a protein mainly used in ovarian cancer diagnoses, holds great potential to become an OH marker. It is currently being investigated by cardiologists as it corresponds to the volume status in heart failure (HF) and ventricular hypertrophy, which are also associated with OH. The need to ascertain a more precise marker of overhydration is urgent mainly because physical examinations are exceptionally inaccurate. The signs and symptoms of overhydration, such as edema or a gradual increase in body mass, are not always present, notably in patients with chronic kidney disease. Metabolic disruptions and cachexia can give a false picture of the hydration status. This review paper summarizes the existing knowledge on the assessment of a patient's hydration status, focusing specifically on kidney diseases and the role of Ca-125.
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Affiliation(s)
| | - Alicja Rydzewska-Rosołowska
- 2nd Department of Nephrology, Hypertension, and Internal Medicine with Dialysis Unit, Medical University of Bialystok, 15-276 Bialystok, Poland; (B.E.N.); (K.K.); (I.G.); (T.H.)
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11
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Mussnig S, Krenn S, Hecking M, Wabel P. Assessment of bioimpedance spectroscopy devices: a comparative study and error analysis of gold-plated copper electrodes. Physiol Meas 2024; 45:025001. [PMID: 38237199 DOI: 10.1088/1361-6579/ad205b] [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: 10/11/2023] [Accepted: 01/18/2024] [Indexed: 02/06/2024]
Abstract
Objective. Bioimpedance spectroscopy (BIS) is a non-invasive diagnostic tool to derive fluid volume compartments from frequency dependent voltage drops in alternating currents by extrapolating to the extracellular resistance (R0) and intracellular resistance (Ri). Here we tested whether a novel BIS device with reusable and adhesive single-use electrodes produces results which are (in various body positions) equivalent to an established system employing only single-use adhesive electrodes.Approach. Two BIS devices ('Cella' and the 'Body Composition Monitor' [BCM]) were compared using four dedicated resistance testboxes and by measuring 40 healthy volunteers.Invivocomparisons included supine wrist-to-ankle (WA) reference measurements and wrist-to-wrist (WW) measurements with pre-gelled silver/silver-chloride (Ag/AgCl) electrodes and WW measurements with reusable gold-plated copper electrodes.Main results. Coefficient of variation were <1% for all testbox measurements with both BIS devices. Accuracy was within ±1% of true resistance variability, a threshold which was only exceeded by the Cella device for all resistances in a testbox designed with a lowR0/Riratio.Invivo, WA-BIS differed significantly between BIS devices (p< 0.001). Reusable WW electrodes exhibited larger resistances than WW-BIS with Ag/AgCl electrodes (R0: 738.36 and 628.69 Ω;Ri: 1508.18 and 1390 Ω) and the relative error varied from 7.6% to 31.1% (R0) and -15.6% to 37.3% (Ri).Significance. Both BIS devices produced equivalent resistances measurements but different estimates of body composition bothinsilicoand in WA setupsinvivo, suggesting that the devices should not be used interchangeably. Employing WW reusable electrodes as opposed to WA and WW measurement setups with pre-gelled Ag/AgCl electrodes seems to be associated with measurement variations that are too large for safe clinical use. We recommend further investigations of measurement errors originating from electrode material and current path.
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Affiliation(s)
- Sebastian Mussnig
- Medical University of Vienna, Department of Medicine III, Division for Nephrology and Dialysis, Vienna, Austria
- Medical University of Vienna, Center for Public Health, Department of Epidemiology, Vienna, Austria
| | - Simon Krenn
- AIT Austrian Institute of Technology GmbH, Center for Health & Bioresources, Medical Signal Analysis, Vienna, Austria
| | - Manfred Hecking
- Medical University of Vienna, Department of Medicine III, Division for Nephrology and Dialysis, Vienna, Austria
- Medical University of Vienna, Center for Public Health, Department of Epidemiology, Vienna, Austria
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12
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Pinter J, Smyth B, Stuard S, Jardine M, Wanner C, Rossignol P, Wheeler DC, Marshall MR, Canaud B, Genser B. Effect of Dialysate and Plasma Sodium on Mortality in a Global Historical Hemodialysis Cohort. J Am Soc Nephrol 2024; 35:167-176. [PMID: 37967469 PMCID: PMC10843362 DOI: 10.1681/asn.0000000000000262] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/12/2023] [Indexed: 11/17/2023] Open
Abstract
SIGNIFICANCE STATEMENT This large observational cohort study aimed to investigate the relationship between dialysate and plasma sodium concentrations and mortality among maintenance hemodialysis patients. Using a large multinational cohort of 68,196 patients, we found that lower dialysate sodium concentrations (≤138 mmol/L) were independently associated with higher mortality compared with higher dialysate sodium concentrations (>138 mmol/L). The risk of death was lower among patients exposed to higher dialysate sodium concentrations, regardless of plasma sodium levels. These results challenge the prevailing assumption that lower dialysate sodium concentrations improve outcomes in hemodialysis patients. The study confirms that until robust evidence from randomized trials that are underway is available, nephrologists should remain cautious in reconsideration of dialysate sodium prescribing practices to optimize cardiovascular outcomes and reduce mortality in this population. BACKGROUND Excess mortality in hemodialysis (HD) patients is largely due to cardiovascular disease and is associated with abnormal fluid status and plasma sodium concentrations. Ultrafiltration facilitates the removal of fluid and sodium, whereas diffusive exchange of sodium plays a pivotal role in sodium removal and tonicity adjustment. Lower dialysate sodium may increase sodium removal at the expense of hypotonicity, reduced blood volume refilling, and intradialytic hypotension risk. Higher dialysate sodium preserves blood volume and hemodynamic stability but reduces sodium removal. In this retrospective cohort, we aimed to assess whether prescribing a dialysate sodium ≤138 mmol/L has an effect on survival outcomes compared with dialysate sodium >138 mmol/L after adjusting for plasma sodium concentration. METHODS The study population included incident HD patients from 875 Fresenius Medical Care Nephrocare clinics in 25 countries between 2010 and 2019. Baseline dialysate sodium (≤138 or >138 mmol/L) and plasma sodium (<135, 135-142, >142 mmol/L) concentrations defined exposure status. We used multivariable Cox regression model stratified by country to model the association between time-varying dialysate and plasma sodium exposure and all-cause mortality, adjusted for demographic and treatment variables, including bioimpedance measures of fluid status. RESULTS In 2,123,957 patient-months from 68,196 incident HD patients with on average three HD sessions per week dialysate sodium of 138 mmol/L was prescribed in 63.2%, 139 mmol/L in 15.8%, 140 mmol/L in 20.7%, and other concentrations in 0.4% of patients. Most clinical centers (78.6%) used a standardized concentration. During a median follow-up of 40 months, one third of patients ( n =21,644) died. Dialysate sodium ≤138 mmol/L was associated with higher mortality (multivariate hazard ratio for the total population (1.57, 95% confidence interval, 1.25 to 1.98), adjusted for plasma sodium concentrations and other confounding variables. Subgroup analysis did not show any evidence of effect modification by plasma sodium concentrations or other patient-specific variables. CONCLUSIONS These observational findings stress the need for randomized evidence to reliably define optimal standard dialysate sodium prescribing practices.
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Affiliation(s)
- Jule Pinter
- Department of Medicine, Division of Nephrology, University Hospital Würzburg, Würzburg, Germany
| | - Brendan Smyth
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
- Department of Renal Medicine, St George Hospital, Sydney, Australia
| | - Stefano Stuard
- Global Medical Office, FMC Germany, Bad Homburg, Germany
| | - Meg Jardine
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
- Concord Repatriation General Hospital, Sydney, Australia
| | - Christoph Wanner
- Department of Medicine, Division of Nephrology, University Hospital Würzburg, Würzburg, Germany
- Department of Clinical Research and Epidemiology, Renal Research Unit, Comprehensive Heart Failure Center, Wuerzburg, Germany
| | - Patrick Rossignol
- Université de Lorraine, Centre d’Investigations Cliniques-Plurithématique 1433 CHRU de Nancy, U1116 Inserm and F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
- Princess Grace Hospital, and Monaco Private Hemodialysis Centre, Monaco
| | - David C. Wheeler
- Department of Renal Medicine, University College London, London, United Kingdom
| | | | | | - Bernd Genser
- High5Data GmbH, Heidelberg, Germany
- Department of General Medicine, Center for Preventive Medicine & Digital Health, Mannheim Medical Faculty, Ruprecht Karls University Heidelberg, Heidelberg, Germany
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Mayne KJ, Staplin N, Keane DF, Wanner C, Brenner S, Cejka V, Stegbauer J, Judge PK, Preiss D, Emberson J, Trinca D, Dayanandan R, Lee R, Nolan J, Omata A, Green JB, Cherney DZI, Hooi LS, Pontremoli R, Tuttle KR, Lees JS, Mark PB, Davies SJ, Hauske SJ, Steubl D, Brückmann M, Landray MJ, Baigent C, Haynes R, Herrington WG. Effects of Empagliflozin on Fluid Overload, Weight, and Blood Pressure in CKD. J Am Soc Nephrol 2024; 35:202-215. [PMID: 38082486 PMCID: PMC7615589 DOI: 10.1681/asn.0000000000000271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/26/2023] [Indexed: 02/03/2024] Open
Abstract
SIGNIFICANCE STATEMENT SGLT2 inhibitors reduce risk of kidney progression, AKI, and cardiovascular disease, but the mechanisms of benefit are incompletely understood. Bioimpedance spectroscopy can estimate body water and fat mass. One quarter of the EMPA-KIDNEY bioimpedance substudy CKD population had clinically significant levels of bioimpedance-derived "Fluid Overload" at recruitment. Empagliflozin induced a prompt and sustained reduction in "Fluid Overload," irrespective of sex, diabetes, and baseline N-terminal pro B-type natriuretic peptide or eGFR. No significant effect on bioimpedance-derived fat mass was observed. The effects of SGLT2 inhibitors on body water may be one of the contributing mechanisms by which they mediate effects on cardiovascular risk. BACKGROUND CKD is associated with fluid excess that can be estimated by bioimpedance spectroscopy. We aimed to assess effects of sodium glucose co-transporter 2 inhibition on bioimpedance-derived "Fluid Overload" and adiposity in a CKD population. METHODS EMPA-KIDNEY was a double-blind placebo-controlled trial of empagliflozin 10 mg once daily in patients with CKD at risk of progression. In a substudy, bioimpedance measurements were added to the main trial procedures at randomization and at 2- and 18-month follow-up visits. The substudy's primary outcome was the study-average difference in absolute "Fluid Overload" (an estimate of excess extracellular water) analyzed using a mixed model repeated measures approach. RESULTS The 660 substudy participants were broadly representative of the 6609-participant trial population. Substudy mean baseline absolute "Fluid Overload" was 0.4±1.7 L. Compared with placebo, the overall mean absolute "Fluid Overload" difference among those allocated empagliflozin was -0.24 L (95% confidence interval [CI], -0.38 to -0.11), with similar sized differences at 2 and 18 months, and in prespecified subgroups. Total body water differences comprised between-group differences in extracellular water of -0.49 L (95% CI, -0.69 to -0.30, including the -0.24 L "Fluid Overload" difference) and a -0.30 L (95% CI, -0.57 to -0.03) difference in intracellular water. There was no significant effect of empagliflozin on bioimpedance-derived adipose tissue mass (-0.28 kg [95% CI, -1.41 to 0.85]). The between-group difference in weight was -0.7 kg (95% CI, -1.3 to -0.1). CONCLUSIONS In a broad range of patients with CKD, empagliflozin resulted in a sustained reduction in a bioimpedance-derived estimate of fluid overload, with no statistically significant effect on fat mass. TRIAL REGISTRATION Clinicaltrials.gov: NCT03594110 ; EuDRACT: 2017-002971-24 ( https://eudract.ema.europa.eu/ ).
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Affiliation(s)
- Kaitlin J Mayne
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- School of Cardiovascular and Metabolic Health, College of Medical and Veterinary Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Natalie Staplin
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - David F Keane
- CÚRAM SFI Research Centre for Medical Devices, HRB-Clinical Research Facility Galway, National University of Ireland Galway, Galway, Ireland
| | - Christoph Wanner
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | | | | | - Johannes Stegbauer
- Department of Nephrology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- CARID, Cardiovascular Research Institute Düsseldorf, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Dusseldorf, Germany
| | - Parminder K Judge
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - David Preiss
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jonathan Emberson
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Daniele Trinca
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Rejive Dayanandan
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Ryonfa Lee
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - John Nolan
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Akiko Omata
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | | | | | - Lai Seong Hooi
- Department of Medicine and Haemodialysis Unit, Sultanah Aminah Hospital, Johor Bahru, Malaysia
| | - Roberto Pontremoli
- Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa, Italy
| | - Katherine R Tuttle
- Providence Inland Northwest Health, University of Washington, Spokane, Washington
| | - Jennifer S Lees
- School of Cardiovascular and Metabolic Health, College of Medical and Veterinary Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Patrick B Mark
- School of Cardiovascular and Metabolic Health, College of Medical and Veterinary Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Simon J Davies
- School of Medicine, Keele University, Newcastle, United Kingdom
| | - Sibylle J Hauske
- Boehringer Ingelheim International GmbH, Ingelheim upon Rhein, Germany
- The Fifth Department of Medicine, University Medical Center Mannheim, Mannheim, Germany
| | - Dominik Steubl
- Boehringer Ingelheim International GmbH, Ingelheim upon Rhein, Germany
- University of Heidelberg, Mannheim, Germany
- Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Martina Brückmann
- Boehringer Ingelheim International GmbH, Ingelheim upon Rhein, Germany
- The First Department of Medicine, University Medical Center Mannheim, Mannheim, Germany
| | - Martin J Landray
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Colin Baigent
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Richard Haynes
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - William G Herrington
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Helman J, Wahlgren H, Andersson L, Morelle J, Öberg CM. Quantifying Ultrafiltration in Peritoneal Dialysis Using the Sodium Dip. KIDNEY360 2024; 5:195-204. [PMID: 38236202 PMCID: PMC10914194 DOI: 10.34067/kid.0000000000000358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/10/2024] [Indexed: 01/19/2024]
Abstract
Key Points Ultrafiltration (UF) is a key component of clinical peritoneal dialysis prescription, but the traditional method to assess UF is hampered by large inaccuracies. Here we propose a novel method, based on a computational model and on a single dialysate sodium measurement, to accurately estimate UF and osmotic conductance to glucose in patients on peritoneal dialysis. Background Volume overload is highly prevalent among patients treated with peritoneal dialysis (PD), contributes to hypertension, and is associated with an increased risk of cardiovascular events and death in this population. As a result, optimizing peritoneal ultrafiltration (UF) is a key component of high-quality dialysis prescription. Osmotic conductance to glucose (OCG) reflects the water transport properties of the peritoneum, but measuring it requires an accurate quantification of UF, which is often difficult to obtain because of variability in catheter patency and peritoneal residual volume. Methods In this study, we derived a new mathematical model for estimating UF during PD, on the basis of sodium sieving, using a single measure of dialysate sodium concentration. The model was validated experimentally in a rat model of PD, using dialysis fluid with two different sodium concentrations (125 and 134 mmol/L) and three glucose strengths (1.5%, 2.3%, and 4.25%). Then, the same model was tested in a cohort of PD patients to predict UF. Results In experimental and clinical conditions, the sodium-based estimation of UF rate correlated with UF rate measurements on the basis of volumetry and albumin dilution, with a R 2 =0.35 and R 2 =0.76, respectively. UF on the basis of sodium sieving was also successfully used to calculate OCG in the clinical cohort, with a Pearson r of 0.77. Conclusions Using the novel mathematical models in this study, the sodium dip can be used to accurately estimate OCG, and therefore, it is a promising measurement method for future clinical use.
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Affiliation(s)
- Jakob Helman
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund, Sweden
| | - Hedda Wahlgren
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund, Sweden
| | - Linn Andersson
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund, Sweden
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
- UCLouvain School of Medicine, Université catholique de Louvain, Brussels, Belgium
| | - Carl M. Öberg
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund, Sweden
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15
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Zheng D, Liu Y, Li Y, Jin J, He Q, Shen X. Lung Ultrasound and Bioelectrical Impedance Analysis for Fluid Status Assessing Patients Undergoing Maintenance Hemodialysis. Int J Clin Pract 2024; 2024:1232211. [PMID: 38229934 PMCID: PMC10791474 DOI: 10.1155/2024/1232211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/12/2023] [Accepted: 12/30/2023] [Indexed: 01/18/2024] Open
Abstract
Background Volume overload is a fatal complication for people undergoing hemodialysis. Therefore, regulating a patient's "dry weight" based on their fluid status is imperative. Clinical experiences are too subjective to accurately judge a patient's fluid status, but techniques have emerged for improved fluid control in the two decades. Specifically, lung ultrasonography (LUS) uses a unique aspect of ultrasound images, the B-lines, to evaluate extravascular lung water, which has increasingly attracted attention. However, the role of B-line quantification in predicting short-mid-term death and/or cardiovascular complications is unclear. Methods Patients undergoing MHD at the hemodialysis center of Zhejiang Provincial People's Hospital from October 1, 2020, to February 28, 2021, were examined using LUS and a bioelectrical impedance analysis before and after dialysis, and related clinical data were collected. All patients were followed up for one year after the examination, and deaths and first cardiovascular events (e.g., stroke, myocardial infarction, and heart failure) during this period were recorded. Results 98 patients were enrolled and divided into three groups in relation to their mild (<16 B-lines), moderate (16-30 B-lines), or severe (>30 B-lines) hypervolemia, defined by the number of B-lines. The long-term survival rate was significantly lower in the severe group than in the mild and moderate groups. LUS and bioelectrical impedance-related parameters (e.g., extracellular water-to-water ratio) were closely related to cardiac ultrasound parameters (left ventricular ejection fraction) (P < 0.001). The optimal B-line cutoff value on LUS for predicting fluid overload (defined clinically) in patients on hemodialysis was 11.5 lines (AUC = 0.840, 95% confidence interval 0.735-0.945, P < 0.001), and the diagnostic sensitivity and specificity were both 76.5%. During the one-year follow-up period, ten deaths and six cardiovascular events occurred. The survival rate was significantly lower in the severe group than in the mild group (log-rank test χ2 = 10.050, P=0.002) but did not differ between the severe and moderate groups (χ2 = 2.629, P=0.105). Conclusion LUS is a cheap, noninvasive, simple, and repeatable volume-monitoring method that can assist with individualized fluid volume management in patients undergoing MHD. LUS results may also help to predict the short-mid-term survival rate of patients to a certain extent.
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Affiliation(s)
- Danna Zheng
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu, China
- 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
| | - Yuting Li
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Juan Jin
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Qiang He
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xiaogang Shen
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
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Scalise F, Quarti-Trevano F, Toscano E, Sorropago A, Vanoli J, Grassi G. Renal Denervation in End-Stage Renal Disease: Current Evidence and Perspectives. High Blood Press Cardiovasc Prev 2024; 31:7-13. [PMID: 38267652 PMCID: PMC10925565 DOI: 10.1007/s40292-023-00621-1] [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: 11/30/2023] [Accepted: 12/22/2023] [Indexed: 01/26/2024] Open
Abstract
In patients with end-stage renal disease (ESRD) undergoing haemodialysis, hypertension is of common detection and frequently inadequately controlled. Multiple pathophysiological mechanisms are involved in the development and progression of the ESRD-related high blood pressure state, which has been implicated in the increased cardiovascular risk reported in this hypertensive clinical phenotype. Renal sympathetic efferent and afferent nerves play a relevant role in the development and progression of elevated blood pressure values in patients with ESRD, often leading to resistant hypertension. Catheter-based bilateral renal nerves ablation has been shown to exert blood pressure lowering effects in resistant hypertensive patients with normal kidney function. Promising data on the procedure in ESRD patients with resistant hypertension have been reported in small scale pilot studies. Denervation of the native non-functioning kidney's neural excitatory influences on central sympathetic drive could reduce the elevated cardiovascular morbidity and mortality seen in ESRD patients. The present review article will focus on the promising results obtained with renal denervation in patients with ESRD, its mechanisms of action and future perspectives in these high risk patients.
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Affiliation(s)
- Filippo Scalise
- Department of Interventional Cardiology, Policlinico di Monza, Monza, Italy
| | - Fosca Quarti-Trevano
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20052, Monza, Milan, Italy
| | - Evelina Toscano
- Department of Interventional Cardiology, Policlinico di Monza, Monza, Italy
| | - Antonio Sorropago
- Department of Interventional Cardiology, Policlinico di Monza, Monza, Italy
| | - Jennifer Vanoli
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20052, Monza, Milan, Italy
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20052, Monza, Milan, Italy.
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Goto J, Ott M, Stegmayr B. Myocardial markers are highly altered by higher rates of fluid removal during hemodialysis. Hemodial Int 2024; 28:17-23. [PMID: 37875435 DOI: 10.1111/hdi.13124] [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: 05/23/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION Although hemodialysis is lifesaving in patients with kidney failure extensive interdialytic weight gain (IDWG) between dialyses worsens the prognosis. We recently showed a strong correlation between IDWG and predialytic values of cardiac markers. The aim of the present study was to evaluate if the cardiac markers N-terminal pro-B-type natriuretic peptide (proBNP) and troponin T were influenced by IDWG and speed of fluid removal (ultrafiltration-rate). METHODS Twenty hemodialysis patients performed in total 60 hemodialysis (three each). Predialytic values of proBNP and troponin T and changes from predialysis to 180 min hemodialysis (180-0 min) were compared with the IDWG calculated in percent of body weight. The ultrafiltration-rate was adjusted (UF-rateadj ) to IDWG: (100 × weight gain between dialysis [kg])/(estimated body dry weight [kg] × length of hemodialysis session [hours]). RESULTS UF-rateadj correlated (Spearman) with (1) predialytic values of IDWG (r = 0.983, p < 0.001), proBNP (r = 0.443, p < 0.001), and troponin T (r = 0.296, p = 0.025); and (2) differences in proBNP180-0min (r = 0.572, p < 0.001) and troponin T180-0min (r = 0.400, p = 0.002). UF-ratesadj above a breakpoint of 0.60 caused more release of proBNP180-0min (p = 0.027). Remaining variables in multiple regression analysis with ProBNP180-0min as dependent factor were predialytic proBNP (p < 0.001) and the ultrafiltration-rate (p < 0.001). CONCLUSION Higher UF-rateadj during dialysis was correlated to increased levels of cardiac markers. Data support a UF-rateadj lower than 0.6 to limit such increase. Further studies may confirm if limited fluid intake and a lower UF-rateadj should be recommended to prevent cardiac injury during dialysis.
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Affiliation(s)
- Junko Goto
- Department of Public Health and Clinical Medicine, Umea University, Umeå, Sweden
- Faculty of Medicine Graduate School of Medicine, Intensive Care, University of Yamanashi, Yamanashi, Japan
| | - Michael Ott
- Department of Public Health and Clinical Medicine, Umea University, Umeå, Sweden
| | - Bernd Stegmayr
- Department of Public Health and Clinical Medicine, Umea University, Umeå, Sweden
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Malik J, Valerianova A, Pesickova SS, Hruskova Z, Bednarova V, Michalek P, Polakovic V, Tesar V. CZecking heart failure in patients with advanced chronic kidney disease (Czech HF-CKD): Study protocol. J Vasc Access 2024; 25:294-302. [PMID: 35676802 DOI: 10.1177/11297298221099843] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND Heart failure (HF) is a frequent cause of morbidity and mortality of end-stage kidney disease (ESKD) patients on hemodialysis. It is not easy to distinguish HF from water overload. The traditional HF definition has low sensitivity and specificity in this population. Moreover, many patients on hemodialysis have exercise limitations unrelated to HF. Therefore, we postulated two new HF definitions ((1) Modified definition of the Acute Dialysis Quality Improvement working group; (2) Hemodynamic definition based on the calculation of the effective cardiac output). We hypothesize that the newer definitions will better identify patients with higher number of endpoints and with more advanced structural heart disease. METHODS Cohort, observational, longitudinal study with recording predefined endpoints. Patients (n = 300) treated by hemodialysis in six collaborating centers will be examined centrally in a tertiary cardiovascular center every 6-12 months lifelong or till kidney transplantation by detailed expert echocardiography with the calculation of cardiac output, arteriovenous dialysis fistula flow volume calculation, bio-impedance, and basic laboratory analysis including NTproBNP. Effective cardiac output will be measured as the difference between measured total cardiac output and arteriovenous fistula flow volume and systemic vascular resistance will be also assessed non-invasively. In case of water overload during examination, dry weight adjustment will be recommended, and the patient invited for another examination within 6 weeks. A composite major endpoint will consist of (1) Cardiovascular death; (2) HF worsening/new diagnosis of; (3) Non-fatal myocardial infarction or stroke. The two newer HF definitions will be compared with the traditional one in terms of time to major endpoint analysis. DISCUSSION This trial will differ from others by: (1) detailed repeated hemodynamic assessment including arteriovenous access flow and (2) by careful assessment of adequate hydration to avoid confusion between HF and water overload.
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Affiliation(s)
- Jan Malik
- Third Department of Internal Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Anna Valerianova
- Third Department of Internal Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Satu Sinikka Pesickova
- B. Braun Avitum, Dialysis Center Ohradni, Prague, Czech Republic
- Department of Nephrology, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Zdenka Hruskova
- Department of Nephrology, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Vladimira Bednarova
- Department of Nephrology, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Pavel Michalek
- Department of Anaesthesiology and Intensive Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Vladimir Polakovic
- Internal Department Strahov, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Vladimir Tesar
- Department of Nephrology, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
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Vinje V, Bomholt T, Lundby C, Oturai P, Rix M, Lindhard K, Hornum M. Intravascular volumes and the influence on anemia assessed by a carbon monoxide rebreathing method in patients undergoing maintenance hemodialysis. Hemodial Int 2024; 28:40-50. [PMID: 37827985 DOI: 10.1111/hdi.13118] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION Fluid overload is a major challenge in hemodialysis patients and might cause hypervolemia. We speculated that hemodialysis patients reaching dry weight could have undetected hypervolemia and low hemoglobin (Hb) concentration (g/dL) due to hemodilution. METHODS The study included hemodialysis patients (n = 22) and matched healthy controls (n = 22). Blood volume, plasma volume, red blood cell volume, and total Hb mass were determined using a carbon monoxide (CO)-rebreathing method in hemodialysis patients reaching dry weight and controls. Blood volume measurements were also obtained by a dual-isotope labeling technique in a subgroup for validation purposes. FINDINGS In the hemodialysis group, the median specific blood volume was 89.3 mL/kg (interquartile range [IQR]: 76.7-95.4 mL/kg) and was higher than in the control group (79.9 mL/kg [IQR: 70.4-88.0 mL/kg]; p < 0.037). The median specific plasma volume was 54.7 mL/kg (IQR: 47.1-61.0 mL/kg) and 44.0 mL/kg (IQR: 38.7-49.5 mL/kg) in the hemodialysis and control groups, respectively (p < 0.001). Hb concentration was lower in hemodialysis patients (p < 0.001), whereas no difference in total Hb mass was observed between groups (p = 0.11). A correlation was found between blood volume measured by the CO-rebreathing test and the dual-isotope labeling technique in the control group (r = 0.83, p = 0.015), but not the hemodialysis group (r = 0.25, p = 0.60). DISCUSSION The hemodialysis group had increased specific blood volume at dry weight due to high plasma volume, suggesting a hypervolemic state. However, correlation was not established against the dual-isotope labeling technique underlining that the precision of the CO-rebreathing test should be further validated. The total Hb mass was similar between hemodialysis patients and controls, unlike Hb concentration, which emphasizes that Hb concentration is an inaccurate marker of anemia among hemodialysis patients.
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Affiliation(s)
- Vårin Vinje
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Tobias Bomholt
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Carsten Lundby
- Centre for Physical Activity Research, Rigshospitalet, Copenhagen, Denmark
- Section for Health and Exercise Physiology, Faculty of Social and Health Sciences, Inland Norway University of Applied Sciences, Lillehammer, Norway
| | - Peter Oturai
- Department of Clinical Physiology and Nuclear Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Rix
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kristine Lindhard
- Department of Nephrology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mads Hornum
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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20
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Kourtidou C, Georgianos PI, Vaios V, Liakopoulos V. Prescribing the optimal dialysate sodium concentration for managing hypertension and volume overload in hemodialysis: one size does not fit to all patients. J Hum Hypertens 2024; 38:84-87. [PMID: 37794131 DOI: 10.1038/s41371-023-00870-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 09/18/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023]
Affiliation(s)
- Christodoula Kourtidou
- 2nd Department of Nephrology, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis I Georgianos
- 2nd Department of Nephrology, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Vasilios Vaios
- 2nd Department of Nephrology, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vassilios Liakopoulos
- 2nd Department of Nephrology, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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21
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Ng JKC, Lau SLF, Chan GCK, Tian N, Li PKT. Nutritional Assessments by Bioimpedance Technique in Dialysis Patients. Nutrients 2023; 16:15. [PMID: 38201845 PMCID: PMC10780416 DOI: 10.3390/nu16010015] [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: 10/23/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 01/12/2024] Open
Abstract
Bioelectrical impedance analysis (BIA) has been extensively applied in nutritional assessments on the general population, and it is recommended in establishing the diagnosis of malnutrition and sarcopenia. The bioimpedance technique has become a promising modality through which to measure the whole-body composition in dialysis patients, where the presence of subclinical volume overload and sarcopenic obesity may be overlooked by assessing body weight alone. In the past two decades, bioimpedance devices have evolved from applying a single frequency to a range of frequencies (bioimpedance spectroscopy, BIS), in which the latter is incorporated with a three-compartment model that allows for the simultaneous measurement of the volume of overhydration, adipose tissue mass (ATM), and lean tissue mass (LTM). However, clinicians should be aware of common potential limitations, such as the adoption of population-specific prediction equations in some BIA devices. Inherent prediction error does exist in the bioimpedance technique, but the extent to which this error becomes clinically significant remains to be determined. Importantly, reduction in LTM has been associated with increased risk of frailty, hospitalization, and mortality in dialysis patients, whereas the prognostic value of ATM remains debatable. Further studies are needed to determine whether modifications of bioimpedance-derived body composition parameters through nutrition intervention can result in clinical benefits.
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Affiliation(s)
- Jack Kit-Chung Ng
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong 999077, China; (J.K.-C.N.); (S.L.-F.L.); (G.C.-K.C.)
| | - Sam Lik-Fung Lau
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong 999077, China; (J.K.-C.N.); (S.L.-F.L.); (G.C.-K.C.)
| | - Gordon Chun-Kau Chan
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong 999077, China; (J.K.-C.N.); (S.L.-F.L.); (G.C.-K.C.)
| | - Na Tian
- Department of Nephrology, General Hospital of Ningxia Medical University, Yinchuan 750004, China;
| | - Philip Kam-Tao Li
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong 999077, China; (J.K.-C.N.); (S.L.-F.L.); (G.C.-K.C.)
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Al Nusair H, Hamdan W, Garma J, Eid A, Alnjadat R, Al-Nsair N, Fonbuena M, Davao C. The Implementation of a Modified Fluid Assessment Tool to Improve the Clinical Assessment, Detection, and Management of Blood Pressure Control and Fluid Alterations Among Hemodialysis Patients. Int J Nephrol Renovasc Dis 2023; 16:261-268. [PMID: 38107557 PMCID: PMC10723595 DOI: 10.2147/ijnrd.s440990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/29/2023] [Indexed: 12/19/2023] Open
Abstract
Background Fluid overload is a common complication of the care of End-stage Renal Disease patients that may lead to prolonged hospitalization and mortality. This warrants an effective and systemic approach to early recognition and management to improve patient outcomes. Aim This study aims to evaluate the effect of a modified fluid assessment tool to improve accurate clinical assessments, detection, and management of blood pressure control and fluid alteration among hemodialysis patients. Methods In this retrospective study, data were collected from forty-three dialysis patients who were seen and followed up from a dialysis unit of an acute care hospital during 8 weeks of standard care. A modified assessment tool was used to systematically highlight the appropriateness of the patient set dry weight using intradialytic weight gain (IWDG) and patient blood pressure. Paired sample t-test and repeated measure ANOVA within-group analysis were applied to compare the mean difference score for IDWG and the mean arterial pressure within the study group, respectively. Result A total of 43 patients were enrolled (mean age, 59.07) (ranges 27-88 years) (SD - 14.30); 51.16% female; 79% Emirati Nationals, with Chronic Kidney Disease. A repeated measure ANOVA analysis showed a significant difference in the mean arterial pressure within the study group based on time, over six measurements (p = 0.001). However, the difference between the pre- and post-intra-dialytic weight gain mean scores yields insignificant results (p = 0.346). Conclusion The implementation of a modified assessment tool improved blood pressure control, increased staff and physician involvement in assessing patient dry weight facilitated through fluid status evaluation, methodical assessment of dry weight, and precise fluid removal calculation, enhancing overall blood pressure and fluid management in HD patients.
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Affiliation(s)
- Hussam Al Nusair
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
| | - Wael Hamdan
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
| | - Joy Garma
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
| | - Ahmed Eid
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
| | - Rafi Alnjadat
- Applied Health Sciences, Al-Balqa Applied University, Irbid, Jordan
| | - Nezam Al-Nsair
- College of Nursing, Xavier University, Cincinnati, OH, USA
| | - Mariezl Fonbuena
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
| | - Christin Davao
- Dialysis Department, Sheikh Khalifa General Hospital, Umm Al Quwain, United Arab Emirates
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Ramos-Gordillo JM, Pérez-Campuzano C, Relles-Andrade E, Peña-Rodríguez JC. The role of plasma volume and fluid overload in the tolerance to ultrafiltration and hypotension in hemodialysis patients. Ren Fail 2023; 45:2151917. [PMID: 36632765 PMCID: PMC9848374 DOI: 10.1080/0886022x.2022.2151917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Ultrafiltration (UF) in hemodialysis (HD) patients is accompanied by irregular falls in plasma volume (PV) and blood pressure (BP). METHODS We obtained in 321 patients (large cohort), body weight (BW), BP, samples of blood to determine hemoglobin (Hb) and hematocrit (Ht), Pre and Post HD. We estimated the % variation of the PV and its effect on the BP. In a small cohort of 38/321 patients, arterial blood was drawn Pre and Post HD and at 2, 48, and 72 h to determined Hb and Ht and % variation of the PV. Bio-impedance spectroscopy (BIS) was performed, in the same times, to estimate: dry weight (DW), total body water (TBW), extracellular water (ECW), Fluid overload (FO) and phase angle (PhA). RESULTS We divided our large cohort in two groups. The Hypotensive group with a fall equal or more than 20 mmHg (96/321,30%) and Normotensive group with a drop equal or less than 19 mmHg (225/321,70%). The UF was 2.73 ± 0.72 L in the Hypotensive group and 2.53 ± 0.85 L in the Normotensive group (p < 0.0001). The % PV was -11.7 ± 17.8 in the Hypotensive group and -8.53 ± 10.07 in the Normotensive group (p < 0.0001). The systolic blood pressure (SBP) correlated with the % change of the PV (r = -0.232; p < 0.0001). The FO was contrasted with the % of water removed by UF (r = -0.890; p < 0.0001). CONCLUSION The SBP drop was secondary to the fall in the PV after UF. The FO was irregular and modulates in part the fall in the SBP.
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Affiliation(s)
| | | | | | - José Carlos Peña-Rodríguez
- Centro de Diagnóstico Ángeles (CEDIASA), Mexico City, México D.F.,CONTACT José Carlos Peña Avenida Ejercito Nacional No 516 esquina Temístocles, Colonia Polanco, Alcaldía Miguel Hidalgo, Mexico City, CP.11550, México D.F
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24
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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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25
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Oka T, Sakaguchi Y, Hattori K, Asahina Y, Kajimoto S, McCallum W, Tighiouart H, Sarnak MJ, Kaimori JY, Isaka Y. Association of Longitudinal B-Type Natriuretic Peptide Monitoring With Kidney Failure in Patients With CKD: A Cohort Study. Am J Kidney Dis 2023; 82:559-568. [PMID: 37354935 DOI: 10.1053/j.ajkd.2023.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 05/10/2023] [Indexed: 06/26/2023]
Abstract
RATIONALE & OBJECTIVE Both hypervolemia and hypovolemia are associated with chronic kidney disease (CKD) progression. Although longitudinal monitoring of B-type natriuretic peptide (BNP) may aid physicians' decision making about the optimization of volume status, its clinical benefit remains uncertain in CKD. This study assessed the association between BNP monitoring and the risk of incident kidney replacement therapy (KRT). STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS A total of 2,998 outpatients with stages 3-5 of nondialyzed CKD referred to the department of nephrology at an academic hospital. EXPOSURE BNP monitoring. OUTCOME KRT, acute kidney injury (AKI), and heart failure hospitalization. ANALYTICAL APPROACH Marginal structural models, which create a balanced pseudo population at each time point, were applied to account for potential time-dependent confounders. Inverse probability weighted pooled logistic regression models were employed to estimate hazard ratios. RESULTS At baseline, the median age and estimated glomerular filtration rate were 66 years and 38.1mL/min/1.73m2, respectively. During the follow-up period (median, 5.9 [IQR, 2.8-9.9] years), 449 patients required KRT, 765 had AKI, and 236 were hospitalized for heart failure. After adjustment for time-updated clinical characteristics and physician-specific practice styles, BNP monitoring was associated with lower risks of KRT (HR, 0.44 [95% CI, 0.21-0.92]), AKI (HR, 0.36 [95% CI, 0.18-0.72]), and heart failure hospitalization (HR, 0.37 [95% CI, 0.14-0.95]). The association between BNP monitoring and KRT was attenuated after additional adjustment for AKI or heart failure hospitalization as a time-varying covariate. LIMITATIONS Residual confounding by measured and unmeasured variables or indications for BNP measurements. CONCLUSIONS BNP monitoring was associated with a lower risk of KRT among patients with CKD that did not require dialysis. This association is potentially mediated through a reduced risk of AKI or heart failure hospitalization. PLAIN-LANGUAGE SUMMARY Both volume overload and volume depletion are deleterious to kidney function. B-type natriuretic peptide (BNP) is a biomarker that reflects volume status not only in heart failure but also in nondialysis chronic kidney disease (CKD). Although longitudinal BNP monitoring may aid physicians' decision making about the optimization of volume status, its clinical benefit remains uncertain in CKD. In this cohort study analyzing 2,998 patients with nondialyzed CKD, BNP monitoring was associated with a lower risk of kidney replacement therapy, acute kidney injury, and heart failure hospitalization over the follow-up period. The association with kidney replacement therapy may be mediated through a reduced risk of acute kidney injury or heart failure hospitalization. BNP monitoring may aid physicians in optimal fluid management, potentially conferring better kidney outcomes.
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Affiliation(s)
- Tatsufumi Oka
- Department of Nephrology, Graduate School of Medicine, Osaka University, Osaka, Japan; Division of Nephrology, Boston, Massachusetts
| | - Yusuke Sakaguchi
- Department of Inter-Organ Communication Research in Kidney Diseases, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Koki Hattori
- Department of Nephrology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yuta Asahina
- Department of Nephrology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Sachio Kajimoto
- Department of Nephrology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | | | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts; Tufts Medical Center, and Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | | | - Jun-Ya Kaimori
- Department of Inter-Organ Communication Research in Kidney Diseases, Graduate School of Medicine, Osaka University, Osaka, Japan.
| | - Yoshitaka Isaka
- Department of Nephrology, Graduate School of Medicine, Osaka University, Osaka, Japan
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26
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Anaya AB, Lee MM, Neu AM, Swartz SM, Geer JJ, Warady BA. Standardizing Blood Pressure Measurements in Pediatric Hemodialysis: a Collaborative Journey. Curr Hypertens Rep 2023; 25:329-334. [PMID: 37505377 DOI: 10.1007/s11906-023-01255-3] [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] [Accepted: 06/30/2023] [Indexed: 07/29/2023]
Abstract
PURPOSE OF REVIEW This manuscript details the development and execution of a quality improvement (QI) initiative aimed at standardizing blood pressure (BP) measurement practices in pediatric hemodialysis (HD) units across a national dialysis collaborative. RECENT FINDINGS Although there are recommendations for the detection and treatment of hypertension in the pediatric population, currently there is no data or recommendations specific to the methodology of measuring blood pressure in a pediatric hemodialysis setting. In 2016, the Standardizing Care to Improve Outcomes in Pediatric End Stage Kidney Disease (SCOPE) Collaborative assembled a dedicated working group to thoroughly examine BP measurement practices across participating pediatric HD centers and, drawing from current research, to establish a standardized best practice for BP measurement in pediatric HD patients both in-center and at home. Employing QI methodology, the working group devised a standardized "BP Bundle" and implemented it throughout the SCOPE Collaborative. This work led to successful practice improvement by establishing a consistent approach to BP measurement in pediatric HD patients cared for in SCOPE centers. With a standard best practice now in place and over 85% compliance with the BP Bundle across the SCOPE Collaborative, researchers and healthcare professionals can more accurately study and ultimately enhance the cardiovascular health of pediatric HD patients.
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Affiliation(s)
- Audrey B Anaya
- UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Marsha M Lee
- UCSF Benioff Children's Hospital, San Francisco, CA, USA
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Mussnig S, Schmiedecker M, Waller M, Niknam J, Paschen C, Schneditz D, Hecking M, Krenn S. Differences in bioimpedance-derived fluid status between two versions of the Body Composition Monitor. Nutrition 2023; 114:112131. [PMID: 37467529 DOI: 10.1016/j.nut.2023.112131] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/08/2023] [Accepted: 06/10/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVES The Body Composition Monitor (BCM) (Fresenius Medical Care) measures body impedances in alternating currents to subsequently calculate fat and lean tissue mass, fluid compartments, and overhydration (OH). The aim of this study was to investigate differences between two versions of the BCM (an older version, 3.2.5, and a newer version, 3.3.3). METHODS Between September 2021 and December 2021, 28 hemodialysis patients were included to undergo BCM measurements before each of 14 consecutive dialysis sessions with versions 3.2.5 and 3.3.3 devices. Measurements were performed according to instructions provided by the manufacturer. Differences between BCM devices were tested for statistical significance using paired Wilcoxon tests, neglecting clustering. RESULTS A total of 288 measurement pairs of 27 patients were left after exclusion of 43 flawed data points. The mean difference in OH between both BCM devices was 0.548 L (higher for version 3.2.5). Analysis of impedance data revealed differences in the high-frequency spectrum, quantifiable by the intracellular resistance, Ri (median Ri version 3.2.5 = 1750.3 Ω; Ri version 3.3.3 = 1612.45 Ω; P < 0.001), and the time delay, Td (median Td version 3.2.5 = 1.85 ns; Td version 3.3.3 = 8.88 nanoseconds; P < 0.001). CONCLUSIONS This study finds that results between the two versions of the BCM differed in a clinically meaningful fashion and that the newer version 3.3.3 device had a bias toward less OH. Circulating BCM devices should be checked for versions and only devices of the same version should be used for each patient to ensure better within-patient consistency.
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Affiliation(s)
- Sebastian Mussnig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Schmiedecker
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Maximilian Waller
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Janosch Niknam
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Christopher Paschen
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Daniel Schneditz
- Division of Physiology and Pathophysiology, Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Medical University of Graz, Graz, Austria
| | - Manfred Hecking
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria.
| | - Simon Krenn
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria; Medical Signal Analysis, Center for Health & Bioresources, AIT Austrian Institute of Technology, Vienna, Austria
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28
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Chisavu L, Mihaescu A, Bob F, Motofelea A, Schiller O, Marc L, Dragota-Pascota R, Chisavu F, Schiller A. Trends in mortality and comorbidities in hemodialysis patients between 2012 and 2017 in an East-European Country: a retrospective study. Int Urol Nephrol 2023; 55:2579-2587. [PMID: 36917413 PMCID: PMC10012315 DOI: 10.1007/s11255-023-03549-6] [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: 01/04/2023] [Accepted: 03/05/2023] [Indexed: 03/15/2023]
Abstract
PURPOSE The aim of this study was to evidence trends and changes in mortality, comorbid conditions, prognosis, and causes of death after 5 years of continuous evolution of hemodialysis (HD) patients in Romania. METHODS We included two cohorts of stable HD patients (901 from 2012 and 1396 from 2017). Both cohorts were followed up for 1 year. The 5-year survivors of the 2012 cohort were identified in 2017 and their data changes were assessed. RESULTS The 2017 patients were older, with longer time on dialysis, higher serum creatinine and urea levels, and required higher ultrafiltration volume per dialysis. They also had lower hemoglobin, lower C-reactive protein, higher albumin, higher calcium bicarbonate, and higher parathyroidectomy prevalence. The 2017 cohort presented with lower average dialysis flow, less administration of iron sucrose, had more catheters, lower hepatitis C prevalence, higher diabetes mellitus prevalence, higher heart valve calcifications, higher heart rate disorders, higher prevalence of left ventricular hypertrophy, and lower ejection fraction. Cardiovascular disease was the main cause of death in both years (50% in 2012 and 45.6% in 2017), followed by sepsis and cancer. The mortality was higher in 2017 compared to 2012 (14.1 vs 6.6%). The 5-year mortality was 37.2% with an average of 7.44%/year. The risk of death increased with age, higher C-reactive protein, higher phosphate, lower hemoglobin, and lower albumin. CONCLUSION Cardiovascular disease remains the main causes of death in HD-treated patients but with decreasing trend. Developing regional therapeutic strategies for quality care with early intervention will most likely improve mortality.
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Affiliation(s)
- Lazar Chisavu
- University of Medicine and Pharmacy "Victor Babes" Timisoara, Timisoara, Romania
- Avitum BBraun Dialysis Centre, Timisoara, Romania
| | - Adelina Mihaescu
- University of Medicine and Pharmacy "Victor Babes" Timisoara, Timisoara, Romania.
- Emergency County Hospital "Pius Brinzeu" Timisoara, Timisoara, Romania.
| | - Flaviu Bob
- University of Medicine and Pharmacy "Victor Babes" Timisoara, Timisoara, Romania
- Emergency County Hospital "Pius Brinzeu" Timisoara, Timisoara, Romania
| | - Alexandru Motofelea
- University of Medicine and Pharmacy "Victor Babes" Timisoara, Timisoara, Romania
- Emergency City Hospital of Timisoara, Timisoara, Romania
| | | | - Luciana Marc
- University of Medicine and Pharmacy "Victor Babes" Timisoara, Timisoara, Romania
- Avitum BBraun Dialysis Centre, Timisoara, Romania
| | - Razvan Dragota-Pascota
- University of Medicine and Pharmacy "Victor Babes" Timisoara, Timisoara, Romania
- Emergency County Hospital "Pius Brinzeu" Timisoara, Timisoara, Romania
| | - Flavia Chisavu
- University of Medicine and Pharmacy "Victor Babes" Timisoara, Timisoara, Romania
- Emergency Hospital for Children "Louis Turcanu" Timisoara, Timisoara, Romania
| | - Adalbert Schiller
- University of Medicine and Pharmacy "Victor Babes" Timisoara, Timisoara, Romania
- Emergency County Hospital "Pius Brinzeu" Timisoara, Timisoara, Romania
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Pinter J, Genser B, Moissl U, Stuard S, Kooman J, Canaud B, Wanner C. Hyponatraemia and fluid overload are associated with higher risk of mortality in dialysis patients. Nephrol Dial Transplant 2023; 38:2248-2256. [PMID: 36861328 DOI: 10.1093/ndt/gfad041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND The 5-year mortality rate for haemodialysis patients is over 50%. Acute and chronic disturbances in salt and fluid homeostasis contribute to poor survival and are established as individual mortality risk factors. However, their interaction in relation to mortality is unclear. METHODS We used the European Clinical Database 5 to investigate in a retrospective cohort analysis the relationship between transient hypo- and hypernatremia, fluid status and mortality risk of 72 163 haemodialysis patients from 25 countries. Incident haemodialysis patients with at least one valid measurement of bioimpedance spectroscopy were followed until death or administrative censoring from 1 January 2010 to 4 December 2019. Fluid overload and depletion were defined as >2.5 L above, and -1.1 L below normal fluid status, respectively. N = 2 272 041 recorded plasma sodium and fluid status measurements were available over a monthly time grid and analysed in a Cox regression model for time-to-death. RESULTS Mortality risk of hyponatremia (plasma sodium <135 mmol/L) was slightly increased when fluid status was normal [hazard ratio (HR) 1.26, 95% confidence interval (CI) 1.18-1.35], increased by half when patients were fluid depleted (HR 1.56, 95% CI 1.27-1.93) and accelerated during fluid overload (HR 1.97, 95% CI 1.82-2.12). CONCLUSIONS Plasma sodium and fluid status act independently as risk factors on mortality. Patient surveillance of fluid status is especially important in the high-risk subpopulation of patients with hyponatremia. Prospective patient-level studies should examine the effects of chronic hypo- and hypernatremia, risk determinants, and their outcome risk.
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Affiliation(s)
- Jule Pinter
- University Hospital Würzburg, Würzburg, Germany
| | - Bernd Genser
- Centre for Preventive Medicine & Digital Health Baden Württemberg, Ruprecht Karls University Heidelberg, Mannheim, Germany
- High5Data GmbH, Heidelberg, Germany
| | - Ulrich Moissl
- Global Research and Development, FMC Deutschland GmbH, Bad Homburg, Germany
| | - Stefano Stuard
- Global Medical Office, FMC Germany, Bad Homburg, Germany
| | - Jeroen Kooman
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bernard Canaud
- Global Research and Development, FMC Deutschland GmbH, Bad Homburg, Germany
- Global Medical Office, FMC Germany, Bad Homburg, Germany
- School of Medicine, University of Montpellier, Montpellier, France
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30
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Echefu G, Stowe I, Burka S, Basu-Ray I, Kumbala D. Pathophysiological concepts and screening of cardiovascular disease in dialysis patients. FRONTIERS IN NEPHROLOGY 2023; 3:1198560. [PMID: 37840653 PMCID: PMC10570458 DOI: 10.3389/fneph.2023.1198560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/10/2023] [Indexed: 10/17/2023]
Abstract
Dialysis patients experience 10-20 times higher cardiovascular mortality than the general population. The high burden of both conventional and nontraditional risk factors attributable to loss of renal function can explain higher rates of cardiovascular disease (CVD) morbidity and death among dialysis patients. As renal function declines, uremic toxins accumulate in the blood and disrupt cell function, causing cardiovascular damage. Hemodialysis patients have many cardiovascular complications, including sudden cardiac death. Peritoneal dialysis puts dialysis patients with end-stage renal disease at increased risk of CVD complications and emergency hospitalization. The current standard of care in this population is based on observational data, which has a high potential for bias due to the paucity of dedicated randomized clinical trials. Furthermore, guidelines lack specific guidelines for these patients, often inferring them from non-dialysis patient trials. A crucial step in the prevention and treatment of CVD would be to gain better knowledge of the influence of these predisposing risk factors. This review highlights the current evidence regarding the influence of advanced chronic disease on the cardiovascular system in patients undergoing renal dialysis.
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Affiliation(s)
- Gift Echefu
- Division of Cardiovascular Medicine, The University of Tennessee Health Science Center, Memphis, TN, United States
| | - Ifeoluwa Stowe
- Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge, LA, United States
| | - Semenawit Burka
- Department of Internal Medicine, University of Texas Rio Grande Valley, McAllen, TX, United States
| | - Indranill Basu-Ray
- Department of Cardiology, Memphis Veterans Affairs (VA) Medical Center, Memphis, TN, United States
| | - Damodar Kumbala
- Nephrology Division, Renal Associates of Baton Rouge, Baton Rouge, LA, United States
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31
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Zoccali C, Mallamaci F, Adamczak M, de Oliveira RB, Massy ZA, Sarafidis P, Agarwal R, Mark PB, Kotanko P, Ferro CJ, Wanner C, Burnier M, Vanholder R, Wiecek A. Cardiovascular complications in chronic kidney disease: a review from the European Renal and Cardiovascular Medicine Working Group of the European Renal Association. Cardiovasc Res 2023; 119:2017-2032. [PMID: 37249051 PMCID: PMC10478756 DOI: 10.1093/cvr/cvad083] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/29/2022] [Accepted: 01/09/2023] [Indexed: 05/31/2023] Open
Abstract
Chronic kidney disease (CKD) is classified into five stages with kidney failure being the most severe stage (stage G5). CKD conveys a high risk for coronary artery disease, heart failure, arrhythmias, and sudden cardiac death. Cardiovascular complications are the most common causes of death in patients with kidney failure (stage G5) who are maintained on regular dialysis treatment. Because of the high death rate attributable to cardiovascular (CV) disease, most patients with progressive CKD die before reaching kidney failure. Classical risk factors implicated in CV disease are involved in the early stages of CKD. In intermediate and late stages, non-traditional risk factors, including iso-osmotic and non-osmotic sodium retention, volume expansion, anaemia, inflammation, malnutrition, sympathetic overactivity, mineral bone disorders, accumulation of a class of endogenous compounds called 'uremic toxins', and a variety of hormonal disorders are the main factors that accelerate the progression of CV disease in these patients. Arterial disease in CKD patients is characterized by an almost unique propensity to calcification and vascular stiffness. Left ventricular hypertrophy, a major risk factor for heart failure, occurs early in CKD and reaches a prevalence of 70-80% in patients with kidney failure. Recent clinical trials have shown the potential benefits of hypoxia-inducible factor prolyl hydroxylase inhibitors, especially as an oral agent in CKD patients. Likewise, the value of proactively administered intravenous iron for safely treating anaemia in dialysis patients has been shown. Sodium/glucose cotransporter-2 inhibitors are now fully emerged as a class of drugs that substantially reduces the risk for CV complications in patients who are already being treated with adequate doses of inhibitors of the renin-angiotensin system. Concerted efforts are being made by major scientific societies to advance basic and clinical research on CV disease in patients with CKD, a research area that remains insufficiently explored.
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Affiliation(s)
- Carmine Zoccali
- Renal Research Institute, 315 E, 62nd St., New York, NY 10065, USA
- Associazione Ipertensione Nefrologia e Trapianto Renale (IPNET) c/o Nefrologia e CNR, Grande Ospedale Metropolitano, Contrada Camporeale, 83031 Ariano Irpino Avellino, Italy
| | - Francesca Mallamaci
- Nephrology and Transplantation Unit, Grande Ospedale Metropolitano Reggio Cal and CNR-IFC, Via Giuseppe Melacrino 21, 89124 Reggio Calabria, Italy
| | - Marcin Adamczak
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Francuska 20-24 St. 40-027 Katowice, Poland
| | - Rodrigo Bueno de Oliveira
- Department of Internal Medicine (Nephrology), School of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | - Ziad A Massy
- Ambroise Paré University Hospital, APHP, Boulogne Billancourt/Paris, and INSERM U-1018, Centre de recherche en épidémiologie et santé des populations (CESP), Equipe 5, Paris-Saclay University (PSU) and University of Paris Ouest-Versailles-Saint-Quentin-en-Yvelines (UVSQ), FCRIN INI-CRCT, Villejuif, France
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Indiana University School of Medicine and Richard L. Roudebush VA Medical Center, 1481 W 10th St, Indianapolis, IN 46202, USA
| | - Patrick B Mark
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Peter Kotanko
- Renal Research Institute, LLC Icahn School of Medicine at Mount Sinai, 315 East 62nd Street, 3rd Floor, New York, NY 10065, USA
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Michel Burnier
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine and Pediatrics, University Hospital, Ghent, Belgium
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Francuska 20-24 St. 40-027 Katowice, Poland
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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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Hallgren C, Svensson CJ, Ullerstam T, Olin M, Dezfoolian H, Kashioulis P, Oras J. Validating a Simplified Lung Ultrasound Protocol for Detection and Quantification of Pulmonary Edema in Patients With Chronic Kidney Disease Receiving Maintenance Hemodialysis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2013-2021. [PMID: 36928585 DOI: 10.1002/jum.16219] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES Pulmonary edema is a common clinical problem and lung ultrasound (LUS) presents an efficient method for evaluating this pathology. This study aims to investigate if a clinically efficient LUS protocol can quantify the level of extravascular lung fluid in patients receiving hemodialysis, and to develop a simplified B-line scoring system based on this protocol. METHODS A simple 8-area LUS approach was used for the assessment of the extravascular fluid status in patients before, during, and after receiving hemodialysis. The LUS assessments were compared to the amount of removed fluid over time. To determine the best B-line score system, different scorings for each zone were tested in a linear mixed model with pseudo R-square model fit against removed fluid. The B-line score was further validated through correlations with changes in oxygen saturation, grade of dyspnea, and body weight over time. RESULTS A total of 53 patients were included and examined on 108 hemodialysis occasions. Median fluid removal was 2.3 L. The B-line score model with best fit was a score of 0 points in a zone with 0 or 1 B-lines, 1 point with 2 or 3 B-lines, 2 points with 3 or more B-lines, and 3 points with any interstitial confluence. Using this B-line score, we found a significant association with amount of removed fluid, oxygen saturation, grade of dyspnea, and change in body weight. CONCLUSION A straightforward protocol for LUS and B-line score system was shown valid for quantification of pulmonary edema and fluid removal in hemodialysis patients. The scoring system developed here can be useful also in other patient groups, but this requires further validation.
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Affiliation(s)
- Carl Hallgren
- Department of Anesthesia, Operation and Intensive Care, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Carl Johan Svensson
- Department of Anesthesia, Operation and Intensive Care, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Tobias Ullerstam
- Department of Anesthesia, Operation and Intensive Care, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Max Olin
- Department of Anesthesia, Operation and Intensive Care, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Hamid Dezfoolian
- Department of Kidney Diseases, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Pavlos Kashioulis
- Department of Kidney Diseases, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Jonatan Oras
- Department of Anesthesia, Operation and Intensive Care, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Kim IS, Kim S, Yoo TH, Kim JK. Diagnosis and treatment of hypertension in dialysis patients: a systematic review. Clin Hypertens 2023; 29:24. [PMID: 37653470 PMCID: PMC10472689 DOI: 10.1186/s40885-023-00240-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 05/24/2023] [Indexed: 09/02/2023] Open
Abstract
In patients with end-stage renal disease (ESRD) undergoing dialysis, hypertension is common but often inadequately controlled. The prevalence of hypertension varies widely among studies because of differences in the definition of hypertension and the methods of used to measure blood pressure (BP), i.e., peri-dialysis or ambulatory BP monitoring (ABPM). Recently, ABPM has become the gold standard for diagnosing hypertension in dialysis patients. Home BP monitoring can also be a good alternative to ABPM, emphasizing BP measurement outside the hemodialysis (HD) unit. One thing for sure is pre- and post-dialysis BP measurements should not be used alone to diagnose and manage hypertension in dialysis patients. The exact target of BP and the relationship between BP and all-cause mortality or cause-specific mortality are unclear in this population. Many observational studies with HD cohorts have almost universally reported a U-shaped or even an L-shaped association between BP and all-cause mortality, but most of these data are based on the BP measured in HD units. Some data with ABPM have shown a linear association between BP and mortality even in HD patients, similar to the general population. Supporting this, the results of meta-analysis have shown a clear benefit of BP reduction in HD patients. Therefore, further research is needed to determine the optimal target BP in the dialysis population, and for now, an individualized approach is appropriate, with particular emphasis on avoiding excessively low BP. Maintaining euvolemia is of paramount importance for BP control in dialysis patients. Patient heterogeneity and the lack of comparative evidence preclude the recommendation of one class of medication over another for all patients. Recently, however, β-blockers could be considered as a first-line therapy in dialysis patients, as they can reduce sympathetic overactivity and left ventricular hypertrophy, which contribute to the high incidence of arrhythmias and sudden cardiac death. Several studies with mineralocorticoid receptor antagonists have also reported promising results in reducing mortality in dialysis patients. However, safety issues such as hyperkalemia or hypotension should be further evaluated before their use.
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Affiliation(s)
- In Soo Kim
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Pyungan-dong, Dongan-gu, Anyang, 431-070, Korea
| | - Sungmin Kim
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Pyungan-dong, Dongan-gu, Anyang, 431-070, Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - Jwa-Kyung Kim
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Pyungan-dong, Dongan-gu, Anyang, 431-070, Korea.
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Gu J, Bai E, Ge C, Winograd J, Shah AD. Peritoneal equilibration testing: Your questions answered. Perit Dial Int 2023; 43:361-373. [PMID: 36350033 DOI: 10.1177/08968608221133629] [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] [Indexed: 09/08/2023] Open
Abstract
The peritoneal equilibration test (PET), first described in 1987, is a semiquantitative assessment of peritoneal transfer characteristics in patients undergoing peritoneal dialysis. It is typically performed as a 4-h exchange using 2.27/2.5% dextrose dialysate with serial measurements of blood and dialysate creatinine, urea, and glucose concentrations. The percentage absorption of glucose and D/P creatinine ratio are used to determine peritoneal solute transfer rates. It is used to both help guide peritoneal dialysis prescriptions and to prognosticate. There are several derivative tests which have been described in the literature. In this review, we describe the original PET, the various iterations of the PET, the information gleaned, and the use in the setting of poor solute clearance and in the diagnosis of membrane dysfunction, and limitations of the PET.
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Affiliation(s)
- Joey Gu
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Eric Bai
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Connie Ge
- University of Massachusetts Chan Medical School, Worcester, USA
| | - Jacob Winograd
- Warren Alpert Medical School of Brown University, Providence, RI, USA
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, USA
| | - Ankur D Shah
- Warren Alpert Medical School of Brown University, Providence, RI, USA
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, USA
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de Roij van Zuijdewijn CLM, Rootjes PA, Nubé MJ, Bots ML, Canaud B, Blankestijn PJ, van Ittersum FJ, Maduell F, Morena M, Peters SAE, Davenport A, Vernooij RWM, Grooteman MPC. Long-term peridialytic blood pressure changes are related to mortality. Nephrol Dial Transplant 2023; 38:1992-2001. [PMID: 36496176 PMCID: PMC10469106 DOI: 10.1093/ndt/gfac329] [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: 08/05/2022] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND In chronic haemodialysis (HD) patients, the relationship between long-term peridialytic blood pressure (BP) changes and mortality has not been investigated. METHODS To evaluate whether long-term changes in peridialytic BP are related to mortality and whether treatment with HD or haemodiafiltration (HDF) differs in this respect, the combined individual participant data of three randomized controlled trials comparing HD with HDF were used. Time-varying Cox regression and joint models were applied. RESULTS During a median follow-up of 2.94 years, 609 of 2011 patients died. As for pre-dialytic systolic BP (pre-SBP), a severe decline (≥21 mmHg) in the preceding 6 months was independently related to increased mortality [hazard ratio (HR) 1.61, P = .01] when compared with a moderate increase. Likewise, a severe decline in post-dialytic diastolic BP (DBP) was associated with increased mortality (adjusted HR 1.96, P < .0005). In contrast, joint models showed that every 5-mmHg increase in pre-SBP and post-DBP during total follow-up was related to reduced mortality (adjusted HR 0.97, P = .01 and 0.94, P = .03, respectively). No interaction was observed between BP changes and treatment modality. CONCLUSION Severe declines in pre-SBP and post-DBP in the preceding 6 months were independently related to mortality. Therefore peridialytic BP values should be interpreted in the context of their changes and not solely as an absolute value.
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Affiliation(s)
- Camiel L M de Roij van Zuijdewijn
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Nephrology, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Diabetes & Metabolism, Amsterdam, The Netherlands
| | - Paul A Rootjes
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Nephrology, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Diabetes & Metabolism, Amsterdam, The Netherlands
| | - Menso J Nubé
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Nephrology, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Diabetes & Metabolism, Amsterdam, The Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Bernard Canaud
- Center of Excellence Medical, Fresenius Medical Care GmbH, Bad Homburg, Germany
- University of Montpellier, Research and Training Unit Medicine, Montpellier, France
| | - Peter J Blankestijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frans J van Ittersum
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Nephrology, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Diabetes & Metabolism, Amsterdam, The Netherlands
| | | | - Marion Morena
- PhyMedExp, INSERM, CNRS, University of Montpellier, Département de Biochimie et Hormonologie, CHU Montpellier, Montpellier, France
| | - Sanne A E Peters
- George Institute for Global Health, University of Oxford, Oxford, UK
| | - Andrew Davenport
- Royal Free Hospital, University College London Medical School, London, UK
| | - Robin W M Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Muriel P C Grooteman
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Nephrology, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Diabetes & Metabolism, Amsterdam, The Netherlands
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Morelle J, Lambie M, Öberg CM, Davies S. The Peritoneal Membrane and its Role in Peritoneal Dialysis. Clin J Am Soc Nephrol 2023; 19:01277230-990000000-00223. [PMID: 37616463 PMCID: PMC10861113 DOI: 10.2215/cjn.0000000000000282] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 08/03/2023] [Indexed: 08/26/2023]
Abstract
A healthy and functional peritoneal membrane is key to achieve sufficient ultrafiltration and to restore fluid balance, a major component of high-quality prescription in patients treated with peritoneal dialysis (PD). Variability in membrane function at the start of PD or changes over time on treatment influence dialysis prescription and outcomes, and dysfunction of the peritoneal membrane contributes to fluid overload and associated complications. In this review, we summarize the current knowledge about the structure, function and pathophysiology of the peritoneal membrane with a focus on clinical implications for patient-centered care. We also discuss the molecular and genetic mechanisms of solute and water transport across the peritoneal membrane, including the role of aquaporin water channels in crystalloid vs. colloid osmosis; why and how to assess membrane function using peritoneal equilibration tests; the etiologies of membrane dysfunction and their specific management; and the impact of genetic variation on membrane function and outcomes in patients treated with PD. This review also identifies the gaps in current knowledge and perspectives for future research to improve our understanding of the peritoneal membrane and, ultimately, to improve the care of patients treated with PD.
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Affiliation(s)
- Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
- UCLouvain School of Medicine, UCLouvain, Brussels, Belgium
| | - Mark Lambie
- Faculty of Medicine and Health Sciences, Keele University, Keele, United Kingdom
| | - Carl M. Öberg
- Division of Nephrology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Simon Davies
- Faculty of Medicine and Health Sciences, Keele University, Keele, United Kingdom
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Hamrahian SM, Vilayet S, Herberth J, Fülöp T. Prevention of Intradialytic Hypotension in Hemodialysis Patients: Current Challenges and Future Prospects. Int J Nephrol Renovasc Dis 2023; 16:173-181. [PMID: 37547077 PMCID: PMC10404053 DOI: 10.2147/ijnrd.s245621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023] Open
Abstract
Intradialytic hypotension, defined as rapid decrease in systolic blood pressure of greater than or equal to 20 mmHg or in mean arterial pressure of greater than or equal to 10 mmHg that results in end-organ ischemia and requires countermeasures such as ultrafiltration reduction or saline infusion to increase blood pressure to improve patient's symptoms, is a known complication of hemodialysis and is associated with several potential adverse outcomes. Its pathogenesis is complex and involves both patient-related factors such as age and comorbidities, as well as factors related to the dialysis prescription itself. Key factors include the need for volume removal during hemodialysis and a suboptimal vascular response which compromises the ability to compensate for acute intravascular volume loss. Inadequate vascular refill, incorrect assessment or unaccounted changes of target weight, acute illnesses and medication interference are further potential contributors. Intradialytic hypotension can lead to compromised tissue perfusion and end-organ damage, both acutely and over time, resulting in repetitive injuries. To address these problems, a careful assessment of subjective symptoms, minimizing interdialytic weight gains, individualizing dialysis prescription and adjusting the dialysis procedure based on patients' risk factors can mitigate negative outcomes.
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Affiliation(s)
| | - Salem Vilayet
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Johann Herberth
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
- Medicine Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Tibor Fülöp
- Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
- Medicine Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
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Wijaya A, Marbun MBH, Nugroho P, Rinaldi I. The Association Between Fluid Overload and Endothelial Dysfunction in Chronic Kidney Failure Patients Undergoing Hemodialysis Twice a Week. Cureus 2023; 15:e44381. [PMID: 37779742 PMCID: PMC10540707 DOI: 10.7759/cureus.44381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Fluid overload causes excessive systemic vasoconstriction and decreased perfusion of peripheral tissues, leading to abnormalities in cardiopulmonary physiological functions. Prolonged fluid overload caused by inadequate hemodialysis may cause heart dilatation, left ventricular hypertrophy, hypertension, and a decrease in coronary reserves, which later will develop into coronary ischemia, leading to increased morbidity and mortality of cardiovascular disease (CVD). Endothelial dysfunction plays a role in excessive vasoconstriction on fluid overload. Brain natriuretic peptide (BNP) and asymmetric dimethylarginine (ADMA) are used as parameters of fluid overload and endothelial dysfunction, respectively. This study is conducted to describe the relationship between fluid overload with endothelial dysfunction. METHOD This study is a cross-sectional study of kidney failure patients who underwent hemodialysis twice weekly for at least three months. BNP and ADMA were used as parameters for fluid overload and taken prior to hemodialysis. RESULT From 126 subjects, the proportion with fluid overload (BNP>356 pg/ml) was found to be 64.3% with the median age of subjects being 52 years (47-62). There was 47.6% population with endothelial dysfunction (ADMA>100 ng/ml). Presumptive causes of primary chronic kidney disease (CKD) were hypertension (38.9%), diabetes mellitus (DM) (28.6%), and glomerulonephritis (21.4%). There was no significant association between fluid overload and endothelial dysfunction (PR=1,042, p=0.832 CI 95%=0.714-1.521). CONCLUSION There was no relationship between fluid overload and endothelial dysfunction.
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Affiliation(s)
- Adi Wijaya
- Internal Medicine, Cipto Mangunkusumo Hospital - Faculty of Medicine Universitas Indonesia, Jakarta, IDN
| | | | - Pringgodigdo Nugroho
- Internal Medicine, Cipto Mangunkusumo Hospital - Faculty of Medicine Universitas Indonesia, Jakarta, IDN
| | - Ikhwan Rinaldi
- Internal Medicine, Cipto Mangunkusumo Hospital - Faculty of Medicine Universitas Indonesia, Jakarta, IDN
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Barra ABL, da Silva APR, Canziani MEF, Lugon JR, de Matos JPS. Survival in hemodialysis in Brazil according to the source of payment for the treatment: Public Healthcare System (SUS) versus private insurance. J Bras Nefrol 2023; 45:302-309. [PMID: 36662571 PMCID: PMC10697161 DOI: 10.1590/2175-8239-jbn-2022-0131en] [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: 09/02/2022] [Accepted: 11/07/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Brazil has the largest public and universal healthcare system in the world, but little is known about the outcomes of patients on hemodialysis (HD) in the country according to the source of funding for the treatment. OBJECTIVE To compare the profile and survival of patients under HD treatment funded by the Public Healthcare System (SUS) to those with private insurance. METHODS Retrospective analysis of adults undergoing HD between 2012 and 2017 in 21 dialysis centers in Brazil that provided both by the SUS and private health insurance. Participants, regardless of the paying source, received similar dialysis treatment. Data were censored after 60 months of follow-up or at the end of 2019. RESULTS 4,945 patients were included, 59.7% of which were financed by the SUS. Patients financed by SUS, compared to those with private insurance, were younger (58 vs. 60 years; p < 0.0001) and with a lower prevalence of diabetes (35.8% vs. 40.9%; p < 0.0001). The 60-month survival rates in these groups were 51.1% and 52.1%, respectively (p = 0.85). In the analysis of the subdistribution proportional hazard ratio by the Fine-Gray model, including adjustment for concurrent outcomes, a significant increase in the risk ratio for death was found (1.22 [95% confidence interval 1.04 to 1.43]) in patients with treatment funded by the SUS. CONCLUSIONS Patients on HD with treatment funded by the SUS have a higher adjusted risk of death when compared to those with private insurance, despite similar dialysis treatment. Factors not directly related to dialysis therapy could explain this difference.
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Affiliation(s)
- Ana Beatriz Lesqueves Barra
- Universidade Federal Fluminense, Faculdade de Medicina, Programa de
Pós-Graduação em Ciências Médicas, Niterói, RJ, Brazil
- Fresenius Medical Care Brasil, Rio de Janeiro, RJ, Brazil
| | - Ana Paula Roque da Silva
- Universidade Federal Fluminense, Faculdade de Medicina, Programa de
Pós-Graduação em Ciências Médicas, Niterói, RJ, Brazil
| | | | - Jocemir Ronaldo Lugon
- Universidade Federal Fluminense, Faculdade de Medicina, Programa de
Pós-Graduação em Ciências Médicas, Niterói, RJ, Brazil
- Universidade Federal Fluminense, Faculdade de Medicina, Divisão de
Nefrologia, Niterói, RJ, Brazil
| | - Jorge Paulo Strogoff de Matos
- Universidade Federal Fluminense, Faculdade de Medicina, Programa de
Pós-Graduação em Ciências Médicas, Niterói, RJ, Brazil
- Universidade Federal Fluminense, Faculdade de Medicina, Divisão de
Nefrologia, Niterói, RJ, Brazil
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Mermelstein A, Raimann JG, Wang Y, Kotanko P, Daugirdas JT. Ultrafiltration Rate Levels in Hemodialysis Patients Associated with Weight-Specific Mortality Risks. Clin J Am Soc Nephrol 2023; 18:767-776. [PMID: 36913263 PMCID: PMC10278805 DOI: 10.2215/cjn.0000000000000144] [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: 10/07/2022] [Accepted: 02/27/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND We hypothesized that the association of ultrafiltration rate with mortality in hemodialysis patients was differentially affected by weight and sex and sought to derive a sex- and weight-indexed ultrafiltration rate measure that captures the differential effects of these parameters on the association of ultrafiltration rate with mortality. METHODS Data were analyzed from the US Fresenius Kidney Care (FKC) database for 1 year after patient entry into a FKC dialysis unit (baseline) and over 2 years of follow-up for patients receiving thrice-weekly in-center hemodialysis. To investigate the joint effect of baseline-year ultrafiltration rate and postdialysis weight on survival, we fit Cox proportional hazards models using bivariate tensor product spline functions and constructed contour plots of weight-specific mortality hazard ratios over the entire range of ultrafiltration rate values and postdialysis weights (W). RESULTS In the studied 396,358 patients, the average ultrafiltration rate in ml/h was related to postdialysis weight (W) in kg: 3W+330. Ultrafiltration rates associated with 20% or 40% higher weight-specific mortality risk were 3W+500 and 3W+630 ml/h, respectively, and were 70 ml/h higher in men than in women. Nineteen percent or 7.5% of patients exceeded ultrafiltration rates associated with a 20% or 40% higher mortality risk, respectively. Low ultrafiltration rates were associated with subsequent weight loss. Ultrafiltration rates associated with a given mortality risk were lower in high-body weight older patients and higher in patients on dialysis for more than 3 years. CONCLUSIONS Ultrafiltration rates associated with various levels of higher mortality risk depend on body weight, but not in a 1:1 ratio, and are different in men versus women, in high-body weight older patients, and in high-vintage patients.
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Affiliation(s)
- Ariella Mermelstein
- Renal Research Institute, New York, New York
- Katz School of Science and Health at Yeshiva University, New York, New York
| | - Jochen G. Raimann
- Renal Research Institute, New York, New York
- Katz School of Science and Health at Yeshiva University, New York, New York
| | - Yuedong Wang
- University of California—Santa Barbara, Santa Barbara, California
| | - Peter Kotanko
- Renal Research Institute, New York, New York
- Icahn School of Medicine at Mount Sinai, New York, New York
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Malik J, Valerianova A, Pesickova SS, Michalickova K, Hladinova Z, Hruskova Z, Bednarova V, Rocinova K, Tothova M, Kratochvilova M, Kaiserova L, Buryskova Salajova K, Lejsek V, Sevcik M, Tesar V. Heart failure with preserved ejection fraction is the most frequent but commonly overlooked phenotype in patients on chronic hemodialysis. Front Cardiovasc Med 2023; 10:1130618. [PMID: 37324637 PMCID: PMC10267437 DOI: 10.3389/fcvm.2023.1130618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 05/09/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Heart failure (HF) is a serious complication of end-stage kidney disease (ESKD). However, most data come from retrospective studies that included patients on chronic hemodialysis at the time of its initiation. These patients are frequently overhydrated, which significantly influences the echocardiogram findings. The primary aim of this study was to analyze the prevalence of heart failure and its phenotypes. The secondary aims were (1) to describe the potential of N-terminal pro-brain natriuretic peptide (NTproBNP) for HF diagnosis in ESKD patients on hemodialysis, (2) to analyze the frequency of abnormal left ventricular geometry, and (3) to describe the differences between various HF phenotypes in this population. Methods We included all patients on chronic hemodialysis for at least 3 months from five hemodialysis units who were willing to participate, had no living kidney transplant donor, and had a life expectancy longer than 6 months at the time of inclusion. Detailed echocardiography together with hemodynamic calculations, dialysis arteriovenous fistula flow volume calculation, and basic lab analysis were performed in conditions of clinical stability. Excess of severe overhydration was excluded by clinical examination and by employing bioimpedance. Results A total of 214 patients aged 66.4 ± 14.6 years were included. HF was diagnosed in 57% of them. Among patients with HF, HF with preserved ejection fraction (HFpEF) was, by far, the most common phenotype and occurred in 35%, while HF with reduced ejection fraction (HFrEF) occurred only in 7%, HF with mildly reduced ejection fraction (HFmrEF) in 7%, and high-output HF in 9%. Patients with HFpEF differed from patients with no HF significantly in the following: they were older (62 ± 14 vs. 70 ± 14, p = 0.002) and had a higher left ventricular mass index [96(36) vs. 108(45), p = 0.015], higher left atrial index [33(12) vs. 44(16), p < 0.0001], and higher estimated central venous pressure [5(4) vs. 6(8), p = 0.004] and pulmonary artery systolic pressure [31(9) vs. 40(23), p = 0.006] but slightly lower tricuspid annular plane systolic excursion (TAPSE): 22 ± 5 vs. 24 ± 5, p = 0.04. NTproBNP had low sensitivity and specificity for diagnosing HF or HFpEF: with the use of the cutoff value of 8,296 ng/L, the sensitivity of HF diagnosis was only 52% while the specificity was 79%. However, NTproBNP levels were significantly related to echocardiographic variables, most significantly to the indexed left atrial volume (R = 0.56, p < 10-5) and to the estimated systolic pulmonary arterial pressure (R = 0.50, p < 10-5). Conclusions HFpEF was by far the most common heart failure phenotype in patients on chronic hemodialysis and was followed by high-output HF. Patients suffering from HFpEF were older and had not only typical echocardiographic changes but also higher hydration that mirrored increased filling pressures of both ventricles than in those of patients without HF.
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Affiliation(s)
- Jan Malik
- 3rd Department of Internal Medicine, First Faculty of Medicine, General University Hospital, Charles University, Prague, Czechia
| | - Anna Valerianova
- 3rd Department of Internal Medicine, First Faculty of Medicine, General University Hospital, Charles University, Prague, Czechia
| | | | | | - Zuzana Hladinova
- Department of Nephrology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czechia
| | - Zdenka Hruskova
- Department of Nephrology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czechia
| | - Vladimira Bednarova
- Department of Nephrology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czechia
| | | | - Monika Tothova
- Dialysis Center Motol, Fresenius Medical Care, Prague, Czechia
| | | | - Lucie Kaiserova
- 3rd Department of Internal Medicine, First Faculty of Medicine, General University Hospital, Charles University, Prague, Czechia
| | - Kristina Buryskova Salajova
- 3rd Department of Internal Medicine, First Faculty of Medicine, General University Hospital, Charles University, Prague, Czechia
| | - Vaclav Lejsek
- 3rd Department of Internal Medicine, First Faculty of Medicine, General University Hospital, Charles University, Prague, Czechia
| | - Martin Sevcik
- 3rd Department of Internal Medicine, First Faculty of Medicine, General University Hospital, Charles University, Prague, Czechia
| | - Vladimir Tesar
- Department of Nephrology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czechia
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Canaud B, Kooman J, Davenport A, Campo D, Carreel E, Morena-Carrere M, Cristol JP. Digital health technology to support care and improve outcomes of chronic kidney disease patients: as a case illustration, the Withings toolkit health sensing tools. FRONTIERS IN NEPHROLOGY 2023; 3:1148565. [PMID: 37675376 PMCID: PMC10479582 DOI: 10.3389/fneph.2023.1148565] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/07/2023] [Indexed: 09/08/2023]
Abstract
Cardiovascular disease (CVD) is a major burden in dialysis-dependent chronic kidney disease (CKD5D) patients. Several factors contribute to this vulnerability including traditional risk factors such as age, gender, life style and comorbidities, and non-traditional ones as part of dialysis-induced systemic stress. In this context, it appears of utmost importance to bring a closer attention to CVD monitoring in caring for CKD5D patients to ensure early and appropriate intervention for improving their outcomes. Interestingly, new home-used, self-operated, connected medical devices offer convenient and new tools for monitoring in a fully automated and ambulatory mode CKD5D patients during the interdialytic period. Sensoring devices are installed with WiFi or Bluetooth. Some devices are also available in a cellular version such as the Withings Remote Patient Monitoring (RPM) solution. These devices analyze the data and upload the results to Withings HDS (Hybrid data security) platform servers. Data visualization can be viewed by the patient using the Withings Health Mate application on a smartphone, or with a web interface. Health Care Professionals (HCP) can also visualize patient data via the Withings web-based RPM interface. In this narrative essay, we analyze the clinical potential of pervasive wearable sensors for monitoring ambulatory dialysis patients and provide an assessment of such toolkit digital medical health devices currently available on the market. These devices offer a fully automated, unobtrusive and remote monitoring of main vital functions in ambulatory subjects. These unique features provide a multidimensional assessment of ambulatory CKD5D patients covering most physiologic functionalities, detecting unexpected disorders (i.e., volume overload, arrhythmias, sleep disorders) and allowing physicians to judge patient's response to treatment and recommendations. In the future, the wider availability of such pervasive health sensing and digital technology to monitor patients at an affordable cost price will improve the personalized management of CKD5D patients, so potentially resulting in improvements in patient quality of life and survival.
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Affiliation(s)
- Bernard Canaud
- Montpellier University, School of Medicine, Montpellier, France
- Global Medical Office, Fresenius Medical Care (FMC), Fresnes, France
| | - Jeroen Kooman
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Andrew Davenport
- UCL Department of Renal Medicine, Royal Free Hospital, University College, London, United Kingdom
| | | | | | - Marion Morena-Carrere
- PhyMedExp, University of Montpellier, INSERM, CNRS, Department of Biochemistry and Hormonology, University Hospital Center of Montpellier, Montpellier, France
| | - Jean-Paul Cristol
- PhyMedExp, University of Montpellier, INSERM, CNRS, Department of Biochemistry and Hormonology, University Hospital Center of Montpellier, Montpellier, France
- AIDER-Santé, Ch. Mion Foundation, Montpellier, France
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Stigger K, Ribeiro LR, Cordeiro FM, Böhlke M. Incidence of hospital admissions in bioimpedance-guided fluid management among maintenance hemodialysis patients-Results of a randomized controlled trial. Hemodial Int 2023. [PMID: 37067785 DOI: 10.1111/hdi.13076] [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: 09/10/2022] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 04/18/2023]
Abstract
INTRODUCTION Hemodialysis is life-sustaining in kidney failure. However, proper regulation of body fluids depends on an accurate estimate of target weight. This trial aims to compare clinical endpoints between target weight estimation guided by bioimpedance spectroscopy and usual care in hemodialysis patients. METHODS This is an open-label, parallel-group, controlled trial that randomized, through a table of random numbers, adult patients on maintenance hemodialysis to target weight estimation based on monthly clinical evaluation alone or added to evaluation by bioimpedance twice a year. The primary outcome was survival, and the secondary outcomes were the rate of hospital admissions, change in blood pressure (BP), and antihypertensive drugs load. Participants were followed for 2 years. Survival analysis was performed using Kaplan-Meier estimator and Log-rank test, and hospital admissions were analyzed by the incidence-rate ratio. FINDINGS One hundred and ten patients were randomized to the usual care (52) or bioimpedance (58) groups, with a mean age of 57.4 (15.4) years, 64 (58%) males. There was no difference between the groups at baseline. Survival was not significantly different between groups (log-rank test p = 0.68), but the trial was underpowered for this outcome. There was also no difference between the groups in the change in systolic or diastolic BP or in the number of antihypertensive drugs being used. The incidence rate of hospital admissions was 3.1 and 2.1 per person-year in usual care and bioimpedance groups, respectively, with a time-adjusted incidence rate ratio of 1.48 (95% CI: 1.20-1.82, p = 0.0001) and attributable fraction of risk among exposed individuals of 0.32 (95% CI: 0.17-0.45). DISCUSSION The inclusion of bioimpedance data to guide the estimation of target weight in hemodialysis patients had no detectable impact on survival or BP control, but significantly reduced the incidence rate of hospital admissions. The study was registered at ClinicalTrials.gov Identifier: NCT05272800.
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Affiliation(s)
- Kaiane Stigger
- Postgraduate Program in Health and Behavior, Universidade Católica de Pelotas, Pelotas, Brazil
| | - Larissa Ribas Ribeiro
- Postgraduate Program in Health and Behavior, Universidade Católica de Pelotas, Pelotas, Brazil
- Dialysis and Transplantation Unit, University Hospital São Francisco de Paula, Universidade Católica de Pelotas, Pelotas, Brazil
| | - Fernanda Moraez Cordeiro
- Postgraduate Program in Health and Behavior, Universidade Católica de Pelotas, Pelotas, Brazil
- Dialysis and Transplantation Unit, University Hospital São Francisco de Paula, Universidade Católica de Pelotas, Pelotas, Brazil
| | - Maristela Böhlke
- Postgraduate Program in Health and Behavior, Universidade Católica de Pelotas, Pelotas, Brazil
- Dialysis and Transplantation Unit, University Hospital São Francisco de Paula, Universidade Católica de Pelotas, Pelotas, Brazil
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Wang CH, Negoianu D, Zhang H, Casper S, Hsu JY, Kotanko P, Raimann J, Dember LM. Dynamics of Plasma Refill Rate and Intradialytic Hypotension During Hemodialysis: Retrospective Cohort Study With Causal Methodology. KIDNEY360 2023; 4:e505-e514. [PMID: 36790867 PMCID: PMC10278774 DOI: 10.34067/kid.0000000000000082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/18/2023] [Indexed: 02/16/2023]
Abstract
Key Points Directly studying plasma refill rate (PRR) during hemodialysis (HD) can offer insight into physiologic mechanisms that change throughout HD. PRR at the start and during HD is associated with intradialytic hypotension, independent of ultrafiltration rate. A rising PRR during HD may be an early indicator of compensatory mechanisms for impending circulatory instability. Background Attaining the optimal balance between achieving adequate volume removal while preserving organ perfusion is a challenge for patients receiving maintenance hemodialysis (HD). Current strategies to guide ultrafiltration are inadequate. Methods We developed an approach to calculate the plasma refill rate (PRR) throughout HD using hematocrit and ultrafiltration data in a retrospective cohort of patients receiving maintenance HD at 17 dialysis units from January 2017 to October 2019. We studied whether (1 ) PRR is associated with traditional risk factors for hemodynamic instability using logistic regression, (2 ) low starting PRR is associated with intradialytic hypotension (IDH) using Cox proportional hazard regression, and (3 ) time-varying PRR throughout HD is associated with hypotension using marginal structural modeling. Results During 180,319 HD sessions among 2554 patients, PRR had high within-patient and between-patient variability. Female sex and hypoalbuminemia were associated with low PRR at multiple time points during the first hour of HD. Low starting PRR has a higher hazard of IDH, whereas high starting PRR was protective (hazard ratio [HR], 1.26, 95% confidence interval [CI], 1.18 to 1.35 versus HR, 0.79, 95% CI, 0.73 to 0.85, respectively). However, when accounting for time-varying PRR and time-varying confounders, compared with a moderate PRR, while a consistently low PRR was associated with increased risk of hypotension (odds ratio [OR], 1.09, 95% CI, 1.02 to 1.16), a consistently high PRR had a stronger association with hypotension within the next 15 minutes (OR, 1.38, 95% CI, 1.30 to 1.45). Conclusions We present a straightforward technique to quantify plasma refill that could easily integrate with devices that monitor hematocrit during HD. Our study highlights how examining patterns of plasma refill may enhance our understanding of circulatory changes during HD, an important step to understand how current technology might be used to improve hemodynamic instability.
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Affiliation(s)
- Christina H. Wang
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dan Negoianu
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Sabrina Casper
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Jesse Y. Hsu
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter Kotanko
- Renal Research Institute, New York, New York
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Laura M. Dember
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Cihoric M, Kehlet H, Højlund J, Lauritsen ML, Kanstrup K, Foss NB. Bioimpedance spectroscopy fluid analysis in acute high-risk abdominal surgery, a prospective clinician-blinded observational feasibility study. J Clin Monit Comput 2023; 37:619-627. [PMID: 36333575 PMCID: PMC9638275 DOI: 10.1007/s10877-022-00934-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
Objective assessment of fluid status in critical surgical care may help optimize perioperative fluid administration and prevent postoperative fluid retention. We evaluated the feasibility of hydration status and fluid distribution assessment by Bioimpedance spectroscopy Analysis (BIA) in patients undergoing acute high-risk abdominal (AHA) surgery. This observational study included 73 patients undergoing AHA surgery. During the observational period (0-120 h), we registered BIA calculated absolute fluid overload (AFO) and relative fluid overload (RFO), defined as AFO/extracellular water ratio, as well as cumulative fluid balance and weight. Based on RFO values, hydration status was classified into three categories: dehydrated (RFO < - 10%), normohydrated (- 10% ≤ RFO ≤ + 15%), overhydrated RFO > 15%. We performed a total of 365 BIA measurements. Preoperative overhydration was found in 16% of patients, increasing to 66% by postoperative day five. The changes in BIA measured AFO correlated with the cumulative fluid balance (r2 = 0.44, p < .001), and change in weight (r2 = 0.55, p < .0001). Perioperative overhydration measured with BIA was associated with worse outcome compared to patients with normo- or dehydration. We have demonstrated the feasibility of obtaining perioperative bedside BIA measurements in patients undergoing AHA surgery. BIA measurements correlated with fluid balance, weight changes, and postoperative clinical complications. BIA-assessed fluid status might add helpful information to guide fluid management in patients undergoing AHA surgery.
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Affiliation(s)
- M Cihoric
- Department of Anaesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegaard allé 30, 2650, Hvidovre, Capital Region of Denmark, Denmark.
| | - H Kehlet
- Section for Surgical Pathophysiology, JMC, Rigshospitalet, Copenhagen, Capital Region of Denmark, Denmark
| | - J Højlund
- Department of Anaesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegaard allé 30, 2650, Hvidovre, Capital Region of Denmark, Denmark
| | - M L Lauritsen
- Gastrounit, Surgical Section, Hvidovre University Hospital, Hvidovre, Capital Region of Denmark, Denmark
| | - K Kanstrup
- Gastrounit, Surgical Section, Hvidovre University Hospital, Hvidovre, Capital Region of Denmark, Denmark
| | - N B Foss
- Department of Anaesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegaard allé 30, 2650, Hvidovre, Capital Region of Denmark, Denmark
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Suzuki Y, Otsuka T, Yoshioka Y, Iida T, Maruyama S, Watanabe H, Kaseda R, Yamamoto S, Kaneko Y, Goto S, Aoyagi R, Narita I. Assessing fluid volume and determining outcomes of acute heart failure using plasma human atrial natriuretic peptide. Clin Exp Nephrol 2023; 27:565-573. [PMID: 36941501 DOI: 10.1007/s10157-023-02333-1] [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: 12/08/2022] [Accepted: 02/25/2023] [Indexed: 03/22/2023]
Abstract
BACKGROUND The post-dialysis plasma level of human atrial natriuretic peptide (hANP) reflects the fluid volume in patients on hemodialysis. The threshold hANP level is reportedly 100 pg/mL; however, the clinical usefulness of the threshold hANP level for volume control has not been sufficiently studied. METHODS We conducted a single-center, retrospective, observational study that included 156 hemodialysis patients without atrial fibrillation. First, we examined the usefulness of the threshold hANP level (100 pg/mL) for predicting hypoxemia due to congestion in a short-term observational study from December 30, 2015 to January 5, 2016. Subsequently, we conducted a 5-year follow-up study wherein the outcomes were hospitalization due to acute heart failure (AHF), development of cardiovascular diseases (CVD), and all-cause death. Finally, we collected echocardiography data to investigate the relationship between cardiac function and hANP. RESULTS Our short-term observational study showed that patients with an hANP level ≥ 100 pg/mL developed hypoxemia due to congestion (odds ratio, 3.52; 95% confidence interval, 1.06-11.71; P = 0.040). At the 5-year follow-up, patients with an hANP level ≥ 100 pg/mL had significantly higher rates of hospitalization due to AHF, CVD, and all-cause death based on the log-rank test (P = 0.003, P = 0.019, P < 0.001, respectively). Cardiac disfunctions were significantly associated with the high hANP level. CONCLUSIONS The hANP level is indicative of both fluid volume and cardiac dysfunction. A threshold hANP level of 100 pg/mL can serve as a predictive marker for AHF and a practical indicator for volume control.
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Affiliation(s)
- Yuya Suzuki
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Chuo-Ku, Niigata, 951-8510, Japan
| | - Tadashi Otsuka
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Chuo-Ku, Niigata, 951-8510, Japan.
| | - Yuki Yoshioka
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Tomomichi Iida
- Department of Nephrology, Tachikawa General Hospital, Niigata, Japan
| | - Shingo Maruyama
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Chuo-Ku, Niigata, 951-8510, Japan
| | - Hirofumi Watanabe
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Chuo-Ku, Niigata, 951-8510, Japan
| | - Ryohei Kaseda
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Chuo-Ku, Niigata, 951-8510, Japan
| | - Suguru Yamamoto
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Chuo-Ku, Niigata, 951-8510, Japan
| | - Yoshikatsu Kaneko
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Chuo-Ku, Niigata, 951-8510, Japan
| | - Shin Goto
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Chuo-Ku, Niigata, 951-8510, Japan
| | - Ryuji Aoyagi
- Department of Nephrology, Tachikawa General Hospital, Niigata, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Chuo-Ku, Niigata, 951-8510, Japan
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Association between Intra- and Extra-Cellular Water Ratio Imbalance and Natriuretic Peptides in Patients Undergoing Hemodialysis. Nutrients 2023; 15:nu15051274. [PMID: 36904273 PMCID: PMC10005491 DOI: 10.3390/nu15051274] [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: 02/02/2023] [Revised: 02/24/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023] Open
Abstract
Natriuretic peptides are associated with malnutrition and volume overload. Over-hydration cannot simply be explained by excess extracellular water in patients undergoing hemodialysis. We assessed the relationship between the extracellular and intracellular water (ECW/ICW) ratio, N-terminal pro-B-type natriuretic peptide (NT-proBNP), human atrial natriuretic peptide (hANP), and echocardiographic findings. Body composition was examined by segmental multi-frequency bioelectrical impedance analysis in 368 patients undergoing maintenance dialysis (261 men and 107 women; mean age, 65 ± 12 years). Patients with higher ECW/ICW ratio quartiles tended to be older, were on dialysis longer, and had higher post-dialysis blood pressure and lower body mass index, ultrafiltration volume, serum albumin, blood urea nitrogen, and creatinine levels (p < 0.05). The ECW/ICW ratio significantly increased with decreasing ICW, but not with ECW. Patients with a higher ECW/ICW ratio and lower percent fat had significantly higher natriuretic peptide levels. After adjusting for covariates, the ECW/ICW ratio remained an independent associated factor for natriuretic peptides (β = 0.34, p < 0.001 for NT-proBNP and β = 0.40, p < 0.001 for hANP) and the left ventricular mass index (β = 0.20, p = 0.002). The ICW-ECW volume imbalance regulated by decreased cell mass may explain the reserve capacity for fluid accumulation in patients undergoing hemodialysis.
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Davenport A. Why is Intradialytic Hypotension the Commonest Complication of Outpatient Dialysis Treatments? Kidney Int Rep 2023; 8:405-418. [PMID: 36938081 PMCID: PMC10014354 DOI: 10.1016/j.ekir.2022.10.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/30/2022] [Accepted: 10/31/2022] [Indexed: 11/11/2022] Open
Abstract
Intradialytic hypotension (IDH) is the most frequent complication of hemodialysis (HD) treatments with a frequency of 10% to 12% for patients with chronic kidney disease attending for outpatient treatments and is associated with both temporary ischemic stress to vital organs, including the heart and brain, and increased patient mortality. Although there have been many different definitions of IDH over the years, an absolute nadir systolic blood pressure (SBP) has the strongest association with patient outcomes. The unifying pathophysiology is one of reduced effective blood volume, resulting in lower plasma tonicity, and if this cannot be adequately compensated for by activation of neurohumeral systems, then arteriolar tone and blood pressure fall. The risk factors for developing IDH are numerous, ranging from patient-related factors, including age and comorbidity with reduced cardiac reserve, to patient compliance with dietary and lifestyle advice, to reactions with the extracorporeal circuit and medications, choice of dialysate composition and temperature, setting of postdialysis target weight, ultrafiltration rate, and profiling. Advances in dialysis machine technology by providing real time estimates of the effective circulating volume and adjusting dialysate composition to maintain vascular tonicity are being developed, but currently require more sophisticated biofeedback loops to be clinically effective in preventing IDH. While awaiting advances in artificial intelligence, the clinician continues to rely on patient education to limit interdialytic weight gains, frequent assessment of the postdialysis target weight, adjusting dialysate composition and temperature, introducing convective therapies to increase thermal losses, and altering dialysis session duration and frequency to reduce ultrafiltration rate requirements.
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Affiliation(s)
- Andrew Davenport
- Department of Renal Medicine, Royal Free Hospital, Faculty of Medical Sciences, University College London, London, UK
- Correspondence: Andrew Davenport, UCL Department of Nephrology, Royal Free Hospital, University College London, Rowland Hill Street, London NW3 2PF, UK.
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50
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Song L, Quan ZL, Zhao LY, Cui DM, Zhong M, Zhou LF, Sun CY, Chen YG, Mo YW, Feng Z, Tao Y, Ye Z, Chen Y, Liang H, Lin T, Liu S, Liang XL, Fu X. Impact of pulmonary hypertension on arteriovenous fistula failure of hemodialysis patients: A 10 years follow-up cohort study. J Vasc Access 2023; 24:261-270. [PMID: 34227421 DOI: 10.1177/11297298211027408] [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] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is common in patients with end-stage renal disease (ESRD). Arteriovenous fistulas (AVF) creation may involve in the pathogenesis of PH. The aim of this study was to explore the impact of PH after AVF creation on the AVF failure rate in maintenance hemodialysis (MHD) patients. METHODS From January 1, 2009, to January 1, 2019, we retrospectively collected data of 578 MHD patients in Guangdong Provincial People's Hospital Blood Purification Center, China. Patients were followed-up until AVF failure or death or May 25, 2020. According to the systolic pulmonary artery pressure (SPAP) within 1 year after the establishment of AVF, the MHD patients were divided into three groups: SPAP ⩽ 35 mmHg, 35 < SPAP < 45 mmHg, SPAP ⩾ 45 mmHg. The primary outcome was AVF failure defined as AVF cannot complete hemodialysis. The secondary outcomes were all-cause mortality. RESULTS A total of 578 patients were analyzed. The average age was 60.66 ± 15.34 years (58.1% men). Of these, 26.1% of patients were reported PH. The SPAP exhibited a left-skewed nonparametric distribution and the overall SPAP after the creation of AVF was 39.00 (29.00-52.00) mmHg. The median follow-up was 5.8 (5.5-6.3) years. Overall, 12.8% (74/578) patients were reported AVF failure events. There was no significant difference in AVF failure rate among three groups (p = 0.070). A total of 111 (19.2%) died during the follow-up period. Compared with the SPAP ⩽35 mmHg group, only the all-cause death rate significantly increased in MHD patients with PH (p < 0.001). CONCLUSIONS The secondary pulmonary hypertension after AVF creation did not increase the risk of AVF failure in MHD patients, but significantly increased the risk of mortality for this portion of the patients. Future larger sample sizes, multi-center, and prospective trials are needed to make sure which type of access will benefit on their survival for MHD patients with SPAP ⩾35 mmHg.
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Affiliation(s)
- Li Song
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zi-Lin Quan
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Li-Yan Zhao
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Dong-Mei Cui
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Mi Zhong
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Li-Fang Zhou
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- School of Nursing, Southern Medical University, Guangzhou, China
| | - Chun-Yan Sun
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- School of Nursing, Southern Medical University, Guangzhou, China
| | - Ying-Gui Chen
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- School of Nursing, Southern Medical University, Guangzhou, China
| | - Ya-Wen Mo
- StateKey Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Zhonglin Feng
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yiming Tao
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhiming Ye
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yuanhan Chen
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Huaban Liang
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ting Lin
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shuangxin Liu
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xin-Ling Liang
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xia Fu
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- School of Nursing, Southern Medical University, Guangzhou, China
- ShanTou University Medical College, Shantou, China
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