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Nekooeian M, Roozbeh J, Ezzatzadegan Jahromi S, Moaref A, Masjedi F. The superiority of bioimpedance vs. echocardiography and pitting edema in predicting automated office blood pressure in continuous ambulatory peritoneal dialysis patients. Ther Apher Dial 2024; 28:272-283. [PMID: 37850431 DOI: 10.1111/1744-9987.14074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/22/2023] [Accepted: 10/09/2023] [Indexed: 10/19/2023]
Abstract
INTRODUCTION To achieve optimal blood pressure control in continuous ambulatory peritoneal dialysis (CAPD) patients, identifying methods of volume assessment with the strongest correlation with blood pressure is essential. METHODS In this cross-sectional study, 52 CAPD patients were assigned to automated office blood pressure (AOBP) measurement, assessment of pedal pitting edema, bioimpedance analysis (BIA), and inferior vena cava collapsibility index (IVCCI%) measurement. Data were analyzed using STATA ver.17, and the significance level was p < 0.05. RESULTS Fifty-two patients were divided based on their AOBP readings. 29 (55.8%) of patients had uncontrolled AOBP. Overhydration (OH) and the grade of pitting edema were significantly higher in the uncontrolled AOBP group. OH was identified as the best variable for predicting blood pressure (p ≤ 0.001) and detecting uncontrolled blood pressure (AUC = 0.832) using multivariate linear regression and ROC analysis, respectively. CONCLUSION BIA-derived OH was the best variable for predicting systolic and diastolic AOBP, outperforming IVCCI% and pitting edema.
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Affiliation(s)
- Mohammad Nekooeian
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Jamshid Roozbeh
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shahrokh Ezzatzadegan Jahromi
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Internal Medicine, School of Medicine, Shiraz University of Medical Science, Shiraz, Iran
| | - Alireza Moaref
- Department of Cardiology, School of Medicine, Shiraz University of Medical Science, Shiraz, Iran
- Cardiovascular Research Center, Shiraz University of Medical Science, Shiraz, Iran
| | - Fatemeh Masjedi
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Mohamed M, Matthie J, Fan SL. Bioimpedance spectroscopy: Is a picture worth a thousand words? Semin Dial 2022. [PMID: 35466475 DOI: 10.1111/sdi.13084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/22/2022] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Abstract
Volume status can be difficult to assess in dialysis patients. Peripheral edema, elevated venous pressure, lung crackles, and hypertension are taught as signs of fluid overload, but sensitivity and specificity are poor. Bioimpedance technology has evolved from early single frequency to multifrequency machines which apply spectroscopic analysis (BIS), modeling data to physics-based mixture theory. Bioimpedance plots can aid the evaluation of hydration status and body composition. The challenge remains how to use this information to manage dialysis populations, particularly as interventions to improve over hydration, sarcopenia, and adiposity are not without side effects. It is therefore of no surprise that validation studies for BIS use in peritoneal dialysis patients are limited, and results from clinical trials are inconsistent and conflicting. Despite these limitations, BIS has clinical utility with potential to accurately evaluate small changes in body tissue components. This article explains the information a BIS plot ("picture") can provide and how it can contribute to the overall clinical assessment of a patient. However, it remains the role of the clinician to integrate information and devise treatment strategies to optimize competing patient risks, fluid and nutrition status, effects of high glucose PD fluids on membrane function, and quality of life issues.
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Affiliation(s)
- Maha Mohamed
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK
| | | | - Stanley L Fan
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK
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Wang Y, Gu Z. Effect of bioimpedance-defined overhydration parameters on mortality and cardiovascular events in patients undergoing dialysis: a systematic review and meta-analysis. J Int Med Res 2021; 49:3000605211031063. [PMID: 34496645 PMCID: PMC8438275 DOI: 10.1177/03000605211031063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 06/18/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the role of bioimpedance-defined overhydration (BI-OH) parameters in predicting the risk of mortality and cardiovascular (CV) events in patients undergoing dialysis. METHODS We searched multiple electronic databases for studies investigating BI-OH indicators in the prediction of mortality and CV events through 23 May 2020. We assessed the effect of BI-OH indexes using unadjusted hazard ratios (HRs) and 95% confidence intervals (CIs). Sensitivity analysis was used for each outcome. RESULTS We included 55 studies with 104,758 patients in the meta-analysis. Extracellular water/total body water (ECW/TBW) >0.4 (HR 5.912, 95% CI: 2.016-17.342), ECW/intracellular water (ICW) for every 0.01 increase (HR 1.041, 95% CI: 1.031-1.051), and OH/ECW >15% (HR 2.722, 95% CI: 2.005-3.439) increased the risk of mortality in patients receiving dialysis. ECW/TBW >0.4 (HR 2.679, 95% CI: 1.345-5.339) and ECW/ICW per increment of 10% (HR 1.032, 95% CI: 1.017-1.047) were associated with an increased risk of CV events in patients undergoing dialysis. A 1-degree increase in phase angle was a protective factor for both mortality (HR 0.676, 95% CI: 0.474-0.879) and CV events (HR 0.736, 95% CI: 0.589-0.920). CONCLUSIONS BI-OH parameters might be independent predictors for mortality and CV events in patients undergoing dialysis.
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Affiliation(s)
- Yajie Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zejuan Gu
- Department of Nursing, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, Jiangsu, China
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Mok NMY, Fan N, Finney H, Fan SLS. Relationship between sodium removal, hydration and outcomes in peritoneal dialysis patients. Nephrology (Carlton) 2021; 26:676-683. [PMID: 33893694 DOI: 10.1111/nep.13885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Fluid overload (FO) in peritoneal dialysis (PD) patients is associated with mortality. We explore if low daily sodium removal is an independent risk factor for mortality. We examined severely FO PD patients established for >1 year in expectation that PD prescription would have been optimized for solute clearance and ultrafiltration. We also wish to determine the relationship between kt/v and sodium removal. METHODS Retrospective analysis of 231 PD patients with FO ≥2.0 L and compared with 218 PD patients who were euvolaemic throughout their PD treatment. Patients were followed up until death censored for transplantation. RESULTS Mean daily sodium removal in overhydrated patients was only 75 mmoles (=1.7 g). CAPD usage was more common in patients with the highest sodium removal. Achievement of UK guidelines for solute clearance and daily fluid removal were not independent predictors of mortality. Markers of sarcopenia (low serum albumin and high CRP) were associated with increased mortality, but these parameters were not independent predictors in a model that included functional assessment (Karnofsky score). Daily sodium removal was not predictive of mortality but the imprecision of clinically used sodium assay should be noted. The correlation between Na and kt/v is statistically significant but R2 was weak at .07. CONCLUSION While diabetic males were more likely to become overhydrated, these factors did not increase mortality further. Traditional targets of 'dialysis adequacy' did not predict survival. Kt/v is not a good indicator of sodium removal which can be surprisingly low. Measuring sodium clearance may help clinicians optimize PD modality (CAPD vs. APD).
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Affiliation(s)
- Natalie M-Y Mok
- Departments of Renal Medicine and Transplantation, Barts Health NHS Trust, London, United Kingdom
| | - Nicholas Fan
- Departments of Renal Medicine and Transplantation, Barts Health NHS Trust, London, United Kingdom
| | - Hazel Finney
- Department of Clinical Biochemistry, Barts Health NHS Trust, London, United Kingdom
| | - Stanley L-S Fan
- Departments of Renal Medicine and Transplantation, Barts Health NHS Trust, London, United Kingdom
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Bron AJ, Willshire C. Tear Osmolarity in the Diagnosis of Systemic Dehydration and Dry Eye Disease. Diagnostics (Basel) 2021; 11:387. [PMID: 33668748 PMCID: PMC7996182 DOI: 10.3390/diagnostics11030387] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/23/2022] Open
Abstract
Systemic dehydration due to inadequate water intake or excessive water loss, is common in the elderly and results in a high morbidity and significant mortality. Diagnosis is often overlooked and there is a need for a simple, bedside diagnostic test in at-risk populations. Body hydration is highly regulated with plasma osmolality (pOsm) being tightly controlled over a wide range of physiological conditions. By contrast, normal tear osmolarity (tOsm) is more variable since the tear film is exposed to evaporation from the open eye. While plasma hyperosmolality is a diagnostic feature of systemic dehydration, tear hyperosmolality, with other clinical features, is diagnostic of dry eye. Studies in young adults subjected to exercise and water-deprivation, have shown that tOsm may provide an index of pOsm, with the inference that it may provide a simple measure to diagnose systemic dehydration. However, since the prevalence of both dry eye and systemic dehydration increases with age, the finding of a raised tOsm in the elderly could imply the presence of either condition. This diagnostic difficulty can be overcome by measuring tear osmolality after a period of evaporative suppression (e.g., a 45 min period of lid closure) which drives tOsm osmolality down to a basal level, close to that of the pOsm. The arguments supporting the use of this basal tear osmolarity (BTO) in the diagnosis of systemic dehydration are reviewed here. Further studies are needed to confirm that the BTO can act as a surrogate for pOsm in both normally hydrated subjects and in patients with systemic dehydration and to determine the minimum period of lid closure required for a simple, "point-of-care" test.
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Affiliation(s)
- Anthony J. Bron
- Nuffield Department of Clinical Neurosciences and Nuffield Laboratory of Ophthalmology, University of Oxford, Oxford OX2 6HZ, UK
| | - Catherine Willshire
- Ophthalmology Research, Hinchingbrooke Hospital, North West Anglia Trust, Huntingdon PE29 6NT, UK;
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Comparison of Body Composition Monitor and InBody 720 Bioimpedance Devices for Body Composition Estimation in Hemodialysis Patients and Healthy Controls. Symmetry (Basel) 2021. [DOI: 10.3390/sym13010150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Bioelectric impedance devices have become a standard of care not only for peritoneal dialysis but also for hemodialysis patients. We compared the most important body composition variables (extracellular water, intracellular water, total body water and fat mass) measured with the multifrequency bioelectric impedance device InBody 720 (MF-BIA) and bioimpedance spectroscopy body composition monitor Fresenius (BIS BCM) in hemodialysis patients (n = 51, 175.1 + 7.8 cm, 82.2 + 15.2 kg) and healthy controls (n = 51, 175.1 + 7.6 cm, 82.3 + 15.3 kg). The MF-BIA InBody 720 device compared to the BIS BCM device showed significantly larger total body water and intracellular water estimates and significantly smaller extracellular water and body fat estimates in hemodialysis patients (p < 0.001). These differences (p < 0.001) were similar in the cohort of healthy controls; moreover, we observed high correlations in all variables between the hemodialysis patients and the healthy controls (0.80–0.95, p < 0.001). The mean relative differences in the order of 8% were lower for extracellular water and total body fat, but the limits of agreement were still wide enough to be clinically significant. We conclude that the results of the measurements with InBody 720 and BCM Fresenius cannot be used interchangeably. Physicians and nutritionists involved in the care of hemodialysis patients should be aware of this discrepancy between the two devices and should try to use the same device to track the body in their hemodialysis population in a longitudinal direction.
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Dao Bui Quy Q, Pham Ngoc Huy T, Nguyen Duc L, Pham Van M, Nguyen Huu D, Nguyen Duy T, Tran Viet T, Do Q, Le Viet T. Overhydration and low serum prealbumin predict peritoneal dialysis-related peritonitis in continuous ambulatory peritoneal dialysis patients. BMC Nephrol 2020; 21:512. [PMID: 33238904 PMCID: PMC7690099 DOI: 10.1186/s12882-020-02178-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/19/2020] [Indexed: 11/11/2022] Open
Abstract
Background In this study, we focused on the role of overhydration (OH) and low serum prealbumin concentration in predicting peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients over a 3-year period. Methods We measured serum prealbumin concentration and OH by body composition monitor in 278 CAPD patients (159 males and 119 females) with a mean age of 46 years and a median peritoneal dialysis (PD) duration of 21 months. Cases of PD-related peritonitis were collected over 3 years. Results After the 3-year follow-up, 44 patients were diagnosed with PD-related peritonitis (15.8%). Low education, serum glucose, prealbumin, and OH were independent risk factors for predicting peritonitis over 36 months in CAPD patients. Based on the ROC curve model and Kaplan-Meier analysis, we realized that low prealbumin and high OH were independent predictors of 3-year peritonitis in CAPD patients (Prealbumin: AUC = 0.838, cut-off value = 32.5 mg/dL, Se = 90.9%, Sp = 32.9%; OH: AUC = 0.851, cut-off value = 1.33 L, Se = 79.5%, Sp = 85.5%; and log-rank test p < 0.001, respectively). Conclusion Overhydration and low serum prealbumin were the independent predictors of PD-related peritonitis in CAPD patients.
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Affiliation(s)
| | | | | | - My Pham Van
- University of Medicine Pham Ngoc Thach, Ho Chi Minh, Viet Nam
| | | | - Toan Nguyen Duy
- Military Hospital 103, Ha Noi, Viet Nam.,Vietnam Military Medical University, Ha Noi, Viet Nam
| | - Tien Tran Viet
- Military Hospital 103, Ha Noi, Viet Nam.,Vietnam Military Medical University, Ha Noi, Viet Nam
| | - Quyet Do
- Vietnam Military Medical University, Ha Noi, Viet Nam
| | - Thang Le Viet
- Military Hospital 103, Ha Noi, Viet Nam. .,Vietnam Military Medical University, Ha Noi, Viet Nam.
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Alexandrou ME, Balafa O, Sarafidis P. Assessment of Hydration Status in Peritoneal Dialysis Patients: Validity, Prognostic Value, Strengths, and Limitations of Available Techniques. Am J Nephrol 2020; 51:589-612. [PMID: 32721969 DOI: 10.1159/000509115] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/25/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The majority of patients undergoing peritoneal dialysis (PD) suffer from volume overload and this overhydration is associated with increased mortality. Thus, optimal assessment of volume status in PD is an issue of paramount importance. Patient symptoms and physical signs are often unreliable indexes of true hydration status. SUMMARY Over the past decades, a quest for a valid, reproducible, and easily applicable technique to assess hydration status is taking place. Among existing techniques, inferior vena cava diameter measurements with echocardiography and natriuretic peptides such as brain natriuretic peptide and N-terminal pro-B-type natriuretic peptide were not extensively examined in PD populations; while having certain advantages, their interpretation are complicated by the underlying cardiac status and are not widely available. Bioelectrical impedance analysis (BIA) techniques are the most studied tool assessing volume overload in PD. Volume overload assessed with BIA has been associated with technique failure and increased mortality in observational studies, but the results of randomized trials on the value of BIA-based strategies to improve volume-related outcomes are contradictory. Lung ultrasound (US) is a recent technique with the ability to identify volume excess in the critical lung area. Preliminary evidence in PD showed that B-lines from lung US correlate with echocardiographic parameters but not with BIA measurements. This review presents the methods currently used to assess fluid status in PD patients and discusses existing data on their validity, applicability, limitations, and associations with intermediate and hard outcomes in this population. Key Message: No method has proved its value as an intervening tool affecting cardiovascular events, technique, and overall survival in PD patients. As BIA and lung US estimate fluid overload in different compartments of the body, they can be complementary tools for volume status assessment.
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Affiliation(s)
- Maria-Eleni Alexandrou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece,
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Schwaiger E, Simon A, Wabel P, Schairer B, Berner C, Signorini L, Ernstbrunner M, Evstatiev R, Schwabl P, Hinterholzer G, Frommlet F, Vychytil A, Müller CJ, Hecking M. Bioimpedance spectroscopy for fluid status assessment in patients with decompensated liver cirrhosis: Implications for peritoneal dialysis. Sci Rep 2020; 10:2869. [PMID: 32071351 PMCID: PMC7028989 DOI: 10.1038/s41598-020-59817-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 01/31/2020] [Indexed: 01/08/2023] Open
Abstract
Bioimpedance spectroscopy (BIS) is routinely used in peritoneal dialysis patients and might aid fluid status assessment in patients with liver cirrhosis, but the effect of ascites volume removal on BIS-readings is unknown. Here we determined changes in BIS-derived parameters and clinical signs of fluid overload from before to after abdominal paracentesis. Per our pre-specified sample size calculation, we studied 31 cirrhotic patients, analyzing demographics, labs and clinical parameters along with BIS results. Mean volume of the abdominal paracentesis was 7.8 ± 2.6 L. From pre-to post-paracentesis, extracellular volume (ECV) decreased (20.2 ± 5.2 L to 19.0 ± 4.8 L), total body volume decreased (39.8 ± 9.8 L to 37.8 ± 8.5 L) and adipose tissue mass decreased (38.4 ± 16.0 kg to 29.9 ± 12.9 kg; all p < 0.002). Correlation of BIS-derived parameters from pre to post-paracentesis ranged from R² = 0.26 for body cell mass to R² = 0.99 for ECV. Edema did not correlate with BIS-derived fluid overload (FO ≥ 15% ECV), which occurred in 16 patients (51.6%). In conclusion, BIS-derived information on fluid status did not coincide with clinical judgement. The changes in adipose tissue mass support the BIS-model assumption that fluid in the peritoneal cavity is not detectable, suggesting that ascites (or peritoneal dialysis fluid) mass should be subtracted from adipose tissue if BIS is used in patients with a full peritoneal cavity.
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Affiliation(s)
- Elisabeth Schwaiger
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine II, Kepler University Hospital, Med Campus III, Linz, Austria
| | - Amrei Simon
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Peter Wabel
- Fresenius Medical Care, Research and Development, Bad Homburg, Germany
| | - Benjamin Schairer
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Carolin Berner
- 1st Medical Department, Division for Nephrology, Sozialmedizinisches Zentrum Süd, Vienna, Austria
| | - Lorenzo Signorini
- Dipartimento di Nefrologia e Dialis, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Matthäus Ernstbrunner
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Rayko Evstatiev
- Department of Internal Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Philipp Schwabl
- Department of Internal Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Georg Hinterholzer
- 1st Medical Department, Division for Nephrology, Sozialmedizinisches Zentrum Süd, Vienna, Austria
| | - Florian Frommlet
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Andreas Vychytil
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Christian J Müller
- Department of Internal Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Manfred Hecking
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria.
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Wang AYM, Dong J, Xu X, Davies S. Volume management as a key dimension of a high-quality PD prescription. Perit Dial Int 2020; 40:282-292. [PMID: 32063208 DOI: 10.1177/0896860819895365] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Appropriate volume control is one of the key goals in a peritoneal dialysis (PD) prescription. As such it is an important component of the International Society of Peritoneal Dialysis (ISPD) guideline for "High-quality PD prescription" necessitating a review of the literature on volume management. The workgroup recognized the importance of including within its scope measures of volume status and blood pressure in prescribing high-quality PD therapy. METHODS A Medline and PubMed search for publications addressing volume status and its management in PD since the publication of the 2015 ISPD Adult Cardiovascular and Metabolic Guidelines, from October 2014 through to July 2019, was conducted. RESULTS There were no randomized controlled trials on blood pressure intervention and six randomized trials of bioimpedance-guided volume management. Generally, all studies were of small sample size, short duration, and used surrogate markers as primary outcomes. As a consequence, only "practice points" were drawn. High-quality goal-directed PD prescription should aim to achieve and maintain clinical euvolemia taking residual kidney function and its preservation into account, so that both fluid removal from peritoneal ultrafiltration and urine output are considered and residual kidney function is not compromised. Blood pressure should be included as a key objective parameter in assessing the quality of PD prescription but there is currently no evidence for a specific target in PD. Clinical examination remains the keystone of routine clinical care. CONCLUSIONS High-quality goal-directed PD prescription should include volume management as one of the key dimensions.
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Affiliation(s)
- Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China
| | - Jie Dong
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, China
| | - Xiao Xu
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, China
| | - Simon Davies
- Faculty of Medicine and Health Sciences, Keele University and University Hospitals of North Midlands, Stoke-on-Trent, UK
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Tabinor M, Elphick E, Dudson M, Kwok CS, Lambie M, Davies SJ. Bioimpedance-defined overhydration predicts survival in end stage kidney failure (ESKF): systematic review and subgroup meta-analysis. Sci Rep 2018; 8:4441. [PMID: 29535377 PMCID: PMC5849723 DOI: 10.1038/s41598-018-21226-y] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 01/25/2018] [Indexed: 12/13/2022] Open
Abstract
Both overhydration and comorbidity predict mortality in end-stage kidney failure (ESKF) but it is not clear whether these are independent of one another. We undertook a systematic review of studies reporting outcomes in adult dialysis patients in which comorbidity and overhydration, quantified by whole body bioimpedance (BI), were reported. PubMed, EMBASE, PsychInfo and the Cochrane trial database were searched (1990-2017). Independent reviewers appraised studies including methodological quality (assessed using QUIPS). Primary outcome was mortality, with secondary outcomes including hospitalisation and cardiovascular events. Of 4028 citations identified, 46 matched inclusion criteria (42 cohorts; 60790 patients; 8187 deaths; 95% haemodialysis/5% peritoneal dialysis). BI measures included phase angle/BI vector (41%), overhydration index (39%) and extra:intracellular water ratio (20%). 38 of 42 cohorts had multivariable survival analyses (MVSA) adjusting for age (92%), gender (66%), diabetes (63%), albumin (58%), inflammation (CRP/IL6-37%), non-BI nutritional markers (24%) and echocardiographic data (8%). BI-defined overhydration (BI-OH) independently predicted mortality in 32 observational cohorts. Meta-analysis revealed overhydration >15% (HR 2.28, 95% CI 1.56-3.34, P < 0.001) and a 1-degree decrease in phase angle (HR 1.74, 95% CI 1.37-2.21, P < 0.001) predicted mortality. BI-OH predicts mortality in dialysis patients independent of the influence of comorbidity.
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Affiliation(s)
- Matthew Tabinor
- Institute for Applied Clinical Sciences, Keele University, Newcastle-under-Lyme, UK
| | - Emma Elphick
- Institute for Applied Clinical Sciences, Keele University, Newcastle-under-Lyme, UK
| | - Michael Dudson
- Institute for Applied Clinical Sciences, Keele University, Newcastle-under-Lyme, UK
| | - Chun Shing Kwok
- Institute for Applied Clinical Sciences, Keele University, Newcastle-under-Lyme, UK
| | - Mark Lambie
- Institute for Applied Clinical Sciences, Keele University, Newcastle-under-Lyme, UK
| | - Simon J Davies
- Institute for Applied Clinical Sciences, Keele University, Newcastle-under-Lyme, UK.
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Willshire C, Bron AJ, Gaffney EA, Pearce EI. Basal Tear Osmolarity as a metric to estimate body hydration and dry eye severity. Prog Retin Eye Res 2018; 64:56-64. [PMID: 29476817 DOI: 10.1016/j.preteyeres.2018.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 02/02/2018] [Accepted: 02/20/2018] [Indexed: 01/28/2023]
Abstract
The osmolarities of various bodily fluids, including tears, saliva and urine, have been used as indices of plasma osmolality, a measure of body hydration, while tear osmolarity is used routinely in dry eye diagnosis, the degree of tear hyperosmolarity providing an index of disease severity. Systemic dehydration, due to inadequate water intake or excessive water loss is common in the elderly population, has a high morbidity and may cause loss of life. Its diagnosis is often overlooked and there is a need to develop a simple, bedside test to detect dehydration in this population. We hypothesize that, in the absence of tear evaporation and with continued secretion, mixing and drainage of tears, tear osmolarity falls to a basal level that is closer to that of the plasma than that of a tear sample taken in open eye conditions. We term this value the Basal Tear Osmolarity (BTO) and propose that it may be measured in tear samples immediately after a period of evaporative suppression. This value will be particular to an individual and since plasma osmolarity is controlled within narrow limits, it is predicted that it will be stable and have a small variance. It is proposed that the BTO, measured immediately after a defined period of eye closure, can provide a new metric in the diagnosis of systemic dehydration and a yardstick against which to gauge the severity of dry eye disease.
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Affiliation(s)
- C Willshire
- Vision and Eye Research Unit, Anglia Ruskin University, Cambridge, UK
| | - A J Bron
- Vision and Eye Research Unit, Anglia Ruskin University, Cambridge, UK; Nuffield Department of Clinical Neurosciences and Nuffield Laboratory of Ophthalmology, University of Oxford, UK.
| | - E A Gaffney
- Wolfson Centre of Mathematical Biology, Mathematical Institute, University of Oxford, UK
| | - E Ian Pearce
- School of Health and Life Sciences, Glasgow Caledonian University, UK
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Scotland G, Cruickshank M, Jacobsen E, Cooper D, Fraser C, Shimonovich M, Marks A, Brazzelli M. Multiple-frequency bioimpedance devices for fluid management in people with chronic kidney disease receiving dialysis: a systematic review and economic evaluation. Health Technol Assess 2018; 22:1-138. [PMID: 29298736 PMCID: PMC5776406 DOI: 10.3310/hta22010] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is a long-term condition requiring treatment such as conservative management, kidney transplantation or dialysis. To optimise the volume of fluid removed during dialysis (to avoid underhydration or overhydration), people are assigned a 'target weight', which is commonly assessed using clinical methods, such as weight gain between dialysis sessions, pre- and post-dialysis blood pressure and patient-reported symptoms. However, these methods are not precise, and measurement devices based on bioimpedance technology are increasingly used in dialysis centres. Current evidence on the role of bioimpedance devices for fluid management in people with CKD receiving dialysis is limited. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of multiple-frequency bioimpedance devices versus standard clinical assessment for fluid management in people with CKD receiving dialysis. DATA SOURCES We searched major electronic databases [e.g. MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Science Citation Index and Cochrane Central Register of Controlled Trials (CENTRAL)] conference abstracts and ongoing studies. There were no date restrictions. Searches were undertaken between June and October 2016. REVIEW METHODS Evidence was considered from randomised controlled trials (RCTs) comparing fluid management by multiple-frequency bioimpedance devices and standard clinical assessment in people receiving dialysis, and non-randomised studies evaluating the use of the devices for fluid management in people receiving dialysis. One reviewer extracted data and assessed the risk of bias of included studies. A second reviewer cross-checked the extracted data. Standard meta-analyses techniques were used to combine results from included studies. A Markov model was developed to assess the cost-effectiveness of the interventions. RESULTS Five RCTs (with 904 adult participants) and eight non-randomised studies (with 4915 adult participants) assessing the use of the Body Composition Monitor [(BCM) Fresenius Medical Care, Bad Homburg vor der Höhe, Germany] were included. Both absolute overhydration and relative overhydration were significantly lower in patients evaluated using BCM measurements than for those evaluated using standard clinical methods [weighted mean difference -0.44, 95% confidence interval (CI) -0.72 to -0.15, p = 0.003, I2 = 49%; and weighted mean difference -1.84, 95% CI -3.65 to -0.03; p = 0.05, I2 = 52%, respectively]. Pooled effects of bioimpedance monitoring on systolic blood pressure (SBP) (mean difference -2.46 mmHg, 95% CI -5.07 to 0.15 mmHg; p = 0.06, I2 = 0%), arterial stiffness (mean difference -1.18, 95% CI -3.14 to 0.78; p = 0.24, I2 = 92%) and mortality (hazard ratio = 0.689, 95% CI 0.23 to 2.08; p = 0.51) were not statistically significant. The economic evaluation showed that, when dialysis costs were included in the model, the probability of bioimpedance monitoring being cost-effective ranged from 13% to 26% at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year gained. With dialysis costs excluded, the corresponding probabilities of cost-effectiveness ranged from 61% to 67%. LIMITATIONS Lack of evidence on clinically relevant outcomes, children receiving dialysis, and any multifrequency bioimpedance devices, other than the BCM. CONCLUSIONS BCM used in addition to clinical assessment may lower overhydration and potentially improve intermediate outcomes, such as SBP, but effects on mortality have not been demonstrated. If dialysis costs are not considered, the incremental cost-effectiveness ratio falls below £20,000, with modest effects on mortality and/or hospitalisation rates. The current findings are not generalisable to paediatric populations nor across other multifrequency bioimpedance devices. FUTURE WORK Services that routinely use the BCM should report clinically relevant intermediate and long-term outcomes before and after introduction of the device to extend the current evidence base. STUDY REGISTRATION This study is registered as PROSPERO CRD42016041785. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Elisabet Jacobsen
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - David Cooper
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | | | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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