Measurement of transcellular fluid shift during haemodialysis. Part 2. In vitro and clinical evaluation

Revisiting the concept of constant tissue conductivities for volume estimation in dialysis patients using bioimpedance spectroscopy

RATIONALE

Current estimation of body fluid volumes in hemodialysis patients using bioimpedance analysis assumes constant specific electrical characteristics of biological tissues despite a large variation in plasma Na⁺ concentrations [Na⁺], ranging from 130 to 150 mmol/L. Here, we examined the potential effect of variable [Na⁺] on bioimpedance-derived volume overload.

METHOD

Volumes were calculated from published whole-body extra- and intracellular resistance data and relationships using either "standard" or "revised" specific electrical characteristics modeled as functions of [Na⁺].

RESULT

With "standard" assumptions, volumes increased with increasing [Na⁺]. The increase in volume overload was about 0.5 dm³ and 3% of extracellular volume per 10 mmol/dm³ of [Na⁺] in a 75 kg patient. This increase was abolished when the same bioimpedance data were analyzed under "revised" conditions.

DISCUSSION

The overestimation in extracellular volume overload in the range of 0.5 dm³ per 10 mmol/dm³ [Na⁺] perfectly matches the positive relationship determined in a large cohort of hemodialysis patients. The bias may be considered moderate when interpreting data of individual patients, but may become important when comparing data of larger patient groups. The bias disappears when analysis of bioimpedance data accounts for differences in tissue electrical properties, using individual [Na⁺].

Optimal current frequency for the detection of changes in extracellular water in patients on hemodialysis by measurement of total body electrical resistance

BACKGROUND & AIMS

Measurement of total body electrical resistance (TBER) to an alternating current is useful to monitor extracellular water (ECW) in patients on hemodialysis (HD). Which current frequency is preferable is subject of ongoing debate. The aim of this study was to quantify the implications of TBER measurements at current frequencies ranging from 0 to 1000 kHz for ECW monitoring in patients on HD.

METHODS

Bioimpedance spectroscopy measurements were performed in 39 patients on HD using the Body Composition Monitor (BCM, Fresenius Medical Care). TBER data at 5, 50, 200, 500, and 1000 kHz were compared with the extrapolated TBER at 0 kHz (TBER₀) assessed by Cole-Cole analysis. Sensitivity of each TBER configuration was evaluated at individual level, by assessment of the smallest ultrafiltration (UF) volume that induced a significant change in TBER, i.e. a change in TBER ≥ 2.7%.

RESULTS

TBER precision was very high for all frequencies, with coefficients of variation of 0.25%-0.28%. Baseline TBER decreased with increasing current frequency. TBER was 2.9% lower at 5 kHz (P < 0.001), 11.6% lower at 50 kHz, and up to 22.0% lower at 1000 kHz. This pattern is attributed to a progressive increase in intracellular current conduction at higher frequencies. Sensitivity to volume changes induced by UF also decreased with increasing current frequency. At 0 and 5 kHz, an UF volume ≤ 0.5 L was sufficient to induce a significant increase in TBER in 87% of patients. This decreased to 69% at higher frequencies.

CONCLUSION

ECW monitoring by TBER requires measurement at 5 kHz or less to ensure optimal performance.

Impact of diffusion, ultrafiltration, and posture on total body electrical resistance in patients on hemodialysis

Monitoring of hydration in patients on hemodialysis (HD) by currently available bioelectrical impedance analysis (BIA) methods is hampered by limited accuracy. This may be caused by changes in total body electrical resistance (TBER) that are induced by processes other than ultrafiltration (UF). To identify these sources of error, we examined the impact of UF, diffusion, and postural change (PC), separately. Extracellular TBER (TBER_e) was measured by bioimpedance spectroscopy every 30 min in 23 patients on HD, for 2 h during diffusion-only (DO), followed by 2-h UF-only (UFO). The impact of PC from upright to semi-recumbent position was assessed by a 2-h TBER_e measurement on the day after HD. TBER_e increased by 23.5 ± 12.4 Ω (P < 0.001) during DO and by 40.0 ± 16.2 Ω (P < 0.001) during UFO. PC, evaluated on a separate day, was associated with an increase in TBER_e of 27.6 ± 26.0 Ω (P < 0.001). TBER_e changes during DO were mainly attributed to PC and to a lesser extent to electrolyte exchange. Extrapolation of the data to a conventional 4-h HD session indicates that about 32% of the total increase in TBER_e is not related to UF. In conclusion, a significant part of the increase in TBER during HD is not related to UF but can be attributed to other processes such as the effects of PC and diffusion-related electrolyte exchange. These factors have to be taken into account when TBER-guided UF is considered.NEW & NOTEWORTHY Current BIA methods have limited accuracy in patients on HD. This may be related to the incorrect assumption that all changes in total body electrical resistance (TBER) are caused by changes in body water volumes. The present study indicates that two-thirds of the change in TBER during a conventional 4-h HD session can be attributed to fluid extraction, and that the remaining part is caused by other processes such as postural change and electrolyte exchange. This may cause volume prediction errors when not recognized.

Bioelectrical Impedance Analysis: Clinical Tool in Assessing Total Body Water and Thoracic Fluid

Bioelectrical impedance analysis forms a non-invasive tool for detection of body fluids. Total body measurement gives total body water (TBW) and, in case of multi-frequency analysis, of intra- and extracellular fluid volume. The thoracic approach measures thoracic fluid (TF). The set-up of both techniques is discussed. An overview is given of the clinical usefulness of the total body technique to monitor fluid changes and the process of refill during hemodialysis and to detect dry weight. The simultaneous measurement of TBW and TF was applied to obtain a more detailed picture of the body fluids. In a group of healty subjects the age dependency of both variables was shown. During hemodialyss TBW and TF showed a major and comparable decrease. Fluid retention during cardiac surgery led to a slightly more pronounced increase of TF than of TBW. The combination of both impedance techniques offers clinicians a means to monitor alterations in fluid status in patients in more detail.

Effect of Intravenous Infusion Solutions on Bioelectrical Impedance Spectroscopy

BACKGROUND

Bioelectrical impedance (BIA) is often used to measure body fluid spaces and thereby body composition. However, in acute animal studies, we found that impedance was driven by the saline content of intravenous (IV) fluids and not by the volume. The aim of the study was to investigate the effect of 3 different fluids acutely administered on the change in impedance, specifically resistance (R).

MATERIALS AND METHODS

Nine healthy adults participated in 3 treatment (0.9% saline, 5% dextrose, and a mixture of 0.3% saline + 3.3% dextrose) experiments on nonconsecutive days. They all received 1 L of one of the treatments intravenously over a 1-hour period. Repeated BIA measurements were performed prior to IV infusion and then every 5 minutes for the 1-hour infusion period, plus 3 more measurements up to 15 minutes after the completion of the infusion.

RESULTS

The change in R in the 0.9% saline infusion experiment was significantly lower than that of the glucose and mixture treatment ( P < .001).

CONCLUSION

Bioelectrical impedance spectroscopy and BIA measure salt rather than the volume changes over the infusion period. Hence, in patients receiving IV fluids, BIA of any kind (single frequency or multifrequency) cannot be used to measure body fluid spaces or body composition.

How does adding and removing liquid from socket bladders affect residual-limb fluid volume?

Adding and removing liquid from socket bladders is a means for people with limb loss to accommodate residual-limb volume change. We fit 19 people with transtibial amputation using their regular prosthetic socket with fluid bladders on the inside socket surface to undergo cycles of bladder liquid addition and removal. In each cycle, subjects sat, stood, and walked for 90 s with bladder liquid added, and then sat, stood, and walked for 90 s again with the bladder liquid removed. The amount of bladder liquid added was increased in each cycle. We used bioimpedance analysis to measure residual-limb fluid volume. Results showed that the preferred bladder liquid volume was 16.8 +/- 8.4 mL (mean +/- standard deviation), corresponding with 1.7% +/- 0.8% of the average socket volume between the bioimpedance voltage-sensing electrodes. Residual-limb fluid volume driven out of the residual limb when bladder liquid was added was typically not recovered upon subsequent bladder liquid removal. Of the 19 subjects, 15 experienced a gradual residual-limb fluid volume loss over the test session. Care should be taken when implementing adjustable socket technologies in people with limb loss. Reducing socket volume may accentuate residual-limb fluid volume loss.

Effects of elevated vacuum on in-socket residual limb fluid volume: case study results using bioimpedance analysis

Bioimpedance analysis was used to measure the residual limb fluid volume of seven transtibial amputee subjects using elevated vacuum sockets and nonelevated vacuum sockets. Fluid volume changes were assessed during sessions with the subjects sitting, standing, and walking. In general, fluid volume losses during 3 or 5 min walks and losses over the course of the 30 min test session were less for elevated vacuum than for suction. Numerous variables, including the time of day that data were collected, soft tissue consistency, socket-to-limb size and shape differences, and subject health, may have affected the results and had an equivalent or greater effect on limb fluid volume compared with elevated vacuum. Researchers should well consider these variables in the study design of future investigations on the effects of elevated vacuum on residual limb volume.

Clinical utility of in-socket residual limb volume change measurement: case study results

Bioimpedance analysis was used to measure conductive tissue extracellular fluid (ECF) volume changes in the residual limbs of four unilateral transtibial amputee subjects during standing and walking conditions. Results showed that all residual limbs experienced ECF volume decreases during 5 min standing intervals. During 5 min of walking immediately after a standing interval, the residual limbs of healthy subjects increased in ECF volume while those of diseased subjects, one with peripheral vascular disease and another with cardiovascular insufficiency and a high-salt intake, decreased. One subject demonstrated less absolute value ECF volume change during standing and walking at 12 months post-surgical revision compared with at six months. Presentation of bioimpedance data to patients improved compliance to practitioner recommendations and patient understanding. Results were useful towards clinical assessment, patient education, and decision-making about treatment.

WHO class-specific equations using height for predicting body weight: crude indicator for dry weight in haemodialysis patients

AIM

Body weight (BW) might be related to total body water, and the difference between a patient's actual BW and ideal BW (IBW) might be the volume marker. However, there has been no information about the association between IBW and dry weight (DW) in haemodialysis (HD) patients.

METHODS

First, we analysed the relationship between DW and IBW in 51 HD patients. The IBW was calculated by 21 x Height (Ht)(2). Weight status was analysed by the WHO classification. Second, in 12 436 controls, linear equations using Ht(2) were sought to predict the BW in each sex and WHO class. Third, using these equations, predicted BW (PW) was compared with DW in each WHO class at the initiation and after 1 year in 619 new HD patients, retrospectively.

RESULTS

Among 51 HD patients, 38 were normal weight in whom there was no difference between DW and IBW. In each sex and WHO class of the 12 436 controls, linear equations using Ht(2) were developed to predict BW. These equations were applied to 619 new HD patients. In males, there were no differences between PW and DW in underweight (UW), overweight (OW), obese (OB) and extremely obese (EOB) patients at the initiation of the HD. In females, there were no differences between PW and DW in OW patients. Despite no statistical differences, there were wide ranges of distribution from -6 to 6 kg between PW and DW.

CONCLUSIONS

BW had a linear relationship with Ht(2) and might be predictable by the WHO class-specific equation using Ht(2). These equations might be useful as a crude indicator of DW in HD patients.

Extracellular and intracellular volume variations during postural change measured by segmental and wrist-ankle bioimpedance spectroscopy

Extracellular (ECW) and intracellular (ICW) volumes were measured using both segmental and wrist-ankle (W-A) bioimpedance spectroscopy (5-1000 kHz) in 15 healthy subjects (7 men, 8 women). In the 1st protocol, the subject, after sitting for 30 min, laid supine for at least 30 min. In the second protocol, the subject, who had been supine for 1 hr, sat up in bed for 10 min and returned to supine position for another hour. Segmental ECW and ICW resistances of legs, arms and trunk were measured by placing four voltage electrodes on wrist, shoulder, top of thigh and ankle and using Hanai's conductivity theory. W-A resistances were found to be very close to the sum of segmental resistances. When switching from sitting to supine (protocol 1), the mean ECW leg resistance increased by 18.2%, that of arm and W-A by 12.4%. Trunk resistance also increased but not significantly by 4.8%. Corresponding increases in ICW resistance were smaller for legs (3.7%) and arm (-0.7%) but larger for the trunk (21.4%). Total body ECW volumes from segmental measurements were in good agreement with W-A and Watson anthropomorphic correlation. The decrease in total ECW volume (when supine) calculated from segmental resistances was at 0.79 l less than the W-A one (1.12 l). Total ICW volume reductions were 3.4% (segmental) and 3.8% (W-A). Tests of protocol 2 confirmed that resistance and fluid volume values were not affected by a temporary position change.

Continuous monitoring of plasma, interstitial, and intracellular fluid volumes in dialyzed patients by bioimpedance and hematocrit measurements

Bioimpedance spectroscopy (BIS) permits evaluation of extra- and intracellular fluid volumes in patients. We wished to examine whether this technique, used in combination with hematocrit measurement, can reliably monitor fluid transfers during dialysis. Ankle to wrist BIS measurements were collected during 21 dialysis runs while hematocrit was continuously monitored in the blood line by an optical device. Extracellular (ECW) and intracellular (ICW) water volumes were calculated using Hanai's electrical model of suspensions. Plasma volume variations were calculated from hematocrit, and changes in interstitial volume were calculated as the difference between ECW and plasma volume changes. Because accuracy of ICW was too low, changes in ICW were calculated as the difference between ultrafiltered volume and ECW changes. Total body water (TBW) volumes calculated pre- and postdialysis were, respectively, 3.25+/-3.2 and 1.95+/-2.5 liters lower on average than TBW given by Watson et al.'s correlation. Average decreases in fluid compartments expressed as percentage of ultrafiltered volume were as follows: plasma, 18%; interstitial, 28%, and ICW, 54%. When the ultrafiltered volume was increased in a patient in successive runs, the relative contributions of ICW and interstitial fluid were augmented so as to reduce the relative drop in plasma volume.

Reversibility of artifacts of fluid volume measurements by bioimpedance caused by position changes during dialysis

The effect of temporary position changes, sitting up from supine, on extracellular (ECW) and intracellular (ICW) resistances and fluid volumes calculated from whole body bioimpedance using a Xitron 4200 impedancemeter was investigated on 8 patients during dialysis for a total of 11 tests. It was found that ECW resistance decreased instantaneously by an average of 2.3% when the patient sits up, due to plasma and interstitial fluid shift into the legs which decreases leg resistance, the major contributor to total resistance. This drop in resistance is incorrectly interpreted by the device as an increase in ECW volume which averages 235 ml. But this effect is completely reversible and both ECW resistance and fluid volume rapidly resume their normal course when the patient returns to his initial position. No significant variation in ICW resistance was observed in any of the patients at the position change. We conclude that segmental impedance, which has been proposed to minimize this artifact, is not advisable in dialysis monitoring and that it is simpler to ignore or switch off measurements during the position change so that later data are not affected by it.

Measurement of intercompartmental fluid shifts during haemodialysis in children

Seven children (age range 12-19 years, post-dialysis weights 23-43 kg) were studied during 20 haemodialysis sessions. Impedance between wrist and ankle (on the non-fistula side) was recorded using the Xitron 4000B analyser. A 2 ml sample of blood was taken for total protein and haematocrit from the arterial line at the start of dialysis. At approximately 20 minute intervals during dialysis, the time and volume of ultrafiltrate removed were recorded, and a simultaneous measurement of whole body impedance made over 25 logarithmically spaced frequencies in the range 5-500 kHz. A 2 ml sample of blood was also taken, from which serum protein and haematocrit were calculated. Hypotensive episodes occurred during four haemodialysis sessions. The percentage change in extracellular fluid (ECF) volume was calculated, at each sample time for each session, using the impedance measurements and ultrafiltration measurements (denoted delta Vi and delta U respectively). Changes in the intravascular volume were estimated using measurements of haematocrit and serum protein (and denoted delta Vh and delta Vp respectively). Least-squares regression gave delta Vi = 3.77 delta Vh, 1.33 delta Vp and 0.39 delta U, and r2 = 0.72, 0.94 and 0.95 respectively (p < 0.0001 in each case) for the 16 dialysis sessions without hypotensive episodes. Similar analysis of four dialysis sessions with hypotensive episodes gave similar relationships with correlation coefficients 0.64, 0.92 and 0.94. These relationships may not be accounted for by the anthropometric terms alone in the impedance equations. Impedance measurements also detected the addition of 300 ml isotonic saline given at the onset of each of the four hypovolaemic episodes. The regression equations support the following hypothesis: during haemodialysis, ultrafiltrate is removed from the intravascular volume but is replenished by fluid from the interstitial volume. The reduction in ECF volume measured by impedance (where the ECF comprises the intravascular and interstitial volumes) delta Vi is therefore greater than delta Vh and delta Vp, which only measure intravascular volume, but less than delta U since the ECF is replenished by fluid from the interstitial space. That delta Vh is greater than delta Vp may be due to protein loss during dialysis. The results suggest that whole body impedance measurements reflect changing body water distribution during dialysis in children.

Phonatory effects of body fluid removal

Adequate body and vocal fold hydration are believed to be critical to phonation. We hypothesized that body fluid reduction, without dehydration, would increase phonation threshold pressure (P(th)) and be associated with patient-perceived increases in phonatory effort and worsening voice quality. Using a single-subject, full-reversal design, a controlled volume of body fluid was repeatedly removed via ultrafiltration from adults with end stage renal disease (2 women, 4 men, ages 40-85 yrs). Two additional men (ages 81 and 68 yrs) served as placebo and healthy true controls, respectively. P(th), vocal effort and quality, blood pressure, and heart rate were assessed longitudinally. P(th) increased significantly with fluid volume reduction (3-4% of body weight from a hypervolemic to a grossly normovolemic body state) and reversed to baseline with fluid replacement in 4 of 6 treated subjects. Effects were observed with net ultrafiltration rates greater than or equal to 1.0 L/h; these effects were not observed in control subjects. Fluid loss accounted for 31.6% of variance in P(th) and 40.0% of variance in perceived vocal effort. Heart rate, systolic blood pressure, and/or diastolic blood pressure were significantly correlated with P(th) or fluid volume reduction in 6 subjects, including the placebo control (-.70 < or = r < or = -.44). Results indicate that substantial extracellular volume depletion without body dehydration causes voice symptoms, an effect possibly mediated by autonomic nervous control. We propose that mechanisms intrinsic to the vocal fold regulate its water flux and respond to hydration challenges.

Fluid volumes determination by impedance spectroscopy and hematocrit monitoring: application to pediatric hemodialysis

A method for extracting fluid volumes from multifrequency bioimpedance, which takes into account the body geometry and the presence of nonconducting elements, was tested on 12 young dialyzed patients against correlations for total body water volumes (TBW) from Watson et al. and Humes et al. Our calculations of TBW from impedance were found to overestimate Humes' values by 0.25 L (0.8%) postdialysis and by 2.08 L (6.5%) predialysis. Extracellular water (ECW) was found to contribute an average of 93% of ultrafiltered volume. Intracellular water volume (ICW) determination from impedance was found to be too imprecise to predict its variation during dialysis; therefore, ICW variations were calculated as the difference between ultrafiltration and ECW changes. The continuous recording of hematocrit by an optical device monitored changes in plasma and interstitial volumes. In most cases, ultrafiltration was compensated mainly by a contribution from interstitial fluid, and the drop in plasma volume was generally moderate.

Sum of segmental bioimpedance analysis during ultrafiltration and hemodialysis reduces sensitivity to changes in body position

BACKGROUND

Bioimpedance, a noninvasive technique to analyze body composition, has attracted interest in determining body hydration in hemodialysis patients. However, the so-called whole-body (wrist-to-ankle) bioimpedance analysis (WBIA) is sensitive to changes in regional fluid distribution and tends to underestimate fluid changes during ultrafiltration in hemodialysis patients. The aim of this study was to show that volume changes calculated from a new approach, that is, segmental bioimpedance analysis (SBIA), are not affected by changes in body position.

METHODS

Ten male patients (age 44 +/- 8 years, target weight 70.8 +/- 10 kg) were studied during their regular hemodialysis treatment while maintaining either a sitting or a supine body position throughout the study. Extracellular volume was calculated from extracellular resistance obtained from bioimpedance data measured for a range of frequencies (5 to 500 kHz) using the Xitron BIS4000B analyzer. Wrist-to-ankle measurements were compared with segmental arm, trunk, and leg measurements.

RESULTS

Changes in extracellular volume estimated from wrist-to-ankle measurements only reached 80 +/- 13% and 65 +/- 17% of the actual change in body mass during sitting and supine dialysis treatments, respectively. However, when segmental measurements were analyzed, the calculated change in extracellular volume was 101 +/- 6% and 100 +/- 3% of the actual change in body mass during the sitting and supine treatments, respectively.

CONCLUSIONS

SBIA properly identifies regional fluid changes and provides an appropriate measure of fluid changes caused by ultrafiltration and hemodialysis. The volume estimation based on the sum of segmental bioimpedance measurements is independent of body position, which is a prerequisite for applications in everyday practice.

Comparison of optical, electrical, and centrifugation techniques for haematocrit monitoring of dialysed patients

Haematocrits were measured as a function of ultrafiltration in a simulated haemodialysis circuit using bovine blood (plasma conductivity 12 mS cm-1) and hypotonic (8.6 mS cm-1) or hypertonic (16 mS cm-1) dialysates as well as in the absence of dialysate. A comparison was made between measurements by light absorption due to haemoglobin, by impedance in the blood line at 5 kHz using Hanai's model of blood conductivity, by conductivity measurements of blood samples at 1.2 kHz using a conductimeter, by centrifugation of blood samples and by calculations using fluid conservation. The validity of Hanai's model was verified to be satisfactory by direct blood and plasma conductivity measurements. In the absence of ionic transfer the impedance device underestimated the haematocrit by 5 to 7%. This underestimation reached 18% in the case of hypertonic dialysate, but this effect can be minimised if the haematocrit necessary for calibration is measured by centrifugation after 15 min of dialysate circulation when ionic balance is achieved. It was found that the optical method monitors haemoglobin concentration rather than red cell volume changes and is not affected by osmotic red cell swelling in the case of hypotonic dialysate. It can be concluded that the light absorption technique is both more accurate and more convenient to use than impedance.

Effect of intravenous saline, albumin, or hydroxyethylstarch on blood volume during combined ultrafiltration and hemodialysis

It is generally advocated to use saline or albumin infusions during symptomatic hypotension during dialysis. However, because of their side effects and/or costs, they are of limited use. Hydroxyethylstarch (HES), a synthetic colloid with a long-standing volume effect, is used in the management of hypovolemia. In this study, the efficacy of three fluids (isotonic saline [0.9%], albumin [20%], and HES [10%]) was assessed during three treatment sessions with combined ultrafiltration and hemodialysis, which differed in the type of fluid given intravenously. Changes in relative blood volume (BV), systolic BP (SBP), and vascular reactivity (venous tone [VT]) were compared. An intravenous infusion of 100 ml of fluid was given when the decrease in BV versus baseline was more than 10% as measured by a continuous optical reflection method. The ultrafiltration was continued. BV decreased significantly versus baseline independent of the intravenous fluid administration in all three treatment sessions. However, when we compared BV values at the end of the dialysis session with those at the time of infusion, BV continued to decrease significantly with saline (change in BV -4.56 +/- 2.75%; P < 0.05) and albumin (change in BV -2.13 +/- 2.51%; P < 0.05), but not with HES (change in BV -0.15 +/- 2.17%; NS). Between albumin and HES there were no significant differences in changes in BV (NS), whereas between HES and saline (P < 0.05) and between albumin and saline (P < 0.05) the differences in BV changes were significant. SBP remained unchanged within each session. Although SBP tended to decrease more with saline compared to albumin and HES, the difference was not significant. The higher decrease in BV and SBP with saline was counterbalanced by a significantly higher increase in VT, while VT remained unchanged in the other two sessions. It is concluded that HES is a promising fluid in preserving blood volume, comparable to albumin, but superior to saline.

Assessment of dry weight in hemodialysis: an overview

Fluid balance is an integral component of hemodialysis treatments to prevent under- or overhydration, both of which have been demonstrated to have significant effects on intradialytic morbidity and long-term cardiovascular complications. Fluid removal is usually achieved by ultrafiltration to achieve a clinically derived value for "dry weight." Unfortunately, there is no standard measure of dry weight and as a consequence it is difficult to ascertain adequacy of fluid removal for an individual patient. Additionally, there is a lack of information on the effect of ultrafiltration on fluid shifts in the extracellular and intracellular fluid spaces. It is evident that a better understanding of both interdialytic fluid status and fluid changes during hemodialysis is required to develop a precise measure of fluid balance. This article describes the current status of dry weight estimation and reviews emerging techniques for evaluation of fluid shifts. Additionally, it explores the need for a marker of adequacy for fluid removal.

Dynamics of segmental extracellular volumes during changes in body position by bioimpedance analysis

Extracellular volume (ECV) of arms, trunk, and legs determined from segmental bioimpedance data in 11 healthy men (31.6 +/- 7 yr) obtained at the end of a 30-min equilibration phase in the supine body position was compared with ECV determined from whole body measurements (ECVWB). ECV was calculated from extracellular resistance (RECV) identified from the bioimpedance spectrum for a range of 10 frequencies. Whole body RECV (527.6 +/- 55.6 Omega) was equal to the sum of RECV in the arms, trunk, and legs (241.6 +/- 36. 3, 49.2 +/- 5.1, and 236.3 +/- 25.5 Omega, respectively). The sum of equilibrated ECV in arms (1.31 +/- 0.25 liters), trunk (10.08 +/- 1.65 liters), and legs (2.80 +/- 0.82 liters) was smaller than ECVWB (20.90 +/- 2.59 liters). In six subjects who changed from a standing to a supine body position, ECV decreased in arms (-2.59 +/- 2.51%, P = NS) and legs (-10.96 +/- 3.02%, P < 0.05) but increased in the trunk (+4.2 +/- 3.2%, P < 0.05). ECVWB also decreased (-4.98 +/- 1. 41%, P < 0.05). However, the sum of segmental extracellular volumes remained unchanged (-0.06 +/- 0.07%, P = NS). The sum of segmental ECVs is not sensitive to changes in body position, which otherwise interferes with the estimation of ECV in bioimpedance analysis when ECVWB is used.

A model of artefacts produced by stray capacitance during whole body or segmental bioimpedance spectroscopy

We have developed a novel model for the simulation of artefacts which are produced by stray capacitance during bioimpedance spectroscopy. We focused on whole body and segmental measurements in the frequency range 5-1000 kHz. The current source was assumed to by asymmetric with respect to ground as is the case for many commercial devices. We considered the following stray pathways: 1, cable capacitance; 2, capacitance between neighbouring electrode leads; 3. capacitance between different body segments and earth; 4, capacitance between signal ground of the device and earth. According to our results the pathways 3 and 4 cause a significant spurious dispersion in the measured impedance spectra at frequencies > 500 kHz. During segmental measurements the spectra have been found to be sensitive to an interchange of the electrode cable pairs. The sensitivity was also observed in vivo and is due to asymmetry of the potential distribution along the segment with respect to earth. In contrast to previously published approaches, our model renders possible the simulation of this effect. However, it is unable to fully explain the deviations of in vivo measured impedance spectra from a single Cole circle. We postulate that the remaining deviations are due to a physiologically caused superposition of two dispersions from two different tissues.

Monitoring relative fluid balance alterations in haemodialysis of diabetic patients by electrical impedance

Measurements of total-body electrical impedance in the frequency range between 200 Hz and 300 kHz were performed on 37 diabetic patients undergoing chronic haemodialysis. Special attention was paid to the instrument design, where a self-balancing differential current source was used, reducing considerably the common-mode voltage at the amplifier input. The patient-instrument interface includes screened leads, separately driven by unity-gain buffers. The measurement error was < 1% for the impedance within the range of 20 to 1000 omega and < 0.3 degree (mean) for the phase angle. Impedance/phase and ultrafiltration measurements were carried out throughout the entire procedure. Total and extracellular water were computed and compared with extracted fluid volumes. The trends of change of the extracellular and intracellular fluid volumes during and immediately after dialysis corresponded to the respective clinical condition of the patients and enabled us to divide them into four groups. This approach is a step toward continuous monitoring and adaptive treatment, tailored to the individual patient needs.

Predicting body cell mass with bioimpedance by using theoretical methods: a technological review

The body cell mass (BCM), defined as intracellular water (ICW), was estimated in 73 healthy men and women by total body potassium (TBK) and by bioimpedance spectroscopy (BIS). In 14 other subjects, extracellular water (ECW) and total body water (TBW) were measured by bromide dilution and deuterium oxide dilution, respectively. For all subjects, impedance spectral data were fit to the Cole model, and ECW and ICW volumes were predicted by using model electrical resistance terms RE and Rt in an equation derived from Hanai mixture theory, respectively. The BIS ECW prediction bromide dilution was r = 0.91, standard error of the estimate (SEE) 0.90 liter. The BIS TBW prediction of deuterium space was r = 0.95, SEE 1.33 liters. The BIS ICW prediction of the dilution-determined ICW was r = 0.87, SEE 1.69 liters. The BIS ICW prediction of the TBK-determined ICW for the 73 subjects was r = 0.85, SEE = 2.22 liters. These results add further support to the validity of the Hanai theory, the equation used, and the conclusion that ECW and ICW volume can be predicted by an approach based solely on fundamental principles.

Extra- and intracellular volume monitoring by impedance during haemodialysis using Cole-Cole extrapolation

A method is presented for monitoring the relative variation of extracellular and intracellular fluid volumes using a multifrequency impedance meter and the Cole-Cole extrapolation technique. It is found that this extrapolation is necessary to obtain reliable data for the resistance of the intracellular fluid. The extracellular and intracellular resistances can be approached using frequencies of, respectively, 5 kHz and 1000 kHz, but the use of 100 kHz leads to unacceptable errors. In the conventional treatment the overall relative variation of intracellular resistance is found to be relatively small.

Continuous measurements by impedance of haematocrit and plasma volume variations during dialysis

A technique for continuous measurements of haematocrit and plasma volume in the arterial line of dialysed patients has been tested in vitro and in vivo. This method uses impedance measurements at 5 kHz and requires a single haematocrit measurement. It relies on two assumptions: that plasma resistivity does not change during dialysis and that blood resistivity obeys Hanai's model. Both assumptions are verified during in vitro tests. Haematocrits measured in vivo by this method are found to be in good agreement with direct measurements from blood samples. The haematocrit variation is then used to monitor changes in plasma volume, assuming conservation of erythrocyte volume. In addition, it is possible to obtain the variation in interstitial volume by combining these data with body impedance measurements.

Effect of postural changes on the reliability of volume estimations from bioimpedance spectroscopy data

Bioimpedance spectroscopy (BIS) has been suggested for the assessment of fluid shifts between intracellular (ICV) and extracellular volume (ECV) during dialysis. The electrical tissue parameters are estimated by fitting a Cole-Cole model to the impedance data. Those parameters are used for the calculation of ICV and ECV with a fluid distribution model (FDM). We investigated whether postural changes cause artifacts in the volume data measured with a commercial BIS system. This is of importance at the beginning of dialysis, when the patient lies down for treatment. Volume estimations were performed during tilt table experiments with 11 healthy volunteers. Impedance spectra (5 to 500 kHz) were recorded for the total body as well as for body segments (leg and arm) during three phases: (1) 30 minutes resting in a supine position after standing; (2) 30 minutes 70 degrees head up tilt; and (3) a 30-minute resting period in a supine position. ECV and ICV were estimated with a commercially utilized FDM which is based on Hanai's mixture theory. A monoexponential function was fitted to the data for extracting the time constants and the extrapolated steady state values of the volume changes. The ECV and ICV data changed significantly during all three periods, that is, a steady state could not be reached within 30 minutes. During phase 1 the ECV decreased by 1.8 +/- 0.7%, in the tilt phase it increased by 3.8 +/- 1.1%, and in phase 3 it decreased again by 2.9 +/- 1%. The ICV increased by 3.6 +/- 2.4% during phase 1 and decreased by 6.8 +/- 5.1% during tilting; in phase 3 it increased by 4.6 +/- 1.7%. The time constants were 36.4 +/- 12.7 minutes (ECV) and 10.8 +/- 5.4 minutes (ICV) during phase 3. Segmental measurements revealed that the legs contribute significantly to the measured volume changes. The absolute volume changes in ICV and ECV differed significantly in all phases, and the same was found for the time constants during phases 1 and 3. From this discrepancy it is concluded that the measured volume changes are artifacts that are caused by extracellular fluid redistribution. Furthermore, it appears unlikely that the measured fluid shifts actually occur between ECV and ICV in the absence of osmotic changes in the body fluids. The validity of the method for a reliable assessment of volume changes during dialysis appears questionable, as dialysis-induced volume changes lie in the same range as the orthostatically-induced spurious volume changes.

Influence of ionic shifts during dialysis on volume estimations with multifrequency impedance analysis

During dialysis the ion concentrations in many body fluids change significantly. The influence of these changes on the accuracy of volume measurements with bioimpedance spectroscopy is investigated by the following procedure: Plasma ion concentrations and impedance spectra (5-500 kHz) are measured during six standard haemodialyses. Intracellular ion concentrations are estimated using a multi-compartment model. Intra- (ICV) and extracellular (ECV) volumes are calculated using a fluid distribution model (FDM) based on Hanai's mixture theory. The input variables of the FDM are intra- and extracellular resistance data that have been fitted from impedance spectra with a Cole-Cole model. Resistivity changes (RCs) due to concentration changes of Na+, K+, Cl-, HCO3- and unspecified intracellular ions are estimated. The FDM is corrected for the RCs. Corrected ICVs and ECVs are calculated and compared with uncorrected values. The range of relative RCs between the start and end of the dialyses is -3.2% to 1.4% in the ECV and -3.7% to 1.7% in the ICV. From the RCs, volume estimation errors of -1.0% to 1.9% (ECV) and -1.2% to 2.1% (ICV) relative to the initial values have been calculated. At the end of dialysis, the percentage of the error with respect to the volume change is < 15% for the ECV but > 20% for the ICV. Consequently, a correction of the FDM for RCs is necessary to obtain more reliable ICV data.

A review of in vivo experimental methods to determine the composition of the human body

This review of experimental methods employed in the measurement of the composition of the human body covers the developments that have occurred over the past 30 years. Early methods such as hydrodensitometry and skinfold anthropometry have been superseded by dual-energy x-ray absorptiometry and bioelectrical impedance spectroscopy. The measurement of the whole-body abundance of certain elements by isotopic dilution, neutron activation analysis and x-ray fluorescence can give important information of clinical significance, but neutron activation facilities remain available in only a few centres worldwide. The relatively simple, rapid and risk-free electrical methods such as multifrequency bioelectrical impedance analysis, which can be employed at the bedside, have been found to be more complicated in their interpretation. Electromagnetic methods may only measure the composition of the human body at its surface. X-ray computed tomography and magnetic resonance imaging have not yet been employed much in body composition measurements. Some models for the composition of the human body are reviewed.

Assessment of excess fluid distribution in chronic hemodialysis patients using bioimpedance spectroscopy

Sodium and water homeostasis is abnormal in hemodialysis (HD) patients, however, the distribution of the excess fluid (extracellular vs. intracellular) has not been fully characterized. We studied the distribution of fluid using bioimpedance spectroscopy to determine if HD patients have an excess of fluid in any specific compartment relative to controls. Dual-energy x-ray absorptiometry was used to measure lean body mass and bone mineral content. The resistive index (RI) for extracellular water volume (RIECW), was significantly increased in patients pre-HD when corrected for bone mineral content (RIECW:BMC) (pre-HD, 19.0 +/- 3.3; controls, 15.8 +/- 1.7 cm2-ohms(-1)-kg -1; P < 0.01). This value decreased to the control range following HD (15.2 +/- 2.5 cm2-ohms(-1)-kg(-1). The intracellular water volume to bone mineral content (RIICW:BMC) was not different between controls and HD patients. These data suggest that hemodialysis patients carry their excess fluid volume primarily in the extracellular compartment and that bioimpedance spectroscopy coupled with a stable measure of lean tissue such as bone mineral content can determine the degree of relative excess hydration.

A multifrequency multichannel electrical impedance data acquisition system for body fluid shift monitoring

This paper discusses some important issues for the design of electrical impedance measurement systems intended for body fluid shift monitoring, in particular during dialysis treatments. We have studied two common signal generation systems: digital synthesis and carrier recovery. We have found that in prolonged measurement applications, digital synthesis yields the best performance. On the demodulation side, we balance the demodulator errors between the real and imaginary parts by rotating the demodulation axes. We use segmental multifrequency impedance measurements to estimate the values of intracellular and extracellular impedance by adjusting the parameters of a Cole-Cole model for each segment measured. We stress the need to perform segmental measurements in order to accurately measure the segments of interest, in particular the trunk during dialysis treatments. Our results show that there is a sharp disequilibrium between the intracellular and extracellular compartments in the very first dialysis period. This fact generates the need to continuously measure segmental impedance instead of comparing initial and final values.

Assessment of the Best Compatible Dialysis System: Feasible Application for Bioelectrical Impedance

Since the introduction of hemodialysis procedure several attempts have been made to elucidate the material tissue interaction in order to evaluate the behaviour of immunosystem cellular and humoral responses to the material of patients on renal replacement therapy. Biochemical and sierological parameters have been considered as method for assessment of the best compatible dialysis. Nevertheless blood tests don't probably reflect the most important symptoms of clinical relevance. Thus we have applied bioelectrical impedance to assess the whole procedure/patient system. Resistance (R) changes during hemodialysis resulted strictly inversely correlated to the body weight variations during HD session (R < 0.96). Reactance (Xc) has also shown a progressive increase associated with an increment of phase angle, while Xc during clinical events such as hypotension, vomiting or cramps showed some transient falls. Also nutritional status and clinical well-being manifested a close relationship with bioelectrical parameters. It is therefore our feeling that BIA monitoring will provide a feasible tool to assess dialysis adequacy, of which biocompatibility represent a crucial aspect.

Relationships between parameters describing low-frequency electrical admittance locus plot of human palmar skin

Using a two-frequency three-electrode method, unipolar electrical admittance was measured in the palmar skin of 48 normal healthy humans. Characteristics of and relationships between the phase angle pi alpha/2, the conductance extrapolated at zero frequency G(O) and ion relaxation time tau obtained from the Cole-Cole equation were examined in a low-frequency region (up to 354 Hz). At base-line resting values, the three admittance parameters were interrelated according to the regression model; log tau i = A + B alpha i + D log G(O)i + epsilon i with R2 > or = 0.7434 (p < or = 0.0001), where A, B and D determined from regression analysis showed inter- and intra-individual variation. Multi-factor analyses of variance showed that alpha was greater in women than men (0.8025 versus 0.7545, p < 0.0023), and log G(O) decreased significantly with age (covariate coefficient = -0.0058 log microS cm-2 per year, p < 0.04). For evoked responses, alpha showed a very small change (maximum < 5%), tau decreased while G(O) increased. With increasing frequency, conductance responses increased in absolute amplitudes but decreased in relative changes (amplitude change divided by static level). Statistical analyses from clinical experimental materials (total 130 subjects) showed that the capacitive behaviour of admittance (due to alpha) presented significant variation between controls and patient groups. This may shed new light on the nature of the skin electrical admittance/impedance.

Interstitial fluid volume during cardiac surgery measured by means of a non-invasive conductivity technique

Fluid accumulation in the interstitium is frequently found after cardiac surgery. In extreme this can lead to pulmonary and myocardial oedema. The origin of this accumulation is not exactly known and may be twofold. It is probably a combination of the noninfectious whole body inflammatory response and a change in Starling forces due to a decrease in colloid osmotic pressure (COP) which is caused by the primed extracorporeal circuit. To study the changes in interstitial fluid volume (ISFV) a non-invasive conductivity technique was used. The relationship between temperature and conductivity was first investigated in vitro. A linear relationship was found between conductivity and different saline solutions and temperature. From the in vitro experiments it can be concluded that temperature corrected conductivity does not depend on haematocrit. After the in vitro experiments eleven patients undergoing cardiac surgery were studied. During the first minutes of cardiopulmonary bypass (CPB) a steep significant decrease in COP to 61.4 +/- 6.9% (from 19.6 +/- 1.1 to 12.0 +/- 1.2 mmHg), and a rise in ISFV to 105.5 +/- 2.8% (from 12.3 +/- 1.4 mS to 14.0 +/- 1.3 mS) was noticed. After this decrease COP increased significantly, till the end of the operation, but did not reach the pre-operative level. An increase in ISFV was noticed till the rewarming point. After this point no significant change in ISFV was noticed. Furthermore, a significant correlation was found between the fluid balance and the ISFV increase at the start, at the end of CPB, and at the end of the operation.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of alternating current frequency on flow related admittance changes of blood: a concept for improvement of impedance cardiography

Impedance cardiography is based on admittance changes induced by volume changes of the intrathoracic blood vessels, but also by the longitudinal orientation of red blood cells induced by flow. An experiment was set up to separate these two phenomena and to study their frequency dependence. Admittance changes of flowing blood with variable haematocrit, of a saline solution and of plasma were measured in an in vitro set-up. Four different alternating current frequencies were used: 100 kHz, 5 MHz, 15 MHz and 20 MHz. The measured admittance appeared to be dependent on blood flow: when blood flow increased, admittance in the longitudinal direction increased. This increase was stronger for higher haematocrits, probably due to the longitudinal orientation of the blood cells. At higher frequencies, the orientation effect of the red cells became negligibly small. No frequency or flow dependent admittance change was detected when saline or plasma was used as the perfusate. It is concluded that the orientation effect can be neglected at high frequencies. Impedance cardiography in this range will give more reliable information about volume changes.

Non-invasive conductivity technique to detect changes in haematocrit: in vitro validation

An on-line haematocrit measurement in extracorporeal circuits might be useful under some clinical circumstances (e.g. haemodialysis or cardiac surgery). As no such measurement exists, a device has been developed that makes it possible to detect haematocrit (Ht) continuously without a loss of blood. It is a multi-frequency system for the detection of electrical conductivities. The aim of this study was to investigate whether this device can measure Ht alterations properly. Ht alterations were induced by adding pure mannitol and 20% mannitol to fresh human blood. Furthermore, the effect of both mannitol substances on the intracellular ion content, intracellular conductivity and Ht were investigated. Alternations in Ht were established by the addition of 1000, 800, 600, 400, 200 and 0 mg of pure mannitol to 10 ml of fresh human blood, and 3.0, 2.5, 2.0, 2.0, 1.5, 1.0, 0.5 and 0 ml of 20% mannitol to fresh human blood until a total volume of 10 ml was achieved. Although their effects were significantly different, pure mannitol and 20% mannitol both caused a reduction in mean cellular volume, and thus in Ht. A highly significant correlation was found between Ht and intracellular conductivity (r = 0.90, p < 0.001). In addition to these effects, addition of pure mannitol and 20% mannitol had different effects on the intracellular ion content. Pure mannitol caused an increase in intracellular ion content due to a transcellular ion shift, whereas 20% mannitol induced a decrease. From this study, it can be concluded that the multi-frequency conductivity method observes changes in Ht (and intracellular fluid volume) in an accurate manner.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of extra-cellular fluid volume measurement in children by 99Tcm-DPTA clearance and multi-frequency impedance techniques

Comparisons of extra-cellular fluid (ECF) volume estimates made by isotope dilution and electrical impedance techniques have been made in a group of 16 children. For each patient an estimate of ECF volume (Vt) was obtained from measurements of the blood clearance of 99Tcm-diethylene triamine penta-acetate (DPTA) which was compared with two estimates (Vi1 and Vi2) of ECF volume obtained from measurements of the whole-body electrical impedance at 50 frequencies in the range 1 kHz to 1.348 MHz and a third estimate Vh based on patient height, L, alone. The observed frequency response of the impedance measurements was fitted to a three-element equivalent-circuit model of whole-body impedance and gave a value of the ECF resistance R. Vi1 was obtained from Vi1 = a (L2/R) + b. Vi2 was given by c(W1/2L2/R)2/3 where W is the patient weight, and Vh was given by dL2 + e. The constants a, b, c, d, e were determined by comparison with Vt and were equal to 0.335 l omega m-2 (standard error = 0.01 1 omega m-2), 0.42 l (0.25 l), 0.33 l (omega 2kg-1m-4)1/2 0.007 l (omega 2kg-1m-4)1/3, 4.92 l m-2 (2.8 x 10(-5) lm-2), 0.13 l (0.41 l), respectively. Vi1, Vi2, Vh were linearly correlated with Vt (r2 = 0.98, 0.99, 0.95, respectively, p < 0.001), and upper and lower levels of agreement were given by +/- 0.95 l (Vt and Vi1), 1.44 l and -1.12 l (Vt and Vi2), +/- 1.5 l (Vt and Vh), respectively. Thus inclusion of the impedance data accounted for greater volume variation, but differences between the techniques were not significant (paired t-test and Mann-Whitney analysis) suggesting that more accurate and detailed measurements are required.

Determination of capillary leakage due to recombinant interleukin-2 by means of noninvasive conductivity measurements

One of the most common side effects of treatment with recombinant interleukin-2 (IL-2) is capillary leakage. Its genesis is not completely understood. The aim of the study was to determine whether capillary leakage can be monitored by means of a noninvasive conductivity technique and to study its starting point. Eight patients with advanced renal cell cancer were studied in a medium care section of the Department of Medical Oncology, University Hospital over 4 days during treatment sessions of continuous, intravenously administered IL-2 (mean dose of 15.6 x 10(6) IU.m-2.day-1). The fluid shift from the intravascular to the extra- and intracellular compartments was monitored by means of noninvasive conductivity measurements. Changes in blood volume were calculated from serial erythrocyte counts. The clinical parameters of capillary leakage (oliguria, positive fluid balance, and gain in mass) were recorded. The mean gain in mass was 9% after 4 days of IL-2 treatment. The extracellular fluid volume increased significantly [46 (SD 23.2)%; P < 0.01], whereas the intracellular fluid volume did not change. The increase in blood volume (BV) amounted to 7% (P < 0.05). The decline in albumin concentration was significantly more than the increase in BV [38 (SD 4.3)%; P < 0.01], indicating capillary albumin leakage. The main changes were observed after the 2nd day of treatment. From this study, it is suggested that conductivity measurements are a suitable method to monitor capillary leakage induced by IL-2, and could be used to detect the exact onset and severity of this leakage.(ABSTRACT TRUNCATED AT 250 WORDS)

Measurement of transcellular fluid shift during haemodialysis. Part 1. Method

A method is presented to measure transcellular fluid shifts during haemodialysis based on a simplified model of the electrical admittance of biological tissues. It allows for the measurement of intracellular and extracellular conductivities and their ratios. The method is noninvasive, clean and harmless, and can be easily computerised in order to be performed continuously. A typical example is given of a recording during haemodialysis.