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Krenn S, Schmiedecker M, Schneditz D, Hödlmoser S, Mayer CC, Wassertheurer S, Omic H, Schernhammer E, Wabel P, Hecking M. Feasibility of Dialysate Bolus-Based Absolute Blood Volume Estimation in Maintenance Hemodialysis Patients. Front Med (Lausanne) 2022; 9:801089. [PMID: 35223900 PMCID: PMC8866453 DOI: 10.3389/fmed.2022.801089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 01/04/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Absolute blood volume (ABV) is a critical component of fluid status, which may inform target weight prescriptions and hemodynamic vulnerability of dialysis patients. Here, we utilized the changes in relative blood volume (RBV), monitored by ultrasound (BVM) upon intradialytic 240 mL dialysate fluid bolus-infusion 1 h after hemodialysis start, to calculate the session-specific ABV. With the main goal of assessing clinical feasibility, our sub-aims were to (i) standardize the BVM-data read-out; (ii) determine optimal time-points for ABV-calculation, "before-" and "after-bolus"; (iii) assess ABV-variation. METHODS We used high-level programming language and basic descriptive statistics in a retrospective study of routinely measured BVM-data from 274 hemodialysis sessions in 98 patients. RESULTS Regarding (i) and (ii), we automatized the processing of RBV-data, and determined an algorithm to select the adequate RBV-data points for ABV-calculations. Regarding (iii), we found in 144 BVM-curves from 75 patients, that the average ABV ± standard deviation was 5.2 ± 1.5 L and that among those 51 patients who still had ≥2 valid estimates, the average intra-patient standard deviation in ABV was 0.8 L. Twenty-seven of these patients had an average intra-patient standard deviation in ABV <0.5 L. CONCLUSIONS We demonstrate feasibility of ABV-calculation by an automated algorithm after dialysate bolus-administration, based on the BVM-curve. Based on our results from this simple "abridged" calculation approach with routine clinical measurements, we encourage the use of multi-compartment modeling and comparison with reference methods of ABV-determination. Hopes are high that clinicians will be able to use ABV to inform target weight prescription, improving hemodynamic stability.
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Affiliation(s)
- Simon Krenn
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria.,AIT Austrian Institute of Technology, Center for Health & Bioresources, Medical Signal Analysis, Vienna, Austria
| | - Michael Schmiedecker
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Daniel Schneditz
- Division of Physiology, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Sebastian Hödlmoser
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Christopher C Mayer
- AIT Austrian Institute of Technology, Center for Health & Bioresources, Medical Signal Analysis, Vienna, Austria
| | - Siegfried Wassertheurer
- AIT Austrian Institute of Technology, Center for Health & Bioresources, Medical Signal Analysis, Vienna, Austria
| | - Haris Omic
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Eva Schernhammer
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | | | - Manfred Hecking
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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2
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Keane D, Glyde M, Dasgupta I, Gardiner C, Lindley E, Mitra S, Palmer N, Dye L, Wright M, Sutherland E. Patient perspectives of target weight management and ultrafiltration in haemodialysis: a multi-center survey. BMC Nephrol 2021; 22:188. [PMID: 34016069 PMCID: PMC8138996 DOI: 10.1186/s12882-021-02399-7] [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: 02/20/2021] [Accepted: 04/30/2021] [Indexed: 12/29/2022] Open
Abstract
Background Decisions around planned ultrafiltration volumes are the only part of the haemodialysis prescription decided upon at every session. Removing too much fluid or too little is associated with both acute symptoms and long-term outcomes. The degree to which patients engage with or influence decision-making is not clear. We explored patient perspectives of prescribing ultrafiltration volumes, their understanding of the process and engagement with it. Methods A questionnaire developed for this study was administered to 1077 patients across 10 UK Renal Units. Factor analysis reduced the dataset into factors representing common themes. Relationships between survey results and factors were investigated using regression models. ANCOVA was used to explore differences between Renal Units. Results Patients generally felt in control of their fluid management and that they were given the final say on planned ultrafiltration volumes. Around half of the respondents reported they take an active role in their treatment. However, respondents were largely unable to relate signs and symptoms to fluid management practice and a third said they would not report common signs and symptoms to clinicians. A fifth of patients reported not to know how ultrafiltration volumes were calculated. Patients responded positively to questions relating to healthcare staff, though with significant variation between units, highlighting differences in perception of care. Conclusions Despite a lack of formal acknowledgement in fluid management protocols, patients have significant involvement in decisions regarding fluid removal during dialysis. Furthermore, substantial gaps remain in patient knowledge and engagement. Formalizing the role of patients in these decisions, including patient education, may improve prescription and achievement of target weights. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02399-7.
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Affiliation(s)
- David Keane
- Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK. .,Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
| | - Megan Glyde
- School of Psychology, University of Leeds, Leeds, UK
| | - Indranil Dasgupta
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - Sandip Mitra
- Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK.,Devices for Dignity, NIHR MedTech & In-vitro Diagnostics Co-operative, Sheffield, UK
| | | | - Louise Dye
- School of Psychology, University of Leeds, Leeds, UK
| | - Mark Wright
- Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ed Sutherland
- School of Psychology, University of Leeds, Leeds, UK
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3
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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: 1.0] [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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4
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Canaud B, Kooman J, Selby NM, Taal M, Francis S, Kopperschmidt P, Maierhofer A, Kotanko P, Titze J. Sodium and water handling during hemodialysis: new pathophysiologic insights and management approaches for improving outcomes in end-stage kidney disease. Kidney Int 2020; 95:296-309. [PMID: 30665570 DOI: 10.1016/j.kint.2018.09.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/22/2018] [Accepted: 09/24/2018] [Indexed: 02/07/2023]
Abstract
Space medicine and new technology such as magnetic resonance imaging of tissue sodium stores (23NaMRI) have changed our understanding of human sodium homeostasis and pathophysiology. It has become evident that body sodium comprises 3 main components. Two compartments have been traditionally recognized, namely one that is circulating and systemically active via its osmotic action, and one slowly exchangeable pool located in the bones. The third, recently described pool represents sodium stored in skin and muscle interstitium, and it is implicated in cell and biologic activities via local hypertonicity and sodium clearance mechanisms. This in-depth review provides a comprehensive view on the pathophysiology and existing knowledge gaps of systemic hemodynamic and tissue sodium accumulation in dialysis patients. Furthermore, we discuss how the combination of novel technologies to quantitate tissue salt accumulation (e.g., 23NaMRI) with devices to facilitate the precise attainment of a prescribed hemodialytic sodium mass balance (e.g., sodium and water balancing modules) will improve our therapeutic approach to sodium management in dialysis patients. While prospective studies are required, we think that these new diagnostic and sodium balancing tools will enhance our ability to pursue more personalized therapeutic interventions on sodium and water management, with the eventual goal of improving dialysis patient outcomes.
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Affiliation(s)
- Bernard Canaud
- Centre for Medical Excellence, Fresenius Medical Care Deutschland, Bad Homburg, Germany; Montpellier University, Montpellier, France.
| | - Jeroen Kooman
- Maastricht Universitair Medisch Centrum - Maastricht, Netherlands
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, University of Nottingham, Royal Derby Hospital Campus, Derby, UK
| | - Maarten Taal
- Centre for Kidney Research and Innovation, University of Nottingham, Royal Derby Hospital Campus, Derby, UK
| | - Susan Francis
- Sir Peter Mansfield Imaging Centre, University of Nottingham, UK
| | | | | | - Peter Kotanko
- Renal Research Institute, New York, New York, USA; Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jens Titze
- Division of Cardiovascular and Metabolic Disease, Duke-NUS, Singapore; Division of Nephrology, Duke University Medical Center, Durham, North Carolina, USA; Division of Nephrology and Hypertension, University Clinic Erlangen, Germany
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5
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Zsom L, Faludi M, Fülöp T, Dossabhoy NR, Rosivall L, Tapolyai MB. The association of overhydration with chronic inflammation in chronic maintenance hemodiafiltration patients. Hemodial Int 2019; 23:384-391. [PMID: 30834635 DOI: 10.1111/hdi.12742] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/05/2019] [Accepted: 02/10/2019] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Achieving euvolemia is one of the major challenges when treating end-stage renal disease (ESRD) patients receiving maintenance renal replacement therapy. Fluid overload is recognized as an independent predictor of mortality in ESRD, but its association with chronic inflammation is less well explored especially in chronic maintenance hemodiafiltration. METHODS We performed a cross-sectional study of 87 prevalent ESRD patients receiving chronic maintenance hemodiafiltration (vintage 66.5 ± 57.1 months) with bioimpedance analysis to characterize the degree of percent overhydration (OH%). We also compared the levels of inflammatory markers, including C-reactive protein (CRP), serum albumin, neutrophil/lymphocyte ratio (NLR), and hemoglobin red cell distribution width (RDW) for the overhydrated (OH% ≥ 15%) versus euvolemic (OH% < 15%) groups. Linear regression analysis was performed to explore relationships between the degree of OH and inflammatory indicators. FINDINGS The cohort represented an all-European population with a mean age of 60.9 ± 14.7 years and prevalence of diabetes mellitus of 27%. The entire cohort's OH% was 14.9% ± 5.1% (range -11.1% to 39.0%); further, the <15% group of patients' OH% was 8.0% ± 8.5% versus 20.9% ± 5.1% in the OH% ≥ 15% group (P < 0.0001). Forty-seven patients (53%) were overhydrated by traditional criteria (OH% ≥15%) and 20 patients (23%) were severely overhydrated (OH% > 20%). The euvolemic (OH% <15%) versus severely overhydrated (OH% > 20%) groups had significant differences in markers of inflammation: CRP (9.8 ± 10.6 vs. 21.5 ± 21.6 mg/L, P < 0.006), serum albumin (37.6 ± 02.9 vs. 34.5 ± 5.3 g/L, P < 0.004), and NLR (3.06 ± 1.25 vs. 3.92 ± 2.04; P < 0.004). On linear regression, significant correlations were found between OH% and CRP (r = 0.2899, P < 0.006), serum albumin (r = -0.3670; P < 0.0005), RDW (r = 0.2992; P < 0.005), and NLR (r = 0.2900; P < 0.006). DISCUSSION In a prevalent hemodiafiltration cohort, OH was common and correlated with several inflammatory markers.
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Affiliation(s)
| | - Mária Faludi
- Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Tibor Fülöp
- Medical Services, Ralph H. Johnson VA Medical Center, Charleston, South Carolina, United States of America.,Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Neville R Dossabhoy
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States of America.,Overton Brooks VA Medical Center, Shreveport, Louisiana, United States of America
| | - László Rosivall
- Institute of Pathophysiology, Semmelweis University, Budapest, Hungary
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6
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Golestaneh L. Decreasing hospitalizations in patients on hemodialysis: Time for a paradigm shift. Semin Dial 2018; 31:278-288. [DOI: 10.1111/sdi.12675] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Ladan Golestaneh
- Nephrology Division; Department of Medicine; Montefiore Medical Center; Albert Einstein College of Medicine; Bronx NY USA
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7
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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: 28] [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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8
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Ferreira J, Pau I, Lindecrantz K, Seoane F. A Handheld and Textile-Enabled Bioimpedance System for Ubiquitous Body Composition Analysis. An Initial Functional Validation. IEEE J Biomed Health Inform 2016; 21:1224-1232. [PMID: 28113962 DOI: 10.1109/jbhi.2016.2628766] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In recent years, many efforts have been made to promote a healthcare paradigm shift from the traditional reactive hospital-centered healthcare approach towards a proactive, patient-oriented, and self-managed approach that could improve service quality and help reduce costs while contributing to sustainability. Managing and caring for patients with chronic diseases accounts over 75% of healthcare costs in developed countries. One of the most resource demanding diseases is chronic kidney disease (CKD), which often leads to a gradual and irreparable loss of renal function, with up to 12% of the population showing signs of different stages of this disease. Peritoneal dialysis and home haemodialysis are life-saving home-based renal replacement treatments that, compared to conventional in-center hemodialysis, provide similar long-term patient survival, less restrictions of life-style, such as a more flexible diet, and better flexibility in terms of treatment options and locations. Bioimpedance has been largely used clinically for decades in nutrition for assessing body fluid distributions. Moreover, bioimpedance methods are used to assess the overhydratation state of CKD patients, allowing clinicians to estimate the amount of fluid that should be removed by ultrafiltration. In this work, the initial validation of a handheld bioimpedance system for the assessment of body fluid status that could be used to assist the patient in home-based CKD treatments is presented. The body fluid monitoring system comprises a custom-made handheld tetrapolar bioimpedance spectrometer and a textile-based electrode garment for total body fluid assessment. The system performance was evaluated against the same measurements acquired using a commercial bioimpedance spectrometer for medical use on several voluntary subjects. The analysis of the measurement results and the comparison of the fluid estimations indicated that both devices are equivalent from a measurement performance perspective, allowing for its use on ubiquitous e-healthcare dialysis solutions.
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9
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Antlanger M, Hecking M, Haidinger M, Werzowa J, Kovarik JJ, Paul G, Eigner M, Bonderman D, Hörl WH, Säemann MD. Fluid overload in hemodialysis patients: a cross-sectional study to determine its association with cardiac biomarkers and nutritional status. BMC Nephrol 2013; 14:266. [PMID: 24295522 PMCID: PMC4219439 DOI: 10.1186/1471-2369-14-266] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Accepted: 11/26/2013] [Indexed: 12/30/2022] Open
Abstract
Background Chronic fluid overload is associated with higher mortality in dialysis patients; however, the link with cardiovascular morbidity has not formally been established and may be influenced by subclinical inflammation. We hypothesized that a relationship exists between fluid overload and [i] cardiovascular laboratory parameter as well as between fluid overload and [ii] inflammatory laboratory parameters. In addition, we aimed to confirm whether volume status correlates with nutritional status. Methods We recorded baseline characteristics of 244 hemodialysis patients at three hemodialysis facilities in Vienna (Austria) and determined associations with volume measurements using the body composition monitor (Fresenius/Germany). In one facility comprising 126 patients, we further analyzed cardiovascular, inflammatory and nutritional parameters. Results We detected predialysis fluid overload (FO) in 39% of all patients (n = 95) with FO defined as ≥15% of extracellular water (ECW). In this subgroup, the absolute FO was 4.4 +/-1.5 L or 22.9 ± 4.8% of ECW. A sub-analysis of patients from one center showed that FO was negatively associated with body mass index (r = -0.371; p = <0.001), while serum albumin was significantly lower in fluid overloaded patients (p = 0.001). FO was positively associated with D-Dimer (r = 0.316; p = 0.001), troponin T (r = 0.325; p < 0.001), and N-terminal pro-B-type natriuretic peptide (r = 0.436; p < 0.001), but not with investigated inflammatory parameters. Conclusions Fluid overload in HD patients was found to be lower in patients with high body mass index, indicating that dry weight was inadequately prescribed and/or difficult to achieve in overweight patients. The association with parameters of cardiovascular compromise and/or damage suggests that fluid overload is a biomarker for cardiovascular risk. Future studies should determine if this applies to patients prior to end-stage renal disease.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Marcus D Säemann
- Department of Internal Medicine III - Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna Austria.
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10
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Hecking M, Karaboyas A, Saran R, Sen A, Hörl WH, Pisoni RL, Robinson BM, Sunder-Plassmann G, Port FK. Predialysis serum sodium level, dialysate sodium, and mortality in maintenance hemodialysis patients: the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2011; 59:238-48. [PMID: 21944663 DOI: 10.1053/j.ajkd.2011.07.013] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Accepted: 07/08/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Predialysis serum sodium concentrations recently have been linked to patient characteristics and outcomes in hemodialysis patients and may have implications for the dialysate sodium prescription. STUDY DESIGN Prospective cohort study. PARTICIPANTS 11,555 patients from 12 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS), phases I (1996-2001) and III (2005-2008). PREDICTORS Demographics, comorbid conditions, laboratory measurements (model 1); mean serum sodium level, dialysate sodium concentration (model 2). OUTCOMES Serum sodium level, using adjusted linear mixed models (model 1); all-cause mortality, using Cox proportional hazards models (model 2). RESULTS Median follow-up was 12 months, with 1,727 deaths (15%) occurring during the study period (12,274 patient-years). Mean serum sodium level in the DOPPS countries was 138.5 ± 2.8 mEq/L. Japan had the highest (139.1 ± 2.6 mEq/L) and Australia/New Zealand had the lowest mean serum sodium level (137.4 ± 2.8 mEq/L). Serum sodium level was associated positively with male sex, black race, body mass index, serum albumin level, and creatinine level and negatively with neurologic and psychiatric disease, white blood cell count, and intradialytic weight loss (0.16 mEq/L lower per 1% loss). Higher serum sodium level was associated with lower adjusted all-cause mortality in a continuous model (HR, 0.95 per 1 mEq/L higher; 95% CI, 0.93-0.97). Dialysate sodium prescription was not associated with serum sodium level. Mortality analyses restricted to the serum sodium tertile with the highest mortality (serum sodium <137 mEq/L) showed lower mortality risk in patients with dialysate sodium prescriptions >140 mEq/L. LIMITATIONS Causality cannot be established in this observational study, which does not consider potential effects of dialysate sodium level on postdialysis thirst, dietary salt and water intake, interdialytic weight gain, and cardiovascular stability. CONCLUSIONS Lower serum sodium levels are associated with certain hemodialysis patient characteristics and higher adjusted risk of death. The lower mortality observed in our adjusted analyses in patients with serum sodium levels <137 mEq/L dialyzed against dialysate sodium prescriptions >140 mEq/L is intriguing, may be related to intradialytic cardiovascular stability, and deserves further study.
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Affiliation(s)
- Manfred Hecking
- Arbor Research Collaborative for Health, Ann Arbor, MI 48104, USA
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Onofriescu M, Mardare NG, Segall L, Voroneanu L, Cuşai C, Hogaş S, Ardeleanu Ş, Nistor I, Prisadă OV, Sascău R, Covic A. Randomized trial of bioelectrical impedance analysis versus clinical criteria for guiding ultrafiltration in hemodialysis patients: effects on blood pressure, hydration status, and arterial stiffness. Int Urol Nephrol 2011; 44:583-91. [DOI: 10.1007/s11255-011-0022-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Accepted: 06/10/2011] [Indexed: 01/10/2023]
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Mistrík E, Dusilová Sulková S, Bláha V, Kalousová M, Knízek J, Moucka P, Herout V, Kadlec M, Stilec R, Sobotka L. Evaluation of skin microcirculation during hemodialysis. Ren Fail 2010; 32:21-6. [PMID: 20113261 DOI: 10.3109/08860220903375286] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cardiovascular mortality in hemodialysis (HD) patients remains high despite improvements in HD technique such as dialysis adequacy, dialysis fluid purity, and membrane biocompatibility. Optimal fluid balance to maintain optimal hemodynamic stability during hemodialysis (HD) procedure is essential. At the present time, hemodynamic stability is conventionally assessed as stability of macrocirculation, especially as maintenance of systemic blood pressure with no attention paid to peripheral perfusion. Peripheral ischemic vascular disease represents a serious problem with high mortality and morbidity. We estimated skin microcirculation changes during HD using new device, Laser Doppler Line Scanner (Moor Instruments, Devon, UK). AIMS The aims were to introduce the novel method of detection of skin perfusion changes during hemodialysis and to evaluate possible relationship of these to ultrafiltration as well as to selected biochemical characteristics. METHODS In 36 hemodynamically stable patients, we performed paired measurements of skin blood flow in both hands before and during HD with registering the time of dialysis and the total ultrafiltration achieved. RESULTS We found a significant decrease in a majority of the evaluated areas. However, the skin blood flow change was not homogenous as it decreased more on the fingers. CONCLUSION To our knowledge, this is the first study when the microcirculatory changes during hemodialysis are demonstrated and evaluated in large skin surface area, and showing not only a decrease in a majority of areas but also the heterogeneity of the changes.
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Affiliation(s)
- Erik Mistrík
- Department of Gerontology, Nephrology and Metabolism, University Hospital and Medical Faculty, Charles University, Hradec Kralove, Czech Republic.
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Machek P, Jirka T, Moissl U, Chamney P, Wabel P. Guided optimization of fluid status in haemodialysis patients. Nephrol Dial Transplant 2010; 25:538-44. [PMID: 19793930 PMCID: PMC2809248 DOI: 10.1093/ndt/gfp487] [Citation(s) in RCA: 155] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Accepted: 08/21/2009] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Achieving normohydration remains a non-trivial issue in haemodialysis therapy. Guiding the haemodialysis patient on the path between fluid overload and dehydration should be the clinical target, although it can be difficult to achieve this target in practice. Objective and clinically applicable methods for the determination of the normohydration status on an individual basis are needed to help in the identification of an appropriate target weight. METHODS The aim of this prospective trial was to guide the patient population of a complete dialysis centre towards normohydration over the course of approximately 1 year. Fluid status was assessed frequently (at least monthly) in haemodialysis patients (n = 52) with the body composition monitor (BCM), which is based on whole body bioimpedance spectroscopy. The BCM provides the clinician with an objective target for normohydration. The patient population was divided into three groups: the hyperhydrated group (relative fluid overload >15% of extracellular water (ECW); n = 13; Group A), the adverse event group (patients with more than two adverse events in the last 4 weeks; n = 12; Group B) and the remaining patients (n = 27; Group C). RESULTS In the hyperhydrated group (Group A), fluid overload was reduced by 2.0 L (P < 0.001) without increasing the occurrence of intradialytic adverse events. This resulted in a reduction in systolic blood pressure of 25 mmHg (P = 0.012). Additionally, a 35% reduction in antihypertensive medication (P = 0.031) was achieved. In the adverse event group (Group B), the fluid status was increased by 1.3 L (P = 0.004) resulting in a 73% reduction in intradialytic adverse events (P < 0.001) without significantly increasing the blood pressure. CONCLUSION The BCM provides an objective assessment of normohydration that is clinically applicable. Guiding the patients towards this target of normohydration leads to better control of hypertension in hyperhydrated patients, less intradialytic adverse events and improved cardiac function.
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Affiliation(s)
- Petr Machek
- Fresenius Medical Care Ds, Prague, Czech Republic
| | - Tomas Jirka
- Fresenius Medical Care Ds, Prague, Czech Republic
| | | | - Paul Chamney
- Fresenius Medical Care D GmbH, Bad Homburg, Germany
| | - Peter Wabel
- Fresenius Medical Care D GmbH, Bad Homburg, Germany
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Wizemann V, Wabel P, Chamney P, Zaluska W, Moissl U, Rode C, Malecka-Masalska T, Marcelli D. The mortality risk of overhydration in haemodialysis patients. Nephrol Dial Transplant 2009; 24:1574-9. [PMID: 19131355 PMCID: PMC2668965 DOI: 10.1093/ndt/gfn707] [Citation(s) in RCA: 469] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Accepted: 11/24/2008] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND While cardiovascular events remain the primary form of mortality in haemodialysis (HD) patients, few centres are aware of the impact of the hydration status (HS). The aim of this study was to investigate how the magnitude of the prevailing overhydration influences long-term survival. METHODS We measured the hydration status in 269 prevalent HD patients (28% diabetics, dialysis vintage = 41.2 +/- 70 months) in three European centres with a body composition monitor (BCM) that enables quantitative assessment of hydration status and body composition. The survival of these patients was ascertained after a follow-up period of 3.5 years. The cut off threshold for the definition of hyperhydration was set to 15% relative to the extracellular water (ECW), which represents an excess of ECW of approximately 2.5 l. Cox-proportional hazard models were used to compare survival according to the baseline hydration status for a set of demographic data, comorbid conditions and other predictors. RESULTS The median hydration state (HS) before the HD treatment (DeltaHSpre) for all patients was 8.6 +/- 8.9%. The unadjusted gross annual mortality of all patients was 8.5%. The hyperhydrated subgroup (n = 58) presented DeltaHSpre = 19.9 +/- 5.3% and a gross mortality of 14.7%. The Cox adjusted hazard ratios (HRs) revealed that age (HRage = 1.05, 1/year; P < 0.001), systolic blood pressure (BPsys) (HRBPsys = 0.986 1/mmHg; P = 0.014), diabetes (HRDia = 2.766; P < 0.001), peripheral vascular disease (PVD) (HRPVD = 1.68; P = 0.045) and relative hydration status (DeltaHSpre) (HRDeltaHSpre = 2.102 P = 0.003) were the only significant predictors of mortality in our patient population. CONCLUSION The results of our study indicate that the hydration state is an important and independent predictor of mortality in chronic HD patients secondary only to the presence of diabetes. We believe that it is essential to measure the hydration status objectively and quantitatively in order to obtain a more clearly defined assessment of the prognosis of haemodialysis patients.
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Wabel P, Moissl U, Chamney P, Jirka T, Machek P, Ponce P, Taborsky P, Tetta C, Velasco N, Vlasak J, Zaluska W, Wizemann V. Towards improved cardiovascular management: the necessity of combining blood pressure and fluid overload. Nephrol Dial Transplant 2008; 23:2965-71. [DOI: 10.1093/ndt/gfn228] [Citation(s) in RCA: 211] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Santos SFF, Peixoto AJ. Revisiting the dialysate sodium prescription as a tool for better blood pressure and interdialytic weight gain management in hemodialysis patients. Clin J Am Soc Nephrol 2008; 3:522-30. [PMID: 18199846 PMCID: PMC6631087 DOI: 10.2215/cjn.03360807] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Hypertension and chronic volume overload are complications often seen in hemodialysis patients. Current hemodialysis practices adopt a standard dialysate sodium prescription that is typically higher than the plasma sodium concentration of most patients. As a general rule, hemodialysis patients have stable predialysis plasma sodium concentrations, and each patient has a fixed "osmolar set point." Hypertonic dialysate sodium prescriptions, including sodium modeling, predispose to positive sodium balance and lead to higher blood pressure and increased interdialytic weight gain. Conversely, lowering or individualizing dialysate sodium reduces thirst, interdialytic weight gain, and blood pressure in non-hypotension prone dialysis patients. Optimization of the dialysate sodium prescription is an important step in achieving sodium balance and improving blood pressure control in hypertensive hemodialysis patients.
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Affiliation(s)
- Sergio F. F. Santos
- Division of Nephrology, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil; and
| | - Aldo J. Peixoto
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut and Medical Service and Renal Section, VA Connecticut Healthcare System, West Haven, Connecticut
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Kliger AS, Gellens M. Will Innovations in Dialysis Improve Dialysis Care? Adv Chronic Kidney Dis 2007. [DOI: 10.1053/j.ackd.2007.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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