Effect of Fluid Management Guided by Bioimpedance Spectroscopy on Cardiovascular Parameters in Hemodialysis Patients: A Randomized Controlled Trial
TL;DR: Assessment of fluid overload with bioimpedance spectroscopy provides better management of fluid status, leading to regression of left ventricular mass index, decrease in blood pressure, and improvement in arterial stiffness.
About: This article is published in American Journal of Kidney Diseases.The article was published on 2013-06-01. It has received 290 citations till now. The article focuses on the topics: Body water & Ambulatory blood pressure.
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TL;DR: The 2015 update of the KDOQI Clinical Practice Guideline for Hemodialysis Adequacy is intended to assist practitioners caring for patients in preparation for and during hemodialysis.
722 citations
Cites background from "Effect of Fluid Management Guided b..."
...In one small clinical trial, targeted reduction in ECV using bioimpedance guidance improved BP, LVH, and arterial stiffness when compared to usualcare assessment of dry weight and determination of ultrafiltration rate.(180) However, the effect of controlling BP and reducing LVH on patient-centered outcomes such as hospitalization, CV morbidity, and mortality remains unknown....
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TL;DR: In conclusion, chronic exposure to FO in ESRD is a strong risk factor for death across discrete BP categories and treatment policies that account for fluid status monitoring are preferable to policies that accounts solely for predialysis BP measurements.
Abstract: Sustained fluid overload (FO) is considered a major cause of hypertension, heart failure, and mortality in patients with ESRD on maintenance hemodialysis. However, there has not been a cohort study investigating the relationship between chronic exposure to FO and mortality in this population. We studied the relationship of baseline and cumulative FO exposure over 1 year with mortality in 39,566 patients with incident ESRD in a large dialysis network in 26 countries using whole-body bioimpedance spectroscopy to assess fluid status. Analyses were applied across three discrete systolic BP (syst-BP) categories ( 160 mmHg), with nonoverhydrated patients with syst-BP=130-160 mmHg as the reference category; >200,000 FO measurements were performed over follow-up. Baseline FO value predicted excess risk of mortality across syst-BP categories ( 160 mmHg: HR, 1.30; 95% CI, 1.19 to 1.42; all P 160 mmHg: HR, 1.62; 95% CI, 1.39 to 1.90). In conclusion, chronic exposure to FO in ESRD is a strong risk factor for death across discrete BP categories. Whether treatment policies that account for fluid status monitoring are preferable to policies that account solely for predialysis BP measurements remains to be tested in a clinical trial.
269 citations
TL;DR: The conflict between the desire to achieve adequate resuscitation of shock and the need to mitigate the harmful effects of fluid overload is discussed.
Abstract: In patients with acute kidney injury (AKI), optimization of systemic haemodynamics is central to the clinical management. However, considerable debate exists regarding the efficacy, nature, extent and duration of fluid resuscitation, particularly when the patient has undergone major surgery or is in septic shock. Crucially, volume resuscitation might be required to maintain or restore cardiac output. However, resultant fluid accumulation and tissue oedema can substantially contribute to ongoing organ dysfunction and, particularly in patients developing AKI, serious clinical consequences. In this Review, we discuss the conflict between the desire to achieve adequate resuscitation of shock and the need to mitigate the harmful effects of fluid overload. In patients with AKI, limiting and resolving fluid overload might prompt earlier use of renal replacement therapy. However, rapid or early excessive fluid removal with diuretics or extracorporeal therapy might lead to hypovolaemia and recurrent renal injury. Optimal management might involve a period of guided fluid resuscitation, followed by management of an even fluid balance and, finally, an appropriate rate of fluid removal. To obtain best clinical outcomes, serial fluid status assessment and careful definition of cardiovascular and renal targets will be required during fluid resuscitation and removal.
240 citations
TL;DR: In longitudinal studies BIA can identify changes in hydration following a defined intervention, and spontaneous loss in TBW consequent on muscle wasting not appreciated clinically, resulting in a failure to sufficiently reduce the dry weight.
239 citations
TL;DR: After 2.5 years, this study found a greater decline in arterial stiffness, relative fluid overload, and systolic BP in the bioimpedance group than the clinical-methods group.
210 citations
References
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TL;DR: Members of the Chamber Quantification Writing Group are: Roberto M. Lang, MD, Fase, Michelle Bierig, MPH, RDCS, FASE, Richard B. Devereux,MD, Frank A. Flachskampf, MD and Elyse Foster, MD.
Abstract: Members of the Chamber Quantification Writing Group are: Roberto M. Lang, MD, FASE, Michelle Bierig, MPH, RDCS, FASE, Richard B. Devereux, MD, Frank A. Flachskampf, MD, Elyse Foster, MD, Patricia A. Pellikka, MD, Michael H. Picard, MD, Mary J. Roman, MD, James Seward, MD, Jack S. Shanewise, MD, FASE, Scott D. Solomon, MD, Kirk T. Spencer, MD, FASE, Martin St John Sutton, MD, FASE, and William J. Stewart, MD
10,834 citations
TL;DR: The best method for LVM-E identified combined cube function geometry with a modified convention for determination of left ventricular internal dimension (LVID), posterior wall thickness (PWT), and interventricular septal thickness (IVST), which excluded the thickness of endocardial echo lines from wall thicknesses and included the thickness in LVID.
Abstract: An accurte echocardiographic (E) method for determination of left ventricular mass (LVM) was derived from systematic analysis of the relationship between the antemortem left ventricular echogram and postmortem anatomic LVM in 34 adults with a wide range of anatomic LVM (101-505 g). No subject had massive myocardial infarction, ventricular aneurysm, severe right ventricular volume overload or hypertrophic cardiography. The best method for LVM-E identified combined cube function geometry with a modified convention for determination of left ventricular internal dimension (LVID), posterior wall thickness (PWT), and interventricular septal thickness (IVST), which excluded the thickness of endocardial echo lines from wall thicknesses and included the thickness of left septal and posterior wall endocardial echo lines in LVID (Penn Convention, P). By this method, anatomic LVM = 1.04 ([LVIDp + PWTp + IVSTp]3--[LVIDp]3) -- 14 g; r = 0.96, SD= 29 g, N= 34. Standard echo measurements gave less accurate results, as did previously reported methods for LVM-E. LVM-Dp is an accurate, widely applicable method for the study of left ventricular hypertrophy.
4,515 citations
TL;DR: Central aortic pressures can be accurately estimated from radial tonometry with the use of a generalized TF, and the reconstructed waveform can provide arterial compliance estimates but may underestimate the augmentation index because the latter requires greater fidelity reproduction of the wave contour.
Abstract: Background Central aortic pressures and waveform convey important information about cardiovascular status, but direct measurements are invasive. Peripheral pressures can be measured noninvasively, and although they often differ substantially from central pressures, they may be mathematically transformed to approximate the latter. We tested this approach, examining intersubject and intrasubject variability and the validity of using a single averaged transformation, which would enhance its applicability. Methods and Results Invasive central aortic pressure by micromanometer and radial pressure by automated tonometry were measured in 20 patients at steady state and during hemodynamic transients (Valsalva maneuver, abdominal compression, nitroglycerin, or vena caval obstruction). For each patient, transfer functions (TFs) between aortic and radial pressures were calculated by parametric model and results averaged to yield individual TFs. A generalized TF was the average of individual functions. TFs varied among patients, with coefficients of variation for peak amplitude and frequency at peak amplitude of 24.9% and 16.9%, respectively. Intrapatient TF variance with altered loading (>20% variation in peak amplitude) was observed in 28.5% of patients. Despite this, the generalized TF estimated central arterial pressures to ≤0.2±3.8 mm Hg error, arterial compliance to 6±7% accuracy, and augmentation index to within −7% points (30±45% accuracy). Individual TFs were only marginally superior to the generalized TF for reconstructing central pressures. Conclusions Central aortic pressures can be accurately estimated from radial tonometry with the use of a generalized TF. The reconstructed waveform can provide arterial compliance estimates but may underestimate the augmentation index because the latter requires greater fidelity reproduction of the wave contour.
1,211 citations
TL;DR: This preliminary study revealed that frequent nocturnal hemodialysis improved left ventricular mass, reduced the need for blood pressure medications, improved some measures of mineral metabolism, and improved selected measures of quality of life.
Abstract: ContextMorbidity and mortality rates in hemodialysis patients remain excessive. Alterations in the delivery of dialysis may lead to improved patient outcomes.ObjectiveTo compare the effects of frequent nocturnal hemodialysis vs conventional hemodialysis on change in left ventricular mass and health-related quality of life over 6 months.Design, Setting, and ParticipantsA 2-group, parallel, randomized controlled trial conducted at 2 Canadian university centers between August 2004 and December 2006. A total of 52 patients undergoing hemodialysis were recruited.InterventionParticipants were randomly assigned in a 1:1 ratio to receive nocturnal hemodialysis 6 times weekly or conventional hemodialysis 3 times weekly.Main Outcome MeasuresThe primary outcome was change in left ventricular mass, as measured by cardiovascular magnetic resonance imaging. The secondary outcomes were patient-reported quality of life, blood pressure, mineral metabolism, and use of medications.ResultsFrequent nocturnal hemodialysis significantly improved the primary outcome (mean left ventricular mass difference between groups, 15.3 g, 95% confidence interval [CI], 1.0 to 29.6 g; P = .04). Frequent nocturnal hemodialysis did not significantly improve quality of life (difference of change in EuroQol 5-D index from baseline, 0.05; 95% CI, −0.07 to 0.17; P = .43). However, frequent nocturnal hemodialysis was associated with clinically and statistically significant improvements in selected kidney-specific domains of quality of life (P = .01 for effects of kidney disease and P = .02 for burden of kidney disease). Frequent nocturnal hemodialysis was also associated with improvements in systolic blood pressure (P = .01 after adjustment) and mineral metabolism, including a reduction in or discontinuation of antihypertensive medications (16/26 patients in the nocturnal hemodialysis group vs 3/25 patients in the conventional hemodialysis group; P < .001) and oral phosphate binders (19/26 patients in the nocturnal hemodialysis group vs 3/25 patients in the conventional dialysis group; P < .001). No benefit in anemia management was seen with nocturnal hemodialysis.ConclusionThis preliminary study revealed that, compared with conventional hemodialysis (3 times weekly), frequent nocturnal hemodialysis improved left ventricular mass, reduced the need for blood pressure medications, improved some measures of mineral metabolism, and improved selected measures of quality of life.Trial Registrationisrctn.org Identifier: ISRCTN25858715
670 citations