Abstract
BackgroundDry weight assessment in hemodialysis (HD) remains a challenge. The aim of the study was to investigate the prevalence of subclinical pulmonary congestion using lung ultrasound (LUS) in maintenance HD patients with no clinical or bioimpedance signs of hyperhydration. The correlation between B-lines Score (BLS) and brain natriuretic peptide (BNP) was also evaluated.MethodsTwenty-four HD patients underwent LUS and BNP dosage at the end of the mid-week HD session, monthly for 6 months . LUS was considered as positive when BLS was >15. Hospitalizations and cardiovascular events were also evaluated in relation to the BLS.ResultsLUS+ patients at baseline were 16 (67%), whereas 11 (46%) showed LUS + in at least 50% of the measurements (rLUS+ patients). Only the rLUS+ patients had a higher number of cardiovascular events [p=0.019, OR: 7.4 (CI 95%. 1.32-39.8)] and hospitalizations [p=0.034, OR 5.5 (CI 95% 1.22- 24.89)]. A BNP level of 165 pg/ml was identified as cut-off value for predicting pulmonary congestion, defined by BLS >15.ConclusionPrevalence of pulmonary congestion as assessed by LUS and persistent or recurrent BLS >15 were quite prevalent findings in euvolemic HD patients. In the patients defined as rLUS+, a higher rate of cardiovascular events and hospital admissions was registered. BNP serum levels > 165 pg/ml resulted predictive of pulmonary congestion at LUS. In the dialysis care, regular LUS examination should be reasonably included among the methods useful to detect subclinical lung congestion and to adjust patients’ dry weight.
Highlights
Dry weight assessment in hemodialysis (HD) remains a challenge
brain natriuretic peptide (BNP) serum levels may be useful as marker of hyper-hydration; its concentration may be affected by multiple factors but it may be assumed as a marker of myocardial cell distension in response to circulating volume overload
This study shows that the presence of pulmonary congestion as detected by lung ultrasound is quite prevalent in HD patients, even when no clinical or instrumental signs of hyperhydration exist
Summary
Dry weight assessment in hemodialysis (HD) remains a challenge. The aim of the study was to investigate the prevalence of subclinical pulmonary congestion using lung ultrasound (LUS) in maintenance HD patients with no clinical or bioimpedance signs of hyperhydration. Physical examination includes the presence of dyspnea, shortness of breath, peripheral edema, rales at pulmonary auscultation, peritoneal or pleural effusion, or uncontrolled hypertension Bioelectrical impendance analysis, both as multifrequence and as monofrequence technique, is able to estimate body fluid volumes and give clinician a valid instrument to asses changes in body fluids with time. BNP serum levels may be useful as marker of hyper-hydration; its concentration may be affected by multiple factors but it may be assumed as a marker of myocardial cell distension in response to circulating volume overload All these three methods may be affected by body volume changes, that is a crucial point in the real life care of the hemodialysis patients. LUS can detect extra vascular lung water, a relatively small but fundamental component of body fluid volumes and, at the same time, quantify lung congestion. A European multicenter trial is underway to test LUS, as systematic monitoring of “lung water”, to reduce mortality through correct definition of dry weight, evaluating heart failure and acute cardiac injury, especially for high risk patients (history of myocardial infarction, stable and unstable angina, NYHA III-IV) (https://clinicaltrials.gov n.NCT02310061) [11]
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