Abstract
BackgroundVolume overload poses a major risk in hemodialysis patients but simple detection methods are lacking. We propose a novel marker, the Interdialytic Creatinine Rise (IDCR), readily calculated as the change in serum creatinine over time (in mg/dL/h), to assess volume overload and predict mortality risk in hemodialysis patients.MethodsFirst, we calculated IDCR changes with volume in a prospective cohort of 35 hospitalized hemodialysis patients awaiting hemodialysis and 33 hospitalized patients undergoing hemodialysis every other day. Second, in a prospective cohort of 25 outpatients, IDCR cutoff values associated with hypervolemia were determined between two treatments and compared with simultaneous volume assessments by their nephrologist. Third, IDCR as a mortality predictor was studied using survival analysis in a longitudinal retrospective cohort study of 39 maintenance hemodialysis patients followed from 2012 until death or 2017.ResultsIDCR decreased by − 0.014 mg/dL/h each day (95%CI − 0.017,− 0.010; p < 0.001) without dialysis due to fluid volume gain and increased by 0.013 mg/dL/h (95%CI 0.008,0.017; p < 0.001) from before to after each successive hemodialysis due to fluid removal.Choosing an IDCR cutoff value of ≤0.1 had sensitivity of 82% and specificity of 79% in diagnosing volume overload with the area under the ROC curve of 0.78 (95%CI 0.59,0.97).The hazard ratio of death for each 0.01 decrease in IDCR was 1.64 (95%CI 1.31,2.07; p < 0.001). If IDCR decreased to less than 0.05 mg/dL/h, the median survival was 32 days and the odds ratio of death within 2 months was 38 (95%CI 8, 131; p < 0.001).ConclusionsIn this pilot study, IDCR is shown to be a novel metric that decreases with fluid retention and increases after fluid removal. IDCR can assist clinicians in detection or exclusion of volume overload in hemodialysis patients and provide prognostic value in identifying those at high risk for death.
Highlights
Volume overload poses a major risk in hemodialysis patients but simple detection methods are lacking
The rate of increase of serum creatinine concentration between hemodialysis sessions depends upon two opposing processes – net creatinine retention due to its production with minimal excretion opposed by fluid intake increasing the total body volume diluting the creatinine concentration
Study 1: Evaluation of Interdialytic Creatinine Rise (IDCR) changes with volume in hospitalized hemodialysis patients We tested the hypothesis that the calculated IDCR decreases as volume is gained in patients awaiting hemodialysis and increases after hemodialysis as volume is removed by ultrafiltration
Summary
Volume overload poses a major risk in hemodialysis patients but simple detection methods are lacking. We theorized that this new measure, the IDCR, calculated as the difference between two serum creatinine concentrations from the same interdialytic period divided by the time difference of respective blood sample collections (expressed in mg/dL per hour), would be closely related to total body volume and could serve as a marker of volume overload. In this pilot study, we have demonstrated that low IDCR values are associated with volume overload, and when very low, are indicative of a markedly increased risk of patient mortality
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