Intravascular Volume Depletion Research Articles

Does Routine Bioimpedance-Guided Fluid Management Provide Additional Benefit to Non-Anuric Peritoneal Dialysis Patients? Results from COMPASS Clinical Trial.

In peritoneal dialysis (PD) patients, volume overload is related to cardiac dysfunction and mortality, while intravascular volume depletion is associated with a rapid decline in the residual renal function (RRF). This study sought to determine the clinical usefulness of bioimpedance spectroscopy (BIS)-guided fluid management for preserving RRF and cardiac function in PD patients. This is a multicenter, prospective, open-label study that was conducted over a 1-year period (NCT01887262). Non-anuric (urine volume > 500 mL/day) subjects on PD were enrolled. Subjects in the control group received fluid management based on the clinical information alone. Those in the BIS group received BIS-guided fluid management along with clinical information. The subjects (N = 137, mean age 51.3 ± 12.8 years, 54% male) were randomly assigned to the BIS group (n = 67) or to the control group (n = 70). There were no significant differences between the 2 groups with regard to age, sex ratio, cause of kidney failure, duration of PD, baseline comorbidity, RRF, PD method, or peritoneal transport type. At baseline, the 2 groups were not different in terms of RRF (glomerular filtration rate [GFR], 5.1 ± 2.9 vs 5.5 ± 3.7 mL/min/1.73 m2). After follow-up, changes in the GFR between the 2 groups were not different (-1.5 ± 2.4 vs -1.3 ± 2.6 mL/min/1.73 m2, p = 0.593). Over the 1-year study period, both groups maintained stability of various fluid status parameters. Between the 2 groups, there were no differences in the net change of various fluid status parameters such as overhydration (OH) and extracellular water/total body water (ECW/TBW). A net change in ECW over 1 year was slightly but significantly higher in the control group (net increase, 0.57 ± 1.27 vs 0.05 ± 1.63 L, p = 0.047). However, this difference was not translated into an improvement in RRF in the BIS group. There were no differences in echocardiographic parameters or arterial stiffness at the end of follow-up. Routine BIS-guided fluid management in non-anuric PD patients did not provide additional benefit in volume control, RRF preservation, or cardiovascular (CV) parameters. However, our study cannot be generalized to the whole PD population. Further research is warranted in order to investigate the subpopulation of PD patients who may benefit from routine BIS-guided fluid management.

The Case | Labile creatinine levels in a patient with breast cancer

The Case | Labile creatinine levels in a patient with breast cancer

This Is the Year to Listen to Yourself.

This Is the Year to Listen to Yourself.

An unusual case of relative polycythemia with complication of pseudocyst of pancreas

Relative polycythemia is a term used to describe an elevation of the hematocrit level either caused by an acute transient state of hemoconcentration associated with intravascular fluid depletion or a chronic sustained relative polycythemia caused by contraction of the plasma volume. Relative polycythemia can occur when the plasma volume is reduced due to intravascular volume depletion during acute pancreatitis episode, complicating as pseudocyst of pancreas. We report a case of Relative Polycythemia with pseudocyst of Pancreas a secondary complication of pancreatitis.

Vascular contractile reactivity in hypotension due to reduced renal reabsorption of Na+ and restricted dietary Na.

Reduced renal Na+ reabsorption along with restricted dietary Na+ depletes intravascular plasma volume which can then result in hypotension. Whether hypotension occurs and the magnitude of hypotension depends in part on compensatory angiotensin II-mediated increased vascular resistance. We investigated whether the ability of vascular resistance to mitigate the hypotension was compromised by decreased contractile reactivity. In vitro reactivity was investigated in aorta from mouse models of reduced renal Na+ reabsorption and restricted dietary Na+ associated with considerable hypotension and renin-angiotensin system activation: (1) the Na+-Cl--Co-transporter (NCC) knockout (KO) with Na+ restricted diet (0.1%, 2weeks) and (2) the relatively more severe pendrin (apical chloride/bicarbonate exchanger) and NCC double KO. Contractile sensitivity to KCl, phenylephrine, and/or U46619 remained unaltered in aorta from both models. Maximal KCl and phenylephrine contraction expressed as force/aorta length from NCC KO with Na+-restricted diet remained unaltered, while in pendrin/NCC double KO were reduced to 49 and 64%, respectively. Wet weight of aorta from NCC KO with Na+-restricted diet remained unaltered, while pendrin/NCC double KO was reduced to 67%, consistent with decreased medial width determined with Verhoeff-Van Gieson stain. These findings suggest that hypotension associated with severe intravascular volume depletion, as the result of decreased renal Na+ reabsorption, may in part be due to decreased contractile reactivity as a consequence of reduced vascular hypertrophy.

Acute Dehydration in Nephrotic Syndrome: A Case Report

The management of acutely dehydrated children with relapsed nephrotic syndrome (NS) can be challenging when edema and intravascular volume depletion are present simultaneously. In that condition the excess in body fluid, typically associated with NS, may be inappropriately low, with regard to albumin level, and the excess in fluid is not promptly shifted into the vascular bed because of the low plasma protein concentration. This peculiar condition exposes the child to a greater risk of acute kidney injury (AKI) particularly if albumin infusion is provided. Here in a case of dehydration in ongoing NS is described in order to highlight the danger of infusing albumin when dehydration coexists. The present case report provides a framework for discussing an unusual and preventable pathophysiological mechanism of AKI related to the inappropriate administration of albumin infusion.

Burn State of the Science

Recognition of fluid creep has driven a large amount of the scientific investigation in the area of acute fluid resuscitation for burn patients. The role of colloids in ameliorating fluid creep is controversial, despite the fact that a fluid-sparing effect of colloids has been recognized for some time. All but one of the available prospective studies using colloids are more than a decade old, and a modern randomized controlled trial (RCT) comparing crystalloids to colloids is long overdue. While urinary output continues to be the main endpoint for fluid titration, there has been a moderate amount of interest in the use of transpulmonary thermodilution to guide fluid resuscitation. The available studies have found that transpulmonary thermodilution has had an inconsistent effect on limiting fluid resuscitation volumes and improving clinical outcomes. Computerized Decision Support Systems show great promise in optimizing fluid titration and reducing fluid resuscitation volumes, and an RCT comparing Computerized Decision Support Systems with conventional titration approaches will be the important next step. Use of high-dose vitamin C (ascorbic acid) has become a popular approach to limit fluid resuscitation volumes and edema formation, but it has been investigated in only two clinical studies: one a pseudo-randomized prospective study and the other a retrospective study. Improvements in clinical outcome have not been convincingly demonstrated, and concerns persist surrounding the possibility of induction of an osmotic diuresis, leading to intravascular volume depletion. An RCT is urgently required to evaluate high-dose vitamin C as an adjunct to crystalloid resuscitation compared with the use of crystalloids alone.

Minimal Change Disease.

Minimal change disease (MCD) is a major cause of idiopathic nephrotic syndrome (NS), characterized by intense proteinuria leading to edema and intravascular volume depletion. In adults, it accounts for approximately 15% of patients with idiopathic NS, reaching a much higher percentage at younger ages, up to 70%-90% in children >1 year of age. In the pediatric setting, a renal biopsy is usually not performed if presentation is typical and the patient responds to therapy with oral prednisone at conventional doses. Therefore, in this setting steroid-sensitive NS can be considered synonymous with MCD. The pathologic hallmark of disease is absence of visible alterations by light microscopy and effacement of foot processes by electron microscopy. Although the cause is unknown and it is likely that different subgroups of disease recognize a different pathogenesis, immunologic dysregulation and modifications of the podocyte are thought to synergize in altering the integrity of the glomerular basement membrane and therefore determining proteinuria. The mainstay of therapy is prednisone, but steroid-sensitive forms frequently relapse and this leads to a percentage of patients requiring second-line steroid-sparing immunosuppression. The outcome is variable, but forms of MCD that respond to steroids usually do not lead to chronic renal damage, whereas forms that are unresponsive to steroids may subsequently reveal themselves as FSGS. However, in a substantial number of patients the disease is recurrent and requires long-term immunosuppression, with significant morbidity because of side effects. Recent therapeutic advances, such as the use of anti-CD20 antibodies, have provided long-term remission off-therapy and suggest new hypotheses for disease pathogenesis.

A case of tubo-ovarian abscesses due to Corynebacterium striatum which was able to be treated with immediately operation intervention

In the past 25 years the treatment of shock in myocardial infarction has evolved into a physiologic approach based on on-line measurements of hemodynamic variables. This has aided in the development of new pressor agents so that a family of pharmacologic agents is now available. Appropriate use of vasodilators and recognition and treatment of intravascular volume depletion have increased survival. Recognition and appropriate treatment of the preshock state have decreased the incidence of shock. The criteria for use of mechanical support and surgical intervention are soundly established; the use of thrombolytic therapy and balloon angioplasty for this syndrome is ready to be evaluated.

Nephrotoxicity of anticancer treatment.

Severe adverse systemic drug events occur commonly as a result of treatment of cancer patients. Nephrotoxicity of chemotherapeutic agents remains a significant complication limiting the efficacy of the treatment. A variety of renal disease and electrolyte disorders can result from the drugs that are used to treat malignant disease. The kidneys are a major elimination pathway for many antineoplastic drugs and their metabolites. Tumour lysis syndrome, an emergency in haematooncology, occurs most often after the initiation of cytotoxic therapy in patients with high-grade lymphomas and acute lymphoblastic leukaemia. Chemotherapeutic agents can affect the glomerulus, tubules, interstitium and renal microvasculature, with clinical manifestations that range from asymptomatic elevation of serum creatinine to acute renal failure requiring dialysis. Some factors such as intravascular volume depletion, as well as concomitant use of other drugs or radiographic ionic contrast media, can potentiate or contribute to the nephrotoxicity. Cytotoxic agents can cause nephrotoxicity by a variety of mechanisms. The most nephrotoxic chemotherapeutic drug is cisplatin, which is often associated with acute kidney injury. Many other drugs such as alkylating agents, antimetabolites, vascular endothelial growth factor pathway inhibitors and epidermal growth factor receptor pathway inhibitors may have toxic effects on the kidneys. The aim of this review is to discuss the issue of nephrotoxicity associated with chemotherapy. In routine clinical practice, monitoring of kidney function is mandatory in order to identify nephrotoxicity early, allowing dosage adjustments or withdrawal of the offending drug.

OS 19-04 CHRONIC DIURETIC THERAPY DOES NOT IMPAIR THE EFFECTIVENESS OF PATIROMER IN HYPERKALEMIC PATIENTS WITH CKD

Objective: Diuretics, alone or in combination, are frequently prescribed in chronic kidney disease (CKD) and heart failure (HF) patients to reduce volume, blood pressure, and/or for symptom control. Clinicians may also use them to reduce the risk of hyperkalemia, but high doses of diuretics may lead to adverse events from intravascular volume depletion or gout. Patiromer is a non-absorbed K+-binding polymer recently approved by the FDA for the treatment of hyperkalemia (HK). We compared patiromer's effects in RAASi-treated CKD patients with HK on different types of diuretics to patients not receiving diuretics in the treatment phase of OPAL-HK. Design and Method: CKD patients (n = 243) with baseline serum K+ 5.1 to < 6.5 mEq/L on RAASi received patiromer (4.2 or 8.4 g twice daily to start) in the 4-week treatment phase of OPAL-HK. For this post hoc analysis, change in serum-K+ from baseline to week 4 was assessed in patients stratified by baseline diuretic use: 1) loop only, 2) thiazide/thiazide-like only, 3) combination of loop and thiazide/thiazide-like, 4) any (alone or in combination), and 5) none. Subjects receiving aldosterone antagonists alone were allocated to the “No Diuretics” group. Results: Across groups, mean (SD) age ranged from 62.9 (10.5) to 65.4 (8.6) years and % male from 51% to 67%. Mean serum K+ decreased from baseline at week 4 in all subgroups (Table). Reductions in serum K+ did not differ in patients receiving any diuretic vs those not on diuretics. Patiromer was well tolerated; mild-to-moderate constipation was the most common AE (14.4% and 7.6%, respectively, in patients not on diuretics and on any diuretics), with 1 patient in each group discontinuing. Hypokalemia (serum K +< 3.5 mEq/L) was reported in 3.7% and 2.3%, respectively Conclusions: The serum K+-lowering efficacy of patiromer in HK patients was unaffected by concomitant diuretics.

111 - Plasma Volume is Normal but Heterogeneously Distributed and True Anemia is Highly Prevalent in Patients with Stable Heart Failure

Background: Both intravascular volume overload and depletion as well as anemia are associated with increased hospital admissions and mortality in patients with heart failure. The purpose of this study was to accurately measure plasma volume and red cell mass (RCM) in stable patients with chronic heart failure with reduced ejection fraction (HFrEF) and gain more insight into plasma volume regulation and anemia in stable conditions of HFrEF. Methods and Results: Plasma volume and RCM measurement based on 99Tc-labeled red blood cells, venous blood samples and clinical parameters were obtained in 24 stable HFrEF patients under optimal medical therapy. Measured plasma volume values were compared with predicted values based on body surface area. Plasma volume was on average normal (99,98% of predicted) but heterogeneously distributed (variations of 81% up to 133%). Neurohumoral activation and medication use were not associated with plasma volume status. Furthermore, anemia based on measurement of RCM was more prevalent than anemia based on hemoglobin concentration and present in up to 75% of subjects, but exceptional dilutional. Conclusion: In stable chronic HFrEF patients under optimal medical therapy, plasma volume is overall normal but heterogeneously distributed. Anticipated factors such as neurohumoral activation and heart failure medication were not associated with plasma volume status. Furthermore, anemia is more common than assessed by hemoglobin.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Vascular refilling is independent of volume overload in hemodialysis with moderate ultrafiltration requirements.

Introduction Blood volume changes and vascular refilling during hemodialysis (HD) and ultrafiltration (UF) have been assumed to depend on volume overload (Vo ). It was the aim to study the magnitude of vascular refilling in stable HD patients with moderate volume expansion in everyday dialysis using novel technical approaches. Methods Patients were studied during routine dialysis and UF based on clinical dry weight assessment. Pre-dialysis Vo was independently measured by bioimpedance spectroscopy. Vascular refilling volume (Vref ) was calculated as: Vref = Vuf - ΔV, where ΔV is the absolute blood volume change determined by on-line dialysate dilution using a commercial on-line hemodiafiltration machine incorporating a relative blood volume monitor, and where Vuf is the prescribed UF volume. Findings Thirty patients (dry weight: 81.0 ± 17.8 kg) were studied. Pre-dialysis Vo was 2.46 ± 1.45 L. Vuf was 2.27 ± 0.71 L, specific UF rate was 6.45 ± 2.43 mL/kg/h, and since ΔV was 0.66 ± 0.31 L, Vref was determined as 1.61 ± 0.58 L, corresponding to a constant refilling fraction (Fref ) of 70.6 ± 10.6%. Vref strongly correlated with Vuf (r(2) = 0.82) but was independent of Vo and other volumes. Fref was also independent of Vo and other volumes normalized for various measures of body size. Discussion While vascular refilling and Fref is independent of Vo in treatments with moderate UF requirements, intravascular volume depletion increases with increasing UF requirements. The relationship between blood volume and Vo needs to be more closely examined in further studies to optimize volume control in everyday dialysis.

Management of Cardio-Renal Syndrome and Diuretic Resistance.

Diuretic resistance in acute heart failure has emerged as a powerful predictor of adverse outcome, which is often independent of underlying glomerular filtration rate (GFR). Metrics of diuretic efficacy differ in their accuracy, convenience, and biological plausibility, which should be taken into account when interpreting their results. Loop diuretic efficacy depends on adequate delivery of both the pharmacological agent itself and its substrate (i.e., sodium chloride) to the loop diuretic site of action at the luminal side of the thick ascending limb of Henle's loop. This requires an adequate dosing strategy, with higher doses needed when GFR is low. Importantly, the kidneys are able only to regulate the effective circulatory volume. Thus, specific problems of intravascular volume depletion and poor cardiac output with impaired renal perfusion should be addressed. Addition of thiazide-type diuretics should be considered when a progressive decrease in loop diuretic efficacy is observed with prolonged use (i.e., the braking phenomenon). Furthermore, thiazide-type diuretics are a useful addition in patients with low GFR to maximally boost fractional sodium excretion when nephron perfusion is poor. However, thiazide-type diuretics limit free water excretion and should be withheld in cases of hypotonic hyponatremia. Mineralocorticoid receptor antagonists (MRA) and acetazolamide are interesting options to increase loop diuretic efficacy, but further study is needed to assess whether improved diuretic efficacy also translates into clinical outcome benefits. Finally, ultrafiltration should be considered in patients with refractory diuretic resistance as persistent volume overload after decongestive treatment is associated with worse outcomes. Whether more upfront use of individually tailored ultrafiltration is superior to pharmacological therapy remains to be shown by adequately powered randomized clinical trials.

Republication: Correlations between venous collapsibility and common hemodynamic and ventilatory parameters: A multivariable assessment

Introduction: Although the venous collapsibility index (VCI) and central venous pressure (CVP) have been shown to correlate reasonably well, little has been reported on the relationships between VCI and other commonly used hemodynamic variables (i.e., HR, blood pressure). This is a retrospective, post hoc analysis of data from a recently completed 3-year prospective study of VCI in critically ill and injured patients. Materials and Methods: A total of 267 previously recorded data pairs in a group of 82 adults (≥18 to Results: Male patients had significantly greater maximum IVC diameters (2.12 ± 0.89 cm) than female patients (1.81 ± 0.61 cm,P 50%) more accurately correlated to expected SBP and DBP behavior. Conclusions: These preliminary results suggest that DBP may correlate with volume status-based VCI behavior than either SBP or MAP and that VCI may be more accurate in patients experiencing intravascular volume depletion. While these findings are not entirely surprising, further studies are warranted to improve our understanding of the clinical implications and relevance of these findings. The following core competencies are addressed in this article: Medical knowledge, Patient care. Republished with permission from: Patil P, Kelly N, Papadimos TJ, Bahner DP, Stawicki SP. Correlations between venous collapsibility and common hemodynamic and ventilatory parameters: A multi-variable assessment. OPUS 12 Scientist 2014;8(1):1-5.

Relative polycythemia in acute pancreatitis: a series of case report

Polycythemia is an unusual manifestation of acute pancreatitis. When polycythemia does occur, it is almost invariably due to intravascular fluid depletion, contraction of Plasma volume, Gaisbock’s Syndrome, Primary congenital and familial polycythemia, polycythemia vera, Hypoxia as in high altitude, pulmonary cyanotic congenital heart diseases, hypoventilation syndromes like sleep apnea, Smoker’s Polycythemia, carbonmonoxide intoxication caused by industrial exposure, Erythropoietin secreting tumors, post renal transplantation erythrocytosis and congenital polycythemias. This case series report presents four patients with acute pancreatitis and relative polycythemia due to reduction in plasma volume as a result of intravascular volume depletion, as demonstrated by Haemoglobin and Hematocrit during acute pancreatitis and the significance of this association is discussed. Among the case series, the case 1 was relative polycythemia with acute pancreatitis presented as pseudocyst, whereas the case 2, 3 and 4 presented as relative polycythemia with necrotizing pancreatitis. The clinical course of the patient suggested that the relative polycythemia developed subsequent to the clinical onset of acute pancreatitis. It is believed that this represents the first recorded case series in the English Literature of acute pancreatitis with Relative Polycythemia due to reduction in plasma volume as a result of intravascular volume depletion. Four Patients presented with Relative polycythemia during acute pancreatitis was found.

Perioperative care of infants with pyloric stenosis.

Pyloric stenosis (PS) is one of the most common surgical conditions affecting neonates and young infants. The definitive treatment for PS is surgical pyloromyotomy, either open or laparoscopic. However, surgical intervention should never be considered urgent or emergent. More importantly, emergent medical intervention may be required to correct intravascular volume depletion and electrolyte disturbances. Given advancements in surgical and perioperative care, morbidity and mortality from PS should be limited. However, either may occur related to poor preoperative resuscitation, anesthetic management difficulties, or postoperative complications. The following manuscript reviews the current evidence-based medicine regarding the perioperative care of infants with PS with focus on the preoperative assessment and correction of metabolic abnormalities, intraoperative care including airway management (particularly debate related to rapid sequence intubation), maintenance anesthetic techniques, and techniques for postoperative pain management. Additionally, reports of applications of regional anesthesia for either postoperative pain control or as an alternative to general anesthesia are discussed. Management recommendations are provided whenever possible.

Medical students can easily acquire intraosseous cannulation skills

Background In life-threatening emergencies with intravascular volume depletion, shock, or even cardiac arrest, obtaining conventional intravascular access can be difficult due to peripheral vascular shutdown. Intraosseous (IO) access is recommended during resuscitation when conventional intravenous access is difficult and is a fast and safe method for administration of fluids, blood products, and medications. However, lack of training in the procedure may be a reason why the use of the IO access is still limited in resuscitation. The goal of this study was to investigate if medical students can obtain competencies in IO access taught on a human cadaver course.

65-Year-Old Woman With Intermittent Fevers, Lower Extremity Paresthesia, Weight Loss, and Malaise

65-Year-Old Woman With Intermittent Fevers, Lower Extremity Paresthesia, Weight Loss, and Malaise

Urinary neutrophil gelatinase-associated lipocalin as an early predictor of disease severity and mortality in acute pancreatitis.

In reference to our earlier publication, laboratory tests that reflect severe intravascular volume depletion can be used for predicting the severity of acute pancreatitis (AP). The aim of the study was to assess whether urinary level of neutrophil gelatinase-associated lipocalin (NGAL) could represent a useful marker of AP severity. We observed a cohort of 104 prospectively enrolled patients. The patients were classified into 3 groups: mild AP, moderately severe AP, and severe AP. Urine samples were collected on admission (NGAL-as) and during the first 24 hours (NGAL-first day) for examination of urinary level of NGAL concentrations from the first day. Acute pancreatitis was considered severe in 16 (15%) patients, moderately severe in 25 (24%) patients, and mild in 63 (61%) patients.There were statistically significant trends for an increase in severity (P = 0.04, P = 0.003) and mortality (P < 0.031, P = 0.01) with raising NGAL-as and NGAL-first day concentrations, respectively. The areas under the curve for severity predicted by NGAL-as and NGAL-first day were 0.75 and 0.93, respectively. The areas under the curve for mortality prediction by NGAL-as and NGAL-first day were 0.980 and 0.92, respectively. The urinary level of NGAL is a promising new diagnostic and prognostic factor for severe AP in an early stage of the disease.