Fluid Overload Research Articles

#1988 VExUS score as a method to guide diuretic treatment in CKD patients with congestive nephropathy by right heart failure

Abstract Background and Aims Congestive nephropathy is a kidney dysfunction caused by the impact of elevated venous pressures on renal hemodynamics and most of all it is due to right heart failure. Venous congestion can lead to a circulation vicious hormonal activation, increased intra-abdominal pressure, excessive renal tubular reabsorption of sodium and volume overload. In CKD with right heart failure, management of the patient is difficult because may be hard to identify a condition of fluid overload and when to stop intravenous diuretic treatment. Inferior caval vein (ICV) diameter and ICV index (reduction of diameter with respiration) have been used to identify fluid overload and guide diuretic treatment. However, in CKD patients with heart failure the ICV may not change rapidly and could overestimate the need of intravenous diuretics. This is why VExUS has been useful in both diagnosis and monitoring therapeutic. The VExUS method is a new approach, documented in the literature for the first time once in 2020. In this study we report the usefulness of the VExUS (Venous Excess Ultrasound Score) method for the diagnosis of overload volume and venous congestion and in setting an adequate therapy. It consists of Doppler evaluation of the abdominal veins: hepatic, portal and intrarenal. In fact, the acute renal failure, in the patients studied, is to be attributed in the first instance to venous congestion rather than underfilling, resulting from decompensation and therefore requiring diuretic therapy. Method This retrospective study was conducted in CKD patients (stages 3-4) with acute kidney injury (creatinine level: 6.3-2.6 mg/dl) due to right heart failure admitted at the U.O.C. Nephrology at the S. Maria della Pietà Hospital in Nola and UOC Nephrology of Univ. of Campania. The VExUS method defines 3 degrees (score 0-3) of congestion based on the severity of the anomalies on hepatic, portal and intrarenal venous Doppler. All patients have been treated with diuretics i.v. based on a VEXUS score>1, and then returned to oral treatment when VEXUS score returned to 0. VExUS assessment was performed at admission, repeated every 48 hours and the last score has been considered here (on average 1 week). The relationship between change in VExUS score and ICV index vs creatinine levels was studied by correlation analysis. Lung POCUS (point of care pulmonary ultrasonography) has also been used for all patients to identify a possible contemporary overload caused by LV failure. Results Thirty patients have been included. The use of diuretics reduced the VExUS score and the ICV diameter. However, diuretic treatment changed the ICV diameter by a smaller extent (−30%) compared to the VExUS score (−80%), and one patient showed clear reduction of VExUS score, without any modification of the ICV diameter, suggesting that the latter is a slower indicator of recovery compared to VExUS. Indeed, the change of VExUS score was highly correlated to the improvement of creatinine levels (Pearson's correlation 0.837, p < 0.001). The change of IVC diameter explained in comparison a smaller amount of variability of the creatinine improvement (Pearson's correlation 0.65, p = 0.008). Conclusion VExUS is a promising and reliable tool in the management of congestive nephropathy in patients with CKD and right heart failure. VExUS is superior to VCI diameter and should be used routinely, along with clinical, laboratory, and other ultrasound parameters, because of its usefulness, repeatability, low cost and ease of execution.

#201 Bedside lung ultrasound and bioimpedance spectroscopy for assessment of volume status in chronic kidney disease patients on hemodialysis

Abstract Background and Aims Fluid balance is important in patients with chronic kidney disease undergoing hemodialysis (HD). Majority of HD treatment incorporate a prescription for fluid removal targeted to patient's dry weight. Overestimation of dry weight causes hypertension, left ventricular hypertrophy and heart failure, while underestimation is responsible for chronic dehydration leading to the risk of hypotension. Both complications have a significant impact on the overall morbidity and mortality. Dry weight of the patient is usually assessed by using clinical parameters (edema, BP, JVP etc.), Biochemical parameters (BNP, ANP), Bioimpedance Spectroscopy (BIS) or IVC diameter and collapsibility on ultrasound (VCI index). The use of chest ultrasound to detect lung water has recently received growing attention in clinical research. Ultrasonographic lung comets (counting B-lines artifact) evaluate extravascular lung water and hence is considered as a useful tool to evaluate the hydration status of hemodialysis patients. This study aims to compare the efficacy of body fluid volume status and lung water assessment by clinical methods, Ultrasound chest and Bioimpedance Spectroscopy in chronic kidney disease patients on hemodialysis. Method A cross-sectional study was conducted over a period of 6 months. Dry weight of the patient was assessed by the attending nephrologist based on clinical criteria such as: weight, blood pressure, presence of edema or vascular congestion. A Longitudinal Ultrasound scan of the chest was performed using MicroMaxx Ultrasound System with patient in supine position from second to fourth intercostal space of left hemi-thorax and second to fifth intercostal space of right hemi-thorax along parasternal, midclavicular, anterior axillary and midaxillary lines of each side in a total of 28 sectors. B-lines were defined as hyperechogenic linear artifact emerging from the pleural line, up to the bottom of the screen. Pre and Post dialysis comet score was determined by calculating the total B-lines in each sector. Bioimpedance spectroscopy using Bodystat QuadScan 4000 was performed. Pre and post dialysis total body water (TBW), intracellular water (ICW), extracellular water (ECW) and residual fluid overload (ECW pre HD- ECW post HD) were recorded. Results We conducted 100 assessments on 34 patients presenting to the hospital for maintenance hemodialysis. The mean age of the study population was 54.3 + 11 years with a sex ratio (M/F) of 6:1. Mean systolic blood pressure was 141.1 + 19 mmHg and diastolic blood pressure was 83 + 9.3 mmHg with 3 episodes of intradialytic hypotension. The mean dry weight was 59.8 + 10 Kg and weight gain by clinical assessment was 2.1 + 1.5 Kg. Comet score assessed by ultrasound chest had a mean of 4.54 + 2.53 before dialysis and 1.73 ± 1.36 after dialysis. Residual fluid overload on Bio impedance spectroscopy was 1.11 ± 0.85 litre. The residual fluid overload on Bio impedance spectroscopy and lung ultrasound comet score after dialysis had a significant correlation (p value <0.0001). Of the 100 assessments, 40% had fluid overload after dialysis on Bio impedance and 35% had lung congestion on ultrasound chest even after achieving euvolemia according to the dry weight assessed clinically. Conclusion Lung comets on ultrasound chest and residual volume on bio impedance spectroscopy may precede the development of clinical sign and symptoms in a patient. Therefore, these methods are superior to clinical volume status assessment in chronic kidney disease patients on hemodialysis.

#2532 Identifying risk factors and protective strategies for pulmonary hypertension in chronic hemodialysis patients

Abstract Background and Aims Pulmonary hypertension (PH) is commonly observed and is a predictor of mortality among individuals with end-stage renal disease (ESRD). However, the risk factors associated with PH and its treatment methods have not been thoroughly researched in patients undergoing chronic hemodialysis. Our objective is to investigate the risk factors and explore potential protective measures for PH in patients undergoing chronic hemodialysis. Method From January 1st to December 31st of 2015, 116 patients at a hemodialysis (HD) center met the inclusion criterion of receiving maintenance HD for a minimum of three months. None of the patients met any of the exclusion criteria, which included conditions like chronic obstructive pulmonary disease, interstitial lung disease, or liver cirrhosis. Each of these patients underwent echocardiography and bioimpedance spectroscopy (BIS) the day following their HD session. PH was identified in cases where the pulmonary artery systolic pressure exceeded 35 mmHg. Results Out of the cohort, 17 patients (14.7%) were diagnosed with PH, as shown in Table 1. These patients had fewer prescriptions of calcium channel blockers (CCBs; 5.9% vs. 40.4%, P=0.006) and a higher cardiac–thoracic ratio (CTR; 55% vs. 50%, P=0.04) compared to those without PH. Anthropometric measurements were comparable between the patients with and without PH. BIS revealed a higher extracellular water ratio (13.4% vs. 9.1%, P=0.05) and extracellular-to-intracellular (E/I) body water ratio (1.02 vs. 0.96, P=0.049) in patients with PH. In univariate logistic regression analysis, several factors were associated with PH: CCB prescription [odds ratio (OR) 0.092, 95% confidence interval (CI): 0.011–0.723, P=0.023], interventricular septum thickness (IVS, cm; OR 1.19, 95% CI: 1.046–1.355, P=0.008), ejection fraction (%; OR 0.951, 95% CI: 0.916–0.987, P=0.009), and a higher E/I ratio (>1.03; OR 5.333, 95% CI: 1.055–26.95, P=0.043). In the multivariate regression analysis, CCB prescription (OR 0.027, 95% CI: 0.001–0.478, P=0.014) and IVS (OR 1.333, 95% CI: 1.108–1.605, P=0.002) emerged as the strongest predictors of PH, as detailed in Table 2. Conclusion PH is linked to a lower frequency of CCB prescriptions and structural heart disease. Additionally, fluid overload in the trunk and limbs, as indicated by a higher CTR and E/I water ratio, is also associated with PH. Our study suggests that CCBs could protect against PH in ESRD patients. Additionally, previous research indicating that a subset of PH patients responds well to CCBs [1] suggests that ESRD patients might share similar pathophysiological mechanisms with this subset, further supporting the potential use of CCBs in treating PH among ESRD patients.

#598 Successful application of allo-hemodialysis in a porcine model of embolization-induced acute kidney injury

Abstract Background and Aims Annually, millions of kidney patients, primarily in low- and low-middle income nations, die prematurely due to the lack of affordable kidney replacement therapy. We propose a novel, low-cost alternative dialysis modality called allo-hemodialysis (alloHD), where blood of a patient with kidney failure flows counter-current to the blood of a healthy subject (“buddy”) through the dialyzer [1]. Uremic solutes and excess fluid are then excreted by the buddy's healthy kidneys. We have already demonstrated the technical feasibility of alloHD in pigs with acute kidney injury (AKI) induced by renal artery ligation [2]. In this study, we explored alloHD in a less invasive porcine model of AKI induced by renal artery embolization. Method The protocol was approved by the Committee for the Purpose of Control and Supervision of Experiments on Animals (CPCSEA), New Delhi, India. We studied two female Yorkshire pigs (weight 80-90 kg) with central venous catheter as vascular access. AKI was induced by embolization of both kidneys by transcatheter deployment of Contour™ Poly Vinyl Alcohol particles (Boston Scientific, Marlborough, MA, USA). The AKI pig and the buddy pig were connected to the dialysate and blood compartments, respectively, of a Nipro Cellentia 17H dialyzer. The AKI pig was then dialyzed for 4 hours against the healthy buddy pig. During alloHD, both pigs were anticoagulated with heparin (5,000 IU/h) and the buddy pig was sedated with 1-2% isoflurane gas. Blood samples were collected before, during, and after alloHD for measurements of blood urea nitrogen (BUN) and creatinine. Results We performed nine alternate day alloHD sessions with the same pair of pigs. During alloHD, BUN and Creatinine levels declined in the AKI pig (Fig. 1) and increased—as expected—transiently above baseline in the buddy pig and then trended towards baseline post-dialysis (Fig. 1). We found no indication of hemolysis or coagulation of the extracorporeal circuit in any of the nine alloHD sessions. The animals were sacrificed after the 9th session. Conclusion We demonstrated the feasibility of alloHD in a porcine embolization AKI model. This study corroborates and complements our previous experience with alloHD in a porcine model of AKI induced by renal artery ligation. Given these promising results, we are investigating the potential for advancing to a clinical trial.

A double-blinded randomised controlled study of fluid restriction versus liberal fluid during induction of labour: A pilot study.

Excess intravenous fluid for women requiring an induction of labour may adversely affect the duration of labour and maternal/neonatal outcomes. This study aimed to determine the difference in duration of labour and outcomes with a low background infusion rate, compared to liberal background intravenous fluid management. A double blind randomised controlled pilot study was performed on 200 women who underwent induction of labour at a single institution. Women were randomised to an intravenous rate of 40 mL/h versus 250 mL/h of Hartmann's solution. Fluid boluses were strictly controlled to limit bias. This trial was registered with the Australian clinical trial registry: ACTRN12621001298808. Analysis of the total amount of fluid received showed good separation with Group 1 (40 mL/h) receiving 1,736 mL less than Group 2 (250 mL/h), median (interquartile range) 841 mL (458, 1691) versus 2,577 mL (1620, 4326) (P < 0.001). Median duration of labour was shorter in Group 1 by 24 min (P = ns). Subset analysis of nulliparous women showed that duration of labour was shorter in Group 1 by 83.5 min (P = ns). As this was a pilot study, a significant difference in duration of labour or secondary outcomes was not seen. Given the increasing numbers of nulliparous women having an induction of labour, potential for adverse maternal and neonatal outcomes and the associated higher rate of operative birth, this study guides power calculations and supports proof of concept for future research into optimum fluid management during induction of labour for these women.

#1748 The burden of cardiorenal syndrome: epidemiological data and treatment: a one-center experience

Abstract Background and Aims Cardiorenal syndrome (CRS) is an entity combining cardiac and renal dysfunction in a bi-directional way. Six subtypes of CRS have been described, all of which are associated with high morbidity and mortality rates. CRS treatment—no matter the subtype—is until nowadays a field of investigation, aiming to the reduction of fluid overload and venous congestion. The primary endpoint of this study was to estimate the frequency of cardiorenal induced AKI compared to other AKI etiologies in hospitalized patients. We furthermore aimed to determine the burden of the therapeutic regimen in hospitalization duration and renal deterioration. Method This is a retrospective, quantitative analysis of hospitalized adult patients in General Hospital of Athens Hippokration suffering from AKI of various etiologies. No age or sex limitations were used for the purposes of this study. Results A total amount of 1163 patients were enrolled over the course of 18 months. 430 (36.9%) of these patients were hospitalized in the cardiologic department, suffering from either acute or chronic heart failure (66.5% of which were men) with a mean age of 74.4 ± 11.4 years. Mean creatinine level at hospital admission was 2.7 ± 2 mg/dl. Out of these patients, 33.9% were treated using diuretics alone, while 25.5% also needed hemodialysis. Mean number of days of hospitalization was 9.4 ± 5.8 days and 11 ± 8.8 days, while creatinine exit was 2.9 ± 1.5 mg/dl and 4.2 ± 3 mg/dl respectively. Conclusion Cardiorenal syndrome is a quite common cause of AKI in patients being hospitalized. In our study, patients that needed treatment with diuretics compared to those requiring a combination of diuretics and hemodialysis had less days of hospitalization and a better kidney function outcome.

#1595 Use of machine learning directed interventions to reduce fluid related hospital admissions in hemodialysis patients

Abstract Background and Aims Patients with end-stage kidney disease (ESKD) are hospitalized nearly two times per year on average; volume overload, infections and other cardiovascular complications are amongst the most common causes of hospitalization. We developed a machine learning (ML) model to predict haemodialysis (HD) patients at imminent risk of hospitalization due to fluid overload within the next 7 days. Patients identified as high risk by the model were assessed, intervened, and triaged on by group of telephonic nurses. The goal of this analysis is to evaluate the impact of the ML model-directed interventions on fluid related hospital admissions and all cause hospital admissions. Method We used data from a group of ESKD patients on HD modality who were identified as high risk by the ML model between baseline months April 2022 and June 2023. These high-risk patients were eligible to receive an assessment by telephonic nurses. The follow-up months were defined as the month immediately following the baseline month. Intervention group was identified as the high-risk patients where a clinical chart review was performed with needs identified, clinical chart review was performed and patients were managed by the clinic, some contact was made over phone/mail by the telephonic nurse, or some clinical recommendation was made. High-risk patients without any intervention or activity documented by the telephonic nurse served as the control population. We used linear regression analysis with repeated measures to account for within patient variability to produce estimated outcome rates with 95% confidence intervals adjusting for baseline factors such as average ML model risk score, average albumin, gender, race, age, vintage, comorbidities like chronic heart failure, diabetes, hypertension, ischemic heart disease, and primary insurance. Results There were 15,878 patients (36,932 patient months) in the group that received intervention; there were 51,800 patients (398,594 patient months) in the group that did not receive intervention. The pooled analysis (Table 1) showed a 38% reduction in all cause hospital admission rate between the baseline and follow-up months for the group that received intervention and there was a 34% reduction in all cause hospital admission rate for the group that did not receive any intervention. There was a 36% reduction in the fluid related hospital admission rate between the baseline and follow-up months for the group that received intervention and there was a 32% reduction in the fluid related hospital admission for the group that did not receive any intervention. Conclusion There is a larger magnitude reduction in fluid related hospital admissions and all cause hospital admissions between the baseline and follow-up months for the high-risk group as identified by the ML model that received intervention from the nurses compared to those that did not receive any intervention. Further studies are necessary to prove this association.

#1816 CA 125 as a surrogate marker for plasma volume in patients with cardiorenal syndrome

Abstract Background and Aims Assessing volume status in heart failure (HF) and end-stage chronic kidney disease (CKD) is challenging. Plasma volume expansion is an early step in the pathophysiology of decompensated HF and an independent risk factor for death and HF hospitalization, and should be addressed early. Evaluating plasma volume, especially its variation with diuretic therapy, can be a useful clinical tool for guiding decongestive therapy. There's a growing need for accurate and simple tools to guide clinician decisions on patient volume management. Cancer antigen 125 (CA125), a glycoprotein produced in mesothelial cells in the pericardium, pleura, or peritoneum, is primarily associated with ovarian and gynecological malignancies. Recent studies link CA125 to inflammation and congestion. In acute HF, elevated CA125 is associated with fluid overload indicators like increased central venous and pulmonary wedge pressure. Elevated CA125 in acute HF patients is linked to worse outcomes in death and hospital stay length. Evidence supports CA125-guided therapy in acute HF, but its role in managing chronic volume overload is still uncertain. We aim to assess the relationship between CA125 levels and estimated plasma volume (ePV). Method A retrospective unicentric observational study was conducted between June 2022, and April 17, 2023, at the Renocardiac clinic of a tertiary hospital. Clinical data were extracted from electronic patient records. CKD staging was determined following the Kidney Disease Improving Global Outcomes (KDIGO) classification. ePV was calculated using the Kaplan-Hakim formula. CA125 and ePV were assessed for the same patient in 2 different visits and their variation was calculated. The correlation between CA125 and ePV, as well as CA125 and ePV variation, was evaluated using Spearman's rank correlation coefficient for bivariate analysis, conducted with IBM SPSS®. Results This study comprised 65 patients, totaling 124 hospital visits. The patient demographic was 67.7% male, with a mean age of 76.4 (±12.47) years. In terms of CKD staging, 48.5% were classified as KDIGO 5, 40.6% as KDIGO 4, 9.4% as KDIGO 3, and 1.5% as KDIGO 2. HF etiology distribution included 59% ischemic, 9.8% hypertensive, 6.5% valvular, and 24.5% other causes. The mean ejection fraction was 37.35 (±12.36)% and 19% had preserved ejection fraction; 75% of them were treated with prognostic-modifying medication, including SGLT2 inhibitors. This proportion was lower (19%) in patients with reduced ejection fraction, receiving ACE/angiotensin ± neprilysin inhibitor + mineralocorticoid receptor inhibitor + beta-blocker + SGLT2 inhibitor. During the follow-up period, 13 hospitalizations, 1 major adverse cardiovascular event (MACE), and 5 deaths were recorded. The mean CA125 level was 193.98 (±154.55) U/mL, and patients had a mean ePV of 2.41 (±1.19) L. A significant positive correlation was found between CA125 levels and ePV (r = 0.355, p = 0.000). However, there was no significant correlation between the variation of CA125 and ePV levels between visits (p = 0.535). Conclusion This study focuses on a population with limited implementation of disease-modifying therapy due to advanced CKD, complicating the clinical management of volume status, kidney function, potassium levels, and long-term prognosis in both CKD and HF. CA125 shows potential clinical utility as a marker of congestion, aiding clinicians in assessing volume status by correlating with plasma volume. However, this study found no correlation between CA125 variation and changes in plasma volume. The outpatient nature of the studied population, typically euvolemic, may hinder assessing the relationship between CA125 and ePV changes. Future studies with larger sample sizes are essential to clarify this relationship and potentially identify volume-expanded patients early.

#1784 The potential impact of chronic subclinical hypervolemia on left ventricular hypertrophy in children on dialysis: a prospective longitudinal study

Abstract Background and Aims Hypervolemia poses a significant challenge in pediatric patients undergoing dialysis, potentially leading to severe complications such as left ventricular hypertrophy (LVH) and cardiac dysfunction. Accurately assessing fluid status in growing children on dialysis could be particularly difficult, and although several non-invasive methods are emerging, each individual measurement has its own strengths and diagnostic limitations in terms of sensitivity and specificity. To date, only a few studies in children have compared the use of different methods simultaneously to detect fluid status, and none of these have evaluated the potential cardiovascular impact of a prolonged subclinical hypervolemia. The latter can be defined as a condition of euvolemia at clinical assessment but hypervolemia at technical evaluation. We evaluated the role of three methods—lung ultrasound (LUS), bioimpedance spectroscopy (BIS), and ultrasound assessment of inferior vena cava collapsibility index (IVC-CI)—in detecting subclinical hypervolemia and examined the cardiac implications. Method In this prospective observational longitudinal study, we included 23 children (&amp;lt;18 years) who were receiving chronic hemodialysis or peritoneal dialysis at the regional pediatric nephrology center of Meyer University Children's Hospital IRCSS, Florence, Italy, between 01/06/2018 and 01/11/2020. We excluded patients with clinical signs of fluid overload. Each patient underwent a multiparametric evaluation of their fluid status (physical examination, LUS, IVC-CI, BIS) every 2 months, and an echocardiography every six months starting from a baseline evaluation. The LVH was defined as a left ventricular mass index (LVMI) of ≥ 95th percentile or a left ventricular wall-thickness z-score &amp;gt; 2 z-score. We divided the patients into two groups and arbitrarily assigned them to the subclinical hypervolemia (SH) group if they had at least two out of three parameters of fluid overload at different methods (≥5 B-lines at LUS, overhydration normalized to extracellular water “OH/ECW” &amp;gt; 7% at BIS, and/or IVC-CI &amp;lt; 40%) in the absence of clinical signs of fluid overload. The others were included in the euvolemic (EU) group. The overload rate by weight (clinical OH), prescribed by the physician clinically, was calculated as the proportional increase from the dry weight (kg of fluid overload / dry weight in kg × 100). Results The two analyzed groups did not differ regarding gender, age and BSA (Table). The clinical OH was significantly higher in the SH population than in the EU group (2.2 ± 1.84 vs 1.30 ± 2.16%, p &amp;lt; 0.01). In the correlation analysis, we found that clinical OH positively correlated with the number of B-lines by LUS (R = 0.2923, p &amp;lt; 0.001) and OH/ECW by BIS (R = 0.4144, p &amp;lt; 0.001), while there was a negative correlation with IVC-CI (R = −0.2597, p = 0.019). However, each method taken individually (LUS, BIS, and IVC-CI) appeared to be inaccurate in predicting fluid status in several individual cases. Although the frequency of hypertension did not differ between the SH and EU groups, uncontrolled hypertension, treatment-resistant hypertension, and hospital admission for hypertensive crises were more frequent in the SH group, with the latter being statistically significant (67% vs 0%, p &amp;lt; 0.01). Furthermore, in the entire cohort, we observed a significant linear correlation between LVMI values and the average values of pre-HD systolic blood pressure recorded in the prior six months (R2 = 0.16, p = 0.002). It is worth noting that the presence of LVH at the last follow-up was significantly more prevalent in the SH group (75% vs 27%, p = 0.04). Conclusion Chronic subclinical hypervolemia, detected with a multi-method evaluation (including LUS, BIS, and IVC-CI), was significantly correlated with clinical OH and associated with a higher risk of LVH. To mitigate the intrinsic limitations of each technique, adopting two or more methods simultaneously can bypass and minimize the risk of evaluative error in assessing fluid status, and help reduce cardiovascular risk.

#1348 Acute kidney injury: evaluation of factors to predict the need of dialysis therapy

Abstract Background and Aims Acute kidney injury (AKI) is a clinical syndrome with heterogeneous pathophysiological mechanisms, associated with higher morbidity and mortality risk. The existing evidence shows that an episode of AKI increases the risk of chronic kidney disease and end-stage kidney disease, with considerable effects on long term outcomes. Current risk prediction scores were mostly calculated in the setting of contrast induced nephropathy and cardiac surgery reporting the patient's risk of AKI immediately before and after the invasive procedure. To date, no scoring models are available to assess the risk of progression and necessity of renal replacement therapy (RRT) for patients in the course of AKI. Method A prospective observational cohort study was conducted enrolling patients with AKI treated within the Nephrology, Dialysis and Kidney Transplant Unit of IRCCS Azienda Ospedaliero-Universitaria di Bologna from January 2022 to July 2023. The inclusion criteria were: 1) age &amp;gt;18 years, 2) stage 3 AKI according to the current KDIGO guidelines or presence of urgent RRT indication (severe hyperkalemia, metabolic acidosis or fluid overload refractory to medical treatment). The indication for RRT was given based on clinical judgement. Type of RRT, dialyzer and ultrafiltration rate were applied according to the clinical features of the patient. The primary endpoint was the association between AKI features and RRT. Secondary endpoints were evaluation of patients treated with RRT for factors associated with renal recovery. Results We studied 56 patients. The mean age ± SD was 69.8 ± 15.3 years (range, 18-94) and 37 (66.1%) were males. 18 patients (32.1%) were treated with conservative therapy and 38 (67.9%) with RRT. The factors correlated with the necessity of RRT were previous cardiovascular disease (p = 0.002), diabetes mellitus (p = 0.017), Charlson score &amp;gt;5 (p = 0.035), volume overload (p = 0.002), urine output level (p = 0.033) and C reactive protein (CRP; p = 0.020). Multivariate analysis found significant association of cardiovascular disease (OR, 5.94; 95% CI, 1.45 to 24.34; p = 0.013) and elevated CRP (OR, 1.08; 95% CI, 1.00 to 1.16; p = 0.049) during AKI episode with the RRT need in the study cohort. Higher ultrafiltration rate during RRT was correlated with non recovery of kidney function (OR, 1.86; 95% CI, 1.09 to 3.14; p = 0.021). Conclusion Cardiovascular disease and higher CRP were associated with necessity of RRT. More intensive fluid removal during RRT resulted as negative predictor of kidney function recovery. Further studies with larger study samples and randomized design are necessary to confirm these findings.

#730 Dialysis-induced changes in systolic, diastolic, and pulse pressure in maintenance hemodialysis patients

Abstract Background and Aims Hemodialysis (HD) therapy has a strong impact on cardiovascular function in both the short and long term. In the short term, the dialysis-induced changes in blood volume directly affect the arterial blood pressure (BP), frequently leading to intradialytic hypotension or hypertension, both associated with adverse outcomes. The aim of this study was to investigate the dialysis-induced changes in systolic (SBP), diastolic (DBP), and pulse pressure (PP) in maintenance HD patients and to assess their relationship with pre-HD BP. Methods 197 maintenance HD patients were studied during the middle dialysis session of the week. The mean pre-dialysis fluid overload was 2.0 ± 1.6 L (calculated as the difference between the pre-dialysis body weight and the target weight). All HD sessions lasted approximately 4 h and were performed using mainly low-flux dialyzers. SBP and DBP were measured pre-HD and post-HD using a sphygmomanometer. PP was calculated as SBP minus DBP. The patients were divided into two groups: A) patients with an intradialytic decline in SBP (∆SBP &amp;lt;0), and B) patients with an increase or no change in SBP during HD (∆SBP ≥0). Paired data were compared using the Student's t-test. Correlations between variables were assessed using Spearman's rho (ρ). Results During HD, SBP decreased in 120 (61%) patients (in 20 cases by more than 30 mmHg), remained unchanged in 11 (6%) patients, and increased in 66 (33%) patients (in 13 cases by more than 20 mmHg). DBP decreased in 94 (48%) patients, remained unchanged in 46 (23%) patients, and increased in 57 (29%) patients. In 76 (39%) patients both SBP and DBP decreased, whereas in 33 (17%) patients both SBP and DBP increased. In group A (n = 120), SBP, DBP, and PP decreased by 21 ± 16 mmHg (P &amp;lt; 0.001), 8 ± 11 mmHg (P &amp;lt; 0.001), and 13 ± 14 mm Hg (P &amp;lt; 0.001), respectively. In group B (n = 77), SBP, DBP, and PP increased by 12 ± 10 mmHg (P &amp;lt; 0.001), 4 ± 11 mmHg (P &amp;lt; 0.001), and 8 ± 13 mmHg (P &amp;lt; 0.001), respectively. Pre-HD SBP was 144 ± 23 mmHg in group A and 128 ± 25 mmHg in group B (P &amp;lt; 0.001). Pre-HD DBP was 80 ± 15 mmHg in group A and 68 ± 11 mmHg in group B (P &amp;lt; 0.001). In all patients combined, ∆SBP was similarly correlated with pre-HD SBP and pre-HD DBP (ρ = −0.42 in both cases, P &amp;lt; 0.001), whereas ∆DBP was more strongly correlated with pre-HD DBP (ρ = −0.52, P &amp;lt; 0.001) than with pre-HD SBP (ρ = −0.22, P &amp;lt; 0.01). ∆SBP was correlated with ∆DBP (ρ = 0.55, P &amp;lt; 0.001) and highly correlated with ∆PP (ρ = 0.78, P &amp;lt; 0.001). According to linear regression, SBP tended to increase during HD in patients with pre-HD SBP &amp;lt;118 mmHg (Fig. 1A), whereas DBP tended to increase in patients with pre-HD DBP &amp;lt;68 mmHg (Fig. 1B). Conclusions Patients with dialysis-induced decline in SBP (group A) had a significantly higher pre-HD BP (both SBP and DBP) compared with patients with an increasing or stable SBP (group B). This suggests that a high decline in SBP during HD appears to be more likely in patients with elevated pre-HD BP and that HD appears to have a pressure-normalizing effect in such patients. Similarly, a dialysis-induced increase in SBP or DBP appears to be more likely in patients with low values of pre-HD SBP or DBP, respectively.

#523 Continuous electronic urine output monitoring for the management of acute cardio-renal syndrome in patients with acute decompensated heart failure

Abstract Background and aims : Patients admitted for acute decompensated heart failure (ADHF) are at high risk for type I cardio-renal syndrome (CRS) related to venous congestion and diuretic resistance. Positive fluid balance has been associated with adverse outcomes including acute kidney injury (AKI) and mortality. In critically ill patients urine output (UO) is used both to assess deterioration of renal function as well as for management of fluid balance. We investigated the possible effect of real-time UO monitoring, fluid balance, renal outcomes and 30-day mortality of patients admitted to the cardiac intensive care unit (ICU) with ADHF. Methods We performed a case series of 50 patients admitted to the cardiac ICU from July 2021 and June 2023 with ADHF. Their standard foley catheter was connected to an electronic monitoring system (Clarity-RMS sensor kit) that continuously monitors UO in real-time. Its technology is described elsewhere (1). The UO monitoring system displays UO trends on the consoles that are updated in real-time. UO trends were utilized to guide an individualized approach for the pharmacologic management of each patient, based on blood pressure, hourly UO and total fluid balance. Daily and accumulated fluid balance was registered at up to 72 hours following admission. Patient outcomes included change in fluid balance, incidence of AKI and 30-day mortality. The case series group was than compared to a historical group of 50 matched controlled patients admitted between 2019-2020. Patients were matched according to cause of admission, age and glomerular filtration rate. Results In the study cohort the median age was 71 ± 12 years, and 36 (72%) were men. In the historical cohort the median age was 71 ± 13 years, and 36 (72%) were men. Patients in the electronic urinary monitoring cohort demonstrated significantly more negative daily and cumulative fluid balance as compared to the historical cohort, (P &amp;lt; 0.001 for all, Fig. 1). Incidence of AKI and the combined endpoint of AKI and 30-day mortality was significantly lower in the electronic UO monitoring cohort (24% vs. 46%, p = 0.0197 and 40% vs 78%, P &amp;lt; 0.0001 respectively). These changes were more prominent in the subgroup of patients with chronic kidney disease (Fig. 2). Conclusion We demonstrated that real time monitoring of UO was associated with better prevention of fluid overload and the management of type I CRS in patients with ADHF. Further studies on larger populations are required to validate the potential utility of UO trending in the management of critically ill patients with ADHF.

#1157 Body mass and fluid balance in dialysis: global profiles in Apollo Dial DB

Abstract Background and Aims Fluid management is a fundamental component of dialysis care. Achieving euvolemia and avoiding fluid overload can be challenging in dialysis. Apollo Dial DB, an anonymised dialysis database from a global kidney care network, was used to gain deeper insights in patterns of patient body mass and fluid balance during dialysis treatments worldwide. Method Apollo Dial DB, a global anonymised dialysis database, contains real-world data from patients in 40 countries beginning January 2018 throughout March 2021. Parameters include demographics, diagnoses, laboratories, medications, treatments, quality of life, and outcomes. This analysis assessed body mass and fluid status parameters on patients in Asia-Pacific (AP), Europe, Middle East, and Africa (EMEA), Latin America (LA), Northern America (NA). In addition, bioimpedance for body compositions of patients was assessed as it was available in AP, EMEA, and LA. Results The first version of the Apollo Dial DB includes data on 543, 169 patients, with 4.6% from AP, 13.9% from EMEA, 7.0% from LA, and 74.5% from NA countries. EMEA and NA have a higher proportion of patients in the bigger height categories versus the AP and LA regions (Table 1). There is a difference in mean body weight post dialysis of more than 10 kg between regions; the highest weights were observed in EMEA and NA in contrast to the AP and LA regions. Average albumin levels were consistent in all global regions. Intradialytic weight gain is lowest in EMEA at 1.8 kg and highest in NA at 2.2 kg between treatments. While ultrafiltration volume ranged from 2.0 L to 2.4 L, being the highest in AP and NA. Bioimpedance measures defining body compositions were available for the majority of patients in AP (59.3%), EMEA (86.9%), and LA (90.7%). Patient averages in EMEA are slightly higher for ATM, FTM, LTM, TBW than for LA and AP; this is somewhat explained by the differences in body weight between the cohorts (Fig. 1). Conclusion A descriptive analysis of the body mass and fluid status across minor and major regions bring to light key profiles and differences in the characteristics of dialysis patients across the world and fluid management practices in dialysis care. Differences in intradialytic weight gain may deserve further analysis considering the impact of dialysis modality on fluid balance, such as potential influences of convective therapies. These findings act as benchmarks for the nephrology community. Apollo Dial DB offers opportunities for investigators to conduct global analytics and advance kidney disease research.

#1555 The effects of different interdialytic intervals on cardiorespiratory fitness assessed with CPET in hemodialysis patients

Abstract Background and Aims Long interdialytic interval in thrice-weekly hemodialysis is associated with excess cardiovascular and all-cause mortality risk. Impaired cardiorespiratory fitness is a strong predictor of mortality in hemodialysis. This study investigated differences in cardiorespiratory fitness assessed with cardiopulmonary exercise testing (CPET) between the end of the 2-day and the 3-day interdialytic interval. Method A total of 28 hemodialysis patients, randomized in two different sequences of evaluation underwent CPET and spirometry examination at the end of the 2-day and the 3-day intervals. The primary outcome was the difference in oxygen uptake at peak exercise [VO2peak (ml/kg/min)] assessed with CPET. Volume status was assessed with interdialytic-weight-gain (IDWG), lung ultrasound, bioimpedance spectroscopy (BIS), and inferior vena cava measurements. A total of 14 age- and sex-matched controls were also evaluated. Results Hemodialysis patients at the end of both 2-day and 3-day intervals presented lower values in all major CPET parameters than controls. VO2peak (ml/kg/min) was significantly higher at the end of the 2-day than the 3-day interval (15.24 ± 4.18 vs 13.64 ± 2.76; p &amp;lt; 0.001); similar were the results for VO2peak (ml/min) (1188 ± 257 vs 1074 ± 224; p &amp;lt; 0.001) and VO2peak (%predicted) (58.9 ± 9.2 vs 52.3 ± 8.6; p &amp;lt; 0.001). Numerical but no statistically significant differences were detected in VO2-anaerobic-threshold(ml/kg/min) and VO2-anaerobic-threshold(ml/min) between the two time-points. Maximal work load (90.1 ± 23.2 vs 79.3 ± 25.1; p &amp;lt; 0.001), exercise duration, HR at peak exercise and oxygen pulse also showed lower values at the end of the 3-day interval. FEV1 levels were similar between the two evaluations. Generalized-linear-mixed-model analysis including IDWG as random covariate attenuated the observed differences in VO2peak (ml/kg/min). Changes in BIS-derived overhydration indexes were moderately correlated with changes of VO2peak (ml/kg/min). Conclusion The 3-day interval was associated with further impairment of VO2 at peak exercise. This effect was predominantly driven by excess fluid accumulation during the extra interdialytic day.

Lung Ultrasound to Evaluate Fluid Status and Optimize Early Volume-Expansion Therapy in Children with Shiga Toxin-Producing Escherichia Coli-Haemolytic Uremic Syndrome: A Pilot Study.

Background: Shiga toxin-producing Escherichia coli-haemolytic uremic syndrome (STEC-HUS) can result in kidney and neurological complications. Early volume-expansion therapy has been shown to improve outcomes, but caution is required to avoid fluid overload. Lung ultrasound scanning (LUS) can be used to detect fluid overload and may be useful in monitoring hydration therapy. Methods: This prospective observational pilot study involved children with STEC-HUS who were recruited from a regional paediatric nephrology centre. B-line quantification by LUS was used to assess fluid status at the emergency department (ED) admission and correlated with the decrease in patient weight from the target weight. A control group of children on chronic dialysis therapy with episodes of symptomatic fluid overload was also enrolled in order to establish a B-line threshold indicative of severe lung congestion. Another cohort of "healthy" children, without renal or lung-related diseases, and without clinical signs of fluid overload was also enrolled in order to establish a B-line threshold indicative of euvolemia. Results: LUS assessment was performed in 10 children with STEC-HUS at ED admission, showing an average of three B-lines (range 0-10). LUS was also performed in 53 euvolemic children admitted to the ED not showing kidney and lung disease (healthy controls), showing a median value of two B-lines (range 0-7), not significantly different from children with STEC-HUS at admission (p = 0.92). Children with STEC-HUS with neurological involvement during the acute phase and those requiring dialysis presented a significantly lower number of B-lines at admission compared to patients with a good clinical course (p < 0.001). Patients with long-term renal impairment also presented a lower number of B-lines at disease onset (p = 0.03). Conclusions: LUS is a useful technique for monitoring intravenous hydration therapy in paediatric patients with STEC-HUS. A low number of B-lines at ED admission (<5 B-lines) was associated with worse short-term and long-term outcomes. Further studies are needed to determine the efficacy and safety of an LUS-guided strategy for reducing complications in children with STEC-HUS.

Association of Fluid Balance and Hemoglobin Decline With Neurological Outcome After Aneurysmal Subarachnoid Hemorrhage.

To explore the relationship between fluid balance and hemoglobin decline with secondary infarctions and neurologic outcome in aneurysmal subarachnoid hemorrhage (aSAH) patients. Secondary analysis of the Earlydrain trial, a prospective randomized controlled study investigating prophylactic lumbar drain use in aSAH patients. Patients with aSAH treated in ICUs at 19 tertiary hospitals in Germany, Switzerland, and Canada. From January 2011 to January 2016, 287 patients were enrolled in the Earlydrain trial. Only files with complete information on both daily hemoglobin and balance values were used, leaving 237 patients for analysis. Investigation of fluid balance management and hemoglobin levels during the initial 8 days post-aSAH to establish thresholds for unfavorable outcomes and assess their impact on secondary infarctions and 6-month neurologic outcome on the modified Rankin Scale (mRS). Patients with unfavorable outcome after 6 months (mRS > 2) showed greater hemoglobin decline and increased cumulative fluid balance. A significant inverse relationship existed between fluid balance and hemoglobin decline. Thresholds for unfavorable outcome were 10.4 g/dL hemoglobin and 4894 mL cumulative fluid balance in the first 8 days. In multivariable analysis, fluid balance, but not fluid intake, remained significantly associated with unfavorable outcome, while the influence of hemoglobin lessened. Fluid balance but not hemoglobin related to secondary infarctions, with the effect being significant after inverse probability of treatment weighting. Transfusion was associated with unfavorable outcomes. Increased fluid balance influences hemoglobin decline through hemodilution. Fluid overload, rather than a slight decrease in hemoglobin levels, appears to be the primary factor contributing to poor outcomes in aSAH patients. The results suggest aiming for euvolemia and that a modest hemoglobin decline may be tolerated. It may be advisable to adopt a restrictive approach to transfusions, as they can potentially have a negative effect on outcome.

An observational prospective cross-sectional study on extravascular lung water by lung ultrasound as a guide to fluid resuscitation therapy in adult septic shock in tertiary care hospital in central India

Background Septic shock is a life-threatening condition characterized by systemic inflammation and organ dysfunction, with fluid resuscitation being a cornerstone of management. However, indiscriminate fluid administration can lead to fluid overload and worsen outcomes. Extravascular lung water (EVLW) estimation by lung ultrasound has emerged as a promising tool for guiding fluid therapy in septic shock, allowing clinicians to assess pulmonary edema and tailor resuscitation strategies accordingly. Methods This prospective observational study aims to evaluate the utility of EVLW estimation by lung ultrasound in guiding fluid resuscitation therapy in adult patients with septic shock admitted to a rural tertiary care teaching hospital. Eligible patients admitted to the intensive care unit (ICU) will undergo baseline demographic and clinical assessments, including lung ultrasound, to quantify EVLW using B-line analysis. Fluid resuscitation therapy will be initiated based on EVLW findings, with subsequent adjustments guided by repeat lung ultrasound examinations at 6, 12, 24, and 48 hours post-initiation. Outcome measures include changes in mean PaO2/FiO2 ratios, respiratory parameters, renal function, fluid balance, and mortality rates. Expected Outcome We anticipate that EVLW-guided fluid resuscitation therapy will lead to more precise and tailored management of septic shock, potentially reducing the incidence of fluid overload, ARDS, and renal dysfunction. By optimizing fluid management strategies based on individual patient characteristics and responses, we aim to improve clinical outcomes and enhance the delivery of care for patients with septic shock.

Urgency or Emergency – A Report on Hypertensive Crisis with Severe Retinopathy

Hypertensive crisis is a common condition encountered in primary care clinics. It may result from uncontrolled hypertension or a known cardiovascular risk disease but may also be the first occurrence of undiagnosed secondary hypertension. However, there is confusion on the classification of whether certain atypical presentations, particularly in young patients without acute symptoms and exact duration of symptoms, are to be considered as hypertensive urgency or emergency. Some abnormal signs, such as proteinuria or retinopathy, could be signs of an existing progression of underlying chronic disease rather than a manifestation of acute hypertensive crisis. Nonetheless, in any situation where the findings have occurred recently without prior follow-up, they should be treated as if they are signs of an acute hypertensive crisis. Bedside clues, such as concomitant anaemia and proteinuria, are valid evidence for the presence of end-stage renal disease (ESRD) causing the hypertensive crisis, even without the features of fluid overload or failure symptoms. We report the case of a young man presented with an acute hypertensive crisis with an isolated one-month history of blurred vision. Despite the initial dilemma, the case was treated as a hypertensive emergency due to the presence of retinopathy and overt proteinuria. The renal profile later confirmed that the patient had ESRD. This case proves that ESRD is still possible even in a young patient without a long medical history or other supporting signs. Making the right decision on the first visit saved the patient’s life.

Physiological changes and the Mallampati classification: Tracheal intubation complications

Introduction: Difficulty in tracheal intubation is a significant factor in morbidity and mortality. Mallampati has therefore made it possible to predict it in advance. Its classification is based on the visualization of pharyngeal structures and is a simple anesthetic assessment. In practice, some circumstances can modify Mallampati's classification, making intubation more complex, and knowledge of these is of medical importance. Objectives: To review the literature on circumstances that alter Mallampati's classification. Methods: A literature review was carried out on possible physiological alterations responsible for changes in the Mallampati classification. We searched the Medline, Scielo and CRD databases for the terms: “Mallampati modification” and “Mallampati score” associated with “anaphylaxis” and “labor” and the articles were submitted to critical analysis. Results: Among the interferences in the Mallampati score is anaphylaxis, which results in upper airway edema, affecting the classification. In addition, pregnancy and labor can influence the score. Some factors such as breast growth, weight gain and pharyngeal edema increase the index in pregnant women. In addition, there is airway edema, explained by exertion and increased venous pressure in the upper body. In addition, fluid overload and the antidiuretic effect of oxytocin cause changes in the airways. Another situation is that of pediatric patients, where 13% of respiratory problems during anesthesia are related to intubation difficulties. In children between 4 and 8 years old without malformations, the index has proved applicable. However, it is impossible to use it in children under 4 years of age. Conclusions: The Mallampati score complements the judgment of a general examination that includes anamnesis and physical inspection of the craniofacial structure to identify risk factors, taking into account other situations that may interfere with the classification. Therefore, an understanding of its limitations is necessary for its correct application.

Using continuous electronic urine output monitoring for the management of acute cardio-renal syndrome in patients with acute decompensated heart failure

Abstract Funding Acknowledgements None. Background Patients admitted for acute decompensated heart failure (ADHF) are at high risk for type I cardio-renal syndrome (CRS) related to venous congestion and diuretic resistance. Positive fluid balance has been associated with adverse outcomes including acute kidney injury (AKI) and mortality. In critically ill patients urine output (UO) is used both to assess deterioration of renal function as well as for management of fluid balance .We investigated the possible effect of real-time UO monitoring, fluid balance, renal outcomes and 30-day mortality of patients admitted to the cardiac intensive care unit (ICU) with ADHF. Methods We performed a case series of 50 patients admitted to the cardiac ICU from July 2021 and June 2023 with ADHF. Their standard foley catheter was connected to an electronic monitoring system that continuously monitors UO in real-time. Its technology is described elsewhere (1). The UO monitoring system displays UO trends on the consoles that are updated in real-time. UO trends were utilized to guide an individualized approach for the pharmacologic management of each patient, based on blood pressure, hourly UO and total fluid balance. Daily and accumulated fluid balance was registered at up to 72 hours following admission. Patient outcomes included change in fluid balance, incidence of AKI and 30-day mortality. The case series group was than compared to a historical group of 50 matched controlled patients admitted between 2019-2020. Patients were matched according to cause of admission, age and glomerular filtration rate. Results In the study cohort the median age was 71±12 years, and 36 (72%) were men. In the historical cohort the median age was 71±13 years, and 36 (72%) were men. Patients in the electronic urinary monitoring cohort demonstrated significantly more negative daily and cumulative fluid balance as compared to the historical cohort, (P&amp;lt;0.001 for all, Figure 1). Incidence of AKI and the combined endpoint of AKI and 30-day mortality was significantly lower in the electronic UO monitoring cohort (24% vs. 46%, p=0.0197 and 40% vs 78%, P&amp;lt;0.0001 respectively). These changes were more prominent in the subgroup of patients with chronic kidney disease (Figure 2). Conclusion We demonstrated that real time monitoring of UO was associated with better prevention of fluid overload and the management of type I CRS in patients with ADHF. Further studies on larger populations are required to validate the potential utility of UO trending in the management of critically ill patients with ADHF.Fluid balance renal senseAKI and 30-day mortality