Improve Fluid Management Research Articles

Sodium-glucose co-transporter 2 inhibitors in left ventricular assist device and heart transplant recipients: a mini-review.

In recent years, sodium-glucose co-transporter 2 inhibitors (SGLT2i) emerged as promising therapeutic agents in managing heart failure (HF). They demonstrated a significant impact on reducing HF hospitalizations and related mortality in patients with reduced and preserved ejection fraction. However, evidence supporting their use in patients with left ventricular assist device (LVAD) and heart transplant (HT) recipients is still limited. We identified six key studies investigating the safety and efficacy of SGLT2i in LVAD and HT recipients. In patients with LVAD, prescription of SGLT2i was predominantly associated with improved fluid management and reduced pulmonary artery pressures. However, the results regarding their effects on body weight, hemoglobin A1c, diuretic use, and right ventricular function were contradictory. In terms of safety, SGLT2i were generally well-tolerated in the LVAD population, and the reported incidence of adverse events was low. In HT recipients, SGLT2i were associated with better glycemic control and weight reduction. No relevant adverse events were reported. Despite these encouraging results, the long-term safety and efficacy of SGLT2i in these vulnerable patient populations are yet to be investigated. Future randomized controlled trials are needed to address existing gaps in evidence and help integrate SGLT2i into clinical practice for LVAD and HT recipients.

Efficacy of acetazolamide as adjunct therapy in improving fluid management in patients with acute congestive heart failure: a systematic review and meta-analysis of randomized controlled trials

Abstract Introduction Persistent congestion in acute congestive heart failure despite conventional treatments highlights the need for innovative therapeutic approaches. Evaluating acetazolamide as adjunctive therapy for reducing volume overload is significant. Our meta-analysis examines randomized clinical trials to assess acetazolamide's efficacy in improving fluid management in acute congestive heart failure. Methods We systematically searched Embase, PubMed, and the Cochrane Library in January 2024 for randomized controlled trials comparing the addition of acetazolamide to diuretic therapy versus standard diuretic therapy in patients with acute congestive heart failure. Article selection was conducted independently by two authors. Statistical analyses, including the weighted mean differences (MD) and assessment of heterogeneity using the I² statistic, were performed using R software version 5.4.1. Results Three studies comprising 596 patients were included. Of these, 297 (50%) received acetazolamide as adjunctive diuretic therapy, while 299 (50%) received standard diuretic therapy with a loop diuretic. Among participants, 385 (65%) were male, with a mean age of 72.76 years (±11.13). Acetazolamide adjunctive therapy led to an increase in natriuresis at day 2, expressed in milimoles (mmol), (MD 80.30; 95% CI [45.10-115.51]; p<0.00001; I2=29%), and a trend towards higher natriuresis volume, expressed in liters (L), at day 2 (MD 0.56; 95% CI [-0.37-1.48]; p=0.24; I2=87%), although the latter lacked statistical significance. Conclusions Our findings suggest that acetazolamide adjunctive therapy may have potential benefits in improving fluid management and possibly enhancing clinical outcomes in patients with acute congestive heart failure. Further research is warranted to validate these findings and explore the long-term effects of acetazolamide therapy.

Early Autocalibrated Arterial Waveform Analysis for the Management of Burn Shock-A Cohort Study.

Adequate fluid therapy is crucial for resuscitation after major burns. To adapt this to individual patient demands, standard is adjustment of volume to laboratory parameters and values of enhanced hemodynamic monitoring. To implement calibrated parameters, patients must have reached the intensive care unit (ICU). The aim of this study was, to evaluate the use of an auto-calibrated enhanced hemodynamic monitoring device to improve fluid management before admission to ICU. We used PulsioflexProAqt® (Getinge) during initial treatment and burn shock resuscitation. Analysis was performed regarding time of measurement, volume management, organ dysfunction, and mortality. We conducted a monocentre, prospective cohort study of 20 severely burned patients, >20% total body surface area (TBSA), receiving monitoring immediately after admission. We compared to 57 patients, matched in terms of TBSA, age, sex, and existence of inhalation injury out of a retrospective control group, who received standard care. Hemodynamic measurement with autocalibrated monitoring started significantly earlier: 3.75(2.67-6.0) hours (h) after trauma in the study group versus 13.6(8.1-17.5) h in the control group (P < .001). Study group received less fluid after 6 h: 1.7(1.2-2.2) versus 2.3(1.6-2.8) ml/TBSA%/kg, P = .043 and 12 h: 3.0(2.5-4.0) versus 4.2(3.1-5.0) ml/TBSA%/kg, P = .047. Dosage of norepinephrine was higher after 18 h in the study group: 0.20(0.12-0.3) versus 0.08(0.02-0.18) µg/kg/min, P = .014. The study group showed no adult respiratory distress syndrome versus 21% in the control group, P = .031. There was no difference in other organ failures, organ replacement therapy, and mortality. The use of auto-calibrated enhanced hemodynamic monitoring is a fast and feasible way to guide early fluid therapy after burn trauma. It reduces the time to reach information about patient's volume capacity. Management of fluid application changed to a more restrictive fluid use in the early period of burn shock and led to a reduction of pulmonary complications.

Fluid overload and association of hidden fluid administration: Improve fluid assessment and management using “FAM” protocol at enaya specialized care center

Fluid overload and association of hidden fluid administration: Improve fluid assessment and management using “FAM” protocol at enaya specialized care center

Facilitators and barriers of appropriate and timely initial fluid administration in sepsis: A qualitative study

BackgroundSepsis is a medical emergency requiring prompt recognition, and early administration of intravenous fluids and antibiotics. While compliance with appropriate and timely administration of intravenous fluids has been found to be poor, the reasons are not well understood. Therefore, we have explored the experiences and perceptions of emergency nurses and medical officers from four hospitals to identify the associated facilitators and barriers. MethodsQualitative design incorporating six focus group discussions and thematic analysis of data. A hybrid approach using both inductive and deductive reasoning was used. FindingsFour key themes were developed: 1. Overcrowding and understaffing threaten appropriate fluid management in sepsis; 2. Variations in clinical practice results in suboptimal fluid management; 3. Challenges with clinical recognition of sepsis impedes timely fluid administration; 4. Top-down approach is necessary to improve fluid management. ConclusionThemes highlighted the specific challenges associated with fluid administration in sepsis in the emergency department setting providing potential strategies to be implemented to improve practice and ultimately patient outcomes.

Improving fluid management using “FAM” protocol by involving multidisciplinary team members at enaya specialized care center

Improving fluid management using “FAM” protocol by involving multidisciplinary team members at enaya specialized care center

Low-Fouling Zwitterionic Polymeric Colloids as Resuscitation Fluids for Hemorrhagic Shock.

Colloids, known as volume expanders, have been used as resuscitation fluids for hypovolemic shock for decades, as they increase plasma oncotic pressure and expand intravascular volume. However, recent studies show that commonly used synthetic colloids have adverse interactions with human biological systems. In this work, a low-fouling amine(N)-oxide-based zwitterionic polymer as an alternative volume expander with improved biocompatibility and efficacy is designed. It is demonstrated that the polymer possesses antifouling ability, resisting cell interaction and deposition in major organs, and is rapidly cleared via renal filtration and hepatic circulation, reducing the risk of long-term side effects. Furthermore, in vitro and in vivo studies show an absence of adverse effects on hemostasis or any acute safety risks. Finally, it is shown that, in a head-to-head comparison with existing colloids and plasma, the zwitterionic polymer serves as a more potent oncotic agent for restoring intravascular volume in a hemorrhagic shock model. The design of N-oxide-based zwitterionic polymers may lead to the development of alternative fluid therapies to treat hypovolemic shock and to improve fluid management in general.

Patient and Staff Perceptions on Using Bioelectrical Impedance Analysis in an Outpatient Haemodialysis Setting: A Qualitative Descriptive Study.

Bioelectrical impedance analysis (BIA) is an objective hydration and body composition assessment method recommended for use in haemodialysis patients. Limited research exists on the acceptability and utility of BIA in clinical practice. This qualitative study explored patient and staff acceptability and perceived value of BIA in an outpatient haemodialysis setting at a tertiary public hospital in Queensland, Australia. Participants included five patients receiving outpatient haemodialysis and 12 multidisciplinary clinical staff providing care to these patients. Semi-structured interviews were employed and data were analysed thematically. Patients were satisfied with the BIA measurement process and most thought the BIA data would be useful for monitoring changes in their nutrition status. Clinical staff valued BIA data for improving fluid management, assessing nutrition status and supporting patient care. Staff recommended targeting BIA use to patient groups who would benefit the most to improve its uptake in the haemodialysis setting. Conclusions: BIA use in the outpatient haemodialysis setting is acceptable and provides valuable objective data to support health-related behaviour changes in patients and enhance clinical practice. Implementation of BIA should be tailored to the local context and staff should be supported in its use.

Cost-effectiveness and value of information analysis of multiple frequency bioimpedance devices for fluid management in people with chronic kidney disease having dialysis

BackgroundAmong people with chronic kidney disease (CKD) on dialysis, sub-optimal fluid management has been linked with hospitalisation, cardiovascular complications and death. This study assessed the cost-effectiveness using multiple-frequency bioimpedance guided fluid management versus standard fluid management based on clinical judgment.MethodsA Markov model was developed to compare expected costs, outcomes and quality adjusted life years of the alternative management strategies. The relative effectiveness of the bioimpedance guided approach was informed by a systematic review of clinical trials, and focussed reviews were conducted to identify baseline event rates, costs and health state utility values for application in the model. The model was analysed probabilistically and a value of information (VOI) analysis was conducted to inform the value of conducting further research to reduce current uncertainties in the evidence base.ResultsFor the base-case analysis, the incremental cost-effectiveness ratio (ICER) for bioimpedance guided fluid management versus standard management was £16,536 per QALY gained. There was a 59% chance of the ICER being below £20,000 per QALY. Form the VOI analysis, the theoretical upper bound on the value of further research was £53 million. The value of further research was highest for parameters relating to the relative effectiveness of bioimpedance guided management on final health outcomes.ConclusionsMultiple frequency bioimpedance testing may offer a cost-effective approach to improve fluid management in patients with CKD on dialysis, but further research would be of value to reduce the current uncertainties.

549 Lessons Learned from Two Survivors of Greater Than 90% Total Body Surface Area Full Thickness Burn Injuries Using a Dermal Biodegradable Substitute and Autologous Skin Cell Suspension: A Case Series

Abstract Introduction Advances in burn injury knowledge, critical care, and pharmacological developments have increased survival rates among extensive burn patients. Survival now dependents not just on skin coverage, but effective control of SIRS response, metabolic derangement, fluid loss and sepsis. Novel synthetic dermal substitutes create robustness, thickness, and pliability of the skin in addition to an improved aesthetic appearance while; point-of-care autologous skin cell harvesting enhances treatment by amplifying small split-thickness skin samples to produce an autologous skin cell suspension (ASCS) to cover a larger burn area. This study reports on two survivors with greater than 90% total body surface area full-thickness burns utilizing a combined treatment of a dermal substitute along with ASCS and traditional burn management strategies. Methods Chart review of two patients with &amp;gt;90% burns and inhalation injury after being trapped in a burning vehicle following a traffic collision occurred. Most of the burns in both patients were “leathery” and consistent with full thickness, sparing only the plantar and dorsal aspect of the feet and bilateral small areas of the hip in Patient 1. Patient 2 had fourth-degree burns in some areas of the chest and flank with only the bilateral groin regions and feet spared. The patients were treated with a multi-step process which included using allograft, dermal substitute, and ASCS with split-thickness skin grafts (STSG) in place of cultured epidermal autograft to achieve coverage of &amp;gt;90% burns with high meshed ratio. Results The dermal substitute was limited to deep burns that penetrated down to fat, muscle, and/or joints. Fluid loss was well controlled by the dermal substitute during initial resuscitation. Post reconstruction, areas covered with the dermal substitute and grafted with autogenous STSG with ASCS exhibited less hypertrophy and contracture bands. The elbow and knee joints showed minimal restriction with passive motion and good skin compliance, but contractures persisted in areas where 4th degree tendon and fascia thermal injury occurred. Areas that showed signs of infection were trimmed or unroofed and allowed to drain while maintaining the remainder of the dermal substitute. Conclusions The use of dermal substitutes and ASCS allowed the care team to achieve SIRS control, improved fluid management, enhanced skin coverage, and reduced hospitalization stay. The process experienced in these cases shows promise for future patients with extensive burns. Both patients were able to survive and show improvement during rehabilitation.

Novel Negative-Pressure Wound Therapy System Provides Accurate Pressure Delivery and Exceptional Fluid Handling Capability.

Negative-pressure wound therapy (NPWT) is a widely accepted modality in the treatment of complex wounds.1 However, there are fundamental requirements2 not incorporated in all current NPWT systems that must be met in order to realize its full clinical benefits, which include (1) accurately delivering a set level of negative pressure to the wound bed, (2) creating a pressure gradient between the wound bed and the waste canister to efficiently remove fluid and prevent stagnation in the tubing, and (3) maintaining a sealed wound environment. The objective of this investigation3 was to use a simulated wound model to compare the ability of two NPWT systems (System A, Invia® Liberty™ [Medela AG] and System B, V.A.C.ULTA™ [3M+KCI]) to deliver set levels of NPWT and simultaneously manage volumes of simulated wound exudate.* TEST METHOD 1: ACCURATE PRESSURE DELIVERY TO THE WOUND BED This test assessed the ability of System A and System B to accurately deliver set pressure to the wound at three different heights with respect to the wound model and was repeated at two different pressure settings. Data were recorded three times at each height and pressure setting (Figure 1).Figure 1.: TEST METHODOLOGY FOR 1 M ABOVE, SAME LEVEL, AND 1 M BELOWResults. Both System A and System B accurately and precisely delivered the set level of negative pressure regardless of their position relative to the wound model without pressure loss. (Figure 1). TEST METHOD 2: EFFICIENT EXUDATE REMOVAL System A and System B were compared to assess their ability to efficiently remove simulated wound fluid at a pressure setting of −125 mmHg. The test was repeated three times per system. Wound models were dressed with the respective black foam dressing kits specific to each NPWT system, and the systems were set up to simulate the delivery of therapy with the wound and at the same height. After each system’s wound dressing was applied, therapy was initiated and allowed to reach a steady state (~10 minutes), and pressure sensors confirmed pressure at the wound bed of −125 mmHg. After this, 150 ml of simulated wound fluid was introduced into the wound model. Measurements of airflow cycles, pressure at the wound bed, and fluid weight in the canister were continuously recorded (Figure 2). This test method simulated a bolus fluid challenge and measured each NPWT system’s distinct ability to efficiently react and manage wound fluid. (The results shown here represent a set pressure of 125 mmHg with the device at the same level as the wound model; similar observations were made at a set pressure of −75 mmHg [data not shown].)Figure 2.: TEST METHOD AT THE SAME LEVELResults. System A removed simulated wound fluid more efficiently than System B, evacuating 89% of the fluid from the simulated wound into the canister in less than 20 minutes after introduction of the fluid. System B did not attain 89% fluid removal throughout the 125-minute duration of the experiment (Figure 3).Figure 3.: COMPARISON OF EXUDATE REMOVAL RATESIn less than 20 minutes, System A was able to reestablish a set pressure of −125 mmHg, returning patency and delivering consistent levels of therapy at the wound bed. System B fluctuated widely from the set pressure (−125 mmHg) throughout the test method. In addition, System B had frequent excursions that exceeded +/−10 mmHg of the set pressure, directly impacting its ability to maintain set pressure at the wound bed (Figure 4).Figure 4.: COMPARISON OF PRESSURE DELIVERY AT THE WOUND BEDCONCLUSIONS This study demonstrated the Intelligent Pressure Control™ and Dynamic Exudate Removal™ technologies provided by System A; it improved fluid management and helped reduce the risk of tubing blockages from simulated exudate while maintaining a set pressure at the wound bed. The results confirm the Intelligent Pressure Control™ feature illustrated by System A meets the standard of care. Further, the results of the bolus fluid challenge illustrate that the Dynamic Exudate Removal™ (unique to System A) allowed for faster and more efficient removal of fluid volumes while maintaining set pressure at the wound bed when compared with System B. Accordingly, System A innovates the standard of care.

P1079NOVEL ULTRAFILTRATION RATE FEEDBACK CONTROLLER FOR ATTAINMENT OF RELATIVE BLOOD VOLUME TARGETS DURING HEMODIALYSIS

Abstract Background and Aims Preciado et al. have identified half-hourly relative blood volume (RBV) targets (at 30, 60…180 min) during hemodialysis (HD) that are associated with significantly improved patient survival. Attainment of these RBV targets would necessitate incessant adjustments to the ultrafiltration rate (UFR) by the dialysis nurse, which is logistically not feasible. We developed a novel proportional-integral controller that takes RBV data from the commercially available CLiC® device as an input and provides UFR suggestions to guide the RBV curve into the desired targets. The clinician specifies the desired UF goal and the maximum allowed upward/downward deviation from this goal, and the Controller then optimizes the RBV trajectory within the limits allowed by the clinician’s prescription. The present study is aimed to characterize the behavior of this novel feedback controller. Method We conducted a single-arm, prospective, interventional pilot study in subjects on chronic HD at three Avantus Renal Therapy Dialysis Centers in New York City. Subjects were treated with Fresenius 2008T HD machines. RBV was measured with the CLiC® device. CLiC® and HD machine data were fed into a research laptop running the UFR Feedback Controller software. The UFR recommendations (generated every 10 minutes) were evaluated by dialysis nurses who then either implemented or rejected them as they deemed clinically appropriate. The nurses were instructed to only override Controller recommendations if medically indicated, but not in an attempt to manage the subjects’ RBV trajectories themselves. Results Fifteen subjects (58.9 ± 15.3 years, 33% white, 53% black, dialysis vintage 4.1 ± 2.4 years, baseline interdialytic weight gain 2.6 ± 0.8 L, treatment time 222 ± 28 min) were studied (63 study visits, 4.2 ± 1.9 visits per subject). Of 300 analyzed RBV target timepoints, 63% had RBVs within the desired target range, 33% of the RBVs were above and 4% were below target. Stratified by timepoint, the on-target percentage increased from 37% at 30 min to 73% at 180 min into HD, while the proportion of RBVs above or below target decreased. In subjects with at least 4 complete study visits (N=8), looking at each of their first 4 complete visits, on average 71.8% of subjects were within the desired RBV target at 180 min into HD. The rate of intradialytic morbid events did not appear to be outside of the ordinary. There was no indication of adverse events related to the use of the UFR Feedback Controller. The Figure shows an example study visit where the UFR Feedback Controller modulates the UFR on an ongoing basis throughout the treatment to keep the RBV curve close to the ideal target trajectory (red line, defined by connecting the RBVs associated with the lowest all-cause mortality). Solid black line: RBV curve (left y-axis); dashed black line: UFR (right y-axis); green boxes: half-hourly RBV target ranges associated with improved survival. Conclusion The UFR Feedback Controller behaves as expected, steering the patients’ RBV curves toward the predefined target ranges where possible, while simultaneously guaranteeing that the prescribed fluid removal goal will be achieved. Preciado et al. had reported approx. one third of patients within the favorable RBV target range at 3h into HD. In contrast, while our pilot study was relatively small, with use of our novel UFR Feedback Controller, approx. 72% of subjects were within the desired RBV target range at 3h into HD. This novel UFR feedback control technology holds great promise for improving fluid management and clinical outcomes in HD patients without requiring additional staff time.

Thoracic fluid content: a novel parameter for detection of pulmonary edema in parturients with preeclampsia.

Acute pulmonary oedema is a serious complication of preeclampsia. Early detection of pulmonary edema in preeclampsia would improve fluid management and would also allow earlier detection of severe cases. The aim of this work is to evaluate the ability of thoracic fluid content measured by electrical cardiometry for early detection of pulmonary edema in parturients with preeclampsia. A prospective observational study included a cohort of preeclamptic parturients. On admission, lung ultrasound score was calculated, and thoracic fluid content was recorded using electrical cardiometry ICON device. Area under receiver operating characteristic (AUROC) curve was calculated for lung ultrasound score, thoracic fluid content for detection of pulmonary edema. Spearman correlation coefficient was calculated for correlation between lung ultrasound score and thoracic fluid content. Sixty patients were included in the study; of them, 6 patients (10%) required diuretics for pulmonary edema. Patients with pulmonary edema had higher lung ultrasound score and thoracic fluid content compared to other patients. Good correlation was reported between Lung ultrasound score and thoracic fluid content (r = 0.82). Thoracic fluid content and lung ultrasound score showed excellent diagnostic properties for pulmonary edema {AUROC: 0.941 (0.849-0.986), best cut-off value: 40kohm-1}, and {AUROC: 0.961 (0.887-0.994), best cut-off value of 15.7}. In parturients with preeclampsia, both lung ultrasound score and thoracic fluid content showed excellent properties for detection pulmonary edema. The high negative predictive value of both tests makes them useful screening tests to rule out pulmonary edema. The excellent correlation between both measures suggests that electrical cardiometry could be a promising surrogate to ultrasound for assessment of extravascular lung water.

Perspectives on clinical use of bioimpedance in hemodialysis: focus group interviews with renal care professionals

BackgroundInadequate volume control may be a main contributor to poor survival and high mortality in hemodialysis patients. Bioimpedance measurement has the potential to improve fluid management, but several dialysis centers lack an agreed fluid management policy, and the method has not yet been implemented. Our aim was to identify renal care professionals’ perceived barriers and facilitators for use of bioimpedance in clinical practice.MethodsQualitative data were collected through four focus group interviews with 24 renal care professionals: dieticians, nephrologists and nurses, recruited voluntarily from a nation-wide selection of hemodialysis centers, having access to a bioimpedance-device. The participants were connected to each other and a moderator via equipment for telemedicine and the sessions were recorded. The interviews were semi-structured, focusing on the participants’ perceptions of use of bioimpedance in clinical practice. Thematic content analysis was performed in consecutive steps, and data were extracted by employing an inductive, interactive, comparative process.ResultsSeveral barriers and facilitators to the use of bioimpedance in clinical practice were identified, and a multilevel approach to examining barriers and incentives for change was found to be applicable to the ideas and categories that arose from the data. The determinants were categorized on five levels, and the different themes of the levels illustrated with quotations from the focus groups participants.ConclusionsDeterminants for use of bioimpedance were identified on five levels: 1) the innovation itself, 2) the individual professional, 3) the patient, 4) the social context and 5) the organizational context. Barriers were identified in the areas of credibility, awareness, knowledge, self-efficacy, care processes, organizational structures and regulations. Facilitators were identified in the areas of the innovation’s attractiveness, advantages in practice, and collaboration. Motivation, team processes and organizational capacities appeared as both barriers and facilitators.

A mini-fluid challenge of 150 mL predicts fluid responsiveness using ModelflowR pulse contour cardiac output directly after cardiac surgery

Study objectiveThe mini-fluid challenge may predict fluid responsiveness with minimum risk of fluid overloading. However, the amount of fluid as well as the best manner to evaluate the effect is unclear. In this prospective observational pilot study, the value of changes in pulse contour cardiac output (CO) measurements during mini-fluid challenges is investigated. DesignProspective observational study. SettingIntensive Care Unit of a university hospital. PatientsTwenty-one patients directly after elective cardiac surgery on mechanical ventilation. InterventionsThe patients were subsequently given 10 intravenous boluses of 50mL of hydroxyethyl starch with a total of 500mL per patient while measuring pulse contour CO. MeasurementsWe measured CO by minimal invasive ModelflowR (COm) and PulseCOR (COli), before and one minute after each fluid bolus. We analyzed the smallest volume that was predictive of fluid responsiveness. A positive fluid response was defined as an increase in CO of >10% after 500mL fluid infusion. Main resultsFifteen patients (71%) were COm responders and 13 patients (62%) COli responders. An increase in COm after 150mL of fluid >5.0% yielded a positive and negative predictive value (+PV and −PV) of 100% with an area under the curve (AUC) of 1.00 (P<0.001). An increase in COli >6.3% after 200mL was able to predict a fluid response in COli after 500mL with a +PV of 100% and −PV of 73%, with an AUC of 0.88 (P<0.001). ConclusionThe use of minimal invasive ModelflowR pulse contour CO measurements following a mini-fluid challenge of 150mL can predict fluid responsiveness and may help to improve fluid management.

Effect of Combined Peritoneal Dialysis and Hemodialysis on Health-Related Quality of Life.

In Japan, combined peritoneal dialysis (PD) and hemodialysis (HD) therapy is performed widely as an established modality of renal replacement therapy. This combination therapy is indicated for patients who cannot maintain adequate solute clearance using a standard PD prescription, or those who have uremic symptoms or a state of persistent fluid overload. A common treatment schedule for combined PD + HD therapy consists of 5 days of PD and one HD session per week. A 4- to 5-h HD session is performed with a high-flux membrane dialyzer. On the HD day and the following day, patients are released from bag exchange for PD, defined as a PD holiday. The effectiveness of combined PD + HD therapy for solute clearance and fluid management has been recognized, but only a few reports have considered whether combined PD + HD therapy improves health-related quality of life (HRQOL) in uremic PD patients. We prospectively assessed clinical parameters and HRQOL by using the Short Form Health Survey-Version 2 (SF-36) and the Kidney Disease Quality of Life Instrument-Short Form (KDQOL-SF) before and 1 year after initiation of combined PD + HD therapy in 10 Japanese PD patients who could not achieve adequate solute clearance or fluid volume control. After starting combined PD + HD therapy, body weight and urine volume decreased and renal anemia and azotemia improved. Evaluation of HRQOL with the SF-36 showed improvement in physical function (72.9 ± 12.4 vs. 79.1 ± 12.4, p < 0.05). KDQOL scores for the symptoms/problems (68.3 ± 12.2 vs. 80.2 ± 17.6, p < 0.05) and effect of kidney disease (77.2 ± 12.1 vs. 82.8 ± 14.5, p < 0.05) showed significant improvement. Combined PD + HD therapy improved fluid volume management and uremic symptoms, leading to better HRQOL. Key Messages: Combined therapy improved fluid management and uremic symptoms, leading to better HRQOL.

The Body Composition Monitor: a flexible tool for routine fluid management across the haemodialysis population

Bioimpedance measurements with the Body Composition Monitor (BCM) have been shown to improve fluid management in haemodialysis. However, there is a lack of a sufficiently robust evidence-base for use of the BCM outside of standard protocols. This study aims to define the error associated with BCM measurement using alternate paths and timings to allow the use of BCM with confidence in a range of clinical scenarios. BCM measurements were made in 48 healthy controls and in 48 stable haemodialysis patients before and immediately after dialysis. The effect of utilising alternative measurement paths was assessed using mixed effects models and the effect of measuring post-dialysis was assessed by comparing changes in BCM-measured overhydration (OH) with weight changes over dialysis. The data from healthy controls suggest that there is no difference in BCM-measured OH between all the whole-body paths other than the ankle-to-ankle measurement. Dialysis patients showed similar results other than having higher BCM-measured OH when measured across the site of a vascular access. There was good agreement between BCM-measured OH from the standard path and change in weight, suggesting post-dialysis measurements can be utilised. These results suggest BCM protocols can be flexible regarding measurement paths and timing of measurement to ensure as many patients as possible can benefit from the technology.

Use of the Body Composition Monitor for Fluid Status Measurements in Subjects with High Body Mass Index

Background: Fluid management is a central aspect of haemodialysis (HD). Body composition monitor (BCM)-measured overhydration (OH) can improve fluid management strategies, but there remains uncertainty about its use in subjects with high body mass index (BMI). This study explored whether the observed tendency for HD patients with high BMI to complete dialysis fluid depleted according to BCM is associated with an artefact in the BCM models, or with systematic differences in the prescription and delivery of treatment. Methods: To isolate the effect of BMI from effects relating to treatment, BCM measurements were made on 20 healthy subjects with high BMI. Mean OH was compared with a previously reported cohort of healthy subjects with normal BMI. To further explore BCM-measured OH in HD patients, measurements were made pre- and post-dialysis on 10 patients with high BMI alongside relative blood volume monitoring. Body shape was classified to assess associations between shape and OH. Results: The mean OH for healthy subjects with high BMI was -0.1 litres, which was not different from that of healthy subjects with normal BMI. Median BCM-measured OH for HD patients was 1.8 and -1.8 litres pre- and post-dialysis respectively, while blood volume and blood pressure were maintained. Body shape correlated with OH in control subjects but not HD patients. Conclusions: We found no evidence of systematic bias in BCM-measured OH with high BMI in healthy subjects. BCM-measured post-dialysis fluid depletion in asymptomatic patients with high BMI appears to result from greater tolerance of ultrafiltration and ability to maintain blood volume.

Evidence of improved fluid management in patients receiving haemodialysis following a self-affirmation theory-based intervention: A randomised controlled trial

Objective: Haemodialysis patients are at risk of serious health complications; yet, treatment non-adherence remains high. Warnings about health risks associated with non-adherence may trigger defensive reactions. We studied whether an intervention based on self-affirmation theory reduced resistance to health-risk information and improved fluid treatment adherence.Design: In a cluster randomised controlled trial, 91 patients either self-affirmed or completed a matched control task before reading about the health-risks associated with inadequate fluid control.Outcome measures: Patients’ perceptions of the health-risk information, intention and self-efficacy to control fluid were assessed immediately after presentation of health-risk information. Interdialytic weight gain (IDWG), excess fluid removed during haemodialysis, is a clinical measure of fluid treatment adherence. IDWG data were collected up to 12 months post-intervention.Results: Self-affirmed patients had significantly reduced IDWG levels over 12 months. However, contrary to predictions derived from self-affirmation theory, self-affirmed participants and controls did not differ in their evaluation of the health-risk information, intention to control fluid or self-efficacy.Conclusion: A low-cost, high-reach health intervention based on self-affirmation theory was shown to reduce IDWG over a 12-month period, but the mechanism by which this apparent behaviour change occurred is uncertain. Further work is still required to identify mediators of the observed effects.

Associations of Posthemodialysis Weights above and below Target Weight with All-Cause and Cardiovascular Mortality.

Fluid removal via ultrafiltration is a primary function of hemodialysis, and inadequate volume control is associated with significant morbidity and mortality among chronic dialysis patients. Treatment-to-treatment fluid removal goals are typically calculated on the basis of interdialytic weight gain and prescribed target weight. The clinical effect of frequent missed target weights is unclear. This study was designed to evaluate the associations of postdialysis weights above and below the prescribed target weight (separately) and outcomes. Data were taken from a national cohort of 10,785 prevalent, thrice-weekly, in-center hemodialysis patients dialyzing from 2005 to 2008 (median time at risk, 2.1 [25th percentile, 75th percentile] years) at a single dialysis organization. Patients were characterized as having an above target weight miss if their postdialysis weight was >2 kg above target weight in at least 30% of baseline treatments (14.6% of cohort), or they were characterized as control otherwise. Below target weight miss characterization was analogous for patients with postdialysis weight >2 kg below target weight (6.6% of cohort). Coprimary endpoints were all-cause and cardiovascular mortality. Above target weight miss in at least 30% of treatments (versus not) was associated with greater all-cause mortality (adjusted hazard ratio, 1.28; 95% confidence interval, 1.15 to 1.43); and below target weight miss in at least 30% of treatments (versus not) was associated with greater all-cause mortality (adjusted hazard ratio, 1.22; 95% confidence interval, 1.05 to 1.40). Both above and below target weight misses were also significantly associated with greater cardiovascular mortality. Secondary analyses demonstrated dose-response relationships between target weight misses and mortality. Results from sensitivity analyses considering the difference in postdialysis and target weights as a proportion of body weight were analogous to the primary results. Postdialysis weights >2 kg above and below target weight are associated with higher all-cause and cardiovascular mortality. Consistent target weight achievement is a viable target for improving fluid management.