Subclinical Volume Overload Research Articles

Assessment of volume status of pediatric hemodialysis patients.

Accurate volume status assessment and dry weight achievement are the most challenging goals for a nephrologist. We aimed to evaluate the role of ultrasonographic parameters including lung ultrasound and inferior vena cava (IVC) measurements as practical methods of volume status assessment in children on hemodialysis by comparing them with established techniques, such as clinical evaluation and bioimpedance spectroscopy. A prospective cross-sectional study compared pre- and post-dialysis volume status using bioimpedance spectroscopy (BIS) parameters and clinical data with ultrasonographic lung B-lines and IVC parameters in children on regular hemodialysis. A total 60 children (mean age 9.4 ± 2.8years) were enrolled. Twenty patients (33.3%) were clinically overloaded to varying degrees (17 patients had mild to moderate signs of fluid overload and 3 patients had moderate to severe signs of fluid overload). All other patients (66.7%) were clinically euvolemic. Sonographic parameters were significantly lower post-dialysis than pre-dialysis, including lung B-line count and IVC diameter. IVC collapsibility index mean was significantly higher post-dialysis than pre-dialysis. There was a significant correlation between the lung B-line count, IVC parameters, and BIS-measured overhydration both before and after hemodialysis. Nine patients had ≥ 8 B-lines post-dialysis, only three of them were hypertensive. Clinical criteria alone are not specific for determining accurate fluid status in pediatric hemodialysis patients. Lung B-line score, IVC parameters, and BIS may be complementary to each other and to clinical data. Lung B-lines outperform IVC measurements and BIS in subclinical volume overload detection in pediatric hemodialysis patients.

Nutritional Assessments by Bioimpedance Technique in Dialysis Patients.

Bioelectrical impedance analysis (BIA) has been extensively applied in nutritional assessments on the general population, and it is recommended in establishing the diagnosis of malnutrition and sarcopenia. The bioimpedance technique has become a promising modality through which to measure the whole-body composition in dialysis patients, where the presence of subclinical volume overload and sarcopenic obesity may be overlooked by assessing body weight alone. In the past two decades, bioimpedance devices have evolved from applying a single frequency to a range of frequencies (bioimpedance spectroscopy, BIS), in which the latter is incorporated with a three-compartment model that allows for the simultaneous measurement of the volume of overhydration, adipose tissue mass (ATM), and lean tissue mass (LTM). However, clinicians should be aware of common potential limitations, such as the adoption of population-specific prediction equations in some BIA devices. Inherent prediction error does exist in the bioimpedance technique, but the extent to which this error becomes clinically significant remains to be determined. Importantly, reduction in LTM has been associated with increased risk of frailty, hospitalization, and mortality in dialysis patients, whereas the prognostic value of ATM remains debatable. Further studies are needed to determine whether modifications of bioimpedance-derived body composition parameters through nutrition intervention can result in clinical benefits.

#4877 THE EFFECT OF NURSE-LED 8-ZONE LUNG ULTRASOUND GUIDED TITRATION OF DRY WEIGHT ON HYPERTENSION IN APPARENTLY EUVOLAEMIC HAEMODIALYSIS PATIENTS

Abstract Background and Aims Hypertension related to subclinical volume overload is a common clinical problem in hemodialysis patients. Lung ultrasound (LUS) is a validated technique for minute titration of dry weight, but has limited adoption in clinical practice because it is currently a physician (nephrologist)-led methodology and time consuming with 24-lung zones needing to be imaged. This study aims to show that (1) a simplified 8-zone LUS protocol is effective at dry weight titration in clinically euvolaemic chronic haemodialysis patients, as determined by 24-hour ambulatory blood pressure monitoring (ABPM), and that (2) nurse-led LUS for dry weight titration is feasible and safe. Method This was a 6-week pre and post intervention study in 13 clinically euvolemic haemodialysis patients with chronic hypertension. 4 senior dialysis nurses with at least 4 years of dialysis nursing experience respectively were trained in LUS image acquisition and interpretation via a 1 day workshop by a certified Nephrologist and passed an image interpretation test. 8-zone LUS (which has been described by Volpicelli et al.[1]) was performed midweek, weekly. A Nephrologist reviewed all the acquired LUS images retrospectively. Dry weight was titrated down at a rate not exceeding 0.3 kg per week if LUS Kerley B lines exceeded 3 in any lung zone. All patients underwent 24-hour ABPM at baseline and after 6 weeks. Nurses underwent a post study qualitative survey to elucidate success factors and confidence in LUS technique. Results The study cohort was predominantly male (69%) and diabetic (92%), with an average age of 68 ± 10 years. The average time required for a nurse to complete 1 LUS scan was 3 ± 0.4 minutes. 75% of the cohort had dry weight reduction post-study, which ranged from 0.08 – 0.9% of initial dry weight. Correspondingly, the median number of ultrasonographic B-lines reduced from 4 to 3, although this did not reach statistical significance. Overall, there were reductions in 24-hour systolic BP (146.42±17.03 vs 139.08±12.40 mmHg; p = 0.067) and diastolic BP (72.75±11.79 vs 70.75±11.69 mmHg; p = 0.561). Similarly, there were trends towards improvements in pre- and post-dialysis systolic and diastolic BPs, although only pre-dialysis diastolic BPs showed statistically significant improvement (80±16.05 to 72.33±13.32 mmHg, p = 0.046). This may be related to small sample size. Nil adverse outcomes such as intra-dialytic hypotension, vascular thrombosis, cardiovascular events or fluid overload were reported during the study. 1 patient demised from pneumonia sepsis, which was deemed to be unrelated to the study. All nurses expressed confidence in LUS image acquisition and interpretation following the workshop. Their confidence was further bolstered by the end of the study. They also felt that point-of-care LUS was a useful skill for experienced haemodialysis nurses who were often responsible for day to day adjustment of fluid removal on dialysis. Conclusion We have demonstrated that nurse-led 8-zone LUS can effectively and safely titrate dry weight in chronic haemodialysis patients, as evidenced by improvements in 24-hours ABPM. Importantly, these results are similar to that of randomized controlled trials such as the LUST study where LUS was physician-led. There remains little doubt about the importance of LUS in volume assessment. In-depth studies are required to determine the competencies of, and risk-benefit assessment for nurse-led LUS, to improve the clinical relevance and penetrance of this tool.

Volume Status Assessment by Lung Ultrasound in End-Stage Kidney Disease: A Systematic Review.

Lung ultrasound is a noninvasive bedside technique that can accurately assess pulmonary congestion by evaluating extravascular lung water. This technique is expanding and is easily available. Our primary outcome was to compare the efficacy of volume status assessment by lung ultrasound with clinical evaluation, echocardiography, bioimpedance, or biomarkers. The secondary outcomes were all-cause mortality and cardiovascular events. We conducted a MEDLINE literature search for observational and randomized studies with lung ultrasound in patients on maintenance dialysis. From a total of 2363 articles, we included 28 studies (25 observational and 3 randomized). The correlation coefficients were pooled for each variable of interest using the generic inverse variance method with a random effects model. Among the clinical parameters, New York Heart Association Functional Classification of Heart Failure status and lung auscultation showed the highest correlation with the number of B-lines on ultrasound, with a pooled r correlation coefficient of .57 and .36, respectively. Among echocardiographic parameters, left ventricular ejection fraction and inferior vena cava index had the strongest correlation with the number of B-lines, with a pooled r coefficient of .35 and .31, respectively. Three randomized studies compared a lung ultrasound-guided approach with standard of care on hard clinical endpoints. Although patients in the lung ultrasound group achieved better decongestion and blood pressure control, there was no difference between the 2 management strategies with respect to death from any cause or major adverse cardiovascular events. Lung ultrasound may be considered for the identification of patients with subclinical volume overload. Trials did not show differences in clinically important outcomes. The number of studies was small and many were of suboptimal quality. The included studies were heterogeneous and of relatively limited quality.

PREVALENCE OF APPARENT-TREATMENT RESISTANT HYPERTENSION IN PERITONEAL DIALYSIS PATIENTS ASSESSED WITH THE USE OF 24-HOUR AMBULATORY BLOOD PRESSURE MONITORING

Objective: The prevalence of apparent-treatment resistant hypertension (aTRH) among patients with predialysis chronic kidney disease is 2–3 times higher than in the general population. The aim of the present study was to investigate the prevalence of aTRH in end-stage kidney disease (ESKD) patients undergoing peritoneal dialysis (PD). Design and method: A total of 140 ESKD patients treated with PD in 4 centers of Northern Greece underwent 24-hour ambulatory blood pressure monitoring with the oscillometric device Mobil-O-Graph (IEM, Stolberg, Germany). aTRH was defined as 24-hour ambulatory blood pressure (BP) equal or higher than 130/80 mmHg, despite the use of at least 3 antihypertensive medications of different categories or controlled hypertension in patients treated with at least 4 antihypertensives. Loop diuretics that are commonly prescribed in PD patients for long-term preservation of residual kidney function are generally ineffective in lowering BP and were not considered as a separate antihypertensive drug category in our analysis. To explore the association of volume overload with the severity of hypertension, the body composition of study participants was analyzed via bioimpendence spectroscopy (BCM, Fresenius Medical Care, Germany). Results: Of the 140 PD patients enrolled in the study, 42 (30%) had aTRH, 45 (32.1%) had uncontrolled hypertension under treatment with < 3 BP-lowering medications and the remaining 53 patients (37.9%) were either normotensives or had controlled hypertension with < 3 antihypertensives. The prevalence of aTRH among drug-treated hypertensives was 32.5%. Overhydration > 2.5L with the use of bioimpendence spectroscopy was detected in 38.1% of patients with aTRH, in 15.6% of patients with uncontrolled hypertension and in 18.9% of normotensives or patients with controlled hypertension (P< 0.05). Conclusions: The present study showed that aTRH affects approximately 30% of ESKD patients undergoing PD. However, the prevalence of true-resistant hypertension in this high-risk population is probably lower, since 38.1% of patients with aTRH had subclinical volume overload detected with the method of bioimpendence spectroscopy.

Left Heart Failure Caused by Capacity Overload in Peritoneal Dialysis Patients.

Background This study sets out to investigate the incidence of acute left ventricular failure in peritoneal dialysis patients with different volume loads and to analyze the related risk factors for LVF in these patients. Methods This study involved patients who received peritoneal dialysis in our hospital between September 2018 and January 2021. The demographic data and biochemical indicators of the patients were collected. The bioimpedance analysis method was used to determine the volume overload [overhydration (OH)] level of patients, and cardiac color Doppler ultrasound was used to detect changes in their cardiac structure. According to the LVF diagnostic criteria of symptoms and laboratory tests, the patients were divided into the LVF and non-LVF groups and then divided according to their OH level into the normal volume (OH ≤1.1 L) and volume overload (OH >1.1 L) groups. The incidence of LVF in was analyzed in patients with different volume loads, and logistic regression was used to identify the risk factors for LVF. Results Among the 226 peritoneal dialysis patients enrolled in this study, 125 patients (55.3%) had LVF. The normal volume group (n = 68, 30.1%) included 22 patients (32.4%) with LVF, and the volume overload group (n = 158, 69.9%) included 84 patients (53.2%) with LVF. In the volume overload group, 74 patients (46.8%) had subclinical volume overload, including 35 patients (47.3%) with LVF, and 84 patients (53.2%) had clinical volume overload, including 65 patients (77.4%) LVF. Multivariate logistic regression analysis revealed a high OH level (OR = 1.862, 95% CI: 1.353–2.668, P < 0.001) and low hemoglobin level (OR = 0.845, 95% CI: 0.721–0.980, P = 0.008) to be independent risk factors for LVF. Conclusions LVF has a high incidence in peritoneal dialysis patients, especially those with volume overload. A high OH level and low hemoglobin level are independent risk factors for LVF.

A Case of Severe Tricuspid Valve Regurgitation in a Patient Undergoing Orthotopic Liver Transplantation: Whether to Proceed, or Not

A 38-year-old male presented for orthotopic liver transplantation complicated by new-onset torrential tricuspid regurgitation before incision. Subclinical volume overload and functional tricuspid regurgitation created a challenging scenario in which the benefits of expeditious transplant were weighed against the risks of allograft congestion and failure. Intraoperative transesophageal echocardiography proved critical in diagnosing severe tricuspid regurgitation and guided clinical decision making. In this article, we describe the intraoperative presentation of acutely elevated right heart pressures and the subsequent management of this patient prior to ultimately successful liver transplantation.

Are there any further modalities for prediction of subclinical volume overload in advanced stages of chronic kidney disease?

Background Subclinical volume overload in chronic kidney disease (CKD) patient represents a debatable issue. Although many tools were used to detect volume overload in such patients, many non-specific results were due to presence of comorbidities. Bioimpedance spectroscopy is an objective fluid status assessment method, which is shown superior to classical methods in many studies. Combining some of these tools may improve their accuracy and specificity. Inferior vena cava collapsibility index (IVCCI) with brain natriuretic peptide (BNP) can be combined for more specific volume assessment. This study was performed to assess the usage of combined IVCCI and BNP levels in CKD patients to predict subclinical volume overload.MethodsOne hundred and ten patients with CKD (stages 4 and 5) not on dialysis and having normal left ventricular systolic function were included in this study. Exclusion criteria were: (1) patients with other causes of raised BNP than volume overload and (2) patients on diuretics. A complete medical history was obtained, and thorough examination and laboratory tests were performed for all included patients. IVCCI and BNP serum levels were evaluated. The patients who exhibited an overhydration (OH)/extracellular water (ECW) ratio of >15% were considered to have volume overload.ResultsTwenty-six patients (23.6%) had subclinical hypervolemia as diagnosed by OH/ECW ratio of >15%. IVCCI ≤ 38% had higher diagnostic performance than BNP ≥ 24 pg/mL. Combining both IVCCI ≤ 38% and BNP ≥ 24 pg/mL increased the specificity and positive predictive value for detection of subclinical hypervolemia.ConclusionCombined elevated BNP level and decreased IVCCI are more precise tools for subclinical volume overload detection in CKD patients.

Volume overload in hemodialysis: diagnosis, cardiovascular consequences, and management.

Volume overload in haemodialysis (HD) patients associates with hypertension and cardiac dysfunction and is a major risk factor for all-cause and cardiovascular mortality in this population. The diagnosis of volume excess and estimation of dry weight is based largely on clinical criteria and has a notoriously poor diagnostic accuracy. The search for accurate and objective methods to evaluate dry weight and to diagnose subclinical volume overload has been intensively pursued over the last 3 decades. Most methods have not been tested in appropriate clinical trials and their usefulness in clinical practice remains uncertain, except for bioimpedance spectroscopy and lung ultrasound (US). Bioimpedance spectroscopy is possibly the most widely used method to subjectively quantify fluid distributions over body compartments and produces reliable and reproducible results. Lung US provides reliable estimates of extravascular water in the lung, a critical parameter of the central circulation that in large part reflects the left ventricular end-diastolic pressure. To maximize cardiovascular tolerance, fluid removal in volume-expanded HD patients should be gradual and distributed over a sufficiently long time window. This review summarizes current knowledge about the diagnosis, prognosis and treatment of volume overload in HD patients.

Are There Any Further Modalities for Prediction of Subclinical Volume Overload in Advanced Stages of CKD?

Are There Any Further Modalities for Prediction of Subclinical Volume Overload in Advanced Stages of CKD?

THE ASSOCIATION BETWEEN SUBCLINICAL VOLUME OVERLOAD AND CARDIOVASCULAR OUTCOME AND ALL-CAUSE MORTALITY IN A HEALTHY THAI POPULATION

Excess extracellular water leads to poor health outcomes in chronic kidney disease patients. Data on this association are scarce in healthy population. This study aims to determine the association subclinical volume overload (SVO) as measured by multifrequency bioelectrical impedance analysis (MF-

Longitudinal increases in blood biomarkers of inflammation or cardiovascular disease and the incidence of venous thromboembolism

Background We previously showed that participants in the population-based Atherosclerosis Risk in Communities (ARIC) cohort with elevated levels of blood biomarkers of inflammation or cardiac disease were at increased risk of venous thromboembolism (VTE). Objective We hypothesized that ARIC participants with larger 6-year increases in the levels of three biomarkers - C-reactive protein (CRP), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and troponin T - would also have an increased subsequent risk of VTE. Methods We measured changes in the levels of these biomarkers in 9844 participants from 1990-1992 to 1996-1998, and then identified VTEs through 2015. Results A greater 6-year rise in the level of NT-proBNP, but not in that of CRP or troponin T, was significantly associated with increased VTE incidence over a median of 17.6 years of follow-up. After adjustment for other VTE risk factors, those whose NT-proBNP level rose from < 100 pg mL-1 to ≥ 100 pg mL-1 had a hazard ratio for VTE of 1.44 (95% confidence interval [CI] 1.15-1.80), as compared with the reference group with an NT-proBNP level of < 100 pg mL-1 at both times. This hazard ratio was slightly higher (1.66, 95% CI 1.19-2.31) during the first 10 years of follow-up, but was attenuated (1.24, 95% CI 0.99-1.56) after adjustment for prevalent and incident coronary heart disease, heart failure, and atrial fibrillation. Conclusions The two most likely explanations for our results are that: (i) an increasing NT-proBNP level reflects increasing subclinical volume overload and potentially increased venous stasis or subclinical PE that had gone unrecognized over time; or (ii) an increasing NT-proBNP level is a risk marker for impending cardiac disease that places patients at risk of VTE.

Volume-Kidney Interaction in Chronic Heart Failure - Impact of Subclinical Volume Expansion and Chronic Kidney Disease on Clinical Outcomes

ObjectivesAssess the impact of volume-kidney interactions on outcomes in clinically “euvolemic” chronic heart failure (HF) patients with co-existing chronic kidney disease (CKD).BackgroundCardio-renal interactions are complex and bi-directional and may in part be mediated by the extent of intravascular volume overload. The impact of subclinical volume expansion on outcomes in HF patients with CKD has not been previously examined.MethodsPlasma volume (PV) was prospectively measured in 110 stable HF patients with varying degrees of CKD using a standardized radiolabeled albumin indicator-dilution technique. To examine the interactive roles of volume expansion and CKD the cohort was dichotomized by median PV and then further stratified by cohort median creatinine (sCr), eGFR, and BUN and analyzed for outcomes of HF-related mortality or 1st hospitalization using Kaplan-Meier method.ResultsSubclinical volume overload was demonstrated in 76% of the cohort. Over 1.5 years, sCr and BUN above and eGFR below (Fig.) cohort median values identified highest risk for the composite end-point but only in severe PV expansion (≥ median expansion of +26%) (p=0.02). In normal to moderate PV expansion (< +26% expansion) worse renal function was not associated with increased risk (p=0.578).ConclusionsIn clinically stable chronic HF patients with co-existing CKD, subclinical PV expansion is common, and importantly the extent of PV expansion impacts outcomes including early HF mortality. However, better kidney function mitigates the deleterious effects of severe PV expansion, while mild-moderate expansion balances the risks of worse renal function. Thus, volume-kidney interactions are complex with volume status modulating the impact of CKD on outcomes in chronic HF. Figures. Risk Stratification by Median eGFR in Chronic Heart Failure Patients with A. Severe Plasma Volume Expansion (PV ≥ Median of +26% Above Normal Volume) B. Mild-Moderate Plasma Volume Expansion (PV < Median of +26% Above Normal Volume) Assess the impact of volume-kidney interactions on outcomes in clinically “euvolemic” chronic heart failure (HF) patients with co-existing chronic kidney disease (CKD). Cardio-renal interactions are complex and bi-directional and may in part be mediated by the extent of intravascular volume overload. The impact of subclinical volume expansion on outcomes in HF patients with CKD has not been previously examined. Plasma volume (PV) was prospectively measured in 110 stable HF patients with varying degrees of CKD using a standardized radiolabeled albumin indicator-dilution technique. To examine the interactive roles of volume expansion and CKD the cohort was dichotomized by median PV and then further stratified by cohort median creatinine (sCr), eGFR, and BUN and analyzed for outcomes of HF-related mortality or 1st hospitalization using Kaplan-Meier method. Subclinical volume overload was demonstrated in 76% of the cohort. Over 1.5 years, sCr and BUN above and eGFR below (Fig.) cohort median values identified highest risk for the composite end-point but only in severe PV expansion (≥ median expansion of +26%) (p=0.02). In normal to moderate PV expansion (< +26% expansion) worse renal function was not associated with increased risk (p=0.578). In clinically stable chronic HF patients with co-existing CKD, subclinical PV expansion is common, and importantly the extent of PV expansion impacts outcomes including early HF mortality. However, better kidney function mitigates the deleterious effects of severe PV expansion, while mild-moderate expansion balances the risks of worse renal function. Thus, volume-kidney interactions are complex with volume status modulating the impact of CKD on outcomes in chronic HF. Figures. Risk Stratification by Median eGFR in Chronic Heart Failure Patients with A. Severe Plasma Volume Expansion (PV ≥ Median of +26% Above Normal Volume) B. Mild-Moderate Plasma Volume Expansion (PV < Median of +26% Above Normal Volume)

Subclinical volume overload in stable outpatients with chronic heart failure.

Objective The objective of this study was to characterize stable outpatients with subclinical volume overload in chronic heart failure (CHF) by using bioelectrical impedance analysis (BIA) measurem...

Subclinical volume overload in stable outpatients with chronic heart failure

Objective The objective of this study was to characterize stable outpatients with subclinical volume overload in chronic heart failure (CHF) by using bioelectrical impedance analysis (BIA) measurements.Methods and results Venous blood sampling and BIA were performed in consecutive CHF patients (n = 58) free from clinical signs of volume overload and treated with oral loop diuretics. Subclinical volume overload was defined as excess extracellular water on BIA. Patients with (n = 34) versus without (n = 24) subclinical volume overload were significantly older (72 ± 10 versus 65 ± 9 years; P-value = 0.016), had higher systolic blood pressure (126 ± 20 versus 114 ± 17 mmHg; P-value = 0.012), and took angiotensin-converting enzyme inhibitors more often (65% versus 33%; P-value = 0.032). Dyspnoea symptoms were similar among both groups. Subclinical volume overload was associated with low serum albumin (P-value = 0.014) and protein levels (P-value = 0.041). In contrast, serum sodium levels (141 ± 3 versus 139 ± 2 mEq/L; P-value = 0.033) but not chloride levels (99 ± 14 versus 101 ± 3 mEq/L; P-value = 0.980) were significantly higher in patients with versus without subclinical volume overload, respectively. The former versus latter group also demonstrated lower plasma aldosterone levels [276 (195-475) versus 400 (306-717) ng/L, respectively; P-value = 0.032].Conclusions Subclinical volume overload assessed by BIA in stable CHF is associated with low serum protein levels, increased serum sodium but not serum chloride, as well as decreased neurohumoral activation.

Associations of N-terminal pro–B-type natriuretic peptide with kidney function decline in persons without clinical heart failure in the Heart and Soul Study

Subclinical volume overload in the absence of diagnosed heart failure (HF) may be an underrecognized contributor to kidney function decline in coronary artery disease (CAD) patients. We evaluated associations of circulating N-terminal pro-B-type natriuretic peptide (NT-proBNP), a marker of ventricular stretch, with change in estimated glomerular filtration rate (eGFR). We evaluated 535 patients with stable CAD and no history of HF, who were enrolled in the Heart and Soul Study and followed for 5 years. N-terminal pro-B-type natriuretic peptide was measured at baseline. We evaluated the associations of NT-proBNP with change in kidney function over 5 years: (a) annual percent change in eGFR, (b) rapid kidney function loss (> 3% per year for 5 years), and (c) incident eGFR < 60 mL/min per 1.73 m2. In multivariable models, we adjusted for demographics, comorbid conditions, echocardiographic parameters, medications, and baseline kidney function. Among 535 participants, median NT-proBNP was 130.6 (interquartile range 61.8-280.9) pg/mL, and median B-type natriuretic peptide (BNP) was 32.5 (14.4-75.9) pg/mL. Individuals with NT-proBNP levels in the highest quartile (> 280.9 pg/mL) had a greater odds of rapid kidney function loss after full adjustment (odds ratio 2.95; 95% CI 1-8.65; P = .0492). Associations with incident eGFR < 60 mL/min per 1.73 m2 were also significant (adjusted odds ratio 4.23; 95% CI 1.05-16.98; P = .0422). Results were similar when analyzed using BNP as the predictor. N-terminal pro-B-type natriuretic peptide and BNP are strongly and independently associated with accelerated kidney function loss, even in the absence of clinical HF. These findings suggest that subclinical cardiovascular dysfunction may contribute to elevated kidney disease risk in persons with CAD.

Bioimpedance-Guided Fluid Management in Maintenance Hemodialysis: A Pilot Randomized Controlled Trial

Chronic subclinical volume overload happens very frequently in hemodialysis patients and is associated directly with hypertension, increased arterial stiffness, left ventricular hypertrophy, and ultimately higher mortality. Randomized controlled parallel-group trial. 131 patients from one hemodialysis center, randomly assigned into 2 groups. Dry weight prescription using results derived from repeated 3-month bioimpedance measurements to guide ultrafiltration for strict volume control (bioimpedance group; n=62) compared with clinical judgment without bioimpedance measures (clinical-methods group; n=69) for 2.5 years. The primary outcome was all-cause mortality over 2.5 years (the duration of the intervention). Secondary outcomes were change in relative arterial stiffness, fluid overload, and blood pressure (BP) over 2.5 years. Bioimpedance measurements were performed using a Body Composition Monitor device. Pulse wave velocity analysis was performed at baseline, 2.5 years (end of intervention), and 3.5 years (end of study). Relative fluid overload and BP were assessed at 3-month intervals. The unadjusted HR for all-cause death in the bioimpedance group (vs the clinical-methods group) was 0.100 (95% CI, 0.013-0.805; P=0.03). After 2.5 years, we found a greater decline in arterial stiffness, relative fluid overload, and systolic BP in the bioimpedance group than the clinical-methods group. Between-group differences in change from baseline to the end of intervention were-2.78 (95% CI,-3.75 to 1.80)m/s for pulse wave velocity (P<0.001),-2.99% (95% CI,-5.00% to-0.89%) for relative fluid overload (P=0.05), and-2.43 (95% CI,-7.70 to 2.84)mmHg for systolic BP (P=0.4). Echocardiography was not performed as cardiovascular assessment and the caregivers were not masked to the intervention. Our study showed improvement in both surrogate and hard end points after strict volume control using bioimpedance to guide dry weight adjustment. These findings need to be confirmed in a larger trial.

Postdialysis blood pressure rise predicts long-term outcomes in chronic hemodialysis patients: a four-year prospective observational cohort study

BackgroundThe blood pressure (BP) of a proportion of chronic hemodialysis (HD) patients rises after HD. We investigated the influence of postdialysis BP rise on long-term outcomes.MethodsA total of 115 prevalent HD patients were enrolled. Because of the fluctuating nature of predialysis and postdialysis BP, systolic BP (SBP) and diastolic BP before and after HD were recorded from 25 consecutive HD sessions during a 2-month period. Patients were followed for 4 years or until death or withdrawal.ResultsKaplan-Meier estimates revealed that patients with average postdialysis SBP rise of more than 5 mmHg were at the highest risk of both cardiovascular and all-cause mortality as compared to those with an average postdialysis SBP change between -5 to 5 mmHg and those with an average postdialysis SBP drop of more than 5 mmHg. Furthermore, multivariate Cox regression analysis indicated that both postdialysis SBP rise of more than 5 mmHg (HR, 3.925 [95% CI, 1.410-10.846], p = 0.008) and high cardiothoracic (CT) ratio of more than 50% (HR, 7.560 [95% CI, 2.048-27.912], p = 0.002) independently predicted all-cause mortality. We also found that patients with an average postdialysis SBP rise were associated with subclinical volume overload, as evidenced by the significantly higher CT ratio (p = 0.008).ConclusionsA postdialysis SBP rise in HD patients independently predicted 4-year cardiovascular and all-cause mortality. Considering postdialysis SBP rise was associated with higher CT ratio, intensive evaluation of cardiac and volume status should be performed in patients with postdialysis SBP rise.

Subclinical Volume Overload and Hypertension Uncovered by Exercise Testing in Healthy Anaemic Haemodialysis Patients

Subclinical Volume Overload and Hypertension Uncovered by Exercise Testing in Healthy Anaemic Haemodialysis Patients