Volume Status In Patients Research Articles

Intravascular volume status in patients with moderate to severe COVID-19: a case series

The Article Abstract is not available.

Remote dielectric sensing predicts elevated left atrial pressure in patients with atrial fibrillation

BackgroundThere are currently no established non-invasive indices of echocardiography for elevated left atrial pressure (LAP) especially in patients with atrial fibrillation (AF). Remote dielectric sensing (ReDS) is a novel non-invasive electromagnetic energy-based technology that quantifies total lung fluid, enabling the monitoring of volume status in patients with heart failure. The utility of ReDS for estimating LAP in patients with AF remains unknown. MethodsWe prospectively investigated patients with AF in whom LAP was directly measured during catheter ablation for AF, and ReDS measurements were conducted the day before ablation. Elevated LAP was defined as LAP ≥ 15 mmHg. ResultsA total of 61 patients were included (median age 66 years, 38 % female). Among them, 26 patients had elevated LAP. There was a positive correlation between ReDS and LAP (r = 0.363, P = 0.004). Receiver operating characteristic curve analysis for the prediction of elevated LAP demonstrated that the best cut-off value of ReDS was 30 %, with a sensitivity of 65 %, specificity of 69 %, and an area under the curve of 0.703 (95 % confidence interval 0.568–0.837). Multivariate logistic regression analysis revealed that ReDS was an independent predictor of elevated LAP, among covariates including left ventricular ejection fraction, the ratio of early transmitral flow velocity to septal mitral annular early diastolic velocity, and left atrial volume index. ConclusionsOur results suggest ReDS could be a valuable marker of elevated LAP even in patients with AF. Further studies are needed to elucidate the effectiveness of a ReDS-guided decongestive strategy in patients with heart failure.

Use of lung ultrasound to assess volume status and its association with physical examination in patients with chronic kidney disease.

Defining the optimal hydration status in patients with chronic kidney disease (CKD) is challenging, and the quest for an objective accurate method continues. Lung ultrasound (LUS) is a well-validated technique to estimate volume status. Previous studies examining the relationship between LUS and physical examination demonstrated conflicting results. We aimed to evaluate the correlation between LUS results and physical examination for assessing volume status in patients with CKD, and to compare different LUS protocols. A prospective, single-center trial correlating physical examination findings to LUS results in different CKD groups, including non-dialysis and dialysis patients. Hemodialysis patients were tested twice, before and after dialysis, to compare results with ultrafiltration volume. Different LUS protocols were performed and compared, including 16-, 12-, and 8-zone measurements. We recruited 175 participants. A strong positive correlation was demonstrated between 16- and 12-zone protocols [r=.91 (P<.001)] and between 12- and 8-zone protocols (r=.951, P<.001). Correlation was significant in various CKD groups. While blood pressure did not correlate with LUS score, there was a significant correlation between LUS and other components of the physical examination including lung crackles (OR=1.15 (95%CI 1.096-1.22), P<.01), pleural effusion (OR=1.15 (95%CI 1.09-2.13), P<.01) and peripheral edema (r=.24, P<.001). Ultrafiltration volume did not correlate significantly with change in LUS scores pre- and post-dialysis (r=.169, P=.065). Most components of physical examination findings correlated with extravascular lung water assessment on LUS in CKD patients. The use of a simplified pragmatic LUS protocol may facilitate LUS use in clinical practice.

Dialysis parameters associated with SARS-CoV-2 infection and prognosis in end-stage kidney disease

Background The Covid-19 pandemic has affected patients with end-stage kidney disease (ESKD). Whether dialysis parameters have a prognostic value in ESKD patients with Covid-19 remains unclear. Materials and Methods We retrospectively evaluated clinical characteristics, blood pressure (BP) and dialysis parameters in ESKD patients undergoing maintenance outpatient hemodialysis, with (Covid-ESKD) and without (No-Covid-ESKD) Covid-19, at four Brazilian hemodialysis facilities. The Covid-ESKD (n = 107; 54% females; 60.8 ± 17.7 years) and No-Covid-ESKD (n = 107; 62% females; 58.4 ± 14.6 years) groups were matched by calendar time. The average BP and dialysis parameters were calculated during the pre-infection, acute infection, and post-infection periods. The main outcomes were Covid-19 hospitalization and all-cause mortality. Results Covid-ESKD patients had greater intradialytic and postdialysis systolic BP and lower predialysis weight, postdialysis weight, ultrafiltration rate, and interdialytic weight gain during acute-illness compared to 1-week-before-illness, while these changes were not observed in No-Covid-ESKD patients. After 286 days of follow-up (range, 276–591), there were 18 Covid-19-related hospitalizations and 28 deaths among Covid-ESKD patients. Multivariable logistic regression analysis showed that increases in predialysis systolic BP from 1-week-before-illness to acute-illness (OR, 95%CI = 1.06, 1.02–1.10; p = .004) and Covid-19 vaccination (OR, 95%CI = 0.16, 0.04–0.69; p = .014) were associated with hospitalization in Covid-ESKD patients. Multivariable Cox-regression analysis showed that Covid-19-related hospitalization (HR, 95%CI = 5.17, 2.07–12.96; p < .001) and age (HR, 95%CI = 1.05, 1.01–1.08; p = .008) were independent predictors of all-cause mortality in Covid-ESKD patients. Conclusion Acute Covid-19 illness is associated with variations in dialysis parameters of volume status in patients with ESKD. Furthermore, increases in predialysis BP during acute Covid-19 illness are associated with an adverse prognosis in Covid-ESKD patients.

Portal vein Doppler tracks volume status in patients with severe tricuspid regurgitation: a proof-of-concept study.

Renal and liver congestion are associated with adverse outcomes in patients with tricuspid regurgitation (TR). Currently, there are no valid sonographic indicators of fluid status in this population. Intra-renal venous Doppler (IRVD) is a novel method for quantifying renal congestion but its interpretation can be challenging in severe TR due to altered haemodynamics. This study explores the potential of portal vein Doppler (PVD) as an alternative marker for decongestion during volume removal in patients with severe TR. Forty-two patients with severe TR undergoing decongestive therapy were prospectively enrolled. Inferior vena cava diameter, PVD, and IRVD were sequentially assessed during volume removal. Improvement criteria were portal vein pulsatility fraction (PVPF) < 70% and renal venous stasis index (RVSI) < 0.5 for partial improvement, and PVPF < 30% and RVSI < 0.2 for complete improvement. After volume removal, PVPF significantly improved from 130 ± 39% to 47 ± 44% (P < 0.001), while IRVD improved from 0.72 ± 0.08 to 0.54 ± 0.22 (P < 0.001). A higher proportion of patients displayed improvement in PVD compared to IRVD (partial: 38% vs. 29%, complete: 41% vs. 7%) (P < 0.001). Intra-renal venous Doppler only improved in patients with concomitant improvement in severe TR. Portal vein Doppler was the only predictor of achieving ≥5 L of negative fluid balance [area under the ROC curve (AUC) 0.83 P = 0.001]. This proof-of-concept study suggests that PVD is the only sonographic marker that can track volume removal in severe TR, offering a potential indicator for decongestion in this population. Further intervention trials are warranted to determine if PVD-guided decongestion improves patient outcomes in severe TR.

Utility of the Venous Excess Ultrasound (VEXUS) score to track dynamic change in volume status in patients undergoing fluid removal during haemodialysis – the ACUVEX study

BackgroundThe use of ultrasound assessment, including the Venous Excess Ultrasound (VEXUS) score, is increasingly being utilised as part of fluid status assessment in clinical practice. We aimed to evaluate the ability of the VEXUS score to track fluid removal during the course of the dialysis session and explore the relationship between traditional measures of fluid status and venous congestion.MethodsSingle-centre, observational study in patients undergoing intermittent haemodialysis, who presented above their target dry weight. Patients had serial assessment using VEXUS, lung ultrasound and selected echocardiographic measures, before, during and after fluid removal.ResultsAmongst 33 patients analysed, 5 (15%) had an elevated VEXUS score (> 0). There was no difference in starting weight, dry weight or amount of fluid removed in patients with a normal VEXUS score and those with an elevated VEXUS score. In all patients with elevated VEXUS scores, the degree of venous congestion improved during the course of fluid removal. All patients with an elevated VEXUS score had evidence of both right and left ventricular systolic impairment.ConclusionIn patients with ESRF undergoing haemodialysis, the incidence of venous congestion as measured by the VEXUS is low. In patients with elevated VEXUS scores, removal of fluid through haemodialysis improves the venous congestion score. The pattern of LV and RV systolic dysfunction suggests that VEXUS may be a reflection of cardiac failure rather than venous volume status.Trial registrationEthical approval was provided by South Central-Berkshire Research and Ethics Committee and registered on clinicaltrials.org (IRAS305720). Trial registration: ISRCTN14351189 – Retrospectively registered on 30/11/2023.

HEMODİYALİZ HASTALARINDA VOLÜM DURUMUNUN YAŞAM KALİTESİ, ANKSİYETE, DEPRESYON VE UYKU KALİTESİ ÜZERİNE ETKİSİ

Objectives&#x0D; To determine the volume status of patients undergoing&#x0D; hemodialysis using the bioimpedance method and to&#x0D; investigate the relationship of volume status with the&#x0D; patients’ quality of life, anxiety, depression, and sleep&#x0D; quality.&#x0D; Material and Method&#x0D; This cross-sectional study included a total of 100&#x0D; patients undergoing hemodialysis at the Hemodialysis&#x0D; Unit in March 2016. The volume status of the patients&#x0D; was determined using bioelectrical impedance&#x0D; analysis (BIA) performed with a body composition&#x0D; monitor before their mid-week hemodialysis sessions.&#x0D; The quality of life was evaluated using the 36-item&#x0D; Short Form Survey, sleep quality was assessed using&#x0D; the Pittsburg Sleep Quality Index (PSQI), depression&#x0D; screening was performed with the Beck Depression&#x0D; Inventory, and anxiety screening was undertaken with&#x0D; the Beck Anxiety Inventory. The patients were divided&#x0D; into three groups according to the extracellular fluid/&#x0D; total body fluid (ECF/TBF) ratio, which is one of the&#x0D; BIA parameters: Group 1,

Comparison of lung ultrasonography, transthoracic echocardiography and clinical findings in assessing volume status in patients receiving renal replacement therapy

While transthoracic echocardiography and clinical findings are used to assess body volume status, lung ultrasonography (LUS), which is a non-invasive method, has also been used in assessing hypervolemia in recent years. This study aims to compare LUS, transthoracic echocardiography (TTE) and clinical findings in the assessment of body volume status in patients receiving renal replacement therapy (RRT). The study included 99 subjects who received RRT and were followed-up in our hospital. The patients were randomly selected from kidney transplant patients and those who had been receiving peritoneal dialysis (PD) or hemodialysis (HD) for at least the past three months. In addition, a control group consisting of 52 healthy subjects was also enrolled. LUS and TTE were simultaneously performed (within 24 hours). The mean left atrial (LA) diameter was 37.8±2.7 mm, 37.9±3.4 mm, 38.6±3.5 mm and 29.0±4.4 mm in patients who received PD, kidney transplantation, HD and in the control group, respectively. There was a moderate positive correlation between the total number of B-lines and LA diameter (mm) in the combined group consisting of the patient and control groups (p=0.0001, r=0.286). In this study, the number of B-lines on LUS has been found to be higher in patients receiving renal replacement therapy due to the effect of hypervolemia compared to the control group. However, there was no statistically significant difference in terms of the number of B-lines and LA diameter in echocardiography.

Fractional excretion of urea nitrogen can identify true worsening renal function in patients with acute heart failure

Abstract Background Worsening renal function (WRF) often occurs during decongestive treatment in acute heart failure (AHF). Although WRF has previously been associated with worse prognosis, recent studies have revealed that it may not contribute to an unfavorable outcome in the setting of adequate decongestion achieved. Therefore, there is growing interest to identify patients who develop "true WRF" with poor outcomes. Purpose Fractional excretion of urea nitrogen (FEUN), which is used to differentiate causes of renal failure, has emerged as a surrogate marker of volume status in patients with AHF complicated by renal dysfunction. Recent study has reported that a low FEUN value (FEUN ≤32.1%) represents intravascular dehydration, whereas a high FEUN value (FEUN &amp;gt;38.0%) reflects intravascular congestion, both being independent adverse prognostic factors. Therefore, we hypothesized that FEUN could identify "true WRF" in patients with AHF. Methods We examined 801 hospitalized patients with AHF and renal dysfunction (defined as discharge estimated glomerular filtration rate &amp;lt;60 mL/min/1.73 m²) whose FEUN was measured at discharge. The patients were divided into four groups as follows: no WRF (n=683); WRF with low FEUN (≤32.1%) (n=36); WRF with medium FEUN (&amp;gt;32.1% and ≤38.0%) (n=25); and WRF with high FEUN (&amp;gt;38.0%) (n=57). WRF was defined as an increase in serum creatinine ≥0.3 mg from admission to discharge. FEUN was calculated by the following formula: (urinary urea × serum creatinine) × 100 / (serum urea × urinary creatinine). The primary endpoint was the composite of all-cause death and heart failure (HF) readmission within 1-year after discharge. Results Regarding baseline characteristics, the WRF with low FEUN group had lower left ventricular ejection fraction, whereas the WRF with high FEUN group had poorer renal function. During the median follow-up period of 300 days, 18 all-cause deaths and 165 HF readmissions occurred. Kaplan–Meier analysis showed that patients without WRF had a significantly higher event-free survival rate than those with WRF. In addition, the WRF with medium FEUN group had a significantly higher event-free survival rate similar to that of the no WRF group, whereas the WRF with low FEUN and WRF with high FEUN groups had lower event-free survival rates. In multivariable Cox regression analysis, the WRF with low FEUN (hazard ratio, 1.91; 95% confidence interval, 1.02–3.57; P=0.043) and WRF with high FEUN (hazard ratio, 1.71; 95% confidence interval, 1.02–2.89; P=0.043) groups were independently associated with poor outcomes, even after adjusting for confounders. Conclusion Our study suggests that FEUN can identify prognostically relevant WRF and may be a useful marker for guiding decongestive therapy in patients with AHF complicated by WRF.Table 1Figure 1

Predicting dry weight change in Hemodialysis patients using machine learning

BackgroundMachine Learning has been increasingly used in the medical field, including managing patients undergoing hemodialysis. The random forest classifier is a Machine Learning method that can generate high accuracy and interpretability in the data analysis of various diseases. We attempted to apply Machine Learning to adjust dry weight, the appropriate volume status of patients undergoing hemodialysis, which requires a complex decision-making process considering multiple indicators and the patient’s physical conditions.MethodsAll medical data and 69,375 dialysis records of 314 Asian patients undergoing hemodialysis at a single dialysis center in Japan between July 2018 and April 2020 were collected from the electronic medical record system. Using the random forest classifier, we developed models to predict the probabilities of adjusting the dry weight at each dialysis session.ResultsThe areas under the receiver-operating-characteristic curves of the models for adjusting the dry weight upward and downward were 0.70 and 0.74, respectively. The average probability of upward adjustment of the dry weight had sharp a peak around the actual change over time, while the average probability of downward adjustment of the dry weight formed a gradual peak. Feature importance analysis revealed that median blood pressure decline was a strong predictor for adjusting the dry weight upward. In contrast, elevated serum levels of C-reactive protein and hypoalbuminemia were important indicators for adjusting the dry weight downward.ConclusionsThe random forest classifier should provide a helpful guide to predict the optimal changes to the dry weight with relative accuracy and may be useful in clinical practice.

Noninvasive Hemodynamic Profiling of Patients Undergoing Hemodialysis Using a Handheld Ultrasound Device

INTRODUCTION: Accurate determination of volume status for patients with end-stage renal disease is essential in determining ultrafiltration rate during hemodialysis (HD). To complement the current dry weight method, inferior vena cava (IVC) collapsibility, made accessible by point of-care ultrasonography, is considered. This study determined the utility of IVC measurement in estimating the volume status of patients during HD in comparison to clinical parameters. METHODS: A single-center cross-sectional design including 53 HD patients was conducted, with IVC measurements done through the Butterfly iQ ultrasound (Butterfly Network, Burlington, Massachusetts). RESULTS: Most patients were hypervolemic before HD based on weight (94.3%) and IVC collapsibility index (IVC-CI; 75.5%), but only 30% had clinical symptoms. Body weight, maximum IVC diameter, minimum IVC diameter, and indexed IVC size significantly decreased after HD, whereas IVC-CI, blood pressure, and heart rate were unchanged. For the subset of patients with symptoms, absolute values of IVC measures were higher, but did not significantly change after HD, unlike in those without symptoms. For volume classification, there are discrepancies in the classifications based on the different measures, with most improvement seen when weight was used, but which was not reflected in IVC-CI. Change in weight and IVC measures were not significantly correlated. DISCUSSION: This pilot study showed that the current dry weight method provides ultrafiltration rate estimation without causing intradialytic events. However, IVC can be a supplemental parameter to set higher targets and increase volume removal enough to cause intravascular change, especially in symptomatic patients. The incongruencies in classifying volume status suggest that there is no single measure to determine hemodynamic status and that using multiple parameters may provide a more reliable estimate. KEYWORDS: inferior vena cava measurement, volume status in hemodialysis, point-of-care ultrasonography

ESTIMATION OF PLASMA VOLUME IN PATIENTS PRESENTING WITH ACUTE DECOMPENSATED HEART FAILURE USING KAPLAN – HAKIM FORMULA AND CORRELATION OF PLASMA VOLUME SHIFT WITH OUTCOMES

Objective: Simple and non-invasive methods are required to estimate the plasma volume expansion to assess the congestion status in heart failure patients. To determine the effectiveness of Kaplan–Hakim formula in the quantification of the plasma volume expansion in acute decompensated heart failure (ADHF) and the correlation of the outcome factors with plasma volume shift (PVS). Methods: This prospective study included 384 participants diagnosed with ADHF. Newly diagnosed cases and patients receiving treatment for the past 6 months were included. Kaplan–Hakim formula was used to estimate the plasma volume. Duration of hospital stay, subsequent hospitalization for heart failure (HHF), cardiovascular disease mortality, and all-cause mortality rate at the end of follow-up time was also noted. Results: Among the study participants, 88 patients (22.92%) had PVS &lt;5%, while the remaining 88.5% of the patients had PVS more than or equal to 5%. A strong association between guideline-recommended dose of ACEi/ARBs, beta-blockers, and normalcy of plasma volume status (p&lt;0.001) was found. The mean duration of stay, number of repeated hospitalization, the incidence of worsening renal function, CV mortality rate, and all-cause mortality rate were significantly lower in participants with PVS ≥5% in comparison to those who had PVS &lt; 5%. Kaplan–Hakim formula is a more practical and easy way to measure volume status in patients with ADHF. Conclusion: The use of RAAS antagonists and beta-blockers in their optimal dosage is associated with favorable plasma volume status in chronic HF patients.

Utility of fractional excretion of urea nitrogen in heart failure patients with chronic kidney disease.

Maintenance of euvolaemia with diuretics is critical in heart failure (HF) patients with chronic kidney disease (CKD); however, it is challenging because no reliable marker of volume status exists. Fractional excretion of urea nitrogen (FEUN) is a useful index of volume status in patients with renal failure. We aimed to examine whether FEUN is a surrogate marker of volume status for risk stratification in HF patients with CKD. We examined 516 HF patients with CKD (defined as discharge estimated glomerular filtration rate<60mL/min/1.73m2 ) whose FEUN was measured at discharge (median age, 80years; 58% male). The patients were divided into four groups according to quartile FEUN value at discharge: low-FEUN, FEUN≤32.1; medium-FEUN, 32.1<FEUN≤38.0; high-FEUN, 38.0<FEUN≤43.7; and extremely-high-FEUN, FEUN>43.7. FEUN was calculated by the following formula: (urinary urea×serum creatinine)×100/(serum urea×urinary creatinine). During the 3year follow-up, 131 HF readmissions occurred. Kaplan-Meier analysis showed that the HF readmission rate was significantly lower in the medium-FEUN group than in the other three groups (log-rank test, P=0.029). Multivariate Cox regression analysis identified the low-FEUN, high-FEUN, and extremely-high-FEUN values as independent factors associated with post-discharge HF readmission. In the analysis of 130 patients who underwent right heart catheterization during hospitalization, a significant correlation between FEUN value and right atrial pressure was observed (R=0.243, P=0.005). Multivariate linear regression analysis revealed that FEUN value at discharge decreased in a dose-dependent manner with loop diuretics. In HF patients with CKD, FEUN is a potential marker of volume status for risk stratification of post-discharge HF readmission. Low FEUN value (FEUN≤32.1) may represent intravascular dehydration, whereas high FEUN value (FEUN>38.0) may represent residual congestion; both of them were independent risk factors for HF readmission. FEUN may be useful to determine euvolaemia and guide fluid management in HF patients with CKD.

Utility of Bedside Lung Ultrasound in the Assessment of Volume Status in Patients on Chronic Haemodialysis

Aim: The estimation of the ‘dry weight’ in a patient on haemodialysis with end-stage renal disease is an important clinical challenge to date. Physical examination has its limitations in the precise assessment of volume status. The monitoring of blood volume, natriuretic peptides, and bioimpedance spectroscopy are explored as a guide for the ultrafiltration process during haemodialysis (HD) therapy. Unfortunately, none of these methods has shown promising results when used in isolation and has serious limitations. The point-of-care lung ultrasonography has emerged recently as an adjunct to physical examination as a non-invasive, radiation-free technique to estimate extravascular lung water. In this study, the authors aimed to compare the volume status assessment in end-stage renal disease patients on HD using conventional clinical methods, bio-electrical impedance, and chest ultrasound (US). Materials and Methods: A prospective cohort study was conducted on 34 patients undergoing regular HD in the Department of Nephrology dialysis centre at the University College of Medical Sciences Guru Teg Bahadur Hospital, Delhi, India, a multi-speciality tertiary care centre. Parameters included to assess the dry weight of patients were bio-impedance spectroscopy and chest US, measured in two phases: 30 minutes before and 10–60 minutes following the HD session. Results: A total of 100 assessments were done on 34 patients over 6 months. The mean pre-HD extracellular water was 17.52±2.69 L and post-HD was 16.38±2.46 L, showing a significant reduction (&lt;0.001). The bioimpedance analysis showed that 44% of the volume status assessments had fluid overload (≥1.1 L), even when the patients were considered to be in a state of clinical euvolemia, while 79% of the assessments had a Comet Score of ≥3 suggesting a fluid overload state. Most assessments showed a significant reduction in the number of B-lines (i.e., 62% [Comet Score of between 0–2]). The mean post-HD Comet Score was 1.73±1.36 (37%). Conclusion: Chest US to assess Comet Score is highly correlated with the clinical signs and symptoms. Lung Comet Scores can also be highly correlated with ultrafiltration volume, and thus can be used as a good marker for achieving dry weight in dialysis patients.

Bioimpedance-Guided Monitoring of Volume Status in Patients With Kidney Disease: A Systematic Review and Meta-Analysis.

Bioimpedance technologies are increasingly used to determine fluid status in patients with chronic kidney disease and those with end-stage kidney disease on dialysis. We aimed to determine whether this technology improves clinical outcomes as compared with usual care. We performed a systematic review and meta-analysis of trials, comparing fluid management guided by bioimpedance technologies to standard of care in patients with chronic kidney disease. Our primary outcome was all-cause mortality. Secondary outcomes included blood pressure control, all-cause hospitalization, major adverse cardiovascular events, and change in left ventricular mass index. Our search identified 819 citations of which 12 randomized controlled trials were included (2420 patients). No studies of non-dialysis-dependent chronic kidney disease patients met inclusion criteria. Mean age was 55 years and mean follow-up was 1 year. There was a statistically significant difference in all-cause mortality between both arms studied (risk ratio [RR] 0.64, 95% confidence interval [CI]: 0.44, 0.99). Better blood pressure control was observed in the bioimpedance arm of the included articles, weighted mean differences (WMD) -3.13 mm Hg (95% CI: -5.73, -0.53 mm Hg) for systolic blood pressure and WMD -2.50 mm Hg (95% CI: -4.36, -0.64 mm Hg) for diastolic blood pressure. No difference was observed concerning the other outcomes. Among patients on maintenance dialysis, bioimpedance-guided volume management showed decreased all-cause mortality and blood pressure but no significant difference in all-cause hospitalization, major adverse cardiac event, or change in left ventricular mass index. This may be due to a younger population sample than previous articles. Moreover, our study identified a knowledge gap by highlighting the lack of studies evaluating this technology in non-dialysis-dependent chronic kidney disease patients.

Abstract 11691: Self-Reported Sodium Intake Identifies a Sodium Vulnerable State With Increased Response to Spironolactone in HFpEF

Introduction: Asking patients about sodium intake is standard practice in heart failure (HF). Hypothesis: Self-reported sodium intake in HF with preserved ejection fraction (HFpEF) reflects a vulnerability to sodium intake driven by aldosterone. Methods: The TOPCAT trial registered self-reported sodium intake at baseline. Cox-regression and linear-mixed models were used to assess the relationship between self-reported sodium intake and outcome. Interaction analysis between self-reported sodium intake and the treatment effect of spironolactone on HF-outcome, blood pressure (BP), dyspnea and edema at follow-up were used to assess sodium vulnerability mediated by an aldosterone effect. Results: Self-reported sodium intake of 1748 HFpEF patients included in TOPCAT were divided according to tertiles of sodium intake (47% low, 35% moderate and 18% reported high sodium intake). After covariate adjustment lower self-reported sodium intake associated with higher risk for HF-admission (p=0.009). Patients with a lower sodium intake demonstrated higher E-wave and LV-end diastolic volume and higher estimated plasma volume (p&lt;0.001). Lower sodium intake was associated with a larger treatment effect of spironolactone on HF-admission (HR=0.69, 95%CI 0.53-0.91 vs highest tertile HR=1.37 95%CI 0.79-2.38, p-interaction=0.030). Additionally, linear-mixed models indicated larger BP-reduction (Figure) and larger reduction in dyspnea and edema (p-interaction all&lt;0.001) in patients with lower sodium intake receiving spironolactone. Conclusions: Low self-reported sodium in HFpEF is associated with volume status and higher risk of HFH. The more pronounced treatment effect with spironolactone on HF-outcome, BP and volume status in patients with the lowest self-reported sodium intake potentially suggests that low self-reported sodium intake is an indicator of a sodium vulnerable, potentially aldosterone driven, state.

Plasma brain injury markers are associated with volume status but not muscle health in heart failure patients

Background: Neurofilament light chain protein (NfL) and tau are plasma biomarkers of neuronal injury which can be elevated in patients with neurodegenerative diseases. N-terminal pro-brain natriuretic peptide (NT-proBNP) is an established marker of volume status in patients with heart failure (HF) and plasma cBIN1 score (CS) is an emerging biomarker of cardiac muscle health. It is not known if, in HF patients, there is a correlation between cardiac markers and brain injury markers.Methods: We studied ambulatory HF patients with either preserved and reduced ejection fraction (N = 50 with 25 HFrEF and 25 HFpEF) and age and sex matched healthy controls (N = 50). Plasma NT-proBNP and CS were determined using commercial kits. A bead-based ELISA assay was used to quantify femtomolar concentrations of plasma neuronal markers NfL and total tau.Results: Plasma levels of NT-proBNP and CS in heart failure patients were significantly higher than those from healthy controls. In both patients with HFrEF and HFpEF, we found independent and direct correlations between the volume status marker NT-proBNP, but not the cardiomyocyte origin muscle health marker CS, with NfL (r = 0.461, p = 0.0007) and tau (r = 0.333, p = 0.0183).Conclusion: In patients with HF with or without preserved ejection fraction, plasma levels of NfL and tau correlate with volume status rather than muscle health, indicating volume overload-associated neuronal injury.

MPN-541 Estimated Plasma Volume Status in Patients With Primary Myelofibrosis and Associated Thrombotic and Mortality Risks.

Blood plasma experiences substantial changes in both volume and composition in patients with chronic myeloproliferative neoplasms (MPN) and represents a large reservoir of cytokines and other mediators of inflammation. Higher estimated plasma volume status (ePVS) has recently been shown to correlate with increased thrombotic risk in polycythemia vera patients. To estimate clinical and prognostic associations of ePVS in patients with myelofibrosis. Retrospective cohort study. 6 hematology centers. 238 myelofibrosis patients, 168 with PMF, 34 with post-PV SMF and 36 with post-ET SMF. ePVS was calculated using the Strauss derived Duarte formula: (100-hematocrit (%)/hemoglobin (g/dL) and expressed as dl/g. Overall survival (OS) and time to thrombosis (TTT). Median ePVS was 5.8 dl/g and it did not significantly differ between PMF and SMF patients. Among other associations, higher ePVS was significantly associated with higher degree of bone-marrow fibrosis, absence of JAK2-mutation, lower white blood cells (WBC), platelets and hemoglobin, presence of circulatory blasts, higher C-reactive protein, higher lactate dehydrogenase, lower albumin and higher Charlson comorbidity index in an overall cohort, as well as with more pronounced splenomegaly and higher Dynamic International Prognostic Scoring System (DIPSS) risk in primary myelofibrosis (PMF) and higher Mysec-PM risk in secondary myelofibrosis (SMF) patients (P<0.05 for all analyses). Higher ePVS (>5.6 dl/g) was associated with shorter overall-survival (OS) in PMF (HR=2.8, P<0.001) and SMF (HR=2.55, P=0.025) and with shorter time-to-thrombosis in PMF (>7 dl/g, HR=4.1, P=0.009) patients. Associations with overall survival diminished in multivariate analyses after adjustments for DIPSS and Mysec-PM, respectively. Association with TTT remained significant independently of JAK2, WBC and chronic kidney disease. Myelofibrosis patients with more advanced disease features and more pronounced inflammation have higher ePVS, indicative of expanded plasma volume. Higher ePVS is associated with impaired survival in PMF and SMF and higher thrombotic risk in PMF patients.

Effects of dapagliflozin on volume status and systemic haemodynamics in patients with chronic kidney disease without diabetes: Results from DAPASALT and DIAMOND.

AimsTo assess the effect of sodium‐glucose cotransporter‐2 inhibitor dapagliflozin on natriuresis, blood pressure (BP) and volume status in patients with chronic kidney disease (CKD) without diabetes.Materials and methodsWe performed a mechanistic open‐label study (DAPASALT) to evaluate the effects of dapagliflozin on 24‐hour sodium excretion, 24‐hour BP, extracellular volume, and markers of volume status during a standardized sodium diet (150 mmol/d) in six patients with CKD. In parallel, in a placebo‐controlled double‐blind crossover trial (DIAMOND), we determined the effects of 6 weeks of dapagliflozin on markers of volume status in 53 patients with CKD.ResultsIn DAPASALT (mean age 65 years, mean estimated glomerular filtration rate [eGFR] 39.4 mL/min/1.73 m2, median urine albumin:creatinine ratio [UACR] 111 mg/g), dapagliflozin did not change 24‐hour sodium and volume excretion during 2 weeks of treatment. Dapagliflozin was associated with a modest increase in 24‐hour glucose excretion on Day 4, which persisted at Day 14 and reversed to baseline after discontinuation. Mean 24‐hour systolic BP decreased by −9.3 (95% confidence interval [CI] −19.1, 0.4) mmHg after 4 days and was sustained at Day 14 and at wash‐out. Renin, angiotensin II, urinary aldosterone and copeptin levels increased from baseline. In DIAMOND (mean age 51 years, mean eGFR 59.0 mL/min/1.73 m2, median UACR 608 mg/g), compared to placebo, dapagliflozin increased plasma renin (38.5 [95% CI 7.4, 78.8]%), aldosterone (19.1 [95% CI −5.9, 50.8]%), and copeptin levels (7.3 [95% CI 0.1, 14.5] pmol/L).ConclusionsDuring a standardized sodium diet, dapagliflozin decreased BP but did not increase 24‐hour sodium and volume excretion. The lack of increased natriuresis and diuresis may be attributed to activation of intra‐renal compensatory mechanisms to prevent excessive water loss.

Comparison of inferior vena cava collapsibility and central venous pressure in assessing volume status in shocked patients

Determination of intravascular volume status in patients admitted to the emergency centre is critical. Physical signs of hypovolaemic, distributive, cardiogenic, and obstructive shock frequently overlap, making an accurate diagnosis of shock state difficult. This is problematic because fluid loading is considered the first step in haemodynamically unstable patients' resuscitation. Yet, multiple studies have shown that only approximately 50% of haemodynamically unstable patients in the intensive care unit and operating theatre respond to a fluid challenge. This study aims to provide an accurate estimation of intravascular volume status using bedside noninvasive methods as an essential part of the assessment of volume status in shocked patients.This is a cross-sectional analytical study conducted on 102 shocked patients presented to the emergency centre. IV fluid boluses were standardized to be administered at 500 mL every 30 min over 120 min, as clinically indicated. Concurrent measurements of inferior vena cava collapsibility index (IVC-ci) were performed shortly before the initiation of IV bolus (i.e., time 0), and then at 30, 90, and 120 min, we measured both venous collapsibility index (CI) and central venous pressure (CVP). At each session, we recorded patient demographics, fluid responsiveness, and vital sign assessments.We discovered that IVC-ci at cut-off point 40 has a sensitivity of 93.3% and specificity of 70.7% with an AUC of 0.908 and a good 95% CI (0.84-0.975), implying that IVC-ci of 40% or higher can indicate fluid responsiveness in shocked patients. CVP, despite having a good sensitivity of 88.6%, high specificity of 100%, and a significant p-value, is not a reliable detector of fluid responsiveness due to its small AUC value and low 95% CI.IVC-ci could be a good tool with moderate reliability for detecting fluid responsiveness because it is a less invasive and fast method.