Extracellular Fluid/Intracellular Fluid Volume Ratio as a Novel Risk Indicator for All-Cause Mortality and Cardiovascular Disease in Hemodialysis Patients

Kim, Eun Jung; Choi, Moon-Gi; Lee, Jeoung Hwan; Oh, Ji Eun; Seo, Jungpil; Lee, Young Ki; Yoon, Jong Il; Kim, Hyung Jik; Noh, Jung Woo; Koo, Ja Ryong

doi:10.1371/journal.pone.0170272

Cited by 65 publications

(86 citation statements)

References 28 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Compared to the l‐BNP group, the h‐BNP group had less muscle strength, lower body weight, lower lean tissue index and lower levels of hemoglobin and albumin, but higher CRP levels. These findings indicate malnutrition and inflammation, which have been associated with overhydration . However, although the h‐BNP group had higher CRP levels, we were not able to confirm the association between overhydration and IL‐6 and TNF‐alpha or any other inflammatory markers, which has been found in studies with larger samples …”

Section: Discussioncontrasting

confidence: 84%

Brain natriuretic peptide reflects individual variation in hydration status in hemodialysis patients

Stenberg

Melin

Lindberg

et al. 2019

Hemodialysis International

View full text Add to dashboard Cite

Introduction: Fluid management in hemodialysis patients is a controversial topic. Brain natriuretic peptide (BNP) is secreted from the heart in response to volume overload, and may be a marker of overhydration in hemodialysis patients. Our aim was to investigate the correlation between BNP and overhydration in a cohort of hemodialysis patients, and to find out whether BNP and overhydration correlate in repeated measurements within individuals with elevated BNP. Methods: The study was prospective, observational, and had a cross‐sectional part and a longitudinal follow‐up. The distribution of BNP was investigated in a cohort of 64 hemodialysis patients. Blood samples and bioimpedance spectroscopy measurements were performed before midweek dialysis. Subsequently, 11 study participants with elevated BNP concentrations (>500 pg/mL) were assessed in another nine dialysis sessions each. These individuals also had their cardiac function and heart rate variability (HRV) examined. Findings: BNP was above 500 pg/mL in 38% of the participants, and correlated positively with overhydration (rs = 0.381), inflammation and malnutrition, but not with systolic blood pressure. In comparison to participants with BNP below 500 pg/mL, participants with elevated BNP were older, had lower muscle strength, lower bodyweight and lower levels of hemoglobin and albumin. Echocardiography revealed cardiac anomalies in all 11 participants in the longitudinal follow‐up, and HRV, as measured by SDNN, was pathologically low. In repeated measurements, the between‐individuals variation of BNP in relation to overhydration was greater (SD = 0.581) than the within‐person variation (SD = 0.285). Discussion: BNP correlates positively to overhydration, malnutrition, and inflammation. In a subgroup of patients with elevated BNP, who are mainly elderly and frail, BNP reflects individual variation in hydration status, and hence seems to be a modifiable marker of overhydration. These data suggest that BNP is best applied for measuring changes in hydration status within an individual over time.

show abstract

Section: Discussioncontrasting

confidence: 84%

Brain natriuretic peptide reflects individual variation in hydration status in hemodialysis patients

Stenberg

Melin

Lindberg

et al. 2019

Hemodialysis International

View full text Add to dashboard Cite

show abstract

“…In this respect, it should be noted that ECV/TBW ratio, which is also often used in the assessment of fluid status, may also be influenced by a reduction in body cell mass leading to a reduction in intra-cellular volume [37]. We also observed lower levels of lean tissue mass and serum albumin levels in patients with more advanced FO [2].…”

Section: Non-cardiovascular Factors On Abnormalities In Fluid Statussupporting

confidence: 51%

Body Fluids in End-Stage Renal Disease: Statics and Dynamics

Kooman

Sande²

2018

Blood Purif

View full text Add to dashboard Cite

Background: Abnormalities in fluid status in hemodialysis (HD) patients are highly prevalent and are related to adverse outcomes. Summary: The inherent discontinuity of the HD procedure in combination with an often compromised cardiovascular response is a major contributor to this phenomenon. In addition, systemic inflammation and endothelial dysfunction are related to extracellular fluid overload (FO). Underlying this relation may be factors such as hypoalbuminemia and an increased capillary permeability, leading to an altered fluid distribution between the blood volume (BV) and the interstitial fluid compartments, compromising fluid removal during dialysis. Indeed, whereas estimates of extracellular volume by bioimpedance spectroscopy are highly predictive of mortality, absolute BV assessed by the saline dilution technique was predictive of intra-dialytic morbidity. Changes in relative BV during HD are positively related to ultrafiltration rate (UFR) and, at least in some studies, negatively to FO. High UFR is also related to changes in central venous oxygen saturation (S_cvO₂), a marker for tissue perfusion. On the one hand, high UFR and more pronounced declines in S_cvO₂, but on the other hand, flat relative BV curves are also predictive of mortality; the relation between outcome which statics and dynamics of fluid status appears to be complex. Key Message: While technological developments enable the clinician to monitor statics and dynamics of fluid status and hemodynamics during HD in an accessible way, the role of technology-based interventions needs further study.

show abstract

“…In this same study, an association between FO and other markers of inflammation, namely, endotoxin and C-reactive protein (CRP) was also found [21]. The association between CRP as a marker of inflammation and FO was further confirmed in a study of 59 PD patients [19] and in a single-center study, using segmental BIA, in CKD patients [22]. A larger study, performed by Hung et al [23] showed significant associations between IL-6 as well as tumor necrosis factor alpha with the OH:ECW ratio in 338 CKD patients.…”

Section: Evidence For the Relation Between Fo And Inflammationmentioning

confidence: 75%

“…The increased mortality risk appears to persist, albeit to a lesser degree, even after the resolution of both risk factors during a subsequent 3 months follow-up period (HR 3.28 with resolution of both risk factors, as compared to a HR of 9.44 with persistent presence of inflammation and FO) [10]. Interestingly, these results are contradicted by another study in which the ECW:ICW ratio, assessed by segmental BIA, nullified the effects of CRP on outcome [22]. However, this ratio is a combined marker of FO and/or malnutrition, given the fact that a loss of LTM may be reflected by a reduction of ICW.…”

Section: Combined Effects Of Fo and Inflammation On Outcomementioning

confidence: 99%

“…The relation between markers of FO and malnutrition has also been described in the literature [23, 45, 46]. However, sometimes the interpretation may be hampered by the fact that the ECW:total body water was used as a marker of FO [46], whereas this is likely a combined risk marker expressing either FO, malnutrition, or both [22]. FO has also been associated with the malnutrition-inflammation-atherosclerosis syndrome [19, 23].…”

Section: Fo and Inflammation: Part Of A Broader Spectrum?mentioning

confidence: 99%

See 1 more Smart Citation

Fluid Overload and Inflammation Axis

et al. 2018

View full text Add to dashboard Cite

Extracellular fluid overload (FO), which is assessed using bioimpedance technologies, is an important predictor of outcome in dialysis patients and in patients with early stages of chronic kidney disease. While traditional cardiovascular abnormalities are assumed to mediate this risk, recently also, the importance of noncardiovascular factors, such as systemic inflammation and malnutrition has been shown. While both FO and inflammation are independent risk factors for mortality, recent studies have shown that their combined presence can lead to a cumulative risk profile. From a pathophysiologic viewpoint, FO and inflammation can also be mutually reinforcing. Inflammation could contribute to FO by hypoalbuminemia, capillary leakage, and a (unnoticed) decline in lean and/or fat tissue mass resulting in incorrect estimation of dry weight. Reciprocally, FO could lead to inflammation by the translocation of endotoxins through a congested bowel wall or by a proinflammatory effect of tissue sodium. The relative importance of these putative factors is, however, not clear yet and epidemiological studies have shown no clear temporal direction regarding the relationship between FO and inflammation. FO and inflammation appear to be part of (dynamic) clusters of risk factors, including malnutrition and hyponatremia. Technology-guided fluid management of the often vulnerable dialysis patient with FO and inflammation cannot yet be based on evidence from randomized controlled trials, in which these specific patients were in general not included. In the absence of those trials, treatment should be based on identifying actionable causes of inflammation and on the judicious removal of excess volume based on frequent clinical reassessment.

show abstract

Extracellular Fluid/Intracellular Fluid Volume Ratio as a Novel Risk Indicator for All-Cause Mortality and Cardiovascular Disease in Hemodialysis Patients

Cited by 65 publications

References 28 publications

Brain natriuretic peptide reflects individual variation in hydration status in hemodialysis patients

Brain natriuretic peptide reflects individual variation in hydration status in hemodialysis patients

Body Fluids in End-Stage Renal Disease: Statics and Dynamics

Fluid Overload and Inflammation Axis

Contact Info

Product

Resources

About