Pre-dialysis fluid status, pre-dialysis systolic blood pressure and outcome in prevalent haemodialysis patients: results of an international cohort study on behalf of the MONDO initiative

Dekker, Marijke; Konings, Constantijn; Canaud, Bernard; Carioni, Paola; Guinsburg, Adrián; Madero, Magdalena; Net, Jeroen van der; Raimann, Jochen G.; Sande, Frank van der; Stuard, Stefano; Usvyat, Len; Wang, Yuedong; Xu, Xiaoqi; Kotanko, Peter; Kooman, Jeroen P.

doi:10.1093/ndt/gfy095

Cited by 35 publications

(39 citation statements)

References 32 publications

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“…Also, pre-dialytic fluid depletion was associated with outcome but interestingly only when accompanied by low pre-dialytic systolic blood pressure [46]. Lung comets assessed by ultrasound, which are a marker of regional fluid accumulation, are also predictive of outcome [62].…”

Section: Can Technology Aid the Clinical Decision Process?mentioning

confidence: 99%

“…The prevalence of FO, defined as a predialytic OH: ECV ratio above 15% or an absolute OH volume of > 2.5 l varied between 25 and 46% [3,4], and 60-63% when a cut-off limit of an absolute OH volume of > 1.1 l or an OH: ECV ratio > 7% was used [1,46]. The question as to why it is so difficult to achieve normovolemia in daily clinical practice arises due to an imbalance between fluid and sodium intake, and the possibility to remove fluid adequately despite the discontinuity, which is an integral component of HD.…”

Section: The Dry Weight Conceptmentioning

confidence: 99%

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

Kooman

Sande²

2018

Blood Purif

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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.

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Section: Can Technology Aid the Clinical Decision Process?mentioning

confidence: 99%

Section: The Dry Weight Conceptmentioning

confidence: 99%

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

Kooman

Sande²

2018

Blood Purif

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“…One caveat of longitudinal risk prediction models in ESRD patients could be that the predictive value of parameters might partly depend on the interaction with others. As an example, low systolic BP was associated with increased mortality and patients with fluid depletion or fluid overload but an improved survival in normovolemic patients [81]. In addition, a decrease in serum phosphate may be associated with improved outcomes in wellnourished patients but may be predictive of mortality in patients with progressive signs of malnutrition [76].…”

Section: Do We Have Evidence That Longitudinal Data Improve Outcome Pmentioning

confidence: 99%

Cycles, Arrows and Turbulence: Time Patterns in Renal Disease, a Path from Epidemiology to Personalized Medicine?

et al. 2018

Self Cite

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Patients with end-stage renal disease (ESRD) experience unique patterns in their lifetime, such as the start of dialysis and renal transplantation. In addition, there is also an intricate link between ESRD and biological time patterns. In terms of cyclic patterns, the circadian blood pressure (BP) rhythm can be flattened, contributing to allostatic load, whereas the circadian temperature rhythm is related to the decline in BP during hemodialysis (HD). Seasonal variations in BP and interdialytic-weight gain have been observed in ESRD patients in addition to a profound relative increase in mortality during the winter period. Moreover, nonphysiological treatment patters are imposed in HD patients, leading to an excess mortality at the end of the long interdialytic interval. Recently, new evidence has emerged on the prognostic impact of trajectories of common clinical and laboratory parameters such as BP, body temperature, and serum albumin, in addition to single point in time measurements. Backward analysis of changes in cardiovascular, nutritional, and inflammatory parameters before the occurrence as hospitalization or death has shown that changes may already occur within months to even 1–2 years before the event, possibly providing a window of opportunity for earlier interventions. Disturbances in physiological variability, such as in heart rate, characterized by a loss of fractal patterns, are associated with increased mortality. In addition, an increase in random variability in different parameters such as BP and sodium is also associated with adverse outcomes. Novel techniques, based on time-dependent analysis of variability and trends and interactions of multiple physiological and laboratory parameters, for which machine-learning approaches may be necessary, are likely of help to the clinician in the future. However, upcoming research should also evaluate whether dynamic patterns observed in large epidemiological studies have relevance for the individual risk profile of the patient.

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“…Chronic overhydration has been identified as an independent predictor of mortality in hemodialysis patients. [1][2][3] Overhydration is associated with inflammation, 4 left ventricular hypertrophy, left ventricular dilation, arterial hypertension, and the eventual development of congestive heart failure. 5,6 More than 25% of all hemodialysis patients are overhydrated, while a large proportion have a fluid deficit.…”

Section: Introductionmentioning

confidence: 99%

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

Stenberg

Melin

Lindberg

et al. 2019

Hemodialysis International

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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.

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Pre-dialysis fluid status, pre-dialysis systolic blood pressure and outcome in prevalent haemodialysis patients: results of an international cohort study on behalf of the MONDO initiative

Cited by 35 publications

References 32 publications

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

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

Cycles, Arrows and Turbulence: Time Patterns in Renal Disease, a Path from Epidemiology to Personalized Medicine?

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

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