Randomized trial of bioelectrical impedance analysis versus clinical criteria for guiding ultrafiltration in hemodialysis patients: effects on blood pressure, hydration status, and arterial stiffness

Onofriescu, Mihai; Mardare, Nicoleta; Segall, Liviu; Voroneanu, Luminița; Cusai, Claudiu; Hogaş, Simona; Ardeleanu, Serban; Nistor, Ionuţ; Prisada, Octavian; Sascău, Radu Andy; Covic, Adrian

doi:10.1007/s11255-011-0022-y

Cited by 62 publications

(58 citation statements)

References 41 publications

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“…Trials on bioimpedance-guided fluid management have observed improvements in BP control and other cardiovascular parameters (7)(8)(9). However, the important question of the most appropriate/optimal target for fluid management remains under debate.…”

Section: Discussionmentioning

confidence: 99%

“…Recent studies investigating BIS-guided fluid management observed significant improvements in cardiovascular parameters, but each trial used different BIS measurement schedules, targets, and protocols for active fluid management (7)(8)(9)(10). In addition, none of these trials considered the concept of TAFO as a target for individual fluid management in a representative dialysis population.…”

Section: Introductionmentioning

confidence: 99%

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Bioimpedance-Guided Fluid Management in Hemodialysis Patients

Moissl

Arias‐Guillén

Wabel

et al. 2013

Clinical Journal of the American Society of Nephrology

143

126

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SummaryBackground and objectives Achieving and maintaining optimal fluid status remains a major challenge in hemodialysis therapy. The aim of this interventional study was to assess the feasibility and clinical consequences of active fluid management guided by bioimpedance spectroscopy in chronic hemodialysis patients.Design, setting, participants, & measurements Fluid status was optimized prospectively in 55 chronic hemodialysis patients over 3 months (November 2011 to February 2012. Predialysis fluid overload was measured weekly using the Fresenius Body Composition Monitor. Time-averaged fluid overload was calculated as the average between pre-and postdialysis fluid overload. The study aimed to bring the time-averaged fluid overload of all patients into a target range of 0.560.75 L within the first month and maintain optimal fluid status until study end. Postweight was adjusted weekly according to a predefined protocol.Results Time-averaged fluid overload in the complete study cohort was 0.961.6 L at baseline and 0.661.1 L at study end. Time-averaged fluid overload decreased by 21.2061.32 L (P,0.01) in the fluid-overloaded group (n=17), remained unchanged in the normovolemic group (n=26, P=0.59), and increased by 0.5960.76 L (P=0.02) in the dehydrated group (n=12). Every 1 L change in fluid overload was accompanied by a 9.9 mmHg/L change in predialysis systolic BP (r=0.55, P,0.001). At study end, 76% of all patients were either on time-averaged fluid overload target or at least closer to target than at study start. The number of intradialytic symptoms did not change significantly in any of the subgroups.Conclusions Active fluid management guided by bioimpedance spectroscopy was associated with an improvement in overall fluid status and BP.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Bioimpedance-Guided Fluid Management in Hemodialysis Patients

Moissl

Arias‐Guillén

Wabel

et al. 2013

Clinical Journal of the American Society of Nephrology

143

126

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“…27,28 Sipahi et al 29 found BIS findings to be related with echocardiographic findings of OH in PD patients.…”

Section: Discussionmentioning

confidence: 98%

Volume Status in Patients on Peritoneal Dialysis: The Role of Apelin and Bio-Impedance Spectroscopy

et al. 2012

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One of the main factors determining the survival of peritoneal dialysis (PD) patients is volume status. We aimed to investigate hydration status of PD patients by bio-impedance spectroscopy (BIS) and echocardiography and to study the relation of them with apelin, which has effects related with volume status like vasodilation, positive inotropism, and inhibition of ADH release and RAS antagonism. Chronic PD patients without active cardiac disease or clinically prominent hypervolemia were included. Besides the demographic, clinical, and laboratory data, BIS and echocardiographic findings together with apelin levels were recorded. The study included 21 patients. Of them, eight patients were euvolemic, one patient was hypovolemic, and others have some degree of overhydration (1.1-6.8 L) with BIS, although all were euvolemic clinically. Mean apelin level was 1.49 AE 0.49 ng/mL. Apelin level was positively correlated with ejection fraction and negatively with total body water (TBW), intracellular and extracellular water, lean tissue mass, and left atrium diameter. On linear regression model, TBW was the major determinant of apelin. Although apelin is expected to increase in hypervolemic patients, the negative correlation with body water in this study may be related with yet unknown role of apelin in dialyzed patients. They may have important roles in volume status in future.

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“…A total of five RCTs (published in six papers 60,61,63,76,77,81 ) and eight non-randomised studies (published in nine papers 30,50,[82][83][84][85][86][87][88] ) were included in the review of clinical effectiveness. There was some question over whether or not the RCTs by Onofriescu et al 81 and Onofriescu et al 60 may be reporting the same trial or outcomes from an overlapping patient population.…”

Section: Characteristics Of the Included Studiesmentioning

confidence: 99%

“…There was some question over whether or not the RCTs by Onofriescu et al 81 and Onofriescu et al 60 may be reporting the same trial or outcomes from an overlapping patient population. The principal investigators of each trial were contacted, but no replies were forthcoming.…”

Section: Characteristics Of the Included Studiesmentioning

confidence: 99%

Multiple-frequency bioimpedance devices for fluid management in people with chronic kidney disease receiving dialysis: a systematic review and economic evaluation

Scotland

Cruickshank

Jacobsen

et al. 2018

Health Technol Assess

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BackgroundChronic kidney disease (CKD) is a long-term condition requiring treatment such as conservative management, kidney transplantation or dialysis. To optimise the volume of fluid removed during dialysis (to avoid underhydration or overhydration), people are assigned a ‘target weight’, which is commonly assessed using clinical methods, such as weight gain between dialysis sessions, pre- and post-dialysis blood pressure and patient-reported symptoms. However, these methods are not precise, and measurement devices based on bioimpedance technology are increasingly used in dialysis centres. Current evidence on the role of bioimpedance devices for fluid management in people with CKD receiving dialysis is limited.ObjectivesTo evaluate the clinical effectiveness and cost-effectiveness of multiple-frequency bioimpedance devices versus standard clinical assessment for fluid management in people with CKD receiving dialysis.Data sourcesWe searched major electronic databases [e.g. MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Science Citation Index and Cochrane Central Register of Controlled Trials (CENTRAL)] conference abstracts and ongoing studies. There were no date restrictions. Searches were undertaken between June and October 2016.Review methodsEvidence was considered from randomised controlled trials (RCTs) comparing fluid management by multiple-frequency bioimpedance devices and standard clinical assessment in people receiving dialysis, and non-randomised studies evaluating the use of the devices for fluid management in people receiving dialysis. One reviewer extracted data and assessed the risk of bias of included studies. A second reviewer cross-checked the extracted data. Standard meta-analyses techniques were used to combine results from included studies. A Markov model was developed to assess the cost-effectiveness of the interventions.ResultsFive RCTs (with 904 adult participants) and eight non-randomised studies (with 4915 adult participants) assessing the use of the Body Composition Monitor [(BCM) Fresenius Medical Care, Bad Homburg vor der Höhe, Germany] were included. Both absolute overhydration and relative overhydration were significantly lower in patients evaluated using BCM measurements than for those evaluated using standard clinical methods [weighted mean difference –0.44, 95% confidence interval (CI) –0.72 to –0.15,p = 0.003,I2 = 49%; and weighted mean difference –1.84, 95% CI –3.65 to –0.03;p = 0.05,I2 = 52%, respectively]. Pooled effects of bioimpedance monitoring on systolic blood pressure (SBP) (mean difference –2.46 mmHg, 95% CI –5.07 to 0.15 mmHg;p = 0.06,I2 = 0%), arterial stiffness (mean difference –1.18, 95% CI –3.14 to 0.78;p = 0.24,I2 = 92%) and mortality (hazard ratio = 0.689, 95% CI 0.23 to 2.08;p = 0.51) were not statistically significant. The economic evaluation showed that, when dialysis costs were included in the model, the probability of bioimpedance monitoring being cost-effective ranged from 13% to 26% at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year gained. With dialysis costs excluded, the corresponding probabilities of cost-effectiveness ranged from 61% to 67%.LimitationsLack of evidence on clinically relevant outcomes, children receiving dialysis, and any multifrequency bioimpedance devices, other than the BCM.ConclusionsBCM used in addition to clinical assessment may lower overhydration and potentially improve intermediate outcomes, such as SBP, but effects on mortality have not been demonstrated. If dialysis costs are not considered, the incremental cost-effectiveness ratio falls below £20,000, with modest effects on mortality and/or hospitalisation rates. The current findings are not generalisable to paediatric populations nor across other multifrequency bioimpedance devices.Future workServices that routinely use the BCM should report clinically relevant intermediate and long-term outcomes before and after introduction of the device to extend the current evidence base.Study registrationThis study is registered as PROSPERO CRD42016041785.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Randomized trial of bioelectrical impedance analysis versus clinical criteria for guiding ultrafiltration in hemodialysis patients: effects on blood pressure, hydration status, and arterial stiffness

Abstract: BIA is not inferior and possibly even better than clinical criteria for assessing dry weight and guiding ultrafiltration in HD patients.

Cited by 62 publications

References 41 publications

Bioimpedance-Guided Fluid Management in Hemodialysis Patients

Bioimpedance-Guided Fluid Management in Hemodialysis Patients

Volume Status in Patients on Peritoneal Dialysis: The Role of Apelin and Bio-Impedance Spectroscopy

Multiple-frequency bioimpedance devices for fluid management in people with chronic kidney disease receiving dialysis: a systematic review and economic evaluation

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