The effect of dry-weight reduction guided by lung ultrasound on ambulatory blood pressure in hemodialysis patients: a randomized controlled trial

Abstract

Approximately 85% of hemodialysis patients are hypertensive, but less than 30% achieve adequate blood pressure (BP) control. Reduction of volume overload is fundamental for BP control, but clinical criteria to estimate dry-weight are inaccurate. In the present study we examined the effect of dry-weight reduction with a lung-ultrasound-guided strategy on ambulatory BP in 71 clinically euvolemic hemodialysis patients with hypertension. Patients were equally randomized into an active group, following a strategy for dry-weight reduction guided by pre-hemodialysis lung ultrasound, and a control group with standard-of-care treatment. All patients underwent 48-hour ambulatory BP monitoring (ABPM) at baseline and after eight weeks. Overall, more patients in the active than in the control group had dry weight reduction, 54.3% compared to 13.9%, respectively. The ultrasonographic-B line change during follow-up was significantly different (-5.3±12.5 in active versus D2.2±7.6 in control group), which corresponded to significant differences in dry weight changes between the groups. The magnitude of reductions in 48-hour systolic BP (-6.61±9.57 vs.-0.67±13.07) and diastolic BP (-3.85±6.34 vs.-0.55±8.28) was significantly greater in the active group. Similarly, intradialytic BP, 44-hour BP, and daytime or night-time systolic/diastolic BP during both days of the interdialytic interval were significantly reduced in the active group but remained unchanged in the control group. The percentage of patients experiencing one or more intradialytic hypotensive episodes was marginally lower in the active group (34.3% vs. 55.6%). Thus, a lung-ultrasound-guided strategy for dry-weight reduction can effectively and safely reduce ambulatory BP levels in hemodialysis patients. Clinical implementation of this simple technique can help increase BP control in this population.

Systolic and diastolic hypertension among patients on hemodialysis: Musings on volume overload, arterial stiffness, and erythropoietin

“…An average reduction of 0.71 kg in postdialysis weight was observed in the lung ultrasound group, whereas dry-weight was increased by 0.51 kg in the control group. 24 Compared with standard-of-care treatment, lung ultrasound-guided volume management was accompanied by an average reduction of 5.9/3.3 mm Hg in 48-hour intra-and interdialytic BP. 24 The process of dry-weight probing based on clinical judgment in order to achieve a patient's dry-weight is challenging.…”

“…24 Compared with standard-of-care treatment, lung ultrasound-guided volume management was accompanied by an average reduction of 5.9/3.3 mm Hg in 48-hour intra-and interdialytic BP. 24 The process of dry-weight probing based on clinical judgment in order to achieve a patient's dry-weight is challenging. Although intensified ultrafiltration increases the incidence of intradialytic hypotension, its well documented adverse cardiovascular effects found in patients prone to this complication of dialysis cannot necessarily be extrapolated to (and certainly does not have the benefits from) the use of dry-weight probing.…”

“…Similarly, in a sub‐study of the ongoing LUST trial, 71 hypertensive hemodialysis patients without clinically overt volume expansion were randomized to a lung ultrasound‐guided management of dry‐weight vs standard‐of‐care treatment for 8 weeks. An average reduction of 0.71 kg in postdialysis weight was observed in the lung ultrasound group, whereas dry‐weight was increased by 0.51 kg in the control group . Compared with standard‐of‐care treatment, lung ultrasound‐guided volume management was accompanied by an average reduction of 5.9/3.3 mm Hg in 48‐hour intra‐ and interdialytic BP …”

Blood pressure and volume management in dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

“…140 Data on the effectiveness of bioimpedance-guided volume management on symptoms and hospitalizations are mixed. 136,141,142 Lung ultrasound-guided volume management improves BP control, 143 and an ongoing trial of lung ultrasound-guided treatment and cardiovascular outcomes is underway (LUST Study, NCT02310061). The biggest barriers to using these technologies are cost (of the test itself and time to administer it) and availability.…”

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“…Although the data is still scarce, in a randomized controlled trial the use of lung ultrasound was associated with a reduction in heart failure hospitalizations 7 . Another recent trial showed that lung ultrasound is an effective way to guide dry--weight reduction in hemodialysis patients and is associated with better blood pressure control 8 . Also, as we move towards a value--based healthcare reimbursement system, POCUS can result in more judicious utilization of the resources and enhanced patient satisfaction, which can result in savings to the healthcare system.…”