PRESERVARE PER PROLUNGARE

CONTROLLO DEL BILANCIO DEI FLUIDI CON BCM

Dott. Gianpaolo Amici, U.O. Nefrologia e Dialisi, Ospedale di Treviso

USRDS 2009 Adjusted mortality rates

USRDS 2009 Change in hospitalization rates

USRDS 2004 Risk of death (cause and modality)

Ipervolemia, ipertensione e patologia cardiovascolare in DP

Lameire N, et al. Cardiovascular diseases in peritoneal dialysis patients: the size of the problem. Kidney Int Suppl. 1996 Nov;56:S28-36.

Lameire N, Van Biesen W. Importance of blood pressure and volume control in peritoneal dialysis patients. Perit Dial Int. 2001 Mar-Apr;21(2):206-11.

Khandelwal M, et al. Volume expansion and sodium balance in peritoneal dialysis patients. Part I: Recent concepts in pathogenesis. Adv Perit Dial. 2003;19:36-43.

Khandelwal M, et al. Volume expansion and sodium balance in peritoneal dialysis patients. Part II: Newer insights in management. Adv Perit Dial. 2003;19:44-52.

Wang AY. Cardiovascular risk factors in peritoneal dialysis patients revisited. Perit Dial Int. 2007 Jun;27 Suppl 2:S223-7.

Wang AY. The John F. Maher Award Recipient Lecture 2006. The "heart" of peritoneal dialysis:residual renal function. Perit Dial Int. 2007 Mar-Apr;27(2):116-24.

Van Biesen W, et al. Residual renal function and volume status in peritoneal dialysis patients: a conflict of interest? J Nephrol. 2008 May-Jun;21(3):299-304.

Brunkhorst R. Hypervolemia, arterial hypertension and cardiovascular disease: a largely neglected problem in peritoneal dialysis. Clin Nephrol. 2008; Apr;69(4):233-8.

Carvalho MJ, Rodrigues A. Importance of residual renal function and peritoneal dialysis in anuric patients. Contrib Nephrol. 2009;163:155-60.

Piraino B. Cardiovascular complications in peritoneal dialysis patients. Contrib Nephrol. 2009;163:102-9.

Wang MC, et al.BLOOD PRESSURE AND LEFT VENTRICULAR HYPERTROPHY IN PATIENTS ON DIFFERENT PERITONEAL DIALYSIS REGIMENSPerit Dial Int 2001; 21: 36–42

“In this study, ambulatory nighttime systolic BP load >30% had an independent association with LVH. Office and home BP measurements were correlated with ABPM in PD patients. The result that CCPD patients had a higher LVMI than CAPD patients may be due to a relative volume overload during the daytime in CCPD patients”.

ObjectiveApart from adequate management of the fluid status in peritoneal dialysis (PD) patients the nutritional aspect of the therapy is equally important for the patient’s morbidity and mortality. In this cross-sectional study body composition data was obtained with the Body Composition Monitor (BCM, Fresenius Medical Care) to identify relevant variables for optimized nutritional outcomes.

MethodsWe screened 973 PD patients from 28 centers in 6 European countries. 639 patients met the inclusion/exclusion criteria. Body composition, blood pressure (BP), dialysis modality and prescription, pre-existing diseases, comorbidities, and antihypertensive medication were documented and analyzed.

ResultsMean body mass index (26.3±5.1 kg/mq) and fat tissue index (12.6±6.0 kg/mq) were slightly above the normal range whereas mean lean tissue index (13.4±3.4 kg/mq, LTI) was within normal range at a mean weight of 72.2±15.4kg and height of 166±9.6 cm. Patients on glucose PD solutions alone had a statistically significantly better outcome than those on polyglucose or amino acid solutions in regard of nutritional parameters like lean tissue index.

ConclusionsThe study provides essential information on nutritional status in a large representative cohort of European PD patients. BCM measurement enables clinicians to obtain objective data on patient’s body composition regarding fat tissue, lean tissue, and fluid status in routine clinical practice to optimize PD therapy and patient outcomes.

Nutritional Assessment Using Body Composition Monitoring in Peritoneal Dialysis Patients. Variables Determining Body Mass,

Fat Tissue and Lean Tissue Index. Covic A (Van Biesen W), et al.

Devolder I, et al.BODY COMPOSITION, HYDRATION, AND RELATED PARAMETERS IN HEMODIALYSIS VERSUS PERITONEAL DIALYSIS PATIENTS.Perit Dial Int 2010; 30: 208–214

“Although much clinical attention is paid to volume status, 24% of patients still have clinically relevant volume overload. Implementation of a reliable and clinically applicable tool to assess volume status is therefore necessary. It is possible to obtain comparable volume status in PD and HD patients”.

i(t)

~

measurement

U(t)

Apply AC

BCM-Body Composition MonitorPrincipio di base delle frequenze multiple

Zero frequency

(Cell behaves as an insulator)

Cell

Medium frequency

(50 kHz)

(Cell behaves as a partial insulator)

High frequency

(Cell behaves as an ordinary conductor)

Cell

Cell

ECW

ECW

ECW

Range di misurazione: la curva dell‘impedenza

Physiologic impedance curve of patient

Information about body composition

Solo con Bioimpedance spectroscopy (BIS) è possibile valutare la curva fisiologica dell‘impedenza.

Solo con Bioimpedance spectroscopy (BIS) è possibile valutare la curva fisiologica dell‘impedenza.

BIA BIS

BIA BIS

Meas. range BIS

Rinf

R0

5kHz1MHz

BIA (50 kHz)

Resistance

Reaktance

Come sono le curve di impedenza nei pazienti?

Resistance [Ohm]

200 300 400 500 600 700 800 900

Re

ak

tan

ce

[O

hm

]

0

10

20

30

40

50

60healthy subject

malnourished patient

fluid overloaded patient

The impedance curves of patients are very different from healthy subjects.To assess the body composition in healthies the complete curve must be measured.

The impedance curves of patients are very different from healthy subjects.To assess the body composition in healthies the complete curve must be measured.

Resistance

Reactance

Impedenza multifrequenza e composizione corporea

5kHz5kHz1MHz1MHz

Fluid Model • ECW, ICW

Body Model• Lean tissue• Fat• excess Fluid

Weight, Height

R R0

Excessfluid

Leantissue

Adiposetissue

Proteins& minerals

Lipids &minerals

≈ 100% water

20 % water

70% water

Il modello a 3 compartimentiBase del modello di composizione corporea del BCM ….

Moissl UM, et al. Physiol Meas 2006; 27: 921-933.Chamney PW, et al. Am J Clin Nutr 2007; 85: 80-9.

BCM – aspetto delle schermate

… measures non-invasively, fast and easy

… quantifies individual overhydration (L)

… provides a basis for nutritional

assessment

… determines urea distribution volume (L)

Grafico analisi di un singolo paziente nel tempo con software BCM

Body Composition measured with BCM

10.4.06 17.4.06 24.4.06 1.5.06 8.5.06 15.5.06 22.5.06 29.5.06

weig

ht

[kg

]

10

20

30

40

50

60

70

LTM BCM

Fat BCM

Overhydration BCM

Combining Blood Pressure and Fluid Overload

Fluid Overload

BP

[m

mH

g]

Normovolemia

Normotension

140

1.1 L

- heart disease- medication

-1.1 L

• hypertension• hypervolemia

• normotension• hypervolemia

• hypertension• normovolemia

• normotension• normovolemia

PA e idratazione con BCM in dialisi

Towards improved cardiovascular management: the necessity of combining blood pressure and fluid overload

P. Wabel, et al. NDT, 2008. 500 prevalent HD patients from 8 European centers (Germany, Poland, UK, Portugal, Cz)

Letteratura sul BCM

Moissl UM, et al. Body fluid volume determination via body composition spectroscopy in health and disease. Physiol Meas. 2006 Sep;27(9):921-33.

Chamney PW, et al. A whole-body model to distinguish excess fluid from the hydration of major body tissues. Am J Clin Nutr. 2007 Jan;85(1):80-9.

Wizemann V, et al. Whole-body spectroscopy (BCM) in the assessment of normovolemia in hemodialysis patients. Contrib Nephrol. 2008;161:115-8.

Wabel P, et al. Towards improved cardiovascular management: the necessity of combining blood pressure and fluid overload. Nephrol Dial Transplant. 2008 Sep;23(9):2965-71.

Wizemann V, et al. The mortality risk of overhydration in haemodialysis patients. Nephrol Dial Transplant. 2009 May;24(5):1574-9.

Wabel P, et al. Importance of whole-body bioimpedance spectroscopy for the management of fluid balance. Blood Purif. 2009;27(1):75-80.

Crepaldi C, et al. Application of body composition monitoring to peritoneal dialysis patients. Contrib Nephrol. 2009;163:1-6.

Machek P, et al. Guided optimization of fluid status in haemodialysis patients. Nephrol Dial Transplant. 2010 Feb;25(2):538-44.

Devolder I, et al. Body composition hydration and related parameters in hemodialysis versus peritoneal dialysis patients. Perit Dial Int 2010; 30: 208—14.

BCM e BIA - PhA

2

3

4

5

6

7

8

9

Pha

se A

3 4 5 6 7

Phi 50 kHz [°]

Bivariate Normal Ellipse P=0,950

Phi 50 kHz [°]

Phase A

Variable

5,110769

5,284615

Mean

1,040727

1,089311

Std Dev

0,887227

Correlation

0,0000

Signif. Prob

39

Number

Correlation

Bivariate Fit of Phase A By Phi 50 kHz [°]

-2,0

-1,5

-1,0

-0,5

0,0

0,5

1,0

1,5

2,0

Diff

eren

ce: P

hi 5

0 kH

z [°

]-P

hase

A

Phase A

Phi 50 kHz [°]

3 4 5 6 7 8

Mean: (Phase A+Phi 50 kHz [°])/2

Phi 50 kHz [°]

Phase A

Mean Difference

Std Error

Upper95%

Lower95%

N

Correlation

5,11077

5,28462

-0,1738

0,08134

-0,0092

-0,3385

39

0,88723

t-Ratio

DF

Prob > |t|

Prob > t

Prob < t

-2,13718

38

0,0391

0,9805

0,0195

Difference: Phi 50 kHz [°]-Phase A

Matched Pairs

BCM e BIA - R

300

350

400

450

500

550

600

650

700

750

R B

IA

300 350 400 450 500 550 600 650 700 750

Z 50 kHz [Ohm]

Bivariate Normal Ellipse P=0,950

Z 50 kHz [Ohm]

R BIA

Variable

512,0513

504,4359

Mean

81,50739

79,51028

Std Dev

0,991845

Correlation

0,0000

Signif. Prob

39

Number

Correlation

Bivariate Fit of R BIA By Z 50 kHz [Ohm]

-50

-40

-30

-20

-10

0

10

20

30

40

50

Diff

eren

ce: Z

50

kHz

[Ohm

]-R

BIA

R BIA

Z 50 kHz [Ohm]

300 350 400 450 500 550 600 650 700 750

Mean: (R BIA+Z 50 kHz [Ohm])/2

Z 50 kHz [Ohm]

R BIA

Mean Difference

Std Error

Upper95%

Lower95%

N

Correlation

512,051

504,436

7,61538

1,67703

11,0103

4,22044

39

0,99185

t-Ratio

DF

Prob > |t|

Prob > t

Prob < t

4,541

38

<.0001

<.0001

1,0000

Difference: Z 50 kHz [Ohm]-R BIA

Matched Pairs

Massa magra con BCM e PhA BIA

2

3

4

5

6

7

8

9

Pha

se A

6 8 10 12 14 16 18 20

LTI [kg/m²]

Bivariate Normal Ellipse P=0,950

LTI [kg/m²]

Phase A

Variable

13,23243

5,275676

Mean

2,910332

1,100355

Std Dev

0,665987

Correlation

0,0000

Signif. Prob

37

Number

Correlation

Bivariate Fit of Phase A By LTI [kg/m²]

Iperidratazione e dati ecocardiografici in 40 pazienti di Treviso

40

45

50

55

60

65

70

75

80

85

EC

C F

E%

-3 -2 -1 0 1 2 3 4 5 6

OH [L]

Bivariate Normal Ellipse P=0,950

OH [L]

ECC FE%

Variable

1,331429

67,07714

Mean

1,923198

8,726501

Std Dev

-0,33729

Correlation

0,0475

Signif. Prob

35

Number

Correlation

Bivariate Fit of ECC FE% By OH [L]

100

150

200

250

LVM

I Dev

ereu

x-P

enn

g/m

q-3 -2 -1 0 1 2 3 4 5 6

OH [L]

Bivariate Normal Ellipse P=0,950

OH [L]

LVMI Devereux-Penn g/mq

Variable

1,331429

164,0497

Mean

1,923198

50,15456

Std Dev

0,346941

Correlation

0,0412

Signif. Prob

35

Number

Correlation

Bivariate Fit of LVMI Devereux-Penn g/mq By OH [L]

Funzione renale e iperidratazione con BCM in 40 pazienti di Treviso

0

500

1000

1500

2000

Diu

resi

res

idua

-3 -2 -1 0 1 2 3 4 5 6

OH [L]

Bivariate Normal Ellipse P=0,950

OH [L]

Diuresi residua

Variable

1,228947

638,4211

Mean

1,74339

521,4145

Std Dev

-0,32197

Correlation

0,0487

Signif. Prob

38

Number

Correlation

Bivariate Fit of Diuresi residua By OH [L]

-1

0

1

2

3

4

5

6

7

8

GF

R m

l/min

-3 -2 -1 0 1 2 3 4 5 6

OH [L]

Bivariate Normal Ellipse P=0,950

OH [L]

GFR ml/min

Variable

1,165714

2,36

Mean

1,795082

2,222174

Std Dev

-0,41823

Correlation

0,0124

Signif. Prob

35

Number

Correlation

Bivariate Fit of GFR ml/min By OH [L]

Composizione corporea e tempo in DP in 40 pazienti di Treviso

15

20

25

30

35

BM

I [k

g/m

²]

0 25 50 75 100 125 150

Età dial

Bivariate Normal Ellipse P=0,950

Età dial

BMI [kg/m²]

Variable

32,4114

25,12687

Mean

32,33393

3,861442

Std Dev

0,357082

Correlation

0,0278

Signif. Prob

38

Number

Correlation

Bivariate Fit of BMI [kg/m²] By Età dial

10

20

30

40

50

rel F

at [%

]

0 25 50 75 100 125 150

Età dial

Bivariate Normal Ellipse P=0,950

Età dial

rel Fat [%]

Variable

34,05556

32,62222

Mean

32,44065

9,435226

Std Dev

0,449396

Correlation

0,0060

Signif. Prob

36

Number

Correlation

Bivariate Fit of rel Fat [%] By Età dial