© Borgis - Postępy Nauk Medycznych 2/2013, s. 127-130
*Ryszard Gellert1, Danuta Kobus2, Dorota Daniewska1, Ewa Wolska1, Marcin Czystowski2
Napływ płynu dializacyjnego do jamy otrzewnej u pacjentów dializowanych otrzewnowo nie wpływa na wyniki pomiaru przewodnienia metodą bioimpedancji
Bioimpedance-based overhydration valuation in peritoneal dialysis patients is not affected by the dialysis fluid intraperitoneal inflow
1Department of Nephrology, Medical Centre for Postgraduate Education, Bielański Hospital, Warszawa
Head of Department: prof. Ryszard Gellert, MD, PhD
2IV Clinical Ward of Internal Medicine and Nephrolgy Unit, Bielański Hospital, Warszawa
Head of IV Clinical: prof. Ryszard Gellert, MD, PhD
Streszczenie
Wprowadzenie. Obecność płynu dializacyjnego w jamie otrzewnej u pacjentów dializowanych otrzewnowo zmienia ciężar ciała, ale nie wpływa na odczyty pomiarów przestrzeni wodnych dokonywanych metodą bioimpedancji przed i po opróżnieniu otrzewnej, jako że płyn ten jest traktowany jako transcelularny.
Cel. Ocenić, czy napływ płynu dializacyjnego do otrzewnej wpływa na ocenę przewodnienia metodą bioimpedancji.
Materiał i metody. Pomiary wykonano u 5 dorosłych mężczyzn dializowanych otrzewnowo przed i po wpuszczeniu płynu dializacyjnego do jamy otrzewnej. Użyto Body Composition Monitor (Fresenius Medical Care).
Wyniki. Wartości przewodnienia były takie same przed i po wpuszczeniu płynu dializacyjnego, zmieniły się natomiast nieznacznie niektóre parametry antropometryczne
Wnioski. Bioimpedancja jest użyteczna w ocenie aktualnego przewodnienia u pacjentów dializowanych otrzewnowo, ale porównywanie wyników pomiarów wykonanych w dłuższych odstępach czasu wymaga, by dokonywać ich przed wprowadzeniem płynu dializacyjnego do jamy otrzewnej.
Summary
Introduction. Peritoneal dialysis fluid in peritoneal cavity affects the body weight, but is overlooked by the bio-impedance measurements, as shown after draining this fluid out.
Aim. To evaluate if dialysis fluid inflow affects over-hydration measured using bio-impedance method.
Material and methods. Body Composition Monitor (Fresenius Medical Care) was used to measure water compartments in 5 male peritoneal dialysis patients, prior to, and immediately after dialysis fluid inflow.
Results. Dialysis fluid inflow did not affect over-hydration measurements, but slightly influenced anthropometric data.
Conclusions. Bio-impedance is a useful tool to evaluate current over-hydration in peritoneal dialysis patients, but for the best accuracy of longitudinal comparisons the measurement should be done after the dialysis fluid has been drained out.
Introduction
Euhydration, the adequate hydration, is crucial to prognosis in dialysis patients. It seems even more important than low molecular substances clearance, for it predicts outcome (1), which the clearance does not (2). Out of the range of definite over- and dehydration, hydration level is very difficult to evaluate, for it is subjective. The evaluation of patient’s hydration depends mainly on clinical judgment and experience of the physician. The blood volume indicators, the vena cava diameter and plasma NTproBNP, poorly correlate with hydration status in dialysis patients (3, 4). The evaluation of hydration is so difficult for significant amounts of water can be stored in the interstitial tissue. Mild hyperhydration in dialysis patients usually presents as hypertension, decreased haemoglobin and albumin levels, which in fact reflect the increase in blood volume.
Moreover, the comorbidities frequent in patients on dialysis – diabetes, chronic heart failure, malnutrition, and hypertension, add blur to the patients’ hydration image. Thus, the dialysis staff are in constant search for improved evaluation of body water content in renal patients.
Not only the water content, but also its distribution is important to health. The total body water (TBW) is contained in three separate compartments. Most of water is kept inside the cells (intracellular water – ICW) and between them (extracellular water – ECW). Some additional water (1-3% of body weight, BW) is sequestered inside the body cavities (transcellular water – TCW). The TCW is contained in peritoneal, pleural and pericardial cavities, inside the digestive tract, and the central nervous system. Measuring the ICW, TBW and ECW has been for years a cumbersome task, for it was performed with the use of dilution techniques. These techniques require time from injection to equilibration and are of no use in dynamic situations.
Lately, the bio-impedance, and the bio-impedance vector became an accepted, and widely used method to evaluate the TBW, ICW, and ECW. The basis for measurement is to evaluate body impedance to electrical currents of low (ECW+ICW) and high frequency (ECW). ICW is calculated as the difference between the two. The TCW is not registered with this method. The method is practically non-invasive, and the relevant equipment is commercially available. Among them, the Body Composition Monitor (BCM-FMC, Fresenius Medical Care, Germany), which is a bio-impedance spectroscopy device for clinical use, was validated by reference methods (5, 6), and has been also used in PD patients (7).
Peritoneal dialysis offers a unique situation, where abrupt TCW changes can be observed and directly, and precisely measured. One can expect, that intra-peritoneal water and electrolyte abrupt influx should not influence the readings of ICW and ECW, alike the efflux does not interfere with them (8). It is also of interest how the increased body weight influences the derived body composition parameters.
Aim
Based on the literature reviewed we hypothesised the quick peritoneal dialysis fluid inflow would not influence the bio-impedance-based measurements of ECW, ICW, TBW and TBW excess (over-hydration), alike the emptying of peritoneal cavity does it not. We also assumed that the increased body weight resulting from peritoneal fluid inflow could influence some other BCM-FMC readings.
Objectives
The primary endpoint of this retrospective observational study adopting bio-impedance method to evaluate ICW and ECW was to register stability of ICW and ECW despite acute changes in peritoneal fluid volume. The secondary endpoint was to register changes in body parameters resulting from the abrupt changes in the weight of tissues, which are neither ECW nor ICW.
Material and methods
Patients
Body water compartments were measured in adult males, stable, slightly overydrated on clinical evaluation, receiving chronic APD for CKD 5. The data were obtained at the end of staff training in using BCM-FMC in clinical practise. At this stage we performed, as a routine, the double analysis with the objective of assessing the repeatability of measurements.
Measurements
The BCM-FMC (Fresenius Medical Care), which measures the impedance spectroscopy at 50 different frequencies between 5 kHz and 1 MHz, was used to measure PD patients’ hydration, and the readings were registered in medical records. The BCM-FMC is supposed to overlook the fluid sequestered within the trunk (9, 10).
Statistics
Mean and standard deviation served to evaluate data distribution, and the double tail, paired Student t-test was applied to evaluate differences between the means. All analyses were performed using standard Excell software.
Results
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Piśmiennictwo
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