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Aims and objectives. To assess the degree of overhydration in our peritoneal dialysis patients and to examine the factors
contributing to overhydration.
Background. Volume control is critical for the success of peritoneal dialysis, but dry weight has been difficult to ascertain
accurately. Chronic fluid overload and hypertension are among the leading causes of mortality in dialysis patients.
Design. A cross-sectional observational study.
Methods. The body composition monitor (Fresenius Medical Care, Bad Homburg, Germany) is a bioimpedance spectroscopy device that has been validated for the assessment of overhydration. We used this body composition monitor device on
all patients on continuous ambulatory peritoneal dialysis at our institution who met the inclusion criteria to assess their
degree of overhydration.
Results. Thirty four (17 men, 17 women; mean age 445 142 years) of a 45 continuous ambulatory peritoneal dialysis
patients were enrolled. The mean overhydration was 24 24 l. Fifty per cent of the patients were 2 l overhydrated.
Overhydration correlated with male gender, low serum albumin, increasing number of antihypertensive agents and duration
of dialysis. There was no difference in overhydration between diabetic and non-diabetic patients. Men were more overhydrated than women, had lower Kt/V and were older. Although, there was no difference in blood pressure between the genders, men had a trend towards a higher usage of antihypertensive agents.
Conclusion. Our study demonstrates that overhydration is common in peritoneal dialysis patients. Blood pressure should
ideally be controlled with adherence to dry weight and low salt intake rather than adding antihypertensive agents even in
the absence of clinical oedema.
Relevance to clinical practice. Body composition monitor is a simple, reliable and inexpensive tool that can be routinely
used in the outpatient clinic setting or home visit to adjust the dry weight and avoid chronic fluid overload in between nephrologists review.
Key words: bioimpedance, body composition monitor, fluid status, overhydration, peritoneal dialysis
Accepted for publication: 13 June 2012
741
RA Cader et al.
Introduction
When treating patients on peritoneal dialysis (PD), the
assessment of fluid status is of utmost importance as dry
weight is based on euvolaemia. Volume control is critical
for the success of PD, but dry weight in PD patients has
been difficult to ascertain accurately on clinical criteria
alone and has a high interobserver variability. Chronic fluid
overload and hypertension are among the leading causes of
mortality in dialysis patients (Wizemann et al. 2009, Paniagua et al. 2010). In contrast, dehydration can lead to hypotension causing further reduction in the residual renal
function. Decline in residual renal function is also associated with increased mortality (Rocco et al. 2002, van der
Wal et al. 2011).
In general, blood pressure (BP) and oedema-free status are
used to adjust the dry weight in a patient who is otherwise
not overloaded. However, patients can have no oedema but
still be volume overloaded. A general rule of thumb is that at
least three litres of fluid need to be retained in a patient of
average weight before oedema develops. Overhydration
(OH) is associated with hypertension and left ventricular
hypertrophy (Ozkahya et al. 2002).
Studies have shown good BP control can be achieved by
controlling fluid status (Chazot & Charra 2007). It has
been postulated that PD patients are more fluid overloaded
than haemodialysis patients (Chen et al. 2009).
Euvolaemia is a predictor of outcome in PD patients
(Van Biesen et al. 2008) as volume overload is related to
cardiac dysfunction (Konings et al. 2002), inflammation
and mortality (Tonbul et al. 2006). Euvolaemia is probably
a more important adequacy parameter than small solute
clearance, as fluid status (Paniagua et al. 2010) but not
small solute clearance (Paniagua et al. 2000) predicts outcome. European Automated Peritoneal Dialysis Outcome
Study (EAPOS) has shown that ultrafiltration was associated with better patient survival rather than solute clearance (Brown et al. 2003).
Until recently, we have not been able to objectively measure the degree of fluid overload in our PD patients. Direct
measurement of extracellular (ECW) and total body water
(TBW) by dilution methods is the ideal gold standard, but
it is expensive, laborious and not readily available (Woodrow 2007). With the advent of bioimpedance spectroscopy,
it has been possible to accurately assess the hydration status
of patients (Kraemer et al. 2006). The body composition
monitor (BCM; Fresenius Medical Care, Bad Hamborg,
Germany) is a bioimpedance spectroscopy device for
clinical use and has been validated against available gold
standard methods (Moissl et al. 2006).
742
The BCM (Fresenius Medical Care) measures the impedance spectroscopy at 50 different frequencies between
5 kHz1 MHz. BCM gives values for extracellular water
(ECW), intracellular water (ICW) and TBW by measuring
the bioimpedance. The difference between the measured
ECW and expected ECW is OH. OH is 100% extracellular
water. It also breaks down the body weight in terms of lean
tissue mass (LTM) and fat tissue mass (FTM).
BCM was performed in the morning when the patient
attended the PET. Electrodes were attached to the ipsilateral arm and foot with the patient in the supine position.
There is very little data as to whether bioimpedance spectroscopy measures fluid in the trunk (Sipahi et al. 2011). It
is not clear whether having an empty stomach makes any
difference, and the evidence is debatable (Devolder et al.
2010). Our patients had a full abdomen with their usual
PD fluid volume. As studies have shown good reproducibility of BCM-derived parameters, we only did BCM once for
each patient (Katzarski et al. 1996).
There are issues with the best way to express the OH.
Expressing ECW/ICW as absolute values induces the problem of scaling to body size. Some studies have used ratios
of extracellular water to height, weight, ICW or TBW used
to express fluid overload, but the ideal scaling parameter
remains a matter of debate (Engel & Davies 2007). For this
reason, we have expressed the ECW in relation to ICW,
TBW and height.
Statistical analysis was conducted using SPSS software version 19 (SPSS Inc, Chicago, IL, USA). Continuous data are
presented as mean SD unless otherwise stated. We used
Students independent and paired t-test for parametric data
and MannWhitney U-test for non-parametric data. Oneway ANOVA was used for multiple categories. Pearsons correlation and linear and logistic regression were used for univariate and multivariate analysis, respectively. A p-value
<005 was considered significant.
Results
A total of 34 of the 45 PD patients were recruited. Four
patients were excluded (two patients were on CAPD <
three months, one patient under 18 years and one patient
had a below knee amputation), and seven patients did not
consent. The baseline demographic data, laboratory and
BCM results are presented in Table 1. Our PD patients
were fluid overloaded, and the mean OH was 24 24 l.
Majority of our patients were on antihypertensive agents,
and 79% were on an ACE inhibitor, 6% on an angiotensin II receptor blocker, and 15% were on other agents.
We examined whether gender played a role in OH and
2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 741748
BCM in CAPD
Table 1 Baseline demographics, laboratory and body composition
monitor data of peritoneal dialysis patients (n = 34)
Mean
or %
Age (years)
Gender (male)
445
50
Race
Malay
Chinese
Other
Height (m)
Weight (kg)
Body mass index (kg/m2)
Duration (months)
65
32
3
161
657
254
407
1442
811
29
94
12
Standard
deviation
142
008
142
46
299
262
151
25
236
325
266
89
59
01195
1430
IQR
561
294
530
88
88
201
066
047
018
153
910
376
53
335
47
24
328
160
168
096
049
993
2183
3391
24
70
38
37
015
004
206
1026
911
743
RA Cader et al.
Table 2 Demographic and hydration parameters between male and
female peritoneal dialysis patients
Male
(n = 17)
Age (years)
Height (m)
Weight (kg)
Body mass index (kg/m2)
Duration (months)
Blood pressure (mm Hg)
Systolic
Diastolic
No of antihypertensive
agent
High transporter
Ultrafiltration (ml/day)
Kt/V
NPCR
Albumin (g/l)
Residual renal function
(ml/min)
Overhydration (l)
Total body water
(TBW) (l)
Extracellular water
(ECW) (l)
Intracellular water
(ICW) (l)
ECW/ICW (l)
ECW/height (l/m2)
ECW/TBW
Lean tissue mass (kg)
Fat tissue mass (kg)
494
166
706
259
460
Female
(n = 17)
148
006
125
36
353
1482 232
845 164
271 131
n=3
1549
183
063
382
396
156
608
249
355
p-value
120
006
144
55
233
1401 291
778 134
194 097
0043
<0001
0041
057
032
038
020
006
641
036
018
47
n=3
1312 458
219 051
063 018
369 48
No difference
023
0023
050
041
361 236
374 60
119 180
281 448
0002
<0001
186 32
147 25
<0001
189 35
135 24
<0001
015
0026
0017
<0001
072
10
112
049
391
212
016
182
004
92
104
093
87
048
288
225
013
130
003
56
105
744
p-value
Gender (male)
Age (years)
Height (m)
Weight (kg)
Body mass index (kg/m2)
Duration (months)
0302
0362
0081
0068
0431
0002
0083
0035
0351
0702
0011
0212
0006
0480
0041
0304
0440
0738
0756
0724
0347
0290
0228
0974
0004
0819
0077
0009
<0001
<0001
<0001
0045
0096
Discussion
Our patients on PD were fluid overloaded. The mean OH
was 24 24 l and in keeping with other studies (Van
Biesen et al. 2011). Majority of our patients were overhydrated, and some were as high as 6 l. Studies have shown
PD patients are more fluid overloaded than HD patients
(Devolder et al. 2010) and reported OH pre-HD as
19 17 l, post-HD as 06 17 l and PD as 21 23 l.
Our findings also demonstrated PD patients to be fluid
overloaded.
Studies have shown that fluid overload or the presence of
diabetes in HD patients to be associated with a higher mortality (Wizemann et al. 2009). In our study, patients were
overhydrated and are likely to have a higher mortality
based on the evidence from Wizeman et al. People with
diabetes on PD are believed to be more fluid overloaded
than their non-diabetic counterparts (Davenport &
Willicombe 2010). There was no difference between diabetic and non-diabetic patients in terms of absolute OH in
our study. However, the number of people with diabetes in
our study was small, and our study was not powered to
analyse this aspect.
BCM in CAPD
2 l OH
(n = 17)
p-value
409 109
n=5
n = 12
157 007
613 137
251 49
481 164
n = 12
n=5
164 007
707 135
257 43
0007
0053
072
362 222
452 362
040
1372 203
808 166
056 105
1510 301
815 140
423 191
013
089
<0001
398 41
219 053
1404 423
354 43
180 027
1460 699
0005
0017
042
184 099
288 120
009
<0001
<0001
<0001
030
134
046
87
323
23
003
12
79
217 104
189
052
112
355
29
003
19
102
219 104
014
095
745
RA Cader et al.
Conflict of interest
All authors declare there is no conflict of interest.
Contributions
Study design: RAC, HAG, RM, NCTK, WHWH, ARWK,
SI; data collection and analysis: RAC, HAG, WHWH,
ARWK, SI and manuscript preparation: RAC, HAG,
NCTK.
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