Inferior vena cava diameter and collapsibility index as a marker of fluid status in regular hemodialysis patients

Background Patients with renal failure suffer from fluid overload which is a risk factor for mortality and morbidity. Therefore, fluid status assessment in patients on regular hemodialysis is very important. Dry weight assessment by clinical parameters is not always reliable. We evaluate the role of inferior vena cava ultrasound in estimating fluid overload in regular hemodialysis patients. Results A total of 45 persons, 30 end-stage renal disease patients on regular hemodialysis in group A (18 men and 12 women) and 15 healthy persons in group B (10 men and 5 women), were included in the study. The patients in group A ages ranged from 29 to 70 years with a mean of 48.38 ± 12.70 years and in group B ages ranged from 25 to 55 years with a mean of 34.93 ± 8.26. By clinical methods, the mean dry weight was 68.37 kg (68.37 ± 10.42). After HD mean, IVCe decreased from 2.01 ± 0.29 to 1.79 ± 0.22 cm (P < 0.001) similarly, mean IVCi decreased from 0.99 ± 0.48 to 0.64 ± 0.39 cm (P < 0.001). Changes in IVCD were significantly correlated with alterations in body weight following dialysis (P < 0.001). The IVC-CI increased significantly after dialysis (P < 0.001). IVCD and its IVC-CI reflected alterations in fluid status (P < 0.001). Considering the clinical parameters of fluid status, following HD mean, heart rate increased from 81.80 ± 5.15 beats per minute to 89.87 ± 6.42, (P < 0.001), systolic blood pressure decreased from 130 ± 18.43 mmHg to 113.33 ± 15.27 (P < 0.001), and diastolic blood pressure decreased from 80.17 ± 10.12 mmHg to 71.50 ± 9.29 (P < 0.001). Conclusion It was found a significant correlation between IVCD and IVC-CI with ultrafiltration of hemodialysis. Thus, IVC ultrasound can be used in dry weight assessment in ESRD patients on regular HD by measurement of IVCD and IVC-CI before and after hemodialysis.

THE RELATIONSHIP BETWEEN THE LONG IN HEMODIALIZATION WITH STATUS OF EXCESS VOLUME OF LIQUID IN CHRONIC KIDNEY FAILURE PATIENTS

Chronic kidney disease is a chronic disease that progresses damage to the kidneys which disrupts the body’s fluid and electrolyte balance which affects all body systems. PGK is currently it is one of the many diseases that have become a concern in the world including in Indonesia. One phenomenon that often occurs is an increase in fluid volume between two times of dialysis. The purpose of this study was to find out the long relationship between hemodialysis and excess fluid volume status in patients with chronic renal failure in the Hemodialysis room at Ibnu Sina Gresik Hospital. This was an analytical study with a correlative analytic design. Data were collected by using the contingency coefficient. The result of this study shows that older respondents underwent <1 year of hemodialysis with excess fluid status >2,5 BB post HD as much 81,2%, which is more dominant than patients who undergo > 1-year hemodialysis with excess fluid status >2,5 BB post HD as much 58% of the total resulting in p-value 0,103 where p>0,05 so it can be concluded that there is no long relationship to undergo hemodialysis with excess fluid volume status in patients with chronic kidney disease. It is expected that patients undergoing hemodialysis can be more obedient to the recommended diet so that it does not cause other complications and can improve the quality of life patients

1318 Peri and Post-operative Fluid Management in Relation to Outcomes in Free Flap Reconstructive Surgery - A Systematic Review

Aim Free tissue transfer is one of the options available in the armamentarium of the reconstructive surgeon. Being a highly demanding and skilled procedure, success is dependent not only on the technical aspect of the anastomosis, but also on other variables including a patient’s fluid status. In order to address the controversy surrounding optimal fluid balance in free flap reconstruction, a systematic review of studies investigating the influence of peri and post- operative fluid balance on free flap reconstruction outcomes was carried out. Method We searched the Medline database from 1970 to 2020 and manually searched the bibliographies of relevant studies. The articles were graded according to the level of evidence set out by the Centre for Evidenced-Based Medicine and followed the PRISMA guidelines. Results Of the 62 abstracts screened, we identified 14 studies that met the inclusion criteria. Of the 14 studies, 12 studies concluded that excessive fluid therapy led to either medical or surgical complications (including free flap complications) or increased length of hospital stay. One study concluded that restricted fluid therapy led to a higher complication rate of delayed thrombotic events. One study reported no difference between volume of fluid administered with respect to pulmonary complications. Conclusions An important aspect of successful microvascular reconstruction involves determining a patient’s fluid status and targeted optimal resuscitation. This is best achieved with goal directed fluid therapy using tools such as an oesophageal doppler or other arterial waveform- based systems. Further good quality trials are required to determine which system is superior.

Urine di-(2-Ethylhexyl) Phthalate Metabolites Are Independently Related To Body Fluid Status in Adults: Results From a U.S. Nationally Representative Survey

Background Di-(2-ethylhexyl) phthalate (DEHP) has been utilized in many daily used products for decades. Previous studies have reported DEHP exposure could induce renin-angiotensin-aldosterone system activation and increase epithelial sodium channel (ENaC) activity, which contributes to extracellular fluid (ECF) volume expansion. However, there is also no previous study to evaluate the association between DEHP exposure and body fluid status. Methods We selected 1,678 subjects (aged ≧ 18 years) from a National Health and Nutrition Examination Survey (NHANES) in 2003–2004 to determine the relationship among urine DEHP metabolites and body composition (body measures, bioelectrical impedance analysis (BIA)). Results After weighted for sampling strategy, we reported higher levels of DEHP metabolites was correlated with increases in body measures (body weight, body mass index (BMI), waist), parameters of BIA (estimated fat mass, percent body fat, ECF, and ECF /intracellular fluid (ICF) ratio) in multiple linear regression analysis. The relationship between DEHP metabolites with ECF/ICF ratio were more evident in subjects with younger age (20–39 year-old), women, non-Hispanic white ethnic, and subjects who were not active smokers. Conclusions Besides positively correlated with body measures and body fat, we found urine DEHP metabolites are positively correlated with ECF, ECF/ICF ratio in the US general adult population. It is necessary to do further research to clarify this causal relationship.

POCUS for Nephrologists - Basic Principles and a General Approach

Point of care ultrasonography (POCUS) has evolved as a valuable adjunct to physical examination in the recent past and various medical specialties have embraced it. However, POCUS training and scope of practice remain relatively undefined in nephrology. The utility of diagnostic POCUS beyond kidney and vascular access is under-recognized. Assessment of fluid status is a frequent dilemma faced by nephrologists in day-to-day practice where multi-organ POCUS can enhance the sensitivity of conventional physical examination. POCUS also reduces fragmentation of care, facilitates timely diagnosis, and expedites management. While the need for further imaging studies is obviated in selected cases, POCUS is not meant to serve as an alternative to consultative imaging. In addition, utility of POCUS depends on the skills and experience of the operator, which in turn depends on the quality of training. In this review, we discuss the rationale behind nephrologists performing POCUS, discuss case examples to illustrate the basic principles of focused ultrasonography, and share our experience-based opinion about developing a POCUS training program at the institutional level.

The impact of fluid status and decremental PEEP strategy on cardiac function and lung and kidney damage in mild-moderate experimental acute respiratory distress syndrome

Background We evaluated the effects of abrupt versus gradual PEEP decrease, combined with standard versus high-volume fluid administration, on cardiac function, as well as lung and kidney damage in an established model of mild-moderate acute respiratory distress syndrome (ARDS). Methods Wistar rats received endotoxin intratracheally. After 24 h, they were treated with Ringer’s lactate at standard (10 mL/kg/h) or high (30 mL/kg/h) dose. For 30 min, all animals were mechanically ventilated with tidal volume = 6 mL/kg and PEEP = 9 cmH2O (to keep alveoli open), then randomized to undergo abrupt or gradual (0.2 cmH2O/min for 30 min) PEEP decrease from 9 to 3 cmH2O. Animals were then further ventilated for 10 min at PEEP = 3 cmH2O, euthanized, and their lungs and kidneys removed for molecular biology analysis. Results At the end of the experiment, left and right ventricular end-diastolic areas were greater in animals treated with high compared to standard fluid administration, regardless of PEEP decrease rate. However, pulmonary arterial pressure, indicated by the pulmonary acceleration time (PAT)/pulmonary ejection time (PET) ratio, was higher in abrupt compared to gradual PEEP decrease, independent of fluid status. Animals treated with high fluids and abrupt PEEP decrease exhibited greater diffuse alveolar damage and higher expression of interleukin-6 (a pro-inflammatory marker) and vascular endothelial growth factor (a marker of endothelial cell damage) compared to the other groups. The combination of standard fluid administration and gradual PEEP decrease increased zonula occludens-1 expression, suggesting epithelial cell preservation. Expression of club cell-16 protein, an alveolar epithelial cell damage marker, was higher in abrupt compared to gradual PEEP decrease groups, regardless of fluid status. Acute kidney injury score and gene expression of kidney injury molecule-1 were higher in the high versus standard fluid administration groups, regardless of PEEP decrease rate. Conclusion In the ARDS model used herein, decreasing PEEP abruptly increased pulmonary arterial hypertension, independent of fluid status. The combination of abrupt PEEP decrease and high fluid administration led to greater lung and kidney damage. This information adds to the growing body of evidence that supports gradual transitioning of ventilatory patterns and warrants directing additional investigative effort into vascular and deflation issues that impact lung protection.