Fansan Zhu

Body fluid volume determination via body composition spectroscopy in health and disease

The assessment of extra-, intracellular and total body water (ECW, ICW, TBW) is important in many clinical situations. Bioimpedance spectroscopy (BIS) has advantages over dilution methods in terms of usability and reproducibility, but a careful analysis reveals systematic deviations in extremes of body composition and morbid states. Recent publications stress the need to set up and validate BIS equations in a wide variety of healthy subjects and patients with fluid imbalance. This paper presents two new equations for determination of ECW and ICW (referred to as body composition spectroscopy, BCS) based on Hanai mixture theory but corrected for body mass index (BMI). The equations were set up by means of cross validation using data of 152 subjects (120 healthy subjects, 32 dialysis patients) from three different centers. Validation was performed against bromide/deuterium dilution (NaBr, D2O) for ECW/TBW and total body potassium (TBK) for ICW. Agreement between BCS and the references (all subjects) was -0.4 +/- 1.4 L (mean +/- SD) for ECW, 0.2 +/- 2.0 L for ICW and -0.2 +/- 2.3 L for TBW. The ECW agreement between three independent reference methods (NaBr versus D2O-TBK) was -0.1 +/- 1.8 L for 74 subjects from two centers. Comparing the new BCS equations with the standard Hanai approach revealed an improvement in SEE for ICW and TBW by 0.6 L (24%) for all subjects, and by 1.2 L (48%) for 24 subjects with extreme BMIs (<20 and >30). BCS may be an appropriate method for body fluid volume determination over a wide range of body compositions in different states of health and disease.

Validation of Changes in Extracellular Volume Measured During Hemodialysis Using a Segmental Bioimpedance Technique

Sum of segmental bioimpedance analysis (BIAs) has recently been introduced as a more accurate estimation of extracellular volume (ECV). The current study was designed to compare the changes in ECV estimated by whole body bioimpedance (BIA(W)) and BIAs and to determine whether BIAs could be used to accurately estimate changes in ECV compared with the ultrafiltration volume (UFV) as measured by the dialysis machine. Ten men (age, 49 +/- 10 years; dry weight, 78 +/- 13 kg) were studied during hemodialysis (HD). A multifrequency bioimpedance analyzer (BIS4000B; Xitron Technologies, San Diego, CA) and a digital switch developed by the authors were used to automatically collect data from three body segments (arm, trunk, and leg) and the whole body using the stated technique. There was a significant difference in delta ECV(W) and UFV at the end of the treatment (2.75 +/- 0.74 L vs 3.95 +/- 0.73 L, p < 0.05) because fluid removal from the trunk has almost no effect on whole body resistance. However, delta ECVs was not significantly different from UFV (3.76 +/- 0.65 L vs 3.95 +/- 0.73 L, p = NS). BIAs is a more accurate approach to monitor changes in ECV during HD than is BIA(W) because changes in local resistance can be allocated to segments with uniform geometry and resistivity. This is a prerequisite for future studies on dynamics of regional fluid distribution during hemodialysis.

Bioimpedance, dry weight and blood pressure control: new methods and consequences.

Purpose of reviewChronic overhydration contributes to the development of left ventricular hypertrophy and a high cardiovascular mortality in end-stage renal disease. Assessment of dry weight is highly dependent on clinical assessment. Bioimpedance technology offers the potential to quantify body fluid compartments and to facilitate dry weight prescription. This review covers recent innovative approaches to dry weight assessment using bioimpedance technology. Recent findingsThree different bioimpedance approaches to determine dry weight have been published. The normovolemic/hypervolemic slope method applies whole body multifrequency bioimpedance to assess predialysis total body extracellular fluid volume and compares the extracellular fluid volume/body weight relation at hypervolemia with the standard value in normovolemic individuals. The resistance–reactance graph method uses whole body single frequency bioimpedance for assessment of hydration state and nutritional status from height-adjusted resistance and reactance. The resulting resistance–reactance vector is set in relation to a distribution range in a normovolemic population. An alternative method uses segmental bioimpedance in the form of continuous intradialytic calf bioimpedance to record changes in calf extracellular volume during dialysis. Dry weight by this method is defined as the weight at which calf extracellular volume is not further reduced despite ongoing ultrafiltration. SummaryAlthough promising, none of these methods has gained much popularity, probably due to the difficulties in understanding bioimpedance and the lack of gold standard methods for dry weight determination. Bioimpedance will improve dry weight assessment, but further refinement of the methods as well as large-scale clinical studies to demonstrate the accuracy and the clinical value of objective dry weight determination are needed.

Current state of bioimpedance technologies in dialysis

Determination of body hydration and nutritional status are significant problems in dialysis patients. In practice, clinical evaluation is usually used to estimate the ultrafiltration target, since accurate knowledge of dry weight is lacking. Several methods have been proposed for non-clinical dry weight assessment; these include natriuretic peptides, measurement of inferior vena cava diameter and collapsibility on inspiration by ultrasound and intradialytic relative blood volume change. Unfortunately these methods suffer from several shortcomings, such as poor specificity (natriuretic peptides), operator dependence (inferior vena cava diameter measurements) and poor correlation with extracellular volume (continuous blood volume measurement) [1]. After years of bioimpedance analysis (BIA) research in dialysis patients, this technique is now increasingly used clinically. BIA as a means to determine extracellular volume (ECV) or/and intracellular volume (ICV) has been validated by applying dilution methods as the gold standard. Body composition analysis by BIA has been compared to magnetic resonance imaging (MRI) and appropriate regression models have been developed to estimate fat and muscle content [2,3]. This editorial deals with the principles of BIA techniques, and their clinical application in fluid management, body composition and nutrition.

A method for the estimation of hydration state during hemodialysis using a calf bioimpedance technique

Although many methods have been utilized to measure degrees of body hydration, and in particular to estimate normal hydration states (dry weight, DW) in hemodialysis (HD) patients, no accurate methods are currently available for clinical use. Biochemcial measurements are not sufficiently precise and vena cava diameter estimation is impractical. Several bioimpedance methods have been suggested to provide information to estimate clinical hydration and nutritional status, such as phase angle measurement and ratio of body fluid compartment volumes to body weight. In this study, we present a calf bioimpedance spectroscopy (cBIS) technique to monitor calf resistance and resistivity continuously during HD. Attainment of DW is defined by two criteria: (1) the primary criterion is flattening of the change in the resistance curve during dialysis so that at DW little further change is observed and (2) normalized resistivity is in the range of observation of healthy subjects. Twenty maintenance HD patients (12 M/8 F) were studied on 220 occasions. After three baseline (BL) measurements, with patients at their DW prescribed on clinical grounds (DW(Clin)), the target post-dialysis weight was gradually decreased in the course of several treatments until the two dry weight criteria outlined above were met (DW(cBIS)). Post-dialysis weight was reduced from 78.3 +/- 28 to 77.1 +/- 27 kg (p < 0.01), normalized resistivity increased from 17.9 +/- 3 to 19.1 +/- 2.3 x 10(-2) Omega m(3) kg(-1) (p < 0.01). The average coefficient of variation (CV) in three repeat measurements of DW(cBIS) was 0.3 +/- 0.2%. The results indicate that cBIS utilizing a dynamic technique continuously during dialysis is an accurate and precise approach to specific end points for the estimation of body hydration status. Since no current techniques have been developed to detect DW as precisely, it is suggested as a standard to be evaluated clinically.

Methods and Reproducibility of Measurement of Resistivity in the Calf Using Regional Bioimpedance Analysis

The usefulness of regional bioimpedance analysis (RBIA) in determining the dry weight in dialysis patients is currently being investigated. The aim of this study was to evaluate the reproducibility of measurement of resistivity in the calf. Methods: Twenty-five normal subjects and 10 patients undergoing regular hemodialysis were studied. Four electrodes inserted into a blood pressure cuff were placed on the calf. Bioimpedance was continuously measured over 3- to 5-min periods (Xitron Hydra). After a resting period of 1 min, cuff pressure was increased to above the systolic blood pressure (SBP) for a few seconds to expel excess ECF fluid and then deflated. The effect on recordings of moving the electrodes 2 cm higher and then 2 cm lower than the normal position was studied in 8 normal subjects. In a second study of reproducibility, post-dialysis measurements were made twice in 10 patients who maintained the same post-dialysis target weight throughout the study period. Results: The mean resting resistivity (ρ₀) in normal subjects was 532.6 ± 95 Ω·cm rising to 583.9 ± 99.7 Ω·cm when cuff pressure was applied (ρp). The average values of ρ₀ and ρp in patients post-dialysis were 489 ± 74 and 537 ± 77 respectively showing that there were no significant differences in ρ₀ and ρp between normal subjects and patients post-dialysis. The mean values of change in resistivity when the electrodes were shifted between the lowest and highest positions on the calf were –3.66 ± 4.45 and –1.44 ± 3.82%, respectively. Repeat measurement of resistivity in patients post-dialysis varied by 2.04 ± 2.29% while post-dialysis body weight varied by 0.17 ± 0.47%. Conclusion: In this study, resistivity measurement by RBIA at the calf showed similar levels of fluid loading in patients post-dialysis as in normal subjects. This study also showed that change in electrode position resulted in a mean change in resistivity of <5% and repeated measurements showed a change in resistivity <3% while body weight changes were <0.2%. This technique appears to have an acceptable level of reproducibility for its application to the assessment of patient hydration.

Estimation of normal hydration in dialysis patients using whole body and calf bioimpedance analysis.

Prescription of an appropriate dialysis target weight (dry weight) requires accurate evaluation of the degree of hydration. The aim of this study was to investigate whether a state of normal hydration (DW(cBIS)) as defined by calf bioimpedance spectroscopy (cBIS) and conventional whole body bioimpedance spectroscopy (wBIS) could be characterized in hemodialysis (HD) patients and normal subjects (NS). wBIS and cBIS were performed in 62 NS (33 m/29 f) and 30 HD patients (16 m/14 f) pre- and post-dialysis treatments to measure extracellular resistance and fluid volume (ECV) by the whole body and calf bioimpedance methods. Normalized calf resistivity (ρ(N)(,5)) was defined as resistivity at 5 kHz divided by the body mass index. The ratio of wECV to total body water (wECV/TBW) was calculated. Measurements were made at baseline (BL) and at DW(cBIS) following the progressive reduction of post-HD weight over successive dialysis treatments until the curve of calf extracellular resistance is flattened (stabilization) and the ρ(N)(,5) was in the range of NS. Blood pressures were measured pre- and post-HD treatment. ρ(N)(,5) in males and females differed significantly in NS. In patients, ρ(N)(,5) notably increased with progressive decrease in body weight, and systolic blood pressure significantly decreased pre- and post-HD between BL and DW(cBIS) respectively. Although wECV/TBW decreased between BL and DW(cBIS), the percentage of change in wECV/TBW was significantly less than that in ρ(N)(,5) (-5.21 ± 3.2% versus 28 ± 27%, p < 0.001). This establishes the use of ρ(N)(,5) as a new comparator allowing a clinician to incrementally monitor removal of extracellular fluid from patients over the course of dialysis treatments. The conventional whole body technique using wECV/TBW was less sensitive than the use of ρ(N)(,5) to measure differences in body hydration between BL and DW(cBIS).

Relationship between adiposity and cardiovascular risk factors in prevalent hemodialysis patients.

OBJECTIVE Increased body mass index (BMI) is associated with reduced all-cause and cardiovascular (CV) mortality in hemodialysis (HD) patients, whereas CV risk increases with BMI in the general population. In the general population, obesity is associated with inflammation, decreased high-density lipoprotein (HDL) cholesterol, increased low-density lipoprotein (LDL) cholesterol, and triglycerides (TGs), all risk factors for CV disease. Low-density lipoprotein cholesterol does not predict CV risk in HD, whereas increased C-reactive protein and interleukin-6 (IL-6), low HDL and apolipoprotein (apo) AI, and increased fasting TGs do predict risk. Renal failure is associated with dyslipidemia and inflammation in normal-weight patients. We hypothesized that the effects of obesity may be obscured by renal failure in HD. METHODS We explored the relationship between adipose tissue pools and distribution, i.e., subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) (measured by magnetic resonance imaging) and measures of inflammation (C-reactive protein, IL-6, ceruloplasmin, and alpha1 acid glycoprotein), HDL and LDL cholesterol, total TGs, apo AI, apo B, apo CII (an activator of lipoprotein lipase), apo CIII (an inhibitor of lipoprotein lipase), and the adipokines, leptin and adiponectin, in 48 patients with prevalent HD. RESULTS AND CONCLUSIONS Total TG concentrations were positively correlated with VAT controlled for age, sex, and weight. Both apo CII and apo CIII were correlated only with VAT. Adiponectin was inversely correlated with VAT, and leptin was positively associated with SAT. C-reactive protein and alpha1 acid glycoprotein were weakly associated with SAT, whereas ceruloplasmin was strongly associated with VAT according to multiple regression analysis. In contrast, apo B, LDL, apo AI, HDL, and IL-6 were not correlated with any measure of body composition, potentially mitigating the effects of obesity in HD.

Assessment of Extracellular Fluid Volume and Fluid Status in Hemodialysis Patients: Current Status and Technical Advances

The assessment of extracellular fluid volume (ECV) and fluid status is both important and challenging in hemodialysis patients. Extracellular fluid is distributed in two major sub‐compartments: interstitial fluid and plasma. A variety of methods are used to assess the ECV, with tracer dilution techniques considered gold standard. However, ECV defined as the distribution space of bromide, sodium, chloride, and ferrocyanide appears to be larger than the distribution volume of inulin and sucrose, suggesting a partial distribution into the intracellular volume. Relative blood volume monitoring, measurement of inferior vena cava diameter by ultrasound and biochemical markers are indirect methods, which do not reflect the ECV and fluid status accurately. Bioimpedance spectroscopy (BIS) techniques enable assessment of ECV and intracellular volume. Currently, BIS appears to be the most practical method for assessing ECV volume and fluid status in dialysis patients.

Application of Bioimpedance Techniques to Peritoneal Dialysis

Peritoneal dialysis (PD) has been used as a home dialysis therapy for renal replacement for more than 30 years. In a recent assessment of treatment quality, the mortality of patients on PD was referenced as being higher than of those on hemodialysis. Several reports suggest that a high proportion of PD patients are overhydrated. Clinical assessment of dry weight in PD patients is difficult and further complicated by the paucity of signs and symptoms indicative of dehydration (such as intradialytic hypotension or muscle cramps). Monitoring tools used for fluid status estimation during hemodialysis, e.g. online blood volume and blood pressure measurement, are not readily available in PD patients. Bioimpedance analysis technique has been considered as a potential tool to measure body fluid non-invasively, inexpensively and simply. Although Bioimpedance analysis has been used in clinical studies for more than 20 years, the knowledge of the electrical properties of body tissues is still evolving. In this review we aim to clarify the principles of different bioimpedance techniques and to introduce their applications in PD patients.