Chronic Kidney Disease, Fluid Overload and Diuretics: A Complicated Triangle

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Abstract

Background

Despite promising role of diuretics to manage fluid overload among chronic kidney disease (CKD) patients, their use is associated with adverse renal outcomes. Current study aimed to determine the extent of renal deterioration with diuretic therapy.

Methods

A total 312 non-dialysis dependent CKD (NDD-CKD) patients were prospectively followed-up for one year. Fluid overload was assessed via bioimpedance spectroscopy. Estimated GFR (eGFR) was calculated from serum creatinine values by using Chronic Kidney Disease- Epidemiology Collaboration (CKD-EPI) equation.

Results

Out of 312 patients, 64 (20.5%) were hypovolemic while euvolemia and hypervolemia were observed in 113 (36.1%) and 135 (43.4%) patients. Overall 144 patients were using diuretics among which 98 (72.6%) were hypervolemic, 35 (30.9%) euvolemic and 11 (17.2%) were hypovolemic. The mean decline in estimated GFR of entire cohort was -2.5 ± 1.4 ml/min/1.73m ² at the end of follow up. The use of diuretics was significantly associated with decline in eGFR. A total of 36 (11.5%) patients initiated renal replacement therapy (RRT) and need of RRT was more profound among diuretic users.

Conclusions

The use of diuretics was associated with adverse renal outcomes indicated by decline in eGFR and increasing risk of RRT initiation in our cohort of NDD-CKD patients. Therefore, it is cautiously suggested to carefully prescribe diuretics by keeping in view benefit versus harm for each patient.

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Most cited references 21

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Importance of Whole-Body Bioimpedance Spectroscopy for the Management of Fluid Balance

Peter Wabel, Paul Chamney, Ulrich Moissl … (2009)

Introduction: Achieving normohydration remains a non-trivial issue in haemodialysis therapy. Preventing the deleterious effects of fluid overload and dehydration is difficult to achieve. Objective and clinically applicable methods for the determination of a target representing normohydration are needed. Methods: Whole-body bioimpedance spectroscopy (50 frequencies, 5–1,000 kHz) in combination with a physiologic tissue model can provide an objective target for normohydration based on the concept of excess extracellular volume. We review the efficacy of this approach in a number of recent clinical applications. The accuracy to determine fluid volumes (e.g. extracellular water), body composition (e.g. fat mass) and fluid overload was evaluated in more than 1,000 healthy individuals and patients against available gold standard reference methods (e.g. bromide, deuterium, dual-energy X-ray absorptiometry, air displacement plethysmography, clinical assessment). Results: The comparison with gold standard methods showed excellent accordance [e.g. R 2 (total body water) = 0.88; median ± SD (total body water) = –0.17 ± 2.7 litres]. Agreement with high-quality clinical assessment of fluid status was demonstrated in several hundred patients (median ± SD = –0.23 ± 1.5 litres). The association between ultrafiltration volume and change in fluid overload was reflected well by the method (median ± SD = 0.015 ± 0.8 litres). The predictive value of fluid overload on mortality underlines forcefully the clinical relevance of the normohydration target, being secondary only to the presence of diabetes. The objective normohydration target could be achieved in prevalent haemodialysis patients leading to an improvement in hypertension and reduction of adverse events. Conclusion: Whole-body bioimpedance spectroscopy in combination with a physiologic tissue model provides for the first time an objective and relevant target for clinical dry weight assessment.

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Effect of fluid management guided by bioimpedance spectroscopy on cardiovascular parameters in hemodialysis patients: a randomized controlled trial.

Soner Duman, Huseyin Toz, Ercan Ok … (2013)

Fluid overload is the main determinant of hypertension and left ventricular hypertrophy in hemodialysis patients. However, assessment of fluid overload can be difficult in clinical practice. We investigated whether objective measurement of fluid overload with bioimpedance spectroscopy is helpful in optimizing fluid status. Prospective, randomized, and controlled study. 156 hemodialysis patients from 2 centers were randomly assigned to 2 groups. Dry weight was assessed by routine clinical practice and fluid overload was assessed by bioimpedance spectroscopy in both groups. In the intervention group (n = 78), fluid overload information was provided to treating physicians and used to adjust fluid removal during dialysis. In the control group (n = 78), fluid overload information was not provided to treating physicians and fluid removal during dialysis was adjusted according to usual clinical practice. The primary outcome was regression of left ventricular mass index during a 1-year follow-up. Improvement in blood pressure and left atrial volume were the main secondary outcomes. Changes in arterial stiffness parameters were additional outcomes. Fluid overload was assessed twice monthly in the intervention group and every 3 months in the control group before the mid- or end-week hemodialysis session. Echocardiography, 48-hour ambulatory blood pressure measurement, and pulse wave analysis were performed at baseline and 12 months. Baseline fluid overload parameters in the intervention and control groups were 1.45 ± 1.11 (SD) and 1.44 ± 1.12 L, respectively (P = 0.7). Time-averaged fluid overload values significantly decreased in the intervention group (mean difference, -0.5 ± 0.8 L), but not in the control group (mean difference, 0.1 ± 1.2 L), and the mean difference between groups was -0.5 L (95% CI, -0.8 to -0.2; P = 0.001). Left ventricular mass index regressed from 131 ± 36 to 116 ± 29 g/m(2) (P < 0.001) in the intervention group, but not in the control group (121 ± 35 to 120 ± 30 g/m(2); P = 0.9); mean difference between groups was -10.2 g/m(2) (95% CI, -19.2 to -1.17 g/m(2); P = 0.04). In addition, values for left atrial volume index, blood pressure, and arterial stiffness parameters decreased in the intervention group, but not in the control group. Ambulatory blood pressure data were not available for all patients. Assessment of fluid overload with bioimpedance spectroscopy provides better management of fluid status, leading to regression of left ventricular mass index, decrease in blood pressure, and improvement in arterial stiffness. Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

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Volume overload correlates with cardiovascular risk factors in patients with chronic kidney disease.

Che-Hsiung Wu, Wei-Chun Hung, Yi Wang … (2014)

Volume overload is a predictor of mortality in dialysis patients. However, the fluid status of patients with chronic kidney disease (CKD) but not yet on dialysis has not been accurately characterized. We used the Body Composition Monitor, a multifrequency bioimpedance device, to measure the level of overhydration in CKD patients, focusing on the association between overhydration and cardiovascular disease risk factors. Overhydration was the difference between the amount of extracellular water measured by the Body Composition Monitor and the amount of water predicted under healthy euvolemic conditions. Volume overload was defined as an overhydration value at and above the 90th percentile for the normal population. Of the 338 patients with stages 3-5 CKD, only 48% were euvolemic. Patients with volume overload were found to use significantly more antihypertensive medications and diuretics but had higher systolic blood pressures and an increased arterial stiffness than patients without volume overload. In a multivariate analysis, male sex, diabetes, pre-existing cardiovascular disease, systolic blood pressure, serum albumin, TNF-α, and proteinuria were independently all associated with overhydration. Thus, volume overload is strongly associated with both traditional and novel risk factors for cardiovascular disease. Bioimpedance devices may aid in clinical assessment by helping to identify a high-risk group with volume overload among stages 3-5 CKD patients.

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Author and article information

Contributors

Jaap A. Joles: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 21 July 2016

Publication date Collection: 2016

Volume: 11

Issue: 7

Electronic Location Identifier: e0159335

Affiliations

[1 ]Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, University Sains Malaysia, Penang, 11800, Malaysia

[2 ]Chronic Kidney Disease Resource Centre, School of Medical Sciences, Health Campus, University Sains Malaysia, Kubang Kerain, 16150, Kelantan, Malaysia

University Medical Center Utrecht, NETHERLANDS

Author notes

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: YHK AS ASA. Performed the experiments: YHK ASA. Analyzed the data: YKH AHK THM. Contributed reagents/materials/analysis tools: THM YHK. Wrote the paper: YHK THM. Final approval of manuscript: AS ASA.

* E-mail: yusrahabib@ 123456ymail.com (YHK); drazreenadnan@ 123456gmail.com (ASA)

Article

Publisher ID: PONE-D-16-02378

DOI: 10.1371/journal.pone.0159335

PMC ID: 4956320

PubMed ID: 27442587

SO-VID: 53b0237e-6830-4612-808b-2dc6e21a8253

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 28 March 2016

Date accepted : 30 June 2016

Page count

Figures: 2, Tables: 5, Pages: 13

Funding

The authors have no support or funding to report.

Custom metadata

Data Availability Individual data points are available upon request due to ethical restrictions by Medical Research Advisory Committee [Jawatankuasa Etika Penyelidikan Manusia USM (JEPeM-USM)] as stated in “Rule Number 3” (Privacy and Confidentiality of data) of “Ethical Considerations” and these rules are available on its official website ( www.jepem.kk.usm.my) by downloading “Template for Research Protocol”. Furthermore, confidentiality of medical information of patients is strictly required by ethical board and following statement was also consented to the patients during data collection. However, individual data points can be provided to the researchers who meet the criteria for access to confidential data via approval from the Medical Research Advisory Committee and the Chronic Kidney Disease Resource Center, School of Medical Sciences University Sains Malaysia; contact person (In-charge Data and Records) zamli@ 123456usm.my .

Chronic Kidney Disease, Fluid Overload and Diuretics: A Complicated Triangle

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Abstract

Background

Methods

Results

Conclusions

Related collections

PLOS Climate

Most cited references 21

Importance of Whole-Body Bioimpedance Spectroscopy for the Management of Fluid Balance

Effect of fluid management guided by bioimpedance spectroscopy on cardiovascular parameters in hemodialysis patients: a randomized controlled trial.

Volume overload correlates with cardiovascular risk factors in patients with chronic kidney disease.

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