PRESERVARE PER PROLUNGARE CONTROLLO DEL BILANCIO DEI FLUIDI CON BCM Dott. Gianpaolo Amici, U.O. Nefrologia e Dialisi, Ospedale di Treviso

USRDS 2009 Adjusted mortality rates USRDS 2009 Change in hospitalization rates USRDS 2004 Risk of death (cause and modality)

Ipervolemia, ipertensione e patologia cardiovascolare in DP Lameire N, et al. Cardiovascular diseases in peritoneal dialysis patients: the size of the problem. Kidney Int Suppl. 1996 Nov;56:S28-36. Lameire N, Van Biesen W. Importance of blood pressure and volume control in peritoneal dialysis patients. Perit Dial Int. 2001 Mar-Apr;21(2):206-11. Khandelwal M, et al. Volume expansion and sodium balance in peritoneal dialysis patients. Part I: Recent concepts in pathogenesis. Adv Perit Dial. 2003;19:36-43. Khandelwal M, et al. Volume expansion and sodium balance in peritoneal dialysis patients. Part II: Newer insights in management. Adv Perit Dial. 2003;19:44-52. Wang AY. Cardiovascular risk factors in peritoneal dialysis patients revisited. Perit Dial Int. 2007 Jun;27 Suppl 2:S223-7. Wang AY. The John F. Maher Award Recipient Lecture 2006. The "heart" of peritoneal dialysis:residual renal function. Perit Dial Int. 2007 Mar-Apr;27(2):116-24. Van Biesen W, et al. Residual renal function and volume status in peritoneal dialysis patients: a conflict of interest? J Nephrol. 2008 May-Jun;21(3):299-304. Brunkhorst R. Hypervolemia, arterial hypertension and cardiovascular disease: a largely neglected problem in peritoneal dialysis. Clin Nephrol. 2008; Apr;69(4):233-8. Carvalho MJ, Rodrigues A. Importance of residual renal function and peritoneal dialysis in anuric patients. Contrib Nephrol. 2009;163:155-60. Piraino B. Cardiovascular complications in peritoneal dialysis patients. Contrib Nephrol. 2009;163:102-9.

Wang MC, et al. BLOOD PRESSURE AND LEFT VENTRICULAR HYPERTROPHY IN PATIENTS ON DIFFERENT PERITONEAL DIALYSIS REGIMENS Perit Dial Int 2001; 21: 36–42 “In this study, ambulatory nighttime systolic BP load >30% had an independent association with LVH. Office and home BP measurements were correlated with ABPM in PD patients. The result that CCPD patients had a higher LVMI than CAPD patients may be due to a relative volume overload during the daytime in CCPD patients”.

Nutritional Assessment Using Body Composition Monitoring in Peritoneal Dialysis Patients. Variables Determining Body Mass, Fat Tissue and Lean Tissue Index. Covic A (Van Biesen W), et al. Objective Apart from adequate management of the fluid status in peritoneal dialysis (PD) patients the nutritional aspect of the therapy is equally important for the patient’s morbidity and mortality. In this cross-sectional study body composition data was obtained with the Body Composition Monitor (BCM, Fresenius Medical Care) to identify relevant variables for optimized nutritional outcomes. Methods We screened 973 PD patients from 28 centers in 6 European countries. 639 patients met the inclusion/exclusion criteria. Body composition, blood pressure (BP), dialysis modality and prescription, pre-existing diseases, comorbidities, and antihypertensive medication were documented and analyzed. Results Mean body mass index (26.3±5.1 kg/mq) and fat tissue index (12.6±6.0 kg/mq) were slightly above the normal range whereas mean lean tissue index (13.4±3.4 kg/mq, LTI) was within normal range at a mean weight of 72.2±15.4kg and height of 166±9.6 cm. Patients on glucose PD solutions alone had a statistically significantly better outcome than those on polyglucose or amino acid solutions in regard of nutritional parameters like lean tissue index. Conclusions The study provides essential information on nutritional status in a large representative cohort of European PD patients. BCM measurement enables clinicians to obtain objective data on patient’s body composition regarding fat tissue, lean tissue, and fluid status in routine clinical practice to optimize PD therapy and patient outcomes.

Devolder I, et al. BODY COMPOSITION, HYDRATION, AND RELATED PARAMETERS IN HEMODIALYSIS VERSUS PERITONEAL DIALYSIS PATIENTS. Perit Dial Int 2010; 30: 208–214 “Although much clinical attention is paid to volume status, 24% of patients still have clinically relevant volume overload. Implementation of a reliable and clinically applicable tool to assess volume status is therefore necessary. It is possible to obtain comparable volume status in PD and HD patients”.

BCM-Body Composition Monitor Principio di base delle frequenze multiple ~ measurement U(t) Apply AC Zero frequency (Cell behaves as an insulator) Cell Medium frequency (50 kHz) (Cell behaves as a partial insulator) High frequency (Cell behaves as an ordinary conductor) ECW

Range di misurazione: la curva dell‘impedenza Information about body composition Reaktance BIA  BIS g b a Meas. range BIS Physiologic impedance curve of patient BIA (50 kHz) 1MHz 5kHz R R i n f Resistance Solo con Bioimpedance spectroscopy (BIS) è possibile valutare la curva fisiologica dell‘impedenza.

Come sono le curve di impedenza nei pazienti? healthy subject malnourished patient fluid overloaded patient The impedance curves of patients are very different from healthy subjects. To assess the body composition in healthies the complete curve must be measured.

Impedenza multifrequenza e composizione corporea Reactance 5kHz 1MHz R R0 Resistance Fluid Model ECW, ICW Body Model Lean tissue Fat excess Fluid Weight, Height 

Il modello a 3 compartimenti Base del modello di composizione corporea del BCM …. Excess fluid ≈ 100% water Proteins & minerals Lean tissue 70% water Lipids & minerals Adipose tissue 20 % water Moissl UM, et al. Physiol Meas 2006; 27: 921-933. Chamney PW, et al. Am J Clin Nutr 2007; 85: 80-9.

BCM – aspetto delle schermate … quantifies individual overhydration (L) … determines urea distribution volume (L) … measures non-invasively, fast and easy … provides a basis for nutritional assessment

Grafico analisi di un singolo paziente nel tempo con software BCM

Combining Blood Pressure and Fluid Overload hypertension hypervolemia hypertension normovolemia BP [mmHg] - heart disease - medication 140 normotension normovolemia Normotension normotension hypervolemia -1.1 L 1.1 L Normovolemia Fluid Overload

PA e idratazione con BCM in dialisi Towards improved cardiovascular management: the necessity of combining blood pressure and fluid overload P. Wabel, et al. NDT, 2008. 500 prevalent HD patients from 8 European centers (Germany, Poland, UK, Portugal, Cz)

Letteratura sul BCM Moissl UM, et al. Body fluid volume determination via body composition spectroscopy in health and disease. Physiol Meas. 2006 Sep;27(9):921-33. Chamney PW, et al. A whole-body model to distinguish excess fluid from the hydration of major body tissues. Am J Clin Nutr. 2007 Jan;85(1):80-9. Wizemann V, et al. Whole-body spectroscopy (BCM) in the assessment of normovolemia in hemodialysis patients. Contrib Nephrol. 2008;161:115-8. Wabel P, et al. Towards improved cardiovascular management: the necessity of combining blood pressure and fluid overload. Nephrol Dial Transplant. 2008 Sep;23(9):2965-71. Wizemann V, et al. The mortality risk of overhydration in haemodialysis patients. Nephrol Dial Transplant. 2009 May;24(5):1574-9. Wabel P, et al. Importance of whole-body bioimpedance spectroscopy for the management of fluid balance. Blood Purif. 2009;27(1):75-80. Crepaldi C, et al. Application of body composition monitoring to peritoneal dialysis patients. Contrib Nephrol. 2009;163:1-6. Machek P, et al. Guided optimization of fluid status in haemodialysis patients. Nephrol Dial Transplant. 2010 Feb;25(2):538-44. Devolder I, et al. Body composition hydration and related parameters in hemodialysis versus peritoneal dialysis patients. Perit Dial Int 2010; 30: 208—14.

BCM e BIA - PhA

BCM e BIA - R

Massa magra con BCM e PhA BIA

Iperidratazione e dati ecocardiografici in 40 pazienti di Treviso

Funzione renale e iperidratazione con BCM in 40 pazienti di Treviso

Composizione corporea e tempo in DP in 40 pazienti di Treviso