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MANAGING CLINICAL ISSUES

Assessment of fluid status in CAPD patients using the body


composition monitor
Rizna A Cader, Halim A Gafor, Rozita Mohd, Norella CT Kong, Suriani Ibrahim, Wan Haslina Wan
Hassan and Wan Khadijah Abdul Rahman

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

Authors: Rizna A Cader, MRCP, Consultant Nephrologist,


Nephrology Unit, Department of Medicine, Universiti Kebangsaan
Malaysia Medical Centre, Kuala Lumpur; Halim A Gafor, MMed,
Consultant Nephrologist, Nephrology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur; Rozita Mohd, MMed, Consultant Nephrologist, Nephrology
Unit, Department of Medicine, Universiti Kebangsaan Malaysia
Medical Centre, Kuala Lumpur, Malaysia; Norella CT Kong,
FRACP, Emeritus Professor of Medicine and Nephrology, Nephrology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur; Suriani Ibrahim, Dip Nurs,
Staff Nurse, Nephrology Unit, Department of Medicine, Universiti

Kebangsaan Malaysia Medical Centre, Kuala Lumpur; Wan


Haslina Wan Hassan, Dip Nurs, Staff Nurse, Nephrology Unit,
Department of Medicine, Universiti Kebangsaan Malaysia Medical
Centre, Kuala Lumpur; Wan Khadijah Abdul Rahman, Dip Nurs,
Staff Nurse, Nephrology Unit, Department of Medicine, Universiti
Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
Correspondence: Rizna A Cader, Consultant Nephrologist, Nephrology Unit, Department of Medicine, Universiti Kebangsaan Malaysia
Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Cheras,
Kuala Lumpur 56000, Malaysia. Telephone: +603 91456097.
E-mail: Rizna_c@hotmail.com

2012 Blackwell Publishing Ltd


Journal of Clinical Nursing, 22, 741748, doi: 10.1111/j.1365-2702.2012.04298.x

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

BCM is a simple, cheap and non-invasive tool that can


be used to assess OH. BCM has been used in haemodialysis
(Wizemann et al. 2009, Machek et al. 2010) and PD
(Sipahi et al. 2011, Van Biesen et al. 2011) patients. Studies
have shown BCM values of >20 l are in keeping with OH
(Luo & Wang 2011) and that a relative OH of more than
15% measured using BCM was associated with increased
cardiovascular mortality (Wizemann et al. 2009).
Van Biesen et al. (2011) have reported at least 60% of
patients on PD are overhydrated with 252% being severely
fluid overloaded. Studies have reported the use of BCM has
enabled better assessment of OH compared to conventional
clinical methods in PD patients (Luo et al. 2011). We therefore wanted to accurately measure the degree of OH in our
PD patients and understand the risk factors associated with
OH using BCM.

Design and methods


This study was a cross-sectional observational study. All
patients on continuous ambulatory peritoneal dialysis
(CAPD) at our institution who met the inclusion criteria
were enrolled. Our primary objective was to assess the
degree of OH in our PD patients, and secondary objective
was to examine the factors contributing to OH to enable us
to improve our PD prescription.
Informed consent was obtained. Our inclusion criteria
included patients 18 years or older, those established on
CAPD for more than four months with a stable PD prescription. Patients were excluded if they have had an amputation, pacemaker or metal implants as this would interfere
with the BCM.
Patients attended their peritoneal equilibrium test (PET)
routinely every four months. During a six-month period
(August 2010February 2011), all PD patients who
attended for the PET were screened, and those who met the
inclusion criteria were enrolled. During the PET visit,
routine blood tests were taken. In addition, height, weight,
BP and BCM were measured. Weight used was the actual
body weight minus the PD fluid in kg. Blood pressure
readings were taken in the seated position and a mean of
two BP readings (five minute interval) was used.
The following demographics were collected: age, gender,
race, body weight and height, body mass index (BMI),
comorbidities such as diabetes, hypertension, ischaemic
heart disease, duration of PD, number of antihypertensive
agents used, use of angiotensin converting enzyme/angiotensin II receptor blockers, serum urea, creatinine and albumin. Results of PD therapy were collected, including PD
adequacy (weekly Kt/V) and peritoneal equilibration test.
2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 741748

Managing clinical issues

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

Blood pressure (mm Hg)


Systolic
Diastolic
Diabetic
Hypertension
Ischaemic heart disease
No of antihypertensive agent
0
1
2
3
4
5
Residual renal function (ml/min)
Ultrafiltration (ml/day)
Transporters
Low
Low average
High average
High
Kt/V
NPCR
Serum level
Urea (mmol/l)
Creatinine (lmol/l)
Albumin (g/l)
Overhydration (l)
Total body water (TBW) (l)
Extracellular water (l)
Intracellular water (l)
Extracellular/Intracellular water (l)
Extracellular/TBW
Extracellular/height (l/m2)
Fat tissue mass (kg)
Lean tissue mass (kg)

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

found the men to be more overhydrated (361 26 l vs.


119 180 l, p = 0023). Demographic and hydration
parameters between genders are tabulated in Table 2.

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

On univariate analysis, OH was associated with male


gender, height, duration of PD, low serum albumin and
number of antihypertensive agents. Univariate analysis of
OH is tabulated on Table 3. Serum albumin also positively
correlated with nPCR (R = 0425, p = 0017). As expected,
there was a positive correlation between RRF and 24 hour
ultrafiltration (R = 0449, p = 001). BMI and albumin had
a trend towards positive correlation with R = 035,
p = 0053 (trend towards patients with higher BMI having
higher albumin which is associated with less OH, but we
could not establish this statistically).
Patients were divided on the basis of OH into two groups
(<2 l OH and  2 l OH). There were more men in the
 2 l OH group than women, consistent with our earlier
stated findings. Patients with severe OH were taller and
had a lower serum albumin and lower Kt/V. These results
are shown on Table 4. On multivariate analysis with OH,
serum albumin (p  0001), gender (p = 0001), number

744

Table 3 Univariate analysis of overhydration


R-value

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

Blood pressure (mm Hg)


Systolic
Diastolic
No of antihypertensive agents
Ultrafiltration (ml/day)
Kt/V
Albumin (g/l)
ECW (l)
ECW/height (l/m2)
ECW/TBW
Lean tissue mass (kg)
Fat tissue mass (kg)

0212
0006
0480
0041
0304
0440
0738
0756
0724
0347
0290

0228
0974
0004
0819
0077
0009
<0001
<0001
<0001
0045
0096

of antihypertensive agents used (p = 0009) and duration


on dialysis (p = 0012) were the most significant predictors
of OH in our study population. Statistically significant
values are highlighted in bold.

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.

2012 Blackwell Publishing Ltd


Journal of Clinical Nursing, 22, 741748

Managing clinical issues

BCM in CAPD

Table 4 Association between patient characteristics and severity of


overhydration (OH)
<2 l OH
(n = 17)
Age (years)
Male
Female
Height (m)
Weight (kg)
Body mass
index (kg/m2)
Duration (months)
Blood pressure
(mm Hg)
Systolic
Diastolic
Mean
overhydration (l)
Albumin (g/l)
Kt/V
Ultrafiltration
(ml/day)
Number of
antihypertensive
agent
ECW (l)
ECW/TBW
ECW/height (l/m2)
Lean tissue
mass (kg)
Fat tissue mass (kg)

 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

While others have demonstrated that high transporters


tended to be hypertensive, our analysis did not reach statistical significance (Lausevic et al. 2006). This is because of
the small numbers of high transporters in our cohort and
the fact that BP was controlled with multiple, possibly
newer and more efficacious antihypertensive agents. On the
other hand, our low transporters had higher serum albumin
levels than high transporters (383 45 vs. 342 45 g/dl,
p = 0048). This is keeping with other studies (Churchill
et al. 1998).
Interestingly, our data showed that men were more overhydrated than women and others have reported this (Tang
et al. 2011). On subanalysis, there were no differences in
BP, duration of PD, BMI, ultrafiltration volume or albumin
between the male and female patients. However, the men
were significantly older (p = 0043) and had a lower Kt/V
than women (p = 0023). Their transporter status was no
different. There were equal numbers of people with diabetes in both groups.
2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 741748

Are the men just not compliant? Or do they have better


residual renal function? Residual renal function was no different between the genders. There was also no relationship
between residual renal function and OH. We did find a correlation (albeit weak) between low serum albumin and OH,
but there was no significant difference in the serum albumin
between men and women. We have already shown a trend
towards OH with low Kt/V, and this could partly explain
the OH in men. As the men were taller and heavier than
the women, they had a significantly higher LTM than the
women. Although lean tissue comprises of water, this is
intracellular, so it would not contribute to the OH. Because
of the significantly higher LTM, the men have higher ICW
compared to the women. Even when the ECW was adjusted
for height (as the men are also taller), the men were still
more overhydrated than the women. The trend in lower
Kt/V may contribute to the OH in men, but we speculate
the other reason for OH is that the men were less compliant
with their fluid and salt restriction compared to women.
We did not specifically study the salt intake of the
patients although they are all advised on a low salt diet on
every clinic visit. Salt intake contributes to fluid overload
(Chen et al. 2007, Ortega & Materson 2011). Majority of
the men were working (which means eating out more),
whereas only about half of the women were working.
These factors may also contribute to the fluid overload in
men (Huang et al. 2011). In this part of the world, there is
an excessive use of monosodium glutamate and salt laden
sauces in the preparation of meals. All the four patients
with known IHD were men. Asymptomatic heart failure
may also contribute to the fluid overload. On further analysis, two other patients had membrane failure and were
awaiting fistula maturation and, both these male patients
were significantly fluid overloaded by 68 and 76 l, respectively. Even when adjusting for these two outliers, the men
were still overhydrated (333 217 vs. 119 180,
p = 0005).
Does a lower Kt/V equate with OH? The women in our
study certainly had a significantly higher Kt/V than the
men. When we look at the two groups <2 l OH and  2 l
OH, again, we notice the difference in Kt/V between the
groups. On univariate analysis with OH, there was a trend
towards significance between lower Kt/V and OH. There
was no significant relationship between residual renal function and OH in our study. Others have shown that reducing residual function is associated with OH (Cheng et al.
2006). On the other hand, there is emerging evidence that
salt and fluid intake contributes more to volume overload
than the decline in residual renal function in CAPD patients
(Cheng et al. 2006).

745

RA Cader et al.

Using 2 l as a cut-off value, those who were  2 l OH


had a higher BP than those with <2 l OH, albeit not significant. However, there was a trend towards a higher use of
antihypertensive agents in patients with  2 l OH. It has
been well established that hypertension is mainly due to
fluid overload in dialysis patients (Wizemann et al. 2009).
However, in our study, we did not find any correlation
between OH and BP. This is because the BP was confounded by the increasing use of antihypertensive agents to
achieve BP control. On univariate analysis, we have shown
the increase in antihypertensive agents to correlate well
with OH. Hence, there is the need to control hypertension
with fluid restriction and lowering dry weight rather than
increasing antihypertensive agents regardless of whether the
patient is clinically oedematous or not.
We found an association between serum albumin and
OH. Similarly, John et al. (2010) have shown that a low
serum albumin is an independent predictor of OH in PD
patients. A low serum albumin is also associated with poor
cardiovascular morbidity and outcomes (Mehrotra et al.
2011). The largest BCM study to date (Euro BCM)
reported that majority of PD patients were fluid overloaded
(Van Biesen et al. 2011). Predictors of OH include lower
serum albumin, lower BMI, male gender, diabetes, higher
systolic BP and the use of at least one exchange per day
with the highest hypertonic glucose (Van Biesen et al.
2011). Our study findings are similar in terms of serum
albumin and male gender. However, we were unable to
demonstrate the BP effect because of the high usage of
antihypertensive agents. None of our patients were on the
highest hypertonic glucose solution.
Studies have shown malnutrition to be associated with
OH (Tinroongroj et al. 2011). Malnutrition inflammation
syndrome can contribute to a change in peritoneal permeability leading to high peritoneal membrane transport, peritoneal albumin loss and decrease in ultrafiltration volume.
This will inevitably lead to fluid overload. We noted that
our high transporters tended to have a lower serum albumin and are probably suffering from relative malnutrition
(p = 0052). There was also an inverse relationship between

albumin and OH. Our study supports Tinroongroj et al.


(2011) that malnutrition is associated with OH. On multivariate analysis with OH, serum albumin, gender, number
of antihypertensive agents used and duration on dialysis
were the most significant predictors of OH in our study
population.
There is evidence that icodextrin improves ultrafiltration
and fluid overload in PD patients (Takatori et al. 2011).
The mean ultrafiltration volume in our patients is commendable. None of our patients were on icodextrin because
of the expense. Our study has some limitations in that the
numbers were small, and there were few patients with diabetes or high transporter status. We did not look into the
cardiac assessment of these patients, but most of our PD
patients were young, non-diabetic and gainfully employed.
Hence, cardiac disease was not an immediate concern.
In conclusion, patients on PD are more overhydrated than
by our clinical assessment. Important predictors of OH are
a low serum albumin, male gender, high usage of antihypertensive agents and longer duration on PD. Blood pressure
should be controlled by the adjustment of dry weight
through fluid and salt restriction, rather than increasing
antihypertensive agents even in the absence of clinical
oedema. BCM is a simple, reliable and inexpensive tool that
can complement our clinical assessment in the outpatient
clinical practice. BCM device is small and can be carried
around by PD nurses during home visits to adjust the dry
weight of patients in between nephrologist assessments.

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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