Utilização da bioimpedância multifrequencial na determinação do estado de hidratação e seu impacto em desfechos intermediários em diálise peritoneal
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2021-08-27
Autores
Costa, Fabiana Lourenço [UNESP]
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Universidade Estadual Paulista (Unesp)
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INTRODUÇÃO: Hiperidratação é comum nos pacientes com doença renal crônica tratados por diálise peritoneal (DP) e possui associação com o risco de morte cardiovascular. A avaliação da água corporal e de sua distribuição é um dos principais desafios no acompanhamento desses pacientes. A bioimpedância multifrequencial (BIAMULT), pelo monitor de composição corporal BCM (Fresenius Medical Care®), é uma das ferramentas que têm sido propostas para determinação da água corporal em pacientes dialíticos. Dessa forma, objetivou-se avaliar a BIAMULT como ferramenta complementar de controle hídrico em DP e seu impacto sobre desfechos intermediários cardiovasculares e inflamatórios, comparado ao controle baseado apenas na avaliação clínica associada à bioimpedância unifrequencial (BIAUNI). CASUÍSTICA E MÉTODOS: Estudo randomizado controlado de intervenção, em pacientes adultos prevalentes em DP, com seguimento de nove meses. Os pacientes foram divididos em dois grupos: CONTROLE e BIAMULT. A partir dos prontuários, foram obtidos dados demográficos, clínicos e dialíticos. Foram avaliados BIAUNI e BIAMULT, parâmetros laboratoriais, monitorização da pressão arterial de 24 horas, eletrocardiografia, ecocardiografia e velocidade de onda de pulso (VOP). No grupo BIAMULT, os dados de BIAMULT foram disponibilizados à equipe médica e puderam ser utilizados como base para prescrição. Os dados da BIAMULT não foram disponibilizados no grupo CONTROLE. RESULTADOS: Um total de 34 pacientes completaram os nove meses de seguimento, 17 pacientes em cada grupo. Houve diferença significante entre os grupos quanto ao controle hídrico, sendo que ao final do estudo o grupo BIAMULT apresentou maior proporção de pacientes com a relação do índice de hiperidratação pela água extracelular (OH/AEC%) ≤15% quando comparado ao grupo CONTROLE (94,1% vs 52,9%; p = 0,007). Houve diferença significante entre os grupos CONTROLE e BIAMULT quanto ao OH (2,1 ± 1,6 vs 0,9 ± 1,1 L; p = 0,019) e OH/AEC% (11,8 ± 8,9 vs 5,0 ± 7,1 %; p = 0,025) no momento final do estudo. O grupo CONTROLE apresentou aumento significante da concentração do fator de necrose tumoral alfa (TNF-α) entre os momentos inicial e seis meses [11,9 (6,0 - 24,1) vs 44,7 (9,4 - 70,6) pg/ml; p = 0,011] e inicial e nove meses [11,9 (6,0 - 24,1) vs 39,4 (27,9 - 62,6) pg/ml; p = 0,013], bem como do fragmento N-terminal do peptídeo natriurético tipo B (NT-proBNP) entre o momento inicial e nove meses [239 (171,5 - 360,5) vs 356 (219 - 1555) pg/ml; p = 0,027]. Quanto aos parâmetros cardiovasculares, no grupo BIAMULT, houve redução significante da VOP radial [7,7 (6,9 - 9,2) vs 6,5 (5,5 - 8,4) m/s; p=0,012] e do débito cardíaco (5,5 ± 0,6 vs 4,9 ± 0,6 L/min; p = 0,015) em nove meses. No grupo CONTROLE, houve aumento significante da pressão arterial sistólica média central (106,8 ± 11,2 versus 117,6 ± 16,5 mmHg; p = 0,009) e da pressão arterial diastólica central (90,4 ± 9,8 versus 103,3 ± 12,5 mmHg; p=0,003) em nove meses. Em contrapartida, houve redução significante da massa ventricular esquerda (MVE) (204,5 ± 64,4 versus 190,4 ± 69,7 g; p = 0,028) e da MVE indexada pela altura (52,0 ± 15,0 versus 48,0 ± 16,0 g/m2,7; p = 0,011) nesse grupo. Quanto à MVE indexada pela superfície corpórea, houve redução significante no grupo CONTROLE (109,6 ± 30,8 versus 101,2 ± 28,9 g/m²; p = 0,010), assim como no grupo BIAMULT (107,7 ± 24,9 versus 96,1 ± 27,0 g/m²; p = 0,030) aos nove meses. CONCLUSÕES: Os resultados sugerem que a BIAMULT é superior como método auxiliar à avaliação clínica associada à BIAUNI quanto ao controle hídrico de pacientes em DP.
INTRODUCTION: Overhydration is common among patients with chronic kidney disease undergoing peritoneal dialysis (PD), and it is associated with greater risk of cardiovascular death. The assessment of body water and its distribution is one of the main challenges in clinical monitoring of these patients. Multifrequency bioimpedance (BIAMULT) using the body composition monitor BCM (Fresenius Medical Care®), is one of the tools have been proposed to estimate the body water in dialysis patients. Thus, our objective was to evaluate the BIAMULT as a complementary tool of fluid control in PD and its impact on intermediate cardiovascular and inflammatory outcomes, compared to control based only on clinical assessment associated with unifrequency bioimpedance (BIAUNI). MATERIALS AND METHODS: We performed a randomized controlled study of intervention in adult patients prevalent in PD, with a nine-month follow-up. Patients were divided into two groups: CONTROL and BIAMULT. Demographic, clinical and dialysis data were collected from the medical records. BIAUNI and BIAMULT, laboratory parameters, 24-hour blood pressure monitoring, electrocardiography, echocardiography and pulse wave velocity (PWV) were evaluated. In BIAMULT group, the BIAMULT data were made available to the medical team and could be used as a basis for prescribing. BIAMULT data were not made available in the CONTROL group. RESULTS: A total of 34 patients completed the nine-month follow-up, 17 patients in each group. There was a significant difference between the groups regarding the parameters of hidration control, and at the end of the study the BIAMULT group had a greater difference in patients with the ratio of overhydration (OH) by extracellular water (OH/ECW%) ≤ 15% when compared to the group CONTROL (94,1% vs 52,9%; p = 0.007). There was a significant difference between the CONTROL and BIAMULT groups regarding OH (2,1 ± 1,6 vs 0,9 ± 1,1 L; p = 0,019) and OH/ECW% (11,8 ± 8,9 vs 5,0 ± 7,1%; p = 0,025) at the end of the study. The CONTROL group has a significant increase in the tumor necrosis factor alpha (TNF-α) concentration between baseline and six months [11,9 (6,0 - 24,1) vs 44,7 (9,4 - 70,6) pg/ml; p = 0,011] and baseline and nine months [11,9 (6,0 - 24,1) vs 39,4 (27,9 - 62,6) pg/ml; p = 0,013], as well as the N-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP) between baseline and nine months [239 (171,5 - 360,5) vs 356 (219 - 1555) pg/ml; p = 0,027]. For cardiovascular parameters, in BIAMULT group, there was a significant reduction in radial PWV [7,7 (6,9 - 9,2) vs 6.5 (5,5 - 8,4) m/s; p = 0,012] and cardiac output (5,5 ± 0,6 vs 4,9 ± 0,6 L/min; p = 0,015) at nine months. In the CONTROL group, there was a significant increase in mean central systolic blood pressure (106,8 ± 11,2 vs 117,6 ± 16,5 mmHg; p = 0,009) and in central diastolic blood pressure (90, 4 ± 9,8 vs 103,3 ± 12,5 mmHg; p = 0,003) at nine months. On the other hand, there was a significant reduction in left ventricular mass (LVM) (204,5 ± 64,4 versus 190,4 ± 69,7 g; p = 0,028) and in indexed for height LVM (52,0 ± 15,0 versus 48.0 ± 16,0 g/m2,7; p = 0,011) in this group. As for the LVM indexed by body surface, there was a significant reduction in the CONTROL group (109,6 ± 30,8 vs 101,2 ± 28,9 g/m²; p = 0,010), as well as in the BIAMULT group (107,7 ± 24,9 vs 96,1 ± 27,0 g/m²; p = 0,030) at nine months. CONCLUSIONS: The results obtained that a BIAMULT is superior as an auxiliary method to the clinical evaluation associated with BIAUNI regarding the fluid control of patients on PD.
INTRODUCTION: Overhydration is common among patients with chronic kidney disease undergoing peritoneal dialysis (PD), and it is associated with greater risk of cardiovascular death. The assessment of body water and its distribution is one of the main challenges in clinical monitoring of these patients. Multifrequency bioimpedance (BIAMULT) using the body composition monitor BCM (Fresenius Medical Care®), is one of the tools have been proposed to estimate the body water in dialysis patients. Thus, our objective was to evaluate the BIAMULT as a complementary tool of fluid control in PD and its impact on intermediate cardiovascular and inflammatory outcomes, compared to control based only on clinical assessment associated with unifrequency bioimpedance (BIAUNI). MATERIALS AND METHODS: We performed a randomized controlled study of intervention in adult patients prevalent in PD, with a nine-month follow-up. Patients were divided into two groups: CONTROL and BIAMULT. Demographic, clinical and dialysis data were collected from the medical records. BIAUNI and BIAMULT, laboratory parameters, 24-hour blood pressure monitoring, electrocardiography, echocardiography and pulse wave velocity (PWV) were evaluated. In BIAMULT group, the BIAMULT data were made available to the medical team and could be used as a basis for prescribing. BIAMULT data were not made available in the CONTROL group. RESULTS: A total of 34 patients completed the nine-month follow-up, 17 patients in each group. There was a significant difference between the groups regarding the parameters of hidration control, and at the end of the study the BIAMULT group had a greater difference in patients with the ratio of overhydration (OH) by extracellular water (OH/ECW%) ≤ 15% when compared to the group CONTROL (94,1% vs 52,9%; p = 0.007). There was a significant difference between the CONTROL and BIAMULT groups regarding OH (2,1 ± 1,6 vs 0,9 ± 1,1 L; p = 0,019) and OH/ECW% (11,8 ± 8,9 vs 5,0 ± 7,1%; p = 0,025) at the end of the study. The CONTROL group has a significant increase in the tumor necrosis factor alpha (TNF-α) concentration between baseline and six months [11,9 (6,0 - 24,1) vs 44,7 (9,4 - 70,6) pg/ml; p = 0,011] and baseline and nine months [11,9 (6,0 - 24,1) vs 39,4 (27,9 - 62,6) pg/ml; p = 0,013], as well as the N-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP) between baseline and nine months [239 (171,5 - 360,5) vs 356 (219 - 1555) pg/ml; p = 0,027]. For cardiovascular parameters, in BIAMULT group, there was a significant reduction in radial PWV [7,7 (6,9 - 9,2) vs 6.5 (5,5 - 8,4) m/s; p = 0,012] and cardiac output (5,5 ± 0,6 vs 4,9 ± 0,6 L/min; p = 0,015) at nine months. In the CONTROL group, there was a significant increase in mean central systolic blood pressure (106,8 ± 11,2 vs 117,6 ± 16,5 mmHg; p = 0,009) and in central diastolic blood pressure (90, 4 ± 9,8 vs 103,3 ± 12,5 mmHg; p = 0,003) at nine months. On the other hand, there was a significant reduction in left ventricular mass (LVM) (204,5 ± 64,4 versus 190,4 ± 69,7 g; p = 0,028) and in indexed for height LVM (52,0 ± 15,0 versus 48.0 ± 16,0 g/m2,7; p = 0,011) in this group. As for the LVM indexed by body surface, there was a significant reduction in the CONTROL group (109,6 ± 30,8 vs 101,2 ± 28,9 g/m²; p = 0,010), as well as in the BIAMULT group (107,7 ± 24,9 vs 96,1 ± 27,0 g/m²; p = 0,030) at nine months. CONCLUSIONS: The results obtained that a BIAMULT is superior as an auxiliary method to the clinical evaluation associated with BIAUNI regarding the fluid control of patients on PD.
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Palavras-chave
Diálise peritoneal, Doença renal crônica, Bioimpedância elétrica, Doença cardiovascular, Hiperidratação, Inflamação, Peritoneal dialysis, Chronic kidney disease, Bioelectrical impedance, Cardiovascular disease, Overhydration, Inflammation