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Background Patients with end-stage renal disease are exposed to extreme volume shifts and thereby cardiovascular strain as a consequence of interdialytic weight gain, fluid removal during hemodialysis and also chronic fluid overload. In long-term hemodialysis patients, higher IDWG (interdialytic weight gain) is associated with poor survival and increased cardiovascular death. Patients with the lowest interdialytic fluid retention have the greatest survival. It was found that increased interdialytic volume load is associated with increased both LVMI and FGF-23 level. Objective To evaluate correlation between hypervolemia, left ventricular hypertrophy and FGF-23 in prevalent hemodialysis patients. Patients and Methods This cross sectional study was conducted in Ain shams university hospital and Al Agoza hospital, on 60 prevalent hemodialysis patients.Three patient died during the study. Results FGF-23 had a positive correlation with (weight gain, (PO4)3-, PTH, IVS, PW and LVMI). Conclusion FGF-23 might be a marker of volume overload and LVH in ESRD patients, as it positively correlated with (weight gain, IVS, PW and LVMI). FGF-23 is a marker of bone diseases, as it positively correlated with (PO4)3- and PTH. Volume overload has a negative impact on morbidity and mortality in ESRD patients.

Background The changes in loading conditions, atrial function, and the different echocardiographic parameters before and after transcatheter atrial septal defect (ASD) closure are still under study. So we felt the need to evaluate the echocardiographic changes that occur and detect the timing after closure at which the right-sided heart hemodynamics, and measurements are back to normal. Objectives To evaluate the changes in cardiac hemodynamics, loading conditions, and atrial function after percutaneous closure of ASD using echocardiography. Patients and Methods The study included 30 patients referred to percutaneous closure of ASD in Ain Shams University hospital we performed echocardiography before, 1 week, and 3 months after closure. Results The study showed that RV dimensions and volumes decreased significantly 1 week, and 3 months after ASD closure (p Conclusion In our study, we have concluded that RV dimensions and volumes decreased significantly 1 week, and 3 months after ASD closure. RA dimensions and volumes decreased significantly 1 week, and 3 months after ASD closure. RA peak systolic strain, and strain rate increased significantly 1 week, and 3 months after ASD closure, as a result of improvement of the RA wall velocity, due to relief of the volume overload after closure of the shunt. LA peak systolic strain, and strain rate showed no significant difference before, 1week, and 3 months after ASD closure. Abbreviations list ASD (atrial septal defect), RV (right ventricle), RA (right atrium), LA (left atrium).

Background Volume overload is considered as an important clinical problem in end stage renal disease patients. It is associated with morbid situations such as pulmonary hypertension and lung congestion. Aim of the Work to assess the effect of increased the patient weight between haemodialysis sessions that is known as interdialytic weight gain (IDWG) on pulmonary hypertension using Echocardiography (Echo) and lung congestion using lung ultrasound (LUS) in two groups: First group with IDWG < 3.5% of their dry weight while Second group with IDWG > 3.5% of their dry weight, compare between the two groups and to detect statistically the effects of IDWG & ultrafiltration on PAP and lung congestion. Patients and Methods This observational cross sectional study was conducted at on 60 patients who have end stage kidney disease &are currently on haemodialysis at Nasser Institute Hospital: 30 patients with an IDWG < 3.5% and 30 patients with an IDWG > 3.5% of their dry weight. Pulmonary artery pressure was measured by echo and patients classified according to PAP into mild, moderate and severe pulmonary hypertension. Lung congestion in all patients was measured by lung ultrasound and patients classified into minimal, mild, moderate and severe lung congestion. Results Our study showed that pulmonary hypertension prevalence was 30% while lung congestion was 100%. pulmonary hypertension pathophysiology includes acute and chronic processes and HD therapy alone is not effective in complete treatment of pulmonary hypertension and require medical treatment. Patients with increased IDWG > 3.5% (group 2) had pre HD higher PAP than those with IDWG < 3.5% (group 1) and patients with IDWG > 3.5% had more change in their PAP post HD session than those with IDWG < 3.5% but no significant difference between the change after the HD session in both groups. HD duration is an important factor in PH development over years. There is a significant relation anemia and hypercalcemia with PH. Patients with more increased IDWG > 3.5% (group 2) had higher pulmonary congestion than those with IDWG < 3.5% (group 1) and patients with IDWG < 3.5% had more change in their lung congestion level after the HD session than those with IDWG > 3.5% but no statistical significance between the change in both groups. There was a significant relation between HD therapy duration with pulmonary congestion measured prior to the session. Conclusion on the short term increased IDWG% affect lung congestion more than pulmonary hypertension.

Background and Aims Assessment of volume status is an important prognostic factor in hemodialysis (HD) patients. Several methods have been suggested to estimate it: bioimpedance analysis, brain natriuretic peptide levels (BNP) and lung and inferior vena cava (IVC) ultrasonography (US), which are emerging as a valuable technique in this field. Our aim was to evaluate effectiveness of lung US in assessment of volume status in chronic HD patients and compare it with the gold standard bioimpedance technique. Method Cross-sectional study of 58 prevalent HD patients. Several analytical data were analyzed, including BNP, albumin and sodium levels. Lung and IVC US were performed to assess the presence and distribution of B-lines and the diameter and respiratory collapsibility of IVC, respectively. Fresenius® body composition monitor (BCM) was the bioimpedance technique used. It defines hyperhydration as relative fluid overload (RFO) >15%. Both US and BCM were performed at the same day, immediately before the middle week HD session. Categorical variables are presented as frequencies and percentages, continuous variables as means and standard deviations, or medians and interquartile ranges (IQR) for variables with skewed distributions. Statistical analysis was performed using SPSS® version 25 for Windows. Results The average age was 75.3±1.6 years and 56.9% were male. The average time in HD was 36.6±4.1 months. Half of the patients (n=29) presented B-lines in lung US. The diameter of IVC was significantly higher in this group of patients, both inhaling (1.3±0.4 vs 0.9±0.4; p=0.001) and exhaling (2.0±0.4 vs 1.6±0.5; p Although not statistically significant, the RFO was higher in patients with presence of B-lines compared to those who did not present it (10.2±10.6% vs 5.4±6.9%; p=0.061). Considering the mean RFO value in patients with B-lines, we observed that its presence was significantly higher in patients with RFO > 10% compared to those with RFO < 10% (58.6% vs 31%; p=0.035). Besides, patients with RFO > 10% also presented higher BNP (9878±34646 pg/mL vs 3945±8634 pg/mL; p=0.009) and lower albumin levels (3.4±0.5 vs 3.7±0.4; p= 0.039) than other group. Conclusion Lung US seems to be a valuable tool to diagnose overhydration earlier than BCM, which currently defines hyperhydration as RFO >15%. In this study we verified that patients with lower levels of RFO (>10%) already presented signals of fluid overload, such as presence of B-lines at lung US, higher BNP and lower albumin levels. These findings support the benefit of lung US in guiding fluid removal and may change the practice in our HD unit to probe the ideal dry weight for chronic dialysis patients.

Background and Aims Continuous Renal Replacement Therapy is required in 2.6% to 5% of patients who have undergone cardiovascular surgery. Although its implementation is frequent, several aspects of this therapeutic measure still remain uncertain. Method The data of all patients who were surgically treated during a 3-year period (2017-2019) at a single cardiovascular department were collected and the cases in which continuous renal replacement therapy was used were identified. From this group, the data of those that received dialysis for the first time were analyzed. Results In about 5% of patients renal replacement was inevitable, and the mortality rate among them reached 57.6%. The mean duration of renal therapy was 8.4 days. The investigation of laboratory parameters in different stages revealed certain aspects about the expected outcomes. The survival rate varied significantly in relation to the indication for CRRT. Fluid overload and electrolytic disorders were associated with high survival rate, while oliguria or anuria, acidosis or intoxications were linked to increased mortality rate. Conclusion Despite CRRT being associated with high mortality rates, it is the only option for life-threatening conditions in clinical practice. The indication for CRRT is a key factor for the prognosis, decision-making and the overall management of a patient.

Aims To investigate the effects of adequate reactions to telemedicine alerts triggered by fluid index threshold crossings (FTC) on clinical outcomes in the OptiLink HF trial. Methods We separated adequate from inadequate reactions to FTC transmissions in patients with remote impedance-based monitoring (RM) of fluid status in the OptiLink HF trial. Adequate contacts had to meet the following criteria: i) initial telephone contact within 2 working days after FTC transmission, ii) follow-up contacts according to study protocol, and iii) medical intervention initiated after FTC due to true fluid overload. We compared time to cardiovascular (CV) death or heart failure (HF) hospitalization and all CV- and HF-hospitalizations at follow-up between RM patients contacted adequately or inadequately and patients with usual care (UC). Results In the RM group, transmission of at least one FTC alert occurred in 356 patients (70.5%; n=505). While 113 patients (31.7%; n=356) have been contacted adequately after every FTC, in 243 patients (68.3%; n=356) at least one FTC was not responded by an adequate contact. Adequate responses to RM significantly reduced risk of the primary endpoint (hazard ratio (HR), 0.68; 95% confidence interval (CI) 0.48–0.95; p=0.025, figure 1), and led to a significantly lower number of CV (52.1±7.5 vs. 99.9±19.8; p=0.007) and HF hospitalizations per 100 patient years when compared with UC (26.1±4.4 vs. 67±15.2; p=0.007). Conclusion RM with adequate reactions to FTC alerts significantly reduced total number of both CV and HF hospitalizations and improved clinical outcomes in patients with advanced HF and implantable cardioverter defibrillator (ICD). Funding Acknowledgement Type of funding source: None

Introduction The Fontan circulation is successful in abolishing cyanosis and chronic volume overload in congenital heart disease (CHD) patients with single ventricle physiology. “Fontan failure” is a major cause of poor quality of life and mortality in these patients. Recently, pulmonary arterial hypertension (PAH) therapies have been used in Fontan patients with variable success, even though patients included in these studies are generally at the best end of the spectrum. Aim To assess contemporary patterns of PAH therapy in Fontan patients in large specialist CHD centres. Methods We identified all adult patients with a Fontan-type circulation under active follow-up in 8 specialist CHD centres between 2009 and 2019. Patients on PAH therapies were matched by age and gender to untreated patients (1:1 or 1:2). Baseline data were collated immediately prior to initiation of therapy (treated group) or from a synchronous routine clinical assessment (untreated group). Results During the study period, 70 Fontan patients were started on PAH therapy (6.5% of those under follow-up). The majority 63 (90.0%) were started on monotherapy with a phosphodiesterase-5 (PDE5) inhibitor, 6 (8.6%) patients were started on an endothelin receptor antagonist (ERA) and 1 (1.4%) received early sequential therapy with a PDE5 inhibitor and ERA. Prostacyclin analogues were not used, and no patients received triple therapy. Overall, 51 (72.9%) patients started therapy electively (49% in outpatient clinic, 51% as day case admission), while 18 (25.7%) were treated following urgent hospital admission with fluid overload +/− acute kidney injury. The remainder (2,2.9%) started therapy following cardiac surgery. Adverse events during treatment were rare. Patients starting PAH therapy were matched to 112 untreated patients (table 1). Patients were well matched between groups for age (p=0.52) and sex (p=0.27). Treated patients were more likely to be significantly impaired than matched patients (56.7% vs. 8.6% in NYHA class III/IV, p Conclusion A small minority of Fontan patients followed in specialist centres receive PAH therapies. PAH therapy was reserved in most centres for patients with more advanced disease, targeting predominantly those with a “failing Fontan” in an individualised approach, in line with the recent adult CHD American Heart Association (AHA) guidelines. Further studied are needed to establish the role of PAH therapies in Fontan patients, provided that adult patients with advanced disease who are at increased risk of adverse outcome are included. Figure 1 Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Dr Constantine received an educational grant from Actelion Pharmaceuticals, a Janssen company of Johnson & Johnson, which helped to pay for travel for data collection.

Background and Aims Refilling volume had not been a measurable parameter in clinical practice so far, because the knowledge of absolute blood volume (BV) is necessary. Recently, we developed a simple method to determine absolute BV, thus enabling quantification of the refilling volume. The overnight dialysis is particularly suitable for studying the refilling process due to negligible external influences and the extended treatment time. Method At the beginning of the dialysis (t=0), before starting the ultrafiltration (UF), a defined online bolus of 240 ml dialysate was infused by pressing the emergency button on the haemodiafiltration (HDF) machine (5008, FMC). The subsequent increase in relative BV (RBVpost-RBVpre) was measured with the integrated BV monitor, and absolute BV at t=0 was calculated: absolute BV in ml = bolus volume 240 ml x 100% / increase in relative BV in%. Absolute BV at any other time t was calculated as: Vt = V0 x RBVt (in %) / 100 At constant UF rate refilling volume (Vref) is given for every hour (h) as: Vref h = UFV h – drop in absolute BVh (beginning – end) The refilling fraction is expressed as refilling/UF ratio: Ref% = Vref/UFV x 100, in % Before treatment, volume overload was evaluated by bioimpedance spectroscopy (BIS) using the body composition monitor (FMC). Results Refilling volume and refilling fraction were studied in 10 stable chronic haemodialysis (HD) patients during an extended (7 hour) nocturnal HD session. Specific BV at treatment start was 74.9 ± 11.8 mL/kg and dropped to 68.6 mL/kg at dialysis end. The constant UF rate was set to 406 ± 120 mL/h (specific UF rate 4.81 ± 1.83 mL/kg/h). In the first hour refilling volume amounted only to 23% of UF volume. Refilling fraction reached its maximum in the 2nd, 3 rd and 4th hour at about mean 90% (91.5%, 88.7%, and 91.1% respectively) of UF volume. From the 5th hour on, refilling volume and refilling fraction decreased (5th hour 81.3%, 6th hour 72.5%, and 7th hour 70.0% of UF volume). In the 5th hour, cumulative UF volume exceeded volume overload (1.1 ± 1.0 L) measured by BIS in 9 of 10 patients. Refilling fraction cumulatively increased up to the 4th hour. Thereafter, cumulative ratio remained constant at 70 – 75% due to the decrease in refilling volume. This did not change during the further course of dialysis. Cumulative refilling volume showed a strong correlation (r2 = 0.88; p Conclusion After the first hour, when sufficient refilling takes place, refilling volume is in a stable ratio of approximately 90 % of UF volume. Refilling is low in the first hour, and, therefore, refilling volume amounted cumulatively only about 70 to 75% of UF volume during usual dialysis duration. Thereby, absolute BV will be reduced by approximately 250 to 300 ml per liter UF. This must be taken into account in volume management in order to avoid intradialytic complications. As expected, refilling decreases when volume overload in the interstitial space is removed. Due to the reduced refilling, there will be an additional gap in BV.

Background and Aims One of the major symptoms of severe nephrotic syndrome is fluid retention. Fluid overload can induce cardiovascular damage. NT-proBNP (N-terminal pro-brain natriuretic peptide) and hsTnT (high sensitivity troponin T) are well known markers of this disorder. The aim of the study was to evaluate the association between volumes of body water compartments and markers of cardiovascular damage in patients with severe nephrotic syndrome (SNS) defined as nephrotic range proteinuria and hypalbuminaemia ≤ 2.5 g/dl. Method 40 patients with SNS and eGFR >30 ml/min/1.73m2 formed the study group (SNSG) and 40 healthy volunteers without SNS matched according to age, sex, height, body mass and kidney function formed the control group (CG). In all participants serum creatinine, serum albumin concentration, daily proteinuria, hsTnT and NT-proBNP were measured. Body water compartments such as extracellular water (ECW), intracellular water (ICW), total body water (TBW), overhydration (OH) were assessed using Body Composition Monitor, Fresenius Medical Care. For statistical analysis Spearman’s correlation coefficients, chi2 or Mann-Whitney U tests were used (Statistica v 13.1). Results SNSG included 28 males (70%) and 12 females. Median age was 55 years (IQR 30-65), the mean daily proteinuria was 10.5 ±5.0 g. The characteristics of the study parameters in two groups are described in the table. Significantly higher hsTnT (18 vs 6 ng/l, p=0.0001) and NT-proBNP (294.8 vs 47.1 pg/ml, p=0.0003) levels were observed in the severe nephrotic syndrome group in comparison (SNSG) to CG. In SNSG extracellular water was significantly higher (20.9 ±5,2 vs 17.4 ±3.3 L, p=0.001) and intracellular water (ICW) was significantly lower (18.9 ±5.2 vs 21.4 ±4.8 L, p=0.034) in comparison to CG. Interestingly total body water (TBW) did not differ between the groups (39.8 ±8.6 vs 38.8 ±7.7 L, p=0.603). Also overhydration which is a derivative of ECW, was higher in SNSG (OH: 4.2 vs 0.3 L, p Conclusion In the severe nephrotic syndrome group fluid retention was associated with the increase in ECW and the decrease in ICW whereas TBW was the same in both groups. Such constellation can indicate for intracellular underhydration which was not describe so far. Overhydration, which is a derivative of ECW, positively correlated with markers of cardiovascular damage and can be important for patients with resistant SNS and can influence their prognosis.

Background and Aims Peritoneal protein loss (PPL) in peritoneal effluent is a well-recognised detrimental result of peritoneal dialysis treatment since its inception. Hydrostatic convection is a major drive for peritoneal protein transport; therefore venous congestion may have a role in peritoneal protein loss (Krediet RT et al Perit Dial Int. 2019 ). The aim of this study was to explore the importance of overhydration on the magnitude of peritoneal protein clearance in incident PD patients. Method A total of 97 adult incident PD patients were included. A standard peritoneal equilibration test, 24-hour urine and dialysate collection, and multifrequency bioimpedance analysis were performed. Independent-samples t test and Pearson correlation coefficient were performed to evaluate relevant clinical associations and linear multivariable regression was done. Results Statistically significant univariable relationships for 24h PPL were found for continuous ambulatory PD technique (CAPD) and, with a correlation coefficient >0.20, for age, pulse pressure, 4-hour dialysate/plasma creatinine and extracellular water/total body water. On multivariable analysis, type of PD technique (β=0.327, p=0.011), 4-hour dialysate/plasma creatinine (β=0.247, p=0.037), and extracellular water/total body water (β=0.304, p=0.016) were significant independent predictors of peritoneal protein loss. Conclusion Overhydration revealed the most important connection with peritoneal protein loss. Mortality has been associated with PPL in some studies, but not others. This could be a result of this relationship, as volume overload has been strongly related with lower survival.

Background and Aims Fluid overload is associated with increased morbidity and mortality in hemodialysis (HD) patients. In-patient treatment of fluid overload was previously estimated to occur at a rate of 13.7 episodes/100 patient-years and estimated to cost $266 million over a 2.5-year period (Arneson 2010). We developed a model to predict which patients treated at a large dialysis provider are at imminent risk of hospitalization due to fluid overload and may benefit from additional interventions. Method We built a machine learning (ML) model using clinical and HD treatment data to identify which patients have the highest risk of hospital admission for fluid overload within 7 days of the current outpatient dialysis treatment. Next, we partnered with a team of remote nurses who perform chart reviews, needs identification, and communication outreach when warranted with the goal to reduce hospital admissions. Patients were identified from the ML model and displayed in a worklist on a computer dashboard, ranked by their risk score on that day. The computer dashboard also contained relevant clinical information to enhance the patient review process. Results Model results from prospective data (> 9M predictions in a two-month period) show the model has an area under the receiver operating curve (AUROC) of 0.79, sensitivity of 65%, and specificity of 78% (Figure 1). Weekly chart reviews increased 18% from 26 weeks before the pilot compared to 14 weeks after the pilot began; total communication outreach increased 31% across the same time frame. Further, the nurses using the dashboard anecdotally reported that the dashboard reduced the amount of time required to decide to perform a chart review or perform communication outreach. Conclusion Our predictive model successfully identifies patients at high risk for fluid overload hospital admissions. Understanding the nurse workflow, how they manage this patient population, and which components can be made more efficient enabled them to increase the number of chart reviews and communication outreach.

Background and Aims Assessment of optimal hydration status in patients with end-stage renal disease (ESRD) on peritoneal dialysis (PD) is a challenge. Multiple diagnostic options to determine hydration status in PD patients are available. Multifrequency bioimpedance spectroscopy (MBIS) is a cheap, simple and non-invasive method of estimating body composition, including estimates of total body water (TBW), extracellular water (ECW), intracellular water (ICW) and the ratio between both spaces (ECW/ICW). Lung ultrasonography (LUS) and lung B-lines (lung comets) can be used for the evaluation of extravascular lung water. Ultrasound evaluation of inferior vena cava (UIVC) provides rapid, non-invasive assessment of a patient's hemodynamic and volume status. N-terminal pro-brain natriuretic peptide (NT-proBNP) is related to fluid status and fluid distribution. The aim of our study was to assess fluid status in PD patients comparing four different methods: MBIS, LUS, UIVC and NT-proBNP. Method We performed a single-centre cohort study in 19 PD patients. The body composition was measured using the portable whole-body MBIS device, Body Composition Monitor-BCM(®) (Fresenius Medical Care, Bad Homburg, Germany), LUS with portable US device (VScan, General Electrics Corporate), UIVC index with SonoSite US device. NT-proBNP was measured in a one-step sandwich chemiluminescent immunoassay (Dimension Vista® System 1500, Siemens Healthcare Diagnostics Inc., Newark, NJ, USA). Results The mean age of patients was 54 ± 10 years, mean dialysis vintage 53 (10-194) months, 63% were men. Thirteen (68.4%) patients had fluid overload (FO) > 1.1 L. Data of patients are presented in table 1. We found a statistically significant correlation between the number of lung comets and ECW/ICW ratio (r = 0.496, P = 0.031) and NT-proBNP (r = 0.759, P < 0.0001). In contrast, there was no significant correlation between the number of lung comets and UIVC (r = 0.221, P < 0.364). Conclusion According to our results, LUS with lung comets, MBIS with ECW/ICW ratio and NT-proBNP are useful and complementary methods for evaluation of fluid status in PD patients.

Background and Aims Hyponatremia in dialysis patients is a strong indicator of poor outcome in dialysis patients that requires early detection to facilitate clinical workup and management. However, plasma sodium concentration as determined by lab methods (Na-Lab) is measured at the best monthly in clinical practice. Recently, online monitoring of predialytic plasma Na (pPlNa) as estimated from dialysate conductivity using an electrolyte model has become available at every hemodialysis session, thus providing an unprecedented close and almost continuous monitoring of this crucial indicator. This could be used as diagnostic tool to identify changes in patient status and alert earlier the physician. Method In a monocentric retrospective clinical study in 114 patients on maintenance hemodialysis (>90% online postdilution HDF) for whom online pPlNa was available for a period of at least 12 months at least once a week, kinetics of pPlNa were analyzed. For 10 patients with hyponatremic episodes as manifested in pPlNa, the agreement between time course of pPlNa and Na-Lab and the correlation to the manifestation of clinical findings was explored. Results Time course of pPlNa and Na-Lab showed very good agreement. Hyponatremia onset was clinically related to diagnoses such as fluid overload and congestive heart failure, diarrhea secondary to inflammatory bowel disease, sepsis, liver cirrhosis, cancer and use of loop diuretics. Conclusion The clinical examples show that due to the good agreement of the time course of online monitoring of pPlNa and Na-Lab, pPlNa can be used as adjuvant diagnostic tool for the early detection of onset and progression of morbid events. Due to its routine availability variations in pPlNa could be used to timely trigger clinical workup and investigations.

Background and Aims Earlier studies provided considerably variable estimates on the prevalence and control rates of hypertension in hemodialysis because of their heterogeneity in definitions and blood pressure (BP) measurement techniques applied to detect hypertension. Method In the present study, 116 clinically stable hemodialysis patients from 3 dialysis centers of Northern Greece underwent home BP monitoring for 1 week with the validated automatic device HEM-705 (Omron, Healthcare). Routine BP recordings taken before and after dialysis over 6 consecutive sessions were also prospectively collected and averaged. Hypertension was defined as: (i) 1-week averaged home BP ≥135/85 mmHg; (ii) 2-week averaged predialysis BP ≥140/90 mmHg; (iii) 2-week averaged postdialysis BP ≥130/80 mmHg. Participants on treatment with ≥1 antihypertensives were also classified as hypertensives. Results The prevalence of hypertension was 88.8% by home, 86.2% by predialysis and 91.4% by postdialysis BP recordings. In all, 96 participants (82.7%) were being treated with an average of 1.7 antihypertensive medications. Among drug-treated participants, 32.6% were controlled by home, 50.5% by predialysis and 45.3% by postdialysis BP recordings. In multivariate logistic regression analysis, greater use of antihypertensive medications and postdialysis overhydration, assessed with bioimpendence spectroscopy, were both independently associated with higher odds of inadequate home BP control. Conclusion This study shows that epidemiology of hypertension in hemodialysis differs considerably between routine dialysis-unit and home BP recordings. Since greater antihypertensive drug use and postdialysis overhydration appeared to be the major determinants of inadequate home BP control, then management of hypertension should be initially relied on strategies targeting to control volume overload.

Background and Aims Fluid status evaluation is essential to adjust the dry weight(DW) in chronic hemodialysis (HD) patients. Bioelectric impedance is a non invasive technique. Its contribution in HD population is well demonatrated. The aim of this study is to compare evaluation of fluid status clinically and by bioimpedance analysis. Method It’s a transversal study conducted in December 2018.We included chronic dialysis patients( for more 3 months) having 3 dialysis sessions(DS) a week. Bioimpedance analysis (BIA) was performed before and after DS. Results There were 26 patients with an average age of 51,4 years. Sex ratio was 3,33 . Average period spent in HD was 73,7 months. Vascular access was a native arteriovenous fistula in 24 patients, and a catheter in 2 patients. Seven patients had residual diuresis. Average ultrafiltration rate was 2,82 L (10 mL/Kg/h). Before DS, 20 patients had no clinical signs of fluid overload. Unconformity with BIA was noted in 12 patients, with a subclinical overload in all cases. Six patients had clinical signs of fluid overload (including hypertension (HT) in 5 cases), which was concordant with BIA. After DS, 22 patients reached their DW with a correct hydration status, 2 patients still had clinical signs of fluid overload, and 2 had isolated HTA. BIA revealed the persistence of fluid overload in 10 patients contrasting with the absence of clinical signs of hypervolemia in 8 patients. Patients who kept only HT had a normal hydration status. Conclusion Fluid status is an important adequacy issue in the treatment of renal failure. It’s a modifiable risk factor associated to mortality. Bioimpedance analysis is a great help to precise dry weight that must be integrated into our daily practice.

Background and Aims The southern state of India, Kerala was hit by the worst flood in the last century on 16.08.18, due to unprecedented monsoon rains. The Indian government had declared it a Level 3 Calamity. According to the Kerala government, over 483 people died, about a million people were evacuated. This paper describes the experience of the Hemodialysis (HD) unit at Aster Medcity, which was forcibly closed due to floods. The Nephrology department does over 1100 dialysis treatments per month and about 60 kidney transplants per year. Aim To study unexpected shutdown of hemodialysis unit and its effect on maintenance hemodialysis patients. Method This is a descriptive study of forced closure of HD unit due to floods. The sequence of events till shut down after the decision of closure has been retrospectively studied by reviewing the minutes of meetings with chief of medical services and memory recall of the Nephrology team involved in the process. Role of HD nurses during the period of flood was also studied. HD patients were interviewed and impact of floods on them was recorded, including, ability to find an alternate HD unit, any missed HD sessions, access to medicines and admissions in hospital. The characteristics of HD patients was recorded. After reopening of our HD unit, 30days assessment was done for clinical consequences including, hospitalization, infections, vascular access problems and seroconversion. Results The services of HD unit were suspended from midnight 17.08.18 to 27.08.18. The HD unit is at the ground floor of the hospital. The HD unit has 13 HD machines, which were used for 77 maintenance HD patients (Males: 55; Females: 22). The mean age was 61 ±14 years and the median dialysis vintage was 2 years. Vascular access was a catheter (tunnelled and non-tunnelled) in 19 patients, arterio-venous fistula in 57 patients and arterio-venous graft in 1 patient. Patients known to have Diabetes were 77.7%, Hypertension 91%, Coronary artery disease were 26 in number and chronic liver disease were 5. Hospital authorities decided to evacuate the hospital 24 hours before the floods hit the hospital premises. The Nephrology team comprised of 4 consultants, 6 residents, 33 dialysis nurses and technicians and a social worker. The HD unit was closed after draining the reverse osmosis (RO) plant at 10pm on 16.08.18. The lead consultant contacted potentially safe HD units in other parts of the state; willingness for accepting HD patients and the surge capacity of each HD unit was recorded. The HD patients were informed over telephone the centers they can approach and HD summary (includes diagnosis and HD details) was sent to them via e-mail. All HD patients were reminded to comply with diet restrictions and inform the shelter camp regarding the same. Accordingly, 77 HD patients were accommodated in 25 HD units. 12 dialysis nurses provided their services voluntarily at other HD units unaffected by floods. 15 HD patients were displaced from their homes due to floods. 19 HD patients missed one HD session; 5 HD patients missed two HD sessions; 1 patient missed three HD sessions. Our HD unit reopened on 27.08.18 after complete disinfection of the RO plant and servicing of HD machines by the manufacturer. All patients returned to our HD unit. In the first 30 days after floods, 3 patients were admitted to intensive care unit with fluid overload, 3 patients were admitted with respiratory tract infection, 2 patients had an AV fistula dysfunction, 3 patients developed catheter related blood stream infection. There was no seroconversion. There was no mortality in HD patients during and one month after flood. Conclusion The timely decision to suspend dialysis services played a crucial role in preparing for HD unit closure, arranging alternate HD places for patients and providing treatment summaries. However, the increase in adverse clinical consequences heralds the drop in the quality of healthcare services during natural disasters.

Background and Aims The imbalance between UF and refilling rate is considered a major cause for intradialytic hypotension. Recent studies report a feasable and noninvasive method to estimate vascular refilling by determining absolute blood volume. It was the aim of this study to analyze absolute blood volume in a group of haemodialysis patients and to examine vascular refilling volume. Method Thirty stable chronic HD patients were studied (36,7% female, 63,3% male), aged 71,07 ± 13,31 years. Dialysis duration and UF requirements were based on physician prescription. Vascular refilling was calculated as: VREF = VUF – ΔV, where ΔV is the difference between absolute blood volume at the beginning and the end of dialysis. Relative blood volume monitor (BVM) was used. Hemodial Int. 2016;20(3):484–91. Results Absolute blood volume at the beginning of the dialysis was 6,27 ± 2,78 L (92,44 ± 32,66 ml/kg) and at the end 5,83 ± 2,77 L (85,94 ± 30,44 ml/kg). Ultrafiltration (UF) volume was 2,64 ± 0,82 L (11,14 ± 4,02 ml/kg/h). Vascular refilling was calculated as 2,24 ± 0,74 L, with a refilling fraction of 85,33 ± 11,07%. We found a strong correlation between refilling volume and UF volume (r2 0,861) (Figure 1), and a mild correlation between refilling volume and predialysis volume overload (r2 0,529). Conclusion Measurement of absolute blood volume is easy and noninvasive, and it allows us to study refilling volume. We found a strong correlation between UF volume and refilling volume.

Background and Aims Volume overload is considered as an important clinical problem in HD patients. It is associated with morbid situations such as pulmonary hypertension and lung congestion. to assess the effect of increased (IDWG) on pulmonary hypertension, and lung congestion. Method This observational cross sectional study was conducted at on 60 HD patients, that were divided into Group I: 30 patients with an IDWG < 3.5% and, Group II: 30 patients with an IDWG > 3.5% of their dry weight. Pulmonary artery pressure was measured by echo and patients classified according to PAP into mild, moderate and severe pulmonary hypertension. Lung congestion in all patients was measured by lung ultrasound and patients classified into minimal, mild, moderate and severe lung congestion. Results Our study showed that pulmonary hypertension prevalence was 30% while lung congestion was 100%. Patients with increased IDWG > 3.5% (group 2) had pre HD higher PAP than those with IDWG < 3.5% (group 1) and patients with IDWG > 3.5% had more change in their PAP post HD session than those with IDWG < 3.5% but no significant difference between the change after the HD session in both groups. HD duration is an important factor in PH development over years. There is a significant relation anemia and hypercalcemia with PH. Patients with more increased IDWG > 3.5 % (group 2) had higher pulmonary congestion than those with IDWG < 3.5% (group 1) and patients with IDWG < 3.5% had more change in their lung congestion level after the HD session than those with IDWG > 3.5% but no statistical significance between the change in both groups. There was a significant relation between HD therapy duration with pulmonary congestion measured prior to the session. Conclusion on the short term increased IDWG affect lung congestion more than pulmonary hypertension.

Background and Aims Sleep disorders are common among end stage renal disease (ESRD)patients undergoing hemodialysis (HD). The etiology of sleep disorders in these patients is known to be multifactorial. However, the role of hydration status in sleep disorders in HD patients is not well studied. Therefore, our aim was to study the effect of predialysis fluid overload on sleep quality in HD patients. Methods This cross-sectional study included 100 prevalent HD patients from HD unit of El Sahel teaching hospital. fluid status and fluid compartments [total body water (TBW)], extracellular water (ECW)] and overhydration index (OH) were analyzed by a portable whole-body bio-impedance spectroscopy (Body Composition Monitor ‘BCM’) before mid-week dialysis session. Overhydration was defined as OH/ECW ≥15%. HD patients were then classified into 2 groups: Group 1 (non- overhydrated) and Group 2 (Overhydrated) according to OH/ECW. Sleep quality were assessed in all patients by Pittsburgh Sleep Quality Index (PSQI) questionnaire. Patients with Concurrent diagnosis of either obstructive sleep Apnea or psychiatric disorder and patients on any medications which affect the sleep pattern were excluded. Results our study included 100 HD patients (49 male, 51 female - mean age 49.3 ±11). 42 patients (42%) had overhydration (i.e. Group 2). Poor sleep quality (defined as PSQI score ≥5) was reported in 57% (n=57) of HD patients included in our study. Poor sleep quality was significantly higher in the HD patients with overhydrated (Group 2). Total PSQI scores were significantly higher in overhydrated patients (Group2) compared to non-overhydrated patients (Group1) (7.92±3.32 vs 4.83±2.27, P= Conclusion We may conclude from our study that sleep disorders are prevalent in HD patients. Predialysis fluid overload in HD patients may be associated significantly with poor sleep quality.

Introduction The most common cause of mortality among chronic hemodialysis (HD) patients is cardiovascular disease. Hypervolemia is an important risk factor for hypertension and cardiovascular mortality in HD patients that include chronic volume overload and interdialytic weight gain (IDWG).IDWG affects cardiovascular morbidity and mortality Daily fluctuations in extracellular fluid volume might promote cardiac remodeling resulting in left ventricular hypertrophy (LVH) and cardiac fibrosis. Aim of the study to assess interdialytic weight gain and (its relation to morbidity and mortality) among patients on maintenance hemodialysis. Patient and methods 100 ESRD patients on regular hemodialysis included in study in Ain Shams University hospitals in march 2016 and followed up after one year in march 2017. Type of study cohort study Patients were divided into two groups according to interdialytic weight gain (IDWG): Group I (high IDWG) 50 patients with Absolute weight gain 4kg or more. Or relative IDWG more than 3.5% of total body weight. Group II (low IDWG) 50 patients with absolute weight gain less than 3kg Or relative IDWG less than 3.5% of total body weight. Echocardiography (TTE) for all patients at the start of the study and followed up after one year for detecting outcomes included all-cause mortality, cardiovascular mortality, hospitalization for heart failure/volume overload, hospitalization for myocardial infarction, stroke. Results we found that patient with high (IDWG) group II has significantly higher increase in left ventricular mass index (LVMI),inferior vena cava (IVC) diameter and significantly higher decrease in ejection fraction more than low IDWG group I. Conclusions Patients with high IDWG group II at higher risk of increase LVMI, decrease ejection fraction, increase in interventricular septum (IVS), increase in inferior vena cava diameter more than patients of low IDWG group I and has more cardiovascular morbidity and mortality.

Ultrafiltration (UF) mechanically removes excess fluid volume through an extracorporeal circuit and has been applied to clinical situations in which volume removal is the mainstay of therapy. Because of this ability, UF serves as an enticing method to treat acute heart failure (AHF) in which most symptoms are driven by congestion due to excess volume. Additional physiologic properties of UF and the biochemical composition of the extracted fluid confer additional theoretic benefits in the treatment of AHF. Herein the concepts underlying UF, clinical evidence evaluating its efficacy, and ongoing challenges understanding the role of UF are reviewed.

Anecdotally, many clinicians expect blood components to arrive in standard volumes. Blood components do not come in uniform sizes, however, and institutional experience has revealed platelet units to vary considerably in volume. Since many clinicians are not the ones examining blood products and their volumes prior to transfusion, there is a potential to transfuse a high-volume unit inadvertently to a patient at risk of transfusion-associated fluid overload (TACO), a leading cause of transfusion-related fatalities. The intent of this study was to examine the allocation practices of high-volume platelet units at an academic medical center. Over a six-month period, blood bank technical staff prospectively logged the allocation of high-volume apheresis platelet units with volumes greater than or equal to 400 mL. The staff member who issued the product logged the reason(s), if any, why he or she selected the unit for a particular patient when more than one ABO type-specific product was available. No patient identifiers or data were logged or analyzed in this study. Eighty-seven high-volume platelet units were recorded during the study period. The volumes ranged from 395 to 872 mL, with an average and standard deviation of 571 mL and 92 mL, respectively. Blood bank staff listed the following reasons for their allocation of high-volume platelet unit as follows: the product expiration date in 23 cases (26%), patient age in 13 cases (15%), patient sex in 12 cases (14%), and intraoperative use in 10 cases (11%). This study enumerated the variability in platelet unit volume, with some units containing likely double or triple the volume of the ordering clinicians expectations. Blood bank technologists made clinical decisions in the allocation of high-volume units in three-quarters of the documented cases. This underscores a need to provide clearly-defined guidelines for allocating such units, as well as a mechanism for clinicians to request lower-volume units, particularly for patients at risk of TACO.

Objective: To stablish a middle range theory for the understanding of the causal mechanisms and clinical consequentes of the nursing diagnosis Excess Fluid Volume (00026) among pregnant women. Method: The Middle Range Theory was constructed in five stages: defining of construction approach, establishing main concepts, elaborating propositions, developing a pictorial diagram, and establishing the causal relationships and evidence for practice of the Middle Range Theory. Results: We identified 14 clinical indicators and 6 causal factors of Excess Fluid Volume. A pictorial diagram was developed and relationships between Excess Fluid Volume elements were established with 6 propositions for them. Conclusion: The Middle Range Theory included both physiological and pathological conditions to explain Excess Fluid Volume. This Middle Range Theory might help in the better understanding of interactions between causal factors and clinical indicators of Excess Fluid Volume. RESUMEN Objetivo: Establecer una teoría de medio alcance para la comprensión de los mecanismos causales y consecuencias clínicas del diagnóstico de enfermería Volumen de Líquidos Excesivo (00026) en gestantes. Métodos: La teoría de medio alcance ha sido construida en cinco etapas: Definición del abordaje de construcción; Definición de los conceptos principales; Desarrollo de un esquema pictorial; Construcción de las proposiciones; y Establecimiento de las relaciones de causalidad y de evidencias para la práctica. Resultados: Han sido identificados 14 indicadores clínicos y 6 factores causales de Volumen de Líquidos Excesivo. Ha sido construido un diagrama pictorial y establecidas relaciones entre los elementos de Volumen de Líquidos Excesivo, con seis proposiciones para ellos. Conclusión: La teoría de medio alcance incluyó condiciones fisiológicas y patológicas para explicar el Volumen de Líquidos Excesivo; ella puede ayudar en la mejor comprensión de las interacciones entre los factores casuales e indicadores clínicos de Volumen de Líquidos Excesivo. RESUMO Objetivo: Estabelecer uma teoria de médio alcance para a compreensão dos mecanismos causais e consequências clínicas do diagnóstico de enfermagem Volume de Líquidos Excessivo (00026) em gestantes. Métodos: A Teoria de Médio Alcance foi construída em cinco etapas: Definição da abordagem de construção; Definição dos conceitos principais; Desenvolvimento de um esquema pictorial; Construção das proposições e Estabelecimento das relações de causalidade e de evidências para a prática. Resultados: Foram identificados 14 indicadores clínicos e 6 fatores causais de Volume de líquidos excessivo. Foi construído um diagrama pictorial e estabelecidas relações entre os elementos de Volume de líquidos excessivo, com seis proposições para eles. Conclusão: A Teoria de Médio Alcance incluiu tanto condições fisiológicas como patológicas para explicar o Volume de Líquidos Excessivo. A Teoria de Médio Alcance pode ajudar na melhor compreensão das interações entre os fatores causais e indicadores clínicos de Volume de líquidos excessivo.

Introduction Tricuspid regurgitation (TR) importance is growing in the last years. Its presence is associated with a worse prognosis. A new severity classification has been published, adding massive and torrential to the classical TR classification. However, both clinical profile of the patients as well as right chambers morphologic and functional changes have not been described compared to the severe TR patients. Methods Consecutive patients undergoing an echocardiographic study in 9 Spanish hospitals within a three-month period with at least moderate TR were prospectively included. All studies with severe TR were selected for analysis. TR assessment was performed as recommended by the European Association of Cardiovascular Imaging. TR severity grades was performed according to Hanh & Zamorano new published classification. Two cohorts were made: patients with severe TR and patients with massive or torrential TR. Results A total of 644 patients with severe or bigger TR were analysed. Severe TR was present in 540 (84%), massive was present in 83 (13%) and torrential in 21 (3%) Baseline characteristics of the study population are shown in table 1. No differences were found in NYHA class or atrial fibrillation incidence between groups. Pacemaker was more frequent in massive/torrential group (30% vs 19%; 0,014). Patients with massive/torrential TR presented worst RV remodelling data: -RV was dilated (RV telediastolic basal diameter >42mm) in 84.2% of patients with massive/torrential TR vs 57% of patients with severe TR (p -Right atrium was bigger in patients with massive/torrential TR (21 ± 0.8 cm2/m2 vs 17.2 ± 0,3 cm2/m2; p -Tricuspid annulus diameter was bigger between massive/torrential TR patients (26.7 ± 0.6 cm/m2 vs 23.6 ± 0.3 cm/m2; p > 0.001). No significant differences in prevalence of RV function (TAPSE Conclusions In this large multicentre cohort of patients, the presence of massive/torrential TR seems to be associated with a differential RV and RA remodelling, reflecting the greater volume overload seen in these patients. Further studies are needed to define prognosis implication of our findings and its role in clinical decision making. Table 1 Variable Severe (n = 540) Massive/Torrential (n = 104) Body mass index 26,6 (±0,3) 26.4(±0,6) 0.350 Woman 336 (62%) 69 (66%) 0.438 Atrial firilation 298(55%) 61(59%) 0.514 Age (years) 76,5 (±0,5) 77,5(±1,1) 0.209

Background Donation after circulatory death (DCD) heart transplantation has been debated over the past decades because of the shortage of donor. The right ventricular dysfunction is one of the remaining problems for clinical implication of DCD heart transplantation. DCD hearts suffering from the volume overload have a potential to aggravate the right ventricular dysfunction after heart transplantation. The c-fos mRNA is one of the “immediate” response genes to mechanical stresses, such as myocardial cell stretch, without neural and humoral factors. In this study, we assessed myocardial stretch during asphyxiated cardiac arrest using c-fos mRNA expression. Purpose The purpose of this study is to reveal the impact of right ventricular volume overload during asphyxiated cardiac arrest. Methods Male Wistar rats (8 weeks of age, n=18) were anesthetized with paralyzed ventilation. The trachea was dissected and ligated to initiate asphyxiation. Hearts were harvested at 3 time points: 0, 15 and 30 minutes after termination of the ventilation. Free walls of right and left ventricle were sectioned and immersed in RNA stabilization solution as soon as possible. Total RNA was extracted from these tissues using a guanidine thiocyanate-phenol-chloroform method and cDNA was synthesized using a reverse transcriptase. Next, we measured the quantified expression level by using the droplet digital PCR method with a probe and primers for c-fos gene. Expression of c-fos level was divided by extracted TATA binding protein (TBP) level as a control marker, the ratio of c-fos and TBP was used in analysis. Results In the left ventricle, the expression of c-fos rapidly increased by 15 minutes (0.81±0.24 (c-fos/TBP), p Conclusion These results suggest that the volume overload to the right ventricle during asphyxiated cardiac arrest prolongs compared to that to the left ventricle, which may cause the right ventricular dysfunction after DCD heart transplantation.

Aim: To analyze the behavior of B-type natriuretic peptide (BNP) in the presence of defining characteristics (DCs) of the nursing diagnosis Excess fluid volume (00026) in patients hospitalized for acute decompensated heart failure. Methods: Cohort study of patients admitted with acute decompensated heart failure (September 2015 to September 2016) defined by Boston Criteria. Patients hospitalized for up to 36 h with BNP values ≥ 100 pg/ml were included; BNP values at baseline-final assessment were compared by Wilcoxon test, the number of DCs at baseline-final assessment was compared by paired t-test. Results: Sixty-four patients were included; there was a significant positive correlation between delta of BNP and the number of DCs present at initial clinical assessment. Conclusions: The behavior of BNP was correlated to the DCs indicating congestion. With clinical compensation, DCs and BNP decreased. The use of this biomarker may provide additional precision to the nursing assessment. RESUMEN Objetivo: Analizar el comportamiento del péptido natriurético tipo B (BNP) en presencia de características definitorias (CD) del diagnóstico de enfermería Exceso de volumen de líquidos (00026) en pacientes hospitalizados por insuficiencia cardíaca aguda descompensada (ICAD). Métodos: Estudio de cohorte de pacientes ingresados con ICAD (septiembre/2015 a septiembre/2016).Se incluyeron pacientes hospitalizados hasta 36 h con valores de BNP ≥ 100 pg / ml; Los valores de BNP en la evaluación inicial basal se compararon mediante la prueba de Wilcoxon, el número de CD en la evaluación inicial basal se comparó mediante el Test-T apareado. Resultados: Se incluyeron 64 pacientes; hubo una correlación positiva significativa entre el delta del BNP y las CD presentes en la evaluación clínica inicial. Conclusiones: El comportamiento del BNP se correlacionó con las CD que indican congestión. Con compensación clínica, las CD y el BNP disminuyeron. El uso del BNP puede proporcionar precisión adicional a la evaluación de enfermería. RESUMO Objetivo: Analisar o comportamento do peptídeo natriurético tipo B (BNP) na presença de características definidoras (CDs) do diagnóstico de enfermagem Excesso de volume de líquidos (00026) em pacientes hospitalizados por insuficiência cardíaca descompensada. Métodos: Estudo de coorte com pacientes internados com insuficiência cardíaca descompensada (setembro-2015 a setembro-2016), definida pelos Critérios de Boston. Pacientes hospitalizados por mais de 36 horas, valor de BNP ≥ 100 pg/ml foram incluídos; valores de BNP basal-final foram comparados pelo teste Wilcoxon; as CDs no basal-final foram comparadas pelo teste t pareado. Resultados: Sessenta e quatro pacientes foram incluídos; houve correlação positiva significativa entre o delta de BNP com o número de CDs presentes na avaliação clínica inicial. Conclusões: O comportamento do BNP foi correlacionado com as CDs, indicando congestão. Com a compensação clínica, as CDs e a concentração de BNP diminuíram. O uso deste biomarcador pode fornecer precisão adicional à avaliação de enfermagem.

Background Intradialytic hypertension (IDH) increases morbidity and mortality. The prevalence in South Africa is unknown. The pathogenesis is unclear, but it has been suggested that IDH may be due to subclinical fluid overload. The objective of this study was to determine the prevalence of IDH and to evaluate its association with fluid overload using bioimpedance spectroscopy (BIS). Methods A cross-sectional study involving 190 chronic haemodialysis patients in the Western Cape province of South Africa was conducted between January 2013 and May 2014. IDH was defined as a >10 mmHg increase in systolic blood pressure in at least four of six prior consecutive haemodialysis sessions. Results The prevalence of IDH was 28.4% (n = 54). There was a trend towards pre-dialysis overhydration in the IDH group when compared with controls {2.6 L [95% confidence interval (CI) 1.7–3.4] versus 1.8 L [95% CI 1.4–2.1], respectively; P = 0.06} as measured by BIS, but no difference in mean ultrafiltration (UF) volume (2.4 versus 2.6 L; P = 0.30). A trend towards greater use of antihypertensive drugs was noted in the IDH group [2.5 drugs (95% CI 2.15–2.87) versus 2.1 (95% CI 1.82–2.30); P = 0.05]. More participants in the IDH group received calcium channel blockers (54 versus 36; P = 0.03). Conclusions The prevalence of IDH in our treatment centres is much higher than previously reported. Subclinical fluid overload may be a major contributing factor to the mechanism of this condition. The use of BIS identifies patients who may benefit from additional UF.

OBJECTIVES: The glucagon-like peptide 2 (GLP-2) analog teduglutide (TED) is a novel therapy for intestinal failure that reduces need for parenteral support. Degree of response may correlate to location of surgical anastomoses. TED may worsen heart failure (HF) and gastrointestinal (GI) neoplasms. Using a large database we characterize American patients prescribed TED. METHODS: The Explorys national database (Cleveland, OH, USA) is an aggregate of de-identified patient data from 26 US healthcare systems. SNOMED classification was used to identify consecutive patients prescribed TED, 2015–2020. Demographics and comorbidities were collected. Preceding surgeries, suspected inciting conditions, and incident symptoms/events post TED were searched using the temporal attributes feature on Explorys. RESULTS: Of 72 million patients, 170 are prescribed TED. Age range of majority was 45–69 years. 70% were female, 82% caucasian and 12% African American. 70 used medicare, and 70 private insurance. In 50 patients, initial BMI was > 30, 40 had BMI

Objective Fluid resuscitation is integral to resuscitation guidelines and critical care. However, fluid overload (FO) yields increased morbidity. Methods Prospective observational study of Red Cross War Memorial Children's Hospital pediatric intensive care unit admissions (February to March 2013). FO % = (fluid in minus fluid out) [liters]/weight [kg] × 100%. Primary outcomes FO ≥ 10%, 28 day mortality. Results Median [interquartile range (IQR)] age: 9.5 (2.0-39.0) months, median (IQR) admission weight: 7.9 (3.6-13.7) kg. Median (IQR) FO with admission weight: 3.5 (2.1-4.9)%; three patients had FO ≥ 10%. The 28 day mortality was 10% (n = 10). Patients who died had higher mean (IQR) FO using admission weight [4.9 (2.9-9.3)% vs. 3.4 (1.9-4.8)%; p = 0.04]. Conclusions Low FO ≥ 10% prevalence with 28 day mortality 10%. Higher FO% with admission weight associated with mortality (p = 0.04). We advocate further investigation of FO% as a simple bedside tool.

It is well known that one of the main determinants of mortality and morbidity in chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients is fluid overload acting on the cardiovascular system causing hypertension, increased arterial stiffness, left ventricular hypertrophy and eventually heart failure. Therefore, assessment and management of volume status is crucial. Bioimpedance spectroscopy is one of the most popular and practical methods for volume evaluation. Volume evaluation should be a routine part of following CKD and ESRD patients, in order to decrease associated mortality and morbidity.

Objectives To consensually validate the operational definitions of the nursing diagnoses activity intolerance, excessive fluid volume, and decreased cardiac output in patients with decompensated heart failure. Method Consensual validation was performed in two stages: analogy by similarity of defining characteristics, and development of operational definitions and validation with experts. Results A total of 38 defining characteristics were found. Operational definitions were developed and content-validated. One hundred percent of agreement was achieved among the seven experts after five rounds. “Ascites” was added in the nursing diagnosis excessive fluid volume. Conclusion The consensual validation improves interpretation of human response, grounding the selection of nursing interventions and contributing to improved nursing outcomes. Implications for Practice Support the assessment of patients with decompensated heart failure. Objetivos Realizar a validacao consensual das definicoes operacionais dos diagnosticos de enfermagem Intolerância a atividade, Volume de liquidos excessivo e Debito cardiaco diminuido em pacientes com insuficiencia cardiaca descompensada. Metodo Validacao consensual em duas etapas: Analogia de semelhanca das caracteristicas definidoras e desenvolvimento de definicoes operacionais e validacao com expertst. Resultados Foram encontradas 38 caracteristicas definidoras para os diagnosticos de enfermagem. Suas definicoes operacionais foram desenvolvidas e seu conteudo validado. Os resultados mostram que houve 100% de concordância entre os sete experts apos cinco rodada. As definicoes operacionais foram classificadas com base no nivel de concordânica. “Ascite” foi acrescentada ao diagnostico Volume de liquidos excessivo. Conclusao A validacao consensual melhora a interpretacao das respostas humanas, embasando a selecao de intervencoes de enfermagem e contribuindo para melhorar os resultados. Implicacoes Para A Pratica Apoio a avaliacao dos pacientes com insuficiencia cardiaca descompensada.

Background Volume expansion (VE) in neonates or infants during volatile anaesthesia may lead to fluid overload if inappropriate. Transoesophageal Doppler (TED), a non-invasive cardiac output monitoring technique, can provide a comprehensive estimation of the volaemic status. We evaluated whether intraoperative TED-derived parameters can predict volume responsiveness. Methods Neonates and infants under general anaesthesia without myocardial dysfunction were prospectively included when the attending anaesthetist, blinded to TED measurements, decided to provide VE based on clinical appreciation and standard monitoring data. Standard and TED-derived data were recorded before and after VE. After VE, patients were classified as responders and non-responders, if their indexed stroke volume (iSV) increased by more than 15% or not, respectively. The attending anaesthetist assessment of VE responsiveness was recorded at the end of VE. Results Fifty patients aged 42 (4) post-conceptional weeks were included, among which 26 (52%) were responders. Baseline iSV was the only parameter associated with VE responsiveness. Baseline iSV was fairly correlated with VE-induced changes in iSV (ρ=−0.64) and was associated with an area under the receiver operating characteristic curve of 0.90 (0.80, 0.99). Using a cut-off of 25 ml m−2, baseline iSV predicted volume responsiveness with a sensitivity of 92% and a specificity of 83%. Attending anaesthetists’ assessment of VE effectiveness agreed only moderately with TED measurements of iSV changes. Conclusions TED-derived iSV measurement during volatile anaesthesia is useful to predict and follow VE responsiveness in neonates and infants without myocardial dysfunction.

PURPOSE To validate the content of the priority Nursing Interventions Classification (NIC) interventions and Nursing Outcomes Classification (NOC)-suggested outcomes for cardiac patients with the nursing diagnosis excess fluid volume in the Brazilian context. METHODS The content of the interventions and outcomes was scored by seven expert nurses using a Likert scale, using the Fehring model. FINDINGS From the 83 activities of the priority NIC interventions, nine had scores lower than 0.5 (nonuseful) and 50 had scores higher than 0.8 (major); from the 53 indicators of the suggested NOC outcomes, eight scored lower than 0.5 and 26 had scores higher than 0.8. CONCLUSIONS The majority of the NIC interventions and NOC outcomes were considered useful by the Brazilian Cardiology expert nurses. IMPLICATIONS FOR PRACTICE Clinical studies are an important strategy for validation of the usefulness of North American Nursing Diagnosis Association, NIC, and NOC language in clinical protocols. Additional studies are necessary to confirm the findings of this pilot study.

Most patients hospitalized for acutely decompensated heart failure (ADHF) present with symptoms and signs of volume overload, which is also associated with substantially high rates of death and rehospitalization in ADHF.To review the recent experimental and clinical evidence on existing therapeutic algorithms and investigational drugs used for the treatment of volume overload in ADHF patients.A systematic search of peer-reviewed publications was performed on Medline and EMBASE from January 1990 to March 2012. The results of unpublished trials were obtained from presentations at national and international meetings.Apart from intrinsic renal insufficiency and neurohormonal activation, volume overload through venous congestion may be the primary haemodynamic factor triggering the worsening of renal function in ADHF patients. It is well known that heart and kidneys are closely interrelated and an acute or chronic disorder in one organ may induce acute or chronic dysfunction in the other organ. Established therapeutic strategies, (e.g. loop diuretics, vasodilators, and inotropes), are sometimes associated with limited clinical success due to tolerance and the need for frequent up titration of the doses in order to achieve the desired effect. That leads to an increasing interest in novel options, such as the use of adenosine A1 receptor antagonists, vasopressin antagonists, and renal-protective dopamine. Initial clinical trials have shown quite encouraging results in some heart failure subpopulations but have failed to demonstrate a clear beneficial role of these agents. On the other hand, ultrafiltration appears to be a more promising therapeutic procedure that will improve volume regulation, while preserving renal and cardiac function.Further clinical studies are required in order to determine their net effect on renal function and potential cardiovascular outcomes. Until then, management of volume overload in ADHF patients remains a challenge for the clinicians.

Proper patient selection, diligent fluid management, and attention to body temperature are important safety considerations in large-volume lipoplasty (LVL). Complications related to fluid overload, lidocaine toxicity, coagulopathies, and lengthy combined surgical procedures are preventable and not directly linked to LVL technique. Benefits as well as morbidity and mortality from LVL can be weighed against risk factors such as obesity, a prediabetic condition, and/or adverse effects of weight-loss medications. The author describes how she incorporates safeguards into her LVL procedures. (Aesthetic Surg J 2001;21:545-548.).