Peritoneal Dialysis International, Vol. 35, pp. 604–606 Printed in Canada. All rights reserved.
0896-8608/15 $3.00 + .00 Copyright © 2015 International Society for Peritoneal Dialysis
CORRESPONDENCE Impact of the Limitations in Fluid Overload Assessment by Bioimpedance Spectroscopy KEY WORDS: Bioimpedance spectroscopy; body composition; limitations.
Nephrology Department1 Hospital Universitari Arnau de Vilanova, Lleida, Spain Nephrology Department2 Hospital General Universitario Gregorio Marañón, Madrid, Spain *email: [email protected] doi: 10.3747/pdi.2015.00164
Editor: We thank Minguela et al. for their notes on our paper. They state some doubts about our conclusions due to the following facts. The mean overhydration deviation (180 mL) may not be large enough as to have direct clinical consequences, as we already mention in the article, but it represents 10% of the patients’ total fluid overload, so it should be taken into account when performing the test. It is true that the tests were always performed in the same order (full abdomen first), mainly for 2 reasons: first, it was more suitable for patients, since they arrive at the clinic with the dialysate in the abdomen; secondly, there is no apparent reason why the order should affect the results of the study. If any of the factors that they mention (the order in which tests are performed, the amount of ultrafiltration or performing the test at the beginning of the dwell) interfered with the test results, performing the test with a full abdomen first should increase fluid overload in the second test in response to a volume transfer from blood to the peritoneal cavity. Hence, we would have obtained negative results or a tendency to overestimation when performing the test with a dry abdomen, but our results go in the opposite direction. We did not analyze differences in residual renal function, but patients were their own controls for comparisons. Our data confirm the results of previous studies done with different bioimpedance devices. We agree with our colleagues that it has some limitations, and that larger studies could contribute to a better understanding of the subject.
Editor: We read with interest the article by Arroyo et al. about the importance of having or not having fluid in the peritoneal cavity when measuring bioimpedance. We have doubts about the affirmation that peritoneal fluid overestimates the state of hydration. The authors state that peritoneal fluid leads to overestimating corporal water. But, when we analyze the data, the difference between the 2 measures is only 180 mL while the usual peritoneal exchange volume is 2 L. Also, the order was not randomized (firstly with peritoneal fluid) and the lapse time between the 2 measures could have been up to 2 hours. A kind of bias could have influenced these results instead of peritoneal fluid per se. For instance, it is possible that patients had kidney function that could have filtered the fluid. Ultrafiltration is another possible bias as it depends on the dwell time. If the fluid was measured at the start of the dwell, it is possible that part of the volume passed from the blood to the peritoneal cavity. A randomized trial or different measures (before and after an exchange) would probably help to resolve these doubts about the need to measure with a full or empty peritoneal cavity.
DISCLOSURES
DISCLOSURES
The authors have no financial conflicts of interest to declare.
The authors have no financial conflicts of interest to declare.
D. Arroyo1,2* N. Panizo2 S. Abad2 A. Vega2 A. Rincón2 A.P. de José2 J.M. López-Gómez2 604
Fluid in the Peritoneal Cavity When Measuring Bioimpedance
J.I. Minguela* B. Aurrekoetxea I. Jimeno R. Ruiz de Gauna Nephrology Department Hospital Universitario Álava, Vitoria-Gasteiz (Álava), Spain
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
PDI
SEPTEMBER 2015 – VOL. 35, NO. 5 CORRESPONDENCE
*email: [email protected] REFERENCE 1. Arroyo D, Panizo N, Abad S, Vega A, Rincón A, Pérez de San José A, et al. Intraperitoneal fluid overestimates hydration status assessment by bioimpedance stpectroscopy. Perit Dial Int 2015; 35:85–9. doi: 10.3747/pdi.2015.00109
A Patient with Encapsulating Peritoneal Sclerosis Complicated with Hepatic Portal Venous Gas Who Survives Conservative Treatment Editor: Hepatic portal venous gas (HPVG) is a rare but serious condition that has been associated with a poor prognosis. It occurs when intraluminal gas or gas produced by intestinal bacteria enters the portal venous circulation. Hepatic portal venous gas has been reported in many illnesses, ranging from benign conditions to potentially lethal diseases that require urgent surgical intervention. Intestinal obstruction is a common manifestation in patients with encapsulating peritoneal sclerosis (EPS). However, among the various diseases, HPVGassociated EPS has not been described. We report on a patient with EPS complicated by intestinal obstruction that lead to the development of HPVG. The patient made an uneventful recovery with medical treatment. A 76-year-old female patient who had had end-stage renal disease for 15 years received maintenance hemodialysis 3 times a week. She had stopped peritoneal dialysis (PD) 2 years prior due to EPS. The patient presented to our emergency department with progressive worsening of abdominal pain over the previous 3 days. On examination, she was hypothermic, with a body temperature of 35.1°C, blood pressure 80/40 mmHg, respiratory rate 20 breaths per minute, and heart rate 111 beats per minute. Abdominal examination revealed a soft abdomen with no guarding or rigidity on light palpation. The patient’s bowel sound was hypoactive. The abdomen and pelvis computed tomography (CT) scan showed a large quantity of ascites and free air in the intrahepatic portal veins and along the falciform ligaments (Figure 1). Disproportional dilatation of the proximal small bowel and collapse of the distal ileum and colon were also found. These findings suggested intestinal obstruction at the jejuno-ileal junction. In addition, a large quantity of loculated fluid accumulation was noted in the anterior peritoneum, with peritoneal thickening. The walls of the small bowel were calcified. Her ascites tap showed the presence of bloody fluid collection. A diagnosis of EPS was made based upon her clinical symptoms and radiological features. After being admitted to the intensive care unit, the patient was found to have a white blood cell count of 19,430 cells/μL and C-reactive protein of 38.4 mg/dL. Because of high anesthetic and surgical risks, a laparotomy was not performed. We had kept the patient on nothing per os and gave her 500 mg
Figure 1 — Computed tomography in a patient with peritoneal sclerosis. A large amount of loculated fluid had accumulated in the anterior peritoneum, with peritoneal thickening. Intestinal obstruction at jejuno-ileal junction was found due to an adhesion band around the jejuno-ileal junction. Air was noted in the intrahepatic portal veins and along the falciform ligament (arrows).
Figure 2 — Computed tomography in the patient after medical treatment. Computed tomography showed resolution of hepatic portal venous gas (HPVG). Hepatic portal veins were patent without air retention.
intravenous meropenem daily as the empirical antibiotic of choice and parenteral nutrition. The patient’s blood pressure improved after fluid resuscitation. The blood culture results yielded growth of Enterococcus raffinosus, and she received teicoplanin 400 mg daily intravenously in addition to meropenem. The patient’s clinical condition gradually improved, with decreased abdominal pain and increased bowel movement. On day 6 after admission, she was transferred to a regular ward and started intake of free water. Her blood cultures on day 10 showed negative bacterial growth. On day 14, an abdominal CT showed a patent portal vein without any air retention (Figure 2). On day 15, she was discharged home.
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
605
0896-8608/15 $3.00 + .00 Copyright © 2015 International Society for Peritoneal Dialysis
CORRESPONDENCE Impact of the Limitations in Fluid Overload Assessment by Bioimpedance Spectroscopy KEY WORDS: Bioimpedance spectroscopy; body composition; limitations.
Nephrology Department1 Hospital Universitari Arnau de Vilanova, Lleida, Spain Nephrology Department2 Hospital General Universitario Gregorio Marañón, Madrid, Spain *email: [email protected] doi: 10.3747/pdi.2015.00164
Editor: We thank Minguela et al. for their notes on our paper. They state some doubts about our conclusions due to the following facts. The mean overhydration deviation (180 mL) may not be large enough as to have direct clinical consequences, as we already mention in the article, but it represents 10% of the patients’ total fluid overload, so it should be taken into account when performing the test. It is true that the tests were always performed in the same order (full abdomen first), mainly for 2 reasons: first, it was more suitable for patients, since they arrive at the clinic with the dialysate in the abdomen; secondly, there is no apparent reason why the order should affect the results of the study. If any of the factors that they mention (the order in which tests are performed, the amount of ultrafiltration or performing the test at the beginning of the dwell) interfered with the test results, performing the test with a full abdomen first should increase fluid overload in the second test in response to a volume transfer from blood to the peritoneal cavity. Hence, we would have obtained negative results or a tendency to overestimation when performing the test with a dry abdomen, but our results go in the opposite direction. We did not analyze differences in residual renal function, but patients were their own controls for comparisons. Our data confirm the results of previous studies done with different bioimpedance devices. We agree with our colleagues that it has some limitations, and that larger studies could contribute to a better understanding of the subject.
Editor: We read with interest the article by Arroyo et al. about the importance of having or not having fluid in the peritoneal cavity when measuring bioimpedance. We have doubts about the affirmation that peritoneal fluid overestimates the state of hydration. The authors state that peritoneal fluid leads to overestimating corporal water. But, when we analyze the data, the difference between the 2 measures is only 180 mL while the usual peritoneal exchange volume is 2 L. Also, the order was not randomized (firstly with peritoneal fluid) and the lapse time between the 2 measures could have been up to 2 hours. A kind of bias could have influenced these results instead of peritoneal fluid per se. For instance, it is possible that patients had kidney function that could have filtered the fluid. Ultrafiltration is another possible bias as it depends on the dwell time. If the fluid was measured at the start of the dwell, it is possible that part of the volume passed from the blood to the peritoneal cavity. A randomized trial or different measures (before and after an exchange) would probably help to resolve these doubts about the need to measure with a full or empty peritoneal cavity.
DISCLOSURES
DISCLOSURES
The authors have no financial conflicts of interest to declare.
The authors have no financial conflicts of interest to declare.
D. Arroyo1,2* N. Panizo2 S. Abad2 A. Vega2 A. Rincón2 A.P. de José2 J.M. López-Gómez2 604
Fluid in the Peritoneal Cavity When Measuring Bioimpedance
J.I. Minguela* B. Aurrekoetxea I. Jimeno R. Ruiz de Gauna Nephrology Department Hospital Universitario Álava, Vitoria-Gasteiz (Álava), Spain
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
PDI
SEPTEMBER 2015 – VOL. 35, NO. 5 CORRESPONDENCE
*email: [email protected] REFERENCE 1. Arroyo D, Panizo N, Abad S, Vega A, Rincón A, Pérez de San José A, et al. Intraperitoneal fluid overestimates hydration status assessment by bioimpedance stpectroscopy. Perit Dial Int 2015; 35:85–9. doi: 10.3747/pdi.2015.00109
A Patient with Encapsulating Peritoneal Sclerosis Complicated with Hepatic Portal Venous Gas Who Survives Conservative Treatment Editor: Hepatic portal venous gas (HPVG) is a rare but serious condition that has been associated with a poor prognosis. It occurs when intraluminal gas or gas produced by intestinal bacteria enters the portal venous circulation. Hepatic portal venous gas has been reported in many illnesses, ranging from benign conditions to potentially lethal diseases that require urgent surgical intervention. Intestinal obstruction is a common manifestation in patients with encapsulating peritoneal sclerosis (EPS). However, among the various diseases, HPVGassociated EPS has not been described. We report on a patient with EPS complicated by intestinal obstruction that lead to the development of HPVG. The patient made an uneventful recovery with medical treatment. A 76-year-old female patient who had had end-stage renal disease for 15 years received maintenance hemodialysis 3 times a week. She had stopped peritoneal dialysis (PD) 2 years prior due to EPS. The patient presented to our emergency department with progressive worsening of abdominal pain over the previous 3 days. On examination, she was hypothermic, with a body temperature of 35.1°C, blood pressure 80/40 mmHg, respiratory rate 20 breaths per minute, and heart rate 111 beats per minute. Abdominal examination revealed a soft abdomen with no guarding or rigidity on light palpation. The patient’s bowel sound was hypoactive. The abdomen and pelvis computed tomography (CT) scan showed a large quantity of ascites and free air in the intrahepatic portal veins and along the falciform ligaments (Figure 1). Disproportional dilatation of the proximal small bowel and collapse of the distal ileum and colon were also found. These findings suggested intestinal obstruction at the jejuno-ileal junction. In addition, a large quantity of loculated fluid accumulation was noted in the anterior peritoneum, with peritoneal thickening. The walls of the small bowel were calcified. Her ascites tap showed the presence of bloody fluid collection. A diagnosis of EPS was made based upon her clinical symptoms and radiological features. After being admitted to the intensive care unit, the patient was found to have a white blood cell count of 19,430 cells/μL and C-reactive protein of 38.4 mg/dL. Because of high anesthetic and surgical risks, a laparotomy was not performed. We had kept the patient on nothing per os and gave her 500 mg
Figure 1 — Computed tomography in a patient with peritoneal sclerosis. A large amount of loculated fluid had accumulated in the anterior peritoneum, with peritoneal thickening. Intestinal obstruction at jejuno-ileal junction was found due to an adhesion band around the jejuno-ileal junction. Air was noted in the intrahepatic portal veins and along the falciform ligament (arrows).
Figure 2 — Computed tomography in the patient after medical treatment. Computed tomography showed resolution of hepatic portal venous gas (HPVG). Hepatic portal veins were patent without air retention.
intravenous meropenem daily as the empirical antibiotic of choice and parenteral nutrition. The patient’s blood pressure improved after fluid resuscitation. The blood culture results yielded growth of Enterococcus raffinosus, and she received teicoplanin 400 mg daily intravenously in addition to meropenem. The patient’s clinical condition gradually improved, with decreased abdominal pain and increased bowel movement. On day 6 after admission, she was transferred to a regular ward and started intake of free water. Her blood cultures on day 10 showed negative bacterial growth. On day 14, an abdominal CT showed a patent portal vein without any air retention (Figure 2). On day 15, she was discharged home.
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
605
