The Korean Journal of Medicine

The Korean Association of Internal Medicine (대한내과학회)
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Relative Association of Overhydration and Muscle Wasting with Mortality in Hemodialysis Patients: Assessment by Bioelectrical Impedance Analysis

혈액투석 환자에서 Bioelectrical Impedance Analysis를 활용하여 측정한 과수분량과 근육량 감소와 사망률의 상관관계

  • Kim, Eunju (Department of Internal Medicine, CHA Bundang Medical Center, CHA University) ;
  • Seo, Sang Oh (Department of Internal Medicine, CHA Bundang Medical Center, CHA University) ;
  • Choi, Yu Bum (Department of Internal Medicine, CHA Bundang Medical Center, CHA University) ;
  • Lee, Mi Jung (Department of Internal Medicine, CHA Bundang Medical Center, CHA University) ;
  • Lee, Jeong Eun (Department of Internal Medicine, Yongin Severance Hospital) ;
  • Kim, Hyung Jong (Department of Internal Medicine, CHA Bundang Medical Center, CHA University)
  • 김은주 (차의과학대학교 분당차병원 내과) ;
  • 서상오 (차의과학대학교 분당차병원 내과) ;
  • 최유범 (차의과학대학교 분당차병원 내과) ;
  • 이미정 (차의과학대학교 분당차병원 내과) ;
  • 이정은 (용인세브란스병원 내과) ;
  • 김형종 (차의과학대학교 분당차병원 내과)
  • Received : 2017.11.23
  • Accepted : 2017.12.31
  • Published : 2018.12.01
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Abstract

Background/Aims: Assessment of fluid status in hemodialysis patents is very important. Overhydration in hemodialysis is associated with generalized edema, cardiovascular complications, and hypertension. The aim of this study was to determine the factors correlated with mortality of hemodialysis patients, assessing body muscle mass and fluid status using bioelectrical impedance analysis (BIA). Methods: This study enrolled 93 patients who underwent hemodialysis between January 2010 and May 2015 at CHA Bundang Medical Center. Medical records of enrollees up to June 2017 were reviewed retrospectively. These included laboratory results (serum albumin, C-reactive protein [CRP], lipid profile, etc.) and BIA data (extracellular water, intracellular water, total body water, soft lean mass, fat free mass, skeletal muscle mass, etc.). Results: Eleven of 93 patients had expired by May 2017. Among the surviving subjects, mean age was younger, CRP levels were lower, albumin levels were higher, and extracellular water/total body water (ECW/TBW) ratios were lower than in the expired patient group. Kaplan-Meier survival analysis revealed that overhydration (ECW/TBW > 0.4) was associated with higher mortality. Conclusions: In hemodialysis patients, overhydration is an important factor in mortality, and BIA could be a reliable modality in its assessment. We suggest that, for hemodialysis patients, overhydration is more of a risk factor for mortality than is muscle wasting.

목적: 혈액투석 환자에서 체수분 상태는 중요한데 혈액투석 이후의 과수분 상태는 고혈압, 부종, 심혈관계 합병증을 유발할 수 있다. 혈액투석 환자의 근육량 평가 및 체수분 상태를 측정할 수 있는 BIA 검사를 이용하여 혈액투석 환자에서 이환율, 생존율과 관련된 인자를 알아보고자 하였다. 방법: 본 연구는 후향적 연구로 2010년 1월부터 2015년 5월 30일까지 BIA를 측정한 말기 신부전으로 진단받고 투석을 3개월 이상 시행한 환자를 대상으로 하였으며, 2017년 6월 30일까지 추적 관찰하였다. 혈액투석 환자에서 시행하는 기본 혈액 검사와 BIA data (ECW, ICW, TBW, SLM, FFM, SMM 등)를 참조하여 환자의 이환율, 생존율 등을 분석하였다. 결과: 사망군과 생존군에서 SLM, SMM, FFM의 차이는 없었다. 생존군에서 사망군보다 나이, C-반응단백 수치가 낮았고, 혈청 알부민, 부갑상샘호르몬, 인이 높았으며, 총 체액량(TBW) 중 세포외액량(ECW)의 비율은 사망군에서 좀 더 높은 결과를 보였다($0.39{\pm}0.01$ vs. $0.40{\pm}0.01$; p < 0.05). 과수분군을 ECW/TBW ratio > 0.4로 정의하였을 때 Kaplan-Meier 생존분석에서 과수분군에서 통계적으로 유의하게 사망률이 높았다. 결론: 혈액투석 환자에서 BIA로 측정한 근육량 감소과 과수분 상태는 환자의 사망률과 이환율과 관련된 중요한 인자로 생각되며, 근육량 감소보다는 과수분 상태가 사망률과 좀 더 밀접한 관련이 있을 것으로 생각된다.

Keywords

References

  1. Donadio C, Consani C, Ardini M, et al. Estimate of body water compartments and of body composition in maintenance hemodialysis patients: comparison of single and multifrequency bioimpedance analysis. J Ren Nutr 2005;15:332-344. https://doi.org/10.1016/j.jrn.2005.04.001
  2. Meireles MS, Wazlawik E, Bastos JL, Garcia MF. Comparison between nutritional risk tools and parameters derived from bioelectrical impedance analysis with subjective global assessment. J Acad Nutr Diet 2012;112:1543-1549. https://doi.org/10.1016/j.jand.2012.07.005
  3. Locatelli F, Fouque D, Heimburger O, et al. Nutritional status in dialysis patients: a European consensus. Nephrol Dial Transplant 2002;17:563-572. https://doi.org/10.1093/ndt/17.4.563
  4. Abad S, Sotomayor G, Vega A, et al. The phase angle of the electrical impedance is a predictor of long-term survival in dialysis patients. Nefrologia 2011;31:670-676.
  5. Chertow GM, Lowrie EG, Wilmore DW, et al. Nutritional assessment with bioelectrical impedance analysis in maintenance hemodialysis patients. J Am Soc Nephrol 1995;6:75-81.
  6. Cooper BA, Aslani A, Ryan M, et al. Comparing different methods of assessing body composition in end-stage renal failure. Kidney Int 2000;58:408-416. https://doi.org/10.1046/j.1523-1755.2000.00180.x
  7. Lukaski HC, Bolonchuk WW, Hall CB, Siders WA. Validation of tetrapolar bioelectrical impedance method to assess human body composition. J Appl Physiol (1985) 1986;60:1327-1332. https://doi.org/10.1152/jappl.1986.60.4.1327
  8. Tsai YC, Chiu YW, Tsai JC, et al. Association of fluid overload with cardiovascular morbidity and all-cause mortality in stages 4 and 5 CKD. Clin J Am Soc Nephrol 2015;10:39-46. https://doi.org/10.2215/CJN.03610414
  9. Kim YJ, Jeon HJ, Kim YH, et al. Overhydration measured by bioimpedance analysis and the survival of patients on maintenance hemodialysis: a single-center study. Kidney Res Clin Pract 2015;34:212-218. https://doi.org/10.1016/j.krcp.2015.10.006
  10. de Mutsert R, Grootendorst DC, Indemans F, et al. Association between serum albumin and mortality in dialysis patients is partly explained by inflammation, and not by malnutrition. J Ren Nutr 2009;19:127-135. https://doi.org/10.1053/j.jrn.2008.08.003
  11. Scribner BH, Buri R, Caner JE, Hegstrom R, Burnell JM. The treatment of chronic uremia by means of intermittent hemodialysis: a preliminary report. 1960. J Am Soc Nephrol 1998;9:719-726; discussion 719-726.
  12. Kaysen GA. The microinflammatory state in uremia: causes and potential consequences. J Am Soc Nephrol 2001;12:1549-1557.
  13. Joki N, Hase H, Tanaka Y, et al. Relationship between serum albumin level before initiating haemodialysis and angiographic severity of coronary atherosclerosis in end-stage renal disease patients. Nephrol Dial Transplant 2006;21:1633-1639. https://doi.org/10.1093/ndt/gfl037
  14. Dumler F. Hypoalbuminemia is a marker of overhydration in chronic maintenance patients on dialysis. ASAIO J 2003;49:282-286. https://doi.org/10.1097/01.MAT.0000065465.52748.BB
  15. Fan S, Sayed RH, Davenport A. Extracellular volume expansion in peritoneal dialysis patients. Int J Artif Organs 2012;35:338-345. https://doi.org/10.5301/ijao.5000080
  16. Demirci MS, Demirci C, Ozdogan O, et al. Relations between malnutrition-inflammation-atherosclerosis and volume status. The usefulness of bioimpedance analysis in peritoneal dialysis patients. Nephrol Dial Transplant 2011;26:1708-1716. https://doi.org/10.1093/ndt/gfq588
  17. Gallar-Ruiz P, Digioia C, Lacalle C, et al. Body composition in patients on haemodialysis: relationship between the type of haemodialysis and inflammatory and nutritional parameters. Nefrologia 2012;32:467-476.
  18. Huang CX, Tighiouart H, Beddhu S, et al. Both low muscle mass and low fat are associated with higher all-cause mortality in hemodialysis patients. Kidney Int 2010;77:624-629. https://doi.org/10.1038/ki.2009.524
  19. Hung SC, Kuo KL, Peng CH, et al. Volume overload correlates with cardiovascular risk factors in patients with chronic kidney disease. Kidney Int 2014;85:703-709. https://doi.org/10.1038/ki.2013.336
  20. Onofriescu M, Siriopol D, Voroneanu L, et al. Overhydration, cardiac function and survival in hemodialysis patients. PLoS One 2015;10:e0135691. https://doi.org/10.1371/journal.pone.0135691
  21. Park KH, Shin JH, Hwang JH, Kim SH. Utility of volume assessment using bioelectrical impedance analysis in critically ill patients receiving continuous renal replacement therapy: a prospective observational study. Korean J Crit Care Med 2017;32:256-264. https://doi.org/10.4266/kjccm.2017.00136
  22. Chazot C, Wabel P, Chamney P, Moissl U, Wieskotten S, Wizemann V. Importance of normohydration for the long-term survival of haemodialysis patients. Nephrol Dial Transplant 2012;27:2404-2410. https://doi.org/10.1093/ndt/gfr678