Comparison between clinical judgment and integrated lung and inferior vena cava ultrasonography for dry weight estimation in hemodialysis patients

Abstract

Introduction: Correct dry weight estimation is very crucial for hemodialysis (HD) patients to maintain euvolemia. Most dialysis centers practice clinical judgment for dry weight estimation, which is subjective and can differ significantly from the actual weight. We designed this study to redefine the clinically estimated dry weight of patients on HD using integrated lung–inferior vena cava (IVC) ultrasonography (USG) and compare the symptoms arising due to volume overload and/or volume depletion before and after modifying the dry weight. Methods: Breathlessness and orthostatic giddiness were scored and documented for 2 weeks while patients were on HD based on clinically estimated dry weight and again for 2 weeks after redefining dry weight using lung–IVC USG. New dry weight was defined as the weight of the patient at which the number of B‐lines was <4 on eight site lung USG and IVC collapsibility index was between 50% and 75%. Findings: After redefining the dry weight, 34 patients (group I) had change in dry weight and 40 (group II) had no change. There was 0.21 ± 1.80 reduction in the score for orthostatic giddiness in group I and 0.03 ± 0.16 in group II (P = 0.147). The score for breathlessness during the 24 hours following dialysis reduced by 0.21 ± 0.41 in group I, but did not change in group II (P = 0.003). Score for breathlessness in the predialysis day reduced by 0.56 ± 0.56 in group I and by 0.05 ± 0.22 in group II (P < 0.001). Discussion: Symptoms related to volume overload and depletion were less when HD prescription was based on lung–IVC USG defined dry weight.

Ultrasonographic Assessment of Extravascular Lung Water in Hospitalized Patients Requiring Hemodialysis: A Prospective Observational Study

“…B-lines were defined as an echogenic, coherent, dynamic, wedge-shaped signal with a narrow origin in the near field of the image arising from the pleural line and extending to the screen’s edge [6]. TBLN ≥4 suggests increased EVLW [4]. In this study, we performed the analyses using the full cohort and a subcohort in which participants were found to have ≥4 TBLN at predialysis.…”

“…There is no consensus regarding the optimal method of extracellular volume assessment in HD patients [2, 3]. Volume assessment is usually based on clinical judgment [4], but dry weight estimation is subjective and can often be inaccurate and differ significantly from the actual dry weight.…”

Recommendations for Lung Ultrasound in Internal Medicine

“…Experts’ comments [ 66 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 ]: Studies concerning dialysis patients most frequently follow the protocol of assessing 28 scans of the anterolateral chest, adapted from cardiologic examinations. The interpretation of the examination results is sometimes modified by resigning from the notion of “mild congestion”.…”

Lung Ultrasound to Diagnose Pulmonary Congestion Among Patients on Hemodialysis: Comparison of Full Versus Abbreviated Scanning Protocols

“…7 They propose dry weight reduction guided by 8-zone LUS with 2 anterior and 2 lateral zones in each hemithorax which, in conjunction with inferior vena cava assessment, was shown to decrease symptoms of dyspnea among patients with ESKD on HD. 8 A similar protocol among outpatients with chronic heart failure showed that patients in the highest tertile of B-lines had a 4-fold increase in the composite outcome of heart failure hospitalization or all-cause mortality. 9 pulmonary congestion, quantified using a further simplified 4zone LUS, was shown to decrease with diuretic therapy and identified patients at risk for adverse events in-hospital and on discharge among patients hospitalized with acute decompensated heart failure.…”