Use of lung ultrasonography to determine the accuracy of clinically estimated dry weight in chronic hemodialysis patients

1. Use of lung ultrasonography to determine the accuracy
of clinically estimated dry weight in chronic hemodialysis
patients
Moh’d Sharshir, MD
Nephrology Fellow

2. Introduction
• Volume expansion is an
insidious and modifiable risk
factor associated with a high
occurrence of death in end-
stage renal disease (ESRD)
patients receiving hemodialysis
(HD).
Kalantar-Zadeh K, Regidor DL, Kovesdy CP et al (2009) Fluid retention is associated with cardiovascular mortality in patients undergoing long-term hemodialysis. Circulation 119:671–679

3. Introduction
• Fluid accumulation, as
measured by interdialytic
weight gain, predicts death and
cardiovascular events
independently of other risk
factors in this population.
Wizemann V, Wabel P, Chamney P et al (2009) The mortality risk of overhydration in haemodialysis patients. Nephrol Dial Transplant 24:1574–1579

4. Introduction
• Chronic overhydration leads to numerous
cardiovascular manifestations such as
pulmonary edema, hypertension, and
peripheral edema.

5. Introduction
• A demonstrable decrease in morbidity
and mortality following the reversal of
overhydration has been well documented
[3–5].

6. Introduction
• Thus, one of the major goals in the care
of chronic hemodialysis patients is to
remove excess fluid in order to reach the
state of what has been termed “dry
weight.”
• Despite decades of research, a gold
standard for the determination of dry
weight (DW) remains elusive.

7. Introduction
The goal of this study was to evaluate the utility of LUS to determine
the accuracy of prescribed dry weight (DW) in chronic hemodialysis
(HD) patients and to ascertain the adequacy of fluid removal.
They hypothesized that the number of B-lines found in patients
before therapy compared to the number at the end of a dialysis
session would reveal the degree of success regarding fluid removal.

8. Introduction
Trezzi et al. investigated
the real-time reduction in
“B-lines” (sonographic
findings representing
pulmonary interstitial
edema) in hemodialysis
patients using LUS.
01
investigators concluded
that the number of B-lines
was associated with
accumulated fluid before
treatment as well as with
decreases during
intradialytic weight loss.
02
Trezzi M, Torzillo D, Ceriani E et al (2013) Lung ultrasonography for the assessment of rapid extravascular water variation: evidence from hemodialysis patients. Intern Emerg Med 8:409–415

9. Introduction
A substudy of the LUST
Trial by Torino et al.
01
discovered that traditional
physical examination,
including lung auscultation
and presence of peripheral
edema, had very poor
correlation with the
presence of excess lung
water as demonstrated by
lung sonography.
02
Torino C, Gargani L, Sicari R et al (2016) The Agreement Between Auscultation and Lung Ultrasound in Hemodialysis Patients: the LUST Study. Clin J Am Soc Nephrol 11:2005–2011

10. Methods
Our study was performed on patients with ESRD undergoing
hemodialysis at Lenox Hill Hospital in New York City, USA.
This study was conducted on 20 patients
from January 1, 2017 to April 1, 2017.

11. Methods
Inclusion criteria were:
All subjects must be on
chronic HD at least three
times a week and have a
dialysis vintage of at least 3
months.
Exclusion criteria were:
Interstitial lung disease.
Consolidation on CXR.
NYHA III-IV heart failure.
Inability to obtain standing
weights.
Recent acute coronary
syndrome (within 4 weeks).
Bleeding complications
during the admission.

12. Methods
1
Lung ultrasound was
performed immediately
before and after (within 15
min) each dialysis
session.
2
B-lines were defined as
an echogenic artifact with
a narrow origin on the
pleural line

13. Methods

14. Methods
• For this study, the initial treatment EDW (Estimated dry
weight) was prescribed by reference to the patient’s
recent HD flow sheet and bedside clinical evaluation.

15. Methods
• In stable patients who appeared to exhibit excess fluid, fluid
removal was continued as tolerated during the procedure.
• For patients who exhibited residual B-lines at the end of the
first HD session, a subsequent HD session employed a
challenge for a new DW

16. Baseline patient
information

17. Baseline patient
information

18. Exploratory end points

19. Exploratory end points
• Among these patients, B-lines disappeared in 7 patients at the end of the HD session (mean
B-lines 4.2–0).
• One patient was 0.3 kg away from the prescribed DW, but the mean variance in the other 6
patients was 1.7 kg below DW.
• Of the remaining 10 patients, eight decreased but did not eliminate the B-lines (mean B-lines
15.5–3.8) and were 3.8 kg below DW.
• Two patients could not reach DW or eliminate the B-lines (mean B-lines 24.5–10.0) and were
3.2 kg above DW.
• Both patients exhibited more profound cardiac insufficiency than initially recognized.

20. Exploratory end points
• Eight patients who had residual B-lines at the end of the first HD session.
• had their DW re-estimated and had a second consecutive HD session in which
their DW was further challenged.
• Of these 8 patients, two patients were able to eliminate the B-lines (mean 2.5–0)
and reached 1.2 kg below EDW.
• The other six patients did not eliminate the B-lines (mean 11.5–4.2) but were able
to reach 0.6 kg below EDW following the challenge.

21. Correlation analyses of the lung sonographic
parameters to the hemodialysis parameters
 Statistical significance (P < 0.05) was achieved for correlation
between the intradialytic percentage change in B-lines and
the percent change in total body weight reduction (r = 0.40)
and with the intradialytic percentage change in B-lines and the
ultrafiltration rate (r = 0.33).

22. Correlation analyses of the lung sonographic
parameters to the hemodialysis parameters
 However, statistical significance was not reached for
correlation between the absolute change in B-lines and the
absolute change in body weight or the absolute change in
systolic blood pressure or diastolic blood pressure.

23. Adverse events
o Eight adverse events occurred during this study.
 They consisted of intradialytic hypotension with SBP ≤ 90 mmHg at
any point intradialysis (5 out of 25 dialysis sessions).
 Cramping (3 out of 25 dialysis sessions).
 Nausea (1 out of 25 dialysis sessions).
 Dizziness (1 out of 25 dialysis sessions.

24. Conclusions
• This study supports the hypothesis that reduction in B-lines
during HD can provide accurate information regarding
changes in pulmonary fluid content.
• LUS is a valuable diagnostic tool for recognizing both the
adequacy of fluid removal and the occurrence of error in the
estimation of dry weight by usual clinical parameters.