|Year : 2022 | Volume
| Issue : 2 | Page : 200-204
Is Inferior vena cava diameter, a reliable indicator for fluid status in end-stage renal disease patients? - A prospective observational study
Viral Trivedi, Megha Prajapati, Devendra Jayantibhai Prajapati, Guruprasad Bhosale, Janki Nayak, Harsh Panchal
Department of Anesthesia, IKDRC-ITS, Ahmedabad, Gujarat, India
|Date of Submission||05-Apr-2021|
|Date of Acceptance||19-Jul-2021|
|Date of Web Publication||30-Jun-2022|
Dr. Megha Prajapati
PG Hostel, Civil Hospital Campus Medicity, Asarva, Ahmedabad, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: Adequate allograft perfusion is the key component of renal-transplant surgeries. This requires meticulous management of volume status in end-stage renal disease (ESRD) patients on maintenance hemodialysis (MHD). Various methods have been tried to unveil the most dependable parameter. So far, central venous pressure (CVP) has been a reliable parameter for guiding fluid therapy. Recently, in the past decade, inferior vena cava (IVC) diameter (IVCD) has emerged as a promising indicator for volume assessment in critically ill patients. However, very limited data are available regarding use of IVC diameter in ESRD patients. This study is an attempt to determine the efficacy of IVC diameter in predicting the volume status of renal-transplant recipients by comparing it with conventional method, CVP. Methods: Enrolling 60 live donor renal-transplant recipients from a single center, the mean IVCD and IVC collapsibility index (IVC-CI) were measured and compared with CVP. IVC measurements were recorded using bedside ultrasonography. CVP was measured using central venous catheter placed in superior vena cava, through a water column on a standardized scale. The data were analyzed using SPSS Version 20. Results: The mean age of the participants was 38.92 ± 10.46 years. The mean CVP was 6.78 ± 2.86 cmH2O, the mean IVCD was 1.30 ± 0.43 cm, the mean IVC-CI was 24.27% ± 15.45%. Based on Pearson's correlation test, there was no linear correlation between CVP and IVCD as well as CVP and IVC-CI. Conclusion: For the assessment of fluid status and fluid responsiveness in ESRD patients with MHD, ultrasound assessment of IVCD and IVC-CI is not routinely helpful.
Keywords: Caval index, central venous pressure, inferior vena cava, ultrasound, volume status
|How to cite this article:|
Trivedi V, Prajapati M, Prajapati DJ, Bhosale G, Nayak J, Panchal H. Is Inferior vena cava diameter, a reliable indicator for fluid status in end-stage renal disease patients? - A prospective observational study. Indian J Transplant 2022;16:200-4
|How to cite this URL:|
Trivedi V, Prajapati M, Prajapati DJ, Bhosale G, Nayak J, Panchal H. Is Inferior vena cava diameter, a reliable indicator for fluid status in end-stage renal disease patients? - A prospective observational study. Indian J Transplant [serial online] 2022 [cited 2022 Sep 25];16:200-4. Available from: https://www.ijtonline.in/text.asp?2022/16/2/200/349355
| Introduction|| |
Perioperative fluid management is extremely crucial for optimal graft function of renal-transplant recipients. Various methods of volume assessment have been described, but no single gold standard measure has been proven to exist in end-stage renal disease (ESRD) patients for accurate measurement of intravascular volume.,, Central venous pressure (CVP) is still the cornerstone method in the field of renal transplantation to guide the fluid. Ultrasonographic inferior vena cava (IVC) diameter (IVCD) has rapidly emerged as a noninvasive and reproducible method of volume status assessment for critically ill patients. Till now, no clinical documented study in the field of renal transplantation is available to assess the role of IVCD for ESRD patients' volume status assessment by comparing it with most commonly used conventional method CVP. We aim to answer this question in regard to clinical application of IVCD in ESRD patients on MHD.
| Methods|| |
For our prospective observational study, the sample size of 60 patients was calculated using computer software to determine correlation coefficient (rho) of 0.5, using a 5% significance level (α = 0.05) and 80% statistical power (β =0.2). After taking institutional ethical committee approval and written informed consent, 60 renal-transplant recipients (ESRD patients on MHD) were enrolled in the study on the day of renal transplantation. The duration of this study is 2 years from data collection to report writing.
Patient's ≥18 years of age with an intrathoracic central venous catheter terminating in the distal superior vena cava were included in the study.
Patients with clinical signs of elevated abdominal pressure, thrombosis or narrow lumen of right internal jugular vein (IJV), intracardiac shunts, and valvular heart diseases were excluded.
After taking written informed consent and induction of balanced general anesthesia, under all aseptic precautions, right-sided IJV cannulated with double-lumen IJV catheter for CVP measurement under ultrasonography vascular probe guidance. Two different resident doctors were designated for CVP measurement and IVCD measurement. Both of them were not the part of this study. With patient in the supine position, mid-axillary line was taken as the zero point in the centimeter (cm) of H2O scale placed just besides patient head on intravenous fluid stand. Two three ways were connected to IJV catheter to guide the fluid in centimeter of water column on pint stand from attached fluid line. Two different values were measured in two different phases of the respiratory cycle (considering the well-known fact of venous collapsibility during respiration) and mean value is calculated in cm of H2O. A designated resident doctor for subxyphoid IVC diameter measurement was given 1 week training at radiology department to decrease operated-related measurement bias. For IVCD measurement, Philips Ultrasound abdominal curvilinear probe (C5-1) of ultrasound machine was used as shown in [Figure 1]. IVC measurements were made 1 cm distal to the confluence of the hepatic vein and IVC, using two-dimensional mode and M-mode ultrasonography in the subxyphoid region. Two different values are measured in expiration and inspiration and the mean value is calculated. No intravascular fluid was administered between CVP and IVCD measurements.
Age, sex, body mass index registration number, heart rate, noninvasive blood pressure, and IVC collapsibility index (CI) data were analyzed for association. The IVC-CI was calculated, from the data, as follows: IVC-CI = [(IVCD maximum − ICVD minimum)/(IVC diameter maximum)] ×100.
The Statistical Package for the Social Science (IBM SPSS Version 20) software was used for data analysis. Quantitative variables are expressed as mean ± standard deviation and qualitative variables are expressed as frequency as well as in percentage. For correlation of two variables, Pearson's correlation was used to test the association between CVP mean value and IVC mean diameter as well as CVP mean value and IVC-CI. The level of significance was set at P < 0.05 for statistical analysis.
The authors certify that patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names and initials would not be published, and all standard protocols will be followed to conceal their identity.
The study has been approved by Institutional ethics committee of IKDRC-ITS with reference number IKDRCITSEC/2/2019. The study was performed according to the guidelines in Declaration of Helsinki.
| Results|| |
A total of 60 patients were included in this study. Out of these, 68% (n =41 ) were male and 32% (n = 19) were female with a mean age of 38.92 ± 10.46 years. This is presented in [Table 1]. This shows gender discrepancy and social status of our center in the renal-transplant field. The mean CVP was 6.78 ± 2.86 cm H2O. The mean ICVD was 1.30 ± 0.43 cm and IVCD min 0.98 ± 0.39 cm. The mean IVC-CI was 24.27% ±15.45%. The mean heart rate was 89.63 ± 18.24. The mean systolic blood pressure was 129.25 ± 23.15. The mean diastolic blood pressure was 83.47 ± 15.19. All these parameters are presented in [Table 2] and [Figure 2]. The Pearson's correlation analysis revealed that there is no significant linear correlation between IVCD mean and CVP (r = 0.23) as well as IVC-CI mean and CVP mean (0.14). These are presented in [Figure 3] and [Figure 4].
|Table 1: Demographic profile: Mean age of our study participants were 38.92±10.46 years|
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|Table 2: Mean of vitals (heart rate, systolic blood pressure, diastolic blood pressure) and variables (central venous pressure, inferior vena cava diameter, inferior vena cava-collapse index)|
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|Figure 2: Mean of vitals and variables HR: Heart rate, SBP: Systolic blood pressure, DBP: Diastolic blood pressure, CVP: Central venous pressure, IVCD: Inferior vena cava diameter, CI: Collapse index|
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|Figure 3: Correlation between the CVP and IVCD max. CVP: Central venous pressure, IVCD: Inferior vena cava diameter|
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|Figure 4: Correlation between the CVP and IVC-CI. CVP: Central venous pressure, CI: Collapse index, IVC: Inferior vena cava|
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P value of comparative analysis between mean values of CVP and IVCD (0.08) as well as CVP and IVC-CI (0.30) is presented in [Table 3] and [Table 4] which are statistically not significant (P > 0.05).
|Table 3: Correlation between the central venous pressure and inferior vena cava diameter maximum|
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|Table 4: Correlation between the central venous pressure and inferior vena cava-collapse index|
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| Discussion|| |
Adequate intravenous fluid therapy is crucial in renal-transplant recipients to ensure early and good graft perfusion for successful kidney transplantation., CVP has been considered the cornerstone to guide the fluid therapy for decades; it was the only available simple tool worldwide. However, the revolutionary advances in assessing the dynamic preload variables together with the availability of new equipment to precisely measure the effect of intravenous fluids on the cardiac output had created good alternatives to CVP [Figure 5]., IVCD measurement using ultrasound probes has emerged as a good alternative to CVP in critical care settings. Despite the critical role of fluid therapy in the field of transplantation, there are only a few clinical studies that compared the conventional CVP-guided fluid therapy with the other modern techniques and their relation to the outcome in renal transplantation. Our work sheds some light as we compared CVP with IVCD for ESRD patients with MHD.
The IVCD and IVC-CI are associated with volume status and found to be significantly higher in patients with volume loss. Ultrasound measurement of IVCD has been shown to be consistently low in hypovolemic patients., Ultrasound could provide a safe, rapid, noninvasive, and easily repeatable assessment of volume status in the emergency center. It may be used as an alternative adjunctive measure of volume status. Due to limited studies and insufficient data, the use of IVC diameter as a stand-alone measure of volume status in ESRD patients is not popular till now.
Due to changes in cardiovascular physiology of ESRD patients with MHD, overload and congestion are very serious problems causing morbidity and mortality in day-to-day life. Therefore, it is quite important to avoid volume overload and maintain dry weight in HD patients. Best time to assess these groups of patients is on the day of renal transplant as they are optimized properly. Hence, in our study, we took all measurements just before renal-transplant surgery as they were optimized properly.
Respiration is associated with changes in venous return by changing intrathoracic pressure. This phenomenon is associated with changing in CVP and IVCD with respiration cycle. To counter this problem in our study, we calculated mean value from maximum and minimum measured values of CVP and IVCD., Juhl-Olsen et al. did research on finding the best approach of IVC diameter measurement following acute blood loss and concluded that there are no differences in approaching IVC in perpendicular (short) axis and longitudinal (long) axis. This finding support our study as in our methodology we used perpendicular subxyphoid axis for IVC measurement.
Pearson's correlation analysis of mean CVP and mean IVCD as well as mean CVP and mean IVC-CI in our study group patients showed no linear correlation. Altered cardiovascular physiology in terms of blood volume and right heart pressure of ESRD patients could be one of the leading reasons for no correlation., There are few published studies which are supporting our study.
In one of the interesting retrospective studies done by Govender et al., the authors conducted on 24 critically ill patients with median age group of 36 years showed no correlation between CVP and IVC-CI. They took the data from critically ill patients admitted to emergency center of their hospital. Moreover, their findings are supporting our study.
In a recent article by Millington, the author concluded that IVCD is not so helpful in majority of patients even though it is easy, rapid, and reproducible method of volume assessment. This findings correlated with our study as the conclusion of our study is suggestive of IVCD is not correlating with CVP for volume status analysis of ESRD patients.
Another study done by Muller et al. found that low variations in IVCD (<50%) do not exclude fluid responsiveness. It suggests that IVC-CI if high does not exclude volume responsiveness. Moreover, this finding is supporting our study in regard that CVP mean value is not correlating with IVC-CI for volume analysis. Very interesting meta-analysis done by Orso et al. includes 26 studies of IVC-CI and 5 studies on IVCD measurement to find out their volume association concluded that ultrasonographic measurement of IVCD and their respiratory variations are not reliable indicator of fluid responsiveness. Moreover, this meta-analysis is supporting our study.
Limitation and future directions
IVCD does not only depend on volume status but also it may be affected by respiration, blood volume, right heart function, and intra-abdominal or intrathoracic pressure changes. It is also shown that IVC imaging can be challenging, especially in patients with large body habitus, excessive bowel gas, or large amounts of intrathoracic air. Furthermore, since ultrasonography findings are highly conductor dependent, the results might change between people to person.,, There are studies suggesting that IVC ultrasonography may give false results depending on the approaches taken by the conductor. They state that the axis of collapse and the level of collapse should be determined carefully since it may change the outcome. Thus, we conclude that even though IVCD is a good indicator for volume status analysis in critical care patients, but its utility should be studied on larger trial for ESRD patients where it is not so reliable indicator of volume assessment.
| Conclusion|| |
For the assessment of fluid status and fluid responsiveness in ESRD patients with MHD, ultrasound assessment of IVCD and IVC-CI are not routinely helpful.
We sincerely thank to the whole department of anesthesia and radiology for providing cordial environment to conduct the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]