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158: Peripheral Blood Hematocrit Is a Poor Surrogate for Red Blood Cell Volume in Patients With Volume Excess or Depletion
A62
NKF 2009 Spring Clinical Meetings Abstracts
157
159
INTRAVASCULAR BLOOD VOLUME ANALYSIS AND NORMALIZED HEMATOCRIT MAY IMPROVE VOLUME AND ANEMIA OPTIMIZATION IN CKD Luana Pillon, *1, Robert Rigolosi, 2, Alexander Vitievsky, 2 and Jeffrey Koslowski, 2. 1 New York University School of Medicine, New York and 2Columbia University. Anemia evaluation is inextricably linked to volume status. We hypothesize that Blood Volume Analysis (BVA) and normalized hematocrit (nHct) will improve intravascular (plasma, RBC) volume assessment leading to a more accurate anemia assessment. Methods: Included were 5 patients (pts) (60-86 yrs) classified as non-anemic (Hgb 10-12g/dl) at steady state, following ultrafiltration (UF) with hemodialysis or peritoneal dialysis. Pts who were not considered anemic and those with iodine allergy were excluded. Tagged tracer dilution intravascular BVA measurement was performed by an independent blinded physician providing plasma volume (PV) Total Blood Volume (TBV), RBC volume (RBCV) and nHct. BVA data classified pts (normo-, hypo- and hypervolemic) based upon +/- 8% deviation from ideal TBV. Results: BVA data (Table 1) showed 2/5 pts (pt 4, pt 5) were anemic (low nHct) and hypovolemic (low TBV); Pts 2-5 were RBC depleted. Pt 5 was severely volume depleted (low: TBV, RBC, PV). Table1. Blood Volume Data % Dev % Dev from pHct % Dev from Patient Age from nHct BVA ID (yrs)/ ITBV IRBCV(Normal IPV(Normal %(Normal % Evaluation 30-36) n=5 sex (Normal 10%) 8%) 8%) 1 60/F -0.7 -10.7 4.9 36.0 35.7 Normovolemic 2 83/M -5.0 -29.5 11.7 33.4 31.7 Normovolemic 3 86/M +5.7 -28.9 29.2 30.0 32.0 Normovolemic 4 77/M -9.6 -35.7 8.2 32.0 28.9 Hypovolemic 5 66/F -31.1 -45.6 -23.0 31.6 21.8 Hypovolemic I=Ideal; Dev=Deviation Conclusions: 1) Volume assessment requires objective measurements, 2) nHct distinguished true anemia from hemodilution, 3) BVA and nHct may provide objective assessment of BV, distinguishing RBC and/or plasma deficit/excess leading to improved volume (UF, diuresis, plasma, RBC) and anemia management.
158
160
PERIPHERAL BLOOD HEMATOCRIT IS A POOR SURROGATE FOR RED BLOOD CELL VOLUME IN PATIENTS WITH VOLUME EXCESS OR DEPLETION. Luana Pillon *1 and Timothy Manzone, 2 1Division of Nephrology, New York University School of Medicine and 2Section of Nuclear Medicine, Christiana Care Health System, DE. We hypothesize that peripheral hematocrit (pHct) is a good proxy for red blood cell volume (RBCV) in all states of hydration. Methods: We enrolled 978 (469 F, 509 M) pts, ages (19-95, median 67.9 yrs), many race/ethnicities and BMIs. Included were pts with critical illness, renal, cardiovascular, and hematological diagnosis, referred for tagged blood volume assessment (BVA), who had simultaneous pHct analyzed. Pts pregnant, nursing or with iodine allergy were excluded. Blinded measurements were made and interpreted by 2 independent physicians. Correlations were made between pHct and tagged isotope volumes. Results: Table 1. Blood Volume Data Avg Dev Avg of nHct BVA Volume pHct Avg from Status % (30- nHct pHCT 36) (%) Hypovolemic 5.93 34.21 28.28 (213 pts) (18%) Euvolemic (393 pts)
BLOOD PRESSURE CONTROL IN CKD BY ANTIHYPERTENSIVE MEDICATION: NHANES 1999-2006 Laura Plantinga, Edgar Miller, III, Lesley Stevens, Rajiv Saran, Bruce Robinson, Nicole Flowers, Linda Geiss, and Neil Powe, for the CDC CKD Surveillance Team Johns Hopkins University, Baltimore, Maryland; Tufts-NEMC, Boston, Massachusetts; University of Michigan, Ann Arbor, Michigan; and Centers for Disease Control and Prevention, Atlanta, Georgia, United States Recent guidelines recommend more aggressive blood pressure (BP) control in patients with chronic kidney disease (CKD), preferably with the use of ACE inhibitors (ACEIs)/ARBs and with multiple antihypertensive medications (AHMs) as necessary. We examined use of AHMs and level of BP control among 1651 adults (20+ years) with CKD and hypertension in NHANES 1999-2006 data. BP control was defined as systolic BP <130 and diastolic BP <80 mmHg. CKD was defined as an eGFR <60 ml/min/1.73 m2; hypertension was defined by self-reported diagnosis, high BP, or use of AHMs. We examined BP control by type of medication and participant characteristics using tests; adjustment was performed using multivariable logistic regression. One-third (34%) of participants with CKD and hypertension were not receiving an AHM; 24% were on ACEIs/ARBs, 19% were on diuretics, and 30% were on other AHMs, including beta blockers (14%) and calcium channel blockers (11%). Overall, 62% of those treated with AHMs were on single agents. With adjustment for age, sex, and race, BP control using ACEIs/ARBs was observed in 37%; diuretics, 33%; and any other AHM, 31%. BP control using ACEIs/ARBs was predicted by younger age (P=0.047) and no albuminuria (P=0.034) but not by use of multiple agents (P=0.901). Nearly one-third of those with CKD and hypertension in the community do not appear to be receiving AHMs. Moreover, of those who were on AHMs, fewer than half demonstrated controlled BP, and the majority were receiving monotherapy. More aggressive BP control strategies, including multiple medications and greater use of ACEI/ARBs, are needed for those with CKD and hypertension.
0.16 37.41 37.25 (0.4%)
Hypervolemic 7.99 37.45 45.44 (372 pts) (21%)
Avg RBCV Range of Dev from Dev of Ideal, ml nHct from pHCT (%) (Normal 10%) 1.6-26.0 -587 ml (-7% -57%) (-32.3%) 0.05-4.48 -238 ml ((+0.14% 12.1%) +7.9%) 2.2-43.7 (+8% +76%)
108 ml (+5.9%)
Avg Plasma Volume Dev from Ideal, ml (Normal 8%) -239 ml (-8.6%) 211 ml (6.84%)
955 ml (30.95%)
Conclusions: By comparing tagged measurements of RBCV to pHct, we found that pHct is a poor surrogate for RBCV in all but euvolemic patioents. PHct may falsely indicate: a low RBCV in states of excess fluid and high RBCV when PV is low. Normalized hematocrit (nHct) which adjusts pHct for volume abnormality may better assess anemia in patients with uncertain volume status. Avg=Average; Dev=Deviation
PREVALENCE OF CHRONIC KIDNEY DISEASE IS HIGH IN PERSONS WITH UNDIAGNOSED OR PRE-DIABETES IN THE UNITED STATES Laura Plantinga, Deidra Crews, Josef Coresh, Rajiv Saran, Elizabeth Hedgeman, Meda Pavkov, Mark Eberhardt and Neil Powe, for the CDC CKD Surveillance Team Johns Hopkins University, Baltimore, Maryland; University of Michigan, Ann Arbor, Michigan; and Centers for Disease Control and Prevention, Atlanta, GA, and Hyattsville, Maryland, United States Diabetes is the leading cause of chronic kidney disease (CKD) in the United States; however, little is known about recent community prevalence of CKD in persons with undiagnosed or pre-diabetes. We estimated CKD prevalence in NHANES 1999-2006 participants who were >20 years old, responded to the diabetes questionnaire, and had fasting plasma glucose (FPG) measurements. Diabetes status was defined as follows: diagnosed diabetes, self-report of a provider diagnosis; undiagnosed diabetes, FPG ≥126 mg/dl without a selfreported diagnosis; pre-diabetes, FPG ≥100 and <126 mg/dl; no diabetes, FPG <100 mg/dl. CKD was defined by an eGFR <60 ml/min/m2 or albumin-to-creatinine ratio of >30 mg/g. CKD prevalence was examined using multivariable logistic regression. Among 8,145 adults, 826 had diagnosed diabetes, 256 had undiagnosed diabetes, 2,272 had pre-diabetes, and 4,791 had no diabetes. After adjustment for age, sex, and race/ethnicity, prevalence of CKD in those with diagnosed diabetes was high, at 32.1%; CKD prevalence was also considerably higher in those with undiagnosed diabetes (23.6%) and pre-diabetes (16.9%), compared to those without diabetes (11.8%; P<0.001 across groups). Of all cases of CKD, 37.1% occurred in participants with undiagnosed or pre-diabetes. Only 3.0% and 3.9%, respectively, of those with CKD in these groups were aware of their CKD. Older and female participants with no or pre-diabetes were more likely to have CKD than their younger and male counterparts. No significant age or sex differences in CKD prevalence were observed among those with diagnosed or undiagnosed diabetes. CKD prevalence is high and awareness is low among persons with undiagnosed and pre-diabetes, who would likely benefit from interventions to prevent progression of both CKD and diabetes.
NKF 2009 Spring Clinical Meetings Abstracts
157
159
INTRAVASCULAR BLOOD VOLUME ANALYSIS AND NORMALIZED HEMATOCRIT MAY IMPROVE VOLUME AND ANEMIA OPTIMIZATION IN CKD Luana Pillon, *1, Robert Rigolosi, 2, Alexander Vitievsky, 2 and Jeffrey Koslowski, 2. 1 New York University School of Medicine, New York and 2Columbia University. Anemia evaluation is inextricably linked to volume status. We hypothesize that Blood Volume Analysis (BVA) and normalized hematocrit (nHct) will improve intravascular (plasma, RBC) volume assessment leading to a more accurate anemia assessment. Methods: Included were 5 patients (pts) (60-86 yrs) classified as non-anemic (Hgb 10-12g/dl) at steady state, following ultrafiltration (UF) with hemodialysis or peritoneal dialysis. Pts who were not considered anemic and those with iodine allergy were excluded. Tagged tracer dilution intravascular BVA measurement was performed by an independent blinded physician providing plasma volume (PV) Total Blood Volume (TBV), RBC volume (RBCV) and nHct. BVA data classified pts (normo-, hypo- and hypervolemic) based upon +/- 8% deviation from ideal TBV. Results: BVA data (Table 1) showed 2/5 pts (pt 4, pt 5) were anemic (low nHct) and hypovolemic (low TBV); Pts 2-5 were RBC depleted. Pt 5 was severely volume depleted (low: TBV, RBC, PV). Table1. Blood Volume Data % Dev % Dev from pHct % Dev from Patient Age from nHct BVA ID (yrs)/ ITBV IRBCV(Normal IPV(Normal %(Normal % Evaluation 30-36) n=5 sex (Normal 10%) 8%) 8%) 1 60/F -0.7 -10.7 4.9 36.0 35.7 Normovolemic 2 83/M -5.0 -29.5 11.7 33.4 31.7 Normovolemic 3 86/M +5.7 -28.9 29.2 30.0 32.0 Normovolemic 4 77/M -9.6 -35.7 8.2 32.0 28.9 Hypovolemic 5 66/F -31.1 -45.6 -23.0 31.6 21.8 Hypovolemic I=Ideal; Dev=Deviation Conclusions: 1) Volume assessment requires objective measurements, 2) nHct distinguished true anemia from hemodilution, 3) BVA and nHct may provide objective assessment of BV, distinguishing RBC and/or plasma deficit/excess leading to improved volume (UF, diuresis, plasma, RBC) and anemia management.
158
160
PERIPHERAL BLOOD HEMATOCRIT IS A POOR SURROGATE FOR RED BLOOD CELL VOLUME IN PATIENTS WITH VOLUME EXCESS OR DEPLETION. Luana Pillon *1 and Timothy Manzone, 2 1Division of Nephrology, New York University School of Medicine and 2Section of Nuclear Medicine, Christiana Care Health System, DE. We hypothesize that peripheral hematocrit (pHct) is a good proxy for red blood cell volume (RBCV) in all states of hydration. Methods: We enrolled 978 (469 F, 509 M) pts, ages (19-95, median 67.9 yrs), many race/ethnicities and BMIs. Included were pts with critical illness, renal, cardiovascular, and hematological diagnosis, referred for tagged blood volume assessment (BVA), who had simultaneous pHct analyzed. Pts pregnant, nursing or with iodine allergy were excluded. Blinded measurements were made and interpreted by 2 independent physicians. Correlations were made between pHct and tagged isotope volumes. Results: Table 1. Blood Volume Data Avg Dev Avg of nHct BVA Volume pHct Avg from Status % (30- nHct pHCT 36) (%) Hypovolemic 5.93 34.21 28.28 (213 pts) (18%) Euvolemic (393 pts)
BLOOD PRESSURE CONTROL IN CKD BY ANTIHYPERTENSIVE MEDICATION: NHANES 1999-2006 Laura Plantinga, Edgar Miller, III, Lesley Stevens, Rajiv Saran, Bruce Robinson, Nicole Flowers, Linda Geiss, and Neil Powe, for the CDC CKD Surveillance Team Johns Hopkins University, Baltimore, Maryland; Tufts-NEMC, Boston, Massachusetts; University of Michigan, Ann Arbor, Michigan; and Centers for Disease Control and Prevention, Atlanta, Georgia, United States Recent guidelines recommend more aggressive blood pressure (BP) control in patients with chronic kidney disease (CKD), preferably with the use of ACE inhibitors (ACEIs)/ARBs and with multiple antihypertensive medications (AHMs) as necessary. We examined use of AHMs and level of BP control among 1651 adults (20+ years) with CKD and hypertension in NHANES 1999-2006 data. BP control was defined as systolic BP <130 and diastolic BP <80 mmHg. CKD was defined as an eGFR <60 ml/min/1.73 m2; hypertension was defined by self-reported diagnosis, high BP, or use of AHMs. We examined BP control by type of medication and participant characteristics using tests; adjustment was performed using multivariable logistic regression. One-third (34%) of participants with CKD and hypertension were not receiving an AHM; 24% were on ACEIs/ARBs, 19% were on diuretics, and 30% were on other AHMs, including beta blockers (14%) and calcium channel blockers (11%). Overall, 62% of those treated with AHMs were on single agents. With adjustment for age, sex, and race, BP control using ACEIs/ARBs was observed in 37%; diuretics, 33%; and any other AHM, 31%. BP control using ACEIs/ARBs was predicted by younger age (P=0.047) and no albuminuria (P=0.034) but not by use of multiple agents (P=0.901). Nearly one-third of those with CKD and hypertension in the community do not appear to be receiving AHMs. Moreover, of those who were on AHMs, fewer than half demonstrated controlled BP, and the majority were receiving monotherapy. More aggressive BP control strategies, including multiple medications and greater use of ACEI/ARBs, are needed for those with CKD and hypertension.
0.16 37.41 37.25 (0.4%)
Hypervolemic 7.99 37.45 45.44 (372 pts) (21%)
Avg RBCV Range of Dev from Dev of Ideal, ml nHct from pHCT (%) (Normal 10%) 1.6-26.0 -587 ml (-7% -57%) (-32.3%) 0.05-4.48 -238 ml ((+0.14% 12.1%) +7.9%) 2.2-43.7 (+8% +76%)
108 ml (+5.9%)
Avg Plasma Volume Dev from Ideal, ml (Normal 8%) -239 ml (-8.6%) 211 ml (6.84%)
955 ml (30.95%)
Conclusions: By comparing tagged measurements of RBCV to pHct, we found that pHct is a poor surrogate for RBCV in all but euvolemic patioents. PHct may falsely indicate: a low RBCV in states of excess fluid and high RBCV when PV is low. Normalized hematocrit (nHct) which adjusts pHct for volume abnormality may better assess anemia in patients with uncertain volume status. Avg=Average; Dev=Deviation
PREVALENCE OF CHRONIC KIDNEY DISEASE IS HIGH IN PERSONS WITH UNDIAGNOSED OR PRE-DIABETES IN THE UNITED STATES Laura Plantinga, Deidra Crews, Josef Coresh, Rajiv Saran, Elizabeth Hedgeman, Meda Pavkov, Mark Eberhardt and Neil Powe, for the CDC CKD Surveillance Team Johns Hopkins University, Baltimore, Maryland; University of Michigan, Ann Arbor, Michigan; and Centers for Disease Control and Prevention, Atlanta, GA, and Hyattsville, Maryland, United States Diabetes is the leading cause of chronic kidney disease (CKD) in the United States; however, little is known about recent community prevalence of CKD in persons with undiagnosed or pre-diabetes. We estimated CKD prevalence in NHANES 1999-2006 participants who were >20 years old, responded to the diabetes questionnaire, and had fasting plasma glucose (FPG) measurements. Diabetes status was defined as follows: diagnosed diabetes, self-report of a provider diagnosis; undiagnosed diabetes, FPG ≥126 mg/dl without a selfreported diagnosis; pre-diabetes, FPG ≥100 and <126 mg/dl; no diabetes, FPG <100 mg/dl. CKD was defined by an eGFR <60 ml/min/m2 or albumin-to-creatinine ratio of >30 mg/g. CKD prevalence was examined using multivariable logistic regression. Among 8,145 adults, 826 had diagnosed diabetes, 256 had undiagnosed diabetes, 2,272 had pre-diabetes, and 4,791 had no diabetes. After adjustment for age, sex, and race/ethnicity, prevalence of CKD in those with diagnosed diabetes was high, at 32.1%; CKD prevalence was also considerably higher in those with undiagnosed diabetes (23.6%) and pre-diabetes (16.9%), compared to those without diabetes (11.8%; P<0.001 across groups). Of all cases of CKD, 37.1% occurred in participants with undiagnosed or pre-diabetes. Only 3.0% and 3.9%, respectively, of those with CKD in these groups were aware of their CKD. Older and female participants with no or pre-diabetes were more likely to have CKD than their younger and male counterparts. No significant age or sex differences in CKD prevalence were observed among those with diagnosed or undiagnosed diabetes. CKD prevalence is high and awareness is low among persons with undiagnosed and pre-diabetes, who would likely benefit from interventions to prevent progression of both CKD and diabetes.