Key result
Pedal edema and pulmonary crackles had limited accuracy in detecting excess predialysis fluid overload > 2.2 L (AUC 0.534 and 0.551, respectively) among asymptomatic dialysis patients.
Why the study?
Assessment of dry-weight in dialysis patients is challenging without reliable markers, prompting evaluation of pedal edema and pulmonary crackles to diagnose hypervolemia against bioimpedance spectroscopy.
Does physical examination (pedal edema and pulmonary crackles) accurately detect hypervolemia in asymptomatic patients on chronic dialysis?
Cross-Sectional (n=107)
Does physical examination (pedal edema and pulmonary crackles) accurately detect hypervolemia in asymptomatic patients on chronic dialysis?
Effect estimate: AUC 0.534 (pedal edema); AUC 0.551 (pulmonary crackles) (95% CI 0.416-0.651 (pedal edema); 0.432-0.671 (pulmonary crackles))
Physical examination signs such as pedal edema and pulmonary crackles have poor diagnostic accuracy for detecting fluid overload in asymptomatic dialysis patients compared to bioimpedance spectroscopy.
INTRODUCTION: Assessment of dry-weight among patients on dialysis is challenging in the absence of reliable markers to define fluid overload (FO). This study aimed to explore the value of two simple clinical signs, pedal edema, and crackles at pulmonary auscultation, in diagnosing hypervolemia, using bioimpendence spectroscopy (BIS) as reference standard. METHODS: In a cohort of 107 asymptomatic dialysis patients, FO was assessed with physical examination and BIS shortly before the mid-week dialysis session. Patients were also asked to perform home blood pressure (BP) monitoring with a validated, automatic device (HEM-705, Omron, Healthcare) for 1 week in order to determine their BP outside of dialysis. FINDINGS: Patients within the high tertile of predialysis FO had longer dialysis vintage, lower serum albumin and higher home systolic BP, despite the more aggressive treatment with a higher average number of antihypertensives daily. In receiver-operating-characteristic (ROC) curve analysis, pedal edema (area under curve [AUC]: 0.534; 95% confidence interval [CI]: 0.416-0.651) and pulmonary crackles (AUC: 0.551; 95% CI: 0.432-0.671) had limited accuracy in detecting excess predialysis FO > 2.2 L. The agreement of pedal edema (k-coefficient: 0.065) and pulmonary crackles (k-coefficient: 0.122) with BIS-derived FO was poor. In multivariate linear regression analysis, longer dialysis vintage (β: 0.306, p < 0.001) and higher home systolic BP (β: 0.287, p < 0.01) were the two factors that were associated with predialysis FO. CONCLUSIONS: This study showed that among asymptomatic dialysis patients, pedal edema and pulmonary crackles in physical examination had limited discriminatory power in detection of FO, as assessed with the method of BIS.
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Tsikliras et al. (2021) conducted a cross-sectional in Chronic dialysis (n=107). Physical examination (pedal edema and pulmonary crackles) vs. Bioimpedance spectroscopy (BIS) was evaluated on Detection of excess predialysis fluid overload > 2.2 L (AUC 0.534 (pedal edema); AUC 0.551 (pulmonary crackles), 95% CI 0.416-0.651 (pedal edema); 0.432-0.671 (pulmonary crackles)). Pedal edema and pulmonary crackles had limited accuracy in detecting excess predialysis fluid overload > 2.2 L (AUC 0.534 and 0.551, respectively) among asymptomatic dialysis patients.
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