JLE

Néphrologie & Thérapeutique

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Conservative management option in elderly patients Volume 12, issue 2, Avril 2016

Authors

Background/Aim

Fluid overload and cardiac dysfunction is well established in hemodialysis patients. But in predialysis chronic kidney disease, the association of fluid overload and cardiac dysfunction is relatively unknown. In this study, we aimed to investigate the relationship between fluid overload and cardiac dysfunction in predialysis chronic kidney disease patients.

Method

We enrolled 107 consecutive patients in our study. Fluid overload was assessed via body composition monitor. Patients were dichotomized according to the fluid overload status. The patients with FO<1.1L were determined as normovolemic and those with FO≥1.1L as hypervolemic according to the previously reported physiologic model. Left atrial volume index (LAVI), left ventricular end-diastolic–end-systolic index (LVEDVI, LVESVI), E/e’, LVMI and global longitudinal left ventricular left ventricular strain (GLS-%) were evaluated in each patient as markers of cardiac dysfunction. Arterial stiffness was also assessed by Mobil-O-Graph® 24h pulse wave analysis monitor and pWV values were recorded.

Results

Fifty-five patients were normovolemic and 52 patients were hypervolemic. LAVI, LVMI, LDEDVI, LVEDSVI, E/e’ were increased in hypervolemic patients. Also in hypervolemic patients pulse wave velocity was increased and GLS was decreased. Multivariate analysis showed that FO was independently associated with GLS which is the most specific echo-parameter for left ventricular dysfunction.

Conclusion

FO was independently associated with cardiac dysfunction in patients with chronic kidney disease not ongoing dialysis. Effective treatment of hypervolemia may be important in these patients to avoid further cardiac damage.

Le traitement conservateur est parfois proposé comme une alternative à la dialyse pour des patients âgés avec comorbidités multiples. Notre recherche, caractérisée par une analyse transdisciplinaire médicale et sociologique, et basée sur l’analyse des cas, s’efforce de comprendre les raisons et le contexte dans lequel ce choix s’effectue. Les résultats montrent, d’une part, que tous les cas étudiés peuvent être expliqués par deux variables, celles-ci pouvant se combiner : lorsque le patient souffre de pathologies lourdes ; lorsque le patient vit cette insuffisance rénale comme un trouble normal lié à l’âge. D’autre part, deux grandes questions sont mises au jour : la première relève de la pratique médicale, et tient à l’influence de critères toujours présents dans les décisions à prendre (les examens paracliniques et les informations cliniques issues de l’interrogatoire, de l’examen du patient, de la discussion avec ses proches). La seconde relève de l’autonomie du patient et peut être analysée ici au regard de sa capacité à formuler des choix et à les avoir partagés avec ses proches, mais aussi à vivre dans son âge, en l’occurrence son rapport à son corps qui vieillit et à la finitude de son existence. La notion clé de l’échange patient–professionnels renouvelé est de se référer dans la consultation et dans les décisions à prendre à la question des avantages/inconvénients pour la vie du patient et non pas seulement à la question du rapport entre les résultats et les risques médicaux, afin d’échanger avec le patient sur sa vie future et non pas seulement sur l’état de son organe défaillant.

“Conservative management” is as an alternative care pathway offered to patients who elect not to start dialysis often because of a heavy burden of comorbid illness and advanced ages. Our research, characterized by a transdisciplinary medical and social investigation and based on a case by case analysis, intends to understand the reasons and the context in which this choice has to be made. On the first hand, the results show that all the studied cases can be explained by two variables, the latter can be combined: when the patient is suffering from important clinical pathologies; when the patient lives with this renal failure as a trouble linked to the age. On the second hand, two important questions are raised: the first one is about the medical practices and stems from the influence of criteria always present in the decisions to take (the paramedical exams and the clinical information from the interview, the patient's examination and the discussion with his/her close family member). The second one is about the patient's autonomy and can be analyzed regarding to his/her capacity to express his/her choices and share it with his close family. But also, to live in according to his age, that is to say the relation he/she has with his/her edged body and to the limits of his/her existence. The key notion of shared decision-making renewed is to refer in the consultation and the choices to take to the question of the advantages/drawbacks for the patient's life and not only to the question of the connection between the results and the medical risks, in order to exchange view with the patient on his/her future life and not only on the condition of his failed organ.