To Örebro University

BACKGROUND: Optimizing volume status is central to hemodialysis care and may influence patient-reported outcome measures as recovery time. We evaluated the implementation of a structured decision aid (Recova) integrating symptom assessment with bioimpedance spectroscopy in routine hemodialysis practice.

METHODS: A prospective multicenter pre-post within-subjects study was conducted in 10 Swedish hemodialysis clinics. Clinics adopted the intervention on a staggered schedule based on local readiness. Participants were assessed at baseline and after 12 weeks. Outcomes included bioimpedance spectroscopy-derived overhydration and extracellular water, patient-reported recovery time (hours to resume usual activities), and a fluid-related symptom score. Paired measurements were compared.

RESULTS: Of 404 screened patients, 129 consented and 123 initiated the intervention. Recovery time data were available at both time points for 110 participants. Overhydration decreased from 2.6 ± 1.7 to 2.3 ± 2.0 L (p = 0.04) and extracellular water from 18.4 ± 4.0 to 18.0 ± 3.8 L (p = 0.01). Mean recovery time did not change significantly (6.7 ± 7.1 to 5.8 ± 6.2 h; p = 0.22) and median recovery time remained 4 h (IQR 1-10). Fluid-related symptom burden declined over the intervention period. No harms were reported; 13 participants did not complete the 12-week intervention.

CONCLUSIONS: In this multicenter pre-post evaluation, implementation of Recova was associated with modest improvements in bioimpedance spectroscopy-derived volume metrics and fluid-related symptoms, while recovery time did not change significantly. Controlled studies are needed to determine effectiveness and to identify which patients may benefit.

Background: The role of spironolactone treatment in hemodialysis patients is debated, but a survival benefit is suggested. Mineralocorticoids and chronic kidney disease have been linked to cardiovascular fibrosis. Therefore, we hypothesized that spironolactone would affect vascular stiffness, cardiac systolic, and diastolic function in hemodialysis patients.

Methods: This was a randomized crossover study in hemodialysis patients supplemented with an echocardiographic case series. All outcomes reported here were secondary in the trial and were assessed without blinding. Block randomization and allocation determined treatment order. Participants received 50 mg spironolactone daily for 12 weeks and untreated observation for another 12 weeks. Pulse wave velocity (PWV) was measured before and after treatment and observation. Doppler-echocardiography was conducted before and after treatment. Systemic arterial compliance indexed to body surface area (SACi), left ventricular ejection fraction (LVEF), the peak early diastolic mitral inflow velocity (E), the peak late diastolic mitral inflow velocity (A), and the peak early diastolic myocardial lengthening velocity (E') were measured. E/A and E/E' were then calculated. Statistical analyses were conducted per protocol. A generalized linear mixed model with random participant effects was used for PWV. The Wilcoxon signed-rank test was used for echocardiographic variables.

Results: Thirty participants were recruited, 18 completed follow-up, and 17 were included in PWV-analyses. Spironolactone treatment showed a tendency toward an increase in PWV of 1.34 (95% confidence interval: -0.11 to 2.78) m/s, which was not statistically significant (P = 0.07). There were no significant changes in any of the other variables (LVEF, E/A, E/E', or SACi).

Conclusions: We found no evidence supporting an effect of 12-week administration of spironolactone 50 mg daily on vascular stiffness, cardiac systolic, or diastolic function in hemodialysis patients.

Background: Spironolactone treatment reduces mortality in haemodialysis (HD) patients. The objective of this study was to evaluate if spironolactone affects cardiac electric activity in this population.

Methods: Participants were randomised to start with spironolactone 50 mg daily or observation (12 weeks) with subsequent washout (6 weeks) and crossover to the other intervention (12 weeks). Long-term electrocardiograms were recorded and assessed with blinding to treatment. The primary outcome was premature ventricular complexes (PVC), and secondary outcomes were atrial premature contractions (APC) and heart rate variability (HRV).

Results: . HRV time-domain variables increased during treatment, the standard deviation of all beat-to-beat intervals by 18 (95% CI: 3.3 to 32) milliseconds (ms) and the standard deviation of the averages of beat-to-beat intervals in all 5-min segments of the entire recording by 16 (95% CI: 1.5 to 30) ms. There were no significant differences in other variables.

Conclusion: Spironolactone treatment increases PVCs in HD, indicating a possible proarrhythmic effect. However, improved cardiac autonomic function, as indicated by an increased HRV, may contribute to the survival benefit from spironolactone treatment in HD patients.