“BCM (Body Composition Monitoring) can decide the way to manage fluid for dialysis patients and confirm an appropriate range. If you can maintain the fluid condition of people with kidney problems to a normal level through this fluid management, it will significantly help control blood pressure and improve symptoms.”
So said Dr. Elizabeth J. Lindley at St. James's University Hospital in the United Kingdom, who recently visited Korea, emphasizing the importance of the fluid management of people with chronic kidney diseases, based on BioImpedance Spectroscopy (BIS).
BCM is a device that analyzes the body fluid and composition of chronic kidney disease patients, marketed by Fresenius Medical Care Korea프레제니우스메디칼케어코리아(CEO: Choi Sung-ok최성옥). It was introduced in Korea in 2009 and was registered as a new medical technology in 2014. People subject to the application of the new medical technology are those with imbalanced body fluid, such as patients with kidney diseases, heart failure, and inflammatory intestinal diseases. Treatments using the device are not getting insurance benefits.
“BCM is helpful for patients with remaining kidney functions. If patients can maintain kidney function for a long time, it means they can prolong their kidney’s lifespan and can live longer,” said Lindley based on her experiences at St. James’s University Hospital.
Korea Business Review met the British expert to hear her views about BIS, chronic kidney diseases, and fluid management.
Question: Why do you stress “BIS-based fluid management” in treating kidney disease patients?
Answer: People with chronic kidney diseases can’t remove fluid from their body sufficiently due to poor kidney function. Because they can accumulate much fluid, removing fluid is important through dialysis. If they can’t remove it through dialysis, however, they can come down with cardiovascular diseases such as hypertension and edema.
In the past, doctors sought causes from dialysis durations when patients complained about low blood pressure and other symptoms. Since medical professionals began to use BCM, however, they have come to confirm the evident ground of removing excessive fluid. Doctors in the clinical fields understood its technological concept, but the progress of technology has increased its medical usefulness.
Q: We are curious about examination processes using BCM and BIS technology. And what are advantages for patients who use BCM?
A: Doctors mainly conduct BCM check before dialysis. They measure twice, by checking blood pressure and weight first and once again by attaching electrodes to one hand and one foot. The existing equipment took five minutes, but BCM has reduced the time.
Patients can maintain fluid condition at nearly normal level by using BCM. We are now treating about 500 patients at eight centers (run by St. James’s). In the beginning, we ran into limits to examining all patients because we had only two BCM units. That drove patients into volunteer fundraising, allowing the other six centers to have BCM. This is only one example, which shows how the use of BCM has contributed to improving patients’ quality of life.
Q: How do doctors use BCM in the clinical field?
A: If a patient is found with the excessive fluid of one liter in pre-dialysis check and reduces two liters of fluid through dialysis, we can judge him in a low-fluid condition. Accordingly, we don’t need to conduct another BCM checkup after dialysis. What matters is to grasp patients’ dry weight target. Doctors can control the amount of dialysis after they identify patients’ current fluid conditions and dry weights. For physicians to use BCM, they should decide treatment methods by comprehensively taking their BCM data and clinical conditions into account. Patients with kidney diseases can have fluid in their lungs even though they suffer from dehydration in other organs. As BCM can’t identify fluid in lungs, however, they should consider it.
Dialysis frequency can differ by patients’ situation, and doctors have to check the conditions of child patients at least once a month. They need to know whether the increase in young patients is related to their growth or excessive fluid. About other patients, medical professionals will also have to check them if there are meaningful changes in the fluid conditions. Hospitalized patients need to get BCM check, too, because their weight can vary according to nutritional conditions.
Q: Is it necessary to apply BIS-based fluid management to chronic kidney disease patients, at their early stage?
A: Chronic kidney disease patients at an early stage may accumulate body fluid not because of kidney diseases but because of heart-related problems. If patients accumulate fluid in their body6 because of cardiac insufficiency, doctors will find the BIS checkup helpful in deciding the timing for dialysis. As there are patients, who accumulate fluid caused by problems not just with kidney but with heart, heart internal medicine department as well as kidney internal medicine department will be able to use it in the future.
Customized treatments have become in dialysis, too. For example, young people who have kidney problems but maintain good health otherwise tend to lead healthy lives at home and workplaces. On the other hand, doctors should take different treatment approaches for elderly patients who mostly stay at home.
Q: The customized treatment does not hit close home to me aside from peritoneum dialysis and blood dialysis.
A: It is possible to provide personalized treatments in consideration of patients’ conditions, such as duration and frequency of dialysis, and decision on temperature. Doctors can also judge whether they put a priority on patients’ life expectancy or their conditions in deciding the amount of fluid to be removed through dialysis. For example, it is better to eliminate fluid as much as possible for patients with long life expectancy because excessive fluid can lead to cardiovascular diseases. On the other hand, doctors can control the amount of fluid properly for patients with short life expectancy because the objective of treatment can be to help them maintain good conditions, not removing it as much as possible.
Q: Would you introduce clinical results related to BIS-based fluid management?
A: Doctors have sufficiently conducted Randomized Controlled Tria (RCT) through BIS to check excessive fluid amount for dialysis patients and confirm their clinical usefulness. Such research has shown patients who got fluid management through BIS lived longer than those who didn’t. It is necessary to conduct additional research into whether patients can improve kidney functions or maintain their current remaining functions if doctors apply BIS to patients who got dialysis in the early stage. In this vein, some British experts are conducting randomized controlled trials called BISTRO. They are recruiting patients now and will confirm whether BCM can maintain kidney functions for a long time.
Q: On what grounds do you think the use of BCM has improved patients’ kidney functions?
A: Most of the patients have come to prevent excessive fluid and dehydration, which they had not known before, through the BCM check. And it prevents additional damage to the kidneys of dialysis patients caused by excessive fluid and sudden dehydration. Also, the patients can apparently know about improvement in their kidney functions. It was after the development of BCM that they realized the necessity for such monitoring. The management of patients has become easier because doctors could know the time to start and stop treatments. BCM is the most sensitive device to check the body fluid and composition of dialysis patients.
Q: How much money should patients in England pay for the BCM examination?
A: In the center, the number of patients who stopped dialysis was seven times higher than before the use of BCM. Patients in England pay only $2 for one electrode for the examination.
Q: Are there any other products for patients’ fluid management than BCM?
A: Various products are using BIS technology, but BCM is the only one based on dialysis patients’ management and validated by science. In the past, we used other devices, but it is hard to convince nurses at the dialysis center, who didn’t want to use them in the medical field. If other devices finish scientific validation and apply user-friendly interface, we can consider using them, but they have not so far.
There are three criteria to select the BIS device. It has to show scientific validation and have a user-friendly interface. The most important thing is it doesn’t need to compare data with those of healthy patient groups, is convenient to use and apply to clinical trials. Other devices have to compare data from dialysis patients with those of healthy patients groups, causing inconvenience.
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