THE ASSESSMENT OF HYDRATION IN ADVANCED CANCER USING NOVEL - - PowerPoint PPT Presentation

THE ASSESSMENT OF HYDRATION IN ADVANCED CANCER USING NOVEL TECHNOLOGY: THE USE OF BIOELECTRICAL IMPEDANCE VECTOR ANALYSIS (BIVA) IN THE PALLIATIVE CARE SETTING

THURSDAY 23RD APRIL

DR AMARA NWOSU ACL – UNIVERSITY OF LIVERPOOL

HYDRATION IN CANCER

• Oral intake decreases in advanced cancer.
• Physiology of hydration advanced cancer

differs from non-cancer.

• Lack of hydration assessment tools in

advanced cancer.

• Uncertainty of benefits vs risks of clinically

assisted hydration.

• There is a lack of evidence to guide

healthcare professionals.

• Distressing to patients, relatives and staff.

BIOELECTRICAL IMPEDANCE ANALYSIS (BIA)

• Painless, quick, non-invasive, portable.
• Electrical resistance through the body.
• Validated against gold standard reference

methods.

POWERPOINT PRESENTATION

JULY 2012 V1.0

Th Theo eore reti tical cal bas asis is of Bioelectri electrical cal Impedanc edance e Anal alysis ysis

IN THE HUMAN CELL

• Has ability to

conduct electric charge.

• Functions like an

electrical circuit.

• Impedance is
• pposition to

electrical flow.

H2/R AND TOTAL BODY WATER

• H2/Resistance (impedance index) highly

correlates with TBW (r = 0.9)

• Validated against gold standard reference

methods.

• H2/R and vector analysis (BIVA) overcome

limitations of traditional BIA.

BIA ASSESSMENT METHOD

FAT T MASS SS (FM). M). WATER R = 14%

POWERPOINT PRESENTATION

JULY 2012 V1.0

BIOELECTR LECTRICAL ICAL IMPEDANCE DANCE VECTO TOR R AN ANAL ALYSIS SIS (BIVA) VA)

BIOELECTRICAL IMPEDANCE VECTOR ANALYSIS (BIVA) – RXC GRAPH

BIVA: DIFFERENT ANALYSES

Indivi vidual static assess essmen ment Successive ve measuremen ments ts Rosler et al 2010 2010 Piccoli et al 1998 1998

BIVA: DIFFERENT ANALYSES

Group p comparison

• ns

Comparison son with th other diseases/po popu pulati tion

• ns

Contro tro ls ls Cancer Toso et al 2002 2002 Piccoli et al 2002

THE STUDY AIM

“To improve the understanding of hydration tion in advanced ced cancer er through the addition of bioel elec ectri trica cal impeda dance nce vector

• r analysis (BIVA)

) to the best available clinical assessment tools and biochemical investigations.”

THE STUDY

• 10 month observational prospective study.
• Marie Curie Hospice Liverpool
• Inclusio

lusion: n:

• Palliative cancer patients not receiving U&E

performed (in past 72 hours) by clinical team.

• Exclusio

usion: n:

• Pacemaker
• Clinically assisted hydration at time of

assessment

• Sample size of 90 patients.

POWERPOINT PRESENTATION

JULY 2012 V1.0

Re Results lts – obje ject ctive ve 1

BIA TO EVALUATE HYDRATION, BIOCHEMISTRY, PHYSICAL SIGNS AND SYMPTOMS

H2/R LINEAR REGRESSION

Variable able B (standar dard d error) r) P Constant 96.96 (10.02) .000 Age 0.13 (0.11) .246 Female le

• 13.85 (2.52)

.000 ECOG

• .55 (1.38)

.692 Oedema a present 10.94 (2.89) .000 Ur:Cr ratio

• .019 (0.02)

.423 Physic ical al signs

• 2.55 (1.1)

.023 Symptom

• ms
• 0.29 (0.14)

.038

• R2 = .5; Adju

juste ted R2 = = .45

• F (7, df

df 82) 82)

• SE = 11.58
• P<.001

POWERPOINT PRESENTATION

JULY 2012 V1.0

Result lts – objective ctive 2

BIVA ANALYSIS

POWERPOINT PRESENTATION

JULY 2012 V1.0

POWERPOINT PRESENTATION

JULY 2012 V1.0

POWERPOINT PRESENTATION

JULY 2012 V1.0

Result lts – objective ctive 3

SURVIVAL ANALYSIS

SURVIVAL

Less ss hydrate ate d Not ‘less hydrate ated’ Pre-renal al failure No pre-renal failure

p=. =.00 00 3 p=. =.04 04

HYDRATION ON PRE-RENAL FAILURE

Deceased, n=76 (84.4%) %) Median survi viva val = 62 days 30 day morta tality ty, n=23 (25.6%) %) 7 day mortality, y, n=4 (4.4%) %)

COX REGRESSION

• Increasing H2/R associated with longer

survival (p=.003)

• Increasing ur:cr ratio associated with shorter

survival (p=.002)

• Cox regression:
• Confou

nfounders ders

• Metastatic disease and performance

status

• Adjustme

tment: t:

• H2/R and ur:cr still significant
• Less-hydration not significant following

adjustment

POWERPOINT PRESENTATION

JULY 2012 V1.0

Result lts – objective ctive 4

LONGITUDINAL ANALYSIS

OBJECTIVE 4

• Twenty four (26.7%) had multiple

assessments.

• Suggests patients less hydrated and more

cachetic on final assessment.

• Ur:cr ratio and H2/R difference (final –

baseline) not associated with survival

POWERPOINT PRESENTATION

JULY 2012 V1.0

MAI AIN STUDY FINDING INGS

• 90 patients (RR = 76.3%)
• Hydration:

– Normal al = 43 (47.8%) – More hydrat rated d = 37 (41.1%) – Less s hydrat rated d = 10 (11.1%)

• H2/R predicted by gender, symptoms,

physical signs and oedema.

• Higher H2/R = longer survival.
• Shorter survival in ‘less hydration’ and pre-

renal failure.

POWERPOINT PRESENTATION

JULY 2012 V1.0

LIMITATI TATIONS ONS

• Observational study
• Mixed cancer
• Ethnicity
• Only hospice inpatients
• Not representative of dying phase
• Unable to comment on clinically

assisted hydration

POWERPOINT PRESENTATION

JULY 2012 V1.0

POTENTIAL TENTIAL FUTURE URE WORK

• Different conditions, ethnicities,

performance status, stage of disease.

• Dying phase – longitudinal

assessments.

• Survival analysis/prognostication.
• Evaluate response to artificial fluids.

CONCLUSIONS

• BIVA is a feasible body composition

assessment tool in advanced cancer.

• Hydration was associated with clinically
• bservable signs, symptoms and survival.
• Further work is essential to explore how

hydration relates to symptomatic burden in the dying and if artificial fluids improves

• utcomes.

POWERPOINT PRESENTATION

JULY 2012 V1.0

AC ACHIEV EVEMENTS EMENTS

Prizes zes

• National Cancer Research

Institute (NCRI) conference prize, 2012 & 2014

• Twycross research Prize 2014,

Association of Palliative Medicine.

• Early Researcher Award 2015,

EAPC. Publication tions

• Nwosu AC et al. Hydration in

advanced cancer: can bioelectrical impedance analysis improve the evidence base? A systematic review of

• literature. Journal of Pain and

Symptom Management 2013; Sep;46(3):433-446.e6

• Nwosu AC et al. Patients want

to be involved in end-of-life care research. BMJ Support Oral presentati tion

• ns
• Palliative Care Congress,

Harrogate, 2014.

• Sue Ryder Care Centre for

the Study of Supportive, Palliative and End of Life Care, University of Nottingham, 2012 Poster presenta tati tion

• ns
• NCRI Conference,

Liverpool, 2014.

• European Association of

Palliative Care Congress, Lledia, Spain, 2014.

• NCRI Conference,

Liverpool, 2014.

• Liverpool Cancer Research

UK Centre (CRUK), Liverpool, 2013.

• NCRI Conference,

Liverpool, 2012.

POWERPOINT PRESENTATION

JULY 2012 V1.0

AC ACKNOWL NOWLED EDGEM EMENTS ENTS

Supervi rvisors sors

• Professor John Ellershaw
• Dr Catriona Mayland
• Professor Andrea Varro

Fundi nding

• Marie Curie Palliative Care

Institute Liverpool

• University of Liverpool
• The Friends of the University
• f Liverpool

Family

• Clare, Isaac and Theophilus
• Extended family
• MCHL patients and staff
• MCPCIL staff
• Dr Stephen Mason
• Miss Jane Dowson
• Dr Richard Latten
• Mrs Diane Barker
• Dr Trevor Cox
• Professor Frederick Burge
• Professor Tatsuya Morita
• Professor William Fraser
• Mr Bill Taylor

THANK YOU