MONITORING SOFT TISSUE HYDRATION OF HEMODIALYSIS

PATIENTS WITH BIVARIATE IMPEDANCE VECTOR ANALYSIS

AT 50 KHz AND MULTIFREQUENCY ANALYSIS
L. Nescolarde* , A. Piccoli** , J. Rosell***
*

Universidad de Oriente. Facultad de Ciencias Naturales. Departamento de Fsica. Santiago de Cuba. Cuba
**
Dipartimento di Scienze Mediche e Chirurgiche, Cattedra di Nefrologia, Universit di Padova, Italia.
***
Universitat Politcnica de Catalunya. Departament dEnginyeria Electrnica. Barcelona. Espaa.
lexa@eel.upc.es, apiccoli@unipd.it, jrosell@eel.upc.es

Abstract: Fluid removal with hemodialysis (HD) is

associated with an impedance vector displacement on
the resistance-reactance (R-Xc) plane. It is known that
fluid removal is associated with a lengthening and
steepening of vectors measured at 50 kHz frequency.
In this observational study, the impedance vector
distribution has been determined with a mu ltifrequency
impedance analyzer in a group of uremic patients undergoing hemodialysis (HD) in Cuba. Pre- and postHD impedance measurements at 1, 5, 10, 50, 100, and
225 kHz are considered. Measurements at 50 kHz frequency from Cuban patients have been compared with
those from a group of Italian HD patients with comp arable body mass index (BMI) using the RXc graph
method of vector impedance analysis.
Keywords: Impedance vector, bioelectrical impedance analysis, hemodialysis, bioelectrical parameters,
soft tissue hydration.
Introduction
Bioelectrical impedance analysis (BIA) aims to
transform electrical properties of tissues into clinical
information. Instead of using patterns that relate electrical measurements to body composition (as electrocardiography does with heart disorders), conventional
BIA is based on electric models supporting quantitative
estimates of body compartments through regression
equations validated in healthy people. In HD, conventional BIA produces biased estimates of fluids due to
violation of the constant tissue hydration assumption
and to continuous body weight change.
Bioelectrical impedance vector analysis (BIVA or
vector BIA)1,2 relate combined changes in both R and
Xc vector (Z) components to body composition, without need of electric circuit models or regression equations (Fig. 1).
Z at a fixed frequency (50 kHz) is considered a
bivariate random vector representing a measurable
property of soft tissues. Vector standardization by the
subject's height (Z/H, Ohm/m) controls for the different
conductor length. Following the RXc graph method of
BIVA, the intersubject variability of Z is represented
with the bivariate normal distribution on the R-Xc
plane, that is with confidence (95%) and tolerance
ellipses (50%, 75%, and 95%) for mean and individual
vectors, respectively (Fig. 2)1,2 .

From clinical validation studies in adults, soft tissue

hydration can be assessed without prior knowledge of
body weight, as vector displacements parallel to the
major axis of tolerance ellipses indicate progressive
changes in tissue hydration (dehydration with long
vectors, and hyperhydration with apparent edema with
short vectors, out of the lower 75% pole) 1,2 .
In this study, we compared BIVA patterns of Z vector distribution pre- and post-HD at different current
frequency.
Materials and Methods
Whole body (hand-foot), tetrapolar impedance
measurements were obtained (BioScan analyzer, BL960141, Spain) at current frequency of 1 to 250 kHz in
65 patients (41 M, 24 F, 29-65 yr, BMI 16-32 kg/m2 )
undergoing chronic HD (University hospital, Santiago
de Cuba, Cuba).
First, pre- and post-HD impedance measurements at
1, 5, 10, 50, 100, and 225 kHz were considered (Fig.
1). Then, using the RXc graph method, measurements
at 50 kHz from Cuban patients have been compared
with those from a group of Italian HD patients with
comparable BMI (1116 patients, 680 M, 436 F, 2.7 kg
average fluid removal, Akern-RJL Systems, 50 kHz
analyzer), whose gender specific, reference, 50%, 75%
and 95% tolerance ellipses of individual vector were
known (large ellipses in Fig. 2)1 .
Results
The average values of imp edance vector comp onents (R and Xc), at six different frequencies (1, 5, 10,
50, 100, and 225 kHz), before and after HD, are shown
in Table 1.
As depicted in Fig. 1, fluid removal with HD
caused a vector displacement at any current frequency.
Vector displacements with a comparable increase in
vector magnitude, from pre- to post-HD Cole circles,
were observed at 10, 50, 100, and 225 kHz.
Contrary to expectation of vector distribution by increasing frequency along Cole circles, both initial position and displacement of vectors after HD at 1 and 5
kHz were definitely unexpected, particularly at 1 kHz.
While the R component increased at any frequency, the
Xc component (hence the phase angle) only increased

at 50 kHz or more (Table 1, Fig. 1).

Discussion

Figure 1 - Mean vector displacement by current

frequency in pre- and post-HD conditions.
The BIVA pattern observed at 50 kHz (Fig. 2), with
vector lengthening and steepening after fluid removal,
was the same in Cuban (larger arrows) and Italian patients.
Table 1 - Average values of impedance vector preand post- a hemodialysis (HD) session.
Pre-HD
F, kHz
1
5
10
50
100
225

R,
334.3
487.1
476.3
446.9
417.5
342.1

Xc,
292.5
37.8
9.9
57.3
100.6
178.9

Post-HD
R,
449.8
530.1
512.8
485.8
457.3
372.9

Xc,
268.4
19.7
6.8
64.4
111.1
196.1

But, despite a comparable direction, vector displacement was smaller, with shorter pre-HD vectors,
and with a greater variability (larger 95% confidence
ellipses) in Cuban patients (Fig. 2).

HD patients undergo a weight cycling thrice

weekly, as each HD session (4 hours) removes the fluid
accumulated over the previous 2 days spent without
HD 1 . The electrical counterpart of this wet-dry weight
cycling is represented on the R-Xc plane with a backward-forward displacement of the mean impedance
vector at 50 kHz 1 . This BIVA pattern has been observed at any frequency in the present study (Fig. 1).
The unexpected pre-HD position and post-HD displacement of vectors at 1 and 5 kHz on the R-Xc plane
were likely due to measurement error of the analyzer
(despite its apparent accuracy in calibration circuits).
The shorter pre-HD vectors with a smaller vector
displacement in Cuban patients indicated a greater fluid
overload, and less fluid removal prescription with HD.
The greater variability (larger 95% confidence ellipses)
of mean vectors in Cubans, particularly in women, can
be accounted for by a greater heterogeneity of dialysis
prescription (some women were edematous before HD)
in addition to a demographic component (mixed races
of Cuban people) 2 .
These results indicate that the information provided
by impedance measurement distribution pre- and postHD, without transformation of readings with electric
circuit models, is the same at any frequency, as fluid
removal causes a shift upwards and on the right of Cole
circle's loci. Intra- and extracellular electric volume
calculated by multifrequency models are likely flawed
by anisotropy of human tissues, particularly with variable soft tissue hydration.
Using a fixed frequency with optimal measurement
properties (50 kHz), the RXc graph methodology allows an evaluation of soft tissue hydration through
patterns based on percentiles of their electrical properties without prior knowledge of body weight. The target of therapy can be identified in R-Xc regions where
the electrical properties of soft tissues are normal.
Conclusions
The information provided by impedance measurements pre- and post-HD is apparently the same at any
current frequency as fluid removal causes a shift of a
circle on the R-Xc plane. Measurement errors were
greater at lower frequencies up to 10 kHz. The electrical target of therapy can be identified with the RXc
graph method at 50 kHz frequency.
References

Figure 2 - RXc graph in Italian and Cuban patients.

Arrows indicate mean vectors (at 50 kHz) with
95% confidence ellipses, pre- and post-HD.

1. Piccoli A, for the Italian HD-BIA Study Group:

Identification of operational clues to dry weight
prescription in hemodialysis using bioimpedance
vector analysis. Kidney Int 53:1036-1043, 1998.
2. Piccoli A, Pillon L, Dumler F: Impedance vector
distribution by sex, race, body mass index, and age
in the United States: standard reference intervals as
bivariate Z scores. Nutrition 18:153-167, 2002.