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 THURSDAY 23 RD APRIL PALLIATIVE CARE SETTING 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.

Th Theo eore reti tical cal bas asis is of Bioelectri electrical cal Impedanc edance e Anal alysis ysis POWERPOINT PRESENTATION JULY 2012 V1.0

IN THE HUMAN CELL • Has ability to conduct electric charge. • Functions like an electrical circuit. • Impedance is opposition to electrical flow.

H 2 /R AND TOTAL BODY WATER • H 2 /Resistance (impedance index) highly correlates with TBW (r = 0.9) • Validated against gold standard reference methods. • H 2 /R and vector analysis (BIVA) overcome limitations of traditional BIA.

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

POWERPOINT PRESENTATION BIOELECTR LECTRICAL ICAL IMPEDANCE DANCE VECTO TOR R AN ANAL ALYSIS SIS (BIVA) VA) JULY 2012 V1.0

BIOELECTRICAL IMPEDANCE VECTOR ANALYSIS (BIVA) – RXC GRAPH

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

BIVA: DIFFERENT ANALYSES Comparison son with th other Group p comparison ons diseases/po popu pulati tion ons Contro tro ls ls Cancer Piccoli et al 2002 Toso et al 2002 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 or 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. •

Re Results lts – obje ject ctive ve 1 BIA TO EVALUATE HYDRATION, BIOCHEMISTRY, PHYSICAL SIGNS POWERPOINT AND SYMPTOMS PRESENTATION JULY 2012 V1.0

H 2 /R LINEAR REGRESSION Variable able B (standar dard d error) r) P 96.96 (10.02) Constant .000 0.13 (0.11) Age .246 -13.85 (2.52) Female le .000 -.55 (1.38) ECOG .692 Oedema a present 10.94 (2.89) .000 -.019 (0.02) Ur:Cr ratio .423 -2.55 (1.1) Physic ical al signs .023 -0.29 (0.14) Symptom oms .038 R 2 = .5; Adju ted R 2 = juste = • .45 F (7, df df 82) 82) • SE = 11.58 • P<.001 •

Result lts – objective ctive 2 BIVA ANALYSIS POWERPOINT PRESENTATION JULY 2012 V1.0

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Result lts – objective ctive 3 SURVIVAL ANALYSIS POWERPOINT PRESENTATION JULY 2012 V1.0

SURVIVAL 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%) %) HYDRATION ON PRE-RENAL FAILURE No pre-renal Not ‘less failure ated ’ hydrate Less ss Pre-renal al p=. =.00 00 hydrate ate failure p=. =.04 04 d 3

COX REGRESSION • Increasing H 2 /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: • H 2 /R and ur:cr still significant • Less-hydration not significant following adjustment

Result lts – objective ctive 4 LONGITUDINAL ANALYSIS POWERPOINT PRESENTATION JULY 2012 V1.0

OBJECTIVE 4 • Twenty four (26.7%) had multiple assessments. • Suggests patients less hydrated and more cachetic on final assessment. • Ur:cr ratio and H 2 /R difference (final – baseline) not associated with survival

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%) • H 2 /R predicted by gender, symptoms, POWERPOINT physical signs and oedema. PRESENTATION • Higher H 2 /R = longer survival. • Shorter survival in ‘less hydration’ and pre - JULY 2012 renal failure. V1.0

LIMITATI TATIONS ONS • Observational study • Mixed cancer • Ethnicity • Only hospice inpatients • Not representative of dying phase • Unable to comment on clinically POWERPOINT assisted hydration 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. POWERPOINT PRESENTATION JULY 2012 V1.0

CONCLUSIONS BIVA is a feasible body composition • assessment tool in advanced cancer. Hydration was associated with clinically • observable signs, symptoms and survival. Further work is essential to explore how • hydration relates to symptomatic burden in the dying and if artificial fluids improves outcomes.

AC ACHIEV EVEMENTS EMENTS Prizes zes Oral presentati tion ons National Cancer Research Palliative Care Congress, • • Institute (NCRI) conference Harrogate, 2014. prize, 2012 & 2014 Sue Ryder Care Centre for • Twycross research Prize 2014, the Study of Supportive, • Association of Palliative Palliative and End of Life Medicine. Care, University of Early Researcher Award 2015, Nottingham, 2012 • EAPC. Poster presenta tati tion ons Publication tions NCRI Conference, • Nwosu AC et al. Hydration in Liverpool, 2014. POWERPOINT • advanced cancer: can European Association of • PRESENTATION bioelectrical impedance Palliative Care Congress, analysis improve the evidence Lledia, Spain, 2014. base? A systematic review of NCRI Conference, • JULY 2012 literature. Journal of Pain and Liverpool, 2014. Symptom Management 2013; Liverpool Cancer Research • V1.0 Sep;46(3):433-446.e6 UK Centre (CRUK), Nwosu AC et al. Patients want Liverpool, 2013. • to be involved in end-of-life NCRI Conference, • care research. BMJ Support Liverpool, 2012.

AC ACKNOWL NOWLED EDGEM EMENTS ENTS Supervi rvisors sors MCHL patients and staff • Professor John Ellershaw • MCPCIL staff • Dr Catriona Mayland • Dr Stephen Mason • Professor Andrea Varro • Miss Jane Dowson • Fundi nding Dr Richard Latten • Marie Curie Palliative Care • Mrs Diane Barker • Institute Liverpool Dr Trevor Cox POWERPOINT • University of Liverpool • PRESENTATION Professor Frederick Burge The Friends of the University • • of Liverpool Professor Tatsuya Morita • Family JULY 2012 Professor William Fraser • Clare, Isaac and Theophilus • V1.0 Mr Bill Taylor • Extended family •

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