By J. Innostian. Mt. Sierra College. 2018.
Figure 9 shows that absolute overhydration was significantly lower in the BCM assessment group than in the standard clinical assessment group [weighted mean difference (WMD) –0 order nizagara 25 mg without a prescription erectile dysfunction pump implant video. Moderate statistical heterogeneity between trials was apparent cheap 25mg nizagara with visa icd-9 erectile dysfunction diabetes. Figure 10 shows that ROH was significantly lower in the BCM assessment group than in the standard clinical assessment group (WMD –1. ROH was assessed by the BCM in both groups, therefore these results should be interpreted with caution. Randomised controlled trial evidence: subgroup and sensitivity analyses We had initially planned to perform subgroup analyses according to the type of dialysis (HD or PD), the type of population (children aged < 5 years) and ethnicity group, and according to certain characteristics of the patient population, that is, people for whom recommended configurations of electrodes could not be used, people who could not assume the required positions for measurements to be made or people at extremes of body composition measurements. However, because of a lack of available data, we were able to perform only subgroup analyses of SBP and absolute overhydration according to the type of dialysis utilised. Figure 11 presents the forest plot of the subgroup analysis of SBP according to the type of dialysis. As there was only one trial in the PD group, we considered that testing for subgroup effects would have been statistically unsound. We considered that the comparison of the overall effect with the HD group effect (similar to a sensitivity analysis) was a better, more reliable approach. In this case, the effect on blood pressure was still not significant (WMD –1. Figure 12 presents the subgroup analysis for absolute hydration according to the type of dialysis. As described above, we did not perform a test of subgroup effects. In the case of absolute overhydration, there is a difference between the overall effect compared with the HD subgroup effect (WMD –0. We were unable to perform the planned sensitivity analyses (i. Randomised controlled trial evidence: other outcomes Intermediate reported outcomes Hospitalisation 61 76 77, , 76 Three trials reported data on hospitalisation. In the standard clinical assessment group, there were 73 all-cause hospitalisation events, with an incidence of 0. E xp e rim e nt l ontrol M e a n d iffe re nce M e a n d iffe re nce St d y or b grou p M e n S ot l M e n S ot l W e ight V , ra nd om V , ra nd om H n- She ng – – to H r – – to – L o – – to – P once – – to T ot l – – to – H e te roge ne ity: d f T e tfor ov e ra lle ffe ct z – – F ou rs e xp e rim e nt l ou rs control F U R eta - a n a lys i fo a b o lute o ver hydr a tio n df degr ees o ff eedo m ; in ver e va r ia n c e; S D ta n da r d devia tio n E xp e rim e nt l ontrol M e a n d iffe re nce M e a n d iffe re nce St d y or b grou p M e n S ot l M e n S ot l W e ight V , ra nd om V , ra nd om H n- She ng – – to O nofrie cu – – to – P once – – to T ot l – – to – H e te roge ne ity: d f T e tfor ov e ra lle ffe ct z – – F ou rs e xp e rim e nt l ou rs control F U R eta - a n a lys i o fR df degr ees o ff eedo m ; in ver e va r ia n c e; S D ta n da r d devia tio n E xp e rim e nt l ontrol M e a n d iffe re nce M e a n d iffe re nce St d y or b grou p M e n S ot l M e n S ot l W e ight V , ra nd om V , ra nd om H H n- She ng – to H r – – to O nofrie s cu – – to P once – – to Sb tot l – – to H e te roge ne ity: d f T e tfor ov e ra lle ffe ct z P L o – – to Sb tot l – – to H e te roge ne ity: not p p lica b le T e tfor ov e ra lle ffe ct z T ot l – – to H e te roge ne ity: d f T e tfor ov e ra lle ffe ct z – – T e tfor b grou p d iffe re nce F ou rs e xp e rim e nt l ou rs control F U R S ub gr o up a n a lys i fo S B a c c o din g to the typ e o fdia lys i df degr ees o ff eedo m ; in ver e va r ia n c e; S D ta n da r d devia tio n E xp e rim e nt l ontrol M e a n d iffe re nce M e a n d iffe re nce St d y or b grou p M e n S ot l M e n S ot l W e ight V , ra nd om V , ra nd om H H n- She ng – – to H r – – to – P once – – to Sb tot l – – to – H e te roge ne ity: d f T e tfor ov e ra lle ffe ct z P L o – – to – Sb tot l – – to – H e te roge ne ity: not p p lica b le T e tfor ov e ra lle ffe ct z T ot l – – to – H e te roge ne ity: d f T e tfor ov e ra lle ffe ct z – – T e tfor b grou p d iffe re nce d f F ou rs e xp e rim e nt l ou rs control F U R S ub gr o up a n a lys i fo a b o lute o ver hydr a tio n a c c o din g to the typ e o fdia lys i df degr ees o ff eedo m ; in ver e va r ia n c e; S D ta n da r d devia tio n DOI: 10. Four participants were hospitalised in the standard clinical assessment group, with a hospitalisation rate/100 patient-years of 30. The difference between the groups was not statistically significant. The difference from baseline, although not statistically significant, decreased in both groups (from 67% and 53%, respectively). In contrast, there was no change in LVMI in the standard clinical assessment group [from 121 (SD 35) at baseline to 120 (SD 30) at 12 months; p = 0. Clinical outcomes Incidence of cardiovascular events One study reported a combination of acute fluid overload or CV-related events, which included hospitalisation related to CV or cerebrovascular events and episodes of acute fluid overload. Residual renal function No trials reported residual renal function, but two studies reported urinary volume, which could be considered a surrogate measure thereof. By contrast, there was no change in the proportion of anuric patients in the control group and the decrease in urine output in non-anuric patients was not significant at follow-up. Adverse effects associated with hypotensive episodes The top five intradialytic complications reported by Huan-Sheng et al. There were significant differences between the bioimpedance assessment group and the standard clinical assessment group for all of these complications, but not in the same direction. In the bioimpedance assessment group, there was significantly more cramping, chest tightness and headaches, but significantly less hypotension and skin itching. Frequency of intradialytic hypotensive events was reported by Hur et al. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 25 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. ASSESSMENT OF CLINICAL EFFECTIVENESS 90 mmHg, and reported no significant difference between groups at baseline (39 events in 17 patients in the bioimpedance assessment group, and 38 events in 12 patients in the standard clinical assessment group) or 12 months (48 events in 20 patients and 41 events in 15 patients, respectively). No data were available on incidence of oedema or incidence of peritonitis. Patient-reported outcomes Fatigue Only one trial reported details of any specified patient-reported outcomes. The difference between groups was not statistically significant (p = 0.
The letters UF order 50mg nizagara erectile dysfunction guidelines, H buy 100 mg nizagara visa back pain causes erectile dysfunction, H D, and H DF identify the operational these techniques use highly perm eable synthetic m em branes and characteristics in the term inology. Based on these principles, the differ in the driving force for solute rem oval. W hen arteriovenous term inology for these techniques is easier to understand. As shown (AV) circuits are used, the m ean arterial pressure provides the in Figure 19-1 the letter C in all the term s describes the continuous pum ping m echanism. Alternatively, external pum ps generally utilize nature of the m ethods, the next two letters [AV or VV] depict the a venovenous (VV) circuit and perm it better control of blood flow driving force and the rem aining letters [UF, H , H D, H DF] represent rates. The letters AV or VV in the term inology serve to identify the the operational characteristics. The only exception to this is the driving force in the technique. Solute rem oval in these techniques is acronym SCUF (slow continuous ultrafiltration), which rem ains as achieved by convection, diffusion, or a com bination of these two. O ne of the m ajor determ inants of the efficacy of any dialysis procedure in acute FIGURE 19-4 renal failure (ARF) is the ability to m aintain a functioning extracor- Pathways of throm bogenesis in extracorporeal circuits. Anticoagulation becom es a key com ponent in this from Lindhout; with perm ission. Figures 19-4 and 19-5 show the m echanism s of throm bus form ation in an extracorporeal circuit and the interaction of various factors in this process. W hile system ic heparin is the anticoagulant m ost com - heparin solutions 1. The utiliza- tion of these m odalities is largely influenced by prevailing local experience. Schem atic diagram s for heparin, A, and citrate, B, anti- Arterial Venous Filter coagulation techniques for continuous renal replacem ent therapy catheter catheter (CRRT). A schem atic of heparin and regional citrate anticoagula- (a) (b) (d) (c) tion for CRRT techniques. Regional citrate anticoagulation m ini- 3–way stop cock m izes the m ajor com plication of bleeding associated with heparin, Ultrafiltrate but it requires m onitoring of ionized calcium. It is now well-recog- (effluent dialysate nized that the longevity of pum ped or nonpum ped CRRT circuits A plus net ultrafiltrate) is influenced by m aintaining the filtration fraction at less than 20%. N onpum ped circuits (CAVH /H D/H DF) have a decrease in efficacy over tim e related to a decrease in blood flow (BFR), Citrate CRRT Dialysate Calcium whereas in pum ped circuits (CVVH /H D/H DF) blood flow is m ain- NA 117, K4, M g 1. This process is term ed concentration repolarization. Anticoagulant Replacement zero alkali Central CAVH /CVVH — continuous arteriovenous/venovenous hem ofiltra- 4%% trisodium citrate solution zero calcium tion. M ovement of water across the membrane Small molecular weight substances (<500 Daltons) carries solute across the membrane. FIGURE 19-7 M embrane Blood Dialysate M echanisms of solute removal in dialysis. The success of any dialysis procedure depends on an understanding of the operational character- istics that are unique to these techniques and on appropriate use of specific components to deliver the therapy. Solute removal is achieved by diffusion (hemodialysis), A, convection (hemofiltration), B, or a combination of diffusion and convection (hemodiafiltration), C. Adsorption Several solutes are removed from circulation by adsorption to the membrane. This process is C influenced by the membrane structure and charge. In continuous arteriovenous DETERM INANTS OF SOLUTE REM OVAL IN DIALYSIS and venovenous hem odialysis in m ost situa- TECHNIQUES FOR ACUTE RENAL FAILURE tions ulrafiltration rates of 1 to 3 L/hour are utilized; however recently high-volum e hem ofiltration with 6 L of ultrafiltrate pro- IHD CRRT PD duced every hour has been utilized to Small solutes (MW <300) Diffusion: Diffusion: Diffusion: rem ove m iddle– and large–m olecular weight Qb Qd Qd cytokines in sepsis. Fluid balance is Membrane width Convection: Convection: achieved by replacing the ultrafiltrate Qd Qf Qf rem oved by a replacem ent solution. The Middle molecules (MW 500–5000) Diffusion com position of the replacem ent fluid can be Convection: Convection: Convection: varied and the solution can be infused Q Q Q before or after the filter. In Diffusion Adsorption IHD, typically dialysate flow rates far exceed Adsorption blood flow rates (200 to 400 mL/min, Large proteins (MW >50,000) Convection Convection Convection dialysate flow rates 500 to 800 mL/min) and dialysate flow is single pass. However, unlike IHD, the dialysate flow rates are significant- ly slower than the blood flow rates (typical- FIGURE 19-8 ly, rates are 100 to 200 mL/min, dialysate Determ inants of solute rem oval in dialysis techniques for acute renal failure. Solute rem oval flow rates are 1 to 2 L/hr [17 to 34mL/min]), in these techniques is achieved by convection, diffusion, or a com bination of these two. As a consequence, dialysate flow on solute rem oval by solvent drag. As solute rem oval is solely dependent on convective rates become the limiting factor for solute clearance it can be enhanced only by increasing the volum e of ultrafiltrate produced.
Treated water supply system s are designed so that there are no dead-end connections discount 50mg nizagara mastercard erectile dysfunction drugs forum. Because the antiseptic agents (chlorine and Colony-forming units/mL chloram ine) have been rem oved in water treatm ent cheap nizagara 25mg on line erectile dysfunction treatment by homeopathy, the water is prone to develop such problem s if stagnation is allowed. H em odialysis depends on the process of diffusion for rem oval of solutes. The am ount of m aterial rem oved depends on the m agnitude of the concentration gradient, the distance the m olecule FIGURE 1-8 travels, and the area through which diffusion takes place. Principles of Dialysis: Difusion, Convection, and Dialysis M achines 1. The diffusion constant is proportional to the temperature of the solution and inversely proportional to the viscosity and the size of the molecule removed. FIGURE 1-10 250 Effect of blood flow on clearance of various solutes, Fresenius F-5 m em brane. The am ount Urea Creatinine of solute cleared by a dialyzer depends on the am ount delivered to the m em brane. The 200 Phosphate usual blood flow is 300–400 m L/m in, which is adequate to deliver the dialysis prescrip- Vitamin B tion. O n institution of dialysis to a very urem ic patient the blood flow is decreased to 160 12 150 to 180 m L/m in to avoid disequilibrium syndrom e. As tim e goes on, blood flow can be increased to standard flows as the patient adjusts to dialysis. M ost patients require 100 hem odialysis at least thrice weekly. From this graph it is also evident that sm all m olecules such as urea (m olecular weight 60 D) are cleared m ore easily than large m olecules such as vitam in B12 (m olecular weight 1355 D). Because the spent dialysate effluent pum p (see Fig. This causes a flow of water and dissolved substances 0 from blood to the dialysate com partm ent. The process of solute transfer associated with this flow of water is called “convective transport. In the continu- ous renal replacem ent therapies, this is a m ajor m echanism for solute transport. Differences in ultrafiltration 30 coefficient (UFR) are shown for two different m em branes, F-5 and F-50. Bland LA, Favero M S: M icrobiologic aspects of hemodialysis systems. Vlchek DL: M onitoring a hemodialysis water treatment system. In AAM I Association for the Advancement of M edical Instrumentation; 1993:257–265. N ew York : John W iley & for the Advancement of M edical Instrumentation; 1993:267–277. This is accomplished principally by formulating a dialysate whose constituent concentrations are set to approximate normal values in the body. Over time, by diffusional transfer along favorable concentration gradients, the concentrations of solutes that were initially increased or decreased tend to be corrected. W hen an abnormal electrolyte concentration poses immediate danger, the dialysate concentration of that electrolyte can be set at a nonphysio- logic level to achieve a more rapid correction. On a more chronic basis the composition of the dialysate can be individually adjusted in order to meet the specific needs of each patient. Dialysate Composition for Hemodialysis In the early days of hemodialysis, the dialysate sodium concentration was deliberately set low to avoid problems of chronic volume over- load such as hypertension and heart failure. As volume removal became more rapid because of shorter dialysis times, symptomatic hypotension emerged as a common and often disabling problem dur- C H A P T ER ing dialysis. It soon became apparent that changes in the serum sodium concentration— and more specifically changes in serum osmolality— were contributing to the development of this hemodynamic instability. A decline in plasma osmolality during regular hemodialysis favors a 2 2. In this regard, the intradialysis drop in blood pressure space, thus exacerbating the volume-depleting effects of dialy- noted in patients dialyzed against a low-calcium bath, while statistically significant, is minor in degree [22,23]. W ith the advent of high-clearance dialyzers and more effi- for patients who are prone to intradialysis hypotension avoid- cient dialysis techniques, this decline in plasma osmolality ing low calcium dialysate concentration may be of benefit. On the other hand, the use of a lower calcium concentration in the becomes more apparent, as solute is removed more rapidly. In addition, use of 1,25-dihydroxyvitamin D can be ther to enhance the intracellular shift of fluid, as plasma tends liberalized to reduce circulating levels of parathyroid hormone and, thus, the risk of inducing hypercalcemia. W ith dialysate to become calcium concentrations below 1. The use of a higher sodium concentration Dialysate Composition for Peritoneal Dialysis To meet the ultrafiltration requirements of patients on peritoneal dialysate (>140 mEq/L) has been among the most efficacious dialysis, the peritoneal dialysate is deliberately rendered hyper- and best tolerated therapies for episodic hypotension [1–3]. In The high sodium concentration prevents a marked decline in commercially available peritoneal dialysates, glucose serves as the osmotic agent that enhances ultrafiltration.
As depicted cheap nizagara 100 mg without a prescription erectile dysfunction treatment yahoo, early experience in a large m ulticenter p<0 buy nizagara 100 mg lowest price erectile dysfunction under 35. FIGURE 13-17 FIGURE 13-16 In the current era of im m unosuppressive therapy, hypertension A recent m eta-analysis of published trials in renal transplant affects roughly two thirds of transplant recipients. Unlike hyperten- recipients dem onstrated these benefits of the various treatm ents. These m ay be grouped dysfunction or rhabdom yolysis. These adverse events m ay occur conveniently into those originating within the allograft (intrinsic) m ore frequently in transplant recipients owing to the effect of and those originating elsewhere (extrinsic). Levels of 3-hydroxy-3-methylglutaryl coenzyme A (HM G CoA) reductase inhibitors are substantially higher in patients receiving both drugs. HDL— high density lipoprotein; LDL— low density lipoprotein. In these patients it m ay be possible to approach diagnosis and therapy in a fairly Blood pressure ≥140/90 standardized fashion. In transplant recipients with blood pressure readings consistently over 140/90 mm Hg, intervention is warranted. Evaluate allograft function The initial approach includes assessm ent of allograft function, Yes No extracellular fluid volum e (ECF) status, and im m unosuppressive dosing. If these variables are stable, it is reasonable to proceed with Optimal blood levels Reduce dose of antihypertensive therapy. Calcium antagonists (CA) are effective of cyclosporine cyclosporine or or tacrolimus? No tacrolimus agents and m ay offer the added benefit of attenuating cyclosporine- Yes induced changes in renal hem odynam ics. Verapam il, diltiazem , nicardipine, and m ibefradil increase blood levels of cyclosporine ECF volume status Consider salt restriction and tacrolimus and should be used with caution. No and/or diuretic with CAs that m ay lim it their use include cost, refractory edem a, Yes and gingival hyperplasia. Angiotensin antagonists (ACEIs and Administer receptor antagonists) are also effective; their use requires close Intervention fails to antihypertensive agent monitoring of renal function, serum potassium levels, and hematocrit normalize BP (CA, ACEI, or other) levels. Diuretics frequently are useful adjuncts to therapy in recipients owing to the salt retention that often accom panies cyclosporine M ultidrug regimen: Adequate response add agents of different use. O ther antihypertensive m edications offer no particular benefits to therapy? No classes as necessary or drawbacks and can be em ployed as needed. The rationale of Yes m ultidrug therapy is to em ploy agents that block hypertensive responses via interruption of differing pathogenetic pathways. As antihypertensive drugs are added, this consideration should Yes rem ain param ount [31,32]. GFR— glom erular filtration rate; Yes No TRAS— transplanted renal artery stenosis. Continue Re-evaluate allograft antihypertensive therapy function and drug therapy Reassess periodically Consider TRAS FIGURE 13-19 Transplant renal artery stenosis (TRAS). TRAS accounts for less than 5% of cases of hypertension after transplantation. N onetheless, TRAS should always be considered in patients with refractory hypertension who develop renal insufficiency after addition of an ACEI to the therapeutic regim en. Although noninvasive studies (such as a renal scan with captopril) m ay be helpful in diagnosing TRAS, angiography rem ains the gold standard for diagnosis. Revascularization of the allograft by either surgical or angioplastic techniques m ay im prove renal function and am eliorate hypertension [33,34]. Both tacrolim us and m ycophenolate m ofetil (M M F) cause bloating, nausea, vom iting, and diarrhea in a dose-dependent m anner, particularly when used Nausea and in combination [15,16,25]. Some authors have noted that this rather nonspecific GI toxicity occurs m ore com m only with N eoral® than Drug vomiting Diarrhea Other complications with Sandim m une® (both from Sandoz Pharm aceuticals, East Cyclosporine 4 3 Hepatotoxicity, constipation H anover, N J). Tacrolimus 30 32 Hepatotoxicity, constipation MMF 20 31 Constipation, dyspepsia Azathioprine 12 Rare Hepatotoxicity, pancreatitis FIGURE 13-21 (See Color Plate) Endoscopic image of candida esophagitis with diffuse white exudate (panel A) and colitis induced by cytomegalovirus infection with submucosal hemorrhage, ulcers, and diffuse mucosal edema (panel B). The avail- ability and common use of effective prophy- laxis against acid-peptic disease (eg, H2 block- ers, omeprazole, and antacids) have signifi- cantly reduced the frequency of upper gastrointestinal bleeding. However, infectious agents such as cytomegalovirus and candida continue to be problematic, particularly in the setting of the more intense immunosup- pression afforded by drugs such as mycophe- A B nolate mofetil (M M F) and tacrolimus. FIGURE 13-22 H istologic im age of chronic active hepatitis secondary to infection with the hepatitis C virus (H CV).
Any disagreements were resolved by discussion between reviewers discount nizagara 50mg online condom causes erectile dysfunction. Assessment of risk of bias in included studies The standard Cochrane risk-of-bias tool was used to assess the risk of bias in randomised trials (see Appendix 4) buy nizagara 25 mg low cost impotence quit smoking. Studies were not included or excluded based on the risk of bias rating. The Cochrane risk-of-bias tool incorporates the following domains: sequence generation, allocation concealment, blinding, incomplete outcome data and selective outcome reporting. Assessment of other sources of bias was based mainly upon the source of funding for the conduct of the study and potential links with the manufacturers of the devices under investigation. Individual risk-of-bias domains were rated as being at a high, low or unclear risk of bias. Overall classification of studies was based on the assessment of three key domains: sequence generation, allocation concealment and blinding of outcome assessor. Studies were rated as being at a high risk of bias if one or more key domains were rated as being at a high risk of bias; an unclear risk of bias if one or more key domains were rated as being at an unclear risk of bias; or a low risk of bias if all key domains were rated as being at a low risk of bias. Risk of bias of cohort studies was assessed using a modified version of a 17-item checklist previously developed by our research team (see Appendix 5). The checklist was originally adapted from several sources and developed through a partnership with the Review Body for Interventional Procedures (ReBIP) for NICE. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 11 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. ASSESSMENT OF CLINICAL EFFECTIVENESS and selection, description of the intervention, outcome assessment, adequacy of follow-up and performance of statistical analyses. When available, NCT records (published on clinicaltrials. We had originally intended to use the ROBINS-I (Risk Of Bias in Non-randomised studies of Interventions) tool75 to assess the risk of bias in the included non-randomised studies. However, as a result of time constraints, and the fact that many studies were non-comparative cohort studies, we opted for the use of the ReBIP tool. Data analysis The general approach recommended by the Cochrane Collaboration was used for data analysis and synthesis. A random-effects model was used to calculate the pooled estimates of effect. For continuous outcomes, mean differences between groups were pooled. The statistical analyses focused on the five separate outcome measures for which consistent data were reported by at least two studies and were suitable for combining across studies: mortality, SBP, arterial stiffness, absolute overhydration and relative overhydration (ROH). Other relevant outcomes that were reported, but not meta-analysed because they were inconsistently reported across studies, were achievement of target (dry) weight (reported as proportion of patients within 1. Two 60 76, 61 trials reported the HR at 12 months and, for the trial by Ponce et al. The HR was then calculated from the estimated hazard rates. The standard error (SE) was estimated using the method described by Parmar et al. Heterogeneity across trials was explored by visual inspection of forest plots and assessed by means of the chi-squared test and I2-statistic. Four of these trials randomised at the individual level, while Ponce et al. In order to include a cluster randomised trial in a meta-analysis it is necessary to allow for the correlation of participants within clusters. The design factor is 1 + (m – 1)ρ, in which m is the number of clusters and ρ is the intracluster correlation coefficient. Many trials fail to report estimates of the design effect and, therefore, different strategies are used to obtain this required information. The authors decided to increase the variance of the unadjusted trials by 30%. A subgroup analysis was performed according to the type of dialysis: HD versus PD. We were able to conduct subgroup analyses only for the following outcome measures: SBP and absolute hydration. Results Performance of multiple-frequency bioimpedance devices A formal evaluation of the accuracy and validation of the multiple-frequency bioimpedance devices under assessment was beyond the scope of this assessment. However, information on the validation and accuracy of the specified devices was gathered from the available literature. Only information on the validation of the BCM was found in the current literature. The authors concluded that there was good agreement between the BCM and the standard clinical measurements of fluid overload.
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