ICG Case Studies

I would like to share with you a case that demonstrates usefulness of ICG monitoring in a hemodialysis patient.

R.T. is a 63 year old woman from Florida who was started on dialysis in December 2001. She had baseline advanced diabetic nephropathy and ischemic cardiomyopathy. Dialysis was initiated because of intractable CHF/volume overload.

During the first two months of chronic hemodialysis the patient continued to do quite poorly. Massive edema of the lower extremities, massive ascites and pulmonary edema persisted. Removal of fluid during hemodialysis was extremely difficult due to baseline low-normal blood pressure, with frank hypotension developing during hemodialysis.

In the end of February 2002 patient moved to Washington state to live with her son. During initial evaluation on 2/28/2002 she was extremely fatigued and dyspneic at rest, breathing supplemental oxygen via nasal cannula. She was using a walker for ambulation. Her blood pressure was 108/40, pulse 75. She had basilar crackles in her lungs, jugular venous pressure about 12 cm with positive hepatojugular reflux, positive S3, massive ascites, 1+ edema up to the waist.

Initial ICG study showed low normal cardiac index 2.7, "normal" SVR index 2218, elevated thoracic fluid content 39.1.

In the setting of severely decompensated CHF and relative hypotension, presence of a "normal" SVR index was interpreted as inappropriately low. The patient was thought to be a good candidate for trial of midodrine (peripheral alpha agonist). She was started on 20 mg 30 minutes prior to dialysis on dialysis days. The patient was able to tolerate increasing fluid removal on dialysis. Her weight was gradually decreasing.

Repeat evaluation by ICG in monthly intervals showed progressive decrease of weight from baseline 99 kg to 90 kg. Thoracic fluid content decreased from baseline 39.1 to 30.0. It showed excellent correlation with the patient's weight and clinical signs of volume overload.

The patient's cardiac index improved with continuing fluid removal, which gave me significant comfort in continuing to lower her dry weight (falling cardiac index would suggest relative hypovolemia/suboptimal filling pressures).

The patient's SVR index decreased initially and then remained stable (final evaluation by ICG), still within "normal" range.

Most important of all, this patient no longer needs oxygen, she is able to sleep in bed, she walks without use of a cane, she is able to take care of most of her everyday needs, and she is thinking about starting to drive again and eventually moving back to Florida.

Without ICG data showing inappropriately "normal" SVR and normal cardiac index on initial evaluation I would have not started the patient on midodrine, as it is counter intuitive to use a peripheral vasoconstrictor in a patient with decompensated CHF who typically has significantly elevated SVR and low cardiac index. Without midodrine (which maintained her blood pressure during dialysis and allowed for extra fluid removal) she would most certainly not be able to show such remarkable improvement.

In addition, serial monitoring, showing improving hemodynamics gave me great degree of comfort in proceeding with the treatment for this extremely complicated patient.

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