Supplementary Material for: Fluid Volume Estimation by Bioimpedance: Methodological Caveats and Clinical Interpretation

Background: Fluid monitoring is critical for patients on maintenance hemodialysis. Bioimpedance enables estimation of fluid volumes from measures of electrical tissue properties. However, empirical equations are needed to approximate key variables, especially in wrist-to-ankle bioimpedance measurements, introducing potential errors.

Summary: Here, we provide a technical overview of electrical impedance, derivation of fluid volumes from different bioimpedance methods and electrode setups, as well as sources of error including the assumption of constant resistivity, constant body temperature, and vendor-specific equations to derive fluid overload. We summarize the validity of bioimpedance methods in hemodialysis and conclude that irrespective of error sources reported above, segmental bioimpedance, where limbs and the trunk are measured separately, may be more accurate compared to the convenient wrist-to-ankle measurement. We argue that insufficient correction for variable body shape in wrist-to-ankle measurements jeopardizes this methodology, reporting here our analyses by means of theory and data simulation, where we found that conventional wrist-to-ankle bioimpedance underestimated extracellular fluid volume with increasing body fat percentage. The error could be reduced by using subject specific body shape correction based on high-resolution 3D models. Finally, we attempt to provide guidance for identifying and mitigating common issues of wrist-to-ankle bioimpedance.

Key Messages: While more convenient than segmental measurements, wrist-to-ankle bioimpedance may underestimate fluid volumes in obesity when body shape is not properly accounted for. Novel techniques, including smartphone-based 3D scans of the body, could potentially facilitate individualizing body shape correction to improve fluid volume estimates.