Pedal edema and jugular venous pressure for volume overload in peritoneal dialysis patients

Michael A. Garfinkle, James Barton

The diagnostic strength of the jugular venous pressure (JVP) and pedal edema as physical examination tools for the assessment of volume status has been minimally studied. We conducted a prospective observational study in an outpatient peritoneal dialysis clinic in Saskatoon, Canada. Patients were adult (age 18 or older) peritoneal dialysis outpatients without any history of cardiac dysfunction, a central line, and current arteriovenous fistula. JVP was assessed by both a resident and a staff nephrologist, while the presence of edema was assessed by the resident only. Likelihood ratios were calculated for the absence or presence of pedal edema as well as the JVP at multiple cutoffs. The criterion standard for volume overload was defined as an overhydration to extracellular water ratio of greater than or equal to 7 % as determined by bioimpedance (Body Composition Monitor-Fresnius Medical Care). Twenty-five separate patient encounters were assessed. Twelve patients were found to be volume overloaded while 13 were euvolemic. The presence and absence of edema were both significant signs for the presence (+likelihood ratio (LR) 16, 95 % confidence interval (CI) 1.02-260) or absence (-LR 0.44, 95 % CI 0.23-0.83) of volume overload, respectively. The JVP failed to reach statistical significance for the presence or absence of volume overload at any height above the sternal angle, although precision was poor for the positive likelihood ratio at cutoffs above 3 cm and the negative likelihood ratio at the 0 cm cutoff. The presence of pedal edema is a good indicator of volume overload in peritoneal dialysis patients without cardiac dysfunction, although its absence cannot definitively rule out significant water excess. A JVP of 1 to 3 cm was found to be not a clinically significant sign. We are unable to comment on the diagnostic strength of a low (0 cm) or high (JVP >3 cm) due to poor precision.