Bioelectrical impedance analysis of body composition as a tool for assessing nutritional status and predicting clinical outcome after heart transplantation

Introduction. Orthotopic heart transplantation remains the most effective treatment for end-stage heart failure; however, postoperative outcomes are largely determined by the patient’s nutritional status. Traditional markers, such as body mass index and serum albumin levels, are often uninformative due to overhydratation and systemic inflammation. Bioelectrical impedance analysis provides a non-invasive method for assessing body composition and cellular integrity, but its application in heart transplant recipients has been insufficiently studied.

The objective was to evaluate the dynamics of body composition and functional parameters obtained by bioelectrical impedance analysis in the early postoperative period after heart transplantation and to determine their association with clinical outcomes.

Materials and Methods. This single-center prospective observational study included 47 patients who underwent orthotopic heart transplantation. Bioelectrical impedance analysis was performed on postoperative days 3–5, 6–9, and 10–14, measuring phase angle, fat-free mass, extracellular-to-total body water ratio, and other parameters. Laboratory markers of nutritional status (albumin and total serum protein) and clinical outcomes (30-day mortality, infectious complications, duration of stay in the intensive care unit) were analyzed. Statistical analysis comprised correlation tests, receiver operating characteristic curve analysis, and linear regression models.

Results. Within the first 14 days, a statistically significant decrease in bioimpedance analysis parameters was observed against the background of increased hyperhydration. Lower phase angle values and higher extracellular-to-total body water ratios were associated with hypoalbuminemia, infectious complications, and 30-day mortality. Phase angle demonstrated high prognostic accuracy for mortality (area under the curve 0.82–0.89). Prolonged intensive care unit stay correlated with increased hyperhydration and reduced phase angle.

Conclusion. Parameters obtained by bioelectrical impedance analysis, particularly phase angle and fluid distribution, are significant predictors of adverse clinical outcomes after heart transplantation. Incorporating this method into early postoperative monitoring may optimize nutritional support and improve risk stratification. Further multicenter studies are needed to validate these findings.

1. Galyavich A. S., Tereshchenko S. N., Uskach T. M. et al. 2024 Clinical practice guidelines for Chronic heart failure. Russ J Cardiol, 2024, vol. 29, no. 11, pp. 6162. (In Russ.). https://doi.org/10.15829/1560-4071-2024-6162.

2. Gautier S. V., Khomyakov S. M. Organ donation and transplantation in the Russian Federation in 2023. 16th Report from the Registry of the Russian Transplant Society. RJTAO, 2024, vol. 26, no. 3, pp. 8–31. (In Russ.). https://doi.org/10.15825/1995-1191-2024-3-8-31.

3. Drapkina O. M., Skripnikova I. A., Yaralieva E. K. et al. Body composition in patients with heart failure. Cardiovasc Ther Prev, 2022, vol. 21, no. 12, pp. 3451. (In Russ.). https://doi.org/10.15829/1728-8800-2022-3451.

4. Polyakov D. S., Fomin I. V., Belenkov Yu. N. et al. Chronic heart failure in the Russian Federation: what has changed over 20 years of follow-up? Results of the EPOCH-CHF study. Kardiologiia. 2021, vol. 61, no. 4, pp. 4–14. https://doi.org/10.18087/cardio.2021.4.n1628. (In Russ.).

5. Carro A., Panisello J. M., Coats A. J. S. Nutritional status in advanced heart failure and heart transplant patients. Revista Española de Cardiología (English Edition), 2017, vol. 70, no. 8, pp. 626–628. https://doi.org/10.1016/j.rec.2017.02.005.

6. Earthman C. P. Body composition tools for assessment of adult malnutrition at the bedside: a tutorial on research considerations and clinical applications. J Parenter Enteral Nutr, 2015, vol. 39, no. 7, pp. 787–822. https://doi.org/10.1177/0148607115595227.

7. Fiaccadori E., Morabito S., Cabassi A. et al. Body cell mass evaluation in critically ill patients: killing two birds with one stone. Crit Care, 2014, vol. 18, no. 3, pp. 139. https://doi.org/10.1186/cc13852.

8. Hashizume N., Tanaka Y., Yoshida M. et al. Resting energy expenditure prediction using bioelectrical impedance analysis in patients with severe motor and intellectual disabilities. Brain and Development, 2019, vol. 41, no. 4, pp. 352–358. https://doi.org/10.1016/j.braindev.2018.11.003.

9. Hasse J. M., van Zyl J. S., Felius J. et al. Bioimpedance spectroscopy in heart transplantation: posttransplant changes in body composition and effects in outcomes. Transplantation, 2023, vol. 107, no. 11, pp. e305–e317. https://doi.org/10.1097/TP.0000000000004678.

10. Jain V., Karim A., Bansal A. et al. Relation of malnutrition to outcome following orthotopic heart transplantation. The American Journal of Cardiology, 2021, vol. 142, pp. 156–157. https://doi.org/10.1016/j.amjcard.2020.12.056.

11. Jansen A. K., Gattermann T., da Silva Fink J. et al. Low standardized phase angle predicts prolonged hospitalization in critically ill patients. Clinical Nutrition ESPEN, 2019, vol. 34, pp. 68–72. https://doi.org/10.1016/j.clnesp.2019.08.011.

12. Kim H., Levy K., Cassiere H. et al. Use of bioimpedance spectroscopy for postoperative fluid management in patients undergoing cardiac surgery with cardiopulmonary bypass. Journal of Cardiothoracic and Vascular Anesthesia, 2024, vol. 38, no. 11, pp. 2661–2667. https://doi.org/10.1053/j.jvca.2024.08.003.

13. Lima J., Eckert I., Gonzalez M. C. et al. Prognostic value of phase angle and bioelectrical impedance vector in critically ill patients: A systematic review and meta-analysis of observational studies. Clinical Nutrition, 2022, vol. 41, no. 12, pp. 2801–2816. https://doi.org/10.1016/j.clnu.2022.10.010.

14. Lukaski H. C., Kyle U. G., Kondrup J. Assessment of adult malnutrition and prognosis with bioelectrical impedance analysis: phase angle and impedance ratio. Current Opinion in Clinical Nutrition & Metabolic Care, 2017, vol. 20, no. 5, pp. 330–339. https://doi.org/10.1097/MCO.0000000000000387.

15. Malbrain M. L. N. G., Huygh J., Dabrowski W. et al. The use of bio-electrical impedance analysis (BIA) to guide fluid management, resuscitation and deresuscitation in critically ill patients: a bench-to-bedside review. Anaesthesiol Intensive Ther, 2014, vol. 46, no. 5, pp. 381–391. https://doi.org/10.5603/AIT.2014.0061.

16. Marra M., Sammarco R., De Lorenzo A. et al. Assessment of body composition in health and disease using bioelectrical impedance analysis (BIA) and dual energy X-Ray absorptiometry (DXA): a critical overview. Contrast Media & Molecular Imaging, 2019, vol. 2019, pp. 1–9. https://doi.org/10.1155/2019/3548284.

17. McDonagh T. A., Metra M., Adamo M. et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal, 2021, vol. 42, no. 36, pp. 3599–3726. https://doi.org/10.1093/eurheartj/ehab368.

18. Mendonça D. D., da Silva W. V. R., Souza G. C. et al. Body composition and survival in patients with heart failure. JACC: Heart Failure, 2025, vol. 13, no. 6, pp. 943–954. https://doi.org/10.1016/j.jchf.2025.01.016.

19. Moonen H. P. F. X., Van Zanten A. R. H. Bioelectric impedance analysis for body composition measurement and other potential clinical applications in critical illness. Current Opinion in Critical Care, 2021, vol. 27, no. 4, pp. 344–353. https://doi.org/10.1097/MCC.0000000000000840.

20. Mulasi U., Kuchnia A. J., Cole A. J. et al. Bioimpedance at the bedside: current applications, limitations, and opportunities. Nut in Clin Prac, 2015, vol. 30, no. 2, pp. 180–193. https://doi.org/10.1177/0884533614568155.

21. Mundi M. S., Patel J. J., Martindale R. Body composition technology: implications for the ICU. Nut in Clin Prac, 2019, vol. 34, no. 1, pp. 48–58. https://doi.org/10.1002/ncp.10230.

22. Myatchin I., Abraham P., Malbrain M. L. N. G. Bio-electrical impedance analysis in critically ill patients: are we ready for prime time? J Clin Monit Comput, 2020, vol. 34, no. 3, pp. 401–410. https://doi.org/10.1007/s10877-019-00439-0.

23. Rahman A., Jafry S., Jeejeebhoy K. et al. Malnutrition and Cachexia in Heart Failure. J Parenter Enteral Nutr, 2016, vol. 40, no. 4, pp. 475–486. https://doi.org/10.1177/0148607114566854.

24. Scicchitano P., Massari F. The role of bioelectrical phase angle in patients with heart failure. Rev Endocr Metab Disord, 2023, vol. 24, no. 3, pp. 465–477. https://doi.org/10.1007/s11154-022-09757-2.

25. Sheean P., Gonzalez M. C., Prado C. M. et al. American Society for Parenteral and Enteral Nutrition Clinical Guidelines: the validity of body composition assessment in clinical populations. J Parenter Enteral Nutr, 2020, vol. 44, no. 1, pp. 12–43. https://doi.org/10.1002/jpen.1669.

26. Singer P., Blaser A. R., Berger M. M. et al. ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit. Clinical Nutrition, 2023, vol. 42, no. 9, pp. 1671–1689. https://doi.org/10.1016/j.clnu.2023.07.011.

27. Söderström L., Rosenblad A., Thors Adolfsson E. et al. Malnutrition is associated with increased mortality in older adults regardless of the cause of death. Br J Nutr, 2017. Vol. 117, no. 4, pp. 532–540. https://doi.org/10.1017/S0007114517000435.

28. Stellato D., Cirillo M., De Santo L. S. et al. Bioelectrical impedance analysis in heart transplantation: Early and late changes. Seminars in Nephrology, 2001, vol. 21, no. 3, pp. 282–285. https://doi.org/10.1053/snep.2001.21658.

29. Ward L. C., Brantlov S. Bioimpedance basics and phase angle fundamentals. Rev Endocr Metab Disord, 2023, vol. 24, no. 3, pp. 381–391. https://doi.org/10.1007/s11154-022-09780-3.