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Theofilis P, Vordoni A, Kalaitzidis RG. Epidemiology, Pathophysiology, and Clinical Perspectives of Intradialytic Hypertension. Am J Nephrol 2023; 54:200-207. [PMID: 37231809 DOI: 10.1159/000531047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/05/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Individuals with end-stage renal disease on chronic hemodialysis (HD) may encounter numerous HD-associated complications, including intradialytic hypertension (IDHYPER). Although blood pressure (BP) follows a predictable course in the post-HD period, BP levels during the session may vary across the individuals. Typically, a decline in BP is noted during HD, but a significant proportion of patients exhibit a paradoxical elevation. SUMMARY Several studies have been conducted to understand the complexity of IDHYPER, but much remains to be elucidated in the future. This review article aimed to present the current evidence regarding the proposed definitions, the pathophysiologic background, the extent and clinical implications of IDHYPER, as well as the possible therapeutic options that have emerged from clinical studies. KEY MESSAGES IDHYPER is noted in approximately 15% of individuals undergoing HD. Several definitions have been proposed, with a systolic BP rise >10 mm Hg from pre- to post-dialysis in the hypertensive range in at least four out of six consecutive HD treatments being suggested by the latest Kidney Disease: Improving Global Outcomes. Concerning its pathophysiology, extracellular fluid overload is a crucial determinant, with endothelial dysfunction, sympathetic nervous system overdrive, renin-angiotensin-aldosterone system activation, and electrolyte alterations being important contributors. Although its association with ambulatory BP in the interdialytic period is controversial, IDHYPER is associated with adverse cardiovascular events and mortality. Moving to its management, the antihypertensive drugs of choice should ideally be nondialyzable with proven cardiovascular and mortality benefits. Finally, rigorous clinical and objective assessment of extracellular fluid volume is essential. Volume-overloaded patients should be instructed about the importance of sodium restriction, while physicians ought to alter HD settings toward a greater dry weight reduction. The use of a low-sodium dialysate and isothermic HD could also be considered on a case-by-case basis since no randomized evidence is currently available.
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Affiliation(s)
- Panagiotis Theofilis
- Center for Nephrology "G. Papadakis", General Hospital of Nikaia-Piraeus "Ag. Panteleimon", Nikaia, Greece
| | - Aikaterini Vordoni
- Center for Nephrology "G. Papadakis", General Hospital of Nikaia-Piraeus "Ag. Panteleimon", Nikaia, Greece
| | - Rigas G Kalaitzidis
- Center for Nephrology "G. Papadakis", General Hospital of Nikaia-Piraeus "Ag. Panteleimon", Nikaia, Greece
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2
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Iatridi F, Theodorakopoulou MP, Papagianni A, Sarafidis P. Intradialytic hypertension: epidemiology and pathophysiology of a silent killer. Hypertens Res 2022; 45:1713-1725. [PMID: 35982265 DOI: 10.1038/s41440-022-01001-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/16/2022] [Accepted: 07/07/2022] [Indexed: 11/09/2022]
Abstract
The term intradialytic hypertension (IDH) describes a paradoxical rise in blood pressure (BP) during or immediately after the hemodialysis session. Although it was formerly considered a phenomenon without clinical implications, current evidence suggests that IDH may affect up to 15% of hemodialysis patients and exhibit independent associations with future cardiovascular events and all-cause mortality. Furthermore, during the last decade, several studies have tried to elucidate the complex pathophysiological mechanisms responsible for this phenomenon. Volume overload, intradialytic sodium gain, overactivity of the sympathetic-nervous-system and renin-angiotensin-aldosterone system, endothelial dysfunction and dialysis-related electrolyte disturbances have been proposed to be involved in the pathogenesis of the BP increase during hemodialysis. This review attempts to summarize existing evidence on the epidemiology, pathophysiology and clinical characteristics of the distinct phenomenon of IDH.
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Affiliation(s)
- Fotini Iatridi
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Marieta P Theodorakopoulou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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3
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Singh AT, Waikar SS, Mc Causland FR. Association of Different Definitions of Intradialytic Hypertension With Long-Term Mortality in Hemodialysis. Hypertension 2022; 79:855-862. [PMID: 35166122 PMCID: PMC8916991 DOI: 10.1161/hypertensionaha.121.18058] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hypertension is common in hemodialysis patients. A subset of patients experience systolic blood pressure increases from prehemodialysis to posthemodialysis (intradialytic hypertension), which are associated with adverse outcomes. However, little consensus exists on an evidence-based definition. METHODS In 3198 hemodialysis patients, Cox models were fit to examine the association of various definitions of intradialytic hypertension (≥30% of baseline sessions with an increase in prehemodialysis to posthemodialysis systolic blood pressure of (1) ≥0 mm Hg [Hyper0]; (2) ≥10 mm Hg [Hyper10], or (3) ≥20 mm Hg increase [Hyper20]) with all-cause mortality. Effect modification was assessed using interaction terms according to prespecified variables. RESULTS At baseline, mean age was 62±15 years, 57% were male, and 14% were Black. During the baseline period, 47% of individuals met the Hyper0 definition and experienced 32% (hazard ratio, 1.32 [95% CI, 1.05-1.66]) higher adjusted risk of death, compared with no systolic blood pressure increase. Hyper10 was present in 21.2% and associated with 18% higher adjusted risk of death (hazard ratio, 1.18 [95% CI, 0.94-1.48]). Hyper20 was present in 6.8% and associated with 3% higher adjusted risk of death (hazard ratio 1.03 [95% CI, 0.74-1.44]). Effect modification by age and peripheral vascular disease was observed (P interaction=0.04 for age and 0.02 for peripheral vascular disease), with higher associated risk of death for those aged 45 to 70 years and those without peripheral vascular disease. CONCLUSIONS Individuals with any systolic blood pressure increase from prehemodialysis to posthemodialysis had the highest adjusted risk of mortality, compared with other threshold-based definitions.
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Affiliation(s)
- Anika T Singh
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.T.S., F.R.M.C.).,Harvard Medical School, Boston, MA (A.T.S., F.R.M.C.)
| | - Sushrut S Waikar
- Renal Section, Boston Medical Center, MA (S.S.W.).,Boston University School of Medicine (S.S.W.)
| | - Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.T.S., F.R.M.C.).,Harvard Medical School, Boston, MA (A.T.S., F.R.M.C.)
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4
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Singh AT, Mothi SS, Li P, Sabbisetti V, Waikar SS, Mc Causland FR. Endothelin-1 and Parameters of Systolic Blood Pressure in Hemodialysis. Am J Hypertens 2021; 34:1203-1208. [PMID: 34192305 PMCID: PMC9526807 DOI: 10.1093/ajh/hpab104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/21/2021] [Accepted: 06/29/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Hypertension is common in hemodialysis (HD) patients. Increased blood pressure (BP) variability, particularly higher and lower extremes, is associated with adverse outcomes. We explored the association of endothelin-1 (ET-1), a potent vasoconstrictor, with different BP parameters (pre-HD, intra-HD, and post-HD) during HD in a contemporary patient cohort. METHODS This study uses the DaVita Biorepository, a longitudinal prospective cohort study with quarterly collection of clinical data and biospecimens. Unadjusted and adjusted linear mixed effects regression models were fit to determine association of pre-HD ET-1 (log-transformed and quartiles) with HD-related systolic BP (SBP) parameters (pre-HD, nadir intra-HD, and post-HD). As ET-1 was measured at baseline, analyses were restricted to 1 year of follow-up. RESULTS Among 769 participants, mean age was 52 years, 42% were females, and 41% were Black. Mean pre-HD SBP was 152 (±28) mm Hg and mean ET-1 concentration was 2.3 (±1.2) ng/ml. In fully adjusted models, each unit increase in SD of log-transformed ET-1 was associated with a 2.7 (95% confidence interval [CI] 1.5, 4.0) mm Hg higher pre-SBP; 1.6 (95% CI 0.9, 2.3) mm Hg higher nadir SBP; and 2.0 (95% CI 1.1, 2.9) mm Hg higher post-SBP. Each SD increase in log-transformed ET-1 was associated with 21% higher odds of experiencing intradialytic hypertension (odds ratio 1.21; 95% CI 1.10-1.34). CONCLUSIONS Higher baseline ET-1 levels are independently associated with higher SBP and higher odds of intradialytic hypertension. These results highlight a potential role for ET-1 in BP control in HD patients and raise the possibility of ET-1 antagonism as a therapeutic target.
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Affiliation(s)
- Anika T Singh
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA,Correspondence: Anika T. Singh ()
| | - Suraj Sarvode Mothi
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Ping Li
- Department of Nephrology, State Key Laboratory of Kidney Disease, National Clinical Research Center for Kidney Disease, Chinese PLA General Hospital, Beijing, PR China
| | - Venkata Sabbisetti
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston University, Boston, Massachusetts, USA
| | - Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
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Matsuo M, Kojima S, Arisato T, Matsubara M, Koezuka R, Kishida M, Ogawa K, Inoue H, Yoshihara F. Hypocholesterolemia is a risk factor for reduced systemic vascular resistance reactivity during hemodialysis. Hypertens Res 2021; 44:988-995. [PMID: 33707756 DOI: 10.1038/s41440-021-00640-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 01/04/2023]
Abstract
Intradialytic hypotension (IDH) is associated with high mortality. Peripheral vascular resistance and circulating blood volume are important factors in IDH; however, the effects of hemodialysis (HD) on vascular resistance in IDH remain unclear. We herein performed a retrospective observational cohort study to investigate changes in and factors related to vascular resistance during HD. A total of 101 HD patients were divided into two groups (Decreased blood pressure (BP) during HD group: N = 19, Nondecreased BP group: N = 82), and cardiac output was measured with electrical velocimetry (AESCLON) for 3 h. The systemic vascular resistance index (SVRI) was significantly decreased in the Decreased BP group, while the cardiac index was similar in both groups. A multivariate regression analysis identified hypocholesterolemia as a predictor of reduced vascular resistance reactivity during HD. Furthermore, a correlation was found between changes in the SVRI and cholesterol levels in patients with a higher Geriatric Nutritional Risk Index (GNRI) but not in those with a lower GNRI. The present results suggest that hypocholesterolemia contributes to reducing systematic vascular resistance reactivity during HD, which is an important predictor of a reduction in BP during HD. The relationship between hypocholesterolemia and vascular resistance may involve mechanisms other than malnutrition.
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Affiliation(s)
- Miki Matsuo
- Division of Nephrology and Hypertension, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shiori Kojima
- Division of Nephrology and Hypertension, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tetsuya Arisato
- Division of Nephrology and Hypertension, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masaki Matsubara
- Division of Nephrology and Hypertension, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Ryo Koezuka
- Division of Nephrology and Hypertension, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masatsugu Kishida
- Division of Nephrology and Hypertension, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Koji Ogawa
- Clinical Engineering Department, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hiroshi Inoue
- Clinical Engineering Department, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Fumiki Yoshihara
- Division of Nephrology and Hypertension, National Cerebral and Cardiovascular Center, Osaka, Japan.
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Timofte D, Tanasescu MD, Balan DG, Tulin A, Stiru O, Vacaroiu IA, Mihai A, Popa CC, Cosconel CI, Enyedi M, Miricescu D, Papacocea RI, Ionescu D. Management of acute intradialytic cardiovascular complications: Updated overview (Review). Exp Ther Med 2021; 21:282. [PMID: 33603889 PMCID: PMC7851674 DOI: 10.3892/etm.2021.9713] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/13/2020] [Indexed: 02/07/2023] Open
Abstract
An increasing number of patients require renal replacement therapy through dialysis and renal transplantation. Chronic kidney disease (CKD) affects a large percentage of the world's population and has evolved into a major public health concern. Diabetes mellitus, high blood pressure and a family history of kidney failure are all major risk factors for CKD. Patients in advanced stages of CKD have varying degrees of cardiovascular damage. Comorbidities of these patients, include, on the one hand, hypertension, hyperlipidemia, hyperglycemia, hyperuricemia and, on the other hand, the presence of mineral-bone disorders associated with CKD and chronic inflammation, which contribute to cardiovascular involvement. Acute complications occur quite frequently during dialysis. Among these, the most important are cardiovascular complications, which influence the morbidity and mortality rates of this group of patients. Chronic hemodialysis patients manifest acute cardiovascular complications such as intradialytic hypotension, intradialytic hypertension, arrhythmias, acute coronary syndromes and sudden death. Thus, proper management is extremely important.
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Affiliation(s)
- Delia Timofte
- Department of Dialysis, Emergency University Hospital, 050098 Bucharest, Romania
| | - Maria-Daniela Tanasescu
- Department of Medical Semiology, Discipline of Internal Medicine I and Nephrology, Faculty of Medicine, 'Carol Davila̓ University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Nephrology, Emergency University Hospital, 050098 Bucharest, Romania
| | - Daniela Gabriela Balan
- Discipline of Physiology, Faculty of Dental Medicine, Carol Davila̓ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Adrian Tulin
- Department of Anatomy, Faculty of Medicine, 'Carol Davila̓ University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of General Surgery, 'Prof. Dr. Agrippa Ionescu̓ Clinical Emergency Hospital, 011356 Bucharest, Romania
| | - Ovidiu Stiru
- Department of Cardiovascular Surgery, Faculty of Medicine, 'Carol Davila̓ University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Cardiovascular Surgery, 'Prof. Dr. C.C. Iliescu̓ Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Ileana Adela Vacaroiu
- Department of Nephrology and Dialysis, 'Sf. Ioan' Emergency Clinical Hospital, 042122 Bucharest, Romania.,Department of Nephrology, Faculty of Medicine, 'Carol Davila̓ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Andrada Mihai
- Discipline of Diabetes, 'N. C. Paulescu' Institute of Diabetes, Nutrition and Metabolic Diseases, 020474 Bucharest, Romania.,Department II of Diabetes, 'N. C. Paulescu̓ Institute of Diabetes, Nutrition and Metabolic Diseases, 020474 Bucharest, Romania
| | - Cristian Constantin Popa
- Department of Surgery, Faculty of Medicine, 'Carol Davila̓ University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Surgery, Emergency University Hospital, 050098 Bucharest, Romania
| | - Cristina-Ileana Cosconel
- Discipline of Foreign Languages, Faculty of Dental Medicine, 'Carol Davila̓ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Mihaly Enyedi
- Department of Anatomy, Faculty of Medicine, 'Carol Davila̓ University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Radiology, 'Victor Babes̓ Private Medical Clinic, 030303 Bucharest, Romania
| | - Daniela Miricescu
- Discipline of Biochemistry, Faculty of Dental Medicine, 'Carol Davila̓ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Raluca Ioana Papacocea
- Discipline of Physiology, Faculty of Medicine, 'Carol Davila̓ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Dorin Ionescu
- Department of Medical Semiology, Discipline of Internal Medicine I and Nephrology, Faculty of Medicine, 'Carol Davila̓ University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Nephrology, Emergency University Hospital, 050098 Bucharest, Romania
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7
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Intradialytic systolic blood pressure variation can predict long-term mortality in patients on maintenance hemodialysis. Int Urol Nephrol 2021; 53:785-795. [PMID: 33387229 DOI: 10.1007/s11255-020-02701-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 10/29/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE It is unclear which time-points of intradialytic blood pressure (BP) best predict prognosis. Thus, it is important to assess the association between different time-points of intradialytic BP and prognosis in clinical practice. METHODS We recruited patients who underwent hemodialysis from January 2014 to June 2014. Data about dialysis were collected, including intradialytic BP. Cox regression analysis was performed to examine the association between different time-points of intradialytic BP and clinical events, with a follow-up through December 31, 2019. The primary endpoint was all-cause mortality. RESULTS A total of 216 patients were recruited and 62 (30.7%) patients died (6.1 per 100-person year) during the follow-up. Intradialytic SBP varied greatly in fatalities. Univariate and multivariate Cox regression models indicated that the adjusted hazard ratio for death was 1.80 and 5.06 when intradialytic systolic blood pressure (SBP) variation was analyzed in increments of 20 mmHg. Furthermore, we divided intradialytic SBP variation into three categories: < 15 mmHg, 15 ~ 30 mmHg, ≥ 30 mmHg. Kaplan-Meier analysis indicated that both all-cause mortality and cardiovascular mortality increased significantly for patients with intradialytic SBP variation over 30 mmHg (P = 0.006 and 0.021). Univariate and multivariate Cox regression models indicated that the adjusted hazard ratio for death was 3.78 and 12.62 as intradialytic SBP variation ≥ 30 mmHg vs. intradialytic SBP variation < 15 mmHg. CONCLUSION Intradialytic SBP variation, rather than BP of specific intradialytic time-points, has the potential to predict long-term mortality in hemodialysis patients. BP stability is crucial for patients' prognosis.
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Tawfeek GAE, Kora MA, Yassein YS, Baghdadi AM, Elzorkany KM. Association of pre-pro-endothelin gene polymorphism and serum endothelin-1 with intradialytic hypertension in an Egyptian population. Cytokine 2020; 137:155293. [PMID: 33128922 DOI: 10.1016/j.cyto.2020.155293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 07/23/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Intradialytic hypertension (IDH) is a major problem of hemodialysis and it is a multifactorial disorder and need early identification and management. AIM Evaluate the serum concentration of endothelin-1 in patients with IDH and healthy control and the impact of pre-pro-endothelin gene polymorphism on level of endothelin-1 and susceptibility to IDH in Egyptian population. METHODS The patient groups divided into group I, End stage renal disease (ESRD) on chronic hemodialysis with IDH (112); group II, ESRD on chronic hemodialysis without IDH (112); group III, healthy control (112). All undergone to full history, clinical examination, routine laboratory investigations, echocardiography, serum ET-1 level by ELISA and A(8002)G polymorphism detection in pre-pro-endothelin gene by PCR-RFLP. RESULTS Our results showed significantly higher concentration of Endothelin-1 (ET-1) in both patient groups than healthy control and in group with IDH than cases without IDH (p < 0.001). GG, GA and mutated G allele carry the risk of IDH (OR = 15.94, 13.5, 5.51 respectively p < 0.001). There was association between GG and GA genotypes and higher ET-1 level in both patient groups (p < 0.001) and association between GG and GA genotype and higher mean arterial pressure (MAP), delta MAP (DMAP) and increased left ventricular mass index (LVMI) in both patient groups (p = 0.001, 0.028). CONCLUSION Pre-pro-endothelin gene polymorphism A(8002)G is an independent risk factor for IDH through changing the level of ET-1 concentration in Egyptian population undergoing chronic hemodialysis.
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Dry-weight reduction improves intradialytic hypertension only in patients with high predialytic blood pressure. Blood Press Monit 2019; 24:185-190. [PMID: 30807307 DOI: 10.1097/mbp.0000000000000373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of this study was to investigate whether additional volume reduction by ultrafiltration can improve blood pressure in patients with intradialytic hypertension (IDH) defined as at least 10 mmHg systolic blood pressure (SBP) rise during hemodialysis. PATIENTS AND METHODS This prospective, open-label, single-center study included 11 IDH patients with normal predialytic blood pressure (BP) (group A), 11 IDH patients with high predialytic BP (group B), and 18 patients without IDH as control. Serum angiotensin-II, aldosterone (ALD), angiotensin-converting enzyme, endothelin-1, nitric oxide, and asymmetric dimethylarginine were measured before and after the treatments. RESULTS Basic angiotensin-converting enzyme, ALD, endothelin-1, and asymmetric dimethylarginine serum levels were significantly increased in group B compared with control (P < 0.05). On comparing the results from the first and 13th dialysis sessions in group A, the dry weight was reduced by - 0.15 ± 0.16 kg after 12 sessions and the predialytic SBP increased by 3.18 ± 6.25 mmHg before and by 7.37 ± 14.90 mmHg at 4 h during the 13th session. In group B, the dry weight was reduced by 0.67 ± 0.53 kg (P = 0.006 vs. group A) at the 13th session and they had - 12.09 ± 16.20 mmHg less SBP before (P = 0.009 vs. group A) and - 11.82 ± 14.66 mmHg at 4 h of the 13th session. The decrease in dry weight was associated with significantly higher decreases in angiotensin-II and ALD serum levels in group B compared with group A. CONCLUSION Reducing fluid overload in IDH patients with high predialytic BP can effectively improve their BP, but had no effect on BP in normal predialytic BP IDH cases.
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Park SH, Fonkoue IT, Li Y, DaCosta DR, Middlekauff HR, Park J. Augmented Cardiopulmonary Baroreflex Sensitivity in Intradialytic Hypertension. Kidney Int Rep 2018; 3:1394-1402. [PMID: 30450466 PMCID: PMC6224617 DOI: 10.1016/j.ekir.2018.07.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 07/17/2018] [Accepted: 07/23/2018] [Indexed: 11/25/2022] Open
Abstract
Introduction End-stage renal disease (ESRD) patients with a paradoxical increase in blood pressure (BP) during hemodialysis (HD), termed intradialytic hypertension (ID-HTN), are at significantly increased risk for mortality and adverse cardiovascular events. ID-HTN affects up to 15% of all HD patients, and the pathophysiologic mechanisms remain unknown. We hypothesized that ESRD patients prone to ID-HTN have heightened volume-sensitive cardiopulmonary baroreflex sensitivity (BRS) that leads to exaggerated increases in sympathetic nervous system (SNS) activation during HD. Methods We studied ESRD patients on maintenance HD with ID-HTN (n = 10) and without ID-HTN (controls, n = 12) on an interdialytic day, 24 to 30 hours after their last HD session. We measured continuous muscle sympathetic nerve activity (MSNA), beat-to-beat arterial BP, and electrocardiography (ECG) at baseline, and during graded lower body negative pressure (LBNP). Low-dose LBNP isolates cardiopulmonary BRS, whereas higher doses allow assessment of physiologic responses to orthostatic stress. Results The ID-HTN patients had significantly higher pre- and post-HD BP, and greater interdialytic fluid weight gain compared to controls. There was a significantly greater increase in MSNA burst incidence (P = 0.044) during graded LBNP in the ID-HTN group, suggesting heightened cardiopulmonary BRS. The ID-HTN group also had a trend toward increased diastolic BP response during LBNP, and had significantly greater increases in BP during the cold pressor test. Conclusion Patients with ID-HTN have augmented cardiopulmonary BRS that may contribute to increased SNS activation and BP response during HD.
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Affiliation(s)
- Sook H Park
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Research Service Line, Atlanta Veterans Affairs Medical Center, Decatur, Georgia, USA
| | - Ida T Fonkoue
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Research Service Line, Atlanta Veterans Affairs Medical Center, Decatur, Georgia, USA
| | - Yunxiao Li
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Dana R DaCosta
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Research Service Line, Atlanta Veterans Affairs Medical Center, Decatur, Georgia, USA
| | - Holly R Middlekauff
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Jeanie Park
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Research Service Line, Atlanta Veterans Affairs Medical Center, Decatur, Georgia, USA
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Abstract
PURPOSE OF REVIEW Intradialytic hypertension occurs regularly in 10--15% of hemodialysis patients. A large observational study recently showed that intradialytic hypertension of any magnitude increased mortality risk comparable to the most severe degrees of intradialytic hypotension. The present review review discusses the most recent evidence underlying the pathophysiology of intradialytic hypertension and implications for its management. RECENT FINDINGS Patients with intradialytic hypertension typically have small interdialytic weight gains, but bioimpedance spectroscopy shows these patients have significant chronic extracellular volume excess. Intradialytic hypertension patients have lower albumin and predialysis urea nitrogen levels, which may contribute to small reductions in osmolarity that prevents blood pressure decreases. Intradialytic vascular resistance surges remain implicated as the driving force for blood pressure increases, but mediators other than endothelin-1 may be responsible. Beyond dry weight reduction, the only controlled intervention shown to interrupt the blood pressure increase is lowering dialysate sodium. SUMMARY Patients with recurrent intradialytic hypertension should be identified as high-risk patients. Dry weight should be re-evaluated, even if patients do not clinically appear volume overloaded. Antihypertensive drugs should be prescribed because of the persistently elevated ambulatory blood pressure. Dialysate sodium reduction should be considered, although the long term effects of this intervention are uncertain.
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12
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Campos NG, Marizeiro DF, Florêncio ACL, Silva ÍC, Meneses GC, Bezerra GF, Martins AMC, Libório AB. Effects of respiratory muscle training on endothelium and oxidative stress biomarkers in hemodialysis patients: A randomized clinical trial. Respir Med 2018; 134:103-109. [DOI: 10.1016/j.rmed.2017.12.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/04/2017] [Accepted: 12/06/2017] [Indexed: 11/29/2022]
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13
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Correction. Hemodial Int 2017; 21:148. [DOI: 10.1111/hdi.12523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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