1
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Tade G, Hsu HC, Robinson C, Dlongolo N, Teckie G, Solomon A, Dessein PH. The relative potential contribution of volume load and vascular mechanisms to hypertension in non-dialysis and dialysis chronic kidney disease patients. Front Cardiovasc Med 2024; 11:1377887. [PMID: 38689863 PMCID: PMC11060794 DOI: 10.3389/fcvm.2024.1377887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/28/2024] [Indexed: 05/02/2024] Open
Abstract
Background Hypertension is highly prevalent and particularly difficult to treat adequately in patients with chronic kidney disease (CKD). The relative contribution of volume overload and vascular mechanisms to blood pressure measures in CKD and whether these effects differ in non-dialysis compared to dialysis patients is unknown. Methods We determined the potential impact of volume load (stroke volume) and vascular mechanisms (inverse of total arterial compliance (inv TAC) and systemic vascular resistance (SVR)) on mean and brachial and aortic systolic blood pressures in 67 non-dialysis and 48 dialysis chronic kidney disease (CKD) patients. Relationships were determined in confounder adjusted regression models. Results Stroke volume (p value = 0.003) was more strongly associated with mean arterial pressure than SVR (p value = 0.9) (p value for difference = 0.03). When stroke volume and SVR were entered in the same regression model (model R2 = 0.324), they contributed equally to the variation in mean arterial pressure (p value for difference = 0.5). Stroke volume (p value ≤ 0.002) and inv TAC (p value ≤ 0.001) contributed equally to the variation in systolic pressures (p value for difference ≥ 0.9). When stroke volume and inv TAC were entered in the same regression model (model R2 = 0.752 to 0.765), they contributed equally to the variation in systolic blood pressures (p value for difference = 0.7). Stroke volume, TAC and SVR were similar (p value ≥ 0.5) and associated to the same extent with blood pressure measures in non-dialysis and dialysis CKD patients (p value for difference ≥ 0.1). In receiver operator characteristic curve analysis, elevated systolic blood pressure was determined by stroke volume (p value = 0.005) and inv TAC (p value = 0.03) but not SVR (p value = 0.8). The calculated power of the study was 0.999 based on α = 0.05. Conclusions The present investigation suggests that both volume load and vascular mechanisms should be considered in the management of hypertension among patients with CKD. The extent and relative potential impact of volume load and vascular mechanisms on blood pressure measures are as large in non-dialysis compared to dialysis CKD patients.
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Affiliation(s)
- Grace Tade
- Cardiovascular Pathophysiology and Genomics Research Unit, Faculty of Health Sciences, School of Physiology, University of the Witwatersrand, Johannesburg, South Africa
| | - Hon-Chun Hsu
- Cardiovascular Pathophysiology and Genomics Research Unit, Faculty of Health Sciences, School of Physiology, University of the Witwatersrand, Johannesburg, South Africa
- Nephrology Unit, Milpark Hospital, Johannesburg, South Africa
| | - Chanel Robinson
- Cardiovascular Pathophysiology and Genomics Research Unit, Faculty of Health Sciences, School of Physiology, University of the Witwatersrand, Johannesburg, South Africa
| | - Noluntu Dlongolo
- Rheumatology Unit, Rosebank Hospital, Johannesburg, South Africa
| | - Gloria Teckie
- Division of Nephrology, Department of Medicine, Chris Hani Baragwanath Hospital and Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Ahmed Solomon
- Internal Medicine Department, University of the Witwatersrand, Johannesburg, South Africa
| | - Patrick Hector Dessein
- Cardiovascular Pathophysiology and Genomics Research Unit, Faculty of Health Sciences, School of Physiology, University of the Witwatersrand, Johannesburg, South Africa
- Rheumatology Unit, Rosebank Hospital, Johannesburg, South Africa
- Internal Medicine Department, University of the Witwatersrand, Johannesburg, South Africa
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2
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Rope R, Ryan E, Weinhandl ED, Abra GE. Home-Based Dialysis: A Primer for the Internist. Annu Rev Med 2024; 75:205-217. [PMID: 38039393 DOI: 10.1146/annurev-med-050922-051415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
Home-based dialysis modalities offer both clinical and practical advantages to patients. The use of the home-based modalities, peritoneal dialysis and home hemodialysis, has been increasing over the past decade after a long period of decline. Given the increasing frequency of use of these types of dialysis, it is important for clinicians to be familiar with how these types of dialysis are performed and key clinical aspects of care related to their use in patients with end-stage kidney disease.
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Affiliation(s)
- Robert Rope
- Division of Nephrology and Hypertension, Oregon Health & Science University, Portland, Oregon, USA;
| | - Eric Ryan
- Division of Nephrology and Hypertension, Oregon Health & Science University, Portland, Oregon, USA;
| | - Eric D Weinhandl
- DaVita Clinical Research, Minneapolis, Minnesota, USA
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota, USA
| | - Graham E Abra
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California, USA;
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3
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Quinn RR, Lam NN. Home Dialysis in North America: The Current State. Clin J Am Soc Nephrol 2023; 18:1351-1358. [PMID: 37523194 PMCID: PMC10578635 DOI: 10.2215/cjn.0000000000000273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/21/2023] [Indexed: 08/01/2023]
Abstract
There is widespread interest in expanding the uptake of home dialysis in North America. Although kidney transplantation should be the preferred option in eligible patients, home hemodialysis (HD) and peritoneal dialysis (PD) offer cost-effective options for KRT. In this review, the motivation for promoting home dialysis is presented, and the literature supporting it is critically reviewed. Randomized comparisons of home HD and PD with in-center HD have been challenging to conduct and provide only limited information. Nonrandomized studies are heterogeneous in their design and have often yielded conflicting results. They are prone to bias, and this must be carefully considered when evaluating this literature. Home modalities seem to have equivalent clinical outcomes and quality of life when compared with in-center HD. However, the cost of providing home therapies, particularly PD, is lower than conventional, in-center HD. Measures of home dialysis utilization, the philosophy behind their measurement, and important factors to consider when interpreting them are discussed. The importance of understanding measures of home dialysis utilization in the context of rates of kidney failure, the proportion of individuals who opt for conservative care, and rates of kidney transplantation is highlighted, and a framework for proposing targets is presented, using PD as an example.
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Affiliation(s)
- Robert R Quinn
- Cumming School of Medicine , University of Calgary , Calgary, Canada, and
- Department of Community Health Sciences , University of Calgary , Calgary, Canada
| | - Ngan N Lam
- Cumming School of Medicine , University of Calgary , Calgary, Canada, and
- Department of Community Health Sciences , University of Calgary , Calgary, Canada
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4
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Natale P, Ju A, Strippoli GF, Craig JC, Saglimbene VM, Unruh ML, Stallone G, Jaure A. Interventions for fatigue in people with kidney failure requiring dialysis. Cochrane Database Syst Rev 2023; 8:CD013074. [PMID: 37651553 PMCID: PMC10468823 DOI: 10.1002/14651858.cd013074.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND Fatigue is a common and debilitating symptom in people receiving dialysis that is associated with an increased risk of death, cardiovascular disease and depression. Fatigue can also impair quality of life (QoL) and the ability to participate in daily activities. Fatigue has been established by patients, caregivers and health professionals as a core outcome for haemodialysis (HD). OBJECTIVES We aimed to evaluate the effects of pharmacological and non-pharmacological interventions on fatigue in people with kidney failure receiving dialysis, including HD and peritoneal dialysis (PD), including any setting and frequency of the dialysis treatment. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 18 October 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Studies evaluating pharmacological and non-pharmacological interventions affecting levels of fatigue or fatigue-related outcomes in people receiving dialysis were included. Studies were eligible if fatigue or fatigue-related outcomes were reported as a primary or secondary outcome. Any mode, frequency, prescription, and duration of therapy were considered. DATA COLLECTION AND ANALYSIS Three authors independently extracted data and assessed the risk of bias. Treatment estimates were summarised using random effects meta-analysis and expressed as a risk ratio (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI) or standardised MD (SMD) if different scales were used. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS Ninety-four studies involving 8191 randomised participants were eligible. Pharmacological and non-pharmacological interventions were compared either to placebo or control, or to another pharmacological or non-pharmacological intervention. In the majority of domains, risks of bias in the included studies were unclear or high. In low certainty evidence, when compared to control, exercise may improve fatigue (4 studies, 217 participants (Iowa Fatigue Scale, Modified Fatigue Impact Scale, Piper Fatigue Scale (PFS), or Haemodialysis-Related Fatigue scale score): SMD -1.18, 95% CI -2.04 to -0.31; I2 = 87%) in HD. In low certainty evidence, when compared to placebo or standard care, aromatherapy may improve fatigue (7 studies, 542 participants (Fatigue Severity Scale (FSS), Rhoten Fatigue Scale (RFS), PFS or Brief Fatigue Inventory score): SMD -1.23, 95% CI -1.96 to -0.50; I2 = 93%) in HD. In low certainty evidence, when compared to no intervention, massage may improve fatigue (7 studies, 657 participants (FSS, RFS, PFS or Visual Analogue Scale (VAS) score): SMD -1.06, 95% CI -1.47, -0.65; I2 = 81%) and increase energy (2 studies, 152 participants (VAS score): MD 4.87, 95% CI 1.69 to 8.06, I2 = 59%) in HD. In low certainty evidence, when compared to placebo or control, acupressure may reduce fatigue (6 studies, 459 participants (PFS score, revised PFS, or Fatigue Index): SMD -0.64, 95% CI -1.03 to -0.25; I2 = 75%) in HD. A wide range of heterogenous interventions and fatigue-related outcomes were reported for exercise, aromatherapy, massage and acupressure, preventing our capability to pool and analyse the data. Due to the paucity of studies, the effects of pharmacological and other non-pharmacological interventions on fatigue or fatigue-related outcomes, including non-physiological neutral amino acid, relaxation with or without music therapy, meditation, exercise with nandrolone, nutritional supplementation, cognitive-behavioural therapy, ESAs, frequent HD sections, home blood pressure monitoring, blood flow rate reduction, serotonin reuptake inhibitor, beta-blockers, anabolic steroids, glucose-enriched dialysate, or light therapy, were very uncertain. The effects of pharmacological and non-pharmacological treatments on death, cardiovascular diseases, vascular access, QoL, depression, anxiety, hypertension or diabetes were sparse. No studies assessed tiredness, exhaustion or asthenia. Adverse events were rarely and inconsistently reported. AUTHORS' CONCLUSIONS Exercise, aromatherapy, massage and acupressure may improve fatigue compared to placebo, standard care or no intervention. Pharmacological and other non-pharmacological interventions had uncertain effects on fatigue or fatigue-related outcomes in people receiving dialysis. Future adequately powered, high-quality studies are likely to change the estimated effects of interventions for fatigue and fatigue-related outcomes in people receiving dialysis.
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Affiliation(s)
- Patrizia Natale
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Angela Ju
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Giovanni Fm Strippoli
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Valeria M Saglimbene
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Mark L Unruh
- University of New Mexico, Department of Internal Medicine, Albuquerque, New Mexico, USA
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Allison Jaure
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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5
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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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6
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Al Sahlawi MA, Dahlan RA. Nephrologists' Perspectives of the Potential Utilization of Home Hemodialysis in Saudi Arabia. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:730-737. [PMID: 38018714 DOI: 10.4103/1319-2442.390252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023] Open
Abstract
Home hemodialysis (HD) is an attractive renal replacement modality that has been shown to provide several benefits to the patient and health-care system. However, home HD programs have not been well-established in Saudi Arabia. We aimed to explore the perspectives of adult nephrology consultants in Saudi Arabia about the potential utilization of home HD via a survey-based cross-sectional study. The survey was distributed via email to all adult nephrology consultants practicing in Saudi Arabia and registered in the Saudi Society of Nephrology and Transplantation. Out of 236 invited consultants, 151 (64%) participated in the study. Half of the participants defined home HD as a trained patient who can independently perform his/her HD sessions at home. Eighty-one (54%) consultants have never managed a patient on home HD during their nephrology training period. More than 70% of participants believed that home HD provides advantages over in-center HD, and that its utilization in Saudi Arabia would be feasible. Although 40% of participants worked in centers with no accredited nephrology training program, most of the remaining participants believed that the local training program did not provide enough teaching about home HD to trainees. Patients' refusal, the nephrologists' lack of motivation and experience, a lack of administrative support, and the lack of infrastructure and nursing support were identified by most participants as the major barriers to the utilization of home HD in Saudi Arabia. Addressing these barriers would be the first step to facilitate initiatives aiming to establish home HD programs in this country.
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Affiliation(s)
- Muthana A Al Sahlawi
- Department of Internal Medicine, College of Medicine, King Faisal University, Al-Hasa, Saudi Arabia
| | - Randah A Dahlan
- Department of Internal Medicine, Section of Nephrology, King Abdullah Medical City, Makkah, Saudi Arabia
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7
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Sarnak MJ, Auguste BL, Brown E, Chang AR, Chertow GM, Hannan M, Herzog CA, Nadeau-Fredette AC, Tang WHW, Wang AYM, Weiner DE, Chan CT. Cardiovascular Effects of Home Dialysis Therapies: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e146-e164. [PMID: 35968722 DOI: 10.1161/cir.0000000000001088] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Cardiovascular disease is the leading cause of morbidity and mortality in patients with end-stage kidney disease. Currently, thrice-weekly in-center hemodialysis for 3 to 5 hours per session is the most common therapy worldwide for patients with treated kidney failure. Outcomes with thrice-weekly in-center hemodialysis are poor. Emerging evidence supports the overarching hypothesis that a more physiological approach to administering dialysis therapy, including in the home through home hemodialysis or peritoneal dialysis, may lead to improvement in several cardiovascular risk factors and cardiovascular outcomes compared with thrice-weekly in-center hemodialysis. The Advancing American Kidney Health Initiative, which has a goal of increasing the use of home dialysis, is aligned with the American Heart Association's 2024 mission to champion a full and healthy life and health equity. We conclude that incorporation of interdisciplinary care models to increase the use of home dialysis therapies in an equitable manner will contribute to the ultimate goal of improving outcomes for patients with kidney failure and cardiovascular disease.
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8
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Roblero MFS, Rubio MAB, González-Moya M, Varela JC, Alba AP, Gumpert JV, Cigarrán S, Vidau P, Marcos SG, Luquin PA, Piera EC, Mariño AG, Espigares MJ, Molina MD, Molina P. Experience in Spain with the first patients in home hemodialysis treated with low-flow dialysate monitors. Nefrologia 2022; 42:460-470. [PMID: 36400687 DOI: 10.1016/j.nefroe.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 07/12/2021] [Indexed: 06/16/2023] Open
Abstract
Home hemodialysis (HHD) with low-flow dialysate devices has gained popularity in recent years due to its simple design, portability, and ability to provide greater freedom of movement for our patients. However, there are doubts about the adequacy that this technology offers, since it uses monitors with low-flow bath and lactate. The aim of this study was to demonstrate the clinical benefits of low-flow HHD with the NxStage System One® recently introduced in Spain. We present the results of an observational, retrospective cohort study that included the first patients who started short daily HHD with this device in 12 Spanish centers. We analyzed the evolution of 86 patients at 0, 6 and 12 months, including data related to prescription, and evolution of biochemical parameters related to dialysis dose, anemia, mineral-bone metabolism; evolution of residual renal function, medication usage, and causes of withdrawal during the followup. We were able to demonstrate that this NxStage System One® monitor, in patients with HHD, have provided an adequate dialysis dose, with optimal ultrafiltration rate, with improvement of main biochemical markers of dialysis adequacy. The usage of this technique was associated to a decrease of antihypertensive drugs, phosphate binders and erythropoietin agents, with very good results both patient and technique survival. The simplicity of the technique, together with its good clinical outcomes, should facilitate the growth and utilization of HHD, both in incident and prevalent patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Pedro Vidau
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | | | | | | | | | - Mariola D Molina
- Departamento de Matemáticas, Universidad de Alicante, San Vicente del Raspeig, Alicante, Spain
| | - Pablo Molina
- Hospital Universitari Dr Peset, FISABIO, Departamento de Medicina, Universitat de València, Valencia, Spain
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9
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Prasad B, Hemmett J, Suri R. Five Things to Know About Intradialytic Hypertension. Can J Kidney Health Dis 2022; 9:20543581221106657. [PMID: 35756329 PMCID: PMC9218443 DOI: 10.1177/20543581221106657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Bhanu Prasad
- Division of Nephrology, Department of Medicine, Regina General Hospital, SK, Canada
| | - Juliya Hemmett
- Division of Nephrology, Department of Medicine, Foothills Medical Center, Calgary, AB, Canada
| | - Rita Suri
- Division of Nephrology, McGill University Faculty of Medicine, Montreal, QC, Canada
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10
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Yang X, Zhao D, Yu F, Heidari AA, Bano Y, Ibrohimov A, Liu Y, Cai Z, Chen H, Chen X. An optimized machine learning framework for predicting intradialytic hypotension using indexes of chronic kidney disease-mineral and bone disorders. Comput Biol Med 2022; 145:105510. [DOI: 10.1016/j.compbiomed.2022.105510] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 04/07/2022] [Accepted: 04/07/2022] [Indexed: 11/03/2022]
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11
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Weinhandl ED, Forfang D. From Home Dialysis Access to Home Dialysis Quality. Adv Chronic Kidney Dis 2022; 29:52-58. [PMID: 35690405 DOI: 10.1053/j.ackd.2022.02.010] [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: 10/31/2021] [Revised: 02/14/2022] [Accepted: 02/28/2022] [Indexed: 11/11/2022]
Abstract
The number and percentage of patients dialyzing at home has steadily increased during the past decade, and federal policy initiatives have driven interest to a new high. However, the mere utilization of home dialysis does not ensure better outcomes for patients and care partners. Although public reporting systems for dialysis quality are mature and robust, the incorporation of home dialysis quality in those systems is immature; the advent of the End-Stage Renal Disease Treatment Choices payment model brings this problem into sharp relief. The home dialysis modalities present both common and unique targets for quality measurement. For both modalities, therapy duration (or its inverse, technique failure) is a potential target. For peritoneal dialysis, peritonitis, catheter complications, and residual kidney function are additional targets; for home hemodialysis, vascular access infections, dialysis adequacy, and treatment adherence are targets. Patient-reported experience measures are also important; this domain is a long-standing disparity, as in-facility hemodialysis patients have been routinely surveyed for several years. The statistical aspect of quality measurement in home dialysis requires some adaptation, as the typical home dialysis program is small, thus presenting a threat to reliability; pooling programs may be necessary. Ultimately, promoting high-quality home dialysis will likely increase utilization of home dialysis.
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Affiliation(s)
- Eric D Weinhandl
- Satellite Healthcare, San Jose, CA; Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN.
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12
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Torreggiani M, Fois A, Njandjo L, Longhitano E, Chatrenet A, Esposito C, Fessi H, Piccoli GB. Toward an individualized determination of dialysis adequacy: a narrative review with special emphasis on incremental hemodialysis. Expert Rev Mol Diagn 2021; 21:1119-1137. [PMID: 34595991 DOI: 10.1080/14737159.2021.1987216] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The search for the 'perfect' renal replacement therapy has been paralleled by the search for the perfect biomarkers for assessing dialysis adequacy. Three main families of markers have been assessed: small molecules (prototype: urea); middle molecules (prototype β2-microglobulin); comprehensive and nutritional markers (prototype of the simplified assessment, albumin levels; composite indexes as malnutrition-inflammation score). After an era of standardization of dialysis treatment, personalized dialysis schedules are increasingly proposed, challenging the dogma of thrice-weekly hemodialysis. AREAS COVERED In this review, we describe the advantages and limitations of the approaches mentioned above, focusing on the open questions regarding personalized schedules and incremental hemodialysis. EXPERT OPINION In the era of personalized dialysis, the assessment of dialysis adequacy should be likewise personalized, due to the limits of 'one size fits all' approaches. We have tried to summarize some of the relevant issues regarding the determination of dialysis adequacy, attempting to adapt them to an elderly, highly comorbidity population, which would probably benefit from tailor-made dialysis prescriptions. While no single biomarker allows precisely tailoring the dialysis dose, we suggest using a combination of clinical and biological markers to prescribe dialysis according to comorbidity, life expectancy, residual kidney function, and small and medium-size molecule depuration.
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Affiliation(s)
| | - Antioco Fois
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
| | - Linda Njandjo
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France
| | - Elisa Longhitano
- Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, A.o.u. "G. Martino," University of Messina, Messina, Italy
| | - Antoine Chatrenet
- Nèphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France.,Laboratory "Movement, Interactions, Performance" (EA 4334), Le Mans University, Le Mans, France
| | - Ciro Esposito
- Nephrology and Dialysis, ICS Maugeri S.p.A. Sb, Pavia, Italy.,Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Hafedh Fessi
- Department of Nephrology, Hospital Tenon, Paris, France
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13
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Slon Roblero MF, Bajo Rubio MA, González-Moya M, Calviño Varela J, Pérez Alba A, Villaro Gumpert J, Cigarrán S, Vidau P, García Marcos S, Abáigar Luquin P, Coll Piera E, Gascón Mariño A, Espigares MJ, Molina MD, Molina P. Experience in Spain with the first patients in home hemodialysis treated with low-flow dialysate monitors. Nefrologia 2021; 42:S0211-6995(21)00144-2. [PMID: 34393002 DOI: 10.1016/j.nefro.2021.07.001] [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: 12/31/2020] [Revised: 07/06/2021] [Accepted: 07/12/2021] [Indexed: 11/25/2022] Open
Abstract
Home hemodialysis (HHD) with low-flow dialysate devices has gained popularity in recent years due to its simple design, portability, and ability to provide greater freedom of movement for our patients. However, there are doubts about the adequacy that this technology offers, since it uses monitors with low-flow bath and lactate. The aim of this study was to demonstrate the clinical benefits of low-flow HHD with the NxStage System One® recently introduced in Spain. We present the results of an observational, retrospective cohort study that included the first patients who started short daily HHD with this device in 12 Spanish centers. We analyzed the evolution of 86 patients at 0, 6 and 12 months, including data related to prescription, and evolution of biochemical parameters related to dialysis dose, anemia, mineral-bone metabolism; evolution of residual renal function, medication usage, and causes of withdrawal during the followup. We were able to demonstrate that this NxStage System One® monitor, in patients with HHD, have provided an adequate dialysis dose, with optimal ultrafiltration rate, with improvement of main biochemical markers of dialysis adequacy. The usage of this technique was associated to a decrease of antihypertensive drugs, phosphate binders and erythropoietin agents, with very good results both patient and technique survival. The simplicity of the technique, together with its good clinical outcomes, should facilitate the growth and utilization of HHD, both in incident and prevalent patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Pedro Vidau
- Hospital Universitario Central de Asturias, Oviedo, España
| | | | | | | | | | | | - Mariola D Molina
- Departamento de Matemáticas, Universidad de Alicante, San Vicente del Raspeig, Alicante, España
| | - Pablo Molina
- Hospital Universitari Dr Peset, FISABIO, Departamento de Medicina, Universitat de València, Valencia, España
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14
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Roumeliotis A, Roumeliotis S, Chan C, Pierratos A. Cardiovascular Benefits of Extended-Time Nocturnal Hemodialysis. Curr Vasc Pharmacol 2021; 19:21-33. [PMID: 32234001 DOI: 10.2174/1570161118666200401112106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 03/10/2020] [Accepted: 03/11/2020] [Indexed: 01/09/2023]
Abstract
Hemodialysis (HD) remains the most utilized treatment for End-Stage Kidney Disease (ESKD) globally, mainly as conventional HD administered in 4 h sessions thrice weekly. Despite advances in HD delivery, patients with ESKD carry a heavy cardiovascular morbidity and mortality burden. This is associated with cardiac remodeling, left ventricular hypertrophy (LVH), myocardial stunning, hypertension, decreased heart rate variability, sleep apnea, coronary calcification and endothelial dysfunction. Therefore, intensive HD regimens closer to renal physiology were developed. They include longer, more frequent dialysis or both. Among them, Nocturnal Hemodialysis (NHD), carried out at night while asleep, provides efficient dialysis without excessive interference with daily activities. This regimen is closer to the physiology of the native kidneys. By providing increased clearance of small and middle molecular weight molecules, NHD can ameliorate uremic symptoms, control hyperphosphatemia and improve quality of life by allowing a liberal diet and free time during the day. Lastly, it improves reproductive biology leading to successful pregnancies. Conversion from conventional to NHD is followed by improved blood pressure control with fewer medications, regression of LVH, improved LV function, improved sleep apnea, and stabilization of coronary calcifications. These beneficial effects have been associated, among others, with better extracellular fluid volume control, improved endothelial- dependent vasodilation, decreased total peripheral resistance, decreased plasma norepinephrine levels and restoration of heart rate variability. Some of these effects represent improvements in outcomes used as surrogates of hard outcomes related to cardiovascular morbidity and mortality. In this review, we consider the cardiovascular effects of NHD.
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Affiliation(s)
- Athanasios Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefanos Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christopher Chan
- University Health Network, Toronto General Hospital, Toronto, Canada
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15
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Weinhandl ED. Economic Impact of Home Hemodialysis. Adv Chronic Kidney Dis 2021; 28:136-142. [PMID: 34717859 DOI: 10.1053/j.ackd.2021.06.010] [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: 06/16/2020] [Revised: 06/12/2021] [Accepted: 06/21/2021] [Indexed: 11/11/2022]
Abstract
Home hemodialysis (HD) is growing in the United States, but the economics of the modality are largely unknown, especially considering the unique aspects of home HD in the United States . In this review, I focus on details of Medicare coverage, which directly applies to most patients on dialysis and influences the policies of private insurers. Key details in Medicare comprise the relationship between home dialysis training and initial Medicare eligibility, reimbursement for home HD training, coverage of additional HD treatments (ie., in excess of 3 treatments per week), and monthly capitated payments to nephrologists. The overarching narrative is that frequent home HD directly increases Medicare costs for outpatient dialysis, but these added costs can be mitigated by lower inpatient expenditures if increased HD treatment frequency lowers the risk of cardiovascular hospitalization and infection control is emphasized. I also review recent international literature; conventional home HD exhibits a superior cost profile, whereas frequent home HD is generally cost-effective over multiple treatment years (ie, if early technique failure is avoided). Out-of-pocket expenses for patients should be considered. The future economics of home HD in the United States will be determined by new equipment, new adaptations of the modality, and new payment models.
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16
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Lodge MDS, Abeygunaratne T, Alderson H, Ali I, Brown N, Chrysochou C, Donne R, Erekosima I, Evans P, Flanagan E, Gray S, Green D, Hegarty J, Hyde A, Kalra PA, Lamerton E, Lewis D, Middleton R, New D, Nipah R, O'Donoghue D, O'Riordan E, Poulikakos D, Rainone F, Raman M, Ritchie J, Sinha S, Wood G, Tollitt J. Safely reducing haemodialysis frequency during the COVID-19 pandemic. BMC Nephrol 2020; 21:532. [PMID: 33287730 PMCID: PMC7720264 DOI: 10.1186/s12882-020-02172-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 11/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients undergoing haemodialysis (HD) are at higher risk of developing worse outcomes if they contract COVID-19. In our renal service we reduced HD frequency from thrice to twice-weekly in selected patients with the primary aim of reducing COVID 19 exposure and transmission between HD patients. METHODS Dialysis unit nephrologists identified 166 suitable patients (38.4% of our HD population) to temporarily convert to twice-weekly haemodialysis immediately prior to the peak of the COVID-19 pandemic in our area. Changes in pre-dialysis weight, systolic blood pressure (SBP) and biochemistry were recorded weekly throughout the 4-week project. Hyperkalaemic patients (serum potassium > 6.0 mmol/L) were treated with a potassium binder, sodium bicarbonate and received responsive dietary advice. RESULTS There were 12 deaths (5 due to COVID-19) in the HD population, 6 of which were in the twice weekly HD group; no deaths were definitively associated with change of dialysis protocol. A further 19 patients were either hospitalised and/or developed COVID-19 and thus transferred back to thrice weekly dialysis as per protocol. 113 (68.1%) were still receiving twice-weekly HD by the end of the 4-week project. Indications for transfer back to thrice weekly were; fluid overload (19), persistent hyperkalaemia (4), patient request (4) and compliance (1). There were statistically significant increases in SBP and pre-dialysis potassium during the project. CONCLUSIONS Short term conversion of a large but selected HD population to twice-weekly dialysis sessions was possible and safe. This approach could help mitigate COVID-19 transmission amongst dialysis patients in centres with similar organisational pressures.
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Affiliation(s)
| | - Thilini Abeygunaratne
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Helen Alderson
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Ibrahim Ali
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Nina Brown
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | | | - Rosie Donne
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Ibi Erekosima
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Philip Evans
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Emma Flanagan
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Simon Gray
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Darren Green
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Janet Hegarty
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Audrey Hyde
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Philip A Kalra
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Elizabeth Lamerton
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - David Lewis
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Rachel Middleton
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - David New
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Robert Nipah
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Donal O'Donoghue
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Edmond O'Riordan
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Dimitrios Poulikakos
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Francesco Rainone
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Maharajan Raman
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - James Ritchie
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Smeeta Sinha
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - Grahame Wood
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK
| | - J Tollitt
- Department of Renal Medicine, Salford Royal NHS Trust, Stott Lane, Salford, M68HD, UK.
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17
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Huang JC, Tsai YC, Wu PY, Lien YH, Chien CY, Kuo CF, Hung JF, Chen SC, Kuo CH. Predictive modeling of blood pressure during hemodialysis: a comparison of linear model, random forest, support vector regression, XGBoost, LASSO regression and ensemble method. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 195:105536. [PMID: 32485511 DOI: 10.1016/j.cmpb.2020.105536] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 04/30/2020] [Accepted: 05/08/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Intradialytic hypotension (IDH) is commonly occurred and links to higher mortality among patients undergoing hemodialysis (HD). Its early prediction and prevention will dramatically improve the quality of life. However, predicting the occurrence of IDH clinically is not simple. The aims of this study are to develop an intelligent system with capability of predicting blood pressure (BP) during HD, and to further compare different machine learning algorithms for next systolic BP (SBP) prediction. METHODS This study presented comprehensive comparisons among linear regression model, least absolute shrinkage and selection operator (LASSO), tree-based ensemble machine learning models (random forest [RF] and extreme gradient boosting [XGBoost]), and support vector regression to predict the BP during HD treatment based on 200 and 48 maintenance HD patients containing a total of 7,180 and 2,065 BP records for the training and test dataset, respectively. Ensemble method also was computed to obtain better predictive performance. We compared the developed models based on R2, root mean square error (RMSE) and mean absolute error (MAE). RESULTS We found that RF (R2=0.95, RMSE=6.64, MAE=4.90) and XGBoost (R2=1.00, RMSE=1.83, MAE=1.29) had comparable predictive performance on the training dataset. However, RF (R2=0.49, RMSE=16.24, MAE=12.14) had more accurate than XGBoost (R2=0.41, RMSE=17.65, MAE=13.47) on testing dataset. Among these models, the ensemble method (R2=0.50, RMSE=16.01, MAE=11.97) had the best performance on testing dataset for next SBP prediction. CONCLUSIONS We compared five machine learning and an ensemble method for next SBP prediction. Among all studied algorithms, the RF and the ensemble method have the better predictive performance. The prediction models using ensemble method for intradialytic BP profiling may be able to assist the HD staff or physicians in individualized care and prompt intervention for patients' safety and improve care of HD patients.
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Affiliation(s)
- Jiun-Chi Huang
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chun Tsai
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pei-Yu Wu
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | | | - Chih-Feng Kuo
- Graduate Institute of Science Education and Environmental Education, National Kaohsiung Normal University, Kaohsiung, Taiwan
| | - Jeng-Fung Hung
- Graduate Institute of Science Education and Environmental Education, National Kaohsiung Normal University, Kaohsiung, Taiwan
| | - Szu-Chia Chen
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Chao-Hung Kuo
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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18
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Doulton TWR, Swift PA, Murtaza A, Dasgupta I. Uncertainties in BP management in dialysis patients. Semin Dial 2020; 33:223-235. [PMID: 32285984 DOI: 10.1111/sdi.12880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 03/12/2020] [Indexed: 12/21/2022]
Abstract
Hypertension in dialysis patients is extremely common. In this article, we review the current evidence for blood pressure (BP) goals in hemodialysis patients, and consider the effectiveness of interventions by which BP may be lowered, including manipulation of dietary and dialysate sodium; optimization of extracellular water; prolongation of dialysis time; and antihypertensive medication. Although two meta-analyses suggest lowering BP using antihypertensive drugs might be beneficial in reducing cardiovascular events and mortality, there are insufficient rigorously designed trials in hypertensive hemodialysis populations to determine preferred antihypertensive drug classes. We suggest aiming for predialysis systolic BP between 130 and 159 mm Hg, while at the same time acknowledge the significant limitations of the data upon which it is based. We conclude by summarizing current knowledge as regards management of hypertension in the peritoneal dialysis population and make recommendations for future research in this field.
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Affiliation(s)
- Timothy W R Doulton
- Department of Renal Medicine, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, UK
| | - Pauline A Swift
- Department of Nephrology, Epsom and St Helier University Hospitals NHS Trust, Carshalton, Surrey, UK
| | - Asam Murtaza
- Renal Unit, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Indranil Dasgupta
- Renal Unit, University Hospitals Birmingham NHS Trust, Birmingham, UK.,Warwick Medical School, University of Warwick, Warwick, UK
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19
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Maruyama T, Takashima H, Abe M. Blood pressure targets and pharmacotherapy for hypertensive patients on hemodialysis. Expert Opin Pharmacother 2020; 21:1219-1240. [PMID: 32281890 DOI: 10.1080/14656566.2020.1746272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Hypertension is highly prevalent in patients with end-stage kidney disease on hemodialysis and is often not well controlled. Blood pressure (BP) levels before and after hemodialysis have a U-shaped relationship with cardiovascular and all-cause mortality. Although antihypertensive drugs are recommended for patients in whom BP cannot be controlled appropriately by non-pharmacological interventions, large-scale randomized controlled clinical trials are lacking. AREAS COVERED The authors review the pharmacotherapy used in hypertensive patients on dialysis, primarily focusing on reports published since 2000. An electronic search of MEDLINE was conducted using relevant key search terms, including 'hypertension', 'pharmacotherapy', 'dialysis', 'kidney disease', and 'antihypertensive drug'. Systematic and narrative reviews and original investigations were retrieved in our research. EXPERT OPINION When a drug is administered to patients on dialysis, the comorbidities and characteristics of each drug, including its dialyzability, should be considered. Pharmacological lowering of BP in hypertensive patients on hemodialysis is associated with improvements in mortality. β-blockers should be considered first-line agents and calcium channel blockers as second-line therapy. Renin-angiotensin-aldosterone system inhibitors have not shown superiority to other antihypertensive drugs for patients on hemodialysis.
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Affiliation(s)
- Takashi Maruyama
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine , Tokyo, Japan
| | - Hiroyuki Takashima
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine , Tokyo, Japan
| | - Masanori Abe
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine , Tokyo, Japan
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20
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Sarafidis P, Faitatzidou D, Papagianni A. Benefits and risks of frequent or longer haemodialysis: weighing the evidence. Nephrol Dial Transplant 2020; 36:gfaa023. [PMID: 32073626 DOI: 10.1093/ndt/gfaa023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Indexed: 12/28/2022] Open
Abstract
Although the ability of individuals with end-stage renal disease to maintain body homoeostasis is equally impaired during all weekdays, conventional haemodialysis (HD) treatment is scheduled thrice weekly, containing two short and one long interdialytic interval. This intermittent nature of HD and the consequent fluctuations in volume, metabolic parameters and electrolytes have long been hypothesized to predispose to complications. Large observational studies link the first weekday with an increased risk of cardiovascular morbidity and mortality. Several schemes of frequent and/or longer, home or in-centre HD have been introduced, aiming to alleviate the above risks by both increasing total dialysis duration and reducing the duration of interdialytic intervals. Observational studies in this field have non-uniform results, showing that enhanced frequency in home (but not in-centre) HD is associated with reduced mortality. Evidence from the randomized Daily and Nocturnal Trials of the Frequent HD Network suggest the opposite, showing mortality benefits with in-centre daily but not with home nocturnal dialysis. Secondary analyses of these trials indicate that daily and nocturnal schedules do not have equal effects on intermediate outcomes. Alternative schemes, such as thrice weekly in-centre nocturnal HD or every-other-day HD, seem to also offer improvements in several intermediate endpoints, but need further testing with randomized trials. This review summarizes the effects of frequent and/or longer HD methods on hard and intermediate outcomes, attempting to provide a balanced overview of the field.
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Affiliation(s)
- Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Danai Faitatzidou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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21
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Flythe JE, Bansal N. The relationship of volume overload and its control to hypertension in hemodialysis patients. Semin Dial 2019; 32:500-506. [PMID: 31564065 DOI: 10.1111/sdi.12838] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Hypertension is highly prevalent and associated with poor clinical outcomes among individuals receiving maintenance hemodialysis (HD). Volume overload is a key modifiable contributor to hypertension and cardiovascular disease in the HD population. Despite their importance, assessment and treatment of volume overload and hypertension remain major clinical challenges and have substantial implications for both clinical outcomes and patient experiences of care. This review will summarize current data on the diagnosis, epidemiology, pathophysiology, and clinical consequences of hypertension and volume overload in HD patients. We will also identify priorities for future research studies.
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Affiliation(s)
- Jennifer E Flythe
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Nisha Bansal
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington.,Kidney Research Institute, University of Washington, Seattle, Washington
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22
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Abstract
BACKGROUND Cardiovascular (CV) disease is the leading cause of death in dialysis patients, and strongly associated with fluid overload and hypertension. It is plausible that low dialysate [Na+] may decrease total body sodium content, thereby reducing fluid overload and hypertension, and ultimately reducing CV morbidity and mortality. OBJECTIVES This review evaluated harms and benefits of using a low (< 138 mM) dialysate [Na+] for maintenance haemodialysis (HD) patients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 7 August 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs), both parallel and cross-over, of low (< 138 mM) versus neutral (138 to 140 mM) or high (> 140 mM) dialysate [Na+] for maintenance HD patients were included. DATA COLLECTION AND ANALYSIS Two investigators independently screened studies for inclusion and extracted data. Statistical analyses were performed using random effects models, and results expressed as risk ratios (RR) for dichotomous outcomes, and mean differences (MD) or standardised MD (SMD) for continuous outcomes, with 95% confidence intervals (CI). Confidence in the evidence was assessed using GRADE. MAIN RESULTS We included 12 studies randomising 310 patients, with data available for 266 patients after dropout. All but one study evaluated a fixed concentration of low dialysate [Na+], and one profiled dialysate [Na+]. Three studies were parallel group, and the remaining nine cross-over. Of the latter, only two used a washout between intervention and control periods. Most studies were short-term with a median (interquartile range) follow-up of 3 (3, 8.5) weeks. Two were of a single HD session, and two of a single week's HD. Half of the studies were conducted prior to 2000, and five reported use of obsolete HD practices. Risks of bias in the included studies were often high or unclear, lowering confidence in the results.Compared to neutral or high dialysate [Na+], low dialysate [Na+] had the following effects on "efficacy" endpoints: reduced interdialytic weight gain (10 studies: MD -0.35 kg, 95% CI -0.18 to -0.51; high certainty evidence); probably reduced predialysis mean arterial blood pressure (BP) (4 studies: MD -3.58 mmHg, 95% CI -5.46 to -1.69; moderate certainty evidence); probably reduced postdialysis mean arterial BP (MAP) (4 studies: MD -3.26 mmHg, 95% CI -1.70 to -4.82; moderate certainty evidence); probably reduced predialysis serum [Na+] (7 studies: MD -1.69 mM, 95% CI -2.36 to -1.02; moderate certainty evidence); may have reduced antihypertensive medication (2 studies: SMD -0.67 SD, 95% CI -1.07 to -0.28; low certainty evidence). Compared to neutral or high dialysate [Na+], low dialysate [Na+] had the following effects on "safety" endpoints: probably increased intradialytic hypotension events (9 studies: RR 1.56, 95% 1.17 to 2.07; moderate certainty evidence); probably increased intradialytic cramps (6 studies: RR 1.77, 95% 1.15 to 2.73; moderate certainty evidence).Compared to neutral or high dialysate [Na+], low dialysate [Na+] may make little or no difference to: intradialytic BP (2 studies: MD for systolic BP -3.99 mmHg, 95% CI -17.96 to 9.99; diastolic BP 1.33 mmHg, 95% CI -6.29 to 8.95; low certainty evidence); interdialytic BP (2 studies:, MD for systolic BP 0.17 mmHg, 95% CI -5.42 to 5.08; diastolic BP -2.00 mmHg, 95% CI -4.84 to 0.84; low certainty evidence); dietary salt intake (2 studies: MD -0.21g/d, 95% CI -0.48 to 0.06; low certainty evidence).Due to very low quality of evidence, it is uncertain whether low dialysate [Na+] changed extracellular fluid status, venous tone, arterial vascular resistance, left ventricular mass or volumes, thirst or fatigue. Studies did not examine cardiovascular or all-cause mortality, cardiovascular events, or hospitalisation. AUTHORS' CONCLUSIONS It is likely that low dialysate [Na+] reduces intradialytic weight gain and BP, which are effects directionally associated with improved outcomes. However, the intervention probably also increases intradialytic hypotension and reduces serum [Na+], effects that are associated with increased mortality risk. The effect of the intervention on overall patient health and well-being is unknown. Further evidence is needed in the form of longer-term studies in contemporary settings, evaluating end-organ effects in small-scale mechanistic studies using optimal methods, and clinical outcomes in large-scale multicentre RCTs.
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Affiliation(s)
- Joanna L Dunlop
- Counties Manukau HealthDepartment of MedicineOrakau RdAucklandNew Zealand
| | - Alain C Vandal
- Auckland University of TechnologyDepartment of BiostatisticsPrivate Bag 92006AucklandAucklandNew Zealand1142
- Counties Manukau HealthKo AwateaAucklandNew Zealand
| | - Mark R Marshall
- Counties Manukau HealthDepartment of MedicineOrakau RdAucklandNew Zealand
- University of AucklandSchool of Medicine, Faculty of Medical and Health SciencesAucklandNew Zealand
- Baxter Healthcare (Asia) Pty LtdMedical AffairsSingaporeSingapore
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23
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Hamed SA. Neurologic conditions and disorders of uremic syndrome of chronic kidney disease: presentations, causes, and treatment strategies. Expert Rev Clin Pharmacol 2019; 12:61-90. [PMID: 30501441 DOI: 10.1080/17512433.2019.1555468] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Sherifa A. Hamed
- Department of Neurology and Psychiatry, Assiut University Hospital, Assiut, Egypt
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24
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Kansal SK, Morfin JA, Weinhandl ED. Survival and Kidney Transplant Incidence on Home versus In-Center Hemodialysis, following Peritoneal Dialysis Technique Failure. Perit Dial Int 2019; 39:25-34. [DOI: 10.3747/pdi.2017.00207] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 05/09/2018] [Indexed: 02/01/2023] Open
Abstract
Background Peritoneal dialysis (PD) technique failure is often accompanied by complications that increase risks of hospitalization and death. Planned transition to hemodialysis may improve outcomes. Transitioning patients from PD to home hemodialysis (HHD) may improve continuity of lifestyle and facilitate delivery of more frequent treatment. Methods We analyzed United States Renal Data System (USRDS) data to compare the incidence of death and kidney transplant in patients who transferred from PD to HHD and matched patients who transferred from PD to in-center HD (IHD). We used Fine-Gray regression to estimate hazard ratios (HRs) of death and transplant for HHD versus IHD. Results We identified 521 patients who transferred from PD to HHD. Survival in HHD patients was 89.1% at 1 year and 80.5% at 2 years. In intention-to-treat analysis, the HR of death for HHD versus matched IHD patients was 0.76 (95% confidence interval [CI] 0.65 – 0.90). In subsets of non-Medicare and Medicare patients, corresponding HRs were 0.57 (95% CI 0.43 – 0.75) and 0.92 (95% CI 0.75 – 1.13), respectively. Kidney transplant incidence in HHD patients was 10.6% at 1 year and 21.0% at 2 years. In modified intention-to-treat analysis, the HR of transplant for HHD versus matched IHD patients was 1.36 (1.14 – 1.61). Conclusions Transfer to HHD after PD technique failure was rare, but associated with lower risk of death and higher incidence of transplant than transfer to IHD. Heterogeneity in relative risks by Medicare coverage suggests uncertainty about the magnitude of benefit. Still, these data suggest that clinical outcomes after PD technique failure can be improved.
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Affiliation(s)
- Sheru K. Kansal
- Division of Nephrology, University Hospitals, Cleveland, OH, United States
| | - Jose A. Morfin
- Division of Nephrology, UC Davis Health System, Sacramento, CA, United States
| | - Eric D. Weinhandl
- NxStage Medical, Inc., Lawrence, MA, United States
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN, United States
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25
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Ko GJ, Obi Y, Soohoo M, Chang TI, Choi SJ, Kovesdy CP, Streja E, Rhee CM, Kalantar-Zadeh K. No Survival Benefit in Octogenarians and Nonagenarians with Extended Hemodialysis Treatment Time. Am J Nephrol 2018; 48:389-398. [PMID: 30423584 DOI: 10.1159/000494336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 09/21/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND The population of elderly end-stage renal disease patients initiating dialysis is rapidly growing. Although longer treatment is supposed to benefit for hemodialysis (HD) patients through more solute clearance and slower fluid removal, it is not yet clear how treatment session length affects mortality risk in octogenarians and nonagenarians. METHODS In a cohort of 112,026 incident HD patients between 2007 and 2011, we examined the association of treatment session length with all-cause mortality, adjusting for demographics and comorbid conditions. We also used restricted spline functions for age to evaluate continuous changes in the association of short (< 210 min) and extended (≥240 min) HD treatment (vs. 210 to < 240 min) with all-cause mortality over continuous age. RESULTS During the first 91 days of dialysis, patients aged ≥80 years tended to have the lowest treatment session length (median [interquartile range] 211 [193-230] min, r > 0.5). Longer treatment was associated with better survival in patients < 65 and 65 to < 80 years but not in octogenarians/nonagenarians. The association of extended treatment (≥240 min) with better survival was attenuated across age and not significant among patients aged ≥80 years with a hazard ratio of 1.10 (95% CI 0.99-1.20). Shorter treatment sessions (< 210 min) was associated with higher mortality across all age groups. CONCLUSION Extended HD was not associated with lower mortality among octogenarians and nonagenarians, while it was associated with better survival among younger patients. Further studies are needed to determine the optimal treatment session length in elderly incident HD patients.
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Affiliation(s)
- Gang Jee Ko
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, Florida, USA
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, Florida, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, Florida, USA
| | - Tae Ik Chang
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, Florida, USA
- Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyangshi, Republic of Korea
| | - Soo Jeong Choi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, Florida, USA
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee, Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, Florida, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, Florida, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, Florida, USA,
- Department of Medicine, Long Beach Veteran Affairs Health System, Long Beach, California, USA,
- Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California, USA,
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26
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Bucharles SGE, Wallbach KKS, Moraes TPD, Pecoits-Filho R. Hypertension in patients on dialysis: diagnosis, mechanisms, and management. ACTA ACUST UNITED AC 2018; 41:400-411. [PMID: 30421784 PMCID: PMC6788847 DOI: 10.1590/2175-8239-jbn-2018-0155] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 09/05/2018] [Indexed: 12/19/2022]
Abstract
Hypertension (blood pressure > 140/90 mm Hg) is very common in patients undergoing regular dialysis, with a prevalence of 70-80%, and only the minority has adequate blood pressure (BP) control. In contrast to the unclear association of predialytic BP recordings with cardiovascular mortality, prospective studies showed that interdialytic BP, recorded as home BP or by ambulatory blood pressure monitoring in hemodialysis patients, associates more closely with mortality and cardiovascular events. Although BP is measured frequently in the dialysis treatment environment, aspects related to the measurement technique traditionally employed may be unsatisfactory. Several other tools are now available and being used in clinical trials and in clinical practice to evaluate and treat elevated BP in chronic kidney disease (CKD) patients. While we wait for the ongoing review of the CKD Blood Pressure KIDGO guidelines, there is no guideline for the dialysis population addressing this important issue. Thus, the objective of this review is to provide a critical analysis of the information available on the epidemiology, pathogenic mechanisms, and the main pillars involved in the management of blood pressure in stage 5-D CKD, based on current knowledge.
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Affiliation(s)
| | | | | | - Roberto Pecoits-Filho
- Pontifícia Universidade Católica do Paraná, Faculdade de Medicina, Curitiba, PR, Brasil
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27
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Cherukuri S, Bajo M, Colussi G, Corciulo R, Fessi H, Ficheux M, Slon M, Weinhandl E, Borman N. Home hemodialysis treatment and outcomes: retrospective analysis of the Knowledge to Improve Home Dialysis Network in Europe (KIHDNEy) cohort. BMC Nephrol 2018; 19:262. [PMID: 30314451 PMCID: PMC6186139 DOI: 10.1186/s12882-018-1059-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 09/26/2018] [Indexed: 02/06/2023] Open
Abstract
Background Utilization of home hemodialysis (HHD) is low in Europe. The Knowledge to Improve Home Dialysis Network in Europe (KIHDNEy) is a multi-center study of HHD patients who have used a transportable hemodialysis machine that employs a low volume of lactate-buffered, ultrapure dialysate per session. In this retrospective cohort analysis, we describe patient factors, HHD prescription factors, and biochemistry and medication use during the first 6 months of HHD and rates of clinical outcomes thereafter. Methods Using a standardized digital form, we recorded data from 7 centers in 4 Western European countries. We retained patients who completed ≥6 months of HHD. We summarized patient and HHD prescription factors with descriptive statistics and used mixed modeling to assess trends in biochemistry and medication use. We also estimated long-term rates of kidney transplant and death. Results We identified 129 HHD patients; 104 (81%) were followed for ≥6 months. Mean age was 49 years and 66% were male. Over 70% of patients were prescribed 6 sessions per week, and the mean treatment duration was 15.0 h per week. Median HHD training duration was 2.5 weeks. Mean standard Kt/Vurea was nearly 2.7 at months 3 and 6. Pre-dialysis biochemistry was generally stable. Between baseline and month 6, mean serum bicarbonate increased from 23.1 to 24.1 mmol/L (P = 0.01), mean serum albumin increased from 36.8 to 37.8 g/L (P = 0.03), mean serum C-reactive protein increased from 7.3 to 12.4 mg/L (P = 0.05), and mean serum potassium decreased from 4.80 to 4.59 mmol/L (P = 0.01). Regarding medication use, the mean number of antihypertensive medications fell from 1.46 agents per day at HHD initiation to 1.01 agents per day at 6 months (P < 0.001), but phosphate binder use and erythropoiesis-stimulating agent dose were stable. Long-term rates of kidney transplant and death were 15.3 and 5.4 events per 100 patient-years, respectively. Conclusions Intensive HHD with low-flow dialysate delivers adequate urea clearance and good biochemical outcomes in Western European patients. Intensive HHD coincided with a large decrease in antihypertensive medication use. With relatively rapid training, HHD should be considered in more patients.
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Affiliation(s)
| | - Maria Bajo
- Hospital Universitario La Paz, Servicio de Nefrologia, Madrid, Spain
| | - Giacomo Colussi
- Niguarda Hospital, Nefrologia - Centro Trapianti Rene, Milan, Italy
| | - Roberto Corciulo
- Policlinic University, Azienda Ospedaliero-Universitaria Consorziale Policlinico, Bari, Italy
| | - Hafedh Fessi
- Hôpital Tenon, Service de Néphrologie et Dialyses, Paris, France
| | - Maxence Ficheux
- CHR Clémenceau, Service Néphrologie-Hémodialyse-Transplantation, Caen, France
| | - Maria Slon
- Hospital de Navarra, Servicio de Nefrologia, Pamplona, Spain
| | - Eric Weinhandl
- NxStage Medical, Inc., 350 Merrimack Street, Lawrence, MA, 01843, USA. .,Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN, USA.
| | - Natalie Borman
- Queen Alexandra Hospital, Wessex Kidney Centre, Portsmouth, England
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28
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Ward FL, Faratro R, McQuillan RF. Self-cannulation of the vascular access in home hemodialysis: Overcoming patient-level barriers. Semin Dial 2018; 31:449-454. [PMID: 29750827 DOI: 10.1111/sdi.12708] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patients with end-stage kidney disease who are considering home hemodialysis (HHD) face the challenge of learning to self-cannulate their arteriovenous access. Current practice discourages the use of tunneled central venous catheters, with recent indications that self-cannulating patients have superior outcomes. Patient-level barriers do not appear to preclude a successful HHD program and should not be viewed as insurmountable by healthcare staff or patients. The healthcare team must address patient fears while instructing the patient to perform self-cannulation safely. Identification and understanding of the barriers perceived by the patient will allow the patient and healthcare team work collaboratively, toward the goal of independence with self-cannulation both during initial training and follow-up care. The aim of this review was to provide a practical resource to aid in the identification and resolution of these patient-level barriers, with the overall goal of improving the patient experience and medical outcomes in home hemodialysis programs.
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Affiliation(s)
- Frank L Ward
- Department of Nephrology, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Rose Faratro
- Department of Nephrology, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Rory F McQuillan
- Department of Nephrology, University Health Network, Toronto General Hospital, Toronto, ON, Canada
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29
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Abstract
The use of frequent hemodialysis (HD) is growing, with the hope of improving outcomes in end-stage renal disease. We narratively review the three randomized trials, 15 comparative cohort studies, and several case series of frequent HD that empirically demonstrate the potential efficacy and adverse effects of these regimens. Taken together, the randomized studies suggest frequent HD may result in left ventricular mass regression. This effect is most pronounced when left ventricular mass is abnormal, but attenuated by significant residual urine output. Both frequent short and long HD consistently improved blood pressure control and reduced antihypertensive use, despite greater weekly interdialytic weight gains. Serum phosphate was lowered. Frequent short daytime HD improved health-related quality of life, while frequent long overnight HD did not. Regarding adverse effects, frequent HD patients underwent significantly more procedures to salvage arteriovenous vascular accesses. An absolute increase in hypotensive episodes was observed with frequent short HD, while frequent long HD accelerated residual renal function loss and increased perceived caregiver burden. The effect of frequent HD on mortality is controversial, due to conflicting results and limitations of published studies. Finally, pregnancy outcomes may be substantially better with frequent long HD. On the basis of these data, we suggest frequent HD is most likely to benefit patients with left ventricular hypertrophy particularly if there is minimal urine output, those unable to attain dry weight on a thrice weekly schedule, and pregnant women. All patients receiving frequent HD should be advised of and monitored for potential risks.
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Affiliation(s)
- Rita S Suri
- Department of Medicine, University of Montreal, Montreal, Canada
| | - Alan S Kliger
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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30
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Miller BW, Himmele R, Sawin DA, Kim J, Kossmann RJ. Choosing Home Hemodialysis: A Critical Review of Patient Outcomes. Blood Purif 2018; 45:224-229. [PMID: 29478056 DOI: 10.1159/000485159] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIM Home hemodialysis (HHD) has been associated with improved clinical outcomes vs. in-center HD (ICHD). The prevalence of HHD in the United States is still very low at 1.8%. This critical review compares HHD and ICHD outcomes for survival, hospitalization, cardiovascular (CV), nutrition, and quality of life (QoL). METHODS Of 545 publications identified, 44 were not selected after applying exclusion criteria. A systematic review of the identified publications was conducted to compare HHD to ICHD outcomes for survival, hospitalization, CV outcomes, nutrition, and QoL. RESULTS Regarding mortality, 10 of 13 trials reported 13-52% reduction; three trials found no differences. According to 6 studies, blood pressure and left ventricular size measurements were generally lower in HHD patients compared to similar measurements in ICHD patients. Regarding nutritional status, conflicting results were reported (8 studies); some found improved muscle mass, total protein, and body mass index in HHD vs. ICHD patients, while others found no significant differences. There were no significant differences in the rate of hospitalization between HHD and ICHD in the 6 articles reviewed. Seven studies on QoL demonstrated positive trends in HHD vs. ICHD populations. CONCLUSIONS Despite limitations in the current data, 66% of the publications reviewed (29/44) demonstrated improved clinical outcomes in patients who chose HHD. These include improved survival, CV, nutritional, and QoL parameters. Even though HHD may not be preferred in all patients, a review of the literature suggests that HHD should be provided as a modality choice for substantially more than the current 1.8% of HHD patients in the United States.
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31
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Abstract
PURPOSE OF REVIEW This review focuses on recent advances in our understanding of intradialytic hypotension (IDH) and measures that may reduce its frequency. RECENT FINDINGS The frequency and severity of IDH predict the risk for adverse clinical outcomes. The highest mortality risks associated with IDH were observed when the intradialytic systolic blood pressure (SBP) nadirs were <90 and <100 mmHg and the predialysis SBP were ≤159 mmHg or ≥160 mmHg, respectively. Interdialytic weight gain (IDWG) ≥3 kg occurs more frequently among patients with IDH. Prolonged and possibly more frequent dialysis, use of biofeedback devices, dialysate cooling and limiting sodium loading are useful measures to reduce the frequency of IDH. SUMMARY Frequent IDH is associated with high IDWGs and a poor prognosis. Studies on prolonged dialysis, biofeedback devices and cooled dialysate have yielded promising results. Intradialytic relative blood volume monitoring devices have been investigated in preventing IDH but results are mixed. Administration of a sodium/hydrogen exchange isoform 3 inhibitor increases stool sodium but has not been shown to decrease IDWG. IDH continues to be a significant dialysis complication deserving of further investigation.
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32
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Mathew A, McLeggon JA, Mehta N, Leung S, Barta V, McGinn T, Nesrallah G. Mortality and Hospitalizations in Intensive Dialysis: A Systematic Review and Meta-Analysis. Can J Kidney Health Dis 2018; 5:2054358117749531. [PMID: 29348924 PMCID: PMC5768251 DOI: 10.1177/2054358117749531] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 09/30/2017] [Indexed: 11/15/2022] Open
Abstract
Background: Survival and hospitalization are critically important outcomes considered when choosing between intensive hemodialysis (HD), conventional HD, and peritoneal dialysis (PD). However, the comparative effectiveness of these modalities is unclear. Objective: We had the following aims: (1) to compare the association of mortality and hospitalization in patients undergoing intensive HD, compared with conventional HD or PD and (2) to appraise the methodological quality of the supporting evidence. Data Sources: MEDLINE, Embase, ISI Web of Science, CENTRAL, and nephrology conference abstracts. Study Eligibility, Participants, and Interventions: We included cohort studies with comparator arm, and randomized controlled trials (RCTs) with >50% of adult patients (≥18 years) comparing any form of intensive HD (>4 sessions/wk or >5.5 h/session) with any form of chronic dialysis (PD, HD ≤4 sessions/wk or ≤5.5 h/session), that reported at least 1 predefined outcome (mortality or hospitalization). Methods: We used the GRADE approach to systematic reviews and quality appraisal. Two reviewers screened citations and full-text articles, and extracted study-level data independently, with discrepancies resolved by consensus. We pooled effect estimates of randomized and observational studies separately using generic inverse variance with random effects models, and used fixed-effects models when only 2 studies were available for pooling. Predefined subgroups for the intensive HD cohorts were classified by nocturnal versus short daily HD and home versus in-center HD. Results: Twenty-three studies with a total of 70 506 patients were included. Of the observational studies, compared with PD, intensive HD had a significantly lower mortality risk (hazard ratio [HR]: 0.67; 95% confidence interval [CI]: 0.53-0.84; I2 = 91%). Compared with conventional HD, home nocturnal (HR: 0.46; 95% CI: 0.38-0.55; I2 = 0%), in-center nocturnal (HR: 0.73; 95% CI: 0.60-0.90; I2 = 57%) and home short daily (HR: 0.54; 95% CI: 0.31-0.95; I2 = 82%) intensive regimens had lower mortality. Of the 2 RCTs assessing mortality, in-center short daily HD had lower mortality (HR: 0.54; 95% CI: 0.31-0.93), while home nocturnal HD had higher mortality (HR: 3.88; 95% CI: 1.27-11.79) in long-term observational follow-up. Hospitalization days per patient-year (mean difference: –1.98; 95% CI: –2.37 to −1.59; I2 = 6%) were lower in nocturnal compared with conventional HD. Quality of evidence was similarly low or very low in RCTs (due to imprecision) and observational studies (due to residual confounding and selection bias). Limitations: The overall quality of evidence was low or very low for critical outcomes. Outcomes such as quality of life, transplantation, and vascular access outcomes were not included in our review. Conclusions: Intensive HD regimens may be associated with reduced mortality and hospitalization compared with conventional HD or PD. As the quality of supporting evidence is low, patients who place a high value on survival must be adequately advised and counseled of risks and benefits when choosing intensive dialysis. Practice guidelines that promote shared decision-making are likely to be helpful.
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Affiliation(s)
- Anna Mathew
- McMaster University, Hamilton, Ontario, Canada
| | - Jody-Ann McLeggon
- Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Nirav Mehta
- Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Samuel Leung
- Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Valerie Barta
- Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Thomas McGinn
- Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Gihad Nesrallah
- Department of Nephrology, Humber River Hospital, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Ontario, Canada
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33
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Miskulin DC, Gassman J, Schrader R, Gul A, Jhamb M, Ploth DW, Negrea L, Kwong RY, Levey AS, Singh AK, Harford A, Paine S, Kendrick C, Rahman M, Zager P. BP in Dialysis: Results of a Pilot Study. J Am Soc Nephrol 2017; 29:307-316. [PMID: 29212839 DOI: 10.1681/asn.2017020135] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 08/28/2017] [Indexed: 01/13/2023] Open
Abstract
The optimal BP target for patients receiving hemodialysis is unknown. We randomized 126 hypertensive patients on hemodialysis to a standardized predialysis systolic BP of 110-140 mmHg (intensive arm) or 155-165 mmHg (standard arm). The primary objectives were to assess feasibility and safety and inform the design of a full-scale trial. A secondary objective was to assess changes in left ventricular mass. Median follow-up was 365 days. In the standard arm, the 2-week moving average systolic BP did not change significantly during the intervention period, but in the intensive arm, systolic BP decreased from 160 mmHg at baseline to 143 mmHg at 4.5 months. From months 4-12, the mean separation in systolic BP between arms was 12.9 mmHg. Four deaths occurred in the intensive arm and one death occurred in the standard arm. The incidence rate ratios for the intensive compared with the standard arm (95% confidence intervals) were 1.18 (0.40 to 3.33), 1.61 (0.87 to 2.97), and 3.09 (0.96 to 8.78) for major adverse cardiovascular events, hospitalizations, and vascular access thrombosis, respectively. The intensive and standard arms had similar median changes (95% confidence intervals) in left ventricular mass of -0.84 (-17.1 to 10.0) g and 1.4 (-11.6 to 10.4) g, respectively. Although we identified a possible safety signal, the small size and short duration of the trial prevent definitive conclusions. Considering the high risk for major adverse cardiovascular events in patients receiving hemodialysis, a full-scale trial is needed to assess potential benefits of intensive hypertension control in this population.
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Affiliation(s)
- Dana C Miskulin
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Jennifer Gassman
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Ronald Schrader
- Quality Management Department, Dialysis Clinic, Inc., Albuquerque, New Mexico
| | - Ambreen Gul
- Quality Management Department, Dialysis Clinic, Inc., Albuquerque, New Mexico
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David W Ploth
- Department of Medicine, Division of Nephrology, Medical University of South Carolina, Charleston, South Carolina
| | - Lavinia Negrea
- Division of Nephrology and Hypertension, Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Raymond Y Kwong
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; and
| | - Andrew S Levey
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Ajay K Singh
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; and
| | - Antonia Harford
- Quality Management Department, Dialysis Clinic, Inc., Albuquerque, New Mexico.,Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Susan Paine
- Quality Management Department, Dialysis Clinic, Inc., Albuquerque, New Mexico
| | - Cynthia Kendrick
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Mahboob Rahman
- Division of Nephrology and Hypertension, Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Philip Zager
- Quality Management Department, Dialysis Clinic, Inc., Albuquerque, New Mexico; .,Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
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34
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Chou JA, Kalantar-Zadeh K, Mathew AT. A brief review of intradialytic hypotension with a focus on survival. Semin Dial 2017; 30:473-480. [PMID: 28661565 PMCID: PMC5738929 DOI: 10.1111/sdi.12627] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Intradialytic hypotension (IDH), a common complication of ultrafiltration during hemodialysis therapy, is associated with high mortality and morbidity. IDH, defined as a nadir systolic blood pressure of less than 90 mm Hg on more than 30% of treatments, is a relevant definition and is correlated with mortality. Risk factors for IDH include patient demographics, anti-hypertensive medication use, larger interdialytic weight gain, and dialysis prescription features as dialysate sodium, high ultrafiltration rate, and dialysate temperature. A high frequency of IDH events carries a substantial death risk. An ultrafiltration rate >10 mL/h/kg, and even more so >13 mL/h/kg, is highly predictive of cardiovascular and all-cause mortality. Evidence suggests that IDH causes acute reversible segmental myocardial hypoperfusion and contractile dysfunction (myocardial stunning), which can result in long-term loss of myocardial contractility, leading to premature death. IDH also has negative end-organ effects on the brain and gut, contributing to mortality through stroke, and endotoxin translocation with associated inflammation and protein-energy wasting. Given strong association of IDH and dialysis mortality, a paradigm shift to its approach is urgently needed. Randomized controlled trials are required to prospectively test drugs and monitoring devices which may reduce IDH.
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Affiliation(s)
- Jason A Chou
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles, CA, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles, CA, USA
- Fielding School of Public Health at UCLA, Los Angeles, CA, USA
- Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA, USA
| | - Anna T Mathew
- Division of Nephrology, Northwell Health, Great Neck, NY, USA
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35
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Abstract
Intradialytic hypotension (IDH) is a common and often distressful complication of hemodialysis. However, despite its clinical significance, there is no consensus, evidence-based medical definition for the condition. Over the years, numerous definitions have been implemented in both the clinical and research settings. Definition inconsistencies have hindered data synthesis and the development of evidence-based guidelines for the prevention and treatment of IDH, as well as prevented accurate estimation of the population burden of IDH and patient risk assessment. Most existing IDH definitions are comprised of one or more of the following components: (1) intradialytic BP criteria (requisite BP declines or minimum BP thresholds), (2) the provision of interventions aimed at restoring effective arterial volume, and/or (3) patient-reported symptoms. Remarkably, there are insufficient data to inform IDH definition construction, and it remains unknown if a single, universal definition can adequately capture the condition across patient subgroups, and in clinical and research settings.
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Affiliation(s)
- Magdalene M. Assimon
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Jennifer E. Flythe
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
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Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH). J Hypertens 2017; 35:657-676. [PMID: 28157814 DOI: 10.1097/hjh.0000000000001283] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In patients with end-stage renal disease treated with hemodialysis or peritoneal dialysis, hypertension is very common and often poorly controlled. Blood pressure (BP) recordings obtained before or after hemodialysis display a J-shaped or U-shaped association with cardiovascular events and survival, but this most likely reflects the low accuracy of these measurements and the peculiar hemodynamic setting related with dialysis treatment. Elevated BP by home or ambulatory BP monitoring is clearly associated with shorter survival. Sodium and volume excess is the prominent mechanism of hypertension in dialysis patients, but other pathways, such as arterial stiffness, activation of the renin-angiotensin-aldosterone and sympathetic nervous systems, endothelial dysfunction, sleep apnea and the use of erythropoietin-stimulating agents may also be involved. Nonpharmacologic interventions targeting sodium and volume excess are fundamental for hypertension control in this population. If BP remains elevated after appropriate treatment of sodium-volume excess, the use of antihypertensive agents is necessary. Drug treatment in the dialysis population should take into consideration the patient's comorbidities and specific characteristics of each agent, such as dialysability. This document is an overview of the diagnosis, epidemiology, pathogenesis and treatment of hypertension in patients on dialysis, aiming to offer the renal physician practical recommendations based on current knowledge and expert opinion and to highlight areas for future research.
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Jabbari B, Vaziri ND. The nature, consequences, and management of neurological disorders in chronic kidney disease. Hemodial Int 2017; 22:150-160. [PMID: 28799704 DOI: 10.1111/hdi.12587] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Perhaps no other organ in the body is affected as often and in as many ways as the brain is in patients with chronic kidney disease (CKD). Several factors contribute to the neurological disorders in CKD including accumulation of uremic toxins, metabolic and hemodynamic disorders, oxidative stress, inflammation, and impaired blood brain barrier among others. The neurological disorders in CKD involve both peripheral and central nervous system. The peripheral neurological symptoms of CKD are due to somatic and cranial peripheral neuropathies as well as a myopathy. The central neurological symptoms of CKD are due to the cortical predominantly cortical, or subcortical lesions. Cognitive decline, encephalopathy, cortical myoclonus, asterixis and epileptic seizures are distinct features of the cortical disorders of CKD. Diffuse white matter disease due to ischemia and hypoxia may be an important cause of subcortical encephalopathy. A special and more benign form of subcortical disorder caused by brain edema in CKD is termed posterior reversible encephalopathy. Subcortical pathology especially when it affects the basal ganglia causes a number of movement disorders including Parkinsonism, chorea and dystonia. A stimulus-sensitive reflex myoclonus is believed to originate from the medullary structures. Sleep disorder and restless leg syndrome are common in CKD and have both central and peripheral origin. This article provides an overview of the available data on the nature, prevalence, pathophysiology, consequences and treatment of neurological complications of CKD.
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Affiliation(s)
- Bahman Jabbari
- Department of Neurology, Division of Movement disorders, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Nosratola D Vaziri
- Departments of Medicine, Physiology and Biophysics, Division of Nephrology and Hypertension, University of California, Irvine, USA
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Frequent hemodialysis: history of the modality and assessment of outcomes. Pediatr Nephrol 2017; 32:1293-1300. [PMID: 28396942 DOI: 10.1007/s00467-017-3659-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 03/22/2017] [Indexed: 10/19/2022]
Abstract
About 660,000 individuals have end-stage renal disease in the USA, the vast majority of whom are receiving standard, in-center, thrice-weekly hemodialysis (HD). The morbidity and mortality among patients receiving standard HD remain unacceptably high. Studies conducted over the past two decades have provided a substantial amount of information on the advantages and drawbacks of providing more frequent HD treatment, either in-center or at home. In this article I summarize these studies, focusing special attention on the randomized, cross-over study assessing outcomes in children who received either frequent, in-center HD or traditional, thrice-weekly, in-center HD performed by Laskin et al. (Pediatr Nephrol doi: 10.1007/s00467-017-3656-x , 2017).
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Sarafidis PA, Persu A, Agarwal R, Burnier M, de Leeuw P, Ferro CJ, Halimi JM, Heine GH, Jadoul M, Jarraya F, Kanbay M, Mallamaci F, Mark PB, Ortiz A, Parati G, Pontremoli R, Rossignol P, Ruilope L, Van der Niepen P, Vanholder R, Verhaar MC, Wiecek A, Wuerzner G, London GM, Zoccali C. Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH). Nephrol Dial Transplant 2017; 32:620-640. [PMID: 28340239 DOI: 10.1093/ndt/gfw433] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 11/14/2016] [Indexed: 01/07/2023] Open
Abstract
In patients with end-stage renal disease (ESRD) treated with haemodialysis or peritoneal dialysis, hypertension is common and often poorly controlled. Blood pressure (BP) recordings obtained before or after haemodialysis display a J- or U-shaped association with cardiovascular events and survival, but this most likely reflects the low accuracy of these measurements and the peculiar haemodynamic setting related to dialysis treatment. Elevated BP detected by home or ambulatory BP monitoring is clearly associated with shorter survival. Sodium and volume excess is the prominent mechanism of hypertension in dialysis patients, but other pathways, such as arterial stiffness, activation of the renin-angiotensin-aldosterone and sympathetic nervous systems, endothelial dysfunction, sleep apnoea and the use of erythropoietin-stimulating agents may also be involved. Non-pharmacologic interventions targeting sodium and volume excess are fundamental for hypertension control in this population. If BP remains elevated after appropriate treatment of sodium and volume excess, the use of antihypertensive agents is necessary. Drug treatment in the dialysis population should take into consideration the patient's comorbidities and specific characteristics of each agent, such as dialysability. This document is an overview of the diagnosis, epidemiology, pathogenesis and treatment of hypertension in patients on dialysis, aiming to offer the renal physician practical recommendations based on current knowledge and expert opinion and to highlight areas for future research.
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Affiliation(s)
- Pantelis A Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
| | - Michel Burnier
- Service of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland
| | - Peter de Leeuw
- Department of Medicine, Maastricht University Medical Center, Maastricht and Zuyderland Medical Center, Geleen/Heerlen, The Netherlands
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jean-Michel Halimi
- Service de Néphrologie-Immunologie Clinique, Hôpital Bretonneau, François-Rabelais University, Tours, France
| | - Gunnar H Heine
- Saarland University Medical Center, Internal Medicine IV-Nephrology and Hypertension, Homburg, Germany
| | - Michel Jadoul
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Faical Jarraya
- Department of Nephrology, Sfax University Hospital and Research Unit, Faculty of Medicine, Sfax University, Sfax, Tunisia
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz, School of Medicine, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain
| | - Gianfranco Parati
- Department of Cardiovascular, Neural, and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano and Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Roberto Pontremoli
- Università degli Studi and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genova, Italy
| | - Patrick Rossignol
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, UMR 1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, and Association Lorraine de Traitement de l'Insuffisance Rénale, Nancy, France
| | - Luis Ruilope
- Hypertension Unit & Institute of Research i?+?12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Patricia Van der Niepen
- Department of Nephrology and Hypertension, Universitair Ziekenhuis Brussel - VUB, Brussels, Belgium
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, The Netherlands
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Katowice, Poland
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Carmine Zoccali
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
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Ok E, Levin NW, Asci G, Chazot C, Toz H, Ozkahya M. Interplay of volume, blood pressure, organ ischemia, residual renal function, and diet: certainties and uncertainties with dialytic management. Semin Dial 2017; 30:420-429. [PMID: 28581677 DOI: 10.1111/sdi.12612] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Extracellular fluid volume overload and its inevitable consequence, hypertension, increases cardiovascular mortality in the long term by leading to left ventricular hypertrophy, heart failure, and ischemic heart disease in dialysis patients. Unlike antihypertensive medications, a strict volume control strategy provides optimal blood pressure control without need for antihypertensive drugs. However, utilization of this strategy has remained limited because of several factors, including the absence of a gold standard method to assess volume status, difficulties in reducing extracellular fluid volume, and safety concerns associated with reduction of extracellular volume. These include intradialytic hypotension; ischemia of heart, brain, and gut; loss of residual renal function; and vascular access thrombosis. Comprehensibly, physicians are hesitant to follow strict volume control policy because of these safety concerns. Current data, however, suggest that a high ultrafiltration rate rather than the reduction in excess volume is related to these complications. Restriction of dietary salt intake, increased frequency, and/or duration of hemodialysis sessions or addition of temporary extra sessions during the process of gradually reducing postdialysis body weight in conventional hemodialysis and discontinuation of antihypertensive medications may prevent these complications. We believe that even if an unwanted effect occurs while gradually reaching euvolemia, this is likely to be counterbalanced by favorable cardiovascular outcomes such as regression of left ventricular hypertrophy, prevention of heart failure, and, ultimately, cardiovascular mortality as a result of the eventual achievement of normal extracellular fluid volume and blood pressure over the long term.
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Affiliation(s)
- Ercan Ok
- Ege University Medical School, Izmir, Turkey
| | - Nathan W Levin
- Icahn School of Medicine at Mount Sinai Health System, New York, USA
| | - Gulay Asci
- Ege University Medical School, Izmir, Turkey
| | | | - Huseyin Toz
- Ege University Medical School, Izmir, Turkey
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Miskulin DC, Weiner DE. Blood Pressure Management in Hemodialysis Patients: What We Know And What Questions Remain. Semin Dial 2017; 30:203-212. [DOI: 10.1111/sdi.12586] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Dana C. Miskulin
- Department of Medicine; Tufts University School of Medicine; Boston Massachusetts
| | - Daniel E. Weiner
- Department of Medicine; Tufts University School of Medicine; Boston Massachusetts
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Liu F, Sun Y, Xu T, Sun L, Liu L, Sun W, Feng X, Ma J, Wang L, Yao L. Effect of Nocturnal Hemodialysis versus Conventional Hemodialysis on End-Stage Renal Disease: A Meta-Analysis and Systematic Review. PLoS One 2017; 12:e0169203. [PMID: 28107451 PMCID: PMC5249197 DOI: 10.1371/journal.pone.0169203] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 12/12/2016] [Indexed: 12/20/2022] Open
Abstract
Objectives The purpose of this study is to assess the efficacy and safety of nocturnal hemodialysis on end-stage renal disease (ESRD) patients. Methods We searched Medline, EmBase, and the Cochrance Central Register of Controlled Trials for studies up to January 2016. Analysis was done to compare variant outcomes of different hemodialysis schedules, including mortality, cardiovascular-associated variables, uremia-associated variables, quality of life (QOL), side-effects, and drug usage. Results We collected and analyzed the results of 28 studies involving 22,508 patients in our meta-analysis. The mortality results in this meta-analysis indicated that the nocturnal hemodialysis (NHD) group was not significantly different from conventional hemodialysis (CHD) group (Mortality: OR: 0.75; 95% confidence intervals (CIs): 0.52 to 1.10; p = 0.145), but the CHD group had significantly fewer number of hospitalizations than the NHD group (OR: 1.54; 95%CI: 1.32 to 1.79; p<0.001). NHD was superior to CHD for cardiovascular-associated (left ventricular hypertrophy [LVH]: SMD: -0.39; 95%CI: -0.68 to -0.10; p = 0.009, left ventricular hypertrophy index [LVHI]: SMD: -0.64; 95%CI: -0.83 to -0.46; p<0.001) and uremia-associated intervention results (Serum albumin: SMD: 0.89; 95%CI: 0.41 to 1.36; p<0.001). For the assessment of quality of life, NHD treatment significantly improved the patients’ QOL only for SF36-Physical Components Summary (SMD: 0.43; 95%CI: 0.26 to 0.60; p<0.001). NHD intervention was relatively better than CHD for anti-hypertensive drug usage (SMD: -0.48; 95%CI: -0.91 to -0.05; p = 0.005), and there was no difference between groups in our side-effects assessment. Conclusion NHD and CHD performed similarly in terms of ESRD patients’ mortality and side-effects. NHD was superior to CHD for cardiovascular-associated and uremia-associated results, QOL, and drug usage; for number of hospitalizations, CHD was relatively better than NHD.
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Affiliation(s)
- Fangjie Liu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yiting Sun
- Department of Clinical Medicine, China Medical University, Shenyang, Liaoning, China
| | - Tianhua Xu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Li Sun
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Linlin Liu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Wei Sun
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xin Feng
- Blood Purification Center, Liaoning Electric Power Center Hospital, Shenyang, Liaoning, China
| | - Jianfei Ma
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Lining Wang
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Li Yao
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, Liaoning, China
- * E-mail:
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Abstract
Hemodialysis treatment time and Kt/V can both be considered to be primary measures of hemodialysis adequacy, because when either goes to zero, mortality is certain in patients without residual kidney function. Treatment time is important, but it needs to be adjusted based on surface-area-normalized Kt/V, residual kidney function, and expected ultrafiltration rate. Rescaling dose of dialysis measured as Kt/V to body surface area prevents ultrashort dialysis in small patients, women, and children with minimal residual kidney function. Most if not all of the observational studies of associations between outcome and dialysis session length are probably confounded by dose targeting bias. Once adequate Kt/V (taking into account body surface area) has been provided, adequate dialysis time probably is most relevant in terms of limiting the need for a high fluid removal rate. The latter may adversely impact survival by causing recurrent ischemia to cardiovascular and other tissues. There is little high-quality evidence at this time to support a minimum 4-hour treatment time for all patients, regardless of body size, solute removal, or residual kidney function. On the other hand, there is little evidence that prolonging weekly treatment time up to 24 hours per week is harmful. The final decision regarding treatment time is best individualized, based on patient acceptability and experience, residual kidney function, body surface-area-normalized Kt/V, and expected ultrafiltration rate.
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Affiliation(s)
- John T Daugirdas
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
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Van Buren PN, Zhou Y, Neyra JA, Xiao G, Vongpatanasin W, Inrig J, Toto R. Extracellular Volume Overload and Increased Vasoconstriction in Patients With Recurrent Intradialytic Hypertension. Kidney Blood Press Res 2016; 41:802-814. [PMID: 27832647 PMCID: PMC5183549 DOI: 10.1159/000450565] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2016] [Indexed: 01/25/2023] Open
Abstract
Background/Aims Intradialytic hypertension (IH) occurs frequently in some hemodialysis patients and increases mortality risk. We simultaneously compared pre-dialysis, post-dialysis and changes in extracellular volume and hemodynamics in recurrent IH patients and controls. Methods We performed a case-control study among prevalent hemodialysis patients with recurrent IH and hypertensive hemodialysis controls. We used bioimpedance spectroscopy and impedance cardiography to compare pre-dialysis, post-dialysis, and intradialytic change in total body water (TBW) and extracellular water (ECW), as well as cardiac index (CI) and total peripheral resistance index (TPRI). Results The ECW/TBW was 0.453 (0.05) pre-dialysis and 0.427 (0.04) post-dialysis in controls vs. 0.478 (0.03) and 0.461 (0.03) in IH patients (p=0.01 post-dialysis). The ECW/TBW change was −0.027 (0.03) in controls and −0.013 (0.02) in IH patients (p=0.1). In controls, pre- and post-dialysis TPRI were 3254 (994) and 2469 (529) dynes/sec/cm2/m2 vs. 2983 (747) and 3408 (980) dynes/sec/cm2/m2 in IH patients (p=0.002 post-dialysis). There were between-group differences in TPRI change (0=0.0001), but not CI (p=0.09). Conclusions Recurrent intradialytic hypertension is associated with higher post-dialysis extracellular volume and TPRI. Intradialytic TPRI surges account for the vasoconstrictive state post-dialysis, but intradialytic fluid shifts may contribute to post-hemodialysis volume expansion.
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Affiliation(s)
- Peter Noel Van Buren
- University of Texas Southwestern Medical Center, Department of Internal Medicine, Division of Nephrology, Dallas, TX, USA
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Collins AJ, Chan CT. Intensive Hemodialysis: Time to Give the Therapy Greater Consideration. Am J Kidney Dis 2016; 68:S1-S4. [DOI: 10.1053/j.ajkd.2016.05.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/11/2016] [Indexed: 12/26/2022]
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46
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Morfin JA, Fluck RJ, Weinhandl ED, Kansal S, McCullough PA, Komenda P. Intensive Hemodialysis and Treatment Complications and Tolerability. Am J Kidney Dis 2016; 68:S43-S50. [DOI: 10.1053/j.ajkd.2016.05.021] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 05/25/2016] [Indexed: 11/11/2022]
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47
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Bakris GL, Burkart JM, Weinhandl ED, McCullough PA, Kraus MA. Intensive Hemodialysis, Blood Pressure, and Antihypertensive Medication Use. Am J Kidney Dis 2016; 68:S15-S23. [DOI: 10.1053/j.ajkd.2016.05.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 05/25/2016] [Indexed: 01/30/2023]
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Maduell F, Ojeda R, Arias-Guillen M, Rossi F, Fontseré N, Vera M, Rico N, Gonzalez LN, Piñeiro G, Jiménez-Hernández M, Rodas L, Bedini JL. Eight-Year Experience with Nocturnal, Every-Other-Day, Online Haemodiafiltration. Nephron Clin Pract 2016; 133:98-110. [DOI: 10.1159/000446970] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 05/19/2016] [Indexed: 12/15/2022] Open
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49
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Chan CT, Mok MM. In Search of the True Effect of Home Intensive Hemodialysis. Am J Kidney Dis 2016; 67:539-41. [DOI: 10.1053/j.ajkd.2015.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 12/08/2015] [Indexed: 11/11/2022]
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50
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Marshall MR, Polkinghorne KR, Kerr PG, Hawley CM, Agar JW, McDonald SP. Intensive Hemodialysis and Mortality Risk in Australian and New Zealand Populations. Am J Kidney Dis 2016; 67:617-28. [DOI: 10.1053/j.ajkd.2015.09.025] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 09/21/2015] [Indexed: 11/11/2022]
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