Pulse Pressure Is an Independent Predictor of Aortic Stiffness in Patients with Mild to Moderate Chronic Kidney Disease

Changes of Hemodynamic Parameters after Intradialytic Glucose Injection

BACKGROUND

Intradialytic hypotension (IDH) is a frequent complication of hemodialysis (HD). Current methods of IDH prevention are insufficient.

METHODS

We analyzed the intradialytic time course of systolic (SBP), diastolic (DBP), mean arterial (MAP), pulse pressure (PP), and heart rate (HR) in a group of chronic kidney disease (CKD) patients. First, 30 min into HD, a 40% glucose solution was injected into the venous line of the extracorporeal circulation at a dose of 0.5 g/kg of dry weight. Pressures and HR were measured in frequent intervals. Relative volume overload was determined by bioimpedance spectroscopy.

RESULTS

Thirty-five participants were studied. SBP increased after 5, 10, and 20 min of glucose infusion. DBP increased after 2 and 3 h and also at the end of HD. PP increased after 5, 10, and 20 min of glucose infusion and fell after the 2nd and 3rd hour and also at the end of HD. MAP increased after 2 and 3 h of glucose injection and at the end of HD. Significant interactions of the time course of SBP, DBP, MAP, with HR at baseline and of the time course of PP with fluid overload were observed. Symptomatic hypotensive episodes were absent.

CONCLUSIONS

Glucose infusions during HD prevent symptomatic IDH and do not cause severe hypertensive episodes.

Predictors and impact of low diastolic blood pressure and widened pulse pressure following transcatheter aortic valve replacement

BACKGROUND

The association between post-operative diastolic blood pressure (DBP) and pulse pressure (PP) with outcomes following transcatheter aortic valve replacement (TAVR) remains unclear. We sought to assess the prevalence, predictors, and impact of post-operative DBP and PP on presence of post-procedural aortic insufficiency (AI) and mortality in adults undergoing TAVR.

METHODS

The study population included 194 patients who underwent TAVR from 2016 to 2017 at an academic tertiary medical center, of which 176 had invasive arterial pressures available postoperatively. Low DBP and widened PP were defined as ≤40 mmHg and ≥80 mmHg respectively on invasive arterial line on post-operative day 1. Clinical outcomes of interest included post-procedural AI and 1-year all-cause mortality.

RESULTS

Post-operative low DBP and widened PP were noted in 32.4% and 58.5% of the study population. No significant association between post-operative AI and low DBP (p = 0.82) or widened PP (p = 0.32) was noted. There was a trend toward higher rates of mortality in patients with low DBP (19.3% vs 9.2%, p = 0.06) but no difference in mortality in patients with widened PP (10.7% vs 15.1%, p = 0.39) or those with ≥1+ post-procedural AI (16.7% vs 10.7%, p = 0.32). In multivariable analysis, low DBP was associated with a trend toward higher rates of 1-year mortality [odds ratio (OR) 2.43, 95% confidence interval (CI) 0.97-6.11, p = 0.06]. When excluding patients with a post-operative invasive systolic blood pressure < 80 mmHg, low DBP was associated with significantly higher risk-adjusted mortality at 1 year [OR 2.75, 95% CI (1.07-7.07), p = 0.04].

CONCLUSIONS

In this contemporary study of adults undergoing TAVR, low DBP and widened PP were widely prevalent post TAVR. Low DBP was associated with a trend toward higher rates of 1-year mortality but not with post-procedural AI.

Upstroke Time as a Novel Predictor of Mortality in Patients with Chronic Kidney Disease

Upstroke time (UT), measured from the foot-to-peak peripheral pulse wave, is a merged parameter used to assess arterial stiffness and target vascular injuries. In this study, we aimed to investigate UT for the prediction of cardiovascular and all-cause mortality in patients with chronic kidney disease (CKD). This longitudinal study enrolled 472 patients with CKD. Blood pressure, brachial pulse wave velocity (baPWV), and UT were automatically measured by a Colin VP-1000 instrument. During a median follow-up of 91 months, 73 cardiovascular and 183 all-cause mortality instances were recorded. Multivariable Cox analyses indicated that UT was significantly associated with cardiovascular mortality (hazard ratio (HR) = 1.010, p = 0.007) and all-cause mortality (HR = 1.009, p < 0.001). The addition of UT into the clinical models including traditional risk factors and baPWV further increased the value in predicting cardiovascular and all-cause mortality (both p < 0.001). In the Kaplan–Meier analyses, UT ≥ 180 ms could predict cardiovascular and all-cause mortality (both log-rank p < 0.001). Our study found that UT was a useful parameter in predicting cardiovascular and all-cause mortality in CKD patients. Additional consideration of the UT might provide an extra benefit in predicting cardiovascular and all-cause mortality beyond the traditional risk factors and baPWV.

Chronic Kidney Disease Modifies The Relationship Between Body Fat Distribution and Blood Pressure: A Cross-Sectional Analysis

Introduction

Measures of adiposity are related to cardiovascular disease risk, but this relationship is inconsistent in disease states, such as chronic kidney disease (CKD). This study investigated the relationship between adiposity and blood pressure (BP) by CKD status.

Materials and Methods

South Africans of mixed-ancestry (n=1,621) were included. Estimated glomerular filtration rate (eGFR) was based on the modification of diet in renal disease (MDRD) equation, and CKD defined as eGFR <60mL/min/1.73m². Body fat distribution was assessed using anthropometry [body mass index (BMI) and waist circumference (WC)] and dual-energy x-ray absorptiometry (DXA) (n=152). Pulse pressure (PP) and mean arterial pressure (MAP) were calculated from systolic blood pressure (SBP) and diastolic blood pressure (DBP).

Results

In participants without CKD, anthropometric and DXA-derived measures positively correlated with SBP, DBP, MAP and PP (p<0.02 for all), except for leg fat mass (LFM), which was not associated with BP indices (p>0.100 for all). Contrary, in prevalent CKD (6%, n=96), only BMI was inversely associated with PP (p=0.0349). In multivariable analysis, only BMI and WC remained independently associated with SBP, DBP and MAP in the overall sample. Notably, the association between BMI, WC and LFM with SBP and PP, differed by CKD status (interaction: p<0.100 for all), such that only BMI and WC were associated with SBP in those without CKD and inversely associated with PP in those with CKD. LFM was inversely associated with SBP and PP in those with CKD.

Conclusion

In people without CKD, BP generally increases with increasing measures of adiposity. However, excess body fat has a seemingly protective or neutral effect on BP in people with CKD.

Pulse wave velocity differs between ulcerative colitis and chronic kidney disease

BACKGROUND

We hypothesized that a reversal of the physiological stiffness gradient, previously reported in end-stage renal disease, begins in the early stages of chronic kidney disease (CKD) and that chronic inflammation produces a different arterial phenotype in patients with ulcerative colitis (UC).

OBJECTIVES

To assess the extent of arterial stiffening in the central (carotid-femoral pulse wave velocity, cf.-PWV) and peripheral arteries (carotid-radial pulse wave velocity, cr-PWV) and to explore the determinants of the stiffness gradient in UC and in CKD.

METHODS

We enrolled 45 patients with UC, 45 patients with stage 3-4 CKD and 45 matched controls.

RESULTS

Despite the comparable cf.-PWV, the cr-PWV was higher in patients with UC than in those with CKD (median: 8.7 vs. 7.5m/s; p<0.001) and, consequently, the PWV ratio was lower (median: 0.97 vs. 1.12; p<0.001). In patients with CKD a stiffness mismatch was reported starting from stage 3B. The PWV ratio was associated with age and C-reactive protein (beta: 0.08 z-score, 95%CI 0.02-0.14; p=0.01) or active disease (beta: 0.43 z-score, 95%CI 0.003-0.857; p=0.048) in patients with UC and with age and glomerular filtration rate (beta: -0.56 z-score, 95%CI -1.05 to -0.07; p=0.02) in patients with CKD.

CONCLUSIONS

The arterial phenotype differed between UC and CKD. The reversal of the arterial stiffness gradient is evident in CKD patients starting from stage 3B but not in patients with UC and comparable cf.-PWV. In patients with UC, the stiffness of both elastic and muscular arteries is increased as a consequence of inflammation.

Evaluation of arterial stiffness with plasma GGT levels and pulse wave velocity measurement in patients with FMF

OBJECTIVE

Pulse wave velocity (PWV) is a non-invasive technique used to evaluate the arterial elasticity, which is an early indicator of atherosclerosis. Lately, gamma glutamyl transferase (GGT) is considered a determiner of arterial stiffness (AS). In this study, we aimed to evaluate the relationship between GGT levels and AS with PWV in patients with Familial Mediterranean fever (FMF).

MATERIAL AND METHODS

The study was conducted with 60 patients with FMF and 40 controls. Genetic analysis of the patients were performed. AS was assessed by PWV and, after the measurement of PWV, the presence of AS was determined.

RESULTS

Mean PWV values and AS frequency were significantly higher in patients with FMF compared with the control group (p<0.001 and p=0.004, respectively). Mean GGT levels of FMF patients were higher than in the control group but the difference was not statistically different. In the correlation analysis, PWV and AS were positively correlated with FMF (r=0349, p<0.001; r=0.435, p<0.001, respectively). FMF duration and FMF were associated with GGT (r=0.300, p=0.02; r=0199, p=0.047, respectively).

CONCLUSION

Increased PWV values in FMF patients may indicate arterial stiffness. These patients may be followed closely with PWV as an early indicator of atherosclerosis. Therefore, the cardiovascular risk can be determined in the early stages of disease and it may be possible to take necessary precautions.

Acute reversible changes of brachial-ankle pulse wave velocity in children with acute poststreptococcal glomerulonephritis

Acute poststreptococcal glomerulonephritis (APSGN) is the most common form of postinfectious nephritis worldwide. The relationship between inflammation and arterial stiffness has been described elsewhere, but there have been no studies that have analyzed the association between arterial compliance and APSGN. The aim of this study is to assess brachial-ankle pulse wave velocity (baPWV) in pediatric patients with APSGN, and the value of baPWV in predicting the outcome. We evaluated 16 children diagnosed with APSGN, 11 children with acute pyelonephritis (APN), and 25 healthy individuals in our hospital. The baPWV of all candidates was measured. In addition, follow-up of the APSGN group was conducted for baPWV, blood pressure and biochemical parameters. Significantly increased baPWV was observed in the APSGN group at initial diagnosis (P<0.001), in comparison with the APN group and healthy controls. Of these, 13 patients received sequential measurement of baPWV. Overwhelmingly, baPWV was rapidly normalized in 11 patients, whereas 2 boys presented with persistently higher baPWV. During the follow-up period of 2-3 years, both had consistency of proteinuria, and consequently, they progressed to either chronic renal insufficiency or end-stage renal disease (ESRD). In conclusion, the results demonstrate that APSGN involves not only the kidney, but also the arteries outside the kidney. Acute arterial stiffness might persist in patients who do not recover, but develop chronic kidney disease (CKD).

Management of ischemic heart disease in patients with chronic kidney disease

Patients with chronic kidney disease (CKD) and ischemic heart disease (IHD) have strikingly high mortality rates. In the general population, there has been a reduction in the mortality and morbidity rates for IHD through the implementation of effective risk-factor-reduction programs and better interventions for patients with established IHD. No such trend has been observed in patients with end-stage kidney disease. This review article addresses the following topics: (i) epidemiology, pathogenesis, clinical CKD patients with IHD; (ii) diagnostic modalities for IHD and their limitation in CKD patients; (iii) medical treatment options and revascularization strategies for these high-risk patients; and (iv) optimal cardiovascular risk management. Generally, in CKD patients with IHD an aggressive approach to IHD is warranted, a low threshold for diagnostic testing should be employed, and awaiting a clinical trial targeting these patients they should be considered for all proven strategies to improve outcomes.