Presented November, 3 2017.
Peter McCullough, MD, MPH, FACC, FACP, FCCP, FAHA, FNKF
Baylor University Medical Center
EMERGING PRESCRIPTION PROTOCOL FOR MORE FREQUENT HEMODIALYSIS
Ultrafiltration controlled prescription guide that improves treatment tolerability, reduces dialysis-induced cardiomyopathy, addresses chronic fluid overload while meeting clinical targets.
Discussion lead:
Allan Collins, MD, FACP
University of Minnesota School of Medicine
Chief Medical Officer, NxStage Medical, Inc.
CURBSIDE CONSULTATION: HOME DIALYSIS PATIENT CONSIDERATIONS
Biochemical, health-related quality of life, and economic factors when transitioning patients home.
Discussion lead:
Paul Komenda, MD, MHA, FRCPC
Seven Oaks General Hospital
REAL LIFE EXPERIENCE: PHYSICIAN AND PATIENT LEARNINGS
Dr. Kraus will discuss the prescribed regimen while Mr. Davis shares his clinical and lifestyle experiences as a more frequent hemodialysis patient.
Discussion leads:
Michael Kraus, MD, FACP
Indiana University School of Medicine
Evernard Davis III
Current Dialysis Patient, Retired Energy Consultant:
Advancingdialysis.org cardiac arrhythmia in thrice weekly hemodialysisAdvancingDialysis.org
This study used continuous cardiac monitoring to examine arrhythmias in hemodialysis patients over 6 months. It found that:
- Nearly all patients (97%) experienced arrhythmias, with clinically significant arrhythmias occurring in 2/3 of patients. Bradycardia was the most common arrhythmia.
- Arrhythmia rates were highest during the first dialysis session of the week and the long interdialytic gap between sessions. Bradycardic events peaked late in the long gap.
- Atrial fibrillation spiked during dialysis and gradually decreased after, climbing again in the last 36 hours of the long gap.
- Dialysis prescriptions like higher dialysate
Advancing dialysis.org recent findings better management of volume with inten...AdvancingDialysis.org
The document discusses the challenges of managing fluid volume in patients undergoing standard hemodialysis treatment. Fluid accumulates between the three weekly sessions, putting stress on the heart. While ultrafiltration rates have decreased in recent years, cardiovascular hospitalization rates have risen. Standard hemodialysis treatment may not adequately address fluid management issues between, during, and after sessions, indicating poor fluid control.
Advancing dialysis: Recasting kidney failure as cardiovascular diseaseAdvancingDialysis.org
This document discusses issues related to end-stage renal disease (ESRD) and dialysis treatment in the United States. It notes that ESRD represents 7% of the Medicare budget while only treating 1% of the US population. Total Medicare spending on dialysis has risen steadily to over $35 billion per year. The dialysis patient population has also increased over time and now exceeds 500,000 patients, though the annual growth rate has fallen below 2%. Despite increased spending, health outcomes like mortality and hospitalization rates have stabilized in recent years. The document suggests that the main challenge for dialysis is in managing chronic conditions like hypertension, left ventricular hypertrophy, and heart failure, which are major drivers of morbidity and mortality
Advancing dialysis.org recent findings better management of volume with inten...AdvancingDialysis.org
The document discusses the challenges of managing fluid volume in patients undergoing standard hemodialysis treatment given the constraints of a 3 session per week schedule. Fluid accumulates in the body during the long interdialytic gaps, putting stress on the heart and increasing risks. While ultrafiltration rates have decreased slightly over time, cardiovascular hospitalization rates have risen, suggesting fluid management remains a key issue. Studies link higher fluid overload levels to increased mortality risk, indicating more consistent volume control through increased treatment frequency and/or time could help address remaining unmet needs.
Advancing dialysis: Recasting kidney failure as cardiovascular diseaseAdvancingDialysis.org
The document discusses issues related to end stage renal disease (ESRD) and dialysis treatment in the United States. It notes that ESRD represents 7% of the Medicare budget while only treating 1% of the population. While total Medicare spending and spending per patient on dialysis has stabilized in recent years, the total number of dialysis patients has continued to increase and now exceeds 500,000. The document discusses challenges with the current conventional dialysis treatment approach, including its inability to adequately manage issues like fluid overload, hypertension, and cardiovascular disease - which are the major drivers of mortality in ESRD patients. It suggests alternative home dialysis modalities may help address these issues but barriers need to be addressed to increase their utilization
This document summarizes findings from a study on outcomes for patients transitioning from peritoneal dialysis to hemodialysis. It finds that planned transitions and transitioning to home hemodialysis can improve outcomes, including lower mortality rates and higher rates of kidney transplantation compared to emergency transitions and in-center hemodialysis. Specifically, the study found a 24% lower risk of death and 36% higher likelihood of transplantation for patients who transitioned to home hemodialysis. The document also provides indicators that can help medical teams better manage patient transitions from peritoneal dialysis to hemodialysis.
Advancing dialysis multinational guidelines for increased time and frequency ...AdvancingDialysis.org
This document summarizes guidelines from 5 medical societies regarding intensive hemodialysis. The guidelines agree that increasing hemodialysis time or frequency should be considered for patients with large weight gains, high ultrafiltration rates, poorly controlled blood pressure, difficulty achieving dry weight, or poor metabolic control. Specifically, the guidelines recommend intensive hemodialysis for patients with refractory fluid overload, uncontrolled hypertension, hyperphosphataemia, cardiovascular disease, hemodynamic instability, or impaired phosphate control. The conclusion states that physician judgment combined with clinical guidelines should guide decisions about intensive hemodialysis for patients.
This document summarizes a consensus document on hypertension in dialysis patients. It discusses how hypertension is common in dialysis patients and associated with shorter survival. The principal causes of hypertension include volume overload, arterial stiffness, sympathetic nervous system activation, and renin-angiotensin-aldosterone system activation. Treatment strategies should focus on correcting the primary causes of hypertension, which are sodium and volume excess. Non-pharmacological strategies like reducing salt intake, individualizing dialysate sodium, and increasing treatment length and frequency can help reduce blood pressure by managing volume status.
Advancingdialysis.org cardiac arrhythmia in thrice weekly hemodialysisAdvancingDialysis.org
This study used continuous cardiac monitoring to examine arrhythmias in hemodialysis patients over 6 months. It found that:
- Nearly all patients (97%) experienced arrhythmias, with clinically significant arrhythmias occurring in 2/3 of patients. Bradycardia was the most common arrhythmia.
- Arrhythmia rates were highest during the first dialysis session of the week and the long interdialytic gap between sessions. Bradycardic events peaked late in the long gap.
- Atrial fibrillation spiked during dialysis and gradually decreased after, climbing again in the last 36 hours of the long gap.
- Dialysis prescriptions like higher dialysate
Advancing dialysis.org recent findings better management of volume with inten...AdvancingDialysis.org
The document discusses the challenges of managing fluid volume in patients undergoing standard hemodialysis treatment. Fluid accumulates between the three weekly sessions, putting stress on the heart. While ultrafiltration rates have decreased in recent years, cardiovascular hospitalization rates have risen. Standard hemodialysis treatment may not adequately address fluid management issues between, during, and after sessions, indicating poor fluid control.
Advancing dialysis: Recasting kidney failure as cardiovascular diseaseAdvancingDialysis.org
This document discusses issues related to end-stage renal disease (ESRD) and dialysis treatment in the United States. It notes that ESRD represents 7% of the Medicare budget while only treating 1% of the US population. Total Medicare spending on dialysis has risen steadily to over $35 billion per year. The dialysis patient population has also increased over time and now exceeds 500,000 patients, though the annual growth rate has fallen below 2%. Despite increased spending, health outcomes like mortality and hospitalization rates have stabilized in recent years. The document suggests that the main challenge for dialysis is in managing chronic conditions like hypertension, left ventricular hypertrophy, and heart failure, which are major drivers of morbidity and mortality
Advancing dialysis.org recent findings better management of volume with inten...AdvancingDialysis.org
The document discusses the challenges of managing fluid volume in patients undergoing standard hemodialysis treatment given the constraints of a 3 session per week schedule. Fluid accumulates in the body during the long interdialytic gaps, putting stress on the heart and increasing risks. While ultrafiltration rates have decreased slightly over time, cardiovascular hospitalization rates have risen, suggesting fluid management remains a key issue. Studies link higher fluid overload levels to increased mortality risk, indicating more consistent volume control through increased treatment frequency and/or time could help address remaining unmet needs.
Advancing dialysis: Recasting kidney failure as cardiovascular diseaseAdvancingDialysis.org
The document discusses issues related to end stage renal disease (ESRD) and dialysis treatment in the United States. It notes that ESRD represents 7% of the Medicare budget while only treating 1% of the population. While total Medicare spending and spending per patient on dialysis has stabilized in recent years, the total number of dialysis patients has continued to increase and now exceeds 500,000. The document discusses challenges with the current conventional dialysis treatment approach, including its inability to adequately manage issues like fluid overload, hypertension, and cardiovascular disease - which are the major drivers of mortality in ESRD patients. It suggests alternative home dialysis modalities may help address these issues but barriers need to be addressed to increase their utilization
This document summarizes findings from a study on outcomes for patients transitioning from peritoneal dialysis to hemodialysis. It finds that planned transitions and transitioning to home hemodialysis can improve outcomes, including lower mortality rates and higher rates of kidney transplantation compared to emergency transitions and in-center hemodialysis. Specifically, the study found a 24% lower risk of death and 36% higher likelihood of transplantation for patients who transitioned to home hemodialysis. The document also provides indicators that can help medical teams better manage patient transitions from peritoneal dialysis to hemodialysis.
Advancing dialysis multinational guidelines for increased time and frequency ...AdvancingDialysis.org
This document summarizes guidelines from 5 medical societies regarding intensive hemodialysis. The guidelines agree that increasing hemodialysis time or frequency should be considered for patients with large weight gains, high ultrafiltration rates, poorly controlled blood pressure, difficulty achieving dry weight, or poor metabolic control. Specifically, the guidelines recommend intensive hemodialysis for patients with refractory fluid overload, uncontrolled hypertension, hyperphosphataemia, cardiovascular disease, hemodynamic instability, or impaired phosphate control. The conclusion states that physician judgment combined with clinical guidelines should guide decisions about intensive hemodialysis for patients.
This document summarizes a consensus document on hypertension in dialysis patients. It discusses how hypertension is common in dialysis patients and associated with shorter survival. The principal causes of hypertension include volume overload, arterial stiffness, sympathetic nervous system activation, and renin-angiotensin-aldosterone system activation. Treatment strategies should focus on correcting the primary causes of hypertension, which are sodium and volume excess. Non-pharmacological strategies like reducing salt intake, individualizing dialysate sodium, and increasing treatment length and frequency can help reduce blood pressure by managing volume status.
Advancing dialysis - Improving Outcomes for Dialysis Patientsnxstage
Intensive hemodialysis through short daily or frequent nocturnal treatments has been shown in multiple randomized clinical trials to have promising benefits compared to conventional in-center hemodialysis, including reduced risks of death and cardiovascular hospitalization, lower blood pressure and left ventricular mass, improved physical and mental health-related quality of life, and decreased need for phosphate binders and antihypertensive medications. However, the effects on individual outcomes varied between trials.
This document summarizes research on the cardiovascular benefits of intensive hemodialysis compared to conventional hemodialysis. It finds that intensive hemodialysis significantly reduces left ventricular mass and lowers the risks of cardiovascular hospitalization and death. Specifically, short daily hemodialysis was associated with lower risks of hospitalization for heart failure, cerebrovascular disease, and hypertension compared to conventional in-center hemodialysis or peritoneal dialysis.
The SPRINT study compared an intensive blood pressure treatment target of less than 120 mm Hg to a standard target of less than 140 mm Hg in 9,361 patients at high risk for cardiovascular events but without diabetes. At 1 year, the mean systolic blood pressure was 121.4 mm Hg in the intensive group and 136.2 mm Hg in the standard group. After a median follow up of 3.26 years, the primary composite outcome of heart attack, acute coronary syndrome, stroke, heart failure or cardiovascular death occurred less frequently in the intensive group compared to the standard group. All-cause mortality was also lower in the intensive group, though rates of some adverse events were higher.
1) Many hemodialysis patients and their caregivers report fatigue, low blood pressure during dialysis, and muscle cramps as more important symptoms to address than life expectancy.
2) Intensive hemodialysis is associated with significantly lower rates of intradialytic hypotension compared to conventional hemodialysis.
3) Longer post-dialysis recovery times of over 2 hours are linked to higher risks of hospitalization and death for hemodialysis patients, while intensive hemodialysis can significantly reduce average recovery times.
The study found that patients who received aminoglycoside treatment for perioperative cardiac surgery had a substantially higher risk of requiring postoperative dialysis, and this risk was independent of dose size and number. Some findings, such as the disappearance of risk when adjusting for confounding factors in endocarditis patients, were unexpected. Clinicians should be aware of the increased risk of postoperative dialysis associated with aminoglycoside use in cardiac surgery patients.
Anticoagulation in chronic kidney disease dr. mohsen el kossiFarragBahbah
Based on the information provided:
- Her stroke risk can be assessed using CHA2DS2-VASc score:
C = 1 (Congestive heart failure)
H = 1 (Hypertension)
A = 1 (Age 65-74)
D = 1 (Diabetes)
S = 1 (Stroke/TIA/TE)
V = 0
A = 0
S = 1 (Sex category)
c = 2
She has a high stroke risk.
- Given her moderate CKD, I would recommend anticoagulation. A NOAC like Apixaban 2.5mg BD could be used given her eGFR of 32ml/min is above the recommended
Steroid Sparing Regimens in Kidney TransplantationAbdullah Ansari
Mechanisms of action of steroids
Rationale for steroids minimization
Steroid minimization strategies
Very low maintenance dosages
Complete withdrawal early after transplantation (three to six months post-surgery)
Complete withdrawal later after transplantation (six months to one year post-surgery)
Steroid free maintenance, after rapid withdrawal within a week
Complete avoidance
Joint Symposium of the Heart Failure Society of America and the American Coll...drucsamal
1) Approximately half of patients with acute decompensated heart failure (ADHF) develop hemoconcentration (HC), or an increase in blood solutes like hemoglobin and proteins, during diuretic treatment for decongestion.
2) Several retrospective studies have found that patients who develop HC have better clinical outcomes, likely due to achieving better decongestion, however the data does not support using HC routinely in ADHF management.
3) There are many outstanding questions about how to define and measure HC best, and at what level and timing it should be achieved to guide decongestion therapy. Prospective studies are still needed to determine if HC can help guide decongestion treatment.
Five medical societies from North America, Europe, and Asia have released clinical practice guidelines since 2006 that largely agree intensive hemodialysis should be considered for patients with:
- Large weight gains between treatments
- High rates of fluid removal during treatments
- Poorly controlled blood pressure
- Difficulty achieving their dry weight
- Poor control of minerals like phosphorus or potassium
The guidelines indicate intensive hemodialysis may help patients with these issues by providing more frequent or longer hemodialysis sessions. Physician judgment is also important when determining if intensive hemodialysis is appropriate for a given patient.
This document summarizes findings from multiple studies on the effects of intensive hemodialysis on blood pressure and antihypertensive medication use. It finds that over 60% of patients receiving conventional hemodialysis have elevated pre-dialysis blood pressure despite using multiple medications. Randomized clinical trials showed intensive hemodialysis significantly lowers blood pressure by 8-11 mmHg. Studies also found the number of antihypertensive medications prescribed per patient declined by around 36% with intensive hemodialysis.
The document discusses the paradoxical relationship between obesity and mortality in patients with kidney disease undergoing dialysis. Several studies are reviewed that found higher BMI in dialysis patients was associated with lower risks of death and hospitalization, unlike the general population where obesity increases health risks. The studies accounted for various factors and found even extreme obesity was protective. Weight gain over time was also associated with reduced mortality risk. The reasons for this reverse epidemiology are unclear but proposed mechanisms include increased stores of nutrients and anti-inflammatory proteins in adipose tissue.
ICN VIctoria: John Botha on Critical Care Renal FailureGerard Fennessy
Professor John Botha from Frankston Hospital in Melbourne talks at the April 2014 Victorian Intensive Care Network meeting on Renal Failure in Critical Care
1) Dr. SP has a 1.8% risk of needing dialysis after CABG surgery given his risk factors. Fluids such as lactated ringers are preferred over hetastarch if IV fluids are needed.
2) Risk factors for developing acute kidney injury after cardiac surgery include pre-existing chronic kidney disease, diabetes, older age, procedures with longer bypass or clamp times, low hematocrit during bypass, and transfusions of blood products.
3) Prevention strategies include optimizing volume status, avoiding nephrotoxins like NSAIDs, and considering off-pump surgery for high-risk patients. Treatment is largely supportive with fluid management and early use of renal replacement therapy if needed.
This document discusses incremental dialysis, which is an approach to adjusting dialysis dose based on a patient's residual kidney function (RKF). The key points are:
1) Patients starting dialysis often have some remaining RKF, and incorporating this into their dialysis prescription through an incremental approach may help preserve RKF longer.
2) Observational studies have found associations between preserving higher levels of RKF and benefits like improved survival, volume control, and lower inflammation.
3) The optimal approach is to start dialysis at the correct time and adjust the dose incrementally as RKF declines, individualizing treatment for each patient. Some studies found twice-weekly hemodialysis may better preserve RKF
Patient under dialysis with uncontrolled hypertension Haytham Ghareeb
This patient has uncontrolled hypertension despite being on dialysis twice a week and taking multiple antihypertensive medications. There were several issues with his treatment: he was not placed on fluid or sodium restrictions; his interdialytic weight gain was too high; and dialysis frequency and duration were insufficient. Additionally, lifestyle factors like a high salt diet were not addressed. The nephrologist made changes to the dialysis protocol and recommended the patient follow dietary sodium and fluid restrictions to achieve better volume control. Drug therapy was also optimized based on pharmacokinetic properties during dialysis. The goal is to control hypertension while avoiding overly low blood pressure, as both can increase mortality risk in dialysis patients.
Early Goal-Directed Therapy in Septic Shockshivabirdi
Early goal directed therapy (EGDT) aims to balance oxygen delivery and demand through manipulating cardiac preload, afterload and contractility using measures like lactate, base deficit and ScvO2. A study of 263 patients with severe sepsis or septic shock found that those receiving EGDT in the emergency department for at least 6 hours had significantly lower in-hospital, 28-day and 60-day mortality compared to standard therapy. EGDT also resulted in fewer organ dysfunctions, less coagulation abnormalities and cardiovascular collapse.
The document discusses renal replacement therapy options for patients with end-stage renal disease, including hemodialysis, peritoneal dialysis, and kidney transplantation. It provides details on each treatment modality and emphasizes the importance of early referral to a nephrologist to allow time for vascular access placement, transplant evaluation, and patient education. The best vascular access for hemodialysis is an arteriovenous fistula due to its lower risk of infection and greater longevity. All statements regarding kidney transplantation timing and criteria are correct. Screening for malignancies is important in transplant recipients due to higher cancer risks with immunosuppression.
Anticoagulation in chronic kidney disease patientsAnderson Sousa
This document discusses anticoagulation in patients with chronic kidney disease and provides practical guidance on the topic. It reviews the increased risk of thrombosis in chronic kidney disease patients and discusses various anticoagulant and antiplatelet options. Key points addressed include the pharmacokinetics and dosing considerations of unfractionated heparin, low-molecular-weight heparins, warfarin, and newer oral anticoagulants in renal impairment. Monitoring and management strategies are also covered.
This document discusses various potential therapies for acute heart failure. It begins by reviewing the historical focus on diuresis, vasodilators, and inotropes from 1970-2010. Currently, over 90% of patients receive intravenous diuretics as the primary treatment. The document then evaluates several promising new treatment approaches that are being studied, including natriuretic peptides, levosimendan, relaxin, soluble guanylate cyclase activators, rolofylline, cardiac myosin activators, and SERCA2a activators. It provides details on clinical trials and mechanisms of action for these novel therapies. Throughout, the document provides a critical look at challenges and limitations for further developing these new
Sepsis and Early Goal Directed Therapy: Approach in ED outlines sepsis definitions, the theory and components of early goal directed therapy (EGDT) for treating sepsis. EGDT aims to optimize oxygen delivery through fluid resuscitation, vasopressors to maintain blood pressure, scvO2 monitoring and blood transfusions if needed. The document recommends beginning IV antibiotics within 1 hour of recognizing sepsis to improve survival rates. Timely implementation of EGDT's components in the emergency department can help reduce mortality from sepsis.
Advancing dialysis - Improving Outcomes for Dialysis Patientsnxstage
Intensive hemodialysis through short daily or frequent nocturnal treatments has been shown in multiple randomized clinical trials to have promising benefits compared to conventional in-center hemodialysis, including reduced risks of death and cardiovascular hospitalization, lower blood pressure and left ventricular mass, improved physical and mental health-related quality of life, and decreased need for phosphate binders and antihypertensive medications. However, the effects on individual outcomes varied between trials.
This document summarizes research on the cardiovascular benefits of intensive hemodialysis compared to conventional hemodialysis. It finds that intensive hemodialysis significantly reduces left ventricular mass and lowers the risks of cardiovascular hospitalization and death. Specifically, short daily hemodialysis was associated with lower risks of hospitalization for heart failure, cerebrovascular disease, and hypertension compared to conventional in-center hemodialysis or peritoneal dialysis.
The SPRINT study compared an intensive blood pressure treatment target of less than 120 mm Hg to a standard target of less than 140 mm Hg in 9,361 patients at high risk for cardiovascular events but without diabetes. At 1 year, the mean systolic blood pressure was 121.4 mm Hg in the intensive group and 136.2 mm Hg in the standard group. After a median follow up of 3.26 years, the primary composite outcome of heart attack, acute coronary syndrome, stroke, heart failure or cardiovascular death occurred less frequently in the intensive group compared to the standard group. All-cause mortality was also lower in the intensive group, though rates of some adverse events were higher.
1) Many hemodialysis patients and their caregivers report fatigue, low blood pressure during dialysis, and muscle cramps as more important symptoms to address than life expectancy.
2) Intensive hemodialysis is associated with significantly lower rates of intradialytic hypotension compared to conventional hemodialysis.
3) Longer post-dialysis recovery times of over 2 hours are linked to higher risks of hospitalization and death for hemodialysis patients, while intensive hemodialysis can significantly reduce average recovery times.
The study found that patients who received aminoglycoside treatment for perioperative cardiac surgery had a substantially higher risk of requiring postoperative dialysis, and this risk was independent of dose size and number. Some findings, such as the disappearance of risk when adjusting for confounding factors in endocarditis patients, were unexpected. Clinicians should be aware of the increased risk of postoperative dialysis associated with aminoglycoside use in cardiac surgery patients.
Anticoagulation in chronic kidney disease dr. mohsen el kossiFarragBahbah
Based on the information provided:
- Her stroke risk can be assessed using CHA2DS2-VASc score:
C = 1 (Congestive heart failure)
H = 1 (Hypertension)
A = 1 (Age 65-74)
D = 1 (Diabetes)
S = 1 (Stroke/TIA/TE)
V = 0
A = 0
S = 1 (Sex category)
c = 2
She has a high stroke risk.
- Given her moderate CKD, I would recommend anticoagulation. A NOAC like Apixaban 2.5mg BD could be used given her eGFR of 32ml/min is above the recommended
Steroid Sparing Regimens in Kidney TransplantationAbdullah Ansari
Mechanisms of action of steroids
Rationale for steroids minimization
Steroid minimization strategies
Very low maintenance dosages
Complete withdrawal early after transplantation (three to six months post-surgery)
Complete withdrawal later after transplantation (six months to one year post-surgery)
Steroid free maintenance, after rapid withdrawal within a week
Complete avoidance
Joint Symposium of the Heart Failure Society of America and the American Coll...drucsamal
1) Approximately half of patients with acute decompensated heart failure (ADHF) develop hemoconcentration (HC), or an increase in blood solutes like hemoglobin and proteins, during diuretic treatment for decongestion.
2) Several retrospective studies have found that patients who develop HC have better clinical outcomes, likely due to achieving better decongestion, however the data does not support using HC routinely in ADHF management.
3) There are many outstanding questions about how to define and measure HC best, and at what level and timing it should be achieved to guide decongestion therapy. Prospective studies are still needed to determine if HC can help guide decongestion treatment.
Five medical societies from North America, Europe, and Asia have released clinical practice guidelines since 2006 that largely agree intensive hemodialysis should be considered for patients with:
- Large weight gains between treatments
- High rates of fluid removal during treatments
- Poorly controlled blood pressure
- Difficulty achieving their dry weight
- Poor control of minerals like phosphorus or potassium
The guidelines indicate intensive hemodialysis may help patients with these issues by providing more frequent or longer hemodialysis sessions. Physician judgment is also important when determining if intensive hemodialysis is appropriate for a given patient.
This document summarizes findings from multiple studies on the effects of intensive hemodialysis on blood pressure and antihypertensive medication use. It finds that over 60% of patients receiving conventional hemodialysis have elevated pre-dialysis blood pressure despite using multiple medications. Randomized clinical trials showed intensive hemodialysis significantly lowers blood pressure by 8-11 mmHg. Studies also found the number of antihypertensive medications prescribed per patient declined by around 36% with intensive hemodialysis.
The document discusses the paradoxical relationship between obesity and mortality in patients with kidney disease undergoing dialysis. Several studies are reviewed that found higher BMI in dialysis patients was associated with lower risks of death and hospitalization, unlike the general population where obesity increases health risks. The studies accounted for various factors and found even extreme obesity was protective. Weight gain over time was also associated with reduced mortality risk. The reasons for this reverse epidemiology are unclear but proposed mechanisms include increased stores of nutrients and anti-inflammatory proteins in adipose tissue.
ICN VIctoria: John Botha on Critical Care Renal FailureGerard Fennessy
Professor John Botha from Frankston Hospital in Melbourne talks at the April 2014 Victorian Intensive Care Network meeting on Renal Failure in Critical Care
1) Dr. SP has a 1.8% risk of needing dialysis after CABG surgery given his risk factors. Fluids such as lactated ringers are preferred over hetastarch if IV fluids are needed.
2) Risk factors for developing acute kidney injury after cardiac surgery include pre-existing chronic kidney disease, diabetes, older age, procedures with longer bypass or clamp times, low hematocrit during bypass, and transfusions of blood products.
3) Prevention strategies include optimizing volume status, avoiding nephrotoxins like NSAIDs, and considering off-pump surgery for high-risk patients. Treatment is largely supportive with fluid management and early use of renal replacement therapy if needed.
This document discusses incremental dialysis, which is an approach to adjusting dialysis dose based on a patient's residual kidney function (RKF). The key points are:
1) Patients starting dialysis often have some remaining RKF, and incorporating this into their dialysis prescription through an incremental approach may help preserve RKF longer.
2) Observational studies have found associations between preserving higher levels of RKF and benefits like improved survival, volume control, and lower inflammation.
3) The optimal approach is to start dialysis at the correct time and adjust the dose incrementally as RKF declines, individualizing treatment for each patient. Some studies found twice-weekly hemodialysis may better preserve RKF
Patient under dialysis with uncontrolled hypertension Haytham Ghareeb
This patient has uncontrolled hypertension despite being on dialysis twice a week and taking multiple antihypertensive medications. There were several issues with his treatment: he was not placed on fluid or sodium restrictions; his interdialytic weight gain was too high; and dialysis frequency and duration were insufficient. Additionally, lifestyle factors like a high salt diet were not addressed. The nephrologist made changes to the dialysis protocol and recommended the patient follow dietary sodium and fluid restrictions to achieve better volume control. Drug therapy was also optimized based on pharmacokinetic properties during dialysis. The goal is to control hypertension while avoiding overly low blood pressure, as both can increase mortality risk in dialysis patients.
Early Goal-Directed Therapy in Septic Shockshivabirdi
Early goal directed therapy (EGDT) aims to balance oxygen delivery and demand through manipulating cardiac preload, afterload and contractility using measures like lactate, base deficit and ScvO2. A study of 263 patients with severe sepsis or septic shock found that those receiving EGDT in the emergency department for at least 6 hours had significantly lower in-hospital, 28-day and 60-day mortality compared to standard therapy. EGDT also resulted in fewer organ dysfunctions, less coagulation abnormalities and cardiovascular collapse.
The document discusses renal replacement therapy options for patients with end-stage renal disease, including hemodialysis, peritoneal dialysis, and kidney transplantation. It provides details on each treatment modality and emphasizes the importance of early referral to a nephrologist to allow time for vascular access placement, transplant evaluation, and patient education. The best vascular access for hemodialysis is an arteriovenous fistula due to its lower risk of infection and greater longevity. All statements regarding kidney transplantation timing and criteria are correct. Screening for malignancies is important in transplant recipients due to higher cancer risks with immunosuppression.
Anticoagulation in chronic kidney disease patientsAnderson Sousa
This document discusses anticoagulation in patients with chronic kidney disease and provides practical guidance on the topic. It reviews the increased risk of thrombosis in chronic kidney disease patients and discusses various anticoagulant and antiplatelet options. Key points addressed include the pharmacokinetics and dosing considerations of unfractionated heparin, low-molecular-weight heparins, warfarin, and newer oral anticoagulants in renal impairment. Monitoring and management strategies are also covered.
This document discusses various potential therapies for acute heart failure. It begins by reviewing the historical focus on diuresis, vasodilators, and inotropes from 1970-2010. Currently, over 90% of patients receive intravenous diuretics as the primary treatment. The document then evaluates several promising new treatment approaches that are being studied, including natriuretic peptides, levosimendan, relaxin, soluble guanylate cyclase activators, rolofylline, cardiac myosin activators, and SERCA2a activators. It provides details on clinical trials and mechanisms of action for these novel therapies. Throughout, the document provides a critical look at challenges and limitations for further developing these new
Sepsis and Early Goal Directed Therapy: Approach in ED outlines sepsis definitions, the theory and components of early goal directed therapy (EGDT) for treating sepsis. EGDT aims to optimize oxygen delivery through fluid resuscitation, vasopressors to maintain blood pressure, scvO2 monitoring and blood transfusions if needed. The document recommends beginning IV antibiotics within 1 hour of recognizing sepsis to improve survival rates. Timely implementation of EGDT's components in the emergency department can help reduce mortality from sepsis.
EMGuideWire's Radiology Reading Room: Hypertrophic CardiomyopathySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Hypertrophic Cardiomyopathy and is brought to you by Ashley Moore-Gibbs, DNP, Claire Lawson, NP, Laszlo Littmann, MD, and John Symanski, MD.
1) Hypertension is a major risk factor for cardiovascular disease which accounts for a large portion of deaths worldwide.
2) The ALLHAT study was a large clinical trial that compared the effects of different antihypertensive medications on cardiovascular outcomes. It found that a diuretic (chlorthalidone) was more effective at reducing risks than a calcium channel blocker (amlodipine) or ACE inhibitor (lisinopril).
3) While mean blood pressures were similar between groups during the study, the diuretic was superior in reducing risks of heart attacks and heart disease, establishing diuretics as a first-line treatment for hypertension.
The document discusses renal failure and its relationship to cardiovascular disease. It provides statistics on the prevalence, incidence, and mortality rates of renal failure in the US and Australia. It then covers topics such as the structure and function of the kidneys, classification of renal failure, its effects on the cardiovascular system, and approaches to treatment including dialysis, transplantation, and their risks.
This document provides an overview of hypertrophic cardiomyopathy (HCM). It begins with definitions of cardiomyopathy and HCM. It then discusses the historical perspective, genetic basis, morphology, pathophysiology, clinical features, diagnosis, and management of HCM. Some key points include:
- HCM is a genetic heart condition characterized by unexplained thickening of the heart muscle. It is the most common cause of sudden cardiac death in young people.
- The genetic basis involves mutations in genes encoding sarcomere proteins. This leads to impaired relaxation and increased calcium sensitivity of the heart muscle.
- Morphologically, HCM involves asymmetric left ventricular hypertrophy and abnormalities of the mitral valve apparatus. Hist
Cardiology: Treatment of Heart FailureVedica Sethi
Abstract Heart Failure (HF) is the most widely recognized cardiovascular disorder behind medical clinic affirmation for individuals more established than 60 years old. Hardly any regions in medication have advanced as surprisingly as HF treatment in the course of recent decades. Be that as it may, progress has been reliable just for ceaseless HF with diminished discharge part. In intensely decompensated HF and HF with safeguarded discharge part, none of the medications tried to date have been conclusively demonstrated to improve endurance. Deferring or forestalling HF has gotten progressively significant in patients who are inclined to HF. The anticipation of declining interminable HF and hospitalisations for intense decompensation is likewise critical. The target of this paper is to give a compact and down to earth rundown of the accessible medication medicines for HF. The most ideal proof based medication treatment (counting inhibitors of the renin–angiotensin– aldosterone framework and β blockers) is helpful just when ideally actualized. Notwithstanding, usage may be testing. To accept that ailment the executives projects can be useful in giving a multidisciplinary, comprehensive way to deal with the conveyance of ideal clinical consideration. Keywords; heart failure, multidisciplinary approach, Beat-blocker, RAAS framework
This document discusses sudden cardiac death and proposes a new research hypothesis for drug design strategies. It summarizes current understanding of sudden cardiac death pathology from medical literature, which finds various etiologies including ventricular arrhythmias, coronary artery disease, and genetic channelopathies in about 20% of cases. The authors propose developing new diagnostic tests that can evaluate the heart's biochemical and metabolic status under normal and stressed conditions locally in the heart tissue, rather than just plasma, to help prevent unexpected cardiac events and better understand sudden cardiac death pathology. This could involve applying diagnostic strategies from other medical disciplines to cardiology.
This document discusses hypertension and cardiovascular disease. It begins with some statistics on leading causes of global mortality, with cardiovascular diseases being the top cause. It then provides data on the prevalence of hypertension in different countries. Other sections discuss the proportion of hypertensive patients treated versus untreated, how hypertension prevalence increases with age, relationships between blood pressure levels and cardiovascular mortality risk and stroke/heart disease mortality rates. The document emphasizes the importance of controlling systolic blood pressure and discusses factors influencing hypertension prognosis. It provides guidelines on target blood pressure goals.
Did you know that the right kind of salt actually HELPS your heart? How about that blood pressure drugs slow down the heart which decreases oxygen to the brain. Does that sound like a good idea to you? Did you also know that cholesterol is critical for hormone production in the body? It's time for some common sense! You are built to be healthy!
Cardiogenic shock is caused by severe impairment of myocardial function leading to low cardiac output and organ hypoperfusion. It commonly results from acute myocardial infarction and presents as hypotension refractory to fluids with signs of poor organ perfusion. While in-hospital mortality has improved slightly, medium-term mortality remains high at around 50%. Management involves identifying the cause, typically through cardiac catheterization, and revascularization when possible along with organ support.
The document discusses congestive cardiac failure (heart failure) and its management. It provides details on:
- The high prevalence and mortality of heart failure.
- Current medical therapies including ACE inhibitors, beta-blockers, and aldosterone antagonists that have been shown to improve survival.
- Device therapies like cardiac resynchronization therapy and implantable cardioverter defibrillators that treat symptoms and reduce mortality.
- The benefits of multidisciplinary and integrated care approaches including telehealth monitoring in improving outcomes for heart failure patients.
Cardiomyopathy, or heart muscle disease, is a type of progressive heart disease in which the heart is abnormally enlarged, thickened, and/or stiffened. As a result, the heart muscle's ability to pump blood is less efficient, often causing heart failure and the backup of blood into the lungs or rest of the body. The disease can also cause abnormal heart rhythms.
This document discusses biomarkers for acute heart failure syndrome (AHF). It provides definitions of AHF and notes that symptoms are primarily due to pulmonary congestion from elevated left ventricular filling pressures. Biomarkers can help with rapid assessment of hemodynamic status, guide therapy, and assess disease severity and prognosis. Examples of biomarkers discussed include B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP), which reflect myocardial stress and correlate with symptoms severity. Biomarkers are also affected by cardiac and extracardiac factors. Point-of-care testing devices are being developed to rapidly measure biomarker levels to help with triage and guide therapy.
The document discusses heart failure (HF), its epidemiology, pathophysiology, and management. Some key points:
- HF is a major public health problem costing $29.6 billion annually in the US. Hospitalizations are a major driver of costs, and rates are increasing.
- Over 90% of acute decompensated HF hospitalizations are due to fluid overload. Diuretics are standard first-line treatment but resistance limits their effectiveness in many patients.
- Even mild reductions in renal function correlate with increased HF morbidity and mortality. Diuretics can further impair renal function, worsening outcomes.
- Ultrafiltration is an alternative fluid removal method that may benefit patients where diure
The document discusses the physiology of hemostasis, including:
- The essential components of hemostasis including platelet plug formation, coagulation pathways, and fibrinolysis.
- Conditions that can increase the risk of uncontrolled bleeding during surgery such as patient comorbidities, anticoagulant medications, hypothermia and acidosis.
- How achieving optimal hemostasis requires balancing procoagulant, anticoagulant, fibrinolytic and antifibrinolytic factors.
Low dose dopamine increases GFR and RBF. The DAD-HF trial investigated 60 patients randomized to low dose furosemide (continuous infusion 0.5 mg/kg/day) with or without low dose dopamine (2 μg/kg/min). Dopamine preserved renal function compared to furosemide alone in patients with acute decompensated heart failure. There were no significant differences found in a trial comparing high vs low dose furosemide or bolus vs continuous infusion on renal function or symptoms. Novel agents targeting fluid overload, renal function, contractility, and vasomotion may provide new therapeutic options for acute heart failure.
Prof. U. C. SAMAL provides an overview of acute decompensated heart failure and what is new in the field. He discusses similarities and differences between acute myocardial infarction and acute heart failure syndromes. Mortality rates are high for both conditions, though clinical benefits of interventions are greater for acute MI based on published clinical trials. The document then discusses definitions and classifications of acute heart failure syndromes, as well as guidelines for diagnosis and treatment from ESC and ACC/AHA. Biomarkers that can help with diagnosis, prognosis, and guiding therapy are also summarized.
Similar to Advancingdialysis.org 2017 ASN Sponsored Symposium Presentation (20)
AdvancingDialysis.org CMS Kidney Care Choices (KCC) Voluntary Payment ModelAdvancingDialysis.org
This document discusses the Centers for Medicare & Medicaid Services' Kidney Care Choices model, which includes four voluntary payment models - Kidney Care First, Comprehensive Kidney Care Contracting, and three CKCC options. The goals are to delay end-stage renal disease progression, encourage optimal dialysis transitions, support transplant processes, and keep transplant recipients healthy. Participating providers take on financial accountability and risk through these models.
This presentation reviews ETC participant assessment, aggregation, and payment mechanisms, including achievement benchmarks for measurement years 1-, 2-, and 3-.
Intensive hemodialysis was found to improve both physical and mental health-related quality of life in three randomized clinical trials compared to conventional hemodialysis, though the significance of effects varied between individual studies. Intensive hemodialysis decreased Beck Depression Inventory scores more than conventional hemodialysis in the Frequent Hemodialysis Network trials.
This document discusses potential risks associated with intensive hemodialysis treatments. It summarizes several studies that have found infection appears to be more likely with intensive hemodialysis, though the relative importance of treatment frequency versus setting requires further investigation. The document includes a figure from one of the cited studies showing the relative hazards of infection-related hospitalization for short daily hemodialysis compared to conventional in-center hemodialysis and peritoneal dialysis.
This document discusses the effects of intensive hemodialysis on mineral and bone disorder and phosphate binder use. It summarizes findings from several studies that found intensive hemodialysis resulted in reductions in serum phosphorus levels compared to conventional hemodialysis, where levels increased over time. Intensive hemodialysis also reduced the need for and dosage of phosphate binders in patients.
Intensive Hemodialysis, Left Ventricular Hypertrophy and Cardiovascular DiseaseAdvancingDialysis.org
Cardiovascular-related deaths in prevalent dialysis patients are common.
The long interdialytic interval, commonly referred to as the 2-day “Killer Gap,” is a time of heightened risk of mortality and morbidity with conventional hemodialysis. Multiple randomized clinical trials show intensive hemodialysis significantly reduces left ventricular mass and more frequent hemodialysis has associated with lower risk of cardiovascular-related hospitalizations.
Chandrima Spa Ajman is one of the leading Massage Center in Ajman, which is open 24 hours exclusively for men. Being one of the most affordable Spa in Ajman, we offer Body to Body massage, Kerala Massage, Malayali Massage, Indian Massage, Pakistani Massage Russian massage, Thai massage, Swedish massage, Hot Stone Massage, Deep Tissue Massage, and many more. Indulge in the ultimate massage experience and book your appointment today. We are confident that you will leave our Massage spa feeling refreshed, rejuvenated, and ready to take on the world.
Visit : https://massagespaajman.com/
Call : 052 987 1315
Hypertension and it's role of physiotherapy in it.Vishal kr Thakur
This particular slides consist of- what is hypertension,what are it's causes and it's effect on body, risk factors, symptoms,complications, diagnosis and role of physiotherapy in it.
This slide is very helpful for physiotherapy students and also for other medical and healthcare students.
Here is summary of hypertension -
Hypertension, also known as high blood pressure, is a serious medical condition that occurs when blood pressure in the body's arteries is consistently too high. Blood pressure is the force of blood pushing against the walls of blood vessels as the heart pumps it. Hypertension can increase the risk of heart disease, brain disease, kidney disease, and premature death.
Unlocking the Secrets to Safe Patient Handling.pdfLift Ability
Furthermore, the time constraints and workload in healthcare settings can make it challenging for caregivers to prioritise safe patient handling Australia practices, leading to shortcuts and increased risks.
As Mumbai's premier kidney transplant and donation center, L H Hiranandani Hospital Powai is not just a medical facility; it's a beacon of hope where cutting-edge science meets compassionate care, transforming lives and redefining the standards of kidney health in India.
COPD Treatment in Ghatkopar,Mumbai. Dr Kumar DoshiDr Kumar Doshi
Are you or a loved one affected by Chronic Obstructive Pulmonary Disease (COPD)? Discover comprehensive and advanced treatment options with Dr. Kumar Doshi, a preeminent COPD specialist based in Ghatkopar, Mumbai.
Dr. Kumar Doshi is dedicated to delivering the highest standard of care for COPD patients. Whether you are seeking a diagnosis, a second opinion, or exploring new treatment avenues, this presentation will guide you through the exceptional services available at his practice in Ghatkopar, Mumbai.
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - ...rightmanforbloodline
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - 34.
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - 34.
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - 34.
Exploring the Benefits of Binaural Hearing: Why Two Hearing Aids Are Better T...Ear Solutions (ESPL)
Binaural hearing using two hearing aids instead of one offers numerous advantages, including improved sound localization, enhanced sound quality, better speech understanding in noise, reduced listening effort, and greater overall satisfaction. By leveraging the brain’s natural ability to process sound from both ears, binaural hearing aids provide a more balanced, clear, and comfortable hearing experience. If you or a loved one is considering hearing aids, consult with a hearing care professional at Ear Solutions hearing aid clinic in Mumbai to explore the benefits of binaural hearing and determine the best solution for your hearing needs. Embracing binaural hearing can lead to a richer, more engaging auditory experience and significantly improve your quality of life.
This particular slides consist of- what is Pneumothorax,what are it's causes and it's effect on body, risk factors, symptoms,complications, diagnosis and role of physiotherapy in it.
This slide is very helpful for physiotherapy students and also for other medical and healthcare students.
Here is a summary of Pneumothorax:
Pneumothorax, also known as a collapsed lung, is a condition that occurs when air leaks into the space between the lung and chest wall. This air buildup puts pressure on the lung, preventing it from expanding fully when you breathe. A pneumothorax can cause a complete or partial collapse of the lung.
At Malayali Kerala Spa Ajman, Full Service includes individualized care for every client. We specifically design each massage session for the individual needs of the client. Our therapists are always willing to adjust the treatments based on the client's instruction and feedback. This guarantees that every client receives the treatment they expect.
By offering a variety of massage services, our Ajman Spa Massage Center can tackle physical, mental, and emotional illnesses. In addition, efficient identification of specific health conditions and designing treatment plans accordingly can significantly enhance the quality of massaging.
At Malayali Kerala Spa Ajman, we firmly believe that everyone should have the option to experience top-quality massage services regularly. To achieve that goal we offer cheap massage services in Ajman.
If you are interested in experiencing transformative massage treatment at Malayali Kerala Spa Ajman, you can use our Ajman Massage Center WhatsApp Number to schedule your next massage session.
Contact @ +971 529818279
Visit @ https://malayalikeralaspaajman.com/
Comprehensive Rainy Season Advisory: Safety and Preparedness Tips.pdfDr Rachana Gujar
The "Comprehensive Rainy Season Advisory: Safety and Preparedness Tips" offers essential guidance for navigating rainy weather conditions. It covers strategies for staying safe during storms, flood prevention measures, and advice on preparing for inclement weather. This advisory aims to ensure individuals are equipped with the knowledge and resources to handle the challenges of the rainy season effectively, emphasizing safety, preparedness, and resilience.
2024 HIPAA Compliance Training Guide to the Compliance OfficersConference Panel
Join us for a comprehensive 90-minute lesson designed specifically for Compliance Officers and Practice/Business Managers. This 2024 HIPAA Training session will guide you through the critical steps needed to ensure your practice is fully prepared for upcoming audits. Key updates and significant changes under the Omnibus Rule will be covered, along with the latest applicable updates for 2024.
Key Areas Covered:
Texting and Email Communication: Understand the compliance requirements for electronic communication.
Encryption Standards: Learn what is necessary and what is overhyped.
Medical Messaging and Voice Data: Ensure secure handling of sensitive information.
IT Risk Factors: Identify and mitigate risks related to your IT infrastructure.
Why Attend:
Expert Instructor: Brian Tuttle, with over 20 years in Health IT and Compliance Consulting, brings invaluable experience and knowledge, including insights from over 1000 risk assessments and direct dealings with Office of Civil Rights HIPAA auditors.
Actionable Insights: Receive practical advice on preparing for audits and avoiding common mistakes.
Clarity on Compliance: Clear up misconceptions and understand the reality of HIPAA regulations.
Ensure your compliance strategy is up-to-date and effective. Enroll now and be prepared for the 2024 HIPAA audits.
Enroll Now to secure your spot in this crucial training session and ensure your HIPAA compliance is robust and audit-ready.
https://conferencepanel.com/conference/hipaa-training-for-the-compliance-officer-2024-updates
DECODING THE RISKS - ALCOHOL, TOBACCO & DRUGS.pdfDr Rachana Gujar
Introduction: Substance use education is crucial due to its prevalence and societal impact.
Alcohol Use: Immediate and long-term risks include impaired judgment, health issues, and social consequences.
Tobacco Use: Immediate effects include increased heart rate, while long-term risks encompass cancer and heart disease.
Drug Use: Risks vary depending on the drug type, including health and psychological implications.
Prevention Strategies: Education, healthy coping mechanisms, community support, and policies are vital in preventing substance use.
Harm Reduction Strategies: Safe use practices, medication-assisted treatment, and naloxone availability aim to reduce harm.
Seeking Help for Addiction: Recognizing signs, available treatments, support systems, and resources are essential for recovery.
Personal Stories: Real stories of recovery emphasize hope and resilience.
Interactive Q&A: Engage the audience and encourage discussion.
Conclusion: Recap key points and emphasize the importance of awareness, prevention, and seeking help.
Resources: Provide contact information and links for further support.
International Cancer Survivors Day is celebrated during June, placing the spotlight not only on cancer survivors, but also their caregivers.
CANSA has compiled a list of tips and guidelines of support:
https://cansa.org.za/who-cares-for-cancer-patients-caregivers/
Joker Wigs has been a one-stop-shop for hair products for over 26 years. We provide high-quality hair wigs, hair extensions, hair toppers, hair patch, and more for both men and women.
The best massage spa Ajman is Chandrima Spa Ajman, which was founded in 2023 and is exclusively for men 24 hours a day. As of right now, our parent firm has been providing massage services to over 50,000+ clients in Ajman for the past 10 years. It has about 8+ branches. This demonstrates that Chandrima Spa Ajman is among the most reasonably priced spas in Ajman and the ideal place to unwind and rejuvenate. We provide a wide range of Spa massage treatments, including Indian, Pakistani, Kerala, Malayali, and body-to-body massages. Numerous massage techniques are available, including deep tissue, Swedish, Thai, Russian, and hot stone massages. Our massage therapists produce genuinely unique treatments that generate a revitalized sense of inner serenely by fusing modern techniques, the cleanest natural substances, and traditional holistic therapists.
2. AdvancingDialysis.org
Disclosures
Mike Kraus, MD,
FACP
Allan J. Collins, MD,
FACP
Peter McCullough,
MD, MPH, FACC,
FACP, FCCP, FAHA,
FNKF
Paul Komenda, MD,
MHA, FRCPC
Bill Davis
Scientific Advisory
Board Member:
NxStage Medical, Inc.
Unrestricted
Educational Grants:
NxStage Medical, Inc.
Keryx
Biopharmaceuticals,
Inc.
Satellite Healthcare
Inc.
Fresenius Medical
Care
Chief Medical
Officer NxStage
Medical
Consulting
Epidemiology:
FibroGen
Dialysis Providers:
Executive Director
Peer Kidney Care
Initiative with 7 NPO
and 6 FP CMO
provider groups
Scientific Advisory
Board Member:
NxStage Medical, Inc.
Consulting
Epidemiology:
Fresenius
Scientific Advisory
Board Member:
NxStage Medical,
Inc., Boehringer
Ingelheim, Otsuka,
Alexion
Paid Speaker:
NxStage Medical, Inc.
3. AdvancingDialysis.org
Important information
All forms of hemodialysis, including treatments performed in-center and at
home, involve some risks. In addition, there are certain risks unique to
treatment in the home environment. Patients differ and not everyone will
experience the reported benefits of more frequent hemodialysis.
Certain risks associated with hemodialysis treatment are increased when
performing nocturnal therapy due to the length of treatment time and
because therapy is performed while the patient and care partner are
sleeping.
4. AdvancingDialysis.org
Addressing a
Case in Unmet
Need
Case in Unmet Need
Discussion Lead:
Michael Kraus, MD, FACP
Indiana University School of Medicine
1. The DOPPS Practice Monitor. http://www.dopps.org/DPM/. Accessed May 20, 2015.
5. AdvancingDialysis.org
Where it all begins
• Mr. B.D.
‒ 52 yo bm
‒ APKD
‒ Prior PD, transplant times 13 years
‒ Transplant with acute failure due to Renal vein thrombosis, initiates
thrice weekly HD (Texas)
‒ PD cavity is full of adhesions on laparoscopy
‒ Continues on in-center dialysis
‒ Transfers to your dialysis shift
6. AdvancingDialysis.org
Hemodialysis
• IHD 4 hours daily, 3x/week
• Hypertension controlled on 3 drugs
• Increased PO4
• Post dialysis fatigue
• On transplant list – no partner
Due to dialysis he abruptly “retired”
Lives in Florida 6-months a year and wants to be more active
Increased frequency home hemodialysis
7. AdvancingDialysis.org
After training and going home
• Afib
• Echo – LVH (1.4 cm septum and PW thickness), Decreased LVEF 30%,
diastolic dysfunction
• Pulmonary Hypertension
• Minimal diffuse valvular changes
• Cardiac Catheterization with normal coronary anatomy
8. AdvancingDialysis.org
Cardiovascular
Clinical
Considerations
Discussion Lead:
Peter McCullough, MD, MPH, FACC, FACP, FCCP, FAHA, FNKF
Baylor University Medical Center
2. Kotanko P, Garg AX, Depner T, et al. Effects of frequent hemodialysis on blood pressure: Results from the
randomized frequent hemodialysis network trials. Hemodial Int. 2015;19(3):386-401. doi:10.1111/hdi.12255.
11. AdvancingDialysis.org
AUDIENCE POLL:
Which choice discloses the three major mechanisms of
left ventricular failure?
1) Pressure overload, volume overload, and cardiomyopathy
2) Atrial fibrillation, reduced ejection fraction, mitral regurgitation
3) Excess salt intake, hypertension, and myocardial infarction
4) Viral infarction, alcohol intake, and B-vitamin deficiency
5) Erythropoietin toxicity, left ventricular hypertrophy, and tachycardia
10
16. AdvancingDialysis.org
Antihypertensive Medications
Needed in Home HD Patients
Statistically Significant Decline in Utilization
Nair S. et al. New European evidence with Home HD Patients: 12 months follow-up in KIHDNEy cohort.
Presented at 54th ERA-EDTA conference 2017, Madrid.
Mean
Agents/day
% using
No Rx
% using
≥2 Rx
Baseline 1.51 27% 42%
Month 6 1.12 36% 34%
Month 12 0.91 42% 25%
p for trend <0.001 <0.001 <0.001
18. AdvancingDialysis.org
Clinical Consequences of
Increased Left Ventricular
Mass
Thickening of the LV wall (left
ventricular hypertrophy) can
stimulate a vicious cycle
• Lead to more LVH progression
• Complicated by ESRD uremic
risk factors
• Lead to heart failure
• Lead to arrhythmias and
sudden death
19. AdvancingDialysis.org
AUDIENCE POLL:
With home hemodialysis there is a reduction in left
ventricular hypertrophy. With each 10-gram reduction in
LV mass, what is the associated reduction in mortality?
1) 8%
2) 18%
3) 28%
4) 38%
5) 48%
10
20. AdvancingDialysis.org
More Frequent
Hemodialysis
Regression of Left
Ventricular Hypertrophy
1. McCullough PA, Chan CT, Weinhandl ED, Burkart JM, Bakris
GL. Intensive Hemodialysis, Left Ventricular Hypertrophy, and
Cardiovascular Disease. American Journal of Kidney Diseases,
Volume 68, Issue 5, S5 - S14.
…each 10-point
decrement in percentage
change in left ventricular
mass was associated
with 28% lower risk for
cardiovascular death…1
22. AdvancingDialysis.org
High Ultrafiltration Rates Correlated
to Intradialytic Hypotension
15.4
13.5
3.4
0.6
0
2
4
6
8
10
12
14
16
18
Center
3x/wk
Center
5x/wk
Home
5x/wk
Home
Nocturnal
-41.7
-18.5
-1.5
17.1
-50
-40
-30
-20
-10
0
10
20
30
Center
3x/wk
Center
5x/wk
Home
5x/wk
Home
Nocturnal
1.Jefferies et.al. Frequent hemodialysis schedules are associated with reduced levels of dialysis-induced
cardiac injury (Myocardial stunning). Clin J Am Soc Neprhol 2011 June, 6(6); 1326-1332.
Higher Ultrafiltration Rates Greater Drops in Blood Pressures
23. AdvancingDialysis.org
Regional Wall Motion Abnormalities
Shown to Increase Mortality Risk1
15.4
13.5
3.4
0.6
0
2
4
6
8
10
12
14
16
18
Center
3x/wk
Center
5x/wk
Home
5x/wk
Home
Nocturnal
4.8 4.6
3.3
3.0
0
1
2
3
4
5
6
Center
3x/wk
Center
5x/wk
Home
5x/wk
Home
Nocturnal
1.Burton, JO et al., Hemodialysis-Induced Cardiac Injury: Determinants and Associated Outcomes. Clin J Am Soc
Nephrol 4: 914–920, 2009. 2.Jefferies et.al. Frequent hemodialysis schedules are associated with reduced levels of
dialysis-induced cardiac injury (Myocardial stunning). Clin J Am Soc Neprhol 2011 June, 6(6); 1326-1332.
Higher Ultrafiltration Rates More Wall Motion Abnormalities2
24. AdvancingDialysis.org
AUDIENCE POLL:
Regional wall motion abnormalities of the left ventricle
over the course of dialysis are associated with all of the
above except:
1) Use of cinacalcet
2) Intradialytic hypotension
3) High ultrafiltration rate
4) Three times per week dialysis
5) Higher mortality
10
25. AdvancingDialysis.org
AGGRESSIVE
ULTRAFILTRATION
RATES
HYPOVOLEMIA
INTRADIALYTIC
HYPOTENSION
REGIONAL WALL MOTION
ABNORMALITIES
CARDIAC HYPO-
PERFUSION
2/3 of conventional
hemodialysis patients suffer
from recurrent HD-induced
ischemic injury1
MYOCARDIAL
STUNNING
1.Jefferies et.al. Frequent hemodialysis schedules are associated with reduced levels of dialysis-induced cardiac
injury (Myocardial stunning). Clin J Am Soc Neprhol 2011 June, 6(6); 1326-1332. Graphical summary source: Flythe
JE, Brunelli SM: The risks of high ultrafiltration rate in chronic hemodialysis: implications for patient care. Semin Dial 24(3):259-265, 2011
27. AdvancingDialysis.org
Over 41% of all deaths were
cardiovascular-related, with
nearly identical percentages in
hemodialysis and peritoneal
dialysis patients.1
CHAPTER 1, FIGURE 2:
Distribution of primary cause of death in
hemodialysis patients, 2011 to 2013.2
1.Saran R, Li Y, Robinson B, et al. US Renal Data System 2014 Annual Data Report: Epidemiology of Kidney
Disease in the United States. 2.Am J Kidney Dis Off J Natl Kidney Found. 2015;66(1 Suppl 1):Svii, S1-305.
doi:10.1053/j.ajkd.2015.05.001
Cardiovascular-related Deaths in
Prevalent Dialysis Patients are
Common
28. AdvancingDialysis.org
The FHN Trial Group. In-Center Hemodialysis Six
Times per Week versus Three Times per Week. The
New England Journal of Medicine. 010:363;2287-2300.
Frequent
Hemodialysis
Associated with
12-month
Improvements in
Several
Cardiovascular
Markers1
Likely due to improved
control of extracellular
volume excess.
Left ventricular mass
Adjusted mean reduction of
16.4±2.9 g versus 2.6±3.2
(P<0.001)
12%
REDUCTION
FHN RANDOMIZED CLINICAL TRIAL FINDINGS:
Hypotensive episodes
10.9% vs. 13.6% of monitored
sessions with at least one
episode, (P=0.04)
20%
FEWER
Systolic blood pressure
Adjusted mean SPB decrease
9.7±18.2 mm Hg versus 0.9±16.2
mm Hg (P<0.001)
7%
DECREASE
Antihypertensive agents
Change from baseline agents
decreased 0.87±1.85 versus
−0.23±1.35 (P< .001)
32%
LESS
29. AdvancingDialysis.org
Daily home hemodialysis patients had
20%-25% fewer CV hospital days per patient-
year than in-center HD patients:
↓ 25% lower risk for cerebrovascular disease
↓ 41% lower risk for heart failure, fluid
overload, and cardiomyopathy
↓ 16% lower risk for hypertensive disease
McCullough PA, Chan CT, Weinhandl ED, Burkart JM, Bakris GL. Intensive Hemodialysis, Left Ventricular
Hypertrophy, and Cardiovascular Disease. American Journal of Kidney Diseases, Volume 68, Issue 5, S5 - S14.
Cardiovascular Benefit of
Home Dialysis
30. AdvancingDialysis.org
58%
5-year survival
+8,000
HHD Patients
More Frequent
HHD*
50%
5-year survival
+45,000
PD Patients
Peritoneal Dialysis
40%
5-year survival
+420,000
Conventional HD Patients
In-center HD
More frequent HHD is
associated with better 5-year
relative survival
5-year patient survival after initiating
treatment
U.S. Renal Data System, USRDS 2015 Annual Data Report: Table 6.3. Adjusted survival (%) by (a) treatment
modality and incident cohort year (year of ESRD onset), and (b) age, sex, race, and primary cause of ESRD,
for ESRD patients in the 2008 incident cohort (initiating ESRD treatment in 2008) Abbreviation: ESRD, end-
stage renal disease. *Data source: NxStage patient data on file
31. AdvancingDialysis.org
Addressing Unmet Needs
in Cardiorenal Care
Chronic Fluid Overload and
Mortality in ESRD
FO = Fluid Overload
Determined by Bioimpedence
1.Carmine Zoccali et al. Chronic Fluid Overload
and Mortality in ESRD. JASN 2017;28:2491-2497.
doi: 10.1681/ASN.2016121341
33. AdvancingDialysis.org
AUDIENCE POLL:
How do you think of therapy prescription for more
frequent home hemodialysis?
1) Solute removal to achieve target
KT/V
2) Fluid control
3) Patient tolerance to the therapy
4) PO4 control
5) All the above
10
34. AdvancingDialysis.org
AUDIENCE POLL:
More frequent HD is targeted at which areas of unmet
need?
1) Fluid overload
2) Uncontrolled BP
3) LVH/Heart Failure
4) Patient tolerance to the therapy
5) All the above
10
35. AdvancingDialysis.org
Pathophysiology and Outcomes
Challenges with Thrice-Weekly Hemodialysis
1.Rocco MV, Burkart JM. Prevalence of missed treatments and early sign-offs in hemodialysis patients. J Am
Soc Nephrol. 1993 Nov;4(5):1178-83.
Fluid
Overload
Uncontrolled
Hypertension
Left Ventricular
Hypertrophy
Heart Failure
Hospitalizations
and Death
“Early Sign-
Offs”
and “No-Shows”
1
High
Ultrafiltration
Rate
Intradialytic
Hypotension
Cramping,
Dizziness,
Nausea, etc.
Long Post-
Dialysis
Recovery Time
Poor QOL
Intervention:
Lower Ultrafiltration Rate,
but Maintain Session
Length
37. AdvancingDialysis.org
Dialysis Recovery
Time is Associated
with All-cause
Mortality
Kaplan- Meier Unadjusted
Chazot et al; Blood Purification 2017; 44:89-97
All-cause Mortality
<6.8 ml/kg/hr
≥6.8 ml/kg/hr
38. AdvancingDialysis.org
Dialysis therapy prescription
General Concepts: Two Part Approach
(Consistent with John Agar Hemodialysis International Editorial, 2015)
Set Fluid removal per week
‒ Set desired dry weight
‒ Limit UFR to reduce cardiac/organ system stunning
‒ Limit UFR <10ml/kg/hr for safety and tolerability (reduce recovery time)
NxStage mean UFR 6-7 ml/kg/hr short daily; 2-3 ml/kg/hr Nocturnal
Standardized weekly KT/V: normalized volumes cleared of Urea
‒ 2.1 per week of continuous removal (minimum) from Guidelines
‒ Mainly addresses the dietary intake for a week
‒ Provides basic removal of K, adds HCO3, and removes protein uremic toxins
Large molecules and PO4 take greater time for removal because of large
spaces and slow transport (30+ hours per week)
39. AdvancingDialysis.org
Fluid Removal Rates and Control of
Volume is a Core Unmet Need
• The range of fluid removal rates has been a subject of
discussion (<7ml/kg/hr, <10ml/kg/hr, <13 ml/kg/hr)
• UFR appears to relate to how patients feel, hypotensive
episodes, recovery time and associated mortality (lower the
rate the better)
• Tolerability of fluid removal is the key element when trying to
achieve a desired target weight to control HTN and treat heart
failure
• Lowering UFR on conventional three times per week HD is very
challenging to implement in a fixed schedule
40. AdvancingDialysis.org
How should treatment time and frequency be
determined?
1) Whatever we can get the patient to do
2) UF time per week is based on tolerable UFR and total volume to be
removed
3) Set the number of treatment per week to fit minimum UF time per week
4) All the above
AUDIENCE POLL:
10
41. AdvancingDialysis.org
Therapy Rx Principles: Weekly
CALCULATE RESULT PRESCRIBEINPUT
UF TIME / WEEK
KG gain
/ Week
1500 mL/day x7
10.5 liters/week
QUF limit
<10 mL/kg/h
< 700 mL/h ♂
< 500 mL/h ♀
15
Total Hours
/ Week
Sessions / Week
Hours / Session
42. AdvancingDialysis.org
High Saturation Dialysate:
Dialysate + UF = Volume Cleared
• The high saturation of dialysate means for each liter of dialysate
used it equals a liter cleared of solutes
‒ Urea
‒ Creatinine
‒ PO4
• Ultrafiltration adds convective clearance removing solutes at the
same concentration as in the blood
• The single pool volumes cleared each treatment is essentially the
volume of dialysate plus the UF divided by the patient TOTAL Body
Water
43. AdvancingDialysis.org
How do low flow systems deliver enough solute clearance
vs. conventional HD?
1) High dialysate saturation maximizes solute removal similar to PD
2) Total time per week and frequency are used to deliver the weekly total
dose
3) PO4 removal is also improved based on greater dialysate saturation at
lower Qd
4) All the above
AUDIENCE POLL:
10
44. AdvancingDialysis.org
Weekly Total Normalized Water
Cleared of Urea (KxT)
Based on continuous STD weekly Kt/V
I
II
III
IV
V
eGFRStageContinuous
Clearance
15
eGFR (ml/min)
30
60
90
STD L/wk Urea
80-90 L/wk
80-90 L/wk
128 L/wk
342 L/wk
605 L/wk
1000 L/wk
HD x 3
HD x 6
nocturnal
Transplant
PD x 7
HD x 5
Normal
49. AdvancingDialysis.org
High Saturation Dialysate:
Dialysate + UF = Volume Cleared (KxT)
• The high saturation of dialysate means for each liter of dialysate used it
equals a liter cleared of solutes
‒ Urea
‒ Creatinine
‒ PO4
• Ultrafiltration adds convective clearance removing solutes at the same
concentration as in the blood
• The single pool volumes cleared each treatment is essentially the volume
of dialysate plus the UF divided by the patient TOTAL Body Water
50. AdvancingDialysis.org
Leypoldt and Collins Dosing Protocol
ASN Abstract/Poster - Based on V: Dialysate Volume rounded*
*Tabulated values are dialysis volumes in L per treatment (obtained by dividing Kt by 0.85) predicted to achieve
a weekly stdKt/V of 2.1 rounded up to the nearest 5 L.
Dialysate Volume needed to nearest 5 liters
51. AdvancingDialysis.org
In Sum
Therapy Rx can be addressed in two parts
‒ Volume to be removed per week by addressing UFR
‒ Solute removal based on Normalized Volumes of Total Body Water cleared
per week and per treatment
UF volume per week is divided by tolerable UFR to obtain hours needed
per week
STD Weekly KT/V provides the target normalized volumes per week to be
cleared overall
‒ spKT/V is used to determine normalized volume cleared per treatment
‒ Dialysate needed per treatment is computed based on saturation of the
dialysate rounded up to the nearest 5 liters
The dosing calculator will give alternatives for various schedules
52. AdvancingDialysis.org
Conclusions
• Therapy prescription for any dialysis is targeted at Volume to be removed
and solute to be cleared
• Volume removal is the first step to address control of CVD areas and
tolerability of therapy
• All dialysis modalities use solute clearance as the basis of therapy Rx:
Blood Side or Dialysate Side
• Conventional HD is based on Blood side clearance
• PD and HHD is based on dialysate clearance
• More frequent HD can deliver comparable, if not superior, therapy
compared to conventional HD
57. AdvancingDialysis.org
Improved LVM
Better BP
Lower PO4
N=245 (2010)
Randomized Control Trials
JAMA, September 19, 2007—Vol 298, No. 11
Improved LVM
Better BP
Lower PO4
N=52 (2007)
? Improved LVM
(p=0.09)
Better BP
Lower PO4
N=82 (2011)
58. AdvancingDialysis.org
“Sunk Costs”
Komenda P et al. An economic assessment model for in-center, conventional home, and more frequent home
hemodialysis. Kidney International. Volume 81, Issue 3, Pages 307-313 (February 2012). DOI:
10.1038/ki.2011.338
• If Intensive Home
Hemodialysis unlikely to last
more than 12-24 months, not
a cost effective option
• Not taking into consideration
PATIENT time for training.
60. AdvancingDialysis.org
The Cycler and Cartridge
Simple interface using shapes, colors,
and diagrams to aid in operation of system
Color coded cartridge clamps to match
fluid pathways
62. AdvancingDialysis.org
Significantly reduced post-dialysis
recovery time
Study of Medicare patients starting more
frequent home hemodialysis with NxStage
System One Key Findings:
• 87% improvement in time to
recovery and significant
improvement in quality of life
measures
1Jaber BL, Lee Y, Collins AJ, et al. Effect of daily hemodialysis on depressive symptoms and postdialysis
recovery time: interim report from the FREEDOM (Following Rehabilitation, Economics and Everyday-Dialysis
Outcome Measurements) Study. Am J Kidney Dis. 2010;56(3):531-539.
67. AdvancingDialysis.org
B.D.
• BP normal and no meds
• Activity increased
• Serial Echo with improved LVEF (60%) No wma or Valvular disease
• No recurrence A Fib
His story
Previously Approved (APM2540)
There are risks associated with all forms of dialysis, but one item to point out is that certain risks are unique to home as treatments are done without the presence of a medial professional.
New with Previously Reviewed content (APM2542)
New – Patient has a Speaking Agreement with NxStage
New – Patient has a Speaking Agreement with NxStage
New – Patient has a Speaking Agreement with NxStage
New – Previously Reviewed Content
New
New
New
Previously Approved (APM1978)
New
New
New
New? Perhaps reviewed for International
New
Previously Reviewed – But not used in Approved content – only speaker slides
New
New with Previously Reviewed Content
New
Redrawn from Previously Approved (APM1978)
Redrawn from Previously Approved (APM1978)
New
Summarized and Redrawn from Previously Approved (APM1978)
New
Previously Reviewed and Approved – APM2489
Previously Approved (APM1978)
New
Redrawn from Previously Approved (APM1978)
New
New with Previously Approved content (APM2920)
New
New
Previously Reviewed (no comments, not approved in Agile)
New
Previously Reviewed (no comments, not approved in Agile)
Previously Reviewed (no comments, not approved in Agile)
New
New
Modified from Previously Reviewed Content 10/17 (no comments, not approved in Agile)
New
New
Previously Reviewed Content 10/17 (no comments, not approved in Agile)
Previously Reviewed Content 10/17 (no comments, not approved in Agile)
Previously Reviewed Content 10/17 (no comments, not approved in Agile)
Modified from Previously Reviewed Content 10/17 (no comments, not approved in Agile)
Modified from Previously Reviewed Content 10/17 (no comments, not approved in Agile)
Re-formatted from Previously Reviewed Content 10/17 (no comments, not approved in Agile)
Re-formatted from Previously Reviewed Content 10/17 (no comments, not approved in Agile)
Re-formatted from Previously Reviewed Content 10/17 (no comments, not approved in Agile)
Re-formatted from Previously Reviewed Content 10/17 (no comments, not approved in Agile)
New. (Approved Graphic APM2920)
New
New
Home dialysis decreased after Medicare introduced the composite rate in 1983 despite a more than tripled dialysis population:
From 1983 – 2002, percentage of dialysis patients home: PD 10.4% to 8.1%; HHD 1.9% to 0.4%
New
New
New
New
Previously Approved (APM645)
New with Previously Approved content (APM2945)
Redesigned from Previously Approved APM1978
New
New
New – Paul Komenda has written consent from patient