Overview of different methods to control and manage blood pressure in hemodialysis/dialysis patients including latest research derived methods. Includes non-pharmacologic and pharmacologic methods and their efficacy.
Hyertension in patients on regular hemodialysisEhab Ashoor
Everything about hypertension in patients on regular hemodialysis, including management, Resistant hypertension, Intra-dialytic hypertension and Hypertensive urgencies.
Hyertension in patients on regular hemodialysisEhab Ashoor
Everything about hypertension in patients on regular hemodialysis, including management, Resistant hypertension, Intra-dialytic hypertension and Hypertensive urgencies.
Recent Advancements in the treatment of Hypertension.Akshata Darandale
Uncontrolled blood pressure had become most common cause of death accounting for more than 7 million deaths per year worldwide. Despite the availability of potent lifestyle and pharmacologic approaches, rates of control of blood pressure are unsatisfactory and additional strategies to curb the burden of hypertension are warranted. Several novel pharmacological and device-based approaches have recently been tested and may prove helpful to achieve better blood pressure control rates and thereby improve cardiovascular outcomes in patients with hypertension.
Total body sodium is the major determinant of extracellular
fluid volume. Increased total body sodium and fluid volume
is an inevitable consequence of end-stage renal failure
because kidneys have a key role in the regulation of sodium
balance
Management of HTN according to gender. This slides will answer some questions such as
1. Why there is BP variability difference between male and female?
2. What's the regulatory mechanism of HTN in gender?
Methods: Central Venous Pressure and Physician administration of Intravenous ...Todd Belok
Our study is using the independent variables of low CVP coupled with hypotension and dependent variable of physician administered fluids to test how the Venus 1000 can alter physician actions in the emergency department setting.
The actual prevalence of RH may be lower than what is
perceived in the literature when triple-A (accuracy of BP
measurement, adherence of medications, and adequacy
of anti-HTN medications) are ensured. It is important to
emphasize that the sea of RH starts when the shore of secondary
HTN is over and the island of RfH is still uncharted. RfH is
emerging as a novel phenotype, and growing evidence suggest
that these patients have sympathetic hyperactivity. However,
the role of beta-blockers and interventions such as RDN and
baroreceptor activation techniques is yet to be studied.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Recent Advancements in the treatment of Hypertension.Akshata Darandale
Uncontrolled blood pressure had become most common cause of death accounting for more than 7 million deaths per year worldwide. Despite the availability of potent lifestyle and pharmacologic approaches, rates of control of blood pressure are unsatisfactory and additional strategies to curb the burden of hypertension are warranted. Several novel pharmacological and device-based approaches have recently been tested and may prove helpful to achieve better blood pressure control rates and thereby improve cardiovascular outcomes in patients with hypertension.
Total body sodium is the major determinant of extracellular
fluid volume. Increased total body sodium and fluid volume
is an inevitable consequence of end-stage renal failure
because kidneys have a key role in the regulation of sodium
balance
Management of HTN according to gender. This slides will answer some questions such as
1. Why there is BP variability difference between male and female?
2. What's the regulatory mechanism of HTN in gender?
Methods: Central Venous Pressure and Physician administration of Intravenous ...Todd Belok
Our study is using the independent variables of low CVP coupled with hypotension and dependent variable of physician administered fluids to test how the Venus 1000 can alter physician actions in the emergency department setting.
The actual prevalence of RH may be lower than what is
perceived in the literature when triple-A (accuracy of BP
measurement, adherence of medications, and adequacy
of anti-HTN medications) are ensured. It is important to
emphasize that the sea of RH starts when the shore of secondary
HTN is over and the island of RfH is still uncharted. RfH is
emerging as a novel phenotype, and growing evidence suggest
that these patients have sympathetic hyperactivity. However,
the role of beta-blockers and interventions such as RDN and
baroreceptor activation techniques is yet to be studied.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
3. Hypertension in dialysis patients is common,
remains often uncontrolled, and, when diagnosed
objectively with out-of-dialysis blood pressure (BP)
monitoring, is directly associated with excess risk
for mortality.
The pathogenesis of hypertension is multifactorial,
but volume overload is the most important cause of
hypertension in these patients.
When BP remains uncontrolled despite aggressive
volume management, non–volume-dependent
mechanisms are involved as mediators of
sustained hypertension
4.
5.
6. Peridialytic Blood Pressure Recordings
BP recordings taken shortly before (predialysis) or after dialysis
(postdialysis) are the basis for the diagnosis of hypertension among
dialysis patients, mainly because these measurements are readily
available.
Peridialytic BP remains insuffciently accurate, even when a greater
number of recordings are averaged over six dialysis sessions.
Thus, BP variability is not the sole factor that accounts for poor
diagnostic performance of peridialysis BP recordings.
7. Intradialytic (During Dialysis) BP Recordings
The diagnostic accuracy of peridialytic BP is improved when these
recordings are considered jointly with BP measurements during the
entire dialysis procedure
the average of intradialytic and peridialytic BP over six consecutive
dialysis sessions was superior to predialysis or postdialysis BP alone in
predicting interdialytic ambulatory BP.
A midweek median cut-off systolic BP (SBP) of 140 mm Hg provided
80% sensitivity and 80% speci city in diagnosing hypertension.
Therefore, median intradialytic BP can be used to quickly screen for
hypertension at the bedside, but this is a method of last resort.
Interdialytic BP recordings, though less convenient, may be better for
the long-term management of hypertension.
8. Interdialytic (Between Dialysis) Recordings
Home BP monitoring (HBPM) is an established technique
recommended by guidelines and widely adopted in clinical practice
A 1-week average home SBP of 150 mm Hg or above provided 80%
sensitivity and 84.1% specificity in diagnosing hypertension.
In the Dry Weight Reduction in Hypertensive Hemodialysis Patients
(DRIP) trial, home BP could track changes in interdialytic ambulatory
BP
Contrary to the poor reproducibility of pre- and postdialysis BP, home
BP had even greater test-retest reliability than interdialytic ambulatory
BP.
For the long-term management of dialysis patients, its recommended to
use twice daily home BP recordings after a midweek dialysis session
for 4 days.
9. Interdialytic ambulatory BP monitoring (ABPM) is the gold
standard technique for diagnosing hypertension
A unique advantage of ABPM is that BP can be recorded
during sleep, enabling the diagnosis of nocturnal
hypertension and non-dipping BP patterns
ABPM also has some weaknesses (i.e., limited availability
and costs of equipment, need for training, patient discomfort)
that limit the wide adoption of this technique in practice.
10.
11. Prevalence, Treatment, and Control of Hypertension
Epidemiology of hypertension among patients on dialysis differs depending
on the method of BP measurement
In A cross-sectional study of 369 patients, the prevalence of hypertension
(defined as interdialytic BP ≥135/85 mm hg or antihypertensive drug use)
was 82%.
Although 89% of hypertensive dialysis patients were being treated,
adequate ambulatory bp control was achieved in only 38%.
Subsequent studies using HBPM or ABPM confirmed that the burden of
hypertension in the dialysis population is high and its control poor.
Among patients on peritoneal dialysis the burden of hypertension and
prognostic association of bp with mortality follows a pattern similar to that
seen among hemodialysis.
12. Prognosis
In sharp contrast with the direct and linear association between BP and
outcome in the general population, large-scale cohort studies
conducted in dialysis patients showed a U-shaped or J-shaped
association of peridialytic BP with mortality.
Two separate cohort studies showed that BP measurement technique
strongly confounds the relation of BP with mortality
In these studies, increasing interdialytic SBP assessed either with
HBPM or with ABPM was directly associated with higher mortality risk.
Home SBP between 120 to 130 mm Hg and 44-hour ambulatory SBP
ranging from 110 to 120 mm Hg were associated with the best
prognosis.
13. THERAPEUTIC TARGETS
The optimal BP threshold for the diagnosis and
management of hypertension in the dialysis
population is unknown
In the meantime, it is recommended that
controlling home SBP to levels below 140 mm
Hg is a reasonable target in dialysis patients
If a home BP-guided strategy is not feasible,
lowering midweek median intradialytic SBP
below 140 mm Hg is an alternative strategy
14. Once an accurate diagnosis is made, the initial
management of hypertension is based on
nonpharmacologic strategies that target and maintain
euvolemia.
Dietary Na restriction
Individualized dialysate Na
Gentle and gradual dry weight reduction with the guidance of
symptoms
Adequate delivery of dialysis time
15. Probing of Dry Weight
There is no consensus on the optimal definition of
dry weight.
In 2009 Sinha and Agarwal stated that dry weight
reflects the lowest tolerated postdialysis weight at
which the patient experiences minimal signs and
symptoms of either hypovolemia or hypervolemia
According to this dentition, the management of dry
weight is based on an iterative process of gentle
and gradual intensification of ultrafiltration guided by
the patient’s symptoms
16. Benefits of Probing Dry Weight
Dry weight was probed without increasing the dialysis duration in the
DRIP trial
In DRIP, 150 dialysis patients who had uncontrolled hypertension
despite stable background treatment with 2.7 antihypertensive
medications daily were randomized in a 2:1 ratio to ultrafiltration and
control groups
In the ultrafiltration group, postdialysis weight was gradually reduced
until the development of symptoms indicating dry weight achievement
A modest reduction in dry weight by 0.9 kg from baseline to 4 weeks
provoked an average placebo-subtracted reduction of −6.9 mm Hg in
44- hour SBP and a placebo-subtracted reduction of −3.1 mm Hg in 44-
hour diastolic BP (DBP)
17. Assessment and Management of Dry Weight
Among hypertensive dialysis patients, the management of dry weight
should not be based on the presence or absence of clinically overt
hypervolemia.
An important sign that should raise the suspicion of volume excess is
the use of multiple bp-lowering medications in a dialysis patient.
The mediator of sustained hypertension in these patients is subclinical
volume excess
Several cross-sectional studies showing an increasing number of
prescribed antihypertensive medications to be paradoxically associated
with worse BP control.
These observations suggest that intensification of antihypertensive
therapy is likely to fail to control BP if volume excess is not primarily
addressed, supporting a “volume-first” approach of hypertension.
18.
19. Unlike the typical decline in BP with ultrafiltration, BP increases during
dialysis in approximately 10% to 15% of patients.
This paradoxical hemodynamic response is described as intradialytic
hypertension
Earlier studies suggested that this phenomenon may be mediated
through release of vasoconstrictors in response to ultrafiltration.
On this basis, the management of intradialytic hypertension often relied
on interruption of ultrafiltration and/or immediate administration of
potent short-acting antihypertensive agents.
20. A high interdialytic weight gain (IDWG) is often (but erroneously)
considered as equivalent with hypervolemia.
However, recent studies using more objective methods in the
assessment of dry weight inform us that IDWG and volume overload
are two discrete components of the dynamic fluid balance.
patients with steeper relative plasma volume(RPV) slopes and
therefore most euvolemic had the highest IDWG.
In contrast, patients with the greatest volume expansion based on RPV
monitoring had the lowest IDWG and these patients tolerated the
greatest dry weight reduction during follow-up(−1.5 kg).
Therefore, a low IDWG may reflect volume excess, particularly when
accompanied by other clinical indications, such as uncontrolled
interdialytic hypertension.
21. However, more recent studies showed a close relation between
intradialytic and interdialytic hypertension
In a post hoc analysis of the DRIP trial, probing of dry weight in patients
with intradialytic hypertension was effective in normalizing both
intradialytic and interdialytic BP profiles
Therefore, persistent BP elevation during dialysis may be another
signal of volume excess
22. Potential Hazards of Probing Dry
Weight
Probing of dry weight may be associated
with potential hazards, such as higher risk
for intradialytic hypotension, vascular
access thrombosis, and more rapid loss of
residual renal function.
In DRIP, probing of dry weight provoked
temporal intradialytic symptoms of
hypotension, but these symptoms did not
unduly affect any domain of health-related
quality of life
23. Dietary sodium restriction is an established
nonpharmacologic approach to limit IDWG and facilitate the
achievement of dry weight.
International guidelines recommend that among patients on
dialysis, dietary sodium intake should not exceed 80 to 100
mmol (1.8–2.3 g; equivalent to 4.5–5.8 g sodium chloride)
daily.
Observational studies support this guidance, showing that
compared with pharmacologic management of
hypertension, sodium restriction together with adequate
adjustment in dry weight was associated with greater
regression of LVH and reduced incidence of intradialytic
hypotension.
24. Sodium loading in hemodialysis patients occurs when the prescription of
dialysate sodium concentration results in a positive sodium gradient during
dialysis
this therapeutic approach perpetuates a vicious cycle.
Intradialytic sodium gain is directly associated with increased sense of
thirst and greater IDWG, resulting in higher ultrafiltration requirements
during the subsequent dialysis sessions.
The higher ultrafiltration rates can aggravate the risk of intradialytic
hypotension, which might result in the prescription of even higher dialysate
sodium concentrations
Lowering the dialysate sodium concentration could possibly interrupt this
vicious cycle.
25. The benefit/risk ratio of this intervention was investigated in a meta-
analysis of 12 trials involving 266 patients
Compared with neutral (138–140 mEq/L) or high (>140 mEq/L)
dialysate sodium, a low sodium concentration (<138 mEq/L) was
associated with reduced IDWG and improvement in BP
However, these benefits were accompanied by higher risk for
intradialytic cramps and hypotension.
It is recommended that lowering of dialysate sodium concentration
should be gradual and individualized.
26. The prescription of dialysis duration varies considerably across countries.
Approximately one-third of patients in the united states are prescribed
hemodialysis with a duration of less than 200 minutes.
Among several other risks, nonadherence to the dialysis regimen has been
associated with worse bp control
Patients with shorter dialysis duration require more dialysis sessions to
achieve the bp-lowering benefit of probing dry weight
Therefore, shorter delivered dialysis is a barrier to dry weight achievement,
limiting the opportunity for adequate BP control.
27. Despite assiduously adhering to the volume-first
management strategies, a large fraction of dialysis
patients remain hypertensive, and drug therapy is
necessary to achieve an adequate control of BP.
Treatment should be guided by evidence from trials
done in the dialysis population and not on
extrapolation of evidence from trials conducted in
earlier stages of kidney disease or in the general
population
28.
29. Β-BLOCKERS
The safety and efficacy of β-blocker–based and angiotensin-converting
enzyme (ACE) inhibitor–based regimens were compared in the
hypertension in hemodialysis patients treated with atenolol or lisinopril
(HDPAL) trial
In HDPAL, 200 hypertensive dialysis patients with echocardiographic
LVH were randomized to atenolol or lisinopril
Atenolol appeared to be more effective in controlling hypertension
Compared with lisinopril, atenolol provoked a greater reduction in aortic
pulse wave velocity over the first 6 months of follow-up.
The incidence of serious adverse cardiovascular events was 2.36-fold
higher in the lisinopril group than in the atenolol group
30. CALCIUM CHANNEL
BLOCKERS
Long-acting dihydropyridine calcium channel blockers (CCBs) such as
amlodipine or felodipine are useful in combination with other agents,
such as atenolol, and represent our second-line choice
The efficacy of this drug class is supported by a double-blind trial in
which 251 hypertensive dialysis patients
amlodipine provoked a significant reduction of ∼10 mm Hg in SBP over
30 months of follow-up.
there was a significant reduction by 47% in the composite secondary
outcome of cardiovascular events and all-cause mortality
31. ACE INHIBITORS/ANGIOTENSIN
RECEPTOR BLOCKERS
In the Fosinopril in Dialysis (FOSIDIAL) trial fosinopril had no benefit on
cardiovascular outcomes.
In the Olmesartan Clinical Trial in Okinawa Patients under Okinawa
Dialysis Study (OCTOPUS) trial—enrolling 469 hypertensive dialysis
patients—the ARB Olmesartan was not superior to control for improving
the primary composite cardiovascular outcome or all-cause mortality
over a mean follow-up of 3.5 years
the evidence to support the use of ACE inhibitors or ARBs for cardio-
protection in patients on dialysis is thin.
Therefore, we use ACE inhibitors and ARBs as a third-line option in
dialysis patients with inadequately controlled BP despite combination
treatment with atenolol and a long-acting CCB.
32. MINERALOCORTICOID
RECEPTOR AGONISTS
Among patients not on dialysis with heart failure and reduced ejection
fraction, add-on therapy with spironolactone or eplerenone confers a
substantial cardioprotective benefit
However, the safety and efficacy of mineralocorticoid receptor
antagonists (MRAs) among patients on dialysis has not been
adequately studied.
In a 2016 meta-analysis of nine trials (including 829 patients), MRA use
was associated with improvement in cardiovascular and all-cause
mortality, but this benefit was accompanied by a threefold higher risk of
hyperkalemia
33. VASODILATORS
Many patients on dialysis are prescribed vasodilators such as
hydralazine or minoxidil
Hydralazine is short acting, which is why it needs to be administered 3
times daily.
In reviewing ABPM data on patients on this drug, we often note large
drops in SBP with rapid increases to baseline; therefore discouraging
its use.
Minoxidil prescription is associated with hirsutism that is troublesome
for women and sometimes can cause pericardial effusions.
Editor's Notes
5.69 grams in a teaspoon of salt,
(FOSIDIAL) trial,81 397 French dialysis
first-line management of hypertension among patients on dialysis relies
on nonpharmacologic strategies that target the achievement and maintenance of euvolemia. The adequate
management of volume follows four principles: probing of dry weight, dietary sodium restriction, individualized
prescription of the dialysate sodium concentrations, and adequate delivery of dialysis time.
use β-blockers, particularly atenolol administered 3 times per week
immediately postdialysis, as rst-line therapy. We use long-acting calcium channel blockers (CCBs), such as
amlodipine or felodipine, as second-line therapy in patients with uncontrolled BP despite the adequate management
of dry weight and the administration of atenolol. Angiotensin-converting enzyme (ACE) inhibitors or
angiotensin receptor blockers (ARBs) are our third-line option. Because of concerns related to hyperkalemia and
in anticipation of stronger safety and efcacy data from ongoing randomized trials, we do not recommend the
wide use of mineralocorticoid receptor antagonists for the management of hypertension among patients on
dialysis