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.
journal club is one of the important academic activity during MD/MS courses. Present PPT is a journal club presented on an article that compare two antihypertensives and the presentation also includes critical analysis of the article.
Naturopathic Treatmentfor the Prevention ofCardiovascular Disease: A Randomized Pragmatic TrialCCNM – Journal Club Sept 30th, 2010Dugald Seely, ND, MScDirector; Research & Clinical EpidemiologyThe Canadian College of Naturopathic Medicine
Rivaroxaban with or without aspirin in patients with stable peripheral or car...Bhargav Kiran
Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomised, double-blind, placebo-controlled trial
Prevention of recurrent stroke in atrial fibrillation Jacek StaszewskiJacek Staszewski
Prevention of recurrent stroke in atrial fibrillation. Comaprison of NOAC vs VKA. Riks of hemorrhagic stroke. When anticoagulation should be initiated following acute stroke.
Direct Oral Anticoagulants in Patients With Atrial Fibrillation and Liver Dis...Shadab Ahmad
Guidelines for the treatment of nonvalvular atrial fibrillation (AF) recommend oral anticoagulation (OAC) for stroke prevention with either warfarin or direct oral anticoagulants (DOACs), with a stronger recommendation for DOACs in the general population.
Advanced liver disease is known to increase the risk for bleeding and affects the hepatic clearance and metabolism of drugs.
Even so, OAC is associated with a lower risk for ischemic stroke and no difference in bleeding, including intracranial hemorrhage (ICH), in patients with AF and liver cirrhosis, and thus OAC should still be considered in this population.
journal club is one of the important academic activity during MD/MS courses. Present PPT is a journal club presented on an article that compare two antihypertensives and the presentation also includes critical analysis of the article.
Naturopathic Treatmentfor the Prevention ofCardiovascular Disease: A Randomized Pragmatic TrialCCNM – Journal Club Sept 30th, 2010Dugald Seely, ND, MScDirector; Research & Clinical EpidemiologyThe Canadian College of Naturopathic Medicine
Rivaroxaban with or without aspirin in patients with stable peripheral or car...Bhargav Kiran
Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomised, double-blind, placebo-controlled trial
Prevention of recurrent stroke in atrial fibrillation Jacek StaszewskiJacek Staszewski
Prevention of recurrent stroke in atrial fibrillation. Comaprison of NOAC vs VKA. Riks of hemorrhagic stroke. When anticoagulation should be initiated following acute stroke.
Direct Oral Anticoagulants in Patients With Atrial Fibrillation and Liver Dis...Shadab Ahmad
Guidelines for the treatment of nonvalvular atrial fibrillation (AF) recommend oral anticoagulation (OAC) for stroke prevention with either warfarin or direct oral anticoagulants (DOACs), with a stronger recommendation for DOACs in the general population.
Advanced liver disease is known to increase the risk for bleeding and affects the hepatic clearance and metabolism of drugs.
Even so, OAC is associated with a lower risk for ischemic stroke and no difference in bleeding, including intracranial hemorrhage (ICH), in patients with AF and liver cirrhosis, and thus OAC should still be considered in this population.
Sydney Sexual Health Centre Journal Club presentation by Gwamaka E.M. on The Journal of Infectious Diseases Volume 214 Issue 10, published in November 2016.
The Journal of Infectious Diseases has been published continuously since 1904 and describes itself as "the premier global journal for original research on infectious diseases". Research published in the JID includes studies in microbiology, immunology, epidemiology, and related disciplines, on the pathogenesis, diagnosis, and treatment of infectious diseases; on the microbes that cause them; and on disorders of host immune responses. JID is an official publication of the Infectious Diseases Society of America.
The Sydney Sexual Health Centre Journal Club allows our team to stay up-to-date with what is being published in the field of sexual health. Staff members take turns to read, review and share the contents of an allocated journal. Journal Club encourages knowledge sharing and discussion about topics raised.
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:
Newer Oral Anticoagulant in Chronic Kidney DiseaseAbdullah Ansari
Kidney specific mechanisms leading to atrial fibrillation
Possible mechanism of CKD progression in atrial fibrillation
Atherosclerosis Risk in Communities (ARIC) study
Guidelines
Pulmonary embolism & deep vein thrombosis
Nephrotic syndrome
Problems with Vit K antagonists in CKD
Non Vit K oral anticoagulants
Site of action of NOACs and VKAs
Pharmacology of Direct Oral Anticoagulants
Trials for NOACs
Dose NOACs according to renal function
Laboratory monitoring of NOACs
Anticoagulant reversal of NOACs
Chlorthalidone for poorly controlled hypertension in chronic kidney diseasesShadab Ahmad
Given the central role of volume excess in the pathogenesis of hypertension in CKD, and the low cost of thiazide diuretics, there is a need to study the use of these drugs to lower BP among patients with uncontrolled hypertension and moderately advanced CKD.
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.
Sydney Sexual Health Centre Journal Club presentation by Gwamaka E.M. on The Journal of Infectious Diseases Volume 214 Issue 10, published in November 2016.
The Journal of Infectious Diseases has been published continuously since 1904 and describes itself as "the premier global journal for original research on infectious diseases". Research published in the JID includes studies in microbiology, immunology, epidemiology, and related disciplines, on the pathogenesis, diagnosis, and treatment of infectious diseases; on the microbes that cause them; and on disorders of host immune responses. JID is an official publication of the Infectious Diseases Society of America.
The Sydney Sexual Health Centre Journal Club allows our team to stay up-to-date with what is being published in the field of sexual health. Staff members take turns to read, review and share the contents of an allocated journal. Journal Club encourages knowledge sharing and discussion about topics raised.
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:
Newer Oral Anticoagulant in Chronic Kidney DiseaseAbdullah Ansari
Kidney specific mechanisms leading to atrial fibrillation
Possible mechanism of CKD progression in atrial fibrillation
Atherosclerosis Risk in Communities (ARIC) study
Guidelines
Pulmonary embolism & deep vein thrombosis
Nephrotic syndrome
Problems with Vit K antagonists in CKD
Non Vit K oral anticoagulants
Site of action of NOACs and VKAs
Pharmacology of Direct Oral Anticoagulants
Trials for NOACs
Dose NOACs according to renal function
Laboratory monitoring of NOACs
Anticoagulant reversal of NOACs
Chlorthalidone for poorly controlled hypertension in chronic kidney diseasesShadab Ahmad
Given the central role of volume excess in the pathogenesis of hypertension in CKD, and the low cost of thiazide diuretics, there is a need to study the use of these drugs to lower BP among patients with uncontrolled hypertension and moderately advanced CKD.
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.
Mr. AMF 62 years presented with central chest pain on exertion for last 4 monthsHypertension(BP-220/120 mmHg) for last 4 years, taking 4 anti hypertensives.Diabetes for last 5 years (HbA1c-9.3%).Smoking for 8 years.Dyslipedemic for 3 years. H/o 5 times hospital admissions due to heart failure in last 3 years.ECG-Anterior wall ischemiaEF-58%During careful clinical exam- renal bruit on left side.Coronary angiogram done and revealed DVD. Renal angiogram showed significant left renal artery stenosis. Coronary angioplasty and left renal artery angioplasty done.
Mr AMF now have no chest pain on exertion after 3 months of coronary angioplasty.
Now BP is controlled (130/85 mm Hg), taking B blockers and ARB due to intolerance of ACE inhibitors.
No hospital admission during this period.
Diabetes and serum lipids are controlled.
Management of Hypertension in Diabetic Patients with Chronic Kidney Disease: ...O. E.Nyandi PhD
South Pacific Medical Education Conference Presentation byDr Osborne E Nyandiva on Conference Presentation : Management of Hypertension in Diabetic Patients with Chronic Kidney Disease: A pathologist perspective view in SAMOA and NEW ZEALAND
Diabetes is associated with markedly increased cardiovascular risk, a risk compounded with imposition of chronic kidney disease (CKD). More than 80% of people with diabetes and CKD have hypertension, and many have an obliterated nocturnal blood pressure “dip,” the normal physiological drop in blood pressure during sleep. Appropriate blood pressure measurement is the Achilles heel of hypertension management, especially in diabetic kidney disease (DKD). The prevalence of kidney disease and diabetes is increasing among the people of the Pacific with an unknown proportion having metabolic syndrome. The preponderance of those with diabetic kidney disease (DKD) will not progress to kidney failure, but rather will succumb to cardiovascular disease (CVD).
Management of Hypertension in Diabetic Patients with Chronic Kidney Disease: ...O. E.Nyandi PhD
Diabetes is associated with markedly increased cardiovascular risk, a risk compounded with imposition of chronic kidney disease (CKD). More than 80% of people with diabetes and CKD have hypertension, and many have an obliterated nocturnal blood pressure “dip,” the normal physiological drop in blood pressure during sleep. Appropriate blood pressure measurement is the Achilles heel of hypertension management, especially in diabetic kidney disease (DKD).
pulmonary hypertension with left to right shunts .pptxHaytham Ghareeb
this presentation discuss the management step by step approach style of pulmonary hypertension due to congenital heart disease and left to right shunts
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.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Title: Sense of Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
2. History
• A 60 years old male
• Diabetic on insulin
• Obese with BMI of 40
• Hypertensive with uncontrolled hypertension
• ESRD due to advanced diabetic nephropathy
3. Primary care physician
• He requested an ECG denoting only LVH
• This was confirmed by echocardiography showing LVH, grade 2 DD
and no decrease in systolic LV functions
• He decided to monitor his blood pressure via office readings once a
week 2 hours post dialysis
- Creat : 5 mg/dl
- Hb: 10 gm
- LDL: 120
- HA1c: 7.5
4. Treatment
• Ramipril 5 mg once
• Atenolol 50 mg once
• ASA 81 mg once
• Atorvastatin 10 mg once
• Patient remain uncontrolled with BP: 170/96
• His doctor added to him torsemide 40 mg
• And still the patient is uncontrolled
5. Nephrologist
• He decided that this patient needs RRT in the form of hemodialysis
• He had a MDM with the primary physician
• They decided to give the patient 2 sessions of dialysis every week
• He did not set a special protocol for this patient in dialysis sessions
6. Patient
• He had a false sensation of safety due to dialysis
• He consumed 6gm of salt per day
• He had no fluid restriction
• He achieved and inter dialysis weight gain of 5 Kg
7. The result is uncontrolled hypertension
and signs of heart failure
In your opinion What are
the fallacies done in this case?
8. Life style pitfals
• Fluid restriction
• Sodium restriction to not more than 2gm/day equivalent to 5 gm
table salt per day
• Inter dialysis Weight gain that must not exceed 0.8 kg/ day
9. Nephrologist
• dialysis should be at least three times a week
• total duration should be at least 12 hours per week
• Increase in treatment time and or frequency should be considered
in resistant hypertension
• Daily sessions if feasible helps in reducing BP
• Nocturnal session found to better control BP with less medications
• Special protocol for ultrafiltration of more fluid and usage of less
intradialytic sodium must be acquired
EBPG guideline on dialysis strategies. Nephrol Dial
Transplant 22 [Suppl 2]: ii5–ii21, 2007
10. The goal is to reach a Dry Weight
• Criteria to determining DW:
oNo marked fall in BP during dialysis.
oNo hypertension (predialysis BP at the beginning of the week <140/90
mm Hg).
oNo peripheral edema.
oNo pulmonary congestion on chest X-ray.
oCardiothoracic ratio ≤50% (≤53% in females).
11. Primary health care physician
• He did not set a life style modification program to the patient
• He did not offer him a weight reduction program to improve his blood
pressure via weight reduction
• No investigations were requested for secondary hypertension
specially Reno vascular hypertension
12. • Blood pressure monitoring :
oIts not accurate to depend on one office reading of blood pressure
oBP variation in dialysis patient is very common
oPredialysis reading over estimate mean BP by 10 mmHg
oPost dialysis reading under estimate the mean BP by 7 mmHG
oThe best way is either Ambulatory blood pressure monitoring or
home blood pressure readings
oA morning and an evening home readings are ideal to monitor blood
pressure
Primary health care physician
13. • The treatment choice :
o ACE inhibitors and ARBS are the groups of choice for patients with HD They also reduce
LV mass and reduces mortality
o Beta blockers are very important in hypertensive patients with dialysis as they tends to
improve mortality
o Calcium channel blockers specially Dyhydropiridines are
effective for overhydrated state commonly observed in HD patients although there is
scanty data about their mortality benefit
o There is no role for diuretics in treating patients with ESRD specially if they are anuric
o High intensity statin therapy must be taken into consideration in such patients with
cardiovascular risk and dyslipidemia
Primary health care physician
15. Pharmacokinetic properties of ACE Inhibitors in ESRD
T1/2(h)
normal
T1/2(h)
ESRD
Initial
dose in
HD
Maintenance
dose in HD
Removal
during HD
Captopril 2-3 20-30 12.5 q24h 25-50 q24h Yes
Enalapril 11 prolonged 2.5 q24h
or q48h
2.5-10 q24h
or q48h
Yes
Fosinopril 12 prolonged 10 q24h 10-20 q24h Yes
Lisinopril 13 54 2.5 q24h
or q48h
2.5-10 q24h
or q48h
Yes
Ramipril 11 prolonged 2.5-5q24h 2.5-10 q24h yes
Henrich W. Principles and Practice of Dialysis
16. Pharmacokinetic properties of ARB’s in ESRD
T1/2(h)
normal
T1/2(h)
ESRD
Initial dose
in HD
Maintenance
dose in HD
Removal
during HD
Candesartan 9 ? 4 q24h 8-32 q24h No
Irbesartan 11-15 11-15 75-150 q24h 150-300 q24h No
Losartan 2 4 50 q24h 50-100 q24h No
Telmisartan 24 ? 40 q24h 20-80 q24h No
Valsartan 6 ? 80 q24h 80-160 q24h No
Henrich W. Principles and Practice of Dialysis
17. Pharmacologic properties of β-blockers in chronic dialysis patients
T1/2(h)
normal
T1/2(h)
ESRD
Initial dose
in HD
Maintenance
dose in HD
Removal
during HD
Acebutolol 3.5 3.5 200 q24h 200-300 q24h yes
Atenolol 6-9 <120 25 q48h 25-50 q48h Yes
Carvedilol 4-7 4-7 5 q24h 5 q24h no
Metoprolol 3-4 3-4 50 b.i.d. 50-100 b.i.d. high
Propranolol 2-4 2-4 40 b.i.d. 40-80 b.i.d. yes
Henrich W. Principles and Practice of Dialysis
18. Blood pressure remaining above goal in spite of
concurrent use of 3 antihypertensive agents of
different classes.
Resistant Hypertension
19. Resistant Hypertension you must search for
• The use of non steroidal anti-inflammatory drugs
• Renovascular hypertension
• Increasing cysts in polysystic kidney disease
• Concomitant use of erythropoietin therapy
• Presence of sleep breathing disorders
• Compliance
20. Drugs that can be used in addition
• Transdermal clonidine at weekly intervals.
• Minoxidil, a potent vasodilator used with beta blockers
Use of transdermal clonidine in chronic hemodialysis patients. Clin Nephrol 1993;39:32-36
Use of minoxidil in the azotemic patient. J Cardiovasc Pharmacol 1980;2:173-S180
23. Anatomical Location of Renal
Sympathetic Nerves
• Arise from T10-L1
• Follow the renal artery
to the kidney
• Primarily lie within the
adventitia
The Journal of Clinical Hypertension. 14, pages 799–801,2012
Circulation. 2002;106:1974–1979
24. • appears at the end of dialysis when water removal is completed.
• Pathogenesis and therapy are not well documented.
oUltrafiltration
oHypovolemia
opre-existing hypertension
oHypercalcemia
oImprovement of hypoxia
oantihypertensives that are remove during dialysis.
Paradoxical hypertension
25. So what we did was:
• We advised the patient about life style and diet habits
• We modify the protocols of dialysis including frequency, duration and
the amount of sodium
• We offered the patient a new regime for drug therapy stressing upon
patient compliance
• We rained the patient for home readings
26. Aggressive Treatment
oValsartan 160 mg o.d
oAmlodipine 10 mg o.d
oCarvidilol 25 mg o.d
oAtorvastatin 40 mg o.d
We achieved a goal of 110/70 blood pressure
Is it an optimum goal for mortality benefit ?
27. U shape mortality relation ship
• This means that the lower BP is not the better in terms of mortality
benefits
• Among 16,959 dialysis patients in the US, low SBP (120mmHg) was
associzated with increased mortality among HD patient
• High SBP (150mmHg) was associated with increased mortality among
patients who survived at least 3 years.
Changing relationship of blood pressure with mortality
over time among hemodialysis patients. J
Am Soc Nephrol 17: 513–520, 2006
29. In conclusion
• Patient with resistant hypertension and HD needs very special care
• Volume restriction and dietary sodium reduction are of most important
• Achieving proper dry weight is very important
• The choice of drugs must be tailored upon patient
• Special care must be taken upon the effect of dialysis upon the
antihypertensive drugs
• Too low blood pressure is as harmful as too high blood pressure