Is 44-hour better than 24-hour ambulatory blood pressure monitoring in hemodialysis?

The aim of this study is to evaluate if hemodialysis (HD) patients with similar blood pressure (BP) in the whole inter-HD period could have different target organ lesions and survival if the behavior of BP differs from the first to the second day of the inter-HD period. The present study compares 44-hour ambulatory BP monitoring (ABPM) patterns in 45 HD patients. Three BP patterns emerged: group A (n = 15) had similar BPs throughout (138 +/- 11/88 +/- 12 in the first 22 h vs. 140 +/- 11/87 +/- 12 mm Hg in the second 22-hour period); group B (n = 15) had a significant systolic BP rise from the first to the second period (132 +/- 15/80 +/- 12 vs. 147 +/- 12/86 +/- 13 mm Hg, p < 0.05); group C (n = 15) had significantly higher BPs (p < 0.05) than the other 2 groups throughout the whole inter-HD period, with no significant change between the 2 halves (172 +/- 14/108 +/- 12 vs. 173 +/- 18/109 +/- 14 mm Hg). Ventricular mass and survival during the 30-month follow-up period were statistically significantly better in group A, intermediate in group B and worse in group C. The data suggest that a 44-hour ABPM is more accurate than a 24-hour one in evaluating organ lesion and prognosis in HD patients.     

Short-term administration of omega-3 fatty acids in hemodialysis patients with balanced lipid metabolism.

BACKGROUND: At present, it is discussed whether omega-3 fatty acids show anti-inflammatory, antithrombogenic, and antiatherosclerotic effects, also in patients with chronic renal failure. METHODS: In this prospective study, 11 hemodialysis (HD) patients, ages 59 +/- 17 years, who had balanced lipid metabolism and had been on HD for 53 +/- 47 months, were treated with a moderate dose of omega-3 fatty acids (1.2 g/day combined with 11.2 g/day pectin) for 12 weeks. Serum concentrations of c-reactive protein, homocysteine (Hcy), lipids, complement factors, blood gas analyses, 24-hour blood pressure, heart rate variability, electrocardiography, shunt blood flow, and recirculation, as well as peripheral oxygen saturation at the hand and foot, were measured at the start (t0w), and after 12 weeks (t12w) of therapy. Results Several assessed cardiovascular risk factors were significantly influenced. Levels of very-low-density lipoproteins (t0w, 77 +/- 26; t12w, 63 +/- 32 mg/dL; P <.05) and triglycerides (t0w, 261 +/- 157; t12w, 228 +/- 131 mg/dL; P =.068) were decreased. However, Hcy concentrations increased from 35.5 +/- 32.5 to 43.5 +/- 36.7 micromol/L ( P <.01) after 12 weeks. Anti-inflammatory and investigated clinical parameters did not significantly change during the study period. CONCLUSION: Limited positive effects on metabolic parameters were evaluated by short-term administration of omega-3 fatty acids in HD patients. Based on previous studies and on suspicion of atherosclerotic disorder in examined HD patients, we suppose that only high doses of omega-3 fatty acids given for a longer time influence inflammation and atherosclerosis.     

Blunted nocturnal blood pressure decrease and left-ventricular mass in hypertensive hemodialysis patients

Left-ventricular hypertrophy (LVH) represents a frequent complication in hemodialysis (HD) patients. Hypertension is a well-known risk factor of cardiac morbidity which is present in 2 of 3 patients: among them about 60% have a blunted nocturnal decrease of blood pressure (BP). Although some large studies on essential hypertensives have documented that non-dipper patients have a higher number of cardiac events and a higher left ventricle (LV) mass than dipper ones, conflicting results have been reported for dialysis patients. Therefore, the aim of our study was to assess differences in LV mass between dipper and non-dipper hypertensive HD patients. We studied 66 patients with 24-hour ambulatory BP monitoring performed on HD and on inter-HD day. They were classified as dipper when a decrease of at least 10% of nocturnal systolic blood pressure on the inter-HD day was present. Echocardiography and bioimpedance were performed. 29% of the patients were classified as dippers and 71% as non-dippers. The 48-hour systolic and diastolic BP were not significantly different between the two groups (SBP: dipper = 144 +/- 12.9 mm Hg, non-dipper = 149 +/- 17.8 mm Hg; DBP: dipper = 80 +/- 9.9 mm Hg, non-dipper = 81 +/- 10.6 mm Hg). LV mass index (LVMi) did not differ between the two groups (dipper = 143.1 +/- 40.7 g/m(2); non-dipper = 159.4 +/- 46.3 g/m(2)). No differences were reported between dipper and non-dipper patients regarding extracellular water distribution (ECW: 48.1 +/- 7.7 vs. 49.8 +/- 10.8%). SBP night/day ratio and 48-hour SBP were not correlated to LVMi. A strong correlation was reported between ECW% and LVMi (r = 0.53, p < 0.001). In conclusion, 2 of 3 hypertensive HD patients are non-dipper, and this condition does not seem to be associated with significant differences in 48-hour blood pressure and LV mass. Volume overload appears to be the main independent determinant of LVH in these patients.     

Prediction of hypertension in chronic hemodialysis patients.

BACKGROUND: There are no universally accepted criteria for the diagnosis of hypertension in hemodialysis (HD) patients. We sought to determine the clinical performance of predialysis and postdialysis systolic and diastolic blood pressure values (BPs) in diagnosing hypertension or assessing its control. METHODS: Seventy patients [77% African American, 46% females, mean age 59 +/- 17 (SD) years, 34% diabetics] on chronic HD underwent a single 44-hour interdialytic ambulatory blood pressure monitoring (ABPM) and concomitant recording of BP by conventional syphygmomanometer in the HD unit for two weeks. Hypertension was defined as systolic BP (SBP) > or =135 mm Hg or diastolic BP (DBP) > or =85 mm Hg on an average 44-hour ABPM. RESULTS: Average ABP was 144 +/- 22/81 +/- 11 mm Hg. Seventy-three percent of the patients had systolic hypertension; 40% had diastolic hypertension, and 24% were normotensive or had well-controlled BP. Area under the curve of receiver operating characteristic (ROC) curves exceeded 80% for all BPs, but the thresholds for best sensitivity and specificity were markedly different for predialysis and postdialysis BPs. A two-week averaged predialysis BP of > 150/85 mm Hg or a postdialysis BP of > 130/75 mm Hg had at least 80% sensitivity in diagnosing hypertension. Specificity of at least 80% was achieved if predialysis BP of > 160/90 mm Hg or postdialysis BP of > 140/80 mm Hg was used. There was poor agreement between HD unit BP and ABP values. CONCLUSIONS: HD unit BP values can be used to identify the presence or absence of hypertension, although prediction of ambulatory BPs from HD unit BP values cannot be made reliably in individual patients.     

Treatment of post-dialytic orthostatic hypotension with an inflatable abdominal band in hemodialysis patients

The purpose of this study was to ascertain whether abdominal compression with an inflatable abdominal band, a device we developed, improved post-dialytic orthostatic hypotension (OH) in hemodialysis (HD) patients. Twenty-five chronic HD patients with intractable post-dialytic OH were recruited. Post-HD changes in systolic blood pressure (DeltaSBP) in the supine and standing positions were compared in the patients, measured with or without the use of the band. The study showed DeltaSBP after HD without the band was significantly greater than that measured before HD (-36.1+/-18.2 vs -13.1+/-16.8 mm Hg; P<0.0001). DeltaSBP after HD with the band was reduced significantly in comparison to DeltaSBP after HD without the band (-19.4+/-21.2 vs -36.1+/-18.2 mm Hg; P<0.002). Use of the band did not cause an elevation in SBP in the supine position (149.0+/-29.6 vs 155.4+/-25.7 mm Hg); however, it did increase SBP upon standing (129.6+/-27.3 vs 117.2+/-22.6 mm Hg; P<0.05). Eight patients in whom an increase in SBP of 25 mm Hg or more was achieved with the band were classified as responders. Ejection fraction was significantly higher (76.4+/-11.1 vs 61.9+/-13.6%; P<0.02) and atrial natriuretic peptide concentration significantly lower (27.9+/-22.0 vs 68.9+/-47.5 pg/ml; P<0.02) in responders than in non-responders. We conclude that the abdominal band was effective for overcoming post-dialytic OH, without elevating supine SBP in some patients.     

Seasonal variations of blood pressure in hemodialysis and renal transplant recipients

Seasonal variations influence blood pressure (BP) in healthy persons. Its effects on BP in renal replacement therapy, especially after renal transplantation (RTX), have not been proven clearly. We studied 80 stable RTX and 82 hemodialysis (HD) patients for 4 years. Systolic and diastolic BP, body weight (BW), cholesterol (Chol), triglyceride (TG), fasting blood sugar (FBS), blood urea nitrogen (BUN), and creatinine (Cr) were measured monthly. Their relationship with environmental temperature and humidity changes were assessed by Pearson tests and Fourier analysis. Ambient temperature and humidity were between 2.5 degrees C to 25.4 degrees C and 68% to 31% in the winters versus summers, respectively. The mean systolic BP in HD patients was 144 +/- 18 mm Hg and 140 +/- 15 mm Hg during the winter and summer, respectively (P =.004). For the RTX recipients, it was 133 +/- 12 mm Hg in winter and 128 +/- 19 mm Hg in summer (P <.001). The decrement in diastolic BP in warmer seasons was even more significant than that in systolic BP in both HD and RTX groups. Also, BW in summer was significantly lower than winter among HD (61.1 +/- 10 kg vs 63.2 +/- 9 kg; P <.001) and RTX (64.4 +/- 8 kg vs 65.6 +/- 8.4; P <.001) groups. Serum Chol, TG, and FBS did not change significantly during summer and winter in the both groups. Among RTX recipients, BUN level was greater in summer than winter seasons (24.2 +/- 15 vs 39.4 +/- 20 mg/dL; P =.01), but serum Cr did not differ. The degree of humidity did not correlate with BP, BW, or the above biochemical markers. We conclude that BP and BW are decreased in warmer seasons in both HD and RTX patients. The changes are not accompanied by changes in biochemical markers except for BUN in RTX patients.     

Aortic and large artery compliance in end-stage renal failure

Pulse wave velocity (PWV) was measured in the aorta, right leg and arm of 90 control subjects (CS) and 92 hemodialysis patients (HD) of the same age and mean arterial pressure (MAP). Blood chemistry, including blood lipids, and echographic dimensions of the aorta, were measured in all subjects. Presence of aortic calcification was evaluated by abdominal X-ray and echography. Whereas femoral and brachial PWV were only slightly increased in HD (P less than 0.05), the aortic PWV was significantly elevated (1113 +/- 319 cm/sec) in comparison with CS (965 +/- 216 cm/sec; P = 0.0016). Aortic diameters were larger in HD, both at the root of aorta (32.7 +/- 4 vs. 28.2 +/- 2.8 mm; P less than 0.0001) and aortic bifurcation (16.9 +/- 3.1 vs. 14.6 +/- 2.2 mm; P less than 0.0001). Although the MAP was similar in HD (109.9 +/- 19.3 mm Hg) and CS (110.2 +/- 17.2 mm Hg), the pulse pressure was significantly increased in HD patients (76.6 +/- 23.7 vs. 63.9 +/- 22 mm Hg; P = 0.007). In the two populations, aortic PWV was found to increase with age (P less than 0.0001) and MAP (P less than 0.0001). The presence of aortic calcification showed only a borderline relationship with the increase in aortic PWV (P = 0.050 in CS and P = 0.069 in HD). As change in PWV is directly related to change in distensibility, and the aortic diameters were increased in HD, these results indicate that aortic wall compliance is decreased in HD, resulting in an increase in the pulsatile component of arterial pressure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Can haemodialysis-induced hypotension be predicted?

BACKGROUND: During haemodialysis (HD) ultrafiltration may affect the central blood volume to an extent that blood pressure decreases. Thoracic electrical impedance (TI) is applied to monitor the central blood volume and we evaluated if it can be used to predict HD-induced hypotension. METHODS: In 12 hypotensive prone (H) and 13 non-hypotensive prone (N) patients, blood pressure and heart rate were recorded during one dialysis session every 30 min, while TI, thoracic intracellular water (Th(ICW)) and total body impedance (TBI) were followed every 10 min. Hypotension was defined as a decrease in systolic blood pressure (SAP) >/=30 mm Hg or a SAP < 90 mm Hg. RESULTS: All 12 H patients developed hypotension after 190 +/- 10 min (mean +/- SE) as SAP decreased 35 +/- 5 mm Hg, while the 13 N patients maintained blood pressure. TBI increased in all patients and the increase was similar (60 +/- 5 and 56 +/- 6 Omega in H and N patients, respectively). In N patients TI did not change significantly for the first 2 h of HD, while it became elevated by 2.8 +/- 0.6 Omega (1.5 kHz) and 2.3 +/- 0.7 Omega (100 kHz) by the end of the dialysis. In H patients, the increase in TI took place at the onset of HD to reach higher values (by 7.0 +/- 0.5 Omega at 1.5 kHz and 5.9 +/- 0.5 Omega at 100 kHz). Th(ICW) was changed only in H patients (decreased by 7.9 +/- 2.1 Siemens (S) 10(-4), p < 0.05), while HR increased (9 +/- 2 beats/min) in 8 of 12 H patients, while it decreased in 1 patient (by 9 beats/min). CONCLUSIONS: The results suggest that in HD patients hypotension is elicited by a reduction in the central blood volume that affects heart rate and the distribution of red cells within the body. To prevent HD-induced hypotention, the ultrafiltration rate could be reduced when an increase in thoracic impedance approaches 5 Omega, or when an index of intracellular water decreases by 6 10(-4).     

Profile of interdialytic blood pressure in hemodialysis patients

BACKGROUND AND METHODS: Hypertension is a common problem in hemodialysis (HD). However, its behavior during the interdialytic period is not completely known and is infrequently monitored in clinical practice. Thus, for better understanding of interdialytic blood pressure (BP), we analyzed the interdialytic blood pressure profile using 44-hour ambulatory blood pressure monitoring (ABPM) data in 71 unselected, stable HD patients. RESULTS: There was an increase in BP during the interdialytic period (awake day 1: 135/84 +/- 23/14 mm Hg; awake day 2: 140/86 +/- 22/15 mm Hg, p < 0.05; sleep day 1: 130/77 +/- 24/15 mm Hg; sleep day 2: 136/80 +/- 24/15 mm Hg, p < 0.05). The correlation between the average 44-hour BP and interdialytic weight gain (IDWG) was not significant (r = -0.07 for systolic BP and r = -0.09 for diastolic BP). The number of non-dipper patients was high, 77% on interdialytic day 1 and 83% on interdialytic day 2 for systolic BP. Uncontrolled hypertension (average 44 h BP > or =135/85 mm Hg) was diagnosed in 58 (55%) patients. Patients with uncontrolled hypertension had higher pre- and posthemodialysis BP, higher BP on each interdialytic day and night, and higher night/day diastolic BP ratio on the second interdialytic day. These patients were also taking a greater number of vasoactive medications (1.5 vs. 0.6 in those with controlled BP, p = 0.001). There were no significant differences related to kt/V, hematocrit, or weekly erythropoietin dose between patients with controlled or uncontrolled BP. Hemodialysis shift assignment (morning or afternoon) did not impact on BP levels or diurnal profile. CONCLUSION: In HD patients, interdialytic BP is often poorly controlled, there is a progressive rise in BP, and a trend toward loss of nocturnal decline in BP as the interdialytic period progresses. Further research is needed to determine whether treatment directed to interdialytic BP changes can alter outcomes in HD patients.     

Experimental cardiac tamponade with a myocardial wound: the effect of rapid intravenous infusion of saline.

In order to demonstrate that the evolution of cardiac tamponade from a ventricular wound is different from that without myocardial wounding, the effects of a rapid infusion of saline solution on hemodynamic behavior and pericardial pressure (PP) were evaluated in dogs with cardiac tamponade caused by ventricular perforation (group C), animals without cardiac tamponade (group A), and animals with cardiac tamponade induced by infusion of saline into the pericardium (group B). We found that blood pressure (BP) increased from 107.5 +/- 15.5 mm Hg to 126 +/- 4 mm Hg in group A; increased from 64.5 +/- 17.9 mm Hg to 117.5 +/- 22.17 mm Hg in group B; and increased from 60.75 +/- 46.5 mm Hg to 76 +/- 14.4 mm Hg in group C. Central venous pressure (CVP) increased from 3.75 +/- 0.96 cm H2O to 9.5 +/- 3.3 cm H2O in group A; increased from 8 +/- 2.4 cm H2O to 16.25 +/- 3.1 cm H2O in group B; and rose from 7.75 +/- 2.6 cm H2O to 20.66 +/- 5.03 cm H2O in group C. Cardiac output (CO) increased from 3.9 +/- 1.2 L/min to 18.93 +/- 3.96 L/min in group A; increased from 1.23 +/- 0.3 L/min to 5.4 +/- 1.7 L/min in group B; and increased from 1.8 +/- 0.66 L/min to 3.53 +/- 1.31 L/min in group C.(ABSTRACT TRUNCATED AT 250 WORDS)     

The influence of increasing dialysis treatment time and reducing dry weight on blood pressure control in hemodialysis patients: a prospective study.

A good blood pressure control can be achieved with long hemodialysis sessions (dialysis center of Tassin, France). However, it is not well known whether a higher dialysis dose or a lower dry weight is responsible for this phenomenon. In a preliminary study, 21 hypertensive dialysis patients, dialyzed three times a week for 3-5 h, were randomized into three groups during a 3-month study period. In 6 patients, the dialysis treatment time was increased by 2 h, and the dry weight was gradually decreased (group 1). In 7 patients the dialysis treatment time was increased by 2 h without a change in dry weight (group 2). In 8 patients the dry weight was gradually lowered without changing the dialysis treatment time (group 3). Before and after the study, cardiac index and left ventricular mass index (echocardiography) and forearm vascular resistance (strain gauge plethysmography) were determined on a middialytic day. The blood pressure was assessed by 48-hour ambulatory monitoring. The antihypertensive medication was reduced when the postdialytic blood pressure became <130/80 mm Hg. The dry weight was reduced by 2.6 +/- 1.4 kg in group 1 and by 2.3 +/- 0.8 kg in group 3 (p < 0.05). The number of classes of antihypertensive medication was reduced from 3.3 to 1.8 in group 1 (NS), from 2.4 to 1.7 in group 2 (NS), and from 3.1 to 1.3 in group 3 (p < 0.05). The dose of the remaining antihypertensive drugs was reduced by 50% in group 1 (p < 0.05), by 32% in group 2 (NS), and by 72.2% in group 3 (p < 0.05). The interdialytic systolic blood pressure decreased significantly after increasing the dialysis time without changing the dry weight (group 2: 7 +/- 5 mm Hg; p < 0.05). The systolic blood pressure was also lower in the other patients groups: group 1: 13 +/- 26 mm Hg, group 3 : 7 +/- 16 mm Hg (NS). The pulse pressure decreased significantly in group 2 (7 +/- 5 mm Hg; p < 0.05) and in group 3 (6 +/- 7 mm Hg; p < 0.05) and tended to decrease in group 1 (11 +/- 12 mm Hg; p = 0.08). The diastolic blood pressure and the day-night blood pressure difference did not change significantly, nor did cardiac index and left ventricular mass index. The forearm vascular resistance tended to decrease in the patients on long dialysis sessions. This preliminary study suggests that the dialysis treatment time might have an independent beneficial effect on blood pressure control.     

Polymorphic genes for kinin receptors,nephropathy and blood pressure in type 2 diabetic patients

BACKGROUND/AIMS: There is evidence that hereditary predisposition contributes to the development of diabetic nephropathy and hypertension. Polymorphisms in the genes for bradykinin receptors (B(1)R and B(2)R) were found to be associated with decreased risk of the development of end-stage renal disease. This study examines whether B(1)R G(-699)C and B(2)R C(181)T polymorphisms are associated with microalbuminuria or overt nephropathy, or blood pressure variation in type 2 diabetic subjects. METHODS: B(1)R and B(2)R polymorphisms were determined in 153 type 2 diabetic patients with microalbuminuria, 132 with overt nephropathy (macroalbuminuria or chronic renal failure), and 161 patients with normoalbuminuria despite diabetes duration longer than 10 years. RESULTS: Distributions of the examined polymorphisms did not differ between patients with microalbuminuria or overt nephropathy, compared to normoalbuminuric control subjects. Patients carrying the B(2)R T allele had lower DBP, compared with non-carriers: 83.6 +/- 12.0 vs. 87.4 +/- 12.1 mm Hg, p < 0.05. Among patients not receiving ACEI, both SBP and DBP was significantly lower in B(2)R T allele carriers, compared to non-carriers (137.2 +/- 20.3 vs. 146.5 +/- 21.7 mm Hg, and 80.3 +/- 11.9 vs. 85.8 +/- 11.6 mm Hg, p < 0.05). CONCLUSIONS: Examined polymorphisms are not associated with the increased risk of incipient or overt nephropathy in type 2 diabetic patients. B(2)R C(181)T polymorphism may contribute to blood pressure variation in these subjects.     

Abnormal albuminuria and blood pressure rise in incipient diabetic nephropathy induced by exercise

The aim of the study was to evaluate the influence of light to moderate dynamic work (450 kpm/min followed by 600 kpm/min during 20 min each) on the blood pressure and renal protein handling in insulin-dependent diabetic patients with incipient nephropathy (D3) (elevated baseline albumin excretion but without clinical proteinuria). Fifteen male diabetic patients (D3) with a mean age of 26.5 +/- 4.8 years (SD) and a diabetes duration of 15.6 +/- 3.4 years (SD), 11 comparable diabetic patients with normal urinary albumin excretion (D2), and ten non-diabetic subjects (C) were studied. In D3 baseline diastolic blood pressure was elevated [92.1 mm Hg +/- 6.0 (mean +/- SD)] compared to D2 (80.9 mm Hg +/- 4.8, 2P = 0.003%) and C (79.5 mm Hg +/- 12.4, 2P = 1.2%). Baseline systolic blood pressure was not significantly different in the three groups, but systolic blood pressure was more elevated at 600 kpm/min in D3 (193.0 mm Hg +/- 23.0) compared to D2 (170.5 +/- 17.3, 2P = 1.2%) and C (157.5 mm Hg +/- 20.9, 2P = 0.07%). Baseline albumin excretion in D3 was 82.6 micrograms/min X/ divided by 2.5 (geometric mean X/ divided by tolerance factor) and during exercise the maximal albumin excretion rose to 195.0 micrograms/min X/ divided by 2.6 (2P = 0.01%). In D2 albumin excretion rose from 3.3 micrograms/min X/ divided by 1.9 to 7.9 micrograms/min X/ divided by 1.5 (2P = 0.02%). The albumin excretion in C did not change during exercise. A highly significant correlation between maximal exercise induced systolic blood pressure and maximal exercise induced albumin excretion was demonstrable in D3.(ABSTRACT TRUNCATED AT 250 WORDS)     

Leukopenia and thrombocytopenia in hemodialysis patients with hepatitis B or C virus infection and non-hemodialysis patients with hepatitis cirrhosis

AIMS: To investigate the relation of leukopenia and thrombocytopenia in hemodialysis (HD) patients with hepatitis C virus (HCV) infection. MATERIALS AND METHODS: The study included 86 HD patients with hepatitis B surface antigen-negative and hepatitis C antibody-negative, 28 HD patients with hepatitis C antibody-positive, 22 HD patients with hepatitis B surface antigen-positive, 78 non-HD patients with hepatitis B-induced liver cirrhosis and 38 non-hemodialysis patients with hepatitis C-induced liver cirrhosis. The following parameters were checked: anti-HCV, hepatitis B surface antigen, hemoglobin, hematocrit, white blood cells, platelets, calcium, phosphate, iron, ferritin, albumin, globulin, aspartate transaminase (AST), alanine transaminase (ALT) and C-reactive protein. The history of blood transfusions, medications, erythropoietin doses and adequate dialysis (KTNV) for 6 consecutive months was also recorded from charts. RESULTS: The HD patients with positive serum anti-HCV and non-HD patients with hepatitis B- or C-induced liver cirrhosis had higher prevalences of leukopenia (39.3%, 43.6% and 50% vs. 15.1%; p < 0.001) and thrombocytopenia (67.9%, 89.7% and 81.6% vs. 34.9%: p < 0.001) than HD patients with serum anti-HCV(-)HbsAg(-). The WBC (4,432 +/- 1,394, 4,792 +/- 2,263 and 4,624 2,446 vs. 5,590 +/- 1,500/mm3; p < 0.001) and platelet counts (140 +/- 45, 80 +/- 50 and 89 +/- 65 vs. 186 +/- 62 x 10(3)/mm3; p < 0.001) of HD patients with positive serum anti-HCV and non-HD patients with hepatitis B- or C-induced cirrhosis were also lower than HD patients without anti-HCV antibody. The liver cirrhosis patients had more thrombocytopenia than the HD patients with anti-HCV(+). The WBC and platelet counts did not vary between HD patients with HbsAg(+) and HD patients with anti-HCV(-)HBsAg(-). The durations of HD, hepatitis and liver cirrhosis were not related to the leukopenia or thrombocytopenia (p > 0.05). CONCLUSIONS: HCV infection associated with leukopenia and/or thrombocytopenia in HD patients is as common as in non-HD patients with liver cirrhosis. This may be due to the direct effect of hemopoiesis rather than the hyperspleenism of liver cirrhosis patients. There is a need for further prospective investigation to ascertain the clinical significance of leukopenia and thrombocytopenia in HD patients with anti-HCV(+). The prevalence of leukopenia and thrombocytopenia was higher in HD patients with hepatitis C than in HD patients with hepatitis B and HD patient without hepatitis.     

Improvement of Intradialytic Hypotension in Diabetic Hemodialysis Patients Using Vitamin E‐Bonded Polysulfone Membrane Dialyzers

Currently, there are no detailed reports on the effects of vitamin E‐bonded polysulfone (PS) membrane dialyzers on intradialytic hypotension (IDH) in diabetic hemodialysis (HD) patients. This study was designed to evaluate changes in intradialytic systolic blood pressure (SBP) using “VPS‐HA” vitamin E‐bonded super high‐flux PS membrane dialyzers. The subjects were 62 diabetic HD patients whose intradialytic SBP fell by more than 20%. Group A comprised patients who required vasopressors to be able to continue treatment or who had to discontinue therapy due to their lowest intradialytic SBP being observed at 210 min (28 patients). Group B comprised patients who showed no symptoms and required no vasopressors but showed a gradual reduction in blood pressure, with the lowest intradialytic SBP seen at the end of dialysis (34 patients). The primary outcome was defined as the lowest intradialytic SBP after 3 months using VPS‐HA. Secondary outcomes included changes in the following: lowest intradialytic diastolic blood pressure, pulse pressure, pulse rate, plasma nitric oxide and peroxynitrite, serum albumin, and hemoglobin A1c. Group A's lowest intradialytic SBP had significantly improved at 3 months (128.0 ± 25.1 mm Hg vs. 117.1 ± 29.2 mm Hg; P = 0.017). Group B's lowest intradialytic SBP had significantly improved at 1 month (134.4 ± 13.2 mm Hg vs. 121.5 ± 25.8 mm Hg; P = 0.047) and 3 months (139.1 ± 20.9 mm Hg vs. 121.5 ± 25.8 mm Hg; P = 0.011). We conclude that VPS‐HA may improve IDH in diabetic HD patients.     

Impact of volume control on left ventricular hypertrophy in dialysis patients

BACKGROUND: Left ventricular hypertrophy (LVH), which strongly predicts cardiac mortality, is seen in more than 60% of end-stage renal disease patients. The aim of this study was to prospectively investigate the effect of salt restriction and strict volume control on blood pressure and LVH. METHOD: Nineteen hypertensive patients on chronic hemodialysis (HD) treatment (age 52 +/- 17 years, 7 women) were included in the study. Treatment consisted of 12-h HD per week, during which as much ultrafiltration (UF) was applied as possible without an excessive blood pressure (BP) drop. Special attention was given to dietary salt restriction. Predialysis mean BP (MBP), body weight (BW), cardio-thoracic index (CTI) and echocardiographic results were recorded at baseline and after 6 and 12 months. RESULTS: All patients reached acceptable BP (< 140/90 mmHg) within three months (10-75 days) with our strict volume control strategy. Mean pre-dialysis BP was 127 +/- 17/78 +/- 9 mm Hg at baseline, 120 +/- 9/75 +/- 6 mm Hg at the 6th month and 118 +/- 11/73 +/- 5 mm Hgat the 12th month. The incidence of symptomatic hypotension gradually decreased from a mean of 22% to 11% and 7%, respectively during follow-up. Left ventricular mass index decreased from 164 +/- 64 to 112 +/- 36 g/m2. CTI, left atrial, left ventricular systolic and diastolic diameters significantly decreased in all patients. Inter-dialytic weight gain was 930 +/- 70 g/day in the follow-up period. Hematocrit did not significantly differ at the first, second and last visits. CONCLUSION: Normal BP and improvement of cardiac structure, in particular a reduction of LVH could be reached in all our patients by intensifying salt restriction and UF.     

Effects of PEEP on the intracranial system of patients with head injury and subarachnoid hemorrhage: the role of respiratory system compliance

BACKGROUND: Positive end-expiratory pressure (PEEP) can be effective in improving oxygenation, but it may worsen or induce intracranial hypertension. The authors hypothesized that the intracranial effects of PEEP could be related to the changes in respiratory system compliance (Crs). METHODS: A prospective study investigated 21 comatose patients with severe head injury or subarachnoid hemorrhage receiving intracranial pressure (ICP) monitoring who required mechanical ventilation and PEEP. The 13 patients with normal Crs were analyzed as group A and the 8 patients with low Crs as group B. During the study, 0, 5, 8, and 12 cm H2O of PEEP were applied in a random sequence. Jugular pressure, central venous pressure (CVP), cerebral perfusion pressure (CPP), intracranial pressure (ICP), cerebral compliance, mean velocity of the middle cerebral arteries, and jugular oxygen saturation were evaluated simultaneously. RESULTS: In the group A patients, the PEEP increase from 0 to 12 cm H2O significantly increased CVP (from 10.6 +/- 3.3 to 13.8 +/- 3.3 mm Hg; p < 0.001) and jugular pressure (from 16.6 +/- 3.1 to 18.8 +/- 3.2 mm Hg; p < 0.001), but reduced mean arterial pressure (from 96.3 +/- 6.7 to 91.3 +/- 6.5 mm Hg; p < 0.01), CPP (from 82.2 +/- 6.9 to 77.0 +/- 6.2 mm Hg; p < 0.01), and mean velocity of the middle cerebral arteries (from 73.1 +/- 27.9 to 67.4 +/- 27.1 cm/sec; F = 7.15; p < 0.001). No significant variation in these parameters was observed in group B patients. After the PEEP increase, ICP and cerebral compliance did not change in either group. Although jugular oxygen saturation decreased slightly, it in no case dropped below 50%. CONCLUSIONS: In patients with low Crs, PEEP has no significant effect on cerebral and systemic hemodynamics. Monitoring of Crs may be useful for avoiding deleterious effects of PEEP on the intracranial system of patients with normal Crs.     

Modified reperfusate after long-term preservation of the heart

Warm (30 degrees C) blood cardioplegia (K = 22 mEq/L) with glutamate (26 mmol/L) as a reperfusate was compared with unmodified blood reperfusion after prolonged hypothermic storage of the isolated canine heart. After cardioplegic arrest, three groups of hearts (n = 5 each) were excised and stored at 2 degrees C. In groups 1 and 2, reperfusion with unmodified blood was undertaken after six and 24 hours of storage, respectively, and in group 3, reperfusion with modified warm blood cardioplegia containing glutamate was administered after 24 hours of storage. After reperfusion, no significant difference in left ventricular developed pressure was noted between groups 1 (110 +/- 15 mm Hg), 2 (127 +/- 14 mm Hg), and 3 (98 +/- 13 mm Hg). Similarly, no difference in maximum rate of rise of left ventricular pressure was noted between groups 1 (1,456 +/- 171 mm Hg/s), 2 (1,905 +/- 395 mm Hg/s), and 3 (1,450 +/- 291 mm Hg/s). Group 3 (modified reperfusate) had improved diastolic compliance compared with group 2 (0.776 mm Hg/mL versus 1.395 mm Hg/mL; p less than 0.02). We conclude that our modified reperfusate improves diastolic function after 24 hours of hypothermic storage, but does not result in improved systolic function.     

Arterial pulse pressure and its association with reduced stroke volume during progressive central hypovolemia

BACKGROUND: The reduction of stroke volume (SV) during hemorrhage reflects the degree of blood loss, but accurate assessment of SV in bleeding patients in the field currently is not possible. In a previous pilot study, we reported that arterial pulse pressure and estimated sympathetic nerve activity (SNA) in trauma patients who died of hemorrhagic injuries was significantly lower than that observed in patients who did not die. For the current study, we measured mean arterial blood pressure (MAP), pulse pressure (PP), SV, and muscle sympathetic nerve activity (MSNA) in human subjects during progressive lower body negative pressure (LBNP) to test the hypothesis that a reduction in PP tracks the reduction of SV and change in MSNA during graded central hypovolemia in humans. METHODS: After a 12-minute baseline data collection period, 13 men were exposed to LBNP at -15 mm Hg for 12 minutes followed by continuous stepwise increments to -30, -45, and -60 mm Hg for 12 minutes each. RESULTS: Comparing baseline to -60 mm Hg chamber decompression, systolic blood pressure (SBP) decreased (from 129 +/- 3.0 to 111 +/- 6.1 mm Hg; p = 0.005) and diastolic pressure was unchanged (78 +/- 3.0 versus 81 +/- 4.0 mm Hg; p = 0.55). Pulse pressure decreased (from 50 +/- 2.5 to 29 +/- 4.0 mm Hg; p = 0.0001). LBNP caused linear reductions in PP and SV (from 125 +/- 9.2 to 47 +/- 6.4; r2 = 0.99), and increases in MSNA (from 14 +/- 3.5 to 36 +/- 4.6 bursts/min; r2 = 0.96) without a significant change in MAP (r2 = 0.28). PP was inversely correlated with MSNA (r2 = 0.88) and positively correlated with SV (r2 = 0.91). CONCLUSIONS: Reduced PP resulting from progressive central hypovolemia is a marker of reductions in SV and elevations in SNA. Therefore, when SBP is >90 mm Hg, PP may allow for early, noninvasive identification of volume loss because of hemorrhage and more accurate and timely triage.