Hypertension,fluid overload and micro inflammation are associated with left ventricular hypertrophy in maintenance hemodialysis patients

Abstract

This cross-sectional study aims to identify the potential risk factors of left ventricular hypertrophy (LVH) in hemodialysis (HD) patients. Echocardiography, anthropometric measurements and biochemical analyses were performed for 112 HD patients. In univariate analysis, body mass index, systolic blood pressure, diastolic blood pressure, glycosylated hemoglobin, glycated albumin, high sensitivity C-reactive protein (hs-CRP), cardiac troponin T (cTnT), amino-terminal pro-B-natriuretic peptide (NT-proBNP) and carotid artery intima-media thickness were positively correlated with left ventricular mass index (LVMI); pre-albumin, serum creatinine, left ventricular ejection fraction (LVEF) and fractional shortening were negatively correlated with LVMI. Linear regression analysis showed systolic blood pressure, NT-proBNP and LVEF were independently associated with LVMI. According to a binary logistic regression model, higher systolic blood pressure, NT-proBNP and hs-CRP levels showed independent correlation with LVH. Receiver operator characteristic curves analysis showed the associations between NT-proBNP and LVH more closely than hs-CRP and cTnT. The area under the curve for NT-proBNP, hs-CRP and cTnT was 0.762 (95% CI: 0.660–0.864, p?<?0.001), 0.734 (95% CI: 0.624–0.844, p?<?0.001) and 0.677 (95% CI: 0.563–0.790, p?=?0.004), respectively. These data support the main conclusions: hypertension, fluid overload and micro inflammation are associated with LVH in maintenance HD patients. It demonstrates traditional and nontraditional risk factors all play important roles in the development of LVH.     

Nitric oxide in blood pressure regulation, with special reference to patients undergoing hemodialysis

Recently, numerous studies have shown that nitric oxide plays several crucial roles in the regulation of blood pressure. Although nitric oxide produced by endothelial nitrix oxide synthase is thought to be most important for fine adjustments of blood pressure, other sources of nitrix oxide, such as neuronal and inducible types of nitrix oxide synthases, may also participate directly or indirectly in certain forms of hypertensive and hypotensive disorders. In this review. I discuss the possible roles of nitric oxide in the regulation of blood pressure in patients with impaired renal function, especially those undergoing chronic hemodialysis. I also mention the possible roles of nitric oxide in the pathogenesis of hypertension induced by erythropoietin in patients with end-stage renal diseases.     

血液透析患者左心室肥厚相关因素分析

目的探讨血液透析患者左心室肥厚(LVH)发生情况及相关危险因素。 方法横断面调查选取江苏大学附属医院血液净化中心维持性血液透析(MHD)患者84例,采集一般情况、生化指标和同期心脏彩色多普勒超声检查结果,按左室心肌质量指数(LVMI)分为左室肥厚组(n＝50)和左室正常组(n＝34),比较两组相关指标的差异。应用Spearman秩相关和多元线性回归分析评价影响左室肥厚的危险因素。 结果左室肥厚组尿素清除指数(Kt/V)、血红蛋白、透析龄均低于正常组,收缩压高于左室正常组,差异有统计学意义(P<0.05)。Spearman秩相关提示LVMI与尿素清除指数(Kt /V)呈负相关(r＝－0.342,P<0.05),与超滤量、收缩压呈正相关(r ＝0.291、0.256,P<0.05)。多元线性回归分析提示Kt /V、收缩压、超滤量与血液透析患者左室肥厚相关(P<0.05)。 结论Kt /V是左室肥厚的保护因素,高收缩压、高超滤量是透析患者左室肥厚的独立危险因素。提高透析充分性,控制收缩压及透析间期入液量可能利于减少左室肥厚的发生。     

Analysis of synovial fluid components of hydrarthrosis in long-term hemodialysis patients

The synovial fluid components in long-term hemodialysis patients (HD; 43 knees in 43 patients) were investigated and compared with those in patients with osteoarthritis (OA; 21 knees in 21 patients) and rheumatoid arthritis (RA; 26 knees in 26 patients). The average ages in the three groups were, respectively, 60.7 years (range, 34–79 years), 63.2 years (range, 48–88 years), and 59.7 years (range, 37–76 years). The duration of hemodialysis in the HD group averaged 14.0 years (range, 4–24 years). The concentrations of hyaluronic acid, protein, and isomers of chondroitin sulfate (chondroitin 6-sulfate [C6S] and chondroitin 4-sulfate [C4S]) in the synovial fluid, and its viscosity were measured. Differences in each of the parameters were investigated according to disease clinical stage, roentgenological grade, and periods of dialysis in the HD group. The viscosity of the synovial fluid and the concentration of hyaluronic acid in HD patients were similar to those in OA patients; however, the C6S/C4S ratio in the synovial fluid of HD patients was similar to that in RA patients. The latter finding suggests that synovitis may be present in the hydrarthrosis of HD patients. The cause of this synovitis in HD patients remains to be elucidated. Received for publication Feb. 19, 1998; accepted on July 29, 1998     

Body mass index for chronic hemodialysis patients: Stable hemodialysis and mortality

Body mass index (BMI) is used as a reference for weight control programs in the general population and in morbidity and mortality studies in diabetes patients. However, the implications of BMI in chronic hemodialysis patients is unclear. We studied the BMI of chronic hemodialysis patients, focusing on problems encountered during outpatient hemodialysis therapy and on 2-year mortality. Outpatients with chronic hemodialysis (n = 258; 144 men, 114 women) were divided into four groups: (i) patients with stable hemodialysis; (ii) patients with marked hypotension requiring catecholamine infusion during hemodialysis; (iii) patients with excessive interdialysis weight gain requiring occasional additional hemodialysis; and (iv) patients with troublesome hemodialysis due to other causes. The statistical differences between the average BMI among these groups were evaluated, and were subdivided into sex, age and the duration of hemodialysis history. The 2-year mortality rates of these patients were also studied according to their BMI. In patients under 60 years of age, those with excessive interdialysis weight gain had statistically larger BMI (23.2; n = 35) compared to patients with good hemodialysis control (20.1; n = 178), regardless of gender and hemodialysis history. The mortality rate was at a minimum at approximately 20 BMI in patients under 60 years of age. However, lower BMI was associated with a greater mortality rate in patients 60 years or over. For chronic hemodialysis patients, the BMI associated with stable hemodialysis and minimum mortality is approximately 20, in those under 60 years of age. The BMI of aged hemodialysis patients should be considered separately in morbidity and mortality studies.     

Correlation between hypervolemia,left ventricular hypertrophy and fibroblast growth factor 23 in hemodialysis patients

Abstract

Introduction: Left ventricular hypertrophy (LVH) is a significant risk factor for cardiovascular complications in hemodialysis (HD) patients. Hypervolemia has been accepted as an independent risk factor for progressive LVH in HD patients. Additionally, high FGF23 levels have been a significant predictor of cardiovascular mortality and morbidity in chronic kidney disease and HD patients. The aim of our study is to investigate the correlation among LVH, interdialytic volume increase and FGF-23 in the patients on a chronic hemodialysis program. Design and methods: A total of 97 chronic hemodialysis patients (64.43?±?11.28 years old, M/F:47/50) were included in the study. Human FGF-23 ELISA kit was used for FGF-23 analysis of predialysis blood samples. Echocardiographic evaluation was performed in all of the patients after dialysis. Left Ventricular Mass Index (LVMI) was calculated by using the Devereux Formula. We collected the following data: LVMI, FGF-23 levels, interdialytic fluid gain, blood pressure changes, and the other biochemical and clinical parameters. Results: Mean LVMI of the patients was 184.41?±?48.62?g/m². LVMI of the patients with daily urine output >250?mL was found significantly lower. Statistically significant positive correlation was found between predialysis systolic blood pressure, predialysis diastolic blood pressure, predialysis mean arterial blood pressure and LVMI measurements (p?<?0.01). Mean interdialytic volume excess was correlated with LVMI measurements of the patients (r?=?0.459; p?<?0.01). Increased FGF-23 levels (159.79?±?134.99?ng/L) predicted increased LVMI measurements of the patients (r?=?0.322; p?<?0.01). In addition, FGF-23 levels were also increased as the interdialytic fluid volume increased (r?=?0.326; p?<?0.05). A positive correlation was also found between FGF-23 levels and interventricular septum thickness (r?=?0.238; p?<?0.05). Predialysis mean arterial blood pressure, predialysis volume overload and presence of diabetes were determined to be independent risk factors on LVMI on multivariate regression analysis. Conclusion: Our study showed that interdialytic volume overload increased both LVMI and FGF-23 values. We can consider that interdialytic volume control exerts positive effects on increased FGF-23 levels which predict the negative cardiovascular outcomes.     

Nephrogenic adenoma of the bladder in a chronic hemodialysis patient

BACKGROUND: Nephrogenic adenoma is an uncommon, benign metaplastic lesion occurring in the urothelium, usually as a response to chronic irritation or trauma. It is rarely encountered in hemodialysis patients. Endoscopically, these lesions can easily be mistaken for malignant tumors. METHODS/RESULTS: We report on a case of nephrogenic adenoma of the bladder in a chronic hemodialysis patient that was large and mistakenly diagnosed as transitional cell carcinoma in the initial biopsy. Histopathological examination of the total cystectomy specimen demonstrated the correct diagnosis of nephrogenic adenoma. CONCLUSION: Increased awareness by urologists and pathologists of nephrogenic adenoma may lead to its more accurate diagnosis.     

459例维持性血液透析患者骨密度相关因素的研究

目的探讨维持性血液透析(maintenance hemodialysis,MHD)患者跟骨骨密度(bone mineral density,BMD)与透析相关的临床因素及骨代谢、生化指标之间的关系。方法选取2014年6月至2015年2月大连市中心医院MHD患者459例。记录MHD患者性别、年龄、原发病、透析时间、透析治疗方式、使用肝素类型、心血管疾病、主动脉钙化情况。同期检测患者治疗前血钙、血磷、碱性磷酸酶(alkaline phosphatase,ALP)、甲状旁腺素(parathyroid hormone,PTH)、血白蛋白(albumin,Alb)、血红蛋白(hemoglobin,Hb)、碳酸氢根(HCO_3~(2-))水平,计算尿素清除指数(Kt/V)情况。使用美国Sahara超声骨密度仪进行跟骨BMD测量。结果低通量透析患者较高通量透析患者BMD降低(P0.05),有主动脉钙化患者较无主动脉钙化患者BMD降低(P0.01);不同透析时间之间、糖尿病与非糖尿病之间BMD无明显差异。低分子肝素组与普通肝素组BMD比较无明显统计学差异。心血管疾病组与无心血管疾病组之间BMD无统计学差异。血磷及A1b水平与BMD呈正相关(r=0.136,P0.01;r=0.148,P0.01)。女性、年龄≥60岁、低通量透析、有主动脉钙化的患者更易发生骨质疏松,Logistic回归分析显示年龄≥60岁(OR=0.92,95%CI 0.892-0.949)、女性(OR=0.376,95%CI 0.203-0.697)、主动脉钙化(OR=0.01,95%CI:0.000-0.213)是MHD患者骨质疏松的独立危险因素。结论透析治疗方式、血管钙化可能是影响骨密度的因素,血磷和白蛋白水平在骨的生物学功能和骨的矿化过程可能发挥了重要的作用;高龄、女性、主动脉钙化可能是MHD患者骨质疏松的独立危险因素。     

Staphylococcus aureus bacteremia in patients on chronic hemodialysis

Staphylococcus aureus bacteremia occurred 96 times in 58 of 671 patients on chronic hemodialysis during a nine-year period. Seventy-one instances of bacteremia originated in the vascular access site and resulted in the loss of the access device in 45 episodes. The overall mortality was 8%, and the incidence of infective endocarditis was 4%. Death occurred more often when bacteremia arose from an identifiable site other than the vascular access device (P less than .02). Patients who developed one or more metastatic foci of infection had a higher incidence of primary treatment failure (P less than .001) and a higher mortality (P less than .001) than did those with no metastatic infection. Although meaningful comparisons of differing antibiotic regimens could not be made, patients receiving antibiotic therapy for 28 days or longer relapsed less frequently (P less than .05). These data suggest that chronic hemodialysis patients with S aureus bacteremia have a relatively low mortality and a low risk of infective endocarditis. Antibiotic treatment, however, should be given for at least 28 days in order to minimize the risk of relapse.     

维持性血液透析患者心血管钙化的发生率及相关因素

目的 探讨维持性血液透析患者心血管钙化的发生率及相关因素.方法 选择接受维持性血液透析≥3月的非住院患者60例,完善相关实验室检查,腹部侧位X线片检测腹主动脉钙化评分(Kauppila法),心脏超声检测心脏瓣膜钙化情况,并计算心血管钙化指数.结果 本组患者影像学检查可见钙化的总发生率为68.3％,腹主动脉钙化的患者中5≤腹主动脉钙化评分＜ 16者占41.4％,瓣膜钙化以主动脉瓣为主(占64.5％).有钙化组与无钙化组患者的年龄、血钙、心血管钙化指数存在差异(均P ＜0.05),而透析龄(月)、身高、体质量、握力、血磷、血红蛋白、血清总蛋白、血清白蛋白、血脂未见差异(均P≥0.05).结论 本组患者心血管钙化部位不均衡,随患者年龄和血钙水平的增加,心血管钙化的发生风险升高.     

Fluid volumes determination by impedance spectroscopy and hematocrit monitoring: application to pediatric hemodialysis

A method for extracting fluid volumes from multifrequency bioimpedance, which takes into account the body geometry and the presence of nonconducting elements, was tested on 12 young dialyzed patients against correlations for total body water volumes (TBW) from Watson et al. and Humes et al. Our calculations of TBW from impedance were found to overestimate Humes' values by 0.25 L (0.8%) postdialysis and by 2.08 L (6.5%) predialysis. Extracellular water (ECW) was found to contribute an average of 93% of ultrafiltered volume. Intracellular water volume (ICW) determination from impedance was found to be too imprecise to predict its variation during dialysis; therefore, ICW variations were calculated as the difference between ultrafiltration and ECW changes. The continuous recording of hematocrit by an optical device monitored changes in plasma and interstitial volumes. In most cases, ultrafiltration was compensated mainly by a contribution from interstitial fluid, and the drop in plasma volume was generally moderate.     

Drugs acting on the heart: antihypertensive drugs

Antihypertensive drugs are used commonly in anaesthesia and intensive care medicine. Patients might require antihypertensive drugs before surgery for the treatment of essential hypertension, pre-eclampsia or, occasionally for conditions such as phaeochromocytoma; during surgery as part of a deliberate hypotensive anaesthetic technique; or to reduce postoperative cardiovascular complications. Here, we discuss the physiology of blood pressure control, the pharmacology of antihypertensive drugs, current guidelines, and practical applications of antihypertensive therapy.     

Clinical outcomes for maintenance hemodialysis patients using a high-flux (FX60) dialyzer

Abstract

Aims: To investigate the clinical outcomes of maintenance hemodialysis (HD) patients using a high-flux (FX60) dialyzer. Method: Thirty patients undergoing dialysis for at least 2 years with a low-flux dialyzer were switched to the FX60 dialyzer for 3 years. Clinical and biochemical analysis was performed monthly for each patient. The parameters monitored included blood pressure, hemoglobin, albumin, intact parathyroid hormone (iPTH), calcium and phosphorus levels, the adequacy of dialysis (Kt/V), beta2-microglobulin (β2-MG) clearance rate, as well as antihypertensive and erythropoietin (EPO) medications. Results: After 3 years of dialysis with an FX60 dialyzer, the mean arterial blood pressure fell, hemoglobin increased, serum phosphate level decreased, iPTH declined and medication doses decreased. Conclusions: Dialysis with the FX60 dialyzer has a better clinical outcome for rectifying renal anemia, controlling hypertension and lowering serum phosphate levels making it a better choice for long-term HD patients.     

Factors affecting outcome of intracerebral hemorrhage in patients undergoing chronic hemodialysis

To date, despite a markedly high incidence of intracerebral hemorrhage (ICH) in patients with end-stage renal disease, only few studies have focused on factors that affect patient's prognosis. To elucidate these factors, we retrospectively investigated 22 consecutive patients who had chronic renal failure, were maintained by hemodialysis (HD), had suffered from ICH, and were hospitalized and treated in our institute from 2006 to 2008. Hematoma volume, blood pressure on admission, blood pressure 3 days after ICH onset, and neurological deterioration significantly affected patient mortality. Progression of neurological symptoms during HD was observed often in patients with hematoma of more than 60 mL or in patients with pontine hemorrhages. Age, gender, duration of HD, anti-platelet or anticoagulant therapies, or maximal dose of nicardipine did not affect patient's prognosis. Based on this study we conclude that controlling blood pressure on admission and within 3 days after onset of ICH may be the most important factor that would improve patient's prognosis. Further, special care might be required for patients with large hematomas (more than 60 mL) or those with brainstem hemorrhages, because progression of neurological symptoms occurs often in such patients.     

Automated individualization of dialysate sodium concentration reduces intradialytic plasma sodium changes in hemodialysis

In standard care, hemodialysis patients are often treated with a center‐specific fixed dialysate sodium concentration, potentially resulting in diffusive sodium changes for patients with plasma sodium concentrations below or above this level. While diffusive sodium load may be associated with thirst and higher interdialytic weight gain, excessive diffusive sodium removal may cause intradialytic symptoms. In contrast, the new hemodialysis machine option “Na control” provides automated individualization of dialysate sodium during treatment with the aim to reduce such intradialytic sodium changes without the need to determine the plasma sodium concentration. This proof‐of‐principle study on sodium control was designed as a monocentric randomized controlled crossover trial: 32 patients with residual diuresis of ≤1000 mL/day were enrolled to be treated by high‐volume post‐dilution hemodiafiltration (HDF) for 2 weeks each with “Na control” (individually and automatically adjusted dialysate sodium concentration) versus “standard fixed Na” (fixed dialysate sodium 138 mmol/L), in randomized order. Pre‐ and post‐dialytic plasma sodium concentrations were determined at bedside by direct potentiometry. The study hypothesis consisted of 2 components: the mean plasma sodium change between the start and end of the treatment being within ±1.0 mmol/L for sodium‐controlled treatments, and a lower variability of the plasma sodium changes for “Na control” than for “standard fixed Na” treatments. Three hundred seventy‐two treatments of 31 adult chronic hemodialysis patients (intention‐to‐treat population) were analyzed. The estimate for the mean plasma sodium change was ?0.53 mmol/L (95% confidence interval: [?1.04; ?0.02] mmol/L) for “Na control” treatments and ?0.95 mmol/L (95% CI: [?1.76; ?0.15] mmol/L) for “standard fixed Na” treatments. The standard deviation of the plasma sodium changes was 1.39 mmol/L for “Na control” versus 2.19 mmol/L for “standard fixed Na” treatments (P = 0.0004). Whereas the 95% CI for the estimate for the mean plasma sodium change during “Na control” treatments marginally overlapped the lower border of the predefined margin ±1.0 mmol/L, the variability of intradialytic plasma sodium changes was lower during “Na control” versus “standard fixed Na” treatments. Thus, automated dialysate sodium individualization by “Na control” approaches isonatremic dialysis in the clinical setting.     

Intradialytic hypotension is associated with dialytic age in patients on chronic hemodialysis

Abstract

Objective: Intradialytic hypotension (IDH) is common in patients on chronic hemodialysis, but knowledge on determinants is still unclear. The present study aims at evaluating the association between IDH and dialytic age (DA) in patients on chronic hemodialysis. Methods: Between January 2012 and January 2013, 82 patients on chronic hemodialysis for at least 1?year were screened for inclusion in the present study. Of these, 14 were excluded because of advanced heart failure (n.9), history of alcohol/substance abuse (n.1), diagnosis of dementia (n.2), actual instability of clinical conditions requiring hospitalization (n.2). IDH was defined as a decrease in systolic blood pressure ≥20?mmHg or a decrease in mean arterial pressure (MAP) by 10?mmHg associated with clinical events and need for nursing interventions. The number of IDH episodes in 10 consecutive hemodialysis sessions was recorded for each patient. Linear and logistic regressions were adopted to assess the adjusted association between IDH and DA. Results: The mean DA was 92?±?81. Eleven patients (16%) experienced IDH. DA was associated with IDH (OR?=?1.01; 95% CI?=?1.01–1.02; p?=?0.048), after adjusting for potential confounders. DA was associated with the numbers of IDH events in the unadjusted model (B?=?0.02; 95% CI?=?0.01–0.03; p?=?0.042), after adjusting for age and sex (B?=?0.01; 95% CI?=?0.01–0.03; p?=?0.042) as well as in the multivariable model (B?=?0.02; 95% CI?=?0.01–0.05; p?=?0.045). Conclusion: DA is associated with an increased probability of IDH and with increased number of IHD events. Studies are needed to understand the underlying factors of such an association.     

维持性血液透析患者容量管理的最佳证据总结

目的检索、评价并整合维持性血液透析患者容量管理的最佳证据,为完善维持性血液透析患者容量管理提供参考。方法系统检索循证资源及文献数据库、专业协会网站中有关维持性血液透析患者容量管理的证据,包括临床决策、指南、证据总结、最佳临床实践信息册、推荐实践、专家共识及系统评价。结果共纳入文献12篇,包括临床决策2篇、指南6篇、专家共识1篇、证据总结2篇、系统评价1篇,从评估与监测、钠水限制、容量超负荷处理、提高患者依从性4个方面汇总14条证据。结论医护人员可结合所在机构环境与患者意愿,选择性应用证据,为患者制定个性化容量管理方案,从而提高护理质量。