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Prior studies have shown that among patients with chronic kidney disease not yet on dialysis, the faster progression of kidney injury in men than in women is, at least partly, explained by sex differences in ambulatory blood pressure (BP) control. The present study aimed to investigate potential differences in the levels of ambulatory BP and intensity of antihypertensive treatment between men and women with end-stage kidney disease undergoing long-term peritoneal dialysis (PD). In a case-control design, 48 male PD patients were matched for age and heart failure status with 48 female patients in a 1:1 ratio. Ambulatory BP monitoring was performed with an oscillometric device, the Mobil-O-Graph (IEM, Stolberg, Germany). The BP-lowering medications actually taken by the patients were prospectively recorded. No gender-related differences were observed in 24 h systolic BP (129.0 ± 17.9 vs. 128.5 ± 17.6 mmHg, p = 0.890). In contrast, 24 h diastolic BP was higher in men than in women (81.5 ± 12.1 vs. 76.8 ± 10.3 mmHg, p = 0.042). As compared with women, men were being treated with a higher average number of antihypertensive medications daily (2.4 ± 1.1 vs. 1.9 ± 1.1, p = 0.019) and were more commonly receiving calcium-channel-blockers (70.8% vs. 43.8%, p = 0.007) and ß-blockers (85.4% vs. 66.7%, p = 0.031). In conclusion, the present study shows that among PD patients, the levels of ambulatory BP and intensity of antihypertensive treatment are higher in men than in women. Longitudinal studies are needed to explore whether these gender-related differences in the severity of hypertension are associated with worse cardiovascular outcomes for male patients undergoing PD.
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PURPOSE OF REVIEW: Acute heart failure (AHF) is among the leading causes for unplanned hospital admission. Despite advancements in the management of chronic heart failure, the prognosis of AHF remains poor with high in-hospital mortality and increased rates of unfavorable post-discharge outcomes. With this review, we aim to summarize current data on AHF epidemiology, focus on the different patient profiles and classifications, and discuss management, including novel therapeutic options in this area. RECENT FINDINGS: There is significant heterogeneity among patients admitted for AHF in their baseline characteristics, heart failure (HF) aetiology and precipitating factors leading to decompensation. A novel classification scheme based on four distinct clinical scenarios has been included in the most recent ESC guidelines, in an effort to better risk stratify patients and guide treatment. Intravenous diuretics, vasodilators, and inotropes remain the cornerstone of management in the acute phase, and expansion of use of mechanical circulatory support has been noted in recent years. Meanwhile, many treatments that have proved their value in chronic heart failure demonstrate promising results in the setting of AHF and research in this field is currently ongoing. Acute heart failure remains a major health challenge with high in-hospital mortality and unfavorable post-discharge outcomes. Admission for acute HF represents a window of opportunity for patients to initiate appropriate treatment as soon as possible after stabilization. Future studies are needed to elucidate which patients will benefit the most by available therapies and define the optimal timing for treatment implementation.
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Cuidados Posteriores , Insuficiencia Cardíaca , Humanos , Enfermedad Aguda , Alta del Paciente , Insuficiencia Cardíaca/tratamiento farmacológico , Insuficiencia Cardíaca/epidemiología , Diuréticos/uso terapéuticoRESUMEN
BACKGROUND: Apparent treatment-resistant hypertension (aTRH) is defined as failure to achieve adequate blood pressure (BP) control despite taking ≥3 antihypertensive medications from different categories or when taking ≥4 antihypertensives regardless of BP levels. METHODS: In this cross-sectional study, we estimated the prevalence of aTRH in 140 patients receiving long-term peritoneal dialysis (PD) in four centers of Northern Greece, using the "gold-standard" method of ambulatory BP monitoring for the assessment of BP control status. The presence of subclinical overhydration was evaluated with the method of bioimpedance spectroscopy (BIS). RESULTS: Incorporating the diagnostic threshold of 130/80 mmHg for 24-hour ambulatory BP, the prevalence of aTRH in the overall study population was 30%. Compared to patients without aTRH, those with aTRH tended to be older in age, had higher PD vintage, had higher dialysate-to-plasma creatinine ratio, had more commonly history of diabetes mellitus, and were more commonly current smokers. With respect to the volume status, the overhydration index in BIS was higher in those with versus without aTRH (2.0â ±â 1.9 L vs. 1.1â ±â 2.0 L, Pâ <â 0.05). The prevalence of volume overload, defined as an overhydration index in BISâ >â 2.5 L, was also higher in the subgroup of patients with aTRH (38.1% vs. 18.4, Pâ =â 0.01). CONCLUSION: The present study showed that among patients on PD, the prevalence of aTRH was 30%. However, 38% of PD patients with aTRH had subclinical overhydration in BIS, suggesting that the achievement of adequate volume control may be a therapeutic opportunity to improve the management of hypertension in this high-risk patient population.The present study showed that among patients on PD, the prevalence of aTRH was 30%. However, 38% of PD patients with aTRH had subclinical overhydration in BIS, suggesting that the achievement of adequate volume control may be a therapeutic opportunity to improve the management of hypertension in this high-risk patient population. CLINICAL TRIALS REGISTRATION: Trial Number NCT03607747.
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Hipertensión , Diálisis Peritoneal , Humanos , Prevalencia , Estudios Transversales , Antihipertensivos/uso terapéutico , Presión SanguíneaRESUMEN
Whether hemodialysis patients should be allowed or even encouraged to eat during dialysis remains a controversial topic. This cross-over study aimed to evaluate the impact of feeding during dialysis on intradialytic blood pressure (BP) profile and dialysis adequacy in 26 patients receiving thrice-weekly, in-center hemodialysis. Over three consecutive mid-week dialysis sessions, intradialytic BP was monitored using the Mobil-O-Graph device (IEM, Stolberg, Germany). Blood samples were also obtained for the determination of the urea reduction ratio (URR). At baseline, patients underwent dialysis without the provision of a meal. In phases A and B, a meal with either high-protein (1.5 gr/kg of body weight) or low-protein (0.7 gr/kg of body weight) content was administered 1 h after the initiation of dialysis. The sequence of meals (high-protein and low-protein or vice versa) was randomized. Average intradialytic systolic BP (SBP) was similar on all three occasions. However, compared with baseline, the standard deviation (SD) (11.7 ± 4.1 vs. 15.6 ± 7.6 mmHg, p < 0.01), coefficient of variation (CV) (9.5 ± 3.7% vs. 12.4 ± 6.0%, p < 0.01) and average real variability (ARV) (9.4 ± 3.9 vs. 12.1 ± 5.2 mmHg, p < 0.01) of intradialytic SBP were higher in phase A. Similarly, compared with the baseline evaluation, all three indices of intradialytic SBP variability were higher in phase B (SD: 11.7 ± 4.1 vs. 14.1 ± 4.5 mmHg, p < 0.05; CV: 9.5 ± 3.7% vs. 11.1 ± 3.8%, p < 0.05; ARV: 9.4 ± 3.9 vs. 10.9 ± 3.9 mmHg, p < 0.05). Compared with dialysis without a meal, the consumption of a high-protein or low-protein meal resulted in a lower URR (73.4 ± 4.3% vs. 65.7 ± 10.7%, p < 0.001 in phase A and 73.4 ± 4.3% vs. 67.6 ± 4.3%, p < 0.001 in phase B, respectively). In conclusion, in the present study, feeding during dialysis was associated with higher intradialytic SBP variability and reduced adequacy of the delivered dialysis.
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Comidas , Diálisis Renal , Presión Sanguínea/fisiología , Peso Corporal , Estudios Cruzados , Humanos , Fallo Renal CrónicoRESUMEN
PURPOSE: Observational studies have shown that among patients on hemodialysis, hyperkalemia is strongly associated with excess risk for cardiovascular-related hospitalizations and sudden cardiac death. However, the actual burden of hyperkalemia, the rates of its recurrence and seasonality in its variation still remain unclear. METHODS: Between June 2020 and May 2021, 1786 mid-week pre-dialysis serum potassium (sK) measurements were retrospectively recorded from 149 patients receiving thrice-weekly hemodialysis in a single-center in Thessaloniki, Greece. The prevalence, recurrence and seasonal variation of hyperkalemia were assessed using three pre-specified sK thresholds (≥ 5.1, ≥ 5.5 and ≥ 6.0 mmol/L). RESULTS: At baseline, 60.4%, 42.2% and 13.4% of patients had sK levels ≥ 5.1, ≥ 5.5 and ≥ 6.0 mmol/L, respectively. At any time-point during follow-up, 85.2%, 69.8% and 38.9% of patients experienced at least one hyperkalemic event ≥ 5.1, ≥ 5.5 and ≥ 6.0 mmol/L, respectively. Of the 104 patients experiencing an initial sK elevation ≥ 5.5 mmol/L, hyperkalemia at the same threshold reoccurred in 60.6% at month 1, in 47.1% at month 2 and in 46.1% at month 3 of follow-up. Seasonal variation was also observed, with the prevalence of hyperkalemia to be significantly higher in summer. Shorter delivered hemodialysis < 4 h/session (OR: 2.568; 95% CI 1.045-6.313) and the use of a high dialysate K concentration (OR: 14.646; 95% CI 2.727-78.647) were the 2 factors that were independently associated with hyperkalemia. CONCLUSION: The present study shows that among hemodialysis patients, the rates of hyperkalemia prevalence and recurrence are very high, reflecting the large unmet need to identify more effective potassium-lowering therapeutic interventions in this high-risk population.
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Hiperpotasemia , Humanos , Hiperpotasemia/epidemiología , Hiperpotasemia/etiología , Potasio , Prevalencia , Diálisis Renal/efectos adversos , Estudios Retrospectivos , Estaciones del AñoRESUMEN
INTRODUCTION: Prior studies conducted in peritoneal dialysis (PD) patients in the late 1990s provided considerably variable estimates of the prevalence and control of hypertension. The present study aimed to investigate the current state of hypertension management in this high-risk population. METHODS: In 140 stable PD patients, we performed standardized automated office blood pressure (BP) measurements and 24-h ambulatory BP monitoring (ABPM) using the Mobil-O-Graph device (IEM, Germany). Office and ambulatory hypertension was diagnosed in patients with office BP ≥140/90 mm Hg and 24-h BP ≥130/80 mm Hg, respectively. Patients treated with ≥1 BP-lowering medications were also classified as hypertensives. RESULTS: The prevalence of office and ambulatory hypertension was 92.9% and 95%, respectively. In all, 92.1% of patients were being treated with an average of 2.4 BP-lowering medications daily. Adequate BP control was achieved in 52.3% and 38.3% of hypertensives by office BP and ABPM, respectively. The agreement between these 2 techniques in the identification of patients with BP levels above the diagnostic thresholds of hypertension was moderate (k-statistic: 0.524). In all, 5% of patients were normotensives with both techniques, 31.4% had controlled hypertension, 5% had white-coat hypertension, 19.3% had masked hypertension, and 39.3% had sustained hypertension. Isolated nocturnal hypertension was detected in 23.6% of patients, whereas no patient had isolated daytime hypertension. CONCLUSION: Among PD patients, hypertension is highly prevalent and remains often inadequately controlled. The use of ABPM enables the better classification of severity of hypertension and identification of isolated nocturnal hypertension, which is a common BP phenotype in the PD population.
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Hipertensión , Diálisis Peritoneal , Presión Sanguínea/fisiología , Determinación de la Presión Sanguínea , Monitoreo Ambulatorio de la Presión Arterial/métodos , Humanos , Hipertensión/diagnóstico , Hipertensión/tratamiento farmacológico , Hipertensión/epidemiología , Diálisis Peritoneal/efectos adversosRESUMEN
BACKGROUND: The newly introduced device Mobil-O-Graph (IEM, Stolberg, Germany) combines brachial cuff oscillometry and pulse wave analysis, enabling the determination of pulse wave velocity (PWV) via complex mathematic algorithms during 24-h ambulatory blood pressure monitoring (ABPM). However, the determinants of oscillometric PWV in the end-stage kidney disease (ESKD) population remain poorly understood. METHODS: In this study, 81 ESKD patients undergoing long-term peritoneal dialysis underwent 24-h ABPM with the Mobil-O-Graph device. The association of 24-h oscillometric PWV with several demographic, clinical and haemodynamic parameters was explored using linear regression analysis. RESULTS: In univariate analysis, among 21 risk factors, 24-h PWV exhibited a positive relationship with age, body mass index, overhydration assessed via bioimpedance spectroscopy, diabetic status, history of dyslipidaemia and coronary heart disease, and it had a negative relationship with female sex and 24-h heart rate. In stepwise multivariate analysis, age (ß: 0.883), 24-h systolic blood pressure (BP) (ß: 0.217) and 24-h heart rate (ß: -0.083) were the only three factors that remained as independent determinants of 24-h PWV (adjusted R 2 = 0.929). These associations were not modified when all 21 risk factors were analysed conjointly or when the model included only variables shown to be significant in univariate comparisons. CONCLUSION: The present study shows that age together with simultaneously assessed oscillometric BP and heart rate are the major determinants of Mobil-O-Graph-derived PWV, explaining >90% of the total variation of this marker. This age dependence of oscillometric PWV limits the validity of this marker to detect the premature vascular ageing, a unique characteristic of vascular remodelling in ESKD.
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Fallo Renal Crónico , Diálisis Peritoneal , Rigidez Vascular , Presión Sanguínea/fisiología , Monitoreo Ambulatorio de la Presión Arterial , Femenino , Humanos , Fallo Renal Crónico/terapia , Masculino , Diálisis Peritoneal/efectos adversos , Análisis de la Onda del Pulso , Rigidez Vascular/fisiologíaRESUMEN
Prior studies have associated automated peritoneal dialysis (APD) with less effective volume and blood pressure (BP) control as compared with continuous ambulatory peritoneal dialysis (CAPD). Our study aimed to compare the volume status, ambulatory BP profile and severity of arterial stiffness between patients treated with CAPD versus APD. In a case-control design, 28 CAPD patients were matched in 1:1 ratio with 28 controls receiving APD for age, gender and diabetic status. Body composition was assessed with the method of bioimpendence spectroscopy. Twenty-four hours ambulatory BP monitoring with the Mobil-O-Graph device (IEM, Germany) was performed to determine peripheral and central hemodynamic parameters, heart rate-adjusted augmentation index (AIx75) and pulse wave velocity (PWV). Standardized office BP, antihypertensive medication use and extracellular-to-total body water ratio did not differ between CAPD and APD groups. Twenty-four hours brachial systolic BP (129.0 ± 17.3 vs. 128.1 ± 14.2 mmHg, P = 0.83) and 24-h aortic systolic BP (116.9 ± 16.4 vs. 116.4 ± 11.6 mmHg, P = 0.87) were similar in patients treated with CAPD versus APD. Similarly, there was no significant difference between PD modalities in severity of arterial stiffness, as assessed with 24-h AIx75 (24.8 ± 8.9 vs. 22.5 ± 9.1, P = 0.36) and 24-h PWV (9.1 ± 2.4 vs. 8.8 ± 2.1 m/s, P = 0.61). The present study suggests that there is no difference in peripheral and central hemodynamic parameters as well as in the severity of arterial stiffness between CAPD and APD. However, these observations should be interpreted within the context of clinical characteristics of patients included in this case-control study. The comparative effectiveness of these 2 PD modalities warrants further investigation in larger longitudinal studies.
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Fallo Renal Crónico , Diálisis Peritoneal Ambulatoria Continua , Diálisis Peritoneal , Rigidez Vascular , Estudios de Casos y Controles , Femenino , Humanos , Fallo Renal Crónico/terapia , Masculino , Diálisis Peritoneal/métodos , Diálisis Peritoneal Ambulatoria Continua/efectos adversos , Análisis de la Onda del PulsoRESUMEN
Large observational studies showed a U-shaped association of clinic blood pressure (BP) with mortality among patients undergoing peritoneal dialysis (PD). Whether ambulatory BP provides a more direct risk signal in this population remains unknown. In a prospective cohort of 108 PD patients, standardized clinic BP was recorded at baseline with the validated device HEM-705 (Omron, Healthcare, Bannockburn, IL, USA) and 24-h ambulatory BP monitoring was performed using the Mobil-O-Graph monitor (IEM, Stolberg, Germany). Over a median follow-up of 16 months (interquartile range: 19 months), 47.2% of the overall population reached the composite outcome of non-fatal myocardial infarction, non-fatal stroke, or all-cause death. In Cox-regression analysis, systolic but not diastolic BP was prognostically informative. Compared with the reference quartile 1 of 24-h systolic BP (SBP), the multivariate-adjusted hazard ratio for the composite outcome was 1.098 (95% confidence interval (CI): 0.434-2.777) in quartile 2, 1.004 (95% CI: 0.382-2.235) in quartile 3 and 2.449 (95% CI: 1.156-5.190) in quartile 4. In contrast, no such association was observed between increasing quartiles of clinic SBP and composite outcome. The present study shows that among PD patients, increasing ambulatory SBP is independently associated with higher risk of adverse cardiovascular events and mortality, providing superior prognostic information than standardized clinic SBP.
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INTRODUCTION: Assessment of dry-weight among patients on dialysis is challenging in the absence of reliable markers to define fluid overload (FO). This study aimed to explore the value of two simple clinical signs, pedal edema, and crackles at pulmonary auscultation, in diagnosing hypervolemia, using bioimpendence spectroscopy (BIS) as reference standard. METHODS: In a cohort of 107 asymptomatic dialysis patients, FO was assessed with physical examination and BIS shortly before the mid-week dialysis session. Patients were also asked to perform home blood pressure (BP) monitoring with a validated, automatic device (HEM-705, Omron, Healthcare) for 1 week in order to determine their BP outside of dialysis. FINDINGS: Patients within the high tertile of predialysis FO had longer dialysis vintage, lower serum albumin and higher home systolic BP, despite the more aggressive treatment with a higher average number of antihypertensives daily. In receiver-operating-characteristic (ROC) curve analysis, pedal edema (area under curve [AUC]: 0.534; 95% confidence interval [CI]: 0.416-0.651) and pulmonary crackles (AUC: 0.551; 95% CI: 0.432-0.671) had limited accuracy in detecting excess predialysis FO > 2.2 L. The agreement of pedal edema (k-coefficient: 0.065) and pulmonary crackles (k-coefficient: 0.122) with BIS-derived FO was poor. In multivariate linear regression analysis, longer dialysis vintage (ß: 0.306, p < 0.001) and higher home systolic BP (ß: 0.287, p < 0.01) were the two factors that were associated with predialysis FO. CONCLUSIONS: This study showed that among asymptomatic dialysis patients, pedal edema and pulmonary crackles in physical examination had limited discriminatory power in detection of FO, as assessed with the method of BIS.
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BACKGROUND: Among patients with end-stage kidney disease (ESKD), arterial stiffness is considered as a powerful predictor of cardiovascular (CV) morbidity and mortality. However, the relevance of aortic pulse wave velocity (PWV) as a prognostic biomarker for CV risk estimation is not yet fully clear. METHODS: We performed a systematic search of Medline/PubMed database from inception through August 21, 2019 to identify observational cohort studies conducted in ESKD patients and exploring the association of PWV with CV events and mortality. RESULTS: Whereas "historical" cohort studies showed aortic PWV to be associated with higher risk of CV and all-cause mortality, recent studies failed to reproduce the independent predictive value of aortic PWV in older ESKD patients. Studies using state-of-the-art prognostic tests showed that the addition of aortic PWV to standard clinical risk scores could only modestly improve CV risk reclassification. Studies associating improvement in PWV in response to blood pressure (BP)-lowering with improvement in survival cannot demonstrate direct cause-and-effect associations due to their observational design and absence of accurate methodology to assess the BP burden. CONCLUSION: Despite the strong pathophysiological relevance of arterial stiffness as a mediator of CV disease in ESKD, the assessment of aortic PWV for CV risk stratification in this population appears to be of limited value. Whether aortic PWV assessment is valuable in guiding CV risk factor management and whether such a therapeutic approach is translated into improvement in clinical outcomes, is an issue of clinical relevance that warrants investigation in properly-designed randomized trials.
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Enfermedades Cardiovasculares/diagnóstico , Fallo Renal Crónico , Análisis de la Onda del Pulso , Rigidez Vascular , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/fisiopatología , Enfermedades Cardiovasculares/terapia , Factores de Riesgo de Enfermedad Cardiaca , Humanos , Fallo Renal Crónico/diagnóstico , Fallo Renal Crónico/mortalidad , Fallo Renal Crónico/terapia , Estudios Observacionales como Asunto , Valor Predictivo de las Pruebas , Pronóstico , Medición de RiesgoRESUMEN
Historically, eating during the hemodialysis treatment has been associated with increased risk for adverse intradialytic symptoms and events, risks that have resulted in the implementation of restrictive in-center nutrition policies. Recent studies, however, have recorded a shift in clinical practice with a higher proportion of physicians following the view that administration of intradialytic meals and supplements represents a simple and effective approach to enhance caloric intake and improve nutritional status among patients on hemodialysis. This shift towards less restrictive in-center nutrition practices is mainly supported by evidence from observational studies associating intradialytic nutritional supplementation with improvements in protein-energy wasting, inflammatory state, and health-related quality of life. In sharp contrast, earlier and recent interventional studies have documented that feeding during the hemodialysis treatment provokes a rapid postprandial decline in blood pressure and raises the incidence of symptomatic intradialytic hypotension. Furthermore, other studies have shown that postprandial redistribution in intravascular volume and enhanced blood supply to the gastrointestinal circulation may interfere with the adequacy of the delivered hemodialysis. Those who defend the position that intradialytic nutritional support is beneficial do not dispute the physiology of postprandial hemodynamic response, but they argue against its clinical significance. In this article, we provide an overview of studies that explored the effect of eating during the hemodialysis treatment on intradialytic hemodynamic stability and adequacy of the delivered hemodialysis. We reason that these risks have important clinical implications that are not counteracted by anticipated benefits of this strategy on caloric intake and nutritional status.
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Dietoterapia/tendencias , Suplementos Dietéticos , Ingestión de Alimentos/fisiología , Ingestión de Energía/fisiología , Hemodinámica/fisiología , Comidas , Política Nutricional/tendencias , Fenómenos Fisiológicos de la Nutrición/fisiología , Estado Nutricional , Diálisis Renal/efectos adversos , Medición de Riesgo , Humanos , Periodo Posprandial , Desnutrición Proteico-Calórica/prevención & control , Calidad de Vida , RiesgoRESUMEN
BACKGROUND: Earlier studies provided considerably variable estimates on the prevalence and control rates of hypertension in haemodialysis because of their heterogeneity in definitions and blood pressure (BP) measurement techniques applied to detect hypertension. MATERIALS AND METHODS: In this cross-sectional study, 116 clinically stable haemodialysis patients from 3 dialysis centres of Northern Greece underwent home BP monitoring for 1 week with the validated automatic device HEM-705 (Omron, Healthcare). Routine BP recordings taken before and after dialysis over 6 consecutive sessions were also prospectively collected and averaged. Hypertension was defined as: (a) 1-week averaged home BP ≥ 135/85 mm Hg; (b) 2-week averaged predialysis BP ≥ 140/90 mm Hg; and (c) 2-week averaged postdialysis BP ≥ 130/80 mm Hg. Participants on treatment with ≥1 antihypertensives were also classified as hypertensives. RESULTS: The prevalence of hypertension was 88.8% by home, 86.2% by predialysis and 91.4% by postdialysis BP recordings. In all, 96 participants (82.7%) were being treated with an average of 2.0 ± 1.1 antihypertensive medications. Among drug-treated participants, 32.6% were controlled by home, 50.5% by predialysis and 45.3% by postdialysis BP recordings. In multivariate logistic regression analysis, greater use of antihypertensive medications and postdialysis overhydration, assessed with bioimpedance spectroscopy, were both independently associated with higher odds of inadequate home BP control. CONCLUSIONS: This study shows that the prevalence, but mainly the control rates of hypertension in patients on haemodialysis, differs between peridialytic and interdialytic BP recordings. Therefore, the wider use of home BP monitoring may improve the determination of BP control status in this high-risk population.
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Antihipertensivos/uso terapéutico , Hipertensión/tratamiento farmacológico , Fallo Renal Crónico/terapia , Diálisis Renal , Desequilibrio Hidroelectrolítico/fisiopatología , Anciano , Instituciones de Atención Ambulatoria , Monitoreo Ambulatorio de la Presión Arterial , Composición Corporal , Espectroscopía Dieléctrica , Femenino , Humanos , Hipertensión/epidemiología , Hipertensión/fisiopatología , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Prevalencia , Resultado del TratamientoRESUMEN
BACKGROUND: Encapsulating-peritoneal-sclerosis (EPS) is a rare, but serious and life-threatening complication of peritoneal dialysis (PD). Treatment of EPS consists of discontinuation of PD and maintenance of nutritional status, whereas the role of corticosteroids, tamoxifen and other immunosuppresive agents is not yet fully elucidated. CASE-PRESENTATION: We report the case of a 28-year-old patient, who developed a severe form of calcifying EPS after a 6-year-long therapy with automated PD. The clinical presentation was severe with repeated episodes of total bowel obstruction, weight loss and malnutrition that mandated his prolonged hospitalization. Initial treatment included corticosteroids and tamoxifen (20 mg/day) with a clinically meaningful improvement in gastrointestinal function and nutritional status over the first 6-12 months. Corticosteroids were discontinued at 18 months, but owing to persistence of calcifying lesions and peritoneal thickening in repeated computed-tomography (CT) scans, tamoxifen remained unmodified at a low-dose of 20 mg/day for a 10-year-long period. During follow-up, the patient remained symptoms-free in an excellent clinical condition and the CT findings were unchanged. CONCLUSIONS: Long-term administration of tamoxifen was not accompanied by any drug-related adverse effects and potentially exerted a beneficial action on down-regulation of inflammatory and fibrotic processes and improvement of gastrointestinal function, nutritional status and overall health-related quality of life.
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Calcinosis , Obstrucción Intestinal , Diálisis Peritoneal/efectos adversos , Fibrosis Peritoneal , Calidad de Vida , Tamoxifeno/administración & dosificación , Corticoesteroides/administración & dosificación , Adulto , Antiinflamatorios/administración & dosificación , Antineoplásicos/administración & dosificación , Calcinosis/tratamiento farmacológico , Calcinosis/etiología , Calcinosis/terapia , Humanos , Obstrucción Intestinal/etiología , Obstrucción Intestinal/terapia , Fallo Renal Crónico/terapia , Cuidados a Largo Plazo/métodos , Masculino , Desnutrición/etiología , Desnutrición/terapia , Diálisis Peritoneal/métodos , Fibrosis Peritoneal/etiología , Fibrosis Peritoneal/fisiopatología , Fibrosis Peritoneal/psicología , Fibrosis Peritoneal/terapia , Tomografía Computarizada por Rayos X/métodos , Resultado del Tratamiento , Pérdida de PesoRESUMEN
The International Society of Peritoneal Dialysis recommends that adequate blood pressure (BP) assessment among patients on peritoneal dialysis should at least include measurements performed once-weekly at home and at each visit at clinic. However, the quality of evidence to support this guidance is suboptimal. Using ambulatory daytime BP as reference standard, we explored the diagnostic performance of clinic and home BP recordings in a cohort of 81 stable patients receiving peritoneal dialysis. BP was recorded using 3 different methodologies: (1) triplicate automated clinic BP recordings after a 5-minute seated rest with the validated monitor HEM 705 CP (Omron Healthcare); (2) 1-week averaged home BP recorded with a validated automated monitor on awaking and at bedtime; and (3) ambulatory BP monitoring with the Mobil-O-Graph device (IEM, Germany). The area under the curve of receiver operating characteristic curves in detection of ambulatory daytime systolic BP (SBP) ≥135 mm Hg was similar for clinic [area under the curve, 0.859; 95% CI, 0.776-0.941] and home SBP (area under the curve, 0.895; 95% CI, 0.815-0.976). In Bland-Altman analysis, clinic SBP overestimated daytime ambulatory SBP by 5.02 mm Hg with 95% limits of agreement ranging from -17.92 to 27.96 mm Hg. Similarly, home SBP overestimated daytime ambulatory SBP by 4.23 mm Hg, again with wide 95% limits of agreement (-16.05 to 24.51 mm Hg). These results show that 1-week averaged home SBP is of at least similar accuracy with standardized clinic SBP in diagnosing hypertension confirmed by ambulatory BP monitoring among patients on peritoneal dialysis.
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Monitoreo Ambulatorio de la Presión Arterial/métodos , Presión Sanguínea/fisiología , Hipertensión/diagnóstico , Fallo Renal Crónico/fisiopatología , Diálisis Peritoneal , Adulto , Anciano , Femenino , Humanos , Hipertensión/fisiopatología , Fallo Renal Crónico/terapia , Masculino , Persona de Mediana EdadRESUMEN
Immune-checkpoint-inhibitors (ICPIs) represent a novel class of immunotherapy against several malignancies. These agents are associated with several "immune-mediated" adverse effects, but the reported renal toxicity of ICPIs is less well defined. We present the case of a 60-year-old man with a history of non-small cell lung cancer, who developed acute kidney injury (AKI) approximately 3.5 months after initiation of immunotherapy with nivolumab. Urinalysis revealed sterile pyuria, without microscopic hematuria or proteinuria. Immunological examination was negative. A renal biopsy showed severe interstitial inflammatory infiltration of T-cells, monocytes, and eosinophils without interstitial granulomas and normal appearance of glomeruli, indicating acute interstitial nephritis (AIN) as the cause of AKI. After a short-term course of corticosteroids and permanent nivolumab discontinuation, partial recovery of renal function was noted. AIN is a rare adverse effect of ICPIs that mandates the close monitoring of renal function in patients under immunotherapy with these agents.
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The aim of the present study was to compare the aortic systolic blood pressure (aSBP), heart-rate-adjusted augmentation index (AIx75), and pulse wave velocity (PWV) obtained using the Mobil-O-Graph (IEM, Stolberg, Germany) and SphygmoCor (AtCor, Sydney, Australia) devices in patients receiving peritoneal dialysis (PD).After a 10-minute rest in the supine position, the Mobil-O-Graph and SphygmoCor devices were applied in randomized order in 27 consecutive PD patients. The agreement between the measurements produced by the Mobil-O-Graph and SphygmoCor devices was explored using Bland-Altman analysis.The Mobil-O-Graph-derived aSBP, AIx75, and PWV did not differ from the same measurements obtained with SphygmoCor (aSBP: 120.5 ± 18.2 mmHg vs. 124.4 ± 19.0 mmHg, p = 0.438; AIx75: 27.0% ± 12.4% vs. 24.5% ± 10.6%, p = 0.428; PWV: 9.5 ± 2.1 m/s vs. 10.1 ± 3.1 m/s, p = 0.397). The slight difference in the estimation of aSBP is possibly explained by the difference in brachial SBP used for the calibration of the devices (131.0 ± 20.6 mmHg vs. 134.5 ± 19.7 mmHg, p = 0.525). Mobil-O-Graph-derived measurements correlated strongly with paired measurements obtained with the SphygmoCor device. Bland-Altman plots showed no evidence of asymmetry and a wide range of agreement between the two devices.Our study shows acceptable agreement between Mobil-O-Graph and SphygmoCor in the estimation of arterial stiffness indices in PD patients. Accordingly, the Mobil-O-Graph device accurately performs aortic ambulatory blood pressure monitoring in this population.