Comparison of Chronic Hemodialysis Patients under Strict Volume Control with respect to Cardiovascular Disease.

BACKGROUND: The objective of this study was to determine the effects of strict volume control and nondipper situation on cardiovascular disease in chronic hemodialysis patients. METHODS: This study is an observational and cross-sectional study including 62 patients with normotensive chronic hemodialysis using no antihypertensive drugs. A series of measurements including ambulatory blood pressure monitoring, left ventricular mass index by echocardiography, common carotid artery intima-media thickness by ultrasound, and body fluids by bioimpedance analysis were conducted for all subjects. RESULTS: The patients were divided into two groups as dippers and nondippers according to their ambulatory blood pressure monitoring results. Average 48 h systolic, diastolic, and mean arterial blood pressure and nocturnal systolic, diastolic, and mean arterial blood pressure were significantly different between the dipper and nondipper groups (p<0.05). Before and after dialysis, extracellular fluid/intracellular fluid and extracellular fluid/dry body weight ratios were significantly higher in the nondipper group. Left ventricle mass index and interventricular septum thickness were significantly higher in the nondipper group (p<0.05). Left ventricle ejection fraction was significantly lower and common carotid artery intima-media thickness was higher in the nondipper group with a statistical significance (p<0.05). A two-predictor logistic model was fitted to the data to predict the comparability of dippers and nondippers. CONCLUSION: According to logistic regression analysis, the odds ratio for daytime diastolic blood pressure indicates that nondippers are 0.45 times more likely to have high blood pressure than dippers in daytime. But in night time, nondippers are about 2.55 times more likely to have high blood pressure comparing to dippers. An important finding of this study is that nondipping pattern is associated with cardiac hypertrophy and lower left ventricle ejection fraction in dialysis of patients with no hypertension. The results also suggest that applying strict volume control to achieve a normal blood pressure alone is not sufficient to reduce the risk of cardiovascular morbidity and mortality if the patients do not have a dipper status of nocturnal blood pressure.

Gabapentin therapy for pruritus in haemodialysis patients: a randomized, placebo-controlled, double-blind trial.

BACKGROUND: Uraemic pruritus is a common and distressing symptom in patients on haemodialysis for chronic renal failure. Gabapentin is an anticonvulsant that alleviates neuropathic pain. We conducted a double-blind, placebo-controlled, crossover study to assess its effectiveness against renal itch. METHODS: We enrolled in the trial 25 adult patients on haemodialysis who were asked to daily record the severity of their pruritus on a visual analogue scale. The patients were randomly assigned to receive gabapentin for 4 weeks followed by placebo for 4 weeks or the reverse sequence. Gabapentin or placebo were administered thrice weekly, at the end of haemodialysis sessions. RESULTS: The mean pruritus score of the cohort before the study was 8.4 +/- 0.94. After placebo intake, it decreased to 7.6 +/- 2.6 (P = 0.098). The score of four patients decreased by >50% following placebo. After gabapentin administration, the mean score decreased significantly, to 1.2 +/- 1.8 (P = 0.0001), although one patient's symptoms did not improve significantly. No patient dropped out of the study due to adverse effects from gabapentin. CONCLUSIONS: Our study shows that gabapentin is safe and effective for treating uraemic pruritus in haemodialysis patients. Our results also support the neuropathic hypothesis of uraemic pruritus.

Should the preservation of residual renal function cost volume overload and its consequence left ventricular hypertrophy in new hemodialysis patients?

BACKGROUND: Left ventricular hypertrophy (LVH) is an important predictor of mortality in dialysis patients. The loss of residual renal function (RRF) appears to occur more rapidly in hemodialysis than continuous ambulatory peritoneal dialysis (CAPD). It is more likely that volume expansion in patients on CAPD may preserve RRF. The aim of this study was to investigate whether there is a cause-effect relationship between volume overload and preserving RRF in new hemodialysis patients. METHODS: Nineteen patients with end-stage renal disease (ESRD) starting hemodialysis therapy were included in the study. At the beginning, their elevated blood pressures (BP) were treated with antihypertensive drugs. Thereafter, until normovolemia and normal BP were obtained, strict volume control was applied. The effects of both treatment modalities on the loss of RRF and LVH were evaluated prospectively. RESULTS: At the initial examination, all of the patients were hypertensive and had markedly increased left ventricular mass index (LVMI). The daily urine production was 1575+/-281 mL. At the end of drug treatment period lasting three months, although BP significantly decreased, daily urine production and LVMI only decreased by 12% and 6%, respectively. At the end of the period in which strict volume control was applied, the body weight significantly decreased (from 60+/-5 to 55+/-8 kg, p<0.0001). This decrease in body weight was accompanied by marked decreases in dilated cardiac chamber size and more importantly daily urine production. At the end of this period, while 7 of 19 patients had no residual urine production, residual urine production was below 200 mL/d in the remaining 12 patients. Although the period of volume control was short, there was significant reduction in the LVMI (decreased from 251+/-59 to 161+/-25 gr/m2, p<0.0001). CONCLUSION: The results of our prospective study have clearly shown that the persistence of residual renal function in patients with ESRD starting hemodialysis therapy may largely depend on volume overload. Equally interesting was the finding that despite significantly reduced BP level with hypotensive drugs, there was no marked regression in LVMI. In the contrary, after the volume control period, LVMI was significantly decreased. Our results support the hypotheses that decrease in volume may be more important than pressure reduction in regressing the left ventricular hypertrophy.

Early and vigorous fluid resuscitation prevents acute renal failure in the crush victims of catastrophic earthquakes.

This study analyzes the effects of fluid resuscitation in the crush victims of the Bingol earthquake, which occurred in May 2003 in southeastern Turkey. Questionnaires asking about demographic, clinical, laboratory, and therapeutic features of 16 crush victims were filled in retrospectively. Mean duration under the rubble was 10.3 +/- 7 h, and all patients had severe rhabdomyolysis. Fourteen patients were receiving isotonic saline at admission, which was followed by mannitol-alkaline fluid resuscitation. All but two patients were polyuric. Admission serum creatinine level was lower than and higher than 1.5 mg/dl in 11 and 5 patients, respectively. Marked elevations were noted in muscle enzymes in all patients. During the clinical course, hypokalemia was observed in nine patients, all of whom needed energetic potassium chloride replacement. Four (25%) of 16 victims required hemodialysis. Duration between rescue and initiation of fluids was significantly longer in the dialyzed victims as compared with nondialyzed ones (9.3 +/- 1.7 versus 3.7 +/- 3.3 h, P < 0.03). Sixteen fasciotomies were performed in 11 patients (68%), nine of which were complicated by wound infections. All patients survived and were discharged from the hospital with good renal function. Early and vigorous fluid resuscitation followed by mannitol-alkaline diuresis prevents acute renal failure in crush victims, resulting in a more favorable outcome.

Blood pressure control and left ventricular hypertrophy in long-term CAPD and hemodialysis patients: a cross-sectional study.

BACKGROUND: It is still not clear whether hypertension and left ventricular hypertrophy (LVH) are more common in continuous ambulatory peritoneal dialysis (CAPD) than in hemodialysis (HD) patients. METHODS: To examine this subject, the indices of cardiac performance were compared between 50 HD and 34 CAPD patients. Patients were further divided into two subgroups [long-term (L) CAPD and L-HD] according to dialysis modality and duration of dialysis (more than 60 months' duration). RESULTS: The blood pressure and cardiothoracic index of CAPD patients did not differ from HD patients. On average, the left atrial index was 2 mm/m2 higher in HD patients than in CAPD patients. Left ventricular chamber sizes, wall thickness, and left ventricular mass index (LVMI) in patients on CAPD were similar to those of HD patients. Isovolumic relaxation time (IVRT) of CAPD patients was insignificantly less than that of HD patients (101 +/- 22 and 115 +/- 27 msec respectively). There was no significant difference between the two subgroups (L-HD and L-CAPD) in blood pressure, left atrial diameter, left ventricular chamber size, wall thickness, LVMI, ejection fraction, or IVRT. CONCLUSION: If normovolemia and normotension are obtained by strict volume control without using antihypertensive drugs, the effects of the two modalities of chronic dialysis treatment (HD and CAPD) on cardiac structure and function are not different from each other.