Association of intradialytic blood pressure changes with hospitalization and mortality rates in prevalent ESRD patients.

The relationship between blood pressure (BP) and clinical outcomes among hemodialysis patients is complex and incompletely understood. This study sought to assess the relationship between blood pressure changes with hemodialysis and clinical outcomes during a 6-month period. This study is a secondary analysis of the Crit-Line Intradialytic Monitoring Benefit Study, a randomized trial of 443 hemodialysis subjects, designed to determine whether blood volume monitoring reduced hospitalization. Logistic regression was used to estimate the association between BP changes with hemodialysis (Deltasystolic blood pressure=postdialysis-predialysis systoic BP (SBP) and the primary outcome of non-access-related hospitalization and death. Subjects whose systolic blood pressure fell with dialysis were younger, took fewer blood pressure medications, had higher serum creatinine, and higher dry weights. After controlling for baseline characteristics, lab variables, and treatment group, subjects whose SBP remained unchanged with hemodialysis (N=150, DeltaSBP -10 to 10 mm Hg) or whose SBP rose with hemodialysis (N=58, DeltaSBP > or =10 mm Hg) had a higher odds of hospitalization or death compared to subjects whose SBP fell with hemodialysis (N=230, DeltaSBP < or =-10 mm Hg) (odds ratio: 1.85, confidence interval: 1.15-2.98; and odds ratio: 2.17, confidence interval: 1.13-4.15). Subjects whose systolic blood pressure fell with hemodialysis had a significantly decreased risk of hospitalization or death at 6 months, suggesting that hemodynamic responses to dialysis are associated with short-term outcomes among a group of prevalent hemodialysis subjects. Further research should attempt to elucidate the mechanisms behind these findings.

Sorbents in the treatment of renal failure.

Standard renal replacement therapy in acute renal failure (ARF) and end-stage renal disease (ESRD) is based on membrane technology. The transition from natural cellulosic membranes to synthetic membranes has not been associated with improvement in mortality rates. Modifications of dialysis with continuous arteriovenous hemofiltration and hemodiafiltration to remove middle molecular weight toxins, low molecular weight proteins and peptides (LMWP) and cytokines involved in inflammation appear to have reached their limits. High flux dialyzers are not efficient at removing LMWP and for this reason sorbents to augment or replace dialysis have been used in clinical trials. Removal of LMWP such as beta2-microglobulin, leptin, complement factor D, angiogenin, and cytokines such as IL-1, IL-6, IL-10, IL-18 and TNFalpha, have been established in animal models of sepsis, and in ESRD patients using sorbents in conjunction with high flux dialysis. Sorbent devices added to hemodialysis, or alone in inflammatory states, are being studied in diseases which possess a common pathway of systemic inflammatory response syndrome; these states are sepsis, ARF, cardio-pulmonary bypass, in brain dead subjects prior to explantation of donor organs and ESRD.

Peritoneal dialysis in older individuals.

Peritoneal dialysis is a viable alternative to hemodialysis for management of elderly patients requiring renal replacement therapy. Peritoneal dialysis confers several advantages over hemodialysis for the elderly--namely independence, home treatment and perhaps preservation of residual renal function. Although there are a few contraindications, these are minimal and can largely be overcome with attention to special training and the use of healthcare partners to perform the technique of peritoneal dialysis exchanges.

End-stage renal disease and its management in older adults.

The older patient with renal disease presents the nephrologist with a formidable problem list: treatment of end-stage renal disease (ESRD) in these patients can be viewed as a continuum in the management of several diseases at one time. The older ESRD patient with complex medical problems is a challenge to the health care team, clearly requiring the cooperation of physician, nurse, dialysis technician, social worker, dietician, physical medicine specialist, and a host of other subspecialists. The outcomes, however, are gratifying, in that a satisfactory and enjoyable autumn of life is attainable for many.

Hemodialysis patient management by telemedicine: design and implementation.

The authors describe the design and implementation of a personal computer based telemedicine system for managing patients by telemedicine. With three identical systems connected by high speed T1 lines, the physician (or allied healthcare giver) can interact, by videoconferencing, and by using multimedia files, with patients at two remote hemodialysis sites. The physician is able to visualize specifically the patient's fistula/graft, and auscultate fistula, heart and lung sounds, and incorporate still pictures or audio sounds in the patient's multimedia database folder, which also contains an electronic and paperless medical record. In addition there is the capability of downloading into this database all the machine parameters during dialysis.

Requirements for urology and renal dialysis PC-based telemedicine applications: comparative analysis.

The Imaging Science and Information Systems (ISIS) Center of the Department of Radiology at Georgetown University Medical Center (GUMC) has been developing technical requirements for different telemedicine applications. This paper details the process through which those technical requirements are determined and shows how they may differ substantially, depending on the clinical need. This information is presented in light of two telemedicine applications being undertaken at GUMC: a urology application for the management of patients with surgical stone disease and a nephrology application for monitoring of renal dialysis patients.

Therapeutic uses of aspirin in renal diseases.

Inhibition, by aspirin, of platelet aggregation, prostaglandin synthesis, smooth muscle cell proliferation, and thromboxane genesis has potential therapeutic uses in renal diseases. Clinically, some benefit from aspirin has been shown in some forms of glomerulonephritis but not in others, such as renovascular hypertension, pregnancy-induced hypertension, and diabetic nephropathy. Experimentally, aspirin aided in amelioration of cyclosporine toxicity and in preservation of explanted kidneys being prepared for transplantation.

State of the art lecture: pharmacological intervention for the reduction of progression of diabetic nephropathy - abstract

Reduction of bloodpressure has been known, from the work of Parving et al (1987), to reduce the rate of decline of renal function in the nephropathy associated with Type-1 diabetes mellitus (IDDM), using conventional anti-hypertensive agents. More recently, interest in angiotensin-converting enzyme inhibitors (ACE-Is), and calcium channel blockers (CCBs) in the treatment of diabetic nephropathy, has been forthcoming. In diabetic nephropathy, induced in rats by streptozotocin, ACE-Is clearly alter renal haemodynamics and reduce proteinuria. Reduction of proteinuria is also seen in humans with diabetic nephropathy, and there is a suggestion of preservation of renal function, although no long-term studies have been published. Two studies are underway in non-hypertensive microalbuminuric subjects, but these have also not been published. The group of ACE-Is appears to have similar action in reducing proteinuria in diabetic nephropathy, but the same cannot be said for the CCBs. They differ in their action in reducing proteinuria, and dilitiazem may stand alone in reducing proteinuria in human diabetic nephropathy. Debate continues on the mechanism for reduction in proteinuria. Amelioration in systemic hypertension plays a role for all classes of antihypertensive drugs used, but the ACE-Is may alter glomerular permselectivity and thereby bring about reduction in proteinuria. Dietary reduction or protein intake may also play a protein preserving renal function as may reduction of lipids (AU)