Usefulness of ambulatory blood pressure monitoring in chronic kidney disease: The moroccan experience.

Among patients with chronic kidney disease (CKD), hypertension (HTN) is very common and widely recognized to accelerate the progression of CKD and increase the risk for cardiovascular events. Accumulated data indicate that ambulatory blood pressure monitoring (ABPM) is better in detecting HTN than office blood pressure (BP) measurement. The goal of this study is to describe the ABPM characteristics in a group of CKD and hypertensive patients. A transversal study was conducted over a period of six months, to evaluate the ABPM patterns among a group of hypertensive patients with CKD (Group 1) and compared the data with a control group (Group 2). ABPM was performed with measurement rate every 15 min during daytime and 30 min at night. Nondipping BP patterns were defined as the absence of fall in nocturnal systolic and diastolic BP >10% of daytime values. Masked HTN was defined as controlled office BP (<140/90 mm Hg) with an elevated overall average BP by 24-h ABPM (>125/75 mm Hg), and white-coat HTN was defined as association of elevated BP readings (>140/90 mm Hg) in a clinical setting and normal 24-h average BP levels (<130/80 mm Hg). Fifty patients were included in each group. HTN was much longer in duration among hypertensive patients with CKD and frequently associated with obesity, dyslipidemia, and diabetes (64% vs. 39.60%). Positive proteinuria was present in 82% of CKD patients with HTN. CKD patients with HTN received more antihypertensive drugs than Group 2 patients. HTN was much more uncontrolled among CKD patients (60% vs. 24%), more serious with higher daytime and nighttime SBP, and loss of physiologic dipping during nighttime BP measurement (80%). Out-of-office BP monitoring by ABPM may improve the assessment and the successful management of HTN in patients with CKD. Standardized definitions for the diagnosis of masked and white-coat HTN would facilitate research.

Effects of lowering dialysate calcium concentration on mineral metabolism and hemodynamic parameters in hemodialysis patients.

INTRODUCTION: It has been suggested that a dialysate calcium concentration of 1.5 mmol/L is a compromise between bone protection and cardiovascular risk. This study aimed to investigate the effect of reducing dialysate calcium concentration to 1.5 mmol/L on mineral metabolism and hemodynamic parameters. MATERIALS AND METHODS: Dialysate calcium concentration was changed from 1.75 mmol/L to 1.5 mmol/L for 9 months and observed the effects on mineral metabolism and dialysis outcome parameters in 52 hemodialysis patients. RESULTS: The results at 9 months demonstrated that postdialytic serum calcium level decreased significantly from 109 ± 7 mg/L to 102 ± 6 mg/L, intact parathyroid hormone (PTH) increased from 372 ± 52 pg/mL to 606 ± 80 pg/mL, and the oral alfacalcidol increased from 1.4 ± 0.3 µg/w to 3.3 ± 0.4 µg/w. In patients with low PTH levels, continuous increase of PTH was observed. There were no significant variation in the oral calcium carbonate dose and serum levels of alkaline phosphatase, predialytic calcium, and pre- and postdialytic phosphorus. The ultrafiltration rate and postdialysis systolic blood pressure were significantly lower after reducing the dialysate calcium concentration to 1.5 mmol/L. Intradialytic hypotension and cramps were more frequent with this dialysate calcium concentration. CONCLUSIONS: These findings demonstrated that a decrease in dialysate calcium concentration from 1.75 mmol/L to 1.5 mmol/L improved mineral metabolism by prevention of postdialytic hypercalcemia and releasing oversuppression of PTH, but it was associated with more use of oral alfacalcidol and more hemodynamic impairment.

Infective endocarditis in chronic hemodialysis patients: experience from Morocco.

Since the 1960s, regular hemodialysis (HD) was recognized as a risk factor for the development of infective endocarditis (IE), particularly at vascular access sites. The present report describes our experience at the Etat Major General Agadir, Morocco, of taking care of IE in patients on regular dialysis. A retrospective analysis was made of five cases of IE in patients receiving regular HD having arteriovenous fistula as vascular access. They were sent from four private centers and admitted in our formation between January 2004 and March 2009. Infective endocarditis was detected after 34.5 months following initiation of dialysis. The causative organisms included Staphylococcus and Enterococcus in two cases each and negative blood culture in one case. A recent history of infection (<3 months) of the vascular access was found in three cases. Peripheric embolic phenomena were noted in two cases. A pre-existing heart disease was common and contributed to heart failure. Mortality was frequent due to valvular perforations and congestive heart failure, making the medical treatment alone unsatisfactory. Two patients survived and three of our patients received a prosthetic valve replacement, with a median survival after surgery of 10.3 months/person. The clinical diagnosis of infective endocarditis in regularly dialyzed patients remains difficult, with the presence of vascular calcification as a common risk factor. The vascular catheter infections are the cardinal gateway of pathogenic organisms, which are mainly Staphylococcus. The prognosis is bad and the mortality is significant, whereas medical and surgical treatments are often established in these patients who have many factors of comorbidity.