Pulmonary Hypertension in Hemodialysis Patients
Mitra Mahdavi-Mazdeh1, Seyed Alijavad-Mousavi2, Hooman Yahyazadeh3, Mitra Azadi4, Hajar Yoosefnejad4, Yoosef Ataiipoor5
1 Department of Nephrology, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Pulmonary Medicine, Iran University of Medical Sciences, Tehran, Iran
3 Department of Medicine, Iran University of Medical Sciences, Tehran, Iran
4 Department of Cardiology, Iran University of Medical Sciences, Tehran, Iran
5 Department of Nephrology, Iran University of Medical Sciences, Tehran, Iran
Abstract
The aim of this study was to evaluate the prevalence of primary pulmonary hypertension (PHT) among hemodialysis patients and search for possible etiologic factors. The prevalence of PHT was prospectively estimated by Doppler echocardiogram in 62 long-term hemodialysis patients on the day post dialysis. PHT (> 35 mm Hg) was found in 32 (51.6%) patients with a mean systolic pulmonary artery pressure of 39.6 ± 13.3 mmHg. The hemoglobin and albumin levels were significantly lower in the PHT subgroup (11.1 ± 1.86 vs 9.8 ± 1.97 g/dL and 3.75 ± 0.44 vs 3.38 ± 0.32 g/dL, p = 0.01 and 0.02, respectively). Our study demonstrates a surprisingly high prevalence of PHT among patients receiving long-term hemodialysis. Early detection is important in order to avoid the serious consequences of the disease.
Read full article here
Friday, May 28, 2010
Saturday, May 22, 2010
Regional citrate anticoagulation (RCA) .......
Submitted by Mr CS Soong
Regional citrate anticoagulation is safe in intermittent
high-flux haemodialysis treatment of children and
adolescents with an increased risk of bleeding
Web-Flash: 28 April 2010
Nephrology Dialysis Transplantation - NDT Advance Access
published online on April 26, 2010
Martin Kreuzer 1, Klaus-Eugen Bonzel 2, Rainer Büscher 2,
Gisela Offner 1, Jochen H.H. Ehrich 1 and Lars Pape 1
1 Department of Paediatric Nephrology, Hannover Medical
School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
2 Department of Paediatrics II, Paediatric Nephrology,
University of Duisburg Essen, Hufelandstrasse 55, 45122,
Essen, Germany
Abstract
Background. Regional citrate anticoagulation (RCA) is
strongly recommended for adults with an increased risk of
bleeding complications. The objective of this
retrospective analysis was to evaluate an RCA protocol
concerning feasibility and safety in intermittent
high-flux haemodialysis (iHD) treatment in children and
adolescents.
Methods. Eighteen children and adolescents aged 5–17
years (median 15 years) underwent 74 iHD treatment
sessions with RCA. Twelve of 18 patients presented with
overt local or diffuse haemorrhage before beginning the
HD sessions, and six had an increased risk of
haemorrhagic complications. Forty children on acute
haemodialysis with general heparin anticoagulation,
matched for bleeding risk, age and body surface area,
served as a control group. Citrate 3% solution was begun
with 3.3% blood flow rate, and calcium gluconate 10%
substitution was started with 0.4% of blood flow rate.
Citrate flow was adapted to achieve a post-filter ionized
calcium of 0.30 mmol/L; calcium substitution was adapted
to maintain the patients’ serum calcium levels within the
physiological range. Calcium-free dialysis fluid was
used. The blood flow rate ranged from 3 to 5 mL per
minute and kilogram body weight.
Results. Regional anticoagulation was successfully
achieved within the extracorporeal blood circuit, while
the coagulation of all 18 patients remained within
physiological parameters. No adverse effects of RCA were
observed. In all 18 children, neither new haemorrhage nor
worsening of the bleeding situation occurred, and in
10/12 patients, bleeding stopped during dialysis with
RCA. In contrast, one-third of the control group
developed new haemorrhagic complications or presented
with worsening of pre-existing bleeding during
haemodialysis (P = 0.006).
Conclusion. RCA is feasible, safe and effective in
paediatric intermittent haemodialysis treatment.
Regional citrate anticoagulation is safe in intermittent
high-flux haemodialysis treatment of children and
adolescents with an increased risk of bleeding
Web-Flash: 28 April 2010
Nephrology Dialysis Transplantation - NDT Advance Access
published online on April 26, 2010
Martin Kreuzer 1, Klaus-Eugen Bonzel 2, Rainer Büscher 2,
Gisela Offner 1, Jochen H.H. Ehrich 1 and Lars Pape 1
1 Department of Paediatric Nephrology, Hannover Medical
School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
2 Department of Paediatrics II, Paediatric Nephrology,
University of Duisburg Essen, Hufelandstrasse 55, 45122,
Essen, Germany
Abstract
Background. Regional citrate anticoagulation (RCA) is
strongly recommended for adults with an increased risk of
bleeding complications. The objective of this
retrospective analysis was to evaluate an RCA protocol
concerning feasibility and safety in intermittent
high-flux haemodialysis (iHD) treatment in children and
adolescents.
Methods. Eighteen children and adolescents aged 5–17
years (median 15 years) underwent 74 iHD treatment
sessions with RCA. Twelve of 18 patients presented with
overt local or diffuse haemorrhage before beginning the
HD sessions, and six had an increased risk of
haemorrhagic complications. Forty children on acute
haemodialysis with general heparin anticoagulation,
matched for bleeding risk, age and body surface area,
served as a control group. Citrate 3% solution was begun
with 3.3% blood flow rate, and calcium gluconate 10%
substitution was started with 0.4% of blood flow rate.
Citrate flow was adapted to achieve a post-filter ionized
calcium of 0.30 mmol/L; calcium substitution was adapted
to maintain the patients’ serum calcium levels within the
physiological range. Calcium-free dialysis fluid was
used. The blood flow rate ranged from 3 to 5 mL per
minute and kilogram body weight.
Results. Regional anticoagulation was successfully
achieved within the extracorporeal blood circuit, while
the coagulation of all 18 patients remained within
physiological parameters. No adverse effects of RCA were
observed. In all 18 children, neither new haemorrhage nor
worsening of the bleeding situation occurred, and in
10/12 patients, bleeding stopped during dialysis with
RCA. In contrast, one-third of the control group
developed new haemorrhagic complications or presented
with worsening of pre-existing bleeding during
haemodialysis (P = 0.006).
Conclusion. RCA is feasible, safe and effective in
paediatric intermittent haemodialysis treatment.
Friday, May 21, 2010
Sleep apnea syndrome........
Submitted by Mr CS Soong
Kidney International (2010) 77, 1031–1038;
Sydney C W Tang 1,2, Bing Lam 1, Tzy Jyun Yao 3, Wah Shing
Leung 2, Chung Ming Chu 2, Yiu Wing Ho 2, Mary S M Ip 1 and
Kar Neng Lai 1
1 Department of Medicine, The University of Hong Kong, Queen
Mary Hospital, Hong Kong China
2 Department of Medicine and Geriatrics, United Christian
Hospital, Hong Kong, China
3 Clinical Trials Center, The University of Hong Kong, Queen
Mary Hospital, Hong Kong, China
Abstract
Sleep apnea syndrome is increasingly recognized in
peritoneal dialysis patients; however, its prognostic
implication in this population is unknown.
To study this, we prospectively followed the clinical outcome of 93 peritoneal
dialysis patients with baseline polysomnography. Of these,
51 were diagnosed with the syndrome defined by an
apnea–hypopnea index (AHI) of at least 15 per hour. During a
median follow-up of 41 months, there were 30 deaths, of
which 17 were due to cardiovascular causes.
Kaplan–Meier analysis for the entire follow-up period
indicated that patients with sleep apnea at baseline had
significantly higher all-cause and cardiovascular mortality
during follow-up than those without. Minimal nocturnal
saturation and desaturation indices were predictors of
mortality and cardiovascular events at univariate analysis.
Multivariable Cox regression analysis identified significant
sleep apnea syndrome at baseline as an independent predictor
of increased all-cause mortality independent of age, male
gender, and diabetic status. Further, an absolute increase
in the AHI was associated with an incremental risk of
cardiovascular events.
Thus, sleep apnea syndrome, detected at the start of
peritoneal dialysis, is a novel risk predictor for
subsequent mortality and cardiovascular events.
Tuesday, May 18, 2010
Sodium ramping reduces hypotension......
Sodium ramping reduces hypotension and symptoms during haemodialysis
Dr. HL Tang & Co.
Division of Nephrology, Department of Medicine and Geriatrics, Princess Margaret Hospital, Laichikok, Hong Kong
Objectives. To evaluate the effectiveness of sodium ramping (profiling) in reducing hypotensive episodes and symptoms during haemodialysis.
Design. Prospective study.
Setting. Regional hospital, Hong Kong.
Patients. Thirteen patients who experienced frequent episodes of hypotension and/or symptoms such as cramps, dizziness, chest pain, nausea, vomiting, and headache during haemodialysis in the preceding 4 weeks.
Interventions. Each patient was switched from standard haemodialysis with a constant dialysate sodium concentration of 135 to 140 mmol/L to a ramped sodium haemodialysis for a period of 4 weeks. During this time the dialysate sodium concentration was ramped linearly downwards from 150 mmol/L at the beginning of dialysis to 140 mmol/L at the end of dialysis.
Main outcome measures. Intradialytic hypotensive episodes, intradialytic symptoms, nursing interventions, systolic and diastolic blood pressures, and interdialytic weight gain.
Results. A total of 248 haemodialysis sessions undertaken by 13 patients were analysed. Switching from constant sodium haemodialysis to ramped sodium haemodialysis resulted in a significant reduction in the number of intradialytic hypotensive episodes from 5.8 (standard deviation, 6.4) to 2.2 (3.3) [P<0.05], the total number of intradialytic symptoms from 7.1 (3.4) to 0.9 (1.3) [P<0.01], and nursing interventions from 11.3 (6.3) to 1.7 (3.9) [P<0.01]. Post-dialysis systolic and diastolic blood pressures were higher during ramped sodium haemodialysis compared with constant sodium haemodialysis (systolic blood pressure, 139 [standard deviation, 23] vs 133 [22] mm Hg, P<0.001; diastolic blood pressure, 77 [11] vs 74 [13] mm Hg, P<0.01), and there was a trend towards a smaller drop in blood pressure after dialysis. The interdialytic weight gain with sodium ramping haemodialysis was greater compared with constant sodium haemodialysis (3.1 [standard deviation, 1.0] vs 2.7 [1.1] kg, P<0.001).
Conclusion. Sodium ramping during haemodialysis effectively reduces hypotensive episodes and intradialytic symptoms. Post-dialysis blood pressure is better maintained. A side-effect of sodium ramping is a greater interdialytic weight gain.
Read article in full
Dr. HL Tang & Co.
Division of Nephrology, Department of Medicine and Geriatrics, Princess Margaret Hospital, Laichikok, Hong Kong
Objectives. To evaluate the effectiveness of sodium ramping (profiling) in reducing hypotensive episodes and symptoms during haemodialysis.
Design. Prospective study.
Setting. Regional hospital, Hong Kong.
Patients. Thirteen patients who experienced frequent episodes of hypotension and/or symptoms such as cramps, dizziness, chest pain, nausea, vomiting, and headache during haemodialysis in the preceding 4 weeks.
Interventions. Each patient was switched from standard haemodialysis with a constant dialysate sodium concentration of 135 to 140 mmol/L to a ramped sodium haemodialysis for a period of 4 weeks. During this time the dialysate sodium concentration was ramped linearly downwards from 150 mmol/L at the beginning of dialysis to 140 mmol/L at the end of dialysis.
Main outcome measures. Intradialytic hypotensive episodes, intradialytic symptoms, nursing interventions, systolic and diastolic blood pressures, and interdialytic weight gain.
Results. A total of 248 haemodialysis sessions undertaken by 13 patients were analysed. Switching from constant sodium haemodialysis to ramped sodium haemodialysis resulted in a significant reduction in the number of intradialytic hypotensive episodes from 5.8 (standard deviation, 6.4) to 2.2 (3.3) [P<0.05], the total number of intradialytic symptoms from 7.1 (3.4) to 0.9 (1.3) [P<0.01], and nursing interventions from 11.3 (6.3) to 1.7 (3.9) [P<0.01]. Post-dialysis systolic and diastolic blood pressures were higher during ramped sodium haemodialysis compared with constant sodium haemodialysis (systolic blood pressure, 139 [standard deviation, 23] vs 133 [22] mm Hg, P<0.001; diastolic blood pressure, 77 [11] vs 74 [13] mm Hg, P<0.01), and there was a trend towards a smaller drop in blood pressure after dialysis. The interdialytic weight gain with sodium ramping haemodialysis was greater compared with constant sodium haemodialysis (3.1 [standard deviation, 1.0] vs 2.7 [1.1] kg, P<0.001).
Conclusion. Sodium ramping during haemodialysis effectively reduces hypotensive episodes and intradialytic symptoms. Post-dialysis blood pressure is better maintained. A side-effect of sodium ramping is a greater interdialytic weight gain.
Read article in full
Thursday, May 13, 2010
PRURITUS IN HAEMODIALYSIS PATIENTS
By Dr. Giovambattista Virga
THE SYMPTOM
Pruritus is an unpleasant cutaneous sensation prompting a desire to scratch. It is a common and disturbing symptom among patients (pts) receiving hemodialysis (HD). The percentage of HD pts suffering from pruritus varies reportedly from 50% to 90% [1,2,3,4,5,6,7]. Interestingly, pruritus is typically not seen in acute renal failure [8].
PATHOPHYSIOLOGY
Itch is transmitted by dedicated C neurons and the proximity of dermal mast cells to afferent C neurons has suggested a functional relation between these two cell types: mast cell activation releases tryptase, which activates a receptor localised on C fibre nerve terminals that transmit the itching sensation to the central nervous system. Additionally, receptor activation will lead to a local release of substance P that activates dermal mast cells, resulting in an increased release of TNF- which in turn sensitises nociceptor nerve terminals and enhances their responsiveness [9]. Substance P, a neurotransmitter widely distributed in the afferent sensory neurons, can communicate pain and some itching sensations from the periphery to the central nervous system and is considered potentially responsible for itching [10,11]. It is a potent vasodilator and may serve as a mediator for axon reflex vasodilatation [12].
Read more here...
THE SYMPTOM
Pruritus is an unpleasant cutaneous sensation prompting a desire to scratch. It is a common and disturbing symptom among patients (pts) receiving hemodialysis (HD). The percentage of HD pts suffering from pruritus varies reportedly from 50% to 90% [1,2,3,4,5,6,7]. Interestingly, pruritus is typically not seen in acute renal failure [8].
PATHOPHYSIOLOGY
Itch is transmitted by dedicated C neurons and the proximity of dermal mast cells to afferent C neurons has suggested a functional relation between these two cell types: mast cell activation releases tryptase, which activates a receptor localised on C fibre nerve terminals that transmit the itching sensation to the central nervous system. Additionally, receptor activation will lead to a local release of substance P that activates dermal mast cells, resulting in an increased release of TNF- which in turn sensitises nociceptor nerve terminals and enhances their responsiveness [9]. Substance P, a neurotransmitter widely distributed in the afferent sensory neurons, can communicate pain and some itching sensations from the periphery to the central nervous system and is considered potentially responsible for itching [10,11]. It is a potent vasodilator and may serve as a mediator for axon reflex vasodilatation [12].
Read more here...
Wednesday, May 12, 2010
Sunday, May 9, 2010
H1N1 & CKD stage 5 Patients
The recent bout of H1N1 cases hitting Malaysia is worrisome to ordinary folks but what about CKD stage 5 patients. There are not many articles written on H1N1 and CKD stage 5 patients available todate.
Our own medical expert is of the opinion that CKD stage 5 patients should be encouraged to get the H1N1 vaccine. The dose should be the same. As for the side effect profile not much information is available as the vaccine is fairly new.
Please consult your Consultant Nephrologist before embarking to give your patients the vaccine. But this is something worth thinking about as CKD stage 5 patients are more susceptible to H1N1.
Our own medical expert is of the opinion that CKD stage 5 patients should be encouraged to get the H1N1 vaccine. The dose should be the same. As for the side effect profile not much information is available as the vaccine is fairly new.
Please consult your Consultant Nephrologist before embarking to give your patients the vaccine. But this is something worth thinking about as CKD stage 5 patients are more susceptible to H1N1.
Wednesday, May 5, 2010
Sunday, May 2, 2010
Photos - MSN 2010 Kuching
Photos taken at the recent MSN 2010 in Kuching, Sarawak have been uploaded for you...
Saturday, May 1, 2010
Ligther moments.....
ALWAYS ASK, NEVER ASSUME !!
His request approved, the CNN News photographer quickly used a cell phone to call the local airport to charter a flight.
He was told a twin-engine plane would be waiting for him at the airport
Arriving at the airfield, he spotted a plane warming up outside a hanger.
He jumped in with his bag, slammed the door shut, and shouted, 'Let's go'.
The pilot taxied out, swung the plane into the wind and took off.
Once in the air, the photographer instructed the pilot, 'Fly over the valley and make low passes so I can take pictures of the fires on the hillsides.'
'Why?' asked the pilot.
'Because I'm a photographer for CNN' , he responded, 'and I need to get some close up shots.'
The pilot was strangely silent for a moment, finally he stammered, 'So, what you're telling me, is . . . You're NOT my flight instructor?'
The moral of the story is...........
NEVER ASSUME!!!!!!
When you ASSUME = you make an ASS out of U and ME....
His request approved, the CNN News photographer quickly used a cell phone to call the local airport to charter a flight.
He was told a twin-engine plane would be waiting for him at the airport
Arriving at the airfield, he spotted a plane warming up outside a hanger.
He jumped in with his bag, slammed the door shut, and shouted, 'Let's go'.
The pilot taxied out, swung the plane into the wind and took off.
Once in the air, the photographer instructed the pilot, 'Fly over the valley and make low passes so I can take pictures of the fires on the hillsides.'
'Why?' asked the pilot.
'Because I'm a photographer for CNN' , he responded, 'and I need to get some close up shots.'
The pilot was strangely silent for a moment, finally he stammered, 'So, what you're telling me, is . . . You're NOT my flight instructor?'
The moral of the story is...........
NEVER ASSUME!!!!!!
When you ASSUME = you make an ASS out of U and ME....
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