Prehypertension - Time to Act Preeti Gupta1, Shankar Prasad Nagaraju2, Ankur Gupta2, Kiran B Mandya Chikkalingaiah3 1 Central Government Health Scheme, New Delhi, India 2 Division of Nephrology, The Ottawa Hospital, Ottawa, Canada3 Nephrology Division, University of Tennessee, Memphis, USA Saudi Journal of Kidney Diseases and Transplantation Pg 223-333, Issue 2,  Vol 23  Year 2012 Abstract The term "prehypertension" defined as systolic blood pressure between 120 and 139 mmHg and/or  diastolic pressures between 80 and 89 mmHg has now gained general acceptance. Prehypertension is associated with ~3-fold greater likelihood of developing hypertension, and roughly twice the number of cardiovascular events, than BP < 120/80 mmHg. When compared with normotensive individuals, prehypertensive individuals are more likely to be overweight and obese, to have other cardiovascular risk factors, to progress to established hypertension, and to experience premature clinical cardiovascular disease. The major unresolved issue is the appropriate manage­ment of such patients. Lifestyle modification is recommended for all patients with prehypertension as it effectively reduces rate of cardiovascular events. Presently pharmacological therapy is indicated for some patients with prehypertension who have specific comorbidities, including diabetes mellitus, chronic kidney disease, and coronary artery disease.

Acute removal of common sepsis mediators does not explain the effects of extracorporeal blood purification in experimental sepsis

Zhi-Yong Peng^1,4, Hong-Zhi Wang^1,2,4, Melinda J Carter¹, Morgan V Dileo³, Jeffery V Bishop¹, Fei-Hu Zhou¹, Xiao-Yan Wen¹, Thomas Rimmelé¹, Kai Singbartl¹, William J Federspiel^1,3, Gilles Clermont^1,3 and John A Kellum^1,

1. ¹The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
2. ²Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Intensive Care Unit, Peking University School of Oncology, Beijing Cancer Hospital and Institute, Beijing, China
3. ³McGowan Institute for Regenerative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA

Kidney International (2012) 81, 363–369; doi:10.1038/ki.2011.320; published online 14 September 2011

http://www.nature.com/ki/journal/v81/n4/abs/ki2011320a.html

Abstract

The effect of extracorporeal blood purification on clinical outcomes in sepsis is assumed to be related to modulation of plasma cytokine concentrations. To test this hypothesis directly, we treated rats that had a cecal ligation followed by puncture (a standard model of sepsis) with a modest dose of extracorporeal blood purification that did not result in acute changes in a panel of common cytokines associated with inflammation (TNF-α, IL-1β, IL-6, and IL-10). 

Pre- and immediate post-treatment levels of these cytokines were unchanged compared to the sham therapy of extracorporeal circulation without blood purifying sorbent. The overall survival to 7 days, however, was significantly better in animals that received extracorporeal blood purification compared to those with a sham procedure. This panel of common plasma cytokines along with alanine aminotransferase and creatinine was significantly lower 72 h following extracorporeal blood purification compared to sham-treated rats. Thus, the effects of this procedure on organ function and survival do not appear to be due solely to immediate changes in the usual measured circulating cytokines. 

These results may have important implications for the design and conduct of future trials in sepsis including defining alternative targets for extracorporeal blood purification and other therapies

Non-infected hemodialysis catheters are associated with increased inflammation compared to arteriovenous fistulasNon-infected catheters increase CRP

Stuart L Goldstein, T Alp Ikizler, Michael Zappitelli, Douglas M Silverstein and Juan C Ayus

Kidney International 76, 1063-1069 (November (2) 2009) doi:10.1038/ki.2009.303http://www.nature.com/ki/journal/v76/n10/full/ki2009303a.html

Although hemodialysis catheters predispose to infection which, in turn, causes inflammation, we studied whether they induce inflammation independent of infection. We compared the level of the inflammatory marker C-reactive protein (CRP) in maintenance hemodialysis patients, comparing those dialyzed using a non-infected catheter to those using arteriovenous fistulas. All incident patients had catheters and fistula placement at dialysis initiation. In 35 patients the fistulas matured, the catheters were removed and the patients were evaluated at 6 months (catheter–fistula). 

These results were compared to 15 patients in whom the fistula did not mature and catheter use persisted for 6 months (catheter–catheter). There was a significant 82% reduction in the CRP level in the catheter–fistula group but a 16% increase in the catheter–catheter group at 6 months. The changes in CRP did not differ by gender, diabetes status, or by race, and was not correlated with a change in phosphorus, age, or urea reduction ratio at 1 month following hemodialysis initiation. Decreased CRP was associated with increased hemoglobin and albumin. Patients with persistent fistula use from dialysis initiation through 6 months had consistently low CRP levels over that time period. 

Our study shows that catheters might contribute to increased inflammation independent of infection, and supports avoidance of catheters and a timely conversion to fistulas with catheter removal.

Dietary salt influences postprandial plasma sodium concentration and systolic blood pressure

Rebecca J Suckling¹, Feng J He², Nirmala D Markandu² and Graham A MacGregor²

1. ¹Department of Cardiovascular Medicine, St George's University of London, London, UK
2. ²Barts and The London School of Medicine & Dentistry, Wolfson Institute of Preventive Medicine, London, UK

Kidney International (2012) 81, 407–411; doi:10.1038/ki.2011.369; published online 2 November 2011

The plasma sodium concentration has a direct effect on blood pressure in addition to its effects on extracellular volume regulated through changes in the endothelium. The mechanism for elevated blood pressure seen with habitually increased salt intake is unclear, especially the effect of salt in a single meal on plasma sodium concentration and blood pressure. 

To resolve this we compared the effect of soup with or without 6 g of salt (an amount similar to that in a single meal) on the plasma sodium concentration and blood pressure in 10 normotensive volunteers using a randomized, crossover design. The plasma sodium concentration was significantly increased by 3.13±0.75 mmol/l with salted compared with unsalted soup. Blood pressure increased in volunteers ingesting soup with added salt, and there was a significant positive correlation between plasma sodium concentration and systolic blood pressure. A 1-mmol/l increase in plasma sodium was associated with a 1.91-mm Hg increase in systolic blood pressure by linear regression. 

Thus, changes in plasma sodium concentration occur each time a meal containing salt is consumed. A potential mechanism for the changes in blood pressure seen with salt intake may be through its effects on plasma sodium concentration.

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Does a reduction in dialysate sodium improve blood pressure control in 

haemodialysis patients?

Anoop Shah MRCP1, 2, Andrew Davenport FRCP1

1.UCL Centre for Nephrology, Royal Free Hospital, University College London, Medical School, London.

2. Department of Clinical Toxicology, Guy's and St Thomas’ NHS Foundation Trust, London

Nephrology - Vol. 17 Issue 2 DOI: 10.1111/j.1440-1797.2012.01576.x

Submitted by Mr CS Soong

Abstract

Introduction:  There has been debate as to the value of lower sodium dialysates to control blood pressure in haemodialysis patients, as sodium is predominantly removed by ultrafiltration.

Methods:  Re-audit of clinical practice following reduction in dialysate sodium concentration.

Results:  Overall dialysate sodium concentration decreased from 138.9 ± 1.7 to 137.8 ± 1.7 mmol/l (mean ± standard deviation), resulting in a reduction in pre and post dialysis mean arterial pressure (MAP) of 4 mmHg (from 100.6 ± 15.6 to 97.1 ± 15.6, p < 0.01 and from 91.7 ± 15.6 to 87.1 ± 14.6, p < 0.001 respectively), yet fewer patients were prescribed antihypertensives (49.6 vs 60.6%), and less antihypertensive medications/patient (mean 0.86 vs 1.05), ultrafiltration requirements (2.8% vs 3.2% body weight, p < 0.001), and symptomatic intradialytic hypotension (0.19 vs 0.28 episodes per week, p < 0.001). A multivariable model showed that for a dialysate sodium of 136 mmol/l, younger patients had higher MAP than older patients (0.35 mmHg lower MAP/year older; but with a dialysate sodium of 140 mmol/l, there was minimal association of MAP with age (0.07 mmHg higher MAP/year older).

Conclusion:  Change in clinical practice, amounting to a modest reduction

Health Ministry to hire graduate nurses

By JOSEPH SIPALAN - jsipalan@thestar.com.my

http://thestar.com.my/news/story.asp?file=/2012/2/7/nation/10687110&sec=nation

PUTRAJAYA: The Health Ministry is working on creating vacancies at government hospitals to absorb the large number of unemployed graduate nurses.

Health Minister Datuk Seri Liow Tiong Lai said a special committee, led by Health director-general Datuk Seri Dr Hasan Abdul Rahman, had been set up to find a solution to the issue.

“We are working on a programme to promote those who are already in the system and the vacancies can then be filled up by the graduates,” he said yesterday.

Liow pointed out that the proposed programme aimed to train the current crop of nurses to specialise in one of the many fields in government hospitals and in the process, create vacancies in lower-level positions.

In the long run, however, he said private institutions of higher learning would need to streamline their syllabus to match the demands of the local health industry.

Over the past week, The Star ran several reports highlighting the difficulty faced by nursing graduates from private institutes in finding jobs.

A government study found that over 54% of private nursing diploma graduates could not find work three to four months after graduating in 2010, compared to 21.7% in 2008.

Liow said the main factor leading to the surplus of nursing graduates was that private institutes appeared to not be in touch with the areas of expertise that were in demand.

He said the Government currently runs around 30 colleges, whose graduates are trained to meet the needs of public hospitals.

On the other hand, most of the estimated 70 private nursing colleges nationwide were providing general training and in many cases, did not meet private sector demand for specialised nurses.

“We are not looking at it as a surplus. We do need nurses, and so does the private sector because it is also expanding.

“This is mostly an issue of a mismatch between training and market demand. However, we do not control the numbers (of student intake) in private colleges.

“This is something we will have to work out with the Higher Education Ministry, and hopefully all of this (syllabus and market demand) will be streamlined,” he said.

Liow did not give a deadline for the committee to find a solution, saying that it had only just been formed and held its first meeting recently.

Nasal Carriage of Methicillin-resistant Staphylococcus aureus Is Associated with Higher All-Cause Mortality in Hemodialysis Patients.

1. Chun-Fu Lai*, 
 
2. Chun-Hsing Liao*^†, 
 
3. Mei-Fen Pai*^†, 
 
4. Fang-Yeh Chu^‡,
 
5. Shih-Ping Hsu*^†, 
6. Hung-Yuan Chen*^†, 
 
7. Ju-Yeh Yang*^†, 
 
8. Yen-Ling Chiu*^†,
 
9. Yu-Sen Peng*^†, 
10. Shan-Chwen Chang*, 
 
11. Kuan-Yu Hung*, 
 
12. Tun-Jun Tsai*,
 
13. Kwan-Dun Wu*

Clinical Journal of American Society of Nephrology Jan 2011

Abstract

Background and objectives Methicillin-resistant Staphylococcus aureus(MRSA) nasal carriage is a recognized risk factor for subsequent endogenous infections. However, the association between MRSA carriage and patient survival in hemodialysis patients has not been established.

Design, setting, participants, & measurements In March 2007, this prospective cohort study enrolled 306 outpatients under maintenance hemodialysis from a hospital-based dialysis center in Taiwan. They received two consecutive weekly nasal swab cultures at the beginning of the study. Patients having at least one positive culture of MRSA were defined as MRSA carriers. Subjects were followed up until December 31, 2008. The primary outcome was all-cause mortality. Main secondary outcomes were infection-related mortality and morbidity.

Results We identified 29 MRSA carriers (9.48%) at study entry. After a median of 613 days of follow-up, Kaplan-Meier analysis showed significant survival differences between MRSA carriers and noncarriers (log-rank P = 0.02). Compared with noncarriers, MRSA carriers had a 2.46-fold increased risk of dying from any cause, after adjusting for covariates at the start of follow-up. The adjusted hazard ratios of infection-related mortality and occurrence of subsequent S. aureusinfection in carriers were 4.99 and 4.31, respectively.

Conclusions A major limitation is the relatively small sample size of MRSA carriers. Nevertheless, we demonstrated that there may be an association between MRSA nasal carriage and poor clinical outcomes in an outpatient hemodialysis population. This underscores the need for routine surveillance of MRSA nasal carriage and should alert the physicians of a group at high risk of morbidity and mortality.

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