KDIGO Controversies ConferenceWord文档格式.docx
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KDIGO Controversies ConferenceWord文档格式.docx
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Chazot,Charles...……….....…………………………………......………………6
Ecder,Tevfik...……….....…………………………………......………………8
Erdem,Yunus..……….....…………………………………………....…………10
Goldsmith,David...……….....…………………..…………………………………12
Lebel,Marcel..……….....………………………………………....……………16
Locatelli,Francesco
(2)..……….....………………………………….......……………18
Naicker,Sarala
(2)………….....……………………………………….....………….21
Suzuki,Hiromichi………….....…………………………………………......………25
Vaziri,N.D.……………………………………………………….......………27
Wizemann,Volker………….....……………………………………………….……30
RajivAgarwal,MD
Indianapolis,USA
BPMEASUREMENT,INTERDIALYTICHYPERTENSIONANDTHEROLEOFSALT
RajivAgarwal,MD,ProfessorofMedicine,IndianaUniversity,Indianapolis,IN,USA
Themanagementofhypertensioninhemodialysispatientsiscomplicatedbydifficultiesinmakinganaccuratediagnosisofhypertensioninthesepatients.Itisnowwellrecognizedthatbloodpressuresobtainedinthedialysisunitbeforeandafterdialysisareinaccurate,impreciseandbiasedestimatesofinterdialyticambulatorybloodpressurerecording1.DialysisunitBPsalsocorrelatepoorlywithleftventricularhypertrophy2.Ontheotherhand,themeanorthemedianofalldialysisunitbloodpressuremeasurementsobtainedduringadialysistreatmentcorrelatebestwithinterdialyticambulatorybloodpressures3.Thus,ifdialysisunitbloodpressuresaretobeusedforclinicaldecisionmaking,itappearsthatitmaybebettertousethemedianintradialyticbloodpressureinsteadofpreorpost-dialysisBP.
Self-measuredhomebloodpressuresobtained2-3timesdailyover4daysafteramid-weekdialysisaremuchbetterinpredictinginterdialyticambulatorybloodpressure,targetorgandamageandall-causemortality4-6.Homebloodpressurerecordingswillcorrectlydiagnosehypretension89%ofthetimewheninterdialyticambulatorybloodpressurerecordingsareusedasthereferencestandard4.Thus,homebloodpressuremonitoringshouldbecomethestandardofcarewhenmanaginghypertensioninhemodialysispatients7.Iadvocatetheuseofbloodpressuresobtainedbeforeandafterdialysistoensurehemodynamicstabilitywhereashomebloodpressuresformanaginghypertensioninhemodialysispatients.Whenusinganautomatic,validated,oscillometricdevice(suchasHEM705CP,OmronHealthCare,Bannockburn,IL),homebloodpressuresaveraging150mmHgormorecarries80%sensitivityand84%specificityindiagnosinghypertension4.
InterdialyticambulatoryBPmonitoringremainsausefultoolbecauseitstronglycorrelateswithmeasuresofarterialstiffnesssuchaspulsewavevelocity8.Increasingpulsewavevelocityisassociatedwithhighermeaninterdialyticambulatorysystolicandbloodpressureaswellashigherpulsepressure.Increasingsodiumintake,andconsequentlyincreasedinterdialyticweightgain,ontheotherhandisassociatedwithgreaterinterdialyticslopesofbloodpressure.
(1)AgarwalR,PeixotoAJ,SantosSF,ZoccaliC.Preandpostdialysisbloodpressuresareimpreciseestimatesofinterdialyticambulatorybloodpressure.ClinJAmSocNephrol2006;
1:
389-98.
(2)AgarwalR,BrimNJ,MahenthiranJ,AndersenMJ,SahaC.Out-of-hemodialysis-unitbloodpressureisasuperiordeterminantofleftventricularhypertrophy.Hypertension2006;
47:
62-8.
(3)AgarwalR,MetikuT,TegegneGG,LightRP,BunayeZ,BekeleDM,KelleyK.DiagnosingHypertensionbyIntradialyticBloodPressureRecordings.ClinJAmSocNephrol2008;
3:
1364-72.
(4)AgarwalR,AndersenMJ,BishuK,SahaC.Homebloodpressuremonitoringimprovesthediagnosisofhypertensioninhemodialysispatients.KidneyInt2006;
69:
900-6.
(5)AgarwalR,AndersenMJ,LightRP.LocationNotQuantityofBloodPressureMeasurementsPredictsMortalityinHemodialysisPatients.AmJNephrol2007;
28:
210-7.
(6)AlborziP,PatelN,AgarwalR.Homebloodpressuresareofgreaterprognosticvaluethanhemodialysisunitrecordings.ClinJAmSocNephrol2007;
2:
1228-34.
(7)AgarwalR.Howshouldhypertensionbeassessedandmanagedinhemodialysispatients?
HomeBP,notdialysisunitBP,shouldbeusedformanaginghypertension.SeminDial2007;
20:
402-5.
(8)AgarwalR,LightRP.Arterialstiffnessandinterdialyticweightgaininfluenceambulatorybloodpressurepatternsinhemodialysispatients.AmJPhysiolRenalPhysiol2007;
294:
F303-F308.
PeterJ.Blankestijn,MD
Utrecht,TheNetherlands
HYPERACTIVITYOFTHERENINANDSYMPATHETICNERVOUSSYSTEMINCKDSTAGEVPATIENTS
PeterJ.Blankestijn,UniversityMedicalCenterUtrecht,theNetherlands
MultiplelinesofevidenceindicatethatvolumeoverloadandenhancedactivitiesofthereninsystemandthesympatheticnervoussystemareimportantindetermininghypertensioninCKDstage5(reviewin1).Epidemiologicalstudiesindialysispatientsshowarelationshipbetweensympatheticactivityandcardiovascularmorbidityandmortality(2,3).Therefore,treatmentshouldbeaimedataddressingthesepathophysiologicalmechanisms.AsaconsequencethecombinationofvolumecorrectionandACEinhibitor/AngIIantagonististhecornerstoneoftreatment.
Severaluncertaintiesexist.
1]ACEi/ARBinusualdosagereducesbutnotnormalisessympatheticactivity(4).Higherthanusualdosagemaybenecessarytoobtainfullvascularprotection.Alternatively,theadditionofanothersympatholyticagenttotheACEi/ARBtreatmentmaybebeneficial.SomedataindeedsuggestthattheadditionofabetablockerorcombiningACEiwithARBmightimproveoutcomeindialysispatients(5).
2]Itisverywellpossiblethattheenhancedactivitiesofthereninandsympatheticsystemdecreaseorceasetoexistinthecourseof“dialysislife”asaresultofprogressivedestructionofkidneytissue.Nodataexistonhowtoidentifypatientswhowillespeciallybenefitofpharmacological(asadditiontovolumecorrection)treatment.
3]Frequentdialysis/highdosagehemodialysislowersympatheticoveractity(6).Themechanism(s)is(are)unknown.Itisnotknownwhetherpatientsonintensivedialysisschedulesbenefitofpharmacologicaltreatment.
Someselectedreferences
1.NeumannJ,LigtenbergG,Klein,II,KoomansHA,BlankestijnPJ.Sympathetichyperactivityinchronickidneydisease:
Pathogenesis,clinicalrelevance,andtreatment.KidneyInt2004;
65:
1568-1576.
2.ZoccaliC,MallamaciF,TripepiG,ParlongoS,CutrupiS,BenedettoFA,etal.Norepinephrineandconcentrichypertrophyinpatientswithend-stagerenaldisease.Hypertension2002;
40:
41-6.
3.ZoccaliC,MallamaciF,ParlongoS,CutrupiS,BenedettoFA,TripepiG,etal.Plasmanorepinephrinepredictssurvivalandincidentcardiovasculareventsinpatientswithend-stagerenaldisease.Circulation2002;
105:
1354-9.
4.NeumannJ,LigtenbergG,KleinIH,BoerP,OeyPL,KoomansHA,BlankestijnPJ.Sympathetichyperactivityinhypertensivechronickidneydiseasepatientsisreducedduringstandardtreatment.Hypertension2007;
49:
506-510.
5.CiceG,FerraraL,D'
AndreaA,D'
IsaS,DiBenedettoA,CittadiniA,etal.Carvedilolincreasestwo-yearsurvivalindialysispatientswithdilatedcardiomyopathy:
aprospective,placebo-controlledtrial.JAmCollCardiol2003;
41:
1438-44.
6.ZilchO,VosPF,OeyPL,CramerMJ,LigtenbergG,KoomansHA,BlankestijnPJ.Sympathetichyperactivityinhaemodialysispatientsisreducedbyshortdailyhaemodialysis.JHypertens2007;
25:
1285-1289.
CharlesChazot,MD
Tassin-la-Demi-Lune,France
THELAG-PHENOMENONOFHYPERTENSIONCORRECTIONINHEMODIALYSISPATIENTS:
AREAPPRAISAL
CharlesChazot,MD,Tassin-la-Demi-Lune,France
Thelagphenomenonisthedelaythatisobservedbetweenthereachofdryweightandtheplateauofnormalpredialysisbloodpressure1,2.Ithasbeenreportedinincidenthemodialysis(HD)patientsreceiving8-hourdialysis3timesaweekandinwhichthedryweightmethodwasapplied3.Thisphenomenonisalsodescribedwiththiazidetherapyinhypertensivepatients4.Oneofthestronghypothesestounderstandthesefindingsisthatthelagphenomenonisrelatedtothecorrectionofthecardiovascularremodelingassociatedwiththeextracellularvolume(ECV)overload5.Guyton’sexperimentinnephrectomizeddogsfedwithsaltyfoodhasshownthatafter2weekstheanimalspresentwithsustainedhypertensionandincreasedperipheralresistances6.PeripheralresistancesareoftenreportedincreasedinhypertensiveHDpatients7-9,whereastheywerefoundlowinTassinnormotensivepatients8UncontrolledstudieshaveshownanimprovementofcardiovascularremodelingbystrictvolumecontrolinHDpatients10,11.Themechanismsofvascularremodelinghavebeenrecentlyreviewed5includingtheroleofECVexpansiononouabaï
n-likecompoundsactingasNa-K-ATPaseinhibitors,theroleofhighsodiumintakeonnitricoxideimbalanceandalteredendothelialmetabolism.Inconclusion,theexistenceofthislagphenomenoninHDpatientsstressestheimportanceofthephysiopathologyofsodiumimbalanceandECVoverloadindialysispatients.IthighlightsthefactthatsustainedcorrectionofhypertensionismorethanshorttermECVcorrection.Isaprolongednegativesodiumbalancetheanswer?
NewtoolsareneededtofollownotonlytheECVbutalsothehemodynamicconsequencesofitsexpansion.
1.CharraB,BergstromJ,ScribnerBH.Bloodpressurecontrolindialysispatients:
importanceofthelagphenomenon.AmJKidneyDis1998;
32(5):
720-4.
2.ChazotC,CharraB,VoVanC,etal.TheJanus-facedaspec
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