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      Total Body Water and Failure to Control Blood Pressure by Medication in Hemodialysis Patients

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          Background: Volume overload is the main factor responsible for the pathogenesis of hypertension in dialysis patients. Few studies have evaluated the interpretation of the parameters obtained by bioelectrical impedance (BIA) to manage these patients. The aim of this study was to assess the best cutoff level of volume overload obtained by BIA able to predict the absence of hypertension control in hemodialysis patients. Methods: Volume overload was calculated as the difference between total body water (TBW) measured by bioimpedance and TBW estimated by the Watson formula in chronic stable hemodialysis patients. Inadequate control of blood pressure (BP) was defined as the mean of measurements obtained before five hemodialysis sessions ≥140 × 90 mm Hg. The best cutoff level of volume overload assessed by BIA able to predict the absence of BP control in patients on chronic hemodialysis was determined by the receiver operating characteristic (ROC) curve using the Youden method. Results: We included 205 patients, 53% male, aged 56 ± 14.5 years. The largest area under the ROC curve was found for predialysis volume overload (0.660, 95% CI 0.556-0.765, p = 0.004). The ROC curve of postdialysis volume overload also reaches statistical significance. The best cutoff point was found for predialysis volume overload ≥1.4 liters with a sensitivity of 69% and a specificity of 67%. Conclusion: The association of TBW and inadequate BP control highlights the importance of volume management in hemodialysis patients. Predialysis volume overload of 1.4 liters was the parameter that best discriminated the presence of inadequate BP control.

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          Most cited references 26

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          Fluid balance, dry weight, and blood pressure in dialysis.

          The total amount of sodium present in the body controls the extracellular volume. In advanced renal failure, sodium balance becomes positive and the extracellular volume expands. This leads to hypertension, and vascular changes that lead to adverse cardiovascular consequences in dialysis patients. Controlling the body sodium content and the extracellular volume allows one to better control hypertension and its consequences. This can be achieved by reducing the sodium input (sodium dietary restriction and reasonably low sodium dialysate) and/or by increasing the sodium output (ultrafiltration by convection). The discontinuous nature of hemodialysis causes saw-tooth volume fluctuations. This has led to the concept of dry weight (DW), a crucial component of dialysis adequacy. Assessment and achievement of DW is feasible on pure clinical grounds. But its relative lack of accuracy (and the physicians' progressive lack of interest in bedside examination) has led to several nonclinical methods of assessing DW in an effort to improve the assessment of fluid status in dialysis patients.
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            Hemodialysis-associated hypertension: pathophysiology and therapy.

            The majority of end-stage renal disease (ESRD) patients are hypertensive. Hypertension in the hemodialysis patient population is multifactorial. Further, hypertension is associated with an increased risk for left ventricular hypertrophy, coronary artery disease, congestive heart failure, cerebrovascular complications, and mortality. Antihypertensive medications alone do not adequately control blood pressure (BP) in hemodialysis patients. There are, however, several therapeutic options available to normalize BP in these patients, often without the need for additional drug therapy (eg, long, slow hemodialysis; short, daily hemodialysis; nocturnal hemodialysis; or, most effectively, dietary salt and fluid restriction in combination with reduction of dialysate sodium concentration). Optimal BP in dialysis patients is not different from recommendations for the general population, even though definite evidence is not yet available. Predialysis systolic and diastolic BPs are of particular importance. Left ventricular mass correlates with predialysis systolic BP. Survival is better in hemodialysis patients with a mean arterial pressure below 99 mm Hg as compared with those with higher BP. Low predialysis systolic BP (<110 mm Hg) and low predialysis diastolic BP (<70 mm Hg) are associated with increased mortality, primarily because of severe congestive heart failure or coronary artery disease. Patients that experience repeated intradialytic hypotensive episodes should also be viewed with caution, and predialytic BP values should be reevaluated. A possible treatment option for these patients may be slow, long hemodialysis; short, daily hemodialysis; or nocturnal hemodialysis. Among the antihypertensive agents currently available, angiotensin-converting enzyme (ACE) inhibitors appear to have the greatest ability to reduce left ventricular mass. Pressure load can be satisfactorily determined by using the average value of predialysis BP measurements over 1 month. In selected hemodialysis patients, interdialytic ambulatory blood pressure monitoring (ABPM) may help to determine if the patient is in fact hypertensive. In addition, ABPM provides important information about the change in BP between day and night. Regular home BP monitoring, yearly echocardiography, and treatment of traditional risk factors for cardiovascular disease are recommended. Copyright 2002 by the National Kidney Foundation, Inc.
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              Current state of bioimpedance technologies in dialysis.


                Author and article information

                Nephron Extra
                S. Karger AG
                May – August 2014
                03 July 2014
                : 4
                : 2
                : 95-100
                Botucatu School of Medicine, São Paulo State University, São Paulo, Brazil
                Author notes
                *Patricia Santi Xavier, Internal Medicine Department, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Rubião Junior S/N, Botucatu 18618-97C (Brazil), E-Mail
                363322 PMC4130821 Nephron Extra 2014;4:95-100
                © 2014 S. Karger AG, Basel

                Open Access License: This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial 3.0 Unported license (CC BY-NC) (, applicable to the online version of the article only. Distribution permitted for non-commercial purposes only. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 1, Tables: 2, Pages: 6
                Original Paper


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