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      Effect of Sertraline Hydrochloride on Cardiac Autonomic Dysfunction in Patients with Hemodialysis-Induced Hypotension

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          Background/Aims: It was previously shown that sertraline hydrochloride treatment improved hemodynamic parameters of patients with dialysis induced hypotension (DIH). The aim of this study was to examine the effect of sertraline on the autonomic functions of patients with DIH. Methods: Ten patients with DIH, 10 hemodialysis patients without DIH and 10 healthy control subjects were included into the study. All of the patients were treated with sertraline 50 mg per day for 4 weeks. Pre-treatment and post-treatment heart rate variability (HRV) in supine and tilt position was evaluated. In order to evaluate the autonomic response to tilt position, gap values were calculated by subtracting the HRV in supine position from the HRV in tilt position. Results: Analysis of the HRV response to tilt, demonstrated a paradoxical reduction in the indices of sympathetic modulation and sympathovagal balance in the patients with DIH while there was an increase in normalized powers of low frequency components (LFNU) and low frequency to high frequency components ratio (LFP/HFP) in the patients without DIH and control group. The number of therapeutic interventions for restoration of DIH decreased significantly in the sertraline period (p < 0.001). The gap values of the patients with DIH in LFNU (sympathetic modulation) (p < 0.05) and LFP/HFP (sympathovagal balance) increased in the sertraline period (p < 0.01). The decrease in gap value of normalized powers of high frequency components (parasympathetic modulation) was pronounced in the sertraline period in the patients with DIH (p < 0.05). Conclusion: The preventive effect of sertraline on DIH might be related to the improvement of regulation of autonomic response to hypovolemia.

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          Cardiac Autonomic Neuropathy in Patients with Chronic Renal Failure on Hemodialysis

          To characterize uremic cardiac autonomic neuropathy, we measured plasma catecholamines, analyzed the 24-hour heart rate variability (HRV), and acquired serial images with 123 I-metaiodobenzylguanidine (MIBG) in 44 patients with chronic renal failure on hemodialysis and in 14 controls. Time-domain measures were calculated using the Marquette HRV program. MIBG clearance rates from the heart and lung were evaluated on planar images, and the regional MIBG uptake in the left ventricular myocardium was evaluated with single-photon emission computed tomography. Compared with controls, plasma dopamine and norepinephrine levels were elevated (p < 0.001 and p = 0.03, respectively), and all the time-domain measures of HRV were reduced in the patients (p < 0.001). The MIBG clearance rate from the heart was higher (p < 0.001), that from the lung was lower (p < 0.001), and the myocardial MIBG distribution was more heterogeneous in patients than in controls (total uptake score p ≤ 0.03). These variables were similar between 26 patients without and 18 patients with hypertension. Uremic cardiac autonomic neuropathy may be characterized by high plasma levels of dopamine and norepinephrine, reduced HRV, and abnormal MIBG kinetics in the heart with heterogeneous myocardial MIBG distribution, suggesting cardiac sympathetic overactivity and parasympathetic deterioration. In addition, abnormal MIBG kinetics in the lung may imply pulmonary sympathetic nervous dysfunction and/or endothelial dysfunction in uremic patients.
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            Review Articles: Approach to Patients with Intradialytic Hypotension: A Focus on Therapeutic Options

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              Sertraline Hydrochloride Treatment for Patients with Hemodialysis Hypotension

              Background: Recently some pathogenetic parallels have been drawn between dialysis-induced hypotension and disorders characterized by hemodynamic instability due to autonomic dysfunction, such as neurocardiogenic syncope and idiopathic orthostatic hypotension. Several studies have shown that central serotonergic pathways participate in the abnormal response, and selective serotonin reuptake inhibitors improve the symptoms of patients with neurocardiogenic syncope or idiopathic orthostatic hypotension. In order to evaluate the effectiveness of sertraline on dialysis-induced hypotension a prospective study was designed. Methods: The data of 9 patients from a 4-week pre-sertraline period were compared with the data of a 4-week sertraline (100 mg daily) period. The therapeutic effect of sertraline requires 4 weeks. Therefore the sertraline period was begun 4 weeks after starting the drug. Results: Post-hemodialysis weights and ultrafiltration volumes were similar in the pre-sertraline and sertraline periods. There were also no changes in hematocrit and serum albumin. Both systolic and diastolic blood pressure before dialysis remained unchanged during sertraline treatment. The nadir systolic blood pressure and systolic blood pressure after dialysis increased significantly in the sertraline period. The nadir diastolic pressure was also increased significantly but the increase in post-dialysis diastolic blood pressure did not reach statistical significance. The necessity of therapeutic interventions per dialysis session decreased significantly in the sertraline period compared with pre-sertraline period. Conclusions: This pilot study has shown that sertraline has the potential to be a safe and effective therapy for dialysis hypotension. Long-term clinical and pathophysiological studies are currently in progress.

                Author and article information

                Nephron Physiol
                Nephron Physiology
                S. Karger AG
                January 2003
                30 October 2002
                : 93
                : 1
                : p21-p28
                Departments of aNephrology, bCardiology, cInternal Medicine, and dRadiology, Osmangazi University Medical School, and eONVAK Hemodialysis Center, Eskisehir, Turkey
                66655 Nephron Physiol 2003;93:p21–p28
                © 2003 S. Karger AG, Basel

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                Figures: 1, Tables: 3, References: 32, Pages: 1
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