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      Volume Status and Blood Pressure in Continuous Ambulatory Peritoneal Dialysis Patients

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          The pathophysiology of hypertension in dialysis patients is largely attributed to positive sodium balance and volume expansion. Whereas the relationship between fluid status and blood pressure control in hemodialysis patients is well established, this relationship is not well studied in peritoneal dialysis patients. Methods: 100 stable CAPD patients who had been dialyzed for more than 3 months, as well as 60 healthy controls, were studied cross-sectionally. CAPD patients were divided into three groups according to their blood pressure level: group 1 (normotension), group 2 (controlled hypertension with antihypertensive medication (AHM)) and group 3 (uncontrolled hypertension with AHM). Extracellular water (ECW) and intracellular water (ICW) were measured using bioimpedance spectroscopy in all subjects. Dialysis adequacy and transport test was conducted in each patient. Results: Height normalized ICW (nICW) was much lower, and ECW/ICW was higher in both male and female dialysis patients as compared to healthy controls. nECW was also significantly higher in group 3 when compared to group 1. The dose of AHM was similar in group 2 and group 3. In female CAPD patients, there were no differences in urinary volume (UV) and the total fluid removal among the three patient groups. However, in male CAPD patients, UV and total fluid removal were significantly higher in group 3 than in group 1. Renal and total removal of sodium was also significantly higher in group 3 male patients than group 1. Conclusions: Peritoneal dialysis patients with uncontrolled hypertension are more volume overloaded and their blood pressure may be difficult to control by AHM alone. These findings indicate that volume control preferably by dietary salt and fluid restriction should be intensified in hypertensive CAPD patients.

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          Most cited references 11

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          Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in overweight people with high-normal blood pressure. The Trials of Hypertension Prevention, phase II. The Trials of Hypertension Prevention Collaborative Research Group.

           JA Cutler (1997)
          To provide a firmer basis for preventing high blood pressure (BP), we tested interventions to promote weight loss, dietary sodium reduction, and their combination for lowering diastolic BP, systolic BP, and the incidence of hypertension during a 3- to 4-year period. We conducted a randomized, 2 x 2 factorial, clinical trial, with BP levels measured by blinded observers. Nine academic medical centers recruited 2382 men and women (age range, 30-54 years) not taking antihypertensive drugs, with a diastolic BP of 83 to 89 mm Hg, a systolic BP lower than 140 mm Hg, and a body mass index (the weight in kilograms divided by the square of the height in meters) representing 110% to 165% of desirable body weight. Counseling aimed at helping participants achieve their desirable weight or a 4.5-kg or more weight reduction (in the weight loss and combined groups) and/or sodium intake of 80 mmol/d (in the sodium reduction and combined groups) was provided. From baseline, participants' weight decreased by 4.3 to 4.5 kg at 6 months and by approximately 2 kg at 36 months in the weight loss and combined groups compared with weight changes in the usual care group (all groups, P or = 140 mm Hg systolic or > or = 90 mm Hg diastolic or the use of antihypertensive drugs) was significantly less in each active intervention group than the usual care group (average relative risks, 0.78-0.82). In overweight adults with high-normal BP, weight loss and reduction in sodium intake, individually and in combination, were effective in lowering systolic and diastolic BP, especially in the short-term (6 months). Although the effects on average BP declined over time, reductions in hypertension incidence were achieved.
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            Survival as an index of adequacy of dialysis.

            To examine how patient survival substantiates dialysis adequacy, 20-year actuarial survival experience was calculated for 445 unselected hemodialysis (HD) patients (97 patients accepted on a temporary basis--and usually kept on their regular dialysis scheme--were left out). The dose of dialysis has been the same and unchanged for all patients since beginning: 24 square meter hours of Kiil dialysis (cuprophane) per week with acetate buffered dialysate. KT/V mean (SD) was 1.67 (0.41). Six months after starting dialysis, 98% of patients were normotensive and off all blood pressure (BP) medication. The mean population hematocrit, excluding the only 6 patients receiving erythropoietin supplementation, was 28%. Survival rate was 87% at 5 years, 75% at 10 years, 55% at 15 years, and 43% at 20 years of HD. The satisfactory control of BP without using potentially toxic BP drugs and the higher than usual dose of dialysis are two possible explanations for survival data better than usually reported. We suggest that patient survival should be considered as the best overall index of adequacy of dialysis.
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              Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease.

              A cohort of 432 ESRD (261 hemodialysis and 171 peritoneal dialysis) patients was followed prospectively for an average of 41 months. Baseline and annual demographic, clinical and echocardiographic assessments were performed, as well as serial clinical and laboratory tests measured monthly while on dialysis therapy. The average mean arterial blood pressure level during dialysis therapy was 101 +/- 11 mm Hg. After adjusting for age, diabetes and ischemic heart disease, as well as hemoglobin and serum albumin levels measured serially, each 10 mm Hg rise in mean arterial blood pressure was independently associated with: the presence of concentric LV hypertrophy (OR 1.48, P = 0.02), the change in LV mass index (beta = 5.4 g/m2, P = 0.027) and cavity volume (beta = 4.3 ml/m2, P = 0.048) on follow-up echocardiography, the development of de novo cardiac failure (RR 1.44, P = 0.007), and the development of de novo ischemic heart disease (RR 1.39, P = 0.05). The association with LV dilation was of borderline statistical significance (OR 1.48, P = 0.06). Mean arterial blood pressures greater than 106 mm Hg were associated with both echocardiographic and clinical endpoints. Paradoxically, low mean arterial blood pressure (RR 1.36 per 10 mm Hg fall, P = 0.009) was independently associated with mortality. The association of low blood pressure with mortality was a marker for having had cardiac failure prior to death. We conclude that even moderate hypertension worsens the echocardiographic and clinical outcome in ESRD patients, especially in those without previous clinical cardiac disease.

                Author and article information

                Blood Purif
                Blood Purification
                S. Karger AG
                August 2005
                25 August 2005
                : 23
                : 5
                : 373-378
                aInstitute of Nephrology, Peking University, Beijing, China; bDivisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Karolinska Institutet, Stockholm, Sweden
                87194 Blood Purif 2005;23:373–378
                © 2005 S. Karger AG, Basel

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                Page count
                Figures: 2, Tables: 3, References: 22, Pages: 6
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                Original Paper

                Cardiovascular Medicine, Nephrology

                Volume status, Blood pressure, Peritoneal dialysis


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