KDIGO Controversies ConferenceWord文档格式.docx

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