KDIGO Controversies ConferenceWord文档格式.docx

1、Chazot, Charles .6Ecder, Tevfik .8Erdem, Yunus .10Goldsmith, David .12Lebel, Marcel .16Locatelli, Francesco （2） .18 Naicker, Sarala （2） .21 Suzuki, Hiromichi .25Vaziri, N.D. .27Wizemann, Volker .30Rajiv Agarwal, MDIndianapolis, USABP MEASUREMENT, INTERDIALYTIC HYPERTENSION AND THE ROLE OF SALTRajiv

2、Agarwal, MD, Professor of Medicine, Indiana University, Indianapolis, IN, USAThe management of hypertension in hemodialysis patients is complicated by difficulties in making an accurate diagnosis of hypertension in these patients. It is now well recognized that blood pressures obtained in the dialys

3、is unit before and after dialysis are inaccurate, imprecise and biased estimates of interdialytic ambulatory blood pressure recording 1. Dialysis unit BPs also correlate poorly with left ventricular hypertrophy 2. On the other hand, the mean or the median of all dialysis unit blood pressure measurem

4、ents obtained during a dialysis treatment correlate best with interdialytic ambulatory blood pressures 3. Thus, if dialysis unit blood pressures are to be used for clinical decision making, it appears that it may be better to use the median intradialytic blood pressure instead of pre or post-dialysi

5、s BP.Self-measured home blood pressures obtained 2-3 times daily over 4 days after a mid-week dialysis are much better in predicting interdialytic ambulatory blood pressure, target organ damage and all-cause mortality 4-6. Home blood pressure recordings will correctly diagnose hypretension 89% of th

6、e time when interdialytic ambulatory blood pressure recordings are used as the reference standard 4. Thus, home blood pressure monitoring should become the standard of care when managing hypertension in hemodialysis patients 7. I advocate the use of blood pressures obtained before and after dialysis

7、 to ensure hemodynamic stability whereas home blood pressures for managing hypertension in hemodialysis patients. When using an automatic, validated, oscillometric device （such as HEM 705CP, Omron HealthCare, Bannockburn, IL）, home blood pressures averaging 150 mmHg or more carries 80% sensitivity a

8、nd 84% specificity in diagnosing hypertension 4. Interdialytic ambulatory BP monitoring remains a useful tool because it strongly correlates with measures of arterial stiffness such as pulse wave velocity 8. Increasing pulse wave velocity is associated with higher mean interdialytic ambulatory systo

9、lic and blood pressure as well as higher pulse pressure. Increasing sodium intake, and consequently increased interdialytic weight gain, on the other hand is associated with greater interdialytic slopes of blood pressure. （1） Agarwal R, Peixoto AJ, Santos SF, Zoccali C. Pre and post dialysis blood p

10、ressures are imprecise estimates of interdialytic ambulatory blood pressure. Clin J Am Soc Nephrol 2006;1:389-98. （2） Agarwal R, Brim NJ, Mahenthiran J, Andersen MJ, Saha C. Out-of-hemodialysis-unit blood pressure is a superior determinant of left ventricular hypertrophy. Hypertension 2006;47:62-8.

11、（3） Agarwal R, Metiku T, Tegegne GG, Light RP, Bunaye Z, Bekele DM, Kelley K. Diagnosing Hypertension by Intradialytic Blood Pressure Recordings. Clin J Am Soc Nephrol 2008;3:1364-72. （4） Agarwal R, Andersen MJ, Bishu K, Saha C. Home blood pressure monitoring improves the diagnosis of hypertension i

12、n hemodialysis patients. Kidney Int 2006;69:900-6. （5） Agarwal R, Andersen MJ, Light RP. Location Not Quantity of Blood Pressure Measurements Predicts Mortality in Hemodialysis Patients. Am J Nephrol 2007;28:210-7. （6） Alborzi P, Patel N, Agarwal R. Home blood pressures are of greater prognostic val

13、ue than hemodialysis unit recordings. Clin J Am Soc Nephrol 2007;2:1228-34. （7） Agarwal R. How should hypertension be assessed and managed in hemodialysis patients? Home BP, not dialysis unit BP, should be used for managing hypertension. Semin Dial 2007;20:402-5. （8） Agarwal R, Light RP. Arterial st

14、iffness and interdialytic weight gain influence ambulatory blood pressure patterns in hemodialysis patients. Am J Physiol Renal Physiol 2007;294:F303-F308.Peter J. Blankestijn, MDUtrecht, The NetherlandsHYPERACTIVITY OF THE RENIN AND SYMPATHETIC NERVOUS SYSTEM IN CKD STAGE V PATIENTSPeter J. Blankes

15、tijn, University Medical Center Utrecht, the Netherlands Multiple lines of evidence indicate that volume overload and enhanced activities of the renin system and the sympathetic nervous system are important in determining hypertension in CKD stage 5 （review in 1）. Epidemiological studies in dialysis

16、 patients show a relationship between sympathetic activity and cardiovascular morbidity and mortality （2,3）. Therefore, treatment should be aimed at addressing these pathophysiological mechanisms. As a consequence the combination of volume correction and ACE inhibitor / AngII antagonist is the corne

17、rstone of treatment.Several uncertainties exist. 1 ACEi/ARB in usual dosage reduces but not normalises sympathetic activity （4）. Higher than usual dosage may be necessary to obtain full vascular protection. Alternatively, the addition of another sympatholytic agent to the ACEi/ARB treatment may be b

18、eneficial. Some data indeed suggest that the addition of a betablocker or combining ACEi with ARB might improve outcome in dialysis patients （5）. 2 It is very well possible that the enhanced activities of the renin and sympathetic system decrease or cease to exist in the course of “dialysis life” as

19、 a result of progressive destruction of kidney tissue. No data exist on how to identify patients who will especially benefit of pharmacological （as addition to volume correction） treatment. 3 Frequent dialysis / high dosage hemodialysis lower sympathetic overactity （6）. The mechanism（s） is （are） unk

20、nown. It is not known whether patients on intensive dialysis schedules benefit of pharmacological treatment. Some selected references1. Neumann J, Ligtenberg G, Klein, II, Koomans HA, Blankestijn PJ. Sympathetic hyperactivity in chronic kidney disease: Pathogenesis, clinical relevance, and treatment

21、. Kidney Int 2004;65:1568-1576.2. Zoccali C, Mallamaci F, Tripepi G, Parlongo S, Cutrupi S, Benedetto FA, et al. Norepinephrine and concentric hypertrophy in patients with end-stage renal disease. Hypertension 2002;40:41-6.3. Zoccali C, Mallamaci F, Parlongo S, Cutrupi S, Benedetto FA, Tripepi G, et

22、 al. Plasma norepinephrine predicts survival and incident cardiovascular events in patients with end-stage renal disease. Circulation 2002;105:1354-9.4. Neumann J, Ligtenberg G, Klein IH, Boer P, Oey PL, Koomans HA, Blankestijn PJ. Sympathetic hyperactivity in hypertensive chronic kidney disease pat

23、ients is reduced during standard treatment. Hypertension 2007;49:506-510. 5. Cice G, Ferrara L, DAndrea A, DIsa S, Di Benedetto A, Cittadini A, et al. Carvedilol increases two-year survivalin dialysis patients with dilated cardiomyopathy: a prospective, placebo-controlled trial. J Am Coll Cardiol 20

24、03;41:1438-44.6. Zilch O, Vos PF, Oey PL, Cramer MJ, Ligtenberg G, Koomans HA, Blankestijn PJ. Sympathetic hyperactivity in haemodialysis patients is reduced by short daily haemodialysis. J Hypertens 2007;25:1285-1289.Charles Chazot, MDTassin-la-Demi-Lune, FranceTHE LAG-PHENOMENON OF HYPERTENSION CO

25、RRECTION IN HEMODIALYSIS PATIENTS: A REAPPRAISALCharles Chazot, MD, Tassin-la-Demi-Lune, FranceThe lag phenomenon is the delay that is observed between the reach of dry weight and the plateau of normal predialysis blood pressure 1, 2. It has been reported in incident hemodialysis （HD） patients recei

26、ving 8-hour dialysis 3 times a week and in which the dry weight method was applied 3. This phenomenon is also described with thiazide therapy in hypertensive patients 4. One of the strong hypotheses to understand these findings is that the lag phenomenon is related to the correction of the cardiovas

27、cular remodeling associated with the extracellular volume （ECV） overload 5. Guytons experiment in nephrectomized dogs fed with salty food has shown that after 2 weeks the animals present with sustained hypertension and increased peripheral resistances 6. Peripheral resistances are often reported inc

28、reased in hypertensive HD patients 7-9, whereas they were found low in Tassin normotensive patients 8 Uncontrolled studies have shown an improvement of cardiovascular remodeling by strict volume control in HD patients 10, 11. The mechanisms of vascular remodeling have been recently reviewed 5 includ

29、ing the role of ECV expansion on ouaban-like compounds acting as Na-K-ATPase inhibitors, the role of high sodium intake on nitric oxide imbalance and altered endothelial metabolism. In conclusion, the existence of this lag phenomenon in HD patients stresses the importance of the physiopathology of s

30、odium imbalance and ECV overload in dialysis patients. It highlights the fact that sustained correction of hypertension is more than short term ECV correction. Is a prolonged negative sodium balance the answer? New tools are needed to follow not only the ECV but also the hemodynamic consequences of its expansion. 1. Charra B, Bergstrom J, Scribner BH. Blood pressure control in dialysis patients: importance of the lag phenomenon. Am J Kidney Dis 1998;32（5）:720-4.2. Chazot C, Charra B, Vo Van C, et al. The Janus-faced aspec