Chronic kidney disease (CKD) is a growing public health problem. The incidence of kidney failure is rising in all age groups but particularly in older adults. Individuals in all stages of CKD are at higher risk for development of cognitive impairment and this may be a major determinant in their quality of life. Furthermore, cognitive impairment is associated with an increased risk of death in dialysis patients. Cerebrovascular disease is a strong risk factor for development of cognitive impairment and vascular disease is a more likely cause of cognitive impairment than Alzheimer's disease in patients with CKD. Both traditional and nontraditional vascular risk factors are more common in CKD and dialysis patients may also be at risk for cognitive impairment via nonvascular risk factors and the hemodialysis procedure itself. Unfortunately, because risk factors for cognitive impairment in CKD have not been thoroughly ascertained, evaluation of potential treatments has been limited. Given the high prevalence of cognitive impairment in all stages of CKD, additional studies are needed to evaluate potential risk factors and treatments in this vulnerable population.

No abstract

The optimal BP target for patients receiving hemodialysis is unknown. We randomized 126 hypertensive patients on hemodialysis to a standardized predialysis systolic BP of 110-140 mmHg (intensive arm) or 155-165 mmHg (standard arm). The primary objectives were to assess feasibility and safety and inform the design of a full-scale trial. A secondary objective was to assess changes in left ventricular mass. Median follow-up was 365 days. In the standard arm, the 2-week moving average systolic BP did not change significantly during the intervention period, but in the intensive arm, systolic BP decreased from 160 mmHg at baseline to 143 mmHg at 4.5 months. From months 4-12, the mean separation in systolic BP between arms was 12.9 mmHg. Four deaths occurred in the intensive arm and one death occurred in the standard arm. The incidence rate ratios for the intensive compared with the standard arm (95% confidence intervals) were 1.18 (0.40 to 3.33), 1.61 (0.87 to 2.97), and 3.09 (0.96 to 8.78) for major adverse cardiovascular events, hospitalizations, and vascular access thrombosis, respectively. The intensive and standard arms had similar median changes (95% confidence intervals) in left ventricular mass of -0.84 (-17.1 to 10.0) g and 1.4 (-11.6 to 10.4) g, respectively. Although we identified a possible safety signal, the small size and short duration of the trial prevent definitive conclusions. Considering the high risk for major adverse cardiovascular events in patients receiving hemodialysis, a full-scale trial is needed to assess potential benefits of intensive hypertension control in this population.

Despite their propensity for significant complications, tunneled central venous catheters have become a common means of vascular access in the United States for patients requiring maintenance hemodialysis for end-stage renal disease (ESRD). Reasons for their use include advanced patient age, peripheral vascular disease (arterial and venous), late referral for creation of vascular access, and more importantly, the lack of an interdisciplinary service line on vascular access among vascular surgeons, radiologists, and nephrologists. This review article summarizes complications commonly encountered in dialysis patients who use tunneled central venous catheters for vascular access-mainly thrombosis, stenosis, and infection. Special attention is given to novel approaches for the prevention of catheter-associated infections. Effective prevention and timely treatment of common catheter-associated complications can reduce the substantial morbidity associated with the use of these devices. However, these measures should not detract from the goal of avoiding or limiting the long-term use of catheters, thereby optimizing vascular access management by ensuring the timely availability of functioning arteriovenous fistulas.

There is no widely accepted definition of intradialytic hypertension. Arbitrary clinical definitions have included an increase in blood pressure during or immediately after hemodialysis, a rise in blood pressure during the second or third hour of dialysis, and an increase in blood pressure that is resistant to ultrafiltration. To date, no studies have evaluated the prevalence and prognostic importance of intradialytic hypertension. The pathogenesis of intradialytic hypertension is complex and is due in part to extracellular fluid volume expansion, increased cardiac output, activation of the renin-angiotensin system and the sympathetic nervous system, increased circulating vasoactive substances resulting in peripheral vasoconstriction, erythropoietin use, and fluctuations in electrolytes and removal of antihypertensive medications during the dialysis procedure. Management strategies of intradialytic hypertension are based on expert opinion using the pathophysiologic principles described above. We conclude that additional epidemiologic, basic science, and interventional studies are needed to further elucidate the prevalence, prognostic importance, pathophysiology, and potential treatment of intradialytic hypertension.

Frequent IDH is associated with high IDWGs and a poor prognosis. Studies on prolonged dialysis, biofeedback devices and cooled dialysate have yielded promising results. Intradialytic relative blood volume monitoring devices have been investigated in preventing IDH but results are mixed. Administration of a sodium/hydrogen exchange isoform 3 inhibitor increases stool sodium but has not been shown to decrease IDWG. IDH continues to be a significant dialysis complication deserving of further investigation.

No abstract

No abstract