This systematic review would suggest that midodrine has a role in the therapy of haemodialysis patients experiencing IDH. This conclusion must be viewed with caution, however, given the quality and sample size of the studies included in this review.

Referral to a nephrologist before initiation of chronic dialysis occurs less frequently for blacks than whites, but the reasons for this disparity are incompletely understood. Here, we examined the contribution of racial composition by zip code on access and quality of nephrology care before initiation of renal replacement therapy (RRT). We retrospectively studied a cohort study of 92,000 white and black adults who initiated RRT in the United States between June 1, 2005, and October 5, 2006. The percentage of patients without pre-ESRD nephrology care ranged from 30% among those who lived in zip codes with Ͻ5% black residents to 41% among those who lived in areas with Ͼ50% black residents. In adjusted analyses, as the percentage of blacks in residential areas increased, the likelihood of not receiving pre-ESRD nephrology care increased. Among patients who received nephrology care, the quality of care (timing of care and proportion of patients who received a pre-emptive renal transplant, who initiated therapy with peritoneal dialysis, or who had a permanent hemodialysis access) did not differ by the racial composition of their residential area. In conclusion, racial composition of residential areas associates with access to nephrology care but not with quality of the nephrology care received.

Keywordschronic kidney disease; elderly; management strategies; outcomes Our goals in this review are to describe what is known about the prevalence and clinical implications of non-dialysis dependent chronic kidney disease (CKD) in the elderly and to discuss some of the most common challenges to managing older patients with CKD. Prevalence of CKD in the elderlyThe prevalence of CKD rises dramatically with age. Based on the results of the National Health and Nutrition Examination Survey 1999-2004 (NHANES), more than one third of those aged 70 or older have moderate or severe CKD defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m 2 [1,2]. While all stages of CKD are more common at older ages (including earlier stages of CKD, defined as albuminuria with a preserved eGFR), it is the prevalence of moderate CKD (eGFR 30-59 ml/min/1.73 m 2 ) that increases most dramatically with advancing age (Figure 1).The high prevalence of CKD in the elderly no doubt reflects the presence of a variety of different risk factors for CKD such as diabetes and hypertension in older individuals. However, high rates of CKD in the elderly may also occur because of an age-associated decline in kidney function that is not explained by other known risk factors. Relatively little is known about how renal function changes during the course of "normal" aging. The Baltimore Longitudinal Study of Aging (BLSA) measured change in creatinine clearance over time among a subset of participants without kidney disease or other known comorbidities [3]. Among these participants, creatinine clearance declined on average by 0.75 ml/min/year. However, among some participants in this study, renal function did not decline at all. Results from BLSA thus suggest that on average kidney function tends to decline with aging even among those without comorbidity, but that this decline does not appear to be inevitable.Regardless of the reason(s) for the high prevalence of CKD in the elderly, it is clear that as the population ages we can expect to see a large expansion in the number of older individuals who meet current criteria for CKD. For example, in 2000, there were approximately 25 million adults 70 years or older, accounting for 9% of the population. By the year 2050, based on US

SummaryBackground and objectives The objective of this study was to evaluate the association between neighborhood socioeconomic status and barriers to peritoneal dialysis eligibility and choice.

Lactic acidosis is commonly associated with states of hypoxia and decreased tissue perfusion. Elevated lactic acid levels have also been observed in individuals who are not septic and who are normotensive, but who have received systemic adrenergic agonist therapy. This report presents two patients with acute asthma treated with very large doses of aerosolized and systemic salbutamol, who developed lactic acidosis despite normal systemic hemodynamics and adequate oxygenation. Lactic acidosis was clinically important because it contributed to respiratory failure in one patient, and complicated the assessment and management of acute, severe asthma in the other patient.

In metropolitan areas, PD and HHD generally increased with increased travel distance to the closest home dialysis facility and decreased with greater distance to an IHD facility. Examination of travel distances to PD and HHD facilities separately may provide further insight on specific barriers to these modalities which can serve as targets for future studies examining expansion of home dialysis utilization.

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Volume overload is a factor in development of hypertension in hemodialysis patients. Fluid removal by hemodialysis (HD), however, may cause intradialytic hypotension and associated symptoms. A better understanding of the relationships between blood pressure volume status and the pathophysiology of fluid removal during HD are, therefore, necessary to control blood pressure and to eliminate intradialytic hypotension. The objectives of the study were to determine the amount and direction of change of body fluid compartments after ultrafiltration (UF) and to determine whether any correlations exist between mean arterial pressure (MAP), change in circulating blood volume (deltaBV), total body water (TBW), central blood volume (which constitutes the volume of blood in the lungs, heart, and great vessels [CBV]), and intracellular and extracellular fluid volumes (ICF, ECF). The study population included 20 patients on regular HD. Each individual had their CBV, cardiac output, and peripheral vascular resistance (PVR) measured by means of saline dilution technique and deltaBV monitored by an online hematocrit sensor (Crit Line). MAP was calculated from measured blood pressure and ICF and ECF were measured using bioelectric impedance analysis techniques. Measurements were obtained before and after maximum UF measured by deltaBV (reduction of 6-10% by Crit Line). Ten healthy controls also had ECF and ICF values measured by bioelectric impedance analysis. Before HD, MAP correlated with TBW (r = 0.473, p = 0.035) and CBV (r = 0.419, p = 0.066), suggesting that hypertension here may be due to volume overload. Patients were ECF expanded before HD with an ECF:ICF ratio of 0.96, which was significantly higher than the control ratio of 0.74 (p < 0.0001). During UF, fluid was removed from both ECF and ICF, but more from the ECF volume ratio 0.92 post UF, a significant reduction (p < 0.0001). After UF, MAP no longer correlated with TBW or CBV but correlated with peripheral vascular resistance (r = 0.4575, p = 0.043). After UF, deltaBV correlated inversely with PVR (r = -0.50, p = 0.024). Despite the fall in deltaBV (7.11+/-2.49%) with UF, CBV was maintained. CBV were 0.899 L and 0.967 L pre and post UF, respectively. These data suggest that in hemodialysis patients, predialysis volume status influences predialysis blood pressure. UF causes BV to fall, but CBV is preferentially conserved by increasing PVR, which also maintains blood pressure. Failure of a PVR response likely leads to intradialytic hypotension.