A Standard, Noninvasive Monitoring of Hematocrit Algorithm Improves Blood Pressure Control in Pediatric Hemodialysis Patients

Patel, Hiren P.; Goldstein, Stuart L.; Mahan, John D.; Smith, Beth A.; Fried, Cheryl B.; Currier, Helen; Flynn, Joseph T.

doi:10.2215/cjn.02410706

Cited by 55 publications

(35 citation statements)

References 30 publications

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“…106 It is possible that the latter benefit is, in part, related to diminished use of antihypertensive medication. Accordingly, monthly monitoring of RPV and home BP may offer an attractive way to assess the adequacy of volume control among HD patients.…”

Section: Dry Weight and Outcomesmentioning

confidence: 99%

“…193 A blood volume monitoring protocol in a multicenter study demonstrated improved control of hypertension with decreased need for antihypertensive medications, although no significant change in postdialysis weight was seen. 106 In pediatric PD patients, a plasma atrial natriuretic peptide level .3.0 nmol/L was felt to reflect hypervolemia on one study, 187 but this finding has not yet been replicated.…”

Section: Hypertension In Pediatric Dialysis Patientsmentioning

confidence: 99%

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Assessment and Management of Hypertension in Patients on Dialysis

Agarwal

Flynn

Pogue

et al. 2014

Journal of the American Society of Nephrology

157

156

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Hypertension is common, difficult to diagnose, and poorly controlled among patients with ESRD. However, controversy surrounds the diagnosis and treatment of hypertension. Here, we describe the diagnosis, epidemiology, and management of hypertension in dialysis patients, and examine the data sparking debate over appropriate methods for diagnosing and treating hypertension. Furthermore, we consider the issues uniquely related to hypertension in pediatric dialysis patients. Future clinical trials designed to clarify the controversial results discussed here should lead to the implementation of diagnostic and therapeutic techniques that improve long-term cardiovascular outcomes in patients with ESRD. Hypertension is common among patients with ESRD. In this review, we discuss the diagnosis, epidemiology, and management of hypertension among dialysis patients. We also review areas of existing controversies and briefly discuss the issue of hypertension in pediatric dialysis patients. EPIDEMIOLOGYThe prevalence, treatment, and control of hypertension among people on hemodialysis (HD) have used varying definitions to diagnose hypertension. The epidemiology differs based on how BP is measured: either before and after dialysis or using ambulatory BP recordings. Epidemiology with Routine BP MeasurementsThe prevalence of hypertension (defined as 1-week average predialysis systolic BP [SBP] measurements .150 mmHg or diastolic BP [DBP].85 mmHg or the use of antihypertensive medications) was 86% among 2535 clinically stable adult HD patients participating in a multicenter trial. 1 Among hypertensive patients, 12% did not receive antihypertensive drugs, 58% were treated but not controlled, and only 30% were controlled. The use of antihypertensive drugs has been reported to vary from 59% to 83%. [2][3][4][5] Furthermore, even among children on long-term HD, similar findings have been reported. 6 Several studies have confirmed greater antihypertensive drug use to be associated with poorer control. 7,8 It should be noted that antihypertensive drug use per se do not lead to worse BP control; in the absence of adequate volume control, increasing antihypertensive drug use may simply reflect difficult-to-control BP. Epidemiology Using Ambulatory BP MeasurementsThe prevalence of hypertension (defined by either a 44-hour interdialytic ambulatory BP of $135/85 mmHg or the prescription of any antihypertensive agent) was 86% among 369 chronic HD patients. 8 Although hypertension was being treated with antihypertensive drugs in 89% of patients, it was adequately controlled only in 38%. The independent determinants of poor control were the use of antihypertensive drugs and an expanded extracellular volume state. If patients were volume overloaded, nearly 80% became hypertensive when medications were Published online ahead of print. Publication date available at www.jasn.org.

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Section: Dry Weight and Outcomesmentioning

confidence: 99%

Section: Hypertension In Pediatric Dialysis Patientsmentioning

confidence: 99%

Assessment and Management of Hypertension in Patients on Dialysis

Agarwal

Flynn

Pogue

et al. 2014

Journal of the American Society of Nephrology

157

156

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“…without symptomatic intradialytic hypotension) that allows the patient to maintain a normal interdialytic blood pressure, ideally without the use of antihypertensive medications [3,6]. Despite technological advances in intradialytic relative plasma volume monitoring [9,10] and bioimpedance analysis [11,12], the assessment of dry weight in children remains challenging [6]. However, these new technical tools provide objective measures to corroborate the clinical assessment of dry weight by the dialysis team.…”

Section: Assessing Dry Weight and Idwg In Children On Chronic Dialysismentioning

confidence: 99%

“…To achieve euvolaemia many nephrologists prescribe high ultrafiltration rates [17], especially if the patient appears to tolerate it [3,8]. A patient's tolerance to a higher ultrafiltration rate depends on many factors, including maintaining normal haemoglobin levels, the use of bicarbonate dialysate buffe r, h i g h e r d i a l y s a t e s o d i u m c o n c e n t r a t i o n [ 5 ] , haemodiafiltration technology [18], ultrafiltration or sodium profiling, lowering dialysate temperature and on-line blood volume monitoring [9,10], and has dramatically improved over the last decades [6]. Nonetheless, even a well-tolerated high ultrafiltration rate, such as >1.24 % body weight loss per hour in adults, is associated with greater mortality [19].…”

Section: Managing Idwg: Safely Achieving the Desired Ultrafiltrationmentioning

confidence: 99%

The interdialytic weight gain: a simple marker of left ventricular hypertrophy in children on chronic haemodialysis

Fischbach¹,

Zaloszyc²,

Shroff

2015

Pediatr Nephrol

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Despite multiple advances in haemodialysis (HD) technology over the years, the morbidity and mortality of HD patients remain unacceptably high. Cardiovascular disease is the most common cause of death, and left ventricular hypertrophy (LVH), seen in two-thirds of children on dialysis, is a significant contributor. The importance of volume control is increasingly recognized by nephrologists and now considered to be as important as urea kinetics, both in the day-to-day management and the long-term outcome of dialysis patients. The results published by Paglialonga et al. (10.1007/s00467-014-3005-2) in this issue of Pediatric Nephrology clearly demonstrate that there is a significant correlation between interdialytic weight gain (IDWG) and LVH in oligoanuric children on chronic HD and that children with an IDWG of >4 % are at high risk of LVH. One common practice to achieve euvolaemia is to prescribe very high ultrafiltration rates. However, both volume overload and aggressive fluid removal can induce circulatory stress and multi-organ injury. In adults, ultrafiltration rates of >1.24 % body weight per hour, even if well tolerated, are associated with a significant increase in mortality. Nephrologists should be aware of the risk of a high ultrafiltration rate, especially if tolerance is obtained by a positive dialysate-to-plasma sodium gradient. Haemodiafiltration, which allows for higher ultrafiltration rates with greater intradialytic haemodynamic stability, or more frequent and longer dialysis sessions allow for safe and effective fluid removal.

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“…Studies among hemodialysis patients in adults and children suggest that managing intradialytic RPV may reduce the number of hospital admissions due to fluid overload (14,19), improve BP control, and decrease hypotension-associated dialysis symptoms (20). It is possible that the latter benefit is, in part, related to diminished use of antihypertensive medication.…”

Section: Dry-weight and Outcomesmentioning

confidence: 99%

Dry-Weight

Agarwal

Weir

2010

Clinical Journal of the American Society of Nephrology

145

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Background and objectives: Achieving and maintaining dry-weight appears to be an effective but forgotten strategy in controlling and maintaining normotension among hypertensive patients on hemodialysis.Methods: Qualitative review of literature to define dry-weight and its utility in achieving blood pressure control. Results: The concept of dry-weight has evolved over time and its definition has changed. One such definition defines dry-weight as the lowest tolerated postdialysis weight achieved via gradual change in postdialysis weight at which there are minimal signs or symptoms of hypovolemia or hypervolemia. Although clinical examination does not perform well in detecting latent increase in dry-weight, several technologies such as relative plasma volume monitoring and body impedance analysis are emerging that may help in assessing dry-weight in the future. Sodium restriction is a modifiable risk factor that can lead to better blood pressure (BP) control. However, dietary sodium restriction requires lifestyle modifications that are difficult to implement and even harder to sustain over the long term. Restricting dialysate sodium is a simpler but underexplored strategy that can reduce thirst, limit interdialytic weight gain, and assist the achievement of dry-weight. Achievement of dry-weight can improve interdialytic BP, reduce pulse pressure, and limit hospitalizations.Conclusions: Avoiding medication-directed control of BP may enhance the opportunity to probe dry-weight, facilitate removal of volume, and limit the risk for pressure-volume overload, which may be a significant concern leading to myocardial remodeling in the hemodialysis patient. Probing dry-weight among patients with ESRD has the potential to improve dismal cardiovascular outcomes.

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A Standard, Noninvasive Monitoring of Hematocrit Algorithm Improves Blood Pressure Control in Pediatric Hemodialysis Patients

Cited by 55 publications

References 30 publications

Assessment and Management of Hypertension in Patients on Dialysis

Assessment and Management of Hypertension in Patients on Dialysis

The interdialytic weight gain: a simple marker of left ventricular hypertrophy in children on chronic haemodialysis

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