hypertension in end-stage renal disease patient.ppt
TRANSCRIPT
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SICU Conference
Hypertension in End-Stage Renal Disease Patient
Ri 彭偉倫
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Hypertension and ESRD
Hypertension is a major cause of end-stage renal disease(ESRD)
Base on the 1997 United States Renal Data System report, the incidence rate of hypertension and diabetes mellitus as causes of ESRD continue to increase more rapidly than the other major causes of ESRD
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Hypertension ESRD
Although poorly controlled hypertension may either cause or accelerate the development of renal failure, it can also be a sequence of renal disease
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ESRD and Cardiovascular Disease
Cardiovascular disease is the leading cause of death in patients undergoing dialysis and renal transplantation
Atherosclerosic and cardiovascular disorders have been found to be more prevalent in dialysis patients than in the general population
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Outcomes A number of studies have suggested poorer
outcomes in those patients with ESRD with uncontrolled hypertension
Two Japanese studies suggested that the early correction of elevated systolic pressure was important in determining the ultimate prognosis of the hemodialyzed patients
The patient groups with normal BP had better survival
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Low Blood Pressure
Recent data have shown that abnormally low predialysis systolic blood pressure levels (<110mmHg) were associated with decreased survival on dialysis
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Pathogenesis
Putative Pathogenetic Mechanisms of Hypertension in ESRD PatientsExpanded extracellular fluid volume
Renin angiotension aldosterone stimulation
Increased sympathetic activity
Endogenous digitalis-like factors
Prostaglandins/bradykinins
Altered function of endothelium-derived factors
Erythropoietin administration
Nephron number
Parathyroid hormone secretion
Calcified arterial tree
Worsening of pre-existing essential hypertension
Renal vascular disease
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Expanded Extracellular Fluid Volume
Volume expansion is perhaps the most important factor in the development and maintenance of hypertension in dialyzed patients
It leads to an elevation in BP through the combination of an increased in cardiac output and an inappropriately high systemic resistance
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Increased Sympathetic Activity Sympathetic overactivity is a common finding in
ESRD The afferent signal may arise within the kidney
because sympathetic activation is not seen in aphrenic patients
Chemoreceptors within the kidney by uremic metabolites may be important in generation of these signals
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Endogenous Digitalis-Like Substance
It is believed to be produced in either the hypothalamus or adrenal cortex
Because it inhibits Na+-K+ ATPase activity, cytosolic sodium increases, inhibiting calcium egress, and causing increased smooth muscle calcium content leading to increased smooth muscle tone
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Endothelium-Derived Factors The abnormal endothelial release of
hemodynamically active compounds Elevated plasma levels of endothelin-1, the potent
vasoconstrictor, had been found in uremic patients Uremic plasma contains a higher level of an
endogenous compound, asymmetrical dimethylarginine, that is an inhibitor of NO synthesis
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Erythropoietin
An increased in BP of 10mmHg or more occurs in approximately one third of the patients with renal failure who are treated with erythropoietin
Through increased total peripheral resistance related to increased viscosity and decreased hypoxic vasodilatation
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Hyperparathyroidism
Increase in intracellular calcium induced by parathyroid hormone excess cause vasoconstriction and hypertension
Either vitamin D administration or parathyroidectomy has been shown to lower blood pressure
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Treatment
It has been reported that hypertension is less well controlled in patients undergoing dialysis
In a large cohort of European hemodialysis patients treated for hypertension, it was reported that 87% of the patients with diabetes and 65% of the patients without diabetes had inadequate BP control
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Volume Control
Volume control can either normalized the BP or make hypertension easier to control
Salt and water balance
Dialysis
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Dry Weight(I)
Attaining dry weight will either normalized the BP or male it easier to control in 80% to 90% of patients
The absence of edema does not exclude the hypervolemia
It is the thorniest clinical problem of clinical nephrologists
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Dry Weight(II) Not merely the absence of edema, but the body sodium
content and volume of body water or critical component thereof below which further reduction results in hypotension
Volume removal to correct clinical fluid overload and optimized seated BP without symptomatic orthostatic hypotension after dialysis
Body weight at the end of dialysis at which the patient can remain normotensive until the next dialysis without antihypertensive medication
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Salt and Water Balance
Patient compliance is often sub-optimal
As a result, heavy reliance is placed on the dialysis ultrafiltration capacity to remove this excess fluid
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Lag Phenomenon
In new patients starting dialysis, some period of time passes before volume is controlled, dry weight is achieved, and BP is controlled; this period has been called the lag phenomenon
This is the time required to convert the patient from a catabolic to an anabolic state while the extracellular fluid space slowly stabilized
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Dialysis
Two crossover studies and one long-term project demonstrated that more frequent and longer hemodialysis treatment were associated with normal blood pressures without medications and with regression of left ventricular hypertrophy
Antihypertensive drugs and rapid fluid removal required by shorter dialysis time may limit the degree of fluid removal
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Antihypertensive Drugs(I) Antihypertensive drugs are indicated in patients in
whom hypertension persists, despite seemingly adequate volume control
Elevated BP can usually be controlled by most classes of antohypertensive agents
The selection of antohypertensive agents is frequently dictated by the presence of comorbid conditions
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Antihypertensive Drugs(II)
One European study
Ca2+ channel blocker > ACEI > α blocker > β blocker
These agents are often prescribed in the evening, especially after dialysis
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Antihypertensive Drugs(III)
The addition of antihypertensive drugs may make
dialysis more difficult to deliver and may lead to
the inability to control interdialytic hypertension,
dialysis-induced hypotension, and failure to
achieve dry weight
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Ca2+ channel blockers
They are effective and well tolerated in dialysis patients
They may be particular useful in patients with LVH and diastolic dysfunction
Certain of these agents have a negative inotropic and negative chronotropic effect on the myocardium
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Angiotension-Conveerting Enzyme Inhibitors (I)
Reduce the production of angiotensin II and also decrease degradation of vasodilating bradykinins and prostaglandins
They are well tolerated and are particularly effective in patients with a history of heart failure due to systolic dysfunction and may induce a more rapid regression of LVH
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Angiotension-Conveerting Enzyme Inhibitors (II)
They may aggravate anemia by reducing the action
of erythropoietin
They can trigger an anaphylactoid reaction in
patients dialyzed with a PAN membrane dialyzer
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Angiotension II receptor Antagonists
In a study of 89 patients of whom 20 were undergoing hemodialysis, BP responded well and no significant biochemical alternation were noted
They are not associated with altered kinin metabolism and are not expected to elicit anaphylactoid reaction to PAN membrane dialyzer
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β blockers
They are particularly indicated in patients who have had a recent myocardial infarction or suffer from angina pectoris
Potential side effects include CNS depression, bradycardia, altered lipid profiles, hyperkalemia, altered response to hypoglycemia, and bronchospasm
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α blockers
These agents are commonly used in patients who also have BPH
They have a favorable metabolic side effect profile Orthostatic symptoms may occur, especially in
older patiemts
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Central Sympathetic Agonists
These agents, such as clonidine and nethyldopa,
are used less frequently because of their adverse
effects involving the central nervous system
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Refractory Hypertension (I)
Some dialysis patients are resistant to both volume control and antihypertensive medications
Concurrent use of certain over-the-counter medication
Secondary hypertension
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Refractory Hypertension (II)
If faced with refractory hypertension, the clinician should redouble his efforts to determine whether the patient is truly at dry weight
If a treatable cause cannot be found, minoxidil, in combination with a β blocker may be effective in reducing the BP
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Blood Pressure Control
Lowering the blood pressure too rapidly may be hazardous
Blood pressure should be controlled in a gradual manner to allow for adaptation
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Optimal Blood Pressure Level
The optimal blood pressure level may be best defined by the individual patient’s overall cardiovascular profile, including age, previous and concurrent complications, and comorbid diseases
Blood pressure should be maintained as close to normal as possibleBP < 135/85mmHg by dayBP < 120/80mmHg by night
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Clinical Therapeutic Conclusions Withdraw slowly as many antihypertensive
medications as possible in the process of establishing a rational dry weight
Set a realistic timetable for attaining dry weight Once the dry weight has been established, if BP
remains elevated, it may be necessary to initiate or continue antihypertensive medication, but continue reassessing dry weight
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