Treating blood pressure in HD reduces outcomes (just barely) #NKFClinicals
But we have no idea how low to go and we know that treating BP increases dialysis complications (cramps, nausea, hypotension) #NKFClinicals
Here are guidelines from Europe. No data to support these guidelines. Do not use on treatment blood pressures. #NKFClinicals
No evidence that loop diuretics lower blood pressure in dialysis patients but remaining on loop after starting dialysis reduced hospitalizations and nearly reduced death. #ObservationalData#NKFClinicals#NKFClinicals
ARCADIA trial from Italy. ACE/ARB vs non-RASi therapy. No difference in composite CV, Death, MI, stroke. No difference in BP #NKFClinicals
Now HDPAL Trial:
Atenolol more BOP lowering than lisinopril. Improved outcomes in atenolol compared to lisinopril. #NKFClinicals
ARCADIA vs HDPAL
She suggests that race differences may explain differences in outcomes between Italy and Indiana. #NKFClinicals
CCB
She argues, convincingly, that we should be looking at these drugs vs active controls rather than placebos. #NKFClinicals
Interesting and impressive spironolactone data #NKFClinicals
Dialyzability of common anti-hypertensives
She is concerned about the routine holding of blood pressure medications on dialysis days. #NKFClinicals
Interesting: @taraichang did a cluster RCT of holding anti hypertensive meds on dialysis days. Taking BP meds was non-inferior to holding antihypertensives. #NKFClinicals
What she does and recommends
Home blood pressure
Treat if interdialytic hypertension > 150 mmHg and avoids it is interdialytic SBP < 120.
When we published our study <> of ODS and hyponatremia we were pummeled for including people at low risk of ODS because we included Na levels between 120 and 130. They said it is well known "that ODS is incredibly rare/non-existent at those levels." 1/4evidence.nejm.org/doi/10.1056/EV…
Of course one of the reasons it was thought to be incredibly rare was that no one looked for CPM in patients with Na from 120-130. We found a fair number (≤5 of 12). 2/4
Our findings are replicated in a study from Australia. The authors took a different approach to investigating ODS. Instead of starting w/ hyponatremia and working forward to ODS, they started with a dx of ODS and worked backwards
3/4ncbi.nlm.nih.gov/pubmed/35717664
Gadolinium in dialysis patients.
What's up with that?
#Tweetorial
1/11
Nephrogenic systemic fibrosis (NSF) is an iatrogenic disease that presents with hardening of the skin and other organs. It is often lethal. I treated 5 people with this condition (including one with AKI). Terrible.
2/11
The etiology of NSF was unknown and there were many theories. In 2006, Thomas Grobner published a small case series showing 5 patients developing NSF within weeks of receiving gadolinium contrast for MRI.
3/11pubmed.ncbi.nlm.nih.gov/16431890/
I just recently recommended the Renal Physiology book by Bruce Koeppen and Bruce Stanton. I thought it was a good medical student level text book: pbfluids.com/2023/08/ouwb-s…
But I came across this question in Chapter 8 Regulation of Acid Base. It is a straight forward question asking the learner to interpret simple acid-base cases.
But the question falls apart when you look at the answer...
Michael Emmett on electrolyte artifacts
Pre-analytical and analytical #NKFClinicals
Starting with pseudohyponatremia
These are real cases
The osmolality was 294, so there is a huge gap. 44ish
Implies Artifactual decrease in sodium
Her triglycerides were >6000 #NKFClinicals
Note the different between HCO3 and tCO2 should be closer than 19 and 9. #NKFClinicals