Mahmoud M. Salem

Hypertension in the hemodialysis population: a survey of 649 patients.

Accurate information on prevalence and status of blood pressure control among US hemodialysis patients is lacking. We have surveyed the status of blood pressure control in 649 hemodialysis patients (89.8% black) from 10 dialysis units in Mississippi. Our results show a hypertension prevalence of 72% (hypertension defined as mean arterial pressure prior to dialysis session > or = 114 mm Hg). This mean arterial pressure did not differ among black patients compared with white patients (P = 0.51). The majority of hypertensive patients (80%) had elevation of both systolic and diastolic blood pressure. Isolated systolic hypertension was present in only 20% of hypertensive patients and was not different between black and white patients (P = 0.10). Three hundred eighty-one patients (58.7% of the total population and 81.5% of the hypertensive patients) were receiving antihypertensives. Age was the only significant factor that correlated with blood pressure: older patients (> 65 years) had lower blood pressure (P < 0.0001). Race, time on dialysis, etiology of end-stage renal disease, adequacy of dialysis, and several excess volume parameters had no influence on the blood pressure level. Treated hypertensive patients had a predialysis mean blood pressure only 3 mm Hg less than the untreated hypertensive patients. No differences were found among four classes of antihypertensives with regard to the degree of blood pressure control. Patients with hypertension requiring more than one antihypertensive did not achieve a lower blood pressure than the untreated patients. There was no correlation between use of antihypertensives and the magnitude of decrease in blood pressure after dialysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperparathyroidism in the Hemodialysis Population: A Survey of 612 Patients

There are no epidemiologic studies documenting the prevalence of hyperparathyroidism in the US hemodialysis population. We looked at a random sample of 612 hemodialysis patients enrolled in 10 outpatient dialysis units in Mississippi. Fifty percent of the patients surveyed had an intact serum parathyroid hormone (PTH) level more than three times normal (mean, 622 pg/mL). Another 25% had a less than normal PTH level (mean, 33 pg/mL), suggesting adynamic bone disease. Abnormal serum calcium was also common. Seventeen percent of patients were hypocalcemic and 14% were hypercalcemic. These high point prevalences occurred despite widespread use of calcium supplements and/or vitamin D (used in 90% of the patients surveyed). Black patients tended to have a lower serum calcium and higher PTH level than white patients. We also found that diabetic patients are less likely to have an elevated PTH level than nondiabetic patients. Elevated serum phosphorus was the most important factor correlating with the development of secondary hyperparathyroidism. Causes of inadequate control of hyperparathyroidism in this population require further study.

Hypertension in the hemodialysis population: Any relation to one-year survival?

Few studies have quantified the effect of hypertension on survival in the hemodialysis population. We report the effect of hypertension on 1-year survival in 649 hemodialysis patients (89% black). In univariate analysis, hypertension was associated with improved 1-year survival (relative risk [RR], 0.48; P = 0.002 compared with normotensive patients). This effect of hypertension was mostly caused by the associated antihypertensive treatment because untreated hypertensive patients had survival rates equal to normotensive patients (RR, 0.87; P = 0.70). On the other hand, treated hypertensive patients fared better than normotensive patients (RR, 0.41; P = 0.0006). This was also true in multivariate analysis, in which antihypertensive treatment was associated with reduced RR (RR, 0.55; P = 0.02) whereas the level of blood pressure per se was insignificant (RR, 0.99; P = 0.63 per 1 mm Hg increase in predialysis mean arterial pressure). Other factors of significance in multivariate analysis included age (RR, 1.03/y; P = 0.0004), serum albumin (RR, 0.38/g; P = 0.002), and diabetes mellitus (RR, 1.58; P = 0.06). Our study suggests that antihypertensive treatment has a favorable effect on survival in the hemodialysis population irrespective of the level of blood pressure control.

Focal Segmental Glomerulosclerosis in African Americans: Effects of Steroids and Angiotensin Converting Enzyme Inhibitors

BACKGROUND Focal segmental glomerulosclerosis (FSGS) is a common primary glomerulopathy in African Americans. In this report, we present data on 40 African American patients with FSGS from our medical center. METHODS Patients were identified from a review of all charts seen in our conservative management renal clinic in 1996, a review of renal biopsy rolls (1994-1998), and a review of patients entering the end-stage renal disease (ESRD) program with a primary diagnosis of FSGS (1993- 1997). Charts were reviewed for demographic, biopsy, and treatment data. Patients who were observed for at least 4 months (range, 4-125 months) were included. ESRD was used as the primary endpoint (n = 12). Data were analyzed using univariate and multivariate Cox hazards and Kaplan-Meier survival analysis. Twenty-four patients were treated with angiotensin-converting enzyme (ACE) inhibitors. Similarly, 24 patients were treated with corticosteroids for a mean of 8.75 +/- 2.6 months and a total dose of 9.3 +/- 2.2 g. RESULTS On univariate analysis, factors found to be significant determinants for reaching ESRD were the initial creatinine (P = 0.0001), interstitial fibrosis (P = 0.032), the percentage of globally sclerosed glomeruli (P = 0.0018), and the mean arterial blood pressure over the course of follow-up (P = 0.05). Neither the ACE inhibitors nor the corticosteroids had a significant impact on reaching ESRD. The patients reaching ESRD (n = 12) were analyzed separately. The mean time from biopsy to ESRD was 24.7 +/- 9.8 months. ACE inhibitors prolonged renal survival (P = 0.023), but steroids did not. Initial creatinine was the only factor found to be a significant determinant for ESRD. CONCLUSIONS We conclude that FSGS is common in African Americans. Early diagnosis and blood pressure control are important, but the beneficial effects of steroids and ACE inhibitors in this population are still unclear.

End-stage renal disease survival in blacks and whites.

B suffer an excess burden of end-stage renal disease (ESRD). They are over-represented in almost all types of renal disease. This includes hypertension, lupus, diabetes mellitus, and focal segmental glomerulosclerosis.1,2 Even after adjustment for all known risk factors for ESRD, blacks continue to have a higher incidence of ESRD (approximately twice that of whites).3 In addition, blacks are the fastest growing group in ESRD programs. Currently, African Americans make up approximately 31% of the ESRD population. Several authors have described better survival of blacks on hemodialysis (HD) compared with whites.4 The survival advantage of blacks is true for both diabetic and nondiabetic patients.5 The 2-year survival probability of African Americans is 66.2% in comparison with 59.8% for whites. This improved survival with ESRD is accompanied by an improved quality of life for African Americans. Their enhanced quality of life is reflected by a greatly decreased frequency of withdrawing from dialysis treatments. Although African Americans systematically receive less dialysis than whites [dialyzer clearance time/volume (Kt/V) of 1.05 versus 1.18, respectively], their survival is higher.6 This also occurs despite having more anemia, hypertension, poor vascular access, less adequate dialysis, and less compliance.7 Of interest is a similar trend observed in black patients admitted to the VA hospitals. Jha et al8 studied over 28,000 whites and compared them with over 7000 blacks admitted to the VA hospital system with common medical conditions. Blacks had a relative risk of dying that was 23% less than whites. This difference did not disappear when statistical adjustments were made for multiple variables that may affect mortality.

362 AMBULATORY BLOOD PRESSURE MONITORING IN THE DIALYSIS POPULATION: IS IT ESSENTIAL?

Background Hypertension is endemic in the dialysis population. Nephrologists rely on routine blood pressure (RBP) measurements of predialysis blood pressure (Pre-BP) and postdialysis blood pressure (post-BP) to assess hypertension. Current K-QOQI guidelines recommend target pre-BP and post-BP of 140/90 and 130/80 mm Hg, respectively. The purpose of this study was to assess the relationship of RBP to ambulatory blood pressure (ABP) measurements and to determine the burden of uncontrolled hypertension in our hemodialysis population with ABP measurements. Methods RBP measurements were made by trained dialysis staff with patients after sitting 5 minutes before and after dialysis. Six RBP measurements were averaged, pre- and postdialysis. ABP was measured between the fifth and sixth RBP measurement over the 44-hour interdialytic period with Spacelab ABP monitors. Mean ± SD BP (mm Hg) using both techniques was compared using the paired t-test. Results With n = 35, the mean ABP was 135.5 ± 22.8/80.3 ± 15.1. Mean pre-BP averaged 162.6 ± 22.4/88.2 ± 13.9 (p Conclusion ABP demonstrates BP significantly less than either the pre/post dialysis blood pressures. Routine pre/post blood pressures therefore may overestimate the true burden of hypertension in this patient population. When blood pressure is measured using an average of ABP, a significantly lower percentage of participants were above blood pressure targets.

Albumin as an Adjunct to Diuretics for the Treatment of Edema

Publisher Summary Albumin infusions have been used in conjunction with diuretics to increase natriuresis and diuresis for years. This combination has been usually employed in diseases associated with hypoproteinemia, such as nephrotic syndrome, cirrhosis, and occasionally, malnutrition. In these conditions, diuretic resistance is often encountered. Albumin is most frequently combined with loop diuretics, as they are the most potent diuretics in ones armamentarium and because both agents can be administered intravenously, thus assuring optimal timing for the potential synergistic effect. The indications for the use of albumin with loop diuretics are the subject of controversy. Some authorities recommend temporary trials of hyperoncotic albumin for resistant edema, while other authoritative sources feel that the use of this combination should be discouraged. Evaluation of the role of diuretic–albumin combinations in the treatment of resistant edema is hampered by a lack of large, carefully conducted clinical trials. It should be recognized that unless the conditions inducing sodium retention are rectified, the effects of albumin and diuretic therapy will be very transient.