No abstract

Decreased salivary flow rate causes xerostomia (symptoms of oral dryness) in patients who undergo hemodialysis (HD); however, whether it thus contributes to thirst and excess interdialytic weight gain (IDWG) remains undetermined. In the observational study, 3 mo of data of 90 stable HD patients were collected, and sensations of thirst and xerostomia were assessed by 100-mm visual analog scales (VAS). Multivariate analyses revealed that the VAS oral dryness score was an independent determinant for thirst, daily IDWG, and IDWG%. Unstimulated whole salivary flow rate (UWS) was measured in 45 participants and was negatively correlated with VAS oral dryness score (r ‫؍‬ ؊0.690, P < 0.001), daily IDWG (r ‫؍‬ ؊0.361, P ‫؍‬ 0.016), and daily IDWG% (r ‫؍‬ ؊0.302, P ‫؍‬ 0.045). In the interventional trial, the test drug was 5 mg of oral pilocarpine solution or placebo. Three types of interventions for reducing thirst (the urge to drink) and interdialytic weight gain (IDWG) are identified in the literature: dialysis protocol related (increasing frequency and varying sodium concentration) (6 -9), pharmaceutical (angiotensin-converting enzyme inhibitors [ACEI]) (10 -13), and dietetic interventions (10,14). However, no definite effectiveness could be shown (5), which might be explained by the fact that many of the underlying mechanisms for thirst and drinking behavior remain unknown.Known dipsogenic factors (factors that cause thirst and high fluid intake) in HD patients include high sodium intake, potassium depletion, increased blood urea, sugar and angiotensin II (Ang II) levels, and psychologic factors (2,3,5,10 -16). Another potential dipsogenic factor is the reduction of salivary flow rate. Recently, Brunstrom et al. (17) demonstrated that healthy volunteers consume more water and drink more frequently in the xerostomic state, which is induced by decreasing saliva in the oral cavity. Because xerostomia (symptoms of oral dryness), which is caused by the reduction of salivary flow, is prevalent among HD patients (18 -23), it is conceivable that the decreased salivary flow leads to thirst and excess IDWG. Some observational studies (24,25) have described an association between xerostomia and IDWG in HD patients; however, other known dipsogenic factors (e.g., blood urea, Ang II, sugar level) were not controlled in those studies. In addition, no interventional trial in the literature indexed by Medline has demonstrated the impact of the decreased salivary flow on IDWG. Therefore, whether the decreased salivary flow influences fluid intake in HD patients remains undetermined.We conducted a 3-mo prospective observational study followed by a trial of pilocarpine-a parasympathomimetic agent that has been shown effectively to increase salivary flow in radiation-induced xerostomia or Sjö gren syndrome (26 -29)-to determine whether the reduction of salivary flow contributes to exaggerated thirst and excess IDWG in HD patients and whether pilocarpine can alleviate it.

Xerostomia plays a significant role in increasing IDWG% among diabetic and non-diabetic HD patients. In diabetic patients, the increased IDWG% associated with the increasing HbA(1C) level is largely dependent on the severity of xerostomia, and we speculate that insulin deficiency may operate synergistically with xerostomia in increasing IDWG% in patients with HbA(1C) >or=9%.

Most appeals were again denied after expert review. Better education concerning utilization guidelines and a platform for insurer, insuree, and physician to dialog are needed to improve the effectiveness and efficiency of the appeals system.

Elderly patients with end-stage renal disease may be predisposed to seizures with higher doses of codeine phosphate. It is imperative to adjust the codeine dosage regimen based on patients' renal function to avoid the potential toxicity with overdose.