Increasing Dialysis Sodium Removal on Arterial Stiffness and Left Ventricular Hypertrophy in Hemodialysis Patients

Liu, Jing; Sun, Fang; Ma, Li; Shen, Yang; Xue, Mei; Zhou, Yilun

doi:10.1053/j.jrn.2015.08.005

Cited by 29 publications

(34 citation statements)

References 28 publications

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“…Small, prospective clinical trials comparing DNa in the range of 138-142 mEq/l in the control arm and 135-137 mEq/l in the intervention arm do not consistently show a reduction in BP, IDWG, and postweight with the lower DNa (73)(74)(75)(76)(77)(78)(79)(80). Analyses of the DOPPS data showed an increase in IDWG with higher DNa, but only a slight increase in predialysis systolic BP (+0.9 [95% CI, 0.1-1.6] mmHg per 2 mEq/l increase in DNa), no effect on mortality and the risk of hospitalization was actually decreased with higher DNa (HR 0.97, 95% CI [0.95-1.00] per 2 mEq/l increase in DNa) (81,82).…”

Section: Does Lowering Dialysate Sodium Improve Bp Control?mentioning

confidence: 97%

Blood Pressure Management in Hemodialysis Patients: What We Know And What Questions Remain

Miskulin

Weiner

2017

Seminars in Dialysis

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Despite having thousands of blood pressure (BP) readings on individual dialysis patients over the course of a year, our knowledge about the optimal assessment of BP, the mechanisms underlying hypertension and its management remain incomplete. Observational studies reveal that BP is lower at home than when measured in the dialysis unit. However, we do not know if using home vs. in-center measurements to guide treatment decisions improves BP control and/or clinical outcomes. Moreover, a recent US study suggests that typical hemodialysis patients are unlikely to adhere to home monitoring over the long term. Volume excess is one of probably many factors mediating hypertension in this population. A randomized clinical trial of aggressively challenging dry weight in patients without overt signs of fluid overload was shown to reduce BP, but there was an increase in vascular access thrombosis and intradialytic hypotension episodes. Long-term studies have not been done; thus, we do not know whether "squeezing dry weight" as a means to control BP is of more benefit than harm. Daily or prolonged nocturnal dialysis consistently has been shown to lower BP. To what extent this is a result of enhanced solute clearance vs. removal of excess volume is not clear. Use of bioimpedance or relative blood volume monitoring to guide fluid management has been tested in small studies, but more data are needed to determine whether their use impacts clinical outcomes. Well-designed clinical trials to determine whether a specific antihypertensive drug class is of benefit, independent of BP lowering, are lacking. The BP target that optimizes outcomes HD patients is also unknown. Observational studies consistently show poorer survival with predialysis BP <140/90 mmHg, although such studies likely are confounded by low BP due to cardiovascular disease and other comorbidities. In this review, we discuss what is known and the questions that remain regarding the epidemiology, diagnosis, etiology, and management of hypertension in hemodialysis patients.

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Section: Does Lowering Dialysate Sodium Improve Bp Control?mentioning

confidence: 97%

Blood Pressure Management in Hemodialysis Patients: What We Know And What Questions Remain

Miskulin

Weiner

2017

Seminars in Dialysis

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“…[14][15][16][17] (c) Chlorthalidone and triamterene/HCTZ are superior to HCTZ for reducing CVEs and CHF. 12,18,19 (d) Reducing sodium reduces LVM, [20][21][22][23][24][25][26][27][28] and chlorthalidone and PSD/HCTZ combinations reduce sodium more than HCTZ (Supplement 1 in Appendix S1), [29][30][31] (e) Preserving potassium reduces LVM, [20][21][22][32][33][34] and PSD/ HCTZ combinations are of course superior to HCTZ for preserving potassium. 35,36 To test the hypothesis that this set of diuretics is superior to HCTZ for reducing LVM, a systematic review and network metaanalyses of randomized trials were conducted.…”

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confidence: 99%

Hydrochlorothiazide vs chlorthalidone, indapamide, and potassium‐sparing/hydrochlorothiazide diuretics for reducing left ventricular hypertrophy: A systematic review and meta‐analysis

Roush

Abdelfattah

Song

et al. 2018

J of Clinical Hypertension

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Left ventricular hypertrophy develops in 36%‐41% of hypertensive patients and independently predicts cardiovascular events and total mortality. Moreover, drug‐induced reduction in left ventricular mass (LVM) correlates with improved prognosis. The optimal thiazide‐type diuretic for reducing LVM is unknown. Evidence regarding potency, cardiovascular events, sodium, and potassium suggested the hypothesis that “CHIP” diuretics (CHlorthalidone, Indapamide, and Potassium‐sparing diuretic/hydrochlorothiazide [PSD/HCTZ]) would reduce LVM more than HCTZ. Systematic searches of five databases were conducted. Among the 38 randomized trials, a 1% reduction in systolic blood pressure (SBP) predicted a 1% reduction in LVM, P = 0.00001. CHIP‐HCTZ differences in reducing LVM differed across trials (ie, heterogeneity), making interpretation uncertain. However, among the 28 double‐blind trials, heterogeneity was undetectable, and HCTZ reduced LVM (percent reduction [95% CI]) by −7.3 (−10.4, −4.2), P < 0.0001. CHIP diuretics surpassed HCTZ in reducing LVM: chlorthalidone −8.2 (−14.7, −1.6), P = 0.015; indapamide −7.5 (−12.7, −2.3), P = 0.005; and all CHIP diuretics combined −7.7 (−12.2, −3.1), P < 0.001. The comparison of PSD/HCTZ with HCTZ had low statistical power but favored PSD/HCTZ: −6.0 (−14.1, +2.1), P = 0.149. Thus, compared to HCTZ, CHIP diuretics had twice the effect on LVM. CHIP diuretics did not surpass HCTZ in reducing systolic or diastolic blood pressure: −0.3 (−5.0, +4.3) and −1.6 (−5.6, +2.4), respectively. The strength of evidence that CHIP diuretics surpass HCTZ for reducing LVM was high (GRADE criteria). In conclusion, these novel results have demonstrated that CHIP diuretics reduce LVM 2‐fold more than HCTZ among hypertensive patients. Although generally related to LVM, blood pressure fails to explain the superiority of CHIP diuretics for reducing LVM.

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“…It has been reported that increasing sodium removal by lowering dialysate sodium concentration resulted in decreases in BP and IDWG (15)(16)(17). In addition, our previous study showed that lowering dialysate sodium concentration was associated with improvements in arterial stiffness and LVH in hypertensive HD patients (18).…”

mentioning

confidence: 80%

“…It has been reported that increasing sodium removal by lowering dialysate sodium concentration resulted in decreases in BP and IDWG . In addition, our previous study showed that lowering dialysate sodium concentration was associated with improvements in arterial stiffness and LVH in hypertensive HD patients . As dietary sodium intake was found to exaggerate numerous sympathoinhibitory and sympathoexcitatory reflexes , we therefore hypothesized that dialysis sodium intake may increase BPV.…”

mentioning

confidence: 99%

Impact of Dialysate Sodium Concentration Lowering on Home Blood Pressure Variability in Hemodialysis Patients

et al. 2018

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Blood pressure variability is an independent risk factor for mortality and cardiovascular events in hemodialysis patients. Dialysate sodium concentration may not only have effects on blood pressure but also on blood pressure variability. We investigated whether dialysate sodium concentration lowering could decrease home blood pressure variability in hemodialysis patients. Forty‐three hemodialysis patients at their dry weight assessed by bioimpedance methods with pre‐dialysis serum sodium >136 mmol/L were recruited. Firstly, patients underwent a 1‐month standard dialysis with dialysate sodium concentration of 138 mmol/L, and then the dialysate sodium concentration was decreased to 136 mmol/L for 8 weeks. Home blood pressure was assessed on waking up and at bedtime for 1 week. Coefficient of variation was used to define home blood pressure variability. After the intervention, whole‐day systolic blood pressure variability decreased from 5.7 ± 2.6% to 4.3 ± 1.7% and evening systolic blood pressure variability decreased from 7.9 ± 4.1% to 6.2 ± 3.1%. Morning systolic blood pressure variability had a reduction from 7.8 ± 2.4% to 5.9 ± 3.3% but did not achieve statistical significance (P = 0.077). Whole‐day, morning and evening systolic blood pressure were decreased significantly. Less changes were observed in diastolic blood pressure parameters. Interdialytic weight gain mildly but significantly decreased. Volume parameters, dietary sodium intake and incidence of adverse events were similar throughout the study period. Lowering dialysate sodium concentration could improve home blood pressure variability among hemodialysis patients who had achieved their dry weight.

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Increasing Dialysis Sodium Removal on Arterial Stiffness and Left Ventricular Hypertrophy in Hemodialysis Patients

Cited by 29 publications

References 28 publications

Blood Pressure Management in Hemodialysis Patients: What We Know And What Questions Remain

Blood Pressure Management in Hemodialysis Patients: What We Know And What Questions Remain

Hydrochlorothiazide vs chlorthalidone, indapamide, and potassium‐sparing/hydrochlorothiazide diuretics for reducing left ventricular hypertrophy: A systematic review and meta‐analysis

Impact of Dialysate Sodium Concentration Lowering on Home Blood Pressure Variability in Hemodialysis Patients

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