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191 Intradialytic Hypertension Improves with Maximized Ultrafiltration and the Use of Nondialyzable Antihypertensive Agents
NKF 2011 Spring Clinical Meetings Abstracts
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191 INTRADIALYTIC HYPERTENSION IMPROVES WITH MAXIMIZED ULTRAFILTRATION AND THE USE OF NONDIALYZABLE ANTIHYPERTENSIVE AGENTS Jehona Marku-Podvorica, Rick P. Vaghasiya, Michael F. Michelis Division of Nephrology Lenox Hill Hospital New York, NY USA Intradialytic hypertension (IDH) has been described as an increase in systolic blood pressure (SBP) ≥10 mm Hg during or immediately after hemodialysis. This study sought to determine whether IDH in hemodialysis patients is associated with volume excess, changes in electrolytes, lack of use of nondialyzable antihypertensives or timing of erythropoietin (EPO) injection. Twelve patients, 18 years of age or older, with IDH were included. Six treatments were performed with maximized ultrafiltration by sequential decrease in dry weight until patients experienced symptomatic hypotension or need for saline infusion. Serum sodium, potassium, calcium, glucose and albumin were measured pre and post treatment. Antihypertensive usage as well as timing of EPO were recorded. Nondialyzable antihypertensives such as calcium channel blockers or angiotension II receptor antagonists were added if SBP did not respond to volume removal. Ten patients completed the study. Two patients were removed because of inability to reach estimated dry weight (EDW). Six participants had a decrease in IDH after maximized ultrafiltration. The mean intradialytic increase in SBP pre ultrafiltration in those 6 patients was 38.1 mm Hg ± 5.25 which decreased to 26.3 mm Hg ± 3.72 (p=0.011) post ultrafiltration with one patient cured of IDH. The other four patients were placed on a nondialyzable medication. IDH resolved in three of those four patients. Serum potassium levels decreased by 1.2 mEq/L ± 0.4 (p=0.001), glucose levels decreased by 33.5 mg/dL ± 25.5 (p=0.023) and serum albumin levels increased by 0.4 g/dL ± 0.2 (p=0.01). Improvement in IDH with ultrafiltration and nondialyzable antihypertensives occurred despite these electrolyte changes. Sodium and calcium levels did not change. EPO administration did not influence SBP changes. IDH can be improved by maximized ultrafiltration and nondialyzable antihypertensives. Ninety percent of patients improved, while forty percent were cured of IDH by the use of these maneuvers.
190 OUTPATIENT VERSUS INPATIENT OBSERVATION AFTER PERCUTANEOUS NATIVE KIDNEY BIOPSY; A COSTMINIMIZATION STUDY Saugar Maripuri, David Penson, and Kerri Cavanaugh; Vanderbilt University Medical Center, Nashville, TN, USA. Percutaneous kidney biopsy (PKB) is the primary diagnostic tool for kidney disease. Outpatient “day surgery” (ODS) following PKB in low risk patients has been described as a safe alternative to inpatient observation (IO). This study aimed to determine the least costly strategy while accounting for all institutional costs (IC) including post-PKB complications and death. A cost-minimization study was performed using decision analysis methodology which models relative costs in relation to outcome probabilities yielding an optimum decision. The potential outcomes included major complications (bleeding requiring blood transfusion or advanced intervention), minor complications (bleeding or pain requiring additional observation), and death. Probabilities were obtained from the published literature and a base case selected. IC were obtained for all complications from institutional activity-based cost estimates. The base case assumed an overall complication rate of 10% with major bleeding occurring in 2.5% of patients and death in 0.1% and 0.15% of IO and ODS patients, respectively. The IC of death was estimated at $500,000, which includes insurance costs and potential litigation. ODS cost $1390 per patient compared to $1770 for IO. In order to justify IO for all by cost minimization, the overall complication rate needed to exceed 19%, major complication rate 5.4%, and IC per death $1.1 million. The IC of death for ODS would need to be 50% higher compared to IO in order to favor the latter for all. ODS may be a safe alternative to IO and potentially less costly from the institutional perspective. ODS should be considered for low risk patients who understand the signs of a post-KB complication and who would seek immediate care if they were to arise.
A64
192 IMPACT OF ENDOTHELIN RECEPTOR ANTAGONISTS ON RENAL FUNCTION IN PATIENTS WITH HEART FAILURE Natallia Maroz, Amir Kazory Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida, USA Diuretics are thought to contribute to deterioration of renal function in patients with heart failure (HF). Renal dysfunction is known to be associated with increased morbidity and mortality in this population. Endothelin receptor antagonists (ERA) represent emerging pharmacological therapies that potentially lack the renal adverse effects of diuretics. This study explores the currently available data on the impact of these agents on renal function. Articles cited in PubMed database from 1980 to 2010 using key words: “endothelin receptor antagonist” and “heart failure” were searched. Those clinical randomized controlled trials that exclusively included HF population were identified, and relevant articles were selected. The results of these studies were then reviewed and compared with regards to impact on renal function. A total of 40 relevant articles were identified that used four different ERA (tezosentan, darusentan, erasentan, and bosentan). Twelve randomized, placebo-controlled trials were selected to be included in this study. While 5 studies reported no significant change in renal function, 4 studies did not report it. Surprisingly, one study showed higher incidence of renal failure in study group compared with placebo, and there was a greater rise in serum creatinine level in another study. Urine output decreased significantly in one study with a trend towards renal dysfunction. Hypotension was a common adverse effect of ERA. While there is a promising theoretical basis for use of ERA in patients with HF, currently available data show only modest beneficial impact on renal function for these agents. Future large-sized trials are needed to further evaluate these effects and their potential impact on morbidity and mortality.
Am J Kidney Dis. 2011;57(4):A1-A108
189
191 INTRADIALYTIC HYPERTENSION IMPROVES WITH MAXIMIZED ULTRAFILTRATION AND THE USE OF NONDIALYZABLE ANTIHYPERTENSIVE AGENTS Jehona Marku-Podvorica, Rick P. Vaghasiya, Michael F. Michelis Division of Nephrology Lenox Hill Hospital New York, NY USA Intradialytic hypertension (IDH) has been described as an increase in systolic blood pressure (SBP) ≥10 mm Hg during or immediately after hemodialysis. This study sought to determine whether IDH in hemodialysis patients is associated with volume excess, changes in electrolytes, lack of use of nondialyzable antihypertensives or timing of erythropoietin (EPO) injection. Twelve patients, 18 years of age or older, with IDH were included. Six treatments were performed with maximized ultrafiltration by sequential decrease in dry weight until patients experienced symptomatic hypotension or need for saline infusion. Serum sodium, potassium, calcium, glucose and albumin were measured pre and post treatment. Antihypertensive usage as well as timing of EPO were recorded. Nondialyzable antihypertensives such as calcium channel blockers or angiotension II receptor antagonists were added if SBP did not respond to volume removal. Ten patients completed the study. Two patients were removed because of inability to reach estimated dry weight (EDW). Six participants had a decrease in IDH after maximized ultrafiltration. The mean intradialytic increase in SBP pre ultrafiltration in those 6 patients was 38.1 mm Hg ± 5.25 which decreased to 26.3 mm Hg ± 3.72 (p=0.011) post ultrafiltration with one patient cured of IDH. The other four patients were placed on a nondialyzable medication. IDH resolved in three of those four patients. Serum potassium levels decreased by 1.2 mEq/L ± 0.4 (p=0.001), glucose levels decreased by 33.5 mg/dL ± 25.5 (p=0.023) and serum albumin levels increased by 0.4 g/dL ± 0.2 (p=0.01). Improvement in IDH with ultrafiltration and nondialyzable antihypertensives occurred despite these electrolyte changes. Sodium and calcium levels did not change. EPO administration did not influence SBP changes. IDH can be improved by maximized ultrafiltration and nondialyzable antihypertensives. Ninety percent of patients improved, while forty percent were cured of IDH by the use of these maneuvers.
190 OUTPATIENT VERSUS INPATIENT OBSERVATION AFTER PERCUTANEOUS NATIVE KIDNEY BIOPSY; A COSTMINIMIZATION STUDY Saugar Maripuri, David Penson, and Kerri Cavanaugh; Vanderbilt University Medical Center, Nashville, TN, USA. Percutaneous kidney biopsy (PKB) is the primary diagnostic tool for kidney disease. Outpatient “day surgery” (ODS) following PKB in low risk patients has been described as a safe alternative to inpatient observation (IO). This study aimed to determine the least costly strategy while accounting for all institutional costs (IC) including post-PKB complications and death. A cost-minimization study was performed using decision analysis methodology which models relative costs in relation to outcome probabilities yielding an optimum decision. The potential outcomes included major complications (bleeding requiring blood transfusion or advanced intervention), minor complications (bleeding or pain requiring additional observation), and death. Probabilities were obtained from the published literature and a base case selected. IC were obtained for all complications from institutional activity-based cost estimates. The base case assumed an overall complication rate of 10% with major bleeding occurring in 2.5% of patients and death in 0.1% and 0.15% of IO and ODS patients, respectively. The IC of death was estimated at $500,000, which includes insurance costs and potential litigation. ODS cost $1390 per patient compared to $1770 for IO. In order to justify IO for all by cost minimization, the overall complication rate needed to exceed 19%, major complication rate 5.4%, and IC per death $1.1 million. The IC of death for ODS would need to be 50% higher compared to IO in order to favor the latter for all. ODS may be a safe alternative to IO and potentially less costly from the institutional perspective. ODS should be considered for low risk patients who understand the signs of a post-KB complication and who would seek immediate care if they were to arise.
A64
192 IMPACT OF ENDOTHELIN RECEPTOR ANTAGONISTS ON RENAL FUNCTION IN PATIENTS WITH HEART FAILURE Natallia Maroz, Amir Kazory Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida, USA Diuretics are thought to contribute to deterioration of renal function in patients with heart failure (HF). Renal dysfunction is known to be associated with increased morbidity and mortality in this population. Endothelin receptor antagonists (ERA) represent emerging pharmacological therapies that potentially lack the renal adverse effects of diuretics. This study explores the currently available data on the impact of these agents on renal function. Articles cited in PubMed database from 1980 to 2010 using key words: “endothelin receptor antagonist” and “heart failure” were searched. Those clinical randomized controlled trials that exclusively included HF population were identified, and relevant articles were selected. The results of these studies were then reviewed and compared with regards to impact on renal function. A total of 40 relevant articles were identified that used four different ERA (tezosentan, darusentan, erasentan, and bosentan). Twelve randomized, placebo-controlled trials were selected to be included in this study. While 5 studies reported no significant change in renal function, 4 studies did not report it. Surprisingly, one study showed higher incidence of renal failure in study group compared with placebo, and there was a greater rise in serum creatinine level in another study. Urine output decreased significantly in one study with a trend towards renal dysfunction. Hypotension was a common adverse effect of ERA. While there is a promising theoretical basis for use of ERA in patients with HF, currently available data show only modest beneficial impact on renal function for these agents. Future large-sized trials are needed to further evaluate these effects and their potential impact on morbidity and mortality.
Am J Kidney Dis. 2011;57(4):A1-A108