The effect of a dry-weight probing guided by lung ultrasound on 24hour aortic blood pressure and arterial stiffness in hemodialysis patients

Prevalence of hypertension in patients undergoing hemodialysis is estimated at 85% and the main pathophysiologic mechanism is their inability to maintain sodium and volume control. Reduction of volume overload is fundamental for blood pressure (BP) control, but clinical criteria to estimate dry-weight are inaccurate, despite its widespread use. The aim of this doctoral thesis was to examine the effect of dry-weight reduction with a lung-ultrasound-guided strategy on ambulatory brachial and central systolic (SBP) and diastolic BP (DBP), as well as on arterial stiffness parameters and echocardiographic indices in hypertensive hemodialysis patients. This study followed a single-blind, randomized, parallel-group design and included 71 adult (>18 years) hemodialysis patients with hypertension that were clinically euvolemic with standard clinical criteria and provided written informed consent. Hypertension diagnosis was based on mean home BP values ≥135/85 mmHg. Patients were randomized in the active group (n=35), following a strategy for dry-weight reduction guided by the total number of US-B lines (US-B lines score) prior to dialysis, and a control group (n=36), following standard-of-care treatment. All patients underwent 48-hour ABPM, echocardiographic study, office arterial stiffness measurement and bioelectrical impedance analysis at baseline, after 8-weeks and after 12 months. More patients in the active compared to control group had dry weight reduction during both the 8-week (54.3% vs 13.9%, p18 ετών) ασθενείς υπό αιμοκάθαρση με ΑΥ, οι οποίοι ήταν κλινικά ευογκαιμικοί με τα συνήθη κλινικά κριτήρια και οι οποίοι παρείχαν γραπτή συγκατάθεση συμμετοχής στη μελέτη. Η διάγνωση της ΑΥ βασίστηκε σε ΑΠκατ’οίκον ≥135/85 mmHg. Οι ασθενείς τυχαιοποιήθηκαν στην ομάδα παρέμβασης (n=35), που ακολουθήσε μια στρατηγική μείωσης του ΞΒ, καθοδηγούμενη από το US-B lines score πριν την αιμοκάθαρση και στην ομάδα ελέγχου (n=36), που ακολουθήσε την καθιερωμένη θεραπευτική τακτική. Οι ασθενείς υποβλήθηκαν σε 48ωρη ΑΒΡΜ υπερηχοκαρδιογραφική μελέτη, προσδιορισμό των δεικτών αρτηριακής και σε ανάλυση βιοηλεκτρικής αντίστασης στην έναρξη, μετά από 8 εβδομάδες και 12 μήνες. Περισσότεροι ασθενείς στην ομάδα παρέμβασης συγκριτικά με την ομάδα ελέγχου είχαν μείωση του ΞΒ κατά τη διάρκεια των 8 εβδομάδων (54,3% vs 13,9%, p<0,001) και των 12 μηνών (71,4% vs 22,2%, p<0,001). Οι μεταβολές των US-B lines κατά τη διάρκεια της περιόδου παρακολούθησης των 8 εβδομάδων ήταν -5,31±12,53 στην ομάδα παρέμβασης vs 2,17±7,62 στην ομάδα ελέγχου (p<0,001) που αντιστοιχούσαν σε μεταβολές του ΞΒ -0,71±1,39 vs 0,51±0,98 kg (p<0,001) και κατά τη διάρκεια της περιόδου παρακολούθησης 12 μηνών ήταν -4,34±13,84 στην ομάδα παρέμβασης vs 4,4±16,11 στην ομάδα ελέγχου (p=0,004) που αντιστοιχούσαν σε μεταβολές του ΞΒ -1,42±2,47 vs +0,55±2,33 kg (p=0,001). Η μείωση της 48ωρης βραχυχρόνιας ΑΠ ήταν μεγαλύτερη στην ομάδα παρέμβασης κατά τη διάρκεια των 8 εβδομάδων (ομάδα παρέμβασης: -6,61±9,57/-3,85±6,34, ομάδα ελέγχου: -0,67±13,07/-0,55±8,28 mmHg, p=0,033 και 0,031) και των 12 μηνών συγκριτικά με την ομάδα ελέγχου (ομάδα παρέμβασης: -6,74±13,59/-4,26±7,69, ομάδα ελέγχου: -0,45±14,96/-1,47±9,81 mmHg, p=0,053 και 0,187 για τη 48ωρη ΣΑΠ και ΔΑΠ αντιστοίχως). Η μείωση της 48ωρης ΑΠ ήταν μεγαλύτερη στην ομάδα παρέμβασης κατά τη διάρκεια της παρακολούθησης. Η 48ωρη PWV μειώθηκε στην ομάδα παρέμβασης (Έναρξη: 9,34±1,98, 8 εβδομάδες: 9,08±2,04, p=0,004, 12 μήνες: 9,26±2,01 m/sec, p=0,042) και αυξήθηκε στην ομάδα ελέγχου (Έναρξη: 9,23±1,87, 8 εβδομάδες: 9,29±1,89, p=0,417, 12 μήνες: 9,43±2,08 m/sec, p=0,034) κατά την παρακολούθηση. Αντίθετα, ο 48ωρος AIx(75) δεν μεταβλήθηκε μεταξύ της έναρξης και του τέλους της παρακολούθησης στις ομάδες της μελέτης. Οι μειώσεις των δεικτών μεγέθους του αριστερού (LA) και του δεξιού κόλπου (RA) ήταν μεγαλύτερες στην ομάδα παρέμβασης συγκριτικά με την ομάδα ελέγχου κατά τη διάρκεια των 8 εβδομάδων (LA επιφάνεια: ομάδα παρέμβασης: -1,09±4,61, ομάδα ελέγχου: 0,93±3,06 cm2, p=0.034, RA επιφάνεια: ομάδα παρέμβασης: -1,56±6,17, ομάδα ελέγχου: 0,47±2,31 cm2, p=0,024) και των 12 μηνών παρακολούθησης (LA επιφάνεια: ομάδα παρέμβασης: -1,33±4,49, ομάδα ελέγχου 1,24±4,98 cm2, p=0,008; RA επιφάνεια: ομάδα παρέμβασης: -1,11±6,29, ομάδα ελέγχου: 1,25±3.76 cm2, p=0,061). Οι μειώσεις του τελοδιαστολικού και του τελοσυστολικού όγκου της LV ήταν μεγαλύτερες στην ομάδα παρέμβασης. Οι πιέσεις πλήρωσης της LV μειώθηκαν σημαντικά στην ομάδα παρέμβασης συγκριτικά με την ομάδα ελέγχου. Οι δείκτες συστολικής λειτουργίας παρέμειναν αμετάβλητοι και στις δύο ομάδες. Αξίζει να αναφερθεί ότι το ποσοστό των ασθενών που παρουσίασαν ≥1 επεισόδιο ενδοδιαλυτικής υπότασης ήταν οριακά χαμηλότερο στην ομάδα παρέμβασης κατά τη διάρκεια της παρακολούθησης. Η εφαρμογή της υπο εξέταση θεραπευτικής στρατηγικής για τη μείωση του ΞΒ, βάσει του υπερηχογραφικού ελέγχου των πνευμόνων μπορεί να μειώσει αποτελεσματικά και με ασφάλεια την περιπατητική ΑΠ, τη PWV και τις διαστάσεις των καρδιακών κοιλοτήτων σε ασθενείς υπο αιμοκάθαρση

Human Chorionic Gonadotropin: The Pregnancy Hormone and More

To thoroughly review the uses of human chorionic gonadotropin (hCG) related to the process of reproduction and also assess new, non-traditional theories. Review of the international literature and research studies. hCG and its receptor, LH/CGR, are expressed in numerous sites of the reproductive tract, both in gonadal and extra-goanadal tissues, promoting oocyte maturation, fertilization, implantation and early embryo development. Moreover, hCG seems to have a potential role as an anti-rejection agent in solid organ transplantation. Future research needs to focus extensively on the functions of hCG and its receptor LH/CGR, in an effort to reveal known, as well as unknown clinical potentials

Renin-angiotensin system blockade in patients with chronic kidney disease: benefits, problems in everyday clinical use, and open questions for advanced renal dysfunction.

Management of hypertension and albuminuria are considered among the primary goals of treatment to slow the progression of chronic kidney disease (CKD). Renin-angiotensin system (RAS) blockers, i.e., angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) are the main drugs to achieve these goals. Seminal studies have showed that RAS blockers present significant renoprotective effects in CKD patients with very high albuminuria. In post hoc analyses of such trials, these renoprotective effects appeared more robust in patients with more advanced CKD. However, randomized trials specifically addressing whether RAS blockers should be initiated or maintained in patients with advanced CKD are scarce and do not include subjects with normoalbuminuria, thus, many clinicians are unconvinced for the beneficial effects of RAS blockade in these patients. Further, the fear of hyperkalemia or acute renal decline is another factor due to which RAS blockers are usually underprescribed and are easily discontinued in patients with more advanced CKD; i.e., those in Stages 4 and 5. This review summarizes evidence from the literature regarding the use of RAS blockers in patients with advanced CKD

Volume overload in hemodialysis: diagnosis, cardiovascular consequences, and management.

Volume overload in haemodialysis (HD) patients associates with hypertension and cardiac dysfunction and is a major risk factor for all-cause and cardiovascular mortality in this population. The diagnosis of volume excess and estimation of dry weight is based largely on clinical criteria and has a notoriously poor diagnostic accuracy. The search for accurate and objective methods to evaluate dry weight and to diagnose subclinical volume overload has been intensively pursued over the last 3 decades. Most methods have not been tested in appropriate clinical trials and their usefulness in clinical practice remains uncertain, except for bioimpedance spectroscopy and lung ultrasound (US). Bioimpedance spectroscopy is possibly the most widely used method to subjectively quantify fluid distributions over body compartments and produces reliable and reproducible results. Lung US provides reliable estimates of extravascular water in the lung, a critical parameter of the central circulation that in large part reflects the left ventricular end-diastolic pressure. To maximize cardiovascular tolerance, fluid removal in volume-expanded HD patients should be gradual and distributed over a sufficiently long time window. This review summarizes current knowledge about the diagnosis, prognosis and treatment of volume overload in HD patients

Blood pressure targets in patients with chronic kidney disease: MDRD and AASK now confirming SPRINT

Recent American and European hypertension guidelines are not in agreement regarding blood pressure (BP) targets for persons with chronic kidney disease (CKD). Previous analyses from the African American Study on Kidney Disease (AASK) and Modification of Diet in Renal Disease (MDRD) trials suggested that strict BP control confers nephroprotection for patients with proteinuria, but a mortality benefit was not apparent. In contrast, an analysis of the Systolic Blood Pressure Intervention Trial (SPRINT) subpopulation of CKD patients showed a mortality benefit with the systolic blood pressure (SBP) <120mmHg versus the SBP <140 target. A recent analysis of the combined MDRD and AASK cohorts supports previous evidence on nephroprotection but also findings from the SPRINT trial on all-cause mortality benefits of intensive versus usual BP control in individuals with CKD.Sin financiación4.452 JCR (2020) Q1, 20/89 Urology & Nephrology1.033 SJR (2020) Q1, 16/66 NephrologyNo data IDR 2020UE

A Randomized Controlled Trial on the Efficacy and Safety of Low-Dose hCG in a Short Protocol with GnRH Agonist and Ovarian Stimulation with Recombinant FSH (rFSH) During the Follicular Phase in Infertile Women Undergoing ART

tau his study aims to investigate whether the addition of low-dose hCG throughout stimulation in infertile women undergoing IVF improves IVF outcome parameters. This is a prospective, multicenter, randomized, double-blind, placebo-controlled, Phase IIIb clinical study, conducted in three university IVF units. We studied whether the addition of 100 IU hCG/day to a short GnRH agonist IVF protocol from the onset of the follicular phase (group 1, n=40) or placebo (group 2, n=41) had any impact on the number of high-quality transferred embryos at day 2 and clinical pregnancy rates. The comparison encompassed descriptive statistics, and univariate and multivariate analyses. Concerning the primary outcomes, we found no differences in both the number of high-quality embryos (&gt;= 2) at day 3 [21/40 (52.5%) vs. 14/41 (34.2%), p=0.095] and clinical pregnancy rates [10/40 (25%) vs. 10/41 (24.4%), p=0.949], respectively. Similarly, there were no differences concerning the secondary outcomes preset for this trial. According to the results of the multivariate logistic regression analysis, no significant associations were noted for primary outcomes (clinical pregnancy: adjusted OR=0.89, 95% CI: 0.29-2.75; (&gt;= 2 excellent quality embryos at day 3: adjusted OR=0.54, 95% CI: 0.21-1.42, with group 1 set as reference category); similarly, no differences were noted with respect to secondary outcomes, except from the increased odds of &gt;= 2 poor-quality embryos at day 3 occurring in group 2 (adjusted OR= 11.69, 95%CI: 1.29-106.19). The addition of low-dose hCG to a short GnRH agonist protocol for IVF does not improve the number of top-quality embryos and clinical pregnancy rates

Role of hypertension in kidney transplant recipients.

Cardiovascular events are one of the leading causes of mortality in kidney transplant recipients. Hypertension is the most common comorbidity accompanying chronic kidney disease, with prevalence remaining as high as 90% even after kidney transplantation. It is often poorly controlled. Abnormal blood pressure profiles, such as masked or white-coat hypertension, are also extremely common in these patients. The pathophysiology of blood pressure elevation in kidney transplant recipients is complex and includes transplantation-specific risk factors, which are added to the traditional or chronic kidney disease-related factors. Despite these observations, hypertension management has been an under-researched area in kidney transplantation. Thus, relevant evidence derives either from studies in the general population or from small trials in kidney transplant recipients. Based on the relevant guidelines in the general population, lifestyle modifications should probably be applied as the first step of hypertension management in kidney transplant recipients. The optimal pharmacological management of hypertension in kidney transplant recipients is also not clear. Dihydropyridine calcium channel blockers are commonly used as first line agents because of their lack of adverse effects on the kidney, while other antihypertensive drug classes are under-utilised due to fear of the possible haemodynamic consequences on renal function. This review summarizes the existing data on the pathophysiology, diagnosis, prognostic significance and management of hypertension in kidney transplantation