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    "textoCompleto" => "NEFROLOGÍA. Vol. XXIV. Número Extraordinario (I). 2004 Control del volumen extracelular y de la presión arterial en hemodiálisis de larga duración C. Chazot, M. D. Centre de Rein Artificiel. Tassin. France. Extra-cellular volume (ECV) represents 24% of body weight in adults The determinant compound of ECV is sodium. It is subject to wide and instantaneous variations, essentially due to changes in salt ingestion. The kidney is the key organ of sodium and ECV regulation. The decline in renal function affects the sodium (or ECV) balance. It is often challenged by an excessive salt intake, so that a defect of kidney function leads to a positive sodium (or ECV) balance and high blood pressure. Guyton has experimentally described the mechanisms of HTN in renal failure: ECV expansion, rise of cardiac output (CO), increased organ perfusion, increase of peripheral resistance (TPR) by protective pre-arteriolar vasoconstriction, with sustained hypertension (HTN) 1. Hence almost all patients with renal failure are hypertensive when starting dialysis. Soon after dialysis treatment was developed, it became clear that high blood pressure was a serious problem. According to Scribner, adequate control of the extra-cellular volume was the key to treat HTN in dialysis patients 2. In the first 10 years of dialysis, the consensus was that the control of HTN was achieved in a large majority of patients by UF and a low salt diet 3, 4 and the normalization of ECV by dialysis treatment was defined by Thomson et al. as the «dry weight»5. In our experience, dry weight is the post dialysis body weight that allows the pre-dialysis BP to remain normal, without the need for antihypertensive drugs, despite the interdialytic weight gain. At her/his dry weight, the patient has no clinical signs of fluid overload or dehydration 6. This definition points to BP as the key indicator of ECV. Normal blood pressure is the goal but also the best indicator of its single most determinant factor, the ECV. In the early 90's, Cheigh et al 7 in the United States reported that HTN was not controlled in dialysis patients. It was confirmed by subsequent studies. At the same time, we have reported in a cross sectional ambulatory BP monitoring study 11 or prospective data 12 the adequate BP control in patients treated with long hour HD treatment, despi38 te the worsening comorbidity of ESRD patients. In this last study 12, it is shown that 6 months in average are necessary to stabilize blood pressure at a normal level in a cohort of 61 patients beginning dialysis treatment, whereas antihypertensive drugs are tapered and stopped. It can be speculated, but it remains to be confirmed, that this delay is necessary to correct the cardiovascular remodelling induced by chronic ECV overload during the predialysis period. This hypothesis would also explain that acute ECV overload induced by interdialytic weight gain is not associated with HTN in these patients after 6 months of HD treatment. In our opinion, one of the reasons of the HTN current burden in HD patients relies on the neglect of ECV overload as the primary mechanism of HTN in dialysis patients. Forgetting of the dry weight quest and low salt diet recommendation seem usual, whereas the easy temptation of prescribing antihypertensive medication whose effectiveness may be doubtful in this setting is frequent. The other reason is the reduction of dialysis time inducing high UF rate and inadequate vascular refilling, leading to cramps and hypotension episodes jeopardizing the target dry weight achievement. Charra has described this phenomenon as the «vicious circle of short dialysis»13. Oskahya et al 14 have confirmed that low salt diet, tapering of antihypertensive drugs, and aggressive UF policy may normalize blood pressure in patients treated with short dialysis session. This experience strengthens the idea that the will of the nephrologist is essential in obtaining the normalization of ECV and blood pressure. Reducing UF rate and intradialytic events, long hour dialysis is an easier way to achieve the normalization of ECV. In conclusion, long hour HD treatment reduces greatly the side effects of ECV correction and allows for an easy normalization of BP in this setting. The experience of other centers treating patients with sequential long hour dialysis 15 confirms that it is a «method effect» rather than a «center effect». HEMODIÁLISIS DE LARGA DURACIÓN BIBLIOGRAFÍA 1. Guyton AC, Coleman TG, Granger HJ: Circulation: overall regulation. Annu Rev Physiol 34: 13-46, 1972. 2. Scribner BH: A personalized history of chronic hemodialysis. Am J Kidney Dis 16: 511-519, 1990. 3. Vertes V, Cangiano JL, Berman LB, Gould A: Hypertension in end-stage renal disease. N Engl J Med 280: 978-981, 1969. 4. Blumberg A, Nelp WB, Hegstrom RM, Scribner BH: Extracellular volume in patients with chronic renal disease treated for hypertension by sodium restriction. Lancet 2: 69-73, 1967. 5. Thomson GE, Waterhouse K, McDonald HP, Jr., Friedman EA: Hemodialysis for chronic renal failure. Clinical observations. Arch Intern Med 120: 153-167, 1967. 6. Charra B, Laurent G, Chazot C, Calemard E, Terrat JC, Vanel T, Jean G, Ruffet M: Clinical assessment of dry weight. Nephrol Dial Transplant 11: 16-19, 1996. 7. Cheigh JS, Milite C, Sullivan JF, Rubin AL, Stenzel KH: Hypertension is not adequately controlled in hemodialysis patients. Am J Kidney Dis 19: 453-459, 1992. 8. Salem MM: Hypertension in the hemodialysis population: a survey of 649 patients. Am J Kidney Dis 26: 461-468, 1995. 9. Fishbane SA, Scribner BH: Blood pressure control in dialysis patients. Semin Dial 15: 144-145, 2002. 10. Mittal S, Kher V, Gulati S, Agarwal LK, Arora P: Chronic renal failure in India. Ren Fail 19: 763-770, 1997. 11. Chazot C, Charra B, Laurent G, Didier C, Vo Van C, Terrat JC, Calemard E, Vanel T, Ruffet M: Interdialysis blood pressure control by long haemodialysis sessions. Nephrol Dial Transplant 10: 831-837, 1995. 12. Chazot C, Charra B, Vo Van C, Jean G, Vanel T, Calemard E, Terrat JC, Ruffet M, Laurent G: The Janus-faced aspect of «dry weight». Nephrol Dial Transplant 14: 121-124, 1999. 13. Charra B: Control of blood pressure in long slow hemodialysis. Blood Purif 12: 252-258, 1994. 14. Ozkahya M, Toz H, Unsal A, Ozerkan F, Asci G, Gurgun C, Akcicek F, Mees EJ: Treatment of hypertension in dialysis patients by ultrafiltration: role of cardiac dilatation and time factor. Am J Kidney Dis 34: 218-221, 1999. 15. Covic A, Goldsmith DJ, Venning MC, Ackrill P: Long-hours home haemodialysis-the best renal replacement therapy method? Qjm 92: 251-260, 1999. 39 "
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año/Mes Html Pdf Total
2024 Noviembre 5 13 18
2024 Octubre 45 48 93
2024 Septiembre 68 49 117
2024 Agosto 60 69 129
2024 Julio 50 41 91
2024 Junio 55 71 126
2024 Mayo 43 34 77
2024 Abril 49 44 93
2024 Marzo 36 26 62
2024 Febrero 36 33 69
2024 Enero 38 35 73
2023 Diciembre 28 34 62
2023 Noviembre 34 29 63
2023 Octubre 31 39 70
2023 Septiembre 32 24 56
2023 Agosto 37 30 67
2023 Julio 35 30 65
2023 Junio 38 24 62
2023 Mayo 47 42 89
2023 Abril 28 17 45
2023 Marzo 26 19 45
2023 Febrero 39 27 66
2023 Enero 37 24 61
2022 Diciembre 48 29 77
2022 Noviembre 54 24 78
2022 Octubre 40 51 91
2022 Septiembre 36 48 84
2022 Agosto 39 34 73
2022 Julio 38 45 83
2022 Junio 28 37 65
2022 Mayo 43 34 77
2022 Abril 30 49 79
2022 Marzo 46 34 80
2022 Febrero 31 26 57
2022 Enero 29 40 69
2021 Diciembre 35 28 63
2021 Noviembre 33 36 69
2021 Octubre 23 38 61
2021 Septiembre 41 42 83
2021 Agosto 28 30 58
2021 Julio 41 26 67
2021 Junio 22 16 38
2021 Mayo 31 25 56
2021 Abril 34 17 51
2021 Marzo 44 37 81
2021 Febrero 16 18 34
2021 Enero 18 19 37
2020 Diciembre 18 12 30
2020 Noviembre 30 7 37
2020 Octubre 22 16 38
2020 Septiembre 19 1 20
2020 Agosto 24 6 30
2020 Julio 25 13 38
2020 Junio 12 8 20
2020 Mayo 34 14 48
2020 Abril 30 18 48
2020 Marzo 27 12 39
2020 Febrero 34 18 52
2020 Enero 34 17 51
2019 Diciembre 18 16 34
2019 Noviembre 29 11 40
2019 Octubre 7 9 16
2019 Septiembre 17 15 32
2019 Agosto 10 13 23
2019 Julio 22 26 48
2019 Junio 16 12 28
2019 Mayo 22 22 44
2019 Abril 47 39 86
2019 Marzo 13 17 30
2019 Febrero 9 8 17
2019 Enero 12 17 29
2018 Diciembre 31 21 52
2018 Noviembre 32 10 42
2018 Octubre 39 9 48
2018 Septiembre 34 11 45
2018 Agosto 19 15 34
2018 Julio 16 8 24
2018 Junio 19 9 28
2018 Mayo 16 12 28
2018 Abril 15 5 20
2018 Marzo 14 8 22
2018 Febrero 15 5 20
2018 Enero 15 4 19
2017 Diciembre 23 4 27
2017 Noviembre 10 7 17
2017 Octubre 21 4 25
2017 Septiembre 8 3 11
2017 Agosto 24 9 33
2017 Julio 17 5 22
2017 Junio 11 4 15
2017 Mayo 21 5 26
2017 Abril 15 5 20
2017 Marzo 14 7 21
2017 Febrero 9 2 11
2017 Enero 9 3 12
2016 Diciembre 10 4 14
2016 Noviembre 27 3 30
2016 Octubre 22 5 27
2016 Septiembre 38 1 39
2016 Agosto 77 3 80
2016 Julio 82 6 88
2016 Junio 63 0 63
2016 Mayo 74 0 74
2016 Abril 26 0 26
2016 Marzo 41 0 41
2016 Febrero 43 0 43
2016 Enero 49 0 49
2015 Diciembre 63 0 63
2015 Noviembre 49 0 49
2015 Octubre 43 0 43
2015 Septiembre 41 0 41
2015 Agosto 39 0 39
2015 Julio 32 0 32
2015 Junio 19 0 19
2015 Mayo 18 0 18
2015 Abril 6 0 6
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