Intensive dialysis and blood pressure control: A review

The prevalence of hypertension in hemodialysis (HD) patients has increased over the years. In the early days of maintenance HD blood pressure (BP) control was achieved in most patients. As sessions were shortened, the prevalence of hypertension increased. Yet, in principle, dialysis is able to control hypertension. Today, in programs using long HD, most patients are normotensive without antihypertensive medication. The same is true for patients on daily dialysis, but not for those on short thrice‐weekly HD. In all studies reporting BP normalization, dry weight is regularly achieved. Why the poor control of hypertension now? At first sight the shortened session duration is the culprit. This is suggested by several epidemiologic observations and strongly supported by a prospective experience of changing the HD schedule (short to long HD or conversely) in the same group of patients. Recent studies, however, using strict volume control show that BP normalization can be obtained in conventional 3 x 4 hr/week dialysis with relatively low delivered Kt/V_urea. Therefore, prolonging the dialysis time and/or increasing the dialysis dose are not required to achieve BP control. Intensive dialysis most probably normalizes BP by getting the extracellular volume and the amount of sodium in the body back to normal. It acts in conjunction with a moderate dietary sodium restriction and the use of reasonably low dialysate sodium. With this approach improved BP control can be achieved in the vast majority of HD patients.     

Low Serum Parathyroid Hormone Is a Predictor of Early Death after Hip Arthroplasty in Hemodialysis Patients

Background and Purpose:  Colloid osmotic pressure (COP) in plasma rises by ultrafiltration during hemodialysis, and it consequently causes plasma refilling in which water moves from interstitial tissue to capillary space. Although hemodynamic stability is one of the important factors for good dialysis outcome, no informative and convenient indicators are available other than monitoring of blood pressure. Thus, we measured COP during hemodialysis whether COP can be used as an indicator for the hemodynamic status in comparison with hematocrit (Ht). Plasma osmolality, ultrafiltration volume, and the alteration of blood pressure were also measured to examine whether COP is associated with them.
Method:  Sixteen patients hospitalized in this hospital were examined. Amongst them, 10 patients underwent both dialysis and ultrafiltration, while 4 patients received only dialysis and 2 patients were with ultrafiltration only by extracorporeal ultrafiltration method. Ultrafiltration was performed with constant speed to the dry weight for 4 h. The measurements of COP, plasma osmolality, Ht levels, and blood pressure were performed at 30 min (12.5% of the total water removal), 1 h (25%), 2 h (50%), and 3 h (75%) after the start of hemodialysis and also at the end of dialysis (100%).
Result:  COP markedly rose by 26.0% (±13.3%) in the patients who received both dialysis and ultrafiltration, whereas Ht rose by only 13.6% (±5.21%). And the curve for COP increase was sigmoid shape, whereas that for Ht showed linear change. On the other hand, in the patients whose Ht levels showed low values, the curves for both COP and Ht showed similar pattern.
Conclusion:  These results suggest that COP is a more sensitive indicator to be monitored for the hemodynamic status than Ht during hemodialysis.     

Hemodialysis‐related headache

Headache is one of the most frequently encountered neurological symptoms during hemodialysis. According to International Classification of Headache criteria dialysis‐related headache was defined as the headache occurring during hemodialysis with no specific characteristic. It resolves spontaneously within 72 hours after the hemodialysis session ends. There are few studies in the literature investigating the clinical features of dialysis headache. The pathophysiology of hemodialysis‐related headache is not known, but various triggering factors have been identified, including changes in blood pressure, serum sodium and magnesium levels during hemodialysis sessions, caffeine deprivation and stress. The aim of this article is to evaluate and analyze features of headache in patients undergoing hemodialysis.     

Effects of end‐stage renal disease and dialysis modalities on blood ammonia level

Introduction: Uremia results in a characteristic breath odor (uremic fetor) which is largely due to its high ammonia content. Earlier studies have shown a strong correlation between breath ammonia and blood urea levels and a 10‐fold reduction in breath ammonia after hemodialysis in patients with chronic kidney disease. Potential sources of breath ammonia include: (i) local ammonia production from hydrolysis of urea in the oropharyngeal and respiratory tracts by bacterial flora, and (ii) release of circulating blood ammonia by the lungs. While the effects of uremia and hemodialysis on breath ammonia are well known their effects on blood ammonia are unknown and were explored here. Methods: Blood samples were obtained from 23 hemodialysis patients (immediately before and after dialysis), 14 peritoneal dialysis patients, and 10 healthy controls. Blood levels of ammonia, creatinine, urea, and electrolytes were measured. Findings: No significant difference was found in baseline blood ammonia between hemodialysis, peritoneal dialysis and control groups. Hemodialysis procedure led to a significant reduction in urea concentration (P < 0.001) which was paradoxically accompanied by a modest but significant (P < 0.05) rise in blood ammonia level in 10 of the 23 patients studied. Change in blood ammonia pre‐ and post‐hemodialysis correlated with change in serum bicarbonate levels (r = 0.61, P < 0.01). On subgroup analysis of patients who had a rise in blood ammonia levels after dialysis, there was a strong correlation with drop in mean arterial pressure (r = 0.88, P < 0.01). The nadir intradialytic systolic blood pressure trended lower in the hemodialysis patients who had a rise in blood ammonia compared to the patients who manifested a fall in blood ammonia (124 ± 8 vs. 136 ± 6 mmHg respectively, P = 0.27). Discussion: Fall in blood urea following hemodialysis in ESRD patients was paradoxically accompanied by a modest rise in blood ammonia levels in 43% of the patients studied, contrasting prior reported effects of hemodialysis on breath ammonia. In this subgroup of patients, changes in blood ammonia during hemodialysis correlated with rise in blood bicarbonate and fall in mean arterial blood pressure.     

Pre to post‐dialysis plasma sodium change better predicts clinical outcomes than dialysate to plasma sodium gradient in quotidian hemodialysis

Sodium balance across a hemodialysis treatment influences interdialytic weight gain (IDWG), pre‐dialysis blood pressure, and the occurrence of intradialytic hypotension, which associate with patient morbidity and mortality. In thrice weekly conventional hemodialysis patients, the dialysate sodium minus pre‐dialysis plasma sodium concentration (δDPNa+) and the post‐dialysis minus pre‐dialysis plasma sodium (δPNa+) are surrogates of sodium balance, and are associated with both cardiovascular and all‐cause mortality. However, whether δDPNa+ or δPNa+ better predicts clinical outcomes in quotidian dialysis is unknown. We performed a retrospective analysis of clinical and demographic data from the Southwestern Ontario Regional Home Hemodialysis program, of all patients since 1985. In frequent nocturnal hemodialysis, δPNa+ was superior to δDPNa+ in predicting IDWG (R² = 0.223 vs. 0.020, P = 0.002 vs. 0.76), intradialytic change in systolic (R² = 0.100 vs. 0.002, P = 0.02 vs. 0.16) and diastolic (R² = 0.066 vs. 0.019, P = 0.02 vs. 0.06) blood pressure, and ultrafiltration rate (R² = 0.296 vs. 0.036, P = 0.001 vs. 0.52). In short hours daily hemodialysis, δDPNa+ was better than δPNa+ in predicting intradialytic change in diastolic blood pressure (R² = 0.101 vs. 0.003, P = 0.02 vs. 0.13). However, δPNa+ was better than δDPNa+ in predicting IDWG (R² = 0.105 vs. 0.019, P = 0.04 vs. 0.68) and pre‐dialysis systolic blood pressure (R² = 0.103 vs. 0.007, P = 0.02 vs. 0.82). We also found that the intradialytic blood pressure fall was greater in frequent nocturnal hemodialysis patients than in short hours daily patients, when exposed to a dialysate to plasma sodium gradient. These results provide a basis for design of prospective trials in quotidian dialysis modalities, to determine the effect of sodium balance on cardiovascular outcome.     

Fluid balance, dry weight, and blood pressure in dialysis

The total amount of sodium present in the body controls the extracellular volume. In advanced renal failure, sodium balance becomes positive and the extracellular volume expands. This leads to hypertension, and vascular changes that lead to adverse cardiovascular consequences in dialysis patients. Controlling the body sodium content and the extracellular volume allows one to better control hypertension and its consequences. This can be achieved by reducing the sodium input (sodium dietary restriction and reasonably low sodium dialysate) and/or by increasing the sodium output (ultrafiltration by convection). The discontinuous nature of hemodialysis causes saw-tooth volume fluctuations. This has led to the concept of dry weight (DW), a crucial component of dialysis adequacy. Assessment and achievement of DW is feasible on pure clinical grounds. But its relative lack of accuracy (and the physicians' progressive lack of interest in bedside examination) has led to several nonclinical methods of assessing DW in an effort to improve the assessment of fluid status in dialysis patients.     

An overlooked complication of hemodialysis: Hoarseness

In hemodialysis patients, some degree of transient hoarseness may occur at the end of the dialysis, and it may be a wearisome, recurrent, and severe state for some hemodialysis patients. However, to date, it has not been a well‐defined complication of hemodialysis. The aim of this study was to state this complication and to throw light on it. Four hundred fifty‐nine hemodialysis patients were questioned about any change in voice quality during hemodialysis. The patients who had this complaint (n = 70) were included in the study, and the group of patients who suffered hoarseness (subgroup 1: severe, subgroup 2: moderate, subgroup 3: mild) were compared with each other and with the control group, which did not suffer hoarseness (n = 51). Hoarseness was found in 15.2% of the hemodialysis patients. The duration of their hoarseness was minumum 1 to maximum 24 hours. In the control group, coronary artery disease (P = 0.056), congestive heart failure (P = 0.049), autonomic neuropathy (P = 0.001), severe intradialytic hypotensive attacks (P = 0.000), heart valve abnormalities (P = 0.000), and left ventricular diastolic dysfunction (P = 0.000) were significantly lower than in hoarseness group. Older age (P = 0.024), coronary artery disease (P = 0.014), autonomic neuropathy (P = 0.011), and intradialytic hypotensive attacks (P = 0.0001), were associated with severe and moderate hoarseness. In the comparison of % change for systolic and diastolic blood pressure between the hoarseness subgroups, diastolic blood pressure change was not different (P = 0.521), but systolic blood pressure change was statistically lower in mild group than moderate (P = 0.033) and severe subgroup (P = 0.029). Dialysis‐induced hypotension may be the main contributor of transient hoarseness. Especially elderly and cardiovascularly compromised patients, who are vulnerable to rapid changes in volume status may experience it to serious extent and this complication may be mediated by autonomic nervous control related with volume depletion.     

Does Blood Pressure Control by Gentle Ultrafiltration Improve Survival in Hemodialysis Patients?

Agentle ultrafiltration can be achieved using a long and slow hemodialysis. It is easier to achieve gentle ultrafiltration if the interdialytic weight intake is moderate ( i.e., if the patient maintains a low sodium diet) and if diffusion allows for a negative or nil sodium balance during the session ( i.e., dialysate sodium < 140 mmol/L). A gentle ultrafiltration allows control of blood pressure by reducing the extracellular volume to its ideal level, the “dry weight,” at the end of the session. Controlling blood pressure reduces cardiovascular mortality, which is by far the foremost cause of death in hemodialysis. Controlling blood pressure means reducing the occurrence of both hypertension and hypotension. Hypotension has been reported to correlate with mortality in hemodialysis as much as or more than hypertension itself. This “U‐curve” phenomenon is not paradoxical. It displays two distinct facts on the same figure: an increased early mortality in hypotensive patients (hypotension is a marker of frailty or congestive heart failure, both of which cause increased mortality) and, on the other hand, the well‐established, long‐term increased mortality in hypertensive patients. Hypotension is not a mandate to undertreat hypertension.     

Role of bicarbonate dialysis in prevention of serious arrhythmias in high‐risk cardiac patients undergoing regular hemodialysis

Background: Cardiac arrhythmias are considered as one of the most important causes of mortality in patients on hemodialysis. Arrhythmias frequently occur in patients with chronic renal failure on regular hemodialysis with reported incidences varying from 30–48% of patients. These abnormalities can span from supraventricular to severe ventricular arrhythmia. There is an increased frequency of occurrence and clustering of arrhythmias around the dialysis time. Aim of the study: To detect the difference between acetate and bicarbonate dialysis as regard to the type and frequency of arrhythmia in those patients. Study design: This study was done on 20 male patients age 51–73, all have history of heart disease. Patients were divided into 2 equal groups using acetate in group 1 and bicarbonate in group 2. All patients were on regular hemodialysis (4 hours, thrice weekly). Careful history and clinical examination were done. Pre‐dialysis investigations included serum creatinine, blood urea nitrogen, serum sodium, potassium, calcium and phosphorus, serum albumin, hemoglobin, and arterial blood gases. Post‐dialysis serum potassium and arterial blood gases were measured. ECG and forty‐eight hours ambulatory monitor (Holter monitor)(before, during, and after hemodialysis, till the end of the dialysis day and throughout the following day) were performed. Results: Group 1 showed significantly less post‐dialysis supraventricular arrhythmias than in dialysis day (210.9 ± 236 and 62.3 ± 14.4), respectively. Significantly less ventricular arrhythmias in post‐dialysis than in dialysis day (30.7 ± 50.4, and 106.2 ± 128.4), respectively. While in Group 2 there were insignificant differences regarding supraventricular arrhythmias (21.9 ± 28.9 and 16.6 ± 36.3) and ventricular arrhythmias (22.9 + 7.8 and 29.6 + 12.8) in dialysis day than in post‐dialysis day. There was significantly higher frequency of supraventricular and ventricular arrhythmias in the dialysis day in acetate hemodialysis in comparison to bicarbonate hemodialysis. Conclusion: Bicarbonate hemodialysis is less arrhythmogenic in comparison to acetate hemodialysis and has better effect on the blood pH and greater degree of base repletion. Continuous ambulatory ECG recording (Holter) is a useful tool in detecting arrhythmias in dialysis patients.     

The Case for Every‐Other‐Day Dialysis

Until daily dialysis becomes widely available, we believe that hemodialysis patients would benefit enormously from every‐other‐day dialysis (EODD), which may be implemented both by home patients and in centers. Benefits of EODD over the routine, three‐times‐weekly schedule would include decreased mortality after the weekend interval without dialysis; increased weekly dose of dialysis, resulting in better rehabilitation; and improved blood pressure control.     

Inappropriately elevated endothelin‐1 plays a role in the pathogenesis of intradialytic hypertension

The aim of this study is to investigate the effects of endogenous vasoactive substances on the occurrence of intradialytic hypertension (IDH) in patients during maintenance hemodialysis. Thirty‐four maintenance hemodialysis patients were enrolled in this trial, and 17 of them were diagnosed with IDH (defined as an increase in blood pressure of at least 10 mmHg during or immediately after a hemodialysis session), while 17 age‐matched and sex‐matched controls without IDH were selected for a retrospective comparison. We collected patients' blood samples before and after a dialysis session and measured the plasma levels of N‐terminal fragment brain natriuretic peptide, renin, angiotensin‐II, aldosterone (ALD), angiotensin‐converting enzyme (ACE), endothelin‐1 (ET‐1), nitric oxide (NO), norepinephrine (NOR), and adrenomedullin. The post‐dialysis serum ET‐1 concentrations were significantly higher (4.09 ± 2.06 vs. 2.75 ± 1.34 pg/mL, P < 0.05), while the post‐dialysis ratio of NO to ET‐1 was lower (17.79 ± 5.65 vs. 24.78 ± 12.04, P < 0.05) in IDH patients compared with the control group. Post‐dialysis ALD and NOR values were significantly lower (P < 0.01) and ACE levels were significantly higher (P < 0.01) than the pre‐dialysis concentrations only in the control and not in the IDH group. All other measured factors did not differ significantly between the groups and between pre‐dialysis and post‐dialysis determinations. Compared with blood angiotensin‐II, ALD, ACE, NOR, adrenomedullin, N‐terminal fragment brain natriuretic peptide, and NO status, inappropriately elevated ET‐1 plasma concentrations may play a predominant role in the pathogenesis of IDH.     

Interdialytic blood pressure obtained by ambulatory blood pressure measurement and left ventricular structure in hypertensive hemodialysis patients

Unlike in subjects with normal renal function, the relationship between hypertension and cardiovascular morbidity and mortality in dialysis patients is still being debated. In order to clarify this issue, we performed 44-hour ambulatory blood pressure measurements (ABPM) during the interdialytic period in a group of 164 hypertensive patients, the blood pressure (BP) control based on conventional antihypertensive strategy previously, on chronic hemodialysis treatment in the Mediterranean region of Turkey. These results were then compared with their echocardiographic data. This is a cross-sectional analysis. The mean ABPM during 44 hours was close to the manually measured predialysis value, but there was a gradual increase in the ABPM values in the interdialytic period. When divided into a group with mild or no left ventricular hypertrophy (LVH) (45 patients) and severe LVH (119 patients), the latter had significantly higher BP levels in all separate periods, while the difference in predialysis BP was not significant. Patients with severe LVH had larger left atrium and left ventricular diameters, and consumed more antihypertensive drugs. Systolic BP during the night before dialysis showed the strongest relation to LVH, but interdialytic weight gain was also independently related to LVH. Yet, 56% of the patients with systolic BP <135 had severe LVH. There is not only an association between BP and presence of LVH, but it is shown that volume expansion is also an important independent determinant of LVH. This may explain the difficulty in identifying hypertension as a cardiac risk factor in these patients.     

Sodium,hypertension, and an explanation of the “lag phenomenon” in hemodialysis patients

Sodium balance is precisely regulated by intake and output. The kidneys are responsible for adjusting sodium excretion to maintain balance at varying intakes. Our distant ancestors were herbivores. Their diet contained little sodium, so they developed powerful mechanisms for conserving sodium and achieving low urinary excretion. About 10,000 years ago, early humans became villagers and discovered that food could be preserved in brine. This led to increased consumption of salt. High salt intake increases extracellular volume (ECV), blood volume, and cardiac output resulting in elevation of blood pressure. High ECV induces release of a digitalis‐like immunoreactive substance and other inhibitors of Na⁺‐K⁺‐ATPase. As a consequence, intracellular sodium and calcium concentrations increase in vascular smooth muscles predisposing them to contraction. Moreover, high ECV increases synthesis and decreases clearance of asymmetrical dimethyl‐l ‐arginine leading to inhibition of nitric oxide (NO) synthase. High concentration of sodium and calcium in vascular smooth muscles, and decreased synthesis of NO lead to an increase in total peripheral resistance. Restoration of normal ECV and blood pressure are attained by increased glomerular filtration and decreased sodium reabsorption. In some individuals, the kidneys have difficulty in excreting sodium, so the equilibrium is achieved at the expense of elevated blood pressure. There is some lag time between reduction of ECV and normalization of blood pressure because the normal levels of Na⁺‐K⁺‐ATPase inhibitors and asymmetrical dimethyl‐l ‐arginine are restored slowly. In dialysis patients, all mechanisms intended to increase renal sodium removal are futile but they still operate and elevate blood pressure. The sodium balance must be achieved via dialysis and ultrafiltration. Blood pressure is normalized a few weeks after ECV is returned to normal, i.e., when the patient reaches dry body weight. This is called the “lag phenomenon.”     

Management of acute kidney injury in neurotrauma

Fortunately, the incidence of acute kidney injury (AKI) in neurotrauma is low and decreasing. Whereas the majority of AKI occurs in older patients with pre-existing chronic kidney disease, neurotrauma typically occurs in children and young adults with normal renal function. The development of outreach trauma teams has improved initial resuscitation, reducing both volume responsive and volume unresponsive cases of AKI. Most cases occur in the setting of multiple organ trauma with muscle injury, or patients who subsequently develop multiple organ failure. Once AKI has developed and renal replacement therapy is required, continuous modalities of renal replacement therapy offer an advantage to the patient with compromised cerebral perfusion and intracranial hypertension, by reducing the rate of change in serum urea, compared with standard intermittent therapies of hemodialysis and hemofiltration, thus minimizing abrupt changes in serum osmolality. Continuous hemodialysis and hemofiltration are better suited to maintain a normal or high serum sodium and thermal losses through the extracorporeal circuit, than peritoneal dialysis. Dialyzers should preferably be minimally bioincompatible and of a small surface area. In patients at risk of intracranial hemorrhage and those with invasive intracranial monitoring, systemic anticoagulants should either be avoided or regional anticoagulants should be used.     

We Should Strive for Optimal Hemodialysis: A Criticism of the Hemodialysis Adequacy Concept

Adequacy of hemodialysis is frequently equated with Kt/V_urea , the amount of urea clearance (K) multiplied by time (t) and divided by urea distribution volume (V). Several formulas have been developed to calculate Kt/V_urea from the pre‐ and post‐dialysis urea concentrations. In three‐times‐weekly hemodialysis, a single pool (spKt/V_urea) value of 1.3 per treatment is commonly considered to indicate adequate therapy.
Despite providing the recommended spKt/V_urea of 1.3 per treatment, short dialysis with rapid ultrafiltration is associated with multiple intradialytic and interdialytic complications. Patients experience cramps, nausea, vomiting, headaches, fatigue, hypotensive episodes during dialysis, and hangover after dialysis; patients remain fluid overloaded with subsequent poor blood pressure control, left ventricular hypertrophy, diastolic dysfunction, and high cardiovascular mortality.
According to Webster's dictionary, "optimal" means most desirable or satisfactory; "adequate" means sufficient for a specific requirement or barely sufficient or satisfactory. Optimal dialysis is the method of dialysis yielding results that cannot be further improved. New approaches, including hemeral quotidian or long nocturnal dialysis, provide opportunities to abandon the notion that adequate dialysis is "good enough" for our patients. Optimal dialysis should be our goal. Dialysis sessions should be long and frequent enough to provide excellent intra‐ and interdialytic tolerance of hemodialysis, normalization of serum calcium and phosphorus, blood pressure control, normal myocardial morphology and function, and hormonal balance, and to eliminate all, even subtle, uremic symptoms.     

Volume Control in Hemodialysis Patients

Cardiovascular disease is the main cause of the high mortality of dialysis patients and is largely due to poor control of blood pressure. Establishing and maintaining normal extracellular volume (ECV) is required to achieve normotension. The dry weight concept links ECV and blood pressure by a simple clinical relationship. Dry weight is the ideal postdialysis weight that allows a constantly normal blood pressure to be maintained without using antihypertensive medications. Maintenance of normal ECV requires control of salt intake to reduce interdialytic weight gain ( i.e., saline overload) combined with the diffusive and convective removal of salt and water from the body during dialysis sessions. Several problems are to be faced when using the dry weight method. Clinical evaluation must take into account the following confounding factors: weight varies with nutrition, clinical symptoms are unspecific and sometimes discordant, and there is a lag time between ECV and blood pressure changes. On the other hand, achievement of dry weight is hampered by dialysis times that are too short (and weight gains that are too high), by antihypertensive medications, and by poor heart conditions. A longer session time allows for a slower, easier, and more comfortable ultrafiltration.     

Acute complicating symptoms during hemodialysis sessions have well correlation with deranged blood pressure regulation

Objective: This observational study was undertaken to evaluate the frequency of acute complications occurring during dialysis sessions and their association with other clinical and biochemical parameters. Method: Forty‐six maintenance hemodialysis patients were selected and evaluated. Mean of the weekly evaluations of different parameters over a three‐month period is presented here. Result: Age of study subjects was 39 ± 13 years and body mass index (BMI) 21 ± 4 kg/m². Duration of hemodialysis was 41 ± 29 months. Most of the patients were hypertensive (98%), taking multiple anti‐hypertensive drugs. Mean of the blood pressures before and at the end of dialysis sessions over the three month period were: systolic blood pressure (SBP) 159 ± 18 vs. 163 ± 22 (p < 0.05) and diastolic blood pressure (DBP) 92 ± 13 vs. 87 ± 7 mmHg (p < 0.003). Frequency of acute complicating symptoms during dialysis sessions were: headache (75%), rise in blood pressure (73%), leg cramps (67%), vomiting (60%), palpitation (58%), sweating (52%), and hypotension (35%). Raised blood pressure showed a positive correlation with headache (r = 0.50, p < 0.01) and sweating (r = 0.53, p < 0.05). Vomiting and palpitation were more frequent at low post‐dialysis blood pressure (vomiting vs. post‐SBP‐r = ?0.41, p < 0.05 and palpitation vs. post‐DBP‐r = ?0.48, p < 0.05), and these patients were likely to get inadequate dialysis (hypotension vs. Kt/V‐r = ?0.63, p < 0.01). Pre and post dialysis weight variation was 53 ± 11 vs. 51 ± 11 kg (p < 0.001), average ultrafiltration during dialysis (UF)?2.39 (0.5–4) liter and single session Kt/V was 0.95 ± 0.38. The rising tendency of post‐dialysis blood pressure correlated positively with increasing UF (SBP vs. UF‐r = 0.36, p < 0.01 and DBP vs. UF‐r = 0.25, p < 0.05). Conclusion: From this study it may be concluded that acute complications during dialysis sessions have a significant correlation with deranged blood pressure regulation, and optimum control of blood pressure could provide better dialysis.     

Antiangiogenic factors and maternal hemodynamics during intensive hemodialysis in pregnancy

We report on a 21‐year‐old pregnant patient with IgA nephropathy who was initiated on intensive hemodialysis (8 hours of hemodialysis 3 times a week) at a gestational age of 26 weeks on the basis of worsening kidney function resulting in rapidly progressive fatigue and difficulties in metabolic control. Throughout the pregnancy, and while on intensive hemodialysis, 24‐hour ambulatory blood pressure control was within the target, and results of weekly 24‐hour measurement of central hemodynamics and pulse wave velocity, and of serial levels of circulating (anti‐)angiogenic factors were comparable to normal pregnancies. Estimated fetal growth evolved along the 50th percentile, and no polyhydramnios was detected. After induction for a sudden, unexplained increase in blood pressure, she delivered a healthy boy of 2480 g at a gestational age of 36 weeks. This case adds to the expanding literature that supports the use of intensive hemodialysis in pregnant patients with end‐stage renal disease and illustrates, for the first time, the potential use of serial (anti‐) angiogenic factors and 24‐hour measurements of blood pressure and hemodynamic indices in order to facilitate monitoring of these complicated patients.