An establishment of vascular access through superior vena cava for a patient with multiple central venous stenosis or occlusion.

The patency of vascular access is of vital importance to dialysis patients. Access dysfunction is largely caused by vessel stenosis and thrombosis. Nephrologists usually find themselves helpless when all treatments fail and the vascular access seems to have exhausted. Here we report a successful establishment of vascular access through superior vena cava for a critical patient with multiple central venous stenosis or occlusion. To our knowledge, it is the first case ever reported on the successful establishment of vascular access through superior vena cava under such a complicated condition of vascular exhaustion.

Dual Blockade of the Renin-angiotensin-aldosterone System in Type 2 Diabetic Kidney Disease.

OBJECTIVE: To examine the efficacy and safety of dual blockade of the renin-angiotensin-aldosterone system (RAAS) among patients with type 2 diabetic kidney disease. DATA SOURCES: We searched the major literature repositories, including the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE, for randomized clinical trials published between January 1990 and October 2015 that compared the efficacy and safety of the use of dual blockade of the RAAS versus the use of monotherapy, without applying any language restrictions. Keywords for the searches included "diabetic nephropathy," "chronic kidney disease," "chronic renal insufficiency," "diabetes mellitus," "dual therapy," "combined therapy," "dual blockade," "renin-angiotensin system," "angiotensin-converting enzyme inhibitor," "angiotensin-receptor blocker," "aldosterone blockade," "selective aldosterone blockade," "renin inhibitor," "direct renin inhibitor," "mineralocorticoid receptor blocker," etc. STUDY SELECTION: The selected articles were carefully reviewed. We excluded randomized clinical trials in which the kidney damage of patients was related to diseases other than diabetes mellitus. RESULTS: Combination treatment with an angiotensin-converting enzyme inhibitor supplemented by an angiotensin II receptor blocking agent is expected to provide a more complete blockade of the RAAS and a better control of hypertension. However, existing literature has presented mixed results, in particular, related to patient safety. In view of this, we conducted a comprehensive literature review in order to explain the rationale for dual blockade of the RAAS, and to discuss the pros and cons. CONCLUSIONS: Despite the negative results of some recent large-scale studies, it may be immature to declare that the dual blockade is a failure because of the complex nature of the RAAS surrounding its diversified functions and utility. Further trials are warranted to study the combination therapy as an evidence-based practice.

[Ambulatory arterial stiffness index and associated factors in patients with diabetic kidney disease].

OBJECTIVE: To compare arterial stiffness between diabetic kidney disease and non-diabetic kidney diseaseand to identify factors predicting ambulatory arterial stiffness index (AASI). METHODS: Forty-four patients with diabetic kidney disease (DKD group) and thirty-one patients with non-diabetic kidney disease (NDKD group) were recruited for this study. All of the participants had hypertension. The AASI (indirect reflex global arterial stiffness)and short-term blood pressure variability (BPV) were measured using a 24-h ambulatory BP monitoring, and compared.between DKD and NDKD groups using analyses of covariance, correlation analysis and multivariate linear regression model. RESULTS: DKD patients had significantly higher levels of AASI than NDKD patients (0.55 +/- 0.14 vs. 0.45 +/- 0.16, P < 0.05). The 24-h systolic and daytime systolic BP variability of DKD patients was also higher than NDKD patients. In DKD patients, the correlation analysis revealed that the AASI showed association with 24-h systolic BP variability (24 hSBPV), 24-h diastolic BP variability (24 hDBPV),daytime diastolic BP variability (dDBPV), nighttime systolic BP variability (nSBPV) and nighttime diastolic BP variability (nDBPV), and nDBPV and age showed strong associations with AASI. CONCLUSION: Although both DKD and NDKD patients suffered from arterial stiffness, greater AASI and short-term BPV was detected in DKD patients. AASI is associated with nDBPV and age. Optimal short-term BPV control in hypertensive type 2 diabetic patients with overt nephropathy may improve arterial elasticity.

Influence of HbA1c on short-term blood pressure variability in type 2 diabetic patients with diabetic nephropathy.

The aim of this study was to understand the characteristics of blood pressure (BP) variability in subjects with diabetic nephropathy (DN), and identify the probable predictors affecting BP variability. Fifty-one chronic kidney disease (CKD)-hypertensive patients without diabetes (NDN group) and sixty type 2 diabetic patients with overt DN (DN group) were enrolled in this study. The values of short-term BP variability were obtained from 24 h ambulatory BP monitoring (ABPM). Variance analysis or nonparametric analysis revealed that 24-h systolic BP variability and nighttime systolic BP variability of the DN group were significantly higher than those of the NDN group [(12.23±3.66) vs. (10.74±3.83) mmHg, P<0.05; (11.23±4.82) vs. (9.48±3.69) mmHg, P<0.05]. Then the patients of the DN group were divided into two groups according to glycated hemoglobin (HbA1c) level: Group A (HbA1c<7%) and Group B (HbA1c≥7%), and the t-test showed that patients in Group B had larger 24-h diastolic, daytime diastolic, and nighttime systolic/diastolic BP variability compared with Group A. In the DN group, partial correlation analysis revealed that HbA1c exhibited a strong association with 24-h diastolic, daytime diastolic, nighttime systolic and diastolic BP variability (P<0.001, P<0.001, P<0.05, and P<0.001, respectively). Taken together, larger short-term BP variability was detected in hypertensive type 2 diabetic patients with overt nephropathy and renal insufficiency. It may imply that the optimal BP variability level could benefit from a better glycaemic control.