Late thrombotic complications after SARS-CoV-2 infection in hemodialysis patients.

INTRODUCTION: There is an increased risk of thrombotic complications in patients with COVID-19. Hemodialysis patients are already at an increased risk for thromboembolic events such as stroke and pulmonary embolism. The aim of our study was to determine the incidence of late thrombotic complications (deep vein thrombosis, pulmonary embolism, stroke, new-onset vascular access thrombosis) in maintenance hemodialysis patients after recovery from COVID-19. METHODS: We performed a retrospective cohort study of 200 prevalent hemodialysis patients in our center at the start of the pandemic. We excluded incident patients after the cohort entry date and those who required hemodialysis for acute kidney injury, and excluded patients with less than 1 month follow-up due to kidney transplantation or death from non-thrombotic causes. FINDINGS: One-hundred and eighty five prevalent hemodialysis patients finally met the inclusion criteria; 37 patients (17.6%) had SARS-CoV-2 infection, out of which 10 (27%) died during the acute phase of disease without evidence of thrombotic events. There was an increased risk of thrombotic events in COVID-19 survivors compared to the non-infected cohort (18.5% vs. 1.9%, p = 0.002) after a median follow-up of 7 months. Multivariate regression analysis showed that COVID-19 infection increased risk for late thrombotic events adjusted for age, sex, hypertension, diabetes, antithrombotic treatment, and previous thrombotic events (Odds Ratio (OR) 26.4, 95% confidence interval 2.5-280.6, p = 0.01). Clinical and laboratory markers did not predict thrombotic events. CONCLUSIONS: There is an increased risk of late thrombotic complications in hemodialysis patients after infection with COVID-19. Further studies should evaluate the benefit of prolonged prophylactic anticoagulation in hemodialysis patients after recovery from COVID-19.

Utilidad del MAPA y bioimpedancia para el tratamiento y control de la HTA en pacientes en hemodiálisis crónica / Usefulness of ABPM and bioimpedance for the treatment and control of hypertension in patients on chronic haemodialysis

INTRODUCCIÓN: La hipertensión arterial (HTA) en los pacientes en hemodiálisis (HD) es muy frecuente y se asocia a un aumento de la morbimortalidad. Los objetivos de nuestro trabajo han sido: 1. Conocer la tensión arterial (TA) en la sesión de HD. 2. Estudiar la TA, en el periodo interdialítico, mediante monitorización ambulatoria de presión arterial (MAPA) de 44 horas. 3. Conocer la concordancia entre la TA en la sesión de HD y MAPA. 4. Valorar los cambios de tratamiento después de la realización del MAPA. 5. Realizar una bioimpedancia espectroscópica (BIS) a todos los pacientes y en los hiperhidratados e hipertensos, según MAPA, valorar cambios en la TA después de ajustar el peso seco (PS). 6. Conocer factores asociados a la TA sistólica (TAS) y TA diastólica (TAD) promedio del MAPA. MATERIAL Y MÉTODOS: Estudio prospectivo observacional, que incluyó a 100 pacientes de nuestra unidad de diálisis. Se han recogido las tensiones pre y post-HD, durante dos semanas y, posteriormente, colocamos a los pacientes un aparato de MAPA a mitad de semana, durante 44 horas. Previo a comenzar la siguiente sesión de diálisis, realizamos una BIS. A aquellos pacientes hiperhidratados e hipertensos, según MAPA, se les realizó un segundo MAPA para valorar cambios en los valores de TA. RESULTADOS: Según MAPA, el 65% de pacientes presentaron una TA diurna > 135/85 mmHg, 90% TA nocturna > 120/70 mmHg y 76% TA promedio > 130/80 mmHg. El 11% presentó un patrón dipper, 51% no dipper y 38% riser. Las TAS y TAD promedio fueron 4,7 mmHg (3,8%) y 1,1 mmHg (1,64%) más altas el segundo día. En el 6% de pacientes fue necesario bajar la dosis de antihipertensivos, 9% suspenderlos, 28% aumentar dosis y 17% añadir un nuevo fármaco. La TAD pre-HD es la que mejor concordancia presenta con el MAPA. Después de realizar BIS y ajustar PS hubo un descenso significativo en todas las cifras de TA. El análisis univariante mostró que la TAS promedio fue más alta en pacientes con baño alto en calcio, mayor cantidad de fármacos antihipertensivos y mayores dosis de eritropoyetina (EPO). El análisis multivariante mostró asociación significativa para EPO y número de fármacos (p < 0,01). La TAD promedio fue más alta en pacientes más jóvenes, con Charlson más bajos, menor índice de masa corporal (IMC), menos diuresis, no diabéticos y con mayores dosis de EPO. El estudio de regresión lineal mostró como variables significativas la edad (p < 0,005), IMC (p < 0,03) y EPO (p < 0,03). CONCLUSIONES: Nuestro estudio muestra: 1. La variabilidad de criterio de HTA, según utilicemos cifras de TA durante la sesión de HD o MAPA. 2. La variabilidad de TA en el periodo interdiálisis. 3. La TAD prediálisis es la que mejor concordancia presenta con el MAPA. 4. La utilización conjunta de la BIS y el MAPA mejora el control de la TA. 5. La dosis de EPO es el factor más importante asociado a la HTA en nuestros pacientes

INTRODUCTION: Hypertension is very common in haemodialysis (HD) patients, and is associated with increased morbidity and mortality rates. The goals of our research were to: 1. Measure blood pressure (BP) during HD sessions; 2. Study BP in between HD sessions with 44-hour Ambulatory Blood Pressure Monitoring (ABPM); 3. Identify differences between the BP recorded during HD and with the ABPM; 4. Evaluate changes in treatment after the ABPM; 5. Perform bioimpedance spectroscopy (BIS) on all patients and, in those hyper-hydrated or hypertensive according to ABPM, assess for changes in BP after adjusting the dry weight; 6. Identify factors associated with average systolic and diastolic BP measured by ABPM. MATERIAL AND METHODS: Prospective observational study, which included 100 patients from our dialysis unit. We measured BP before and after the HD sessions for two weeks and then, mid-week, we attached the ABPM device to the patients for 44 hours. Before starting the following dialysis session, we performed BIS. A second ABPM was performed on hyper-hydrated patients and patients hypertensive according to ABPM to evaluate changes in BP values. RESULTS: According to the ABPM, 65% of patients had daytime BP > 135/85 mmHg, 90% night-time BP > 120/70 mmHg and 76% average BP > 130/80 mmHg; 11% had a dipper pattern, 51% non-dipper and 38% riser. The average systolic and diastolic BP readings were 4.7 mmHg (3.8%) and 1.1 mmHg (1.64%) higher on the second day. The dose of antihypertensive medication had to be lowered in 6% of patients, 9% had to stop taking it, 28% needed increased doses and 17% had to add a new drug. The pre-HD diastolic BP best matched the ABPM. After performing the bioimpedance and adjusting dry weight, there was a statistically significant decrease in all BP values. The univariate analysis showed that the average systolic BP was higher in patients with a high-calcium dialysis bath, more antihypertensive drugs and higher doses of EPO. The multivariate analysis showed significant association for EPO and number of drugs (p < 0.01). The average diastolic BP was higher in younger patients and patients with lower Charlson index, lower body mass index and less diuresis, those on higher doses of EPO and non-diabetics. The linear regression study showed age (p < 0.005), body mass index (p < 0.03) and EPO (p < 0.03) as significant variables. CONCLUSIONS: Our study shows: 1. The variability of hypertension criteria according to use of BP values from during the HD session or ABPM; 2. The variability of BP in the interdialysis period; 3. That the pre-dialysis diastolic BP best corresponds with the ABPM. 4. That the use of both BIS and ABPM improves the control of BP; 5. That the dose of EPO is the most important factor associated with hypertension in our patients

Usefulness of ABPM and bioimpedance for the treatment and control of hypertension in patients on chronic haemodialysis.

INTRODUCTION: Hypertension is very common in haemodialysis (HD) patients, and is associated with increased morbidity and mortality rates. The goals of our research were to: 1. Measure blood pressure (BP) during HD sessions; 2. Study BP in between HD sessions with 44-h Ambulatory Blood Pressure Monitoring (ABPM); 3. Evaluate changes in treatment after the ABPM; 4. Perform bioimpedance spectroscopy (BIS) on all patients and, in those hyper-hydrated or hypertensive according to ABPM, assess for changes in BP after adjusting the dry weight; 5. Identify factors associated with average systolic and diastolic BP measured by ABPM. MATERIAL AND METHODS: Prospective observational study, which included 100 patients from our dialysis unit. We measured BP before and after the HD sessions for two weeks and then, mid-week, we attached the ABPM device to the patients for 44 h. Before starting the following dialysis session, we performed BIS. A second ABPM was performed on hyper-hydrated patients and patients hypertensive according to ABPM to evaluate changes in BP values. RESULTS: According to the ABPM, 65% of patients had daytime BP > 135/85 mmHg, 90% night-time BP > 120/70 mmHg and 76% average BP > 130/80 mmHg; 11% had a dipper pattern, 51% non-dipper and 38% riser. The average systolic and diastolic BP readings were 4.7 mmHg (3.8%) and 1.1 mmHg (1.64%) higher on the second day. The dose of antihypertensive medication had to be lowered in 6% of patients, 9% had to stop taking it, 28% needed increased doses and 17% had to add a new drug. The pre-HD diastolic BP best matched the ABPM. After performing the bioimpedance and adjusting dry weight, there was a statistically significant decrease in all BP values. The univariate analysis showed that the average systolic BP was higher in patients with a high-calcium dialysis bath, more antihypertensive drugs and higher doses of EPO. The multivariate analysis showed significant association for EPO and number of drugs (p < 0.01). The average diastolic BP was higher in younger patients and patients with lower Charlson index, lower body mass index and less diuresis, those on higher doses of EPO and non-diabetics. The linear regression study showed age (p < 0.005), body mass index (p < 0.03) and EPO (p < 0.03) as significant variables. CONCLUSIONS: Our study shows: 1. The variability of hypertension criteria according to use of BP values from during the HD session or ABPM; 2. The variability of BP in the interdialysis period; 3. That the pre-dialysis diastolic BP best corresponds with the ABPM. 4. That the use of both BIS and ABPM improves the control of BP; 5. That the dose of EPO is the most important factor associated with hypertension in our patients.

Usefulness of ABPM and bioimpedance for the treatment and control of hypertension in patients on chronic haemodialysis. / Utilidad del MAPA y bioimpedancia para el tratamiento y control de la HTA en pacientes en hemodiálisis crónica.

INTRODUCTION: Hypertension is very common in haemodialysis (HD) patients, and is associated with increased morbidity and mortality rates. The goals of our research were to: 1. Measure blood pressure (BP) during HD sessions; 2. Study BP in between HD sessions with 44-hour Ambulatory Blood Pressure Monitoring (ABPM); 3. Identify differences between the BP recorded during HD and with the ABPM; 4. Evaluate changes in treatment after the ABPM; 5. Perform bioimpedance spectroscopy (BIS) on all patients and, in those hyper-hydrated or hypertensive according to ABPM, assess for changes in BP after adjusting the dry weight; 6. Identify factors associated with average systolic and diastolic BP measured by ABPM. MATERIAL AND METHODS: Prospective observational study, which included 100 patients from our dialysis unit. We measured BP before and after the HD sessions for two weeks and then, mid-week, we attached the ABPM device to the patients for 44 hours. Before starting the following dialysis session, we performed BIS. A second ABPM was performed on hyper-hydrated patients and patients hypertensive according to ABPM to evaluate changes in BP values. RESULTS: According to the ABPM, 65% of patients had daytime BP > 135/85 mmHg, 90% night-time BP > 120/70 mmHg and 76% average BP > 130/80 mmHg; 11% had a dipper pattern, 51% non-dipper and 38% riser. The average systolic and diastolic BP readings were 4.7 mmHg (3.8%) and 1.1 mmHg (1.64%) higher on the second day. The dose of antihypertensive medication had to be lowered in 6% of patients, 9% had to stop taking it, 28% needed increased doses and 17% had to add a new drug. The pre-HD diastolic BP best matched the ABPM. After performing the bioimpedance and adjusting dry weight, there was a statistically significant decrease in all BP values. The univariate analysis showed that the average systolic BP was higher in patients with a high-calcium dialysis bath, more antihypertensive drugs and higher doses of EPO. The multivariate analysis showed significant association for EPO and number of drugs (p < 0.01). The average diastolic BP was higher in younger patients and patients with lower Charlson index, lower body mass index and less diuresis, those on higher doses of EPO and non-diabetics. The linear regression study showed age (p < 0.005), body mass index (p < 0.03) and EPO (p < 0.03) as significant variables. CONCLUSIONS: Our study shows: 1. The variability of hypertension criteria according to use of BP values from during the HD session or ABPM; 2. The variability of BP in the interdialysis period; 3. That the pre-dialysis diastolic BP best corresponds with the ABPM. 4. That the use of both BIS and ABPM improves the control of BP; 5. That the dose of EPO is the most important factor associated with hypertension in our patients.

Embarazo en mujeres en diálisis crónica: revisión / Pregnancy in women on chronic dialysis: a review

La frecuencia de embarazos en mujeres en diálisis es extremadamente baja, aunque el porcentaje de gestaciones con éxito ha aumentado a lo largo de los años, siendo, según distintas series, superior al 70%. Estos embarazos no están exentos de complicaciones tanto para la madre como para el feto, el manejo de las cuales requiere el trabajo conjunto del nefrólogo, el ginecólogo, el enfermero y el nutricionista. A día de hoy no es posible encontrar un tratamiento sistemático nefrológico y ginecológico en este tipo de pacientes. Las principales medidas que se deberían adoptar incluirían: aumento del tiempo de diálisis, mantener bajos niveles de urea prediálisis, evitar hipotensiones e hipertensión materna, así como infecciones urinarias y fluctuaciones electrolíticas. Se requiere, además, una adecuada monitorización fetal (AU)

The frequency of pregnancy in women on dialysis is extremely low, but the percentage of successful pregnancies in this context has increased over the years, with some studies placing the survival rate above 70%. These pregnancies are not exempt from both maternal and foetal complications, and so their management requires the joint efforts of nephrologists, gynaecologists, nurses, and nutritionists. Currently, we have been unable to establish consistent systematic treatment from both nephrological and gynaecological specialists in these patients. The main changes that need to be made are: increased time on dialysis, maintaining low levels of pre-dialysis urea, avoiding: maternal hypertension and hypotension, anaemia, urinary tract infections, and fluctuations in electrolytes. Adequate foetal monitoring is also necessary (AU)

Pregnancy in women on chronic dialysis: a review.

The frequency of pregnancy in women on dialysis is extremely low, but the percentage of successful pregnancies in this context has increased over the years, with some studies placing the survival rate above 70%. These pregnancies are not exempt from both maternal and foetal complications, and so their management requires the joint efforts of nephrologists, gynaecologists, nurses, and nutritionists. Currently, we have been unable to establish consistent systematic treatment from both nephrological and gynaecological specialists in these patients. The main changes that need to be made are: increased time on dialysis, maintaining low levels of pre-dialysis urea, avoiding: maternal hypertension and hypotension, anaemia, urinary tract infections, and fluctuations in electrolytes. Adequate foetal monitoring is also necessary.