Resistant Hypertension

Resistant hypertension is defined as blood pressure that remains above goal despite treatment with the optimal dosage of three antihypertensive agents, including a diuretic.

Patient characteristics more likely to be associated with resistant hypertension include:
1. Older age
2. BMI above 30
3. Higher baseline blood pressure
4. Diabetes mellitus
5. Black race.

Excessive consumption of dietary salt and alcohol contributes to resistant hypertension. Many patients with resistant hypertension have secondary hypertension caused by primary aldosteronism or renovascular hypertension, and these conditions should be excluded.

Treatment of resistant hypertension should include appropriate lifestyle modifications, discontinuation of agents that may increase blood pressure such as NSAIDs, and correction of secondary causes of hypertension. Mineralocorticoid receptor antagonists are particularly effective in treating resistant hypertension even in the absence of hyperaldosteronism. The Anglo-Scandinavian Cardiac Outcomes Trial evaluated the efficacy of spironolactone among 1411 participants with an average age of 63 years who received this medication mainly as a fourth-line antihypertensive agent for uncontrolled blood pressure. After 1 year of treatment, blood pressure in these patients decreased by approximately 21.9/9.5 mm Hg.

Ardavan Mashhadian D.O.
Nephrologist
1400 S Grand Ave Suite 615, Los Angeles, CA 90015
(213) 537-0328

Managing High Blood Pressure

Lifestyle modifications are recommended for all patients with hypertension, including prehypertension. The Dietary Approaches to Stop Hypertension (DASH) study showed that 8 weeks of a diet of fruits, vegetables, low-fat dairy products, whole grains, poultry, fish, and nuts, along with a reduction in fats, red meat, and sweets, caused an 11.4-mm Hg decrease in systolic pressure and a 5.5-mm Hg decrease in diastolic pressure. In addition, patients using the DASH diet who consumed less than 100 mmol/d of sodium had a systolic pressure 3 mm Hg and a diastolic pressure 1.6 mm Hg less than those who consumed high amounts of sodium.

Weight reduction in a patient whose weight is 10% above ideal body weight lowers blood pressure by an average of 5 to 7 mm Hg. Alcohol consumption should be limited to two drinks daily for men and one for women, because excess amounts of alcohol may contribute to hypertension and resistance to antihypertensive medications. Regular aerobic exercise also modestly decreases blood pressure. In addition, patients should be counseled about smoking cessation.

The goal of treatment of hypertension is to reduce cardiovascular morbidity and mortality by lowering blood pressure. Lowering blood pressure has definitively been shown to reduce stroke, myocardial infarction, heart failure, and overall cardiovascular mortality. Evidence obtained from clinical trials suggests that the goal of antihypertensive treatment is to reduce blood pressure to below 140/90 mm Hg in the general population. The American Heart Association recommends a blood pressure target of 130/80 mm Hg for those with coronary artery disease, carotid artery disease, peripheral artery disease, abdominal aortic aneurysm, and a Framingham 10-year risk score of 10% or greater. However, data clearly demonstrate a linear, progressive increased risk of ischemic heart disease and stroke in patients with blood pressures higher than 115/75 mm Hg, which suggests that these targets may be too high. Clinical trials addressing lower blood pressure targets are currently being planned.

Ardavan Mashhadian D.O.
Nephrologist
1400 S Grand Ave Suite 615, Los Angeles, CA 90015
(213) 537-0328

Code Status

Few days ago, I saw a perfectly healthy nurse in emergency department as a patient. He was worried that he had been exposed to carbon monoxide. He had a patient in hospital for a long time that had brain injury from exposure to carbon monoxide. Now he was worried for similar outcomes. I checked his blood gas, reassured him and sent him home.

Few days later, I saw Mr. M a 35 year old man with history of kidney stones transferred from nursing home to hospital for evaluation of decrease mentation.  As soon as he arrived, emergency physicians rushed to him, placed a large line on him and started fluid and antibiotics. Mr. M was cold, clammy and unable to provide any history. So I called his parents.

His mother picked up the phone and in a calm tone told me that she was aware that he was in hospital again. Mr. M had suffered anoxic brain injury at age 19 when he was working on his car and got exposed to carbon monoxide. Since then, he has developed mental retardation and has become bed bound.

I looked at Mr. M vitals. He was very sick and unstable. After the first round of resuscitation,  I call his mother again. As I was dialing the numbers, I was thinking to myself how to update the family and respectfully ask them about his code status at 2 o'clock in the morning. I thought to myself, over a decade had passed from the accident. During this time, his parent must have seen many different physicians and spent many hours in emergency department and hospitals. The nursing staff told me, Mr. M had been hospitalized many times and family requested full code during the previous admissions.

I knew Mr. M only for few minutes, and I was not sure how to approach the family about the code status. After thinking about this for few minutes, I decided to actually share my dilema with the mother. After updating her, I told her how difficult it was for me to bring this subject. I told her about my feelings. This time, she started to cry.

My shift was almost over. As I was preparing my documents for sign-off, the ICU resident came to bedside and told me Mr. M parents had decided to change his code status to DNR (Do Not Resuscitate).

Ardavan Mashhadian D.O.
Nephrologist
1400 S Grand Ave Suite 615, Los Angeles, CA 90015
(213) 537-0328

Dialysis Access

Dialysis patients have many comorbidities. This ranges from heart disease all the way to vision problems. One of the biggest comorbidites with dialysis patients is the management of dialysis access. Unfotunately, I see a lot of hospital admissions for acute dialysis. Due to lack of access, hospital doctors are forced to place a central-line in the neck or groin and start dialysis as soon as possible. The central line placement and management is much more difficult than managing AV fistula. In additon, it exposes the patients to higher risk of infection, bacteremia, and infective endocarditis.

Chronic kidney patients need to stablish care with a caring nephrologist and start being prepared for dialysis in stage 4-5. A close follow up is required to make sure volume status and electrolytes are monitored. This prevents such patients present to emergency room in need of acute dialysis with no prepration.

The best dialysis access is AV fistula which takes 4-6 months before it is ready to be used. Unfortunately many patients start dialysis with temporarly access line in hospital, and then switched to tunneled cath dialysis access. Finally if they have good followup, the AV fistula access is placed. And even then, some the fistulas fail before they are ready to be used or take 6 months to mature.

As you see, the process gets longer and longer and meanwhile patient is exposed to high risk of blood borne infections. In fact, it is not uncommon to find some patients to be dependent on these central-lines for a longtime before they present to hospital for severe infection.

The treatment of temporarly dialysis central line is a nightmare. Why? Because most of the times, the treatment requires the removal of these lines and leave patient with no access for dialysis. Even worse is when the temporarly dialysis line has been in the body for such a long time that blood clots have formed around it.

The management of line infection in dialysis patients requires close cordination between nephrologist, cardiologists, hopital physicians, surgeons, and Interventional radiologist. As you see, the process becomes more and more difficult. Prolong hospitalization of such patients exposes them to more infections and complications.

It is very important to stablish care with nephrologist early in the process. This way, many complications can be avoided. AV fistula placement before need of acute dialysis decreases morbidity and mortality.

What access did you or your loved one used for dialysis for the first time?

Ardavan Mashhadian D.O.
Nephrologist
1400 S Grand Ave Suite 615, Los Angeles, CA 90015
(213) 537-0328

Peritoneal Dialysis Complications

Complications
1. Peritonitis and Catheter-Related Infections: Peritonitis is thought to occur most often by touch contamination, but may also occur in the setting of a catheter exit site or tunnel infection. Patients with peritonitis usually present with cloudy peritoneal fluid and abdominal pain. Infections due to gram-positive cocci (Staphylococcus epidermidis and Staphylococcus aureus) tend to be most common (60–70% episodes) compared to infections with gram-negative bacteria (15–25%) or fungi (2–3%). Treatment should be continued for a total of 2 weeks, while more severe infections due to S aureus, pseudomonas, or multiple gram-negative organisms should be treated for 3 weeks. Patients should be taught to perform routine exitsite care in order to prevent catheter infections. Daily cleansing with antibacterial soap and water is recommended by most centers. The daily application of mupirocin or gentamicin cream to the exit site has been shown to be effective in reducing catheter infections and related peritonitis.

2. Mechanical Complications such as hernia, scrotal or labial edema.

3. Encapsulating Peritoneal Sclerosis: a rare but serious condition characterized by extensive intraperitoneal fibrosis and encasement of bowel loops.

4. Ultrafiltration Failure

5. Metabolic Complications

Indications for peritoneal dialysis catheter removal:
1. Refractory peritonitis: failure to respond to appropriate antibiotics within 5 days

2. Fungal peritonitis

3. Relapsing peritonitis

4. Peritonitis in the setting of severe exit site or tunnel infection

5. Peritonitis due to multiple enteric organisms in the setting of a surgical abdomen

Dietary modifications:
A protein intake of at least 1.2 g/kg is recommended for PD patients.

National Kidney Foundation has great handbook. To view please Click Here
For information on nutrition and peritoneal dialysis please Click Here

Ardavan Mashhadian D.O.
Nephrologist
1400 S Grand Ave Suite 615, Los Angeles, CA 90015
(213) 537-0328

Types of Peritoneal Dialysis

Types of Peritoneal Dialysis
1. Continuous Ambulatory Peritoneal Dialysis: In CAPD dialysis solution is constantly present in the abdomen, typically being exchanged four to fives times per day, 7 days per week. The dialysis fluid is exchanged manually by the patient using the force of gravity to drain and fill the abdomen.

2. Automated Peritoneal Dialysis: In APD a cycler machine automatically exchanges fluid into and out of the abdomen for the patient. The cycler draws dialysis solution from larger bags (usually 5 L), which it warms to the desired temperature. The patient usually spends between 8 and 10 hours a night on the cycler, disconnects from the cycler in the morning after a final fill is delivered, and then is free to go about daily activities.

3. Intermittent Peritoneal Dialysis: IPD is a form of PD that is usually performed in a hospital or in a dialysis center. It is usually reserved for patients with acute renal failure or end-stage renal failure and sometimes for patients immediately after catheter placement who are uremic and need more urgent dialysis.

Not all patients' peritoneal membranes transport solute at the same rate. In clinical practice, a patient's peritoneal membrane transport characteristics can be determined by measuring the creatinine equilibration curve and the glucose absorption curve during a standardized peritoneal equilibration test (PET). Patients are classified principally into one of four transport categories: high, high-average, low-average, and low. High transporters tend to do better on regimens that have frequent, short duration dwells, such as APD, whereas low transporters tend to do better on regimens with longer duration dwells, such as CAPD. Average transporters are generally able to do well on a variety of PD regimens.


National Kidney Foundation has great handbook. To view please Click Here
For information on nutrition and peritoneal dialysis please Click Here

Ardavan Mashhadian D.O.
Nephrologist
1400 S Grand Ave Suite 615, Los Angeles, CA 90015
(213) 537-0328

Peritoneal Dialysis Indications and Contraindications

http://pinterest.com/amashhadian/peritoneal-dialysis/

Peritoneal dialysis (PD) PD is a form of dialysis in which a dialysis solution is instilled in the peritoneal cavity, periodically drained, and exchanged with fresh solution through a single, indwelling peritoneal catheter. It is a established form of renal replacement therapy that is used around the world. United States Renal Data System (USRDS) data from 1998 to 2002 indicate that the prevalent PD population decreased by 3.5% per year, with only 8% of prevalent dialysis patients being treated with PD in 2002. In contrast to the experience in the United States, the prevalent number of patients with end-stage renal disease receiving PD has exceeded 60% in other countries, such as in Mexico and Hong Kong. The cause for these differences is likely multifactorial and is related to access to PD, physician expertise, patient mix, and reimbursement.

Indications:
1. PD continues to be the preferred dialysis modality for infants and young children

2. Patients with severe hemodynamic instability on hemodialysis

3. Patients with difficult vascular access

Contraindications:
1. The one absolute contraindication to chronic PD is an unsuitable peritoneum due to the presence of extensive adhesions, fibrosis, or malignancy.

2. Abdominal hernias

3. Presence of colostomy, ileostomy, nephrostomy, or ileal conduit

4. Recurrent chronic backache with preexisting disc disease

5. Severe psychological and social problems

6. Severe diverticular disease of the colon

7. Severe neurologic disease, movement disorder, or severe arthritis preventing self care. (caregivers can be trained to perform the peritoneal dialysis)

8. Severe chronic obstructive pulmonary disease

9. Malnutrition

Studies investigating differences in patient mortality between PD and hemodialysis (HD) have been conflicting. Most reports have shown no significant difference in survival between PD and non-diabetic HD patients.



National Kidney Foundation has great handbook. To view please Click Here
For information on nutrition and peritoneal dialysis please Click Here

Ardavan Mashhadian D.O.
Nephrologist
1400 S Grand Ave Suite 615, Los Angeles, CA 90015
(213) 537-0328