Is antioxidant therapy beneficial for people with chronic kidney disease?

People with chronic kidney disease (CKD) have high risk of developing heart disease and dying prematurely. Although heart disease has many causes, damage caused by poor oxygen exchange in the body’scells (oxidative stress) is thought to be a major problem.

People withCKD often have evidence of oxidative stress and this is positively associated with the rate of kidney disease progression. A cochrane systemic review assessed how antioxidant therapy influenced outcomes for patients with CKD. Overall, we found that antioxidant therapy did not reduce the risk of heart disease or death in people with CKD, but that this could vary depending on CKD stage.

There was some evidence to suggest that people on dialysis may benefit from antioxidant treatment, and that these therapies could reduce the risk of kidney disease becoming worse. However, these results are based on very limited evidence and further studies are needed to confirm if antioxidant therapy could be of benefit for people with CKD.

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

Dialysis Introduction

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

Chronic Kidney Disease & High Blood Pressure

Control of hypertension is the single most important intervention to delay progression of chronic kidney disease (CKD). Extracellular fluid volume expansion is one of the most important factors leading to persistent hypertension in patients with CKD. Older individuals and black patients are more likely to be salt-sensitive and exhibit an antihypertensive response to sodium restriction or diuretic therapy.

If hypertension and proteinuria persist despite sodium restriction, the addition of a diuretic may be beneficial. Thiazide diuretics, if not used as a first-choice antihypertensive drug, are almost always indicated as an additional drug in patients with incompletely controlled hypertension, because these agents augment most other agents used as monotherapy.

Most hypertensive patients will require more than one antihypertensive drug to lower BP below target levels. The combination of diuretics with renin-angiotensin system (RAS) antagonists offers several advantages to include additive BP-lowering efficacy and enhanced reductions in urinary protein excretion. Thiazide diuretics are associated with metabolic complications that are particularly evident when used in high doses. When used in combination with RAS blockade, metabolic complications such as hypokalemia are minimized. The avoidance of hypokalemia has been linked to less thiazide-induced glucose intolerance. Patient persistence on therapy is dependent on well tolerated drug combinations.

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

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