Blood purification
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Review
Treatment of hypertension in renal failure patients: when do we overtreat? When do we undertreat?
Despite the commonplace nature of hypertension in chronic dialysis patients, many issues remain unresolved. According to current JNC/V (see text) recommendation, a systolic blood pressure of < 120 mm Hg is optimal, 120-129 mm Hg is normal, and one of 130-139 mm Hg is high-normal. The majority of dialysis patients receiving treatment in the United States is probably not maintained in the optimal blood pressure range. ⋯ In contrast to nonrenal failure patients, normotensive ESRD patients may show an increase of left ventricular mass over time. Although left ventricular hypertrophy can be reversed with good blood pressure control, patients are often undertreated based on analysis of dialysis clinic blood pressures. Even if clinic systolic blood pressure levels are optimal, chronic dialysis patients may still have unacceptably high ambulatory blood pressure levels due to a rise in nocturnal blood pressure with sleep.
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During sepsis, there is release of various endotoxins from microorganisms which more or less activates cascade systems including release of cytokines such as tumor necrosis factor alpha and interleukin 6 and complement components. This causes impairment of vascular integrity and permeability which may progress into septic shock and a disseminated intravascular coagulation which progresses into multiorgan failure, including acute renal failure and subsequent death. Although most endotoxins and cytokines have a molecular size < 50 kD, there is little efficacy in removal of them by hemofiltration filters used for acute dialysis. ⋯ In contrast, these studies showed a survival rate of about 75% by addition of such therapeutic interventions to the conventional intensive care unit treatment. The substitution of the removed plasma products must be considered to include products important for the host defense and coagulation process and to avoid infections, bleeding, or increased coagulation. This type of removal is unselective and probably in the future will include addition of absorption techniques which may add further benefit to the outcome.