Importance of Capillary Leak and Nocturia in Defining and Successfully Treating Idiopathic Edema

Successful treatment of unusual life-threatening complications of idiopathic edema

Pathophysiologic approach to understanding and successfully treating idiopathic edema: Unappreciated importance of nocturia

Background. — Postural hypotension and dizziness are common findings in elderly individuals. Although postural hypotension and postural dizziness are often perceived to be strongly associated entities, evidence to support this view is sparse. In addition, there is a lack of knowledge regarding the relationship of postural hypotension and postural dizziness to potential clinical outcomes, such as falls, syncope, and restricted activity. Methods.— We utilized a cross-sectional examination to study the prevalence and correlates of postural hypotension (drop in systolic blood pressure of ≥20 mm Hg after 1 minute of standing) and postural dizziness (self-reported dizziness on standing) in 9704 nonblack, ambulatory women aged 65 years and older enrolled in the multicenter Study of Osteoporotic Fractures. First, we examined postural hypotension and postural dizziness as outcomes of risk factors that included medical conditions, medications, and physical findings. Then, we examined falls, syncope, and impaired functional status as outcomes of postural hypotension and postural dizziness. Results.— Postural hypotension and postural dizziness were common findings, noted in 14% and 19% of subjects, respectively. However, they were not highly correlated with each other and did not share the same risk factors or associated outcomes. Postural dizziness was more strongly associated than was postural hypotension with history of falling (age-adjusted odds ratios, 1.32 vs 1.02), history of syncope (1.94 vs 1.35), and impaired functional status (1.95 vs 0.76). Conclusion.— Assessment of dizziness on standing appears to be more important than measurement of postural blood pressure change in ascertaining functional status and risk of falls and syncope in elderly individuals. Future prospective studies of postural dizziness are needed to confirm its value as a predictor of clinical outcomes. (Arch Intern Med.1992;152:1058-1064)

Postural hypotension and dizziness are common findings in elderly individuals. Although postural hypotension and postural dizziness are often perceived to be strongly associated entities, evidence to support this view in sparse. In addition, there is a lack of knowledge regarding the relationship of postural hypotension and postural dizziness to potential clinical outcomes, such as falls, syncope, and restricted activity. We utilized a cross-sectional examination to study the prevalence and correlates of postural hypotension (drop in systolic blood pressure of greater than or equal to 20 mm Hg after 1 minute of standing) and postural dizziness (self-reported dizziness on standing) in 9704 nonblack, ambulatory women aged 65 years and older enrolled in the multicenter Study of Osteoporotic Fractures. First, we examined postural hypotension and postural dizziness as outcomes of risk factors that included medical conditions, medications, and physical findings. Then, we examined falls, syncope, and impaired functional status as outcomes of postural hypotension and postural dizziness. Postural hypotension and postural dizziness were common findings, noted in 14% and 19% of subjects, respectively. However, they were not highly correlated with each other and did not share the same risk factors or associated outcomes. Postural dizziness was more strongly associated than was postural hypotension with history of falling (age-adjusted odds ratios, 1.32 vs 1.02), history of syncope (1.94 vs 1.35), and impaired functional status (1.95 vs 0.76). Assessment of dizziness on standing appears to be more important than measurement of postural blood pressure change in ascertaining functional status and risk of falls and syncope in elderly individuals. Future prospective studies of postural dizziness are needed to confirm its value as a predictor of clinical outcomes.

Postural hypotension with a decline of 20 mm Hg or more in systolic blood pressure on standing is considered a potentially dangerous hypotensive response. Postural dizziness is often strongly associated with postural hypotension. However, there is conflicting evidence, and previous studies have been confined to the elderly, not specifically to patients with diabetes. Thus, we evaluated the association between postural hypotension and postural dizziness, and determined the factors most likely related to postural hypotension in patients with diabetes. The subjects were 204 consecutive noninsulin-dependent patients with diabetes and 408 age- and sex-matched control subjects. Postural hypotension was defined as a decline of 20 mm Hg or more in systolic blood pressure 1 minute after standing. Postural dizziness was any feelings of dizziness, lightheadedness, or faintness that occurred while standing during the examination. The prevalence of postural hypotension and postural dizziness in patients with diabetes was higher than in control subjects. Those patients with both diabetes and postural hypotension were older and had higher supine systolic blood pressures and higher plasma glycosylated hemoglobin and fasting glucose levels. They had higher prevalence of postural dizziness, hypertension, and cerebrovascular disease, and lower standing systolic blood pressures than those without postural hypotension. They also were more often being treated with antihypertensive agents. Only 32.8% of patients with diabetes with postural hypotension suffered from postural dizziness. Postural dizziness, hypertension, cerebrovascular disease, and plasma glycosylated hemoglobin levels were independently associated with postural hypotension in patients with diabetes. Postural dizziness, glycemic control, hypertension, and cerebrovascular disease were important determinants of postural hypotension in patients with diabetes. Postural hypotension was associated with postural dizziness, but it cannot be determined clinically just from the presence of postural dizziness because the sensitivity for diagnosis of postural hypotension is low.

Powerful diuretics: A common denominator in landmark hypertension and type 2 diabetes mellitus trials.

Metoclopramide, a dopaminergic inhibitor, was injected (10 mg iv) in 15 normal women and in 9 patients with clinical evidence of idiopathic edema, while on a 130 meq sodium and 50-70 meq potassium diet. The subjects kept a recumbent position during the test. PRA slightly increased at 45 min (p < 0.01) in normal women, A low sodium diet (20–40 meq/day) seemed to accelerate the PRA response, which was significant at 20 min (P < 0.05). In patients with idiopathic edema, PRA consistently increased at 20, 30, and 45 min (P < 0.05). Plasma aldosterone (PA) increased significantly at 10, 20, 30, 45, and 60 min (P < 0.005) both in normal women and in patients. The absolute change of PA from 0–10 min was significantly higher in patients with idiopathic edema (P < 0.001) and preceded the increase of PRA. In 5 normal women, urinary sodium decreased and urinary potassium increased after metoclopramide. Serum electrolytes were not modified. In 2 patients with idiopathic edema and hypokalemia, the treatment with a cent...

To look for intrinsic changes in renal tubular water and sodium metabolism in idiopathic edema (IE), independent of the underlying hormonal and vascular defects. Prospective controlled study in patients with edema referred to a nephrology clinic. Ten female patients with IE were compared with a control group of 4 healthy women. Patients and controls were submitted to a base-line test of water loading and lithium clearances, after 12 hours supine position, to study renal tubular handling of Na and H2O in different nephron sites and 5 h water excretion capacity. Patients were then randomized in 2 groups, both receiving standard treatment during 2 months (low-salt diet--70 to 90 mEq of Na per day, stopping diuretics and laxatives, elastic stockings). Group B received in addition carbidopa/levodopa 25/100--3 tabs/day and captopril 6.25 mg q 8 h. At the end of this 2 months period the base-line tests were repeated. We registered a good clinical response, with an average a.m. weight reduction of 2.8 kg and a decrement of the a.m. to p.m. weight gradient from 2.42 +/- 0.3 kg pre-treatment to 0.6 +/- 0.1 kg afterwards. From the several measurements obtained, only global FENa and Proximal Fraccional Reabsorption of Na were significantly different between patients and controls (0.87 +/- 0.09% vs 2.1 +/- 0.2%, p less than 0.001 and 77.4 +/- 2.9% vs 64.0 +/- 3.5%, p = 0.02 respectively), with no difference in distal Na and H2O reabsorption or water excretion capacity. Two months treatment only partially corrected global FENa, and there were no differences in the clinical and physiological effects between the 2 therapeutic groups. 1--In the absence of orthostatism, H2O and Na metabolism is similar between IE patients and healthy controls, only with an increased selective proximal Na reabsorption in patients. 2--Standard non-pharmacologic therapy was a clinical success, but didn't correct the physiological defect of excessive proximal sodium reabsorption. Treatment results were not improved by pharmacologic intervention.

Two studies were performed to determine the quantitative relationship between salt intake and urinary volume (U(v)) in humans. In study 1, 104 untreated hypertensives were studied on the fifth day of a high- and a low-salt diet. The 24-hour U(v) was 2.2 L (urinary sodium [U(Na)] 277 mmol) on the high-salt diet and decreased to 1.3 L (P<0.001) (U(Na) 20.8 mmol) on the low-salt diet. The reduction in 24-hour U(v) was significantly related to the decrease in 24-hour U(Na) (P<0.001) and predicts that a 100-mmol/d reduction in salt intake would decrease 24-hour U(v) by 367 mL. In study 2, 634 untreated hypertensives were studied on their usual diet. There was a significant relationship between 24-hour U(v) and U(Na) (P<0.001). This predicts that a 100-mmol/d reduction in salt intake would decrease 24-hour U(v) by 454 mL. The International Study of Salt and Blood Pressure (INTERSALT) of 1731 hypertensives and 8343 normotensives on their usual diet showed that 24-hour U(v) was significantly related to U(Na) (P<0.001) and predicted that a 100-mmol/d reduction in salt intake would decrease 24-hour U(v) by 379 and 399 mL in hypertensives and normotensives, respectively. These findings document the important effect that salt intake has on U(v). The recommended reduction in salt intake in the general population is from 10 to 5 g/d. This would reduce fluid intake in the population by approximately 350 mL/d per person. This would have a large impact on the sales of soft drinks, mineral water, and beer.

This study was carried out on 90 patient with insulin dependent for at least 10 year those attending the diabetic clinic and internal medicine consultation unit in Al-Diwamiya Teaching hospital and some popular clinic in Al-Diwaniya city and a 120 age and sex match control subject from patients relatives and medical staff. The blood pressure was measured in supine and standing position for each subject, orthostatic hypotension was defined as a decline in systolic blood pressure of 20mmHg or more one minute after standing, postural dizziness was any feeling of dizziness, light headedness, or faintness that occurred while standing. The prevalence of orthostatic hypotension and postural dizziness was higher in patient with diabetes than in control subject from the 90 diabetic patient a 27 develop orthostatic hypotension while only 16 subject develop orthostatic hypotension from the 120 non diabetic control subjects. Those patients with diabetes and had orthostatic hypotension were older and with high fasting glucose level and higher supine systolic blood pressure and lower standing systolic blood pressure than those without orthostatic hypotension. Postural dizziness among the diabetics patient were higher than its prevalence among non diabetic subject, and there was no significant difference between those who had orthostatic with postural dizziness and postural dizziness without orthostatic hypotension in both diabetic and non diabetic control subject.

BackgroundA few studies have explored the effects of disclosure of genetic testing results on chronic disease predisposition. However, these effects remain unclear in cases of hypertension. Reducing salt intake is an important nonpharmacological intervention for hypertension. We investigated the effects of genetic testing for salt sensitivity on salt restriction behavior using hypothetical genetic testing results.MethodsWe conducted a cross-sectional study using a self-completed questionnaire. We enrolled consecutive outpatients who visited primary care clinics and small hospitals between September and December 2009 in Japan. We recorded the patients’ baseline characteristics and data regarding their salt restriction behavior, defined as reducing salt intake before and after disclosure of hypothetical salt sensitivity genetic test results. Behavioral stage was assessed according to the five-stage transtheoretical model. After dividing subjects into salt restriction and no salt restriction groups, we compared their behavioral changes following positive and negative test results and analyzed the association between the respondents’ characteristics and their behavioral changes.ResultsWe analyzed 1562 participants with a mean age of 58 years. In the no salt restriction group, which included patients at the precontemplation, contemplation, and preparation stages, 58.7% stated that their behavioral stage progressed after a positive test result, although 29.8% reported progression after a negative result (P < 0.001). Conversely, in the salt restriction group, which included patients at the active and maintenance stages, 9.2% stated that they would quit restricting salt intake following a negative test result, and 2.2% reported they would quit following a positive result (P < 0.001). Age < 65 years (adjusted odds ratio [OR] 1.74; 95% confidence interval [CI] 1.12–2.71), female gender (adjusted OR 1.84; CI 1.29–2.62), graduation from college or university (adjusted OR 1.66; CI 1.11–2.49), and desire for genetic testing (adjusted OR 4.53; CI 3.13–6.57) were associated with progression of behavioral stage in the no salt restriction group. Conversely, salt preference (adjusted OR 2.13; CI 1.31–3.49) was associated with quitting salt restriction in the salt restriction group.ConclusionPatients in the no salt restriction group show the possibility of progression from the behavioral stage to the action stage after testing positive for salt sensitivity. Conversely, patients in the salt restriction group, particularly those with a salt preference, would quit salt restriction after testing negative.

BackgroundFunctional status, postural dizziness (PD), and postural hypotension (PH) were important issues in older adults. Only one study on the relationship for the three of them in female was without adjusting some important associated factors. This study was intended to investigate the association of PD and PH with functional status in older people of both genders.MethodsBased on a stratified randomized cluster sampling, 1361 subjects ≥ 65 years in the community were recruited from Tainan City, Taiwan, from 2000 to 2001. PH was defined as a decrease in systolic/diastolic blood pressure of ≥ 20/10 mm Hg after 1 or 2 min of standing. PD was defined by a positive response to dizziness-like symptoms after standing up from a supine position. Functional status included the activities of daily living (ADLs) and instrumental activities of daily living (IADLs).ResultsAfter adjusting other variables, ADL disability (OR: 1.84, 95% CI: 1.35–2.51) and IADL disability (OR: 1.62, 95% CI: 1.21–2.17) were associated with PD, but not PH. In male and female subgroups, ADL disability (male OR: 1.70, 95% CI: 1.08–2.67; female OR 1.96, 95% CI: 1.26–3.07) was associated with PD. In male, IADL disability was associated with PD (OR: 2.32, 95% CI: 1.36–3.95).ConclusionsImpaired functional status, shown using ADLs or IADLs, was positively associated with PD, but not PH in older adults ≥ 65 years. Clinically, it may be important to evaluate PD in older adults with ADL or IADL disability.

To what extent dietary salt intake is involved in the pathogenesis of progressive renal diseases has never been fully understood in humans. To this aim, we investigated the relationship between urinary sodium excretion (under a low salt & low protein diet) and urinary protein excretion/renal function in patients with three major renal diseases: chronic glomerulonephritis(GN), diabetic nephropathy(DN) and nephrosclerosis(NS). The results were as follows; 1) A significant positive correlation was found between urinary sodium excretion (equivalent to the daily salt intake) and daily urinary protein excretion in patients with a GN and DN. However, no relationship was found between the two parameters in patients with NS. 2) Reduction in salt intake led to a significant decrease in daily protein excretion, the effect of which was prominent in patients with GN and DN. 3) A significant positive correlation was found between urinary sodium excretion and estimated protein intake(EPI) in all three groups. 4) There was a significant positive correlation between EPI and urinary protein excretion in DN, but not in GN. 5) Reduction in salt and protein intake(calculated as an EPI) ameliorates the slope of reciprocal creatinine concentration(1/Cr) in patients with GN and DN. These results indicate that slat restriction is strongly associated with the preservation of renal function in patients with GN and DN, suggesting that this dietary strategy can be a useful measure for retarding the progressive nature of these diseases. Of note is that both salt and protein restriction was renoprotective only in patients with DN. Thus, patients with GN and DN must be followed-up on the basis of a salt-restricted diet throughout their clinical course.

Deep Brain Stimulation Ameliorates Postural Hypotension in Parkinson's Disease.

KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for Management of Blood Pressure in CKD