Need For Antihypertensive Medication Research Articles

Intracerebral Hemorrhage as the Presenting Feature of Concurrent Pheochromocytoma and Paragangliomas

all had a pheochromocytoma diagnosed.A careful search of the literature, however, hasnot revealed a case of ICH caused by concurrentpheochromocytoma and paraganglioma tumors ina young adult requiring more than one surgicalintervention.CASE REPORTA 25-year-old woman presented with a suddenonset of dysarthria and right-sided hemiparesis.Brain computed tomography and magnetic reso-nance imaging revealed hemorrhage of the leftbasal ganglia (Figure 1). Her supine blood pressurewas 240⁄130 mm Hg, with a heart rate of 96 beatsper minute. Renal function was normal (serumurea, 27 mg ⁄dL; serum creatinine, 0.71 mg ⁄dL;and negative urinalysis results), and routine labora-tory test findings were within normal limits. Resultsof chest radiography were negative, 12-lead electro-cardiography revealed sinus rhythm with no signsof hypertrophy, and 2-dimensional Doppler echo-cardiography showed a left ventricular ejectionfraction of 70% with mild hypertrophy (interventri-cular septal-diastole, 12.3 mm; left ventricular pos-terior wall-diastole, 13.0 mm).The patient had had paroxysmal attacks ofsevere headaches and tachycardia over a 5-year per-iod, without any other illnesses; blood pressure wasnever measured during these attacks. The suddenonset of severe hypertension in addition to hermedical history raised suspicion of secondaryhypertension and especially pheochromocytoma.Computed tomography and magnetic resonanceimaging of the abdomen revealed an enlarged rightadrenal gland and a rounded mass in proximity tothe upper pole of the left kidney (Figure 2). Thepatient was referred to our hospital.In order to establish the diagnosis of pheochro-mocytoma, biochemical and radiologic studies wereperformed. Urinary catecholamine levels wereincreased (908 lg⁄24 h; reference values <150lg⁄24 h) and plasma noradre naline levels were alsohigh (noradrenaline, 3461 pg ⁄mL; references values<450 pg⁄mL); these were not suppressed by cloni-dine. Scintigraphy with

Epidemiology and outcome of acute kidney injury in New Zealand children

To determine the aetiology, incidence and short-term outcomes of New Zealand children with acute kidney injury (AKI) requiring renal replacement therapy (RRT) over a 6-year period. A retrospective chart review of all children requiring RRT for AKI from January 2001 to December 2006 at Starship Children's Hospital, Auckland, New Zealand was conducted. The primary outcome was survival to discharge. A total of 226 children required RRT for AKI over the 6-year study period. The annual incidence was 4.0 per 100,000 total population under 15 years of age. The commonest causes of AKI were post cardiac surgery (58%), haemolytic uraemic syndrome (17%), sepsis (13%) and glomerulonephritis (4%). The survival rate to hospital discharge was 89%. A total of 40% of all surviving children had one or more abnormalities at the time of discharge suggestive of ongoing renal dysfunction (hypertension, continuing need for antihypertensive medication, reduced estimated glomerular filtration rate or abnormal urinalysis). More Maori and Pacific Island children were treated for AKI than would be expected from population data (P < 0.0001). Sepsis and glomerulonephritis were seen more commonly as causes of AKI in Maori and Pacific Island children compared with New Zealand European children. In our study, 40% of surviving children had evidence of short-term renal dysfunction at discharge following AKI. This suggests that all children should undergo a period of follow-up after any episode of AKI to look for resolution or further development of signs of renal injury.

The Aldosteronoma Resolution Score

To develop a prediction model using information readily available, at clinical presentation, which could determine whether patients with aldosterone-producing adenomas would have complete resolution of hypertension after adrenalectomy. Primary aldosteronism is the most common curable cause of secondary hypertension. However, a large number of patients continue to require antihypertensive medications to control their blood pressure. Differentiating patients that will have complete resolution of hypertension without the need for antihypertensive medications from patients that will require continued use of antihypertensive medications is difficult before adrenalectomy. The predictive logistic regression model was derived using data on 100 patients who underwent adrenalectomy for primary aldosteronism at one tertiary medical center and was externally validated using an independent series of 67 patients from another center. Clinical features were similar for patients in the derivation and validation groups. Four readily available predictors (2 or fewer antihypertensive medications, body mass index < or =25 kg/m, duration of hypertension < or =6 years, and female sex) yielded the best predictive model for complete resolution of hypertension after adrenalectomy. Based on the resulting 4-item aldosteronoma resolution score (ARS), 3 likelihood levels for complete resolution were identified: low (0-1), medium (2-3), and high (4-5) with a predictive accuracy of 27%, 46%, and 75%, respectively. The ARS accurately identifies individuals at low (ARS < or =1) or high (ARS > or =4) likelihood of complete resolution of hypertension without further need of lifelong antihypertensive medications after adrenalectomy for aldosteronoma. This scoring system can help clinicians objectively inform patients of likely clinical outcomes before surgical intervention.

Conversion From Cyclosporine Microemulsion to Tacrolimus in Stable Kidney Transplant Patients With Hypercholesterolemia Is Related to an Improvement in Cardiovascular Risk Profile: A Prospective Study

The aim of this prospective multicenter study was to evaluate the effect of conversion from cyclosporine (CsA) to tacrolimus (Tac) on cardiovascular risk factors in stable kidney transplant patients with hyperlipidemia. Twenty-six patients were switched from CsA to Tac at 81.7 ± 44.4 months after transplantation. Tac was started at 0.15 mg/kg/d. Patient outcomes were evaluated up to 6 months after conversion. Significant reductions were seen in systolic blood pressure (143 ± 13 baseline to 136 ± 9 mm Hg at 6 months, P = .026) as well as the need for antihypertensive medication, with no changes in diastolic blood pressure. There was a significant reduction in total cholesterol (247 ± 41 to 221 ± 35 mg/dL, P = .003), low-density lipoprotein cholesterol (150 ± 24 to 127 ± 27 mg/dL, P = .001), total cholesterol/high-density lipoprotein (HDL) cholesterol ratio (4.9 ± 1.9 to 3.9 ± 1, P = .02), and triglyceride levels (228 ± 175 to 148 ± 71 mg/dL, P = .026). No significant modifications in HDL cholesterol, Apo A1 and Apo-B levels, or in the need for lipid-lowering medication were observed. Glucose levels did not change, but an increase in HbAC1 took place (5.8 ± 1.1 to 6.2 ± 1, P = .002). In men Framingham risk score significantly decreased from 11.5 ± 11.3 to 8.4 ± 7.2. ( P = .0023). In conclusion, elective conversion from CsA to Tac in stable kidney transplant patients with hyperlipidemia was related to an improved blood pressure and lipid profile, both suggesting a decrease in the estimated 10-year coronary heart disease risk in men.

Favorable cardiovascular risk profile and 10-year coronary heart disease incidence in women and men: results from the Progetto CUORE

Cardiovascular risk factor research has recently broadened its focus based on new data indicating the benefits of low risk, i.e. favorable levels of all major risk factors. The aims of this study were to assess further the relation of low risk to coronary heart disease risk, and implications for prevention. We conducted a prospective population-based Italian study, of 7438 men and 13 009 women aged 35-69 years, with a mean follow-up of 10.4 years and validated first coronary events. Baseline coronary heart disease risk was classified into three categories: low risk; unfavorable but not high risk; and high risk. To analyze the relation of these risk profiles to coronary heart disease incidence, age-adjusted, sex-averaged coronary heart disease incidence was calculated for persons free of coronary heart disease and stroke, stratified as baseline low risk, unfavorable but not high risk or high risk. To assess the independent relationship of individual risk factors to coronary heart disease incidence, multivariate proportional hazards models were computed for combinations of risk factors. Only 2.7% of participants met low risk criteria; 81.4% were high risk. Age-adjusted coronary heart disease incidence for the whole cohort was 37.1 out of 10000 person-years (men 59.0; women 15.3). No coronary heart disease events occurred in low-risk men, only two in low-risk women. For women and men who were not high risk, the age-sex standardized coronary heart disease rate was 62% lower than for high-risk participants. Blood pressure, need for antihypertensive medication, smoking, hyperglycemia, diabetes, total and high-density lipoprotein cholesterol were independently related to coronary heart disease risk. Favorable levels of all modifiable readily measured risk factors - rare among Italian adults - assure minimal coronary heart disease risk. Population-wide prevention is needed, especially improved lifestyles, to increase the proportion of the population at low risk.

Role of potassium in regulating blood flow and blood pressure

Unlike sodium, potassium is vasoactive; for example, when infused into the arterial supply of a vascular bed, blood flow increases. The vasodilation results from hyperpolarization of the vascular smooth muscle cell subsequent to potassium stimulation by the ion of the electrogenic Na+-K+ pump and/or activating the inwardly rectifying Kir channels. In the case of skeletal muscle and brain, the increased flow sustains the augmented metabolic needs of the tissues. Potassium ions are also released by the endothelial cells in response to neurohumoral mediators and physical forces (such as shear stress) and contribute to the endothelium-dependent relaxations, being a component of endothelium-derived hyperpolarization factor-mediated responses. Dietary supplementation of potassium can lower blood pressure in normal and some hypertensive patients. Again, in contrast to NaCl restriction, the response to potassium supplementation is slow to appear, taking approximately 4 wk. Such supplementation reduces the need for antihypertensive medication. "Salt-sensitive" hypertension responds particularly well, perhaps, in part, because supplementation with potassium increases the urinary excretion of sodium chloride. Potassium supplementation may even reduce organ system complications (e.g., stroke).

Comparison of Angioplasty and Surgery for Neonatal Aortic Coarctation

The efficacy of balloon dilatation as primary treatment for neonatal aortic coarctation remains controversial. A retrospective comparison between balloon angioplasty and surgery for the treatment of neonatal aortic coarctation was undertaken on 57 neonates younger than 40 days of age (angioplasty, 23 patients; surgery, 34 patients) treated between 1994 and 2004. Cohorts were similar with respect to the preinterventional variables of age, weight, upper extremity systolic blood pressure, coarctation gradient, degree of aortic arch hypoplasia, associated conditions, and mean follow-up (angioplasty, 36 months; surgery, 38 months). Among the angioplasty group, 13 patients (57%) required surgery, and 8 required a second balloon dilatation, of whom 3 patients had an aortic aneurysm. Among the surgery cohort, 6 patients experienced recurrence (18%) after either SFA (3) or XETE anastomosis repair (3). All were successfully treated with balloon angioplasty. Actuarial freedom from any intervention was significantly greater in the surgery cohort as was the degree of aortic arch growth. At latest follow-up, antihypertensive medication was required in 3 of 9 angioplasty patients (33%) and 2 of 27 surgery patients (7%). No repeat intervention was required in the 13 patients who underwent angioplasty followed by surgery. Primary angioplasty is palliative treatment for neonatal aortic coarctation, but it is the treatment of choice for recurrence after surgery. Surgery for neonatal aortic coarctation is associated with fewer reinterventions, improved aortic arch growth, no aortic aneurysm formation, and decreased need for antihypertensive medication when compared with neonates treated primarily with balloon angioplasty.

Immunosuppression in Pediatric Liver and Intestinal Transplantation: A Closer Look at the Arsenal

Immunosuppression in Pediatric Liver and Intestinal Transplantation: A Closer Look at the Arsenal

Early discontinuation of steroids is safe and effective in pediatric kidney transplant recipients

In pediatric kidney transplantation, steroid induced growth retardation and cushingoid features are of particular concern. In children, gradual steroid withdrawal late after kidney transplantation increases the risk of rejection. In this pilot study, we investigated the outcome of pediatric renal transplantation with an early steroid withdrawal protocol. This is a retrospective case-control study of pediatric renal transplants with age-matched historical control. Groups were comparable in terms of HLA matching, donor type and graft ischemia time. In the steroid withdrawal group (SWG, n = 13), induction therapy included mycophenolate mofetil (MMF) and a 5-day course of steroids with Thymoglobulin in 11 and basiliximab in two other patients. In the steroid group (SG, n = 13), in addition to steroids, four patients were given basiliximab, eight were given Thymoglobulin, and one OKT3. Maintenance therapy included tacrolimus (SWG n = 11, SG n = 3) or cyclosporine (SWG n = 2, SG n = 10). Azathioprine was given to all the patients in the SG, except the last two patients of this series who were prescribed MMF. MMF was given to all in the SWG. Patient and graft survival rates were 100% in both groups. In the SWG, no acute rejection episode was detected. In the steroid group, three patients (25%) presented with an acute rejection episode. All but one patient in either group showed immediate graft function. Patients in the steroid-withdrawal group exhibited a significantly higher creatinine clearance at 6 and 12 months post-transplant (95.8 +/- 23.3 vs. 71.3 +/- 21.9, p = 0.03; and 91.3 +/- 21.6 vs. 69.6 +/- 28.6, p = 0.04). In the SWG delta BMI was significantly lower and delta height Z score was significantly higher, and we observed significantly less hyperlipidemia, body disfigurement, and need for anti-hypertensive medication. Early steroid withdrawal in pediatric renal transplant recipients is efficacious and safe and does not increase risk of rejection, preserving optimal growth and renal function, and reducing cardiovascular risk factors.

Hormone replacement therapy and arterial blood pressure in postmenopausal women with hypertension

Background. Data on the effect of hormone replacement therapy (HRT) on blood pressure (BP) in hypertensive menopausal women are limited. Objective. To investigate the association between HRT and longitudinal changes in BP in hypertensive menopausal women. Patients and methods. We recruited a total of 161 hypertensive menopausal women (mean age = 52.2±6.6 years) attending the hypertension clinic in our hospital that required HRT to attenuate the effect of menopause symptoms. These women were followed for up to 36 months, being evaluated every 6 months with measurements of their BP, weight and the number of drugs needed to control their BP. We also measured serum cholesterol levels before and after the initiation of HRT. Results. The systolic BP remained unaffected throughout the whole follow‐up period, whereas the diastolic BP was slightly reduced at 6, 24 and 36 months. This decrease was accompanied by an increased need for antihypertensive medication throughout the entire follow‐up period, while the body weight also increased at 18, 24 and 36 months. No particular differences were noted with respect to ethnicity, history of pre‐eclampsia or surgical menopause, before and after the initiation of HRT. Serum cholesterol levels remained unchanged during the evaluation period. Oestrogen–progestogen combination therapy use was associated with a lower diastolic BP and a smaller number of antihypertensive drugs compared to other forms of HRT. Conclusion. HRT use does not have an adverse gross effect on BP in hypertensive menopausal women who need it, although there may be an increased need for antihypertensive therapy during the 36‐month follow‐up period of our study.

Psychological Stress Tasks in the Prediction of Blood Pressure Level and Need for Antihypertensive Medication: 9-12 Years of Follow-Up.

Increased blood pressure (BP) reactivity to subtypes of psychological stimuli may differentially predict the development of future BP elevation or hypertension. The authors present the 9-12-year follow-up results of 82 (86%) of 95 male participants with different BP levels. They were healthy, untreated, and age-matched volunteers from a routine health checkup carried out on all 35-, 40-, and 45-year-olds from a medium-sized city. Intra-arterial systolic blood pressure (SBP) during the psychological tasks improved the prediction of future casual SBP and noninvasive 24-hr ambulatory SBP compared with predictions from casual diagnostic measurements. Diastolic blood pressure (DBP) was very useful when added to casual DBP in predicting the need for antihypertensive medication. Reactivity to active tasks especially predicts the need for antihypertensive medication.

Rapid Progression of Native Renal Artery Fibromuscular Dysplasia Following Kidney Donation

Fibromuscular dysplasia is the second commonest anatomical abnormality apart from multiple renal arteries in the potential live donors. Pretransplant evaluation of the donors may include an angiography to evaluate the renal arteries, and failure to recognize renal arterial stenosis, particularly fibromuscular dysplasia, by noninvasive methods may eventually lead to hypertension and ischemic renal failure. We report a case of fibromuscular dysplasia that was undetected by computed tomographic angiography prior to donation. One year after kidney donation, it rapidly progressed to severe symptomatic stenosis with hypertension and acute renal failure. Following renal artery angioplasty, her blood pressure normalized over a period of 2 weeks without any need for antihypertensive medications and the serum creatinine returned to her baseline. The acceptability of renal donors with fibromuscular dysplasia depends on the age, race and the availability of the other suitable donors. Mild fibromuscular dysplasia in a normotensive potential renal donor cannot be considered a benign condition. Such donors need regular follow-up postdonation for timely detection and treatment.

Successful withdrawal of steroids in pediatric renal transplant recipients receiving cyclosporine A and mycophenolate mofetil treatment: results after four years.

Despite their numerous systemic side effects, glucocorticoids (steroids) still form a cornerstone in immunosuppressive regimens in pediatric renal transplant recipients. The addition of mycophenolate mofetil (MMF) to a cyclosporine A (CsA)-based immunosuppressive regimen after renal transplantation may allow steroid withdrawal and amelioration or avoidance of steroid-specific side effects. In a retrospective case-control study, covering a mean follow-up period of 46 +/- 2.3 months and 40 patients aged 11.4 +/- 4.9 years, we analyzed the safety and efficacy of steroid withdrawal in pediatric renal transplant recipients receiving CsA micoroemulsion, MMF, and low-dose prednisone treatment. : Steroid withdrawal in all 20 pediatric renal transplant recipients receiving CsA and MMF was successful and not associated with an acute rejection episode; graft function remained stable. At baseline, the degree of growth retardation was comparable between the groups (mean height standard deviation scores [SDSs] -1.60 +/- 0.30 [withdrawal group] and -1.32 +/- 0.39 [case-control group]). After steroid withdrawal, prepubertal patients exhibited a significant catch-up growth with a mean height gain of 1.47 +/- 0.32 SDS, whereas height SDS did not improve in patients receiving steroids. Growth was also improved in pubertal patients who stopped taking steroids. Standardized body mass index in patients who stopped taking steroids decreased significantly by 49% from 0.87 +/- 0.31 SDS to 0.45 +/- 0.30 SDS. After steroid withdrawal, mean arterial blood pressure SDS decreased significantly by 45%. Moreover, the need for antihypertensive medication declined significantly in patients who stopped taking steroids. The white blood cell counts and hemoglobin levels were comparable between the groups. : This study suggests that steroids can be safely and successfully withdrawn in selected pediatric renal transplant recipients receiving immunosuppressive maintenance therapy consisting of CsA and MMF.

Prevalence and clinical significance of isolated ambulatory hypertension in young subjects screened for stage 1 hypertension.

Little is known about the clinical significance of isolated ambulatory hypertension, a condition characterized by low office but elevated ambulatory blood pressure. This study aimed to investigate the prevalence and the predictive value of isolated ambulatory hypertension diagnosed after 3 months of observation for the development of sustained hypertension within a cohort of 871 never-treated stage-1 hypertensive subjects. The study end point was progression to more severe hypertension and need of antihypertensive medication. In 244 subjects (28%), clinic blood pressure declined to <140/90 mm Hg after 3 months. Of these, 124 (14.2% of total) had low clinic and ambulatory blood pressures after 3 months (nonhypertensive subjects), whereas 120 subjects (13.8% of total) showed low clinic but elevated ambulatory blood pressure (isolated ambulatory hypertension). During the 6 years of observation, the number of end points based on multiple clinic blood pressure readings progressively increased from the nonhypertensive subjects (19%) to the subjects with isolated ambulatory hypertension (35%) and to the subjects with high clinic and high ambulatory blood pressures (65%, P<0.0001). In an adjusted proportional hazard model, isolated ambulatory hypertension status was associated with a 2.2 (P=0.02) increase in the risk of reaching the end point in comparison with the nonhypertensive subjects. Final ambulatory systolic blood pressure was also higher in the former than the latter (P=0.03). Our results indicate that among subjects screened for stage 1 hypertension, individuals with isolated ambulatory hypertension after 3 months of observation have increased risk of developing sustained hypertension in later life compared with subjects in whom both clinic and ambulatory blood pressures are normal.

Reduced endothelin-1– and nitric oxide–mediated arteriolar tone in hypertensive renal transplant recipients

The prevalence of hypertension is high in renal transplant recipients. It has been suggested that calcineurin inhibitors (CI) contribute to the development of post-transplant hypertension by stimulating endothelin (ET-1)-mediated and/or reducing nitric oxide (NO)-mediated vascular tone. We tested this hypothesis using 2 groups of renal transplant recipients [normotensive patients without a need for antihypertensive medication (Normo-Tx), and hypertensive patients requiring antihypertensives (Hyper-Tx)] in the presence of CI-based immunosuppression. In addition, we studied matched control subjects (C). BQ 123 (ET-A receptor antagonist), BQ123 + BQ788 (ET-A/B-receptor antagonist), ET-1, L-NMMA (NO-synthase inhibitor), acetylcholine (ACH; endothelium-dependent vasodilator), glyceroltrinitrate (GTN, NO donor), and norepinephrine (NE, endothelium-independent vasoconstrictor) were infused into the brachial artery. Forearm blood flow (FBF) was measured by venous occlusion plethysmography. Endothelium-independent vasomotion in response to GTN and NE was similar in all groups. Vascular responses to selective and combined blockade of ET receptors in both Normo-Tx and Hyper-Tx did not exceed those of C. In fact, we observed a significantly lower increase in FBF after BQ 123 (P= 0.03), as well as after BQ 123/788 (P= 0.03) in Hyper-Tx compared with Normo-Tx. This was associated with an increased vascular sensitivity to exogenous ET-1 in Hyper-Tx compared with Normo-Tx (P= 0.04). Vasoconstriction after L-NMMA was reduced in Hyper-Tx compared with Normo-Tx (P= 0.015), while the response to ACH was reduced in both groups of Tx patients to a similar degree (P= 0.005 vs. C). Our results do not support a major role for the vascular endothelin system in the hypertension of renal transplant recipients, whereas deficient baseline NO production may be a contributing factor.

Sustained beneficial effects on blood pressure during long time retrospective follow-up after endovascular treatment of renal artery occlusion.

We retrospectively evaluated short- and long-term effects of percutaneous transluminal renal angioplasty (PTRA) with or without stent placement of renal artery occlusion (RAO) upon blood pressure (BP), serum (s)-creatinine, and the need for antihypertensive treatment in 34 RAO patients who underwent PTRA during 1996-2002. In 24/34 (71%) treatment was considered technically successful, 22/24 (92%) were treated with PTRA + stent, two with only PTRA. Patients were followed for mean 2.6 (range 0-8) years, during which 14/34 (41%) patients died. In all 34 patients, systolic and diastolic BP (SBP and DBP) before treatment were 184 +/- 30/95 +/- 15 mmHg and had decreased at discharge (to 157 +/- 21/80 +/- 10 mmHg; P < 0.001 for both SBP and DBP), and remained lower after 1 year (154 +/- 20/83 +/- 7 mmHg; P < 0.001 for SBP and P < 0.01 for DBP), and at last follow-up (148 +/- 20/80 +/-12 mmHg; P < 0.001 for both SBP and DBP). No changes occurred in s-creatinine or the number of antihypertensive drugs. Similar results were seen in the subgroup of 24/34 (71%) patients in whom treatment was technically successful. Among the 24 patients undergoing technically successful PTRA, absence of nephrosclerosis (P = 0.035) and a shorter duration of hypertension (P = 0.020) predicted favourable clinical outcome. No adverse effects upon s-creatinine or the need for antihypertensive medication were seen in patients in whom treatment was considered a technical failure. Seven of these patients were treated with PTRA of another renal artery than the occluded, or with embolisation. In conclusion, RAO can be treated with endovascular techniques. Technically successful results with decreasing blood pressure levels were obtained in 71% of patients.

Renal revascularization in Takayasu arteritis–induced renal artery stenosis

Purpose This study was undertaken to define the long-term effects of renal revascularization on blood pressure, and renal and cardiac function in patients with Takayasu arteritis–induced renal artery stenosis (TARAS). Methods Twenty-seven patients (25 women; mean age, 27 years) with TARAS underwent intervention. Primary, primary assisted, and secondary patency rates were determined, and the late effects on blood pressure, renal and cardiac function, and survival were analyzed. Results All patients had hypertension (mean blood pressure, 167/99 mm Hg; 2.5 antihypertensive medications per patient). Mean estimated glomerular filtration rate in patients not receiving hemodialysis was 76 mL/min, and in five patients serum creatinine concentration was greater than 1.5 mg/dL. Three patients were hemodialysis-dependent, and two had intractable congestive heart failure. Forty interventions were performed, including 32 aortorenal bypass procedures, two repeat implantations, four nephrectomies, and two transluminal angioplasty procedures. Postoperative morbidity was 19%. There were no deaths. During follow-up (mean, 68 months), three graft stenoses, all due to intimal hyperplasia, and three graft occlusions occurred. Two of three graft stenoses were successfully revised. At 1, 3, and 5 years of follow-up, primary patency was 87%, 79%, and 79%, respectively; primary assisted patency was 93%, 89%, 89%, respectively; and secondary patency was 93%, 89%, and 89%, respectively. Intervention resulted in a decrease in blood pressure to a mean of 132/79 mm Hg ( P < .0001), and the need for antihypertensive medications was reduced to one per patient ( P < .01). Mean glomerular filtration rate increased to 88 mL/min ( P < .005), and two patients no longer required hemodialysis. Congestive heart failure resolved in both patients, and did not recur. There were three deaths during follow-up, with 5-year and 10-year actuarial survival of 96% and 80%, respectively. Conclusions Renal revascularization to treat TARAS is durable, has a salutary effect on blood pressure, and enhances long-term renal and cardiac function. This response establishes renal revascularization as a successful and durable intervention for TARAS, and a benchmark to which other therapies should be compared.

Nightly home hemodialysis: Five and one‐half years of experience in Lynchburg, Virginia

Lynchburg Nephrology Dialysis Incorporated initiated a nightly home hemodialysis (NHHD) program in September 1997. As of April 30, 2003, 40 patients had completed training; 28 patients were at home and 2 patients were in training. The average age of the patients at the initiation of the home-based therapy was 50 years, with a range of 23 to 81 years. There have been 24,239 treatments at home with a total of 84.86 patient-years on NHHD, the longest patient for 66.7 months and the shortest for 1 month. Patients dialyzed using the Fresenius 2008H machine, 6 to 10 hr, 5 to 6 nights per week. Treatment parameters included a blood flow rate of 200 to 250 mL/min; a dialysis flow rate of 200 to 300 mL/min; and a standard dialysis solution with 2.0 mEq/L potassium, 3.0 to 3.5 mEq/L calcium concentrations, 35 mEq/L HCO(3), and 140 mEq/L sodium. The longitudinal data of each patient in the program for 1, 2, 3, 4, and 5 years were compared to the same patient's pre-NHHD data. There were 25 patients in the program for 1 year, 19 patients for 2 years, 14 patients for 3 years, 6 patients for 4 years, and 4 patients for 5 years. Statistically significant improvement occurred in all five groups' need for antihypertensive medications and phosphate binders, SF36 scores, calcium/phosphorus product, blood pressure, number of hospital admissions, and number of days of stay in the hospital. The mortality rate was 2.4% deaths per patient-year with a 95% confidence interval of 0.9% to 9.4%. In a longitudinal study, NHHD showed significant improvements in patient secondary outcomes. The improvement in these secondary outcomes was associated with an improvement in mortality rate.

Kissing Balloon Technique for Angioplasty of Renal Artery Bifurcation Stenoses

This study evaluates long-term results after using the kissing balloon technique in percutaneous transluminal angioplasty of bifurcation stenoses of the renal artery. Eight patients with proven renal artery stenosis and deterioration of renal function were treated, including one kidney transplant recipient. Follow-up ranged between 3 and 131 months. All interventions were technically successful. All patients improved in one or more of the following: serum creatinine levels and creatinine clearance, blood pressure, and need for antihypertensive medication. The kissing balloon technique is a reliable and safe method for treating bifurcation stenoses of the renal artery, rendering stable long-term results.

The Importance of Systolic Blood Pressure Control and Cardiovascular Disease Prevention.

Hypertension affects up to 75% of individuals 60 years of age and older. Cardiovascular risk is related to increases in systolic blood pressure and pulse pressure and to decreases in diastolic blood pressure, but systolic blood pressure reduction is the major target for improving outcomes in the elderly patient. Hypertension therapy in older individuals should include lifestyle modification, especially weight loss and sodium restriction, which may decrease the need for antihypertensive medication. The starting dose of medication should be one half that used in younger patients. If low initial doses are used, significant attention must be paid to adequate titration; combination therapy is usually required for optimal blood pressure control. The initial agent chosen is rarely the final agent used to achieve the recommended minimal systolic blood pressure goal of less than 140 mm Hg. If more than one agent is required, a diuretic should be included as one of the agents chosen. Although the reduction of blood pressure should occur more gradually in the older patient, the treatment goals should be similar and determined by the underlying concomitant disorder. The minimum goal should remain less than 140/90 mm Hg, with lower goals in diabetic patients and those with renal disease. Patients with isolated systolic hypertension should have a minimum systolic blood pressure goal of less than 140 mm Hg.