1 / 32

Il rischio Cardiovascolare : aspetti patogenetici e diagnostici Il ruolo del Sodio

Il rischio Cardiovascolare : aspetti patogenetici e diagnostici Il ruolo del Sodio Carmine Zoccali. What really defined the decade was the rise of China. By Fareed Zakaria. Huang Ti, 2698–2598 BC (the Yellow Emperor). ‘Hence if too much salt is used for food, the pulse hardens ...’.

boris-ross
Download Presentation

Il rischio Cardiovascolare : aspetti patogenetici e diagnostici Il ruolo del Sodio

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Il rischio Cardiovascolare : aspetti patogenetici e diagnostici Il ruolo del Sodio Carmine Zoccali

  2. What really defined the decade was the rise of China.By Fareed Zakaria Huang Ti, 2698–2598 BC (the Yellow Emperor) ‘Hence if too much salt is used for food, the pulse hardens ...’

  3. Alderman MH, Cohen H, Madhavan S. Dietary sodium intake and mortality: the National Health and Nutrition Examination Survey (NHANES I). Lancet 1998; 351: 781-785. Death (x1000 person years) 30 25 20 15 10 5 0 2008: 23(9):1297–302 1° 2° 3° 4° sodium CV death ……. these results do not support current recommendations for routine reduction of sodium consumption, nor do they justify advice to increase salt intake or to decrease its concentration in the diet…..

  4. -5 mmHg -2 mmHg

  5. The New York Times A Pinch of Science by Michael Alderman 9 February 2009 .......Absent convincing scientific evidence of a benefit to eating less salt, much less an assurance of safety, it might be wiser for the NY dpt. of Health to press for the research that could provide a solid scientific basis for action…… New York City Health Department. 2008 Salt reduction (-40%) in processed food

  6. & Carmine Zoccali End Stage Renal Disease

  7. Extracellular Volume (L) 24 18 12 6 0 Systolic BP (mmHg) 160 150 140 130 120 110 0 1 2 3 4 5 6 Time (months) New hypothesis. The lag phenomenon depnds on a peculiar inhability in ESRD patients for removing “stored” Na. i.e. Na which accumulates in connective tissue bound to proteoglycans “Lag phenomenon”

  8. Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Lymphatic vessels Extracellular Fluids Volume (sodium space) 16-18 L Machnik, A. et al. Nat. Med. 15, 545–552 (2009). Na 150 mmMol/ L Iso-osmotic sodium pool Na Blood Volume 5.6 L (~30% extracellular volume) tonicity enhanced binding protein (TonEBP) VEGF  Blood Pressure

  9. Extracellular Volume (L) 24 18 12 6 0 tonicity enhanced binding protein (TonEBP) Na+ Na+ Systolic BP (mmHg) 160 150 140 130 120 110 Na+ Na+ Na+ Na+ Na+ Na+ VEGF Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ 0 1 2 3 4 5 6 Time (months) Lymphatic vessels Restoration of a disturbed Regulation? “Lag phenomenon”

  10. Mortality % 100 75 50 25 0 Mortality % 100 75 50 25 0 0 1 2 3 4 5 6 years on dialysis Albumin > 4 g/dl Even among patients achieving the top number of performance targets mortality rate remains quite high, about 50% at 6 years or 8 % /year, i.e. a mortality at least 16 times higher than in age and sex matched general population. Ca x P <55 mg2/dl2 Hb > 11 g/dl 0-1 targets Kt/V > 1.2 2 targets Access type, fistula 3 targets -30% 4-5 targets

  11. Albumin > 4 g/dl Ca x P <55 mg2/dl2 Clinically assessing fluids volume Hb > 11 g/dl Symptoms Kt/V > 1.2 Access type, fistula Vena Cava diameter BIA Either not sufficiently reliable or unpractical. None of these methods is actually incorporated in the clinical decision process in the vast majority of dialysis centres. Measurement of Plasma or Blood Volume orExtracellular Volume by radio-isotopic methods. No clinical indicator reflecting fluids volume and cardiac status

  12. Total Na Space (L/m2) 22 20 18 16 14 12 10 Warner GF et al., Circulation 5:915, 1952 Poor discriminatory power of body fluids volume measurements for guiding therapy the modest discriminatory value of body fluids volume estimates for identifying volume expanded patients in clinical practice is not a surprise 1+ 2+ 3+ 4+ Clinically estimated edema Old normal adults

  13. Cardiac Extracellular Fluids function Volume Extracellular Volume (sodium space) 16-18 L LV filling Pressure 8-10 mmHg Blood Volume 5.6 L (~30% extracellular volume) The fundamental parameter for defining the loading conditions of the CV system, i.e. the relationship between circulating volume and CV function

  14. Extracellular Volume (sodium space) LV filling Pressure 8-10 mmHg Like in other conditions, LV filling pressure in ESRD reflects the loading conditions of the left ventricle, i.e. a fundamental factor for central hemodynamics kidney is central in regulating the blood volume –LV filling pressure relationship Externally, intermittently regulated ECV

  15. However highly reliable, this is an invasive technique and therefore it is employed in the acute setting only. Capillary Wedge Pressure a very reliable indicator of LV filling pressure Atrial Pressure Capillary Pressure at alveolar level LV Diastolic (filling) Pressure LV filling pressure depends on 2 components: 1) volume component 2) LV function component therefore it reflects the loading conditions of the LV at a given BV

  16. normal Pulmonary edema Lung water CHEST 127:1690, 2005 Pulmonary Water Capillary Pressure at alveolar level Lung comets ! the number of lung comets is strictly proportional to lung water

  17. Detection of pulmonary congestion by chest ultrasound (US) in dialysis patients. Mallamaci F, Benedetto A, Tripepi R, Rastelli S, Castellino P, Tripepi G, Picano E, Zoccali C In Press Prevalence (%) 50 40 30 20 10 0 Lung Comets (n) 60 50 40 30 20 10 0 Severe lung congestion Moderate lung congestion 20 17 15 <14 14-30 >30 Lung Comets number Hypo Normal Hyper Hydration Status by BIA Predialysis Median # of comets: 18 35% 28%

  18. Detection of pulmonary congestion by chest ultrasound (US) in dialysis patients. Mallamaci F, Benedetto A, Tripepi R, Rastelli S, Castellino P, Tripepi G, Picano E, Zoccali C In Press Prevalence (%) 50 40 30 20 10 0 Severe lung congestion Moderate lung congestion <14 14-30 >30 Lung Comets number Median # of comets: 10 Postdialysis 33% 30%

  19. (mL/m2.7) r=0.33, P=0.002 70 30 r=0.32, P=0.006 60 25 50 Detection of pulmonary congestion by chest ultrasound (US) in dialysis patients. Mallamaci F, Benedetto A, Tripepi R, Rastelli S, Castellino P, Tripepi G, Picano E, Zoccali C In Press 20 LV Ejection Fraction (%) 40 Left atrial Volume Pulmonary Pressure (mmHg) 15 30 10 20 10 5 0 0 0 50 100 150 200 0 50 100 150 200 Lung comets (n) Lung comets (n) 80 70 r=-0.73, P<0.001 60 r=-0.64, P<0.001 50 40 30 20 10 0 50 100 150 200 Lung comets (n) r=0.39, P<0.001 r=0.30, P=0.01

  20. Detection of pulmonary congestion by chest ultrasound (US) in dialysis patients. Mallamaci F, Benedetto A, Tripepi R, Rastelli S, Castellino P, Tripepi G, Picano E, Zoccali C In Press 140 120 100 80 Lung comets changes (n) 60 40 20 0 -20 0 20 40 60 80 100 120 140 160 180 200 Pre-dialysis lung comets (n) r=0.75 P<0.001

  21. Inter-observer agreement 60 40 + 2SD 20 [Lung comets (1st Obs)- Lung comets (2nd Obs)] Average 0 -20 - 2SD -40 0 50 100 150 200 [Lung comets (1st Obs)+ Lung comets (2nd Obs)]/2 Agreement between probes / machines 15 10 5 [Lung comets (3.5 MHz) - Lung comets (3.0 MHz)] 0 -5 -10 -15 0 20 40 60 80 100 [Lung comets (3.5 MHz)+ Lung comets (3.0 MHz)]/2 The measurement of lung comets is a reliable technique for the measurement of pulmonary water Concordance index=0.96, 95% CI: 0.90-0.98 Concordance index=0.98, 95% CI: 0.97-0.99

  22. Peritoneal Dialysis 180 140 100 180 140 100 Systolic BP mmHg Systolic BP mmHg 80 60 40 20 Left Atrial volume ml P <0.001 LVH (%) 90 70 50 30 90 70 50 30 LVH (%) Hemodialysis Peritoneal Dialysis n=201 n=51 New policy Multiply efforts for educating patients at carefully monitoring BP on a daily basis to aim at GLs recommended systolic BP target (<140 mmHg). Systematic use of icodextrin in patients in whom BP is insufficiently controlled or with clinical evidence of volume expansion. Volume expansion : often a major problem PD patients obviously volume expanded. A change in local clinical policies clearly needed 86% 60% 62%

  23. Peritoneal Dialysis 140 100 140 100 Systolic BP mmHg Systolic BP mmHg 45 30 15 0 90 70 50 30 90 70 50 30 57% 60% LVH (%) LVH (%) New policy RC Centre with less experience Clinical policies vary much across centres Clinical experience and background errors make a difference Different emphasis on volume-salt control may translate into occult volume overload in patients being treated in centres with less stringent salt-volume policies. Lung comets monitoring may be useful to achieve salt-volume balance appropriate to individual cardiac / hemodynamic profile Left atrium by the 10% larger

  24. late eighties BIA bielectrical impedance analysis enthusiasm disappointement Lung comets monitoring may be useful to achieve salt-volume balance appropriate to individual cardiac / hemodynamic profile controversy NO APPROPRIATE CLINICAL TRIAL TESTING THE USEFULNESS OF THIS TECHNIQUE OVER 20 YEARS OF CLINICAL APPLICATION. A clinical trial based on a management strategy guided by lung comets needed

  25. S & C La storia dei rapporti tra sale e rischio cardiovascolare a livello di popolazione è lunga e controversa ma è assodato che un eccesso di sale / volume pone alti rischi nell’insufficienza renale. L’eccesso di volume innescato dal sale è difficilmente quantificabile nei pazienti in dialisi. D’altra parte, per l’alta frequenza di disfunzione ventricolare sinistra, la sola misura del volume è insufficiente per guidare l’ultrafiltrazione in questi pazienti. La misura dell’acqua polmonare con gli US è una tecnica promettente in quanto fornisce informazioni affidabili sul grado di congestione polmonare, cioè su un fenomeno da prevenire o correggere tempestivamente nei pazienti in dialisi. L’utilità di questa tecnica deve essere testata in uno specifico trial clinico.

  26. Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Lymphatic vessels Extracellular Fluids Volume (sodium space) 16-18 L Machnik, A. et al. Nat. Med. 15, 545–552 (2009).  Blood Pressure control tonicity enhanced binding protein (TonEBP) Blood Volume 5.6 L (~30% extracellular volume) VEGF

  27. & Carmine Zoccali

  28. …Short dialysis mmHg 180 160 140 120 100 80 60 40 mmHg 180 160 140 120 100 80 60 40 Luik AJ Blood Purif. 1998;16:197-209

  29. 5 yr Survival % 100 80 60 40 20 0 <35 35-44 45-54 55-64 >64 Age at start of dialysis (years) …Clinical policies adopted in Tassin make a difference…. Tassin EDTA USRDS

  30. HR 1.5 1.4 1.3 1.2 1.1 1.0 0.8 All cause mortality 0.5-1.0 1.0-1.5 1.5-2.0 2.0-2.5 2.5-3.0 3.0-3.5 3.5-4.0 >4.0 Kg. Adjusted for malnutrition/inflammation High body weight gain, Better appetite and nutrition status!

  31. Alderman MH, Cohen H, Madhavan S. Dietary sodium intake and mortality: the National Health and Nutrition Examination Survey (NHANES I). Lancet 1998; 351: 781-785. Death (x1000 person years) 30 25 20 15 10 5 0 Death (x1000 person years) 30 25 20 15 10 5 0 2008: 23(9):1297–302 1° 2° 3° 4° sodium 1° 2° 3° 4° calories CV death ……. these results do not support current recommendations for routine reduction of sodium consumption, nor do they justify advice to increase salt intake or to decrease its concentration in the diet…..

More Related