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  1. khaled
  2. General Nephrology Questions
  3. Monday, 30 April 2012
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Dear Experts, I have a  patient 71 years old ,CKD on regular hemodialysis 2 years ago , ischemic heart disease ,hypertensive , diabetic , with a history of previous CABG 2 years ago . The patient is schedulled for dialysis 2 times per week , 4hours each. The patient suffers from uncontrolled hypertension . he takes metoprolol 100 mg in 2 divided doses , amilodipine 5 mg ( he complains of lower limb edema when he increased the dose ), alpha methyl dopa 250 mg 2 times / day .Actually his BP pre dialysis reaches 180 / 100 despite not being overloaded . The patient respond rapidly to sublingual nitrates as it reaches 130 / 70 , but again it rises through the session despite controlling sodium level on the machine . I added ARBS in the form of Micardis 40 mg once / day , but still the patient BP is uncontrolled.
Responses (8)
Accepted Answer Pending Moderation
Hello,

Despite not appearing volume overloaded, I do wonder whether volume is playing a role, particularly as he is only dialyzed twice per week. If he has residual renal function (which I suppose he does given how little dialysis he needs), then I would use loop diuretics and possibly metolazone to control volume and BP better.

Jordan
  1. more than a month ago
  2. General Nephrology Questions
  3. # 1
Accepted Answer Pending Moderation
Dear Dr.Jordan

Actually the patient needs three times per week dialysis as his labs confirms , however , the patient denies his condition and insists to have dialysis only 2 times ( may be for financial purposes )
I forgot to tell you that the patient is on loop diuretic in the form of lasix 80 mg once / day .
can i try to increase alpha methyl dopa to 3 times ?
can i try alpha blockers in the form of minipress for example?
  1. more than a month ago
  2. General Nephrology Questions
  3. # 2
Accepted Answer Pending Moderation
Hello,

I'm not an avid user of aldomet unless desperate. How about any RAS medications like ACE or ARB?

Jordan
  1. more than a month ago
  2. General Nephrology Questions
  3. # 3
Accepted Answer Pending Moderation
Dear Dr.Jordan
I already used ARBs in the form of telmisartan 80 mg once / day as I mentioned .
so you do not prefer aldomet or alpha blockers for this case?
  1. more than a month ago
  2. General Nephrology Questions
  3. # 4
Accepted Answer Pending Moderation
My apologies :( I didn't see that.

If he 'generates' edema when using amlodipine, the patient has residual renal function. I might maximize my use of diuretics first, combining loop diuretics with metolazone. Failing volume control with drugs, sodium restriction and ultrafiltration, you could certainly use drugs like aldomet or alpha blockers but would be cautious with the latter due to postural hypotension.
  1. more than a month ago
  2. General Nephrology Questions
  3. # 5
Accepted Answer Pending Moderation
Dear Dr.Jordan
Thank you for your help
I will dublicate the lasix dose up to 80 mg and add metolazone for him and I will inform you with the case
thank you very much:)
  1. more than a month ago
  2. General Nephrology Questions
  3. # 6
Accepted Answer Pending Moderation
Please do post the follow-up of this case. I'm sure a very common scenario we can all learn from.
  1. more than a month ago
  2. General Nephrology Questions
  3. # 7
Accepted Answer Pending Moderation
Dear Dr.Jordan
Dear Dr.Winters

Actually i increased the loop diuretic to 80 mg as i mentioned . increased aldomet 250 mg to 3 t /day instead of 2 . i stopped the ACEI . i can say the patient BP improved a little as his BP becomes 160 / 90 predialysis , and it goes to 130 / 80 at the end . still i should monitor the patient more .
  1. more than a month ago
  2. General Nephrology Questions
  3. # 8
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