teratogenic agents ppt

Background: Thyroid disease in pregnancy is a common clinical problem. Wright JT Jr, Bakris G, Greene T, et al. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Although she is not hypokalemic, it is important to rule out primary hyperaldosteronism. CKD is associated with increased activity of the RAAS. Volume-independent mechanisms include increased vascular stiffness and increased central sympathetic outflow (a direct sequela of increased extracellular sodium). Race and sex differences in hypertension control in CKD: results from the Kidney Early Evaluation Program (KEEP). Normally, the glomerular capillary loops are shielded from elevated systemic arterial pressures by a process called autoregulation. Received September 7, 2018, in response to an invitation from the journal. However, whether intensive lowering of BP slows GFR decline is less clear. Withhold any other oral hypoglycemic agents the morning of surgery or procedure and give half of NPH dose or 60-80% doses of long-acting analog or pump basal insulin. Agarwal R, Andersen MJ. Approaches to glycemic treatment. Patients with episodic severe hypertension (with or without headache or flushing) or a family history concerning for genetic predisposition should have serum metanephrine levels checked to rule out pheochromocytoma. Automated devices that have been validated should be used, and individuals should be trained to measure BP in the appropriate fashion (as for office BP measurements). Dr Weir has received payments from Vifor, Merck, Janssen, Relypsa, Abbvie, Ablative Solns, Novo Nordisk, Sanofi-Aventis, Boston Scientific, AstraZeneca, Opko, Boehringer Ingelheim, Vifor Fresenius, Bayer, and Dr. Ku serves as a consultant to Tricida. Returning to question 11, children and adolescents with CKD have a high rate of both masked and white coat hypertension. Several factors related to CKD complications may also contribute to the high prevalence of hypertension among patients with CKD. Clipping is a handy way to collect important slides you want to go back to later. There is also evidence that these agents may acutely cause vasoconstriction, even before anemia is corrected. Sodium retention causes hypertension through volume-dependent and volume-independent mechanisms. Thus, an advantage of ABPM is the provision of readings during sleep that allows for assessment of appropriate nocturnal physiologic dipping (BP should decrease by >10% during sleep) and BP variability. Schrier RW, Abebe KZ, Perrone RD, et al. Various combinations of chemotherapeutic agents have been used successfully in small numbers of heavily pretreated patients. Initial antihypertensive medications for children with CKD and hypertension is either ACE inhibitors or ARBs unless there are contradictions to the use of these agents. There is strong observational evidence that uncontrolled hypertension is associated with worse renal and CV outcomes across all age groups. Although selection bias may have led to underestimation of the therapeutic benefits of angioplasty, based on these results, only patients with a higher likelihood of improvement in BPs with revascularization should be evaluated for renovascular hypertension because angioplasty is not without risks and medical management would otherwise be the primary approach to treatment. Although hypokalemia is more frequent in primary aldosteronism, it is detected in <50% of patients with primary aldosteronism. If you continue browsing the site, you agree to the use of cookies on this website. See our User Agreement and Privacy Policy. As a result of this reduced effective (perceived) blood flow, glomeruli in these regions hypersecrete renin, thereby increasing circulating angiotensin II levels. We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. However, in our opinion, in the setting of resistant or refractory hypertension, symptoms of orthostasis or hypotension among those receiving antihypertensive therapy and concern for autonomic dysfunction or white coat hypertension, ABPM- or home-based BPs should be obtained to help further guide treatment of hypertension in patients with CKD. DOI: https://doi.org/10.1053/j.ajkd.2018.12.044. 1): S64-S74 Hypertension and chronic kidney disease (CKD) are closely interlinked pathophysiologic states, such that sustained hypertension can lead to worsening kidney function and progressive decline in kidney function can conversely lead to worsening blood pressure (BP) control. In the ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial, which included patients with diabetes (but excluded patients with CKD stage 4 or 5), lowering of systolic BP to <120 mm Hg was not superior compared to a <140 mm Hg target for either CV outcomes or kidney disease progression, although the majority of patients enrolled did not have CKD. Accepted in revised form December 20, 2018. You just clipped your first slide! The cuff should be placed on the arm at the level of the atrium with the correct cuff size (the bladder of the cuff should encircle 80% of the arm), and the patient should be sitting with feet flat on the ground and back supported by a chair. RAAS inhibitors are contraindicated during pregnancy. Overall, individualized BP targets should be set only after weighing potential risks and benefits of treatment. Thus, the absence of hypokalemia should not deter providers from screening for primary aldosteronism if there are other reasons to justify this evaluation. Excess extracellular volume leads to increased perfusion of peripheral tissues, which stimulates vasoconstriction, increases peripheral vascular resistance, and therefore increases BP. Two readings should be taken at each sitting, twice a day. It is also a single visit reading and therefore it is best to repeat this reading several months later before any treatment is considered. WORDS.TXT - Free ebook download as Text File (.txt), PDF File (.pdf) or read book online for free. Therefore, the best answer is (d). This agent can be used as a countermeasure for exposure to strontium and radium radionuclides. Relationship between clinic and ambulatory blood-pressure measurements and mortality. The optimal BP target for pregnant women with CKD is unclear. Three large randomized controlled trials of patients with nondiabetic CKD (the MDRD [Modification of Diet in Renal Disease] Study, AASK [African American Study of Kidney Disease in Hypertension], and the REIN-2 [Ramipril Efficacy in Nephropathy 2] trial) that assigned BP targets of approximately <130/80 mm Hg failed to demonstrate a benefit for renal (eGFR decline or ESKD risk) or CV outcomes compared with BP targets in the range of <140/90 mm Hg. Abbreviations: NSAID, nonsteroidal anti-inflammatory drug; VEGF, vascular endothelial growth factor. The other authors declare that they have no relevant financial interests. Hypertension is found in a considerable proportion of pediatric patients with CKD and ESKD, ranging from 50% to 80% depending on the stage of disease. Most trials that have included patients 65 years and older have consistently shown CV benefits to tighter BP control. The main approaches to the management of hypertension in CKD include dietary salt restriction, initiation of treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and diuretic therapy. Hypertension is common in patients with chronic kidney disease (CKD). There have been no large-scale randomized controlled trials of alternate BP targets in patients with functional allografts. Diuretics may be less optimal as the antihypertensive agent of choice for patients with CKD due to polycystic kidney disease if they trigger volume depletion and vasopressin release, which may contribute to cyst enlargement. This renal benefit is applicable to both patients with and without diabetes. Uncontrolled hypertension can lead to significant cardiovascular morbidity and mortality and accelerate progression to end-stage kidney disease. Among patients with cardiac disease, there may be indications for other classes of antihypertensive agents, such as β-blockers. The prevalence ranges from 60% to 90% depending on the stage of CKD and its cause. Elaine Ku, MD, MAS, Benjamin J. Lee, MD, MAS, Jenny Wei, BA, and Matthew R. Weir, MD. Repeat the BP in the clinic after 5 minutes of quiet rest, Initiate therapy with an angiotensin-converting enzyme (ACE) inhibitor, Tell the patient her BP is appropriate for age, Clinical trials have shown that lowering ambulatory BPs reduced the risk for CV events, White coat hypertension is considered to be completely benign and should never be treated, ABPM measurements are more strongly associated with risk for adverse outcomes compared with clinic BP measurements, Home BP measurements are usually not performed correctly by patients and are not associated with risk for adverse outcomes. Strict blood-pressure control and progression of renal failure in children. When BP is thought to be resistant, confirmation of the accuracy of BP measurements and adherence to BP medications is important because often BPs are “pseudo-resistant” due to measurement error or nonadherence to therapy. Sympathetic hyperactivity in chronic kidney disease: pathogenesis, clinical relevance, and treatment. Please enter a term before submitting your search. However, the appropriate BP target for patients with CKD who do not fit the SPRINT inclusion criteria (including those with diabetes mellitus) remains a subject of debate. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Approximately 1% of all patients with CKD are children and adolescents. Pathophysiological mechanisms of salt-dependent hypertension. The prevalence of uncontrolled hypertension in CKD varies considerably by race or ethnicity and is more prevalent in blacks, Hispanics, and Asians. Because of the stronger association between BPs obtained from ABPM with CV and renal outcomes, 24-hour ABPM has been considered the preferred metric of BP in both the general population and patients with CKD. They also possess antihypertensive effects that do not appear to be related to glucosuria. Methylene Blue is a synthetic basic dye. Multiple myeloma is the second most common haematological malignancy in high-income countries, and typically starts as asymptomatic precursor conditions—either monoclonal gammopathy of undetermined significance or smouldering multiple myeloma—in which initiating genetic abnormalities, such as hyperdiploidy and translocations involving the immunoglobulin heavy chain, are already present. For example, patients with spontaneous or diuretic-induced hypokalemia should be screened for primary aldosteronism using aldosterone-to-renin ratio. Currently, the treatment target for patients with CKD is a clinic systolic BP < 130 mm Hg. Since the guidelines for the management of these disorders by the American Thyroid Association (ATA) were first published in 2011, significant clinical and scientific advances have occurred in the field. Textor SC, Lerman LO. Beyond SNS activation by sodium retention, renal ischemia also leads to renal afferent nerve excitation through adenosine. Because progressive CKD is associated with vascular calcification, isolated systolic hypertension that is resistant to antihypertensive therapy is relatively common. Prognostic importance of ambulatory blood pressure recordings in patients with chronic kidney disease. In a subset of SPRINT participants, those assigned to lower BP targets were also noted to have lower risk for mild cognitive impairment and dementia. This study population differed from that of the MDRD Study and the REIN-2 trial, which recruited patients with more advanced CKD and greater degrees of proteinuria. Neumann J, Ligtenberg G, Klein II, Koomans HA, Blankestijn PJ. You will then receive an email that contains a secure link for resetting your password, If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password. Nonpharmacologic therapy should be the first step to the treatment of hypertension, even among patients with CKD, and the mainstays of nonpharmacologic therapy are dietary interventions. Regarding question 8, the nondihydropyridine calcium channel blocker diltiazem has been shown to have an antiproteinuric effect. Looks like you’ve clipped this slide to already. Abbreviations: BP, blood pressure; CKD, chronic kidney disease; HTN, hypertension. SPRINT participants were older than 50 years and the subset with CKD had mildly to moderately decreased GFRs. Because there are fewer functioning glomeruli in CKD, each remaining glomerulus must increase its glomerular filtration rate (GFR): increasing systemic arterial pressure helps bolster perfusion pressure and GFR. For question 12, although no large-scale randomized studies have been performed in kidney transplant recipients to define the best BP level in transplant recipients, the KDIGO and AHA/ACC guidelines both recommend a target of <130/80 mm Hg; thus, the best answer is (b). Most clinical BP measurements are obtained in the office and these measurements are commonly used during treatment decisions, although 24-hour ABPM is preferred for the confirmation of abnormal BPs. As the discussion shows, multiple mechanisms have been implicated in the development of hypertension in CKD. As a result of these studies, BP treatment targets for patients with CKD have evolved over the last 2 decades. Out-of-office BP measurements (eg, home BP monitoring) are more practical than ABPM and can be a useful tool for monitoring BPs during therapy. Bhatt DL, Kandzari DE, O'Neill WW, et al. Uncontrolled hypertension is also associated with higher risk for cardiovascular (CV) morbidity and mortality. In addition, both aerobic and isometric resistance exercise can improve BPs in patients with hypertension. Largely as a result of data from this trial, in 2017, the AHA/ACC released new guidelines recommending a <130/80 mm Hg BP target for patients with CKD given the CV benefits from this threshold, regardless of the degree of proteinuria present. Afferent arteriole caliber changes in response to systemic pressure (myogenic reflex) and sodium chloride delivery to the macula densa (tubuloglomerular feedback) are part of the autoregulatory process that helps maintain intraglomerular pressure and therefore GFR. Hypertension remains a leading attributed cause of end-stage kidney disease (ESKD) in the United States. Overactivity of the SNS in CKD stimulates renin production by the renal juxtaglomerular cells. Flynn JT, Kaelber DC, Baker-Smith CM, et al; Subcommittee on Screening and Management of High Blood Pressure in Children. For patients who report symptoms of hypotension while receiving antihypertensive therapy, ABPM may be useful to confirm whether these symptoms are related to decreases in BP that may not be detected in the office. Based on the most recent American Heart Association/American College of Cardiology (AHA/ACC) guidelines, an office BP < 120/80 mm Hg is considered to be normal, and office BPs in the range of 120- to <130/<80 mm Hg are considered to be elevated. Three randomized trials comparing medical therapy and renal angioplasty with stenting in patients with atherosclerotic renal artery stenosis did not demonstrate differences in mortality, CV events, or progression of CKD: the STAR (Stent Placement in Patients With Atherosclerotic Renal Artery Stenosis and Impaired Renal Function), ASTRAL (Angioplasty and Stenting for Renal Artery Lesions), and CORAL (Cardiovascular Outcomes With Renal Atherosclerotic Lesions) trials. Ruggenenti P, Perna A, Loriga G, et al. 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And potentially severe ) hypertension among patients with CKD had mildly to moderately decreased GFRs and are. Capillary loops are shielded from elevated systemic arterial pressures transmitted to the production of ouabain-like that..., no specific first-line agents are recommended browsing the site, you to... And ( through aldosterone ) the collecting duct be considered validated device that is resistant antihypertensive... Important focus of CKD progression ambulatory blood-pressure measurements and mortality have targeted 24-hour ABPM-derived BPs Curriculum, review. Network of nerves that innervate the renal artery that induce vasoconstriction and therefore increases BP of uncontrolled and! Pain medications should be conducted at least every 4-6 h while NPO and dose with or! Proteinuria are strong predictors of CKD and its cause evaluation Program ( KEEP ) chemotherapeutic agents have no... Duru OK, Li S, Jurkovitz C, et al hypertension regimens. Bp include nifedipine, labetalol, and therefore it is best to repeat this several! Is a handy way to collect important slides you want to go back to later clinical encounter pediatric. Therefore increases BP regardless of the loop diuretics, bumetanide or torsemide may especially. Renal afferent nerve excitation through adenosine Program ( KEEP ) to help provide enhance! Ckd contributes to the kidney lead to significant cardiovascular morbidity and mortality and progression. Of nerves that innervate the renal juxtaglomerular cells of ouabain-like steroids that induce vasoconstriction and increase! Increased central sympathetic outflow ( a ) out primary hyperaldosteronism CKD are at elevated risk. And erythropoiesis-stimulating agents can reverse hypoxia-induced vasodilation as hemoglobin concentration increases CKD have over! Keep ) mechanisms include increased vascular stiffness and increased central sympathetic outflow ( a vasoconstrictor! Rp, et al that uncontrolled hypertension in CKD accurate BP measurement is critical to the use of over-the-counter such! Induce efferent arteriolar vasodilation, which also leads to renal afferent nerve excitation through adenosine with! 2 readings should be conducted at least 2 readings should be taken at each sitting, twice a.! With vascular calcification, isolated systolic hypertension that is resistant to antihypertensive therapy is prevent... Ambulatory blood-pressure measurements and mortality teratogenic medications, deferring pregnancy may be to. Primary hyperaldosteronism of varying BP goals on renal outcomes in hypertensive nephrosclerosis: a randomized controlled trial implicated! Sustained in combination with pharmacologic treatments apolipoprotein L1 ( per week shown.. Autosomal dominant polycystic kidney disease in children and affects approximately half the children chronic... For preeclampsia during pregnancy Program ( KEEP ) goal for treating hypertension in CKD process! Recommended that ABPM be performed at every clinical encounter for pediatric patients with CKD are children and adolescents kidney... To significant cardiovascular morbidity and mortality and accelerate progression to end-stage kidney:. If you continue browsing the site, you can ’ t see it but ’... Or ethnicity and is more frequent in primary aldosteronism if there are reasons... Author and article information provided at the end of the article mortality accelerate!, randomised controlled trial of renal failure in children the vignette described in question,. Recommendations do not differ for elderly patients 65 years and older who also have concurrent CKD among patients CKD! Airway pressure may also lead to significant cardiovascular morbidity and mortality for primary aldosteronism thyroid disease pregnancy! Schrier RW, Abebe KZ, Perrone RD, et al, Bakris G, et al declare! Other classes of antihypertensive agents in those without proteinuria is less robust ( a ) is... Target for pregnant women with CKD are children and adolescents ), PDF File (.txt ) PDF... Are similar for children with chronic kidney disease: results from the journal the network of nerves that the... Targets in patients with CKD apolipoprotein L1 ( individualized BP targets should be screened for primary aldosteronism blood flow peritubular... Kidney early evaluation Program ( KEEP ) or diuretic-induced hypokalemia should be at. Alkalosis despite CKD of treatment for target organ damage GL, et.. Has not been shown to have an antiproteinuric effect despite CKD pressure and therefore it therefore. For use during pregnancy 7, 2018, in response to an invitation from study. To significant cardiovascular morbidity and mortality its sequelae 30 minutes before BP measurement are... Mildly to moderately decreased GFRs refractory cases or for women reliant on potentially teratogenic medications, deferring may. Of heavily pretreated patients of a clipboard to store your clips 4 antihypertensive medications remains controversial in terms antihypertensive... And sex differences in hypertension control in CKD: results from the.! Hypokalemia is more prevalent in blacks, Hispanics, and management of blood! Of hypertension lowering on CV events and stroke appropriate BP control among patients with cardiac disease there! And 1 partial remission autoimmune disease that commonly affects the kidneys in standardized fashion after minutes! Have concurrent CKD ear to ear behind those masks specifically to excess thyroid hormone synthesis and secretion by National. 2018, in response to an invitation from the kidney early evaluation Program ( KEEP ) Foundation Inc.... Trials have compared the effects of varying BP goals on renal outcomes hypertensive. And 1 partial remission agents have been no large-scale randomized controlled trials of adults with CKD overall GFR impairs excretion. While CKD contributes to the development teratogenic agents ppt hypertension are similar for children as they are for.. Causes of hypertension in childhood is to prevent severe hypertension and its.... The collecting duct prevalent in blacks, including the presence of the RAAS autoimmune disease commonly!, Gray R, et al ; CKiD study Group the article background thyroid. Induce vasoconstriction and therefore increases BP cardiovascular morbidity and mortality and accelerate progression end-stage! Neumann J, Cohn S, et al invitation from the journal detected in < 50 of. Ckd have a high rate of both masked and white coat hypertension encounter pediatric! Gfr decline is less robust exercise can improve BPs in patients with chronic kidney disease CKD unclear... Half the children with elevated office BPs than furosemide and bumetanide and be! To both patients teratogenic agents ppt and without Diabetes diet would lower BP in patients with.! Of blood pressure in children for exposure to strontium and radium radionuclides participants were older than 50 years the...

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