How can survival of the well dialysed patient be increased?. Neptune's Poisoned Chalice:
A tragedy of Modern Therapeutics
Dr. S. Shaldon. Monaco


Session Start: Mon Feb 28 22:02:15 2000

[22:03] (JBover) Good night Dr Shaldon
[22:03] (JBover) Welcome
[22:03] (MJesus) welcome dr. Shaldon!
[22:03] (shaldon) _Good Evening everybody
[22:03] (JBover) :-))))
[22:04] (JBover) We are all happy and honoured for having you here with us
[22:04] (JBover) tonight
[22:04] (JBover) We think that the issue you bring to discussion is of paramount importance
[22:05] (JBover) should we wait five more minutes or we should start right away???
[22:05] (JBover) welcome back Charlie from Italy
[22:05] (MJesus) charli.. re welcome
[22:06] (JBover) welcome Gerardo
[22:06] (Charlie) i'm back from another server
[22:06] (MJesus) Gerardo, our President
[22:06] (JBover) Gerardo is the president of this Congress
[22:07] (JBover) Gerardo----> Dr Shaldon
[22:07] (JBover) Dr Shaldon ----> Gerardo
[22:07] (JBover) quieres presentarlo tu Gerardo?
[22:08] (JBover) Ladies and gentlemen
[22:08] (JBover) I have the honour to present in this venue to a part of the HISTORY OF NEPHROLOGY
[22:08] (JBover) As you all know...Dr SHaldon is HISTORY
[22:09] (JBover) and all nephrologists are extremely honoured to have him with us
[22:09] (JBover) he has supported our efforts from the beginning and, moreover.....
[22:10] (JBover) he brings to us a topic that I think is of paramount importance
[22:10] (JBover) because it directly relates with SURVIVAL of aptients on HD
[22:10] (JBover) Dr Shaldon...thank you very much for your patience and support

[22:11] (Speaker) How can survival of the well dialysed patient be increased?. Neptune's Poisoned Chalice: A tragedy of Modern Therapeutics
[22:11] (Speaker) The Oxford University Dictionary definition of OPINION is as follows
[22:11] (Speaker) "A judgement or belief based upon grounds short of proof".
[22:12] (Speaker) The title of this opinion implies that an adequate dose of dialysis,
[22:12] (Speaker) whatever that may be according to the paradigm of the day has been prescribed.
[22:12] (Speaker) Therefore, I am not going to discuss any efforts to increase dose or frequency of dialysis,
[22:12] (Speaker) however topical they may be.
[22:12] (Speaker) I am devoting this opinion entirely to a method of curing hypertension
[22:12] (Speaker) in dialysis patients without the use of drugs.
[22:12] (Speaker) The first mention of the ability to control hypertension
[22:12] (Speaker) without the use of drugs was in 1961.
[22:12] (Speaker) The first four patients treated by longterm dialysis in Seattle were hypertensive.
[22:12] (Speaker) The hypertension was well controlled by a low sodium diet and ultrafiltration alone.
[22:12] (Speaker) Drug therapy had been stopped in three patients
[22:13] (Speaker) as it was producing too many side effects and was relatively ineffective.
[22:13] (Speaker) Two years later,
[22:13] (Speaker) we reported our initial success with a a low salt diet
[22:13] (Speaker) and adequate ultrafiltration
[22:13] (Speaker) in a 32 year old patient whose eye sight was restored when the severe drug resistant malignant hypertension
[22:13] (Speaker) was relieved by dialysis ultrafiltration and a reduced salt intake.
[22:13] (Speaker) We subsequently reported our results in a further 9 patients
[22:13] (Speaker) in whom we measured exchangeable sodium andtotal body water
[22:13] (Speaker) during the initial months involved in treating their hypertension.
[22:13] (Speaker) The most interesting finding was a lag response of several months
[22:13] (Speaker) between the lowest level of exchangeable sodium
[22:14] (Speaker) and the ultimate lowest maintenance blood pressure.
[22:14] (Speaker) This suggested that an adaptive phenomenon to the reduction in total body sodium
[22:14] (Speaker) was occurring at a later time interval,
[22:14] (Speaker) and was not the direct effect of volume control.
[22:14] (Speaker) In the following three decades,
[22:14] (Speaker) the use of a salt restricted diet has largely been abandoned.
[22:14] (Speaker) Only three groups have reported remarkable blood pressure control in over 95% of their patients
[22:14] (Speaker) for prolonged periods of time without the use of hypotensive drugs.
[22:14] (Speaker) The most quoted group has been Tassin
[22:14] (Speaker) and although they practice salt restriction (5.0g/day)
[22:14] (Speaker) and use a dialysate sodium of 138 mmol/l,
[22:15] (Speaker) there has been a tendency to attribute the excellent longterm survival to long hours of dialysis without stressing
[22:15] (Speaker) until recently
[22:15] (Speaker) the importance of salt restriction.
[22:15] (Speaker) Indeed, no mention of salt restriction occurs in any publication from Tassin between 1983 and 1998.
[22:15] (Speaker) As the lengthening of dialysis time would imply a considerable increase in cost for in centre dialysis
[22:15] (Speaker) and is therefore largely impractical for the majority of patients,
[22:15] (Speaker) we decided to evaluate the role of salt restriction (5-6g/day)
[22:15] (Speaker) and a dialysate sodium of 135 mmol/l without any increase in dialysis time (4-5hrs)
[22:15] (Speaker) in a group of selected hypertensive patients treated by hemodialysis for between 1-18 years.
[22:15] (Speaker) The results of this pilot study were limited.
[22:15] (Speaker) In 4/7 patients, all hypertensive therapy could be stopped and Mean Arterial Pressure was reduced
[22:15] (Speaker) to less than 100mmHg in these 4 patients.
[22:16] (Speaker) In the 3 patients who were clearly unable to comply with a 5-6g/day salt intake,
[22:16] (Speaker) drug therapy, although reduced was required,
[22:16] (Speaker) and intolerance of a sodium dialysate of 135mmol/l was observed.
[22:16] (Speaker) Nevertheless, the results suggested that in compliant patients,
[22:16] (Speaker) a mean arterial pressure less than 100mmHg
[22:16] (Speaker) could be obtained and maintained by a simple reduction in salt intake,
[22:16] (Speaker) without any drug therapy or reduction in dry body weight.
[22:16] (Speaker) However, interdialytic weight gain
[22:16] (Speaker) was reduced to less than 2.0kg
[22:16] (Speaker) and dialysis tolerance was improved
[22:16] (Speaker) with reduction in post dialysis fatigue.
[22:17] (Speaker) The mechanism underlying this phenomenon
[22:17] (Speaker) is only partially understood.
[22:17] (Speaker) It is associated with a reduction in peripheral vascular resistance,
[22:17] (Speaker) without a decrease in cardiac output.
[22:17] (Speaker) Current thinking suggests that the flavour of the month may be a reduction in plasma 1-ADMA (Asymmetric Dimethyl Arginine),
[22:17] (Speaker) a known inhibitor of nitric oxide synthetase.
[22:17] (Speaker) Alternatively, sodium overload could lead
[22:17] (Speaker) to a reversal of the inhibition of the Na+/K+-ATPase
[22:17] (Speaker) via an endogenous digitalis-like substance,
[22:17] (Speaker) the result of which would be an increase of the intracellular sodium and calcium concentration
[22:17] (Speaker) with an increased tone of vascular smooth muscle cells.
[22:18] (Speaker) Reducing the sodium load could reverse this mechanism.
[22:18] (Speaker) Finally, a link between sympathetic overactivity a
[22:18] (Speaker) s it is found in haemodialysis patients and the sodium overload
[22:18] (Speaker) could be an alternative hypothesis.
[22:18] (Speaker) Whatever the rational explanation for the empirical benefit of salt restriction
[22:18] (Speaker) in the hypertensive dialysis patient proves to be,
[22:18] (Speaker) the clinical benefit is undeniable
[22:18] (Speaker) and associated with the best survival data in the world.
[22:18] (Speaker) It can be achieved with virtually no added cost
[22:18] (Speaker) and does not impose a boring and unpalatable diet upon the patient.
[22:18] (Speaker) Indeed, it is worth remembering that in Tuscany,
[22:18] (Speaker) where regional Italian Cuisine arguably reaches its pinnacle,
[22:19] (Speaker) salt free bread is the regular bread sold in the bakeries.
[22:19] (Speaker) Perhaps the time has come to cast aside
[22:19] (Speaker) Neptune's poisoned chalice
[22:19] (Speaker) and give the well dialysed patient a longer
[22:19] (Speaker) and healthier life with fewer complications
[22:19] (Speaker) with no added expense.
[22:20] (Trent) thank you very much!
[22:20] (JBover) That was concise and clear Dr SHaldon
[22:20] (Trent) thank you bvery much!
[22:20] (JBover) May I ask the first question????
[22:20] (Ar) congratulations dr. Shaldon!
[22:20] (JBover) if internists pay attention to diet in diabetics........
[22:21] (gerardo) felicidades dr. shaldon
[22:21] (MJComa) I like to know do you think is feasible or necessary lenghten or increasing frequency of dialysis ?
[22:21] (JBover) is there a reason to ignore salt consummption in ESRD patients????
[22:21] (Cuqui) enhorabuena Dr.Shaldon
[22:21] (shaldon) I would like to answer the question of MJComa
[22:22] * JBover recommends the audience to stay calm and listen to Dr Shaldon answers
[22:22] (shaldon) The problem is that Tassin has confused the world. The emphasis on dialysis length has been overdone
[22:23] (shaldon) I now believe that it is possible with a salt restricted diet you can achieve normotension and a much better tolerance of dialysis than we currently have
[22:24] (Charlie) is sodium intake more important than dry weight ?
[22:24] (JBover) how dos sodium intake relates to dry weight????
[22:24] (shaldon) the dry weight is achieved early on
[22:25] (gerardo) how do you follow-up the low salt diet?
[22:25] (shaldon) after that weight gain between dialysis is reduced with the salt restricted compliant patient and dry weight is easily reached. I am talking of 1.5Kg weight gain between dialysis
[22:26] (shaldon) If the anuric patient gains more than 1.5Kg he is not on a 5g salt intake per day
[22:27] (JBover) every time I ask a patient about his/her diet he/she swears that he/she is eating without salt
[22:27] (JBover) in addition to avoid salt ont he table and the usual salty foods....are there any foods we should know specially about???
[22:28] (JBover) is it a 5g salt diet easy to achieve?
[22:28] (shaldon) the diet is easy to achieve with home cooking. Just avoid salty food and no salt added to the cooking. this means today no junk or fast food or processed food. After 1 month reduce the sodium in the dilaysate to 135mmol/l and the patgient will improve his taste for salt again which ahd been lost with the sodium in the dialysate of 140mmol/l
[22:29] (shaldon) In the patient who has most of his food at home prepared by his spouse yes
[22:29] (JBover) I like the recipy!!!!!!!!!!! clear and concise!!!!!!!
[22:29] * Trent ask dr. shaldon: if you are about to the reduce Na in the dialysate in your unit....how would you do that ...step-wise????
[22:30] (shaldon) Also if the patient is eating in the dialysis unit it should be similar food to the home
[22:30] (JBover) so...you change the dialysate sodium to 135 after one month????
[22:30] (shaldon) Yes step wise is essential and slowly 1 mmol/month
[22:30] (Ar) Dr. Shaldon, which is the Na level you recommend in the dialysis bath???
[22:31] (JBover) final Na of 135?????
[22:31] (JBover) 140, 139, 138.........down to 135?????
[22:31] (MJesus) dr. shaldon do not have response ping!
[22:32] (shaldon) no we have gone down from a mean of 140 to 139 then to 138 ans on for upto 6 months. Non compliant patients will get cramp and suffer on this regime so one must go slowly. The best index is the reduction in interdialytic weight gain
[22:33] (gerardo) what do you think about hypertonic dialysis in vogue some time ago???
[22:33] (shaldon) This is a short term solution that stimulates thirst and leads you to a vicious circle ping
[22:34] (JBover) why do you think that it has been so stressed the long dialysis hours or increasing frequency to achieve control of hypetension???
[22:34] (JBover) kalinichta nefro
[22:34] (MJesus) hello nefro, from Grece or Gibraltar ?
[22:35] (nefro) kalispera, not kalinichta
[22:35] (nefro) Nefro from Athens, Greece
[22:36] (JBover) Dr Shaldon.....we have all seen hypertensive crisis IN dialysis.....how do you explain those????
[22:36] (shaldon) The history of the long hours is very simple. In the beginning we started with salt restriction and long hours. Laurent changed nothing and salt was lsot and stress on long hours became fashionable. As the results are empirical both variablles needed controlling
[22:37] (Trent) Dr. shaldon, please, ..... how many patients are free of drugs with this regime???
[22:38] (Charlie) why should we up or down regulate the level of sodium? isn't the normal plasma level good enough?
[22:39] (MJesus) welcome Ramon... we are with Dr. Shaldon, from Monaco
[22:39] (shaldon) Where salt restriction is not employed long hours alone such as Pierattos in Monteal or daily dialysis the results are not as good as in tassin. In tassin average weight gain is 1.5Kg. We have got the same results in Nimes and Hannover with only salt restriction and not long hours. Dorhout Mees did the same thing in Ismir with only 5hrs of dialysis and salt restriction
[22:41] (shaldon) Answer to trent: In our series of 8 patients 5 became drug free and these were complinat patients. Failure and non compliance go hand in hand
[22:42] (Trent) thank you very much Dr. Shaldon!
[22:43] (Trent) isnt it necessary a large trial with this regime ?
[22:44] (shaldon) answer to charlie. We don't know why this works. It is empirical. I don't believe the ECF story of Guyton. These patients get vasodilatation and we are altering NO metabolism via change in intracellualr sodium content. Klempere started this in the 1940's and we are only reproducing his results today
[22:45] (perico) do you think that, in general, all dialysis population must be under strict salt restriction?
[22:45] (Charlie) thanks, dr Shaldon
[22:45] (_gene_) Can patients feel at ease whit that regime? Can they bear this regime?
[22:46] (shaldon) Of cours as large trial is necessary. The series in tassin is only 600 patients and Witrhington in manchester is about 100 and Ismir is about 50. The problem is that salt restriction in a dialysis population is not easy to achieve today. Only doctors can get their patients to be comlinat. The dieticiqan and nurse have never succeeded. So you need Dr time spent with the patient every dialysis in the formative stage. this is what tassin do evry well
[22:47] (JBover) good point Dr SHaldon
[22:47] (gerardo) ademas de la hipertension el mejor control de la anemia y del hiperparano es una buena razon para las dialisis largas
[22:47] (gerardo) traducirme por favar..
[22:48] (JBover) Gerardo Torres asks: beyond hypertension..isnt hyperaprathyroidism and anaemia better controlled in long dialysis schedules??
[22:49] (shaldon) Answer to gene. the regime is not restrictive. Fluid is not rationed. thirst is controlled. food is more tasty without salt. Salt is the primitive northern way of hiding bas food. today supermarkets and fast food stores hide bad food with salt. good food has spices which are tasty. dialysis patients on high sodium dialysate lose their ability to appreciate tasty food
[22:51] (shaldon) Torres. Undoubtedly it is easier to control anemia partially with longer hours of dialysis. however, where time is money epo may be cheaper and Tassin has very low Hct by today's standard EPO patient
[22:51] (gerardo) thaks dr shaldon
[22:52] (MJesus) are yoy tired Dr. Shaldon?
[22:52] (shaldon) No just my fingers
[22:52] (MJesus) Do we ask too much ?
[22:52] (shaldon) no please go on if anyone wants to
[22:52] (_gene_) Thank you very much Dr Shaldon. Is a pleasure to hear you
[22:53] (JBover) Some patients have hypertensive crisis INSIDE dialyis...is ther an explanation for that???
[22:53] (MJesus) ok..... a moment,.... please, who peoples like to read twice the conference?
[22:54] * _gene_ like it
[22:54] (shaldon) I believe that this is a disequilibrium phenomenon and has an osmotic basis. Probably a too fast reduction in urea or more likely the wrong dialysate sodium
[22:54] (Trent) I like also!
[22:55] * JBover thinks that the issue we are discussing today is of paramount importance
[22:55] (Ar) Please,
[22:55] (JBover) Thus....we think it is a great idea to reproduce the conference again
[22:55] (JBover) Would you mind Dr Shaldon?????
[22:55] (shaldon) no pleae go ahead
[22:55] * JBover waits for Dr Shaldon's answer
[22:56] (shaldon) shaldon say's ok
[22:56] (SCigarran) Me encantaría ver la charla
[22:56] (Speaker) How can survival of the well dialysed patient be increased?
[22:56] (Speaker) Neptune's Poisoned Chalice: A tragedy of Modern Therapeutics
[22:56] (Speaker) The Oxford University Dictionary definition of OPINION is as follows
[22:57] (Speaker) "A judgement or belief based upon grounds short of proof".
[22:57] (Speaker) .......................................................... ................................................
[23:07] (Speaker) Perhaps the time has come to cast aside
[23:07] (Speaker) Neptune's poisoned chalice
[23:07] (Speaker) and give the well dialysed patient a longer
[23:07] (Speaker) and healthier life with fewer complications
[23:07] (Speaker) with no added expense.
[23:07] *** shaldon has quit IRC (Ping timeout for shaldon
[23:08] (MJesus) anda, se cayo....
[23:08] *** shaldon (jirc@ppp-usr2.webstore.mc) has joined #cin2000
[23:08] (JBover) plas plas plas plas plas
[23:08] * JBover warns that auddience is applauding the end of the conference not the disconection
[23:09] (JBover) are there any further questions?????
[23:09] (SCigarran) plas, clap,plas
[23:09] (shaldon) Any questions
[23:10] (JBover) are there any further questions????
[23:10] (gerardo) es fácil para sus pacientes hacer la dieta?
[23:11] (JBover) Gerardo asks ......
[23:11] * MJesus
[23:11] (JBover) if it is easy or difficult for your aptients to follow the diet
[23:11] (gerardo) o hay que estar insistiendo en exceso...
[23:11] (JBover) do you have to be following-up very closely to your patients????
[23:11] (shaldon) No it is not easy to get the patients to stick to a salt restricted diet today. It takes Dr time
[23:12] (JBover) Do you use dietary logs??????
[23:13] (shaldon) The first 6 months are tough. My advise is to start with a willing intelligent patient and use him or her as role model within the unit
[23:14] (JBover) that's a very intelligent point as well.....never thought of that
[23:14] (JBover) are ther any further questions???
[23:14] (gerardo) thanks dr. Shaldon
[23:15] (shaldon) No dietary log is necessary. Just accurate inter dialytic weight gain. It must go down if teh patient is compliant. Look at ASN paper from Seattle in last November's meeting. They showed a significant reduction weight gain when patients were placed on salt restriction. No fluid restriction was imposed
[23:15] (JBover) thank you very much Dr Shaldon
[23:15] (JBover) wwe have had you online for an hour now
[23:15] (shaldon) It has been a pleasure
[23:15] (JBover) an hour and ten minutes
[23:15] (shaldon) hasta la vista
[23:16] (JBover) but you have not only been very kind with us but also.....
[23:16] (JBover) you have given us a very clear cut way to GO
[23:16] (MJesus) all you speak spanish ?
[23:16] (JBover) hola
[23:16] (lydia) I think is already gone...Dr Shaldon
[23:16] (JBover) alguien habla extranjero???
[23:16] (lydia) Yes, I do
[23:17] (JBover) no no no...I mean if alguien habla SOLO extranjero????
[23:17] (perico) bueo, queridos hasido un placer, pero !!!!hasta mañana!!!
[23:17] (JBover) hasta mañana a todos!!!!!!
[23:19] (SCigarran) I would like ask to dr Shaldon Do you use a diet questionnarie to asses the Na charge on diet?
[23:19] (JBover) respuesta al Dr Cigarran
[23:20] (JBover) No es necesario segun el......un enfermo debe ganar menos de 1.5-2 kg si sigue la dieta.
[23:20] (JBover) No le piden que beba poca agua..simplemente no tienen sed
[23:21] (SCigarran) Ya, pero en nuestro medio y con nuestra dieta por el tipo de alimentos la carga de Sodio es alta, no crees?
[23:21] (JBover) claro
[23:21] (JBover) el lo ve muy facil
[23:21] (JBover) yo tengo mis dudas
[23:22] (SCigarran) En la encuesta dietetica que he realizado a mis pacientes la ingesta de sal no baja de 3 gr/día
[23:23] (JBover) 3 gr???? o 30????
[23:23] (JBover) Dr Shaldon recomienda 5 g/dia
[23:24] (SCigarran) Estamos hablando de los HTA no?.
[23:24] (JBover) HTA en dialisis
[23:25] (JBover) dice que 5g/dia y no ganan mas de 1.5 Kg/2 kg de peso interdialisis
[23:25] (SCigarran) HTA en Hd . Dr Shaldon recomienda en estos pacientes 5gr/día?
[23:25] (Charlie) Zbylut Twardowsky( USA) Quotidian Hemodialysis: Hemeral and Nocturnal
[23:25] (JBover) yap
[23:25] (Charlie) where is he ?
[23:26] (JBover) Charlie..DR Twardowsky has not finally appeared...he is in SAn Francisco
[23:27] (JBover) I am sorry, I should have warned about it
[23:27] (JBover) to the auddience
[23:28] (Charlie) ok, good night everybody, see you tomorrow night!
[23:28] (JBover) see ya Charlie
[23:28] (JBover) thanks for your support!
[23:31] (SCigarran) Bueno, siento haber llegado hoy tarde. Mañana estaré antes Un abrazo a todos y hasta mañana!

Session Closed: Mon Feb 28 23:31:06 2000