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Publications (44)

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    [Show abstract] [Hide abstract] ABSTRACT: Background Nutritional treatment has always represented a major feature of CKD management. Over the decades, the use of nutritional treatment in CKD patients has been marked by several goals. The first of these include the attainment of metabolic and fluid control together with the prevention and correction of signs, symptoms and complications of advanced CKD. The aim of this first stage is the prevention of malnutrition and a delay in the commencement of dialysis. Subsequently, nutritional manipulations have also been applied in association with other therapeutic interventions in an attempt to control several cardiovascular risk factors associated with CKD and to improve the patient's overall outcome. Over time and in reference to multiple aims, the modalities of nutritional treatment have been focused not only on protein intake but also on other nutrients. Discussion This paper describes the pathophysiological basis and rationale of nutritional treatment in CKD and also provides a report on extensive experience in the field of renal diets in Italy, with special attention given to approaches in clinical practice and management. Summary Italian nephrologists have a longstanding tradition in implementing low protein diets in the treatment of CKD patients, with the principle objective of alleviating uremic symptoms, improving nutritional status and also a possibility of slowing down the progression of CKD or delaying the start of dialysis. A renewed interest in this field is based on the aim of implementing a wider nutritional therapy other than only reducing the protein intake, paying careful attention to factors such as energy intake, the quality of proteins and phosphate and sodium intakes, making today’s low-protein diet program much more ambitious than previous. The motivation was the reduction in progression of renal insufficiency through reduction of proteinuria, a better control of blood pressure values and also through correction of metabolic acidosis. One major goal of the flexible and innovative Italian approach to the low-protein diet in CKD patients is the improvement of patient adherence, a crucial factor in the successful implementation of a low-protein diet program.
    Full-text Article · Dec 2016 · BMC Nephrology
  • [Show abstract] [Hide abstract] ABSTRACT: Introduction: in hemodialysis (HD) patients, poor health-related quality of life (HR-QoL) is prevalent and associated with adverse outcomes. HR-QoL is strictly linked to nutritional status of HD patients. Hemodiafiltration with endogenous reinfusion (HFR) is an alternative dialysis technique that combines diffusion, convection and absorption. It reduces burden of inflammation and malnutrition and this effect may cause beneficial effect on HR-QoL. However no data on HR-QoL in HFR is currently available. Methods: we designed a cross-sectional multicentre study in order to compare the HR-QoL in patients treated with HFR versus Bicarbonate HD (BHD). We enrolled adult patients HFR treated for at least 6 months, with life expectancy greater than six months and without overt cognitive deficit. The recruited patients in HFR were matched for age, gender, dialytic vintage and performance in activities of daily living (Barthel index) with BHD treated patients. SF-36 questionnaire for the assessment of HR-QoL was administered. Results: one hundred fourteen patients (57 HFR vs 57 BHD) were enrolled (age 65.413.5 years; dialysis vintage 5.4 (3.3-10.3) years; 53% males) from 18 dialysis non-profit centres in central and southern Italy. As result of matching, no difference in age, gender, dialytic age and Barthel index was found between HFR and BHD patients. In HFR patients we observed better values of physical component score (PCS) of SF-36 than BHD patients (P=0.048), whereas no significant difference emerged in the mental component score (P=0.698). In particular HFR patients were associated with higher Physical Functioning (P=0.045) and Role Physical (P=0.027). Conclusions: HFR is associated with better physical component of HR-QoL than BHD, independently of age, gender, dialysis vintage and invalidity score. Whether these findings translate into a survival benefit must be investigated by longitudinal studies.
    Article · May 2016
  • Lucia Di Micco · Stefania Marzocco · Simona Adesso · [...] · Biagio Di Iorio
    [Show abstract] [Hide abstract] ABSTRACT: Objectives: Aim of our study was to assess the potential effects of high-tone external muscle stimulation (HTEMS) on improvement of endothelial dysfunction (ED) and kidney damage in elderly patients with chronic kidney disease (CKD), sarcopenia and/or serious physical disability with a high Multidisciplinary Prognostic Index (MPI). Methods: We enrolled 12 consecutive CKD patients with MPI > 0,66 from January 1st, 2008 to December 31st, 2014. Six patients underwent a 2-hours HTEMS during the first day (group A) and the other six patients (group B) underwent a sham experiment with HTEMS without power supply. After 24 hours, patients of group A were shifted to group B and viceversa. Nitrite/nitrate (NOx), endotheline-1 (ET-1) and urine creatinine concentration were measured in all patients. Results: During HTEMS urine amount increased by 22% (p=0.049), so did urine creatinine that increased by 40%, (p=0.034) and creatinine clearance that increased by 26% (p=0.041). There was no statistical difference in urine nitrogen (that raised by 11%, p=0.526), urine sodium (that reduced by 42%, p=0.121) and urine potassium levels (p=0,491). At the same time, NOx changed from 44.15.1 to 38.45.3 M/L after 1 hour, to 36.44.8 M/L after 2 hours, to 41.15.7 M/L after 3 hours and to 46,95.0 M/L after 4 hours (p=0.008) during HTEMS, while it did not vary during the sham section of the experiment, respectively 43.66.1 M/L , 436.4 M/L, 42.85.5 M/L, 434.7 M/L, and 42.85.8 M/L (p=0.992). Conclusion: Our study showed that HTEMS may improve microcirculation and, through this mechanism, may reduce kidney damage in elderly patients with CKD and severe muscle atrophy.
    Article · Oct 2015
  • [Show abstract] [Hide abstract] ABSTRACT: In the last decade blood pressure variability (BPV) measured during a follow-up of hypertensive chronic kidney disease (CKD) patients or hemodialysis patients has received a even major attention. The aim of our study is to study the relationship between BPV and mortality and/or dialysis initiation in long survivors CKD patients. We conducted a historical prospective observational multicentric study in 131 subjects still alive at 31st December 2010, when ended a our previous study published on Nephrology Dialysis Transplantation. Long Survivors patients were younger (p<0.01) and had a lower BPV compared to the original population. Moreover, they had creatinine levels significantly lower (p<0.019), so as lower phosphate levels (p<0.05) and higher hemoglobin (p<0.05). During a mean follow-up of 80.713.4 months, 63 patients (48.1%) died and 49 of them (37.4%) started dialysis treatment. In this group, 28 patients died after dialysis initiation. Kaplan-Meier curves showed a significant association between BPV and cardiovascular mortality risk (Hazard Ratio [HR]: 1.061; 95% Confidence Interval [CI]: 1.0351.093; p = 0.001) and between BPV and renal death (HR 1.049; 95% CI: 10121.74; P = 0.001). In conclusions, our data in long survivors patients showed that BPV can be used for mortality cardiovascular and renal death risk stratification in CKD patients.
    Article · May 2015
  • Biagio R Di Iorio · Lucia Di Micco
    Article · Apr 2015
  • Article · Mar 2015 · Giornale italiano di nefrologia: organo ufficiale della Societa italiana di nefrologia
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    [Show abstract] [Hide abstract] ABSTRACT: Background: ESRD (end-stage renal disease) patients have a high cardiovascular mortality risk. A morphofunctional approach of vascular calcifications and myocardial perfusion is needed for the management of ESRD patients. We used SEVR (sub-endocardial viability ratio) and Kauppila score from the dialysis population of the Independent study to create a new morpho-functional score to assess cardiovascular risk in this population (the Solofra score). Materials and methods: 184 patients were followed-up for 36 months. A side lumbar X-ray was performed to assess vascular calcifications of lumbar aorta using the Kauppila score. Central aortic pressure and pulse velocity wave (PWV) were assessed at the carotid artery site. Myocardial perfusion was estimated with SEVR. Independent risk mortality factors were identified with univariate regression analysis (p<0.01); significance was defined as p<0.05. Results: Kauppila score was 13±10(range 0-24); PWV was 9.5±4 m/sec; basal SEVR was 1.3±0.9. We observed an improvement of ROC curves for SEVR and Kauppila score together compared to the ones for SEVR or Kauppila score alone. Conclusion: A quantitative analysis of vascular calcifications should be associated to a qualitative evaluation of arterial damage to better estimate cardiovascular mortality risk of ESRD patients. Further studies are needed to verify our hypothesis.
    Full-text Article · Dec 2014 · Current Hypertension Reviews
  • Biagio Di Iorio · Stefania Marzocco · Lucia Di Micco · [...] · August Heidland
    [Show abstract] [Hide abstract] ABSTRACT: Objectives: The aim of this study was to assess potential effects of hightone external muscle stimulation (HTEMS) on parameters of endothelial dysfunction (ED) in patients with acute kidney injury (AKI). Background: The bad outcome of AKI patients is markedly influenced by ED, microinflammation, oxidative stress and protein hypercatabolism. Recently, we have shown that intradialytic application of HTMS was associated with a faster resolution of AKI. Here, we investigated in the same cohort of patients whether parameters of ED such as nitric oxide (NO), asymmetric-dimethylarginine (ADMA), and endothelin 1 (ET-1) are modulated by HTEMS as compared to non-HTEMS-treated AKI patients. Methods: In a post-hoc study we analyzed plasma samples of the 34 AKI patients stage 5, of whom 17 underwent intradialytic HTEMS treatment while the other 17 served as AKI dialysis controls. Measurements included plasma nitrate and nitrite (NOx), ADMA, ET-1 and were performed before and on days 3, 7, 14, 21, and 28 after start of daily dialysis. Additional 16 healthy volunteers served as controls. Results: Initially, in both AKI groups NOx levels were markedly lower and ADMA and ET-1 levels were higher compared to the healthy controls. After initiation of daily hemodialysis the HTEMS group showed a faster improvement of NOx and ET-1 (after 1 week) and ADMA levels (after 2 weeks) compared to the No- HTEMS group. After 2 weeks, all parameters of the HTEMS group were not different from healthy controls, while the No-HTEMSAKI group needed 3 - 4 weeks. Conclusion: Our findings suggest for the first time that in AKI patients, application of HTEMS is associated with a faster normalization of lowered NOx and elevated ADMA and ET-1 plasma levels. We hypothesize that the more rapid amelioration of these parameters in the HTEMS group contributed to the accelerated recovery of AKI. With regard to the small study groups with different causes of AKI, investigations in a greater number of AKI patients is required.
    Article · Sep 2014 · Clinical nephrology
  • [Show abstract] [Hide abstract] ABSTRACT: Acute aortic dissection (AAD) is a life-threatening condition with high morbidity and mortality, that involves renal arteries in at least 5-10% so leading to renal ischemia and insufficiency. AAD presenting with anuria and the necessity of renal replacement therapy occurs rarely. Here we describe a case of a hypertensive and obese patient presenting with anuria and acute kidney injury, who underwent to hemodialysis and later was diagnosed with aortic dissection. Through this case, we underline the importance of considering AAD as an important differential in patients with a long history of uncontrolled hypertension presenting with anuria.
    Article · Jul 2014 · Giornale italiano di nefrologia: organo ufficiale della Societa italiana di nefrologia
  • Lucia Di Micco · Ernesto D'Avanzo · Antonella De Blasio · [...] · Biagio Di Iorio
    [Show abstract] [Hide abstract] ABSTRACT: Spontaneous ureteric ruptures is a rare condition [1]and bilateral ureteric rupture is even more uncommon. Few cases are described in the literature in which bilateral ureteric rupture is associated to dermatomyositis [2]or to intra-arterial contrast medium application for infrarenal aortic stent placement [3]. We discuss here a case of bilateral ureteric rupture in a 74-year-old man with bladder cancer, presenting oliguric acute kidney failure and a light abdominal pain.
    Article · Jul 2014 · Giornale italiano di nefrologia: organo ufficiale della Societa italiana di nefrologia
  • [Show abstract] [Hide abstract] ABSTRACT: The subendocardial viability ratio (SEVR), a parameter introduced by Buckberg, represents a non-invasive measure of myocardial perfusion related to left ventricular work. AIM. The aim of this study was to verify if dialysis may determine modifications of SEVR and how these modifications are modulated in the 2-day interdialytic period. METHODS.We studied 54 subjects of mean age 6314 years and receiving dialysis for 3215 months. Exclusion criteria were diabetes, resistant hypertension and peripheral vascular diseases and intradialytic hypotension evidenced during the study dialysis session. Pulse wave velocity and SEVR assessments were performed during the third dialysis session of the week, before (pre-HD) and after (post-HD) dialysis, in 2-day interdialytic period after and at the beginning of the following dialysis session. RESULTS.Dialysis reduces PWV, in particular the tertile with the lowest PWV presents the highest percentage reduction (-26%) compared with the second and the third tertiles. In the same way, dialysis leads to an increase of SEVR and patients in the tertile with the highest SEVR values maintain high SEVR values during dialysis and in the interdialytic period. Patients with severe vascular calcifications present higher PWV value and lower SEVR value. CONCLUSIONS.The results of present study demonstrate that ultrafiltration improves PWV (with a mean reduction of 16%) and SEVR (increase of 13%) and that the severity of vascular calcifications influences the effect of ultrafiltration on these two parameters. More studies are certainly necessary to verify our findings. Considered the higher mortality of patients with higher SEVR, it would be important to understand if new dialytic strategies are needed in patients with higher PVW and lower SEVR values.
    Article · Jan 2014 · Giornale italiano di nefrologia: organo ufficiale della Societa italiana di nefrologia
  • Biagio Di Iorio · Lucia Di Micco
    [Show abstract] [Hide abstract] ABSTRACT: The fear of malnutrition, caused by the low-protein diet, conditions in an inappropriate use of a useful nutrition therapy in Chronic Kidney Disease. Often malnutrition is due to reduced intake of energy, because a low (or very low) protein proper diet with adequate amount of calories (30-35 cal/kg bw/day). We analyze the positive aspects of the low-protein diet for optimal control of hypertension, hyperphosphatemia, anemia, and proteinuria that is the goal of pharmacological management Chronic Kidney Disease patients.
    Article · Jan 2014 · Giornale italiano di nefrologia: organo ufficiale della Societa italiana di nefrologia
  • Article · Dec 2013 · Journal of nephrology
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    Full-text Article · Dec 2013 · Journal of nephrology
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    Lucia Di Micco · Robert Ross Quinn · Paul Everett Ronksley · [...] · Pietro Ravani
    [Show abstract] [Hide abstract] ABSTRACT: Background and objectives: Twenty-four-hour urine creatinine excretion is a reliable approximation of muscle mass. Whether changes in urine creatinine predict clinical outcomes in persons with CKD is unknown. This work studied the relationship between urine creatinine and patient and renal survival in people with CKD not requiring renal replacement therapy. Design, setting, participants, & measurements: This longitudinal cohort study included incident stages 3-5 CKD patients referred to the renal clinic at the University Federico II in Naples between January of 1995 and December of 2005. Clinical data and urine creatinine were updated at each visit. Main outcomes were all-cause mortality and kidney failure requiring dialysis. Results: This study enrolled 525 individuals and followed them for a median of 6 years (range of 4 months to 15 years). Urine creatinine excretion declined by 16 mg/d per year (95% confidence interval, 14 to 19) in participants with CKD stages 3a, 3b, and 4, and it remained stable in participants with stage 5 CKD. Per each 20 mg/d decline in urine creatinine, mortality increased by 3% (adjusted hazard ratio, 1.03; 95% confidence interval, 1.01 to 1.05), and the risk of initiating dialysis increased by 2% (adjusted hazard ratio, 1.02; 95% confidence interval, 1.01 to 1.03). These associations were independent of body mass index and GFR. Conclusions: In persons with CKD stages 3 and 4, urine creatinine declines at a rate of 16 mg/d per year. Lower urine creatinine excretion predicts greater risk of kidney failure and patient mortality.
    Full-text Article · Nov 2013 · Clinical Journal of the American Society of Nephrology
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    L Di Micco · P Salvi · A Bellasi · [...] · Biagio Di Iorio
    [Show abstract] [Hide abstract] ABSTRACT: Background: The subendocardial viability ratio (SEVR), calculated by pulse wave analysis, is an index of myocardial oxygen supply and demand. Here we analyze the relation between SEVR and cardiovascular mortality in the chronic kidney disease (CKD) population of a post hoc analysis of a multicenter, prospective, randomized, nonblinded study. Methods: We studied 212 consecutive asymptomatic outpatients receiving care at 12 nephrology clinics in south Italy. Inclusion criteria were age >18 years, 6 months of follow-up before the enrollment and stage 3-4 CKD. Results: During follow-up, 34 subjects died, 29 of them for cardiovascular causes. SEVR correlated inversely with vascular calcifications (r = -0.37) and myocardial mass (r = -0.45); SEVR changed from 1.33 ± 0.24 to 1.36 ± 0.16 (p = NS; baseline and final values, respectively) in living patients, and from 1.16 ± 0.31 to 0.68 ± 0.26 in deceased patients (p < 0.001). Kaplan-Meier curves show that that a greater reduction of SEVR values during the study (third tertile) significantly predicts cardiovascular mortality (p < 0.0001). Conclusions: This post hoc analysis shows that a reduction of SEVR values impacts cardiovascular mortality in CKD patients.
    Full-text Article · May 2013 · Blood Purification
  • Suetonia C Palmer · Lucia Di Micco · Mona Razavian · [...] · Giovanni Fm Strippoli
    [Show abstract] [Hide abstract] ABSTRACT: People with chronic kidney disease (CKD) have an increased risk of heart disease that can block blood supply to the heart or brain causing heart attack or stroke. Drugs that prevent blood clots forming (antiplatelet agents) can prevent deaths caused by clots in arteries in the general adult population. However, there may be fewer benefits for people who have CKD, because blood clots in arteries is a less common cause of death or reason to be admitted to hospital compared with heart failure or sudden death in these people. People with CKD also have an increased tendency for bleeding due to changes in blood clotting mechanisms. Antiplatelet agents may therefore be more hazardous when CKD is present. This review evaluated the benefits and harms of antiplatelet agents to prevent cardiovascular disease and death, and improve dialysis vascular access function in people who have CKD. We identified 44 studies comparing antiplatelet agents with placebo or no treatment and six studies directly comparing one antiplatelet agent with another. Antiplatelet agents prevent heart attack, but not death or stroke, and increase major and minor bleeding in people with CKD. Dialysis access (fistula or Gortex graft) is maintained with antiplatelet treatment, but antiplatelet drugs do not clearly improve fistula maturation or suitability for dialysis. Benefits (fewer deaths and heart attacks) and harms (bleeding) occur irrespective of the stage of CKD or type of antiplatelet used. More studies of anti-blood clotting drugs are needed in people who have CKD, especially in those who have received kidney transplants. We also need studies that compare one anti-clotting drug versus another, particularly newer drugs, and that determine the best treatment for people with both CKD and acute cardiovascular disease and that assess treatment to improve maturation of dialysis vascular access.
    Article · Apr 2013 · Cochrane database of systematic reviews (Online)
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    Stefania Marzocco · Fabrizio Dal Piaz · Lucia Di Micco · [...] · Biagio Di Iorio
    [Show abstract] [Hide abstract] ABSTRACT: Background and objectives: High levels of indoxyl sulfate (IS) are associated with chronic kidney disease (CKD) progression and increased mortality in CKD patients. The aim of this pilot study was to assess whether a very low protein diet (VLPD; 0.3 g/kg bw/day), with a consequent low phosphorus intake, would reduce IS serum levels compared to a low protein diet (LPD; 0.6 g/kg bw/day) in CKD patients not yet on dialysis. Material and methods: This is a post hoc analysis of a preceding cross-over study aimed to analyze FGF23 during VLPD. Here we performed a prospective randomized controlled crossover study in which 32 patients were randomized to receive either a VLPD (0.3 g/kg bw/day) supplemented with ketoanalogues during the first week and an LPD during the second week (group A, n = 16), or an LPD during the first week and a VLPD during the second week (group B, n = 16 patients). IS serum levels were measured at baseline and at the end of each study period. We compared them to 24 hemodialysis patients (HD) and 14 healthy subjects (control). Results: IS serum concentration was significantly higher in the HD (43.4 ± 12.3 µM) and CKD (11.1 ± 6.6 µM) groups compared to the control group (2.9 ± 1.1 µM; p < 0.001). IS levels also correlated with creatinine values in CKD patients (R(2) = 0.42; p < 0.0001). After only 1 week of a VLPD, even preceded by an LPD, CKD patients showed a significant reduction of IS serum levels (37%). Conclusions: VLPD supplemented with ketoanalogues reduced IS serum levels in CKD patients not yet on dialysis.
    Full-text Article · Mar 2013 · Blood Purification
  • Suetonia C Palmer · Lucia Di Micco · Mona Razavian · [...] · Giovanni Fm Strippoli
    [Show abstract] [Hide abstract] ABSTRACT: Antiplatelet agents are widely used to prevent cardiovascular events. The risks and benefits of antiplatelet treatment may be different in people with chronic kidney disease (CKD) for whom occlusive atherosclerotic events are less prevalent, and bleeding hazards might be increased. To summarise the effects of antiplatelet treatment (antiplatelet agent versus control or other antiplatelet agent) for the prevention of cardiovascular and adverse kidney outcomes in individuals with CKD. In January 2011 we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cochrane Renal Group's Specialised Register without language restriction. We selected randomised controlled trials of any antiplatelet treatment versus placebo or no treatment, or direct head-to-head antiplatelet agent studies in people with CKD. Studies were included if they enrolled participants with CKD, or included people in broader at-risk populations in which data for subgroups with CKD could be disaggregated. Two authors independently extracted data from primary study reports and any available supplementary information for study population, interventions, outcomes, and risks of bias. Risk ratios (RR) and 95% confidence intervals (CI) were calculated from numbers of events and numbers of participants at risk which were extracted from each included study. The reported RRs were extracted where crude event rates were not provided. Data was pooled using the random-effects model. We included 50 studies, enrolling 27,139 participants; 44 studies (21,460 participants) compared an antiplatelet agent with placebo or no treatment, and six studies (5679 participants) directly compared one antiplatelet agent with another. Compared to placebo or no treatment, antiplatelet agents reduced the risk of myocardial infarction (17 studies; RR 0.87, 95% CI 0.76 to 0.99), but not all-cause mortality (30 studies; RR 0.93, 95% CI 0.81 to 1.06), cardiovascular mortality (19 studies; RR 0.89, 95% CI 0.70 to 1.12) or stroke (11 studies; RR 1.00, 95% CI 0.58 to 1.72). Antiplatelet agents increased the risk of major (27 studies; RR 1.33, 95% CI 1.10 to 1.65) and minor bleeding (18 studies; RR 1.49, 95% CI 1.12 to 1.97). In terms of dialysis access outcomes, antiplatelet agents reduced access thrombosis or patency failure but had no effect on suitability for dialysis. Meta-regression analysis indicated no differences in the relative benefit or harms of treatment (risk of all-cause mortality, myocardial infarction, or major bleeding) by type of antiplatelet agent or stage of CKD. Limited data were available for direct head-to-head comparisons of antiplatelet drugs, treatment in kidney transplant recipients, primary prevention, or risk of ESKD. Antiplatelet agents reduce myocardial infarction but increase major bleeding. Risks may outweigh harms among people with low annual risks of cardiovascular events, including those with early stages of CKD who do not have clinically-evident occlusive cardiovascular disease.
    Article · Feb 2013 · Cochrane database of systematic reviews (Online)
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    [Show abstract] [Hide abstract] ABSTRACT: Hypertension is responsible for a significantly increased burden of cardiovascular events and it is cause and a consequence of Chronic Kidney Disease (CKD) and a determinant factor in its progression to End Stage Kidney Disease (ESKD). Therefore, nephrologists have been focusing their attention on hypertension control to prevent CKD progression, delaying it but with poor results on cardiovascular mortality reduction. An important effect is the difficulty to adequately reduce BP levels in CKD patients and especially in dialysis patients despite the polipharmacological therapy. We have to take into account other aspects influencing mortality risk in CKD patients .The first aspect to consider is whether brachial blood pressure (BP) measurement is sufficient to describe the complex relationship between the alteration of BP and outcomes in renal subjects. The second aspect to consider is the variability of BP (BPV). We think that BP measurement cannot only take into account brachial BP, because it represents a limited measure of a complex clinical condition in CKD or ESRD patients. The inability to evaluate hypertension in its complexity explains why several aspects are still unrecognized.
    Full-text Article · Feb 2013 · Current Hypertension Reviews