ACTA PSYCHOPATHOLOGICA ISSN 2469-6676 2018 Vol.4 No. 1:2 1 iMedPub Journals Opinion www.imedpub.com DOI: 10.4172/2469-6676.100158 © Under License of Creative Commons Attribution 3.0 License | This article is available from: www.psychopathology.imedpub.com Awad Magbri*, Shauket Rashid and Brar Balhinder Dialysis Access Center of Pitsburgh, PA, USA *Corresponding author: Awad Magbri  elmagbri@hotmail.com MD, FACP, Dialysis Access Center of Pitsburgh, PA, USA. Tel: 4122715106 Citation: Magbri A, Rashid S, Balhinder B (2018) Reversal of the Norm: Pressure Discrepancies on the Two Sides of the Septum in Chronic Kidney Disease Patients with Congestive Heart Failure. Acta Psychopathol Vol.4 No.1:2 Keywords: Hemofltraton; Hemodialysis; Congestve heart failure; Ultra-fltraton; Fluid overload; Intre-atrial septostomy Introducton Normally the right side of the heart is low pressure chambers that accommodate large volume of blood. On the other hand, the lef side of the heart is high pressure chambers that forces blood into the major vessels to distribute it to the vital organs and the rest of the body. Our patent is 67-year-old Caucasian male with end-stage renal disease on hemodialysis (HD) via a tunneled dialysis catheter in the right internal jugular vein for the last 8 months. He has multple chronic comorbidites including morbid obesity with body mass index of 56.21 kg/m 2 . Chronic lymphedema of the lower extremites, paroxysmal atrial fbrillaton, obstructve sleep apnea with pulmonary hypertension on bi-level positve pressure ventlaton (BIPAP). He has chronic congestve heart failure and he is on HD 3-tmes per week. He has no diabetes but sufered from fuid overload and inability of getng fuid of on HD sessions. He also has pressure sores from immobility. His blood pressure is chronically low 81-90/67-74 mmHg before dialysis. This scenario is quite familiar to the nephrologists who care for dialysis patents. The treatment of such patents is difcult, and the mortality is high. Chronic kidney disease (CKD) is very common in congestve heart failure patents. As a mater of fact, patents with CKD die from cardiovascular disease long before they reach dialysis. Many workers have found that both systolic and diastolic blood pressure were inversely associated with mortality [1-7]. This phenomenon of low blood pressure with increased mortality is called “reverse epidemiology” [3,8]. It is not clear that any interventon will prove to be efectve to curb the high mortality and morbidity of hemodialysis patents with congestve heart failure and low blood pressure. The pathophysiology of CKD in cardiac disease is complex and involves both congestve and ischemic nephropathy and both. These patents usually have evidence of congeston with pre- capillary wedge pressure (PCWP) that refects the end-diastolic pressure of the lef side of the heart of <18 mmHg. At the same tme, they have low cardiac index of <2.1 L/m 2 with evidence of low cardiac output and cold extremites. Reversal of the Norm: Pressure Discrepancies on the Two Sides of the Septum in Chronic Kidney Disease Patents with Congestve Heart Failure Received: January 04, 2018; Accepted: January 09, 2018; Published: January 13, 2018 The presence of both ischemic and congestve symptoms in the same patent proved to be a difcult task to manage by HD. It should be noted that chronic hypotension decreases the preload and will eventually leads to vasoconstricton and ischemia to the kidney [9-11]. Constricton of the glomerular eferent arterioles due to angiotensin-II blockade from the drugs used for the treatment of heart failure as well as actvaton of the tubule-glomerular feedback and tubular dysfuncton with sustained decrease in intra-glomerular pressure leads to ischemic nephropathy [12]. It is not unusual to fnd both signs of ischemic nephropathy from chronic hypotension and congestve organomegaly with peripheral edema in the same subject, as is seen in the patent under discussion. These patents ofen have fuid overload and low blood pressure which makes fuid removal on dialysis extremely problematc if not almost impossible. Diferent maneuvers have been used to overcome these hurdles including sodium modelling, use of midodrine, decreasing ultra-fltraton at the end of dialysis, putng the patents in Trendelenburg positon, and lowing the temperature of the dialysate. None of these maneuvers have proven efectve in end-stage renal failure patents on dialysis with concomitant congestve heart failure. Daily slow ultra-fltraton was suggested by some workers [13] to overcome this problem but are not favored by most