[A rare cause of acute renal failure, acute tubulo-interstitial nephritis]

We report the case of an acute renal failure due to an acute interstitial nephropathy (ATIN) induced by non steroidal anti-inflammatory drugs (NSAID). Even though this pathology is a rare cause of acute renal failure, it still requires special attention in view of the fact that it induces a high risk of acute morbidity but it also can evolve into chronic renal failure. Its differential diagnosis with other causes of acute renal failure becomes essential because of the different therapeutic care. In this article, we are going to briefly sum up the reasoning to adopt in order to diagnose an acute renal failure.

[Therapeutic inertia in hypertension: why and how to fight against this attitude?]

Therapeutic inertia, i.e. the absence of introduction of an antihypertensive treatment or on adjustment of its intensity by the medical doctor if the blood pressure is elevated or the goal not reached, is frequent and does play a role in the insufficient control of blood presure in the hypertensive population. The responsibility of the medical doctor is high in this respect. A strict medical approach is required, step by step, to correct this lack of reaction.

[Importance of a bad adherence to the antihypertensive treatment in the hypertensive population. How to improve it?]

Overwhelming evidence indicates that the treatment of arterial hypertension is beneficial, but, in practice, less than 50% of treated hypertensive patients have well-controlled blood pressure. The success of treatment relies upon adherence (for both non pharmacologic and drug treatment) by the patient. This problem of observance is multifactorial. Several factors play a role: the patient, his/her illness, his/her treatment and the therapeutic environment where the relationship between the medical doctor and the patient is crucial. To improve observance, but also treatment persistence we need to think about it. Observance must be discussed with the patient at each visit. An excellent relationship between doctor and patient, education about hypertension, its risks, and the ways to avoid complications, the choice of a well tolerated and simple treatment progressively introduced, the intervention in this management of the family and the pharmacist, the development of home self blood pressure measurement by the patient are all important ways to improve adherence. This could reduce the cardiovascular complications related to high blood pressure and thus decrease the general costs for the society.

[The therapeutic compliance in solid organ transplantation. The case of renal transplantation]

A successful transplantation implies that immunosuppressive drugs will have to be taken during the whole patient's life. Poor drug compliance is a multifactorial problem, that is particularly dangerous in organ transplantation as it can lead to loss of graft function and return to dialysis treatment. The medical doctor must stimulate the patient's adherence to the strict therapeutic drug protocol. The patient must also be reminded at each medical consultation of the importance of such rigorous drug intake. This bad (or non) compliance is particularly well demonstrated a long time after transplantation. The medical staff, all the health participants, but also the family members must continuously fight against non compliance, which is inherent to any chronic disease.

Are ACE-inhibitors or ARB's still needed for cardiovascular prevention in high risk patients? Insights from profess and transcend

The HOPE and EUROPA clinical studies have shown that treatment with the angiotensin-converting enzyme (ACE) inhibitors, ramipril and perindopril, may reduce the occurrence of major cardiovascular events in patients with proven atherosclerotic disease. The recently published results of the PRoFESS and TRANSCEND trials completed the much needed information concerning the use of an angiotensin receptor blocker for patients at high risk of cardiovascular events. PROFESS compared a therapy of telmisartan 80 mg daily with placebo in patients with a recent ischemic stroke. The difference in the primary outcome of first recurrent stroke was not statistically significant between telmisartan and placebo. The secondary outcome of major cardiovascular events showed a relative risk reduction (RRR) of 7% in favour of telmisartan. This tended to be significant (p = 0.06) despite a rather short follow-up period of only 28 months. In TRANSCEND 5926 patients at high risk for cardiovascular events were randomized to a treatment with telmisartan 80 mg daily or placebo for a mean duration of follow-up of 56 months. The primary composite outcome of cardiovascular death, myocardial infarction, stroke or hospitalization for heart failure showed a non-significant 8% RRR in favour of the telmisartan treated patients. The main secondary outcome of cardiovascular death and myocardial infarction or stroke as used in the HOPE trial showed a non-significant RRR of 13% in favour of telmisartan treated patients (p = 0.068 adjusted for multiplicity of comparisons). In comparing the Kaplan-Meier curves for the endpoint of major cardiovascular events used in HOPE, EUROPA, TRANSCEND and PRoFESS, the trends are similar. Results of most of the recently published trials have been neutral.This could partly be explained by major improvements in the optimal background therapy of the patients included. Nevertheless, the results of PRoFESS and TRANSCEND do not contradict the results from previous studies with theACE inhibitors ramipril and perindopril and the ARB telmisartan.

How to treat hypertension in blacks: review of the evidence

Presentation, response to therapy, and clinical outcome differ according to race for patients with hypertension. Black patients have a higher prevalence and earlier onset of hypertension than other ethnic groups, with poorer prognosis than white patients. Blacks are more likely to be salt-sensitive, and to have a low plasma renin activity than are whites. They are at much greater risk of developing cardiovascular and renal complications. Despite many advances in the understanding and treatment of cardiovascular diseases, black patients continue to have increased morbidity and mortality from the end-organ complications of hypertension. The explanations for these observations remain incompletely understood, but genetic differences, added to socio-economic and environmental factors, have been proposed to explain this disparity. The first therapeutic approach is to decrease salt and increase potassium intakes. Diuretics (thiazides and potassium-sparing agents) and calcium channel blockers constitute the first antihypertensive drug choices. The angiotensin-converting-enzyme inhibitors, the angiotensin II receptor blockers and beta-blockers appear to be less effective in blacks with regard to uncomplicated hypertension, especially in older people, but addition of a small dose of diuretic improves their efficacy. These combinations are preferred among patients with chronic kidney disease or heart failure. The goal for blood pressure target is the same in blacks as it is in whites, being a blood pressure of less than 140/90 mmHg in uncomplicated hypertension and less than 130/80 mmHg in patients with diabetes mellitus or chronic kidney disease.

[Advances concerning aliskiren, direct renin inhibitor and aliskiren-hydrochlorothiazide]

Aliskiren (Rasilez), a direct renin inhibitor, is currently indicated for the treatment of essential hypertension, as monotherapy or in combination, especially with hydrochlorothiazide (Rasilez HCT). It may also be use to obtain a more complete blockade of the renin-angiotensin-aldosterone system (RAAS) when it is associated with an angiotensin converting enzyme inhibitor (ACEI) (or an AT1 angiotensin receptor antagonist) (ARA). There is some room for agents that may be more efficacious in reducing the progression of diabetic nephropathy than ACEI or ARA. In this context, the dual blockade of RAAS most probably offers a better efficacy than the simple blockade, but also exposes to a higher risk. Should ongoing trials confirm the preliminary favourable results, aliskiren might reach a forefront position among the armamentarium now available to optimize the RAAS blockade. The present article will summarize advances concerning the biochemical effects of the specific mode of action of aliskiren, especially the potential interferences related to increased renin/pro-renin levels, as well as results of recent clinical trials, not only in hypertension, but also in the fields of diabetes, renal insufficiency and cardiology. The objectives and design of the landmark study ALTITUDE will also be briefly presented.

[Sevikar or Forzaten: olmesartan medoxomil and amlodipine besylate fixed combination in the treatment of hypertension]

The interest for powerful and better tolerated antihypertensive combinations is searched in the field of hypertension, because of a too large number of people still not well controlled. The recent association between an angiotensin receptor blocker, olmesartan, and a long-acting dihydropyridine, amlodipine, reinforces our therapeutic possibilities. The synergistic effect of the two molecules potentiate the antihypertensive activity, which allows improving the quality and the rapidity of the blood pressure control. Furthermore, the fixed combination should improve patient's compliance. The contraindications still remain those of the sartan family. The most frequent side-effect of amlodipine monotherapy, oedema, occurs in a much lower proportion with the addition of olmesartan.

[Monoclonal antibodies in renal transplantation]

Renal transplantation is the best treatment for end-stage renal disease, but requires efficient immunosuppressive therapy. The latter has evolved over recent years with the development of more powerful drugs and of monoclonal antibodies with very specific target. The first monoclonal antibodies, acting against the interleukin 2 receptor, named basiliximab and daclizumab, have showed an excellent tolerance profile and efficacy to reduce acute graft rejection. However, in spite of these properties, the development of delayed graft function or the graft and patient survivals at 1 year were not modified by the use of such specific treatment. One potential advantage could yet be a decreasing need for corticosteroids and sometimes calcineurin inhibitors which could provide some long term benefits for the renal graft, but also the patient. Alemtuzumab, another monoclonal antibody, aimed at the membrane glycoprotein CD52, can also decrease the incidence of acute rejection and the depth of the required immunosuppressive therapy. Other antibodies are still in development with some interesting preliminary results which however demand confirmation in larger studies.

[Why and how should the patient perform a correct home blood pressure measurement?]

Home blood pressure (BP) measurement is a medical prescription. The interpretation of the results must be left to the physician. This method is complementary to the classical office BP measurement and the 24 hour ambulatory blood pressure measurement. It must be proposed to some selected patients on the basis of their capacity of learning and understanding the place of the technique for the diagnosis and the treatment compliance. It allows a more active contribution of the patient to the management of her chronic disease and, this, may improve the prevention of cardiovascular complication. A normal blood pressure during self BP measurement is equal or lower to 135/85 mmHg or even lower in high cardiovascular risk patients. This new technique, already largely used by patients, needs adequate education and good advice for buying a validated device.

[Fixed combination perindopril-amlodipine (Coveram) in the treatment of hypertension and coronary heart disease]

Coveram is a new fixed combination of an angiotensin converting enzyme inhibitor, perindopril, and a calcium antagonist, amlodipine. This new medication is indicated for the treatment of arterial hypertension and/or stable coronary heart disease. Such fixed combination of two molecules that have been extensively evaluated according to evidence-based medicine offers the advantage of an excellent efficacy, associated with a good tolerance profile, and favours patient's compliance. The marketing of different formulations of Coveram combining various dosages allows easy adjustment and titration of each of the components according to the individual patient's characteristics.

[How to manage an arterial hypertension resistant to drug treatment]

The management of arterial hypertension, a well known silent killer, is still a challenge for physicians fighting for an optimal control of blood pressure values. The problem is even more complex when, after a good response, the control of blood pressure becomes again worse. Our case record underscores the different steps allowing to increase the efficacy of blood pressure management in such secondary resistant form of hypertension.

[Detection and estimation of chronic kidney disease]

The prevalence of chronic kidney disease is increasing. An early and precise diagnosis of renal insufficiency requires a measurement of the glomerular filtration rate. Formulas based on serum creatinine to determine the glomerular filtration rate have brought, compared to serum creatinine alone, an improvement in this precision. However, in many clinical conditions, they may give incorrect information. Using 24 h urine collection, calculation of creatinine clearance can be more adequate and accurate in conditions where patient's anthropometric characteristics are far from the normal range. However, this 24 h urine collection is often variable and its validity could be criticized. When a very precise determination of glomerular filtration rate is needed, a method of reference is required such as that using chrome EDTA or iohexol. Each nephrological exploration also needs a urine analysis for detection of proteinuria. When a positive urine dipstick test is noted, a quantification of proteinuria must be done either after 24 h urine collection or more easily by determining the proteinuria/creatininuria ratio on an urine sample.

[Clinical study of the month. The ACCOMPLISH study: challenging the choice of antihypertensive medications in systolic hypertensive patients with high cardiovascular risk]

Arterial hypertension is an important cardiovascular risk factor. The benefit drawn from decreasing and normalizing the blood pressure level is indisputable. The ACCOMPLISH study performed in patients older than 65 with systolic hypertension and a high cardiovascular risk pointed out the interest of well choosing the antihypertensive combination to reduce this risk beyond the decrease of blood pressure. The association of benazepril (an angiotensin converting enzyme inhibitor or ACEI) and amlodipine (a calcium antagonist) has shown significant early cardiovascular protection in such patients as compared to the classic association including the same ACEI and hydrochlorothiazide, in spite of the same target blood pressure reached. This important finding does not contest the interest of a well controlled blood pressure in hypertension, but probably will modify our first antihypertensive combination choice in the future in patients with such cardiovascular profile.

[Management of chronic kidney disease. World Kidney Day, March 13, 2008]

Chronic kidney disease is a worldwide growing problem, especially due to three factors very often encountered together (old age, diabetes mellitus and arterial hypertension). A multidisciplinary approach is needed to reduce this epidemic that has important health implications.This needs of course well trained health partners. On the occasion of the World Kidney Day on March 2008, four lectures were given, which gave an updated overview of the management of chronic kidney insufficiency, a serious problem of public health.

[How to manage chronic kidney disease before dialysis]

Chronic renal failure is usually a silent disease until its late stage, especially in elderly people. Screening for such disease is particularly useful in hypertensive diabetic patients above 50 years. The causes are indeed often vascular or metabolic (directly or not directly linked to diabetes mellitus). Other less frequent causes are yet possible. The search for the right diagnosis of renal insufficiency is always requested to apply the appropriate treatment, combined with medical measures for secondary and tertiary prevention. This review will give general advices to avoid the development of renal disease (stages 3 and 4) or its progression, and also insist on the potential nephrotoxic effects of some drugs.

[Sodium and arterial hypertension --one hundred years of controversies]

Sodium chloride (salt) plays a role in the development and maintenance of high blood pressure (25% of the normotensive population are called sodium sensitive and 50% of the hypertensive people would present a significative decrease either of their blood pressure when low salt diet is applied) or of cardiovascular complications, but also of other diseases (obesity, osteoporosis, kidney stones, cancer,...) The regulation of salt balance is played by the kidneys, the function of which can be genetically (more rarely) or secondarily acquired (most often) disturbed. Salt restriction (maximum 5-6 g/d) with higher potassium intake, is now recommended. This can easier allow the lowering of the blood pressure, especially in resistant forms of hypertension. Proposed to everybody, even normotensive, it could be beneficial reducing the trend of blood pressure increase with age, but also the burden of cardiovascular complications and promoting general health. For reaching these objectives, this reduction in salt consumption needs motivated and well educated people, well labelled food products about salt content and the apprppriate help of food industries.

Screening for proteinuria and chronic kidney disease risk factors in Kinshasa: a World Kidney Day 2007 study

BACKGROUND

Although screening programs for chronic kidney disease (CKD) may be of great value, these programs are not yet implemented in the Democratic Republic of Congo. This study focused on proteinuria and examined its prevalence in terms of the number needed to screen for the different risk factors of CKD. Such knowledge would guide the utility of population screening to prevent end-stage renal disease.

METHODS

A cross-sectional survey was conducted in Kinshasa on the Second World Kidney Day. A sample of 3,018 subjects was interviewed and the following measurements were performed: blood pressure, body mass index, glycemia and urine protein. Logistic regression analysis was used to identify determinants of proteinuria.

RESULTS

The prevalence of proteinuria was 17.1% (95% CI 15.8-18.6). Other CKD risk factors identified were: hypertension, diabetes mellitus, obesity and metabolic syndrome. To identify 1 case of proteinuria, one would need to screen 4 persons with diabetes, 5 persons with hypertension, 4 subjects having metabolic syndrome, 5 persons aged >or=72 years and 9 persons without any of the conditions mentioned above. Age, overweight and diabetes were the strongest factors associated with proteinuria.

CONCLUSIONS

This study indicates that proteinuria and traditional risk factors for CKD are very prevalent in Kinshasa. Realistic policies to stem these conditions should be a public health priority.

[Aliskiren (Rasilez), direct renin inhibitor]

Aliskiren (Rasilez) is the first oral renin inhibitor. Its present indication is essential hypertension, as monotherapy or in combination with other antihypertensive agents (diuretic, calcium antagonist, ...). It may also be associated with an angiotensin converting enzyme inhibitor (or an AT1 angiotensin receptor antagonist) in order to benefit of a dual blockade of the renin-angiotensin-aldosterone system. The usual daily dose is 150 mg, to be increased up to 300 mg if necessary. New clinical trials are ongoing to validate this novel therapeutic approach in other indications such as congestive heart failure and diabetic nephropathy.

[The physiopathology of dialysis-associated hypertension]

Hypertension in subjects on long term dialysis is frequent. Its origins are found in extracellular volume overload, which is complicated by increased peripheral arterial resistance. The latter is affected by many systems, including that of renin-angiotensin, endothelin, nitric oxide, the sympathetic nervous system, and others. The interaction between these factors may explain why the control of hypertension in dialysis patients requires ongoing attention to the many aspects of good dialysis.

[Hypertension and the brain]

The relationships between the brain and arterial hypertension are strong. The brain, through the hypothalamus, can quickly adapt the blood pressure level to maintain the cerebral blood flow. An acute increase in blood pressure, if it overtakes the autoregulatory capacities, needs an urgent intervention to decrease neurological problems such as encephalopathy. In chronic situations, arterial hypertension is a frequent cause of stroke, either ischemic or hemorragic, both in patients free and those who have already suffered from brain damage. Hypertension is also an actor in the genesis of vascular, but also Alzheimer's dementia. A strict control of blood pressure (but also in other atherosclerotic risk factors) into the normal range is needed to protect the brain, and this is more important than the choice of a particular class of antihypertensive agents, except the betablockers. The risk starts from the normal values of blood pressure.

Lessons from ONTARGET

The recently published results of the ONTARGET trial shed a new light on the cardiovascular protection of patients at high risk of a cardiovascular event. Despite a number of trials looking at the efficacy of Angiotensin Converting Enzyme inhibitors (ACEis) or Angiotensin Receptor Blockers (ARBs) in the prevention of cardiovascular events in patients with specific high risk profiles, the question of the equivalence of ACEis and ARBs remained unanswered. The ONTARGET trial has shown that telmisartan 80 mg administered for a median duration of 4.5 years to patients at high risk of developing a major cardiovascular event, is equally effective to ramipril 10 mg. In addition, telmisartan was slightly better tolerated. The comparator ramipril has been chosen as it is currently the gold standard ACEi since the results of the HOPE study, in terms of the composite outcome of cardiovascular death, myocardial infarction and stroke. Moreover, ONTARGET is the first trial to test the hypothesis of superiority of adding an ARB (telmisartan 80 mg) to an ACEi (ramipril 10 mg) over the ACEi ramipril monotherapy in cardiovascular protection of the same broad range of high-risk patients. Surprisingly, despite a more pronounced blood pressure lowering, the combination of the two agents did not lead to an additional decrease in the number of events, but had significantly more side-effects compared to ramipril monotherapy. ONTARGET is a landmark study, performed according to the highest statistical and clinical standards, providing compelling evidence and clear answers to two important clinical questions.

[How I treat... by optimizing the blockade of the renin-angiotensin-aldosterone system]

The blockade of the renin-angiotensin-aldosterone system (RAAS) has been shown to be useful, or even mandatory, in the management of arterial hypertension, congestive heart failure, post-myocardial infarction and nephropathy with albuminuria, due to diabetes or not. Such blockade can be obtained with an angiotensin converting enzyme inhibitor, a specific antagonist of angiotensin II AT1 receptors and/or recently a direct inhibitor of renin such as aliskiren. Various studies have demonstrated the advantage of optimising RAAS blockade in order to benefit of the best cardiorenal protection. The present article describes the various modalities to optimize the RAAS blockade, either by using a maximal dosage of a monotherapy, or by choosing a double inhibition of RAAS. New prospects for the RAAS blockade will be also briefly considered.