[ONTARGET: similar protection of telmisartan and ramipril and lack of benefit of combined therapy in patients at high risk for vascular events]

ONTARGET ("ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial") compared the angiotensin converting enzyme inhibitor ramipril (10 mg/day), the angiotensin-receptor blocker telmisartan 80 mg/day, and the combination of the two drugs in 25,620 patients with vascular disease or high-risk diabetes. After a median follow up of 56 months, no significant differences were observed between the three groups neither in the primary composite outcome (death from cardiovascular causes, myocardial infarction, stroke, or hospitalization for heart failure), nor in each of its components, total mortality and other secondary outcomes. Telmisartan was equivalent to ramipril (non inferiority criterion), but was better tolerated (less cough and angioedema). The combination of the two drugs in this population (without congestive heart failure and proteinuric nephropathy) did not bring increased benefit (no superiority), but was associated with more adverse events (hypotension, syncope and renal dysfunction). In this population, the choice of the molecule in monotherapy remains optional and the use of a dual blockade is not justified in order to have a better cardiovascular protection.

[Clinical case of the month. Antibiotics and hemodialysis: three cases of neurotoxicity from Maxipime]

The metabolism of drugs is altered in dialysed patients. We report three clinical cases of neurological toxicity from cefepime in dialysed patient. This molecule can induce in renal insufficiency patients various reversible neurological manifestations like metabolic encephalopathy, myoclonies, or a state of status epilepticus that mimics sometimes a coma in spite of adequate dosing.

[Dapsone: an opportunity to spare corticoid use for Henoch-Schönlein treatment? A case report]

Dapsone is a sulfone essentially used to treat leprae. We describe, here, a somewhat rare indication of dapsone: corticoid sparing in the treatment of particular forms of Henoch-Schönlein.

[A first drug combination for the treatment of arterial hypertension with a calcium channel antagonist (amlodipine besylate) and an angiotensin receptor blocker (valsartan): Exforge]

Hypertension is a common treatable risk factor for cardiovascular disease. Even when identified and treated, most patients with hypertension do not get to blood pressure goal and they often need at least two antihypertensive agents to achieve blood pressure control. Although various combination therapies are currently available for the treatment of hypertension, development of more powerful therapies is necessary to help implement guideline recommendations that call for more aggressive treatment options and early blood pressure control. Amlodipine/valsartan (Exforge) is a new combination of antihypertensive agents that lower blood pressure via calcium channel blockade and angiotensin receptor antagonism. This potent dual mechanism of action is also likely to attenuate compound-specific adverse events, such as amlodipine-related peripheral oedema. Currently available data show that such a combination is a well-tolerated treatment that gets different kinds of patients with all grades of hypertension to their blood pressure goal.

[Clinical trial of the month. ADVANCE: improved survival and better vascular and renal outcomes with a fixed combination of perindopril and indapamide in patients with type 2 diabetes]

The controlled ADVANCE trial compared the incidence of major macrovascular and microvascular complications in 5,569 type 2 diabetic patients randomised to a fixed combination of perindopril and indapamide and in 5,571 patients randomised to placebo, followed for a mean duration of 4.3 years. Compared with patients assigned placebo, those assigned active therapy had a mean reduction in systolic blood pressure of 5.6 mm Hg and diastolic blood pressure of 2.2 mm Hg, despite the fact physicians were allowed to adjust antihypertensive therapy ad libitum. The relative risk of a major macrovascular and microvascular event (primary endpoint) was reduced by 9% (p = 0.041) in the active group. The separate reductions in macrovascular and microvascular events were similar but were not independently statistically significant. The relative risk of death was significantly reduced by 14% (p = 0.025), essentially due to a lower death rate from cardiovascular diseases (-18%; p = 0.027). The incidence of any coronary event was also significantly reduced (-14 %; p = 0.020), while only a trend was observed for all cerebrovascular events. Finally, renal events were significantly less frequent (-21%; p < 0.0001) whereas all ocular events were only slightly reduced (-5%; NS) in the active group as compared to the placebo group. The fixed combination of perindopril and indapamide was well tolerated and easy to administer. Overall one death due to any cause would be averted among every 79 diabetic patients assigned active therapy for 5 years. There was no evidence that the effects of the study treatment differed by initial blood pressure level or concomitant use of other treatments at baseline.

[New guidelines 2007 for the management of arterial hypertension]

New guidelines for the management of arterial hypertension have just been released by the European Societies of Cardiology and Arterial Hypertension. The global cardiovascular risk is again at the center of this management. The control of high blood pressure goes through an adequate use of antihypertensive agents and the application of healthy lifestyle and diet recommendations. Again, management of all the cardiovascular risk factors is stimulated.

[Benefits of mycophenolate mofetil in non-transplant kidney diseases]

Glomerular diseases remain frequent causes of end-stage renal failure. Immunosuppressive drugs in association with corticosteroids induce remission of proteinuria and stabilize renal function, as well as prevent relapses, but are responsible for severe potential side-effects: infections, secondary malignancies, sterility and alopecia, and even nephrotoxicity. Mycophenolate mofetil (MMF), a well-known drug in transplantation, presents interesting characteristics potentially useful in the treatment of glomerulopathies. Moreover, its side-effect profile is safer. The present review of the literature suggests that MMF is efficient for the treatment of glomerular disease, even if the results of the different studies remain limited and require further confirmation.

[New management of phosphocalcic abnormalities in dialysis patient]

Disorders of the phosphocalcic metabolism are frequent in dialysis patients. Such disorders are difficult to treat and have negative impact on bone health, but also on cardiovascular mortality. Hyperphosphoremia is a strong predictor of cardiovascular mortality. New phosphate binders are now available in Belgium. A new molecule acting on the calcium receptor of the parathyroid glands is able to control secondary and tertiary hyperparathyroidism in dialysis patients. These new therapies, specific for dialysis patients, will be reviewed in this article.

[Evidence for avoiding the use of beta-blockers as first line therapy in hypertension]

Arterial hypertension is a significant risk factor for cardiovascular disease, proportional to the blood pressure level. Treating hypertension reduces the risk. Until recently, beta-blockers were considered as a first line class for hypertension management. The British Hypertension Society has recently pronounced that using beta-blockers as first line antihypertensive therapy is no good choice since these agents are less protective than other antihypertensive classes against cardiovascular disorders and diabetes mellitus, especially when used in association with diuretics.

[What's new in immunosuppression for renal transplantation?]

The goal of immunosuppression in transplantation is to prevent acute rejection and, more recently, chronic renal graft rejection related in part to side-effects of immunosuppressive therapy (hypertension, diabetes, dyslipidaemia,..). The development of new drugs in renal transplantation has improved graft survival, but also the patient's quality of life. A better understanding of the side-effects of immunosuppressive therapy and the observation of optimal drug associations to reduce these side-effects have often led to propose modifications of the immunosuppressive regimen, mainly at the end of the first trimester after renal transplantation. The aim of this overview is to describe the available oral immunosuppressive agents, especially the new ones, their advantages, but also the danger when different drugs are added in acute illness.

[Anemia and cardiovascular risk in the chronic kidney disease population--which hemoglobin target should be reached?]

Anemia is frequent when chronic kidney disease develops. Its correction by the use of erythropoietin improves the quality of life, and exercise tolerance, and decreases the cardiovascular risk. However, this later risk is not further decreased or even is increased when the hemoglobin target is set above 13 g/dl as compared to the recommended hemoglobin level between 11 and 12 g/dl. This last target therefor gives the best cost-beneficial effect ratio in the chronic kidney disease population. This target must be the new one.

[Clinical case of the month. Nutcracker syndrome in association with a painful nephrologic disease]

Compression of the left renal vein between the aorta and the superior mesenteric artery causes a physiological condition, the so-called nutcracker phenomenon, but it can sometimes lead to left venous hypertension, or "nutcracker syndrome". Classical manifestations of which are an association of left flank pain, unilateral proteinuria and unilateral hematuria, without renal impairment. We report an atypical association of nutcracker syndrome with IgM nephropathy.

Hypertension and the kidney

The kidney could be the cause of essential hypertension which can also cause renal disease. High blood pressure is also very common in chronic kidney disease, and is moreover a well-known risk factor for a faster progression of kidney failure. Hypertension and kidneys are thus closely linked. Hypertension must be aggressively treated in patients suffering from chronic kidney disease, with a blood pressure goal of less than 130/80 mmHg, even lower than 125/75 mmHg when proteinuria is over 1g/day, using optimal and effective antihypertensive drugs. Among them, the blockers of the renin-angiotensin axis offer nephroprotective but also cardioprotective properties beyond their effect on blood pressure.

[Angiotensin converting enzyme inhibitors or angiotensin II receptor blocker in cardiovascular and renal pathology in 2006: what does EBM teach us?]

Inhibitors of the renin-angiotensin system have proved their great value in secondary prevention trials for cardiovascular or renal complications. In favour of the preferred use of angiotensin receptor antagonists stand their excellent tolerance and the possible therapeutic escape seen with angiotensin converting enzyme inhibitors. For the preferential use of the latter, the arguments are the absence of a real proof of any superiority of the angiotensin receptor blockers and their higher cost. The wisdom is to initially use angiotensin converting enzyme inhibitors in secondary prevention excepted when they are not well tolerated. The large ONTARGET cardiovascular prevention trial should help solve this controversy.

[Management of mild and moderate forms of chronic kidney disease]

The prevalence of chronic renal insufficiency, the cost related to its presence and the associated high cardiovascular risk are increasing. Early detection is needed, with, in parallel, identification of all frequently associated cardiovascular risk factors. The general practitioner here plays a major role. Sometimes, a first reference to the nephrologist is requested, for instance in the presence of a nephritic or nephrotic syndrome, of an alteration of glomerular filtration rate without any clear explanation , or of a rather advanced renal dysfunction (a GFR < 60 ml/min in people < 65 years or < 45 ml/min in the others). This paper is concerned with mild and moderate forms of kidney disease (stages 1 to 3). In case of progression, a closer collaboration must exist between the general practitioner, the nephrologist and a trained dietician to slow down this progression, limit its consequences and delay as long as possible the initiation of kidney function supplying techniques.

[How to manage chronically low blood pressure?]

Chronic arterial hypotension has been poorly studied. Its mechanisms are not well understood; its treatment (if needed) is disappointing, without any demonstrated improvement of symptoms or prognosis. Thus, a complete medical examination is needed to exclude any organic cause. If none is found, it is important to reassure the patient and to convince him not to use expensive drugs potentially generative of side effects.

[Polyomavirus BK infection in renal transplant recipients]

Beside acute rejection or immunosuppressive therapy toxicity, infection by Polyomavirus BK, usually not aggressive in immunoactive patients, has emerged as an important factor affecting graft function in renal transplant recipients. Indeed, one of the most important complications of BK infection is nephropathy. Viral replication in the urinary tract as assessed by the presence of "decoy cells", or by a positive PCR for BK virus has been detected in up to half of the recipients but only 5% will present nephropathy which is usually the only sign. The most common risk factors for this emerging new cause are new immunosuppressive drugs and rejection episodes. The gold standard to diagnose BK nephropathy is immunohistochemical staining for large T antigen in graft biopsy specimens. Urine cytology examination and DNA BK PCR are used as a screening test. The prognosis in BK nephropathy has been considered to be poor. The early reduction of immunosuppression can improve the prognosis and perhaps also cidofovir or leflunomide use.

[News in the management of calcium and phosphorus metabolism disorders for patient treated by hemodialysis]

Bone metabolism is very frequently disturbed in end stage renal failure hemodialyzed, with secondary hyperparathyroidism development but also serious potential cardiovascular consequences. New treatments will be available very soon in Europe such as new phosphate binders, vitamin D2 analogues or calcimimetics to fight against such medical diseases, with the hope of less risk for vascular complications. The real place of such new medical opportunities needs to be determined. Moreover, studies with morbidity and mortality end-points are waited before estimating the real importance of these new therapeutic tools.

[Diabetic nephropathy]

Diabetic nephropathy is a constantly increasing pathology in western countries. The trend is more pronounced in type 2 diabetic patients than in type 1 diabetic patients. Among individuals with type 2 diabetes, kidney disease is often multifactorial. This paper reviews recent developments in the pathophysiology, epidemiology and treatment of diabetic nephropathy.

[Hypertension and diabetes]

Hypertension frequently accompanies diabetes mellitus, as it is present in 50% of diabetic patients. Hypertension can sometimes preceed diabetes. In type 2 diabetes, insulin resistance plays a major role in the hypertensive risk. In type 1 diabetes, nephropathy is often noted as soon as hypertension is present. Both hypertension and diabetes increase the risk for cardiovascular and renal complications. For their prevention, first of all, modification of the diet with increasing exercise must be proposed, associated to antihypertensive agents with a blood pressure target lower than 130/80 mmHg. Renin-angiotensin blockers constitute the main drug therapy in such patients associated with diuretics or betablocker if angina pectoris is present or even calcium channel blocker when large arteries abnormalities exist. A frequent evaluation of the cardiovascular risk is required together with research of renal dysfunction or microproteinuria.

[Pancreas transplantation in the management of diabetes]

Pancreas transplantation has now become an established option in the treatment of diabetic complications. It normalizes glucose metabolism, prevents, stabilizes and improves the evolution of diabetes-associated lesions. Improvements in surgical procedure and in immunosuppression have better defined its indications. Combined kidney-pancreas transplantation appears today as the best treatment for the diabetic patient with end stage renal disease. Isolated pancreas transplantation is reserved to non-uremic patients with severe diabetic complications or with hyperlabile glycaemic control and severe impairment of quality of life.

[Hypertension due to primary aldosteronism]

Primary aldosteronism is a rare cause of hypertension. However, its incidence seems to be underestimated. It is important to identify this syndrom since the disease is potentially curable. In the present paper, we depict different forms of primary aldosteronism as well as the diagnostic procedures. When the diagnosis is suspected (hypertension associated to spontaneous or diuretic-induced hypokaliemia), the more efficient screening test is the determination of the aldosteron/renin ratio. Saline infusion or posture tests can thereafter confirm the diagnosis. Differential diagnosis between bilateral and unilateral forms of primary aldosteronism can be made by CT-scanner and the response of aldosterone to the posture test. Such a complex assessment leads to the identification of patients who can be surgically treated. This treatment consists in a unilateral adrenalectomy which can be realised by laparoscopy.