701
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Halimi JM, Matthias B, Al-Najjar A, Laouad I, Chatelet V, Marlière JF, Nivet H, Lebranchu Y. Respective predictive role of urinary albumin excretion and nonalbumin proteinuria on graft loss and death in renal transplant recipients. Am J Transplant 2007; 7:2775-81. [PMID: 17949457 DOI: 10.1111/j.1600-6143.2007.02010.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Proteinuria is constituted by urinary albumin (UAE) and nonalbumin proteins (NAP). UAE was shown to predict ESRD and death. Whether NAP predicts graft or patient outcome is unknown in renal transplantation. We retrospectively analyzed the impact of UAE and NAP respectively on end-stage renal disease (ESRD) and death in 616 renal transplant recipients. In subjects with proteinuria <0.25 g/day, 76% of urine proteins were NAP; in those with >1 g/day, 44% of the urine proteins were NAP. Determinants of UAE and NAP were partly different: fasting glucose, body weight, donor cause of death and cyclosporine were significantly associated with NAP (but not UAE); panel reactive antibodies (PRA) and rapamycine were significantly associated with UAE (but not with NAP). NAP expressed as a continuous (HR: per g/day: 4.00 [2.85-5.63], p < 0.0001) or a categorical (presence vs. absence, HR = 29.09[8.80-96.20], p < 0.0001) parameter and UAE (per g/day, HR = 1.86 [1.24-2.78], p < 0.0001) were risk factors for graft loss in univariate analyses. NAP remained significant even after adjustment on UAE. The presence of NAP (HR: 5.37 [2.55-11.34], p < 0.0001) and macroalbuminuria (HR: 4.12 [1.65-10.29], p = 0.0024) were risk factors for death. Proteinuria is made of various proportions of UAE and NAP in renal transplantation; these two parameters provide different information on graft/patient survival.
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Affiliation(s)
- Jean-Michel Halimi
- Department of Nephrology and Clinical Immunology, François Rabelais University, CHU Tours, Tours, France.
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702
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Lucas SM, Stern JM, Adibi M, Zeltser IS, Cadeddu JA, Raj GV. Renal function outcomes in patients treated for renal masses smaller than 4 cm by ablative and extirpative techniques. J Urol 2007; 179:75-9; discussion 79-80. [PMID: 17997440 DOI: 10.1016/j.juro.2007.08.156] [Citation(s) in RCA: 171] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Indexed: 11/17/2022]
Abstract
PURPOSE We examined the effect of radical nephrectomy, partial nephrectomy and radio frequency ablation on renal function in patients with stage T1a renal masses. MATERIALS AND METHODS A total of 242 consecutive patients from July 1995 to March 2005 undergoing primary treatment for unilateral renal masses smaller than 4 cm and a normal contralateral kidney were identified. Renal function was calculated using the modified Modification of Diet in Renal Disease equation. The rate of decrease in the glomerular filtration rate below 60 ml per minute 1.73 m2 was compared among the 3 treatment modalities. RESULTS A total of 86, 85 and 71 patients were treated with radio frequency ablation, partial nephrectomy and radical nephrectomy, respectively. Preoperatively stage 3 chronic kidney disease (glomerular filtration rate less than 60 ml per minute per 1.73 m2) was identified in 65 patients (26.7%), including 26.7%, 27.1% and 26.8% who underwent radio frequency ablation, partial nephrectomy and radical nephrectomy, respectively. Following intervention the 3-year freedom from a glomerular filtration rate decrease of below 60 ml per minute per 1.73 m2 for radio frequency ablation, partial nephrectomy and radical nephrectomy was 95.2%, 70.7% and 39.9%, respectively (p <0.001). Multivariate analysis showed that radical nephrectomy was an independent risk factor vs radio frequency ablation and partial nephrectomy for stage 3 chronic kidney disease (HR 34.3, 95% CI 4.28-275 and 10.9, 95% CI 1.36-88.7, respectively). CONCLUSIONS Decreased renal function is prevalent in patients with small unilateral renal tumors even with a normal contralateral kidney. Ablative or extirpative nephron sparing techniques are effective for preserving renal function in these patients.
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Affiliation(s)
- Steven M Lucas
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9110, USA
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703
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Inrig JK, Gillespie BS, Patel UD, Briley LP, She L, Easton JD, Topol E, Szczech LA. Risk for cardiovascular outcomes among subjects with atherosclerotic cardiovascular disease and greater-than-normal estimated glomerular filtration rate. Clin J Am Soc Nephrol 2007; 2:1215-22. [PMID: 17942781 DOI: 10.2215/cjn.00930207] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Estimating equations for calculating glomerular filtration rate (eGFR) occasionally identify patients with elevated eGFR, yet the prognostic significance remains to be determined. This study sought to define the association of an elevated eGFR on the risk for death and cardiovascular outcomes among subjects with atherosclerotic cardiovascular disease. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data from 8941 subjects who had a history of atherosclerotic vascular disease and were enrolled in the Blockade of the Glycoprotein IIb/IIIa Receptor to Avoid Vascular Occlusion trial were analyzed. Time to the composite end point of death, congestive heart failure, myocardial infarction, or stroke was modeled using Cox proportion hazards regression. Glomerular filtration rate was estimated using the Modification of Diet in Renal Disease and Cockcroft-Gault formulas. RESULTS Compared with subjects with eGFR of 100 to 125 ml/min per 1.73 m2, subjects with eGFR > or = 125 (n = 462) were younger, female, and nonwhite. In addition, subjects with an elevated eGFR were more likely to have diabetes and congestive heart failure. In adjusted analyses, every 10-ml/min per 1.73 m2 decrease in eGFR < 100 was associated with a 13% increased hazard for the composite end point. In addition, every 10-ml/min per 1.73 m2 increase in eGFR > or = 100 was associated with a 9% increased hazard for the composite end point. CONCLUSIONS In individuals with a history of vascular disease, the relationship between eGFR and cardiovascular outcomes may be parabolic, with increased risk among patients with both reduced and elevated eGFR.
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Affiliation(s)
- Jula K Inrig
- Duke Clinical Research Institute, Duke University Medical Center, Box 3646, Durham, NC 27710, USA.
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704
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Ferris M, Hogan SL, Chin H, Shoham DA, Gipson DS, Gibson K, Yilmaz S, Falk RJ, Jennette JC. Obesity, Albuminuria, and Urinalysis Findings in US Young Adults from the Add Health Wave III Study. Clin J Am Soc Nephrol 2007; 2:1207-14. [DOI: 10.2215/cjn.00540107] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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705
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Yoshida M, Tomiyama H, Yamada J, Koji Y, Shiina K, Nagata M, Yamashina A. Relationships among renal function loss within the normal to mildly impaired range, arterial stiffness, inflammation, and oxidative stress. Clin J Am Soc Nephrol 2007; 2:1118-24. [PMID: 17913969 DOI: 10.2215/cjn.01880507] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES This study was conducted to clarify whether individuals with mildly impaired renal function show increased arterial stiffness, microinflammation, and oxidative stress as compared with those with normal renal function and also to examine the association of these parameters with the degree of GFR loss in middle-aged Japanese men with a low cardiovascular risk. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The brachial-ankle pulse wave velocity and plasma levels of C-reactive protein and lipid peroxides were measured in 1873 men (42 +/- 9 yr of age). RESULTS The brachial-ankle pulse wave velocity but not the plasma C-reactive protein or lipid peroxides, was increased in individuals with mildly impaired renal function. The GFR was significantly correlated with the brachial-ankle pulse wave velocity but not with the log-transformed values of C-reactive protein or lipid peroxides. Multivariate linear regression analysis demonstrated a significant relationship between the brachial-ankle pulse wave velocity and the GFR, independent of the conventional atherosclerotic risk factors. This relationship was significant even in individuals with GFR values within the "normal renal function" range. Thus, GFR loss seems to be more closely associated with arterial stiffness than with microinflammation and/or oxidative stress. CONCLUSIONS A weak but significant relationship was observed between the degree of GFR loss and arterial stiffness, even in individuals with GFR values within the normal renal function range. Therefore, increased arterial stiffness may underlie, at least in part, the elevated cardiovascular risk in individuals with mildly impaired renal function.
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Affiliation(s)
- Masanobu Yoshida
- Second Department of Internal Medicine, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Tokyo, Japan
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706
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Halimi JM, Hadjadj S, Aboyans V, Allaert FA, Artigou JY, Beaufils M, Berrut G, Fauvel JP, Gin H, Nitenberg A, Renversez JC, Rusch E, Valensi P, Cordonnier D. Microalbuminuria and urinary albumin excretion: French clinical practice guidelines. DIABETES & METABOLISM 2007; 33:303-9. [PMID: 17702622 DOI: 10.1016/j.diabet.2007.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Revised: 06/26/2007] [Accepted: 06/27/2007] [Indexed: 11/26/2022]
Abstract
Urinary albumin excretion (UAE) may be assayed on a morning urinary sample or a 24 h-urine sample. Values defining microalbuminuria are: 1) 24-h urine sample: 30-300 mg/24 h; 2) morning urine sample: 20-200 mg/ml or 30-300 mg/g creatinine or 2.5-25 mg/mmol creatinine (men) or 3.5-35 mg/mmol (women); 3) timed urine sample: 20-200 mug/min. The optimal use of semi-quantitative urine test-strip is not clearly defined. It is generally believed that microalbuminuria reflects a generalized impairment of the endothelium; however, no definite proof has been obtained in humans. IN DIABETIC SUBJECTS Microalbuminuria is a marker of increased risk of cardiovascular (CV) and renal morbidity and mortality in type 1 and type 2 diabetic subjects. The increase in UAE during follow-up is associated with greater CV and renal risks in type 1 and type 2 diabetic subjects; its decrease during follow-up is associated with lower risks. IN NON-DIABETIC SUBJECTS: Microalbuminuria is a marker of increased risk for diabetes mellitus, deterioration of renal function, CV morbidity and all-cause mortality. It is a marker of increased risk for the development of hypertension in normotensive subjects, and is associated with unfavorable outcome in patients with cancer and lymphoma. Persistence of elevated UAE during follow-up is associated with poor outcome in some hypertensive subjects. Measurement of UAE may be recommended in hypertensive medium-risk subjects with 1 or 2 CV risk factors in whom CV risk remains difficult to assess, and in those with refractory hypertension: microalbuminuria indicates a high CV risk and must lead to strict control of arterial pressure. Studies focused on microalbuminuria in non-diabetic non-hypertensive subjects are limited; most of them suggest that microalbuminuria predicts CV complications and deleterious outcome. Subjects with a history of CV or cerebrovascular disease have an even greater CV risk if microalbuminuria is present than if it is not; however, in all cases, therapeutic intervention must be aggressive regardless of whether microalbuminuria is present or not. It is not recommended to measure UAE in non-diabetic non-hypertensive subjects in the absence of history of renal disease. Monitoring of renal function (UAE, serum creatinine and estimation of GFR) is recommended annually in all subjects with microalbuminuria. MANAGEMENT In patients with microalbuminuria, weight reduction, sodium restriction (<6 g per day), smoking cessation, strict glucose control in diabetic subjects, strict arterial pressure control are necessary; in diabetic subjects: use of maximal doses of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) are recommended; ACEI/ARB and thiazides have synergistic actions on arterial pressure and reduction of UAE; in non-diabetic subjects, any of the five classes of anti-hypertensive medications (ACEI, ARB, thiazides, calcium channel blockers or beta-blockers) can be used.
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Affiliation(s)
- J-M Halimi
- Service de Néphrologie-Immunologie Clinique, CHU de Tours, 37044 Tours cedex, France.
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707
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Welten GMJM, Schouten O, Chonchol M, Hoeks SE, Feringa HHH, Bax JJ, Dunkelgrün M, van Gestel YRBM, van Domburg RT, Poldermans D. Temporary worsening of renal function after aortic surgery is associated with higher long-term mortality. Am J Kidney Dis 2007; 50:219-28. [PMID: 17660023 DOI: 10.1053/j.ajkd.2007.04.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Accepted: 04/04/2007] [Indexed: 11/11/2022]
Abstract
BACKGROUND Little is known about acute changes in renal function in the postoperative period and the outcome of patients undergoing major vascular surgery. Specifically, data are scarce for patients in whom renal function temporarily decreases and returns to baseline at 3 days after surgery. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS 1,324 patients who underwent elective open abdominal aortic aneurysm surgery in a single center. PREDICTOR Renal function (creatinine clearance was measured preoperatively and on days 1, 2, and 3 after surgery. Patients were divided into 3 groups: group 1, improved or unchanged (change in creatinine clearance, +/-10% of function compared with baseline); group 2, temporary worsening (worsening > 10% at day 1 or 2, then complete recovery within 10% of baseline at day 3); and group 3, persistent worsening (>10% decrease compared with baseline). OUTCOMES & MEASUREMENTS All-cause mortality. RESULTS 30-day mortality rates were 1.3%, 5.0%, and 12.6% in groups 1 to 3, respectively. Adjusted for baseline characteristics and postoperative complications, 30-day mortality was the greatest in patients with persistent worsening of renal function (hazard ratio [HR], 7.3; 95% confidence interval [CI], 2.7 to 19.8), followed by those with temporary worsening (HR, 3.7; 95% CI, 1.4 to 9.9). During 6.0 +/- 3.4 years of follow-up, 348 patients (36.5%) died. Risk of late mortality was 1.7 (95% CI, 1.3 to 2.3) in the persistent-worsening group followed by those with temporary worsening (HR, 1.5; 95% CI, 1.2 to 1.4). LIMITATIONS No steady state was achieved to assess renal function. CONCLUSION Although renal function may recover completely after aortic surgery, temporary worsening of renal function was associated with greater long-term mortality.
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Affiliation(s)
- Gijs M J M Welten
- Department of Vascular Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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708
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Chertow GM, Pupim LB, Block GA, Correa-Rotter R, Drueke TB, Floege J, Goodman WG, London GM, Mahaffey KW, Moe SM, Wheeler DC, Albizem M, Olson K, Klassen P, Parfrey P. Evaluation of Cinacalcet Therapy to Lower Cardiovascular Events (EVOLVE): Rationale and Design Overview. Clin J Am Soc Nephrol 2007; 2:898-905. [PMID: 17702710 DOI: 10.2215/cjn.04381206] [Citation(s) in RCA: 130] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The dramatically high rates of mortality and cardiovascular morbidity observed among dialysis patients highlights the importance of identifying and implementing strategies to lower cardiovascular risk in this population. Results from clinical trials undertaken thus far, including trials on lipid reduction, normalization of hematocrit, and increased dialysis dosage, have been unsuccessful. Available data indicate that abnormalities in calcium and phosphorus metabolism, as a result of either secondary hyperparathyroidism alone or the therapeutic measures used to manage secondary hyperparathyroidism, are associated with an increased risk for death and cardiovascular events. However, no prospective trials have evaluated whether interventions that modify these laboratory parameters result in a reduction in adverse cardiovascular outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Evaluation of Cinacalcet Therapy to Lower Cardiovascular Events is a global, phase 3, double-blind, randomized, placebo-controlled trial evaluating the effects of cinacalcet on mortality and cardiovascular events in hemodialysis patients with secondary hyperparathyroidism. Approximately 3800 patients from 22 countries will be randomly assigned to cinacalcet or placebo. Flexible use of traditional therapies will be permitted. The primary end point is the composite of time to all-cause mortality or first nonfatal cardiovascular event (myocardial infarction, hospitalization for unstable angina, heart failure, or peripheral vascular disease, including lower extremity revascularization and nontraumatic amputation). RESULTS The study will be event driven (terminated at 1882 events) with an anticipated duration of approximately 4 yr. CONCLUSIONS Evaluation of Cinacalcet Therapy to Lower Cardiovascular Events will determine whether management of secondary hyperparathyroidism with cinacalcet reduces the risk for mortality and cardiovascular events in hemodialysis patients.
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Affiliation(s)
- Glenn M Chertow
- Department of Medicine, University of California at San Francisco, San Francisco, California, USA
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709
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Abstract
BACKGROUND Kidney disease, especially chronic kidney disease (CKD), is a worldwide public health problem with serious adverse health consequences for affected individuals. Secondary hyperparathyroidism, a disorder characterized by elevated serum parathyroid hormone levels, and alteration of calcium and phosphorus homeostasis are common metabolic complications of CKD that may impact cardiovascular health. MATERIALS AND METHODS Here, we systematically review published reports from recent observational studies and clinical trials that examine markers of altered mineral metabolism and clinical outcomes in patients with CKD. RESULTS Mineral metabolism disturbances begin early during the course of chronic kidney disease, and are associated with cardiovascular disease and mortality in observational studies. Vascular calcification is one plausible mechanism connecting renal-related mineral metabolism with cardiovascular risk. Individual therapies to correct mineral metabolism disturbances have been associated with clinical benefit in some observational studies; clinical trials directed at more comprehensive control of this problem are warranted. CONCLUSIONS There exists a potential to improve outcomes for patients with CKD through increased awareness of the Bone Metabolism and Disease guidelines set forth by the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative. Future studies may include more aggressive therapy with a combination of agents that address vitamin D deficiency, parathyroid hormone and phosphorus excess, as well as novel agents that modulate circulating promoters and inhibitors of calcification.
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Affiliation(s)
- B Kestenbaum
- University of Washington, Seattle, WA 98104-2499, USA.
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710
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Abstract
Accelerated cardiovascular disease is a frequent complication of renal disease. Chronic kidney disease promotes hypertension and dyslipidemia, which in turn can contribute to the progression of renal failure. Furthermore, diabetic nephropathy is the leading cause of renal failure in developed countries. Together, hypertension, dyslipidemia, and diabetes are major risk factors for the development of endothelial dysfunction and progression of atherosclerosis. Inflammatory mediators are often elevated and the renin-angiotensin system is frequently activated in chronic kidney disease, which likely contributes through enhanced production of reactive oxygen species to the accelerated atherosclerosis observed in chronic kidney disease. Promoters of calcification are increased and inhibitors of calcification are reduced, which favors metastatic vascular calcification, an important participant in vascular injury associated with end-stage renal disease. Accelerated atherosclerosis will then lead to increased prevalence of coronary artery disease, heart failure, stroke, and peripheral arterial disease. Consequently, subjects with chronic renal failure are exposed to increased morbidity and mortality as a result of cardiovascular events. Prevention and treatment of cardiovascular disease are major considerations in the management of individuals with chronic kidney disease.
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Affiliation(s)
- Ernesto L Schiffrin
- Department of Medicine, Sir Mortimer B. Davis Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
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711
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Ledoux D, Monchi M, Chapelle JP, Damas P. Cystatin C blood level as a risk factor for death after heart surgery. Eur Heart J 2007; 28:1848-53. [PMID: 17617637 DOI: 10.1093/eurheartj/ehm270] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Pre-operative renal dysfunction is a known risk factor for mortality and morbidity after heart surgery. Despite limited accuracy, serum creatinine is widely used to estimate glomerular filtration rate (GFR). Cystatin C is more accurate for assessing GFR. The aim of the present study was to assess associations between GFR estimated from serum cystatin C levels before heart surgery and hospital mortality, hospital morbidity, and 1 year mortality. METHODS AND RESULTS In a prospective single-centre observational study, clinical risk factors for morbidity and mortality were recorded and serum creatinine and cystatin C levels were measured in patients admitted for heart surgery. Hospital mortality and morbidity and 1 year mortality were recorded. Over an 8 month period, 499 patients were screened, among whom 376 (74.5%) were included in the study. Hospital mortality was 5.6% (21 patients) and 1 year mortality was 10.2%. Hospital morbidity, defined by a length of stay above the 75th percentile, was 22.1% (83 patients). In the multivariable analysis, GFR estimated from serum cystatin C, but not GFR estimated from serum creatinine, was an independent risk factor for hospital morbidity/mortality (odds ratio per 10 mL/min of GFR decrease, 1.20 (1.07-1.34), P = 0.001) and for 1 year mortality (hazards ratio per 10 mL/min of GFR decrease, 1.26 (1.09-1.46), P = 0.002). CONCLUSION Pre-operative GFR estimation from serum cystatin C may provide a better risk assessment than pre-operative GFR estimation from serum creatinine in patients scheduled for heart surgery.
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Affiliation(s)
- Didier Ledoux
- Intensive Care Unit, Liège University Hospital, Sart Tilman Bat B35, B-4000 Liège, Belgium.
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712
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Jordan J, Grassi G. Adrenergic overdrive: a 'not-so-sympathetic' risk factor in renal failure patients. J Hypertens 2007; 25:1197-9. [PMID: 17563531 DOI: 10.1097/hjh.0b013e3281a7369e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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713
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Levey AS, Atkins R, Coresh J, Cohen EP, Collins AJ, Eckardt KU, Nahas ME, Jaber BL, Jadoul M, Levin A, Powe NR, Rossert J, Wheeler DC, Lameire N, Eknoyan G. Chronic kidney disease as a global public health problem: approaches and initiatives - a position statement from Kidney Disease Improving Global Outcomes. Kidney Int 2007; 72:247-59. [PMID: 17568785 DOI: 10.1038/sj.ki.5002343] [Citation(s) in RCA: 940] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Chronic kidney disease (CKD) is increasingly recognized as a global public health problem. There is now convincing evidence that CKD can be detected using simple laboratory tests, and that treatment can prevent or delay complications of decreased kidney function, slow the progression of kidney disease, and reduce the risk of cardiovascular disease (CVD). Translating these advances to simple and applicable public health measures must be adopted as a goal worldwide. Understanding the relationship between CKD and other chronic diseases is important to developing a public health policy to improve outcomes. The 2004 Kidney Disease Improving Global Outcomes (KDIGO) Controversies Conference on 'Definition and Classification of Chronic Kidney Disease' represented an important endorsement of the Kidney Disease Outcome Quality Initiative definition and classification of CKD by the international community. The 2006 KDIGO Controversies Conference on CKD was convened to consider six major topics: (1) CKD classification, (2) CKD screening and surveillance, (3) public policy for CKD, (4) CVD and CVD risk factors as risk factors for development and progression of CKD, (5) association of CKD with chronic infections, and (6) association of CKD with cancer. This report contains the recommendations from the meeting. It has been reviewed by the conference participants and approved as position statement by the KDIGO Board of Directors. KDIGO will work in collaboration with international and national public health organizations to facilitate implementation of these recommendations.
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Affiliation(s)
- A S Levey
- Tufts-New England Medical Center, Boston, Massachusetts, USA.
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714
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Shadman R, Allison MA, Criqui MH. Glomerular Filtration Rate and N-Terminal Pro-Brain Natriuretic Peptide as Predictors of Cardiovascular Mortality in Vascular Patients. J Am Coll Cardiol 2007; 49:2172-81. [PMID: 17543637 DOI: 10.1016/j.jacc.2007.02.047] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2006] [Revised: 02/01/2007] [Accepted: 02/06/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The purpose of this work was to assess the prognostic role of glomerular filtration rate (GFR) and NT-terminal pro-B-type natriuretic peptide (NT-proBNP) for mortality end points in the vascular population. BACKGROUND The GFR and NT-proBNP have been shown to predict mortality end points in free-living and limited vascular populations, independent of traditional risk factors. However, their prognostic power in an unrestricted vascular population is poorly understood. METHODS A total of 412 subjects from a vascular cohort with a history of either peripheral arterial disease (PAD) and/or other cardiovascular disease (CVD) were included in this prospective cohort analysis and followed for an average of 6.7 years. Outcome variables were all-cause mortality, ischemic heart disease (IHD) mortality, and any cardiovascular mortality. The prognostic roles of GFR and NT-proBNP levels were determined using multivariate survival analysis. RESULTS Higher GFR (per 10 ml/min/1.73 m2) was significantly protective for all-cause mortality (hazard ratio [HR] 0.81, p < 0.001), IHD mortality (HR 0.82, p = 0.008), and CVD mortality (HR 0.84, p = 0.005). Conversely, NT-proBNP was not a significant predictor of any mortality end point. The GFR showed the strongest association in subjects with a history of other CVD. Although NT-proBNP did not demonstrate a significant prognostic role in any of the subgroups, the data were suggestive for patients with PAD alone. CONCLUSIONS Glomerular filtration rate was a robust predictor of all-cause, IHD, and cardiovascular mortality in the vascular population, particularly in those with a history of other CVD, while NT-proBNP showed a suggestive association limited to the group with PAD only. These findings suggest that these markers must be selectively applied in the vascular population for greatest clinical utility.
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Affiliation(s)
- Ramin Shadman
- University of California San Diego, San Diego, California 92093, USA
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715
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Cioffi G, Tarantini L, Pulignano G, Del Sindaco D, De Feo S, Opasich C, Dilenarda A, Stefenelli C, Furlanello F. Prevalence, predictors and prognostic value of acute impairment in renal function during intensive unloading therapy in a community population hospitalized for decompensated heart failure. J Cardiovasc Med (Hagerstown) 2007; 8:419-27. [PMID: 17502758 DOI: 10.2459/01.jcm.0000269715.95317.33] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND METHODS Chronic heart failure (CHF) is often associated with impaired renal function. Diuretics and vasodilators may lead to aggravated renal dysfunction (ARD), particularly among patients with decompensated CHF. Although the prevalence of ARD has been evaluated in patients awaiting heart transplantation, little is known about ARD in the community sample of CHF patients. Accordingly, we prospectively assessed the prevalence, predictors and prognostic value of ARD in 79 consecutive patients admitted to our general community hospital for decompensated CHF undergoing intensive unloading therapy (intravenous nitroprusside and furosemide). ARD was defined as a >or= 25% increase in serum creatinine between admission and maximal value of >or= 2 mg/dl. RESULTS Sixteen patients (20%) developed ARD with a mean increase in serum creatinine of 31% (from 1.74 +/- 0.6 to 2.27 +/- 0.9 mg/dl). ARD persisted at 8-day evaluation in seven of 16 subjects (44%) whereas it was reversible in nine (56%). Lower creatinine clearance at baseline [exp beta = 0.93, 95% confidence interval (CI)=0.87-0.99] and the higher dose of furosemide (exp beta=1.02, 95% CI=1.01-1.03) emerged as independent predictors of ARD. During a follow-up of 11 +/- 8 months, death and hospitalization for worsening CHF occurred more frequently in ARD than non-ARD patients (69% versus 17%, P=0.0001; 69% versus 29%, P=0.003, respectively). Persistent ARD was a powerful independent predictor of long-term adverse outcome (odds ratio=11.1; 95% CI=1.12-36.1; P=0.04). CONCLUSIONS Intensive unloading therapy is associated with the development of ARD in one-fifth of the community population hospitalized for decompensated CHF. The magnitude of this phenomenon is not greater than that observed in younger selected populations with advanced CHF, and depends on baseline renal function and increased diuretic dosage. ARD persisting after 8 days from starting intensive unloading is a powerful predictor of subsequent worsened clinical outcome.
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Affiliation(s)
- Giovanni Cioffi
- Department of Cardiology, Villa Bianca Hospital, Trento, Italy.
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716
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Raggi P, Bellasi A, Ferramosca E, Islam T, Muntner P, Block GA. Association of pulse wave velocity with vascular and valvular calcification in hemodialysis patients. Kidney Int 2007; 71:802-7. [PMID: 17311068 DOI: 10.1038/sj.ki.5002164] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The recent Kidney Disease: Improving Quality Outcomes (KDIGO) recommendations called for an investigation of the relationship between various radiological methods to assess cardiovascular calcification and measures of arterial stiffness. Accordingly, in 131 adult maintenance hemodialysis patients, we investigated the association of aortic pulse wave velocity (PWV) with calcification of cardiac valves on echocardiography, coronary artery, and thoracic aorta calcium on computed tomography and a calcification score of the abdominal aorta obtained on a plain abdominal X-ray. All tests were performed within a week. Mean PWV increased as the severity of coronary artery, thoracic, and abdominal aorta calcium scores increased (each P<0.05). No trend was present for number of valves with calcification. After multivariable adjustment, abdominal aorta X-ray calcium scores remained associated with PWV (P=0.004), whereas the association of PWV with thoracic aorta and coronary artery calcium scores became marginal (P=0.308 and P=0.083, respectively). No association was found between number of calcified valves and PWV. This study demonstrates a strong association between abdominal aorta calcification on plain X-ray and PWV and a borderline association with thoracic aorta and coronary artery calcification. Sudden death and congestive heart failure, two frequent causes of death in hemodialysis, are likely caused by increased arterial stiffness that can be closely predicted by the presence of aortic calcification on plain X-rays.
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Affiliation(s)
- P Raggi
- Division of Cardiology and Department of Radiology, Emory University School of Medicine, Atlanta, Georgia 30322, USA, and Department of Nephrology, Ospedale San Paolo, Milan, Italy.
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717
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Nicholls SJ, Tuzcu EM, Hsu A, Wolski K, Sipahi I, Schoenhagen P, Crowe T, Kapadia SR, Hazen SL, Nissen SE. Comparison of coronary atherosclerotic volume in patients with glomerular filtration rates < or = 60 versus > 60 ml/min/1.73 m(2): a meta-analysis of intravascular ultrasound studies. Am J Cardiol 2007; 99:813-6. [PMID: 17350372 DOI: 10.1016/j.amjcard.2006.10.038] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2006] [Revised: 10/11/2006] [Accepted: 10/30/2006] [Indexed: 10/23/2022]
Abstract
The relation between glomerular filtration rate (GFR) <60 ml/min/1.73 m(2) and the extent and progression of coronary atherosclerosis in 989 subjects with coronary artery disease was investigated. Despite being older, more likely to be women, and having a history of hypertension, diabetes, and bypass surgery, total atheroma volume and percent atheroma volume in subjects with a low GFR did not differ from subjects with a GFR >60 ml/kg/min. Similarly, there was no difference in progression rates of total atheroma volume and percent atheroma volume in patients with GFRs lower and higher than 60 ml/min/1.73 m(2) in response to a high rate of use of established preventive therapies. In conclusion, findings suggest that the increased incidence of clinical events in patients with impaired renal function may result from factors other than atherosclerotic burden.
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Affiliation(s)
- Stephen J Nicholls
- Department of Cardiovascular Medicine, Center for Cardiovascular Diagnostics and Prevention, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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718
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Abstract
PURPOSE OF REVIEW The global prevalence of chronic kidney disease is increasing, as are its complications. Central to the diagnosis, evaluation and management of chronic kidney disease is the estimation of glomerular filtration rate. This article summarizes the various equations used to estimate filtration function and the performance of each in clinical practice. RECENT FINDINGS During the past year the prediction equations to estimate glomerular filtration rate, especially the Modification of Diet in Renal Disease Study equation, continued to receive much interest. Many studies have compared the performance of the Modification of Diet in Renal Disease Study equation and the Cockcroft-Gault equation. The performance of these equations in various patient populations, such as patients with advanced heart failure, diabetic patients, renal transplantation patients, and the healthy general population, has been extensively studied. Overall, the Modification of Diet in Renal Disease Study equation has had an acceptable validity and has outperformed the Cockcroft-Gault equation in the various populations, but with some limitations that the physician should account for in clinical practice. SUMMARY The use of the prediction equations to estimate glomerular filtration rate, especially the Modification of Diet in Renal Disease Study equation, should be implemented more frequently in clinical practice. An ever increasing number of studies has validated its use in different patient populations.
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Affiliation(s)
- Ahmad Fawaz
- Department of Medicine, American University of Beirut, Beirut, Lebanon
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719
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Halimi JM, Buchler M, Al-Najjar A, Laouad I, Chatelet V, Marlière JF, Nivet H, Lebranchu Y. Urinary albumin excretion and the risk of graft loss and death in proteinuric and non-proteinuric renal transplant recipients. Am J Transplant 2007; 7:618-25. [PMID: 17217438 DOI: 10.1111/j.1600-6143.2007.01665.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Microalbuminuria and macroalbuminuria constitute risk factors for ESRD and death in non-transplanted populations. Whether microalbuminuria (especially in non-proteinuric patients) and macroalbuminuria constitute risk factors for graft loss and death is presently unknown in renal transplantation. METHODS We retrospectively assessed the association between urinary albumin excretion (UAE) and ESRD and death in renal transplantation. RESULTS UAE was measured in 616 (397 proteinuric; 219 non-proteinuric patients) renal transplant recipients. They were grafted for 62 months (range: 6-192). During the 40 months (3.7-99) thereafter, 31 patients underwent dialysis and 32 died. Microalbuminuria (vs. normoalbuminuria) and macroalbuminuria (vs. microalbuminuria) were powerful risk factors for graft loss [OR: 14.25 (2.88-52.3) and 16.41 (7.46-36.0), respectively, both p < 0.0001], even after adjustments on renal function and diabetes. Among the 219 non-proteinuric patients, microalbuminuria (vs. normoalbuminuria) was a significant risk factor for graft loss [OR: 23.09 (1.93-276.4), p = 0.0132]. Both microalbuminuria (vs. normoalbuminuria) [OR: 5.55 (2.43-12.66), p < 0.0001] and macroalbuminuria (vs. microalbuminuria) [OR: 4.12 (1.65-10.29), p = 0.0024] were predictive of death. CONCLUSIONS Microalbuminuria and macroalbuminuria are powerful independent predictors of ESRD and death. Microalbuminuria is a risk factor for graft loss even in non-proteinuric patients. UAE provides additional information on renal and patient prognosis as compared to proteinuria and renal function.
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Affiliation(s)
- J-M Halimi
- François Rabelais University, Department of Nephrology and Clinical Immunology, CHU Tours, Tours, France.
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720
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Afshinnia F, Spitalewitz S, Chou SY, Gunsburg DZ, Chadow HL. Left Ventricular Geometry and Renal Function in Hypertensive Patients With Diastolic Heart Failure. Am J Kidney Dis 2007; 49:227-36. [PMID: 17261425 DOI: 10.1053/j.ajkd.2006.10.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2006] [Accepted: 10/20/2006] [Indexed: 11/11/2022]
Abstract
BACKGROUND The objective is to define the relationship between cardiac geometry and renal function in hypertensive subjects with and without diastolic heart failure (DHF). METHODS This is a prospective observational study in a tertiary-care teaching institute in a 15-month period of consecutive hospitalized hypertensive patients. Patients on dialysis therapy or with atrial fibrillation, systolic heart failure, gross proteinuria, and glomerular diseases were excluded. Two-dimensional echocardiography was performed and stable glomerular filtration rate (GFR) was calculated by using the Modification of Diet in Renal Disease formula. Patients were classified into stage 1 to 5 chronic kidney disease (CKD). RESULTS Five hundred forty hypertensive patients were separated into 2 groups: 286 patients with DHF and 254 patients without DHF. Mean age was 69.1 +/- 13.7 (SD) years in general. In patients with DHF, from stages 1 to 5 CKD, there was a significant graded increase in left ventricular mass index (from 117.3 to 162.4 g/m(2)) and relative wall thickness (from 0.42 to 0.52) and a significant graded decrease in aortic cusp separation (from 1.85 to 1.55 cm). Among echocardiographic variables, left ventricular mass index and relative wall thickness were associated inversely and aortic cusp separation was associated directly with GFR. In the absence of DHF, only left ventricular mass index was associated inversely with GFR, suggesting a prominent role of aortic cusp separation and relative wall thickness in the variability in GFR in patients with DHF through a hemodynamic disturbance. CONCLUSION Hemodynamic alterations have a prominent role in the variability of GFR in patients with CKD with DHF. Adverse cardiac geometry is linked to the severity of CKD in hypertensive patients, raising the possibility of preserving both cardiac and renal function by means of hypertension control.
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Affiliation(s)
- Farsad Afshinnia
- Department of Internal Medicine at Memorial Medical Center, Sutter-Gould Medical Foundation Inc, Modesto, CA, USA.
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721
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Hase H, Joki N, Ishikawa H, Saijyo T, Tanaka Y, Takahashi Y, Inishi Y, Imamura Y, Nakamura M, Moroi M. Independent risk factors for progression of coronary atherosclerosis in hemodialysis patients. Ther Apher Dial 2007; 10:321-7. [PMID: 16911184 DOI: 10.1111/j.1744-9987.2006.00384.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Not uncommonly, hemodialysis patients with normal results in myocardial perfusion tests can still have a cardiac event within 2 years of evaluation. We examined possible risk factors for progression of coronary atherosclerosis in hemodialysis patients. We prospectively evaluated ability of myocardial perfusion imaging carried out under pharmacologic stress to predict 2-year outcomes in 77 hemodialysis patients, specifically thallium-201 single-photon emission computed tomography (SPECT) using high-dose adenosine triphosphate as the stressor. The primary end-point was a cardiac event (cardiac death, non-fatal acute coronary syndrome, or hospitalization for acute ischemic heart failure). Factors independently influencing duration until a cardiac event in hemodialysis patients were identified using stepwise multiple regression analysis. Myocardial perfusion defects were shown in 36 patients. Patients with a perfusion defect were more likely to have cardiac events than those with normal perfusion (78% vs. 15%, P < 0.001). Time until occurrence of a cardiac event in hemodialysis patients showed a significant, independent association with known coronary artery disease [regression coefficient (RC) = -3.391, P = 0.046], elevated C-reactive protein (RC = -5.813, P = 0.005), and a reversible myocardial perfusion defect (RC = -7.386, P < 0.001). An analysis based on the 'best cut-off' of CRP as identified on the basis of the ROC curve augmented the positive and negative predict value of CRP for the prediction of coronary events to 65 and 74%, respectively. Myocardial perfusion SPECT and measuring the plasma concentration of CRP might be useful for the prediction of hemodialysis patients with progression of coronary atherosclerosis.
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Affiliation(s)
- Hiroki Hase
- Division of Nephrology, Department of Internal Medicine, Toho University Ohashi Hospital, Tokyo, Japan.
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722
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Jones CY. Metabolic syndrome in HIV-infected patients: no different than the general population? Clin Infect Dis 2007; 44:735-8. [PMID: 17278069 DOI: 10.1086/511691] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Accepted: 11/20/2006] [Indexed: 12/28/2022] Open
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723
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Abstract
Assessment and follow-up of renal dysfunction is important in the early detection and management of chronic kidney disease. The glomerular filtration rate (GFR) is the most accurate measurement of kidney disease and is reduced before the onset of clinical symptoms. Drawbacks to the measurement of GFR include the high cost and incompatibility with routine laboratory monitoring. Serum creatinine determination is a mainstay in the routine laboratory profile of renal function. The measurement of serum cystatin C has been proposed as a more sensitive marker for GFR. According to National Kidney Foundation-K/DOQ1 clinical guidelines for chronic kidney disease, serum markers should not be used alone to assess GFR. Based on prediction equations, clinical laboratories should report an estimate of GFR, in addition to reporting the serum value. In this article, information is presented on how best to estimate GFR using prediction equations for adults and for children. Using serum creatinine concentration with the Modification of Diet in Renal Disease (MDRD) study equation offers a suitable estimation of GFR in adults. The cystatin C prediction equation with the use of a prepubertal factor seems superior to creatinine-based prediction equations in children of <14 years.
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Affiliation(s)
- Lothar Thomas
- Department of Laboratory Medicine, Krankenhaus Nordwest, Frankfurt, Germany.
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724
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Izzo JL, Liebson PR, Gorelick PB, Reidy JJ, Mimran A. Assessment of Hypertensive Target Organ Damage. Hypertension 2007. [DOI: 10.1016/b978-1-4160-3053-9.50021-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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725
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Khosla N, Bakris GL. Treatment of Hypertension in Patients with Renal Disease. Cardiovasc Ther 2007. [DOI: 10.1016/b978-1-4160-3358-5.50041-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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726
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The Heart and the Kidney. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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727
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Alfonzo AVM, Simpson K, Deighan C, Campbell S, Fox J. Modifications to advanced life support in renal failure. Resuscitation 2006; 73:12-28. [PMID: 17187916 DOI: 10.1016/j.resuscitation.2006.07.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2006] [Revised: 07/10/2006] [Accepted: 07/17/2006] [Indexed: 11/26/2022]
Abstract
The outcome of cardiopulmonary resuscitation (CPR) has been reported to be worse in patients with renal failure compared with those with normal renal function. It is likely that this increased mortality may be at least partly attributable to sub-optimal and highly variable treatment strategies used in cardiac arrest in patients with renal failure, but this issue has not previously been explored. Such patients undoubtedly pose a challenge to advanced life support (ALS) providers, and renal unit staff are not trained to provide specialist advice after a patient has sustained a cardiac arrest. There are few studies investigating the epidemiology, safety or outcome of cardiac arrest in patients with renal failure and there are no generally accepted resuscitation guidelines for this special circumstance. In this article we discuss the unique problems of resuscitating patients with renal failure and propose a suitable management strategy.
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Affiliation(s)
- Annette V M Alfonzo
- Renal Unit, Queen Margaret Hospital, Whitefield Road, Dunfermline, Fife, Scotland, KY12 0SU, United Kingdom.
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728
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Gross ML, Meyer HP, Ziebart H, Rieger P, Wenzel U, Amann K, Berger I, Adamczak M, Schirmacher P, Ritz E. Calcification of coronary intima and media: immunohistochemistry, backscatter imaging, and x-ray analysis in renal and nonrenal patients. Clin J Am Soc Nephrol 2006; 2:121-34. [PMID: 17699396 DOI: 10.2215/cjn.01760506] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Coronary calcification is a potent predictor of cardiac events. In patients with chronic renal disease, both prevalence and intensity of coronary calcification are increased. It has remained uncertain whether it is the intima of the coronaries or the media that is calcified and whether the morphologic details of calcified plaques differ between renal and nonrenal patients. Autopsy samples of coronaries were obtained from standard sites in 23 renal and 23 age- and gender-matched nonuremic patients. Specimens were examined using light and electron microscopy, immunohistochemistry, backscatter imaging, and x-ray analysis. In coronaries, calcified plaques occupied a similar proportion of the intima area in renal versus nonrenal patients (17.3 +/- 11.9 versus 18.1 +/- 11.9%) but occupied a significantly higher proportion of the media (16.6 +/- 10.6 versus 3.8 +/- 2.31%). Expression of the proteins osteocalcin, C-reactive protein, TGF-beta, and collagen IV was significantly more intensive around coronary plaques of renal compared with nonrenal patients. The non-plaque-bearing intima of renal patients showed minimal staining for fetuin, but fetuin staining was seen surrounding calcified plaques. In addition, more pronounced deposition of C5b-9 was found around coronary plaques of renal patients, and glycophorin deposition pointed to more past intraplaque hemorrhage in renal patients. Calcification by electron backscatter analysis is more intense in the coronary media, but not if the intima is more intense in renal compared with nonrenal patients. A more marked inflammatory response in renal patients is suggested by more frequent presence and greater intensity of markers of inflammation.
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729
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Uhlig K, Macleod A, Craig J, Lau J, Levey AS, Levin A, Moist L, Steinberg E, Walker R, Wanner C, Lameire N, Eknoyan G. Grading evidence and recommendations for clinical practice guidelines in nephrology. A position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2006; 70:2058-65. [PMID: 17003817 DOI: 10.1038/sj.ki.5001875] [Citation(s) in RCA: 157] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Considerable variation in grading systems used to rate the strength of guideline recommendations and the quality of the supporting evidence in Nephrology highlights the need for a uniform, internationally accepted, rigorous system. In 2004, Kidney Disease: Improving Global Outcomes (KDIGO) commissioned a methods expert group to recommend an approach for grading in future nephrology guidelines. This position statement by KDIGO recommends adopting the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach for the grading of evidence and guidelines on interventions. The GRADE approach appraises systematic reviews of the benefits and harms of an intervention to determine its net health benefit. The system considers the design, quality, and quantity of studies as well as the consistency and directness of findings when grading the quality of evidence. The strength of the recommendation builds on the quality of the evidence and additional considerations including costs. Adaptations of the GRADE approach are presented to address some issues pertinent to the field of nephrology, including (1) the need to extrapolate from studies performed predominantly in patients without kidney disease, and (2) the need to use qualitative summaries of effects when it is not feasible to quantitatively summarize them. Further refinement of the system will be required for grading of evidence on questions other than those related to intervention effects, such as diagnostic accuracy and prognosis.
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Affiliation(s)
- K Uhlig
- Department of Medicine, Tufts New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts 02111, USA.
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730
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Levey AS, Stevens LA, Hostetter T. Automatic Reporting of Estimated Glomerular Filtration Rate—Just What the Doctor Ordered. Clin Chem 2006; 52:2188-93. [PMID: 17068166 DOI: 10.1373/clinchem.2006.078733] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Andrew S Levey
- Division of Nephrology, Department of Medicine, Tufts-New England Medical Center, Boston, MA 02111, USA
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731
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Norris K, Bourgoigne J, Gassman J, Hebert L, Middleton J, Phillips RA, Randall O, Rostand S, Sherer S, Toto RD, Wright JT, Wang X, Greene T, Appel LJ, Lewis J. Cardiovascular outcomes in the African American Study of Kidney Disease and Hypertension (AASK) Trial. Am J Kidney Dis 2006; 48:739-51. [PMID: 17059993 DOI: 10.1053/j.ajkd.2006.08.004] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2006] [Accepted: 08/09/2006] [Indexed: 01/13/2023]
Abstract
BACKGROUND Patients with chronic kidney disease are at increased risk for cardiovascular (CV) events. METHODS We randomly assigned 1,094 African Americans with hypertensive nephrosclerosis (glomerular filtration rate [GFR], 20 to 65 mL/min/1.73 m(2) [0.33 to 1.08 mL/s]) to initial antihypertensive treatment with either: (1) a beta-blocker, metoprolol; (2) an angiotensin-converting enzyme inhibitor, ramipril; or (3) a dihydropyridine calcium channel blocker, amlodipine, and either a usual-blood pressure (BP) or low-BP treatment goal. Using a design powered to detect renal outcome differences, we compared the effect of treatment on the CV event rate (cardiac death, myocardial infarction, stroke, and heart failure) during a mean follow-up period of 4.1 years and determined baseline factors that predict CV outcomes. RESULTS Thirty-one patients died of CV disease (0.7%/patient-year), and 149 patients experienced at least 1 CV outcome (3.3%/patient-year). Overall, 202 CV events (4.5%/patient-year) occurred. The CV outcome rate was not related significantly to randomized interventions. In multivariable analyses, 7 baseline risk factors remained independently associated with increased risk for the CV composite outcome after controlling for age, sex, baseline GFR, and baseline proteinuria group: pulse pressure, duration of hypertension, abnormal electrocardiogram result, non-high-density lipoprotein cholesterol level, serum urea nitrogen level, urine protein-creatinine ratio, urine sodium-potassium ratio, and annual income less than 15,000 dollars. CONCLUSION Neither randomized class of antihypertensive therapy nor BP level had a significant effect on the occurrence of CV events, possibly because of limited power. However, this analysis identifies unique and potentially modifiable CV risk factors in this high-risk cohort.
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Affiliation(s)
- Keith Norris
- Charles R. Drew University of Medicine and Science, Lynwood, CA 90262, USA.
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732
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Schwartz GL, Textor SC. Early referral for chronic kidney disease: good for those who need it, but who are they? Mayo Clin Proc 2006; 81:1420-2. [PMID: 17120394 DOI: 10.4065/81.11.1420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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733
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Vettoretti S, Ochodnicky P, Buikema H, Henning RH, Kluppel CA, de Zeeuw D, van Dokkum RPE. Altered myogenic constriction and endothelium-derived hyperpolarizing factor-mediated relaxation in small mesenteric arteries of hypertensive subtotally nephrectomized rats. J Hypertens 2006; 24:2215-23. [PMID: 17053543 DOI: 10.1097/01.hjh.0000249699.04113.36] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Chronic renal failure (CRF) is associated with altered systemic arterial tone and hypertension. Myogenic constriction and endothelium-derived hyperpolarizing factor (EDHF)-dependent relaxation represent major vasoregulatory mechanisms in small systemic arteries. Elevated myogenic response and impaired EDHF might participate in the development of essential hypertension; however, their role in CRF-related hypertension is unknown. We investigated whether myogenic response and EDHF are altered in subtotally nephrectomized (sNX) rats and whether these changes are modifiable by chronic treatment with angiotensin-converting enzyme (ACE) inhibitor. METHODS In a pressure arteriograph, myogenic constriction and EDHF-mediated relaxation were evaluated in small mesenteric arteries isolated from male Wistar rats 15 weeks after either sham operation (n = 7) (SHAM), sNX (n = 12) or sNX followed by 9 weeks of treatment with lisinopril (sNX + LIS, 2.5 mg/kg, n = 13). RESULTS Surprisingly, myogenic response was reduced in hypertensive CRF rats (maximal myogenic tone: 37 +/- 2 and 18 +/- 4%, P < 0.01; peak myogenic index: -0.80 +/- 0.08 and -0.40 +/- 0.12%/mmHg, P < 0.05 in SHAM and sNX respectively). At the same time EDHF-mediated relaxation was also impaired (maximal response: 92 +/- 2 and 77 +/- 5%, P < 0.01; pD2: 6.5 +/- 0.1 and 5.9 +/- 0.1, P < 0.05). Both myogenic response and EDHF were inversely related to the severity of renal failure and restored by treatment with lisinopril to levels found in SHAM animals. CONCLUSION Major constrictive (myogenic) and dilatory (EDHF) mechanisms of small systemic arteries are impaired in hypertensive CRF rats. These alterations do not seem to participate in the development of hypertension, being rather directly related to the severity of renal impairment. Both systemic vascular changes might be restored by renoprotective treatment with ACE inhibitor.
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Affiliation(s)
- Simone Vettoretti
- Department of Clinical Pharmacology, University Medical Center Groningen and Groningen Institute for Drug Exploration (GUIDE), University of Groningen, The Netherlands
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734
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Lichtenstein AH, Appel LJ, Brands M, Carnethon M, Daniels S, Franch HA, Franklin B, Kris-Etherton P, Harris WS, Howard B, Karanja N, Lefevre M, Rudel L, Sacks F, Van Horn L, Winston M, Wylie-Rosett J. Summary of American Heart Association Diet and Lifestyle Recommendations revision 2006. Arterioscler Thromb Vasc Biol 2006; 26:2186-91. [PMID: 16990564 DOI: 10.1161/01.atv.0000238352.25222.5e] [Citation(s) in RCA: 229] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Alice H Lichtenstein
- Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA 02111, USA.
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735
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Viazzi F, Leoncini G, Sacchi G, Parodi D, Ratto E, Falqui V, Parodi A, Vaccaro V, Tomolillo C, Deferrari G, Pontremoli R. Predicting cardiovascular risk using creatinine clearance and an artificial neural network in primary hypertension. J Hypertens 2006; 24:1281-6. [PMID: 16794476 DOI: 10.1097/01.hjh.0000234107.08368.e5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A slight reduction in estimated creatinine clearance is a predictor of unfavorable outcome in patients with primary hypertension. We evaluated how well an artificial neural network (ANN) can assess cardiovascular risk profile on the basis of estimated creatinine clearance and routine, low-cost clinical data, as compared with thorough clinical work-up, which includes an accurate assessment of target organ damage. METHODS A group of 404 untreated patients with essential hypertension (250 men, 154 women; mean age, 47 +/- 9 years) were studied. We compared two different approaches that can be used to allocate patients into different risk classes according to the European Society of Hypertension-European Society of Cardiology guidelines: thorough clinical work-up, including cardiac and vascular ultrasound scan and microalbuminuria; and prediction by an ANN on the basis of estimated creatinine clearance and routine clinical data. RESULTS Thorough evaluation, as recommended by the guidelines, showed that 6% (n = 24) of our patients were at low risk, 20% (n = 81) were at medium risk, 45% (n = 182) were at high risk, and 29% (n = 117) were at very high risk. The ANN approach yielded almost superimposable results (sensitivity, 94%; positive predictive value, 96%; r = 0.95). CONCLUSIONS An ANN can accurately identify the patient's risk status using low-cost, clinical data and estimated creatinine clearance. These results emphasize the value of even a mild reduction in creatinine clearance for the stratification of cardiovascular risk in primary hypertension.
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Affiliation(s)
- Francesca Viazzi
- Department of Internal Medicine and Cardionephrology, Azienda Universitaria Ospedale San Martino, Italy
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736
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Huang WC, Levey AS, Serio AM, Snyder M, Vickers AJ, Raj GV, Scardino PT, Russo P. Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol 2006; 7:735-40. [PMID: 16945768 PMCID: PMC2239298 DOI: 10.1016/s1470-2045(06)70803-8] [Citation(s) in RCA: 1215] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Chronic kidney disease is a graded and independent risk factor for substantial comorbidity and death. We aimed to examine new onset of chronic kidney disease in patients with small, renal cortical tumours undergoing radical or partial nephrectomy. METHODS We did a retrospective cohort study of 662 patients with a normal concentration of serum creatinine and two healthy kidneys undergoing elective partial or radical nephrectomy for a solitary, renal cortical tumour (</=4 cm) between 1989 and 2005 at a referral cancer centre. Glomerular filtration rate (GFR) was estimated with the abbreviated Modification in Diet and Renal Disease Study equation. Separate analysis was undertaken, with chronic kidney disease defined as GFR lower than 60 mL/min per 1.73 m(2) and GFR lower than 45 mL/min per 1.73 m(2). FINDINGS 171 (26%) patients had pre-existing chronic kidney disease before surgery. After surgery, the 3-year probability of freedom from new onset of GFR lower than 60 mL/min per 1.73 m(2) was 80% (95% CI 73-85) after partial nephrectomy and 35% (28-43; p<0.0001) after radical nephrectomy; corresponding values for GFRs lower than 45 mL/min per 1.73 m(2) were 95% (91-98) and 64% (56-70; p<0.0001), respectively. Multivariable analysis showed that radical nephrectomy remained an independent risk factor for patients developing new onset of GFR lower than 60 mL/min per 1.73 m(2) (hazard ratio 3.82 [95% CI 2.75-5.32]) and 45 mL/min per 1.73 m(2) (11.8 [6.24-22.4]; both p<0.0001). INTERPRETATION Because the baseline kidney function of patients with renal cortical tumours is lower than previously thought, accurate assessment of kidney function is essential before surgery. Radical nephrectomy is a significant risk factor for the development of chronic kidney disease and might no longer be regarded as the gold standard treatment for small, renal cortical tumours.
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Affiliation(s)
- William C Huang
- Department of Urology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA
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737
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Hayden MR, Chowdhury NA, Cooper SA, Whaley-Connell A, Habibi J, Witte L, Wiedmeyer C, Manrique CM, Lastra G, Ferrario C, Stump C, Sowers JR. Proximal tubule microvilli remodeling and albuminuria in the Ren2 transgenic rat. Am J Physiol Renal Physiol 2006; 292:F861-7. [PMID: 17032939 DOI: 10.1152/ajprenal.00252.2006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
TG(mRen2)27 (Ren2) transgenic rats overexpress the mouse renin gene, with subsequent elevated tissue ANG II, hypertension, and nephropathy. The proximal tubule cell (PTC) is responsible for the reabsorption of 5-8 g of glomerular filtered albumin each day. Excess filtered albumin may contribute to PTC damage and tubulointerstitial disease. This investigation examined the role of ANG II-induced oxidative stress in PTC structural remodeling: whether such changes could be modified with in vivo treatment with ANG type 1 receptor (AT(1)R) blockade (valsartan) or SOD/catalase mimetic (tempol). Male Ren2 (6-7 wk old) and age-matched Sprague-Dawley rats were treated with valsartan (30 mg/kg), tempol (1 mmol/l), or placebo for 3 wk. Systolic blood pressure, albuminuria, N-acetyl-beta-D-glucosaminidase, and kidney tissue malondialdehyde (MDA) were measured, and x60,000 transmission electron microscopy images were used to assess PTC microvilli structure. There were significant differences in systolic blood pressure, albuminuria, lipid peroxidation (MDA and nitrotyrosine staining), and PTC structure in Ren2 vs. Sprague-Dawley rats (each P < 0.05). Increased mean diameter of PTC microvilli in the placebo-treated Ren2 rats (P < 0.05) correlated strongly with albuminuria (r(2) = 0.83) and moderately with MDA (r(2) = 0.49), and there was an increase in the ratio of abnormal forms of microvilli in placebo-treated Ren2 rats compared with Sprague-Dawley control rats (P < 0.05). AT(1)R blockade, but not tempol treatment, abrogated albuminuria and N-acetyl-beta-d-glucosaminidase; both therapies corrected abnormalities in oxidative stress and PTC microvilli remodeling. These data indicate that PTC structural damage in the Ren2 rat is related to the oxidative stress response to ANG II and/or albuminuria.
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Affiliation(s)
- Melvin R Hayden
- Department of Internal Medicine, University of Missouri, Columbia, USA
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738
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Bökenkamp A, Herget-Rosenthal S, Bökenkamp R. Cystatin C, kidney function and cardiovascular disease. Pediatr Nephrol 2006; 21:1223-30. [PMID: 16838182 DOI: 10.1007/s00467-006-0192-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2006] [Revised: 05/24/2006] [Accepted: 05/26/2006] [Indexed: 11/25/2022]
Abstract
Cystatin C, an endogenous low-molecular-weight marker of glomerular filtration rate, has recently been shown to be associated with future cardiovascular disease in healthy elderly populations and patients with documented atherosclerosis in a dose-dependent manner that possibly reflects a very early stage of chronic renal dysfunction. At the same time, local cystatin C deficiency has been demonstrated in atherosclerotic and aneurismal lesions, suggesting a protective role of cystatin C in the vessel wall, possibly in concert with TGF-beta1. Although cystatin C is not an acute phase reactant, large epidemiological studies have documented a highly significant association between serum cystatin C and mildly increased C-reactive protein (CRP) levels, the hallmark of the chronic inflammatory state associated with atherosclerosis and chronic renal failure. Since cystatin C is produced by all nucleated cells, it is unlikely that local variations in cystatin C synthesis in diseased arteries--rather than global cystatin C production and renal elimination--should determine its serum concentration. Consequently, the present review proposes microinflammation as the unifying concept for both lines of evidence.
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739
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740
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Freda BJ, Francis GS. Natriuretic Peptides and Renal Insufficiency: Clinical Significance and Role of Renal Clearance. Heart Fail Clin 2006; 2:277-90. [PMID: 17386897 DOI: 10.1016/j.hfc.2006.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Benjamin J Freda
- Tufts University School of Medicine, Baystate Medical Center, Springfield, MA, USA
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741
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Lichtenstein AH, Appel LJ, Brands M, Carnethon M, Daniels S, Franch HA, Franklin B, Kris-Etherton P, Harris WS, Howard B, Karanja N, Lefevre M, Rudel L, Sacks F, Van Horn L, Winston M, Wylie-Rosett J. Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee. Circulation 2006; 114:82-96. [PMID: 16785338 DOI: 10.1161/circulationaha.106.176158] [Citation(s) in RCA: 1696] [Impact Index Per Article: 94.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Improving diet and lifestyle is a critical component of the American Heart Association's strategy for cardiovascular disease risk reduction in the general population. This document presents recommendations designed to meet this objective. Specific goals are to consume an overall healthy diet; aim for a healthy body weight; aim for recommended levels of low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides; aim for normal blood pressure; aim for a normal blood glucose level; be physically active; and avoid use of and exposure to tobacco products. The recommendations are to balance caloric intake and physical activity to achieve and maintain a healthy body weight; consume a diet rich in vegetables and fruits; choose whole-grain, high-fiber foods; consume fish, especially oily fish, at least twice a week; limit intake of saturated fat to <7% of energy, trans fat to <1% of energy, and cholesterol to <300 mg/day by choosing lean meats and vegetable alternatives, fat-free (skim) or low-fat (1% fat) dairy products and minimize intake of partially hydrogenated fats; minimize intake of beverages and foods with added sugars; choose and prepare foods with little or no salt; if you consume alcohol, do so in moderation; and when you eat food prepared outside of the home, follow these Diet and Lifestyle Recommendations. By adhering to these diet and lifestyle recommendations, Americans can substantially reduce their risk of developing cardiovascular disease, which remains the leading cause of morbidity and mortality in the United States.
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742
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Stevens LA, Coresh J, Greene T, Levey AS. Assessing kidney function--measured and estimated glomerular filtration rate. N Engl J Med 2006; 354:2473-83. [PMID: 16760447 DOI: 10.1056/nejmra054415] [Citation(s) in RCA: 2004] [Impact Index Per Article: 111.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Lesley A Stevens
- Division of Nephrology, Tufts-New England Medical Center, Boston, MA 02111, USA.
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743
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Fesler P, Ribstein J. Prise en charge de l’hypertension artérielle d’origine rénale. Presse Med 2006; 35:1061-6. [PMID: 16783273 DOI: 10.1016/s0755-4982(06)74748-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Assessment of every hypertensive patient must include the search for kidney disease, i.e. elevated serum creatinine and proteinuria. Antihypertensive therapy may attenuate both the risk of progression toward renal failure and the cardiovascular risk associated with chronic kidney disease, albeit the cause or the consequence of hypertension. Any alteration in renal function will promote salt-sensitivity of blood pressure and increase the deleterious effects of salt intake on target organ damage. The goal of antihypertensive therapy in patients with chronic kidney disease is first to reduce systolic blood pressure below 130 mmHg. The second goal is to lower urinary protein excretion to less than 0.5 g per day. The presence of proteinuria calls for blockers of the renin-angiotensin system among antihypertensive drugs. Global risk management (i.e. fighting tobacco, obesity, dyslipemia) will reduce the renal as well as the cardiovascular risk.
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Affiliation(s)
- Pierre Fesler
- Service de Médecine Interne, Hôpital Lapeyronie, Montpellier
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744
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Jacobi J, Porst M, Cordasic N, Namer B, Schmieder RE, Eckardt KU, Hilgers KF. Subtotal nephrectomy impairs ischemia-induced angiogenesis and hindlimb re-perfusion in rats. Kidney Int 2006; 69:2013-21. [PMID: 16641920 DOI: 10.1038/sj.ki.5000448] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Kidney disease is associated with increased cardiovascular morbidity, but underlying mechanisms are poorly understood. We tested the hypothesis that chronic renal insufficiency impairs angioadaptation in a rat model of hindlimb ischemia. Twenty male Sprague-Dawley rats (8 weeks old) underwent subtotal nephrectomy (5/6SNX) or sham surgery (each n=10). Ten weeks later, unilateral hindlimb ischemia was induced in all animals. Hindlimb perfusion was assessed by laser Doppler perfusion imaging and fluorescent microsphere injection studies 2 weeks after surgery. Ischemia-induced angiogenesis was measured by analyzing capillary density using CD31 immunofluorescence. Expression of vascular endothelial growth factor (VEGF), its receptors (VEGFRs) and inducible as well as endothelial nitric oxide (NO) synthase was measured by real-time reverse transcription-polymerase chain reaction. Laser Doppler hindpaw perfusion was significantly reduced in 5/6SNX compared to sham-operated animals. Impaired hindlimb re-perfusion in 5/6SNX vs control rats was confirmed by fluorescent microsphere injection studies (relative perfusion of ischemic vs non-ischemic limb: 68.9+/-6.4 vs 92.4+/-3.6%, P=0.005). Ischemic skeletal muscle neovascularization increased to a greater extent in sham-operated compared to 5/6SNX rats (69+/-8 vs 29+/-7%, P<0.05). VEGF and VEGFR-1/2 mRNA expression increased in ischemic hindlimbs of control rats, whereas no change or a decrease was observed in 5/6SNX. In contrast, inducible and endothelial NO synthase expression did not significantly differ between sham and 5/6SNX rats. Chronic renal insufficiency impairs angiogenesis and limb perfusion in a rat hindlimb ischemia model. Impaired angioadaptation may contribute to the poor prognosis of patients with renal failure suffering from peripheral arterial disease.
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Affiliation(s)
- J Jacobi
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
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745
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Ng YH, Meyer KB, Kusek JW, Yan G, Rocco MV, Kimmel PL, Benz RL, Beddhu S, Dwyer JT, Toto RD, Eknoyan G, Unruh ML. Hemodialysis timing, survival, and cardiovascular outcomes in the Hemodialysis (HEMO) Study. Am J Kidney Dis 2006; 47:614-24. [PMID: 16564939 DOI: 10.1053/j.ajkd.2005.12.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2005] [Accepted: 12/12/2005] [Indexed: 11/11/2022]
Abstract
BACKGROUND The timing of medical therapies has been shown to influence the outcomes and side effects of treatments for disease. This report examines the extent to which hemodialysis treatment time of day was associated with cardiovascular mortality and morbidity and all-cause mortality in a secondary analysis of the Hemodialysis Study. METHODS Dialysis start time defined dialysis shift: morning beginning between 0400 and 0930 hours (n = 822); midday, between 0930 and 1530 hours (n = 851); and evening, between 1530 and 2200 hours (n = 172). Outcome measures included all-cause mortality, cardiac death, composite end point of all-cause mortality or first cardiac hospitalization, and composite end point of first cardiac hospitalization or cardiac death. RESULTS Morning hemodialysis was associated with a lower likelihood of cardiovascular events compared with the evening shift in all-cause mortality or first cardiac hospitalization (evening versus morning, relative risk [RR], 1.29; 95% confidence interval [CI], 1.01 to 1.65; P = 0.043), as well as first cardiac hospitalization or cardiac death (evening versus morning, RR, 1.44; 95% CI, 1.11 to 1.89; P = 0.007). No differences were noted in the other 2 outcomes, and there was no statistically significant difference between the morning and midday shifts. Although crude mortality rates were greater in the midday compared with morning (RR, 1.21; 95% CI, 1.05 to 1.39; P = 0.008), this association was attenuated after adjustment (RR, 1.04; 95% CI, 0.89 to 1.22; P = 0.64). CONCLUSION Making extensive adjustment for patient characteristics, this report does not support the association of lower all-cause mortality with morning hemodialysis or a particular benefit for older patients.
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Affiliation(s)
- Yue-Harn Ng
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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746
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Nagase M, Shibata S, Yoshida S, Nagase T, Gotoda T, Fujita T. Podocyte injury underlies the glomerulopathy of Dahl salt-hypertensive rats and is reversed by aldosterone blocker. Hypertension 2006; 47:1084-93. [PMID: 16636193 DOI: 10.1161/01.hyp.0000222003.28517.99] [Citation(s) in RCA: 194] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Recent clinical studies implicate proteinuria as a key prognostic factor for renal and cardiovascular complications in hypertensives. The pathogenesis of proteinuria in hypertension is, however, poorly elucidated. Podocytes constitute the final filtration barrier in the glomerulus, and their dysfunction may play a pivotal role in proteinuria. In the present study, we examined the involvement of podocyte injury in Dahl salt-hypertensive rats, an animal model prone to hypertensive glomerulosclerosis, and explored the effects of inhibition of aldosterone. Four-week-old Dahl salt-resistant and salt-sensitive rats were fed a 0.3% or 8.0% NaCl diet. Some salt-loaded Dahl salt-sensitive rats were treated with a selective aldosterone blocker eplerenone (1.25 mg/g diet) or hydralazine (0.5 mmol/L). After 6 weeks, salt-loaded Dahl salt-sensitive rats developed severe hypertension, proteinuria, and glomerulosclerosis. Immunostaining for nephrin, a constituent of slit diaphragm, was attenuated, whereas expressions of damaged podocyte markers desmin and B7-1 were upregulated in the glomeruli of salt-loaded Dahl salt-sensitive rats. Electron microscopic analysis revealed podocyte foot process effacement. Podocytes were already impaired at as early as 2 weeks of salt loading in Dahl salt-sensitive rats, when proteinuria was modestly increased. Both eplerenone and hydralazine partially reduced systemic blood pressure as measured by indirect and direct methods in salt-loaded Dahl salt-sensitive rats, but only eplerenone dramatically improved podocyte damage and retarded the progression of proteinuria and glomerulosclerosis. Our findings suggest that podocyte injury underlies the glomerulopathy of Dahl salt-hypertensive rats and that inhibition of aldosterone by eplerenone is protective against podocyte damage, proteinuria, and glomerulosclerosis in this hypertensive model.
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Affiliation(s)
- Miki Nagase
- Department of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan.
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747
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Fukui M, Mori Y, Tsujimoto S, Takehana K, Sakamoto N, Kishimoto N, Imada T, Maeba H, Nose A, Yamahara H, Kijima Y, Kitamura T, Ueyama T, Kikuchi S, Tokoro T, Masaki H, Nishikawa M, Iwasaka T. ‘Takotsubo’ Cardiomyopathy in a Maintenance Hemodialysis Patient. Ther Apher Dial 2006; 10:94-100. [PMID: 16556144 DOI: 10.1111/j.1744-9987.2006.00308.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
An 84-year-old woman undergoing maintenance hemodialysis presented with chest discomfort lasting several days and electrocardiographic abnormalities. She had stopped smoking 2 weeks earlier and was experiencing irritability. Upon admission, electrocardiography showed ST-segment elevation in leads I, II, aVF, and V2-6 and an abnormal Q wave in leads II, III, and aVF. Ultrasound cardiography showed left ventricular anteroapical akinesia and basal hyperkinesia. The chest discomfort disappeared without specific therapy. During hospital days 1-5, the ST-segment elevation gradually improved. Giant negative T waves then developed. The left ventricular asynergy resolved by day 8. Radionuclide imaging with iodine-123-beta-methyl-p-iodophenyl pentadecanoic acid, but not with technetium-99 m-sestamibi, showed an apical defect. Elective coronary angiography showed no stenosis. 'Takotsubo' cardiomyopathy was diagnosed. After discharge, the patient continued regular dialysis without cardiac symptoms. We concluded that endogenously activated sympathetic nerve action in hemodialysis patients, especially those under emotional or physical stress, might be a causative factor for Takotsubo cardiomyopathy.
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Affiliation(s)
- Masayoshi Fukui
- Department of Medicine II, Kansai Medical University, Osaka, Japan
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748
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Volkova N, McClellan W, Soucie JM, Schoolwerth A. Racial disparities in the prevalence of cardiovascular disease among incident end-stage renal disease patients. Nephrol Dial Transplant 2006; 21:2202-9. [PMID: 16522661 DOI: 10.1093/ndt/gfl078] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Prevalence of coronary heart disease (CHD) and heart failure (HF) is higher among blacks as compared with whites in general population. This study describes unexpected racial differences in the prevalence of CHD and HF among incident dialysis patients, with whites being at a disadvantage. METHODS Data were obtained from Centers for Medicare and Medicaid Services (CMS) 2728 form for incident dialysis patients in Georgia, North Carolina and South Carolina in 1995-2003. The CHD and HF prevalence between races were compared using adjusted odds ratios (ORs). The potential for case ascertainment bias was assessed. RESULTS Compared with whites (n = 23 951), black patients (n = 32 642) had lower prevalence of CHD (15.7 vs 31.2%) and HF (28.1 vs 34.1%). After controlling for age, gender, diabetes, hypertension and smoking, the association of race with CHD varied by gender and diabetes status: OR ranged from 0.36 (0.34-0.39) for non-diabetic males to 0.57 (0.53-0.61) for diabetic females. Racial differences were not fully explained by case ascertainment bias. The race-HF association varied by age, gender and diabetes: among patients aged <55, blacks tended to have higher prevalence than whites (OR ranged from 0.99 (0.90-1.09) for diabetic males to 1.25 (1.13-1.39) for non-diabetic females), but among those aged above 55, blacks were less likely to HF (OR ranged from 0.62 (0.58-0.67) for diabetic males to 0.79 (0.73-0.85) for non-diabetic females). CONCLUSIONS Substantial racial disparities exist in CHD/HF prevalence among incident dialysis patients that persist after controlling for confounders and cannot be fully explained by disease misclassification.
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Affiliation(s)
- Nataliya Volkova
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road, N.E., Atlanta, GA 30322, USA.
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749
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Uhlig K, Balk EM, Lau J, Levey AS. Clinical Practice Guidelines in nephrology—for worse or for better. Nephrol Dial Transplant 2006; 21:1145-53. [PMID: 16520349 DOI: 10.1093/ndt/gfl084] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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750
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Schiele F, Legalery P, Didier K, Meneveau N, Seronde MF, Caulfield F, Ducloux D, Bechetoille P, Magnin D, Faivre R, Bassand JP. Impact of renal dysfunction on 1-year mortality after acute myocardial infarction. Am Heart J 2006; 151:661-7. [PMID: 16504628 DOI: 10.1016/j.ahj.2005.03.033] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2004] [Accepted: 03/27/2005] [Indexed: 12/22/2022]
Abstract
BACKGROUND Survival after acute myocardial infarction (MI) is linked to multiple factors, including mild or severe chronic kidney dysfunction. The aim of this study was to determine to what extent a reduction in glomerular filtration rate (GFR) influences 1-year mortality when risk level at admission and quality of care are taken into account. METHODS A prospective registry was carried out in a geographically delimited area, including all patients admitted with a diagnosis of acute MI over a 6-month period. The GFR was calculated from serum creatinine levels, and patients were stratified into 3 groups: GFR1 >59 mL/min per 1.73 m2, GFR2 >29 and <60 mL/min per 1.73 m2, and GFR3 <30 mL/min per 1.73 m2. A risk index based on initial presentation was calculated. Inhospital and discharge treatments were recorded, taking into account possible contraindications. Patients were followed up for 1 year to assess all-cause mortality rate. RESULTS A total of 754 patients were included, 333 ST-elevation MI and 421 non-ST-elevation MI. Overall 1-year mortality was 11.5%. Patients with impaired GFR were older, with more comorbidities, and received fewer effective therapies (less reperfusion, glycoprotein IIb/IIIa receptor inhibitors, early angiography, beta-blockers, and statins). One-year mortality increased as GFR decreased: GFR1 2.3% (5/215), GFR2 9.4% (31/328), and GFR3 24.2% (51/211) (P < .001 for trend). By multivariable logistic regression, a significant association was found between 1-year mortality and risk index (odds ratio [OR] 1.41, 95% CI 1.16-1.71 per 10% increase in risk index), GFR (OR 0.97, 95% CI 0.95-0.98 per additional GFR unit), use of beta-blockers (OR 0.15, 95% CI 0.05-0.50 for users), and early coronary angiography (OR 0.26, 95% CI 0.32-0.66 for patients submitted to angiography). CONCLUSIONS In patients with acute MI, decreased GFR is associated with higher mortality, and this relation remains strong after adjustment for the level of risk at admission and the effective treatments used.
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Affiliation(s)
- François Schiele
- Department of Cardiology, University Hospital Jean-Minjoz, Besançon, France.
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