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Schnell O, Cappuccio F, Genovese S, Standl E, Valensi P, Ceriello A. Type 1 diabetes and cardiovascular disease. Cardiovasc Diabetol 2013; 12:156. [PMID: 24165454 PMCID: PMC3816572 DOI: 10.1186/1475-2840-12-156] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 10/08/2013] [Indexed: 12/16/2022] Open
Abstract
The presence of cardiovascular disease (CVD) in Type 1 diabetes largely impairs life expectancy. Hyperglycemia leading to an increase in oxidative stress is considered to be the key pathophysiological factor of both micro- and macrovascular complications. In Type 1 diabetes, the presence of coronary calcifications is also related to coronary artery disease. Cardiac autonomic neuropathy, which significantly impairs myocardial function and blood flow, also enhances cardiac abnormalities. Also hypoglycemic episodes are considered to adversely influence cardiac performance. Intensive insulin therapy has been demonstrated to reduce the occurrence and progression of both micro- and macrovascular complications. This has been evidenced by the Diabetes Control and Complications Trial (DCCT) / Epidemiology of Diabetes Interventions and Complications (EDIC) study. The concept of a metabolic memory emerged based on the results of the study, which established that intensified insulin therapy is the standard of treatment of Type 1 diabetes. Future therapies may also include glucagon-like peptide (GLP)-based treatment therapies. Pilot studies with GLP-1-analogues have been shown to reduce insulin requirements.
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Affiliation(s)
- Oliver Schnell
- Forschergruppe Diabetes e.V., Helmholtz Center Munich, Ingolstaedter Landstrasse 1, 85764 Munich-Neuherberg, Germany
| | | | - Stefano Genovese
- Department of Cardiovascular and Metabolic Diseases, Gruppo Multimedica, Sesto San Giovanni, Milan, Italy
| | - Eberhard Standl
- Forschergruppe Diabetes e.V., Helmholtz Center Munich, Ingolstaedter Landstrasse 1, 85764 Munich-Neuherberg, Germany
| | - Paul Valensi
- Service d’Endocrinologie-Diabétologie-Nutrition, Hôpital Jean Verdier, Bondy Cedex, France
| | - Antonio Ceriello
- Insititut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Hospital Clínic Barcelona, Barcelona, Spain
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202
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Clinical relevance of visit-to-visit blood pressure variability: impact on renal outcomes. J Hum Hypertens 2013; 28:403-9. [DOI: 10.1038/jhh.2013.96] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 07/21/2013] [Accepted: 07/26/2013] [Indexed: 01/04/2023]
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203
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Wherrett D, Huot C, Mitchell B, Pacaud D. Le diabète de type 1 chez les enfants et les adolescents. Can J Diabetes 2013. [DOI: 10.1016/j.jcjd.2013.07.049] [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: 10/26/2022]
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204
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Association between blood pressure and target organ damage in patients with chronic kidney disease and hypertension: results of the APrODiTe study. Hypertens Res 2013; 37:172-8. [PMID: 24048482 DOI: 10.1038/hr.2013.127] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Revised: 07/24/2013] [Accepted: 07/25/2013] [Indexed: 11/08/2022]
Abstract
Blood pressure control is the most established practice for preventing the progression of chronic kidney disease. Evidence addressing blood pressure control status or nocturnal blood pressure dipping in Korean hypertensive patients with chronic kidney disease is scarce. We recruited 1317 hypertensive patients (chronic kidney disease stages 2-4, median age 58) from 21 centers in Korea. These patients underwent office and ambulatory blood pressure monitoring. High office and ambulatory blood pressure were defined as >140/90 mm Hg and >135/85 mm Hg (daytime)/ >120/70 mm Hg (nighttime), respectively. The blood pressure control status was as follows: true controlled (19%), white-coat (4.3%), masked (33.9%) and sustained uncontrolled (42.3%) hypertension. The dipping status was as follows: extreme-dipping (14.9%), dipping (33.3%), non-dipping (34.5%) and reverse-dipping (17.3%). Masked and sustained hypertension as well as non-dipping/reverse-dipping was more apparent in proportion to renal dysfunction and the extent of proteinuria. Ageing (58 years), male gender, obesity, diabetic nephropathy and proteinuria (>300 mg g(-1) Cr or dipstick proteinuria1+) were independently associated with sustained uncontrolled hypertension. Diabetic nephropathy, old age, a history of stable angina/heart failure, advanced renal dysfunction and higher proteinuria levels were also significantly associated with non-dipping and reverse-dipping. Half of Korean chronic kidney disease patients had uncontrolled blood pressure and a non-dipping nocturnal blood pressure pattern. Future studies are warranted to assess the predictive values of ambulatory blood pressure for cardiorenal events in Korean chronic kidney disease patients.
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205
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Parati G, Ochoa JE, Salvi P, Lombardi C, Bilo G. Prognostic value of blood pressure variability and average blood pressure levels in patients with hypertension and diabetes. Diabetes Care 2013; 36 Suppl 2:S312-24. [PMID: 23882065 PMCID: PMC3920798 DOI: 10.2337/dcs13-2043] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Gianfranco Parati
- Cardiovascular Medicine, University of Milano-Bicocca, Milan, Italy.
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206
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Lurbe E, Thijs L, Torro MI, Alvarez J, Staessen JA, Redon J. Sexual Dimorphism in the Transition From Masked to Sustained Hypertension in Healthy Youths. Hypertension 2013; 62:410-4. [DOI: 10.1161/hypertensionaha.113.01549] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Empar Lurbe
- From the Pediatric Department, Consorcio Hospital General, University of Valencia (E.L., M.I.T., J.A.); CIBER Physiopathology Obesity and Nutrition (CB06/03), Institute of Health Carlos III, Madrid, Spain (E.L., M.I.T., J.A., J.R.); Division of Hypertension and Cardiovascular Rehabilitation, Department of Cardiovascular Services, Studies Coordinating Centre, University of Leuven, Leuven, Belgium (L.T., J.A.S.); Department of Epidemiology, Maastricht University, Maastricht, The Netherlands (J.A.S.)
| | - Lutgarde Thijs
- From the Pediatric Department, Consorcio Hospital General, University of Valencia (E.L., M.I.T., J.A.); CIBER Physiopathology Obesity and Nutrition (CB06/03), Institute of Health Carlos III, Madrid, Spain (E.L., M.I.T., J.A., J.R.); Division of Hypertension and Cardiovascular Rehabilitation, Department of Cardiovascular Services, Studies Coordinating Centre, University of Leuven, Leuven, Belgium (L.T., J.A.S.); Department of Epidemiology, Maastricht University, Maastricht, The Netherlands (J.A.S.)
| | - Maria Isabel Torro
- From the Pediatric Department, Consorcio Hospital General, University of Valencia (E.L., M.I.T., J.A.); CIBER Physiopathology Obesity and Nutrition (CB06/03), Institute of Health Carlos III, Madrid, Spain (E.L., M.I.T., J.A., J.R.); Division of Hypertension and Cardiovascular Rehabilitation, Department of Cardiovascular Services, Studies Coordinating Centre, University of Leuven, Leuven, Belgium (L.T., J.A.S.); Department of Epidemiology, Maastricht University, Maastricht, The Netherlands (J.A.S.)
| | - Julio Alvarez
- From the Pediatric Department, Consorcio Hospital General, University of Valencia (E.L., M.I.T., J.A.); CIBER Physiopathology Obesity and Nutrition (CB06/03), Institute of Health Carlos III, Madrid, Spain (E.L., M.I.T., J.A., J.R.); Division of Hypertension and Cardiovascular Rehabilitation, Department of Cardiovascular Services, Studies Coordinating Centre, University of Leuven, Leuven, Belgium (L.T., J.A.S.); Department of Epidemiology, Maastricht University, Maastricht, The Netherlands (J.A.S.)
| | - Jan A. Staessen
- From the Pediatric Department, Consorcio Hospital General, University of Valencia (E.L., M.I.T., J.A.); CIBER Physiopathology Obesity and Nutrition (CB06/03), Institute of Health Carlos III, Madrid, Spain (E.L., M.I.T., J.A., J.R.); Division of Hypertension and Cardiovascular Rehabilitation, Department of Cardiovascular Services, Studies Coordinating Centre, University of Leuven, Leuven, Belgium (L.T., J.A.S.); Department of Epidemiology, Maastricht University, Maastricht, The Netherlands (J.A.S.)
| | - Josep Redon
- From the Pediatric Department, Consorcio Hospital General, University of Valencia (E.L., M.I.T., J.A.); CIBER Physiopathology Obesity and Nutrition (CB06/03), Institute of Health Carlos III, Madrid, Spain (E.L., M.I.T., J.A., J.R.); Division of Hypertension and Cardiovascular Rehabilitation, Department of Cardiovascular Services, Studies Coordinating Centre, University of Leuven, Leuven, Belgium (L.T., J.A.S.); Department of Epidemiology, Maastricht University, Maastricht, The Netherlands (J.A.S.)
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207
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Sobiczewski W, Wirtwein M, Gruchala M. Is daytime blood pressure adequate in cardiovascular risk assessment in patients with coronary atherosclerosis? Blood Press 2013; 23:96-101. [DOI: 10.3109/08037051.2013.814747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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208
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Seeman T, Gilík J. Long-term control of ambulatory hypertension in children: improving with time but still not achieving new blood pressure goals. Am J Hypertens 2013; 26:939-45. [PMID: 23645323 DOI: 10.1093/ajh/hpt048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Short-term therapy can decrease blood pressure (BP) to less than the 95th percentile in only about 50% of children. The aim of our study was to investigate the long-term control of hypertension (HT) in children using ambulatory BP monitoring (ABPM). METHODS We analyzed data from all children who started ramipril monotherapy in our center. Controlled HT was defined according to the most current guidelines as systolic and diastolic BP at daytime and nighttime <90th percentile in primary HT and <75th percentile in renoparenchymal HT. RESULTS Thirty-eight children who were on therapy ≥1 year were included. Thirty-two children had renoparenchymal, and 6 had primary HT. The median age at the beginning of therapy was 13.6 years (range = 4.1-18.0 years), and the median time of antihypertensive therapy was 2.6 years (range = 1.0-11.8 years). Thirty-four percent of children received combination therapy; the median number of antihypertensive drugs was 1.5 drugs/patient (range = 1-4). Sixty-eight percent of children had BP <95th percentile, but only 34% of the children had controlled HT. Children with uncontrolled HT had a tendency to have a higher daytime diastolic BP index before the start of therapy than children with controlled HT (0.99±0.11 vs. 0.94±0.11; P = 0.09). There was a significant decrease in prevalence of nondipping (from 47% to 16%; P = 0.006) with therapy. CONCLUSIONS This first pediatric study focusing on long-term control of HT using ABPM showed that long-term control of HT is better than short-term control, but still only one-third of children achieve the new BP goals. The low control of HT might be improved by more intensive therapy.
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Affiliation(s)
- Tomáš Seeman
- Department of Pediatrics, University Hospital Motol, Charles University Prague, Second Medical School, Czech Republic and Biomedical Centre, Faculty of Medicine in Plzen, Charles University in Prague, Plzen, Czech Republic.
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209
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Pediatric ambulatory blood pressure monitoring: diagnosis of hypertension. Pediatr Nephrol 2013; 28:995-9. [PMID: 23591679 DOI: 10.1007/s00467-013-2470-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 03/05/2013] [Accepted: 03/05/2013] [Indexed: 10/26/2022]
Abstract
Pediatric hypertension (HTN) is a growing concern and should be diagnosed and treated aggressively to reduce the global disease burden. Ambulatory blood pressure monitoring (ABPM) is a useful clinical tool providing a more accurate description of the patient's blood pressure (BP) than office BP measurements, and can be considered the "gold standard" in the evaluation of the pediatric patient with a concern for HTN. The American Heart Association have suggested criteria for diagnosing ambulatory HTN, and research continues into further clarification of how to best utilize the large volume of data obtained from an ABPM report. ABPM has some limitations; however, the advantages far outweigh these. Routine use of ABPM is recommended among clinicians to better evaluate and assess the severity of a child's HTN, and for proper management in order to prevent target organ damage and the resulting sequelae, thereby reducing the burden of cardiovascular risk in hypertensive children and adolescents.
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210
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Should mean arterial pressure be included in the definition of ambulatory hypertension in children? Pediatr Nephrol 2013; 28:1105-12. [PMID: 23340855 DOI: 10.1007/s00467-012-2382-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 10/17/2012] [Accepted: 11/16/2012] [Indexed: 01/15/2023]
Abstract
BACKGROUND The diagnosis of hypertension (HTN)/normotension (NT) on ambulatory blood pressure monitoring (ABPM) is usually based on systolic (SBP) or diastolic blood pressure (DBP). The goal of this study was to analyze whether inclusion of mean arterial pressure (MAP) improves the detection of HTN on ABPM. METHODS We retrospectively studied ABPM records in 229 children (116 boys, median age = 15.3 years) who were referred for evaluation of HTN. A diagnosis of HTN was made if: (A) MAP or SBP or DBP was ≥ 1.65 SDS (95th percentile); (B) SBP or DBP was ≥ 1.65 SDS (95th percentile), during 24-h or daytime or night-time in both definitions. RESULTS Using definition A, 46/229 patients had HTN compared to definition B by which only 37/229 patients had HTN (p = 0.001). The level of agreement between the two definitions was very good (kappa = 0.86 ± 0.04), however nine patients (19.5 %) were missed by not using MAP in the definition of HTN. These nine patients had only mild HTN with a median Z score of 1.69. CONCLUSIONS The inclusion of MAP in the definition of ambulatory HTN significantly increased the number of hypertensive patients. MAP may be very helpful in detecting mild HTN in patients with normal/borderline SBP and DBP.
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211
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Latea L, Negrea S, Bolboaca S. Primary non-alcoholic fatty liver disease in hypertensive patients. Australas Med J 2013; 6:325-30. [PMID: 23837080 DOI: 10.4066/amj.2013.1648] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is considered the most common liver disease affecting 15-25% of the general population. AIMS The aim of this study was to investigate the prevalence of NAFLD and the relationship between insulin sensitivity and NAFLD in grade III high and very high cardiovascular additional risk essential hypertensive patients according to the circadian blood pressure (BP) rhythm. METHOD This four-year prospective study was conducted at the Department of Internal Medicine at Cluj-Napoca's Diagnosis and Treatment Centre in Romania. The study included grade III essential hypertensive patients. Hypertensive patients were divided into four groups according to the diurnal index (DI) from ABPM monitoring: dipper (D), non-dipper (ND), reverse-dipper (RD), and extreme-dipper (ED). All hypertensive patients underwent 24 ABPM, blood tests and abdominal ultrasonography for the diagnosis of fatty liver disease. RESULTS Thirty-five hypertensive patients were included in the study, with 31.42% ND, 11.43% RD, 8.57% ED and 48.57% D. The prevalence of NAFLD was significantly higher in ND, RD and ED when compared to D. When compared to the dipper group of hypertensive patients a statistically significantly higher level of plasma insulin was observed: in non-dipper [86.3±17.9pmol/l vs. 62.2±203pmol/l, p<0.05], in reverse dipper [88.3±18.6pmol/l vs. 62.2±20.3pmol/l] and in extreme-dippers [86.7±16.88pmol/l vs. 62.2±20.3 pmol/l, p<0.05]. CONCLUSION The altered dipping status (ND, RD, ED) of hypertension associated with a higher insulin resistance could be the pathogenetic link between the NAFLD and altered blood pressure status. Altered BP status could be a marker of NAFLD in hypertensive patients.
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Affiliation(s)
- Luminita Latea
- "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
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213
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Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, Christiaens T, Cifkova R, De Backer G, Dominiczak A, Galderisi M, Grobbee DE, Jaarsma T, Kirchhof P, Kjeldsen SE, Laurent S, Manolis AJ, Nilsson PM, Ruilope LM, Schmieder RE, Sirnes PA, Sleight P, Viigimaa M, Waeber B, Zannad F, Redon J, Dominiczak A, Narkiewicz K, Nilsson PM, Burnier M, Viigimaa M, Ambrosioni E, Caufield M, Coca A, Olsen MH, Schmieder RE, Tsioufis C, van de Borne P, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Clement DL, Coca A, Gillebert TC, Tendera M, Rosei EA, Ambrosioni E, Anker SD, Bauersachs J, Hitij JB, Caulfield M, De Buyzere M, De Geest S, Derumeaux GA, Erdine S, Farsang C, Funck-Brentano C, Gerc V, Germano G, Gielen S, Haller H, Hoes AW, Jordan J, Kahan T, Komajda M, Lovic D, Mahrholdt H, Olsen MH, Ostergren J, Parati G, Perk J, Polonia J, Popescu BA, Reiner Z, Rydén L, Sirenko Y, Stanton A, Struijker-Boudier H, Tsioufis C, van de Borne P, Vlachopoulos C, Volpe M, Wood DA. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013; 34:2159-219. [PMID: 23771844 DOI: 10.1093/eurheartj/eht151] [Citation(s) in RCA: 3168] [Impact Index Per Article: 288.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Giuseppe Mancia
- Centro di Fisiologia Clinica e Ipertensione, Università Milano-Bicocca, Milano, Italy.
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Abstract
AbstractDiabetic nephropathy (DN) is a leading cause of morbidity and mortality in diabetic patients representing a huge health and economic burden. Alarming recent data described diabetes as an unprecedented worldwide epidemic, with a prevalence of ∼6.4% of the world population in 2010, while the prevalence of CKD among diabetics was approximately 40%. With a clinical field hungry for novel markers predicting DN, several clinical and laboratory markers were identified lately with the promise of reliable DN prediction. Among those are age, gender, hypertension, smoking, sex hormones and anemia. In addition, eccentric left ventricular geometric patterns, detected by echocardiography, and renal hypertrophy, revealed by ultrasonography, are promising new markers predicting DN development. Serum and urinary markers are still invaluable elements, including serum uric acid, microalbuminuria, macroalbuminuria, urinary liver-type fatty acid-binding protein (u-LFABP), and urinary nephrin. Moreover, studies have illustrated a tight relationship between obstructive sleep apnea and the development of DN. The purpose of this review is to present the latest advances in identifying promising predictors to DN, which will help guide the future research questions in this field. Aiming at limiting this paramount threat, further efforts are necessary to identify and control independent modifiable risk factors, while developing an integrative algorithm for utilization in DN future screening programs.
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Shahbazian H, Rezaii I. Diabetic kidney disease; review of the current knowledge. J Renal Inj Prev 2013; 2:73-80. [PMID: 25340133 PMCID: PMC4206005 DOI: 10.12861/jrip.2013.24] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Accepted: 03/14/2013] [Indexed: 12/21/2022] Open
Abstract
Diabetes is the most common cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD) in most parts of the world. 20 to 30% of diabetic patient have diabetic nephropathy in type 1 and type 2. Hyperglycemia is the key of nephropathy creation. Hyperglycemia also by production of toxic materials, advanced glycosylated end product (AGE), increased activity of aldose reductase has some role. Some metabolites of arachidonic acid, hemodynamic derangements and genetic factors have also some role. Although diabetic nephropathy is most common cause of nephropathy in these patients, but diabetic patients are also prone to other urinary tract and renal parenchymal disease and should not be confused with renal failure due to diabetic nephropathy. The principle of treatment of diabetic nephropathy is based on tight control of hyperglycemia, tight control of blood pressure and glomerular pressure, control of dyslipidemia, restriction of protein intake and smoking withdrawal.
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Affiliation(s)
| | - Isa Rezaii
- Department of Nephrology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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216
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Parati G, Ochoa JE, Lombardi C, Salvi P, Bilo G. Assessment and interpretation of blood pressure variability in a clinical setting. Blood Press 2013; 22:345-54. [PMID: 23621743 DOI: 10.3109/08037051.2013.782944] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Blood pressure (BP) is characterized by marked fluctuations occurring within the 24 h as a result of complex interactions between behavioral, environmental, humoral, and neural central or reflex influences. Significant BP variations also occur over more prolonged periods of time (i.e. between days, weeks, months, seasons and even years), not as a random phenomenon but as a result of several interacting factors yet not completely identified. Depending on the method and time interval considered for measurement, the clinical significance and prognostic implications of different types of BP variability (BPV) may substantially differ. Either in the short or in the long term, BPV has been associated with development, progression and severity of cardiac, vascular and renal organ damage and with an increased risk of cardiovascular events and mortality, independently adding to cardiovascular risk, over and above the contribution of elevated mean BP levels. The present paper provides a review on the main methods currently employed for assessment of BPV as well as on the mechanisms, clinical interpretation and prognostic significance of different types of BPV, addressing the question on whether BPV should be a target for antihypertensive treatment for the current prevention of cardiovascular disease.
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Affiliation(s)
- Gianfranco Parati
- Department of Health Sciences, University of Milano-Bicocca , Milan , Italy
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217
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Abstract
Hypertension is a common and serious complication after renal transplantation. It is an important risk factor for graft loss and adverse cardiovascular outcomes. Blood pressure (BP) in transplanted children should be measured not only by clinic BP (cBP) measurement, but also by ambulatory blood pressure monitoring (ABPM), because ABPM has distinct advantages over cBP, specifically the ability to reveal nocturnal, masked or white-coat hypertension. These types of hypertension are common in transplanted children (nocturnal hypertension 36-71 %, masked hypertension 24-45 %). It may also reveal uncontrolled hypertension in treated children, thereby improving control of hypertension. Regular use of ABPM and ABPM-guided therapy of hypertension may help to decrease cardiovascular and renal target organ damage in transplanted children. Therefore, ABPM should be routinely performed in all transplanted children at least once a year, regardless of the values of cBP.
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218
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Lurbe E, Torró MI, Álvarez J. Ambulatory Blood Pressure Monitoring in Children and Adolescents: Coming of Age? Curr Hypertens Rep 2013; 15:143-9. [DOI: 10.1007/s11906-013-0350-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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220
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Karakas MF, Buyukkaya E, Kurt M, Karakas E, Buyukkaya S, Akcay AB, Sen N. Assessment of left ventricular dyssynchrony in dipper and non-dipper hypertension. Blood Press 2013; 22:144-50. [PMID: 23458091 DOI: 10.3109/08037051.2012.745224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Ventricular dyssynchrony is an co-determinant of progression and exacerbation of heart failure (HF). The co-existence of ventricular dyssynchrony with hypertension (HT) and HF were shown, however there is no data regarding the effect of circadian rhythm of blood pressure (BP) on ventricular synchrony. Therefore, we aimed to study the left ventricular synchrony in dipper and non-dipper normotensive and hypertensive participants. METHODS Participants (n = 142) were categorized into four groups as "Normotensive-Dipper" (NT-D) (n = 40), "Normotensive-Non-dipper" (NT-ND) (n = 30), "Hypertensive-Dipper" (HT-D) (n = 38) and "Hypertensive-Non-dipper" (HT-ND) (n = 34). Left ventricular dyssynchrony was investigated by color-coded tissue Doppler imaging. RESULTS Non-dippers had higher 24-h and night-time BP both in normotensives and hypertensives. The incidence of ventricular dyssynchrony (a Ts-SD-12 > 34.4 ms) was higher in the hypertensive group (47.2% vs 24.3%, p = 0.005). The frequency of ventricular dyssynchrony was higher in the HT-ND group than the HT-D group (58.8% vs 36.8%, p = 0.05); however, the frequency of ventricular dyssynchrony was similar among the normotensives (26.7% vs 22.5%, p = 0.45). Ts-SD-12 and Ts-12 were higher in NT-ND group than the NT-D group. CONCLUSIONS Non-dipping BP pattern was associated with impaired left ventricular contraction synchrony in both normotensive and hypertensive participants, which may be related with short- and long-term effects of HT on myocardium.
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Affiliation(s)
- Mehmet Fatih Karakas
- Department of Cardiology, Mustafa Kemal University, Tayfur Ata Sokmen Medical School, Hatay, Turkey.
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Abstract
Blood pressure (BP) is characterized by marked short-term fluctuations occurring within a 24 h period (beat-to-beat, minute-to-minute, hour-to-hour, and day-to-night changes) and also by long-term fluctuations occurring over more-prolonged periods of time (days, weeks, months, seasons, and even years). Rather than representing 'background noise' or a randomly occurring phenomenon, these variations have been shown to be the result of complex interactions between extrinsic environmental and behavioural factors and intrinsic cardiovascular regulatory mechanisms. Although the adverse cardiovascular consequences of hypertension largely depend on absolute BP values, evidence from observational studies and post-hoc analyses of data from clinical trials have indicated that these outcomes might also depend on increased BP variability (BPV). Increased short-term and long-term BPV are associated with the development, progression, and severity of cardiac, vascular, and renal damage and with an increased risk of cardiovascular events and mortality. Of particular interest are the findings from post-hoc analyses of large intervention trials in hypertension, showing that within-patient visit-to-visit BPV is strongly prognostic for cardiovascular morbidity and mortality. This result has prompted discussion on whether antihypertensive treatment should be targeted not only towards reducing mean BP levels but also to stabilizing BPV with the aim of achieving consistent BP control over time, which might favour cardiovascular protection.
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222
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Reversed dipper blood-pressure pattern is closely related to severe renal and cardiovascular damage in patients with chronic kidney disease. PLoS One 2013; 8:e55419. [PMID: 23393577 PMCID: PMC3564807 DOI: 10.1371/journal.pone.0055419] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 12/22/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A non-dipper blood pressure (BP) pattern is very common in chronic kidney disease (CKD) patients and affects the progression and development of cardiovascular disease. However, data on the reversed dipper BP pattern on target-organ damage in Chinese CKD patients are lacking. METHODS A total of 540 CKD patients were enrolled. Ambulatory blood pressure monitoring (ABPM), clinical BP, ultrasonographic assessment and other clinical data were collected. Univariate and multivariate analyses were used to ascertain the relationship between ABPM results and clinical parameters. RESULTS A total of 21.9% CKD patients had a reversed dipper BP pattern, 42% of patients had a non-dipper BP pattern and 36.1% of patients had a dipper BP pattern. Patients with reversed dipper BP pattern had the worst renal function and most severe cardiovascular damages among these CKD patients (p<0.05). The estimated glomerular filtration rate (eGFR) and left ventricular mass index (LVMI) correlated significantly with the rate of decline of nocturnal BP. A reversed dipper BP pattern was an independent factor affecting kidney damage and left ventricular hypertrophy. Age, lower hemoglobin level, higher 24-h systolic BP from ABPM, and higher serum phosphate levels were independent associated with a reversed dipper BP pattern after multivariate logistic regression analyses. CONCLUSION The reversed dipper BP pattern is closely related to severe renal damage and cardiovascular injuries in CKD patients, and special attention should be given to these CKD patients.
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223
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Prevalence of abnormal urinary albumin excretion in elderly people: a Spanish survey. Int Urol Nephrol 2013; 45:553-60. [DOI: 10.1007/s11255-013-0380-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Accepted: 01/09/2013] [Indexed: 11/26/2022]
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224
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Karpettas N, Nasothimiou E, Kollias A, Vazeou A, Stergiou GS. Ambulatory and home blood pressure monitoring in children and adolescents: diagnosis of hypertension and assessment of target-organ damage. Hypertens Res 2013; 36:285-92. [PMID: 23344131 DOI: 10.1038/hr.2012.220] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The prevalence of elevated blood pressure in children and adolescents is more common than previously believed and often represents the early onset of essential hypertension, particularly in adolescents. The definition of hypertension in children is based on distribution criteria and normalcy tables that provide blood pressure percentiles for each measurement method (office, ambulatory and home) according to the individual's age, gender and body size. Owing to the white coat and masked hypertension phenomena, ambulatory blood pressure monitoring is indispensable for the diagnosis of hypertension in children. Home blood pressure monitoring in children has been less well studied, and at present, treatment decisions should not be based solely on such measurements. Hypertension-induced preclinical target-organ damage (mainly echocardiographic left ventricular hypertrophy) is not uncommon in children and should be evaluated in all hypertensive children. Other indices of target-organ damage, such as carotid intima-media thickness, pulse wave velocity and microalbuminuria, remain under investigation in pediatric hypertension.
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Affiliation(s)
- Nikos Karpettas
- Hypertension Center, Third University Department of Medicine, Sotiria Hospital, Athens, Greece
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225
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Blood pressure variability, cardiovascular risk, and risk for renal disease progression. Curr Hypertens Rep 2013; 14:421-31. [PMID: 22903810 DOI: 10.1007/s11906-012-0290-7] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The adverse cardiovascular consequences of high blood pressure (BP) not only depend on absolute BP values, but also on BP variability (BPV). Evidence has been provided that independently of mean BP levels, BP variations in the short- and long-term are associated with the development, progression and severity of cardiac, vascular and renal organ damage, and with an increased risk of CV events and mortality. Alterations in BPV have also been shown to be predictive of the development and progression of renal damage, which is of relevance if considering that impaired renal function in a hypertensive patient constitutes a very potent predictor of future CV events and mortality even in treated subjects. This review will address whether antihypertensive treatment should target alterations in BPV, in addition to reducing absolute BP levels, in order to achieve the highest CV and renal protection in hypertensive and renal patients.
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226
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Nocturnal medications dosing: does it really make a difference in blood pressure control among patients with chronic kidney disease? Curr Hypertens Rep 2013; 14:449-54. [PMID: 22836387 DOI: 10.1007/s11906-012-0295-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Ambulatory blood pressure (BP) monitoring is superior to clinic BP monitoring in predicting long-term consequences of hypertension. This has raised interest in diurnal variation in BP and elevation in nighttime BP as a prognostic and therapeutic target. Several studies have identified prevalence of nocturnal hypertension in patients with accelerated progression of chronic kidney disease and target organ damage. Some studies suggest that nocturnal BP can be lowered by changing administration of antihypertensive medication to bed time; whether that results in retarding kidney disease progression is not very clear. Further research is needed to determine if certain classes of medications or interventions are superior in controlling nocturnal hypertension, and protocols need to be developed to screen patients for monitoring nocturnal BP. Further studies are needed to evaluate long-term renal outcomes of evening dosing in patients with nocturnal hypertension and chronic kidney disease.
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227
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Van Buren PN, Toto RD. The pathogenesis and management of hypertension in diabetic kidney disease. Med Clin North Am 2013; 97:31-51. [PMID: 23290728 DOI: 10.1016/j.mcna.2012.10.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hypertension commonly coexists with diabetes, and its prevalence is even higher in the presence of diabetic kidney disease. The pathogenesis of hypertension in this population stems from increased extracellular volume and increased vasoconstriction that results from mechanisms that may be attributed to both diabetes and the eventual impairment of renal function. Antihypertensive therapy aimed at reducing blood pressure remains a primary goal in preventing the incidence of diabetic kidney and slowing its progression. Initial therapy should consist of an ACE inhibitor or ARB titrated to the maximally tolerated dose. Using combination RAAS therapy further reduces proteinuria, but the benefits of this strategy compared with the potential risks of hyperkalemia and acute deterioration of renal function are still unknown. Endothelin receptor antagonists also lower proteinuria, but these can be associated with volume overload and edema with no clear long-term benefit on renal function yet identified. Further large clinical trials are needed to better understand how progression to ESRD can be slowed or halted in patients with diabetic kidney disease.
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Affiliation(s)
- Peter N Van Buren
- Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75390-8516, USA.
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228
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Sekizuka H, Osada N, Miyake F. Effects of continuous positive airway pressure therapy in three Japanese patients with obstructive sleep apnea and resistant hypertension. Intern Med 2013; 52:2241-4. [PMID: 24088759 DOI: 10.2169/internalmedicine.52.0363] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The following three case reports present the effects of 6-month continuous positive airway pressure (CPAP) therapy on blood pressure (BP) in severe obstructive sleep apnea patients with resistant hypertension. Case 1 A 58-year-old woman exhibited a decreased 24-hour BP and changes in the nocturnal BP dipping pattern from non-dipper to dipper. Case 2 A 64-year-old man showed no improvements in nocturnal BP. Case 3 A 78-year-old man with ischemic cardiomyopathy exhibited changes in the nocturnal BP dipping pattern from non-dipper to dipper. These results suggest that 6-month CPAP therapy improves the nocturnal BP dipping status in some patients with obstructive sleep apnea and resistant hypertension.
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Affiliation(s)
- Hiromitsu Sekizuka
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
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229
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Shatat IF, Jakson SM, Blue AE, Johnson MA, Orak JK, Kalpatthi R. Masked hypertension is prevalent in children with sickle cell disease: a Midwest Pediatric Nephrology Consortium study. Pediatr Nephrol 2013; 28:115-20. [PMID: 22886281 DOI: 10.1007/s00467-012-2275-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 07/12/2012] [Accepted: 07/13/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND The prevalence of hypertension and abnormal blood pressure (BP) patterns on 24-h ambulatory BP monitoring (ABPM) remains unknown in children with sickle cell disease (SCD). METHODS Thirty-eight asymptomatic children with sickle cell disease (SCD) (12 HbSS receiving routine care, 13 HbSC, and 13 HbSS receiving chronic transfusion therapy) underwent 24-h ABPM. Average clinic BP, demographic and biochemical characteristics were collected. RESULTS Median age was 13 years (range 11-16), body mass index (BMI) 19.1 kg/m(2) (range 18.2-21.1), and 50% were male. Seventeen subjects (43.6%) had ambulatory hypertension, while 4 (10.3%) were hypertensive based on their clinic BP. Mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) dip were 8.3 ± 5.9% and 14.7 ± 7.6% respectively. Twenty-three subjects (59%) had impaired SBP dipping, 7 (18%) had impaired DBP dipping, and 5 (13%) had reversed dipping. Clinic and ABP classification were modestly correlated (rho = 0.38, P = 0.02). CONCLUSION Abnormalities in ABP measurements and patterns in children with SCD are prevalent and require more attention from heath care providers. ABPM is a valuable tool in identifying masked hypertension and abnormalities in circadian BP.
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Affiliation(s)
- Ibrahim F Shatat
- Division of Pediatric Nephrology and Hypertension, MUSC Children's Hospital, 96 Jonathan Lucas Street, CSB-428, Charleston, SC 29425, USA.
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230
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Rahman M, Greene T, Phillips RA, Agodoa LY, Bakris GL, Charleston J, Contreras G, Gabbai F, Hiremath L, Jamerson K, Kendrick C, Kusek JW, Lash JP, Lea J, Miller ER, Rostand S, Toto R, Wang X, Wright JT, Appel LJ. A trial of 2 strategies to reduce nocturnal blood pressure in blacks with chronic kidney disease. Hypertension 2012; 61:82-8. [PMID: 23172931 DOI: 10.1161/hypertensionaha.112.200477] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of our study was to determine the effects of 2 antihypertensive drug dose schedules (PM dose and add-on dose) on nocturnal blood pressure (BP) in comparison with usual therapy (AM dose) in blacks with hypertensive chronic kidney disease and controlled office BP. In a 3-period, crossover trial, former participants of the African American Study of Kidney Disease were assigned to receive the following 3 regimens, each lasting 6 weeks, presented in random order: AM dose (once-daily antihypertensive medications taken in the morning), PM dose (once-daily antihypertensives taken at bedtime), and add-on dose (once-daily antihypertensives taken in the morning and an additional antihypertensive medication before bedtime [diltiazem 60-120 mg, hydralazine 25 mg, or additional ramipril 5 mg]). Ambulatory BP monitoring was performed at the end of each period. The primary outcome was nocturnal systolic BP. Mean age of the study population (n=147) was 65.4 years, 64% were men, and mean estimated glomerular filtration rate was 44.9 mL/min per 1.73 m(2). At the end of each period, mean (SE) nocturnal systolic BP was 125.6 (1.2) mm Hg in the AM dose, 123.9 (1.2) mm Hg in the PM dose, and 123.5 (1.2) mm Hg in the add-on dose. None of the pairwise differences in nocturnal, 24-hour, and daytime systolic BP was statistically significant. Among blacks with hypertensive chronic kidney disease, neither PM (bedtime) dosing of once-daily antihypertensive nor the addition of drugs taken at bedtime significantly reduced nocturnal BP compared with morning dosing of antihypertensive medications.
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Affiliation(s)
- Mahboob Rahman
- Division of Nephrology and Hypertension, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.
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231
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Hillis GS, Hata J, Woodward M, Perkovic V, Arima H, Chow CK, Zoungas S, Patel A, Poulter NR, Mancia G, Williams B, Chalmers J. Resting heart rate and the risk of microvascular complications in patients with type 2 diabetes mellitus. J Am Heart Assoc 2012; 1:e002832. [PMID: 23316296 PMCID: PMC3541618 DOI: 10.1161/jaha.112.002832] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 07/27/2012] [Indexed: 12/17/2022]
Abstract
Background A higher resting heart rate is associated with an increased probability of cardiovascular complications and premature death in patients with type 2 diabetes mellitus. The impact of heart rate on the risk of developing microvascular complications, such as diabetic retinopathy and nephropathy, is, however, unknown. The present study tests the hypothesis that a higher resting heart rate is associated with an increased incidence and a greater progression of microvascular complications in patients with type 2 diabetes mellitus. Methods and Results The relation between baseline resting heart rate and the development of a major microvascular event was examined in 11 140 patients who participated in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) study. Major microvascular events were defined as a composite of new or worsening nephropathy or new or worsening retinopathy. Patients with a higher baseline heart rate were at increased risk of a new major microvascular complication during follow-up (adjusted hazard ratio: 1.13 per 10 beats per minute; 95% confidence interval: 1.07–1.20; P<0.001). The excess hazard was evident for both nephropathy (adjusted hazard ratio: 1.16 per 10 beats per minute; 95% confidence interval: 1.08–1.25) and retinopathy (adjusted hazard ratio: 1.11 per 10 beats per minute; 95% confidence interval: 1.02–1.21). Conclusion Patients with type 2 diabetes mellitus who have a higher resting heart rate experience a greater incidence of new-onset or progressive nephropathy and retinopathy. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00145925. http://www.advance-trial.com/static/html/prehome/prehome.asp
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Affiliation(s)
- Graham S Hillis
- The George Institute for Global Health, University of Sydney, Australia.
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232
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Proximal tubular angiotensinogen in renal biopsy suggests nondipper BP rhythm accompanied by enhanced tubular sodium reabsorption. J Hypertens 2012; 30:1453-9. [PMID: 22573118 DOI: 10.1097/hjh.0b013e328353e807] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES The renal capacity for sodium excretion is impaired by a reduction in the glomerular ultrafiltration coefficient and by enhancement of the fractional tubular sodium reabsorption (FRNa), leading to a nondipper circadian blood pressure (BP) rhythm. Angiotensin II in the systemic circulation can be easily filtered across the glomerular capillary walls and stimulates renal proximal tubular angiotensinogen (PT-AGT) production, leading to the activation of intrarenal angiotensin II, which is known to augment the FRNa in animal models. METHODS We performed an immunohistochemical investigation to determine the contribution of PT-AGT to enhancement of FRNa and the nondipper circadian BP rhythm in 40 consecutive patients with primary IgA nephropathy (IgAN). RESULTS Immunostaining for PT-AGT was increased in the IgAN patients compared with control individuals (P = 0.04), and correlated directly with the FRNa (r = 0.39, P = 0.01) and the night/day ratio of BP (r = 0.38, P = 0.02), but not creatinine clearance (r = -0.008, P = 0.9). The night/day ratio of BP was determined by both creatinine clearance (r = -0.36, P = 0.03) and FRNa (r = 0.47, P = 0.006). CONCLUSION Tubular sodium reabsorption is stimulated by intrarenal angiotensin II, as indicated by PT-AGT, and contributes to the genesis of the nondipper BP rhythm. Further studies are needed to evaluate whether or not treatment to prevent sodium retention is useful for patients who exhibit increased PT-AGT in renal biopsies.
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233
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Knudsen ST, Jeppesen P, Frederiksen CA, Andersen NH, Bek T, Ingerslev J, Mogensen CE, Poulsen PL. Endothelial perturbation: a link between non-dipping and retinopathy in type 2 diabetes? ACTA ACUST UNITED AC 2012; 1:208-15. [PMID: 20409852 DOI: 10.1016/j.jash.2007.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2006] [Revised: 02/20/2007] [Accepted: 02/21/2007] [Indexed: 10/23/2022]
Abstract
Reduced diurnal blood pressure (BP) variation ("non-dipping") is associated with both micro- and macrovascular complications in patients with type 2 diabetes. The relation between endothelial perturbation and diurnal BP variation in diabetic subjects has not previously been studied. Seventy-six subjects, stratified to 4 gender-, age-, and duration-matched groups of 19 subjects each, were studied (group A: non-diabetic subjects; group B to D, type 2 diabetic subjects; group B: no retinopathy; group C: minimal background retinopathy; group D: diabetic maculopathy). All subjects underwent a 24-hour ambulatory BP monitoring. von Willebrand factor (vWF), fibrinogen, E-selectin, and intercellular adhesion molecule-1 were measured in plasma. Systolic night/day BP ratio increased gradually in groups A to D: 85.2 +/- 5%, 85.7 +/- 7%, 88.5 +/- 6%, and 90.5 +/- 7%, respectively, P < .05. Among diabetic patients, non-dippers had significantly higher plasma levels of vWF and fibrinogen than dippers (median/interquartile range 1.7/1.4 to 2.1 vs. 1.2/0.9 to 1.5 U/mL, P < .01 and 3.6/3.6 to 3.7 vs. 2.9/2.5 to 3.6 g/L, P = .01). Non-dipping is associated with elevated plasma levels of proteins related to endothelial cell activation as well as with retinopathy in subjects with type 2 diabetes. This finding suggests a possible mechanism linking non-dipping with microvascular complications in these subjects.
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Affiliation(s)
- Søren Tang Knudsen
- Medical Department M (Diabetes & Endocrinology), Aarhus University Hospital, Aarhus, Denmark
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234
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Gabbai FB, Rahman M, Hu B, Appel LJ, Charleston J, Contreras G, Faulkner ML, Hiremath L, Jamerson KA, Lea JP, Lipkowitz MS, Pogue VA, Rostand SG, Smogorzewski MJ, Wright JT, Greene T, Gassman J, Wang X, Phillips RA. Relationship between ambulatory BP and clinical outcomes in patients with hypertensive CKD. Clin J Am Soc Nephrol 2012; 7:1770-6. [PMID: 22935847 DOI: 10.2215/cjn.11301111] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Abnormal ambulatory BP (ABP) profiles are commonplace in CKD, yet the prognostic value of ABP for renal and cardiovascular outcomes is uncertain. This study assessed the relationship of baseline ABP profiles with CKD progression and subsequent cardiovascular outcomes to determine the prognostic value of ABP beyond that of clinic BP measurements. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Between 2002 and 2003, 617 African Americans with hypertensive CKD treated to a clinic BP goal of <130/80 mmHg were enrolled in this prospective, observational study. Participants were followed for a median of 5 years. Primary renal outcome was a composite of doubling of serum creatinine, ESRD, or death. The primary cardiovascular outcome was a composite of myocardial infarction, hospitalized congestive heart failure, stroke, revascularization procedures, cardiovascular death, and ESRD. RESULTS Multivariable Cox proportional hazard analysis showed that higher 24-hour systolic BP (SBP), daytime, night-time, and clinic SBP were each associated with subsequent renal (hazard ratio, 1.17-1.28; P<0.001) and cardiovascular outcomes (hazard ratio, 1.22-1.32; P<0.001). After controlling for clinic SBP, ABP measures were predictive of renal outcomes in participants with clinic SBP <130 mmHg (P<0.05 for interaction). ABP predicted cardiovascular outcomes with no interaction based on clinic BP control. CONCLUSIONS ABP provides additional information beyond that of multiple clinic BP measures in predicting renal and cardiovascular outcomes in African Americans with hypertensive CKD. The primary utility of ABP in these CKD patients was to identify high-risk individuals among those patients with controlled clinic BP.
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Affiliation(s)
- Francis B Gabbai
- VA San Diego Healthcare System and Department of Medicine, University of California San Diego, CA 92161, USA.
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235
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Affiliation(s)
- Michio Fukuda
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Mizuho-ku, Nagoya, Japan.
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236
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Theilade S, Lajer M, Joergensen C, Persson F, Rossing P. Discrepancy Between Tonometric Ambulatory and Cuff-Based Office Blood Pressure Measurements in Patients With Type 1 Diabetes. J Clin Hypertens (Greenwich) 2012; 14:686-93. [DOI: 10.1111/j.1751-7176.2012.00689.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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237
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Ubetagoyena Arrieta M, Areses Trapote R, Artola Aizalde E, Cancela Muñiz V, Arruebarrena Lizarraga D. [Renal function and blood pressure in type 1 diabetes mellitus]. An Pediatr (Barc) 2012; 78:104-8. [PMID: 22819809 DOI: 10.1016/j.anpedi.2012.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Revised: 05/10/2012] [Accepted: 05/28/2012] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Persistent microalbuminuria is the accepted marker for early detection of a high risk of developing diabetic nephropathy in patients diagnosed with Type I Diabetes mellitus. The Ambulatory Blood Pressure Monitoring (ABPM) evaluates the circadian variations of blood pressure while awake and asleep. OBJECTIVE To show the renal function characteristics and the data provided by ABPM in a cohort of insulin dependent diabetic children referred to our hospital. MATERIAL AND METHODS A total of 61 patients with an age range between 6 and 17 years were studied. In each child blood pressure monitoring was arranged, the glomerular filtration rate in 24 hour urine was estimated, and glycosylated haemoglobin (HbA1c), total cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, was measured. RESULTS None of the cases showed persistent microalbuminuria. The renal function showed an increase in the glomerular filtration rate (146.6 ±22 ml/minute/1.73 m(2)). In 39% of the cases there was no drop in systolic blood pressure during the night, whereas 11% of the patients in our series had a decrease in diastolic pressure. The cases were analysed depending on whether or not there had been a physiological arterial or diastolic pressure drop during the night: there were no significant differences in anthropometric data, glycosylated haemoglobin (HbA1c) levels, total cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, glomerular filtration rate (GFR), proteinuria and microalbuminuria between both groups. CONCLUSION In Type I Diabetes Mellitus a decrease in the physiological blood pressure during the night is a frequent finding. There is also an increase in the glomerular filtration rate.
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Affiliation(s)
- M Ubetagoyena Arrieta
- Sección de Nefrología Pediátrica, Hospital Universitario Donostia, San Sebastián, Spain.
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238
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Soydinc HE, Davutoglu V, Sak ME, Ercan S, Evsen MS, Kaya H, Oylumlu M, Buyukaslan H, Sari I. Circadian Variation of Blood Pressure Is Impaired in Normotensive Pregnant Women with Gestational Diabetes Mellitus. Clin Exp Hypertens 2012; 35:128-33. [DOI: 10.3109/10641963.2012.702832] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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239
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Pop-Busui R. What do we know and we do not know about cardiovascular autonomic neuropathy in diabetes. J Cardiovasc Transl Res 2012; 5:463-78. [PMID: 22644723 DOI: 10.1007/s12265-012-9367-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 04/12/2012] [Indexed: 12/16/2022]
Abstract
Cardiovascular autonomic neuropathy (CAN) in diabetes is generally overlooked in practice, although awareness of its serious consequences is emerging. Challenges in understanding the complex, dynamic changes in the modulation of the sympathetic/parasympathetic systems' tone and their interactions with physiologic mechanisms regulating the control of heart rate, blood pressure, and other cardiovascular functions in the presence of acute hyper-or-hypoglycemic stress, other stressors or medication, and challenges with sensitive evaluations have contributed to lower CAN visibility compared with other diabetes complications. Yet, CAN is a significant cause of morbidity and mortality, due to a high-risk of cardiac arrhythmias, silent myocardial ischemia and sudden death. While striving for aggressive risk factor control in diabetes practice seemed intuitive, recent reports of major clinical trials undermine established thinking concerning glycemic control and cardiovascular risk. This review covers current understanding and gaps in that understanding of the clinical implications of CAN and prevention and treatment of CAN.
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Affiliation(s)
- Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
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240
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Flynn JT, Urbina EM. Pediatric ambulatory blood pressure monitoring: indications and interpretations. J Clin Hypertens (Greenwich) 2012; 14:372-82. [PMID: 22672091 DOI: 10.1111/j.1751-7176.2012.00655.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The prevalence of hypertension in children and adolescents is increasing, especially in obese and ethnic children. The adverse long-term effects of hypertension beginning in youth are known; therefore, it is important to identify young patients who need intervention. Unfortunately, measuring blood pressure (BP) is difficult due to the variety of techniques available and innate biologic variation in BP levels. Ambulatory BP monitoring may overcome some of the challenges clinicians face when attempting to categorize a young patient's BP levels. In this article, the authors review the use of ambulatory BP monitoring in pediatrics, discuss interpretation of ambulatory BP monitoring, and discuss gaps in knowledge in usage of this technique in the management of pediatric hypertension.
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Affiliation(s)
- Joseph T Flynn
- Division of Nephrology, Seattle Children's Hospital, Seattle, WA 98105, USA.
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Rincon-Choles H, Abboud HE, Lee S, Shade RE, Rice KS, Carey KD, Comuzzie AG, Barnes JL. Renal histopathology of a baboon model with type 2 diabetes. Toxicol Pathol 2012; 40:1020-30. [PMID: 22552392 DOI: 10.1177/0192623312444025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Naturally occurring type 2 diabetes has been found in a colony of baboons. Ongoing characterization of the baboon colony maintained at the Southwest National Primate Research Center has revealed a significant range of glucose sensitivity with some animals clearly diabetic. Seven baboons, four with diabetes and three without diabetes, underwent histopathological investigation. Three diabetic animals were diagnosed using fasting blood glucose, hemoglobin A1C, and intravenous glucose tolerance test, and a fourth one was known to have hyperglycemia. One control baboon and three baboons with diabetes had microalbuminuria. On kidney biopsy, diabetic baboons had thickening of the glomerular basement membrane and mesangial matrix expansion compared to controls. Immunohistochemistry showed the diabetic animals had increased mesangial expression of cellular fibronectin ED-A. Two diabetic animals with microalbuminuria had evidence of mesangiolysis with the formation of an early nodule. One diabetic animal had a Kimmestiel-Wilson nodule. We conclude that the baboon represents a useful primate model of diabetes and nephropathy that resembles the nephropathy associated with type 2 diabetes in humans.
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Affiliation(s)
- Hernan Rincon-Choles
- Audie L Murphy Division, South Texas Veterans Health Care System, San Antonio, Texas, USA
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242
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243
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Mehta R, Drawz PE. Is nocturnal blood pressure reduction the secret to reducing the rate of progression of hypertensive chronic kidney disease? Curr Hypertens Rep 2012; 13:378-85. [PMID: 21710375 DOI: 10.1007/s11906-011-0217-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Hypertension is a significant risk factor for cardiovascular and renal disease. Lowering blood pressure (BP) has been shown to reduce the incidence of cardiovascular disease, but randomized trials have not demonstrated a benefit of lowering BP for the progression of renal disease except in secondary analyses in patients with significant proteinuria. Recently, there has been increasing interest in measuring BP outside of the clinic, using both home and ambulatory blood pressure monitoring (ABPM). ABPM has the advantage of measuring BP throughout both the day and night. Elevated nighttime BP and a lack of decline in BP from day to night (nondipping) are more potent risk factors for cardiovascular and renal outcomes than elevated daytime or clinic BP. Studies have shown that it is possible to lower nighttime BP and restore normal dipping with the administration of antihypertensive medications in the evening, known as chronotherapy. Evening administration of antihypertensives not only lowers nighttime BP but also is associated with decreased urinary protein excretion, decreased cardiovascular events, and decreased all-cause mortality. Reducing nighttime BP may slow the progression of chronic kidney disease and may be the key to linking the treatment of hypertension with improved renal outcomes.
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Affiliation(s)
- Rupal Mehta
- Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA
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244
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Kohsaka A, Waki H, Cui H, Gouraud SS, Maeda M. Integration of metabolic and cardiovascular diurnal rhythms by circadian clock. Endocr J 2012; 59:447-56. [PMID: 22361995 DOI: 10.1507/endocrj.ej12-0057] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Understanding how the 24-hour blood-pressure rhythm is programmed has been one of the most challenging questions in cardiovascular research. The 24-hour blood-pressure rhythm is primarily driven by the circadian clock system, in which the master circadian pacemaker within the suprachiasmatic nuclei of the hypothalamus is first entrained to the light/dark cycle and then transmits synchronizing signals to the peripheral clocks common to most tissues, including the heart and blood vessels. However, the circadian system is more complex than this basic hierarchical structure, as indicated by the discovery that peripheral clocks are either influenced to some degree or fully driven by temporal changes in energy homeostasis, independent of the light entrainment pathway. Through various comparative genomic approaches and through studies exploiting mouse genetics and transgenics, we now appreciate that cardiovascular tissues possess a large number of metabolic genes whose expression cycle and reciprocally affect the transcriptional control of major circadian clock genes. These findings indicate that metabolic cycles can directly or indirectly affect the diurnal rhythm of cardiovascular function. Here, we discuss a framework for understanding how the 24-hour blood-pressure rhythm is driven by the circadian system that integrates cardiovascular and metabolic function.
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Affiliation(s)
- Akira Kohsaka
- Department of Physiology, Wakayama Medical University School of Medicine, Japan.
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245
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Anantharaman R, Bhansali A, Bhadada SK, Kohli HS, Walia R, Shanmugasundar G, Jayaprakash P. A pilot study on the effect of telmisartan & ramipril on 24 h blood pressure profile & dipping pattern in type 1 diabetes patients with nephropathy. Indian J Med Res 2011; 134:658-63. [PMID: 22199105 PMCID: PMC3249964 DOI: 10.4103/0971-5916.90991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background & objectives: Angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) have been used to normalize the blood pressure and the dipping pattern in patients with type 1 diabetes mellitus (T1DM) and nephropathy. However, there are no data on the effect of the dual blockade on the dipping pattern in these subjects. We therefore, carried out this study to evaluate the effect of administrating an ACEI followed by ARB in the optimum doses in T1DM patients with nephropathy on 24 h blood pressure (BP) profile and nocturnal dipping pattern. Methods: An open label interventional pilot study was done during a one year period involving 30 consecutive patients who were treated with telmisartan 80 mg (0800-1000 h) for eight weeks followed by addition of ramipril 10 mg (1200-1400 h) for the next eight weeks. Ambulatory BP, dipping pattern and albumin excretion rate were studied after each phase. Twenty patients were hypertensive and 10 patients had macro- and 20 patients had microalbuminuria. Results: Telmisartan produced a fall in the clinic BP by 4/1.3 mm Hg (P<0.05 and P<0.362, respectively), 2/1.9 mm Hg in the mean 24 h BP, 1.4/1.1 mm Hg in the day BP and 3.7/3 mm Hg in the trough BP. Addition of ramipril to telmisartan produced a further reduction of 6.3/5.9 mm Hg in the clinic BP (P<0.001 for both), 4.3/4.2 mm Hg in the mean 24 h BP (P<0.01 and P<0.0001, respectively), 5.8/3.9 mm Hg in the day BP (P<0.01 for both), 4.2/2.5 mm Hg in the trough BP, with a reduction of clinic SBP and DBP of 10.3/7.2 mm Hg from the baseline. Telmisartan restored normal systolic dipping pattern in 33.3 per cent of the nondippers (P<0.01) but addition of ramipril was not complimentary. Hyperkalamia (>5.5 mmol/l) was observed only in 2 patients towards the end of the study. Interpretation & conclusions: The dual blockade with telmisartan and ramipril had complimentary effect on lowering of the BP, however, similar beneficial effect on the nocturnal dipping was not observed. Further studies with large number of subjects with longer duration of follow-up are required to validate these observations.
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Affiliation(s)
- R Anantharaman
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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246
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Yang J, Pollock JS, Carmines PK. NADPH oxidase and PKC contribute to increased Na transport by the thick ascending limb during type 1 diabetes. Hypertension 2011; 59:431-6. [PMID: 22203737 DOI: 10.1161/hypertensionaha.111.184796] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Type 1 diabetes triggers protein kinase C (PKC)-dependent NADPH oxidase activation in the renal medullary thick ascending limb (mTAL), resulting in accelerated superoxide production. As acute exposure to superoxide stimulates NaCl transport by the mTAL, we hypothesized that diabetes increases mTAL Na(+) transport through PKC-dependent and NADPH oxidase-dependent mechanisms. An O(2)-sensitive fluoroprobe was used to measure O(2) consumption by mTALs from rats with streptozotocin-induced diabetes and sham rats. In sham mTALs, total O(2) consumption was evident as a 0.34±0.03 U change in normalized relative fluorescence (ΔNRF)/min per mg protein. Ouabain (2 mmol/L) reduced O(2) consumption by 69±4% and 500 μmol/L furosemide reduced O(2) consumption by 58±8%. Total O(2) consumption was accelerated in mTAL from diabetic rats (0.74±0.07 ΔNRF/min/mg protein; P<0.05 versus sham), reflecting increases in ouabain- and furosemide-sensitive O(2) consumption. NADPH oxidase inhibition (100 μmol/L apocynin) reduced furosemide-sensitive O(2) consumption by mTAL from diabetic rats to values not different from sham. The PKC inhibitor calphostin C (1 μmol/L) or the PKCα/β inhibitor Gö6976 (1 μmol/L) decreased furosemide-sensitive O(2) consumption in both groups, achieving values that did not differ between sham and diabetic. PKCβ inhibition had no effect in either group. Similar inhibitory patterns were evident with regard to ouabain-sensitive O(2) consumption. We conclude that NADPH oxidase and PKC (primarily PKCα) contribute to an increase in O(2) consumption by the mTAL during type 1 diabetes through effects on the ouabain-sensitive Na(+)-K(+)-ATPase and furosemide-sensitive Na(+)-K(+)-2Cl(-) cotransporter that are primarily responsible for active transport Na(+) reabsorption by this nephron segment.
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Affiliation(s)
- Jing Yang
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE, USA
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247
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Ramesh Prasad GV. Ambulatory blood pressure monitoring in solid organ transplantation. Clin Transplant 2011; 26:185-91. [DOI: 10.1111/j.1399-0012.2011.01569.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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248
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Conway BR, Rennie J, Bailey MA, Dunbar DR, Manning JR, Bellamy CO, Hughes J, Mullins JJ. Hyperglycemia and renin-dependent hypertension synergize to model diabetic nephropathy. J Am Soc Nephrol 2011; 23:405-11. [PMID: 22193383 DOI: 10.1681/asn.2011060577] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Rodent models exhibit only the earliest features of human diabetic nephropathy, which limits our ability to investigate new therapies. Hypertension is a prerequisite for advanced diabetic nephropathy in humans, so its rarity in typical rodent models may partly explain their resistance to nephropathy. Here, we used the Cyp1a1mRen2 rat, in which the murine renin-2 gene is incorporated under the Cytochrome P4501a1 promoter. In this transgenic strain, administration of low-dose dietary indole-3-carbinol induces moderate hypertension. In the absence of hypertension, streptozotocin-induced diabetes resulted in a 14-fold increase in albuminuria but only mild changes in histology and gene expression despite 28 weeks of marked hyperglycemia. In the presence of induced hypertension, hyperglycemia resulted in a 500-fold increase in albuminuria, marked glomerulosclerosis and tubulointerstitial fibrosis, and induction of many of the same pathways that are upregulated in the tubulointerstitium in human diabetic nephropathy. In conclusion, although induction of diabetes alone in rodents has limited utility to model human diabetic nephropathy, renin-dependent hypertension and hyperglycemia synergize to recapitulate many of the clinical, histological, and gene expression changes observed in humans.
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Affiliation(s)
- Bryan R Conway
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, Scotland, UK.
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249
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Becker AM. Sickle cell nephropathy: challenging the conventional wisdom. Pediatr Nephrol 2011; 26:2099-109. [PMID: 21203778 DOI: 10.1007/s00467-010-1736-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 10/08/2010] [Accepted: 11/02/2010] [Indexed: 01/13/2023]
Abstract
This review explores the current model of sickle cell nephropathy and the limitations of the model. Renal abnormalities are common complications of sickle cell disease (SCD). Beginning in childhood, patients with SCD develop a urinary concentrating defect resulting in polyuria and a predisposition to nocturnal enuresis and dehydration. The current model of sickle cell nephropathy suggests that destruction of the renal medulla induces production of renal vasodilating substances that feedback to the glomerulus causing hyperfiltration. Hyperfiltration leads to glomerulosclerosis and proteinuria, with eventual reduction in kidney function. The crucial steps of vasodilating substance production and hyperfiltration in children with SCD have not been proven. Treatment of sickle cell nephropathy is aimed at the reduction of proteinuria with angiotensin converting enzyme inhibitors or angiotensin receptor blockers. Hydroxyurea and chronic transfusion therapy may also alter the progression of sickle cell nephropathy in children. Further studies are needed to identify an accurate model and effective treatments for sickle cell nephropathy.
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Affiliation(s)
- Amy M Becker
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9063, USA.
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250
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Ritz E, Zeng X. Diabetic nephropathy - Epidemiology in Asia and the current state of treatment. Indian J Nephrol 2011; 21:75-84. [PMID: 21769168 PMCID: PMC3132343 DOI: 10.4103/0971-4065.82122] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- E Ritz
- Department of Internal Medicine, Division Nephrology, Ruperto Carola University of Heidelberg, Germany
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