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Zhang Z, Wang C, Tu T, Lin Q, Zhou J, Huang Y, Wu K, Zhang Z, Zuo W, Liu N, Xiao Y, Liu Q. Advancing Guideline-Directed Medical Therapy in Heart Failure: Overcoming Challenges and Maximizing Benefits. Am J Cardiovasc Drugs 2024; 24:329-342. [PMID: 38568400 PMCID: PMC11093832 DOI: 10.1007/s40256-024-00646-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 05/15/2024]
Abstract
The delayed titration of guideline-directed drug therapy (GDMT) is a complex event influenced by multiple factors that often result in poor prognosis for patients with heart failure (HF). Individualized adjustments in GDMT titration may be necessary based on patient characteristics, and every clinician is responsible for promptly initiating GDMT and titrating it appropriately within the patient's tolerance range. This review examines the current challenges in GDMT implementation and scrutinizes titration considerations within distinct subsets of HF patients, with the overarching goal of enhancing the adoption and effectiveness of GDMT. The authors also underscore the significance of establishing a novel management strategy that integrates cardiologists, nurse practitioners, pharmacists, and patients as a unified team that can contribute to the improved promotion and implementation of GDMT.
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Affiliation(s)
- Zixi Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Cancan Wang
- Department of Metabolic Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China
| | - Tao Tu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Qiuzhen Lin
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Jiabao Zhou
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Yunying Huang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Keke Wu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Zeying Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Wanyun Zuo
- Department of Hematology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China
| | - Na Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Yichao Xiao
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China.
| | - Qiming Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China.
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Ascher SB, Berry JD, Katz R, de Lemos JA, Bansal N, Garimella PS, Hallan SI, Wettersten N, Jotwani VK, Killeen AA, Ix JH, Shlipak MG. Changes in Natriuretic Peptide Levels and Subsequent Kidney Function Decline in SPRINT. Am J Kidney Dis 2024; 83:615-623.e1. [PMID: 37992982 DOI: 10.1053/j.ajkd.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/03/2023] [Accepted: 09/17/2023] [Indexed: 11/24/2023]
Abstract
RATIONALE & OBJECTIVE Novel approaches to the assessment of kidney disease risk during hypertension treatment are needed because of the uncertainty of how intensive blood pressure (BP) lowering impacts kidney outcomes. We determined whether longitudinal N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements during hypertension treatment are associated with kidney function decline. STUDY DESIGN Prospective observational study. SETTING & PARTICIPANTS 8,005 SPRINT (Systolic Blood Pressure Intervention Trial) participants with NT-proBNP measurements at baseline and 1 year. EXPOSURE 1-year change in NT-proBNP categorized as a ≥25% decrease, ≥25% increase, or <25% change (stable). OUTCOME Annualized change in estimated glomerular filtration rate (eGFR) and ≥30% decrease in eGFR. ANALYTICAL APPROACH Linear mixed-effect and logistic regression models were used to evaluate the association of changes in NT-proBNP with subsequent annualized change in eGFR and ≥30% decrease in eGFR, respectively. Analyses were stratified by baseline chronic kidney disease (CKD) status. RESULTS Compared with stable 1-year NT-proBNP levels, a ≥25% decrease in NT-proBNP was associated with a slower decrease in eGFR in participants with CKD (adjusted difference, 1.09%/y; 95% CI, 0.35-1.83) and without CKD (adjusted difference, 0.51%/y; 95% CI, 0.21-0.81; P = 0.4 for interaction). Meanwhile, a ≥25% increase in NT-proBNP in participants with CKD was associated with a faster decrease in eGFR (adjusted difference, -1.04%/y; 95% CI, -1.72 to -0.36) and risk of a ≥30% decrease in eGFR (adjusted odds ratio, 1.44; 95% CI, 1.06-1.96); associations were stronger in participants with CKD than in participants without CKD (P = 0.01 and P < 0.001 for interaction, respectively). Relationships were similar irrespective of the randomized BP arm in SPRINT (P > 0.2 for interactions). LIMITATIONS Persons with diabetes and proteinuria >1 g/d were excluded. CONCLUSIONS Changes in NT-proBNP during BP treatment are independently associated with subsequent kidney function decline, particularly in people with CKD. Future studies should assess whether routine NT-proBNP measurements may be useful in monitoring kidney risk during hypertension treatment. PLAIN-LANGUAGE SUMMARY N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a biomarker in the blood that reflects mechanical stress on the heart. Measuring NT-proBNP may be helpful in assessing the risk of long-term losses of kidney function. In this study, we investigated the association of changes in NT-proBNP with subsequent kidney function among individuals with and without chronic kidney disease. We found that increases in NT-proBNP are associated with a faster rate of decline of kidney function, independent of baseline kidney measures. The associations were more pronounced in individuals with chronic kidney disease. Our results advance the notion of considering NT-proBNP as a dynamic tool for assessing kidney disease risk.
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Affiliation(s)
- Simon B Ascher
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California San Francisco, San Francisco; Division of Hospital Medicine, University of California, Davis, Sacramento.
| | - Jarett D Berry
- Divison of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ronit Katz
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - James A de Lemos
- Divison of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Nisha Bansal
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Pranav S Garimella
- Division of Nephrology-Hypertension, University of California, San Diego, La Jolla
| | - Stein I Hallan
- Department of Clinical and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Nephrology, St Olav University Hospital, Trondheim, Norway
| | - Nicholas Wettersten
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla; Cardiology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA
| | - Vasantha K Jotwani
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California San Francisco, San Francisco
| | - Anthony A Killeen
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Joachim H Ix
- Division of Nephrology-Hypertension, University of California, San Diego, La Jolla; Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA
| | - Michael G Shlipak
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California San Francisco, San Francisco
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Khatri R, Machart P, Bonn S. DISSECT: deep semi-supervised consistency regularization for accurate cell type fraction and gene expression estimation. Genome Biol 2024; 25:112. [PMID: 38689377 PMCID: PMC11061925 DOI: 10.1186/s13059-024-03251-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 04/17/2024] [Indexed: 05/02/2024] Open
Abstract
Cell deconvolution is the estimation of cell type fractions and cell type-specific gene expression from mixed data. An unmet challenge in cell deconvolution is the scarcity of realistic training data and the domain shift often observed in synthetic training data. Here, we show that two novel deep neural networks with simultaneous consistency regularization of the target and training domains significantly improve deconvolution performance. Our algorithm, DISSECT, outperforms competing algorithms in cell fraction and gene expression estimation by up to 14 percentage points. DISSECT can be easily adapted to other biomedical data types, as exemplified by our proteomic deconvolution experiments.
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Affiliation(s)
- Robin Khatri
- Institute of Medical Systems Biology, Center for Molecular Neurobiology, Center for Biomedical AI, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pierre Machart
- Institute of Medical Systems Biology, Center for Molecular Neurobiology, Center for Biomedical AI, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Bonn
- Institute of Medical Systems Biology, Center for Molecular Neurobiology, Center for Biomedical AI, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Canki E, Kho E, Hoenderop JGJ. Urinary biomarkers in kidney disease. Clin Chim Acta 2024; 555:117798. [PMID: 38280489 DOI: 10.1016/j.cca.2024.117798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/22/2024] [Accepted: 01/22/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Chronic kidney disease (CKD) affects many people worldwide and early diagnosis is essential for successful treatment and improved outcome. Unfortunately, current methods are insufficient especially for early disease detection. However, advances in the analytical methods for urinary biomarkers may provide a unique opportunity for diagnosis and management of CKD. This review explores evolving technology and highlights the importance of early marker detection in these patients. APPROACH A search strategy was set up using the terms CKD, biomarkers, and urine. The search included 53 studies comprising 37 biomarkers. The value of these biomarkers for CKD are based on their ability to diagnose CKD, monitor progression, assess mortality and nephrotoxicity. RESULTS KIM-1 was the best marker for diagnosis as it increased with the development of incident CKD. DKK3 increased in patients with declining eGFR, whereas UMOD decreased in those with declining kidney function. Unfortunately, none fulfilled all criteria to adequately assess mortality and nephrotoxicity. CONCLUSION New developments in the field of urinalysis using smart toilets may open several possibilities for urinary biomarkers. This review explored which biomarkers could be used for CKD disease detection and management.
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Affiliation(s)
- Esra Canki
- Department of Medical BioSciences, Radboudumc, Nijmegen, The Netherlands
| | - Esther Kho
- imec within OnePlanet Research Center, Wageningen, The Netherlands
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Hernandez MF, Chang TI. Revisiting Hypertension Treatment in Patients With Chronic Kidney Disease. Semin Nephrol 2024; 44:151514. [PMID: 38735770 DOI: 10.1016/j.semnephrol.2024.151514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
Despite being the world's top risk factor for death and disability, hypertension awareness and control within the chronic kidney disease (CKD) population have decreased. This is particularly important considering the heightened severity and management challenges of hypertension in CKD patients, whose outcomes are often worse compared with persons with normal kidney function. Therefore, finding novel therapeutics to improve blood pressure control within this vulnerable group is paramount. Although medications that target the renin-angiotensin-aldosterone system remain a mainstay for blood pressure control in most stages of CKD, we discuss novel approaches that may expand their use in advanced CKD. We also review newer tools for blood pressure management that have emerged in recent years, including aldosterone synthase inhibitors, endothelin receptor antagonists, and renal denervation. Overall, the future of hypertension management in CKD appears brighter, with a growing arsenal of tools and a deeper understanding of this complex disease.
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Affiliation(s)
- Mario Funes Hernandez
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Tara I Chang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA.
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Chuang MH, Tang YS, Chen JY, Pan HC, Liao HW, Chu WK, Cheng CY, Wu VC, Heung M. Abrupt Decline in Estimated Glomerular Filtration Rate after Initiating Sodium-Glucose Cotransporter 2 Inhibitors Predicts Clinical Outcomes: A Systematic Review and Meta-Analysis. Diabetes Metab J 2024; 48:242-252. [PMID: 38273790 PMCID: PMC10995480 DOI: 10.4093/dmj.2023.0201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 09/25/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGRUOUND The initiation of sodium-glucose cotransporter-2 inhibitors (SGLT2i) typically leads to a reversible initial dip in estimated glomerular filtration rate (eGFR). The implications of this phenomenon on clinical outcomes are not well-defined. METHODS We searched MEDLINE, Embase, and Cochrane Library from inception to March 23, 2023 to identify randomized controlled trials and cohort studies comparing kidney and cardiovascular outcomes in patients with and without initial eGFR dip after initiating SGLT2i. Pooled estimates were calculated using random-effect meta-analysis. RESULTS We included seven studies in our analysis, which revealed that an initial eGFR dip following the initiation of SGLT2i was associated with less annual eGFR decline (mean difference, 0.64; 95% confidence interval [CI], 0.437 to 0.843) regardless of baseline eGFR. The risk of major adverse kidney events was similar between the non-dipping and dipping groups but reduced in patients with a ≤10% eGFR dip (hazard ratio [HR], 0.915; 95% CI, 0.865 to 0.967). No significant differences were observed in the composite of hospitalized heart failure and cardiovascular death (HR, 0.824; 95% CI, 0.633 to 1.074), hospitalized heart failure (HR, 1.059; 95% CI, 0.574 to 1.952), or all-cause mortality (HR, 0.83; 95% CI, 0.589 to 1.170). The risk of serious adverse events (AEs), discontinuation of SGLT2i due to AEs, kidney-related AEs, and volume depletion were similar between the two groups. Patients with >10% eGFR dip had increased risk of hyperkalemia compared to the non-dipping group. CONCLUSION Initial eGFR dip after initiating SGLT2i might be associated with less annual eGFR decline. There were no significant disparities in the risks of adverse cardiovascular outcomes between the dipping and non-dipping groups.
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Affiliation(s)
- Min-Hsiang Chuang
- Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Shuo Tang
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Medical University Research Center of Urology and Kidney, Taipei, Taiwan
| | - Jui-Yi Chen
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Heng-Chih Pan
- Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Hung-Wei Liao
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wen-Kai Chu
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chung-Yi Cheng
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Medical University Research Center of Urology and Kidney, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
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Chen JY, Huang KH, Lin YH, Chueh JS, Wang HY, Wu VC. Association of Dip in eGFR With Clinical Outcomes in Unilateral Primary Aldosteronism Patients After Adrenalectomy. J Clin Endocrinol Metab 2024; 109:e965-e974. [PMID: 38051943 PMCID: PMC10876388 DOI: 10.1210/clinem/dgad709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 11/01/2023] [Accepted: 12/01/2023] [Indexed: 12/07/2023]
Abstract
CONTEXT Primary aldosteronism (PA) leads to kidney function deterioration after treatment, but the effects of the estimated glomerular filtration rate (eGFR) dip following adrenalectomy and its long-term implications are unclear. OBJECTIVE This study aims to examine eGFR dip in patients with unilateral PA (uPA) after adrenalectomy and clarify their long-term prognosis. METHODS This multicenter prospective population-based cohort study, enrolled patients with uPA who underwent adrenalectomy. Patients were divided into 4 groups based on their eGFR dip ratio. Outcomes investigated included mortality, cardiovascular composite events, and major adverse kidney events (MAKEs). RESULTS Among 445 enrolled patients, those with an eGFR dip ratio worse than -30% (n = 74, 16.6%) were older, had higher blood pressure, higher aldosterone concentration, and lower serum potassium levels. During 5.0 ± 3.6 years of follow-up, 2.9% died, 14.6% had cardiovascular composite events, and 17.3% had MAKEs. The group with eGFR dip worse than -30% had a higher risk of MAKEs (P < .001), but no significant differences in mortality (P = .295) or new-onset cardiovascular composite outcomes (P = .373) were found. Multivariate analysis revealed that patients with an eGFR dip ratio worse than -30% were significantly associated with older age (odds ratio [OR], 1.04), preoperative eGFR (OR, 1.02), hypokalemia (OR, 0.45), preoperative systolic blood pressure (OR, 1.03), and plasma aldosterone concentration (OR, 0.99). CONCLUSION Within 5 years post adrenalectomy, 17.3% of patients had reduced kidney function. Notably, individuals with an eGFR dip ratio worse than -30% faced higher MAKE risks, underscoring the need to monitor kidney function in PA patients after surgery.
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Affiliation(s)
- Jui-Yi Chen
- Division of Nephrology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan 71004, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan 71710, Taiwan
| | - Kuo-How Huang
- Department of Urology, College of Medicine, National Taiwan University, Taipei 106319, Taiwan
- Department of Urology, National Taiwan University Hospital, Taipei 100225, Taiwan
| | - Yen-Hung Lin
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100225, Taiwan
| | - Jeff S Chueh
- Department of Urology, College of Medicine, National Taiwan University, Taipei 106319, Taiwan
- Department of Urology, National Taiwan University Hospital, Taipei 100225, Taiwan
| | - Hsien-Yi Wang
- Division of Nephrology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan 71004, Taiwan
- Department of Sport Management, College of Leisure and Recreation Management, Chia Nan University of Pharmacy and Science, Tainan 71710, Taiwan
| | - Vin-Cent Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100225, Taiwan
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Kiernan EA, Hu D, Philbrook HT, Ix JH, Bonventre JV, Coca SG, Moledina DG, Fried LF, Shlipak MG, Parikh CR. Urinary Biomarkers and Kidney Injury in VA NEPHRON-D: Phenotyping Acute Kidney Injury in Clinical Trials. Am J Kidney Dis 2024; 83:151-161. [PMID: 37726051 PMCID: PMC10841767 DOI: 10.1053/j.ajkd.2023.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 06/23/2023] [Accepted: 07/02/2023] [Indexed: 09/21/2023]
Abstract
RATIONALE & OBJECTIVE Urinary biomarkers of injury, inflammation, and repair may help phenotype acute kidney injury (AKI) observed in clinical trials. We evaluated the differences in biomarkers between participants randomized to monotherapy or to combination renin-angiotensin-aldosterone system (RAAS) blockade in VA NEPHRON-D, where an increased proportion of observed AKI was acknowledged in the combination arm. STUDY DESIGN Longitudinal analysis. SETTING & PARTICIPANTS A substudy of the VA NEPHRON-D trial. PREDICTOR Primary exposure was the treatment arm (combination [RAAS inhibitor] vs monotherapy). AKI is used as a stratifying variable. OUTCOME Urinary biomarkers, including albumin, EGF (epidermal growth factor), MCP-1 (monocyte chemoattractant protein-1), YKL-40 (chitinase 3-like protein 1), and KIM-1 (kidney injury molecule-1). ANALYTICAL APPROACH Biomarkers measured at baseline and at 12 months in trial participants were compared between treatment groups and by AKI. AKI events occurring during hospitalization were predefined safety end points in the original trial. The results were included in a meta-analysis with other large chronic kidney disease trials to assess global trends in biomarker changes. RESULTS In 707 participants followed for a median of 2.2 years, AKI incidence was higher in the combination (20.7%) versus the monotherapy group (12.7%; relative risk [RR], 1.64 [95% CI, 1.16-2.30]). Compared with the monotherapy arm, in the combination arm the urine biomarkers at 12 months were either unchanged (MCP-1: RR, -3% [95% CI, -13% to 9%], Padj=0.8; KIM-1: RR, -10% [95% CI, -20% to 1%], Padj=0.2; EGF, RR-7% [95% CI, -12% to-1%], Padj=0.08) or lower (albuminuria: RR, -24% [95% CI, -37% to-8%], Padj=0.02; YKL: RR, -40% to-44% [95% CI, -58% to-25%], Padj<0.001). Pooled meta-analysis demonstrated reduced albuminuria in the intervention arm across 3 trials and similar trajectories in other biomarkers. LIMITATIONS Biomarker measurement was limited to 2 time points independent of AKI events. CONCLUSIONS Despite the increased risk of serum creatinine-defined AKI, combination RAAS inhibitor therapy was associated with unchanged or decreased urinary biomarkers at 12 months. This suggests a possible role for kidney biomarkers to further characterize kidney injury in clinical trials. PLAIN-LANGUAGE SUMMARY The VA NEPHRON-D trial investigated inhibition of the renin-angiotensin-aldosterone system (RAAS) hormonal axis on kidney outcomes in a large population of diabetic chronic kidney disease patients. The trial was stopped early due to increased events of serum creatinine-defined acute kidney injury in the combination therapy arm. Urine biomarkers can serve as an adjunct to serum creatinine in identifying kidney injury. We found that urinary biomarkers in the combination therapy group were not associated with a pattern of harm and damage to the kidney, despite the increased number of kidney injury events in that group. This suggests that serum creatinine alone may be insufficient for defining kidney injury and supports further exploration of how other biomarkers might improve identification of kidney injury in clinical trials.
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Affiliation(s)
- Elizabeth A Kiernan
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David Hu
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Heather Thiessen Philbrook
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Joachim H Ix
- Division of Nephrology-Hypertension, University of California-San Diego, San Diego, California; Veterans Affairs San Diego Healthcare System, San Diego, CA
| | | | - Steven G Coca
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dennis G Moledina
- Section of Nephrology and Clinical and Translational Research Accelerator, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Linda F Fried
- Renal Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Michael G Shlipak
- Kidney Health Research Collaborative, Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Chirag R Parikh
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S219-S230. [PMID: 38078574 PMCID: PMC10725805 DOI: 10.2337/dc24-s011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Park CH, Kim HW, Park JT, Chang TI, Yoo TH, Park SK, Kim Y, Jung JY, Jeong JC, Oh KH, Kang SW, Han SH. The 2021 KDIGO blood pressure target and the progression of chronic kidney disease: Findings from KNOW-CKD. J Intern Med 2023; 294:653-664. [PMID: 37538023 DOI: 10.1111/joim.13701] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
BACKGROUND The 2021 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline for the management of blood pressure (BP) in chronic kidney disease (CKD) recommends a target systolic BP of <120 mmHg as this target can provide cardiovascular benefits. However, it remains unclear whether implementing the new BP target could improve kidney outcomes. METHODS The association between the 2021 KDIGO BP target and CKD progression was examined and compared with the 2012 KDIGO BP target among 1724 participants included in the KoreaN Cohort Study for Outcomes in Patients With CKD. The main exposure was the BP status categorized according to the 2012 or 2021 KDIGO guideline: (1) controlled within the 2021 target, (2) controlled within the 2012 target only, and (3) above both targets. The primary outcome was a composite kidney outcome of ≥50% decline in the estimated glomerular filtration rate from baseline or the initiation of kidney replacement therapy during the follow-up period. RESULTS Composite kidney outcomes occurred in 650 (37.7%) participants during the 8078 person-years of follow-up (median, 4.9 years). The incidence rates of this outcome were 55, 66.5, and 116.4 per 1000 person-years in BP controlled within the 2021 and 2012 KDIGO targets, and BP above both targets, respectively. In the multivariable cause-specific hazard model, hazard ratios for the composite outcome were 0.76 (95% confidence interval (CI), 0.60-0.95) for BP controlled within the 2021 target and 1.36 (95% CI, 1.13-1.64) for BP above both targets, compared with BP controlled within 2012 target only. CONCLUSION The newly lowered BP target by the 2021 KDIGO guideline was associated with improved kidney outcome compared with BP target by the 2012 KDIGO guideline.
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Affiliation(s)
- Cheol Ho Park
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Hyung Woo Kim
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Jung Tak Park
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Tae Ik Chang
- Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Sue Kyung Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yaeni Kim
- Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji Yong Jung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Jong Cheol Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Kidney Research Institute, Seoul, Republic of Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
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11
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Ku E, McCulloch CE, Copeland TP, Inker LA, Tighiouart H, Sarnak MJ. Acute Declines in Estimated GFR in Blood Pressure Target Trials and Risk of Adverse Outcomes. Am J Kidney Dis 2023; 82:454-463. [PMID: 37269972 DOI: 10.1053/j.ajkd.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 03/10/2023] [Indexed: 06/05/2023]
Abstract
RATIONALE & OBJECTIVE Acute decreases in glomerular filtration rate (GFR) occur commonly during intensive blood pressure (BP) lowering. Our objective was to determine the relationship between acute decreases in estimated GFR and patient outcomes. STUDY DESIGN Retrospective observational study. SETTING & PARTICIPANTS Participants from 4 randomized controlled trials of intensive BP lowering in chronic kidney disease (Modification of Diet in Renal Disease study, African American Study of Kidney Disease and Hypertension, Systolic Blood Pressure Intervention Trial, and Action to Control Cardiovascular Risk in Diabetes trial). EXPOSURE A 4-category exposure defined by the level of acute decrease in estimated GFR (defined as>15% vs≤15% between baseline and month 4) and the randomization to intensive versus usual BP control. OUTCOMES Risk of kidney replacement therapy (primary outcome), defined as the need for dialysis or transplant except in the Action to Control Cardiovascular Risk in Diabetes trial, which defined its kidney outcome as a composite occurrence of serum creatinine concentration>3.3mg/dL, kidney failure, or kidney replacement therapy. ANALYTICAL APPROACH Multivariable Cox models. RESULTS We included 4,473 individuals randomly assigned to intensive versus usual BP control who had a total of 351 kidney outcomes and 304 deaths during median follow-up durations of 22 and 24 months, respectively. Approximately 14% of participants exhibited an acute decrease in eGFR, 11.0% in the usual BP treatment arm and 17.8% in the intensive BP treatment arm. In adjusted models, compared with a≤15% eGFR decrease in the usual BP arm, a≤15% eGFR decrease in the intensive BP control arm was associated with lower risk of the kidney outcome (HR, 0.75; 95% CI, 0.57-0.98). In contrast, a>15% decrease in eGFR was associated with a higher risk of the kidney outcome in the usual (HR, 2.47; 95% CI, 1.80-3.38) and intensive BP treatment arms (HR, 1.99; 95% CI, 1.45-2.73) compared with a≤15% decrease in the usual BP arm. LIMITATIONS Observational study, residual confounding. CONCLUSIONS Decreases in eGFR of>15% in the usual and intensive BP treatment arms were associated with a higher risk of kidney outcomes compared with a≤15% decrease in the usual BP arm and may be a harbinger of adverse outcomes.
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Affiliation(s)
- Elaine Ku
- Department of Medicine, Division of Nephrology, University of California San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA.
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Timothy P Copeland
- Department of Medicine, Division of Nephrology, University of California San Francisco, San Francisco, CA
| | - Lesley A Inker
- Department of Medicine, Division of Nephrology, Boston, MA
| | - Hocine Tighiouart
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Mark J Sarnak
- Department of Medicine, Division of Nephrology, Boston, MA
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12
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Tawfik YM, Van Tassell BW, Dixon DL, Baker WL, Fanikos J, Buckley LF. Effects of Intensive Systolic Blood Pressure Lowering on End-Stage Kidney Disease and Kidney Function Decline in Adults With Type 2 Diabetes Mellitus and Cardiovascular Risk Factors: A Post Hoc Analysis of ACCORD-BP and SPRINT. Diabetes Care 2023; 46:868-873. [PMID: 36787937 PMCID: PMC10090906 DOI: 10.2337/dc22-2040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/24/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE To determine the effects of intensive systolic blood pressure (SBP) lowering on the risk of major adverse kidney outcomes in people with type 2 diabetes mellitus (T2DM) and/or prediabetes and cardiovascular risk factors. RESEARCH DESIGN AND METHODS This post hoc ACCORD-BP subgroup analysis included participants in the standard glucose-lowering arm with cardiovascular risk factors required for SPRINT eligibility. Cox proportional hazards regression models compared the hazard for the composite of dialysis, kidney transplant, sustained estimated glomerular filtration rate (eGFR) <15 mL/min/1.73 m2, serum creatinine >3.3 mg/dL, or a sustained eGFR decline ≥57% between the intensive (<120 mmHg) and standard (<140 mmHg) SBP-lowering arms. RESULTS The study cohort included 1,966 SPRINT-eligible ACCORD-BP participants (40% women) with a mean age of 63 years. The mean SBP achieved after randomization was 120 ± 14 and 134 ± 15 mmHg in the intensive and standard arms, respectively. The kidney composite outcome occurred at a rate of 9.5 and 7.2 events per 1,000 person-years in the intensive and standard BP arms (hazard ratio [HR] 1.35 [95% CI 0.85-2.14]; P = 0.20). Intensive SBP lowering did not affect the risk of moderately (HR 0.96 [95% CI 0.76-1.20]) or severely (HR 0.92 [95% CI 0.66-1.28]) increased albuminuria. Including SPRINT participants with prediabetes in the cohort did not change the overall results. CONCLUSIONS This post hoc subgroup analysis suggests that intensive SBP lowering does not increase the risk of major adverse kidney events in individuals with T2DM and cardiovascular risk factors.
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Affiliation(s)
- Yahya M.K. Tawfik
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, MA
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Benjamin W. Van Tassell
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA
| | - Dave L. Dixon
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA
| | - William L. Baker
- Department of Pharmacy Practice, University of Connecticut, Storrs, CT
| | - John Fanikos
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, MA
| | - Leo F. Buckley
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, MA
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13
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van der Giet M. [Blood pressure goals in chronic kidney disease : What is the optimal blood pressure for inhibition of progression and risk reduction?]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:234-239. [PMID: 36719508 DOI: 10.1007/s00108-023-01483-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/23/2023] [Indexed: 06/18/2023]
Abstract
Well-controlled blood pressure is an essential factor in inhibiting the progression of renal failure and also in controlling cardiovascular mortality and morbidity. For decades there has been an intensive search for the optimal blood pressure target values in order to reduce the progression of renal insufficiency to a physiological level as far as possible. In the last few decades, very different target blood pressure values have been defined, which time and again contribute more to confusion than clarity in everyday clinical practice. The present work considers the relevant guidelines; it analyzes the basis on which the sometimes widely varying guidelines were created. All guidelines agree that blood pressure control with a target of less than 140 mm Hg systolic should be achieved in patients with impaired renal function. The European guidelines recommend aiming for a target of 130-140 mm Hg systolic. The American guidelines go one step further and specify a systolic blood pressure target of less than 130 mm Hg. The Kidney Disease: Improving Global Outcomes (KDIGO) organization is even more ambitious. It recommends a blood pressure target of less than 120 mm Hg, whereby in contrast to the European and American guidelines, the level of evidence required in the guidelines is considered to be very weak and the goals should also be achieved if automated, standardized blood pressure measurement is carried out, which is rarely available in everyday practice and may not be feasible. The present overview discusses the arguments for lowering blood pressure with different goals and presents the evidence. Of course, the blood pressure goals in the presence or absence of albuminuria should also be considered.
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Affiliation(s)
- Markus van der Giet
- Medizinische Klinik für Nephrologie und Internistische Intensivmedizin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
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14
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Wu VC, Chan CK, Chueh JS, Chen YM, Lin YH, Chang CC, Lin PC, Chung SD. Markers of Kidney Tubular Function Deteriorate While Those of Kidney Tubule Health Improve in Primary Aldosteronism After Targeted Treatments. J Am Heart Assoc 2023; 12:e028146. [PMID: 36789834 PMCID: PMC10111488 DOI: 10.1161/jaha.122.028146] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Background Targeted treatment with mineralocorticoid receptor antagonists (MRAs) or adrenalectomy in patients with primary aldosteronism (PA) causes a decline in estimated glomerular filtration rate; however, the associated simultaneous changes in biomarkers of kidney tubule health still remain unclear. Methods and Results We matched 104 patients with newly diagnosed unilateral PA who underwent adrenalectomy with 104 patients with unilateral PA who were treated with MRAs, 104 patients with bilateral PA treated with MRAs, and 104 patients with essential hypertension who served as controls. Functional biomarkers were measured before the targeted treatment and 1 year after treatment, including serum markers of kidney function (cystatin C, creatinine), urinary markers of proximal renal tubular damage (L-FABP [liver-type fatty-acid binding protein], KIM-1 [kidney injury molecule-1]), serum markers of kidney tubular reserve and mineral metabolism (intact parathyroid hormone), and proteinuria. Compared with the patients with essential hypertension, the patients with PA had higher pretreatment serum intact parathyroid hormone and urinary creatinine-corrected parameters, including L-FABP, KIM-1, and albumin. The patients with essential hypertension and with PA had similar cystatin C levels. After treatment with MRAs or adrenalectomy of unilateral PA and MRAs of bilateral PA, the patients with PA had increased serum cystatin C and decreased urinary L-FABP/creatinine, KIM-1/creatinine, creatinine-based estimated glomerular filtration rate, intact parathyroid hormone, and proteinuria (all P<0.05). In multivariable regression models, a higher urinary L-FABP/creatinine ratio and older age were significantly correlated with the occurrence of kidney failure (estimated glomerular filtration rate dip ≥30%) in the patients with PA after targeted treatment. Conclusions Compared with the matched patients with essential hypertension, the incident patients with PA at diagnosis had higher levels of several biomarkers, including markers of kidney damage, tubular reserve/mineral metabolism, and proteinuria. Functional kidney failure in the patients with PA after treatment could be predicted by a higher baseline urinary L-FABP/creatinine ratio and older age. After targeted treatments in the patients with bilateral or unilateral PA, these biomarkers of kidney tubule health were restored, but creatinine-based estimated glomerular filtration rate declined, which may therefore reflect hemodynamic changes rather than intrinsic damage to kidney tubular cells.
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Affiliation(s)
- Vin-Cent Wu
- Department of Internal Medicine National Taiwan University Hospital and College of Medicine, National Taiwan University Taipei Taiwan.,TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group Taipei Taiwan.,Primary Aldosteronism Center at National Taiwan University Hospital (NTUH-PAC) Taipei Taiwan
| | - Chieh-Kai Chan
- TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group Taipei Taiwan.,Department of Internal Medicine National Taiwan University Hospital Hsin-Chu Branch Hsin-Chu County Taiwan
| | - Jeff S Chueh
- TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group Taipei Taiwan.,Department of Urology National Taiwan University Hospital and College of Medicine, National Taiwan University Taipei Taiwan
| | - Yung-Ming Chen
- Department of Internal Medicine National Taiwan University Hospital and College of Medicine, National Taiwan University Taipei Taiwan
| | - Yen-Hung Lin
- Department of Internal Medicine National Taiwan University Hospital and College of Medicine, National Taiwan University Taipei Taiwan.,TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group Taipei Taiwan.,Primary Aldosteronism Center at National Taiwan University Hospital (NTUH-PAC) Taipei Taiwan
| | - Chin-Chen Chang
- TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group Taipei Taiwan.,Department of Imaging Medicine National Taiwan University Hospital and College of Medicine, National Taiwan University Taipei Taiwan
| | - Po-Chih Lin
- Department of Internal Medicine National Taiwan University Hospital and College of Medicine, National Taiwan University Taipei Taiwan
| | - Shiu-Dong Chung
- Division of Urology, Department of Surgery Far Eastern Memorial Hospital New Taipei City Taiwan.,Department of Nursing College of Healthcare and Management, General Education Center, Asia Eastern University of Science and Technology New Taipei City Taiwan
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- TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group Taipei Taiwan
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15
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Li F, Sun A, Wu F, Zhang D, Zhao Z. Trends in using of antihypertensive medication among US CKD adults, NHANES 2001-2018. Front Cardiovasc Med 2023; 10:990997. [PMID: 36844731 PMCID: PMC9947777 DOI: 10.3389/fcvm.2023.990997] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
Objective Blood pressure (BP) control rates among adult patients taking antihypertensive medications in the United States have not improved over the last decade. Many CKD adults require more than one class of antihypertensive agent to reach the BP target recommended by the guidelines. However, no study has quantified the proportion of adult CKD patients taking antihypertensive medication who are on monotherapy or combination therapy. Methods National Health and Nutrition Examination Survey data during 2001-2018 was used, including adults with CKD taking antihypertensive medication (age ≥ 20 years, n = 4,453). BP control rates were investigated under the BP targets recommended by the 2021 KDIGO, the 2012 KDIGO, and the 2017 ACC/AHA guidelines. Results The percentages of uncontrolled BP among US adults with CKD taking antihypertensive medication were 81.4% in 2001-2006 and 78.2% in 2013-2018. The proportion of monotherapy of antihypertensive regimen were 38.6, 33.3, and 34.6% from 2001 to 2006, 2007-2012, and 2013-2018, with no obvious difference. Similarly, there was no significant change in percentages of dual-therapy, triple-therapy, and quadruple-therapy. Although proportion of CKD adults not treated with ACEi/ARB decreased from 43.5% in 2001-2006 to 32.7% in 2013-2018, treatment of ACEi/ARB among patients with ACR > 300 mg/g had no significant change. Conclusion The BP control rates among US adult CKD patients taking antihypertensive medications have not improved from 2001 to 2018. Mono-therapy accounted for about one third of adult CKD patients taking antihypertensive medication and not changed. Increasing antihypertensive medication combination therapy may help improve BP control in CKD adults in the United States.
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Affiliation(s)
- Fanghua Li
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Anbang Sun
- Department of Anatomy, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Wu
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Dongshan Zhang
- Department of Emergency Medicine, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China,Emergency Medicine and Difficult Diseases Institute, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China,*Correspondence: Dongshan Zhang,
| | - Zhanzheng Zhao
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China,Zhanzheng Zhao,
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16
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Fujii M, Ohno Y, Ikeda A, Godai K, Li Y, Nakamura Y, Yabe D, Tsushita K, Kashihara N, Kamide K, Kabayama M. Current status of the rapid decline in renal function due to diabetes mellitus and its associated factors: analysis using the National Database of Health Checkups in Japan. Hypertens Res 2023; 46:1075-1089. [PMID: 36732668 PMCID: PMC10164644 DOI: 10.1038/s41440-023-01185-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 02/04/2023]
Abstract
The increasing number of patients undergoing dialysis due to diabetes mellitus (DM) is causing serious economic problems, and its reduction is an urgent policy issue in developed countries, including Japan. We aimed to assess the association between the annual rapid decline in renal function and health checkup measures, including blood pressure, to identify health guidance targets for preventing diabetic nephropathy (DN) and diabetic kidney disease (DKD) among individuals in a medical checkup system ("Tokuteikenshin" program) in 2018. This longitudinal analysis included 3,673,829 individuals who participated in the "Tokuteikenshin" program in 2018, had hemoglobin A1c (HbA1c) levels ≥5.6%, were available for follow-up, and underwent estimated glomerular filtration rate (eGFR) evaluation. We estimated the incidence of the relative annual decrease in eGFR ≥10% per 1000 person-years and odds ratios to evaluate the rapid decline in renal function and determine health guidance goals and their role in preventing DN and DKD. Overall, 20.83% of patients with DM had a rapid decline in renal function within the observation period. A rapid decline in renal function was associated with high systolic blood pressure, poor or strict DM control, increased urinary protein excretion, and decreased blood hemoglobin levels. The incidence of rapid decline in renal function is higher in DM, and appropriate systolic blood pressure and glycemic control are important to prevent the progression to DN or DKD. Our findings will be useful for researchers, clinicians, and other public health care members in establishing effective health guidance and guidelines for CKD prevention.
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Affiliation(s)
- Makoto Fujii
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Yuko Ohno
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Asuka Ikeda
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kayo Godai
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yaya Li
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuko Nakamura
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Daisuke Yabe
- Department of Diabetes, Endocrinology and Metabolism and Department of Rheumatology and Clinical Immunology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, 501-1193, Japan
| | - Kazuyo Tsushita
- Graduate Schools of Nutrition Sciences, Kagawa Nutrition University, 3-9-21 Chiyoda, Sakado, Saitama, 350-0288, Japan
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Kei Kamide
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Mai Kabayama
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
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17
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Zhang Y, Zhai X, Liu K, Ma W, Li S, Zeng J, Yang M, Zhou F, Xiang B, Cao J, Eshak ES. Association of Beta-2 Microglobulin with Stroke and All-Cause Mortality in Adults Aged ≥40 in U.S.: NHANES III. Rev Cardiovasc Med 2023; 24:43. [PMID: 39077409 PMCID: PMC11273124 DOI: 10.31083/j.rcm2402043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 11/19/2022] [Accepted: 11/24/2022] [Indexed: 07/31/2024] Open
Abstract
Background Stroke is the predominant cause of death worldwide. We aimed to investigate the association of serum beta-2 microglobulin ( β 2M) concentrations with risk of stroke and all-cause mortalities in a cohort study. Methods Overall, 4914 U.S. adults (mean age = 63.0 years, 44.3% male) were recruited from the National Health and Nutrition Examination Survey (NHANES Ⅲ). During a median follow-up of 19.4 years, 254 stroke deaths and 3415 all-cause deaths were identified by the National Center for Health Statistics. The associations of β 2M with stroke and all-cause mortalities were investigated by using weighted Cox proportional hazard regression models. Results β 2M was positively associated with stroke and all-cause mortality in unadjusted models and multivariable-adjusted models. The multivariable HR (95% CI) for stroke mortality in Q5 VS Q1 of serum β 2M concentrations was 3.45 (1.33-8.91; p for trend = 0.001) and that for all-cause mortality was 3.95 (3.05-5.12; p for trend < 0.001). In subgroup analyses, the association of β 2M and stroke mortality did not vary by different levels of sociodemographic and general stroke risk factors (p interaction > 0.05). In addition, the magnitude of positive association between β 2M with all-cause mortality did vary by age, ratio of family income to poverty, smoking status, and history of hypertensive (p interaction < 0.05). Conclusions Our findings suggest that support that β 2M may be a marker of stroke and all-cause mortality, which provides a new perspective for the study of cerebrovascular health and long-term survival in the future.
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Affiliation(s)
- Yanan Zhang
- Research Center for Health Promotion in Women, Youth and Children, Hubei
Province Key Laboratory of Occupational Hazard Identification and Control, School
of Public Health, Wuhan University of Science and Technology, 430065 Wuhan,
Hubei, China
| | - Xiaobing Zhai
- Research Center for Health Promotion in Women, Youth and Children, Hubei
Province Key Laboratory of Occupational Hazard Identification and Control, School
of Public Health, Wuhan University of Science and Technology, 430065 Wuhan,
Hubei, China
| | - Keyang Liu
- Public Health, Department of Social Medicine, Osaka University Graduate
School of Medicine, 565-0871 Osaka, Japan
| | - Wenzhi Ma
- Department of Epidemiology and Biostatistics, School of Health Sciences,
Wuhan University, 430071 Wuhan, Hubei, China
| | - Shiyang Li
- Department of Epidemiology and Biostatistics, School of Health Sciences,
Wuhan University, 430071 Wuhan, Hubei, China
| | - Jing Zeng
- Research Center for Health Promotion in Women, Youth and Children, Hubei
Province Key Laboratory of Occupational Hazard Identification and Control, School
of Public Health, Wuhan University of Science and Technology, 430065 Wuhan,
Hubei, China
| | - Mei Yang
- Research Center for Health Promotion in Women, Youth and Children, Hubei
Province Key Laboratory of Occupational Hazard Identification and Control, School
of Public Health, Wuhan University of Science and Technology, 430065 Wuhan,
Hubei, China
| | - Feng Zhou
- Research Center for Health Promotion in Women, Youth and Children, Hubei
Province Key Laboratory of Occupational Hazard Identification and Control, School
of Public Health, Wuhan University of Science and Technology, 430065 Wuhan,
Hubei, China
| | - Bing Xiang
- Research Center for Health Promotion in Women, Youth and Children, Hubei
Province Key Laboratory of Occupational Hazard Identification and Control, School
of Public Health, Wuhan University of Science and Technology, 430065 Wuhan,
Hubei, China
| | - Jinhong Cao
- Department of Epidemiology and Biostatistics, School of Health Sciences,
Wuhan University, 430071 Wuhan, Hubei, China
| | - Ehab S. Eshak
- Public Health and Community Medicine, Faculty of Medicine, Minia
University, Mainroad Shalabyland, 61519 Minia, Egypt
- Advanced Clinical Epidemiology, Medical Data Science Unit, Public Health
Osaka University Graduate School of Medicine, 565-0871 Osaka, Japan
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18
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S191-S202. [PMID: 36507634 PMCID: PMC9810467 DOI: 10.2337/dc23-s011] [Citation(s) in RCA: 109] [Impact Index Per Article: 109.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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19
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Ikeme JC, Katz R, Muiru AN, Estrella MM, Scherzer R, Garimella PS, Hallan SI, Peralta CA, Ix JH, Shlipak MG. Clinical Risk Factors For Kidney Tubule Biomarker Abnormalities Among Hypertensive Adults With Reduced eGFR in the SPRINT Trial. Am J Hypertens 2022; 35:1006-1013. [PMID: 36094158 PMCID: PMC9729764 DOI: 10.1093/ajh/hpac102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 07/21/2022] [Accepted: 09/09/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Urine biomarkers of kidney tubule health may distinguish aspects of kidney damage that cannot be captured by current glomerular measures. Associations of clinical risk factors with specific kidney tubule biomarkers have not been evaluated in detail. METHODS We performed a cross-sectional study in the Systolic Blood Pressure Intervention Trial among 2,436 participants with a baseline estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2. Associations between demographic and clinical characteristics with urine biomarkers of kidney tubule health were evaluated using simultaneous multivariable linear regression of selected variables. RESULTS Each standard deviation higher age (9 years) was associated with 13% higher levels of chitinase-3-like protein-1 (YKL-40), indicating higher levels of tubulointerstitial inflammation and repair. Men had 31% higher levels of alpha-1 microglobulin and 16% higher levels of beta-2 microglobulin, reflecting worse tubule resorptive function. Black race was associated with significantly higher levels of neutrophil gelatinase-associated lipocalin (12%) and lower kidney injury molecule-1 (26%) and uromodulin (22%). Each standard deviation (SD) higher systolic blood pressure (SBP) (16 mmHg) was associated with 10% higher beta-2 microglobulin and 10% higher alpha-1 microglobulin, reflecting lower tubule resorptive function. CONCLUSIONS Clinical and demographic characteristics, such as race, sex, and elevated SBP, are associated with unique profiles of tubular damage, which could reflect under-recognized patterns of kidney tubule disease among persons with decreased eGFR.
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Affiliation(s)
- Jesse C Ikeme
- Kidney Health Research Collaborative, University of California, San Francisco and San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Ronit Katz
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Anthony N Muiru
- Kidney Health Research Collaborative, University of California, San Francisco and San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Michelle M Estrella
- Kidney Health Research Collaborative, University of California, San Francisco and San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Rebecca Scherzer
- Kidney Health Research Collaborative, University of California, San Francisco and San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Pranav S Garimella
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Stein I Hallan
- Department of Nephrology, St Olav’s Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim,Norway
| | - Carmen A Peralta
- Kidney Health Research Collaborative, University of California, San Francisco and San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Cricket Health, Inc., San Francisco, California, USA
| | - Joachim H Ix
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
- Herbert Wertheim School of Public Health, University of California San Diego, San Diego, California, USA
- Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, California, USA
| | - Michael G Shlipak
- Kidney Health Research Collaborative, University of California, San Francisco and San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
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20
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Staplin N, Herrington WG, Murgia F, Ibrahim M, Bull KR, Judge PK, Ng SYA, Turner M, Zhu D, Emberson J, Landray MJ, Baigent C, Haynes R, Hopewell JC. Determining the Relationship Between Blood Pressure, Kidney Function, and Chronic Kidney Disease: Insights From Genetic Epidemiology. Hypertension 2022; 79:2671-2681. [PMID: 36082669 PMCID: PMC9640248 DOI: 10.1161/hypertensionaha.122.19354] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND It is well established that decreased kidney function can increase blood pressure (BP), but it is unproven whether moderately elevated BP causes chronic kidney disease (CKD) or glomerular hyperfiltration. METHODS 311 119 White British UK Biobank participants were included in logistic regression analyses to estimate the odds of CKD (defined as long-term kidney replacement therapy, estimated glomerular filtration rate [eGFR]< 60mL/min/1.73m2, or urinary albumin:creatinine ratio ≥3 mg/mmol) associated with higher genetically predicted BP using genetic risk scores comprising 219 systolic and 223 diastolic BP loci. Analyses estimating associations with clinical categories of eGFR and urinary albumin:creatinine ratio were also conducted, with an eGFR ≥120 mL (min·1.73m2) considered evidence of glomerular hyperfiltration. RESULTS 21 623 participants had CKD: 7781 with reduced eGFR and 15 500 with albuminuria. 1828 participants had an eGFR ≥120 mL/min/1.73m2. Each genetically predicted 10 mmHg higher systolic BP and 5 mmHg higher diastolic BP were associated with a 37% (95% CI, 1.29-1.45) and 19% (1.14-1.25) higher odds of CKD, respectively. Associations were evident for both the reduced eGFR and albuminuria components of the CKD outcome. The odds of hyperfiltration (versus an eGFR ≥60 and <90 mL/min/1.73m2 were 49% higher (95% CI, 1.21-1.84) for each genetically predicted 10 mmHg higher systolic BP. Associations with CKD and hyperfiltration were similar irrespective of preexisting diabetes, vascular disease, or different levels of adiposity. CONCLUSIONS In this general population, genetic epidemiological evidence supports a causal role of life-long differences in BP for decreased kidney function, glomerular hyperfiltration, and albuminuria. Physiological autoregulation may not afford complete renal protection against the moderate BP elevations.
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Affiliation(s)
- Natalie Staplin
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery (N.S., F.M., M.I., J.E., M.J.L., J.C.H.), University of Oxford, Oxford, United Kingdom
| | - William G Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Health Data Research UK (W.G.H., M.J.L.), University of Oxford, Oxford, United Kingdom.,Oxford Kidney Unit, Churchill Hospital, Oxford, United Kingdom (W.G.H., K.R.B., P.K.J., M.T., D.Z., R.H.)
| | - Federico Murgia
- Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery (N.S., F.M., M.I., J.E., M.J.L., J.C.H.), University of Oxford, Oxford, United Kingdom
| | - Maysson Ibrahim
- Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery (N.S., F.M., M.I., J.E., M.J.L., J.C.H.), University of Oxford, Oxford, United Kingdom
| | - Katherine R Bull
- Nuffield Department of Medicine (K.R.B.), University of Oxford, Oxford, United Kingdom.,Oxford Kidney Unit, Churchill Hospital, Oxford, United Kingdom (W.G.H., K.R.B., P.K.J., M.T., D.Z., R.H.)
| | - Parminder K Judge
- Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Oxford Kidney Unit, Churchill Hospital, Oxford, United Kingdom (W.G.H., K.R.B., P.K.J., M.T., D.Z., R.H.)
| | - Sarah Y A Ng
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom
| | - Michael Turner
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Oxford Kidney Unit, Churchill Hospital, Oxford, United Kingdom (W.G.H., K.R.B., P.K.J., M.T., D.Z., R.H.)
| | - Doreen Zhu
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Oxford Kidney Unit, Churchill Hospital, Oxford, United Kingdom (W.G.H., K.R.B., P.K.J., M.T., D.Z., R.H.)
| | - Jonathan Emberson
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery (N.S., F.M., M.I., J.E., M.J.L., J.C.H.), University of Oxford, Oxford, United Kingdom
| | - Martin J Landray
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery (N.S., F.M., M.I., J.E., M.J.L., J.C.H.), University of Oxford, Oxford, United Kingdom.,Health Data Research UK (W.G.H., M.J.L.), University of Oxford, Oxford, United Kingdom.,National Institute for Health Research Oxford Biomedical Research Centre (M.J.L.), University of Oxford, Oxford, United Kingdom
| | - Colin Baigent
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom
| | - Richard Haynes
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Oxford Kidney Unit, Churchill Hospital, Oxford, United Kingdom (W.G.H., K.R.B., P.K.J., M.T., D.Z., R.H.)
| | - Jemma C Hopewell
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery (N.S., F.M., M.I., J.E., M.J.L., J.C.H.), University of Oxford, Oxford, United Kingdom
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21
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[New aspects of pharmacological nephroprotection]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2022; 63:1200-1207. [PMID: 35380212 DOI: 10.1007/s00108-022-01297-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 01/25/2023]
Abstract
Current estimates forecast that chronic kidney diseases will be the fifth most common cause of death worldwide by 2040. The prevalence of chronic renal diseases increases with age and, in many countries, affects patients with overweight, diabetes and hypertension. The primary objective of the treatment of chronic renal diseases is the delay of disease progression. Established markers for the deterioration of renal function include glomerular filtration rate and albuminuria. Pharmacological blockade of the renin-angiotensin-aldosterone system (RAAS) by angiotensin-converting enzyme inhibitors (ACE) or angiotensin receptor blockers (ARB) represents the cornerstone of drug-related nephroprotection. Current Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend the use of ACEI or ARB for diabetic and non-diabetic patients with moderate and heavy albuminuria. In recent years, sodium-glucose linked transporter 2 inhibitors (SGLT-2 ) have been established in the field of cardio- and nephroprotection. Their protective effects occur regardless of blood sugar reduction. Current data suggest that the use of SGLT‑2 inhibitors will soon be part of therapy in non-diabetic kidney disease. One of the first drugs in this substance class, dapagliflozin, is already approved in Germany for the treatment of chronic renal diseases in adults with and without type 2 diabetes.
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22
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Gnanenthiran SR, Borghi C, Burger D, Caramelli B, Charchar F, Chirinos JA, Cohen JB, Cremer A, Di Tanna GL, Duvignaud A, Freilich D, Gommans DHF, Gracia-Ramos AE, Murray TA, Pelorosso F, Poulter NR, Puskarich MA, Rizas KD, Rothlin R, Schlaich MP, Schreinlecher M, Steckelings UM, Sharma A, Stergiou GS, Tignanelli CJ, Tomaszewski M, Unger T, van Kimmenade RRJ, Wainford RD, Williams B, Rodgers A, Schutte AE. Renin-Angiotensin System Inhibitors in Patients With COVID-19: A Meta-Analysis of Randomized Controlled Trials Led by the International Society of Hypertension. J Am Heart Assoc 2022; 11:e026143. [PMID: 36000426 PMCID: PMC9496439 DOI: 10.1161/jaha.122.026143] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Published randomized controlled trials are underpowered for binary clinical end points to assess the safety and efficacy of renin‐angiotensin system inhibitors (RASi) in adults with COVID‐19. We therefore performed a meta‐analysis to assess the safety and efficacy of RASi in adults with COVID‐19. Methods and Results MEDLINE, EMBASE, ClinicalTrials.gov, and the Cochrane Controlled Trial Register were searched for randomized controlled trials that randomly assigned patients with COVID‐19 to RASi continuation/commencement versus no RASi therapy. The primary outcome was all‐cause mortality at ≤30 days. A total of 14 randomized controlled trials met the inclusion criteria and enrolled 1838 participants (aged 59 years, 58% men, mean follow‐up 26 days). Of the trials, 11 contributed data. We found no effect of RASi versus control on all‐cause mortality (7.2% versus 7.5%; relative risk [RR], 0.95; [95% CI, 0.69–1.30]) either overall or in subgroups defined by COVID‐19 severity or trial type. Network meta‐analysis identified no difference between angiotensin‐converting enzyme inhibitors versus angiotensin II receptor blockers. RASi users had a nonsignificant reduction in acute myocardial infarction (2.1% versus 3.6%; RR, 0.59; [95% CI, 0.33–1.06]), but increased risk of acute kidney injury (7.0% versus 3.6%; RR, 1.82; [95% CI, 1.05–3.16]), in trials that initiated and continued RASi. There was no increase in need for dialysis or differences in congestive cardiac failure, cerebrovascular events, venous thromboembolism, hospitalization, intensive care admission, inotropes, or mechanical ventilation. Conclusions This meta‐analysis of randomized controlled trials evaluating angiotensin‐converting enzyme inhibitors/angiotensin II receptor blockers versus control in patients with COVID‐19 found no difference in all‐cause mortality, a borderline decrease in myocardial infarction, and an increased risk of acute kidney injury with RASi. Our findings provide strong evidence that RASi can be used safely in patients with COVID‐19.
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Affiliation(s)
- Sonali R Gnanenthiran
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
| | - Claudio Borghi
- Department of Medical and Surgical Sciences University of Bologna Italy
| | - Dylan Burger
- Department of Cellular and Molecular Medicine, Kidney Research Centre, Ottawa Hospital Research Institute University of Ottawa Canada
| | - Bruno Caramelli
- Interdisciplinary Medicine in Cardiology Unit, InCor University of Sao Paulo Brazil
| | - Fadi Charchar
- School of Health and Life Sciences Federation University Australia Ballarat VIC Australia
| | - Julio A Chirinos
- Division of Cardiovascular Medicine University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division and Department of Biostatistics, Epidemiology, and Informatics University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Antoine Cremer
- Department of Cardiology and Hypertension, Hypertension Excellence Center Hôpital Saint André, Centre Hospitalier Universitaire de Bordeaux & University Bordeaux Bordeaux France
| | - Gian Luca Di Tanna
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
| | - Alexandre Duvignaud
- Department of Infectious Diseases and Tropical Medicine, Division of Tropical Medicine and Clinical International Health Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux & University Bordeaux Bordeaux France
| | | | - D H Frank Gommans
- Department of Cardiology Radboud University Medical Center Nijmegen The Netherlands.,Netherlands Heart Institute Utrecht The Netherlands
| | - Abraham E Gracia-Ramos
- Departamento de Medicina Interna, Hospital General, Centro Médico Nacional "La Raza" Instituto Mexicano del Seguro Social Mexico City Mexico.,Departamento de Medicina Interna Hospital Regional de Alta Especialidad de Zumpango Estado de Mexico Mexico
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health University of Minnesota Minneapolis MN
| | - Facundo Pelorosso
- Asociacion Argentina de Medicamentos Ciudad Autonoma de Buenos Aires Argentina.,Servicio de Anatomía Patologica, Hospital de Alta Complejidad El Calafate SAMIC Santa Cruz Argentina
| | - Neil R Poulter
- Imperial Clinical Trials Unit Imperial College London London UK
| | - Michael A Puskarich
- Department of Emergency Medicine Hennepin County Medical Center University of Minnesota Minneapolis MN
| | - Konstantinos D Rizas
- Medizinische Klinik und Poliklinik I Ludwig Maximilian University Hospital Munich Munich Germany
| | - Rodolfo Rothlin
- Asociacion Argentina de Medicamentos Ciudad Autonoma de Buenos Aires Argentina.,Sociedad Argentina de Farmacología Clínica, Asociacion Medica Argentina Buenos Aires Argentina
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School, Royal Perth Hospital Unit-Royal Perth Hospital Medical Research Foundation University of Western Australia Perth Australia
| | - Michael Schreinlecher
- Department of Internal Medicine III, Cardiology and Angiology Medical University of Innsbruck Innsbruck Austria
| | | | - Abhinav Sharma
- Division of Cardiology McGill University Health Centre Montreal Quebec Canada
| | - George S Stergiou
- Hypertension Center STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital National and Kapodistrian University of Athens Athens Greece
| | | | - Maciej Tomaszewski
- Division of Cardiovascular Sciences, Faculty of Medicine, Biology and Health University of Manchester Manchester UK.,Manchester Academic Health Science Centre Manchester University National Health Service Foundation Trust Manchester Manchester UK
| | - Thomas Unger
- Cardiovascular Research Institute Maastricht-School for Cardiovascular Diseases Maastricht University Maastricht The Netherlands
| | - Roland R J van Kimmenade
- Department of Cardiology Radboud University Medical Center Nijmegen The Netherlands.,Netherlands Heart Institute Utrecht The Netherlands
| | - Richard D Wainford
- Department of Pharmacology and Experimental Therapeutics and the Whitaker Cardiovascular Institute Boston University School of Medicine Boston MA
| | - Bryan Williams
- Institute of Cardiovascular Science University College London and National Institute for Health Research University College London Hospitals Biomedical Research Centre London UK
| | - Anthony Rodgers
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
| | - Aletta E Schutte
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
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23
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Al-Sodany E, Chesnaye NC, Heimbürger O, Jager KJ, Bárány P, Evans M. Blood pressure and kidney outcomes in patients with severely decreased glomerular filtration rate: a nationwide observational cohort study. J Hypertens 2022; 40:1487-1498. [PMID: 35730420 PMCID: PMC9415216 DOI: 10.1097/hjh.0000000000003168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 03/24/2022] [Accepted: 03/24/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVES To investigate the association between blood pressure (BP) and kidney outcomes in patients with estimated glomerular filtration rate less than 30 ml/min per 1.73 m 2 and different degrees of albuminuria. METHODS National observational cohort study of 18 071 chronic kidney disease (CKD) stage 4-5 patients in routine nephrology care 2010-2017. The association between both baseline and repeated clinic office BP and eGFR slope and kidney replacement therapy (KRT) was explored using multivariable adjusted joint models. The analyses were stratified on albuminuria at baseline. RESULTS The adjusted yearly eGFR slope became increasingly steeper from -0,91 (95% CI -0.83 to -1.05) ml/min per 1.73 m 2 per year in those with SBP less than 120 mmHg at baseline to -2.09 (-1.83 to -2.37) ml/min per 1.73 m 2 in those with BP greater than 160 mmHg. Similarly, eGFR slope was steeper with higher DBP. Lower SBP and DBP was associated with slower eGFR decline in patients with albuminuria grade A3 (>30 mg/mmol) but not consistently in albuminuria A1-A2. Those with diabetes progressed faster and the association between BP and eGFR slope was stronger. In repeated BP measurement analyses, every 10 mmHg higher SBP over time was associated with 39% additional risk of KRT. CONCLUSION In people with eGFR less than 30 ml/min per 1.73 m 2 , lower clinic office BP is associated with more favorable kidney outcomes. Our results support lower BP targets also in people with CKD stage 4-5.
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Affiliation(s)
- Ehab Al-Sodany
- Renal Medicine, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Nicholas C. Chesnaye
- ERA-EDTA Registry, Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health Research Institute, Meibergdreef 9, Amsterdam, The Netherlands
| | - Olof Heimbürger
- Renal Medicine, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Kitty J. Jager
- ERA-EDTA Registry, Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health Research Institute, Meibergdreef 9, Amsterdam, The Netherlands
| | - Peter Bárány
- Renal Medicine, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Marie Evans
- Renal Medicine, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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24
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Chávez-Iñiguez JS, Sánchez-Villaseca SJ, García-Macías LA. Cardiorenal syndrome: classification, pathophysiology, diagnosis and management. Literature review. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2022; 92:253-263. [PMID: 34261129 PMCID: PMC9005172 DOI: 10.24875/acm.20000183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 06/03/2021] [Indexed: 12/02/2022] Open
Abstract
The cardiorenal syndrome is a complex entity in which a primary heart dysfunction causes kidney injury (Types 1 and 2) and vice versa (Types 3 and 4), being either acute or chronic events, or maybe the result of a systemic disease that involves both organs (Type 5). Approximately 49% of heart failure cases present some grade of kidney dysfunction, significantly increasing morbidity and mortality rates. Its pathogenesis involves a variety of hemodynamic, hormonal and immunological factors that in the majority of cases produce fluid overload; the diagnosis and treatment of such constitutes the disease’s management basis. Currently, a clinical based diagnosis is insufficient and the use of biochemical markers, such as natriuretic peptides, or lung and heart ultrasound is required. These tools, along with urinary sodium levels, allow the evaluation of therapy effectiveness. The preferred initial decongestive strategy is based on a continuous infusion of a loop diuretic with a step-up dosing regimen, aiming for a minimal daily urine volume of 3 liters, with the possibility to sequentially add potassium sparing diuretics, thiazide diuretics and carbonic anhydrase inhibitors to reach the diuresis goal, leaving ultrafiltration as a last resource due to its higher rate of complications. Finally, evidence-based therapy should be given to improve quality of life, decrease mortality, and delay the deterioration of kidney and heart function over the long term.
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Affiliation(s)
- Jonathan S Chávez-Iñiguez
- Servicio de Nefrología, Hospital Civil Fray Antonio Alcalde, Universidad de Guadalajara, Guadalajara, Jalisco, México
| | - Sergio J Sánchez-Villaseca
- Servicio de Nefrología, Hospital Civil Fray Antonio Alcalde, Universidad de Guadalajara, Guadalajara, Jalisco, México
| | - Luz A García-Macías
- Universidad de Guadalajara, Centro Universitario de Ciencias de la Salud. Guadalajara, Jalisco, México
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25
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Dolui S, Detre JA, Gaussoin SA, Herrick JS, Wang DJJ, Tamura MK, Cho ME, Haley WE, Launer LJ, Punzi HA, Rastogi A, Still CH, Weiner DE, Wright JT, Williamson JD, Wright CB, Bryan RN, Bress AP, Pajewski NM, Nasrallah IM. Association of Intensive vs Standard Blood Pressure Control With Cerebral Blood Flow: Secondary Analysis of the SPRINT MIND Randomized Clinical Trial. JAMA Neurol 2022; 79:380-389. [PMID: 35254390 PMCID: PMC8902686 DOI: 10.1001/jamaneurol.2022.0074] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Antihypertensive treatments benefit cerebrovascular health and cognitive function in patients with hypertension, but it is uncertain whether an intensive blood pressure target leads to potentially harmful cerebral hypoperfusion. OBJECTIVE To investigate the association of intensive systolic blood pressure (SBP) control vs standard control with whole-brain cerebral blood flow (CBF). DESIGN, SETTING, AND PARTICIPANTS This substudy of the Systolic Blood Pressure Intervention Trial (SPRINT) randomized clinical trial compared the efficacy of 2 different blood pressure-lowering strategies with longitudinal brain magnetic resonance imaging (MRI) including arterial spin labeled perfusion imaging to quantify CBF. A total of 1267 adults 50 years or older with hypertension and increased cardiovascular risk but free of diabetes or dementia were screened for the SPRINT substudy from 6 sites in the US. Randomization began in November 2010 with final follow-up MRI in July 2016. Analyses were performed from September 2020 through December 2021. INTERVENTIONS Study participants with baseline CBF measures were randomized to an intensive SBP target less than 120 mm Hg or standard SBP target less than 140 mm Hg. MAIN OUTCOMES AND MEASURES The primary outcome was change in whole-brain CBF from baseline. Secondary outcomes were change in gray matter, white matter, and periventricular white matter CBF. RESULTS Among 547 participants with CBF measured at baseline, the mean (SD) age was 67.5 (8.1) years and 219 (40.0%) were women; 315 completed follow-up MRI at a median (IQR) of 4.0 (3.7-4.1) years after randomization. Mean whole-brain CBF increased from 38.90 to 40.36 (difference, 1.46 [95% CI, 0.08-2.83]) mL/100 g/min in the intensive treatment group, with no mean increase in the standard treatment group (37.96 to 37.12; difference, -0.84 [95% CI, -2.30 to 0.61] mL/100 g/min; between-group difference, 2.30 [95% CI, 0.30-4.30; P = .02]). Gray, white, and periventricular white matter CBF showed similar changes. The association of intensive vs standard treatment with CBF was generally similar across subgroups defined by age, sex, race, chronic kidney disease, SBP, orthostatic hypotension, and frailty, with the exception of an indication of larger mean increases in CBF associated with intensive treatment among participants with a history of cardiovascular disease (interaction P = .05). CONCLUSIONS AND RELEVANCE Intensive vs standard antihypertensive treatment was associated with increased, rather than decreased, cerebral perfusion, most notably in participants with a history of cardiovascular disease. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01206062.
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Affiliation(s)
- Sudipto Dolui
- Department of Radiology, University of Pennsylvania, Philadelphia
| | - John A Detre
- Department of Radiology, University of Pennsylvania, Philadelphia.,Department of Neurology, University of Pennsylvania, Philadelphia
| | - Sarah A Gaussoin
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jennifer S Herrick
- Department of Population Health Sciences, University of Utah, Salt Lake City
| | - Danny J J Wang
- Laboratory of FMRI Technology, Mark & Mary Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles.,Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles
| | - Manjula Kurella Tamura
- Geriatric Research and Education Clinical Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, California.,Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Monique E Cho
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City
| | - William E Haley
- Department of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
| | - Lenore J Launer
- Intramural Research Program, National Institute on Aging, Baltimore, Maryland
| | - Henry A Punzi
- Trinity Hypertension and Metabolic Research Institute, Punzi Medical Center, Carrollton, Texas.,Department of Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Anjay Rastogi
- Department of Medicine, University of California at Los Angeles School of Medicine, Los Angeles
| | - Carolyn H Still
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
| | - Daniel E Weiner
- William B. Schwartz, MD, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Jackson T Wright
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Jeff D Williamson
- Sticht Center on Healthy Aging and Alzheimer's Prevention, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Clinton B Wright
- Stroke Branch (intramural)/Division of Clinical Research (extramural), National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - R Nick Bryan
- Department of Diagnostic Medicine; Dell Medical School, University of Texas at Austin, Austin
| | - Adam P Bress
- Department of Population Health Sciences, University of Utah, Salt Lake City
| | - Nicholas M Pajewski
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ilya M Nasrallah
- Department of Radiology, University of Pennsylvania, Philadelphia
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26
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Mullens W, Martens P, Testani JM, Tang WHW, Skouri H, Verbrugge FH, Fudim M, Iacoviello M, Franke J, Flammer AJ, Palazzuoli A, Barragan PM, Thum T, Marcos MC, Miró Ò, Rossignol P, Metra M, Lassus J, Orso F, Jankowska EA, Chioncel O, Milicic D, Hill L, Seferovic P, Rosano G, Coats A, Damman K. Renal effects of guideline directed medical therapies in heart failure - a consensus document from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2022; 24:603-619. [PMID: 35239201 DOI: 10.1002/ejhf.2471] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/22/2022] [Accepted: 03/01/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
| | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, University Hasselt, Belgium.,Cleveland Clinic, Cleveland, Ohio, United States of America
| | | | | | - Hadi Skouri
- American University of Beirut Medical Center-Beirut, Lebanon
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussel, Jette, Belgium.,Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Marat Fudim
- Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Massimo Iacoviello
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | | | - Andreas J Flammer
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Medical Sciences Le Scotte Hospital Siena, Italy.,School of Nursing and Midwifery, Queen's University, Belfast, Northern Ireland
| | | | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany.,Fraunhofer Institute of Toxicology and Experimental Medicine, Hannover, Germany
| | - Marta Cobo Marcos
- Hospital Universitario Puerta de Hierro Majadahonda, CIBERCV, Madrid, Spain
| | - Òscar Miró
- Emergency Department, Hospital Clínic, Barcelona, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Patrick Rossignol
- Université de Lorraine, Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116, and F-CRIN INI-CRCT, Nancy, France
| | | | - Johan Lassus
- Heart and Lung Center, Cardiology, University of Helsinki and Helsinki University Hospital
| | | | - Ewa A Jankowska
- Institute of Heart Diseases, Wroclaw Medical University AND Institute of Heart Diseases, University Hospital in Wroclaw, Poland
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Davor Milicic
- Department of Cardiovascular Diseases, University of Zagreb School of Medicine & University Hospital Centre Zagreb, Zagreb, Croatia
| | - Loreena Hill
- School of Nursing & Midwifery, Queen's University, Belfast, UK
| | - Petar Seferovic
- Universi Faculty of Medicine, University of Belgrade, and Serbian Academy of Arts and Sciences, Belgrade, Serbia
| | | | | | - Kevin Damman
- University of Groningen, University Medical Center Groningen, The Netherlands
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27
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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28
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Molsberry RJ, Rethy L, Wang MC, Mehta RC, Lloyd-Jones DM, Ning H, Lewis CE, Yancy CW, Shah SJ, Khan SS. Risk-Based Intensive Blood Pressure Lowering and Prevention of Heart Failure: A SPRINT Post Hoc Analysis. Hypertension 2021; 78:1742-1749. [PMID: 34757775 DOI: 10.1161/hypertensionaha.121.18315] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Rebecca J Molsberry
- Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center, School of Public Health, Houston, TX (R.J.M.)
| | - Leah Rethy
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (L.R.)
| | | | | | - Donald M Lloyd-Jones
- Department of Preventive Medicine (D.L.J., H.N., S.S.K.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Hongyan Ning
- Department of Preventive Medicine (D.L.J., H.N., S.S.K.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Cora E Lewis
- Division of Cardiology, Department of Medicine (C.E.L.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | | | - Sadiya S Khan
- Department of Preventive Medicine (D.L.J., H.N., S.S.K.), Northwestern University Feinberg School of Medicine, Chicago, IL
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29
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Ix JH, Shlipak MG. The Promise of Tubule Biomarkers in Kidney Disease: A Review. Am J Kidney Dis 2021; 78:719-727. [PMID: 34051308 PMCID: PMC8545710 DOI: 10.1053/j.ajkd.2021.03.026] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/10/2021] [Indexed: 12/23/2022]
Abstract
For over 70 years, serum creatinine has remained the primary index for detection and monitoring of kidney disease. Tubulointerstitial damage and fibrosis are highly prognostic for subsequent kidney failure in biopsy studies, yet this pathology is invisible to the clinician in the absence of a biopsy. Recent discovery of biomarkers that reflect distinct aspects of kidney tubule disease have led to investigations of whether these markers can provide additional information on risk of chronic kidney disease (CKD) progression and associated adverse clinical end points, above and beyond estimated glomerular filtration rate and albuminuria. These biomarkers can be loosely grouped into those that mark tubule cell injury (eg, kidney injury molecule 1, monocyte chemoattractant protein 1) and those that mark tubule cell dysfunction (eg, α1-microglobulin, uromodulin). These kidney tubule biomarkers provide new opportunities to monitor response to therapeutics used to treat CKD patients. In this review, we describe results from some unique contributions in this area and discuss the current challenges and requirements in the field to bring these markers to clinical practice. We advocate for a broader assessment of kidney health that moves beyond a focus on the glomerulus, and we highlight how such tools can improve diagnostic accuracy and earlier assessment of therapeutic efficacy or harm in CKD patients.
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Affiliation(s)
- Joachim H Ix
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California; Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, California; Kidney Research Innovation Hub of San Diego, San Diego, California.
| | - Michael G Shlipak
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center and University of California, San Francisco, California; Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
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30
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Amatruda JG, Estrella MM, Garg AX, Thiessen-Philbrook H, McArthur E, Coca SG, Parikh CR, Shlipak MG. Urine Alpha-1-Microglobulin Levels and Acute Kidney Injury, Mortality, and Cardiovascular Events following Cardiac Surgery. Am J Nephrol 2021; 52:673-683. [PMID: 34515046 DOI: 10.1159/000518240] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 05/20/2021] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Urine alpha-1-microglobulin (Uα1m) elevations signal proximal tubule dysfunction. In ambulatory settings, higher Uα1m is associated with acute kidney injury (AKI), progressive chronic kidney disease (CKD), cardiovascular (CV) events, and mortality. We investigated the associations of pre- and postoperative Uα1m concentrations with adverse outcomes after cardiac surgery. METHODS In 1,464 adults undergoing cardiac surgery in the prospective multicenter Translational Research Investigating Biomarker Endpoints for Acute Kidney Injury (TRIBE-AKI) cohort, we measured the pre-and postoperative Uα1m concentrations and calculated the changes from pre- to postoperative concentrations. Outcomes were postoperative AKI during index hospitalization and longitudinal risks for CKD incidence and progression, CV events, and all-cause mortality after discharge. We analyzed Uα1m continuously and categorically by tertiles using multivariable logistic regression and Cox proportional hazards regression adjusted for demographics, surgery characteristics, comorbidities, baseline estimated glomerular filtration rate, urine albumin, and urine creatinine. RESULTS There were 230 AKI events during cardiac surgery hospitalization; during median 6.7 years of follow-up, there were 212 cases of incident CKD, 54 cases of CKD progression, 269 CV events, and 459 deaths. Each 2-fold higher concentration of preoperative Uα1m was independently associated with AKI (adjusted odds ratio [aOR] = 1.36, 95% confidence interval 1.14-1.62), CKD progression (adjusted hazard ratio [aHR] = 1.46, 1.04-2.05), and all-cause mortality (aHR = 1.19, 1.06-1.33) but not with incident CKD (aHR = 1.21, 0.96-1.51) or CV events (aHR = 1.01, 0.86-1.19). Postoperative Uα1m was not associated with AKI (aOR per 2-fold higher = 1.07, 0.93-1.22), CKD incidence (aHR = 0.90, 0.79-1.03) or progression (aHR = 0.79, 0.56-1.11), CV events (aHR = 1.06, 0.94-1.19), and mortality (aHR = 1.01, 0.92-1.11). CONCLUSION Preoperative Uα1m concentrations may identify patients at high risk of AKI and other adverse events after cardiac surgery, but postoperative Uα1m concentrations do not appear to be informative.
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Affiliation(s)
- Jonathan G Amatruda
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA,
- Kidney Health Research Collaborative, San Francisco VA Health Care System & University of California, San Francisco, San Francisco, California, USA,
| | - Michelle M Estrella
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Kidney Health Research Collaborative, San Francisco VA Health Care System & University of California, San Francisco, San Francisco, California, USA
- Division of Nephrology, Department of Medicine, San Francisco VA Health Care System, San Francisco, California, USA
| | - Amit X Garg
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | | | | | - Steven G Coca
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chirag R Parikh
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael G Shlipak
- Kidney Health Research Collaborative, San Francisco VA Health Care System & University of California, San Francisco, San Francisco, California, USA
- Department of Medicine, San Francisco VA Health Care System, San Francisco, California, USA
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31
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Abstract
Hypertension is a potent cardiovascular risk factor with deleterious end-organ effects and is especially prevalent among patients with chronic kidney disease. The SPRINT (Systolic Blood Pressure Intervention Trial) enrolled patients at an elevated cardiac risk including patients with mild to moderate chronic kidney disease and found that an intensive systolic blood pressure goal of <120 mm Hg significantly reduced the rates of adverse cardiovascular events and all-cause mortality and nonsignificantly reduced the rates of probable dementia; these results were consistent whether one had chronic kidney disease or not. However, results of intensive blood pressure therapy on chronic kidney disease progression were inconclusive, and there was an increased risk of incident chronic kidney disease and acute kidney injury, but the declines in kidney function appear to be hemodynamically driven and reversible. Overall, an intensive blood pressure target is effective in reducing cardiovascular disease and all-cause mortality and may reduce the risk of probable dementia in patients with mild to moderate chronic kidney disease. More studies are needed to determine its long-term effects on kidney function.
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Affiliation(s)
- Austin H Hu
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Tara I Chang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
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32
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Kalantar-Zadeh K, Jafar TH, Nitsch D, Neuen BL, Perkovic V. Chronic kidney disease. Lancet 2021; 398:786-802. [PMID: 34175022 DOI: 10.1016/s0140-6736(21)00519-5] [Citation(s) in RCA: 491] [Impact Index Per Article: 163.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 02/11/2021] [Accepted: 02/19/2021] [Indexed: 12/11/2022]
Abstract
Chronic kidney disease is a progressive disease with no cure and high morbidity and mortality that occurs commonly in the general adult population, especially in people with diabetes and hypertension. Preservation of kidney function can improve outcomes and can be achieved through non-pharmacological strategies (eg, dietary and lifestyle adjustments) and chronic kidney disease-targeted and kidney disease-specific pharmacological interventions. A plant-dominant, low-protein, and low-salt diet might help to mitigate glomerular hyperfiltration and preserve renal function for longer, possibly while also leading to favourable alterations in acid-base homoeostasis and in the gut microbiome. Pharmacotherapies that alter intrarenal haemodynamics (eg, renin-angiotensin-aldosterone pathway modulators and SGLT2 [SLC5A2] inhibitors) can preserve kidney function by reducing intraglomerular pressure independently of blood pressure and glucose control, whereas other novel agents (eg, non-steroidal mineralocorticoid receptor antagonists) might protect the kidney through anti-inflammatory or antifibrotic mechanisms. Some glomerular and cystic kidney diseases might benefit from disease-specific therapies. Managing chronic kidney disease-associated cardiovascular risk, minimising the risk of infection, and preventing acute kidney injury are crucial interventions for these patients, given the high burden of complications, associated morbidity and mortality, and the role of non-conventional risk factors in chronic kidney disease. When renal replacement therapy becomes inevitable, an incremental transition to dialysis can be considered and has been proposed to possibly preserve residual kidney function longer. There are similarities and distinctions between kidney-preserving care and supportive care. Additional studies of dietary and pharmacological interventions and development of innovative strategies are necessary to ensure optimal kidney-preserving care and to achieve greater longevity and better health-related quality of life for these patients.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, CA, USA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA.
| | - Tazeen H Jafar
- Duke-NUS Graduate Medical School, Singapore; Department of Renal Medicine, Singapore General Hospital, Singapore; Duke Global Health Institute, Durham, NC, USA
| | - Dorothea Nitsch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; United Kingdom Renal Registry, Bristol, UK; Department of Nephrology, Royal Free London NHS Foundation Trust, London, UK
| | - Brendon L Neuen
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Vlado Perkovic
- Faculty of Medicine, University of New South Wales Sydney, Sydney, NSW, Australia
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33
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Joo YS, Kim HW, Nam KH, Young Lee J, Chang TI, Park JT, Yoo TH, Lee J, Kim SW, Oh YK, Oh KH, Kim YS, Ahn C, Kang SW, Han SH. Association Between Longitudinal Blood Pressure Trajectory and the Progression of Chronic Kidney Disease: Results From the KNOW-CKD. Hypertension 2021; 78:1355-1364. [PMID: 34397276 DOI: 10.1161/hypertensionaha.121.17542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Studies on the longitudinal temporal trend of blood pressure (BP) and its impact on kidney function are scarce. Here, we evaluated the association of dynamic changes in systolic blood pressure (SBP) over time with adverse kidney outcomes. We analyzed 1837 participants from the KNOW-CKD (Korean Cohort Study for Outcomes in Patients With Chronic Kidney Disease). The main exposure was 3 distinct SBP trajectories determined by the latent class mixed model (decreasing, stable, and increasing) using 3 SBP measurements at 0, 6, and 12 months. The primary outcome was CKD progression, defined as a composite of halving estimated glomerular filtration rate from baseline value or onset of end-stage kidney disease. SBP declined from 144 to 120 mm Hg in the decreasing SBP trajectory group and rose from 114 to 136 mm Hg in the increasing trajectory group within 1 year. During 6576 person-years of follow-up (median, 3.7 years), the composite outcome occurred in 521 (28.4%) participants. There were fewer primary outcome events in the decreasing (30.6%) and stable (26.5%) SBP trajectory groups than in the increasing trajectory group (33.0%). In the multivariable-adjusted cause-specific hazards model, increasing SBP trajectory was associated with a 1.28-fold higher risk for adverse kidney outcome compared with stable SBP trajectory. However, the risk for the primary outcome did not differ between the decreasing and stable SBP trajectory groups. In this longitudinal CKD cohort study, compared with stable SBP trajectory, increasing SBP trajectory was associated with higher risk for adverse kidney outcome, whereas decreasing SBP trajectory showed similar risk.
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Affiliation(s)
- Young Su Joo
- Department of Internal Medicine, Institute of Kidney Disease Research, College of Medicine, Yonsei University, Seoul, Republic of Korea. (Y.S.J., H.W.K., K.H.N., J.Y.L., J.T.P., T.-H.Y., S.-W.K., S.H.H.).,Division of Nephrology, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Republic of Korea (Y.S.J.)
| | - Hyung Woo Kim
- Department of Internal Medicine, Institute of Kidney Disease Research, College of Medicine, Yonsei University, Seoul, Republic of Korea. (Y.S.J., H.W.K., K.H.N., J.Y.L., J.T.P., T.-H.Y., S.-W.K., S.H.H.)
| | - Ki Heon Nam
- Department of Internal Medicine, Institute of Kidney Disease Research, College of Medicine, Yonsei University, Seoul, Republic of Korea. (Y.S.J., H.W.K., K.H.N., J.Y.L., J.T.P., T.-H.Y., S.-W.K., S.H.H.).,Division of Integrated Medicine, Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea.(K.H.N.)
| | - Jee Young Lee
- Department of Internal Medicine, Institute of Kidney Disease Research, College of Medicine, Yonsei University, Seoul, Republic of Korea. (Y.S.J., H.W.K., K.H.N., J.Y.L., J.T.P., T.-H.Y., S.-W.K., S.H.H.)
| | - Tae Ik Chang
- Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C.)
| | - Jung Tak Park
- Department of Internal Medicine, Institute of Kidney Disease Research, College of Medicine, Yonsei University, Seoul, Republic of Korea. (Y.S.J., H.W.K., K.H.N., J.Y.L., J.T.P., T.-H.Y., S.-W.K., S.H.H.)
| | - Tae-Hyun Yoo
- Department of Internal Medicine, Institute of Kidney Disease Research, College of Medicine, Yonsei University, Seoul, Republic of Korea. (Y.S.J., H.W.K., K.H.N., J.Y.L., J.T.P., T.-H.Y., S.-W.K., S.H.H.)
| | - Joongyub Lee
- Preventive and Management Center, Inha University Hospital, Incheon, Korea (J.L.)
| | - Soo Wan Kim
- Department of Internal Medicine, Institute of Kidney Disease Research, College of Medicine, Yonsei University, Seoul, Republic of Korea. (Y.S.J., H.W.K., K.H.N., J.Y.L., J.T.P., T.-H.Y., S.-W.K., S.H.H.)
| | - Yun Kyu Oh
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Korea (Y.K.O.)
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (K.-H.O., C.A.)
| | - Yong-Soo Kim
- Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea (Y.-S.K.)
| | - Curie Ahn
- Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (K.-H.O., C.A.)
| | - Shin-Wook Kang
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea (S.W.K.)
| | - Seung Hyeok Han
- Department of Internal Medicine, Institute of Kidney Disease Research, College of Medicine, Yonsei University, Seoul, Republic of Korea. (Y.S.J., H.W.K., K.H.N., J.Y.L., J.T.P., T.-H.Y., S.-W.K., S.H.H.)
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34
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McCallum W, Sarnak MJ, Lin F, Ku E. Acute eGFR declines after intensive BP lowering with RAS blockade and risk of kidney failure. J Hum Hypertens 2021; 35:638-641. [PMID: 33542450 PMCID: PMC8914529 DOI: 10.1038/s41371-021-00487-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/28/2020] [Accepted: 01/15/2021] [Indexed: 01/28/2023]
Affiliation(s)
- Wendy McCallum
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA.
| | - Mark J Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA
| | - Feng Lin
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Elaine Ku
- Division of Nephrology and Pediatric Nephrology, University of California San Francisco, San Francisco, CA, USA
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35
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Wettersten N, Katz R, Shlipak MG, Scherzer R, Waikar SS, Ix JH, Estrella MM. Urinary Biomarkers and Kidney Outcomes: Impact of Indexing Versus Adjusting for Urinary Creatinine. Kidney Med 2021; 3:546-554.e1. [PMID: 34401722 PMCID: PMC8350828 DOI: 10.1016/j.xkme.2021.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
RATIONALE & OBJECTIVE Urinary biomarker concentrations are frequently indexed to urinary creatinine (Ucr) concentration in spot samples to account for urine dilution; however, this may introduce biases. We evaluated whether indexing versus adjusting urinary biomarker concentrations for Ucr concentration altered their associations with outcomes. STUDY DESIGN Observational cohort. SETTING & PARTICIPANTS We analyzed data from 2,360 Systolic Blood Pressure Intervention Trial (SPRINT) participants with estimated glomerular filtration rates < 60 mL/min/1.73 m2 and urinary albumin (UAlb) and 8 urinary kidney tubule biomarkers measured at baseline. OUTCOMES The primary outcome was a composite of cardiovascular disease events; secondary outcomes were all-cause mortality and a composite of kidney outcomes (50% estimated glomerular filtration rate decline, end-stage kidney disease, or transplantation). ANALYTICAL APPROACH We used Cox proportional hazards regression to examine the associations of 1/Ucr with outcomes and compared the associations of UAlb and 8 individual urinary tubule biomarkers with outcomes, analyzed by indexing to Ucr, adjusting for 1/Ucr or the biomarker alone (without Ucr concentration). RESULTS During a median follow-up of 3.3 years, 307 composite cardiovascular events, 166 deaths, and 34 composite kidney outcomes occurred. After multivariable adjustment, 1/Ucr was significantly associated with cardiovascular events (HR, 1.27 per 2-fold higher; 95% CI, 1.11-1.45), not associated with either mortality (HR, 1.06; 95% CI, 0.87-1.28) or kidney events (HR, 1.49; 95% CI, 0.95-2.35). For UAlb and urinary tubule biomarker concentrations, most risk estimates were not significantly different when indexed to Ucr concentration versus adjusted for 1/Ucr. LIMITATIONS Cohort excluded patients with diabetes and overall had low levels of albuminuria. CONCLUSIONS 1/Ucr is independently associated with cardiovascular events in trial participants with chronic kidney disease. Indexing versus adjusting for 1/Ucr does not significantly change the associations of most urinary biomarkers with clinical outcomes.
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Affiliation(s)
- Nicholas Wettersten
- Cardiology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA
- Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, CA
| | - Ronit Katz
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Michael G. Shlipak
- Kidney Health Research Collaborative, Department of Medicine, San Francisco VA Health Care System, University of California, San Francisco, CA
| | - Rebecca Scherzer
- Kidney Health Research Collaborative, Department of Medicine, San Francisco VA Health Care System, University of California, San Francisco, CA
| | - Sushrut S. Waikar
- Section of Nephrology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA
| | - Joachim H. Ix
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, San Diego, CA
- Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA
- Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA
| | - Michelle M. Estrella
- Kidney Health Research Collaborative, Department of Medicine, San Francisco VA Health Care System, University of California, San Francisco, CA
- Nephrology Section, Veterans Affairs San Francisco Healthcare System, San Francisco, CA
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Lewis CE, Fine LJ, Beddhu S, Cheung AK, Cushman WC, Cutler JA, Evans GW, Johnson KC, Kitzman DW, Oparil S, Rahman M, Reboussin DM, Rocco MV, Sink KM, Snyder JK, Whelton PK, Williamson JD, Wright JT, Ambrosius WT. Final Report of a Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2021; 384:1921-1930. [PMID: 34010531 PMCID: PMC9907774 DOI: 10.1056/nejmoa1901281] [Citation(s) in RCA: 191] [Impact Index Per Article: 63.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In a previously reported randomized trial of standard and intensive systolic blood-pressure control, data on some outcome events had yet to be adjudicated and post-trial follow-up data had not yet been collected. METHODS We randomly assigned 9361 participants who were at increased risk for cardiovascular disease but did not have diabetes or previous stroke to adhere to an intensive treatment target (systolic blood pressure, <120 mm Hg) or a standard treatment target (systolic blood pressure, <140 mm Hg). The primary outcome was a composite of myocardial infarction, other acute coronary syndromes, stroke, acute decompensated heart failure, or death from cardiovascular causes. Additional primary outcome events occurring through the end of the intervention period (August 20, 2015) were adjudicated after data lock for the primary analysis. We also analyzed post-trial observational follow-up data through July 29, 2016. RESULTS At a median of 3.33 years of follow-up, the rate of the primary outcome and all-cause mortality during the trial were significantly lower in the intensive-treatment group than in the standard-treatment group (rate of the primary outcome, 1.77% per year vs. 2.40% per year; hazard ratio, 0.73; 95% confidence interval [CI], 0.63 to 0.86; all-cause mortality, 1.06% per year vs. 1.41% per year; hazard ratio, 0.75; 95% CI, 0.61 to 0.92). Serious adverse events of hypotension, electrolyte abnormalities, acute kidney injury or failure, and syncope were significantly more frequent in the intensive-treatment group. When trial and post-trial follow-up data were combined (3.88 years in total), similar patterns were found for treatment benefit and adverse events; however, rates of heart failure no longer differed between the groups. CONCLUSIONS Among patients who were at increased cardiovascular risk, targeting a systolic blood pressure of less than 120 mm Hg resulted in lower rates of major adverse cardiovascular events and lower all-cause mortality than targeting a systolic blood pressure of less than 140 mm Hg, both during receipt of the randomly assigned therapy and after the trial. Rates of some adverse events were higher in the intensive-treatment group. (Funded by the National Institutes of Health; SPRINT ClinicalTrials.gov number, NCT01206062.).
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Affiliation(s)
- Cora E Lewis
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - Lawrence J Fine
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - Srinivasan Beddhu
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - Alfred K Cheung
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - William C Cushman
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - Jeffrey A Cutler
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - Gregory W Evans
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - Karen C Johnson
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - Dalane W Kitzman
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - Suzanne Oparil
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - Mahboob Rahman
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - David M Reboussin
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - Michael V Rocco
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - Kaycee M Sink
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - Joni K Snyder
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - Paul K Whelton
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - Jeff D Williamson
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - Jackson T Wright
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
| | - Walter T Ambrosius
- The affiliations of the members of the writing committee are as follows: the Department of Epidemiology, School of Public Health (C.E.L.), and the Divisions of Preventive Medicine (C.E.L.) and Cardiovascular Disease (S.O.), Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham; the Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (L.J.F., J.A.C., J.K.S.); the Division of Nephrology and Hypertension, University of Utah, and Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City (S.B., A.K.C.); the Department of Preventive Medicine, University of Tennessee Health Science Center (W.C.C., K.C.J.), and Medical Service, Veterans Affairs Medical Center (W.C.C.), Memphis; the Department of Biostatistics and Data Science (G.W.E., D.M.R., W.T.A.), the Division of Cardiovascular Medicine (D.W.K.) and Section of Nephrology (M.V.R.), Department of Internal Medicine, and the Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine (K.M.S., J.D.W.), Wake Forest School of Medicine, Winston Salem, NC; the Division of Nephrology and Hypertension, Louis Stokes Cleveland Veterans Affairs Medical Center (M.R.), and the Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University (M.R., J.T.W.), Cleveland; and the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans (P.K.W.)
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Prischl FC, Rossing P, Bakris G, Mayer G, Wanner C. Major adverse renal events (MARE): a proposal to unify renal endpoints. Nephrol Dial Transplant 2021; 36:491-497. [PMID: 31711188 DOI: 10.1093/ndt/gfz212] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND In renal studies, various outcome endpoints are used with variable definitions, making it nearly impossible to perform meta-analyses and deduce meaningful conclusions. Increasing attention is directed towards standardization of renal outcome reporting. METHODS A working group was formed to produce a unifying definition of renal outcomes that can be used by all investigators. We propose major adverse renal events (MARE) as the term for a standardized composite of hard renal outcomes. We discuss the components for inclusion in MARE from existing evidence. RESULTS MARE could include three to five items, considered relevant to patients and regulators. New onset of kidney injury, that is persistent albuminuria/proteinuria and/or decreasing glomerular filtration rate (GFR) <60 ml/min/1.73 m2, persistent signs of worsening kidney disease, development of end-stage kidney disease with estimated GFR <15 ml/min/1.73 m2 without or with initiation of kidney replacement therapy, and death from renal cause are core items of MARE. Additionally, patient reported outcomes should be reported in parallel to MARE as a standard set of primary (or secondary) endpoints in studies on kidney disease of diabetic, hypertensive-vascular, or other origin. CONCLUSIONS MARE as a reporting standard will enhance the ability to compare studies and thus, facilitate meaningful meta-analyses. This will result in standardized endpoints that should result in guideline improvement to better individualize care of patients with kidney disease.
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Affiliation(s)
- Friedrich C Prischl
- Department of Nephrology, 4th Department of Internal Medicine, Klinikum WelsGrieskirchen, Wels, Austria
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - George Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago, Chicago, IL, USA
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
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Zhang Y, Li JJ, Wang AJ, Wang B, Hu SL, Zhang H, Li T, Tuo YH. Effects of intensive blood pressure control on mortality and cardiorenal function in chronic kidney disease patients. Ren Fail 2021; 43:811-820. [PMID: 33966601 PMCID: PMC8118417 DOI: 10.1080/0886022x.2021.1920427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Blood pressure (BP) variability is highly correlated with cardiovascular and kidney outcomes in patients with chronic kidney disease (CKD). However, appropriate BP targets in patients with CKD remain uncertain. METHODS We searched PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) of CKD patients who underwent intensive BP management. Kappa score was used to assess inter-rater agreement. A good agreement between the authors was observed to inter-rater reliability of RCTs selection (kappa = 0.77; P = 0.005). RESULTS Ten relevant studies involving 20 059 patients were included in the meta-analysis. Overall, intensive BP management may reduce the incidence of cardiovascular disease mortality (RR: 0.69, 95% CI: 0.53 to 0.90, P: 0.01), all-cause mortality (RR: 0.77, 95% CI: 0.67 to 0.88, P < 0.01) and composite cardiovascular events (RR: 0.84 95% CI: 0.75 to 0.95, P < 0.01) in patients with CKD. However, reducing BP has no significant effect on the incidence of doubling of serum creatinine level or 50% reduction in GFR (RR: 1.26, 95% CI: 0.66 to 2.40, P = 0.48), composite renal events (RR 1.07, 95% CI: 0.81 to 1.41, P = 0.64) or SAEs (RR: 0.97, 95% CI: 0.90 to 1.05, P = 0.48). CONCLUSION In patients with CKD, enhanced BP management is associated with reduced all-cause mortality, cardiovascular mortality, and incidence of composite cardiovascular events.
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Affiliation(s)
- Yong Zhang
- Department of Nephrology, Jianli People's Hospital, Jingzhou, China
| | - Jing-Jing Li
- Department of Ultrasonic Imaging, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - An-Jun Wang
- Department of Nephrology, Jianli People's Hospital, Jingzhou, China
| | - Bo Wang
- Department of Ultrasound, The First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Shou-Liang Hu
- Department of Nephrology, The First Affiliated Hospital of Yangtze University, Jingzhou, China
| | - Heng Zhang
- Department of Histology and Embryology, Xiang Ya School of Medicine, Central South University, Changsha, China
| | - Tian Li
- School of Basic Medicine, Fourth Military Medical University, Xi'an, China
| | - Yan-Hong Tuo
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Abstract
Rationale & Objective Nearly half the patients with heart failure have chronic kidney disease. Implantation of a left ventricular assist device (LVAD) improves kidney function in some but not all patients, and lack of improvement is associated with worse outcomes. Preimplantation factors that predict change in kidney function after LVAD placement are not well described. Study Design Single-center observational study. Setting & Participants Consecutive patients undergoing LVAD implantation. Predictors 48 diverse preimplantation variables including demographic, clinical, laboratory, hemodynamic, and echocardiographic variables. Outcomes The primary outcome was change in estimated glomerular filtration rate (eGFR) at 1 month after implantation. Secondary outcomes included eGFR changes at 3, 6, and 12 months. Analytic Approach Univariable and multivariable linear regression. Results Among 131 patients, average age was 60 ± 13 years, 83% were men, 47% had pre-existing chronic kidney disease, and mean preimplantation eGFR was 57 ± 23 mL/min/1.73 m2. At 1-month following LVAD implantation, eGFR improved in 98 (75%) patients. Variables associated with 1-month increases in eGFR were younger age, absence of diabetes mellitus (DM), use of inotropes, lower implantation eGFR, and higher implantation serum urea nitrogen, alanine aminotransferase, bilirubin, and creatinine levels. In multivariable models, younger age (β = 7.14 mL/min/1.73 m2 per SD; 95% CI, 3.17-11.10), lower eGFR (β = 7.72 mL/min/1.73 m2 per SD; 95% CI, 3.10-12.34), and absence of DM (β = 10.36 mL/min/1.73 m2; 95% CI, 2.99-17.74) were each independently associated with 1-month improvement in eGFR. Only younger age and lower eGFR were associated with improvements in eGFR at later months. Limitations Single-center study. Loss to follow-up from heart transplantation and death over duration of study. Conclusions Only younger age, lower eGFR, and absence of DM were associated with improvement in eGFR at 1 month. Thus, prediction of eGFR change at 1 month and beyond is limited by using preimplantation variables.
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Agarwal A, Wei G, Boucher R, Ahmed F, Beddhu S. Modification of the effects of intensive systolic blood pressure control on kidney outcomes by baseline body mass index. Nephrology (Carlton) 2021; 26:303-311. [PMID: 33538091 DOI: 10.1111/nep.13857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/18/2020] [Accepted: 01/11/2021] [Indexed: 11/29/2022]
Abstract
AIM Obesity and intensive systolic blood pressure (SBP) control are independently associated with greater risk of acute kidney injury (AKI) and incident chronic kidney disease (CKD). We examined whether baseline body mass index (BMI) modifies the effects of intensive SBP lowering on AKI or incident CKD. METHODS The systolic blood pressure intervention trial (SPRINT) randomized 9361 participants with high blood pressure to an SBP target of either <120 mm Hg or < 140 mm Hg. In a secondary analysis of 9210 SPRINT participants with a baseline BMI of ≥18.5 and < 50 kg/m2 , we examined the interactions of baseline BMI and SPRINT SBP intervention on subsequent AKI and incident CKD. RESULTS Each 5 kg/m2 increase in baseline BMI was associated with higher risk of AKI (hazard ratio [HR] 1.12, 95% confidence interval [CI] 1.01 to 1.25) and incident CKD (HR 1.17, 95% CI 1.01 to 1.32). Intensive SBP control increased the risk of AKI (HR 1.68, 95% CI 1.22-2.11) and incident CKD (HR 3.49, 95% CI 2.47-4.94). The increased risk of AKI with intensive SBP control was consistent across the baseline BMI spectrum (linear interaction p = 0.55); however, the risk of incident CKD with SPRINT intervention increased with higher BMI (linear interaction p = 0.043). CONCLUSION The increased risk of adverse kidney events seen with intensive SBP control in the SPRINT persisted across the baseline BMI spectrum. A higher baseline BMI was associated with an augmented risk of incident CKD with intensive SBP control.
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Affiliation(s)
- Adhish Agarwal
- Division of Nephrology and Hypertension, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Guo Wei
- Division of Nephrology and Hypertension, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Robert Boucher
- Division of Nephrology and Hypertension, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Faris Ahmed
- Division of Nephrology, University of Alabama, Birmingham, Alabama, USA
| | - Srinivasan Beddhu
- Division of Nephrology and Hypertension, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA
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Cheung AK, Chang TI, Cushman WC, Furth SL, Hou FF, Ix JH, Knoll GA, Muntner P, Pecoits-Filho R, Sarnak MJ, Tobe SW, Tomson CR, Mann JF. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int 2021; 99:S1-S87. [PMID: 33637192 DOI: 10.1016/j.kint.2020.11.003] [Citation(s) in RCA: 412] [Impact Index Per Article: 137.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022]
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Li Y, Zhang Y, Shen X, Zhao F, Yan S. The Value of Ketone Bodies in the Evaluation of Kidney Function in Patients with Type 2 Diabetes Mellitus. J Diabetes Res 2021; 2021:5596125. [PMID: 33937415 PMCID: PMC8055418 DOI: 10.1155/2021/5596125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/30/2021] [Accepted: 04/05/2021] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES Recent studies have shown that the slightly elevated circulating levels of ketone bodies (KBs) played a significant role in the treatment of various diseases. This study is aimed at investigating the association between different levels of KBs and kidney function in patients with type 2 diabetes mellitus (T2DM). METHODS A retrospective study of 955 patients with T2DM (426 women and 529 men) admitted to our hospital from December 2017 to September 2019 was conducted. Patients were divided into different groups in line with the levels of KBs (low-normal group: 0.02-0.04 mmol/L, middle-normal group: 0.05-0.08 mmol/L, high-normal group: 0.09-0.27 mmol/L, and slightly elevated group: >0.27 and <3.0 mmol/L). RESULTS In the present study, individuals with high-normal levels of KBs had the lowest risk of diabetic kidney disease (DKD) and increased peak systolic velocity (PSV); those with middle-normal levels of KBs had the lowest risk of increased renal arterial resistive index (RI), with a positive correlation between increased α1-microglobulin and KB concentration. In addition, the indicators of glomerulus, renal tubules, and renal arteries were all poor with slightly elevated circulating levels of KBs, and KB concentration lower than 0.09 mmol/L can be applied as the threshold for low risk of renal function damage. CONCLUSIONS In summary, slightly elevated circulating levels of ketone bodies are not of benefit for renal function in patients with type 2 diabetes mellitus.
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Affiliation(s)
- Yimei Li
- Department of Endocrinology, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
- Diabetes Research Institute of Fujian Province, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
- Metabolic Diseases Research Institute, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
- Fujian Province Clinical Research Center for Metabolic Diseases, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
| | - Yongze Zhang
- Department of Endocrinology, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
- Diabetes Research Institute of Fujian Province, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
- Metabolic Diseases Research Institute, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
- Fujian Province Clinical Research Center for Metabolic Diseases, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
| | - Ximei Shen
- Department of Endocrinology, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
- Diabetes Research Institute of Fujian Province, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
- Metabolic Diseases Research Institute, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
- Fujian Province Clinical Research Center for Metabolic Diseases, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
| | - Fengying Zhao
- Department of Endocrinology, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
- Diabetes Research Institute of Fujian Province, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
- Metabolic Diseases Research Institute, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
- Fujian Province Clinical Research Center for Metabolic Diseases, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
| | - Sunjie Yan
- Department of Endocrinology, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
- Diabetes Research Institute of Fujian Province, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
- Metabolic Diseases Research Institute, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
- Fujian Province Clinical Research Center for Metabolic Diseases, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
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Malhotra R, Katz R, Jotwani V, Agarwal A, Cohen DL, Cushman WC, Ishani A, Killeen AA, Kitzman DW, Oparil S, Papademetriou V, Parikh CR, Raphael KL, Rocco MV, Tamariz LJ, Whelton PK, Wright JT, Shlipak MG, Ix JH. Estimated GFR Variability and Risk of Cardiovascular Events and Mortality in SPRINT (Systolic Blood Pressure Intervention Trial). Am J Kidney Dis 2020; 78:48-56. [PMID: 33333147 DOI: 10.1053/j.ajkd.2020.10.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 10/16/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE AND OBJECTIVE Although low estimated glomerular filtration rate (eGFR) is associated with cardiovascular disease (CVD) events and mortality, the clinical significance of variability in eGFR over time is uncertain. This study aimed to evaluate the associations between variability in eGFR and the risk of CVD events and all-cause mortality. STUDY DESIGN Longitudinal analysis of clinical trial participants. SETTINGS AND PARTICIPANTS 7,520 Systolic Blood Pressure Intervention Trial (SPRINT) participants ≥50 year of age with 1 or more CVD risk factors. PREDICTORS eGFR variability, estimated by the coefficient of variation of eGFR assessments at the 6th, 12th, and 18-month study visits. OUTCOMES The SPRINT primary CVD composite outcome (myocardial infarction, acute coronary syndrome, stroke, heart failure, or CVD death) and all-cause mortality from month 18 to the end of follow-up. ANALYTICAL APPROACH Cox models were used to evaluate associations between eGFR variability and CVD outcomes and all-cause mortality. Models were adjusted for demographics, randomization arm, CVD risk factors, albuminuria, and eGFR at month 18. RESULTS Mean age was 68 ± 9 years; 65% were men; and 58% were White. The mean eGFR was 73 ± 21 (SD) mL/min/1.73 m2 at 6 months. There were 370 CVD events and 154 deaths during a median follow-up of 2.4 years. Greater eGFR variability was associated with higher risk for all-cause mortality (hazard ratio [HR] per 1 SD greater variability, 1.29; 95% CI, 1.14-1.45) but not CVD events (HR, 1.05; 95% CI, 0.95-1.16) after adjusting for albuminuria, eGFR, and other CVD risk factors. Associations were similar when stratified by treatment arm and by baseline CKD status, when accounting for concurrent systolic blood pressure changes, use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and diuretic medications during follow up. LIMITATIONS Persons with diabetes and proteinuria > 1 g/d were excluded. CONCLUSIONS In trial participants at high risk for CVD, greater eGFR variability was independently associated with all-cause mortality but not CVD events.
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Affiliation(s)
- Rakesh Malhotra
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, CA
| | - Ronit Katz
- Kidney Research Institute, University of Washington, Seattle, WA
| | - Vasantha Jotwani
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center and University of California, San Francisco, CA
| | - Adhish Agarwal
- Division of Nephrology and Hypertension, Department of Medicine, University of Utah Health, Salt Lake City, UT
| | - Debbie L Cohen
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William C Cushman
- Medical Service, Veteran Affairs Medical Center and Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Areef Ishani
- Division of Nephrology, Department of Medicine, University of Minnesota and Veteran Affairs Medical Center, Minneapolis, MN
| | - Anthony A Killeen
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Dalane W Kitzman
- Division of Cardiovascular Medicine, Wake Forest School of Medicine, Winston Salem, NC
| | - Suzanne Oparil
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, School of Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Vasilios Papademetriou
- Division of Cardiology, Department of Medicine, Georgetown University and Veteran Affairs Medical Center, Washington, DC
| | - Chirag R Parikh
- Division of Nephrology, Department of Medicine, John Hopkins University, Baltimore, MD
| | - Kalani L Raphael
- Division of Nephrology and Hypertension, Department of Medicine, University of Utah Health, Salt Lake City, UT
| | - Michael V Rocco
- Division of Nephrology, Department of Medicine, Wake Forest School of Medicine, Winston Salem, NC
| | - Leonardo J Tamariz
- Department of Medicine, Miller School of Medicine at the University of Miami, Miami, FL
| | - Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | - Jackson T Wright
- Division of Nephrology and Hypertension, University Hospital Cleveland Medical Center, Cleveland, OH
| | - Michael G Shlipak
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center and University of California, San Francisco, CA; Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Joachim H Ix
- Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA; Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, CA.
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Amatruda JG, Katz R, Peralta CA, Estrella MM, Sarathy H, Fried LF, Newman AB, Parikh CR, Ix JH, Sarnak MJ, Shlipak MG. Association of Non-Steroidal Anti-Inflammatory Drugs with Kidney Health in Ambulatory Older Adults. J Am Geriatr Soc 2020; 69:726-734. [PMID: 33305369 DOI: 10.1111/jgs.16961] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/24/2020] [Accepted: 10/26/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Non-steroidal anti-inflammatory drugs (NSAIDs) can cause kidney injury, especially in older adults. However, previously reported associations between NSAID use and kidney health outcomes are inconsistent and limited by reliance on serum creatinine-based GFR estimates. This analysis investigated the association of NSAID use with kidney damage in older adults using multiple kidney health measures. DESIGN Cross-sectional and longitudinal analyses. SETTING Multicenter, community-based cohort. PARTICIPANTS Two thousand nine hundred and ninty nine older adults in the Health ABC Study. A subcohort (n = 500) was randomly selected for additional biomarker measurements. EXPOSURE Prescription and over-the-counter NSAID use ascertained by self-report. MEASUREMENTS Baseline estimated glomerular filtration rate (eGFR) by cystatin C (cysC), urine albumin-to-creatinine ratio (ACR), kidney injury molecule-1 (KIM-1), and interleukin-18 (IL-18) were measured in 2,999 participants; alpha-1 microglobulin (α1m), neutrophil gelatinase-associated lipocalin (NGAL), propeptide type III procollagen (PIIINP), and uromodulin (UMOD) were measured in 500 participants. GFR was estimated three times over 10 years and expressed as percent change per year. RESULTS Participants had a mean age of 74 years, 51% were female, and 41% African-American. No eGFR differences were detected between NSAID users (n = 655) and non-users (n = 2,344) at baseline (72 ml/min/1.73 m2 in both groups). Compared to non-users, NSAID users had lower adjusted odds of having ACR greater than 30 mg/g (0.67; 95% confidence interval (CI) = 0.51-0.89) and lower mean urine IL-18 concentration at baseline (-11%; 95% CI = -4% to -18%), but similar mean KIM-1 (5%; 95% CI = -5% to 14%). No significant differences in baseline concentrations of the remaining urine biomarkers were detected. NSAID users and non-users did not differ significantly in the rate of eGFR decline (-2.2% vs -2.3% per year). CONCLUSION Self-reported NSAID use was not associated with kidney dysfunction or injury based on multiple measures, raising the possibility of NSAID use without kidney harm in ambulatory older adults. More research is needed to define safe patterns of NSAID consumption.
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Affiliation(s)
- Jonathan G Amatruda
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Kidney Health Research Collaborative, San Francisco VA Medical Center & University of California, San Francisco, San Francisco, California, USA
| | - Ronit Katz
- Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Carmen A Peralta
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Kidney Health Research Collaborative, San Francisco VA Medical Center & University of California, San Francisco, San Francisco, California, USA.,Chief Medical Office, Cricket Health, Inc., San Francisco, California, USA
| | - Michelle M Estrella
- Kidney Health Research Collaborative, San Francisco VA Medical Center & University of California, San Francisco, San Francisco, California, USA.,Division of Nephrology, Department of Medicine, San Francisco VA Medical Center, San Francisco, California, USA
| | - Harini Sarathy
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Division of Nephrology, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Linda F Fried
- University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, Pennsylvania, USA.,VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Anne B Newman
- University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Chirag R Parikh
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Joachim H Ix
- Division of Nephrology-Hypertension, Department of Medicine, University of California, San Diego, California, USA.,Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, California, USA
| | - Mark J Sarnak
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Michael G Shlipak
- Kidney Health Research Collaborative, San Francisco VA Medical Center & University of California, San Francisco, San Francisco, California, USA.,Department of Medicine, San Francisco VA Medical Center, San Francisco, California, USA
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46
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Signorini L, Zaza G, Gambaro G. The challenge of early glomerular filtration rate decline in response to antihypertensive treatment and chronic kidney disease outcomes. Nephrol Dial Transplant 2020; 37:222-229. [PMID: 33155053 DOI: 10.1093/ndt/gfaa171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Indexed: 11/14/2022] Open
Abstract
Hypertension and chronic kidney disease (CKD) are closely linked pathological processes. Combating high blood pressure (BP) is an essential part of preventing CKD progression and reducing cardiovascular (CV) risk. Data from recent randomized controlled trials on patients at high CV risk showed the beneficial effects of intensive action to meet BP targets on mortality related to CV disease. The impact of meeting such targets on renal function is still unclear, however, particularly for patients with CKD. This issue has been the object of several post hoc analyses because lowering BP definitely has a nephroprotective role, but the early decline in glomerular filtration rate (GFR) associated with antihypertensive therapies and strict BP targets is still a concern in nephrology clinical practice. The present review discusses the results of studies on this topic, focusing specifically on the clinical significance of early GFR decline in response to treatment with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, or to different BP targets, in terms of renal and CV outcomes, and how this tips the balance towards continuing or discontinuing antihypertensive therapy.
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Affiliation(s)
| | - Gianluigi Zaza
- Renal Unit, Department of Medicine, University Hospital of Verona, Verona, Italia
| | - Giovanni Gambaro
- Renal Unit, Department of Medicine, University Hospital of Verona, Verona, Italia
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47
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Leontsinis I, Mantzouranis M, Tsioufis P, Andrikou I, Tsioufis C. Recent advances in managing primary hypertension. Fac Rev 2020; 9:4. [PMID: 33659936 PMCID: PMC7894269 DOI: 10.12703/b/9-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Hypertension remains a leading risk factor for cardiovascular mortality and morbidity globally despite the availability of effective and well-tolerated antihypertensive medications. Accumulating evidence suggests a more aggressive blood pressure regulation aimed at lower targets, particularly for selected patient groups. Our concepts of the optimal method for blood pressure measurement have radically changed, maintaining appropriate standard office measurements for initial assessment but relying on out-of-office measurement to better guide our decisions. Thorough risk stratification provides guidance in decision making; however, an individualized approach is highly recommended to prevent overtreatment. Undertreatment, on the other hand, remains a major concern and is mainly attributed to poor adherence and resistant or difficult-to-control forms of the disease. This review aims to present modern perspectives, novel treatment options, including innovative technological applications and developing interventional and pharmaceutical therapies, and the major concerns emerging from several years of research and epidemiological observations related to hypertension management.
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Affiliation(s)
- Ioannis Leontsinis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 108 Vas. Sofias Ave, 11527, Athens, Greece
| | - Manos Mantzouranis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 108 Vas. Sofias Ave, 11527, Athens, Greece
| | - Panagiotis Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 108 Vas. Sofias Ave, 11527, Athens, Greece
| | - Ioannis Andrikou
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 108 Vas. Sofias Ave, 11527, Athens, Greece
| | - Costas Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 108 Vas. Sofias Ave, 11527, Athens, Greece
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48
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Camafort M, Redón J, Pyun WB, Coca A. Intensive blood pressure lowering: a practical review. Clin Hypertens 2020; 26:21. [PMID: 33292735 PMCID: PMC7603713 DOI: 10.1186/s40885-020-00153-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/10/2020] [Indexed: 11/28/2022] Open
Abstract
According to the last Hypertension guideline recommendations, it may be concluded that intensive BP lowering is only advisable in a subgroup of patients where there is a clear net benefit of targeting to lower BP goals. However, taking into account the relevance of correct BP measurement, estimates of the benefits versus the harm should be based on reliable office BP measurements and home BP measurements. There is still debate about which BP goals are optimal in reducing morbidity and mortality in uncomplicated hypertensives and in those with associated comorbidities. In recent years, trials and meta-analyses have assessed intensive BP lowering, with some success. However, a careful examination of the results shows that current data are not easily applicable to the general hypertensive population. This article reviews the evidence on and controversies about intensive BP lowering in general and in specific clinical situations, and the importance of obtaining reliable BP readings in patients with hypertension and comorbidities.
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Affiliation(s)
- Miguel Camafort
- Department of Internal Medicine-ICMiD. Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain. .,Cardiovascular Risk, Nutrition and Aging Research Group. IDIBAPS, Barcelona, Spain. .,Ciber-OBN, Instituto de Salud Carlos III, Madrid, Spain.
| | - Josep Redón
- Ciber-OBN, Instituto de Salud Carlos III, Madrid, Spain.,Hypertension Clinic. Hospital Clinico, University of Valencia, Valencia, Spain
| | - Wook Bum Pyun
- Department of Cardiology, Ewha Womans University. Seoul Hospital, Seoul, South Korea
| | - Antonio Coca
- Department of Internal Medicine-ICMiD. Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain.,Cardiovascular Risk, Nutrition and Aging Research Group. IDIBAPS, Barcelona, Spain
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49
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Ali W, Bakris GL. How to Manage Hypertension in People With Diabetes. Am J Hypertens 2020; 33:935-943. [PMID: 32307510 DOI: 10.1093/ajh/hpaa067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 04/13/2020] [Accepted: 04/15/2020] [Indexed: 11/14/2022] Open
Abstract
Hypertension is a common condition that is often seen in patients with diabetes. Both diseases increase the risk of morbidity and mortality from CV events and kidney disease progression. Factors that influence blood pressure (BP) control in diabetes include the persons' genetic background for hypertension and kidney disease, level of obesity and insulin resistance, the magnitude of preexisting kidney disease, and lifestyle factors, such as level of sodium and potassium intake, sleep quality and exercise effort all of which can affect levels of sympathetic nerve activity and contribute to increased BP variability. Lifestyle intervention is a key component to the effective management of diabetes and hypertension and can markedly reduce event rates of both heart and kidney outcomes. The approach to pharmacologic treatment of BP in diabetes is crucial since certain classes of agents for both BP and diabetes confer significant benefits to reduce cardiorenal outcomes.
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Affiliation(s)
- Waleed Ali
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, The University of Chicago Medicine, Chicago, Illinois, USA
| | - George L Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, The University of Chicago Medicine, Chicago, Illinois, USA
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50
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Carey RM, Whelton PK. Evidence for the Universal Blood Pressure Goal of <130/80 mm Hg Is Strong: Controversies in Hypertension - Pro Side of the Argument. Hypertension 2020; 76:1384-1390. [PMID: 32951472 DOI: 10.1161/hypertensionaha.120.14647] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Robert M Carey
- From the Department of Medicine, University of Virginia Health System, Charlottesville, VA (R.M.C.)
| | - Paul K Whelton
- Departments of Epidemiology and Medicine, Tulane University, New Orleans, LA (P.K.W.)
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