Effects of calcium antagonist, benidipine, on the progression of chronic renal failure in the elderly: a 1-year follow-up

Hypertension control among euvolemic hypertensive hemodialysis patients in Malaysia: a prospective follow-up study

Objectives

Existing literature does not provide enough information on evaluation of factors associated with pre-dialysis controlled hypertension among euvolemic hemodialysis (HD) patients. We conducted a study to evaluate the rate and factors influencing pre-dialysis controlled hypertension among euvolemic HD patients.

Design

A multicenter prospective follow-up study.

Setting

Tertiary care teaching hospital and its associated private dialysis centers.

Participants

This study included 145 euvolemic eligible hypertensive patients. Various sociodemographic, clinical factors and drugs were investigated and analyzed by using appropriate statistical methods to determine the factors influencing hypertension control among the study participants.

Results

On baseline visit, the mean pre-dialysis systolic and diastolic BP (mmHg) of study participants was 161.2 ± 24. and 79.21 ± 11.8 retrospectively, and 30 (20.6%) patients were on pre-dialysis goal BP. At the end of the 6-months follow-up, the mean pre-dialysis systolic BP and diastolic BP (mmHg) of the patients was 154.6 ± 18.3 and 79.2 ± 11.8 respectively, and 42 (28.9%) were on pre-dialysis goal BP. In multivariate analysis, the use of calcium channel blockers (CCBs) was the only variable which had statistically significant association with pre-dialysis controlled hypertension at baseline (OR = 7.530, p-value = 0.001) and final (OR = 8.988, p-value < 0.001) visits.

Conclusions

In present study, the positive association observed between CCBs and controlled hypertension suggests that CCBs are effective antihypertensive drugs in the management of hypertension among euvolemic HD patients.

Strengths and limitations of this study

This study involved a group of patients from tertiary-level teaching hospital and its associated private dialysis centers of Malaysia.To the best of the authors' knowledge, this is the first study to assess the factors influencing pre-dialysis controlled hypertension in a cohort of 145 euvolemic HD patients in a Malaysian setting.For determining the factors influencing hypertenion control multivariate analysis was conducted.Being a prospective follow-up study, the findings of the present study need to be interpreted with caution since it is limited to only 6 months follow up.Nevertheless, a multicenter study with a large sample size and longer follow up time is needed to confirm the findings of the current study.

La population âgée hémodialysée : évaluer et prendre en charge le risque de déclin cognitif

Epidemiological data suggest a large prevalence of cognitive impairment in elderly patients on haemodialysis. They are frequently exposed to pathologies that affect the brain, and hold a plurality of risk factors for neurodegenerative and vascular dementia. Cognitive dysfunctions, because of their medical and socio-economical consequences, may led to discuss the indication for haemodialysis and its profit for the elderly patient. These facts highlight the advantage of a regular assessment of cognitive functions in this population. They also suggest the need in the future of a multidisciplinary intervention for these patients, for a better evaluation of interventions aimed on primary and secondary prevention of cognitive decline in the elderly group.

[Alzheimer's disease: cardiovascular risk factors must be assessed]

BACKGROUND

Dementia is nowadays of major importance in public health. Alzheimer's disease and vascular cognitive impairments are its main aetiology in the elderly. The cause of Alzheimer's disease remains unknown. The factor initiating the physiopathology of this neurodegenerative disease is source of controversy.

CURRENT KNOWLEDGE AND KEY POINTS

The theory of a neurotoxicity initiated by amyloid deposition is questioned. A growing number of data suggest a central role of cardiovascular risk factors and alteration of arterial walls, inducing chronic brain hypoperfusion, as the primary trigger in the physiopathology of the disease. These data are based on epidemiological, physiopathological, neuroimaging, neuropathological and pharmacological studies. However, the exact link between arteriosclerosis, vascular cognitive impairment and Alzheimer's disease remains controversial.

FUTURE PROSPECTS AND PROJECTS

These debates point out the crucial importance of the assessment of cardiovascular risk factors, as a preventable cause, either of cognitive decline, morbidity and mortality. In this aim, major targets could be different when primary or secondary prevention are at stake. These controversies also suggest new research directions towards Alzheimer's disease physiopathology, and for pharmacological interventions aimed on the prevention of cognitive decline or the curative treatment for this disease.

Coronary bypass procedures in patients with renal artery stenosis

BACKGROUND AND AIM OF THE STUDY

We present our experience on patients with renal artery stenosis undergoing myocardial revascularization procedures.

METHODS

Eighteen patients with varying degrees of renal artery stenosis were operated for coronary artery bypass grafting between 1996 and 2003. The overall incidence was 0.15%. There were nine male and nine female patients with a mean age of 62 +/- 8.2 (40-72 years). Four had bilateral and eight had significant unilateral (>50%) renal artery stenoses. Preoperatively, three patients had renal arterial intervention (stenting), and one patient was on hemodialysis. The mean preoperative creatinine value was 2.6 +/- 2.7 mg/dL (range 0.7 to 9.3). The patients were followed medically: two patients underwent off-pump coronary bypass grafting and the others were operated on-pump.

RESULTS

There was only one mortality and two patients required hemodialysis postoperatively. The postoperative mean creatinine values were 3.4 +/- 4.9 mg/dL (range 1.0 to 12.5). No electrolyte imbalances were noted except that one case revealed a transient metabolic acidosis. Five patients required inotropic support with dopamine and two needed diuretic infusions. Only five patients demonstrated a refractory hyper tensive period postoperatively.

CONCLUSIONS

The concomitant correction of renal artery stenosis with CABG is usually not necessary, but the principles for renovascular diseases must be kept in mind and individually oriented strategies must be planned.

An Angiotensin Receptor Blocker Reduces the Risk of Congestive Heart Failure in Elderly Hypertensive Patients with Renal Insufficiency

We examined the efficacy of candesartan in reducing cardiovascular events in hypertensive patients with coexisting chronic kidney disease and cardiovascular diseases. This open-label, prospective study was conducted from 1999 to 2002, and 141 hypertensive subjects 60 to 75 years old with non-diabetic chronic renal insufficiency were enrolled. Before randomization of the patients, we examined their past medical history and found that 69 patients had been hospitalized due to myocardial infarction (MI) or stroke. Therefore, the patients were divided into 2 groups, one with previous histories of MI or stroke and the other with no previous history of Ml or stroke. The patients were randomized to receive either the angiotensin receptor blocker candesartan or conventional treatment. The mean duration of follow-up was 3.1 +/- 0.4 years. The primary outcome was a primary cardiovascular event (MI, stroke, or heart failure) verified by hospitalization. At the end of the study, in the patients with past history of cardiovascular diseases, blood pressure was reduced from 146.4 +/- 7.2/79.2 +/- 5.1 to 34.4 +/- 6.1/72.3 +/- 4.0 mmHg in the candesartan group and from 145.3 +/- 5.1/80.1 +/- 3.8 to 133.4 +/- 5.8/73.8 +/- 4.2 mmHg in the conventional treatment group. In the patients without past history of cardiovascular diseases, blood pressure was reduced from 143.2 +/- 4.3/78.3 +/- 4.8 to 133.8 +/- 5.3/ 73.1 +/- 3.8 mmHg in the candesartan group and from 143.9 +/- 6.8/78.1 +/- 4.2 to 132.6 +/- 5.4/74.5 +/- 4.4 mmHg in the conventional treatment group at the end of the study. There were no significant differences between the candesartan group and the conventional treatment group in the reduction of blood pressures. Among patients with a past history of cardiovascular disease, the serum creatinine concentration increased from 1.49 +/- 0.38 to 1.58 +/- 0.42 by candesartan treatment and from 1.50 +/- 0.32 to 1.89 +/- 0.37 by conventional treatment. On the other hand, in patients with no past history of cardiovascular disease, the serum creatinine concentration increased from 1.44 +/- 0.42 to 1.46 +/- 0.40 by candesartan treatment and from 1.46 +/- 0.44 to 1.51 +/- 0.38 by conventional treatment. Although, there was no significant difference in the incidence of cardiovascular events between the 2 groups with the candesartan-based and conventional-based antihypertensive treatment, in patients without cardiovascular events (12/36 vs. 7/34: these figures indicate events per total participated persons per 3 years; following figures are the same as this), treatment with candesartan reduced the incidence of cardiovascular events in the patients with past history of cardiovascular diseases (20/33 vs. 32/ 38). In particular, candesartan-based treatment reduced the incidence of congestive heart failure by 66.4% in these patients. In conclusion, this prospective, open-labeled randomized study suggests that 1) previous history of cardiovascular diseases is a major risk factor for cardiovascular events; and 2) candesartan is effective for reduction of cardiovascular events in hypertensive patients with coexisting chronic kidney disease and cardiovascular diseases, especially for prevention of congestive heart failure.

Comparison of the effects of angiotensin receptor antagonist, angiotensin converting enzyme inhibitor, and their combination on regression of left ventricular hypertrophy of diabetes type 2 patients on recent onset hemodialysis therapy

Left ventricular hypertrophy (LVH) is frequently found at the initiation of dialysis therapy of diabetic and hypertensive patients, and is highly predictive of future cardiac morbidity and mortality. In patients with hypertension and LVH, both an angiotensin converting enzyme (ACE) inhibitor and an angiotensin type 1 receptor (AT1) antagonist regress LVH. However, it remains controversial whether dual blockade of the renin-angiotensin system will regress LVH in these patients using a combination of ACE inhibitor and AT1 antagonist. Thirty-three type II diabetic patients with end-stage renal disease who had just entered into hemodialysis therapy and were diagnosed as having LVH evaluated by echocardiography were selected from three dialysis units staffed by the faculty of Saitama Medical School, Saitama, Japan between 1999 and 2001. The study was carried out for 1 year. All patients were assigned randomly to three groups with equal number: group I, an ACE inhibitor, enalapril 10 mg daily; group II, an AT1 antagonist, losartan 100 mg daily; group III, combination of enalapril 10 mg and losartan 100 mg daily. All antihypertensive drugs were given 30 min after the cessation of dialysis therapy. LVH was evaluated by echocardiography before the start of administration of drugs, at 6 months and 12 months after the start of drug therapy. Systolic blood pressure levels less than 140 mmHg were the target for the three groups. Using repeated measures analysis of variance, applied to those with four echocardiograms, there were progressive decreases over time in left ventricular mass index, posterior wall thickness and interventricular septum thickness. There were no significant differences in regression of LVH as well as blood pressure control between enalapril and losartan groups; however, dual blockade induced an additional 28% reduction in left ventricular mass index compared with any type of monotherapy. Both ACE inhibitors and AT1 antagonists benefit the regression of LVH in diabetic patients who start dialysis therapy. Moreover, combination therapy with ACE inhibitors and AT1 antagonists would provide more beneficial effects on LVH in these patients than monotherapy.

Le bon usage des médicaments chez la personne âgée

PURPOSE

The frequency of chronic illness and the expenditure of medications increase with the older age. If drug-prescribing is very often beneficial for the patients, elderly subjects are particularly exposed to the side-effects of medications, and to their consequences. Although the age in itself do not generally forbid a medication, it can modify some of the objectives and the modality of the treatment.

CURRENT KNOWLEDGE AND KEY POINTS

Four main factors explain the growing frequency of the iatrogenic pathology in the old age: polymedication, pharmacological modifications that occur with the ageing process, lack of coordination between different prescribers, and physical and psycho-social deficiencies which are the keys for identifying the "frail elderlies".

FUTURE PROSPECTS AND PROJECTS

In regard to the frequent polypathological conditions of the oldest patients, one does not have to consider a sum of sicknesses, but a global situation, and one needs to replace a condition in a general context, and to establish priorities in the goals of the treatment. Appropriate drug-prescribing also needs to take account of the latest medical recommendations concerning numbers of medications, and a more frequent involving of elderly subjects in clinical trials.

Selection of the dose of angiotensin converting enzyme inhibitor for patients with diabetic nephropathy depends on the presence or absence of left ventricular hypertrophy

The coexistence of hypertension increases cardiovascular risks and the rate of deterioration of renal function for diabetic patients. For patients with left ventricular hypertrophy (LVH), the use of an angiotensin converting enzyme (ACE) inhibitor is known to be effective and well tolerated and to be protective against chronic renal insufficiency (CRI). However, serious adverse reactions to ACE inhibitors, such as the rapid deterioration of renal function, have been reported, making physicians hesitant to use these agents. To resolve this dilemma, we compared changes in renal function and left ventricular function and the safety and effectiveness of benazepril, an ACE inhibitor, in patients with diabetic nephropathy, with or without LVH. The age, sex, duration of diabetes, levels of blood pressure and blood glucose and rates of creatinine clearance (CrCl) were compared between 36 diabetic patients with LVH and 36 matched diabetic patients without LVH. The rates of CrCl in all patients were between 14 and 35 ml/min, and all patients received an ACE inhibitor before enrollment. The group comprised 43 men and 29 women, with a mean age of 56 +/- 4 years. These patients were divided into three groups, each of which was subdivided into a group with and a group without LVH. Group I (without LVH) or I-L (with LVH) received a half dose of benazepril (2.5 mg daily), Group II (without LVH) or II-L (with LVH) received a normal daily dose of 5 mg benazepril, and Group III (without LVH) or III-L (with LVH) discontinued the administration of the ACE inhibitor. The follow-up period was 1 year and, during the study, blood pressure was maintained at less than 140/90 mmHg. If the blood pressure control was not satisfactory, benidipine, a calcium antagonist, and/or furosemide, a loop diuretic, and/or guanabenz, a central acting antihypertensive agent, were administered. In the diabetic patients with LVH, the administration of a normal dose of benazepril inhibited the decline of renal function and cardiac function (CrCl: 24.2 +/- 1.5 to 22.0 +/- 2.5 ml/min; EF (ejection fraction): 56 +/- 3 to 54 +/- 6%) compared to the other two groups. In patients without LVH, a half dose of benazepril preserved renal function (23.4 +/- 2.6 to 22.0 +/- 3.1 ml/min; EF: 54 +/- 3 to 56 +/- 3%). Discontinuation of the administration of ACE inhibitor led to the further progression of renal dysfunction and decreases in EF in patients with or without LVH. Our results provide some indications for the use of ACE inhibitors in diabetic patients when renal dysfunction and/or cardiac hypertrophy are present.