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Abstract
PURPOSE OF REVIEW This review considers the relationship between abnormal blood pressure (BP) variability and autonomic dysfunction through an attempt to answer questions about its clinical relevance and pertinence to diabetes and cardiovascular autonomic neuropathy (CAN) and which therapeutic measures can lessen its cardiovascular impact. RECENT FINDINGS Office, ambulatory, and home BP monitoring identify posture-related, circadian, short-term, and long-term BP variabilities. Abnormal BP variability is a risk marker for organ damage, mortality, and cardiovascular events. Moreover, BP variability changes are common in diabetes and associated with CAN and possibly exacerbated by comorbidities like nephropathy, obstructive sleep apnoea syndrome, and chronic pain. The prognostic role of nondipping and reverse dipping is well documented in diabetes. Some findings suggest the possibility of restoring dipping with the dosage time of antihypertensive agents. Diabetes is a favorable scenario for altered BP variability, which might mediate the harmful effects of CAN. Preliminary data suggest the protective effect of targeting BP variability. However, further longitudinal outcome studies are needed. In the meantime, BP variability measures and practical expedients in antihypertensive treatment should be implemented in diabetes.
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Affiliation(s)
- Vincenza Spallone
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier, 1, 00133, Rome, Italy.
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Costa A, Bosone D, Ramusino MC, Ghiotto N, Guaschino E, Zoppi A, D'Angelo A, Fogari R. Twenty-four-hour blood pressure profile, orthostatic hypotension, and cardiac dysautonomia in elderly type 2 diabetic hypertensive patients. Clin Auton Res 2016; 26:433-439. [PMID: 27624333 DOI: 10.1007/s10286-016-0381-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 07/24/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE The aim of this study was to evaluate the relationship between orthostatic hypotension (OH), defined as a decrease in systolic blood pressure (SBP) ≥20 mmHg and/or a decrease in diastolic blood pressure (DBP) ≥10 mmHg, and 24-h ambulatory BP profile in elderly hypertensive type 2 diabetic patients. METHODS After a 2-week antihypertensive wash-out period, 200 hypertensive well-controlled diabetic outpatients, aged 65-75 years, underwent a clinical examination, including BP measurements, ECG, 24-h ABP monitoring (ABPM), an orthostatic test, and three tests for cardiovascular autonomic function assessment [deep breathing, heart rate (HR) variability, resting HR]. RESULTS According to their nighttime BP profile, patients were divided into three groups: dippers (n = 86) (BP fall during nighttime ≥10 %), non-dippers (n = 80) (BP fall during nighttime 0-10 %), and reverse dippers (n = 34) (nighttime BP > daytime BP). Orthostatic test produced a significantly greater orthostatic SBP fall in dippers and even more in reverse dippers. In these latter, a significant fall was observed also in DBP. Prevalence of OH was 9.3 % in dippers, 30 % in non-dippers, and 79.4 % in reverse dippers. CONCLUSIONS In elderly hypertensive type 2 diabetics, a blunted nocturnal BP fall is associated with OH and autonomic dysfunction. These data suggest that ABPM should be performed in the assessment of hypertensive diabetic patients in whom the cardiovascular dysautonomia is suspected or the signs of it are present (such as OH).
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Affiliation(s)
- Alfredo Costa
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Daniele Bosone
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Matteo Cotta Ramusino
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Natascia Ghiotto
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Elena Guaschino
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Annalisa Zoppi
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Angela D'Angelo
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Roberto Fogari
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy.
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Hermida RC, Ayala DE, Mojón A, Fernández JR. Sleep-time BP: prognostic marker of type 2 diabetes and therapeutic target for prevention. Diabetologia 2016; 59:244-54. [PMID: 26399403 DOI: 10.1007/s00125-015-3748-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 08/19/2015] [Indexed: 10/23/2022]
Abstract
AIMS/HYPOTHESIS We investigated the prognostic value of clinic and ambulatory BP (ABP) to predict new-onset diabetes and whether risk reduction is related to the progressive decrease of clinic BP or awake or asleep ABP. METHODS We prospectively evaluated 2,656 individuals without diabetes, 1,292 men and 1,364 women, 50.6 ± 14.3 years of age, with baseline BP ranging from normotension to hypertension according to ABP criteria. At baseline and annually (more frequently if hypertension treatment was adjusted based on ABP) thereafter, ABP and physical activity (wrist actigraphy) were simultaneously monitored for 48 h to accurately derive the awake and asleep BP means. RESULTS During a 5.9-year median follow-up, 190 participants developed type 2 diabetes. The asleep systolic ABP mean was the most significant predictor of new-onset diabetes in a Cox proportional-hazard model adjusted for age, waist circumference, glucose, chronic kidney disease (CKD) and hypertension treatment. Daytime clinic BP and awake or 48 h ABP mean had no predictive value when corrected by the asleep ABP mean. Analyses of BP changes during follow-up revealed a 30% reduction in the risk of new-onset diabetes per 1-SD decrease in asleep systolic ABP mean, independent of changes in clinic BP or awake or 48 h ABP means. CONCLUSIONS/INTERPRETATION Sleep-time BP is a highly significant independent prognostic marker for new-onset diabetes. Alteration in sleep-time BP regulation seems to precede, rather than follow, the development of new-onset diabetes. Most important, lowering asleep BP, a novel therapeutic target requiring ABP evaluation, could be a significant method for reducing new-onset diabetes risk.
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Affiliation(s)
- Ramón C Hermida
- Bioengineering and Chronobiology Laboratories, E.I. Telecomunicación, University of Vigo, Campus Universitario, Vigo, Pontevedra, 36310, Spain.
| | - Diana E Ayala
- Bioengineering and Chronobiology Laboratories, E.I. Telecomunicación, University of Vigo, Campus Universitario, Vigo, Pontevedra, 36310, Spain
| | - Artemio Mojón
- Bioengineering and Chronobiology Laboratories, E.I. Telecomunicación, University of Vigo, Campus Universitario, Vigo, Pontevedra, 36310, Spain
| | - José R Fernández
- Bioengineering and Chronobiology Laboratories, E.I. Telecomunicación, University of Vigo, Campus Universitario, Vigo, Pontevedra, 36310, Spain
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Lyhne JM, Laugesen E, Høyem P, Cichosz S, Christiansen JS, Knudsen ST, Hansen KW, Hansen TK, Poulsen PL. Morning blood pressure surge and target organ damage in newly diagnosed type 2 diabetic patients: a cross sectional study. BMC Endocr Disord 2015; 15:77. [PMID: 26630970 PMCID: PMC4668664 DOI: 10.1186/s12902-015-0068-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 11/13/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Type 2 diabetic patients display significantly higher incidence of cardiovascular (CV) events including stroke compared to non-diabetics. Morning blood pressure surge (MBPS) and blunted systolic night-day (SND) ratio have been associated with CV events in hypertensive patients. No studies have evaluated MBPS in newly diagnosed diabetic patients or studied the association with vascular target organ damage at this early time point of the diabetes disease. METHODS Ambulatory blood pressure monitoring was performed in 100 patients with newly diagnosed type 2 diabetes and 100 age and sex matched controls. MBPS and SND-ratio were calculated. Markers of early vascular target organ damage included pulse wave velocity (PWV), white matter lesions (WML) on brain MRI, and urine albumin/creatinine ratio (UAE). RESULTS No significant differences in MBPS were found between diabetic patients and controls. Neither MBPS or SND-ratio were associated with PWV, UAE or WML in the diabetic group independently of age, gender and 24-h systolic blood pressure. 40.2 % of diabetic patients and 25.8 % of controls were classified as non-dippers (p = 0.03). CONCLUSION MBPS and SND-ratio are not associated with subclinical markers of vascular target organ damage in our study sample of newly diagnosed type 2 diabetic patients.
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Affiliation(s)
- Johanne M Lyhne
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Nørrebrogade 44, DK-8000, Aarhus C, Denmark.
| | - Esben Laugesen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Nørrebrogade 44, DK-8000, Aarhus C, Denmark.
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
- The Danish Diabetes Academy, Odense University Hospital, Odense, Denmark.
| | - Pernille Høyem
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Nørrebrogade 44, DK-8000, Aarhus C, Denmark.
| | - Simon Cichosz
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Nørrebrogade 44, DK-8000, Aarhus C, Denmark.
| | - Jens S Christiansen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Nørrebrogade 44, DK-8000, Aarhus C, Denmark.
| | - Søren T Knudsen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Nørrebrogade 44, DK-8000, Aarhus C, Denmark.
| | - Klavs W Hansen
- Medical department, Diagnostic Center, Regional Hospital Silkeborg, Silkeborg, Denmark.
| | - Troels K Hansen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Nørrebrogade 44, DK-8000, Aarhus C, Denmark.
| | - Per L Poulsen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Nørrebrogade 44, DK-8000, Aarhus C, Denmark.
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Hermida RC, Moyá A, Ayala DE. Ambulatory blood pressure monitoring in diabetes for the assessment and control of vascular risk. ACTA ACUST UNITED AC 2015; 62:400-10. [PMID: 26404624 DOI: 10.1016/j.endonu.2015.03.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 03/26/2015] [Accepted: 03/27/2015] [Indexed: 10/23/2022]
Abstract
The diagnosis of hypertension and the clinical decisions regarding its treatment are usually based on daytime clinic blood pressure (BP) measurements. However, the correlation between BP levels and target organ damage, cardiovascular (CV) risk, and long-term prognosis, is higher for ambulatory (ABPM) than clinic measurements, both in the general population as well as in patients with diabetes. Moreover, there is consistent evidence in numerous studies that the asleep BP better predicts CV events than either the awake or 24h means. The prevalence of abnormal BP pattern and sleep-time hypertension is extensive in diabetes, often leading to inaccurate diagnoses of hypertension and its therapeutic control in the absence of complete and careful assessment of the entire 24h, i.e., daytime and night-time, BP pattern. Accordingly, ABPM should be the preferred method to comprehensively assess and decide the optimal clinical management of patients with diabetes directed to properly reduce elevated sleep-time BP, which might also lead to a significant reduction of CV events.
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Affiliation(s)
- Ramón C Hermida
- Laboratorio de Bioingeniería y Cronobiología, Atlantic Research Center for Information and Communication Technologies (AtlantTIC), Universidad de Vigo, Vigo, España.
| | - Ana Moyá
- Laboratorio de Bioingeniería y Cronobiología, Atlantic Research Center for Information and Communication Technologies (AtlantTIC), Universidad de Vigo, Vigo, España; Centro de Salud de Lérez, Gerencia Única Integrada Pontevedra-Salnés, Servicio Galego de Saúde (SERGAS), Pontevedra, España
| | - Diana E Ayala
- Laboratorio de Bioingeniería y Cronobiología, Atlantic Research Center for Information and Communication Technologies (AtlantTIC), Universidad de Vigo, Vigo, España
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Latea L, Negrea S, Bolboaca S. Primary non-alcoholic fatty liver disease in hypertensive patients. Australas Med J 2013; 6:325-30. [PMID: 23837080 DOI: 10.4066/amj.2013.1648] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is considered the most common liver disease affecting 15-25% of the general population. AIMS The aim of this study was to investigate the prevalence of NAFLD and the relationship between insulin sensitivity and NAFLD in grade III high and very high cardiovascular additional risk essential hypertensive patients according to the circadian blood pressure (BP) rhythm. METHOD This four-year prospective study was conducted at the Department of Internal Medicine at Cluj-Napoca's Diagnosis and Treatment Centre in Romania. The study included grade III essential hypertensive patients. Hypertensive patients were divided into four groups according to the diurnal index (DI) from ABPM monitoring: dipper (D), non-dipper (ND), reverse-dipper (RD), and extreme-dipper (ED). All hypertensive patients underwent 24 ABPM, blood tests and abdominal ultrasonography for the diagnosis of fatty liver disease. RESULTS Thirty-five hypertensive patients were included in the study, with 31.42% ND, 11.43% RD, 8.57% ED and 48.57% D. The prevalence of NAFLD was significantly higher in ND, RD and ED when compared to D. When compared to the dipper group of hypertensive patients a statistically significantly higher level of plasma insulin was observed: in non-dipper [86.3±17.9pmol/l vs. 62.2±203pmol/l, p<0.05], in reverse dipper [88.3±18.6pmol/l vs. 62.2±20.3pmol/l] and in extreme-dippers [86.7±16.88pmol/l vs. 62.2±20.3 pmol/l, p<0.05]. CONCLUSION The altered dipping status (ND, RD, ED) of hypertension associated with a higher insulin resistance could be the pathogenetic link between the NAFLD and altered blood pressure status. Altered BP status could be a marker of NAFLD in hypertensive patients.
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Affiliation(s)
- Luminita Latea
- "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Hermida RC, Smolensky MH, Ayala DE, Portaluppi F, Crespo JJ, Fabbian F, Haus E, Manfredini R, Mojón A, Moyá A, Piñeiro L, Ríos MT, Otero A, Balan H, Fernández JR. 2013 Ambulatory Blood Pressure Monitoring Recommendations for the Diagnosis of Adult Hypertension, Assessment of Cardiovascular and other Hypertension-associated Risk, and Attainment of Therapeutic Goals. Chronobiol Int 2013; 30:355-410. [DOI: 10.3109/07420528.2013.750490] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Prevalence of abnormal urinary albumin excretion in elderly people: a Spanish survey. Int Urol Nephrol 2013; 45:553-60. [DOI: 10.1007/s11255-013-0380-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Accepted: 01/09/2013] [Indexed: 11/26/2022]
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Hermida RC, Ayala DE, Mojón A, Fernández JR. Ambulatory Blood Pressure Thresholds for Diagnosis of Hypertension in Patients With and Without Type 2 Diabetes Based on Cardiovascular Outcomes. Chronobiol Int 2012. [DOI: 10.3109/07420528.2012.702584] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Ayala DE, Moyá A, Crespo JJ, Castiñeira C, Domínguez-Sardiña M, Gomara S, Sineiro E, Mojón A, Fontao MJ, Hermida RC. Circadian pattern of ambulatory blood pressure in hypertensive patients with and without type 2 diabetes. Chronobiol Int 2012; 30:99-115. [PMID: 23098178 DOI: 10.3109/07420528.2012.701489] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
There is strong association between diabetes and increased risk of end-organ damage, stroke, and cardiovascular disease (CVD) morbidity and mortality. Non-dipping (<10% decline in the asleep relative to awake blood pressure [BP] mean), as determined by ambulatory BP monitoring (ABPM), is frequent in diabetes and consistently associated with increased CVD risk. The reported prevalence of non-dipping in diabetes is highly variable, probably due to differences in the study groups (normotensive subjects, untreated hypertensives, treated hypertensives), relatively small sample sizes, reliance only on a single, low-reproducibility, 24-h ABPM evaluation per participant, and definition of daytime and nighttime periods by arbitrary selected fixed clock-hour spans. Accordingly, we evaluated the influence of diabetes on the circadian BP pattern by 48-h ABPM (rather than for 24 h to increase reproducibility of results) during which participants maintained a diary listing times of going to bed at night and awakening in the morning. This cross-sectional study involved 12 765 hypertensive patients (6797 men/5968 women), 58.1 ± 14.1 (mean ± SD) yrs of age, enrolled in the Hygia Project, designed to evaluate prospectively CVD risk by ABPM in primary care centers of northwest Spain. Among the participants, 2954 (1799 men/1155 women) had type 2 diabetes. At the time of study, 525/3314 patients with/without diabetes were untreated for hypertension, and the remaining 2429/6497 patients with/without diabetes were treated. Hypertension was defined as awake systolic (SBP)/diastolic (DBP) BP mean ≥135/85 mm Hg, or asleep SBP/DBP mean ≥120/70 mm Hg, or BP-lowering treatment. Hypertensive patients with than without diabetes were more likely to be men and of older age, have diagnoses of microalbuminuria, proteinuria, chronic kidney disease, obstructive sleep apnea, metabolic syndrome, and/or obesity, plus higher glucose, creatinine, uric acid, and triglycerides, but lower cholesterol and estimated glomerular filtration rate. In patients with diabetes, ambulatory SBP was significantly elevated (p < .001), mainly during the hours of nighttime sleep and initial hours after morning awakening, independent of presence/absence of BP-lowering treatment. Ambulatory DBP, however, was significantly higher (p < .001) in patients without diabetes, mainly during the daytime. Differing trends for SBP and DBP between groups resulted in large differences in ambulatory pulse pressure (PP), it being significantly greater (p < .001) throughout the entire 24 h in patients with diabetes, even after correcting for age. Prevalence of non-dipping was significantly higher in patients with than without diabetes (62.1% vs. 45.9%; p < .001). Largest difference between groups was in the prevalence of the riser BP pattern, i.e., asleep SBP mean greater than awake SBP mean (19.9% vs. 8.1% in patients with and without diabetes, respectively; p < .001). Elevated asleep SBP mean was the major basis for the diagnosis of hypertension and/or inadequate BP control among patients with diabetes; thus, among the uncontrolled hypertensive patients with diabetes, 89.2% had nocturnal hypertension. Our findings document significantly elevated prevalence of a blunted nocturnal BP decline in hypertensive patients with diabetes. Most important, prevalence of the riser BP pattern, associated with highest CVD risk among all possible BP patterns, was more than twice as prevalent in diabetes. Patients with diabetes also presented significantly elevated ambulatory PP, reflecting increased arterial stiffness and enhanced CVD risk. These collective findings indicate that diabetes should be included among the clinical conditions for which ABPM is recommended for proper CVD risk assessment.
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Affiliation(s)
- Diana E Ayala
- Bioengineering and Chronobiology Laboratories, University of Vigo, Campus Universitario, Vigo, Pontevedra, Spain
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Moyá A, Crespo JJ, Ayala DE, Ríos MT, Pousa L, Callejas PA, Salgado JL, Mojón A, Fernández JR, Hermida RC. Effects of Time-of-Day of Hypertension Treatment on Ambulatory Blood Pressure and Clinical Characteristics of Patients With Type 2 Diabetes. Chronobiol Int 2012. [DOI: 10.3109/07420528.2012.702587] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Ercan EA, Ertek S, Is G, Caglar O, Oztas E, Cicero AF, Alhan A, Cehreli S, Tore HF, Erdogan G. Factors Associated With Increased Carotid Intima-Media Thickness and Being Nondipper in Nonobese and Normotensive Young Patients Affected by PCOS. Angiology 2011; 62:543-8. [DOI: 10.1177/0003319711400183] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Polycystic ovary syndrome (PCOS) is characterized by chronic unovulation, hyperandrogenism, and insulin resistance. We evaluated factors that affect “nondipper” status during 24-hour ambulatory blood pressure monitoring (ABPM) and carotid intima-media thickness (cIMT) in PCOS. Forty-two nonobese women newly diagnosed as PCOS and 32 healthy women were included. After biochemical and hormonal measurements, the ovaries were imaged by pelvic ultrasonography and cIMT was measured by B-mode ultrasonography. A 24-hour ABPM was performed thereafter. Carotid IMT and the ratio of nondippers were elevated compared with controls. Homeostasis model assessment insulin resistance index (HOMA-IR) and low-density lipoprotein cholesterol (LDL-C) were found to be related with being a nondipper in PCOS. None of the parameters evaluated were found to correlate with cIMT. In conclusion, patients with PCOS had increased nondipping ratios and cIMT when compared with controls. Insulin resistance and LDL cholesterol are factors that are related to diurnal variation in normotensive and young patients with PCOS.
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Affiliation(s)
- Ebru Akgul Ercan
- Department of Cardiology, Medical Faculty, Ufuk University, Ankara, Turkey
| | - Sibel Ertek
- Department of Endocrinology and Metabolic Diseases, Medical Faculty, Ufuk University, Ankara, Turkey
| | - Gurkan Is
- Department of Cardiology, Medical Faculty, Ufuk University, Ankara, Turkey
| | - Oya Caglar
- Department of Radiology, Medical Faculty, Ufuk University, Ankara, Turkey
| | - Efser Oztas
- Obstetrics and Gynecology Department, Medical Faculty, Ufuk University, Ankara, Turkey
| | - Arrigo Francesco Cicero
- Department of Internal Medicine, Aging and Kidney Diseases, Bologna University, Bologna, Italy
| | - Aslihan Alhan
- Faculty of Science and Literature, Department of Statistics, Ufuk University, Ankara, Turkey
| | - Sengul Cehreli
- Department of Cardiology, Medical Faculty, Ufuk University, Ankara, Turkey
| | - Hasan Fehmi Tore
- Department of Cardiology, Medical Faculty, Ufuk University, Ankara, Turkey
| | - Gurbuz Erdogan
- Department of Endocrinology and Metabolic Diseases, Medical Faculty, Ufuk University, Ankara, Turkey
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Ritz E, Viberti GC, Ruilope LM, Rabelink AJ, Izzo JL, Katayama S, Ito S, Mimran A, Menne J, Rump LC, Januszewicz A, Haller H. Determinants of urinary albumin excretion within the normal range in patients with type 2 diabetes: the Randomised Olmesartan and Diabetes Microalbuminuria Prevention (ROADMAP) study. Diabetologia 2010; 53:49-57. [PMID: 19876613 PMCID: PMC2789932 DOI: 10.1007/s00125-009-1577-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 08/10/2009] [Indexed: 12/22/2022]
Abstract
AIMS/HYPOTHESIS In contrast to microalbuminuric type 2 diabetic patients, the factors correlated with urinary albumin excretion are less well known in normoalbuminuric patients. This may be important because even within the normoalbuminuric range, higher rates of albuminuria are known to be associated with higher renal and cardiovascular risk. METHODS At the time of screening for the Randomised Olmesartan and Diabetes Microalbuminuria Prevention (ROADMAP) Study, the urinary albumin/creatinine ratio (UACR) was 0.44 mg/mmol in 4,449 type 2 diabetic patients. The independent correlates of UACR were analysed. RESULTS Independent correlates of UACR during baseline were (in descending order): night-time systolic BP (r(s) = 0.19); HbA(1c) (r(s) = 0.18); mean 24 h systolic BP (r(s) = 0.16); fasting blood glucose (r(s) = 0.16); night-time diastolic BP (r(s) = 0.12); office systolic BP, sitting (r(s) = 0.11), standing (r(s) = 0.10); estimated GFR (r(s) = 0.10); heart rate, sitting (r(s) = 0.10); haemoglobin (r(s) = -0.10); triacylglycerol (r(s) = 0.09); and uric acid (r(s) = -0.08; all p <or= 0.001). Significantly higher albumin excretion rates were found for the following categorical variables: higher waist circumference (more marked in men); presence of the metabolic syndrome; smoking (difference more marked in males); female sex; antihypertensive treatment; use of amlodipine; insulin treatment; family history of diabetes; and family history of cardiovascular disease (more marked in women). CONCLUSIONS/INTERPRETATION Although observational correlations do not prove causality, in normoalbuminuric type 2 diabetic patients the albumin excretion rate is correlated with many factors that are potentially susceptible to intervention. TRIAL REGISTRATION ClinicalTrials.gov ID no.: NCT00185159 FUNDING This study was sponsored by Daichii-Sankyo.
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Affiliation(s)
- E. Ritz
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | | | - L. M. Ruilope
- Division of Hypertension, Hospital 12 de Octubre, Madrid, Spain
| | - A. J. Rabelink
- Department of Nephrology and Hypertension, Leiden University Medical Center, Leiden, the Netherlands
| | - J. L. Izzo
- Department of Medicine, Erie County Medical Center, Buffalo, NY USA
| | - S. Katayama
- The Fourth Department of Medicine, Saitama Medical School, Saitama, Iruma, Japan
| | - S. Ito
- Department of Clinical Medicine, Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - A. Mimran
- Hospital Lapeyronie, Montpellier, France
| | - J. Menne
- Department of Nephrology and Hypertension, Hanover Medical School, Carl-Neuberg Str. 1, 30625 Hannover, Germany
| | - L. C. Rump
- Medical Clinic, Marienhospital Herne, University Clinic Ruhr-University-Bochum, Herne, Germany
| | - A. Januszewicz
- Department of Hypertension, Institute of Cardiology, Warsaw, Poland
| | - H. Haller
- Department of Nephrology and Hypertension, Hanover Medical School, Carl-Neuberg Str. 1, 30625 Hannover, Germany
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Association between nocturnal blood pressure dipping and insulin metabolism in obese adolescents. Int J Obes (Lond) 2009; 34:472-7. [PMID: 19752880 DOI: 10.1038/ijo.2009.181] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Afsar B, Yilmaz M, Eyileten T. Do patients with uric acid stones exhibit abnormal circadian blood pressure--a hypothesis. Nephrol Dial Transplant 2009; 24:2004; author reply 2004-5. [PMID: 19286692 DOI: 10.1093/ndt/gfp082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Kanbay M, Turgut F, Uyar ME, Akcay A, Covic A. Causes and mechanisms of nondipping hypertension. Clin Exp Hypertens 2009; 30:585-97. [PMID: 18855262 DOI: 10.1080/10641960802251974] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Growing evidence indicates that nondippers have worsened cardiovascular outcomes than dippers. Ambulatory blood pressure monitoring with a lack of nocturnal BP fall (nondipping) have also been shown to be more closely associated with target organ damage and worsened cardiovascular outcome than in patients with essential hypertension with dipping pattern. The underlying pathogenetic mechanisms potentially linking nondipping with cardiovascular disease are not fully understood. There are multiple possible underlying pathophysiologic mechanisms in the impaired BP decline during the night. Extrinsic and intrinsic factors including abnormal neurohormonal regulation, lack of physical activity, nutritional factors such as increased dietary sodium intake, and smoking of tobacco have been implicated for blunted circadian rhythm of BP. Certain diseases such as diabetes and chronic renal diseases also affect the circadian BP rhythm. Currently, the clinical importance of nondipping is known well; however, the relationship between certain disease states and nondipping has not been fully explained yet. This paper will attempt to address to clarify the underlying basis for nondipping and the specific associations with various disease states.
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Affiliation(s)
- Mehmet Kanbay
- Department of Internal Medicine, Section of Nephrology, Fatih University School of Medicine, Ankara, Turkey.
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Bash LD, Selvin E, Steffes M, Coresh J, Astor BC. Poor glycemic control in diabetes and the risk of incident chronic kidney disease even in the absence of albuminuria and retinopathy: Atherosclerosis Risk in Communities (ARIC) Study. ACTA ACUST UNITED AC 2009; 168:2440-7. [PMID: 19064828 DOI: 10.1001/archinte.168.22.2440] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Diabetic nephropathy is the leading cause of kidney failure in the United States. The extent to which an elevated glycated hemoglobin (HbA(1c)) concentration is associated with increased risk of chronic kidney disease (CKD) in the absence of albuminuria and retinopathy, the hallmarks of diabetic nephropathy, is uncertain. METHODS Glycated hemoglobin concentration was measured in 1871 adults with diabetes mellitus followed up for 11 years in the Atherosclerosis Risk in Communities (ARIC) Study. Incident CKD was defined as an estimated glomerular filtration rate less than 60 mL/min/1.73 m(2) after 6 years of follow-up or a kidney disease-related hospitalization. We categorized HbA(1c) concentrations into 4 clinically relevant categories. Albuminuria and retinopathy were measured midway through follow-up. RESULTS Higher HbA(1c) concentrations were strongly associated with risk of CKD in models adjusted for demographic data, baseline glomerular filtration rate, and cardiovascular risk factors. Compared with HbA(1c) concentrations less than 6%, HbA(1c) concentrations of 6% to 7%, 7% to 8%, and greater than 8% were associated with adjusted relative hazard ratios (95% confidence intervals) of 1.4 (0.97-1.91), 2.5 (1.70-3.66), and 3.7 (2.76-4.90), respectively. Risk of CKD was higher in individuals with albuminuria and retinopathy, and the association between HbA(1c) concentration and incident CKD was observed even in participants without either abnormality: adjusted relative hazards, 1.46 (95% confidence intervals, 0.80-2.65), 1.17 (0.43-3.19), and 3.51 (1.67-7.40), respectively; P(trend) = .004. CONCLUSIONS We observed a positive association between HbA(1c) concentration and incident CKD that was strong, graded, independent of traditional risk factors, and present even in the absence of albuminuria and retinopathy. Hyperglycemia is an important indicator of risk of both diabetic nephropathy with albuminuria or retinopathy and of less specific forms of CKD.
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Affiliation(s)
- Lori D Bash
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Esteghamati A, Khalilzadeh O, Abbasi M, Nakhjavani M, Novin L, Esteghamati AR. HOMA-estimated insulin resistance is associated with hypertension in Iranian diabetic and non-diabetic subjects. Clin Exp Hypertens 2008; 30:297-307. [PMID: 18633753 DOI: 10.1080/10641960802269919] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The relationship between insulin resistance (IR) and essential hypertension (HTN) is controversial. The aim of this study was to determine the association of IR estimated by homeostasis model assessment of insulin resistance (HOMA-IR) and HTN in a large sample of Iranian diabetic and non-diabetic population. A total of 2047 diabetic and non-diabetic individuals with or without HTN, aged 30-75 yrs, who were referred to a university general hospital between November 2004 and April 2007 were included in this study. Demographic data and anthropometric characteristics of participants were recorded. Fasting blood samples were collected, and fasting plasma glucose (FPG), serum creatinine, lipids, insulin, C-peptide and HbA1c were measured. HOMA-IR and HOMA derived Beta-cell function (HOMA-B) were also calculated. Age, sex and waist girth adjusted HOMA-IR values were compared between hypertensive and normotensive subjects. Hypertensive patients had significantly higher HOMA-IR than age-, sex-, and waist girth-adjusted normotensive individuals in both non-diabetic (2.163 +/- 0.08 and 1.75 +/- 0.03, p < 0.001) and diabetic (3.40 +/- 0.10 and 3.07 +/- 0.09, p < 0.05) groups. Multivariate logistic regression analysis showed that after adjustment for age, sex, waist girth, BMI, triglyceride, total cholesterol, FPG, and C-peptide, HOMA-IR was a significant independent predictor of HTN in all subjects (odds ratio = 1.117, CI 95% = 1.026-1.216, p < 0.05) and in diabetic and non-diabetic subjects separately (odds ratio = 1.102, CI 95% = 1.009-1.203, p < 0.05 and odds ratio = 1.328, CI 95% = 1.116-1.580, p < 0.01, respectively). In conclusion, this study showed that IR is associated with HTN in Iranian diabetic and non-diabetic subjects.
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Affiliation(s)
- Alireza Esteghamati
- Endocrinology and Metabolism Research Center, Vali-Asr Hospital, Medical Sciences/University of Tehran, Tehran, Iran.
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Reply. Blood Press Monit 2008. [DOI: 10.1097/mbp.0b013e3282f13ede] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Impaired circadian rhythm of cardiac autonomic activity as possible link between insulin resistance and nocturnal nondipping. Blood Press Monit 2008; 13:63; author reply 63-4. [DOI: 10.1097/mbp.0b013e3282f13ece] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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