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Akin S, Aydin Z, Cakir O, Kazan S. Correlation between pulse pressure and urinary albumin excretion in type 2 diabetic patients without microalbuminuria. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2019. [DOI: 10.23736/s0393-3660.18.03973-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Shibata M, Sato KK, Uehara S, Koh H, Kinuhata S, Oue K, Kambe H, Morimoto M, Hayashi T. Blood pressure components and the risk for proteinuria in Japanese men: The Kansai Healthcare Study. J Epidemiol 2017; 27:505-510. [PMID: 28709559 PMCID: PMC5608588 DOI: 10.1016/j.je.2016.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/07/2016] [Indexed: 01/08/2023] Open
Abstract
Background We examined prospectively which of the four blood pressure (BP) components (systolic BP [SBP], diastolic BP [DBP], pulse pressure [PP], and mean arterial pressure [MAP]) was best in predicting the risk of proteinuria. Methods This prospective study included 9341 non-diabetic Japanese middle-aged men who had no proteinuria and an estimated glomerular filtration rate ≥60 mL/min/1.73 m2 and were not taking antihypertensive medications at entry. Persistent proteinuria was defined if proteinuria was detected two or more times consecutively and persistently at the annual examination until the end of follow-up. We calculated the difference in values of Akaike's information criterion (ΔAIC) in comparison of the BP components-added model to the model without them in a Cox proportional hazards model. Results During the 84,587 person-years follow-up period, we confirmed 151 cases of persistent proteinuria. In multiple-adjusted models that included a single BP component, the hazard ratios for persistent proteinuria for the highest quartile of SBP, PP, and MAP were 3.11 (95% confidence interval [CI], 1.79–5.39), 1.87 (95% CI, 1.18–2.94), and 2.21 (95% CI, 1.33–3.69) compared with the lowest quartile of SBP, PP, and MAP, respectively. The hazard ratio for the highest quartile of DBP was 2.69 (95% CI, 1.65–4.38) compared with the second quartile of DBP. Of all models that included a single BP component, those that included SBP alone or DBP alone had the highest values of ΔAIC (14.0 and 13.1, respectively) in predicting the risk of persistent proteinuria. Conclusions Of all BP components, SBP and DBP were best in predicting the risk of persistent proteinuria in middle-aged Japanese men. We examined which blood pressure (BP) components increased risk of proteinuria. We used systolic BP, diastolic BP, pulse pressure, and mean arterial pressure. Systolic and diastolic BP were the best predictors of persistent proteinuria.
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Affiliation(s)
- Mikiko Shibata
- Preventive Medicine and Environmental Health, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kyoko Kogawa Sato
- Preventive Medicine and Environmental Health, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shinichiro Uehara
- Preventive Medicine and Environmental Health, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hideo Koh
- Hematology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shigeki Kinuhata
- Medical Education and General Practice, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Keiko Oue
- Kansai Health Administration Center, Nippon Telegraph and Telephone West Corporation, Osaka, Japan
| | - Hiroshi Kambe
- Kansai Health Administration Center, Nippon Telegraph and Telephone West Corporation, Osaka, Japan
| | - Michio Morimoto
- Kansai Health Administration Center, Nippon Telegraph and Telephone West Corporation, Osaka, Japan
| | - Tomoshige Hayashi
- Preventive Medicine and Environmental Health, Osaka City University Graduate School of Medicine, Osaka, Japan.
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Minutolo R, Borrelli S, De Nicola L. CKD in the Elderly: Kidney Senescence or Blood Pressure–Related Nephropathy? Am J Kidney Dis 2015. [DOI: 10.1053/j.ajkd.2015.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Protogerou A, van Sloten T, Henry R, Dekker J, Nijpels G, Stehouwer C. Pulse pressure measured at the level of the femoral artery, but not at the level of the aorta, carotid and brachial arteries, is associated with the incidence of coronary heart disease events in a population with a high prevalence of type 2 diabetes and impaired glucose metabolism – The Hoorn study. Artery Res 2015. [DOI: 10.1016/j.artres.2014.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Prenner SB, Chirinos JA. Arterial stiffness in diabetes mellitus. Atherosclerosis 2014; 238:370-9. [PMID: 25558032 DOI: 10.1016/j.atherosclerosis.2014.12.023] [Citation(s) in RCA: 210] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 11/17/2014] [Accepted: 12/12/2014] [Indexed: 12/22/2022]
Abstract
Arterial stiffness is an age-related process that is a shared consequence of numerous diseases including diabetes mellitus (DM), and is an independent predictor of mortality both in this population and in the general population. While much has been published about arterial stiffness in patients with DM, a thorough review of the current literature is lacking. Using a systematic literature search strategy, we aimed to summarize our current understanding related to arterial stiffness in DM. We review key studies demonstrating that, among patients with established DM, arterial stiffness is closely related to the progression of complications of DM, including nephropathy, retinopathy, and neuropathy. It is also becoming clear that arterial stiffness can be increased even in pre-diabetic populations with impaired glucose tolerance, and in those with the metabolic syndrome (METS), well before the onset of overt DM. Some data suggests that arterial stiffness can predict the onset of DM. However, future work is needed to further clarify whether large artery stiffness and the pulsatile hemodynamic changes that accompany it are involved in the pathogenesis of DM, and whether interventions targeting arterial stiffness are associated with improved clinical outcomes in DM. We also review of the potential mechanisms of arterial stiffness in DM, with particular emphasis on the role of advanced glycation endproducts (AGEs) and nitric oxide dysregulation, and address potential future directions for research.
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Affiliation(s)
- Stuart B Prenner
- University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 Penn Tower, Philadelphia, PA 19104, USA
| | - Julio A Chirinos
- University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 6 Penn Tower, Philadelphia, PA 19104, USA; Philadelphia VA Medical Center, Division of Cardiology - Suite 8B111, University & Woodland Avenues, Philadelphia, PA 19104, USA.
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Ruilope LM. Arterial Function and Cardiorenal Damage. J Clin Hypertens (Greenwich) 2014; 16:398. [DOI: 10.1111/jch.12318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Luis M. Ruilope
- Instituto de Investigación & Unidad de Hipertension; Hospital 12 de Octubre; Madrid Spain
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Abstract
Chronic kidney disease (CKD) and its associated morbidity pose a worldwide health problem. As well as risk of endstage renal disease requiring renal replacement therapy, cardiovascular disease is the leading cause of premature death among the CKD population. Proteinuria is a marker of renal injury that can often be detected earlier than any tangible decline in glomerular filtration rate. As well as being a risk marker for decline in renal function, proteinuria is now widely accepted as an independent risk factor for cardiovascular morbidity and mortality. This review will address the prognostic implications of proteinuria in the general population as well as other specific disease states including diabetes, hypertension and heart failure. A variety of pathophysiological mechanisms that may underlie the relationship between renal and cardiovascular disease have been proposed, including insulin resistance, inflammation, and endothelial dysfunction. As proteinuria has evolved into a therapeutic target for cardiovascular risk reduction in the clinical setting we will also review therapeutic strategies that should be considered for patients with persistent proteinuria.
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Affiliation(s)
- Gemma Currie
- University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Christian Delles
- University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, UK
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High-normal diastolic blood pressure is a risk for development of microalbuminuria in the general population: the Watari study. J Hypertens 2013; 31:798-804. [PMID: 23340164 DOI: 10.1097/hjh.0b013e32835e2146] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Although hypertension is a well known risk factor for microalbuminuria, it is unclear whether blood pressure less than 140/90 mmHg could be a risk for microalbuminuria. We assessed the relationship between baseline blood pressure and the future onset of microalbuminuria in the general population. METHODS We studied 2603 town inhabitants of Watari, located in the southeastern part of Miyagi prefecture, Japan. Demographic data, medical history, sitting blood pressure, fasting blood chemistry, and urinary albumin-creatinine ratio were measured at baseline and were followed annually during the next 3 years. RESULTS Among 2338 individuals who were normoalbuminuric at baseline (albumin-creatinine ratio <30 mg/g Cr), 161 developed microalbuminuria (albumin-creatinine ratio 30-299 mg/g Cr) during a mean follow-up period of 2.4 years. Incident microalbuminuria patients were older (63.7 ± 8.6 vs. 61.4 ± 10.5 years; P < 0.01), included fewer men (31.1 vs. 40.1%; P < 0.05), had a greater BMI (23.8 ± 3.6 vs. 23.1 ± 3.1 kg/m²; P < 0.01), higher blood pressures (133.5 ± 18.1/75.8 ± 11.9 vs. 127.6 ± 18.1/73.4 ± 11.0 mmHg; P < 0.01 for both systolic and diastolic), higher triglycerides (median 1.18 vs. 1.02 mmol/l; P < 0.01), higher fasting blood glucose (median 5.05 vs. 4.94 mmol/l; P < 0.01), higher urinary albumin excretion (median 13.0 vs. 5.9 mg/g Cr; P < 0.001), and lower serum creatinine concentrations (59.2 ± 12.8 vs. 61.4 ± 13.2 μmol/l; P < 0.05) compared to persistent normoalbuminuric individuals. Multivariate Cox proportional hazards analysis including all covariates revealed that only baseline urinary albumin excretion was an independent predictor for future microalbuminuria, whereas high-normal DBP, triglyceride, and fasting blood glucose concentrations were all significant predictors in the model excluding urinary albumin excretion. CONCLUSIONS High-normal DBP associated with metabolic disorders could initiate glomerular damage, leading to future microalbuminuria.
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Behrens A, Lenfeldt N, Qvarlander S, Koskinen LO, Malm J, Eklund A. Are intracranial pressure wave amplitudes measurable through lumbar puncture? Acta Neurol Scand 2013; 127:233-41. [PMID: 22784234 DOI: 10.1111/j.1600-0404.2012.01701.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The aim of this study was to investigate whether pulsations measured in the brain correspond to those measured in lumbar space, and subsequently whether lumbar punctures could replace invasive recordings. METHODS In ten patients with normal pressure hydrocephalus, simultaneous recordings of the intracranial pressure (ICP; intraparenchymal) and lumbar pressure (LP; cerebrospinal fluid pressure) were performed. During registration, pressure was altered between resting pressure and 45 mmHg using an infusion test. Data were analyzed regarding pulsations (i.e., amplitudes). Also, the pressure sensors were compared in a bench test. RESULTS The correlation between intracranial and lumbar amplitudes was 0.98. At resting pressure, and moderately elevated ICP, intracranial pulse amplitudes exceeded that of lumbar space with about 0.9 mmHg. At the highest ICP, the difference changed to -0.2 mmHg. The bench test showed that the agreement of sensor readings was good at resting pressure, but reduced at higher amplitudes. CONCLUSIONS Compared to intracranial registrations, amplitudes measured through lumbar puncture were slightly attenuated. The bench test showed that differences were not attributable to dissimilarities of the sensor systems. A lumbar pressure amplitude measurement is an alternative to ICP recording, but the thresholds for what should be interpreted as elevated amplitudes need to be adjusted.
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Affiliation(s)
| | | | - S. Qvarlander
- Department of Radiation Sciences - Biomedical Enigneering; Umeå University; Umeå; Sweden
| | - L.-O. Koskinen
- Department of Clinical Neuroscience; Umeå University; Umeå; Sweden
| | - J. Malm
- Department of Clinical Neuroscience; Umeå University; Umeå; Sweden
| | - A. Eklund
- Centre for Biomedical Engineering and Physics; Umeå University; Umeå; Sweden
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Kim JK, Ju YS, Moon SJ, Song YR, Kim HJ, Kim SG. High pulse pressure and metabolic syndrome are associated with proteinuria in young adult women. BMC Nephrol 2013; 14:45. [PMID: 23433013 PMCID: PMC3610196 DOI: 10.1186/1471-2369-14-45] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 02/19/2013] [Indexed: 01/21/2023] Open
Abstract
Background Obesity and metabolic syndrome play causative roles in the increasing prevalence of proteinuria in the general population. However, in young adult women the clinical significance of incidentally discovered proteinuria and its association with metabolic syndrome are unclear. We investigated the prevalence and risk factors for proteinuria in this population. Methods A total of 10,385 women aged 20 to 39 years who underwent health screenings were surveyed. Each patient was tested for proteinuria with a dipstick (−, ±, 1+, 2+, or 3+), and proteinuria was defined as 1+ or greater. Persistent proteinuria was established by confirming proteinuria in a subsequent test. Metabolic syndrome was defined in accordance with the updated National Cholesterol Education Program Adult Treatment Panel III criteria for Asia. Results The mean age was 28.9 ± 5.5 years, and the prevalence of persistent proteinuria was 1.0%. Among these subjects with persistent proteinuria, obesity and metabolic syndrome were found in 10.4% and 5.2%, respectively. Metabolic syndrome, as well as its components of hypertension, hyperglycemia, central obesity, low high-density lipoprotein levels, and high triglyceride levels, was closely related to the presence of proteinuria. In addition, a wide pulse pressure of ≥40 mmHg was another independent risk factor for proteinuria [odds ratio (OR) 3.29, 95% confidence interval (CI) 1.03–11.91)]. This had an additive effect on metabolic syndrome in terms of predicting proteinuria. Even in subjects without metabolic syndrome, the influence of an increased pulse pressure was consistent (OR 2.75, 95% CI 1.03–8.61). Conclusions Specific attention to proteinuria may be necessary in asymptomatic young women aged 20 to 39 years if they have metabolic syndrome or a wide pulse pressure.
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Affiliation(s)
- Jwa-Kyung Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Kidney Research Institute, Hallym University College of Medicine, 896, Pyeongchon-dong, Anyang-si 431-070, Dongan-gu, Korea
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Hirose M, Tomoda F, Koike T, Yamazaki H, Ohara M, Liu H, Kagitani S, Inoue H. Imbalance of renal production between 5-hydroxytryptamine and dopamine in patients with essential hypertension complicated by microalbuminuria. Am J Hypertens 2013; 26:227-33. [PMID: 23382407 DOI: 10.1093/ajh/hps008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND In the kidney, 5-hydroxytryptamine (5-HT) and dopamine (DA) are formed by the same enzyme, l-aromatic amino acid decarboxylase, but act on renal function and glomerular structure in an opposite direction. The present study was designed to explore whether rates of renal production of 5-HT relative to that of DA are altered in patients with essential hypertension and microalbuminuria. METHODS We measured urinary levels of 5-HT and DA, reflecting renal production of 5-HT and DA as well as 24-hour ambulatory blood pressure and urinary albumin excretion in 82 consecutive untreated, essential hypertensives without overt proteinuria. RESULTS Urinary 5-HT excretion and the ratio of urinary 5-HT to DA were significantly higher in 22 patients with microalbuminuria than in the remaining patients with normoalbuminuria, although urinary DA levels did not differ between the groups. The 24-hour systolic and diastolic blood pressures were also higher in the microalbuminuric group than in the normoalbuminuric group. Multiple regression analysis revealed that urinary 5-HT excretion and 24-hour systolic blood pressure were independently associated with urinary albumin excretion. Furthermore, urinary 5-HT excretion was positively correlated with creatinine clearance as well as blood pressure but tended to be negatively correlated with fractional excretion of sodium. CONCLUSIONS Renal production of 5-HT is enhanced compared with that of DA in essential hypertensives with microalbuminuria. This imbalance may contribute to the genesis of hypertensive glomerular damage.
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Affiliation(s)
- Masayo Hirose
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
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Guasch B, Torguet P, Garcia I, Calabia J, Martín N, Maté G, Faur D, Barreiro Y, Molina C, Noboa C, Vallès M. Utilidad de la monitorización ambulatoria de la presión arterial en la evaluación de la rigidez arterial. Correlaciones con la velocidad de onda de pulso y las tensiones arteriales centrales. HIPERTENSION Y RIESGO VASCULAR 2013. [DOI: 10.1016/j.hipert.2012.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Yano Y, Sato Y, Fujimoto S, Konta T, Iseki K, Moriyama T, Yamagata K, Tsuruya K, Yoshida H, Asahi K, Kurahashi I, Ohashi Y, Watanabe T. Association of high pulse pressure with proteinuria in subjects with diabetes, prediabetes, or normal glucose tolerance in a large Japanese general population sample. Diabetes Care 2012; 35:1310-5. [PMID: 22474041 PMCID: PMC3357237 DOI: 10.2337/dc11-2245] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine whether there is a difference in the association between high pulse pressure and proteinuria, independent of other blood pressure (BP) indices, such as systolic or diastolic BP, among subjects with diabetes, prediabetes, or normal glucose tolerance. RESEARCH DESIGN AND METHODS Using a nationwide health checkup database of 228,778 Japanese aged ≥ 20 years (mean 63.2 years; 39.3% men; none had pre-existing cardiovascular disease), we examined the association between high pulse pressure, defined as the highest quintile of pulse pressure (≥ 63 mmHg, n = 40,511), and proteinuria (≥ 1+ on dipstick, n = 12,090) separately in subjects with diabetes (n = 27,913), prediabetes (n = 100,214), and normal glucose tolerance (n = 100,651). RESULTS The prevalence of proteinuria was different among subjects with diabetes, prediabetes, and normal glucose tolerance (11.3 vs. 5.0 vs. 3.9%, respectively; P < 0.001). In subjects with diabetes, but not those with prediabetes or normal glucose tolerance, high pulse pressure was associated with proteinuria independently of significant covariates, including systolic BP (odds ratio 1.15 [95% CI 1.04-1.28]) or diastolic or mean BP (all P < 0.01). In patients with diabetes, a +1 SD increase of pulse pressure (+13 mmHg) was associated with proteinuria, even after adjustment for systolic BP (1.07 [1.00-1.13]) or diastolic or mean BP (all P < 0.05). CONCLUSIONS Among the Japanese general population, there was a significant difference in the association between high pulse pressure and proteinuria among subjects with diabetes, prediabetes, and normal glucose tolerance. Only in diabetes was high pulse pressure associated with proteinuria independent of systolic, diastolic, or mean BP levels.
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Affiliation(s)
- Yuichiro Yano
- Divisions of Community and Family Medicine, University of Miyazaki, Miyazaki, Japan
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Choukem SP, Dzudie A, Dehayem M, Halle MP, Doualla MS, Luma H, Kengne AP. Comparison of different blood pressure indices for the prediction of prevalent diabetic nephropathy in a sub-Saharan African population with type 2 diabetes. Pan Afr Med J 2012; 11:67. [PMID: 22655101 PMCID: PMC3361205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 03/30/2012] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The association between blood pressure (BP) and diabetic kidney diseases in Africans has been less well investigated. We assessed and compared the strength of the association and discriminatory capability of systolic (SBP), diastolic (DBP) BP, pulse pressure (PP) and mean arterial blood pressure (MAP) for nephropathy risk in sub-Saharan Africans with type 2 diabetes. METHODS Participants were 420 consecutive individuals (49% men) with type 2 diabetes receiving chronic care in two main referral centres in the two major cities of Cameroon. Logistic regression models were used to compute the odd ratio (OR) and 95% confidence interval (95% CI) for a standard deviation (SD) higher level of SBP (25 mmHg), DBP (13), PP (18) and MAP (16) with nephropathy risk. Discrimination was assessed and compared with c-statistics and relative integrated discrimination improvement (RIDI, %). RESULTS The adjusted OR (95% CI) for nephropathy with each SD higher BP variable were: 1.45 (1.15-1.84) for SBP, 1.33 (1.06-1.66) for DBP, 1.35 (1.06-1.71) for PP and 1.42 (1.13-1.78) for MAP. C-statistic comparison showed no difference in discrimination of models with each of the BP variables (p-values ≥ 0.69 for c-statistics comparison). However, RIDI statistic always showed and enhancement in models discrimination when other BP variables were replaced with SBP, although such an enhancement was marginal for MAP. Using BP combination modestly improved models? discrimination. CONCLUSION SBP was the best predictor of prevalent nephropathy in this population, while DBP was the less effective. This may have implication for kidney disease risk stratification and protection.
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Affiliation(s)
- Simeon-Pierre Choukem
- Department of Internal Medicine, Douala General Hospital, Douala, Cameroon,Department of Clinical Sciences, Faculty of Health Science, University of Buea, Buea, Cameroon,Corresponding author: Simeon-Pierre Choukem, Department of Internal Medicine, Douala General Hospital P.O. Box 4856 Douala, Cameroon
| | - Anastase Dzudie
- Department of Internal Medicine, Douala General Hospital, Douala, Cameroon,Department of Clinical Sciences, Faculty of Health Science, University of Buea, Buea, Cameroon
| | - Mesmin Dehayem
- Diabetes and Endocrine Unit and National Obesity Centre, Yaounde Central Hospital, Yaounde, Cameroon
| | | | - Marie-Solange Doualla
- Department of Internal Medicine, Douala General Hospital, Douala, Cameroon,Department of Internal Medicine and Subspecialties, Faculty of Medicine and Biomedical Science, University of Yaounde I, Yaounde, Cameroon
| | - Henry Luma
- Department of Internal Medicine, Douala General Hospital, Douala, Cameroon,Department of Internal Medicine and Subspecialties, Faculty of Medicine and Biomedical Science, University of Yaounde I, Yaounde, Cameroon
| | - Andre-Pascal Kengne
- Department of Medicine, Faculty of Health Science, University of Cape Town & Medical Research Council, Cape Town, South Africa
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