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Tong PCY, Chan SCP, Chan WB, Ho KKL, Leung GTC, Lo SHK, Mak GYK, Tse TS. Consensus Statements from the Diabetologists & Endocrinologists Alliance for the Management of People with Hypertension and Type 2 Diabetes Mellitus. J Clin Med 2023; 12:jcm12103403. [PMID: 37240509 DOI: 10.3390/jcm12103403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/04/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Hypertension and type 2 diabetes mellitus (T2DM) are important, intertwined public health issues. People with both conditions face significantly elevated risks of cardiovascular (CV) and renal complications. To optimize patient care, a multidisciplinary expert panel met to review recent evidence on optimal blood pressure (BP) targets, implications of albuminuria, and treatment regimens for hypertensive patients with T2DM, with the aim of providing recommendations for physicians in Hong Kong. The panel reviewed the relevant literature, obtained by searching PubMed for the publication period from January 2015 to June 2021, to address five discussion areas: (i) BP targets based on CV/renal benefits; (ii) management of isolated systolic or diastolic hypertension; (iii) roles of angiotensin II receptor blockers; (iv) implications of albuminuria for CV/renal events and treatment choices; and (v) roles and tools of screening for microalbuminuria. The panel held three virtual meetings using a modified Delphi method to address the discussion areas. After each meeting, consensus statements were derived and anonymously voted on by every panelist. A total of 17 consensus statements were formulated based on recent evidence and expert insights regarding cardioprotection and renoprotection for hypertensive patients with T2DM.
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Affiliation(s)
| | | | - Wing-Bun Chan
- Diabetologists & Endocrinologists Alliance, Hong Kong SAR, China
| | | | | | | | | | - Tak-Sun Tse
- Diabetologists & Endocrinologists Alliance, Hong Kong SAR, China
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Apperloo EM, Pena MJ, de Zeeuw D, Denig P, Heerspink HJL. Individual variability in response to renin angiotensin aldosterone system inhibition predicts cardiovascular outcome in patients with type 2 diabetes: A primary care cohort study. Diabetes Obes Metab 2018; 20:1377-1383. [PMID: 29345404 PMCID: PMC5969103 DOI: 10.1111/dom.13226] [Citation(s) in RCA: 7] [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: 10/23/2017] [Revised: 12/20/2017] [Accepted: 12/27/2017] [Indexed: 12/19/2022]
Abstract
AIMS To assess variability in systolic blood pressure (SBP) and albuminuria (urinary albumin creatinine ratio [UACR]) responses in patients with type 2 diabetes mellitus initiating renin angiotensin aldosterone system (RAAS) inhibition, and to assess the association of response variability with cardiovascular outcomes. MATERIAL AND METHODS We performed an observational cohort study in patients with type 2 diabetes who started RAAS inhibition between 2007 and 2013 (n = 1600). Patients were identified from general practices in the Netherlands. Individual response in SBP and UACR was assessed during 15 months' follow-up. Patients were categorized as: good responders (∆SBP <0 mm Hg and ∆UACR <0%); intermediate responders (∆SBP <0 mm Hg and ∆UACR >0% or ∆SBP >0 mm Hg and ∆UACR <0%); or poor responders (∆SBP >0 mm Hg and ∆UACR >0%). Multivariable Cox regression was performed to test the association between initial RAAS inhibition response and subsequent cardiovascular outcomes. RESULTS After starting RAAS inhibition, the mean SBP change was -13.2 mm Hg and the median UACR was -36.6%, with large between-individual variability, both in SBP [5th to 95th percentile: 48.5-20] and UACR [5th to 95th percentile: -87.6 to 171.4]. In all, 812 patients (51%) were good responders, 353 (22%) had a good SBP but poor UACR response, 268 (17%) had a good UACR but poor SBP response, and 167 patients (10%) were poor responders. Good responders had a lower risk of cardiovascular events than poor responders (hazard ratio 0.51, 95% confidence interval 0.30-0.86; P = .012). CONCLUSIONS SBP and UACR response after RAAS inhibition initiation varied between and within individual patients with type 2 diabetes treated in primary care. Poor responders had the highest risk of cardiovascular events, therefore, more efforts are needed to develop personalized treatment plans for these patients.
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Affiliation(s)
- Ellen M. Apperloo
- University of Groningen, University Medical Centre GroningenDepartment of Clinical Pharmacy and PharmacologyGroningenThe Netherlands
| | - Michelle J. Pena
- University of Groningen, University Medical Centre GroningenDepartment of Clinical Pharmacy and PharmacologyGroningenThe Netherlands
| | - Dick de Zeeuw
- University of Groningen, University Medical Centre GroningenDepartment of Clinical Pharmacy and PharmacologyGroningenThe Netherlands
| | - Petra Denig
- University of Groningen, University Medical Centre GroningenDepartment of Clinical Pharmacy and PharmacologyGroningenThe Netherlands
| | - Hiddo J. L. Heerspink
- University of Groningen, University Medical Centre GroningenDepartment of Clinical Pharmacy and PharmacologyGroningenThe Netherlands
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Araki SI. Comprehensive risk management of diabetic kidney disease in patients with type 2 diabetes mellitus. Diabetol Int 2018; 9:100-107. [PMID: 30603356 PMCID: PMC6224946 DOI: 10.1007/s13340-018-0351-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 02/15/2018] [Indexed: 12/16/2022]
Abstract
Diabetic kidney disease (DKD) in patients with type 2 diabetes mellitus is a leading cause of end-stage renal disease worldwide. An increase in the severity of albuminuria and a decrease in the glomerular filtration rate, by which the DKD stages are categorized, are associated with higher risks of not only end-stage renal disease but also all-cause mortality and cardiovascular mortality. Thus, an optimal management strategy and adequate assessment of therapeutic success are of great clinical and societal relevance to improve the prognosis in patients with type 2 diabetes mellitus and DKD. At present, comprehensive risk management for glycemia, blood pressure, lipid profile, and lifestyle habits is emphasized with respect to cardio-renal protection, rather than one single risk management approach. However, the pharmacological therapy aiming at strict control of these risk factors may be associated with an increased risk of adverse effects, particularly in older adults with diabetes. Accordingly, in the clinical practice of diabetes care, we need to individualize the treatment goals for each risk factor according to the health and social status of each patient with type 2 diabetes mellitus and DKD.
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Affiliation(s)
- Shin-ichi Araki
- Department of Medicine, Shiga University of Medical Science, Otsu, Shiga 520-2192 Japan
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Pacella F, Romano MR, Turchetti P, Tarquini G, Carnovale A, Mollicone A, Mastromatteo A, Pacella E. An eighteen-month follow-up study on the effects of Intravitreal Dexamethasone Implant in diabetic macular edema refractory to anti-VEGF therapy. Int J Ophthalmol 2016; 9:1427-1432. [PMID: 27803859 DOI: 10.18240/ijo.2016.10.10] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 04/14/2016] [Indexed: 11/23/2022] Open
Abstract
AIM To evaluate the long-term efficacy and safety of dexamethasone implants in subjects affected by diabetic macular edema (DME) resistant to anti-vascular endothelial growth factor (VEGF) therapy. METHODS Thirty-two DME patients were enrolled. A 700 microgram slow release Intravitreal Dexamethasone Implant (Ozurdex®) was placed in the vitreous cavity. All patients were followed for 18mo. Best-corrected visual acuity (BCVA) measured with Early Treatment Diabetic Retinopathy Study (ETDRS) and central macular thickness (CMT) exams were carried out at baseline (T0) and after 1 (T1), 3 (T3), 4 (T4), 6 (T6), 9 (T9), 12 (T12), 15 (T15), and 18mo (T18) post injection. RESULTS Repeated measures ANOVA showed an effect of treatment on ETDRS (P<0.0001). Post hoc analyses revealed that ETDRS values were significantly increased at T1, T3, T4, T9, and T15 (P<0.001) as compared to baseline value (T0). At T6, T12, and T18, ETDRS values were still statistically higher than baseline (P<0.001 vs T0). However, at these time points, we observed a trend to return to baseline conditions. ANOVA also showed an effect of treatment (P<0.0001). CMT decreased significantly at T1, T3, T4, T9, and T15 (P<0.001). At T6 (P<0.01), T12 and T18 (P<0.001) CMT was also significantly lower than T0 although a trend to return to the baseline conditions was also observed. CONCLUSION Our findings demonstrate that Intravitreal Dexamethasone Implant is a good option to improve BCVA and CMT in DME patients resistant to anti-VEGF therapy. Our data also show that the use of drugs administered directly into the vitreous allows achieving appropriate and long-lasting concentration at the site of disease without systemic side effects.
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Affiliation(s)
- Fernanda Pacella
- Department of Sense Organs, Faculty of Medicine and Dentistry, Sapienza University of Rome, Rome 00161, Italy
| | | | - Paolo Turchetti
- National Institute for Health, Migration and Poverty (INMP/NIHMP), Rome 00153, Italy
| | - Giovanna Tarquini
- Department of Internal Medicine and Clinical Specialities, Sapienza University of Rome, Rome 00161, Italy
| | - Anna Carnovale
- Department of Internal Medicine and Clinical Specialities, Sapienza University of Rome, Rome 00161, Italy
| | - Antonella Mollicone
- Department of Sense Organs, Faculty of Medicine and Dentistry, Sapienza University of Rome, Rome 00161, Italy
| | - Alessandra Mastromatteo
- Department of Sense Organs, Faculty of Medicine and Dentistry, Sapienza University of Rome, Rome 00161, Italy
| | - Elena Pacella
- Department of Sense Organs, Faculty of Medicine and Dentistry, Sapienza University of Rome, Rome 00161, Italy
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Taguchi K, Ueda S, Fukami K. Accurate estimation of protein/creatinine ratio on urine sample in CKD patients. Clin Exp Nephrol 2016; 20:319-21. [DOI: 10.1007/s10157-016-1229-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 01/07/2016] [Indexed: 11/30/2022]
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Bakris GL, Weir MR. Comparison of Dual RAAS Blockade and Higher-Dose RAAS Inhibition on Nephropathy Progression. Postgrad Med 2015; 120:33-42. [DOI: 10.3810/pgm.2008.04.1758] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Schmieder RE, Schutte R, Schumacher H, Böhm M, Mancia G, Weber MA, McQueen M, Teo K, Yusuf S. Mortality and morbidity in relation to changes in albuminuria, glucose status and systolic blood pressure: an analysis of the ONTARGET and TRANSCEND studies. Diabetologia 2014; 57:2019-29. [PMID: 25037746 DOI: 10.1007/s00125-014-3330-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 06/27/2014] [Indexed: 01/13/2023]
Abstract
AIMS/HYPOTHESIS Urinary albumin excretion is a strong predictor of cardiovascular disease. It is uncertain whether improvement from microalbuminuria or deterioration from normoalbuminuria over time in patients with differing changes in glucose and BP change their cardiovascular risk. METHODS Data on mortality, cardiovascular and renal outcomes were analysed in 22,984 patients from two large parallel randomised clinical trials followed for 56 months. A central laboratory analysed first morning spot urine samples at baseline and after 24 months, and events were recorded over the subsequent 32 months. Patients were stratified by changes in albuminuria, glucose status and mean systolic BP over 2 years. RESULTS There was a strong association between albuminuria status and all-cause and cardiovascular mortality and combined cardiovascular and renal endpoints (all p < 0.0001). Changes in systolic BP control had no effect on mortality, whereas glucose status was significantly associated with all outcomes. Irrespective of BP control or glucose status, patients showing an improvement from microalbuminuria to normoalbuminuria after 2 years were at a lower risk of all outcome measures than patients showing deterioration from normoalbuminuria to microalbuminuria (HR for all-cause mortality 0.65 [0.52-0.83], p = 0.0004). CONCLUSIONS/INTERPRETATION Patients who showed improvement to normoalbuminuria over 2 years were at lower risk of all-cause and cardiovascular mortality and of cardiovascular and renal events than those who deteriorated to microalbuminuria over time. Albuminuria over time was significantly better than glucose status and BP control in predicting mortality and both cardiovascular and renal outcomes in patients at a high cardiovascular risk.
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Affiliation(s)
- Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital of the University Erlangen-Nuremberg, Ulmenweg 18, 91054, Erlangen, Germany,
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Schutte R, Schmieder RE, Huisman HW, Smith W, van Rooyen JM, Fourie CMT, Kruger R, Uys L, Ware L, Mels CMC, Greeff M, Kruger IM, Schutte AE. Urinary albumin excretion from spot urine samples predict all-cause and stroke mortality in Africans. Am J Hypertens 2014; 27:811-8. [PMID: 24515804 DOI: 10.1093/ajh/hpt288] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Increased urinary albumin excretion reflects general vascular damage and predicts adverse cardiovascular and renal outcomes. Albuminuria can be determined from easily collected spot urine samples, especially in low-resource settings. However, no prognostic evidence exists for Africans. METHODS We followed clinical outcomes in 1,061 randomly selected non diabetic, human immunodeficiency virus (HIV)-negative Africans (mean age: 51.5 years; 62.0% women). Baseline urinary albumin-to-creatinine ratio was assessed from spot urine samples. RESULTS Over a median follow-up of 4.52 years, 132 deaths occurred, of which 47 were cardiovascular related. The urinary albumin-to-creatinine ratio averaged 6.1 μg/mg (5th to 95th percentile interval; 1.2-70.0). In multivariable-adjusted analyses, urinary albumin excretion predicted all-cause mortality (hazard ratio (HR), 1.26; 95% confidence interval (CI), 1.07-1.48; P = 0.006), and a tendency existed for cardiovascular mortality (HR, 1.26; 95% CI, 0.97-1.63; P = 0.087), which seemed to be driven by fatal stroke (HR, 1.72; 95% CI, 1.17-2.54; P = 0.006) rather than cardiac mortality (HR, 0.67; 95% CI, 0.41-1.07; P = 0.094). The predictive value remained in 528 hypertensives for both all-cause (HR, 1.38; 95% CI, 1.13-1.69; P = 0.001) and cardiovascular (HR, 1.45; 95% CI, 1.07-1.96; P = 0.017) mortality, again driven by stroke. Our findings also remained significant after we excluded participants with macroalbuminuria, those on antihypertensive treatment, as well as participants who died within 1 year after enrollment. CONCLUSION In nondiabetic HIV-negative Africans, albuminuria predicts all-cause and stroke mortality.
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Affiliation(s)
- Rudolph Schutte
- Hypertension in Africa Research Team, North-West University, Potchefstroom, South Africa
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Oikonomou D, Rudofsky G. [Kidney and eye in diabetes: diagnosis and therapy, useful aspects for general practitioners]. MMW Fortschr Med 2012; 154:71-4. [PMID: 22957388 DOI: 10.1007/s15006-012-0933-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Dimitrios Oikonomou
- Abteilung Innere Medizin I und Klinische Chemie, Universitätsklinikum Heidelberg
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Viana LV, Gross JL, Camargo JL, Zelmanovitz T, da Costa Rocha EPC, Azevedo MJ. Prediction of cardiovascular events, diabetic nephropathy, and mortality by albumin concentration in a spot urine sample in patients with type 2 diabetes. J Diabetes Complications 2012; 26:407-12. [PMID: 22677793 DOI: 10.1016/j.jdiacomp.2012.04.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 04/21/2012] [Accepted: 04/23/2012] [Indexed: 11/16/2022]
Abstract
AIMS To analyze in a random urine spot the predictive value of urinary albumin concentration (UAC) for cardiovascular events, diabetic nephropathy (DN), and death in patients with type 2 diabetes. METHODS In this cohort, urinary albumin (immunoturbidimetry) was measured as 24-h urinary albumin excretion (UAE) and, in a random spot urine, as UAC and albumin:creatinine ratio (ACR). Primary outcomes were: 1) cardiovascular events, 2) DN defined as a composite outcome [macroalbuminuria and/or decreased glomerular filtration rate (GFR) <60 ml/min/1.73 m²], and 3) death. RESULTS A total of 199 type 2 diabetic patients, aged 59.9 ± 9.9 years, were followed for 6.1 ± 2.7 years. UAC ≥14.4 mg/l, as determined by ROC curve, predicted DN and prediction for this and other outcomes were compared with traditional microalbuminuria cutoffs for ACR and UAE. The outcomes frequency was: cardiovascular events = 26.4%, DN = 31.7% (23.5% decreased GFR; 13.6% macroalbuminuria) and death = 8.50%. In Cox analyses, UAC ≥14 mg/l increased the risk (hazard ratio, HR) for cardiovascular events 3.25 times (95% CI 1.43-7.38; P = 0.005), 4.30 for DN composite outcome (95% CI 2.22-8.32; P <0.001), and 5.51 for death (95% CI 1.16-26.22; P = 0.032). Corresponding HRs of ACR ≥30 mg/g were: 2.89 (95% CI 1.29-6.45; P = 0.009) for cardiovascular events, 4.67 (95% CI 2.34-9.34; P <0.001) for DN composite outcome and 5.07 (95% CI 1.01-24.88; P = 0.049) for death. HRs of UAE ≥30 mg/24-h were: 2.20 (95% CI 2.08-2.49; P = 0.030) for cardiovascular events, 6.76 (95% CI 3.32-13.77; P <0.001) for DN composite outcome, and 2.47 (95% CI 0.72-8.42; P = 0.150) for death. CONCLUSIONS In conclusion, random UAC ≥14 mg/l predicted cardiovascular events, diabetic nephropathy, and mortality just as well as ACR. UAC may be used to assess cardiovascular and renal risks in patients with type 2 diabetes.
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Affiliation(s)
- Luciana Verçoza Viana
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Chu CH, Lam HC, Lee JK, Lu CC, Sun CC, Cheng HJ, Wang MC, Chuang MJ. Carotid intima-media thickness in Chinese Type 2 diabetic subjects with or without microalbuminuria. J Endocrinol Invest 2012; 35:254-9. [PMID: 21623152 DOI: 10.3275/7756] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND To examine the association of microalbuminuria (MAU) with the carotid intima-media thickness (CIMT) in Chinese Type 2 diabetic subjects. MATERIALS AND METHODS Two hundred and thirty-nine patients (64±13 yr, 154 males) were divided into 2 groups: one with MAU (no.=119) or one without (no.=120). We recorded clinical and biochemical data as well as CIMT and ankle-brachial index (ABI). RESULTS The patients with MAU had had diabetes mellitus (DM) longer, had higher blood pressure (BP). They also had lower estimated glomerular filtration rate (eGFR) and higher levels of circulating glucose, glycated hemoglobin, high sensitivity C-reactive protein than those without. Lower mean ABI was found in those with MAU, however, they did not have higher mean CIMT (0.72±0.15 vs 0.71±0.16 mm, p=0.525). In patients without MAU, CIMT correlated with age, DM duration, systolic BP, eGFR, albumin- to-creatinine ratio, and ABI. However, in those with MAU, CIMT correlated only with age and eGFR. Multivariate regression analysis revealed that mean CIMT correlated only with age for patients without MAU, but correlated with age and body mass index for those with MAU. Dividing the patients into 5 age groups, we found that the older the patient, the higher the mean CIMT with no group differences between those with and without MAU in both genders. However, patients with eGFR below 60 ml/min/1.73 m(2) had higher mean CIMT than those above (0.75±0.16 vs 0.69±0.14 mm, p=0.005). CONCLUSIONS Type 2 diabetic patients with MAU were not associated with higher CIMT. Conversely, those with deterioration of renal function were more likely associated.
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Affiliation(s)
- C-H Chu
- Department of Rehabilitation Technology, TzuHui Institute of Technology, Pingtung, Taiwan.
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Heerspink HJL, Holtkamp FA, de Zeeuw D, Ravid M. Monitoring kidney function and albuminuria in patients with diabetes. Diabetes Care 2011; 34 Suppl 2:S325-9. [PMID: 21525477 PMCID: PMC3632201 DOI: 10.2337/dc11-s247] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Hiddo J Lambers Heerspink
- Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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Holtkamp FA, de Zeeuw D, de Graeff PA, Laverman GD, Berl T, Remuzzi G, Packham D, Lewis JB, Parving HH, Lambers Heerspink HJ. Albuminuria and blood pressure, independent targets for cardioprotective therapy in patients with diabetes and nephropathy: a post hoc analysis of the combined RENAAL and IDNT trials. Eur Heart J 2011; 32:1493-9. [PMID: 21421598 DOI: 10.1093/eurheartj/ehr017] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
AIMS The long-term cardioprotective effect of angiotensin receptor blockers (ARBs) is associated with the short-term lowering of its primary target blood pressure, but also with the lowering of albuminuria. Since the individual blood pressure and albuminuria response to an ARB varies between and within an individual, we tested whether the variability and discordance in systolic blood pressure (SBP) and albuminuria response to ARB therapy are associated with its long-term effect on cardiovascular outcomes. METHODS AND RESULTS The combined data of the RENAAL and IDNT trials were used. We first investigated the extent of variability and discordance in SBP and albuminuria response (baseline to 6 months). Subsequently, we assessed the combined impact of residual Month 6 SBP and albuminuria level with cardiovascular outcome. In ARB-treated patients, 421 patients (34.5%) either had a reduction in SBP but no reduction in albuminuria, or vice versa, indicating substantial discordance in response in these parameters. The initial reduction in SBP and albuminuria independently correlated with cardiovascular protection: HR per 5 mmHg SBP reduction 0.97 (95% CI 0.94-0.99) and HR per decrement log albuminuria 0.87 (95% CI 0.76-0.99). Across all SBP categories at Month 6, a progressively lower cardiovascular risk was observed with a lower albuminuria level. This was particularly evident in patients who reached the guideline recommended SBP target of ≤130 mmHg. CONCLUSION The SBP and albuminuria response to ARB therapy is variable and discordant. Therapies intervening in the renin-angiotensin-aldosterone system with the aim of improving cardiovascular outcomes may therefore require a dual approach targeting both blood pressure and albuminuria.
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Affiliation(s)
- Frank A Holtkamp
- Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, Groningen, The Netherlands
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Kuritzky L, Toto R, Van Buren P. Identification and Management of Albuminuria in the Primary Care Setting. J Clin Hypertens (Greenwich) 2011; 13:438-49. [DOI: 10.1111/j.1751-7176.2010.00424.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Whaley-Connell AT, Kalaitzidis RG. Should targeting albuminuria be part of a cardiovascular risk reduction paradigm? Cardiol Clin 2010; 28:437-45. [PMID: 20621248 DOI: 10.1016/j.ccl.2010.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the United States as well as the rest of the world. Chronic kidney disease (CKD) is considered a CVD risk equivalent. The development of albuminuria has been identified as an additional possible risk marker that is almost unique to patients with CKD and a marker for predicting CVD risk. This review focuses on clinical and epidemiologic evidence regarding the role of albuminuria in the context of CVD development. It reviews the association of albuminuria with other comorbidities associated with increased cardiovascular risk and the modalities aimed at the reduction of albuminuria and maximizing of cardiovascular risk reduction.
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Affiliation(s)
- Adam T Whaley-Connell
- Department of Internal Medicine, Harry S Truman Veterans Affairs Medical Center, University of Missouri-Columbia School of Medicine, Columbia, MO 65212, USA
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Faulkner MS, Quinn L, Fritschi C. Microalbuminuria and heart rate variability in adolescents with diabetes. J Pediatr Health Care 2010; 24:34-41. [PMID: 20122476 PMCID: PMC2819478 DOI: 10.1016/j.pedhc.2009.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2008] [Revised: 12/20/2008] [Accepted: 01/10/2009] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Limited clinical and research data are available on early renal and cardiovascular complications in youth with diabetes. The possible associations of elevated microalbuminuria to creatinine (MC) ratios with heart rate variability (HRV) were explored in adolescents with type 1 (T1DM) or type 2 (T2DM) diabetes. METHODS A descriptive study was conducted with 41 adolescents with diabetes (n = 31 T1DM vs. n = 10 T2DM). Twenty-four hour Holter recordings for determining HRV, urine spot checks for MC ratio, and the most recent measures of glycosylated hemoglobin (A1c) were obtained. RESULTS HRV was significantly lower in the T2DM group, while body mass index percentile, triglycerides, and diastolic blood pressure were significantly higher. For the T1DM group, clinical case examples provided evidence of elevated MC ratios (>30 mirog/mg) occurring in two female subjects who also had decreased HRV measures. DISCUSSION Although HRV was not significantly associated with MC ratios for the sample, individual clinical findings can be a warning sign for some adolescents with diabetes. Current recommendations for screening of early renal complications and associated treatment are provided.
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Affiliation(s)
- Melissa Spezia Faulkner
- Diabetes Research and Education, College of Nursing, University of Arizona, P.O. Box 210203, Tucson, AZ 5721-0203, USA.
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Abstract
The evaluation of diabetic nephropathy from research and clinical viewpoints depends on the assessment of two continuous variables, albumin excretion rate (AER) and glomerular filtration rate (GFR). These two parameters form the basis of both the European classification of five stages of diabetic nephropathy, assessed according to changes in AER and GFR (hyperfiltration, normoalbuminuria, microalbuminuria, macroalbuminuria and end-stage renal disease), and the National Kidney Foundation classification of five stages of chronic kidney disease based on categories of estimated GFR. Although increases in AER generally precede a decline in GFR, some patients follow a non-albuminuric pathway to renal impairment. In addition, studies indicate that GFR decreases in a linear fashion from normal or above-normal levels. Whether hyperfiltration is part of the pathogenetic process leading to diabetic nephropathy remains unclear. Ideally, both AER and GFR should be assessed at an early stage in patients being evaluated for diabetic nephropathy. New methods such as the use of cystatin-C-based equations for estimating GFR should be considered because current creatinine-based estimates are inaccurate at normal or high GFRs. Serial assessments of both AER and GFR might allow diabetic nephropathy to be diagnosed at early stages of the disease process that are selectively responsive to new interventions. The successful integration of AER categories with the recently defined stages of GFR represents a new challenge in the management of diabetic nephropathy.
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