Baseline cardiovascular risk in subjects with type 2 diabetes and chronic kidney disease from the FLOW trial

Background

Patients with chronic kidney disease and type 2 diabetes (T2D) have a high risk of progression to kidney failure as well as cardiovascular (CV) events. It is established that glucagon-like peptide-1 receptor agonists (GLP-1RAs) improve glycaemic control and reduce body weight. Some CV outcomes trials have shown that GLP-1RAs reduce CV risk in people with T2D at high CV risk; for example, the SUSTAIN 6 trial demonstrated that the GLP-1RA semaglutide significantly lowered the rate of major CV events (CV death, non-fatal myocardial infarction and non-fatal stroke) versus placebo. Some trials have also indicated that GLP-1RAs reduce albuminuria and estimated glomerular filtration rate (eGFR) decline. Based on these previous results indicating potential kidney-protective effects, the FLOW trial (NCT03819153) is evaluating once-weekly, subcutaneous semaglutide 1.0 mg versus placebo on kidney- and CV-related outcomes in participants with T2D. We describe the baseline characteristics and the calculated CV risk of this patient population using the atherosclerotic CV disease (ASCVD) and second manifestations of arterial disease (SMART) risk calculators.

Methods

FLOW is an ongoing, multicentre, randomised, double-blind, parallel-group, event-driven, phase 3b trial, with participants randomised 1:1 to semaglutide or placebo, each in addition to standard of care. Recruitment is complete and 3,535 participants with T2D, an eGFR ≥25–≤75 mL/min/1.73 m2, and urine albumin-to-creatinine ratio ≥100–≤5,000 mg/g have been enrolled. The primary endpoint is time to first occurrence of a kidney composite that includes ≥50% persistent eGFR reduction, kidney failure (persistent eGFR <15 mL/min/1.73 m2 or initiation of chronic dialysis or kidney transplantation), and kidney-related death, or CV death. Key secondary outcomes include time to first occurrence of CV death, myocardial infarction or stroke.

Results

The baseline clinical characteristics and demographics are shown (Table 1). Median age was 68 years, 30% were female, mean diabetes duration was 17 years, and 98% had a history of hypertension. Overall, 52% of participants had a previous CV event. The calculated 10-year risk for ASCVD events in those without prior ASCVD was 31% in males and 18% in females, and in those with previous CV events was 37–56% in males and 35–53% in females depending on the type of CV disease reported in the calculator (Table 2).

Conclusions

The FLOW trial has completed enrolment. Based on the ASCVD and SMART risk calculators, the enrolled population has a substantial risk for adverse CV outcomes. Event ascertainment is ongoing, and the FLOW trial will provide evidence for the potential of semaglutide to improve kidney and CV outcomes in the T2D population.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novo Nordisk

In patients with type 2 diabetes chronic kidney disease is a modifiable cardiovascular risk factor

Background/Introduction

Chronic kidney disease (CKD) in patients with type 2 diabetes (T2D) is associated with an increased risk of cardiovascular (CV) events. The modifiability of CKD-associated CV risk in patients with T2D across a spectrum of CKD stages remains unknown.

Purpose

To test whether CKD, as defined jointly by estimated glomerular filtration rate (eGFR) and albuminuria (urine albumin-to-creatinine ratio [UACR]), is a modifiable CV risk factor in patients with T2D. Furthermore, to estimate the population-wide reduction in first CV events in the US if all eligible patients were treated with finerenone.

Methods

We estimated the incidence rates of CV events (composite of CV death, non-fatal stroke, non-fatal myocardial infarction, or hospitalisation for heart failure) over a median follow-up of 3.0 years in 13,026 patients with CKD and T2D, treated with finerenone or placebo, in a joint analysis by eGFR and UACR categories. Patients were from FIDELITY, a prespecified pooled analysis of two phase III trials, and had an eGFR ≥25 ml/min/1.73 m2 and UACR 30–5000 mg/g at screening.The potential impact of finerenone treatment on the US population was evaluated by simulating the number of first CV events that could be prevented per year with finerenone, using incidence rates from FIDELITY and prevalence rates of CKD in patients with T2D from the National Health and Nutrition Examination Survey (NHANES).

Results

Lower eGFR and higher UACR categories were associated with higher incidences of CV events in finerenone and placebo recipients (Figure). Finerenone reduced CV risk versus placebo (hazard ratio 0.86; 95% CI 0.78–0.95; p=0.0018) without evidence of moderation of risk reduction by combined eGFR and UACR categories (p interaction = 0.66; Figure 1). Using NHANES, a total of 6.4 million treatment-eligible individuals with CKD and T2D were identified; 75% had CKD with an eGFR ≥60 ml/min/1.73 m2 and 25% had CKD with an eGFR <60 ml/min/1.73 m2. Simulations using this NHANES population projected that 1 year of finerenone treatment could prevent 38,359 CV events in US patients with CKD and T2D, with 66% of events prevented in patients with eGFR ≥60 ml/min/1.73 m2.

Conclusions

Higher albuminuria and lower eGFR are associated with increased CV risk in patients with T2D. Across a range of eGFR and albuminuria categories, CV risk is modifiable. Therefore, CKD is a modifiable CV risk factor in part mediated by mineralocorticoid receptor overactivation. UACR screening to identify patients with T2D and albuminuria with an eGFR ≥60 ml/min/1.73 m2 is likely to provide a significant opportunity for population benefits.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bayer AG

Effects of canagliflozin on hyperkalaemia and serum potassium in people with diabetes and chronic kidney disease: insights from the CREDENCE trial

Background

Hyperkalaemia is a common complication of type 2 diabetes mellitus (T2DM) and limits the optimal use of agents that block the renin-angiotensin aldosterone system (RAAS), particularly in patients with chronic kidney disease (CKD). In patients with CKD, sodium glucose cotransporter 2 (SGLT2) inhibitors provide cardiorenal protection, but whether they affect the risk of hyperkalaemia remains uncertain.

Purpose

We sought to assess the effect of canagliflozin on hyperkalaemia and other potassium-related outcomes in people with T2DM and CKD by conducting a post-hoc analysis of the CREDENCE trial.

Methods

The CREDENCE trial randomized 4401 participants with T2DM and CKD to the SGLT2 inhibitor canagliflozin or matching placebo. In this post-hoc analysis using an intention-to-treat approach, we assessed the effect of canagliflozin on a composite outcome of time to either investigator-reported hyperkalaemia or the initiation of potassium binders. We also analysed effects on central laboratory-determined hyper- and hypokalaemia (serum potassium ≥6.0 and <3.5 mmol/L, respectively) and change in serum potassium.

Results

At baseline the mean serum potassium in canagliflozin and placebo arms was 4.5 mmol/L; 4395 (99.9%) participants were receiving renin angiotensin system blockade. Canagliflozin reduced the risk of investigator-reported hyperkalaemia or initiation of potassium binders (HR 0.78, 95% CI 0.64–0.95, p=0.014; Figure 1). The incidence of laboratory-determined hyperkalaemia was similarly reduced (HR 0.77, 95% CI 0.61–0.98, p=0.031; Figure 2); the risk of hypokalaemia (HR 0.92, 95% CI 0.71–1.20, p=0.53) was not increased. Mean serum potassium over time with canagliflozin was similar to that of placebo.

Conclusion

Among patients treated with RAAS inhibitors, SGLT2 inhibition with canagliflozin may reduce the risk of hyperkalaemia in people with T2DM and CKD without increasing the risk of hypokalaemia.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Impact of timing of randomization after an acute coronary syndrome and subsequent events in patients with type 2 diabetes mellitus: an analysis of the EXAMINE trial

Background

The timing of enrolment following an acute coronary syndrome (ACS) may influence cardiovascular (CV) outcomes and potentially treatment effect in clinical trials. Using a large contemporary trial in patients with type 2 diabetes mellitus (T2DM) post-ACS, we examined the impact of timing of enrolment on subsequent CV outcomes.

Methods

EXAMINE was a randomized trial of alogliptin versus placebo in 5380 patients with T2DM and a recent ACS. The primary outcome was a composite of CV death, non-fatal myocardial infarction [MI], or non-fatal stroke. The median follow-up was 18 months. In this post hoc analysis, we examined the occurrence of subsequent CV events by timing of enrollment divided by tertiles of time from ACS to randomization: 8–34, 35–56, and 57–141 days.

Results

Patients randomized early (compared to the latest times) had less comorbidities at baseline including a history of heart failure (HF; 24.7% vs. 33.0%), prior coronary artery bypass graft (9.6% vs. 15.9%), or atrial fibrillation (5.9% vs. 9.4%). Despite the reduced comorbidity burden, the risk of the primary outcome was highest in patients randomized early compared to the latest time (adjusted hazard ratio [aHR] 1.47; 95% CI 1.21–1.74) (Figure 1). Similarly, patients randomized early had an increased risk of recurrent MI (aHR 1.51; 95% CI 1.17–1.96) and HF hospitalization (1.49; 95% CI 1.05–2.10).

Conclusion

In a contemporary cohort of T2DM with a recent ACS, early randomization following the ACS increases the risk of CV events including recurrent MI and HF hospitalization. This should be taken into account when designing future clinical trials.

Figure 1

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Takeda Pharmaceutical

Effects of canagliflozin on cardiovascular death and hospitalization for heart failure by baseline estimated glomerular filtration rate: integrated analyses from the CANVAS Program and CREDENCE

Background

People with type 2 diabetes mellitus (T2DM) have a greater risk of cardiovascular (CV) disease, including hospitalization for heart failure (HHF), a complication that is more common as renal function declines. The sodium glucose co-transporter 2 (SGLT2) inhibitor canagliflozin (CANA) reduced the risk of HHF in patients with T2DM and high CV risk or nephropathy in the CANVAS Program and CREDENCE trials, respectively.

Methods

This post hoc analysis included integrated, pooled data from the CANVAS Program and the CREDENCE trial. The effects of CANA compared with placebo on CV death or HHF, HHF, and CV death were assessed in subgroups defined by baseline eGFR (<45, 45–60, and >60 mL/min/1.73 m2). Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression models, with subgroup by treatment interaction terms added to test for heterogeneity. Interaction P values were calculated by including treatment group and baseline eGFR in the model.

Results

A total of 14,543 participants from the CANVAS Program (N=10,142) and CREDENCE (N=4,401) were included, with mean age, 65 y; 65% male; 75% white; mean eGFR 70.3 mL/min/1.73 m2. 1919 (13.2%) participants had baseline eGFR <45 mL/min/1.73 m2 (mean, 36.7 mL/min/1.73 m2), 2972 (20.4%) participants had eGFR 45–60 mL/min/1.73 m2 (mean, 53.1 mL/min/1.73 m2), and 9649 (66.3%) participants had eGFR >60 mL/min/1.73 m2 (mean, 82.3 mL/min/1.73 m2). Rates of CV death or HHF, HHF, and CV death increased as eGFR declined (Figure). CANA significantly reduced the risk of CV death or HHF and HHF compared with PBO, with consistent effects observed across subgroups.

Conclusions

CV death or HHF, HHF, and CV death event rates increased with lower baseline eGFR. CANA significantly reduced the risk of CV death or HHF, jointly and individually, in participants with T2DM and high CV risk or CKD in the CANVAS Program and the CREDENCE trial, with consistent benefits observed regardless of baseline eGFR.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Janssen Scientific Affairs, LLC

1200Changes in nocturnal blood pressure post-renal denervation: comparison of treatment versus control groups in SYMPLICITY HTN-3

Background

Renal denervation (RDN) impacts blood pressure (BP) differently than anti-hypertensive medications by providing a non-reversible 24-hour change in sympathetic tone that is independent of patient adherence. This might lead to differences in the pattern of BP reduction over the 24-hour period related to diurnal variations in sympathetic tone compared with the timing of drug dosing on BP. This “always on” impact of RDN on BP was observed in the 24-hour Ambulatory BP (ABPM) measurements in the SPYRAL HTN-ON MED and OFF MED trials and raises the question of whether this might also be seen in prior studies of RDN.

Purpose

It is hypothesized that SYMPLICITY HTN-3 did not meet its primary efficacy endpoint, in part, due to improved medication adherence and subsequent BP reductions in the control group. We hypothesized that examination of 24-hour ABPM in HTN-3 would illustrate the effects of improved medication adherence in the control group and reveal differences in the pattern of BP reduction between RDN and control groups, thereby demonstrating an impact on sympathetically mediated BP.

Methods

24-hour ABPM measurements were obtained at baseline and 6 months post-randomization per protocol. ABPM was measured and recorded every 30 minutes and a minimum of 21 daytime and 12 night-time acceptable measurements were required for inclusion in the analysis. Mean and standard error of BP were calculated at each timepoint. Night-time was defined as 1:00–6:00AM.

Results

The figure shows hourly mean ABPM at baseline and 6 months for RDN (A) and sham-control groups (B). Changes in ABPM from baseline to 6 months for RDN and sham control groups are shown in (C). Both the RDN and control groups experienced lower mean hourly BP during the day. In contrast, BP reductions from baseline were greater at night and during the pre-awakening morning hours (1:00–6:00AM) in the RDN group compared with the sham control group. ANCOVA baseline BP-adjusted treatment difference for night-time SBP between RDN and control groups was −3.4 mmHg [95% confidence intervals: −6.7, −0.2; p=0.039]. One possible explanation may be that plasma levels of some antihypertensive medications (such as hydralazine and furosemide) may be lower during night-time hours, lessening the effect of BP reduction in the control group.

Conclusions

Analysis of 24-hour ABPM measurements in the RDN group of HTN-3 demonstrate a consistent separation of curves at 6 months compared with baseline. This separation is also seen in the control group in HTN-3 but is minimal at night-time and in the early morning periods, a time when some medications' impact on BP is lessened. Analyses of ABPM data in additional studies (SYMPLICITY HTN-Japan and SPYRAL First-In-Man trials) are planned to further investigate the role of medication adherence in BP reduction after RDN.

Acknowledgement/Funding

The SYMPLICITY HTN-3 trial is funded by Medtronic.

Resting heart rate is associated with renal disease outcomes in patients with vascular disease: results of the ONTARGET and TRANSCEND studies

BACKGROUND

Resting heart rate (RHR) is associated with cardiovascular disease outcomes in high-risk patients. It is not known whether RHR is predictive of renal outcomes such as albuminuria, end-stage renal disease (ESRD) or doubling of creatinine. We evaluated whether RHR could predict renal endpoints in patients at a high risk of cardiovascular disease. We also tested the effects of RHR at different levels of systolic blood pressure (SBP).

METHODS

We analysed data from 28 757 patients in the ONTARGET and TRANSCEND trials. RHR and SBP were available for a mean of 4.9 ± 0.4 visits (range 3-5) within the first 2 years of the studies. Albuminuria was determined at baseline, at 2 years and at study end.

RESULTS

Mean RHR was predictive of incident micro-albuminuria [hazard ratio (HR) for RHR ≥80 vs. <60 beats min(-1) 1.49, 95% confidence interval (CI) 1.29-1.71, P < 0.0001], incident macro-albuminuria (HR 1.84, 95% CI 1.39-2.42, P < 0.0001), doubling of creatinine (HR 1.47, 95% CI 1.00-2.17, P = 0.050) and ESRD (HR 1.78, 95% CI 1.00-3.16, P = 0.050), and the combined renal end-point (HR 1.51, 95% CI 1.32-1.74, P < 0.0001). Associations were robust at SBPs from <120 to ≥150 mmHg, with the lowest risk at a SBP of 130-140 mmHg.

CONCLUSION

Resting heart rate is a potent predictor of these renal outcomes, as well as their combination, in patients with cardiovascular disease. RHR at all SBP levels should be considered as a possible renal disease risk predictor and should be investigated as a treatment target with RHR-reducing agents.

Efficacy and safety of canagliflozin over 52 weeks in patients with type 2 diabetes mellitus and chronic kidney disease

AIM

This study evaluated the efficacy and safety of canagliflozin, a sodium glucose co-transporter 2 inhibitor, in patients with type 2 diabetes mellitus (T2DM) and within a subset of Stage 3 chronic kidney disease (CKD; estimated glomerular filtration rate [eGFR] ≥ 30 and <50 ml/min/1.73 m(2)).

METHODS

In this 52-week, randomized, double-blind, placebo-controlled study, patients (N = 269; mean eGFR, 39.4 ml/min/1.73 m(2)) received canagliflozin 100 or 300 mg and placebo once daily. Efficacy endpoints included changes in glycated haemoglobin (HbA1c), fasting plasma glucose (FPG), body weight and systolic blood pressure (BP); adverse events (AEs) were also recorded.

RESULTS

At week 52, canagliflozin 100 and 300 mg reduced HbA1c compared with placebo (-0.19, -0.33 and 0.07%, respectively); placebo-subtracted differences (95% confidence interval) were -0.27% (-0.53, 0.001) and -0.41% (-0.68, -0.14). Canagliflozin also lowered FPG, body weight and BP versus placebo. Overall AE incidence was 85.6, 80.9, and 86.7% with canagliflozin 100 and 300 mg and placebo, respectively. Osmotic diuresis-related AEs were more common with both canagliflozin doses, and incidences of urinary tract infections and volume depletion-related AEs were higher with canagliflozin 300 mg versus placebo. Decreases in eGFR (-2.1, -4.0 and -1.6 ml/min/1.73 m(2)) were seen with canagliflozin 100 and 300 mg compared with placebo. Canagliflozin 100 and 300 mg provided median percent reductions in urine albumin to creatinine ratio versus placebo (-16.4, -28.0 and 19.7%).

CONCLUSIONS

Canagliflozin improved glycaemic control and was generally well tolerated in patients with T2DM and within a subset of Stage 3 CKD over 52 weeks.

Efficacy and safety of canagliflozin in subjects with type 2 diabetes and chronic kidney disease

AIMS

Canagliflozin is a sodium glucose co-transporter 2 inhibitor in development for treatment of type 2 diabetes mellitus (T2DM). This study evaluated the efficacy and safety of canagliflozin in subjects with T2DM and stage 3 chronic kidney disease [CKD; estimated glomerular filtration rate (eGFR) ≥30 and <50 ml/min/1.73 m(2)].

METHODS

In this randomized, double-blind, placebo-controlled, phase 3 trial, subjects (N = 269) received canagliflozin 100 or 300 mg or placebo daily. The primary efficacy endpoint was change from baseline in HbA1c at week 26. Prespecified secondary endpoints were change in fasting plasma glucose (FPG) and proportion of subjects reaching HbA1c <7.0%. Safety was assessed based on adverse event (AE) reports; renal safety parameters (e.g. eGFR, blood urea nitrogen and albumin/creatinine ratio) were also evaluated.

RESULTS

Both canagliflozin 100 and 300 mg reduced HbA1c from baseline compared with placebo at week 26 (-0.33, -0.44 and -0.03%; p < 0.05). Numerical reductions in FPG and higher proportions of subjects reaching HbA1c < 7.0% were observed with canagliflozin 100 and 300 mg versus placebo (27.3, 32.6 and 17.2%). Overall AE rates were similar for canagliflozin 100 and 300 mg and placebo (78.9, 74.2 and 74.4%). Slightly higher rates of urinary tract infections and AEs related to osmotic diuresis and reduced intravascular volume were observed with canagliflozin 300 mg compared with other groups. Transient changes in renal function parameters that trended towards baseline over 26 weeks were observed with canagliflozin.

CONCLUSION

Canagliflozin improved glycaemic control and was generally well tolerated in subjects with T2DM and Stage 3 CKD.

Effects of combining simvastatin with rosiglitazone on inflammation, oxidant stress and ambulatory blood pressure in patients with the metabolic syndrome: the SIROCO study

AIM

Individually, statins and thiazolidinediones (TZDs) show positive effects on atherosclerosis progression in cellular and animal models as well as patients with diabetes; however, their combined effects have not been studied. This study examines the effects of simvastatin combined with rosiglitazone on vascular inflammation, oxidant stress, ambulatory blood pressure (BP) and other atherosclerotic factors in patients with the metabolic syndrome.

METHODS

This is a randomized, double blind, placebo-controlled study in 53 subjects with the metabolic syndrome. Participants were randomized to simvastatin 40 mg/day plus placebo vs. simvastatin 40 mg/day plus rosiglitazone 4 mg/day for 6 months. The primary endpoint was the between-group difference in high-sensitivity C-reactive protein (hs-CRP) and secondary variables including urinary isoprostanes, serum malondialdehyde (MDA), ambulatory BP, adiponectin, and lipid and glycaemic profiles.

RESULTS

At study end, the group randomized to the simvastatin/rosiglitazone combination had a greater reduction in hs-CRP of 1.33 mg/dl, (p = 0.029) and showed a trend for a greater reduction in urinary isoprostane (-39%), (p = 0.056) compared to simvastatin/placebo group. Changes in MDA levels did not differed between groups (p = 0.81). 24-h systolic blood pressure (SBP) also showed a 4.5 mmHg reduction at 6 months (p = 0.06). Adiponectin levels increased by 3.91 µg/ml in the combination group over placebo, (p = 0.03) and blood glucose decreased in combination group vs. placebo.

CONCLUSION

Our data show that patients with the metabolic syndrome given a statin/TZD combination manifest greater reductions in markers of vascular inflammation and oxidant stress, 24-h ambulatory BP and increases in adiponectin as well as improved glycaemic indices.

N-terminal prohormone brain natriuretic peptide as a predictor of cardiovascular disease and mortality in blacks with hypertensive kidney disease: the African American Study of Kidney Disease and Hypertension (AASK)

BACKGROUND

Higher levels of N-terminal prohormone brain-type natriuretic peptide (NT-proBNP) predict cardiovascular disease (CVD) in several disease states, but few data are available in patients with chronic kidney disease or in blacks.

METHODS AND RESULTS

The African American Study of Kidney Disease and Hypertension trial enrolled hypertensive blacks with a glomerular filtration rate of 20 to 65 mL x min(-1) x 1.73 m(-2) and no other identified cause of kidney disease. NT-proBNP was measured with a sandwich chemiluminescence immunoassay (coefficient of variation 2.9%) in 994 African American Study of Kidney Disease and Hypertension participants. NT-proBNP was categorized as undetectable, low, moderate, or high. Proteinuria was defined as 24-hour urinary protein-creatinine ratio >0.22. A total of 134 first CVD events (CVD death or hospitalization for coronary artery disease, heart failure, or stroke) occurred over a median of 4.3 years. Participants with high NT-proBNP were much more likely to have a CVD event than participants with undetectable NT-proBNP after adjustment (relative hazard 4.0 [95% confidence interval [CI] 2.1 to 7.6]). A doubling of NT-proBNP was associated with a relative hazard of 1.3 (95% CI 1.0 to 1.6) for coronary artery disease, 1.7 (95% CI 1.4 to 2.2) for heart failure, 1.1 (95% CI 0.9 to 1.4) for stroke, and 1.8 (95% CI 1.4 to 2.4) for CVD death. The association of NT-proBNP with CVD events was significantly stronger (P(interaction)=0.05) in participants with than in those without proteinuria. Higher NT-proBNP was not associated with renal disease progression.

CONCLUSIONS

These results suggest that elevated NT-proBNP levels are associated with higher CVD risk among blacks with hypertensive kidney disease. This association may be stronger in individuals with significant proteinuria.

Achieving blood pressure goals globally: five core actions for health-care professionals. A worldwide call to action

The prevalence of hypertension continues to rise across the world, and most patients who receive medical intervention are not adequately treated to goal. A Working Group including representatives of nine international health-care organizations was convened to review the barriers to more effective blood pressure control and propose actions to address them. The group concluded that tackling the global challenge of hypertension will require partnerships among multiple constituencies, including patients, health-care professionals, industry, media, health-care educators, health planners and governments. Additionally, health-care professionals will need to act locally with renewed impetus to improve blood pressure goal rates. The Working Group identified five core actions, which should be rigorously implemented by practitioners and targeted by health systems throughout the world: (1) detect and prevent high blood pressure; (2) assess total cardiovascular risk; (3) form an active partnership with the patient; (4) treat hypertension to goal and (5) create a supportive environment. These actions should be pursued with vigour in accordance with current clinical guidelines, with the details of implementation adapted to the economic and cultural setting.

Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study

Anatomical abnormalities of the cervical spine at the level of the Atlas vertebra are associated with relative ischaemia of the brainstem circulation and increased blood pressure (BP). Manual correction of this mal-alignment has been associated with reduced arterial pressure. This pilot study tests the hypothesis that correcting mal-alignment of the Atlas vertebra reduces and maintains a lower BP. Using a double blind, placebo-controlled design at a single center, 50 drug naïve (n=26) or washed out (n=24) patients with Stage 1 hypertension were randomized to receive a National Upper Cervical Chiropractic (NUCCA) procedure or a sham procedure. Patients received no antihypertensive meds during the 8-week study duration. The primary end point was changed in systolic and diastolic BP comparing baseline and week 8, with a 90% power to detect an 8/5 mm Hg difference at week 8 over the placebo group. The study cohort had a mean age 52.7+/-9.6 years, consisted of 70% males. At week 8, there were differences in systolic BP (-17+/-9 mm Hg, NUCCA versus -3+/-11 mm Hg, placebo; P<0.0001) and diastolic BP (-10+/-11 mm Hg, NUCCA versus -2+/-7 mm Hg; P=0.002). Lateral displacement of Atlas vertebra (1.0, baseline versus 0.04 degrees week 8, NUCCA versus 0.6, baseline versus 0.5 degrees , placebo; P=0.002). Heart rate was not reduced in the NUCCA group (-0.3 beats per minute, NUCCA, versus 0.5 beats per minute, placebo). No adverse effects were recorded. We conclude that restoration of Atlas alignment is associated with marked and sustained reductions in BP similar to the use of two-drug combination therapy.

Rosiglitazone reduces urinary albumin excretion in type II diabetes

This study examines the effect of rosiglitazone on urinary albumin excretion (UAE) in patients with type II diabetes. Urinary albumin: creatinine ratio (ACR) was measured in a 52-week, open-label, cardiac safety study comparing rosiglitazone and glyburide. Patients were randomised to treatment with rosiglitazone 4 mg b.i.d. or glyburide. ACR was measured at baseline and after 28 and 52 weeks of treatment. Statistically significant reductions from baseline in ACR were observed in both treatment groups at week 28. By week 52, only the rosiglitazone group showed a significant reduction from baseline. Similar results were observed for the overall study population and for the subset of patients with baseline microalbuminuria. For patients with microalbuminuria at baseline, reductions in ACR did not correlate strongly with reductions in glycosylated haemoglobin, or fasting plasma glucose, but showed strong correlation with changes in mean 24-h systolic and diastolic blood pressure for rosiglitazone-treated patients (deltaACR vs deltamean 24-h systolic blood pressure, r=0.875; deltaACR vs deltamean 24-h diastolic blood pressure, r=0.755; P < 0.05 for both). No such correlation was observed for glyburide-treated patients. In conclusion, rosiglitazone treatment was associated with a decrease in urinary albumin excretion. These findings suggest a potential beneficial effect of rosiglitazone in the treatment or prevention of renal and vascular complications of type II diabetes.

Choices and goals in the treatment of the diabetic hypertensive patient

The number of people living in the United States who have diabetes and high blood pressure is over 11 million and rising. Together, these two diseases are devastating to the whole body if not aggressively controlled. The tight recommendations put forth by the Joint National Committee VI for better control of blood pressure and control of proteinuria have helped diminish further organ failure in patients with hypertension and diabetes. Combination therapy has been found to be very effective, and one arm should be an angiotensin converting enzyme inhibitor.

Antihypertensive efficacy of candesartan in comparison to losartan: the CLAIM study

An 8-week, multicenter, double-blind, randomized, parallel-group, forced-titration study was conducted to evaluate the antihypertensive efficacy of candesartan vs. losartan in 654 hypertensive patients with a diastolic blood pressure between 95 and 114 mm Hg from 72 sites throughout the U.S. Eligible patients were randomized to candesartan cilexetil 16 mg once daily, or losartan 50 mg once daily. Two weeks following randomization, patients doubled the respective doses of their angiotensin receptor blockers for an additional 6 weeks. At week 8, candesartan cilexetil lowered trough systolic/diastolic blood pressure by a significantly greater amount than did losartan (13.3/10.9 mm Hg with candesartan cilexetil vs. 9.8/8.7 mm Hg with losartan; p less than 0.001). At the same period, candesartan cilexetil also lowered peak blood pressure by a significantly greater amount than did losartan (15.2 to 11.6 mm Hg with candesartan cilexetil vs. 12.6 to 10.1 mm Hg with losartan; p less than 0.05). There were statistically significantly (p less than 0.05) higher proportions of responders and controlled patients in the candesartan cilexetil group (62.4% and 56.0%, respectively) than in the losartan group (54.0% and 46.9%, respectively). Both treatment regimens were well tolerated; 1.8% in the candesartan cilexetil group and 1.6% in the losartan group withdrew because of adverse events. In conclusion, this forced-titration study confirms that candesartan cilexetil is more effective than losartan in lowering blood pressure when both are administered once daily at maximum doses. Both drugs were well tolerated. (c)2001 by Le Jacq.

Hypertension in patients with diabetes. Strategies for drug therapy to reduce complications

Hypertension in diabetic patients must be treated aggressively if patients are to benefit from reduced risk of morbidity and mortality. Diabetes itself must be diagnosed promptly, particularly in at-risk patients, so appropriate lifestyle modifications can be made at the earliest opportunity. Although this may reduce or delay onset of hypertension, antihypertensive drug treatment should be initiated in the diabetic patient with even high-normal blood pressure. Traditional approaches to management of hypertension are inappropriate for most patients with diabetes. While ACE inhibitors, calcium antagonists, angiotensin II receptor blockers, beta blockers, and low-dose diuretics, alone or in combination, all currently have roles in hypertension management, the outcomes of studies now under way may clarify some still unanswered questions about the dangerous combination of high blood pressure and diabetes.

Lack of evidence of blood pressure-independent protection by renin-angiotensin system blockade after renal ablation

BACKGROUND

The superiority of renin-angiotensin system (RAS) blockade in providing renoprotection has been attributed to class-specific blood pressure "(BP)-independent" mechanisms. However, the conventional BP measurement methodology on which such conclusions are based is inherently limited for an accurate assessment of the fluctuating ambient BP profiles. The present studies were undertaken to rigorously examine the relationship of renoprotection to the antihypertensive effects of RAS blockade using chronic BP radiotelemetry in the 5/6 renal ablation model.

METHODS

Rats with 5/6 renal ablation received either no treatment, the angiotensin-converting enzyme inhibitor benazepril at a dose of 25, 50, and 100 mg/L; or the angiotensin receptor antagonist losartan at a dose of 50, 120, and 180 mg/L of drinking H2O; and were followed for seven weeks.

RESULTS

Glomerulosclerosis (GS) at sacrifice (approximately 7 weeks) demonstrated a close correlation with the average systolic BP in untreated (r = 0.76, N = 20), benazepril-treated (r = 0.80, N = 33), losartan-treated (r = 0.83, N = 32), or all animals combined (r = 0.81, N = 85, P < 0.0001 for all correlations). The slope of the relationship between GS and BP (percentage of increase in GS/mm Hg increase in BP) in untreated rats (0.7 +/- 0.14) was not significantly altered by either benazepril (0.96 +/- 0.13) or losartan (0.60 +/- 0.08), indicating that RAS blockade, by either agent, resulted in renoprotection that was proportionate to the achieved BP reductions.

CONCLUSIONS

These data demonstrate that RAS blockade provides renoprotection in the rat remnant kidney model of progressive GS, primarily through "BP-dependent" and not "BP-independent" mechanisms.

Hypertension in patients with diabetes. Overcoming barriers to effective control

The management of diabetic hypertension poses special problems for the medical community. Although patient adherence is often a major barrier to successful management, physicians' beliefs and prejudices also negatively impact treatment. In addition, healthcare organizations need to provide better support to physicians who feel isolated in their efforts to manage diabetic hypertension. Reductions of morbidity and mortality are achievable goals but require aggressive treatment and improved adherence if they are to be reached.

Hypertension in patients with diabetes. Why is aggressive treatment essential?

Hypertension and diabetes are interrelated diseases. Alone, each condition is a risk factor for cardiovascular disease and, together, they strongly predispose to end-stage renal disease, coronary artery disease, and peripheral vascular and cerebrovascular disease. Pharmacologic treatment of hypertension can substantially reduce morbidity and mortality in diabetic patients with hypertension, but adequate control of blood pressure is seldom achieved in a clinical setting. More aggressive treatment is needed to improve the prognosis for this over-expanding patient population.

Diabetic hypertensive patients: improving their prognosis

Diabetes is a devastating disease with multiple adverse effects on the vasculature. Moreover, hypertension is a prerequisite for patients with diabetes to progress to end-stage renal disease and to develop cardiovascular complications. Adequate control of blood glucose and blood pressure are the two most important factors that predict a favorable renal outcome. Recent studies have also shown that some classes of antihypertensive medications, such as the angiotensin-converting enzyme (ACE) inhibitors, may be ideal initial agents to control blood pressure in the hypertensive diabetic patient and thus to preserve renal function. In addition, nondihydropyridine calcium-channel blockers have been shown to retard the decline in renal function in patients with non-insulin-dependent diabetes mellitus (NIDDM) nephropathy who have lost at least 50% of their renal function. Retrospective analyses demonstrate that a reduction in blood pressure, especially to levels of <130/85 mg Hg in diabetic patients, retards the progression of renal disease. Reduction in arterial pressure to these low levels is probably more important than the agents used to achieve this goal. Because many of these patients require more than one medication to achieve these lower levels of arterial pressure, it is clear that fixed-dose combinations of such agents will both improve the likelihood of achieving a given blood pressure goal as well as medication compliance.

Role of vasopressin in essential hypertension: racial differences

BACKGROUND

Arginine vasopressin (AVP), in addition to being an antidiuretic hormone, might also have pressor effects relevant to the maintenance of hypertension. Results from several experimental and clinical studies suggested that the pressor function of AVP is more important in low-renin hypertension and in the salt-loaded state and that it might be further maximized under sympathetic suppression.

OBJECTIVE

To assess whether selective vasopressin receptor inhibition lowers the blood pressure in a racially diverse group of low-renin hypertensive subjects.

METHODS

Thirty-nine hypertensive subjects (16 Caucasian, 23 African-American) eating a 200 mmol/day sodium diet were administered a single intravenous dose of a selective vasopressin receptor antagonist and their blood pressure was monitored constantly for the ensuing 3 h. The protocol was repeated 3 days later after treatment with a single oral dose of 0.4 mg clonidine.

RESULTS

Of these patients, 54% had their blood sampled for determination of hormone profiles. African-Americans with hypertension had higher baseline plasma AVP levels than did Caucasians (1.13 +/- 0.05 versus 0.37 +/- 0.06 pg/ml, respectively, P < 0.05), and lower plasma renin activity (0.34 +/- 0.07 versus 1.03 +/- 0.08 ng/ml per h, respectively, P < 0.05). Selective vasopressin receptor inhibition lowered the mean arterial pressure in African-Americans but not that in Caucasians (lowering by 28 +/- 4 mmHg in African-Americans versus lowering by 5 +/- 3 mmHg in Caucasians, P < 0.05). Moreover, vasopressin receptor blockade further reduced the arterial pressure in African-Americans but not that in Caucasians after pretreatment with clonidine.

CONCLUSION

AVP seems to play a more important role as a pressor hormone in maintaining the elevation of arterial pressure in African-American hypertensives than it does in Caucasian hypertensives.

Effects of an ACE inhibitor combined with a calcium channel blocker on progression of diabetic nephropathy

It is clear that angiotensin-converting enzyme (ACE) inhibitors slow progression of diabetic nephropathy to a greater extent than other antihypertensive agents when blood pressure (BP) is reduced to levels below 140/90 mm Hg. Recent studies also demonstrate that nondihydropyridine calcium channel blockers (NDCCBs) slow progression of diabetic nephropathy in people with pre-existing renal insufficiency secondary to non-insulin dependent diabetes mellitus. The combined effects of both a CCB and ACE inhibitor have recently been examined in both animal models of diabetes as well as patients with established diabetic nephropathy. These studies demonstrate the following points: (a) at comparable BP levels, a combination of an ACE inhibitor with a NDCCB result in a greater reduction in proteinuria when compared to either components alone; and (b) conversely, addition of an ACE inhibitor to a dihydropyridine CCB (DCCB) yields effects on proteinuria similar to the ACE inhibitor alone. Therefore, addition of an ACE inhibitor to a DCCB demonstrates protection against the effects of DCCB alone. Addition of an ACE inhibitor to a NDCCB does not potentiate the preservation of renal morphology associated with progression of diabetic nephropathy when compared to either of its components alone. Conversely, a DCCB/ACE inhibitor combination yields morphologic results similar to the ACE inhibitor alone. Taken together these results suggest that ACE inhibitors when combined with a NDCCB result in greater reductions in proteinuria, and similar preservation of renal morphology when compared to either of its components alone.

Newer approaches to antihypertensive therapy. Use of fixed-dose combination therapy

Despite the availability of many newer antihypertensive agents, hypertensive patients remain at higher risk of premature death than the general population. This persistence of morbidity and mortality may be accounted for by the frequent failure to achieve adequate blood pressure reduction despite an extensive array of available antihypertensive agents. Such considerations have led to reassessment of the potential role of fixed-dose combination agents in the antihypertensive armamentarium. The rationale for combination therapy relates to the concept that antihypertensive efficacy may be enhanced when 2 classes of agents are combined. In addition, combination therapy enhances tolerability-1 drug of a fixed combination can antagonize some of the adverse effects of the second drug. Fixed-dose combination therapy simplifies the treatment regimen, preventing treatment failures that might result from missed doses. An additional novel concept is the possibility of enhancing salutary effects on target organs, including regressing left ventricular hypertension and retarding progression of renal disease, by combination therapy over and above the effects expected from the fall in arterial pressure alone. The recent approval by the Food and Drug Administration of 2 fixed-dose angiotensin-converting enzyme inhibitor/calcium antagonist combinations has focused attention on and prompted reexamination of this issue.

Effects of different antihypertensive treatments on morphologic progression of diabetic nephropathy in uninephrectomized dogs

We previously reported the renal hemodynamic effects of different antihypertensive regimens in uninephrectomized, alloxan-induced, diabetic (DM) beagle dogs following one year of treatment. Dogs were prospectively randomized to one of five groups (N = 26): nondiabetic controls, Group I; dogs with DM on no antihypertensive drugs, Group II; dogs on a converting enzyme inhibitor, lisinopril (L), Group III; dogs on a calcium antagonist, TA3090 (diltiazem-like), Group IV; and dogs on a combination of each drug, in reduced doses, Group V. The current paper extends our previous studies by describing the morphologic changes that occurred within each group of dogs studied. More than 100 glomeruli from the renal cortex of each dog were evaluated for increases in mesangial volume fraction (Vv), glomerulosclerosis (GS) and ateriolar hyalinosis. The interstitium was also evaluated for associated changes. Increases in Vv were attenuated in all treated groups (0.28 +/- 0.04, DM alone versus 0.16 +/- 0.05 L; 0.21 +/- 0.07, TA-3090; 0.19 +/- 0.06 micron 2/micron 2, L+TA 3090; P < 0.05) compared to untreated DM. An attenuated increase in Vv also correlated with a blunted rise in proteinuria in Groups III (r = 0.79) and V (r = 0.81) but not Group IV (r = 0.29). Development of focal GS was blunted in all treated groups; however, global GS was fourfold greater in Group IV compared to untreated DM. The degree of interstitial fibrosis also correlated with the degree of global GS. These data support the concept that both a converting enzyme inhibitor and heart rate lowering calcium antagonist attenuate morphologic progression of diabetic renal disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Antihypertensive therapy and progression of diabetic renal disease

A number of changes in intrarenal hemodynamics and morphology are characteristic of diabetic nephropathy. These changes include: increases in intraglomerular pressure and volume, glomerular capillary permeability to macromolecules, and mesangial matrix expansion. Most antihypertensive drugs attenuate some of the increases in these parameters. Certain antihypertensive agents, however, have effects on all these parameters. Studies in animal models of diabetes demonstrate that the angiotensin-converting enzyme (ACE) inhibitors reduce both intraglomerular volume and pressure, mesangial matrix expansion, and albuminuria. The calcium antagonists TA-3090 (diltiazem-like) and verapamil recently have been shown to have most of these effects. Conversely, the dihydropyridine calcium antagonists (nifedipine, felodipine, nitrendipine) do not attenuate increases in most of these parameters. In several clinical studies, nifedipine either did not affect or increased urinary albumin excretion in diabetic patients with renal insufficiency. Moreover, in animal models of diabetes, most dihydropyridine compounds do not prevent progression of glomerulosclerosis in spite of blood pressure control. Although the majority of clinical studies support the concept that reduction of arterial pressure preserves renal function, recent long-term clinical studies show that ACE inhibitors and heart-rate-lowering calcium antagonists (diltiazem, verapamil) attenuate progression of diabetes to a greater extent than most other agents do.

Renal effects of antihypertensive medications: an overview

A variety of antihypertensive agents are available for management of elevated arterial pressure. Although these agents all effectively lower arterial pressure, they have somewhat diverse renal hemodynamic profiles. This report reviews the various similarities and differences in renal hemodynamic profiles among the different antihypertensive agents.

Exfoliative dermatitis secondary to tobramycin sulfate

We report a case of exfoliative dermatitis clearly linked to intravenous and intraperitoneal administration of tobramycin. Despite the complicated drug regimen with which the patient was treated, tobramycin was implicated by rechallenge with the drug once before its role was understood and again at an outside hospital.

A liquid chromatographic assay for 5-hydroxytryptophan, serotonin and 5-hydroxyindoleacetic acid in human body fluids

We describe the precision and accuracy of a liquid chromatographic method, which uses internal standards, 6-fluoroserotonin and 5-hydroxyindolecarboxylic acid, in quantitating serotonin and 5-hydroxyindoleacetic acid in human cerebrospinal fluid, plasma and urine. In addition, 5-hydroxytryptophan is measured in the cerebrospinal fluid. The limit of sensitivity of this method is 0.1 pmol/injection, the peak height/concentration ratio is linear in the concentration range of 0.1 pmol to 50 mumol/injection, and the coefficient of variation is of the order of 15% at the limit of sensitivity and below 10% at amounts above 0.5 pmol/injection. No endogenous monoamines or their metabolites interfere with the quantitation of the substances of interest in the body fluids studied.