[About the purple urine bag syndrome]

Urine staining is described as a clinical sign due to the presence of some diseases. The purple colour is rare and can be worrisome. It has only been described in a syndrome called Purple Urine Bag Syndrome (PUBS). This coloration is the result of a urinary tract infection in patients with an indwelling catheter for a long time. An overview of the mechanisms causing this syndrome and of its management and prognosis will be discussed in this short communication.

[Autosomal dominant polycystic kidney disease : a pediatric perspective]

Polycystic kidney disease (PKD) is the most prevalent inherited kidney disease. The disease is usually asymptomatic until adulthood. End-stage renal disease occurs generally after the age of 55 years, with a large inter-individual variability. Renal cyst formation begins early in life, and animal models have shown that treatments able to prevent the cyst growth slow down the renal function decline. A treatment by tolvaptan is currently used in adults to decelerate PKD progression. Until now there is no consensus about the appropriate time to screen for PKD in children. However, these scientific progresses raise the interest of determining early (i.e. pediatric) predictive markers of renal function decline.

[COVID-19 inside dialysis units]

COVID-19 has been the center of global attention and concern for the last months. Patients undergoing dialysis and especially those treated at the hospital are likely to be infected, due to their mandatory presence at the hospital several times a week and due to their intrinsic fragility in regard of chronic kidney disease, often an older age, and the presence of many associated comorbidities. Thereby, patients with chonic kidney disease treated by haemodialysis have higher odds of a more severe COVID-19 infection with a high mortality rate. Prevention is thus a high priority for these patients.

[Kidney injury in COVID-19]

The SARS-CoV-2 virus causes a respiratory distress syndrome, the main symptom of COVID-19 (for "COronaVIrus Disease 2019"). This infectious disease has been causing a major health and socio-economic pandemic since December 2019. The pulmonary alveolus is regarded as the main target of SARS-CoV-2. However, this coronavirus is capable of directly or indirectly affecting other organs, including the kidneys. Here, we summarize the presumed pathophysiology of COVID-19 renal disease. The incidence of acute kidney injury ranges from 0,5 to 22 % of all patients infected with SARS-CoV-2. The need for renal replacement therapy is reported in 5-9 % of patients in intensive care. Histological analysis of renal biopsies mainly shows acute tubular necrosis of varying severity, as well as the congestion of glomerular and peri-tubular capillaries. Endothelitis has been described in few cases. Evidence for a factual inflammation of the glomerulus remains controversial. The medium/long term consequences of COVID-19 nephropathy are unknown and will deserve a tight follow-up.

[Arguments for a role of the gut microbiota in the pathophysiology of hypertension]

The gut microbiota refers to the community of microorganisms living in the mammalian digestive tract. Over the past decades, numerous preclinical and clinical studies have suggested that gut microbiota is involved in the physiological homeostasis of the host, particularly in the immune and metabolic systems. Furthermore, the dysfunction of gut microbiota, also called "dysbiosis", has been associated with various diseases, such as the metabolic syndrome or chronic kidney disease. In this review, we summarize the knowledge about the possible role of gut microbiota in the development of arterial hypertension. We detail the pathophysiological mechanisms, namely involving short-chain fatty acids produced by the bacterial fermentation of food carbohydrates. These metabolites are reabsorbed by the intestinal mucosa and interact with a multitude of G-protein coupled receptors at the surface of cells involved in blood pressure regulation, including renal tubular cells. These observations open up innovative diagnostic and therapeutic approaches in arterial hypertension, which is a major public health problem.

[Novelties in arterial hypertension management in the last decade]

Hypertension remains one of the most important cardiovascular risk factors. In spite of many efforts for its management, the control of high blood pressure remains insufficient. In the last decade, no new antihypertensive drug was released. The main effort to improve blood pressure control was put on the validation of the hypertensive status, the stimulation of home blood pressure measurement and the therapeutic education of the patients. The releasing in 2018 of new guidelines, which are clear and more simple, would help more efficiently fight against hypertension, the still present silent killer. In Europe, the usual blood pressure target has been kept, i.e.a lowering of blood pressure below 140/90 mmHg in all fit patients whatever their age. Lower target could be proposed according to the patient tolerance. Treatment is decided according to cardiovascular risk evaluation. Quickly a combination of two antihypertensive agents in a single pill is proposed to improve efficacy of the treatment. We also need the help of the family, nurses and pharmacists to increase the chance of a better blood pressure control, which is necessary to get an optimal cardiovascular protection.

[Therapeutic innovation in nephrology : 10 years of progress]

Chronic kidney disease (CKD) impairs the quality of life and increases the risk for cardiovascular morbimortality. Intensive research is conducted in order to slow down CKD development and progression. During the past decade, a better understanding of the pathophysiological mechanisms of glomerular diseases has highlighted the benefits of rituximab. Progresses have also been made in the understanding of the mechanisms of autosomal polycystic kidney disease, the most frequent inherited kidney disease. These observations led to the discovery and validation of tolvaptan, a blocker of the V2 receptor of the antidiuretic hormone as an innovative treatment. Type 2 diabetic disease is the leading cause worldwide of endstage kidney disease and dialysis. The development of new drugs, such as the gliflozins (inhibiting the sodium glucose reabsorption in the proximal tubule), has contributed to an improvement in the management of the cardiovascular and renal risks especially reducing congestive heart failure rate. Another important progress in nephrology since the beginning of the new century concerns a more precise estimation of the kidney function, which allows to better evaluate the slope of CKD progression and test the influence of different therapeutic approaches aiming at correcting anemia, hyperkalemia, metabolic acidosis and disturbances of calcium and phosphate. The present review summarizes all of these major advances in the field of CKD diagnosis and treatment, and envisions the future of nephrology for the next decade.

[Input of genetic analyses in the differential diagnosis of kidney cysts]

The incidental finding of renal cysts is a common clinical situation given their high prevalence (~ 50 % after the age of 50) and the continuous improvement of abdomen imaging. Diagnosis is central to appropriately dictate the management of the patient. During the diagnostic work-up, it is important to consider (i) the aspect of the cysts, (ii) their number, (iii) and their location, as well as (iv) the age of the patient and his/her personal and familial medical history, (v) the presence of extra-renal manifestations, (vi) and the renal function (including the urinary sediment). Starting from an atypical clinical case characterized by a rapidly evolving chronic kidney disease associated with bilateral renal cysts, we review the classical diagnostic work-up of kidney cysts. As a conclusion, we propose a diagnostic algorithm including both acquired and hereditary nephropathies.

[New 2018 European guidelines for the management of hypertension and comparison with the 2017 American guidelines]

New European guidelines for high blood pressure management have just been published in 2018, modifying those published in 2013 and may be seen as a response to those published by the American societies late 2017. The latter proposed a new definition of hypertension (blood pressure equal or higher than 130/80 mmHg), a therapeutic approach based on the evaluation of the cardiovascular risk, and a blood pressure target inferior to130/80 mmHg in all patients, even those older than 80 years still valid. The European guidelines, on the contrary, maintain the definition threshold of hypertension to a blood pressure equal or higher than 140/90 mmHg. This diagnosis remains based on blood pressure determination at the medical office, confirmed if possible by the use of out of the clinic blood pressure measurements such as home blood pressure and/or 24h ambulatory blood pressure measurement. In comparison with 2013, these new guidelines are closer to the American ones for the management, with the need to evaluate the cardiovascular risk before deciding to initiate a drug treatment in addition to lifestyle and diet measures. A medical therapy will be initiated if the risk is very high for blood pressure in the range of high normal blood pressure (130-139/85-89 mmHg). The blood pressure target should be inferior to 130/80 mmHg in people inferior to 65 years. For those older the blood pressure target should be inferior to 140 mmHg but superior to 120 mmHg. The antihypertensive therapy would be, in the majority of the population, a two-drug combination, if possible in a single pill to enhance the medication compliance that should be frequently checked. If the blood pressure lowering remains resistant to three drugs including a diuretic used at high dose, spironolactone would be recommended, at a low dose. In comparison with 2013, the device-based therapies (renal denervation) are no longer recommended.

[How I explore… a proteinuria]

The measurement of proteinuria is a very simple tool to screen and manage kidney diseases. Its predictive role is also relevant from a cardiovascular point of view. However, the interpretation of the results is not always easy. Indeed, there are several different methods to detect or measure proteinuria (or albuminuria), varying from the measurement on a 24-hour urine collection to the simplest detection with dipsticks or measurement on a random urine sample. Some methods are measuring total proteins, whereas others are measuring more specifically albuminuria. For all methods, pitfalls exist and will be discussed. A positive result must be confirmed by a quantitative measurement on 24-hour collection or on a first morning sample (this last one can only be interpreted as a ratio to urinary creatinine excretion). Lastly, we will briefly discuss the management of a patient with a new diagnosis of proteinuria (or albuminuria).

[Hypertensive crisis]

Hypertensive crisis has fortunately become rarer due to a better diagnosis and management of arterial hypertension. However, its development needs urgent management with adapted therapy according to the severity of the blood pressure levels and the associated clinical signs. After confirmation of severe hypertension (blood pressure above or equal to 180/120 mmHg), target organ lesions have to be looked for and according to their pre-sence, an urgent hospitalization has to be immediately organized. Starting active drug therapy often occurs in intensive units with the intravenous route of administration.

[Bradykinin and cardiovascular protection. Role of perindopril, an inhibitor of angiotensin conversion enzyme]

The endothelium plays a vital role as part of the cardiovascular continuum. Risk factors such as hypertension and dyslipidemia unbalance angiotensin II - bradykinin homeostasis, leading to endothelial dysfunction and changes in vascular structure that promote atherosclerosis and thrombosis. When dealing with risk factors, treatment should focus on the prevention and restoration of endothelial function. Not all cardiovascular drugs are able to reverse vascular and structural endothelial dysfunction. Increasing levels of bradykinin is an effect of the use of angiotensin-converting enzyme inhibitors (ACE-Is), and also a fundamental part of their mode of action. The cardiovascular protection observed with ACE-I, and not with sartans, can be explained rationally by the specific effects of bradykinin on the endothelium. In the pharmacological class of ACE-Is, perindopril likely produces the strongest effects on bradykinin, which may explain, at least in part, the documented superiority of this drug in the prevention and treatment of cardiovascular disease.

[Which place for thiazide and thiazide-like diuretics in patients with type 2 diabetes ?]

The use of thiazides as antihypertensive agents has been challenged because associated metabolic adverse events, including new-onset diabetes. However, these metabolic disturbances are less marked with low-dose of hydrochlorothiazide and with thiazide-like diuretics such as chlorthalidone and indapamide. In post hoc analyses of subgroups of patients with hypertension and type 2 diabetes, thiazide(-like) diuretics resulted in a significant reduction in cardiovascular events, all-cause mortality and hospitalization for heart failure compared to placebo. Furthermore, they were shown to be non-inferior to other antihypertensive agents, including blockers of the renin-angiotensin system in diabetic patients without albuminuria. Benefits attributed to thiazide(-like) diuretics (especially at low dose) in terms of cardiovascular protection outweigh the risk of worsening glucose control and inducing other metabolic disorders in patients with type 2 diabetes. Thus low dose thiazide(-like) drugs still play a major role in the treatment of hypertension in patients with type 2 diabetes.

Performance of glomerular filtration rate estimation equations in Congolese healthy adults: The inopportunity of the ethnic correction

Context and objective

In the estimation of glomerular filtration rate (GFR), ethnicity is an important determinant. However, all existing equations have been built solely from Caucasian and Afro-American populations and they are potentially inaccurate for estimating GFR in African populations. We therefore evaluated the performance of different estimated GFR (eGFR) equations in predicting measured GFR (mGFR).

Methods

In a cross-sectional study, 93 healthy adults were randomly selected in the general population of Kinshasa, Democratic Republic of the Congo, between June 2015 and April 2016. We compared mGFR by plasma clearance of iohexol with eGFR obtained with the Modified Diet in Renal Disease (MDRD) equation with and without ethnic factor, the Chronic Kidney Disease Epidemiology (CKD-EPI) serum creatinine (SCr)-based equation, with and without ethnic factor, the cystatin C-based CKD-EPI equation (CKD-EPI SCys) and with the combined equation (CKD-EPI SCrCys) with and without ethnic factor. The performance of the equations was studied by calculating bias, precision and accuracy within 30% (P30) of mGFR.

Results

There were 48 women and 45 men. Their mean age was 45.0±15.7 years and the average body surface area was 1.68±0.16m². Mean mGFR was 92.0±17.2 mL/min/1.73m² (range of 57 to 141 mL/min/1.73m²). Mean eGFRs with the different equations were 105.5±30.1 and 87.2±24.8 mL/min/1.73m² for MDRD with and without ethnic factor, respectively; 108.8±24.1 and 94.3x20.9 mL/min/1.73m² for CKD-EPI SCr with and without ethnic factor, respectively, 93.5±18.6 mL/min/1.73m² for CKD-EPI SCys; 93.5±18.0 and 101±19.6 mL/min/ 1.73m² for CKD-EPI SCrCys with and without ethnic factor, respectively. All equations slightly overestimated mGFR except MDRD without ethnic factor which underestimated by -3.8±23.0 mL/min /1.73m². Both CKD-EPI SCr and MDRD with ethnic factors highly overestimated mGFR with a bias of 17.9±19.2 and 14.5±27.1 mL/min/1.73m², respectively. There was a trend for better P30 for MDRD and CKD-EPI SCr without than with the ethnic factor [86.0% versus 79.6% for MDRD (p = 0.21) and 81.7% versus 73.1% for the CKD-EPI SCr equations (p = 0.057)]. CKD-EPI SCrCys and CKD-EPI SCys were more effective than creatinine-based equations.

Conclusion

In the Congolese healthy population, MDRD and CKD-EPI equations without ethnic factors had better performance than the same equations with ethnic factor. The equations using Cys C (alone or combined with SCr) performed better than the creatinine-based equations.

[HYPERURICEMIA AND POTENTIAL RISK OF CARDIOVASCULAR AND RENAL DISEASES]

Besides the well accepted need to treat hyperuricemia associated with gout, some large observational studies and small prospective therapeutic trials have suggested that treating asymptomatic hyperuricemia, especially by xanthine oxidase inhibition, the enzyme producing uric acid, could be beneficial for cardiovascular and renal risk prevention. This article discusses the literature about this promising approach, which, however, requests prospective validation.

[Management of hypophosphatemia: a case report]

Hypophosphatemia is defined by a serum phosphate level lower than 0.8 mmol/l. If hypophosphatemia is chronically maintained, it is associated with muscular, osteous, neurological or cardio-respiratory disorders. We describe a patient with isolated hypophosphatemia, detail the mechanisms of phosphate homeostasis, and envisage the differential diagnosis of hypophosphatemia. Furthermore, we propose a sequential decisional algorithm based on basic biological tests and few complementary investigations. Treatment options are reviewed.

[Depression as a common complication of systemic lupus erythematosus]

Systemic lupus erythematosus (SLE) is an inflammatory disease with multiple and disabling consequences, including the psychological status. The prevalence of major depressive episodes among patients suffering from SLE is significantly higher than in healthy people, or people suffering from other inflammatory diseases. While it is obvious that its chronic disease status with a frequently pejorative ending, as well as the number of treatments it requires, are contributing factors, it is likely that due to its pathogenic mechanisms, SLE causes direct injury to the brain, leading to a depressive symptomatology. Numerous hypotheses are under consideration. We shall review them all, recall a few epidemiologic features, add histology and medical imaging contributions and discuss the importance of setting up a fitting therapy for such patients.

[Fixed dose combination perindopril-indapamide-amlodipine (Triplixam) for the treatment of arterial hypertension]

Triplixam is a fixed dose combination of three well known antihypertensive agents, with complementary activities, to control blood pressure in patients with arterial hypertension: perindopril, an angiotensin converting enzyme inhibitor, indapamide, a diuretic whith thiazide-like effects but also specific properties, and amlodipine, a long-acting calcium antagonist of the dihydropyridine family. The potential synergic action allows better control of blood pressure with once daily administration, while limiting the incidence of adverse events. Various presentations with different dosages are available to facilitate individualized therapy. Warnings and precautions for use of every molecule should of course be respected. Such a fixed dose combination should contribute to limit clinical inertia and to improve therapeutic compliance.

[How to manage chronic kidney disease in the elderly?]

From age 30 onwards, kidney function physiologically decreases although this deterioration cannot yet be called chronic kidney disease. The latter appears in those exposed to cardiovascular risk factors associated with inflammation and oxidative stress. A diffuse atherosclerosis then develops Patients with a decreased glomerular filtration rate, especially below the threshold of 45 ml/min, are characterised by a poor physical heath and by cognitive disorders, leading to frailty. In these conditions, a management strategy to reduce the increased risk of acute kidney injury should be outlined and the need for renal replacement therapy be considered. One must try to maintain the best possible quality of life, promoting in some situations a conservative approach.

[Management of arterial hypertension in the elderly]

High blood pressure is very frequent in the elderly; it represents a real threat for the patient's health and a source of huge costs for the economic system. Systolic hypertension is the most frequent form observed in the old, due to large arteries stiffness. Antihypertensive therapy has proven effective to decrease significantly the cardiovascular morbi-mortality and total mortality in this population. A non pharmacological approach is also very useful, but should not be too restrictive. Blood pressure target in patients older than 65 (and, particularly, in octogenarians) is 150/80 mmHg. Blood pressure should be checked in the upright position before changing the drug dosage. The first line therapy in the old should generally be a calcium channel antagonist or a low dose diuretic.

[New guidelines for hypertension management in 2013]

The 2013 guidelines for arterial hypertension have just been released by the European Societies of Cardiology and Hypertension. As already discussed in earlier versions, the decision to treat must be based on the assessment of the cardiovascular risk. The value of out-of-the office blood pressure measurements to confirm the diagnosis of hypertension is underlined and the authors stress the need for a close follow up of non pharmacological therapeutic measures. A novelty, however, consists in the simplification of the blood pressure target under treatment, which must be < 140/90 mmHg in the vast majority of patients, except for octogenerians whose systolic blood pressure target should be < 150 mmHg. For resistant hypertension, renal denervation and carotid baroreceptor stimulation are proposed as new invasive modes of therapy; their clinical values, however, remain to be confirmed.

[Which blood pressure targets in patients with type 2 diabetes?]

Arterial hypertension is commonly observed in patients with type 2 diabetes and aggravates cardiovascular and renal outcomes. Lowering blood pressure is thus a key objective in this population. However, systolic and diastolic blood pressure levels to be reached remain controversial and targets should probably be adjusted according to patient's individual characteristics ("personalized medicine"). This clinical case summarizes the main arguments for selecting blood pressure targets, as far as benefits/risks ratio is concerned, in type 2 diabetic patients with a metabolic syndrome but without complications, with a nephropathy, or with coronary artery disease.

[Dizziness: hypoglycemia, hypotension or spasmophilia?]

The consultation for dizziness is a common problem in clinical practice. Because of the apparent lack of specificity of the complaints, there is a rather high risk to prescribe a variety of sophisticated exams, which will not be very helpful in absence of a well oriented anamnesis and a pertinent clinical examination. The present paper aims at describing a global medical approach, essentially based upon a detailed anamnesis (semiological, chronological and therapeutical arguments), to which may be added a few simple clinical and technical complementary data. This strategy should allow obtaining quite easily pertinent arguments for a differential diagnosis between reactive hypoglycaemia, (orthostatic) hypotension, and hyperventilation crisis (spasmophilia).

[Clinical vignettes. How to diagnose the cause of edema, a clinical approach]

Oedema is a frequent disorder and the easily detectable consequence of an increase of fluid located in the interstitial tissue. It could be localized or generalized and related either to a primary disturbance of hemodynamics at the capillary level, due to a modification of the Starling's law components with secondary water and saline retention, or to a primary retention of salt and water linked to a kidney abnormality. Generalized forms are pitting oedema, most often painless, white, bilateral and symmetric, distributed at the lower part of the body (localisation according to the gravitation law). They are different in their characteristics from localized oedema or lymphoedema which are tough. We propose a diagnostic approach based on medical history, clinical examination which allows a confident medical diagnosis and so an adapted therapy.

[A rare cause of acute renal failure, acute tubulo-interstitial nephritis]

We report the case of an acute renal failure due to an acute interstitial nephropathy (ATIN) induced by non steroidal anti-inflammatory drugs (NSAID). Even though this pathology is a rare cause of acute renal failure, it still requires special attention in view of the fact that it induces a high risk of acute morbidity but it also can evolve into chronic renal failure. Its differential diagnosis with other causes of acute renal failure becomes essential because of the different therapeutic care. In this article, we are going to briefly sum up the reasoning to adopt in order to diagnose an acute renal failure.

[Therapeutic inertia in hypertension: why and how to fight against this attitude?]

Therapeutic inertia, i.e. the absence of introduction of an antihypertensive treatment or on adjustment of its intensity by the medical doctor if the blood pressure is elevated or the goal not reached, is frequent and does play a role in the insufficient control of blood presure in the hypertensive population. The responsibility of the medical doctor is high in this respect. A strict medical approach is required, step by step, to correct this lack of reaction.

[Importance of a bad adherence to the antihypertensive treatment in the hypertensive population. How to improve it?]

Overwhelming evidence indicates that the treatment of arterial hypertension is beneficial, but, in practice, less than 50% of treated hypertensive patients have well-controlled blood pressure. The success of treatment relies upon adherence (for both non pharmacologic and drug treatment) by the patient. This problem of observance is multifactorial. Several factors play a role: the patient, his/her illness, his/her treatment and the therapeutic environment where the relationship between the medical doctor and the patient is crucial. To improve observance, but also treatment persistence we need to think about it. Observance must be discussed with the patient at each visit. An excellent relationship between doctor and patient, education about hypertension, its risks, and the ways to avoid complications, the choice of a well tolerated and simple treatment progressively introduced, the intervention in this management of the family and the pharmacist, the development of home self blood pressure measurement by the patient are all important ways to improve adherence. This could reduce the cardiovascular complications related to high blood pressure and thus decrease the general costs for the society.

[The therapeutic compliance in solid organ transplantation. The case of renal transplantation]

A successful transplantation implies that immunosuppressive drugs will have to be taken during the whole patient's life. Poor drug compliance is a multifactorial problem, that is particularly dangerous in organ transplantation as it can lead to loss of graft function and return to dialysis treatment. The medical doctor must stimulate the patient's adherence to the strict therapeutic drug protocol. The patient must also be reminded at each medical consultation of the importance of such rigorous drug intake. This bad (or non) compliance is particularly well demonstrated a long time after transplantation. The medical staff, all the health participants, but also the family members must continuously fight against non compliance, which is inherent to any chronic disease.

Are ACE-inhibitors or ARB's still needed for cardiovascular prevention in high risk patients? Insights from profess and transcend

The HOPE and EUROPA clinical studies have shown that treatment with the angiotensin-converting enzyme (ACE) inhibitors, ramipril and perindopril, may reduce the occurrence of major cardiovascular events in patients with proven atherosclerotic disease. The recently published results of the PRoFESS and TRANSCEND trials completed the much needed information concerning the use of an angiotensin receptor blocker for patients at high risk of cardiovascular events. PROFESS compared a therapy of telmisartan 80 mg daily with placebo in patients with a recent ischemic stroke. The difference in the primary outcome of first recurrent stroke was not statistically significant between telmisartan and placebo. The secondary outcome of major cardiovascular events showed a relative risk reduction (RRR) of 7% in favour of telmisartan. This tended to be significant (p = 0.06) despite a rather short follow-up period of only 28 months. In TRANSCEND 5926 patients at high risk for cardiovascular events were randomized to a treatment with telmisartan 80 mg daily or placebo for a mean duration of follow-up of 56 months. The primary composite outcome of cardiovascular death, myocardial infarction, stroke or hospitalization for heart failure showed a non-significant 8% RRR in favour of the telmisartan treated patients. The main secondary outcome of cardiovascular death and myocardial infarction or stroke as used in the HOPE trial showed a non-significant RRR of 13% in favour of telmisartan treated patients (p = 0.068 adjusted for multiplicity of comparisons). In comparing the Kaplan-Meier curves for the endpoint of major cardiovascular events used in HOPE, EUROPA, TRANSCEND and PRoFESS, the trends are similar. Results of most of the recently published trials have been neutral.This could partly be explained by major improvements in the optimal background therapy of the patients included. Nevertheless, the results of PRoFESS and TRANSCEND do not contradict the results from previous studies with theACE inhibitors ramipril and perindopril and the ARB telmisartan.

How to treat hypertension in blacks: review of the evidence

Presentation, response to therapy, and clinical outcome differ according to race for patients with hypertension. Black patients have a higher prevalence and earlier onset of hypertension than other ethnic groups, with poorer prognosis than white patients. Blacks are more likely to be salt-sensitive, and to have a low plasma renin activity than are whites. They are at much greater risk of developing cardiovascular and renal complications. Despite many advances in the understanding and treatment of cardiovascular diseases, black patients continue to have increased morbidity and mortality from the end-organ complications of hypertension. The explanations for these observations remain incompletely understood, but genetic differences, added to socio-economic and environmental factors, have been proposed to explain this disparity. The first therapeutic approach is to decrease salt and increase potassium intakes. Diuretics (thiazides and potassium-sparing agents) and calcium channel blockers constitute the first antihypertensive drug choices. The angiotensin-converting-enzyme inhibitors, the angiotensin II receptor blockers and beta-blockers appear to be less effective in blacks with regard to uncomplicated hypertension, especially in older people, but addition of a small dose of diuretic improves their efficacy. These combinations are preferred among patients with chronic kidney disease or heart failure. The goal for blood pressure target is the same in blacks as it is in whites, being a blood pressure of less than 140/90 mmHg in uncomplicated hypertension and less than 130/80 mmHg in patients with diabetes mellitus or chronic kidney disease.

[Advances concerning aliskiren, direct renin inhibitor and aliskiren-hydrochlorothiazide]

Aliskiren (Rasilez), a direct renin inhibitor, is currently indicated for the treatment of essential hypertension, as monotherapy or in combination, especially with hydrochlorothiazide (Rasilez HCT). It may also be use to obtain a more complete blockade of the renin-angiotensin-aldosterone system (RAAS) when it is associated with an angiotensin converting enzyme inhibitor (ACEI) (or an AT1 angiotensin receptor antagonist) (ARA). There is some room for agents that may be more efficacious in reducing the progression of diabetic nephropathy than ACEI or ARA. In this context, the dual blockade of RAAS most probably offers a better efficacy than the simple blockade, but also exposes to a higher risk. Should ongoing trials confirm the preliminary favourable results, aliskiren might reach a forefront position among the armamentarium now available to optimize the RAAS blockade. The present article will summarize advances concerning the biochemical effects of the specific mode of action of aliskiren, especially the potential interferences related to increased renin/pro-renin levels, as well as results of recent clinical trials, not only in hypertension, but also in the fields of diabetes, renal insufficiency and cardiology. The objectives and design of the landmark study ALTITUDE will also be briefly presented.

[Sevikar or Forzaten: olmesartan medoxomil and amlodipine besylate fixed combination in the treatment of hypertension]

The interest for powerful and better tolerated antihypertensive combinations is searched in the field of hypertension, because of a too large number of people still not well controlled. The recent association between an angiotensin receptor blocker, olmesartan, and a long-acting dihydropyridine, amlodipine, reinforces our therapeutic possibilities. The synergistic effect of the two molecules potentiate the antihypertensive activity, which allows improving the quality and the rapidity of the blood pressure control. Furthermore, the fixed combination should improve patient's compliance. The contraindications still remain those of the sartan family. The most frequent side-effect of amlodipine monotherapy, oedema, occurs in a much lower proportion with the addition of olmesartan.

[Monoclonal antibodies in renal transplantation]

Renal transplantation is the best treatment for end-stage renal disease, but requires efficient immunosuppressive therapy. The latter has evolved over recent years with the development of more powerful drugs and of monoclonal antibodies with very specific target. The first monoclonal antibodies, acting against the interleukin 2 receptor, named basiliximab and daclizumab, have showed an excellent tolerance profile and efficacy to reduce acute graft rejection. However, in spite of these properties, the development of delayed graft function or the graft and patient survivals at 1 year were not modified by the use of such specific treatment. One potential advantage could yet be a decreasing need for corticosteroids and sometimes calcineurin inhibitors which could provide some long term benefits for the renal graft, but also the patient. Alemtuzumab, another monoclonal antibody, aimed at the membrane glycoprotein CD52, can also decrease the incidence of acute rejection and the depth of the required immunosuppressive therapy. Other antibodies are still in development with some interesting preliminary results which however demand confirmation in larger studies.

[Why and how should the patient perform a correct home blood pressure measurement?]

Home blood pressure (BP) measurement is a medical prescription. The interpretation of the results must be left to the physician. This method is complementary to the classical office BP measurement and the 24 hour ambulatory blood pressure measurement. It must be proposed to some selected patients on the basis of their capacity of learning and understanding the place of the technique for the diagnosis and the treatment compliance. It allows a more active contribution of the patient to the management of her chronic disease and, this, may improve the prevention of cardiovascular complication. A normal blood pressure during self BP measurement is equal or lower to 135/85 mmHg or even lower in high cardiovascular risk patients. This new technique, already largely used by patients, needs adequate education and good advice for buying a validated device.

[Fixed combination perindopril-amlodipine (Coveram) in the treatment of hypertension and coronary heart disease]

Coveram is a new fixed combination of an angiotensin converting enzyme inhibitor, perindopril, and a calcium antagonist, amlodipine. This new medication is indicated for the treatment of arterial hypertension and/or stable coronary heart disease. Such fixed combination of two molecules that have been extensively evaluated according to evidence-based medicine offers the advantage of an excellent efficacy, associated with a good tolerance profile, and favours patient's compliance. The marketing of different formulations of Coveram combining various dosages allows easy adjustment and titration of each of the components according to the individual patient's characteristics.

[How to manage an arterial hypertension resistant to drug treatment]

The management of arterial hypertension, a well known silent killer, is still a challenge for physicians fighting for an optimal control of blood pressure values. The problem is even more complex when, after a good response, the control of blood pressure becomes again worse. Our case record underscores the different steps allowing to increase the efficacy of blood pressure management in such secondary resistant form of hypertension.

[Detection and estimation of chronic kidney disease]

The prevalence of chronic kidney disease is increasing. An early and precise diagnosis of renal insufficiency requires a measurement of the glomerular filtration rate. Formulas based on serum creatinine to determine the glomerular filtration rate have brought, compared to serum creatinine alone, an improvement in this precision. However, in many clinical conditions, they may give incorrect information. Using 24 h urine collection, calculation of creatinine clearance can be more adequate and accurate in conditions where patient's anthropometric characteristics are far from the normal range. However, this 24 h urine collection is often variable and its validity could be criticized. When a very precise determination of glomerular filtration rate is needed, a method of reference is required such as that using chrome EDTA or iohexol. Each nephrological exploration also needs a urine analysis for detection of proteinuria. When a positive urine dipstick test is noted, a quantification of proteinuria must be done either after 24 h urine collection or more easily by determining the proteinuria/creatininuria ratio on an urine sample.

[Clinical study of the month. The ACCOMPLISH study: challenging the choice of antihypertensive medications in systolic hypertensive patients with high cardiovascular risk]

Arterial hypertension is an important cardiovascular risk factor. The benefit drawn from decreasing and normalizing the blood pressure level is indisputable. The ACCOMPLISH study performed in patients older than 65 with systolic hypertension and a high cardiovascular risk pointed out the interest of well choosing the antihypertensive combination to reduce this risk beyond the decrease of blood pressure. The association of benazepril (an angiotensin converting enzyme inhibitor or ACEI) and amlodipine (a calcium antagonist) has shown significant early cardiovascular protection in such patients as compared to the classic association including the same ACEI and hydrochlorothiazide, in spite of the same target blood pressure reached. This important finding does not contest the interest of a well controlled blood pressure in hypertension, but probably will modify our first antihypertensive combination choice in the future in patients with such cardiovascular profile.

[Management of chronic kidney disease. World Kidney Day, March 13, 2008]

Chronic kidney disease is a worldwide growing problem, especially due to three factors very often encountered together (old age, diabetes mellitus and arterial hypertension). A multidisciplinary approach is needed to reduce this epidemic that has important health implications.This needs of course well trained health partners. On the occasion of the World Kidney Day on March 2008, four lectures were given, which gave an updated overview of the management of chronic kidney insufficiency, a serious problem of public health.

[How to manage chronic kidney disease before dialysis]

Chronic renal failure is usually a silent disease until its late stage, especially in elderly people. Screening for such disease is particularly useful in hypertensive diabetic patients above 50 years. The causes are indeed often vascular or metabolic (directly or not directly linked to diabetes mellitus). Other less frequent causes are yet possible. The search for the right diagnosis of renal insufficiency is always requested to apply the appropriate treatment, combined with medical measures for secondary and tertiary prevention. This review will give general advices to avoid the development of renal disease (stages 3 and 4) or its progression, and also insist on the potential nephrotoxic effects of some drugs.

[Sodium and arterial hypertension --one hundred years of controversies]

Sodium chloride (salt) plays a role in the development and maintenance of high blood pressure (25% of the normotensive population are called sodium sensitive and 50% of the hypertensive people would present a significative decrease either of their blood pressure when low salt diet is applied) or of cardiovascular complications, but also of other diseases (obesity, osteoporosis, kidney stones, cancer,...) The regulation of salt balance is played by the kidneys, the function of which can be genetically (more rarely) or secondarily acquired (most often) disturbed. Salt restriction (maximum 5-6 g/d) with higher potassium intake, is now recommended. This can easier allow the lowering of the blood pressure, especially in resistant forms of hypertension. Proposed to everybody, even normotensive, it could be beneficial reducing the trend of blood pressure increase with age, but also the burden of cardiovascular complications and promoting general health. For reaching these objectives, this reduction in salt consumption needs motivated and well educated people, well labelled food products about salt content and the apprppriate help of food industries.

Screening for proteinuria and chronic kidney disease risk factors in Kinshasa: a World Kidney Day 2007 study

BACKGROUND

Although screening programs for chronic kidney disease (CKD) may be of great value, these programs are not yet implemented in the Democratic Republic of Congo. This study focused on proteinuria and examined its prevalence in terms of the number needed to screen for the different risk factors of CKD. Such knowledge would guide the utility of population screening to prevent end-stage renal disease.

METHODS

A cross-sectional survey was conducted in Kinshasa on the Second World Kidney Day. A sample of 3,018 subjects was interviewed and the following measurements were performed: blood pressure, body mass index, glycemia and urine protein. Logistic regression analysis was used to identify determinants of proteinuria.

RESULTS

The prevalence of proteinuria was 17.1% (95% CI 15.8-18.6). Other CKD risk factors identified were: hypertension, diabetes mellitus, obesity and metabolic syndrome. To identify 1 case of proteinuria, one would need to screen 4 persons with diabetes, 5 persons with hypertension, 4 subjects having metabolic syndrome, 5 persons aged >or=72 years and 9 persons without any of the conditions mentioned above. Age, overweight and diabetes were the strongest factors associated with proteinuria.

CONCLUSIONS

This study indicates that proteinuria and traditional risk factors for CKD are very prevalent in Kinshasa. Realistic policies to stem these conditions should be a public health priority.

[Aliskiren (Rasilez), direct renin inhibitor]

Aliskiren (Rasilez) is the first oral renin inhibitor. Its present indication is essential hypertension, as monotherapy or in combination with other antihypertensive agents (diuretic, calcium antagonist, ...). It may also be associated with an angiotensin converting enzyme inhibitor (or an AT1 angiotensin receptor antagonist) in order to benefit of a dual blockade of the renin-angiotensin-aldosterone system. The usual daily dose is 150 mg, to be increased up to 300 mg if necessary. New clinical trials are ongoing to validate this novel therapeutic approach in other indications such as congestive heart failure and diabetic nephropathy.

[The physiopathology of dialysis-associated hypertension]

Hypertension in subjects on long term dialysis is frequent. Its origins are found in extracellular volume overload, which is complicated by increased peripheral arterial resistance. The latter is affected by many systems, including that of renin-angiotensin, endothelin, nitric oxide, the sympathetic nervous system, and others. The interaction between these factors may explain why the control of hypertension in dialysis patients requires ongoing attention to the many aspects of good dialysis.

[Hypertension and the brain]

The relationships between the brain and arterial hypertension are strong. The brain, through the hypothalamus, can quickly adapt the blood pressure level to maintain the cerebral blood flow. An acute increase in blood pressure, if it overtakes the autoregulatory capacities, needs an urgent intervention to decrease neurological problems such as encephalopathy. In chronic situations, arterial hypertension is a frequent cause of stroke, either ischemic or hemorragic, both in patients free and those who have already suffered from brain damage. Hypertension is also an actor in the genesis of vascular, but also Alzheimer's dementia. A strict control of blood pressure (but also in other atherosclerotic risk factors) into the normal range is needed to protect the brain, and this is more important than the choice of a particular class of antihypertensive agents, except the betablockers. The risk starts from the normal values of blood pressure.

Lessons from ONTARGET

The recently published results of the ONTARGET trial shed a new light on the cardiovascular protection of patients at high risk of a cardiovascular event. Despite a number of trials looking at the efficacy of Angiotensin Converting Enzyme inhibitors (ACEis) or Angiotensin Receptor Blockers (ARBs) in the prevention of cardiovascular events in patients with specific high risk profiles, the question of the equivalence of ACEis and ARBs remained unanswered. The ONTARGET trial has shown that telmisartan 80 mg administered for a median duration of 4.5 years to patients at high risk of developing a major cardiovascular event, is equally effective to ramipril 10 mg. In addition, telmisartan was slightly better tolerated. The comparator ramipril has been chosen as it is currently the gold standard ACEi since the results of the HOPE study, in terms of the composite outcome of cardiovascular death, myocardial infarction and stroke. Moreover, ONTARGET is the first trial to test the hypothesis of superiority of adding an ARB (telmisartan 80 mg) to an ACEi (ramipril 10 mg) over the ACEi ramipril monotherapy in cardiovascular protection of the same broad range of high-risk patients. Surprisingly, despite a more pronounced blood pressure lowering, the combination of the two agents did not lead to an additional decrease in the number of events, but had significantly more side-effects compared to ramipril monotherapy. ONTARGET is a landmark study, performed according to the highest statistical and clinical standards, providing compelling evidence and clear answers to two important clinical questions.

[How I treat... by optimizing the blockade of the renin-angiotensin-aldosterone system]

The blockade of the renin-angiotensin-aldosterone system (RAAS) has been shown to be useful, or even mandatory, in the management of arterial hypertension, congestive heart failure, post-myocardial infarction and nephropathy with albuminuria, due to diabetes or not. Such blockade can be obtained with an angiotensin converting enzyme inhibitor, a specific antagonist of angiotensin II AT1 receptors and/or recently a direct inhibitor of renin such as aliskiren. Various studies have demonstrated the advantage of optimising RAAS blockade in order to benefit of the best cardiorenal protection. The present article describes the various modalities to optimize the RAAS blockade, either by using a maximal dosage of a monotherapy, or by choosing a double inhibition of RAAS. New prospects for the RAAS blockade will be also briefly considered.