Salud Cardiovascular En Población Migrante Ecuatoriana En Madrid (España). ¿Debemos Preocuparnos? / Cardiovascular Health In An Ecuadorian Migrant Population To Madrid (Spain). Should We Worry?

RESUMEN Antecedentes: La comunidad ecuatoriana es la tercera comunidad extranjera más numerosa en España. Sin embargo, es poco lo que se conoce acerca de su estado de salud cardiovascular (CV) y si los efectos de la migración han causado un detrimento en dicho estado. Métodos: Con el objetivo de conocer la salud CV en una población ecuatoriana de migrantes en Madrid, se realizó un estudio transversal no aleatorizado en el que se incluyeron personas de nacionalidad ecuatoriana, mayores de 25 años, residentes en Madrid desde hace un año o más. Se realizaron encuestas, mediante el uso de cuestionarios previamente validados, para determinar el estado de salud CV de la población, así como el grado de distress psicológico. Resultados: Se incluyeron 165 participantes (68,5% mujeres), con edad promedio de 49 años. El 86,1% de la población estudiada presentó salud cardiovascular pobre y 13,9% intermedia, sin diferencias significativas según el sexo. No hubo individuos que cumplan las 7 variables con valores ideales. Las mujeres presentaron puntuaciones más altas en el cuestionario DASS-21 en comparación a los hombres (p<0,05). Conclusión: En la población migrante ecuatoriana residente en Madrid, más del 85% presentó una salud CV pobre, y ninguno presentó una salud CV ideal. Los factores de riesgo más prevalentes en dicha población fueron pobre actividad física, sobrepeso/obesidad y malos hábitos dietéticos. Se requieren más estudios para identificar la situación real de riesgo CV de la población migrante ecuatoriana. Probablemente, a medio-largo plazo, será necesario implementar políticas de salud especialmente dirigidas a los migrantes.

ABSTRACT Background: The Ecuadorian community is the third largest foreign community in Spain. However, little is known about their cardiovascular (CV) health status and whether the effects of migration have caused a detriment in that state. Methods: With the aim of knowing the CV health in an Ecuadorian population of migrants in Madrid, a non-randomized, cross-sectional study was carried out, which included people of Ecuadorian nationality, older than 25 years, living in Madrid for a year or more. Surveys were conducted through the use of previously validated questionnaires, to determine the health status of the population, as well as the degree of neuro-physiological distress. Results: We included 165 participants (68.5% women), with an average age of 49 years. Of these, 86.1% presented poor cardiovascular health and 13.9% intermediate, without significant differences according to sex. There were no individuals that met the 7 variables consistent with and ideal CV status. Women had higher scores on the DASS-21 questionnaire compared to men (p <0.05). Conclusion: In the Ecuadorian migrant population living in Madrid, more than 85% had poor CV health, and none had an ideal CV health. Most prevalent risk factors in this population were poor physical activity, overweight/obesity and poor dietary habits. More studies are required to identify the real situation of CV risk in the Ecuadorian migrant population. Probably, in the medium-long term, it will be necessary to implement health policies especially addressed to migrants.

Lercanidipine in patients with chronic renal failure: the ZAFRA study.

OBJECTIVE: The objective was primary to evaluate the safe use of a new calcium channel blocker, lercanidipine, in patients with chronic renal failure (CRF). The secondary objective was to study the protective effect of calcium channel blocker on renal function in CRF patients previously treated with ACE inhibitors or angiotensin receptor blockers. DESIGN AND METHODS: The study recruited 203 CRF patients (creatinine >1.4 mg/dL for males, creatinine > 1.2 mg/dL for females, or creatinine clearance <70 mL/min). All patients were receiving ACE inhibitors (63.4%) or angiotensin II antagonist (36.6%) therapy, but they had higher blood pressure than recommended for CRF (130/85 mmHg). No patients were under diuretic treatment. Patients were clinically evaluated 1, 3, and 6 months after starting treatment with lercanidipine. Samples for urine and blood examination were taken during the examination. When needed, a third drug was added to the treatment, excluding diuretics. Creatinine clearance was measured using 24 h urine collection. RESULTS: 175 patients rendered valuable for the study (age 63.9+/-11.9 years, 52.9% males and 47.1% females). Blood pressure (BP) significantly decreased from 162+/-17/93+/-8.3 mmHg to 132+/-12/78+/-6 mmHg. 89.2% of patients showed a significant BP reduction, and 58.1% achieved optimal BP control (<130/85 mmHg). Seven patients (3.4%) showed untoward effects. Not one case of edema was detected, and the prevalence of adverse effects related to vasodilatation was extremely low (three patients, 1.48%). Plasmatic creatinine did not change (1.9+/-0.5 baseline versus 1.9+/-0.6 mg/dL), but creatinine clearance increased at the end visit (41.8+/-16.0 baseline versus 45.8+/-18.0 mL/min, p=0.019). Plasmatic cholesterol also decreased from 221+/-46 to 211+/-35 mg/dL (p=0.001). CONCLUSIONS: Lercanidipine showed a high antihypertensive effect in CRF patients. It has a good tolerability profile and showed an interesting effect on plasmatic lipids. An improvement in renal function, measured through creatine clearance, was detected.

[Doxazosine associated to renin-angiotensin blockers and calcioantagonists in chronic renal failure patients]. / Doxazosina asociada a la combinación bloqueante del eje-renina-angiotensina y calcioantagonista en pacientes con insuficiencia renal crónica.

OBJECTIVE: To evaluate the safety and effectiveness of the alfa-blocker doxazosin GITS in CRF patients. DESIGN AND METHODS: The study recruited 203 CRF patients (creatinine > 1,4 mg/dl for males, creatinine > 1,2 mg/dl for females, or creatinine clearance < 80 ml/min). All patients were receiving ACE inhibitores (63.4%) or angiotensin II antagonist (36.6%) therapy but they had higher blood pressure than recommended for CRF (130/85 mmHg). Patients were clinically evaluated 1, 3 and 6 moths after starting treatment with lercanidipine (10 mg once daily). Patients with high blood pressure in spite of combined therapy with two drugs added doxazosin GITS 4-8 mg once daily to treatment. RESULT: 57 patients rendered evaluable for the study (age 64.8 +/- 12.7 years, 47.4% males and 52.6 females). BP significantly decrease from 164 +/- 17/92 +/- 9 mmHg to 135 +/- 13/78 +/- 8 mmHg. 67.6% patients showed a significant BP reduction and 32.4% gets optimal BP control (< 130/85 mmHg). Two patients (3.6%) showed untoward effects. No biochemical changes were detected. CONCLUSIONS: Doxazosin showed a good antihypertensive effect in CRF patients when used as third drug in resistant severe hypertension. It has a good tolerability profile and showed a neutral profile on biochemical parameters.

[Lercanidipine in diabetic patients with renal failure]. / Lercanidipino en pacientes diabéticos it con insuficiencia renal.

OBJECTIVE: To evaluate the safe use of a new calcium channel blocker, lercanidipine, in diabetic chronic renal failure (CRF) patients. DESIGN AND METHODS: The study recruited 42 diabetic CRF patients (creatinine > 1.4 mg/dl for males, creatinine > 1.2 mg/dl for females, or creatinine clearance < 70 ml/min). Mean age was 68.2 +/- 9.1 years. 53.8% were males and 46.2% females. Three patients were type 1 diabetics and 39 ones were type II. All patients were receiving ACE inhibitors (67.4%) or angiotensin II antagonist (32.6%) therapy but they had higher blood pressure than recommended for CRF patients (130/85 mmHg). No patients were under diuretic treatment. Patients were clinically evaluated 1, 3 and 6 months after starting treatment with lercanidipine. Samples for urine and blood examination were taken during the examination. When needed, a third drug was added to treatment, excluding diuretics. Creatinine clearance was measured using 24 h urine collection. RESULTS: BP significantly decrease from 163 +/- 18/90 +/- 8 mmHg to 134 +/- 12/77 +/- 9 mmHg. One half of patients showed significant reduction of blood pressure, 26.7% reached the target blood pressure (< 130/85 mmHg) and 20.0% gets optimal BP control (< 130/85 mmHg). No one patient showed untoward effects. No edema was detected nor adverse effects related to vasodilatation were found. Plasmatic creatinine did not change (1.9 +/- 0.5 baseline vs 1.8 +/- 0.5 mg/dl) and creatinine clearance increased at the end visit (40.1 +/- 14.5 baseline vs 45.4 +/- 18.2 ml/min) but the difference was not significant. Proteinuria was unchanged. CONCLUSIONS: Lercanidipine showed a good antihypertensive effect in diabetics CRF patients. It has a good tolerability profile and showed neutral effect on plasmatic lipids. Neither impairment of renal function nor increment in proteinuria were detected.

[Apolipoprotein C-II and C-III anomalies in normolipemic and hyperlipemic patients with chronic kidney failure]. / Anormalidades de las apolipoproteínas C-II y C-III en pacientes normolipémicos e hiperlipémicos con insuficiencia renal crónica.

The high incidence of arteriosclerotic disease in patients with chronic renal failure seems to be due to certain peculiarities in their lipid metabolism. These are principally a disorder in the transportation of lipoproteins and a concomitant defect in triglyceride metabolism causing an accumulation of triglyceride-rich-lipoproteins which predispose to atherosclerosis. We studied the disturbances in concentration of apolipoproteins, notably Apo C-II and C-III, which modulate the activity of lipoprotein lipase (LPL), in patients with chronic renal failure (CRF) without replacement therapy and in hemodialysis patients with and without hyperlipidemia. LPL hydrolyses triglycerides in the lipoprotein-triglyceride (LPRTG) core. The main lipid parameters were measured in 4 groups of normolipidemic and hyperlipidemic patients with and without CRF in comparison with healthy controls. We found that the lipolytic activity index (A-I/C-III) was decreased, and Apo C-III levels were increased, in patients with CRF and patients on HD, including normolipidemic patients. We conclude that high Apo C-III levels are found in uremic patients before starting dialysis and do not change during dialysis treatment. This increase could be one of the initial causes of impaired triglyceride catabolism and LPRTG accumulation even in normolipidemic patients with CRF and may be one explanation of the high mortality from cardiovascular disease in these patients.

Hemodialysis with acetate, DL-lactate and bicarbonate: a hemodynamic and gasometric study.

Using invasive techniques we have studied various hemodynamic and gasometric parameters in the course of hemodialysis (HD) with different buffers in an animal model. HD sessions of 180 minutes at zero ultrafiltration were carried out on three groups of eight uremic dogs each, under anesthesia and constant mechanical ventilation. The three groups differed only in the buffer used: acetate (Group AC), equal proportions of DL-lactate and acetate (Group AC+LA), and bicarbonate (Group BC). No hemodynamic changes were seen in Group BC. In the AC and AC+LA groups we observed on minute 1 a decrease of the mean blood pressure (MBP) and of the systemic vascular resistances (SVR). These parameters returned to baseline values within the first 30 minutes in Group AC+LA. In Group AC the SVR also returned to baseline values after the minute 30, but the MBP remained below baseline throughout the study period, together with cardiac index and left ventricular stroke work index decreases. Only in Group AC did we see a flattening of the ventricular function curves. Only in this Group was there a decrease of the arterial oxygen pressure (PaO2) with an associated increase of the alveolo-arterial and arterio-venous O2 differences. The O2 consumption was not modified in any of the groups. Acetate as a single buffer induces hemodynamic instability through peripheral vasodilation and reduction of myocardial contractility. The myocardial depression induced by acetate, in its turn, causes a reduction in PaO2. The mixed acetate+lactate buffer is hemodynamically better tolerated than acetate as single buffer, as it induces only vasodilation.

Heme biosynthesis in uremic patients on CAPD or hemodialysis.

We have analyzed some parameters of porphyrin metabolism in 60 patients with end-stage renal failure, 20 of them on CAPD and the remaining on HD. In comparison with 56 control subjects, both groups of patients showed the three following findings: low erythrocyte aminolevulinate dehydrase activity, inhibition ability for the activity of this enzyme when their plasma was incubated in vitro with normal erythrocytes, and increased plasma porphyrin levels. Like anemia, these abnormalities were more remarkable in patients on HD who also exhibited increased erythrocyte protoporphyrin levels and compensatory porphobilinogen deaminase activities. Mean weekly porphyrin removal through dialysate was higher in CAPD (90.8 micrograms) than in HD patients (30.4 micrograms). Dialysate and plasma porphyrins were correlated in both circumstances (r = 0.714, P < 0.01 and r = 0.637, P < 0.05, respectively). The less pronounced porphyrin abnormalities found in CAPD patients with respect to HD patients may be due to the more efficient capability of peritoneal dialysis for removing from plasma protein-bound substances, as porphyrins and inhibitors of aminolevulinate dehydrase or other enzymes involved in erythropoiesis. Since no close relationship was found between these abnormalities of porphyrin metabolism and hematocrit values, the anemia of uremia cannot be merely considered as a direct consequence of altered heme biosynthetic pathway.

Iron deficiency anemia after successful renal transplantation.

In patients with chronic renal failure, renal transplantation improves anemia and the production of erythropoietin. In patients undergoing hemodialysis the administration of recombinant human erythropoietin improves anemia with a decrease in bodily iron stores. Therefore, one would expect a similar decrease after kidney transplantation. We followed the ferric parameters to determine the incidence of iron deficiency anemia in 24 consecutive renal transplant patients for an interval long enough to achieve steady state values of hemoglobin (5.1 +/- 0.8 months). Hematological parameters and serum levels of iron, ferritin and erythropoietin were measured. The patients were divided into 2 groups according to the decrease in serum ferritin: group 1--16 with a decrease in respect to basal values (114 +/- 56 ng./ml.) and group 2--those without modifications (720 +/- 320 ng./ml.). Except for the similar values, group 1 showed greater improvement in anemia (red blood cells 4.3 x 10(6) +/- 1.1 x 10(6) versus 3.7 x 10(6) +/- 1.5 x 10(6)/ml., p < 0.01) and hematocrit index (38.5 +/- 5.2 versus 33.0 +/- 5.1%, p < 0.05). Four patients had microcythemia (mean corpuscular volume 76.6 +/- 1.4 fluid) with lower hemoglobin values than the other patients in group 1 (10.77 +/- 0.42 versus 12.79 +/- 0.42 gm./dl., p < 0.05). Among the 16 patients in group 1, 7 of 8 whose basal serum ferritin was less than 150 ng./ml. achieved ferritin levels of less than 30 ng./ml. In conclusion, our data support that renal transplantation produces a rapid decrease in iron stores and in some cases induces iron deficiency anemia. This fact should be evaluated and treated properly.

Post-transplant renal artery stenosis: a possible immunological phenomenon.

A retrospective review of 110 consecutive kidney transplants performed during 4 years revealed the development of renal artery stenosis in 9 patients (8.18%). A comparison of this group with a control group similar in patient age and interval elapsed since transplantation revealed no significant differences in donor and recipient ages, degree of HLA compatibility or serum creatinine levels. However, there was a significant difference in the number of acute rejection episodes. In our series only male patients were affected. A sizable proportion of the patients (50%) had no detectable murmur over the graft area despite high blood pressure and increased creatinine levels. The absence of surgical injury during extraction and implantation of the grafts, together with the anatomical site of the stenosis and correlation with the degree of immunological intolerance suggest an immunological factor as the underlying cause in post-transplant renal artery stenosis.

Treatment of hyperlipemia in diabetic patients on dialysis with a physiological substance.

Hyperlipemia is a very frequent complication of the diabetic patient on dialysis. There is difficulty of treatment with the diet, because the dietary restriction already imposed on these patients and the secondary effects and toxicity of the available drugs in uremics aggravate the problem. We have treated 22 diabetic patients on dialysis (8 on hemodialysis and 14 on continuous ambulatory peritoneal dialysis) suffering from hyperlipemia with pantethine, a physiological substance and coenzyme A precursor in the Krebs cycle. With the administration of an oral dose of 900 mg/day we obtained a reduction of total cholesterol (275 +/- 72 vs. 231 +/- 54 mg/dl; p less than 0.001), very-low-density lipoprotein (VLDL)-cholesterol (66 +/- 36 vs. 46 +/- 18 mg/dl; p less than 0.01) and triglycerides (332 +/- 182 vs. 227 +/- 90 mg/dl; p less than 0.01) at 2 months. High-density lipoprotein (HDL)-cholesterol did not change, but the total cholesterol/HDL-cholesterol ratio decreased significantly (p less than 0.05). Total cholesterol, VLDL and triglycerides showed a progressive and significant reduction at 4 and 6 months. No changes were observed in serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase, uric acid, blood glucose and glycosylated hemoglobin. Gastric discomfort in 2 patients and pruritus in another one were the secondary effects related. Pantethine was shown to be a very effective hypolipemic agent in diabetic patients on dialysis with a great tolerance.

Fructosamine levels in CAPD: its value as glycemic index.

We have studied fructosamine (measured by colorimetric methods) and glycosylated hemoglobin (HbA1c) using a high pressure liquid chromatography (HPLC) in 20 uremic patients managed conservatively (8 diabetics and 12 non-diabetics) and 20 patients treated with continuous ambulatory peritoneal dialysis (CAPD) including 12 diabetics and 8 non-diabetics. Twenty healthy subjects were used as control group. We have correlated the mean blood glucose (MBG) of the preceding days to fructosamine and HbA1c measurements. No differences were detected in mean fructosamine and HbA1c levels in non-diabetics patients in the CAPD or conservatively treated groups compared to controls. In diabetic patients undergoing conservative treatment or CAPD, mean fructosamine and HbA1c values were elevated when compared with control group. Both glycemic indicators were increased in most of the diabetic patients, was higher values in those patients with higher MBG. There was a good correlation in CAPD diabetic patients between fructosamine and HbA1c with MBG of the 21 previous days (r = 0.84, p less than 0.01 and r = 0.74, p less than 0.01 respectively). There was also correlation between fructosamine and HbA1c in CAPD diabetic patients (r = 0.78, p less than 0.01). We conclude that fructosamine does not seem to be influenced by uremia or by CAPD. Fructosamine and also glycosylated hemoglobin, when c-fraction is measured and HPLC method is used, can be utilized as glycemic indexes in CAPD diabetic patients.

Peritoneal clearances, protein losses and ultrafiltration in diabetic patients after four years on CAPD.

Peritoneal clearances of urea (C(urea)) and creatinine (Ccr), peritoneal protein losses (PL) and ultrafiltration (UF) were retrospectively evaluated in 12 diabetic patients on continuous ambulatory peritoneal dialysis (CAPD) during a four year study. The average of three determinations each year was calculated. There were not significant differences in C(urea) (ml/24 hours), Ccr (ml/24 hours), PL (g/24 hours) and UF (ml/24 hours) between the four years and basal values or in the year to year studies. Seven patients did not modify their CAPD schedule during the four years study and we did not find any statistical differences in this group in the parameters studied. There was an average incidence of peritonitis of 4.7 episodes, higher in the 2 first years (p less than 0.05). The peritonitis incidence did not affect any of the functional parameters evaluated. The results of our study suggest that C(urea), Ccr, PL and UF in diabetic patients are not affected by long-term CAPD or by the peritonitis incidence.

Diabetic patients on CAPD need less aluminum hydroxide as a phosphate binder than non-diabetics.

A retrospective study was done in 86 patients on dialysis in order to evaluate the doses of aluminum hydroxide (OH3 Al) received to achieve a better serum phosphate control. Thirty-seven patients were treated with continuous ambulatory peritoneal dialysis (CAPD) divided in 22 diabetics and 15 non-diabetics. Forty-nine patients were treated with hemodialysis (HD), 12 diabetics and 37 non-diabetics. The doses of 1-25 Dihidroxycholecalciferol (1-25 DOH-D3) were similar in all patients. The serum phosphate levels were similar in CAPD and HD patients with smaller doses of OH3 AL in CAPD patients (p less than 0.001). Diabetics on either technique need less OH3 AL in CAPD (CAPD p less than 0.01; HD p less than 0.05) to achieve the same or better control of serum phosphorus than non-diabetics. The overload of glucose on CAPD and the maintained hyperglycemia on diabetes mellitus would shift phosphorus into the cell and could explain these results. Finally, the less needs of aluminum hydroxide on diabetic patients could contribute to their protection against aluminum deposition and its effects.

[Is there an etiopathogenic relationship between diabetes mellitus and chronic diffuse hepatopathy?]. / Existen relaciones etiopatogénicas entre la diabetes mellitus y la hepatopatía crónica difusa?

Standard biochemical studies to rule out Diffuse Hepatopathy are performed in 60 diabetic patients in different grades of compensation, having no previous hepatic disease. In order to determine the degree of glucemic compensation, Glicosilated Haemoglobin A1C was analyzed. None of the studied parameters showed statistical difference between the four studied groups (DID, NIDD, compensated versus non compensated), indicating that the specific diabetic heatopathy does not exist. We conclude that the hepatotrophic effect of insulin could be related to previous hepatic lesiones, having no influence when the liver architecture is preserved.