RESUMO
We present the Spanish adaptation made by the CEIPC of the European Guidelines on Cardiovascular Disease Prevention (CVD) in Clinical Practice 2008. This guide recommends the SCORE model for risk evaluation. The aim is to prevent premature mortality and morbidity due to CVD through the management of its related risk factors in clinical practice. The guide focuses on primary prevention and emphasizes the role of the nurses and primary care medical doctors in promoting a healthy life style, based on increasing physical activity, change dietary habits, and non smoking. The therapeutic goal is to achieve a Blood Pressure < 140/90 mmHg, but among patients with diabetes, chronic kidney disease, or definite CVD, the objective is <130/80 mmHg. Serum cholesterol should be < 200 mg/dl and cLDL<130 mg/dl, although among patients with CVD or diabetes, the objective is <100 mg/dl (80 mg/dl if feasible in very high-risk patients). Patients with type 2 diabetes and those with metabolic syndrome must lose weight and increase their physical activity, and drugs must be administered whenever applicable, to reach body mass index (BMI) guided and waist circumference objectives. In diabetic type 2 patients, the objective is glycated haemoglobin <7%. Allowing people to know the guides and developing implementation programs, identifying barriers and seeking solutions for them, are priorities for the CEIPC in order to transfer the recommendations established into the daily clinical practice.
Assuntos
Doenças Cardiovasculares/prevenção & controle , Medicina Clínica/normas , Fatores Etários , Biomarcadores , Pressão Sanguínea , Índice de Massa Corporal , Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/fisiopatologia , Doenças Cardiovasculares/terapia , Colesterol/sangue , Ensaios Clínicos como Assunto , Diabetes Mellitus Tipo 2/prevenção & controle , Humanos , Estilo de Vida , Inibidores da Agregação Plaquetária/uso terapêutico , Padrões de Prática Médica , Fatores de Risco , EspanhaRESUMO
The present CEIPC Spanish adaptation of the European Guidelines on Cardiovascular Disease Prevention in Clinical Practice 2008. This guide recommends the SCORE model for risk evaluation. The aim is to prevent premature mortality and morbidity due to CVD by means of dealing with its related risk factors in clinical practice. The guide focuses on primary prevention and emphasizes the role of the nurses and primary care doctors in promoting a healthy life style, based on increasing physical activity, changing dietary habits, and not smoking. The therapeutic goal is to achieve a Blood Pressure < 140/90 mmHg, but in patients with diabetes, chronic kidney disease, or definite CVD, the objective is < 130/80 mmHg. Serum cholesterol should be < 200 mg/dl and cLDL < 130 mg/dl, although in patients with CVD or diabetes, the objective is < 100 mg/dl (80 mg/dl if feasible in very high-risk patients). Patients with type 2 diabetes and those with metabolic syndrome must lose weight and increase their physical activity, and drugs must be administered whenever applicable, with the objective guided by body mass index and waist circumference. In diabetic type 2 patients, the objective is glycated haemoglobin < 7%. Allowing people to know the guides and developing implementation programs, identifying barriers and seeking solutions for them, are priorities for the CEIPC in order to put the recommendations into practice.
Assuntos
Doenças Cardiovasculares/prevenção & controle , Comportamento , Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/psicologia , Doenças Cardiovasculares/terapia , Humanos , Hipertensão/complicações , Hipertensão/terapia , Fatores de Risco , Fatores Socioeconômicos , EspanhaRESUMO
OBJECTIVE: To assess the prevalence of low serum levels of HDL cholesterol (HDL-C) and its relationship with the presence of cardiovascular disease (CVD) in patients with type 2 diabetes mellitus (DM) and arterial hypertension attended in Internal Medicine and Nephrology offices. METHODS: Cross-sectional, multicenter study, conducted in diabetic patients with hypertension, aged >/= 55 years old. Demographic, clinical and biochemical data were obtained from the patient's hospital records. Low HDL-C was defined as <40 mg/dl (men) or <46 mg/dl (women). The relationship between low HDL-C and CVD was assessed using logistic regression models. RESULTS: In 2,021 patients (mean age: 68.6 years, 48.9% women, 51.1% with established CVD), the prevalence of low HDL-C was 33.7% (95% CI: 31.5-35.7), it being higher in women (38.0%) than in men (29.6%, p<0.001), and higher in patients with previous CVD (37.3% vs. 29.9% in patients without CVD, p=0.001). In the multivariate analysis that included cardiovascular risk factors, an independent relationship between low HDL-C levels and CVD was observed (OR for CVD in patients with low HDL-C: 1.46 [CI 95%: 1.19-1.79, p<0.001]), compared to patients with normal HDL-C blood levels. A second model which was also adjusted for left ventricular hypertrophy and renal disease showed a similar association (OR 1.55 [1.21-2.00], p=0.001). This association was stronger in women than in men. CONCLUSIONS: One out of three patients with diabetes and hypertension examined in Internal Medicine and Nephrology outpatient offices had low serum levels of HDL-C. Low HDL-C showed an independent relationship with a higher prevalence of CVD.
Assuntos
Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/complicações , HDL-Colesterol/sangue , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/complicações , Hipertensão/sangue , Hipertensão/complicações , Idoso , Doenças Cardiovasculares/epidemiologia , Estudos Transversais , Feminino , Humanos , MasculinoRESUMO
BACKGROUND: In the Irbesartan Diabetic Nephropathy Trial (IDNT), treatment with irbesartan demonstrated 23% and 20% reductions in the combined endpoint of doubling of serum creatinine (DSC), end-stage renal disease (ESRD) or death in patients with hypertension, type 2 diabetes and overt nephropathy compared to amlodipine and control respectively. A simulation model was developed to project long-term cost consequences of the IDNT in the Spanish setting. METHODS: A Markov model simulated progression from nephropathy to DSC, ESRD and death in patients with hypertension, type 2 diabetes and overt nephropathy. Treatment-specific probabilities were derived from IDNT. Country-specific ESRD-related data were retrieved from published sources. Delay in onset of ESRD, life expectancy and mean lifetime costs were calculated for patients with baseline age 59 years. Future costs were discounted at 6% per annum, and clinical benefits were discounted at 0% and 6% per annum. Extensive sensitivity analyses were performed. RESULTS: Onset of ESRD was delayed with irbesartan by 1.41 and 1.35 years versus amlodipine and control respectively. When a 25-year (lifetime) horizon was considered, delay in ESRD onset led to anticipated improvements in life expectancy (discounted at 6% shown in brackets) of 0.46 (0.21) years versus amlodipine and 0.75 (0.37) years versus control. Irbesartan was associated with cost savings of 13,673 Euro and 7,632 Euro patient versus amlodipine and control respectively. The results were robust under a wide range of plausible assumptions. CONCLUSIONS: Treating patients with hypertension, type 2 diabetes and overt nephropathy using irbesartan was both cost- and life-saving compared to amlodipine and control in the Spanish setting.
Assuntos
Anti-Hipertensivos/economia , Compostos de Bifenilo/economia , Diabetes Mellitus Tipo 2/economia , Nefropatias Diabéticas/economia , Hipertensão/economia , Tetrazóis/economia , Anti-Hipertensivos/uso terapêutico , Compostos de Bifenilo/uso terapêutico , Análise Custo-Benefício , Diabetes Mellitus Tipo 2/tratamento farmacológico , Nefropatias Diabéticas/tratamento farmacológico , Humanos , Hipertensão/tratamento farmacológico , Irbesartana , Cadeias de Markov , Modelos Econômicos , Espanha , Tetrazóis/uso terapêutico , Resultado do TratamentoRESUMO
Henoch-Schönlein purpura (HSP) is a necrotizing vasculitis affecting small vessels characterized by nontrombocytopenic purpura. The most characteristic clinical manifestations are purpura, arthritis, abdominal pain, abdominal bleeding and nephritis. Lung hemorrhage is a rare symptom associated with the HSP. Although the subclinical alterations of pulmonary function are frequent in patients with PSH without clinical lung manifestations, the presence of lung hemorrhage is an unusual symptom. We report a case of a patient with hemoptysis and HSP previously asymptomatic.
Assuntos
Hemorragia/complicações , Vasculite por IgA/complicações , Rim/patologia , Pneumopatias/complicações , Adulto , Glucocorticoides/uso terapêutico , Hemorragia/diagnóstico , Hemorragia/tratamento farmacológico , Humanos , Vasculite por IgA/diagnóstico , Vasculite por IgA/tratamento farmacológico , Imunoglobulina A/análise , Rim/imunologia , Pneumopatias/diagnóstico , Pneumopatias/tratamento farmacológico , Masculino , Resultado do TratamentoRESUMO
We report two patients with rapidly progressive glomerulonephritis without alveolar hemorrhage. Renal biopsy showed extracapillary glomerulonephritis with linear deposits of immunoglobulin G. Serologically anti-glomerular basement membrane antibodies (Ac AMBG) and ANCA anti-myeloperoxidase were present. All patients were treated with steroids, cyclophosphamide and plasma exchange. One patient needed dialysis, and other one died from a renal biopsy complication. We discuss the epidemiologic, pathogenic and prognostic aspects of this association.
Assuntos
Autoanticorpos/imunologia , Autoantígenos/imunologia , Doenças Autoimunes/imunologia , Glomerulonefrite/imunologia , Glomérulos Renais/imunologia , Peroxidase/imunologia , Idoso , Anticorpos Anticitoplasma de Neutrófilos/imunologia , Doenças Autoimunes/complicações , Membrana Basal/imunologia , Biópsia/efeitos adversos , Terapia Combinada , Ciclofosfamida/uso terapêutico , Progressão da Doença , Evolução Fatal , Feminino , Glomerulonefrite/complicações , Glomerulonefrite/patologia , Hemorragia/etiologia , Humanos , Hipertrofia Ventricular Esquerda/complicações , Doenças do Complexo Imune/imunologia , Doenças do Complexo Imune/patologia , Imunoglobulina G/análise , Imunossupressores/uso terapêutico , Glomérulos Renais/patologia , Glomérulos Renais/ultraestrutura , Metilprednisolona/uso terapêutico , Pessoa de Meia-Idade , Plasmaferese , Prognóstico , Diálise Renal , Espaço RetroperitonealRESUMO
AIMS: To determine the prevalence and the incidence of diabetic nephropathy in Type 1 diabetes mellitus in Spain and to investigate the risk factors for the development of microalbuminuria. METHODS: One thousand five hundred and two patients with Type 1 diabetes mellitus were prospectively followed in 15 hospital diabetes outpatient clinics in Spain. Blood pressure, body weight, HbA(1c), total cholesterol, HDL-cholesterol, triglycerides, plasma creatinine and urinary albumin excretion (UAE) were determined every 3-5 months. RESULTS: A total of 1225 patients (624 males and 601 females), age 30.7+/-9.3 years with diabetes duration of 14.1+/-9.1 years completed 4.3 (4.0-5.1) years of follow-up. At baseline 14.2 (95% CI 12.3-16.3)% of patients had microalbuminuria, 5.1 (3.9-6.4)% macroalbuminuria and 3.4 (2.5-4.6)% kidney failure. During follow-up the annual incidence of microalbuminuria was 2.7 (2.2-3.2)%. In a multiple logistic regression analysis the predictors of progression to microalbuminuria were initial UAE, HbA(1c), diabetes duration, smoking, and HDL-cholesterol <0.9 mmol/l. CONCLUSIONS: The prevalence and incidence of diabetic nephropathy in Spain are comparable to data obtained in similar studies carried out in other countries. The development of microalbuminuria is associated not only with glycaemic control and hypertension, but also to the control of other risk factors such as dyslipaemia and smoking.
Assuntos
Diabetes Mellitus Tipo 1/fisiopatologia , Nefropatias Diabéticas/epidemiologia , Adulto , Albuminúria/epidemiologia , Colesterol/sangue , HDL-Colesterol/sangue , Diabetes Mellitus Tipo 1/sangue , Nefropatias Diabéticas/sangue , Progressão da Doença , Feminino , Seguimentos , Hemoglobinas Glicadas/análise , Humanos , Incidência , Masculino , Ambulatório Hospitalar , Fatores de Risco , Espanha/epidemiologia , Fatores de TempoAssuntos
Nefropatias Diabéticas/complicações , Nefropatias Diabéticas/tratamento farmacológico , Falência Renal Crônica/etiologia , Anemia/etiologia , Distúrbio Mineral e Ósseo na Doença Renal Crônica/etiologia , Nefropatias Diabéticas/diagnóstico , Progressão da Doença , Humanos , Hiperlipidemias/etiologia , Hipertensão/etiologia , Distúrbios Nutricionais/etiologia , Obesidade/etiologiaAssuntos
Diabetes Mellitus Tipo 2/complicações , Nefropatias Diabéticas/tratamento farmacológico , Nefropatias Diabéticas/etiologia , Anti-Hipertensivos/uso terapêutico , Compostos de Bifenilo/uso terapêutico , Glicemia , Ensaios Clínicos como Assunto , Diabetes Mellitus Tipo 2/sangue , Nefropatias Diabéticas/sangue , Humanos , Hipertensão/tratamento farmacológico , Hipertensão/etiologia , Irbesartana , Tetrazóis/uso terapêuticoRESUMO
We report an 85 years-old patient with type 2 diabetes mellitus and both clinical and biochemical nephrotic syndrome. The renal biopsy showed membranous nephropathy at stage I-II. There was no evidence of malignancy. The patient was treated with steroids, and two months later the proteinuria had not improved. The objects under discussion are the factors that should lead to suspect the existence of glomerulonephritis, other than diabetic glomerulosclerosis, suggesting the need for kidney biopsy. We also focus on the prognostic and therapeutic relevance, as well as on the common pathogenic aspects.
Assuntos
Diabetes Mellitus Tipo 2/complicações , Nefropatias Diabéticas/diagnóstico , Glomerulonefrite Membranosa/diagnóstico , Corticosteroides/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Arteríolas/patologia , Biópsia , Diagnóstico Diferencial , Diuréticos/uso terapêutico , Edema/etiologia , Mesângio Glomerular/patologia , Glomerulonefrite Membranosa/complicações , Glomerulonefrite Membranosa/patologia , Humanos , Córtex Renal/patologia , Masculino , Derrame Pleural/etiologia , Proteinúria/etiologiaRESUMO
Assessment of healthcare technology and economics can be used to assess the access to healthcare, its quality and efficacy as well as its cost and cost efficiency. This report addresses these issues for the provision of care for end-stage renal disease (ESRD) patients. An international comparison of access to ESRD treatment modalities was made with reference to the healthcare provider structure in a range of industrial countries. The countries were grouped into 'public' (Beveridge model), 'mixed' (Bismarck model) and 'private' (Private Insurance model). In 'public' provider countries, 20-52% of dialysis patients are treated with home therapies (haemodialysis and peritoneal dialysis), and the number of patients with renal transplants is 45-81% of all ESRD patients. In 'mixed' provider countries, only 9 17% of all dialysis patients are treated with home therapies, and 20-48% of ESRD patients have renal transplants. In 'private' provider countries, 17% of US and 6% Japanese dialysis patients are treated with home therapies. Japan has 0.3% and the US has 26% of ESRD patients who receive renal transplants. It thus seems that provider structure influences access to and choice of ESRD treatment. With a growing elderly population and longer life expectancy, there will be an increased requirement for ESRD treatments in all industrial countries. Equal access to, and quality of ESRD care in the future will require adequate funding and reimbursement strategies in a cost-constrained healthcare environment. growing elderly population, new and innovative healthcare technologies, increasing expectations of the population and the dilemma of economic constraints. Therefore, new disciplines such as health technology assessment and healthcare economics are developing to support the needs of health policy decision makers. Their main objective is to create a balance between the three key factors of a healthcare system: access to healthcare (equity for all), quality of healthcare (efficacy) and finally the cost or cost efficiency of healthcare provision [1; see also Lameire et al., this issue]. This report will assess access to healthcare in a very specific and very costly area that of end-stage renal disease (ESRD). An international comparison of access to ESRD treatment for patients from a series of industrial countries will be used as a means for evaluation of this access.
Assuntos
Prestação Integrada de Cuidados de Saúde , Falência Renal Crônica/terapia , Custos e Análise de Custo , Europa (Continente) , Humanos , Japão , Falência Renal Crônica/economia , Transplante de Rim/economia , Transplante de Rim/estatística & dados numéricos , Diálise Renal/economia , Diálise Renal/estatística & dados numéricos , Estados UnidosRESUMO
OBJECTIVE: To analyze the effects of recombinant human erythropoietin (rHuEPO) therapy on cardiovascular (CV) morbidity and mortality among continuous ambulatory peritoneal dialysis (CAPD) patients. DESIGN: Retrospective comparative study. SETTING: CAPD unit in a university hospital. PATIENTS: Forty-two patients on rHuEPO treatment for at least one year were compared with an rHuEPO nonuser group of 113 patients. Subcutaneous rHuEPO doses were adjusted to a hemoglobin objective level of 10.5-13.5 g/dL. Fifty-seven patients were considered as high cardiovascular risk (HCVR), 17 in the rHuEPO group and 40 in the rHuEPO nonuser group. Ninety-eight patients were classified as low cardiovascular risk (LCVR), 25 of whom were in the rHuEPO group. RESULTS: The incidence of cardiovascular morbidity was more frequent in the rHuEPO nonuser than in the rHuEPO user group (40% vs 22%) and in HCVR than in LCVR patients (59.6% vs 20.4%). By multiple logistic regression analysis, the best model to explain the development of cardiovascular morbidity comprises rHuEPO treatment, CV risk, and age. In the rHuEPO user group, HCVR and LCVR patients did not show significant differences in survival, while in the rHuEPO nonuser group, HCVR patients had a lower survival rate than LCVR patients (p = 0.0003). Cox proportional hazards model revealed that LCVR patients had an excellent prognosis compared with HCVR patients in the rHuEPO nonuser group, but this difference disappeared in the rHuEPO user group. CONCLUSION: These data show a beneficial effect of rHuEPO treatment on cardiovascular morbidity and mortality in CAPD patients, evidenced by the elimination of the correlation between prior cardiovascular risk and subsequent mortality.
Assuntos
Doenças Cardiovasculares/prevenção & controle , Eritropoetina/uso terapêutico , Diálise Peritoneal Ambulatorial Contínua/efeitos adversos , Adulto , Idoso , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/mortalidade , Feminino , Seguimentos , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Proteínas Recombinantes , Análise de Regressão , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do TratamentoRESUMO
Long-term complications of Insulin Dependent Diabetes Mellitus (IDDM) have been associated with several risk factors, particularly the degree of metabolic control and evolution time of the disease. A study was conducted with 219 randomly selected patients with IDDM at our clinic; evolutive, clinical and analytical parameters were assessed and conventional or multiple insulin therapy was evaluated. The classification of glycated hemoglobin (Hb A1c) in quartiles demonstrated a relatively higher incidence of diabetic retinopathy and nephropathy in the upper quartiles versus the lower quartile (p < 0.05). Likewise, patients with multiple insulin therapy had lower retinopathy (24.5% vs. 50.6, p < 0.001) and nephropathy rates (12.9% vs. 26.6%, p < 0.05) compared with those following a conventional insulin therapy. The multivariate analysis showed a statistically significant regression model (p < 0.001) for microalbuminuria level in patients with no established nephropathy; in these patients, the evolution time of IDDM and their Hb A1c level showed a positive independent association, and the use of multiple insulin therapy was a protective factor. The regression analysis of microalbuminuria levels compared with glycated hemoglobin in patients with no established nephropathy showed a value for Hb A1c of 9% as a break-point; from this point upwards microalbuminuria levels increased more markedly. The multivariate analysis here presented can help identify the presence of microalbuminuria in the pathological range in patients with IDDM followed at a hospital clinic from feasible clinical variables (evolution time, glycated hemoglobin level, program of insulin therapy used) establishing a metabolic objective which helps prevent the development of this complication.
Assuntos
Diabetes Mellitus Tipo 1/metabolismo , Nefropatias Diabéticas/metabolismo , Adolescente , Adulto , Idoso , Albuminúria/urina , Criança , Preparações de Ação Retardada , Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 1/tratamento farmacológico , Nefropatias Diabéticas/tratamento farmacológico , Nefropatias Diabéticas/etiologia , Feminino , Hemoglobinas Glicadas/análise , Humanos , Insulina/administração & dosagem , Masculino , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
The aim of this study was to evaluate the role of pulse oral calcitriol in the control of secondary hyperparathyroidism in peritoneal dialysis (PD) patients, addressing the effects after withdrawal. We studied 15 patients with intact parathyroid hormone (iPTH) plasma levels above 250 pg/mL. The initial calcitriol dose was 8 or 4 micrograms/week, administered in two doses, according to whether the iPTH plasma levels were above or below 400 pg/mL. This dose was modified during the follow-up according to the response. Serum iPTH levels decreased in all patients after the first month (559 +/- 243 to 212 +/- 94 pg/mL, p < 0.001). Serum calcium levels significantly increased during therapy, while serum phosphorus levels did not change. The mean duration of the treatment was 95 +/- 57 days. Nine patients reached the target iPTH levels without complications, and in 6 patients the treatment was interrupted because of hypercalcemia. One month after finishing pulse therapy, a significant decrease in serum calcium levels and an increase in iPTH levels were observed. These values were similar to baseline data and were significantly higher than those found during the pulse calcitriol period. Pulse oral calcitriol administration seems to be a short-term, efficient therapy for secondary hyper-parathyroidism in PD patients. However, after the end of pulse therapy, iPTH serum levels return to baseline values, suggesting long-term therapeutic failure.