Prevalence of microalbuminuria in the general population of Seychelles and strong association with diabetes and hypertension independent of renal markers.

OBJECTIVE: Few studies have examined microalbuminuria (MAU) in non-western populations. We assessed the prevalence of MAU in the general population of a middle-income country in the African region and relationships between MAU and selected cardiovascular risk factors. METHODS: An examination survey was conducted in a sample representative of the entire population aged 25-64 years in the Seychelles. MAU adjusted for urine creatinine concentration was measured on the second morning urine using a semiquantitative point-of-care analyzer. RESULTS: A total of 1255 persons attended the survey (participation rate of 80.2%). The age-adjusted prevalence of MAU was 11.4%. At age 25-64 years, the prevalence of MAU was 5% in persons without diabetes and hypertension, 20% in persons with either condition and 41% in persons with both conditions. The overall prevalence of stages 3-4 chronic kidney disease was low at 3.2%. In multivariate analysis, MAU was associated with age [odds ratio (OR) 1.24 for a 10-year increase; 95% confidence interval (CI): 1.02-1.52], hypertension stage I (2.0; 1.1-3.8) and stage II (4.5; 2.3-8.6), obesity (1.7; 1.0-2.8) and diabetes (3.0; 1.9-4.9). These associations were virtually unchanged upon further adjustment for markers of renal function such as serum creatinine, serum cystatin C and calculated renal function. CONCLUSION: The prevalence of MAU was high in this population, and MAU was strongly associated with several cardiovascular risk factors independently of renal function markers. These findings suggest that MAU could be a useful marker of cardiovascular risk in this population and help identify persons in need of a specific cardiovascular risk management.

[Treatment of secondary hyperparathyroidism in dialysis: Report of a case-study of treatment failure]. / Traitement de l'hyperparathyroïdisme secondaire en dialyse : à propos d'un cas d'inefficacité apparente du traitement médicamenteux.

In this case report, we describe the story of a 42-year-old woman on haemodialysis who presented a severe secondary hyperparathyroidism and hyperphosphataemia, despite a heavy drug treatment including 90mg cinacalcet, 3600mg calcium carbonate and 2700mg aluminium hydroxide per day. Confronted to an apparent resistance to the calcimimetic, the question was: is this a true drug resistance or a pseudoresistance with, as clinical consequence, either a further increase of the dose of cinacalcet or a parathyroidectomy. To answer this question, we have monitored for two months drug adherence to phosphate binders and cinacalcet using electronic pillboxes called Medication Event Monitoring System (MEMS) without modifying the drug prescription. Drug adherence monitoring has been associated with a rapid normalisation of all laboratory parameters suggesting that the inefficacy of the treatment was essentially due to a nonadherence rather than due to a true drug resistance. This observation reminds us that nonadherence is one of the most frequent causes of apparent drug resistance, which should be considered in all cases of nonresponse to therapy. This case also illustrates the usefulness of electronic monitoring to identify problems of drug adherence and hence to improve and sustain medication intake in patients, including those on dialysis.

Preemptive versus Non-preemptive simultaneous pancreas-kidney transplantation: a single-center, long-term, follow-up study.

BACKGROUND: Data regarding the timing-before or after initiation of dialysis-of simultaneous pancreas-kidney transplantation (SPKT) in type 1 diabetes mellitus patients with end-stage renal failure are sparse. We studied the effect of preemptive transplantation on patient survival, cardiovascular endpoints, and graft survival, as compared with non-preemptive transplantation. METHODS: All 180 SPKT recipients (aged 23-58 years) who received a SPKT in Leiden between December 1986 and May 2004 were included in the analysis. Sixty-five patients (36.1%) were transplanted preemptively. Mean follow-up time was 6.3 years. RESULTS: Up to 8.2 years after transplantation, we found no differences in patient survival. Later on, divergence occurred: 10-year patient survival was 71.3% in the preemptive group versus 63.8% in the dialysis group and 15-year patient survival was 64.8% versus 45.1% in the dialysis group, leading to an adjusted hazard ratio for mortality of 0.50 (95% CI 0.23-1.06, P=0.070). Cause of death was less often of cardiac origin in the preemptive group (adjusted HR 0.16; 95% CI 0.026-0.95, P=0.044). Graft survival did not follow the same trend. No significant differences were found between the two groups considering allograft survival, cerebrovascular accident, or myocardial infarction. The percentage of patients with minor or major amputation(s) after transplantation was slightly lower in the preemptive group (24.6 vs. 32.1%; adjusted HR 0.87; 95% CI 0.42-1.82, P=0.72). CONCLUSION: Preemptive SPKT offered a patient survival benefit as compared with transplantation performed while already on dialysis and was associated with a lower rate of cardiac deaths.

A new technique for simultaneous validation of two manual nonmercury auscultatory sphygmomanometers (A&D UM-101 and Accoson Greenlight 300) based on the International protocol.

INTRODUCTION: Auscultatory nonmercury manual devices seem good alternatives for the mercury sphygmomanometers in the clinic and for research settings, but individual internal validation of each device is time-consuming. The aim of this study was to validate a new technique capable of testing two devices simultaneously, based on the International protocol of the European Society of Hypertension. METHODS: The concept of the new technique is to measure blood pressure alternatively by two observers using a mercury sphygmomanometer and by two observers using the A&D UM-101 and Accoson Greenlight 300 devices, connected by Y-tube to obtain simultaneous readings with both nonmercury devices. Thirty-three participants were enrolled (mean age 47.2±14.0 years). Nine sequential blood pressure measurements were performed for each participant. RESULTS: Both devices passed phase 1 using 15 participants. In phase 2.1 (n=33), on a maximum of 99 measurements, the Accoson device produced 81/95/99 measurements within 5/10/15 mmHg for systolic blood pressure (SBP) and 87/98/99 for diastolic blood pressure (DBP). The A&D device produced 86/96/99 for SBP and 94/99/99 for DBP. In phase 2.2 (n=33), 30 participants had at least 2 out of 3 SBP obtained with Accoson device within 5 mmHg of the mercury device, as compared with 29 of 33 participants with the A&D device. For DBP, this was 33 of 33 participants for both devices. CONCLUSION: Both the nonmercury devices passed the International protocol. The new technique of simultaneous device testing using a Y-tube represents a time saving application of the International protocol.

Patient adherence and the choice of antihypertensive drugs: focus on lercanidipine.

Despite the development of many effective antihypertensive drugs, target blood pressures are reached in only a minority of patients in clinical practice. Poor adherence to drug therapy and the occurrence of side effects are among the main reasons commonly reported by patients and physicians to explain the poor results of actual antihypertensive therapies. The development of new effective antihypertensive agents with an improved tolerability profile might help to partly overcome these problems. Lercanidipine is an effective dihydropyridine calcium channel blocker of the third generation characterized by a long half-life and its lipophylicity. In contrast to first-generation dihydropyridines, lercanidipine does not induce reflex tachycardia and induces peripheral edema with a lower incidence. Recent data suggest that in addition to lowering blood pressure, lercanidipine might have some renal protective properties. In this review we shall discuss the problems of drug adherence in the management of hypertension with a special emphasis on lercanidipine.