RESUMEN
BACKGROUND: Primary aldosteronism, characterized by overt renin-independent aldosterone production, is a common but underrecognized form of hypertension and cardiovascular disease. Growing evidence suggests that milder and subclinical forms of primary aldosteronism are highly prevalent, yet their contribution to cardiovascular disease is not well characterized. METHODS: This prospective study included 1284 participants between the ages of 40 and 69 years from the randomly sampled population-based CARTaGENE cohort (Québec, Canada). Regression models were used to analyze associations of aldosterone, renin, and the aldosterone-to-renin ratio with the following measures of cardiovascular health: arterial stiffness, assessed by central blood pressure (BP) and pulse wave velocity; adverse cardiac remodeling, captured by cardiac magnetic resonance imaging, including indexed maximum left atrial volume, left ventricular mass index, left ventricular remodeling index, and left ventricular hypertrophy; and incident hypertension. RESULTS: The mean (SD) age of participants was 54 (8) years and 51% were men. The mean (SD) systolic and diastolic BP were 123 (15) and 72 (10) mm Hg, respectively. At baseline, 736 participants (57%) had normal BP and 548 (43%) had hypertension. Higher aldosterone-to-renin ratio, indicative of renin-independent aldosteronism (ie, subclinical primary aldosteronism), was associated with increased arterial stiffness, including increased central BP and pulse wave velocity, along with adverse cardiac remodeling, including increased indexed maximum left atrial volume, left ventricular mass index, and left ventricular remodeling index (all P<0.05). Higher aldosterone-to-renin ratio was also associated with higher odds of left ventricular hypertrophy (odds ratio, 1.32 [95% CI, 1.002-1.73]) and higher odds of developing incident hypertension (odds ratio, 1.29 [95% CI, 1.03-1.62]). All the associations were consistent when assessing participants with normal BP in isolation and were independent of brachial BP. CONCLUSIONS: Independent of brachial BP, a biochemical phenotype of subclinical primary aldosteronism is negatively associated with cardiovascular health, including greater arterial stiffness, adverse cardiac remodeling, and incident hypertension.
Asunto(s)
Enfermedades Cardiovasculares , Hiperaldosteronismo , Hipertensión , Masculino , Humanos , Adulto , Persona de Mediana Edad , Anciano , Femenino , Aldosterona , Remodelación Ventricular , Hipertrofia Ventricular Izquierda/diagnóstico por imagen , Hipertrofia Ventricular Izquierda/epidemiología , Hipertrofia Ventricular Izquierda/complicaciones , Renina , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/complicaciones , Estudios Prospectivos , Estudios de Cohortes , Análisis de la Onda del Pulso , Hipertensión/complicaciones , Hiperaldosteronismo/complicaciones , Hiperaldosteronismo/epidemiología , Atrios CardíacosRESUMEN
BACKGROUND: Sex-based disparities in cardiovascular outcomes may be improved with appropriate hypertension management. OBJECTIVE: To compare the evidence-based evaluation and management of females with late-onset hypertension compared to males in the contemporary era. METHODS: Design: Retrospective population-based cohort study. SETTING: Ontario, Canada. PARTICIPANTS: Residents aged ≥66 years with newly diagnosed hypertension between January 1, 2010, and December 31, 2017. EXPOSURE: Sex (female vs. male). OUTCOMES AND MEASURES: We used Poisson and logistic regression to estimate adjusted sex-attributable differences in the performance of guideline-recommended lab investigations. We estimated adjusted differences in time to the prescription of, and type of, first antihypertensive medication prescribed between females and males, using Cox regression. RESULTS: Among 111,410 adults (mean age 73 years, 53% female, median follow-up 6.8 years), females underwent a similar number of guideline-recommended investigations (adjusted incidence rate ratio, 0.997 [95% confidence interval [CI] 0.99-1.002]) compared to males. Females were also as likely to complete all investigations (0.70% females, 0.77% males; adjusted odds ratio, 0.96 [95% CI 0.83-1.11]). Females were slightly less likely to be prescribed medication (adjusted hazard ratio [aHR] 0.98 [95% CI 0.96-0.99]) or, among those prescribed, less likely to be prescribed first-line medication (aHR, 0.995 [95% CI 0.994-0.997]). CONCLUSIONS: Compared to males, females with late-onset hypertension were equally likely to complete initial investigations with comparable prescription rates. These findings suggest that there may be no clinically meaningful sex-based differences in the initial management of late-onset hypertension to explain sex-based disparities in cardiovascular outcomes.
Asunto(s)
Antihipertensivos , Adhesión a Directriz , Hipertensión , Humanos , Femenino , Masculino , Hipertensión/tratamiento farmacológico , Hipertensión/epidemiología , Hipertensión/terapia , Anciano , Estudios Retrospectivos , Antihipertensivos/uso terapéutico , Adhesión a Directriz/estadística & datos numéricos , Factores Sexuales , Ontario/epidemiología , Anciano de 80 o más Años , Guías de Práctica Clínica como Asunto , Edad de InicioRESUMEN
The objective of this study was 1) to examine pooled effects of hypertension on nitric oxide (NO)-dependent vasodilation during local heating across multiple nonglabrous skin regions, and 2) explore regional differences. Responses were compared between 14 participants with uncomplicated hypertension controlled with medication (7 females, 61 ± 6 yr) and 14 age-matched nonhypertensive controls (6 females; 60 ± 5 yr). Cutaneous vascular conductance, normalized to maximum vasodilation (%CVCmax), was assessed at the upper chest, abdomen, dorsal forearm, thigh, and lateral calf during local heating. Across all regions, local skin temperatures were simultaneously increased from 33°C to 42°C (1°C·10 s-1) and held until a stable heating plateau was achieved (â¼40 min), followed by continuous infusion of 20 mM of NG-nitro-l-arginine methyl ester (l-NAME; â¼40 min) at all sites until a stable l-NAME plateau was achieved. The difference between heating and l-NAME plateaus was defined as the NO-contribution. Statistical equivalence for each heating phase was determined based on equivalence bounds of ±10%CVCmax for between-group differences. Pooled (all-regions) %CVCmax responses were equivalent for baseline (two one-sided t tests; P < 0.001), heating plateau (P = 0.002), l-NAME plateau (P = 0.028), and NO-contribution (P = 0.003). For individual regions, responses were equivalent at baseline for the abdomen, thigh, and calf, the heating plateau for the thigh, and the l-NAME plateau for the calf (all P < 0.05). Conversely, the calf heating plateau was lower in the hypertension group (t test; P < 0.05). Local heat-induced cutaneous vasodilation was statistically equivalent between individuals with uncomplicated, controlled hypertension, and nonhypertensive age-matched adults when pooled across multiple skin sites. Conversely, individual between-region comparisons were generally too variable to permit definitive conclusions.
Asunto(s)
Hipertensión , Vasodilatación , Adulto , Inhibidores Enzimáticos/farmacología , Femenino , Calor , Humanos , Masculino , Microdiálisis , NG-Nitroarginina Metil Éster/farmacología , Óxido Nítrico/metabolismo , Flujo Sanguíneo Regional/fisiología , Piel/irrigación sanguíneaRESUMEN
NEW FINDINGS: What is the central question of this study? Does acute intradermal administration of the antioxidant ascorbate augment local forearm cutaneous vasodilatation and sweating via nitric oxide synthase (NOS)-dependent mechanisms during exercise-heat stress in older adults with uncomplicated controlled hypertension? What is the main finding and its importance? Relative to the control site, ascorbate had no effect on forearm cutaneous vascular conductance (CVC) and sweat rate, although CVC was reduced with NOS inhibition in older adults with hypertension. Acute local administration of ascorbate to forearm skin does not modulate heat loss responses during exercise-heat stress in older adults with hypertension. ABSTRACT: Nitric oxide synthase (NOS) contributes to the heat loss responses of cutaneous vasodilatation and sweating during exercise. However, the contribution of NOS may be attenuated in individuals with uncomplicated, controlled hypertension due to elevated oxidative stress, which can reduce NO bioavailability. We evaluated the hypothesis that the acute local intradermal administration of the antioxidant ascorbate would enhance cutaneous vasodilatation and sweating via NOS-dependent mechanisms during an exercise-heat stress in adults with hypertension. Habitually active adults who were normotensive (n = 14, 7 females, 62 ± 4 years) or had uncomplicated, controlled hypertension (n = 13, 6 females, 62 ± 5 years) performed 30 min of moderate-intensity (50% of their pre-determined peak oxygen uptake) semi-recumbent cycling in the heat (35°C, 20% relative humidity). Cutaneous vascular conductance (CVC) and sweat rate were assessed at four forearm skin sites continuously perfused with (1) lactated Ringer solution (Control), (2) 10 mM antioxidant ascorbate, (3) 10 mM NG -nitro-l-arginine methyl ester (l-NAME), a non-selective NOS inhibitor, or (4) a combination of ascorbate and l-NAME. Relative to Control, no effect of ascorbate was observed on CVC or sweating in either group (P = 0.619). However, l-NAME reduced CVC relative to Control in both groups (P ≤ 0.038). No effect of any treatment on sweating was observed (P ≥ 0.306). Thus, acute local administration of ascorbate to forearm skin does not enhance the activation of heat loss responses of cutaneous vasodilatation and sweating in older adults, and those with hypertension during an exercise-heat stress.
Asunto(s)
Antioxidantes , Ácido Ascórbico , Hipertensión , Anciano , Antioxidantes/administración & dosificación , Ácido Ascórbico/administración & dosificación , Femenino , Respuesta al Choque Térmico , Humanos , Hipertensión/tratamiento farmacológico , Masculino , Persona de Mediana Edad , NG-Nitroarginina Metil Éster/farmacología , Óxido Nítrico , Óxido Nítrico Sintasa , Piel/irrigación sanguínea , Sudoración , Vasodilatación/fisiologíaRESUMEN
RATIONALE & OBJECTIVES: Alpha-blockers (ABs) are commonly prescribed for control of resistant or refractory hypertension in patients with and without chronic kidney disease (CKD). The association between AB use and kidney, cardiac, mortality, and safety-related outcomes in CKD remains unknown. STUDY DESIGN: Population-based retrospective cohort study. SETTINGS & PARTICIPANTS: Ontario (Canada) residents 66 years and older treated for hypertension in 2007 to 2015 without a prior prescription for an AB. EXPOSURES: New use of an AB versus new use of a non-AB blood pressure (BP)-lowering medication. OUTCOMES: 30% or greater estimated glomerular filtration rate (eGFR) decline; dialysis initiation or kidney transplantation (kidney replacement therapy); composite of acute myocardial infarction, coronary revascularization, congestive heart failure, or atrial fibrillation; safety (hypotension, syncope, falls, and fractures) events; and mortality. ANALYTICAL APPROACH: New users of ABs (doxazosin, terazosin, and prazosin) were matched to new users of non-ABs by a high dimensional propensity score. Cox proportional hazards and Fine and Gray models were used to examine the association of AB use with kidney, cardiac, mortality, and safety outcomes. Interactions by eGFR categories (≥90, 60-89, 30-59, and<30mL/min/1.73m2) were explored. RESULTS: Among 381,120 eligible individuals, 16,088 were dispensed ABs and matched 1:1 to non-AB users. AB use was associated with higher risk for≥30% eGFR decline (HR, 1.14; 95% CI, 1.08-1.21) and need for kidney replacement therapy (HR, 1.28; 95% CI, 1.13-1.44). eGFR level did not modify these associations, P interaction=0.3and 0.3, respectively. Conversely, AB use was associated with lower risk for cardiac events, which was also consistent across eGFR categories (HR, 0.92; 95% CI, 0.89-0.95; P interaction=0.1). AB use was also associated with lower mortality risk, but only among those with eGFR<60mL/min/1.73m2 (P interaction<0.001): HRs were 0.85 (95% CI, 0.78-0.93) and 0.71 (95% CI, 0.64-0.80) for eGFR of 30 to 59 and<30mL/min/1.73m2, respectively. LIMITATIONS: Observational design, BP measurement data unavailable. CONCLUSIONS: AB use in CKD is associated with higher risk for kidney disease progression but lower risk for cardiac events and mortality compared with alternative BP-lowering medications.
Asunto(s)
Antagonistas Adrenérgicos alfa/uso terapéutico , Fibrilación Atrial/epidemiología , Insuficiencia Cardíaca/epidemiología , Hipertensión/tratamiento farmacológico , Fallo Renal Crónico/epidemiología , Infarto del Miocardio/epidemiología , Insuficiencia Renal Crónica/metabolismo , Terapia de Reemplazo Renal/estadística & datos numéricos , Accidentes por Caídas/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Antihipertensivos/uso terapéutico , Estudios de Cohortes , Progresión de la Enfermedad , Doxazosina/uso terapéutico , Femenino , Fracturas Óseas/epidemiología , Tasa de Filtración Glomerular , Humanos , Hipertensión/complicaciones , Hipotensión/inducido químicamente , Fallo Renal Crónico/terapia , Masculino , Mortalidad , Revascularización Miocárdica/estadística & datos numéricos , Ontario/epidemiología , Prazosina/análogos & derivados , Prazosina/uso terapéutico , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Insuficiencia Renal Crónica/complicaciones , Estudios Retrospectivos , Síncope/inducido químicamenteRESUMEN
The novel coronavirus disease 2019 (COVID-19) is associated with increased risk of thromboembolic events, but the extent and duration of this hypercoagulable state remain unknown. We describe the first case report of renal allograft infarction in a 46-year-old kidney-pancreas transplant recipient with no prior history of thromboembolism, who presented 26 days after diagnosis of COVID-19. At the time of renal infarct, he was COVID-19 symptom free and repeat test for SARS-CoV-2 was negative. This case report suggests that a hypercoagulable state may persist even after resolution of COVID-19. Further studies are required to determine thromboprophylaxis indications and duration in solid organ transplant recipients with COVID-19.
Asunto(s)
Infarto/etiología , Fallo Renal Crónico/cirugía , Trasplante de Riñón , Riñón/irrigación sanguínea , Trasplante de Páncreas/efectos adversos , Receptores de Trasplantes , COVID-19 , Humanos , Infarto/diagnóstico , Fallo Renal Crónico/epidemiología , Masculino , Persona de Mediana Edad , Pandemias , Tomografía Computarizada por Rayos X , UltrasonografíaAsunto(s)
Hipertensión , Potasio , Humanos , Cloruro de Sodio Dietético , Cloruro de Sodio , Presión SanguíneaRESUMEN
BACKGROUND: Although hemodialysis is a highly effective treatment for diffusive clearance of low molecular weight uremic toxins, its effect on circulating extracellular vesicles and submicron particles is less clear. The purpose of this study was to examine the impact of hemodialysis on circulating levels of submicron particles. METHODS: Plasma samples from patients were collected immediately before and after the mid-week hemodialysis session. Total submicron particles were assessed by nanoparticle tracking analysis and levels of endothelial (CD144+), platelet (CD41+), leukocyte (CD45+), and total (Annexin V+) membrane microparticles (MPs) were assessed by flow cytometry. RESULTS: Total submicron particle number was significantly lower post-dialysis with reductions in particles < 40 nm, 40-100 nm, and 100-1000 nm in size. Circulating annexin V+ MPs, platelet MPs, leukocyte MPs, and endothelial MPs were all reduced following dialysis. Assessment of protein markers suggested that extracellular vesicles were not present in the dialysate, but rather adsorbed to the dialysis membrane. CONCLUSIONS: In summary, hemodialysis is associated with reductions in circulating submicron particles including membrane MPs. Accordingly, there may be significant interdialytic variation in circulating submicron particles. Investigators interested in measuring extracellular vesicles in patients undergoing hemodialysis should therefore carefully consider the timing of biosampling.
Asunto(s)
Vesículas Extracelulares , Fallo Renal Crónico/sangre , Fallo Renal Crónico/terapia , Diálisis Renal , Anexina A5/sangre , Antígenos CD/sangre , Plaquetas/citología , Plaquetas/inmunología , Cadherinas/sangre , Micropartículas Derivadas de Células , Estudios de Cohortes , Femenino , Citometría de Flujo , Soluciones para Hemodiálisis/química , Humanos , Antígenos Comunes de Leucocito/sangre , Leucocitos/citología , Leucocitos/inmunología , Masculino , Persona de Mediana Edad , Nanopartículas/análisisRESUMEN
PURPOSE OF REVIEW: Release of the findings from the Systolic Blood Pressure Intervention Trial has resulted in a renewed examination of intensive blood pressure (BP) lowering. Only a few national hypertension guidelines (Canada and Australia) have changed recommendations, but considerable heterogeneity still exists with respect to the patient population to whom intensive BP lowering may apply. RECENT FINDINGS: There is fairly robust evidence that lower BP targets in nondiabetic chronic kidney disease (CKD) results in a decrease in heart failure and mortality. Similar data exist in patients with diabetes and CKD for reduction in stroke. Consideration of the differences in BP measurement methods in newer trials helps us understand and interpret the findings. SUMMARY: Though often times less is more with respect to therapeutic measures, in patients with CKD, more BP lowering will result in more cardiovascular benefit. Use of newer oscillometric BP devices with adequate resting prior and judicious patient selection are the key aspects to be considered when applying intensive BP lowering.
Asunto(s)
Determinación de la Presión Sanguínea/métodos , Presión Sanguínea , Hipertensión/complicaciones , Hipertensión/tratamiento farmacológico , Insuficiencia Renal Crónica/complicaciones , Antihipertensivos/uso terapéutico , Determinación de la Presión Sanguínea/instrumentación , Insuficiencia Cardíaca/prevención & control , Humanos , Hipertensión/fisiopatología , Guías de Práctica Clínica como Asunto , Accidente Cerebrovascular/prevención & controlRESUMEN
BACKGROUND: Restriction of dietary sodium is routinely recommended for patients with chronic kidney disease (CKD). Whether or not sodium intake is associated with the progression of CKD and mortality remains controversial. We evaluated the association of urinary sodium excretion (as a surrogate for sodium intake) on the need for renal replacement therapy and mortality in patients with advanced CKD. METHODS: We conducted a retrospective study of patients followed at a CKD clinic of a tertiary care hospital from January 2010 to December 2012. Adult patients with advanced CKD (estimated glomerular filtration rate (eGFR) <30 ml/min/1.73 m(2)) were included. Using a time-to-event analysis, we examined the association of urinary sodium excretion as a continuous and also as a categorical variable (categorized as low sodium diet - LSD (<100 mEq/day), medium sodium diet - MSD (100-150 mEq/day), and high sodium diet - HSD (>150 mEq/day) and the outcomes of interest. The primary outcome was defined as composite of progression to end-stage renal disease requiring any type of renal replacement therapy and mortality. The secondary outcome was change in eGFR/year. RESULTS: 341 patients (82 LSD, 116 MSD and 143 HSD) were included in the study (mean follow up of 1.5 years) with a mean eGFR decline of 2.7 ml/min/1.73 m(2)/year. 105 patients (31 %) required renal replacement therapy and 10 (3 %) died. There was no association between urinary sodium excretion and change in the eGFR or need for renal replacement therapy and mortality in crude or adjusted models (unadjusted HR 1.002; 95%CI 1.000-1.004, adjusted HR 1.001; 95%CI 0.998-1.004). CONCLUSION: In patients with advanced CKD (eGFR < 30 ml/min/1.73 m(2)), sodium intake does not appear to impact the progression of CKD to end-stage renal disease; however, more definitive studies are needed.
Asunto(s)
Dieta Hiposódica , Tasa de Filtración Glomerular , Fallo Renal Crónico/fisiopatología , Fallo Renal Crónico/terapia , Sodio en la Dieta/administración & dosificación , Sodio/orina , Anciano , Anciano de 80 o más Años , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Fallo Renal Crónico/mortalidad , Masculino , Persona de Mediana Edad , Terapia de Reemplazo Renal , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
Patients with uncontrolled hypertension on adequate combination and doses of blood pressure-lowering drugs present a diagnostic and therapeutic dilemma. Currently, hypertension guidelines point out uncommon causes of hypertension (either organic such as secondary hypertension or drugs/substances interfering with blood pressure-lowering drugs or causing hypertension) as a cause of hypertension resistance. Non-adherence to drugs, however, is equally, if not more, a cause of hypertension resistance. True resistance to pharmacotherapy is relatively uncommon, as in the majority of patients with non-adherence and/or secondary hypertension, the diagnosis of the problem may potentially lead to better control. Conventionally applied indirect methods to detect non-adherence are inadequate to uncover all cases of non-adherence, especially intentional non-adherence. Rigorous methods to detect non-adherence including direct observed therapy and measuring drug/metabolite levels in body fluids should be considered simultaneously if not before costly and invasive investigations for patients with difficult to control hypertension. However, data on the effectiveness of whether diagnosing non-adherence ultimately controls hypertension is still awaited.
Asunto(s)
Hipertensión/tratamiento farmacológico , Antihipertensivos/uso terapéutico , Biomarcadores/sangre , Resistencia a Medicamentos , HumanosRESUMEN
The KDIGO (Kidney Disease: Improving Global Outcomes) 2012 clinical practice guideline for the management of blood pressure (BP) in chronic kidney disease (CKD) provides the structural and evidence base for the Canadian Society of Nephrology (CSN) commentary on this guideline's relevancy and application to the Canadian health care system. While in general agreement, we provide commentary on 13 of the 21 KDIGO guideline statements. Specifically, we agreed that nonpharmacological interventions should play a significant role in the management of hypertension in patients with CKD. We also agreed that the approach to the management of hypertension in elderly patients with CKD should be individualized and take into account comorbid conditions to avoid adverse outcomes from excessive BP lowering. In contrast to KDIGO, the CSN Work Group believes there is insufficient evidence to target a lower BP for nondiabetic CKD patients based on the presence and severity of albuminuria. The CSN Work Group concurs with the Canadian Hypertension Education Program (CHEP) recommendation of a target BP for all non-dialysis-dependent CKD patients without diabetes of ≤140 mm Hg systolic and ≤90 mm Hg diastolic. Similarly, it is our position that in diabetic patients with CKD and normal urinary albumin excretion, raising the threshold for treatment from <130 mm Hg systolic BP to <140 mm Hg systolic BP could increase stroke risk and the risk of worsening kidney disease. The CSN Work Group concurs with the CHEP and the Canadian Diabetic Association recommendation for diabetic patients with CKD with or without albuminuria to continue to be treated to a BP target similar to that of the overall diabetes population, aiming for BP levels < 130/80 mm Hg. Consistent with this, the CSN Work Group endorses a BP target of <130/80 mm Hg for diabetic patients with a kidney transplant. Finally, in the absence of evidence for a lower BP target, the CSN Work Group concurs with the CHEP recommendation to target BP<140/90 mm Hg for nondiabetic patients with a kidney transplant.
Asunto(s)
Hipertensión/terapia , Guías de Práctica Clínica como Asunto , Insuficiencia Renal Crónica/fisiopatología , Canadá , Nefropatías Diabéticas/fisiopatología , Humanos , Hipertensión/complicaciones , Estilo de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto , Insuficiencia Renal Crónica/complicaciones , Sociedades Médicas , Sodio en la Dieta/administración & dosificaciónRESUMEN
PURPOSE OF REVIEW: Renal sympathetic nerves play a significant role in the development and maintenance of hypertension. Percutaneous catheter-based radioablation of the sympathetic nerves around the renal arteries is a true innovation in follow up to prior animal studies. In this opinion article, we will review the role of the renal sympathetic network in hypertension, and the evidence (or the lack of it) for renal sympathetic denervation as a treatment modality for human hypertension. RECENT FINDINGS: Over the last 5 years, path-breaking research has raised the promise of a dramatically effective therapy for treatment of resistant hypertension in the form of renal sympathetic denervation. Unfortunately, on the basis of limited proof-of-concept and prospective observational studies, this method was widely perceived as a proven therapy for resistant hypertension. As we have learnt from history, only properly designed prospective randomized controlled trials can tell whether that is indeed the truth. SUMMARY: Catheter-based renal sympathetic denervation, despite the recent setbacks, remains a novel and innovative therapeutic intervention, which may still have a role to play in the treatment of carefully selected patients with truly resistant hypertension. Mechanistic studies designed to address the cause of the blood pressure response (or lack thereof) to renal denervation are the next logical step. However, the long-term implications of renal denervation, especially safety issues with respect to the lack of renal sympathetic response in times of physiological need, are not well understood.
Asunto(s)
Ablación por Catéter/métodos , Hipertensión/cirugía , Riñón/inervación , Simpatectomía/métodos , Presión Sanguínea/fisiología , Humanos , Riñón/cirugía , Arteria Renal/inervación , Arteria Renal/cirugíaRESUMEN
BACKGROUND: Quantification of proteinuria (albuminuria) in renal transplant recipients is important for diagnostic and prognostic purposes. Recent guidelines have recommended quantification of proteinuria by spot protein-to-creatinine ratio (PCR) or spot albumin-to-creatinine ratio (ACR). Validity of spot measurements remains unclear in renal transplant recipients. METHODS: Systematic review of adult kidney transplant recipients. Studies that reported the diagnostic accuracy of PCR or ACR as compared with 24-h urine protein or albumin excretion in renal transplant recipients were included. RESULTS: The search identified 8 studies involving 1871 renal transplant recipients. The correlation of the PCR to 24-h protein ranged from 0.772 to 0.998 with a median value of 0.92. PCR sensitivity ranged from 63 to 99 (50% of sensitivities were >90%); PCR specificity varied from 73 to 99 (50% of specificities were >90%). Only one study reported the bias; percent bias ranged from 12 to 21% and accuracy (within 30% of 24 h urine protein) ranged from 47 to 56% depending on the degree of proteinuria. For the ACR, percent bias ranged from 9 to 21%, and the accuracy (within 30%) ranged from 38 to 80%. CONCLUSIONS: The data regarding diagnostic accuracy of PCR and ACR is limited. Only one report studied the absolute measures of agreement (bias and accuracy). We recommend verifying PCR and ACR measurements with a 24-h protein before making any major diagnostic (e.g. biopsy) or therapeutic (e.g. change in immunosuppressive agents) decisions in this population.
Asunto(s)
Creatinina/orina , Rechazo de Injerto/diagnóstico , Trasplante de Riñón , Proteinuria/diagnóstico , Adulto , Femenino , Rechazo de Injerto/complicaciones , Rechazo de Injerto/orina , Humanos , Proteinuria/etiología , Proteinuria/orina , Reproducibilidad de los Resultados , UrinálisisRESUMEN
Historically, primary hypertension (HTN) has been prevalent typically in adults. Recent data however, suggests an increasing number of children diagnosed with primary HTN, mainly in the setting of obesity. One of the factors considered in the etiology of HTN is the autonomous nervous system, namely its dysregulation. In the past, the sympathetic nervous system (SNS) was regarded as a system engaged mostly in buffering major acute changes in blood pressure (BP), in response to physical and emotional stressors. Recent evidence suggests that the SNS plays a much broader role in the regulation of BP, including the development and maintenance of sustained HTN by a chronically elevated central sympathetic tone in adults and children with central/visceral obesity. Consequently, attempts have been made to reduce the SNS hyperactivity, in order to intervene early in the course of the disease and prevent HTN-related complications later in life.
Asunto(s)
Hipertensión/fisiopatología , Sistema Nervioso Simpático/fisiopatología , Factores de Edad , Presión Sanguínea/fisiología , Niño , Humanos , Hipertensión/complicaciones , Obesidad/complicaciones , Obesidad/fisiopatologíaRESUMEN
Hypertension is the single most important and modifiable risk factor for cardiovascular morbidity and mortality worldwide. Non pharmacologic interventions, in particular dietary modifications have been established to decrease blood pressure (BP) and hypertension related adverse cardiovascular events. Among those dietary modifications, sodium intake restriction dominates guidelines from professional organizations and has garnered the greatest attention from the mainstream media. Despite guidelines and media exhortations, dietary sodium intake globally has not noticeably changed over recent decades. Meanwhile, increasing dietary potassium intake has remained on the sidelines, despite similar BP-lowering effects. New research reveals a potential mechanism of action, with the elucidation of its effect on natriuresis via the potassium switch effect. Additionally, potassium-substituted salt has been shown to not only reduce BP, but also reduce the risk for stroke and cardiovascular mortality. With these data, we argue that the focus on dietary modification should shift from a sodium-focused to a sodium- and potassium-focused approach with an emphasis on intervention strategies which can easily be implemented into clinical practice.
Asunto(s)
Sistema Cardiovascular , Hipertensión , Humanos , Potasio , Presión Sanguínea , Sodio , Potasio en la DietaRESUMEN
BACKGROUND: It is unclear whether sex-based differences in cardiovascular outcomes exist in late-onset hypertension. METHODS: This is a population-based cohort study in Ontario, Canada of 266â 273 adults, aged ≥66 years with newly diagnosed hypertension. We determined the incidence of the primary composite cardiovascular outcome (myocardial infarction, stroke, and congestive heart failure), all-cause mortality, and cardiovascular death by sex using Cox proportional hazard models adjusted for demographic factors and comorbidities. RESULTS: The mean age of the total cohort was 74 years, and 135â 531 (51%) were female. Over a median follow-up of 6.6 (4.7-9.0) years, females experienced a lower crude incidence rate (per 1000 person-years) than males for the primary composite cardiovascular outcome (287.3 versus 311.7), death (238.4 versus 251.4), and cardiovascular death (395.7 versus 439.6), P<0.001. The risk of primary composite cardiovascular outcome was lower among females (adjusted hazard ratio, 0.75 [95% CI, 0.73-0.76]; P<0.001) than in males. This was consistent after adjusting for the competing risk of all-cause death with a subdistributional hazard ratio, 0.88 ([95% CI, 0.86-0.91]; P<0.001). CONCLUSIONS: Females had a lower risk of cardiovascular outcomes compared with males within a population characterized by advanced age and new hypertension. Our results highlight that the severity of outcomes is influenced by sex in relation to the age at which hypertension is diagnosed. Further studies are required to identify sex-specific variations in the diagnosis and management of late-onset hypertension due to its high incidence in this group.
Asunto(s)
Hipertensión , Humanos , Masculino , Femenino , Anciano , Hipertensión/epidemiología , Ontario/epidemiología , Incidencia , Factores Sexuales , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/diagnóstico , Anciano de 80 o más Años , Causas de Muerte/tendencias , Estudios de Cohortes , Modelos de Riesgos Proporcionales , Infarto del Miocardio/epidemiología , Infarto del Miocardio/mortalidad , Infarto del Miocardio/diagnóstico , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/mortalidad , Factores de Riesgo , Estudios de Seguimiento , Edad de Inicio , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/mortalidadRESUMEN
In patients with CHF (chronic heart failure) sympathetic activity increases as cardiac performance decreases and filling pressures increase. We hypothesized that in patients with mild-to-moderate CHF, higher than conventional doses of an AT1-receptor [AngII (angiotensin II) type 1 receptor] antagonist would achieve greater central AT1-receptor blockade, resulting in diminished MSNA (muscle sympathetic nerve activity) and augmented MSNA variability, two indices of central effects on sympathetic outflow. In total, 13 patients with ischaemic cardiomyopathy [NYHA (New York Heart Association) class II-III] were weaned off all pharmacological RAS (renin-angiotensin system) modifiers, and then randomized to receive a low (50 mg/day) or high (200 mg/day) dose of losartan. Central haemodynamics, MSNA and its variability, plasma catecholamines, AngI (angiotensin I) and AngII and aldosterone were assessed both before and 3 months after randomization. Neither dose altered BP (blood pressure), PCWP (pulmonary capillary wedge pressure) or CI (cardiac index) significantly. Compared with 50 mg daily, losartan 200 mg/day decreased MSNA significantly (P<0.05), by approximately 15 bursts/min, and increased MSNA variability within the 0.27-0.33 Hz high-frequency range by 0.11 units(2)/Hz (P=0.06). PNE [plasma noradrenaline (norepinephrine)] fell in parallel with changes in MSNA (r=0.62; P<0.05). These findings support the hypothesis that higher than conventional doses of lipophilic ARBs (AT1-receptor blockers) can modulate the intensity and variability of central sympathetic outflow in patients with CHF. The efficacy and safety of this conceptual change in the therapeutic approach to heart failure merits prospective testing in clinical trials.
Asunto(s)
Bloqueadores del Receptor Tipo 1 de Angiotensina II/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Losartán/administración & dosificación , Aldosterona/sangre , Femenino , Insuficiencia Cardíaca/fisiopatología , Humanos , Losartán/uso terapéutico , Masculino , Persona de Mediana Edad , Norepinefrina/sangre , Sistema Nervioso Simpático/efectos de los fármacos , Sistema Nervioso Simpático/fisiopatologíaRESUMEN
BACKGROUND: The prevalence of medication nonadherence in the setting of resistant hypertension (RH) varies from 5% to 80% in the published literature. The aim of this systematic review was to establish the overall prevalence of nonadherence and evaluate the effect of the method of assessment on this estimate. METHODS: MEDLINE, EMBASE, Cochrane, CINAHL, and Web of Science (database inception to November 2020) were searched for relevant articles. We included studies including adults with a diagnosis of RH, with some measure of adherence. Details about the method of adherence assessment were independently extracted by 2 reviewers. Pooled analysis was performed using the random effects model and heterogeneity was explored with metaregression and subgroup analyses. The main outcome measured was the pooled prevalence of nonadherence and the prevalence using direct and indirect methods of assessment. RESULTS: Forty-two studies comprising 71,353 patients were included. The pooled prevalence of nonadherence was 37% (95% confidence interval [CI] 27%-47%) and lower for indirect methods (20%, 95% CI 11%-35%), than for direct methods (46%, 95% CI 40%-52%). The study-level metaregression suggested younger age and recent publication year as potential factors contributing to the heterogeneity. CONCLUSIONS: Indirect methods (pill counts or questionnaires) are insufficient for diagnosis of nonadherence, and report less than half the rates as direct methods (direct observed therapy or urine assays). The overall prevalence of nonadherence in apparent treatment RH is extremely high and necessitates a thorough evaluation of nonadherence in this setting.