Estudio transversal comparativo de las fórmulas CKD-EPI y MDRD-4 a partir de la historia clínica informatizada de Atención Primaria de Barcelona / A comparative, cross-sectional study of the CKD-EPI and MDRD-4 equations from the Primary Care computerized clinical history of Barcelona

Antecedentes: La prevalencia de enfermedad renal crónica (ERC) en España supera el 7%. Su diagnóstico precoz puede ayudar a frenar la evolución. En Atención Primaria (AP) se calcula el filtrado glomerular estimado (FGe) mediante fórmulas basadas en la creatinina plasmática(CrP).Objetivos: Comparar los FG e según las fórmulas MDRD-4 y CKD-EPI a partir de la historia clínica informatizada (HCI) y la clasificación de ERC en una población de AP. Material y métodos: Estudio transversal. Se incluyó a pacientes de 20-99 años, asignados a centros de AP de Barcelona, con CrP entre julio de 2008 y junio de 2010. Se obtuvieron losdatos de la HCI. Se calculó el FGe mediante CKD-EPI y MDRD-4.Resultados: Se estudió a un total de 447.140 personas: 58,7% mujeres, 56,6 (DE 18,8) años. El 32,5% con diagnóstico de hipertensión arterial, 11% con diabetes mellitus y 9,3% con enfermedad cardiovascular asociada. La CrP media fue 0,89 (0,28) mg/dL, FGe por MDRD-4 de 80,59(21,04) mL/min/1,73 m2y por CKD-EPI de 85,03 (21,13) mL/min/1,73 m2. La CKD-EPI, respecto a MDRD-4, clasificó el 2,3% de los pacientes en estadios menos avanzados de ERC, el 96,8% en el mismo y el 0,9% en más avanzados. El índice kappa fue de 0,87. En números absolutos clasificó en estadios 3b-4-5 (posible derivación a nefrología) a 958 pacientes más, con 691 personas >69 años en estadio 3b.Conclusiones: Utilizar una u otra fórmula puede variar el FGe. La CKD-EPI tiende a clasificar enestadios más avanzados en > 69 años. El uso de cada fórmula puede hacer cambiar el número y tipo de derivaciones a nefrología

Background: The prevalence of chronic kidney disease (CKD) in Spain is higher than 7%. Its early diagnóstico can help to delay its progression. Glomerular filtration rate (GFR) based on serum creatinine (SC) is calculated in primary care (PC) to identify CKD. Objectives: To compare GFR by MDRD-4 and CKD-EPI equations obtained from clinical records(CR) and to compare the classification of CKD in a primary care population. Material and methods: A cross-sectional study was performed, including patients 20-99 years old, assigned to primary care centers of Barcelona, with a SC recorded between July 2008 and June 2010. Data were obtained from the CRs. GFR was calculated from MDRD-4 and CKD-EPI equations. Results: A total of 447,140 persons were studied (58.7% females, 56.6 [SD 18.8] years old).Of these 32.5% were diagnosed of hypertension, 11.0% diabetes and 9.3% had some associated cardiovascular disease. SC 0.89 (0.28) mg/dL (78.7 [SD 24.8] mol/L), GFR being 80.59(21.04) mL/min/1.73 m2by MDRD-4, and 85.03 (21.13) mL/min/1.73 m2by CKD-EPI. CKD-EPI compared to MDRD-4 classified 2.3% of patients in less advanced stages of CKD, 96.8% in the same stage and 0.9% in more advanced stages. Kappa coefficient: 0.87. In absolute numbers, CKD-EPI classified in 3b-4-5 stages (candidates for referral to nephrology) 958 patients more,691 of them being patients > 69 years old and stage 3b.Conclusions: Using one equation or another could vary the estimation of GFR. CKD-EPI tends to classify patients older than 69 into more advanced stages. Each equation can change the number and type of referral to nephrology (AU)

El filtrado glomerular reducido según las fórmulas de Cockcroft-Gault y MDRD no siempre predice la morbimortalidad cardiovascular en los pacientes hipertensos atendidos en atención primaria / Decreased glomerular filtration rate using the Cockgroft-Gaultand MDRD formulas does not always predict cardiovascular morbidity and mortality in hypertensive primary care patients

Antecedentes: El deterioro de la función renal se ha asociado con un incremento de la morbimortalidad cardiovascular. El objetivo del estudio fue analizar la asociación del filtrado glomerular (FG) basal, según las fórmulas de Cockcroft-Gault y MDRD, con la incidencia de eventos cardiovasculares (ECV) en una cohorte de personas hipertensas seguida durante 12 años. Métodos: Estudio prospectivo de una muestra aleatoria de 223 hipertensos libres de ECV atendidos en un centro de atención primaria urbano. Se estimó el FG mediante ambas fórmulas. Se consideró ECV la aparición de cardiopatía isquémica, insuficiencia cardíaca, accidente cerebrovascular, vasculopatía periférica o muerte por ECV. Se analizaron los datos mediante el método actuarial y modelos de regresión de Cox. Resultados: La mediana de tiempo de seguimiento fue de 10,7 años (rango intercuartílico,6,5-12,1). El seguimiento fue completo en 191 participantes (85,7%). La supervivencia acumulada fue del 64,7% (intervalo de confianza [IC] del 95%: 57,9-71,6%). La tasa media de incidencia de ECV durante todo el período de seguimiento fue de 3,6 (IC del 95%, 2,7-4,4%) por 100 personas hipertensas/año. El modelo multivariable final mostró que las variables con mayor poder predictivo de ECV en la población de estudio fueron la diabetes y la estimación del FG >60ml/min/1,73 m2mediante fórmula MDRD. Conclusiones: Se observó una relación entre la aparición de ECV y los valores de FG estimados por la fórmula MDRD al inicio del seguimiento superiores a 60 ml/min/1,73 m2, inversa a la eserada. La estimación del FG mediante fórmula de Cockcroft-Gault no se asoció con el riesgo cardiovascular (AU)

Background: Renal function decrease is associated with cardiovascular morbidity and mortality. The aim was to analyze the association of cardiovascular morbidity and mortality with baseline glomerular filtration rate (GFR), according Cockcroft-Gault and MDRD formulas, with incidence of major adverse cardiovascular events (MACEs) in a cohort of hypertensive individuals followed for 12 years. Methods: We performed a prospective study of a random sample of 223 hypertensive patients free of MACEs followed in an urban Primary Care Center. GFR was estimated using both formulas. MACEs were considered the onset of ischemic heart disease, heart failure, stroke, peripheral vascular disease or cardiovascular death. Data were analyzed using the life-table method and Cox regression modeling. Results: Follow-up median was 10.7 (interquartile range, 6.5-12.1) years. Follow-up was complete in 191 participants (85.7%). The cumulative survival was 64.7% (95%Confidence Interval (CI) 57.9%-71.6%). The incidence of MACEs during the follow-up period was 3.6 (95% CI, 2.7-4.4) per 100 subject-years. The final multivariable model showed that the most predictive variables of MACEs in the study population were the presence of diabetes and the estimation of GFR >60 ml/min/1.73 m2by MDRD equation. Conclusions: There was a relationship between the occurrence of MACEs and MDRD formula estimated GFR above60 ml/min/1.73 m2at study entry, inversely to what expected. C-G formula estimated GFR by was not associated with cardiovascular risk (AU)

[Decreased glomerular filtration rate using the Cockckroft-Gault and MDRD formulas does not always predict cardiovascular morbidity and mortality in hypertensive primary care patients]. / El filtrado glomerular reducido según las fórmulas de Cockcroft-Gault y MDRD no siempre predice la morbimortalidad cardiovascular en los pacientes hipertensos atendidos en atención primaria.

BACKGROUND: A decrease in renal function is associated with cardiovascular morbidity and mortality. The aim of this study was to analyse the association of cardiovascular morbidity and mortality with baseline glomerular filtration rate (GFR), calculated according to the Cockcroft-Gault and MDRD formulas, with the incidence of major adverse cardiovascular events (MACEs) in a cohort of hypertensive individuals followed for 12 years. METHOD: We performed a prospective study of a random sample of 223 hypertensive patients free of MACEs, who were followed in an urban Primary Care Centre. GFR was estimated using both formulas. MACEs were considered as the onset of ischaemic heart disease, heart failure, heart attacks, peripheral vascular disease or cardiovascular death. Data were analysed using the life-table method and Cox regression modeling. RESULTS: The median follow-up was 10.7 (interquartile range, 6.5-12.1) years. Follow-up was completed in 191 participants (85.7%). The cumulative survival was 64.7% (95% Confidence Interval (CI), 57.9-71.6). The incidence of MACEs during the follow-up period was 3.6 (95% CI, 2.7-4.4) per 100 subject-years. The final multivariable model showed that the most predictive variables of MACEs in the study population were the presence of diabetes mellitus and the estimation of GFR ≥60 ml/min/1.73 m2 by MDRD equation. CONCLUSIONS: There was a relationship between the occurrence of MACEs and an estimated GFR by MDRD above 60 ml/min/1.73 m2 at study entry, inversely to what was expected. GFR estimated by the C-G formula was not associated with cardiovascular risk.

[Hypertension and anesthesia: consensus statement of the Catalan Associations of Anesthesiology and Hypertension]. / Documento de Consenso sobre Hipertensión Arterial y Anestesia de las Sociedades Catalanas de Anestesiología e Hipertensión Arterial.

The prevalence of hypertension is high in the surgical population. Differing practices and the absence of consensus among physicians involved in caring for hypertensive patients has made it one of the most frequent reasons for cancelling scheduled surgery. The aim of this consensus statement is to outline a practical approach to managing the hypertensive surgical patient. Hypertension is associated with increased risk of perioperative complications, particularly those related to systemic effects and notable fluctuations in blood pressure during surgery. Preoperative assessment should center on a search for signs and symptoms of target organ damage. The anesthesiologist should seek to reduce perioperative fluctuations in arterial pressure, particularly guarding against sustained hypotension. After surgery, antihypertensive medication should be resumed as soon as possible.

Documento de Consenso sobre Hipertensión Arterial y Anestesia de las Sociedades Catalanas de Anestesiología e Hipertensión Arterial / Hypertension and anesthesia: consensus statement of the Catalan associations of anesthesiology and hypertension

La hipertensión arterial (HTA) tiene una elevada prevalenciaen nuestra población quirúrgica. Las diferenciasde criterio y la ausencia de consenso entre los profesionalesimplicados en el cuidado de estos pacientes,han contribuido a que la hipertensión sea una de las causasmás frecuentes de cancelación de una intervención.El objetivo de este documento es ofrecer al clínico unenfoque práctico para abordar el manejo perioperatoriodel paciente hipertenso. La HTA se asocia a un riesgoaumentado de complicaciones perioperatorias, especialmenterelacionado con la repercusión sistémica de lahipertensión y con oscilaciones importantes de la presiónarterial durante la cirugía. La evaluación preoperatoriadebe centrarse en la búsqueda de signos y síntomas delesión de órgano diana. Durante el perioperatorio elanestesiólogo debe minimizar las fluctuaciones de la presiónarterial, evitando especialmente hipotensiones sostenidas,y en el postoperatorio reiniciar lo antes posible lamedicación antihipertensiva(AU)

The prevalence of hypertension is high in the surgicalpopulation. Differing practices and the absence of consensusamong physicians involved in caring for hypertensivepatients has made it one of the most frequent reasons forcancelling scheduled surgery. The aim of this consensusstatement is to outline a practical approach to managing thehypertensive surgical patient. Hypertension is associatedwith increased risk of perioperative complications,particularly those related to systemic effects and notablefluctuations in blood pressure during surgery. Preoperativeassessment should center on a search for signs andsymptoms of target organ damage. The anesthesiologistshould seek to reduce perioperative fluctuations in arterialpressure, particularly guarding against sustainedhypotension. After surgery, antihypertensive medicationshould be resumed as soon as possible(AU)

Prevalencia de disfunción diastólica en los pacientes hipertensos de nuevo diagnóstico y sin tratamiento / Prevalence of diastolic dysfunction in non-treated, newly diagnosed hypertensive patients

Objetivo. El propósito de este estudio observacional es conocer la prevalencia de disfunción diastólica (DD) en los pacientes hipertensos de nuevo diagnóstico y sin tratamiento. Pacientes y métodos. Se han incluido 105 pacientes (69 varones y 36 mujeres), con una edad media de 51,11 años los hombres y 54,25 años las mujeres, con hipertensión arterial de nuevo diagnóstico y sin tratamiento antihipertensivo. El estudio tuvo lugar entre junio de 2002 y junio de 2003. Fueron excluidos los pacientes con cardiopatía isquémica, hipertrófica, valvular, dilatada, fibrilación auricular y enfermedad pulmonar obstructiva crónica (EPOC) evolucionada. A todos los pacientes se les practicó un ecocardiograma doppler. Se consideró que existía DD del ventrículo izquierdo al registrarse al menos dos de los siguientes parámetros ecocardiográficos: tiempo de relajación isovolumétrica (TRIV) > 100 mseg, tiempo de desaceleración de la onda E (TDE) > 250 mseg y cociente E/A 130 g/m2 y en mujeres > 110 g/m2. Resultados. El 60 % de los pacientes estudiados tenían parámetros de DD en el ecocardiograma. El 37,1 % presentaban patrón de DD sin hipertrofia ventricular izquierda (HVI), el 16,2 % presentaban patrón de DD con HVI y un 6,7 % presentaban HVI y patrón de DD por mala relajación del VI. Se observaba una clara correlación entre la presencia de DD y la edad, presión arterial sistólica (PAS), presión del pulso (PP) y el índice de masa corporal (IMC), no encontrándose relación con el sexo y otras variables estudiadas (diabetes, insuficiencia renal, dislipemia, presión arterial diastólica [PAD] y frecuencia cardíaca [FC]). Conclusiones. La prevalencia de la DD valorada por ecocardiograma doppler en pacientes hipertensos de nuevo diagnóstico es muy elevada (60%), observando una correlación directa con la edad de los pacientes, PAS, PP y el IMVI

Objective. This study aims to evaluate the prevalence of diastolic dysfunction (DD) in newly diagnosed hypertensive patients without treatment. Patients and method. 105 patients (69 men and 36 women), with a mean age of 51.11 years in men and 54.25 years in women, with newly diagnosed hypertension and without treatment have been included. The study took place between June 2002 and June 2003. Exclusion criteria were ischemic heart disease, hypertrophy, valvular disease, dilated heart disease, atrial fibrillation and fully-developed COPD. A doppler echocardiogram was practiced on all patients. Diastolic dysfunction was considered to exist if two of the following echocardiographic parameters were found: isovolumetric relaxing time (TRI-V) > 100 ms, deceleration time of the E wave (TDE) > 250 ms, early filling rate peak/late filling rate peak ratio (E/A) 130 g/m2 in men and > 110 g/m2 in women. Results. A total of 60 % of patients had DD parameters and 37.1 % had DD without Left Ventricular Hypertrophy (LVH); 6.7 % had LVH and DD due to impaired relaxation of the left ventricle. There is a clear correlation between DD and age, Systolic Blood Pressure (SBP), Pulse Pressure (PP) and Body Mass index (BMI). We found no relationship with gender and other variables (heart rate, diabetes, renal insufficiency, dyslipidemia, diastolic blood pressure). Conclusion. The prevalence of DD evaluated by doppler echocardiogram is very high in newly diagnosed hypertensive patients (60 %), a direct correlation being observed with the patient's age, SBP, PP and LVMI

[Pharmacogenetics of angiotensin system in non diabetic nephropathy]. / Farmacogenética del sistema de la angiotensina en la nefropatía no diabética.

BACKGROUND: Genetic variability could contribute to the response to pharmacological treatment in patients with nephropathy. In albuminuric diabetic patients the renoprotective effect of angiotensin I-converting enzyme (ACE) inhibition should be lower among homozygotes for the deletion allele (DD) compared to II-homozygotes. METHODS: A total of 71 non-diabetic chronic nephropathy patients were treated with losartan (n = 37) or amlodipine (n = 34). Blood pressure and proteinuria were determined before and after the treatment, and changes in the mean values were statistically compared. Patients were genotyped for the ACE-I/D, angiotensin I receptor type 1 (AGTR1)-1166 A/C, and angiotensinogen (AGT)-M235T polymorphims, and the reduction of blood pressure and proteinuria between the different genotypes were compared. RESULTS: The reduction in systolic or diastolic blood pressure was not found to be different between the ACE-I/D or AGT-M/T genotypes in patients treated with losartan or amlodipine. In patients treated with losartan, we found a significantly higher reduction of diastolic blood pressure in AGTR1-AA patients compared to AC patients (p = 0,0024). We did not find differences in proteinuria-reduction between the different genotypes in patients treated with losartan or amlodipine. CONCLUSIONS: Our data show that the effects of losartan and amlodipine on the absolute mean reduction of blood pressure and proteinuria in non-diabetic nephropathy patients are similar between the different ACE or AGT genotypes. Although based on a small number of patients, the AGTR1-AA genotype was associated with a significantly higher reduction in diastolic blood pressure among losartan-treated patients. Additional studies are necessary to refute or confirm this association.

Farmacogenética del sistema de la angiotensina en la nefropatía no diabética / Pharmacogenetics of angiotensin system in non diabetic nephropathy

Antecedentes: La variación genética podría contribuir a la respuesta farmacológica en los pacientes con nefropatía. Así, entre los pacientes con albuminuria diabética aquellos con el genotipo DD para el gen de la enzima convertidora de la angiotensina (ECA, polimorfismo inserción/delección, I/D) tendrían una menor respuesta renoprotectora ante los inhibidores de la ECA, comparados con los pacientes con genotipo II. Métodos: Estudiamos 71 pacientes con nefropatía crónica no diabética, de los cuales 37 habían sido tratados con losartán y 34 con amlodipino. Determinamos la tensión arterial y la proteinuria antes y después de ser tratados, y los valores medios se compararon estadísticamente. Todos los pacientes fueron genotipados para los polimorfismos I/D de la ECA, 1166 A/C del receptor de tipo 1 de la angiotensina I (AGTR1), y M235T del angiotensinógeno (AGT), y los valores medios de la reducción de la tensión sanguínea y la proteinuria fueron comparados entre los genotipos. Resultados: No hallamos diferencias en la reducción de la presión sanguínea diastólica o sistólica entre los diferentes genotipos de los polimorfismos de la ECA y el AGT, tanto para los pacientes tratados con losartán como con amlodipino. En los pacientes tratados con losartán hubo una reducción significativa de la presión diastólica entre aquellos con genotipo AGTR1-AA comparados con los heterocigotos AC (p = 0,0024). No hallamos diferencias en el nivel de reducción de la proteinuria entre los diferentes genotipos, tanto entre los tratados con losartán como con amlodipino. Conclusiones: De acuerdo con nuestros resultados, los valores medios de reducción de la presión sanguínea en los pacientes con nefropatía no diabética y tratados con losartán o amlodipino serían similares entre los diferentes genotipos de la ECA y el AGT. Aunque nuestro estudio se basó en un número reducido de pacientes, el genotipo AGTR1-AA podría estar asociado con una mayor reducción de la presión diastólica entre los pacientes tratados con losartán

Background: Genetic variability could contribute to the response to pharmacological treatment in patients with nephropathy. In albuminuric diabetic patients the renoprotective effect of angiotensin I-converting enzyme (ACE) inhibition should be lower among homozygotes for the deletion allele (DD) compared to II-homozygotes. Methods: A total of 71 non-diabetic chronic nephropathy patients were treated with losartan (n = 37) or amlodipine (n = 34). Blood pressure and proteinuria were determined before and after the treatment, and changes in the mean values were statistically compared. Patients were genotyped for the ACE-I/D, angiotensin I receptor type 1 (AGTR1)-1166 A/C, and angiotensinogen (AGT)-M235T polymorphims, and the reduction of blood pressure and proteinuria between the different genotypes were compared. Results: The reduction in systolic or diastolic blood pressure was not found to be different between the ACE-I/D or AGT-M/T genotypes in patients treated with losartan or amlodipine. In patients treated with losartan, we found a signiticantly higher reduction of diastolic blood pressure in AGTR1-AA patients compared to AC patients (p = 0,0024). We did not find differences in proteinuria-reduction between the different genotypes in patients treated with losartan or amlodipine. Conclusions: Our data show that the effects of losartan and amlodipine on the absolute mean reduction of blood pressure and proteinuria in non-diabetic nephropathy patients are similar between the different ACE or AGT genotypes. Although based on a small number of patients, the AGTR1-AA genotype was associated with a significantly higher reduction in diastolic blood pressure among losartan-treated patients. Additional studies are necessary to refute or confirm this association

Pielonefritis aguda. Estudio de 153 casos / Acute puelonephritis. A 153 cases study

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Angiotensin II induces superoxide anion production by mesangial cells.

BACKGROUND: The recognized role of angiotensin II (Ang II) in the pathogenesis of the progression of renal disease cannot be solely attributed to Ang II's hemodynamic effects. Indeed, growth stimulating signals driven by Ang II promote mesangial cell (MC) hypertrophy and extracellular matrix production, prominent features of progressive glomerular injury. Superoxide anion (O2-) avidly interacts with nitric oxide, an endogenous vasodilator that inhibits growth factor stimulated MC growth and matrix production. In addition, O2- acting as an intracellular signal is linked to growth related responses such as activation of mitogen activated protein (MAP) kinases. The studies reported herein were designed to investigate: (a) whether Ang II induces MC O2-production and (b) if increased O2- production elicits growth responses in MC. METHODS: MC were exposed to Ang II for 24 or 48 hours. In some experiments, in addition to Ang II, MC were exposed to: diphenylenieodonium (DPI), an inhibitor of the flavin containing NADH/NADPH oxidase; losartan (LOS), an Ang II type 1 (AT1) receptor blocker; PD 98059, a MAP kinases inhibitor; the protein kinase C inhibitors Calphostin C or H-7; and the tyrosine kinase inhibitors, herbymycin A or genistein. RESULTS: Ang II (10(-5) M to 10(-8) M) dose dependently increased MC O2- production up to 125% above control (ED 50 5 x 10(-7) M). LOS as well as DPI, and the PKC inhibitors blocked Ang II stimulated MC O2- production. Ang II dose dependently increased MC 3H-leucine incorporation, and MC protein content, two markers of MC hypertrophy, as well as 3H-thymidine incorporation, a marker of MC hyperplasia. PD98059, a specific inhibitor of MAP kinases prevented Ang II induced MC hypertrophy. Moreover, LOS, DPI, and the PKC inhibitors each independently inhibited MC 3H-leucine incorporation, thereby establishing the specificity of Ang II induced O2- in driving MC hypertrophy. CONCLUSIONS: The current studies demonstrate a previously unrecognized link between Ang II and MC O2- production that may participate in the pathophysiology of progressive renal disease by concomitantly affecting the hemodynamics of the glomerular microcirculation as well as growth related responses of MC to injury.