Overcoming Clinical Inertia in the Treatment of Hypertension.

Objective This study aimed to investigate the antihypertensive goal achievement rate for office blood pressure (OBP) and the rate of clinical inertia (inertia) as factors for non-achievement in hypertensive patients in 2020. After documenting these results in the medical records, we observed changes in the achievement rate of the OBP goals in 2020 and 2022. Methods In Study 1, the participants were 517 outpatients (mean age 68.6±13.2 years, 54% women) who visited the Division of Hypertension regularly between March and September 2020. We investigated the achievement rate of OBP goals during that period and confirmed the prevalence of inertia as a possible factor for failure to achieve OBP goals. In Study 2, the participants were 308 who visited the division, and who had at least one condition for which an OBP of <130/80 should be targeted in both 2020 and 2022 (mean age 66.6±12.4 years, 50% of women in 2020). We investigated the trends in the achievement of OBP for the same period in both years. Results The rate of achievement of the OBP goals in 2020 was 48%. Inertia accounted for 14% of the non-achievement factors. The OBP significantly decreased in 2022 in comparison to 2020. The achievement rate of OBP goals showed an increasing trend from 45% in 2020 to 52% in 2022. Conclusion Attending physicians' awareness of unmet antihypertensive goals can help them overcome inertia and improve blood pressure control in patients.

Presepsin cut-off value for diagnosis of sepsis in patients with renal dysfunction.

Presepsin is used as a marker for diagnosing sepsis, but its serum concentration is affected by renal function. We investigated the effect of the estimated glomerular filtration rate (eGFR) determined by creatinine on the diagnostic accuracy of presepsin to identify the optimal cut-off value in patients with renal dysfunction. A total of 834 patients aged ≥18 years with serum presepsin and creatinine measured on the same day over a period of 1 year were included. Sepsis was diagnosed in three ways: sepsis-1, sepsis-3, and clinical diagnosis (Sep-C). Presepsin showed a significant negative correlation with eGFR (r = -0.55, p<0.01), with median and interquartile ranges of presepsin values for patients in each eGFR category as follows: ≥90, 263 (169-460); ≥60-<90, 309 (205-578); ≥45-<60, 406 (279-683); ≥30-<45, 605 (379-1109); ≥15-<30, 1027 (675-1953); <15, 1977 (1199-3477); and on hemodialysis, 3964 (2343-6967). In receiver operating characteristic (ROC) analysis, the area under the curve (AUC) for sepsis-1 was the lowest (0.64 ± 0.02), while Sep-C (0.80± 0.03) and sepsis-3 (0.75 ± 0.03) were moderately accurate. Comparing AUCs after dividing patients into eGFR ≥60 and <60 showed that the AUC of Sep-C was lower in the eGFR ≥60 group, while the AUC of sepsis-3 was ≥ 0.7 in both groups. The following cut-offs were obtained by ROC analysis for sepsis-3: 466 pg/mL in the ≥60 group and 960 pg/mLin the < 60 group. Presepsin facilitated diagnosis sepsis based on sepsis-3 criteria regardless of renal function. We found that the optimal cut-offs for patients in this study were 500 pg/mL for eGFR ≥ 60 and 1000 pg/mL for < 60. However, future prospective diagnostic studies on sepsis-3 are needed to determine the cut-offs for patients with renal dysfunction.

Differences among hemoglobin thresholds for red blood cell transfusions in patients with hematological diseases in teaching hospitals: a real world data in Japan.

A hemoglobin (Hb) threshold level of 7 g/dL has been proposed for red blood cell (RBC) transfusion in patients with chronic anemia in the Japanese guideline since 2005. However, Hb thresholds for hematological diseases in clinical practice and factors responsible for higher Hb thresholds remain unclear. Hb thresholds were collected for patients with hematological diseases from 32 Japanese teaching hospitals. Uni- and multivariate analyses were used to analyze relationships between Hb threshold level and various patient and hospital factors. In total, 4996 units of RBC were transfused to 1054 patients with hematological diseases in 2421 transfusions. Median age was 68 years. Myelodysplastic syndrome was the most frequent diagnosis. Overall median Hb threshold level was 6.9 g/dL. Multivariate linear regression analysis detected the following variables associated with Hb threshold level: hospital; cardiovascular disease; symptomatic anemia; and hematopoietic stem cell transplantation. Hospital was the most significant factor. Collectively, median Hb threshold level in clinical practice in Japan was similar to the guidelines. Higher Hb threshold level depended on the hospitals at which the transfusions were performed as well as patient condition. Educational approaches directed toward hospitals may be useful to promote transfusion guidelines.

Association of aortic valve calcification with carotid artery lesions and peripheral artery disease in patients with chronic kidney disease: a cross-sectional study.

BACKGROUND: Patients with chronic kidney disease (CKD) reportedly have a high prevalence of aortic valve calcification (AVC). In population-based studies, AVC is considered a manifestation of systemic atherosclerosis. The association of AVC with atherosclerotic lesions has not been fully investigated in predialysis patients. The present study was performed to determine whether carotid artery lesions and peripheral artery disease (PAD) are associated with AVC in patients with CKD not on dialysis. METHODS: In total, 749 patients were included in this cross-sectional study. AVC was evaluated using echocardiography. Carotid artery lesions including carotid artery plaque (CAP) and PAD were simultaneously examined in each patient. A logistic regression analysis was applied to determine the factors associated with AVC. RESULTS: AVC, CAP, and PAD were found in 201, 583, and 123 patients, respectively. In the multivariable analyses adjusted for covariates including the estimated glomerular filtration rate and makers of mineral metabolism (serum calcium, serum phosphorus, parathyroid hormone, 1,25-dihydroxyvitamin D, and fibroblast growth factor 23), AVC was significantly associated with the presence of CAP [odds ratio (OR), 3.37; 95% confidence interval (CI), 1.43-7.95], the presence of PAD (OR, 1.76; 95% CI, 1.10-2.81), the CAP score (per 1.0-point increase) (OR, 1.06; 95% CI, 1.02-1.11), and the ankle-brachial blood pressure index (per 0.1-point increase) (OR, 0.83; 95% CI, 0.72-0.95). CONCLUSIONS: AVC was associated with atherosclerotic lesions independent of kidney function and mineral metabolism. We consider that this association between AVC and atherosclerosis might reflect the burden of shared atherosclerotic risk factors.

Antihypertensive drug reduction for treated hypertensive patients during the summer.

Seasonal winter-summer variation in blood pressure (BP) has been reported, but there are few reports on the reduction of antihypertensive medication during the summer. We aimed to investigate the prevalence and details of drug reduction during the summer among outpatients. Among 667 patients, 90 patients (13.5%) had their medication reduced during the summer. The highest rate of drug reduction was for diuretics (17.5%). The patients whose medications were reduced (Group R) took a larger number of drugs and more frequently took diuretics compared with the subjects whose medications were unchanged (N = 559; with no reduction or increase in drugs, Group UC). Moreover, both the office BP and morning home BP of the patients in Group R were significantly lower compared with those of the patients in Group UC. These results suggest that doctors tend to reduce antihypertensive drugs to avoid an excessive decrease in BP especially in patients receiving combination therapy including diuretics.

Salt Intake, Home Blood Pressure, and Perinatal Outcome in Pregnant Women.

BACKGROUND: The relationship between salt (sodium chloride) intake and pregnancy-induced hypertension (PIH) remains unclear. The aim of this study was therefore to investigate the current status of salt intake during pregnancy and identify effective predictors for PIH. METHODS AND RESULTS: Participants were 184 pregnant women who collected 24-h home urine as well as early morning urine samples. We investigated urinary salt excretion, home blood pressure (HBP) measurements for 7 consecutive days before the 20th and after the 30th gestational week, and the development of PIH. Urinary salt excretion according to early morning urine before the 20th gestational week was 8.6±1.7 g/day, and was significantly correlated with that measured from 24-h collected urine. Early morning urine estimated urinary salt excretion was slightly but significantly increased during pregnancy. HBP was 102±10/63±8 mmHg before the 20th gestational week and 104±12/64±10 mmHg after the 30th gestational week. On multiple regression analysis, serum uric acid and body mass index, but not urinary salt excretion, contributed to HBP both before the 20th and after the 30th gestational week. Fourteen participants (7.6%) developed PIH. On multivariate analysis, higher HBP and older age, but not urinary salt excretion, were significantly associated with PIH. CONCLUSIONS: Higher HBP and older age, but not urinary salt excretion, are predictors of PIH. (Circ J 2016; 80: 2165-2172).

[Diagnostic Ability of Natriuretic Peptides for Heart Failure According to eGFR Level: Comparison between Brain Natriuretic Peptide and Amino-Terminal Probrain Natriuretic Peptide].

Although the influence of reduced kidney function on natriuretic peptides (B-type natriuretic peptide [BNP] and amino terminal probrain natriuretic peptide [NT]) is clear, effect of kidney function on the difference of diagnostic ability for heart failure by these peptides is not obvious. The aim of this study was to examine the relationship between natriuretic peptide concentrations and echocardiographic findings according to eGFR level of the patients. In addition, we compared diagnostic ability of BNP with that of NT according to eGFR level. The eGFR levels were classified by based on CKD stage (≥ 60, 45-59, 30-44, 15-29, < 15 and on maintenance HD). Patients who underwent the measurements of BNP, NT and serum creatinine concentrations, as well as echocardiography between March and October in 2011 were enrolled (n = 1,297). The left ventricular mass index was greater in patients with eGFR < 60 than in those with eGFR ≥ 60, but EF (%) was not different among eGFR level (except eGFR30-44). The percentage of patients with heart failure in those with eGFR < 60 (16.0%) was more than eGFR ≥ 60 (5.8%). Median BNP and NT concentrations were elevated in association with decreasing eGFR level. Using receiver-operator characteristic (ROC) analysis, the area under the ROC curve for BNP and NT that stratified subjects with or without heart failure was not different among eGFR level. In conclusion, BNP and NT levels are elevated depend on decreasing eGFR level, BNP and NT are comparable in the accuracy for diagnosing heart failure at every eGFR level. The cut-off value of BNP and NT should be established according to the eGFR level.

High Salt Intake Is Independently Associated With Hypertensive Target Organ Damage.

The authors tested the hypothesis that high salt intake is associated with hypertensive target organ damage (TOD) independent of blood pressure (BP), and oxidative stress is a modifying factor of this association. A total of 369 community-dwelling Japanese adults (mean age, 67.5 years; 56.6% women) were examined in this observational study. At the patients' annual health check-ups, urinary salt excretion (U-SALT), 8-hydroxy-2'-deoxyguanosine (8-OHdG), and albumin-creatinine ratio (UACR) were measured from first morning urine. U-SALT (ß=0.14, P=.016) and 8-OHdG (ß=0.13, P=.018) were both independently associated with logUACR. U-SALT was associated with TOD independent of BP level, and oxidative stress may be a modifying factor in the association between high salt intake and TOD. The elevation of 8-OHdG may be involved in the pathophysiology of TOD induced by salt intake.

Variability of urinary salt excretion estimated by spot urine in treated hypertensive patients.

Among the several methods used to assess salt intake, estimating 24 h urinary salt excretion by spot urine seems appropriate for clinical practice. In this study, we investigated variability in urinary salt excretion using spot urine in hypertensive outpatients. Participants included 200 hypertensive patients who underwent spot urinary salt excretion at least three times during the observation period. Mean urinary salt excretion and the coefficient of the variation were 8.62 ± 1.96 g/day and 19.0 ± 10.2%, respectively. In the analysis of participants who underwent assessment of urinary salt excretion at least eight times (n = 54), a significant reduction in mean urinary salt excretion was found at the 5th measurement. On the contrary, the coefficient of the variation of urinary salt excretion continued to increase until the 5th measurement, and became stable thereafter. Mean urinary salt excretion was positively correlated with mean clinic diastolic blood pressure (r = 0.27, p < 0.05). Clinic diastolic blood pressure in the high urinary salt excretion group (≥ 10 g/day) was significantly higher than that of the low group (76.2 ± 7.5 vs 73.4 ± 8.3 mmHg, p < 0.05). Mean urinary salt excretion in summer was significantly lower than that of the other seasons (7.75 ± 1.94 vs 9.09 ± 2.68 (spring), 8.72 ± 2.12 (autumn), 8.92 ± 2.17 (winter) g/day, p < 0.01). In conclusion, repeated measurements of urinary salt excretion using spot urine are required to assess daily salt intake of hypertensive patients.

Relationship between salt intake as estimated by a brief self-administered diet-history questionnaire (BDHQ) and 24-h urinary salt excretion in hypertensive patients.

Assessing an individual's salt intake is necessary for providing guidance with respect to salt restriction. However, the methods that exist for assessing salt intake have both merits and limitations. Therefore, the evaluation methods should be selected for their appropriateness to the patients and the environment of the medical facilities. The purpose of the present study was to investigate the validity of a brief self-administered diet-history questionnaire (BDHQ) by comparing the responses with 24-h urinary salt excretion. A total of 136 hypertensive outpatients (54 men and 82 women) were included in this study. All subjects were given the BDHQ and performed 24-h home urine collection. The energy-adjusted salt intake as assessed by the BDHQ was 12.3 (95% confidence interval: 11.8-12.9) g per day, and the urinary salt excretion evaluated by 24-h urinary collection was 9.0 (8.4-9.5) g per day. The energy-adjusted salt intake assessed by the BDHQ correlated significantly with the urinary salt excretion evaluated by 24-h urinary collection (r=0.34, P<0.001). In conclusion, the estimated salt intake evaluated by the BDHQ weakly, but significantly, correlated with 24-h urinary salt excretion. In clinical practice, it seems important to utilize both methods to assess an individual's salt intake in order to provide adequate guidance for salt restriction.

Long-term variability of urinary salt excretion and blood pressure in hypertensive patients.

We investigated the long-term trend and variability of urinary salt (sodium chloride) excretion in hypertensive patients. Subjects included 186 hypertensive patients (103 women and 83 men, mean age: 58.5±10.5 years) who underwent 10 successful 24-h home urine collections over a mean observation period of 7.7 years. We measured 24-h urinary salt excretion and blood pressure (BP) sequentially at the time of each collection and monitored the long-term trend and variability of urinary salt excretion. BP significantly decreased from 145±16/85±11 mm Hg to 130±12/70±11 mm Hg and was associated with an increased use of antihypertensive drugs. The 24-h urinary salt excretion also decreased from 9.5±3.6 g per day at the first measurement to 8.5±3.2 g per day at the 10th measurement. Urinary salt excretion during the observation period ranged from a minimum value of 5.2±1.8 g per day to a maximum value of 13.4±3.6 g per day with a coefficient of variation of 29.2±8.1%. When subjects were assigned to a low, medium and high salt group based on the tertiles of the first measurement of urinary salt excretion and the tertiles based on the mean value of 10 measurements during the observation period, only 56.2% remained in the same category, suggesting that a single measurement of urinary salt excretion can only predict long-term urinary salt excretion in approximately half of the individuals. In conclusion, urinary salt excretion shows large variability such that a single measurement may not be sufficient to assess salt intake in individuals.

Characteristics of the hypertensive patients with good and poor compliance to long-term salt restriction.

Although salt restriction is very important for the management of blood pressure (BP), it is difficult to maintain low salt intake in hypertensive patients. The purpose of the present study is to investigate comparatively the characteristics of hypertensive patients with good or poor compliance to long-term salt restriction. Subjects included 248 hypertensive patients who underwent successful 24-h home urine collection for >5 times with the observation period of 9.4 years in average. When the subjects were categorized based on the mean 24-h urinary salt excretion during the observation period to the groups with good (<8 g/day) or poor (10 g/day or more) compliance to long-term salt restriction, subjects with poor compliance were more frequently to be male, younger and had higher BMI than those with good compliance. Although there were no significant differences in BP and the number of antihypertensive drugs between the subjects with good and poor compliance, the subjects with poor compliance were given more diuretics, more frequently complicated with diabetes mellitus and hyperuricemia and had higher urinary protein excretion than those with good compliance. Thus, strict nutritional intervention and the management of BP as well as the complicated cardiovascular risk are important for the patients with poor compliance to salt restriction.

Acquired fanconi syndrome with osteomalacia secondary to monoclonal gammopathy of undetermined significance.

A 60-year-old woman was admitted because of multiple bone pain. Examination revealed hypophosphatemic osteomalacia and acquired Fanconi syndrome. Further exploration revealed monoclonal gammopathy of undetermined significance (MGUS) excreting urinary Bence Jones protein (kappa light chain). Renal biopsy showed non-specific tubulointerstitial nephritis, yet neither crystalline inclusions in the cytoplasm of the tubular epithelium nor myeloma casts nor amyloid deposits were found. She was treated with supplementation by phosphate, alkali agents, and vitamin D, and responded well to the treatment symptomatically and biochemically. MGUS was observed without chemotherapy. Myeloma had not developed after 10 months follow-up.

Prevalence and lifestyle characteristics of hypertensive patients with metabolic syndrome followed at an outpatient clinic in fukuoka, Japan.

A new guideline on metabolic syndrome (MS) in Japanese was introduced in 2005. The purpose of this study was to evaluate the prevalence and lifestyle characteristics of Japanese hypertensive patients with MS. Subjects were 290 patients (mean age: 64+/-11 years) who had been followed at our hospital. The waist circumference (WC) and body mass index (BMI) were assessed. Subjects who had BMI >or=25 kg/m(2) were defined as having BMI obesity, while abdominal obesity was defined as a WC >or=85 cm in men and >or=90 cm in women, respectively. Since all patients had hypertension, the definition of MS was made when the patient had abdominal obesity plus either dyslipidemia or glucose intolerance, or both. Among the subjects, 230 patients underwent 24-h home urine collection to measure urinary salt and potassium excretions. Dietary habits were also assessed by use of a questionnaire. Mean values of BMI and WC were 24.2+/-3.4 kg/m(2) and 87.1+/-9.6 cm, respectively. Among the total subject group, 39% patients were classified as having BMI obesity, 49% as having abdominal obesity, and 27% as having MS. BMI was significantly correlated with WC both in men (r=0.86; p<0.01) and in women (r=0.79; p<0.01). More men than women belonged to the BMI obesity (46% vs. 33%, p<0.05), abdominal obesity (63% vs. 39%, p<0.01) and MS (39% vs. 18%, p<0.01) groups. There were no significant differences in blood pressure between patients with and without MS, while patients with MS needed a greater number of antihypertensive drugs than those without MS. Mean urinary salt and potassium excretions were 8.9+/-3.8 g/day and 1.9+/-0.7 g/day, respectively. Urinary salt excretion of <6 g (100 mmol of sodium)/day was achieved in 20% of the subjects. Urinary salt excretion in the patients with MS was significantly higher than that in the patients without (10.1+/-4.2 vs. 8.5+/-3.6 g/day; p<0.01). Only 16% of the patients with MS achieved salt restriction (<6 g/day). The patients with MS had a significantly greater the chance to eat out than the patients without MS. They were also less aware of the need to increase their vegetable consumption. The results suggested that MS is prevalent in Japanese hypertensive patients. Patients with MS showed higher urinary salt excretion and needed more antihypertensive drugs to manage their blood pressure. Dietary counseling focusing not only on sodium restriction but also on the need to increase fruit and vegetable consumption seems to be important.