Relationship of mildly increased albuminuria and coronary artery revascularization outcomes in patients with diabetes.

BACKGROUND: The aim of this study was to examine the relationship of albuminuria to cardiovascular disease outcomes in diabetic patients undergoing treatment for stable coronary artery disease. METHODS AND RESULTS: We analyzed data from 2176 participants of the Bypass Angioplasty Revascularization Investigation in type-2 diabetes (BARI-2D) trial, a randomized clinical trial comparing Percutaneous coronary intervention/Coronary artery bypass grafting (PCI/CABG) to medical therapy for people with diabetes. The population was stratified by baseline spot urine albumin-creatinine ratio (uACR) into normal (uACR <10 mg/g), mildly (uACR ≥10 mg/g < 30 mg/g), moderately (uACR ≥30 mg/g < 300 mg/g) and severely increased (uACR ≥300 mg/g) groups, and outcomes compared between groups. Death, myocardial infarction (MI) and/or stroke were experienced by 489 patients at a mean follow-up of 4.3 ± 1.5 years. Compared with normal uACR, mildly increased uACR was associated with a 1.4 times (P = 0.042) increase in all-cause mortality. Additionally, nonwhites with type-II diabetes and stable coronary artery disease who had mildly increased albuminuria had a Hazard ratio (HR) of 3.3 times (P = 0.028) for cardiovascular death, 3.1 times for (P = 0.002) all-cause mortality, and two times for (P = 0.015) MI during follow-up. CONCLUSIONS: Mildly increased albuminuria is a significant predictor of all-cause mortality in those with type-II diabetes mellitus and stable coronary artery disease, as well as for cardiovascular events those who are nonwhites.

Cumulative Kidney Complication Risk by 50 Years of Type 1 Diabetes: The Effects of Sex, Age, and Calendar Year at Onset.

OBJECTIVE: A common belief is that only a minority of patients with type 1 diabetes (T1D) develop advanced kidney disease and that incidence is higher among men and lower in those diagnosed at a younger age. However, because few patients with T1D survived to older ages until recently, long-term risks have been unclear. RESEARCH DESIGN AND METHODS: We examined the 50-year cumulative kidney complication risk in a childhood-onset T1D cohort diagnosed during 1950-80 (n = 932; mean baseline age 29 years, duration 19 years). Participants comprised 144 who died prior to baseline, 130 followed with periodic surveys, and 658 followed with biennial surveys and a maximum of nine examinations for 25 years. Micro- and macroalbuminuria were defined as an albumin excretion rate of 20-199 and ≥200 µg/min, respectively, and end-stage renal disease (ESRD) was defined as dialysis or kidney transplantation. Cumulative incidence was estimated at 10-year intervals between 20 and 50 years, duration and compared by calendar year of diabetes onset. RESULTS: By 50 years, T1D duration, ESRD affected 60% of the cohort; macroalbuminuria, 72%; and microalbuminuria, 88%. Little evidence existed for declines in cumulative incidence in recent cohorts, except for ESRD (microalbuminuria 3% increase, macroalbuminuria no change; ESRD 45% decrease by 40 years of T1D duration). Onset before age 6 years was associated with the lowest risk; incidence generally did not differ by sex. CONCLUSIONS: Some degree of kidney disease in T1D is virtually universal at long durations and not declining, which has major implications for formulating health care and research strategies. ESRD has declined, but continues to affect >25% of the population by 40 years, duration.

Prognostic importance of baseline and serial changes in microalbuminuria in patients with resistant hypertension.

OBJECTIVE: The prognostic value of microalbuminuria is unsettled in resistant hypertension. The objective was to evaluate the importance of baseline and serial changes in albuminuria as predictors of cardiovascular morbidity and mortality in patients with resistant hypertension. METHODS: 531 resistant hypertensives had urinary albumin excretion rate (UAER) measured prospectively at baseline and at the 2nd year of follow-up. Primary endpoints were a composite of fatal and non-fatal cardiovascular events, all-cause and cardiovascular mortalities. Total strokes and coronary heart disease (CHD) events were secondary endpoints. Multiple Cox regression assessed the associations between UAER and endpoints. RESULTS: After a median follow-up of 4.9 years, 72 patients died, 42 from cardiovascular causes; 96 cardiovascular events occurred, 42 strokes and 47 CHD events. After adjustment for several cardiovascular risk factors, baseline UAER, either analyzed as a continuous variable or dichotomized at different cut-off values, was an independent predictor of the composite endpoint, all-cause and cardiovascular mortality, strokes and CHD events. Each 10-fold increase in UAER implied a significant 1.6, 1.5, 2.0, 1.5 and 1.6-fold higher risk, respectively, for each of the above endpoints. Serial changes in microalbuminuria status during follow-up tended to parallel changes in cardiovascular risk, regression of microalbuminuria was associated with a 27% lower risk and development with a 65% higher risk of having a cardiovascular event. CONCLUSIONS: Baseline albuminuria strongly predicts cardiovascular morbidity and mortality in resistant hypertensive patients and serial changes in microalbuminuria may translate into changes in risk. Microalbuminuria reduction may be a goal of anti-hypertensive treatment.

Association between albuminuria, glomerular filtration rate and mortality or recurrence in stroke patients.

BACKGROUND/AIMS: In an attempt to find new predictors of stroke prognosis, we evaluated the association of albuminuria (AUr) and the estimated glomerular filtration rate (eGFR) with the recurrence of stroke and mortality. METHODS: We evaluated and followed for at least 7 months patients with first-ever stroke or transient ischemic attack admitted to a prospective cohort from March 2005 to December 2007. We analyzed traditional CV risk factors, albumin-to-creatinine ratio and eGFR (ml/min/1.73 m(2)) as predictors of mortality or recurrence. RESULTS: From a total of 185 patients included [57% (104/185) men, 64 ± 13 years], 38 patients suffered from a recurrent stroke or died, with a mean follow-up of 25.1 ± 8.7 months. AUr (≥30 mg/g) was found in 50.2% (93/185), and 38.9% (72/185) presented an eGFR <60. In univariate analysis, age >65 years, eGFR ≤50, atrial fibrillation (AF), no alcohol intake and AUr >17 mg/g were associated with the composite endpoint. In a multivariate analysis, AF and AUr >17 mg/g were independent predictors of the composite endpoints, but eGFR ≤50 was not. CONCLUSION: The presence of AUr >17 mg/g is independently associated with death or recurrence after stroke. Further studies should consider the AUr as a predictor for a worse prognosis in these patients.

Hypertension and microalbuminuria in diabetes mellitus: local experience - abstract

Both hypertension and diabetes mellitus are common diseases, affecting approximately 20 percent and 10 percent of the adult population, respectively, and together they are the largest contributor to the group of patients with end-stage renal failure. Gross proteinuria (dipstick) predicts the onset of inexorable decline in renal function in diabetes mellitus and, to a lesser extent, in hypertension. Microalbuminuria (immunoassay) is an early warning sign of impending renal failure in diabetes mellitus, and might occur while the process is reversible. In hypertension, the natural history of patients with microalbuminuria is unclear. This study was designed to compare the clinical progress of hypertensives and hypertensive diabetics with and without microalbuminuria, and to relate this to their haemodynamics. Patients were selected from the University Hospital of the West Indies Hypertensive Clinic on the basis of urinary albumin excretion: 20-200 mg/l microalbuminuric and less than 20 mg/l normalbuminuric. Controls were matched hypertensives and hypertensive diabetics without microalbuminuria. All measurements were made of glomerular filtration rate and renal plasma flow (clearance of 51 Cr EDTA and 125 I Iodohippurate, respectively). Microalbuminuric hypertensives were older, had lower renal flow, higher filtration fraction and renal vascular resistance than controls. Haemodynamic variables were similar in the microalbuminuric diabetics and their controls. After one year, three cardiovascular events occurred among the diabetics with microalbuminuria, supporting the view that microalbuminuria is a marker for widespread vascular pathology. The fourth event occurred in the microalbuminuric hypertensive group (AU)