Markers of microbial translocation predict hypertension in HIV-infected individuals.

OBJECTIVES: The aim of the study was to test the hypothesis that microbial translocation, quantified by levels of lipopolysaccharide (LPS) and subsequent monocyte activation [soluble (sCD14)], is associated with hypertension in HIV-infected individuals. METHODS: In this exploratory substudy, 42 patients were recruited from a larger, longitudinal HIV-infected cohort study on blood pressure. LPS and sCD14 levels were measured retrospectively at the time of nadir CD4 cell count, selecting untreated HIV-infected patients with both advanced immunodeficiency and preserved immunocompetence at the time of nadir. Patients with later sustained hypertension (n = 16) or normotension (n = 26) throughout the study were identified. LPS was analysed using the Limulus Amebocyte Lysate colorimetric assay (Lonza, Walkersville, MD) and sCD14 using an enzyme-linked immunosorbent assay (ELISA). Nonparametric statistical tests were applied. RESULTS: In the HIV-infected patients [median (interquartile range) age 42 (32-46) years; 79% male and 81% Caucasian], LPS and sCD14 levels were both negatively correlated with nadir CD4 cell count. Plasma levels of LPS (P < 0.001) and sCD14 (P = 0.024) were elevated in patients with later hypertension compared with patients with normotension. There was a stepwise increase in the number of patients with hypertension across tertiles of LPS (P = 0.001) and sCD14 (P = 0.007). Both LPS and sCD14 were independent predictors of elevated blood pressure after adjustment for age and gender. For each 10-unit increase in LPS (range 66-272 pg/ml), the increment in mean blood pressure in the first period of blood pressure recording was 0.86 (95% confidence interval 0.31-1.41) mmHg (P = 0.003). CONCLUSIONS: As LPS and sCD14 were both independently associated with elevated blood pressure, microbial translocation may be linked to the development of hypertension.

Telomere length and cardiovascular risk in hypertensive patients with left ventricular hypertrophy: the LIFE study.

Short telomeres are associated with aging and age-related diseases. Our aim was to determine whether short leukocyte telomere length is associated with risk factors and cardiovascular diseases in a high-risk hypertensive population. We measured leukocyte telomere lengths at recruitment in 1271 subjects with hypertension and left ventricular hypertrophy (LVH) participating in the Lifestyle Interventions and Independence for Elders (LIFE) study. At baseline, short mean telomere length was associated with coronary artery disease in males (odds ratio (OR) 0.61, 95% confidence interval (CI) 0.39-0.95), and transient ischemic attack in females (OR 0.62 95% CI 0.39-0.99). Proportion of short telomeres (shorter than 5 kb) was associated with Framingham risk score (r=0.07, P<0.05), cerebrovascular disease (OR 1.18, 95% CI 1.01-1.15) and type 2 diabetes in men (OR 1.07, 95% CI 1.02-1.11). During follow-up, proportion of short telomeres was associated with combined cardiovascular mortality, stroke or angina pectoris (hazard ratio 1.04, 95% CI 1.01-1.07). Telomere length was not associated with smoking, body mass index, pulse pressure or self-reported use of alcohol. Our data suggest that reduced leukocyte telomere length is associated with cardiovascular risk factors and diseases as well as type 2 diabetes, and is a predictor of cardiovascular disease in elderly patients with hypertension and LVH.

The relationship between various measures of obesity and arterial stiffness in morbidly obese patients.

BACKGROUND: Obesity is associated with increased risk of cardiovascular disease. Arterial stiffness assessed by carotid femoral pulse wave velocity (PWV) is an independent predictor of cardiovascular morbidity and mortality. We aimed to investigate how various measures of body composition affect arterial stiffness. METHODS: This is an analysis of cross-sectional baseline data from a controlled clinical trial addressing changes in arterial stiffness after either surgery or lifestyle intervention in a population of morbidly obese patients. High-fidelity applanation tonometry (Millar, Sphygmocor) was used to measure pulse wave velocity (PWV). Carotid femoral PWV is a direct measure of arterial stiffness and is considered to be the gold standard method. The Inbody 720 Body Composition Analyzer was used for bioelectrical impedance analysis (BIA). Spearman's correlation, independent samples t-test, chi-square tests, Fisher's exact test and multiple linear regression analyses were used as statistical methods. RESULTS: A total of 133 patients (79 women), with a mean (SD) age of 43 (11) years were included in the study. Men had a significantly higher prevalence of obesity related comorbidities and significantly higher PWV, 9.1 (2.0) m/s vs. 8.1 (1.8) m/s, p = 0.003, than women. In the female group, PWV was positively correlated with WC, WHtR, BMI and visceral fat area. In the male group, PWV was negatively correlated with BMI. Multiple linear regression analysis showed that increasing BMI, WC, WHtR, visceral fat area and fat mass were independently associated with higher PWV in women, but not in men, after adjustment for age, hypertension and type 2 diabetes. CONCLUSION: Most measures of general and abdominal obesity were predictors of arterial stiffness in female morbidly obese patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT00626964.

"Real-World" use of cinacalcet for managing SHPT in different European countries: analysis of data from the ECHO observational study.

AIMS: The pan-European ECHO observational study evaluated cinacalcet in adult dialysis patients with secondary hyperparathyroidism (SHPT) in "real-world" clinical practice. A sub-analysis compared data for 7 European countries/country clusters: Austria, CEE (Czech Republic and Slovakia), France, Italy, Netherlands, Nordics (Denmark, Finland, Norway, and Sweden), and the UK/Ireland. METHODS: Data on serum intact parathyroid hormone (iPTH), phosphorous, calcium, as well as the usage of cinacalcet, active vitamin D analogues and phosphate binders were compared. RESULTS: 1,865 patients (mean age 58 years) were enrolled: median baseline iPTH levels ranged from 605 pg/ml in Austria to 954 pg/ml in the UK/Ireland. After ~1 year of cinacalcet, median iPTH reductions from baseline ranged from 38% in the UK/Ireland to 58% in the Netherlands. The proportion of patients achieving NKF/K-DOQITM iPTH targets (150 - 300 pg/ml) at Month 12 ranged from 14% in the UK/Ireland to 40% in CEE. In general, use of sevelamer decreased, while use of calcium-based phosphate binders increased, during cinacalcet treatment. Vitamin D changes were more variable. CONCLUSION: The iPTH level at which cinacalcet is initiated in clinical practice differs considerably among different countries: where cinacalcet was started at a lower iPTH level this resulted in better achievement of serum iPTH targets.

Acute kidney injury with renal replacement therapy in trauma patients.

BACKGROUND: Acute kidney injury (AKI) with renal replacement therapy (RRT) is rare in trauma patients. The primary aim of the study was to assess incidence, mortality and chronic RRT dependency in this patient group. METHODS: Adult trauma patients with AKI receiving RRT at a regional trauma referral center over a 12-year period were retrospectively reviewed. RESULTS: Population-based incidence of post-traumatic AKI with RRT was 1.8 persons per million inhabitants per year (p.p.m./year) [95% confidence the interval (CI) 1.5-2.1 p.p.m./year]. In trauma patients admitted to hospital, incidence was 0.5 per thousand (95% CI 0.3-0.7 per thousand) of those treated in intensive care unit (ICU), it was 8.3% (95% CI 5.9-10.8%). The median age was 46 years. Odds ratio (OR) for post-traumatic AKI requiring RRT was higher in males than in females in general population (OR 5.6, 95% CI 2.2-14.0), and in trauma patients admitted to hospital (OR 4.4, 95% CI 1.9-10.3) and ICU (OR 4.5, 95% CI 1.9-10.7). The in-hospital mortality rate was 24% (95% CI 11-37%), 3-month mortality 36% (95% CI 21-51%) and 1-year mortality 40% (95% CI 25-55%). Age was a risk factor for death after 1 year, with 57% (95% CI 7-109%) increased risk for each 10 years added. None of the survivors was dialysis-dependent 3 months or 1 year after trauma. CONCLUSION: AKI in trauma patients requiring RRT was rare in this single-center study. More males than females were affected. Mortality was modest, and renal recovery was excellent as none of the survivors became dependent on chronic RRT.

Blood pressure development and hypertensive retinopathy: 20-year follow-up of middle-aged normotensive and hypertensive men.

Screening for hypertensive organ damage is important in assessing cardiovascular risk in hypertensive individuals. In a 20-year follow-up of normotensive and hypertensive men, signs of end-organ damage were examined, focusing on hypertensive retinopathy. In all, 56 of the original 79 men were reexamined for hypertensive organ damage, including by digital fundus photography. The diameters of the central retinal artery equivalent (CRAE) and vein were estimated and the artery-to-vein diameter ratio calculated. Components of metabolic syndrome were assessed. Fifty percent of the normotensive men developed hypertension during follow-up. Significant differences appeared in CRAE between the different blood pressure groups (P=0.025) while no differences were observed for other markers of hypertensive organ damage. There were significant relationships between CRAE and blood pressure at baseline (r=-0.466, P=0.001) and at follow-up (r=-0.508, P<0.001). A linear decrease in CRAE was observed with increasing number of components of the metabolic syndrome (beta=-3.947, R(2)=0.105, P=0.023). Retinal vascular diameters were closely linked to blood pressures and risk factors of the metabolic syndrome. The diversity in the development of hypertensive organ damage, with changes in retinal microvasculature preceding other signs of damage, should encourage more liberal use of fundus photography in assessing cardiovascular risk in hypertensive individuals.

Renal amyloidosis in intravenous heroin addicts with nephrotic syndrome and renal failure.

BACKGROUND: Renal amyloidosis has emerged as an important differential diagnosis when heroin addicts are admitted to renal clinics with proteinuria and nephrotic syndrome. MATERIAL: We present nine heroin addicts with renal AA amyloidosis, a condition previously not encountered in Norway, who were admitted to our renal clinic during the last 3.5 years. In the same time period a total of 209 patients were biopsied from native kidneys. RESULTS: Heroin abuse was associated with 70% of all biopsy-verified renal AA amyloidosis during this time period. Renal amyloidosis was found in 9 of the 12 heroin addicts that were biopsied. 6 of the 9 heroin addicts with amyloidosis required dialysis within 13 months after admission. CONCLUSION: Renal AA amyloidosis among heroin addicts seems to be associated with chronic suppurative skin infections. AA amyloidosis should always be considered in chronic heroin addicts presenting with proteinuria and renal impairment.

Association between HIV infection and attenuated diurnal blood pressure rhythm in untreated hypertensive individuals.

OBJECTIVE: Hypertensive cardiovascular complications are more closely associated with ambulatory blood pressure (ABP), particularly the attenuated diurnal blood pressure (BP) rhythm (i.e. a fall in systolic blood pressure <10% during the night compared with the day), than with casual BP. The aim of the study was to assess the ABP pattern in an HIV-infected cohort in which hypertension was newly diagnosed. METHODS: ABP over 24 h was compared between 77 newly diagnosed, untreated hypertensive HIV-positive individuals and 76 HIV-uninfected untreated hypertensive controls. RESULTS: More HIV-infected subjects had an attenuated ABP rhythm with a reduced nocturnal fall than HIV-negative hypertensive control subjects (60 vs. 33%, respectively; P=0.001). The dipping pattern was observed despite newly diagnosed hypertension, a low prevalence of microalbuminuria, and the absence of signs of overt kidney disease. Furthermore, the prevalence of nondipping in the HIV-infected subjects was independent of combination antiretroviral treatment. Multiple logistic regression analysis with dipping pattern as the dependent variable showed that HIV status was an independent predictor of nondipping BP [P=0.002; odds ratio (OR) 0.33; 95% confidence interval (CI) 0.17-0.66]; casual SBP (P=0.37; OR 1.001; 95% CI 0.99-1.04) and microalbuminuria (P=0.39; OR 1.56; 95% CI 0.57-4.28) were not associated with dipping pattern. CONCLUSIONS: The prevalence of a nondipping BP pattern in HIV-infected subjects with newly diagnosed hypertension who had not received antihypertensive treatment was high and significantly greater than in hypertensive control subjects.

Tissue Doppler imaging describes diastolic function in men prone to develop hypertension over twenty years.

AIMS: Hypertension is one of several risk factors of cardiovascular disease and is associated with left ventricular (LV) systolic and diastolic dysfunction. A method for reliably detecting the onset of LV dysfunction before transition to irreversible damage of the myocardium would be of crucial importance in subjects with essential hypertension. METHODS AND RESULTS: Subjects with clear differences in BP level, development and duration of the hypertensive disease were examined at the age of 60 yrs: normotensives (n = 17), new hypertensives who developed hypertension over a 20 year period (n = 15) and hypertensives (n = 19). Relationships between conventional echocardiographic and tissue velocities imaging (TVI) parameters compared to LV parameters, and TVI as an estimate of LV function were explored. E'(Lat) (TVI peak early diastolic velocity) (P = 0.006) and E/E'(Lat) (P = 0.002) demonstrated differences in diastolic function between the groups. There were no significant differences regarding systolic myocardial velocities. E'(Lat) correlated to S'(Lat) (TDI peak systolic velocity) (r = 0.32, P = 0.026) and was independently predicted by S'(Lat) (R(2) = 0.24, P = 0.025) in multivariate analysis. E'(Lat) correlated negatively to LV mass index (r = -0.34, P = 0.012), also in multivariate regression analysis (R(2) = 0.12, P = 0.032). CONCLUSIONS: Myocardial diastolic velocities and mitral flow to annulus velocity ratio differentiated LV function between the hypertensive and normotensive groups. The parameters probably reflect changes in relaxation, recoil and contraction and parallel changes in LV mass index.

Metformin and antihypertensive therapy with drugs blocking the renin angiotensin system, a cause of concern?

BACKGROUND: The burden of diabetes mellitus type 2 (DM2) is increasing worldwide. The combination of DM2 and hypertension (HT) is frequently encountered. Concurrent use of drugs blocking the renin angiotensin system (angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB)) and metformin have become frequent in this group of patients. That combination can become life-threatening under certain circumstances. METHOD: We present 5 patients with DM2 and HT who developed severe metformin-associated lactic acidosis in a setting with acute renal failure, precipitated by dehydration and aggravated by the use of ACEI or ARB. RESULTS: None of the patients had reduced renal function before the acute illness. They were admitted to the hospital in critical condition with severe metabolic acidosis (pH 6.60 6.94), high S-lactate (14 - 23 mmol/l) and S-creatinine 796 1,621 micromol/l. They were all hypothermic and 3 were hypoglycemic. All developed circulatory and respiratory collapse. They were treated with either intermittent bicarbonate hemodialysis (HD) or with continuous venovenous hemodiafiltration (CVVHDF) and bicarbonate buffering. All patients recovered without renal sequela. CONCLUSION: We believe that the incidence of metformin-associated lactic acidosis in Norway may become more frequent due to increased use of metformin and drugs blocking the renin angiotensin system. The awareness of lactic acidosis as a complication to the use ofmetformin in predisposed individuals is important. General advice should be given to patients regarding reduction of dosage or withdrawal of the drugs during acute intercurrent illness with dehydration. Early diagnosis and treatment of metformin-associated lactic acidosis are crucial for the patient outcome. Hemodialysis can be life-saving and should be started without delay.

Improved insulin sensitivity with the angiotensin II-receptor blocker losartan in patients with hypertension and other cardiovascular risk factors.

We aimed to compare the effects of two different vasodilating principles, angiotensin II-receptor blockade and calcium channel blockade, on peripheral insulin-mediated glucose uptake in patients with hypertension and other cardiovascular risk factors. Twenty-one hypertensive patients (11 women and 10 men) with mean age 58.6 years (range 46-75 years), body mass index 29.2 +/- 1.0 kg/m(2) and blood pressure 160 +/- 3/96 +/- 2 mm Hg entered a 4-week run-in period with open-label amlodipine 5 mg. Thereafter they were randomized double-blindly to additional treatment with amlodipine 5 mg or losartan 100 mg. After 8 weeks of treatment, all patients underwent clinical examination and laboratory testing, and 17 of them underwent a hyperinsulinaemic isoglycaemic glucose clamp. After a 4-week open-label wash-out phase, the participants crossed over to the opposite treatment regimen and final examinations with hyperinsulinaemic isoglycaemic glucose clamp after another 8 weeks. Blood pressure was lowered to the same level in both treatment periods. The glucose disposal rate was significantly higher after treatment with losartan 100 mg + amlodipine 5 mg compared to amlodipine 10 mg (4.9 +/- 0.4 vs 4.2 +/- 0.5 mg/kg/min, P = 0.039). Thus our data suggest that angiotensin II-receptor blockade with losartan improves glucose metabolism at the cellular level beyond what can be expected by the vasodilatation and blood pressure reduction alone.

Comparison of doxazosin GITS and standard doxazosin in the treatment of high blood pressure.

OBJECTIVE: To examine (1) the relative therapeutic equivalence of 4 mg doxazosin gastrointestinal therapeutic system (DOX GITS) and 4 mg doxazosin standard (DOX-S4) and (2) the efficacy and safety of 4 mg DOX GITS versus 2 mg doxazosin standard (DOX-S2). PATIENTS: Male or female patients aged 18-80 diagnosed with mild-to-moderate essential hypertension (sitting diastolic blood pressure (DBP) 95-110 mmHg and systolic blood pressure (SBP) < 180 mmHg) were randomized into the study. METHODS: This double-blind, parallel, 9-week trial compared DOX-GITS with doxazosin standard (DOX-S) in 310 hypertensive patients. Following a 2-week placebo run-in phase, patients were randomized to receive DOX-GITS at 4 mg/d or DOX-S at 2 or 4 mg/d. DOX GITS dosage remained unchanged at 4 mg throughout the study. Titration in the DOX-S groups was initiated at Week 0 with 1 mg DOX-S and increased to 2 mg DOX-S at Week 1. Dosage in the DOX-S4 group was increased to 4 mg DOX-S at Week 3. Therapeutic equivalence was measured by the change from baseline in sitting diastolic BP (DBP). Efficacy was assessed using the change from baseline for all blood pressure measures. Safety analysis included evaluation of laboratory tests at clinic visits and adverse events (AEs). RESULTS: Therapeutic equivalences between DOX GITS and DOX-S4 and DOX-S2 were established at all study visits except for a significant difference in favor of DOX GITS at Week 1 (p = 0.019) when the dose of DOX-S was 1 mg. All groups had a significant decrease in BP at all study visits compared with baseline. The proportion of patients who reached goal sitting DBP (< 90 mmHg) was similar among the three treatment groups, except at Week 1, when more patients in the DOX GITS group had obtained the goal compared with those in the DOX-S2 group (40.6% vs. 22.3%; p = 0.005). The proportion of patients who reached sitting SBP (< 140 mmHg) goal was similar among groups. AE profiles among the groups were similar. CONCLUSION: DOX GITS was as effective as DOX-S in patients with mild-to-moderate hypertension. The improved pharmacokinetic profile of the GITS formulation compared with the standard formulation allows a therapeutic dose to be delivered earlier and without dose titration. Both formulations of doxazosin were well tolerated.

Plasma leptin in postmenopausal women with coronary artery disease: effect of transdermal 17beta-estradiol and intermittent medroxyprogesterone acetate.

OBJECTIVES: In the present study, the relationship between plasma leptin and other cardiovascular risk factors in high-risk postmenopausal women was assessed, as well as the effect of transdermal 17beta-estradiol unopposed or in combination with intermittent medroxyprogesterone acetate (MPA) on plasma leptin. METHODS: Postmenopausal women (n = 118) with coronary artery disease (CAD) were consecutively recruited from women admitted to hospital for coronary angiography. They were randomized to estradiol plus intermittent MPA or to a control group, and investigated at study inclusion, and after 3 and 12 months. RESULTS: A strong relationship was found between leptin and body mass index (r = 0.69, p < 0.001). Leptin was related to lipid fractions (high-density lipoprotein cholesterol: r = -0.33, p < 0.001; apolipoprotein A: r = -0.28, p = 0.004; and triglycerides: r = 0.27, p = 0.003) and indices of glucose metabolism (C-peptide: r = 0.47, p < 0.001; fasting insulin: r = 0.42, p < 0.001; glucose: r = 0.25, p = 0.008; insulin resistance: r = 0.45, p < 0.001; and insulin secretion: r = 0.36, p < 0.001). In a multiple regression model, only body mass index (p < 0.001) and C-peptide (p = 0.002) remained as independent factors for leptin levels. Despite the association with sex hormone-binding globulin (r = 0.30, p = 0.001), no effect on leptin levels was observed with either unopposed transdermal estradiol or estradiol combined with MPA. CONCLUSION: Plasma leptin is related to other cardiovascular risk factors in postmenopausal women with CAD, but seems to be unaffected by transdermal 17beta-estradiol administration.

Smoking and relation to other risk factors in postmenopausal women with coronary artery disease, with particular reference to whole blood viscosity and beta-cell function.

OBJECTIVES: To investigate possible associations between smoking habits and other coronary risk factors in postmenopausal women with known coronary heart disease (CHD). SETTING: The study was conducted at a university clinic. SUBJECTS: A total of 118 postmenopausal women with CHD verified with angiography, consecutively recruited. INTERVENTIONS: Conventional treatment for CHD. The women were randomized to hormone replacement therapy (HRT) with transdermal 17-beta oestradiol and medroxyprogesterone acetate, or to a control group. RESULTS: Smokers were younger (P = 0.005), had lower body mass index (P = 0.04) and lipoprotein Lp(a) levels (P = 0.02) compared with nonsmokers. Smokers had reduced beta-cell function (homeostasis model assessment, P = 0.006), whereas whole blood viscosity (WBV) was higher at all shear rates. WBV was not affected by HRT over a 12-month period. Oestrone levels were higher in smokers. CONCLUSIONS: Smoking adversely affects insulin secretion (beta-cell function) and WBV in postmenopausal women with established CHD, which could be of importance as a mechanism for the increased risk of CHD in smokers. The importance of smoking as a risk factor, overrides the effect of Lp(a), which is lower in smokers compared with nonsmokers.

Transforming growth factor (TGF)-beta1 inversely related to vascular cell adhesion molecule-1 in postmenopausal women with coronary artery disease. A possible mechanism for the putative cardioprotective role of TGF-beta1?

OBJECTIVE AND DESIGN: Transforming growth factor beta (TGF-beta1) is involved in a variety of physiological processes as well as in many diseases. Both in vitro and in vivo evidence suggest that TGF-beta1 may influence atherogenesis and a dominant protective role of TGF-beta1 on coronary arteries has been proposed. On the other hand, increased levels of soluble adhesion molecules have been found in patients with atherosclerosis, and adhesion of monocytes to the endothelium followed by migration to the intima, has been proved to be an early event in atherosclerosis. The purpose of the present investigation was to look at a possible relationship between circulating active TGF-beta1 and adhesion molecules in postmenopausal women with angiographically verified coronary heart disease (CHD) (n=118). RESULTS: Serum levels of the active form of TGF-beta1 showed a tendency to be lower in patients with increasing number of vessels with more than 50% stenosis (P=0.058), and there was higher TGF-beta1 in the group with one vessel disease compared with those with two or more vessels affected (P=0.041). Additionally, negative association between TGF-beta1 and VCAM-1 was found (r=-0.26, P=0.023). However, no associations were observed between TGF-beta1 and intercellular adhesion molecule-1 (ICAM-1) or E-selectin in the present study. CONCLUSION: We observed an inverse correlation between the active form of TGF-beta1 and VCAM-1 in postmenopausal women with verified CHD. These results may suggest a role of TGF-beta1 in CHD.

Varicella infection in a renal transplant recipient associated with abdominal pain, hepatitis, and glomerulonephritis.

A 36-year-old renal transplant patient developed 9 years after a successful transplantation a fatal secondary varicella infection. The disseminated varicella infection was associated with hepatitis with liver necrosis, disseminated intravascular coagulation and fibrinolysis and glomerulonephritis. To our knowledge this is the first description of glomerulonephritis associated with varicella infection in a renal transplanted patient. The autopsy showed morphologically a mesangial glomerulonephritis with minor proliferative activity and extensive deposits by electronmicroscopy, mainly in the mesangium. The ongoing immunosuppression may have modified the mesangial cell response to the deposition of immune complexes.

Left ventricular mass assessed by electrocardiography and albumin excretion rate as a continuum in untreated essential hypertension.

OBJECTIVE: To study an association between albumin excretion rate and left ventricular mass (LVM) determined by electrocardiogram (ECG)-based criteria, and with respect to ambulatory blood pressure, in patients with newly diagnosed and never-treated essential hypertension. METHODS: We measured 24 h ambulatory blood pressure, albumin excretion rate and LVM in 74 patients with newly diagnosed (within the past year) and never-treated essential hypertension, who were admitted to the hypertension clinic (Ulleval University Hospital). Albumin excretion rate was evaluated by determination of the albumin:creatinine ratio in the first-voided morning urine sample. LVM was assessed by ECG using Cornell voltage-QRS duration product and Sokolow- Lyon criteria. RESULTS: Albumin excretion rate was significantly related to ambulatory blood pressure. There was a weak but significant negative correlation between the decrease in diastolic blood pressure during the night and the rate of excretion of albumin. The patients classified as dippers had a significantly lower albumin excretion rate compared with the non-dippers (1.36+/-0.83 compared with 1.68+/-0.87 mg/mmol; P = 0.03). LVM was found to be significantly related to ambulatory blood pressure. A weak relationship was observed between albumin excretion rate and LVM as evaluated by Cornell criterion (r = 0.23, P = 0.045). When only normoalbuminuric patients were included (i.e. four patients with microalbuminuria were excluded), the relationship was stronger (r = 0.36, P = 0.002). CONCLUSIONS: The present findings show a continuous relationship between albumin excretion rate, LVM and ambulatory blood pressure in newly diagnosed patients with essential hypertension, and suggest the occurrence of early effects on target organs (kidneys and heart). These associations were observed using easily applicable methods such as ECG monitoring and determination of the albumin:creatinine ratio in morning urine samples.

[Bilateral renal artery stenosis--a cause of acute pulmonary edema]. / Bilateral nyrearteriestenose--en årsak til akutt lungeødem.

BACKGROUND: Renal artery stenosis may present as acute pulmonary oedema and be misinterpreted as congestive heart failure. ACE inhibitors and angiotensin-II antagonists are widely used among patients with congestive heart failure and hypertension. MATERIAL AND METHODS: The authors present a patient with congestive heart failure caused by a combination of coronary heart disease and bilateral renal artery stenosis. The patient developed acute kidney failure secondary to ACE inhibitor and angiotensin II antagonist treatment. RESULTS: Mechanisms behind pulmonary oedema secondary to renovascular hypertension are discussed. INTERPRETATION: Revascularisation is the treatment of choice for this patient category.

[24-hour blood pressure monitoring and albumin excretion in urine in hypertension]. / 24-timersblodtrykk og albuminutskilling i urin ved høyt blodtrykk.

BACKGROUND AND OBJECTIVES: Microalbuminuria, a subclinical increase of albumin excretion in urine, is a novel recognized risk factor for atherosclerosis in essential hypertension. This study aimed to look at the association between ambulatory blood pressure and urinary albumin excretion (UAE) in hypertensive subjects. MATERIAL AND METHODS: 140 patients aged 50.1 +/- 11.6 years, referred for 24-hour ambulatory blood pressure monitoring (ABPM), were studied. A separate analysis was performed in 46 persons with newly diagnosed and untreated essential hypertension. Albumin excretion was evaluated by determining the albumin/creatinine ratio (ACR) in the first voided morning urine sample. According to the ACR, patients were categorized as having normoalbuminuria (ACR < 1.5 mg/mmol), borderline microalbuminuria (1.5 < or = ACR < 3.0 mg/mmol) and overt microalbuminuria (ACR > or = 3.0 mg/mmol). RESULTS: ACR was significantly higher in hypertensive than in normotensive individuals (2.17 +/- 2.67 and 1.72 +/- 2.97 mg/mmol respectively, p = 0.012). Average 24-hour, daytime and nighttime systolic as well as diastolic blood pressures were lower in patients with normoalbuminuria than in the other two groups and did not differ among the two microalbuminuric groups. A close relationship between ACR and ambulatory BP was observed, even for the subgroup of newly diagnosed and untreated hypertensive patients. INTERPRETATION: A close relationship is observed between ambulatory blood pressures and albumin excretion rates in the microalbuminuric and normoalbuminuric range. Further studies are needed to assess the threshold level of ACR when screening for microalbuminuria in hypertensive patients.