Cardiovascular morbidity and long term mortality associated with in hospital small increases of serum creatinine.

BACKGROUND: The cardiovascular risk associated with an increase in serum creatinine below the acute kidney injury (AKI) threshold, during hospitalization, has not been studied in depth. We assessed patients' features and outcomes associated with these changes. METHODS: Retrospective cohort study of 12,493 consecutive patients admitted to hospital throughout 12 months. We investigated the patients who had a small creatinine increase (SISCr) between 1.2 and <1.5 times the admission value, and tested the association of creatinine changes with the prevalence of cardiovascular disease (CVD). In a follow-up study, we assessed the all-cause mortality and its relationship with SISCr. RESULTS: Among patients with two or more creatinine measurements, 14.9% showed a SISCr. Older age, female gender and higher estimated glomerular filtration rate (eGFR) at admission were characteristics of these patients. The prevalence of CVD was 14.6% in patients with SISCr vs. 10.7% in those with stable creatinine (p < 0.001). SISCr was detected in 36, 26.6 and 18.9% of chronic heart failure (CHF), chronic ischemic heart disease (CIHD) and acute myocardial infarction (AMI) patients, respectively. The follow-up was 26.7 ± 10.6 months with 770 all-cause deaths. Serum creatinine increase above 20% was associated with a significant higher mortality compared to changes below 20%, adjusted hazard (HR) ratio 1.577 (p < 0.001). A higher risk was found associated with creatinine increases >1.5 times the baseline: HR 1.704 (p < 0.001). CONCLUSIONS: In hospitalized patients, increases in serum creatinine below the AKI threshold are associated with CHF, CIHD and long-term mortality.

Association of reduced kidney function with cardiovascular disease and mortality in elderly patients: comparison between the new Berlin initiative study (BIS1) and the MDRD study equations.

BACKGROUND: New creatinine based equations for estimating glomerular proposed for aged subjects have not been assessed in their association of reduced eGFR with cardiovascular (CV) morbidity or all cause (AC) mortality. PATIENTS: All subjects ≥70 years old (2998) who had been admitted to the hospital during a 12 month period were examined. METHODS: In a cohort study we applied the new Berlin Initiative Study (BIS1) equation. We compared the association of reduced eGFR estimated by BIS1 and MDRD equations, with cardiovascular (CV) disease and all cause (AC) mortality. RESULTS: eGFR was 57 ± 17 mL/min/1.73 m2 by MDRD and 71 ± 28 mL/min/1.73 m2 by BIS1 (P < 0.001). A diagnosis of CV disease was present in 947 patients. CV disease was associated with eGFR < 60 mL/min/1.73 m2 by both formulas: OR 1.179 (CI 1.001-1.390) for BIS1 and OR 1.440 (CI 1.223-1.696) for MDRD. In survival analysis a significant association of eGFR < 60 mL/min/1.73 m2 with AC mortality was found for both equations: MDRD (HR = 1.270, CI 1.111-1.453, P < 0.001), BIS1 (HR = 1.174, CI 1.031-1.338, P = 0.016). The analysis repeated with groups of age showed that the association of mortality with eGFRBIS1 < 60 mL/min/1.73 m2 was lost over 80 years. CONCLUSIONS: In patients >70, admitted to hospital, the implementation of the new BIS1 estimating equation does not modify the relationship, observed with the MDRD formula, of reduced GFR with CV disease or AC mortality.

Characteristics of the Relationship of Kidney Dysfunction with Cardiovascular Disease in High Risk Patients with Diabetes.

We aimed at comparing the relationship of reduced estimated glomerular filtration rate (eGFR) with cardiovascular disease (CVD) and mortality between high risk patients with and without type 2 diabetes mellitus (T2DM). The cross-sectional study evaluated 16,298 participants (1,627 T2DM) acutely admitted to hospital. The longitudinal study comprised 7,508 patients (673 with diabetes and 6,835 without). eGFR was categorized into 6 stages from >90 to <15 mL/min/1.73 m2. Kidney dysfunction was defined by an eGFR < 60 mL/min/1.73 m2. Patients with T2D showed a higher prevalence of CVD (37.9% versus 23.6%; P < 0.001) and kidney dysfunction (25% versus 13.2%; P < 0.001) than in the general population. An association with CVD was found with eGFR stages from 30 to 90 mL/min/1.73 m2 in T2D and from <15 to 90 mL/min/1.73 m2 in general population, in whom the association of eGFR with coronary heart disease was in an inverse relationship (P < 0.01 for trend). Survival, in diabetes, was lower (P = 0.037) but not associated with kidney dysfunction. Conclusions. In a high risk population, patients admitted to hospital, the relationship of kidney function with CVD is different between T2D and the general population. Competing mortality and the presence of other major risk factors in diabetes may be responsible for this difference.

Thrombotic microangiopathic nephropathy, pulmonary hypertension and nephromegaly: case report of a patient treated with endothelin receptor antagonist.

The coexistence of thrombotic microangiopathic nephropathy and pulmonary hypertension has only been described in association with malignancy and its treatment. Here we describe a 14-year-old boy with no prior medical history who presented with hypertension, proteinuria and nephromegaly, and then developed progressive pulmonary hypertension. Renal histology showed lesions consistent with glomerulopathy due to thrombotic microangiopathy (TMA). Pulmonary hypertension was controlled by the use of an oral endothelin receptor antagonist (bosentan). Although renal function deteriorated at the onset of pulmonary hypertension, an improvement was observed after the bosentan treatment. Nephromegaly persisted, but current creatinine clearance values are within the normal range. While this case exemplifies how thrombotic microangiopathic nephropathy may be associated with pulmonary hypertension, a therapeutic role of endothelin antagonists is suggested, not only for pulmonary hypertension but also for microangiopathic nephropathy.

Reduced kidney function and outcome in acute ischaemic stroke: relationship to arterial hypertension and diabetes.

BACKGROUND: Stroke is a dangerous long-term complication of kidney failure, yet its occurrence early in disease is poorly characterized. Our aim was to investigate the association of reduced kidney function, hypertension and diabetes with acute ischaemic stroke and the outcome thereof. METHODS: In this prospective cohort study, the association of reduced kidney function, hypertension and diabetes with stroke and 2-year all-cause mortality was investigated. Glomerular filtration rate (eGFR) was estimated by the simplified Modification of Diet in Renal Disease formula in 13 365 consecutive patients (671 with acute ischaemic stroke) admitted to our clinical facility over a 12-month period. RESULTS: Ischaemic stroke, after adjustment for age and gender, was significantly associated with eGFR <60 mL/min/1.73m(2) [odds ratio (OR) 1.53, 95% confidence interval (CI) 1.30-1.81], hypertension (2.77, 95% CI 2.33-3.28) and diabetes (1.30, 95% CI 1.04-1.63). Multivariate analysis of interaction indicated the absence of an additive effect between eGFR, hypertension and diabetes, on the risk of stroke. Age and gender-adjusted survival analysis by Cox regression showed an association of mortality with reduced eGFR alone (HR = 4.29, 95% CI 1.02-19.60). CONCLUSIONS: In patients acutely admitted to hospital, reduced kidney function, hypertension and diabetes are independently associated with ischaemic stroke, but do not exert a synergic effect. After hospital discharge, mortality is strongly associated with reduced eGFR but with neither hypertension nor diabetes.

Kidney function and mortality in different cardiovascular diseases: relationship with age, sex, diabetes and hypertension.

BACKGROUND: The aim of this study was to investigate the association of reduced kidney function, diabetes and arterial hypertension with mortality in cardiovascular disease patients admitted to hospital. METHODS: This was a prospective cohort study. The setting was the reference hospital for the population area. Unselected consecutive patients (n=7,487) admitted to the hospital over 12 months were enrolled. In all subjects, the estimated glomerular filtration rate (eGFR) was determined, and the association of acute and 36-month mortality with kidney function impairment, diabetes and arterial hypertension was assessed. RESULTS: Short-term mortality (314 deaths) was significantly associated with reduced eGFR only in patients with chronic ischemic heart disease. The study of 36-month survival in the whole cohort showed that mortality (918 deaths) was significantly associated with age, male sex and reduced eGFR. The study repeated for the individual CV conditions showed that reduced eGFR was associated with mortality only in chronic ischemic heart disease. No association with sex of patient, diabetes or arterial hypertension was found. CONCLUSIONS: Although the association between reduced kidney function and CV diseases was confirmed, the analysis of survival in the individual conditions shows that only in chronic ischemic disease is mortality associated with reduced eGFR. Any interaction with 2 major predisposing diseases - diabetes and arterial hypertension - has not been shown.

Resistant arterial hypertension: association with syncronous kidney cancer and adrenal adenoma.

The coexistence of renal cancer and adrenal adenoma is rare. We report the case of a 60-year-old patient with synchronous hypernephroma and adrenal adenoma. The patient presented with resistant hypertension, high plasma renin activity and aldosterone and target organ damage. Removal of the affected kidney cured the hypertension and normalized the plasma renin activity (PRA) and circulating aldosterone. This suggests that the coexistence of kidney cancer and adrenal adenoma may be a curable cause of resistant hypertension. The potential mechanisms accounting for the lack of suppression of PRA are discussed.

Validation of the A&D UA-705 device for self-measurement of blood pressure according to the British Hypertension Society protocol.

OBJECTIVES: We tested the accuracy of the UA-705 blood pressure semi-automatic monitor. METHODS: Device evaluation was performed according to the modified British Hypertension Society protocol released in 1993. Eighty-five patients with characteristics outlined in the British Hypertension Society protocol were recruited among those attending our out-patient clinic. Sequential readings were taken for the main validation test. Outcome was classified according to the British Hypertension Society criteria, which are based on four zones of accuracy differing from the mercury standard by 5, 10 and 15 mmHg, or more. RESULTS: The mean blood pressure difference (+ or -1 SD) between device and observers was 0.4 mmHg (SD 7.7) for systolic blood pressure and 0.3 mmHg (SD 8.2) for diastolic blood pressure. Overall, 96% (observer 1) and 95% (observer 2) of readings between device and observers differed by 15 mmHg or less for both systolic and diastolic blood pressure. The device achieved a grade A for both systolic and diastolic blood pressure. CONCLUSIONS: This study shows that the A&D UA-705 device satisfies the British Hypertension Society standard for accuracy by achieving a grade A for both systolic and diastolic blood pressure.

Regression of left ventricular hypertrophy and cardiovascular risk changes in hypertensive patients.

Hypertensive left ventricular hypertrophy (LVH) may be detected in about one third of people with hypertension. When an individual with elevated blood pressure develops LVH, the risk of adverse cardiovascular events in the ensuing years almost doubles even in the absence of symptoms. Because of this high added risk, hypertension and other modifiable risk factors should be managed aggressively with lifestyle measures and drugs. LVH can be considered a biological assay which reflects and integrates the long-term exposure not only to pressure overload, but also to several hemodynamic and non-hemodynamic factors which may promote progression and instabilization of atherosclerotic lesions and, ultimately, lead to adverse clinical events. LVH can partially or totally regress following antihypertensive treatment and lifestyle changes including losing excessive weight and decreasing salt intake. Angiotensin II antagonists and ACE-inhibitors seem to be the most effective drugs for reversing LVH. Evidence is accumulating that regression of LVH is associated with a significant reduction in the subsequent risk of cardiovascular disease. According to a recent meta-analysis, effective reversal of LVH is associated with a 59% lesser risk of subsequent adverse events as compared with the persistence or new development of LVH.

Validation of the A&D UA-774 (UA-767Plus) device for self-measurement of blood pressure.

OBJECTIVES: To determine the accuracy of the UA-774 (UA-767Plus) blood pressure monitor developed by the A&D Company. METHODS: Device evaluation was performed according to the modified British Hypertension Society (BHS) protocol released in 1993. Eighty-five subjects with characteristics outlined in the BHS protocol were recruited among those attending the outpatient clinic of the Department of Cardiovascular Disease, Hospital 'R. Silvestrini', Perugia, Italy. The A&D blood pressure monitor was evaluated according to the various steps of the protocol. Sequential readings were taken for the main validation test. Outcome was classified according to the criteria of BSH recommendations, which are based on four areas of accuracy differing from the mercury standard by 5, 10 and 15 mmHg, or more. RESULTS: The device achieved a grade A for systolic and a grade A for diastolic blood pressure. Mean blood pressure difference (+/-1 SD) between device and observers was -1.01+/-7.14 mmHg for systolic blood pressure and -1.42+/-7.61 mmHg for diastolic blood pressure. There was no systematic change in the device-observed difference over a wide range of blood pressure values CONCLUSIONS: These data show that the A&D UA-774 (UA-767Plus) device satisfies the BSH recommendations for accuracy for systolic and diastolic blood pressure.