Optimization of potassium management in patients with chronic kidney disease and type 2 diabetes on finerenone.

INTRODUCTION: Patients with type 2 diabetes (T2DM) and chronic kidney disease (CKD) are at high risk of CKD progression and cardiovascular events. Despite treatment with renin-angiotensin system inhibitors and SGLT-2 inhibitors, the residual risk is substantial. There is preclinical and clinical evidence supporting a key role of mineralocorticoid receptor in cardiorenal injury in T2DM. AREAS COVERED: Finerenone is a selective and nonsteroidal mineralocorticoid receptor antagonist that reduces -on preclinical studies- heart and kidney inflammation and fibrosis. Clinical trials have demonstrated that among patients with T2DM and CKD, finerenone reduces CKD progression and the risk of cardiovascular events. The incidence of adverse events is similar than for placebo. Permanent discontinuation of study drug due to hyperkalemia was low (1.7% of finerenone and 0.6% of placebo participants) as was the risk of hyperkalemia-related severe-adverse events (1.1%). We provide an overview of risk factors for hyperkalemia and management of serum potassium in people with CKD and T2DM on finerenone. EXPERT OPINION: As finerenone increases potassium levels in a predictable way, patients at risk of hyperkalemia can be identified early in clinical practice and monitored for an easy management. This will allow people with T2DM and CKD to safely benefit from improved cardiorenal outcomes.

Denervación renal para el tratamiento de la hipertensión arterial resistente en España. Registro Flex-Spyral / Renal denervation for the treatment of resistant hypertension in Spain. The Flex-Spyral Registry

INTRODUCCIÓN Y OBJETIVOS: La denervación renal es una intervención percutánea para el tratamiento de la hipertensión arterial resistente. Estudios aleatorizados han mostrado resultados contradictorios sobre su eficacia. Se presentan los resultados de un registro de denervación en pacientes con hipertensión resistente según práctica clínica en España. MÉTODOS: Registro multicéntrico de pacientes consecutivos con hipertensión arterial resistente tratados con denervación renal en España en el periodo 2009-2018. RESULTADOS: Se ha incluido a 125 pacientes (media de edad, 56±años; el 41% mujeres; media de 14±9 años de evolución de la hipertensión). La presión arterial sistólica y diastólica en la consulta y ambulatoria de 24 h disminuyeron a los 6 meses de la intervención (de 166±20/95±16 a 149±22/87±16mmHg y de 151±14/89±12 a 143±15/84±11; ambas, p < 0,0001). A los 12 meses se mantenía la reducción en la presión arterial con una disminución en el número de fármacos antihipertensivos de 4,9±1,2 a 4,4±1,5 (p = 0,0001). No hubo complicaciones importantes relacionadas con el procedimiento. La tasa de respuesta a la denervación al año fue del 80%, si bien con una amplia variabilidad entre centros. CONCLUSIONES: La denervación renal en pacientes con hipertensión resistente se relacionó con una disminución de las cifras de presión arterial en la consulta y, lo que es más importante, en la monitorización ambulatoria de presión arterial, con una disminución significativa del tratamiento farmacológico

INTRODUCTION AND OBJECTIVES: Renal denervation is a percutaneous intervention for the treatment of resistant hypertension. Randomized studies have shown contradictory results on its efficacy. We present the results of a renal denervation registry for the treatment of resistant hypertension in real-life patients in Spain. METHODS: Multicenter registry of consecutive patients with resistant hypertension treated with renal denervation in Spain between 2009 and 2018. RESULTS: We included 125 patients (mean age, 56 years; 41% female; mean onset of hypertension 14±9 years previously). Office systolic and diastolic blood pressure and ambulatory blood pressure monitoring decreased 6 months after the intervention (166±20/95±16 to 149±22/87±16 mmHg and 151±14/89±12 to 143±15/84±11, both P <.0001). At 12 months, the blood pressure reduction was maintained and the number of antihypertensive drugs decreased from 4.9±1.2 to 4.4±1.5 (P=.0001). There were no significant procedure-related complications. The response rate to denervation at 1 year was 80%, but there were wide differences between centers. CONCLUSIONS: In patients with resistant hypertension, treatment with renal denervation was related to a decrease in office blood pressure and, more importantly, in ambulatory blood pressure monitoring, with a significant reduction in pharmacological treatment

Renal denervation for the treatment of resistant hypertension in Spain. The Flex-Spyral Registry.

INTRODUCTION AND OBJECTIVES: Renal denervation is a percutaneous intervention for the treatment of resistant hypertension. Randomized studies have shown contradictory results on its efficacy. We present the results of a renal denervation registry for the treatment of resistant hypertension in real-life patients in Spain. METHODS: Multicenter registry of consecutive patients with resistant hypertension treated with renal denervation in Spain between 2009 and 2018. RESULTS: We included 125 patients (mean age, 56 years; 41% female; mean onset of hypertension 14±9 years previously). Office systolic and diastolic blood pressure and ambulatory blood pressure monitoring decreased 6 months after the intervention (166±20/95±16 to 149±22/87±16 mmHg and 151±14/89±12 to 143±15/84±11, both P <.0001). At 12 months, the blood pressure reduction was maintained and the number of antihypertensive drugs decreased from 4.9±1.2 to 4.4±1.5 (P=.0001). There were no significant procedure-related complications. The response rate to denervation at 1 year was 80%, but there were wide differences between centers. CONCLUSIONS: In patients with resistant hypertension, treatment with renal denervation was related to a decrease in office blood pressure and, more importantly, in ambulatory blood pressure monitoring, with a significant reduction in pharmacological treatment.

Long-term effect of 2 intensive statin regimens on treatment and incidence of cardiovascular events in familial hypercholesterolemia: The SAFEHEART study.

BACKGROUND: Maximal doses of potent statins are the basement of treatment of familial hypercholesterolemia (FH). Little is known about the use of different statin regimens in FH. OBJECTIVES: The objectives of the study were to describe the treatment changes and low-density lipoprotein cholesterol (LDL-C) goal achievement with atorvastatin (ATV) and rosuvastatin (RV) in the SAFEHEART cohort, as well as to analyze the incidence of atherosclerotic cardiovascular events (ACVEs) and changes in the cardiovascular risk. METHODS: SAFEHEART is a prospective follow-up nationwide cohort study in a molecularly defined FH population. The patients were contacted on a yearly basis to obtain relevant changes in life habits, medication, and ACVEs. RESULTS: A total of 1939 patients were analyzed. Median follow-up was 6.6 years (5-10). The estimated 10-year risk according the SAFEHEART risk equation was 1.61 (0.67-3.39) and 1.22 (0.54-2.93) at enrollment for ATV and RV, respectively (P < .001). There were no significant differences at the follow-up: 1.29 (0.54-2.82) and 1.22 (0.54-2.76) in the ATV and RV groups, respectively (P = .51). Sixteen percent of patients in primary prevention with ATV and 18% with RV achieved an LDL-C <100 mg/dL and 4% in secondary prevention with ATV and 5% with RV achieved an LDL-C <70 mg/dL. The use of ezetimibe was marginally greater in the RV group. One hundred sixty ACVEs occurred during follow-up, being its incidence rate 1.1 events/100 patient-years in the ATV group and 1.2 in the RV group (P = .58). CONCLUSION: ATV and RV are 2 high-potency statins widely used in FH. Although the reduction in LDL-C levels was greater with RV than with ATV, the superiority of RV for reducing ACVEs was not demonstrated.

Nighttime Blood Pressure Patterns and Subclinical Atherosclerosis in Women with Systemic Lupus Erythematosus.

OBJECTIVE: To compare 24-h ambulatory blood pressure (BP) monitoring (ABPM) values and patterns in women with systemic lupus erythematosus (SLE) with those of a matched control group and their relationship with the presence of subclinical atherosclerosis. METHODS: ABPM was assessed in 70 women with SLE and in 65 sex- and age-matched controls without a history of clinic cardiovascular disease (CVD). Carotid-femoral pulse wave velocity (PWV), which is a marker of subclinical atherosclerosis and a predictor of future CVD, was measured. Multivariate logistic analysis was used to determine which explanatory variables were independently associated with the non-dipper pattern and the presence of nocturnal hypertension (HTN) in women with SLE. RESULTS: No differences in PWV were found between patients and controls [median 7.3, interquartile range (IQR) 6.5-8.1 m/s vs median 7.1, IQR 6.5-7.8 m/s, p = 0.474]. The frequency of nondipper pattern (p = 0.025) and nocturnal HTN (p = 0.004) was significantly higher in women with SLE than in controls. White-coat and masked HTN were present in 10% and 11% of patients and in 20% and 8% of controls, respectively (p > 0.05 in all cases). The concordance between office and ambulatory HTN in the SLE and control groups was modest (κ = 0.325 and κ = 0.451, respectively). PWV and chronic kidney disease, and PWV and the Systemic Lupus Erythematosus Disease Activity Index were found to be independently associated with nocturnal HTN and nondipper pattern, respectively. CONCLUSION: Women with SLE were more likely to have an altered nighttime BP pattern than controls. In women with SLE, nondipper pattern and nocturnal HTN were independently associated with increased subclinical atherosclerosis measured by PWV.

Prevalence of and factors associated with hypertension in young and old women with systemic lupus erythematosus.

OBJECTIVE: Hypertension (HT) is more prevalent in patients with systemic lupus erythematosus (SLE) than among the general population and it has been associated with atherosclerotic cardiovascular diseases in these patients. We examined the proportion of HT and factors associated with it in young and old women with SLE. METHODS: Participants (112 women with SLE and 223 healthy age-matched women) were categorized as young (age ≤ 40 years) or old (age > 40 years). We compared cardiovascular and specific SLE-related variables and inflammatory markers in hypertensive and normotensive women with SLE for each age range. We also assessed the factors independently associated with HT in the entire cohort and in each age range by means of a multivariate regression analysis. RESULTS: The prevalence of HT was higher in women with SLE than in controls (56% vs 29%; p < 0.001), and was proportionally higher in younger women with SLE (40% vs 11%; p < 0.001) than in older women with SLE (74% vs 47%; p = 0.001). After adjustment for potential confounders, HT was associated with renal involvement and higher nonobesity-related insulin levels in younger women with SLE. In older patients, HT was associated with age, renal involvement, and obesity. Finally, in the entire cohort, HT was associated with age, insulin, renal involvement, and the Systemic Lupus Erythematosus Disease Activity Index score. CONCLUSION: An association between HT and insulin has been identified in women with SLE, particularly younger ones. Factors associated with HT in women with SLE differed depending on their age. HT was more prevalent in women with SLE than in control subjects, being proportionally higher in young women with SLE.

Metabolic syndrome is associated with increased arterial stiffness and biomarkers of subclinical atherosclerosis in patients with systemic lupus erythematosus.

OBJECTIVE: Aortic pulse wave velocity (PWV) is an independent predictor of risk for atherosclerotic cardiovascular disease. Metabolic syndrome (MetS) is more prevalent in patients with systemic lupus erythematosus (SLE) compared with matched healthy subjects. Aortic PWV is increased in MetS. The purpose of this cross-sectional study was to determine the association between MetS and aortic PWV and other surrogate biomarkers of subclinical atherosclerosis in SLE. METHODS: One hundred twenty-eight patients with SLE were studied. We established the presence of MetS according to the National Cholesterol Education Program Adult Treatment Panel III definition and we measured PWV, glucose, insulin, glycosylated hemoglobin (HbA(1c)), insulin sensitivity (HOMA index), lipid levels, uric acid, homocysteine, fibrinogen, D-dimer, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), interleukin 6 (IL-6), IL-8, IL-10, C3, C4, autoantibodies, SLE Disease Activity Index (SLEDAI), and Systemic Lupus International Collaborating Clinics/ACR Damage Index. Duration of SLE and treatment was also recorded. Multivariate logistic regression analysis was used to identify independent determinants of increased PWV. RESULTS: SLE patients with MetS had higher aortic PWV (9.8 +/- 2.4 vs 8.5 +/- 1.7 m/s; p = 0.002) and increased biomarkers of subclinical atherosclerosis such as CRP, IL-6, C3, uric acid, homocysteine, fibrinogen and D-dimer, compared to those without MetS. HOMA index and insulin and HbA(1c) levels were also higher in this group. No differences were found in variables related to lupus activity (ESR, C4, SLEDAI, IL-8, IL-10, and treatment for SLE). In the multivariate model, increased PWV was associated with age, male sex, MetS, duration of SLE, and CRP. CONCLUSION: MetS may contribute to the development of accelerated atherosclerosis in SLE.

Localized mucosal leishmaniasis due to Leishmania (Leishmania) infantum: clinical and microbiologic findings in 31 patients.

The clinical and microbiologic characteristics of 31 patients with mucosal leishmaniasis due to Leishmania (Leishmania) infantum are described. Twenty-eight (90%) patients were male. Mean age at presentation was 48 +/- 14 years. Thirteen (42%) patients had no underlying disease, while 18 (58%) patients had several other medical conditions. Fifteen (48%) patients were immunocompromised, 7 patients were infected with human immunodeficiency virus (HIV), and 3 were graft recipients. The primary location of lesions was the larynx in 11 (35%) patients, oral mucosa in 10 (32%) patients, and the nose in 5 (16%) patients. Mucosal lesions were painless in all patients but 2 and consisted of whitish, red, or violaceous nodular swelling or tumorlike masses. Ulceration was reported in 6 patients. Pathologically, the lesions showed a chronic inflammatory infiltrate. Granuloma may be seen. The localization of the lesions determined the symptomatology of the disease. Symptoms included hoarseness, difficulty swallowing, and nasal obstruction. The disease presentation was usually protracted, with a mean time from the onset of symptoms to diagnosis of 13 months (range, 3 wk-4.5 yr), and the clinical diagnosis was usually mistaken for neoplasia of the upper aerodigestive tract. No laboratory abnormalities were found in these patients due to the localized disease, apart from those attributed to underlying diseases. Parasites were easily identified in smears or sections by Giemsa stain or hematoxylin-eosin stain. Leishmania was grown in culture in 12 (60%) patients; culture was negative in 8 (40%) patients. Leishmania (Leishmania) infantum was identified in only 9 instances. The following zymodemes were reported: MON-1 (2 patients), MON-24 (2 patients), MON-27 (1 patient), and MON-34 (1 patient). Serologic test results were known in 25 patients. Serology was usually positive at low titer; 6 (24%) patients had negative serologic test results. Twenty patients were treated with antimonial compounds for between 3 and 36 days. Three patients were given drugs other than antimonial drugs. Five patients were treated only locally, by surgery (3 patients) or topical medical therapy. One patient received no therapy, and treatment was not reported in 2 cases. Patients were cured in 25 (89%) cases, and sequelae were uncommon (14%). Relapse was detected in 2 individuals and 1 patient developed visceral leishmaniasis after treatment. Two HIV-coinfected patients died of causes unrelated to leishmaniasis. The results of the present report stress the clinical importance of searching for the presence of Leishmania in patients with suspected neoplasia of the upper respiratory tract if they have visited or resided in zones endemic for Leishmania (Leishmania) infantum. The treatment of choice for these patients is not established yet, but most patients respond to antimonial compounds given for 28 days or less.

A clinical index predicting mortality with Pseudomonas aeruginosa bacteraemia.

The aim of this study was to define risk factors associated with mortality in Pseudomonas aeruginosa bactaeremia and to combine them in a clinical index predicting the risk of death. The study investigated 125 consecutive episodes of P. aeruginosa bacteraemia at this hospital. Crude mortality was 34%, corresponding to 43 patients who died, with 67% of deaths, directly attributable to bacteraemia. A regression logistic model identified five variables that were independently and significantly associated with an increased risk of death: 1) hospitalisation in the intensive care unit; 2) coagulopathy; 3) septic shock; 4) age > or = 65 years; and 5) the clinical condition of the patient. These variables were as recorded at the time that the first positive blood culture was obtained. The sensitivity and specificity of a prediction of death based on the model were 84% and 85%, respectively. An index score, calculated from these variables, divided patients into three groups with increasing likelihood of mortality resulting from P. aeruginosa bacteraemia.