Non-proteinuric diabetic nephropathy is the main cause of chronic kidney disease: Results of a general population survey in Spain.

BACKGROUND: Diabetic nephropathy traditionally produces significant proteinuria prior to the development of renal impairment. However, this clinical paradigm has recently been questioned. The current study evaluated the impact of diabetes mellitus on the prevalence of renal disease in general population. METHODOLOGY: Data from of the HERMEX survey, an observational, cross sectional, population based study were used. The final sample included 2813 subjects (mean age 51.2 years, 53.5% female). Four hundred patients have diabetes. Urinary albumin excretion (UAE) rate was analyzed and glomerular filtration rate (GFR) was estimated using the CKD-EPI formula. RESULTS: Among participants without diabetes, 2.9%(2.2-3.6) had a GFR < 60 ml/min. Prevalence of abnormal UAE in population without diabetes was 3.3% (2.6-4.0). The global prevalence of renal disease was 5.6%(4.8-6.6). Prevalence of GFR <60 ml/min in subjects with diabetes was 8.8%(6.4-11.9)(p<0.001,Chi-square test). Prevalence of abnormal UAE in population with diabetes was 14.1%(7.7-19.8)(p< 0.001,Chi-square test). CKD prevalence was 20.3%(16.6-24.6)(p<0.001,Chi-square test). The logistic regression analysis showed a positive independent association of CKD with age, high blood pressure and albuminuria. No significant relationship was found with diabetes mellitus CONCLUSIONS: CKD is more prevalent in population with diabetes. Nevertheless, most of patients with diabetes and CKD have no albuminuria. An increased cardiovascular burden seems to produce this clinical presentation.

The H.U.G.E. Formula (Hematocrit, Urea, Sex) for Screening Chronic Kidney Disease (CKD) in an Age-Stratified General Population.

AIM: To evaluate the screening power of the HUGE formula for the detection of chronic kidney disease (CKD) in a Spanish population sample obtained from the HERMEX study, a survey of cardiovascular risk factors carried out in the region of Extremadura, stratified by age. DESIGN AND METHODS: This was an observational, cross-sectional, population-based study. The final sample included 2,813 subjects selected from Health Care System records. Anthropometric data and cardiovascular risk factors were recorded. Hematocrit, urea, creatinine and microalbuminuria were analyzed, after which the HUGE formula was applied. Renal function, assessed as eGFR based on serum creatinine, was estimated following the MDRD-4 formula. RESULTS: Using the HUGE formula, the estimated prevalence of CKD was 2.2% (men 2.2%, women 2.1%). The prevalence of CKD increased with age (5.0% in persons aged 60- 70 years and 9.6% in individuals over 70 years of age, p < 0.001) whereas with the MDRD formula the prevalence values were 9.8% and 15.5% respectively. The HUGE formula was seen to be highly specific (0.99). CKD was more common in persons >70 years, obese subjects, hypertensive patients, dyslipidemic subjects and those with microalbuminuria. Multivariate analysis revealed an independent negative association of CKD as the dependent variable with SBP, serum triglyceride levels and microalbuminuria. CONCLUSIONS: The HUGE formula allows the prediction of CKD in the general population to be honed without relying on serum creatinine levels. This method was found to have a higher specificity than the MDRD-4 formula. Moreover, it could reduce the excessively extensive diagnostic suspicion of CKD in women.

The HUGE formula (hematocrit, urea and gender): association with cardiovascular risk.

OBJECTIVES: To evaluate the relationship between chronic renal failure (CFR) defined through HUGE (hematocrit, urea and gender) formula score and the patient's cardiovascular risk measured through cardiovascular disease antecedents such as ischemic cardiopathy, cerebrovascular disease and peripheral arterial disease. DESIGN AND METHODS: The sample consisted of 2,831 subjects. Mean age was 51.2±14.7 years and 53.5% were female. Serum creatinine, urea, hematocrit and 24h proteinuria were analyzed. HUGE score was calculated from gender, urea and hematocrit. GFR was estimated from uncalibrated serum creatinine using the abbreviated Modification of Diet in Renal Disease equation (MDRD-4). UAE was measured in first morning urine sample. RESULTS: Using HUGE formula 2.2% (n = 61) of subjects had CRF. Of them, 12 (19.7%) had cardiovascular disease history. Among patients without CRF (n = 2770), 194 subjects had history of previous cardiovascular diseases (0.07%; p < 0.001 Square Chi test). Using the MDRD-4 formula 4.0% of subjects (n = 113) had a GFR < 60 ml/min. Of them, 18 (15.9%) had cardiovascular disease history. Among patients without CRF (n = 2718), 188 subjects had history of previous cardiovascular diseases (0.07%; p < 0.001 Square Chi test). Odd's ratio for cardiovascular diseases using HUGE definition of CRF was 3.25 (p = 0.001, Mantel-Haenszel test). CFR was associated to higher pulse pressure (PP) and increased urinary albumin excretion. CONCLUSIONS: A significant cardiovascular risk was associated to the diagnosis of CRF through HUGE formula. This relation was closer than the obtained using MDRD estimated GFR in spite of a bigger sample. HUGE formula seems to be a useful tool for diagnosing CRF and evaluate the cardiovascular risk of these patients.

Características clínicas y mortalidad de la insuficiencia cardiaca. Estudio INCAex / Clinical characteristics and mortality of heart failure. INCAex study

Antecedentes y objetivos. La insuficiencia cardiaca es la causante del mayor gasto sanitario en hospitalización y la tercera causa de mortalidad cardiovascular. Fue nuestro objetivo determinar la evolución de las características clínicas, y los factores relacionados con el pronóstico en pacientes ingresados por insuficiencia cardiaca en un área de salud de Extremadura durante 10 años. Pacientes y métodos. Estudio observacional, retrospectivo y unicéntrico en pacientes consecutivos ingresados por insuficiencia cardiaca descompensada en un Hospital General de la provincia de Badajoz en el período 2000/2009. Resultados. Se incluyeron 2.220 pacientes con una edad media de 76,3 (DE±10,1) años, 54% mujeres. Estratificados en 4 períodos de 30 meses, se observó: un significativo incremento de los pacientes mayores de 75 años (55 al 71%; p<0,001) y al alta una mayor prescripción de bloqueadores beta (12 al 34%; p<0,001), estatinas (8 al 31%; p<0,001), y anticoagulantes orales (13 al 25%; p<0,001). La mortalidad intrahospitalaria disminuyó del 13 al 8% (p<0,01) y al año del 30 al 23% (p<0,01). Fueron predictores independientes de mortalidad al año la edad (HR=1,04 [IC del 95%: 1,02-1,05]), la diabetes (HR=1,35 [IC del 95%: 1,11-1,66]) y la insuficiencia renal (HR=1,49 [IC del 95%: 1,18-1,87]). Conclusiones. La mortalidad ha disminuido significativamente en la década a pesar del incremento de la edad. La edad, la diabetes y la insuficiencia renal crónica resultaron predictores independientes de mortalidad al año. La anticoagulación resultó protectora(AU)

Background and objectives. Heart failure is responsible for a major part of hospital health expenditure and the third cause of cardiovascular death. To describe the evolution of clinical features, and factors related to prognosis of patients admitted due to decompensated heart failure in a region of Extremadura during a period 10 years. Patients and methods. Observational, retrospective and single centre study of consecutive patients admitted due to decompensated heart failure in a general hospital in the province of Badajoz, during the period 2000/2009. Results. A total of 2220 patients with mean age of 76.3 (SD±10.1), being 54% female were included in the study. Stratified into four periods (30 months each), a significant increase in patients over 75 years was observed (55 vs. 71%; P<.001), as well as an increase in the prescription of beta blockers at discharge (12 vs. 34%, P<.001), statins (8 vs. 31%; P<.001), and oral anticoagulants (13 vs. 25%; P<.001). Hospital mortality significantly decreased from 13 to 8% (P<.01), and from 30 to 23% (P<.01) at one year follow-up. Age (HR per year=1.04 [95% CI: 1.02 to 1.05]), diabetes (HR=1.35 [95% CI: 1.11 to 1.66]) and chronic renal failure (HR=1.49 [95% CI: 1.18 to 1.87]) were identified as independent predictors of all-cause mortality at one year of follow-up. Conclusions. Total mortality in patients with decompensated heart failure has declined significantly over the last decade, despite the increasing age. Age, diabetes and chronic renal failure were independent predictors of total mortality at one year. Oral anticoagulation was a protective factor(AU)

Prevalence of abnormal urinary albumin excretion in elderly people: a Spanish survey.

OBJECTIVES: HERMEX is a population-based study, which tries to evaluate the prevalence of cardiovascular risk factors in the population of Extremadura, Spain. This report provides the data concerning albuminuria in the elderly people recruited in the survey. DESIGN AND METHODS: 3,402 subjects were randomly selected from the database of the Health Care System of Extremadura. The final sample included 2,813 subjects (mean age 51.2 years, 53.5 % female). Urinary albumin excretion rate (UAER) in the first morning urine sample was analyzed. Albuminuria was diagnosed when UAER (albumin-to-creatinine ratio) was ≥ 22 mg/g in men or ≥ 31 mg/g in women. RESULTS: The prevalence of abnormal UAER in the elderly population was 10.9 % (microalbuminuria: 8.9 %; overt proteinuria: 1.8 %). The younger subjects showed a lower prevalence of microalbuminuria (3.4 %, p < 0.001). Elderly patients showed a higher prevalence of cardiovascular risk factors than the younger ones. The elderly had higher systolic blood pressure and pulse pressure than the younger ones. Furthermore, the elderly subjects had lower plasma levels of HDL cholesterol, but higher triglycerides, glucose, creatinine, and glycosylated hemoglobin; no differences were found for total and LDL cholesterol. When the prevalence of causes of microalbuminuria was compared between age groups, we found a sharp increase in diabetic and, especially, hypertensive patients in the elderly group. The multivariate analysis showed an independent association of microalbuminuria with systolic blood pressure and plasma creatinine. CONCLUSIONS: A high prevalence of abnormal UAER in elderly people was detected in a randomly selected sample of Spanish general population. In most elderly patients, microalbuminuria was associated with high blood pressure and, less frequently, with diabetes mellitus.

Clinical characteristics and mortality of heart failure. INCAex study.

BACKGROUND AND OBJECTIVES: Heart failure is responsible for a major part of hospital health expenditure and the third cause of cardiovascular death. To describe the evolution of clinical features, and factors related to prognosis of patients admitted due to decompensated heart failure in a region of Extremadura during a period 10 years. PATIENTS AND METHODS: Observational, retrospective and single centre study of consecutive patients admitted due to decompensated heart failure in a general hospital in the province of Badajoz, during the period 2000/2009. RESULTS: A total of 2220 patients with mean age of 76.3 (SD±10.1), being 54% female were included in the study. Stratified into four periods (30 months each), a significant increase in patients over 75 years was observed (55 vs. 71%; P<.001), as well as an increase in the prescription of beta blockers at discharge (12 vs. 34%, P<.001), statins (8 vs. 31%; P<.001), and oral anticoagulants (13 vs. 25%; P<.001). Hospital mortality significantly decreased from 13 to 8% (P<.01), and from 30 to 23% (P<.01) at one year follow-up. Age (HR per year=1.04 [95% CI: 1.02 to 1.05]), diabetes (HR=1.35 [95% CI: 1.11 to 1.66]) and chronic renal failure (HR=1.49 [95% CI: 1.18 to 1.87]) were identified as independent predictors of all-cause mortality at one year of follow-up. CONCLUSIONS: Total mortality in patients with decompensated heart failure has declined significantly over the last decade, despite the increasing age. Age, diabetes and chronic renal failure were independent predictors of total mortality at one year. Oral anticoagulation was a protective factor.

The value of a formula including haematocrit, blood urea and gender (HUGE) as a screening test for chronic renal insufficiency.

INTRODUCTION: Despite increasing use in clinical practice, an estimated glomerular filtration rate value (eGFR) of <60 ml/min/1.73 m2 does not necessarily indicate the existence of chronic renal insufficiency (CRI) and this may lead to an over-estimate of CRI particularly in persons seventy years or older. AIM: To find a screening test able to differentiate CRI from the decrease in GFR normally associated with the renal ageing process. METHODS: Medical information of 487 individuals of both sexes aged 16-102 was obtained from nephrologists, internal medicine physicians, cardiologists, geriatricians, family and nuclear medicine doctors from Argentina, Portugal and Spain. Data were assessed and statistically analysed using logistic regression techniques. From the discriminative variables it was derived the HUGE formula. RESULTS: A formula including haematocrit , blood urea, and gender (HUGE), diagnoses CRI regardless of the variables of age, blood creatinine, creatinine clearance, or other eGFR. The HUGE formula is: L = 2.505458 - (0.264418 x Hematocrit) + (0.118100 x Urea) [+ 1.383960 if male]. If L is a negative number the individual does not have CRI; if L is a positive number, CRI is present. Our data demonstrate that the HUGE formula is more reliable than MDRD and CKD-EPI, particularly in persons aged over 70. CONCLUSIONS: Our HUGE screening formula offers a straightforward, easily available and inexpensive method for differentiating between CRI and eGFR < 60 ml/min/1.73 m2 that will prevent a considerable number of aged healthy persons, as much as 1.700.000 in Spain and 2.600.000 in U.K., to be excluded from clinical assays or treatments contraindicated in CRI.

Persistent microalbuminuria after treatment with renin-angiotensin axis blockers: causes and results of treatment intensification.

AIMS: The first phase of this study aimed to determine the causes of persistent microalbuminuria after treatment with renin-angiotensin axis (RAA) blocking drugs. In a second phase we tried to determine if strict control of blood pressure and intensive RAA blockade could induce remission or reduction of microalbuminuria in clinical (primary care) practice. PATIENTS AND METHODS: The study included both diabetic patients and non-diabetic hypertensive patients treated with RAA drugs in the presence of microalbuminuria. 211 patients were recruited (mean age 66.6±11.3 years, 111 men, 117 were diabetic). In the first phase treatment was optimized at standard doses. In the second phase treatment was increased during a three months period to reach a blood pressure (BP) < 130/80 mmHg by adding other antihypertensive treatment and to obtain maximal RAA blockade using long-acting drugs, increased dosage, or adding further medication at night. RESULTS: Initial mean BP was 141±16/81±11 mmHg. BP control was unsatisfactory (control of systolic blood pressure [SBP] 19.3%; diastolic blood pressure [DBP] 37.6%). Dosage of RAA blocking drugs was inadequate in 21% of patients. Only 27.4% of patients were taking antihypertensive drugs at night. 30.1% of patients took once daily short acting drugs. During the studymean SBP was reduced to 137±13 mmHg (p < .001) and DBP decreased to 79±10 mmHg (p < .001). Control of SBP improved to 24.5% and DBP control went to 44.4%. Mean microalbuminuria decreased from 64.4±47.0 mg/day to 50.1±53.0 mg/day (p < .001) and the prevalence of microalbuminuria was reduced to 59.1%. CONCLUSIONS: Persistent microalbuminuria was associated with poor blood pressure control and inadequate drug dosage. Low frequency of administration of drugs at night and inappropriate once-daily pills intake were frequent. Strict control of blood pressure and intensive RAA blockade significantly reduced the prevalence of microalbuminuria.

Enfermedad vascular hipertensiva: evolución de la incidencia en el período 1991-2007 y supervivencia antes de la enfermedad renal terminal / Hypertensive vascular disease: evolution of its incidence in the period 1991-2007 and survival prior to end-stage renal disease

Objetivo: La nefropatía hipertensiva es la segunda causa más común de entrada en tratamiento renal sustitutivo en España, con una incidencia que parece estable desde 1997. Los datos sobre incidencia de nuevos diagnósticos de nefropatía hipertensiva en consulta son escasos al no existir registros similares a los usados en el tratamiento renal sustitutivo. Diseño y métodos: Se ha revisado retrospectivamente la incidencia de este diagnóstico en la base de datos de la Consulta de Nefrología del Hospital Infanta Cristina de Badajoz entre el 1de enero de 1991 y el 31 de diciembre de 2007. El diagnóstico se hizo en la mayor parte de los casos por criterios clínicos. En60 casos se realizó biopsia renal por proteinuria superior a 1g/24 h. Resultados: Durante ese tiempo fueron atendidos en consulta 5.071 pacientes, de los cuales 479 fueron diagnosticados de nefropatía hipertensiva. La incidencia media de nefroangioesclerosis ha sido 44,0 casos pmp, con una edad media de 66,6 ± 12,1 años, siendo el 43,0% mujeres. Se aprecia una tendencia progresiva desde 16,7 pmp en 1991 hasta 89,5pmp en 2007. Las tasas medias fueron 31,8 pmp en el período1991-1995; 32,1 pmp entre 1996 y 2000, y 54,4 en el período2001-2006. La edad media de los pacientes incidentes a lo largo del período estudiado ha seguido una curva en «J»; 53 pacientes (11,6%) han iniciado tratamiento renal sustitutivo durante estos años. La supervivencia estimada antes de llegada a tratamiento renal sustitutivo fue el 96,0% al año, el 85,9%a los 5 años de seguimiento y el 81,6% a los 7 años de seguimiento. Conclusiones: La incidencia de nefropatía hipertensiva parece tender a crecer significativamente en los últimos años a pesar del perfeccionamiento de los tratamientos preventivos utilizados. La mayor permisividad en la edad para la derivación podría influir en estos resultados (AU)

Objective: Hypertensive nephropathy is the second most common cause for starting renal repacement therapy in Spain with a steady incidence since 1997. Data on incidence of hypertensive nephropathy previously to dialysis are scanty because they are not registries similar to those used for renal replacement therapy. Design and methods: It have be enretrospectively studied the records of our hospital Nephrology outpatients clinic from January, 1991 to December, 2007.Diagnosis was commonly made using clinical criteria in most of cases. There were 60 cases whith proteinuria higher than1 g/day and so that renal biopsies were performed. Results: During this time 479 (44.0 pmp) patients were diagnosed of hypertensive nephropathy (mean age 66.6 ± 12.1 years and43.0% were women). Incidence increased from 33.3 pmp(1991) to 76.2 pmp (2006). There was a steady trend to increase incidence since 16.7 pmp in 1991 up to 89.5 pmp in 2007. Mean incidence was 31.8 pmp between 1991 and 1995, 32.1 pmp in the period 1996-2000; and 54.4 pmp from 2001 to 2006.The mean age of incident patients have showed a J curve.53 subjects (11.6%) have started renal replacement therapy. Survival before starting renal replacement therapy was 96.0 at first year, 85.9% at five years and 81.6% after seven years of follow-up. Conclusions: Incidence of hypertensive nephropathy seems to have increased last years specially in spite of therapeutic improvements the prognosis is still unfavourable. Less rectricted age criteria for submitting patients may have influenced these results (AU)

Cystatin C and blood pressure: results of 24 h ambulatory blood pressure monitoring.

BACKGROUND: The relationship between kidney function and blood pressure (BP) components has been studied in chronic kidney disease patients. Whether cystatin C, a marker of kidney function, is associated in the normal range with systolic BP (SBP), diastolic BP (DBP), and pulse pressure (PP) obtained using ambulatory blood pressure monitoring has not been previously studied. METHODS: The sample subjects were 53 males and 34 females, mean age was 59.3+/-13.5 years. 76% were receiving antihypertensive drug treatment. Kidney function was evaluated by measuring serum cystatin C. Microalbuminuria was measured in a 24h urine collection. Glomerular filtration rate (GFR) was estimated using the abbreviated Modification of Diet in Renal Disease equations. The ambulatory BP was measured non-invasively for 24h by the Spacelab devices programmed to measure BP every 15 min during daytime and every 20 min during nighttime. RESULTS: The highest quartile of cystatin C distribution showed an older age and worsel parameters of renal function (cystatin C, serum creatinine and GFR) than the other groups. No differences for gender or diabetes were found. 24h SBP and PP were higher in the fourth quartile compared to the fist one (p<0.01). 24h DBP was lower for the patients in the fourth quartile of cystatin C compared which any one of the other groups (p<0.001). The relationship between cystatin C, as well as GFR, with SBP and PP was statistically significant as renal function comes down. Contrariwise, as cystatin C increases DBP declines; but the correlation with GFR measured through MDRD 4 is not significant. In the same way, no correlation was found for GFR and microalbuminuria, but there was a statistically significant positive relationship between cystatin C and microalbuminuria severity (p<0.01). Multivariate regression analysis confirms these findings. CONCLUSIONS: Both SBP and pulse pressure were significantly associated with kidney function. DBP was negatively correlated with cystatin C concentrations but not with GFR. Cystatin C shows a positive relationship with microalbuminura severity. Cystatin C might have cardiovascular effects beyond its use as a marker of the renal function.

[Hypertensive vascular disease: evolution of its incidence in the period 1991-2007 and survival prior to end-stage renal disease]. / Enfermedad vascular hipertensiva: evolución de la incidencia en el período 1991-2007 y supervivencia antes de la enfermedad renal terminal.

OBJECTIVE: Hypertensive nephropathy is the second most common cause for starting renal replacement therapy in Spain with a steady incidence since 1997. Data on incidence of hypertensive nephropathy previously to dialysis are scanty because there are not registries similar to those used for renal replacement therapy. DESIGN AND METHODS: Retrospectively we studied the records of our hospital Nephrology outpatients clinic from January, 1991 to December, 2007. Diagnosis was commonly made using clinical criteria in most of cases. There were 60 cases with proteinuria higher than 1 g/day and so that renal biopsies were performed. RESULTS: During this time 479 (44.0 pmp) patients were diagnosed of hypertensive nephropathy (mean age 66.6 +/- 12.1 years and 43.0% were women). Incidence increased from 33.3 pmp (1991) to 76.2 pmp (2006). There was a steady trend to increase incidence since 16.7 pmp in 1991 up to 89.5 pmp in 2007. Mean incidence was 31.8 pmp between 1991 and 1995, 32.1 pmp in the period 1996-2000; and 54.4 pmp from 2001 to 2006. The mean age of incident patients showed a J curve. 53 subjects (11.6%) have started renal replacement therapy. Survival before starting renal replacement therapy was 96.0 at first year, 85.9% at five years and 81.6% after seven years of follow-up. CONCLUSIONS: Incidence of hypertensive nephropathy seems to have increased last years specially in spite of therapeutic improvements the prognosis is still unfavourable. Less restricted age criteria for submitting patients may have influenced these results.

Treatment of proteinuria with lercanidipine associated with renin-angiotensin axis-blocking drugs.

OBJECTIVE: Most calcium antagonists do not seem to reduce microalbuminuria or proteinuria. We have tried to assess the antiproteinuric effect of a calcium channel blocker, lercanidipine, in patients previously treated with ACE inhibitors or angiotensin receptor blockers. DESIGN AND METHODS: The study included 68 proteinuric (> 500 mg/day) patients (age 63.1 +/- 12.9 years, 69.1% males and 30.9 females). All patients were receiving ACE inhibitors (51.4%) or angiotensin II receptor blockers (48.6%) therapy but had higher blood pressure than recommended for proteinuric patients (<130/80 mmHg). Patients were clinically evaluated one, three, and six months after starting treatment with lercanidipine (20 mg/day). Samples for urine and blood examination were taken during the examination. When needed, a third drug was added to treatment. Creatinine clearance was measured using 24 h urine collection. RESULTS: BP significantly decreases from 152 +/- 15/86 +/- 11 mmHg to 135 +/- 12/77 +/- 10 mmHg at six months of follow-up (p < 0.001). After six months of treatment, the percentage of normalized patients (BP < 130/80 mmHg) was 42.5%, and the proportion of patients whose BP was below 140/90 mmHg was 58.8%. Plasmatic creatinine did not change nor did creatinine clearance. Plasmatic cholesterol also decreased from 210 +/- 48 to 192 +/- 34 mg/dL (p < 0.001), as did plasma triglycerides (from 151 +/- 77 to 134 +/- 72 mg/dL, p = 0.022). Basal proteinuria was 1.63 +/- 1.34 g/day; it was significantly (p < 0.001) reduced by 23% at the first month, 37% at three months, and 33% at the last visit. CONCLUSIONS: Lercanidipine at 20 mg dose, associated to renin-angiotensin axis-blocking drugs, showed a high antihypertensive and antiproteinuric effect. This antiproteinuric effect seems to be dose-dependent as compared with previous reports and proportionally higher than blood pressure reduction.

Symmetrical ambulatory arterial stiffness index: relationship with microalbuminuria and renal function.

OBJECTIVE: The aim of this study was to investigate the arterial stiffness parameters derived from the proposed linear relationship between SBP and DBP obtained by ABPM, regarding its relationships with two markers of renal disease, microalbuminuria and renal function. DESIGN AND METHODS: One hundred and sixty six patients were studied: 73 males and 93 females mean age 55.2+/-15.5 years. 36.2% were receiving antihypertensive drug treatment. Microalbuminuria was measured in 24-h urine collection as well as albumin to creatinine ratio (ACR) in first morning urine. The ambulatory BP was measured non-invasively for 24 h by the Spacelab devices. RESULTS: Correlation test showed a significant relationship of Sym-AASI with age (p<0.001), serum creatinine (p=0.038), creatinine clearance (-0.423, p<0.001) and GFR (-0.263, p<0.001). On the other hand AASI was also correlated with age (p<0.001) and creatinine clearance (p=0.012), but not with the other parameters studied. 24-h albumin excretion rate was not correlated with Sym-AASI or AASI. Contrariwise, the albumin to creatinine ratio was correlated with Sym-AASI (p=0.013). As expected, AASI and Sym-AASI increase as severity of renal diseases grows. The patients in the highest quartile of Sym-AASI distribution showed an older age (p<0.001) and worse parameters of renal function (GFR, p<0.001; and creatinine clearance, p<0.008). CONCLUSIONS: Sym-AASI, an improved method for detecting arterial stiffness, seems to get an independent relationship with these parameters of renal disease which could not be detected with AASI.

Incidencia creciente de nefropatía diabética en la provincia de Badajoz durante el período 1991-2006 / No disponible

Objetivo: la nefropatía diabética es la causa más común de entrada en tratamiento renal sustitutivo en España, con una incidencia que parece estable desde 1997. Los datos sobre incidencia de nefropatía diabética en consulta son escasos al no existir registros similares a los usados en el tratamiento renal sustitutivo. Diseño y métodos: se ha revisado retrospectivamente la base de datos de la consulta de Nefrología de nuestro hospital entre enero de 1991 y diciembre de 2006. El diagnóstico se hizo en la mayor parte de los casos por criterios clínicos (proteinuria asociada a retinopatía diabética). En 21 casos se realizó biopsia renal por incumplimiento de estos criterios. Resultados: durante ese tiempo, 478 (49,7 pmp) pacientes fueron diagnosticados de nefropatía diabética (edad media 61,2 años, 50,4% mujeres). Se aprecia una tendencia progresiva de crecimiento desde 33,3 pmp en 1991 hasta 76,2 pmp en 2006. No se han producido variaciones significativas en la edad media de los incidentes. Ciento seis pacientes (22,1%) han iniciado tratamiento renal sustitutivo. En el resto de los casos, el diagnóstico más frecuente fue nefroangiosclerosis (129) y glomerulonefritis (n = 103). La supervivencia estimada antes de llegar a tratamiento renal sustitutivo fue del 87,5% al año y del 48% a los cinco años de seguimiento. Conclusiones: la incidencia de nefropatía diabética parece tender a crecer significativamente en los últimos años, sobre todo en el grupo de edad mayor de 70 años. A pesar del perfeccionamiento de los tratamientos, el pronóstico sigue siendo desfavorable. La mayor permisividad en la edad para la derivación puede haber influido en estos resultados (AU)

Objective: Diabetic nephropathy is the most common cause for starting renal repacement therapy in Spain with a steady incidence since 1997. Data on incidence of diabetic nephropathy previously to dialysis are scanty because they are not registries similar to those used for renal replacement therapy. Design and methods: It have been retrospectively studied the records of our hospital Nephrology outward from January, 1991 to December, 2006. Diagnosis was commonly made using clinical criteria (proteinuria plus diabetic retinopathy). There were 21 cases which did not meet theses criteria and so renal biopsy was performed. Results: During this time 478 (49.7 pmp) patients were diagnosed of diabetic nephropathy (mean age 61.2 years, 50.4% women). Incidence increased from 33.3 pmp (1991) to 76.2 pmp (2006). There were not significant changes in the age of patients along the time. Other common diagnosis in diabetic patients were nefroangiosclerosis (129) and glomerulonefritis (n = 103). Survival until renal replacement therapy was 87.5% at one year and 48% at five years of follow up. Conclusions: Incidence of diabetic nephropathy seems to have increase last years specially in the patients aged 70 or older. In spite of therapeutic improvements the prognosis is still unfavourable. Less rectricted age criteria for submitting patients may have influenced these results (AU)

Long-term antiproteinuric effect of dual renin-angiotensin system blockade.

We evaluated the long-term changes on overt proteinuria induced by dual blockade of the renin-angiotensin system (RAS). Dual blockade was produced by adding an angiotensin II receptor blocker (ARB) to treatment with maximal recommended doses of an angiotensin converting enzyme (ACE) inhibitor in proteinuric patients. A total of 28 patients (19 men and 9 women) with proteinuria higher than 1 g/24 h were enrolled in this trial of treatment with the ARB candesartan (from 4 up to 32 mg daily) added to existing treatment with an ACE inhibitor. At 6, 12, 24, and 36 months, we evaluated proteinuria in 24-h urinary collections, office blood pressure (BP), plasmatic creatinine (Cr), serum potassium (K), and 24 h urine collection creatinine clearance (CrC). During monoblockade of the RAS by ACE inhibitor treatment, albuminuria was 2.94 +/- 1.92 mg/24 h; BP was 137/76 mmHg; K+ was 4.8 +/- 0.5 mmol/l, Cr was 1.76 +/- 0.67 mg/dL, and CrC was 62 +/- 31.9 mL/min. After 6 months, dual blockade of the RAS albuminuria was 2.18 +/- 2.29 mg/24 h (P < 0.01 vs. baseline) and BP was 133/75 mmHg (not significant). At 36 months, albuminuria was 2.21 +/- 2.20 mg/24 h (P < 0.05 vs. baseline); BP was 133/73 mmHg (not significant). CrC was not changed along the follow up. A small increment of Cr was detected at 24 months (2.11 +/- 1.06 mg/mL, P < 0.05). The antiproteinuric effect of dual renin-angiotensin system blockade combining candesartan and ACE inhibitors remain after 36 months without losing its initial effect. Blood pressure changes seem not to explain this long-term antiproteinuric effect.

Dual renin-angiotensin system blockade: in patients with single functioning kidney and proteinuria.

AIM: Dual blockade of renin-angiotensin system (RAS) has increased antiproteinuric effects and it has been increasingly used on patients with proteinuria, but could have secondary effects when this kind of treatment is administered to patients with single functioning kidney. The aim of this study has been to assess the efficacy and safety of dual blockade of RAS in this group of patients. DESIGN AND METHODS: Sixteen patients with a single functioning kidney have been treated in our unit with dual RAS blockade due to proteinuria higher than 1 g/24 h. Mean age was 54.7+/-12.1 years, they were 12 males and 4 females. Analytical data of six months visit and last follow up visit have been retrospectively registered. Several different angiotensin conversor enzyme (ACE) inhibitors and angiotensin receptor blocking (ARB) drugs were used at the maximal dose tolerated by the patient. RESULTS: A small but not significant reduction of SBP and DBP were was observed throughout the study. Mean K+ increase in the second visit (from 4.65+/-0.67 to 5.01+/-1.02 mmol/l, not significant). There were no changes neither in plasmatic creatinine (baseline 1.86+/-0.67, 6 months 1.96+/-0.85) nor in creatinine clearance (baseline 65.2+/-26.9, 6 months 61.6+/-23.8 ml/min). Proteinuria was not reduced by dual RAS blockade (baseline 4.26+/-0.24, 6 months 4.25+/-0.39). CONCLUSIONS: Dual RAS blockade seems to be safe but unhelpful in renal patients with proteinuria associated to single functioning kidney.