Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 1.752
Filtrar
1.
Nat Med ; 25(11): 1753-1760, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31700174

RESUMO

Chronic kidney disease is common in the general population and associated with excess cardiovascular disease (CVD), but kidney function does not feature in current CVD risk-prediction models. We tested three formulae for estimated glomerular filtration rate (eGFR) to determine which was the most clinically informative for predicting CVD and mortality. Using data from 440,526 participants from UK Biobank, eGFR was calculated using serum creatinine, cystatin C (eGFRcys) and creatinine-cystatin C. Associations of each eGFR with CVD outcome and mortality were compared using Cox models and adjusting for atherosclerotic risk factors (per relevant risk scores), and the predictive utility was determined by the C-statistic and categorical net reclassification index. We show that eGFRcys is most strongly associated with CVD and mortality, and, along with albuminuria, adds predictive discrimination to current CVD risk scores, whilst traditional creatinine-based measures are weakly associated with risk. Clinicians should consider measuring eGFRcys as part of cardiovascular risk assessment.


Assuntos
Doenças Cardiovasculares/diagnóstico , Taxa de Filtração Glomerular/fisiologia , Falência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/diagnóstico , Adulto , Idoso , Albuminúria/complicações , Albuminúria/diagnóstico , Albuminúria/fisiopatologia , Albuminúria/urina , Bancos de Espécimes Biológicos , Biomarcadores/sangue , Biomarcadores/urina , Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/fisiopatologia , Creatinina/metabolismo , Feminino , Humanos , Falência Renal Crônica/sangue , Falência Renal Crônica/fisiopatologia , Masculino , Pessoa de Meia-Idade , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/fisiopatologia , Fatores de Risco
2.
Clin Lab ; 65(8)2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31414764

RESUMO

BACKGROUND: Diabetic nephropathy (DN) is the leading cause of end-stage renal disease worldwide. Several factors are known to contribute to the development and progression of diabetic nephropathy. Different microRNAs have been shown to contribute in the pathogenesis of DN. This study, aimed to evaluate the expression level of circulating miR-155 in patients with diabetic nephropathy. METHODS: In this case-control study, 83 diabetic patients and normal subjects were evaluated in four groups of normal healthy subjects without diabetes and nephropathy, diabetes without nephropathy, diabetes with microalbuminuria, and diabetes with macroalbuminuria. After RNA extraction from serum and cDNA synthesis, the expression of circulating miR-155 was evaluated by quantitative polymerase chain reaction (qPCR). RESULTS: Expression level of cell-free miR-155 was significantly lower in diabetics compared to the normal healthy controls (p < 0.05). However, no significant difference was found in miR-155 expression level between different diabetes groups with different conditions of kidney function. Furthermore, we detected a significant negative correlation between cell-free miR-155 expression and GFR only in patients with microalbuminuria (r = -0.70, p = 0.001). CONCLUSIONS: It seems that miR-155 can discriminate diabetic and nondiabetic status, but is not an appropriate biomarker for tracking of macroalbuminuria.


Assuntos
Biomarcadores/sangue , Diabetes Mellitus Tipo 2/sangue , Nefropatias Diabéticas/sangue , MicroRNAs/sangue , Idoso , Albuminúria/sangue , Albuminúria/complicações , Albuminúria/diagnóstico , Estudos de Casos e Controles , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/diagnóstico , Nefropatias Diabéticas/complicações , Nefropatias Diabéticas/diagnóstico , Progressão da Doença , Feminino , Expressão Gênica , Humanos , Masculino , MicroRNAs/genética , Pessoa de Meia-Idade , Sensibilidade e Especificidade
3.
Kidney Blood Press Res ; 44(4): 590-603, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31387099

RESUMO

INTRODUCTION: Microalbuminuria is a risk factor for cardiovascular morbidity and mortality in hypertensive patients. However, the relationship between low-grade albuminuria, a higher level of albuminuria below microalbuminuria threshold, and hypertension-related organ damage is unclear. Left ventricular (LV) hypertrophy (LVH) is well recognized to be a subclinical organ damage of hypertension, and LV diastolic dysfunction is also reported to be an early functional cardiac change of hypertension that predicts heart failure. The present study aimed to investigate the association of low-grade albuminuria with LVH and LV diastolic dysfunction in hypertensive patients. METHODS: This cross-sectional observational clinical study was retrospectively performed in 870 hypertensive patients admitted to our hospital. Urinary albumin to creatinine ratio (UACR) was calculated to assess the levels of albuminuria: macroalbuminuria (≥300 mg/g), microalbuminuria (≥30 mg/g, but <300 mg/g), and normal albuminuria (<30 mg/g). Low-grade albuminuria was defined as sex-specific highest tertile within normal albuminuria (8.1-29.6 mg/g in males and 11.8-28.9 mg/g in females). LVH and LV diastolic dysfunction were identified as recommended by American Society of Echocardiography. RESULTS: Of the 870 patients, 765 (87.9%) had normal albuminuria, 77 (8.9%) had microalbuminuria, and 28 (3.2%) had macroalbuminuria. Percentage of LVH and LV diastolic dysfunction was increased with ascending UACR. UACR was independently associated with LVH and LV diastolic dysfunction, even in patients with normal albuminuria. Multivariable logistic regression showed that the patients with the highest tertile within normal albuminuria had nearly 80% increase in LVH and nearly 60% increase in LV diastolic dysfunction (adjusted OR for LVH 1.788, 95% CI 1.181-2.708, p = 0.006; adjusted OR for LV diastolic dysfunction 1.567, 95% CI 1.036-2.397, p = 0.034). After further stratification analyses in patients with normal albuminuria, it was shown that this independent association persisted in female patients, those who were younger than 70 years old, and those with duration of hypertension <15 years. CONCLUSION: Low-grade albuminuria was associated with LVH and LV diastolic dysfunction in hypertensive patients, especially in patients younger than 70 years old, and those with duration of hypertension <15 years.


Assuntos
Albuminúria/complicações , Hipertensão/fisiopatologia , Hipertrofia Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/etiologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Diástole , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Sexuais , Adulto Jovem
4.
Blood Press Monit ; 24(3): 130-136, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30998553

RESUMO

BACKGROUND: In longitudinal research studies with follow-up examinations, the devices used to measure phenotypes may change over time. When a device change occurs, the two devices should be calibrated to each other to ensure that measurements are comparable. This paper details the Jackson Heart Study (JHS) blood pressure (BP) comparability study. PARTICIPANTS AND METHODS: During its second clinic exam (2005-2008), the JHS switched from a random-zero sphygmomanometer (RZS) BP measurement device to an oscillometric device (OD). During this exam, BP measurements from both an RZS and an OD were taken simultaneously in 2117 participants for the purpose of calibration. Five methods for calibrating systolic BP (SBP) and diastolic BP (DBP) were considered: ignoring the change, ordinary least squares regression, adding the average difference, Deming regression, and robust regression. RESULTS: Using the RZS and OD, the mean (SD) SBP was 125.5 (19.2) and 126.5 (19.9), respectively, and the mean (SD) DBP was 76.4 (10.6) and 74.0 (11.0), respectively. The correlation between RZS and the OD was 0.90 for SBP and 0.80 for DBP. The prevalence of high BP and hypertension and associations with albuminuria were similar when applying each of the five calibration methods. Robust regression was chosen for calibration, giving the following equations:(Equation is included in full-text article.)These equations had a higher R statistic than using calibration equations from the Coronary Artery Risk Development in Young Adults Study and the Heinz Nixdorf Recall Study. CONCLUSIONS: The JHS BP data have been calibrated using the above equations for use in future analyses.


Assuntos
Determinação da Pressão Arterial/instrumentação , Determinação da Pressão Arterial/normas , Pressão Sanguínea , Hipertensão/diagnóstico , Oscilometria/instrumentação , Oscilometria/normas , Adulto , Albuminúria/complicações , Calibragem , Feminino , Humanos , Hipertensão/complicações , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Prevalência , Esfigmomanômetros , Adulto Jovem
5.
PLoS One ; 14(4): e0215920, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31022266

RESUMO

BACKGROUND: The impact of low-normal hemoglobin (Hb) levels and anemia on the risk of end-stage renal disease (ESRD) in general populations has rarely been examined. METHODS: 510,620 Korean adults aged 40-80 years without known chronic kidney disease (CKD) underwent health examinations during 2002-2003 and were followed-up until 2013. Incidence of ESRD was identified by hospital discharge and clinical visit records. RESULTS: During a mean follow-up of 10.5, 575 women and 1047 men were diagnosed with ESRD. Lower Hb levels were associated with an increased risk of ESRD at given severity of albuminuria and at given estimated glomerular filtration rate (eGFR). Hb 13-13.9 g/dL in men, Hb 11-11.9 g/dL in women, and trace albuminuria assessed by dipstick urinalysis were associated with more than doubled risk. The risk associated with lower Hb was stronger in older (≥60 years) than younger women. Among 349,993 participants with information on eGFR, the multivariable-adjusted HRs associated with 1 g/dL lower Hb in participants with eGFR values ≥60, 30-59, and <30 mL/min/1.73 m2 were 1.34 (95% CI, 1.17-1.54), 1.55 (1.38-1.74), and 1.75 (1.47-2.09), respectively (Pinteraction between eGFR groups = .06). CONCLUSIONS: Low-normal Hb levels and anemia are risk factors for ESRD incidence in person without CKD and for CKD progression to ESRD. Lower Hb increases the risk of ESRD through synergistic biological interactions with lower eGFR and albuminuria. The impacts of lower Hb may be stronger in older than younger women. Proper management and screening at earlier stage of Hb decline and anemia might reduce the burden of CKD.


Assuntos
Anemia/complicações , Hemoglobinas/metabolismo , Falência Renal Crônica/complicações , Adulto , Idoso , Albuminúria/complicações , Albuminúria/epidemiologia , Albuminúria/fisiopatologia , Anemia/fisiopatologia , Feminino , Taxa de Filtração Glomerular , Humanos , Incidência , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco
6.
Rev. habanera cienc. méd ; 18(2): 217-230, mar.-abr. 2019. tab, graf
Artigo em Espanhol | LILACS | ID: biblio-1014164

RESUMO

Introducción: La hipertensión arterial es un poderoso factor de riesgo de daño renal. La prevalencia es muy alta entre los pacientes con Enfermedad Renal Crónica. Objetivo: Determinar la presencia de Microalbuminuria y su valor como marcador de daño renal en pacientes con diagnóstico de Hipertensión arterial. Material y Métodos: Se realizó un estudio descriptivo, longitudinal y prospectivo de 123 pacientes. Se determinó edad, sexo, cifras de colesterol, triglicéridos, creatinina y microalbuminuria y factores de riesgo vascular. Se utilizó la estadística descriptiva e inferencial. Resultados: El 40,7 Microalbuminuria as a marker of kidney damage in patients with arterial hypertension de los pacientes pertenecen al grupo de más de 70 años con predominio del sexo masculino (65 por ciento), 62,6 Microalbuminuria as a marker of kidney damage in patients with arterial hypertension presentaron microalbuminuria, 97,3 Microalbuminuria as a marker of kidney damage in patients with arterial hypertension tenían factores de riesgo asociados con prevalencia aumentada del tabaquismo, dislipidemia, obesidad y enfermedades vasculares asociadas con RP>1. Predominó el grupo mayor de 70 años, del sexo masculino, con presencia de microalbuminuria. La presencia de más de tres factores de riesgo se asoció a la microalbuminuria. La presencia de microalbuminuria aumentó con los años de evolución de la enfermedad. Predominó el estadio 3 de la Enfermedad Renal Crónica en los pacientes con hipertensión arterial y microalbuminuria y se relacionó directamente con los años de evolución de la hipertensión arterial. Conclusiones: La determinación de la microalbuminuria en los pacientes con hipertensión arterial es un marcador de riesgo importante y sencillo para determinar el daño renal subclínico y está muy relacionado con el incremento de la edad del paciente, años de hipertensión y asociación con otros factores de riesgo vasculares(AU)


Introduction: Arterial hypertension is a powerful risk factor for kidney damage. The prevalence is very high among patients with chronic kidney disease. Objective: To determine the presence of microalbuminuria as a marker of kidney damage in patients with arterial hypertension admitted between September 2016 and September 2017. Material and Methods: A descriptive, longitudinal, prospective study was conducted in 123 patients. Age; sex; cholesterol, triglycerides, creatinine and microalbuminuria levels and vascular risk factors were determined. Descriptive and inferential statistics were used. Results: The 40.7 percent of patients belong to the group of patients of age more than 70 years, predominating the male sex (65 percent); 62.6 percent of them presented microalbuminuria and 97.3 percent had risk factors associated with an increased prevalence of smoking, dyslipidemia, obesity, and vascular diseases associated with RP> 1. The group of patients older than 70 years, male, and with presence of microalbuminuria predominated in the study. The presence of more than three risk factors was associated with microalbuminuria. The presence of microalbuminuria increased with the years of evolution of the disease. Stage 3 of chronic kidney disease predominated in patients with arterial hypertension and microalbuminuria and it was directly related to the years of evolution of arterial hypertension. Conclusions: The determination of microalbuminuria in patients with arterial hypertension is a simple and important risk marker to determine subclinical kidney damage and it is closely related to the increase in the age of the patient, the years of hypertension, and the association with other risk factors for vascular disease(AU)


Assuntos
Humanos , Masculino , Feminino , Idoso , Idoso de 80 Anos ou mais , Albuminúria/complicações , Insuficiência Renal Crônica/etiologia , Hipertensão/complicações , Fatores de Risco , Albuminúria/diagnóstico , Hipertensão/epidemiologia
7.
Diabetes Care ; 42(5): 883-890, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30833370

RESUMO

OBJECTIVE: In type 1 diabetes (T1D), the course of microalbuminuria is unpredictable and timing of glomerular filtration rate (GFR) loss is uncertain. Thus, there is a need to identify the risk factors associated with the development of more advanced stages of kidney disease through large, long-term systematic analysis. RESEARCH DESIGN AND METHODS: Multivariable Cox proportional hazards models assessed the association of baseline and time-dependent glycemic and nonglycemic risk factors for incident macroalbuminuria and reduced estimated GFR (eGFR; defined as <60 mL/min/1.73 m2) over a mean of 27 years in the Diabetes Control and Complications Trial (DCCT) cohort. RESULTS: Higher mean HbA1c (hazard ratio [HR] 1.969 per 1% higher level [95% CI 1.671-2.319]) and male sex (HR 2.767 [95% CI 1.951-3.923]) were the most significant factors independently associated with incident macroalbuminuria, whereas higher mean triglycerides, higher pulse, higher systolic blood pressure (BP), longer diabetes duration, higher current HbA1c, and lower mean weight had lower magnitude associations. For incident reduced eGFR, higher mean HbA1c (HR 1.952 per 1% higher level [95% CI 1.714-2.223]) followed by higher mean triglycerides, older age, and higher systolic BP were the most significant factors. CONCLUSIONS: Although several risk factors associated with macroalbuminuria and reduced eGFR were identified, higher mean glycemic exposure was the strongest determinant of kidney disease among the modifiable risk factors. These findings may inform targeted clinical strategies for the frequency of screening, prevention, and treatment of kidney disease in T1D.


Assuntos
Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 1/epidemiologia , Nefropatias Diabéticas/epidemiologia , Nefropatias Diabéticas/etiologia , Adolescente , Adulto , Albuminúria/complicações , Glicemia/metabolismo , Estudos de Coortes , Diabetes Mellitus Tipo 1/sangue , Diabetes Mellitus Tipo 1/terapia , Nefropatias Diabéticas/tratamento farmacológico , Feminino , Seguimentos , Taxa de Filtração Glomerular/fisiologia , Humanos , Hiperglicemia/complicações , Hiperglicemia/epidemiologia , Hiperglicemia/prevenção & controle , Nefropatias/epidemiologia , Nefropatias/etiologia , Masculino , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Fatores de Risco , Fatores de Tempo , Adulto Jovem
8.
Diabetes Care ; 42(5): 891-902, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30833372

RESUMO

OBJECTIVE: Clinicopathological characteristics, renal prognosis, and mortality in patients with type 2 diabetes and reduced renal function without overt proteinuria are scarce. RESEARCH DESIGN AND METHODS: We retrospectively assessed 526 patients with type 2 diabetes and reduced renal function (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2), who underwent clinical renal biopsy and had follow-up data, from Japan's nationwide multicenter renal biopsy registry. For comparative analyses, we derived one-to-two cohorts of those without proteinuria versus those with proteinuria using propensity score-matching methods addressing the imbalances of age, sex, diabetes duration, and baseline eGFR. The primary end point was progression of chronic kidney disease (CKD) defined as new-onset end-stage renal disease, decrease of eGFR by ≥50%, or doubling of serum creatinine. The secondary end point was all-cause mortality. RESULTS: Eighty-two patients with nonproteinuria (urine albumin-to-creatinine ratio [UACR] <300 mg/g) had lower systolic blood pressure and less severe pathological lesions compared with 164 propensity score-matched patients with proteinuria (UACR ≥300 mg/g). After a median follow-up of 1.9 years (interquartile range 0.9-5.0 years) from the date of renal biopsy, the 5-year CKD progression-free survival was 86.6% (95% CI 72.5-93.8) for the nonproteinuric group and 30.3% (95% CI 22.4-38.6) for the proteinuric group (log-rank test P < 0.001). The lower renal risk was consistent across all subgroup analyses. The all-cause mortality was also lower in the nonproteinuric group (log-rank test P = 0.005). CONCLUSIONS: Patients with nonproteinuric diabetic kidney disease had better-controlled blood pressure and fewer typical morphological changes and were at lower risk of CKD progression and all-cause mortality.


Assuntos
Diabetes Mellitus Tipo 2/complicações , Nefropatias Diabéticas/diagnóstico , Nefropatias Diabéticas/metabolismo , Rim/patologia , Proteinúria/complicações , Idoso , Albuminúria/complicações , Albuminúria/diagnóstico , Albuminúria/patologia , Biópsia , Estudos de Coortes , Creatinina/sangue , Creatinina/urina , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/metabolismo , Diabetes Mellitus Tipo 2/patologia , Nefropatias Diabéticas/patologia , Progressão da Doença , Feminino , Taxa de Filtração Glomerular , Humanos , Japão , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Fenótipo , Prognóstico , Pontuação de Propensão , Estudos Prospectivos , Proteinúria/diagnóstico , Proteinúria/patologia , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/metabolismo , Insuficiência Renal Crônica/patologia , Estudos Retrospectivos , Urinálise
9.
Int Urol Nephrol ; 51(4): 655-669, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30830656

RESUMO

OBJECTIVE: This study summarizes the evidence from randomized controlled trials (RCTs) to assess the effects of SGLT2 inhibitors on renal function and albuminuria in patients with type 2 diabetes. MATERIALS/METHODS: We searched PubMed, Web of Science, Cochrane Library and EMBASE for reports published up to March 2018 and included RCTs reporting estimated glomerular filtration rate (eGFR) and/or urine albumin/creatinine ratio (UACR) changes. Data extraction and assessment of research quality based on Cochrane risk biasing tools. Data were calculated to represent the standardized mean difference (SMD) for each study, and the SMDs with 95% confidence intervals (CIs) were pooled using a random effects model. RESULTS: Fifty-one studies were included that evaluated eGFR levels, and 17 studies were included that evaluated UACR levels. A meta-analysis showed that SGLT2 inhibitors had no significant effect on eGFR levels (SMD - 0.02, 95% CI - 0.06, 0.03, p = 0.45), and eGFR reduction was observed in the subsets of the duration of the trial 12 < duration ≤ 26 weeks (SMD - 0.08, 95% CI - 0.13, - 0.02, p = 0.005) and mean baseline eGFR < 60 ml/min per 1.73 square meters (SMD - 0.22, 95% CI - 0.37, - 0.07, p = 0.004). We found that SGLT2 inhibitors reduced UACR levels in patients with type 2 diabetes (SMD - 0.11, 95% CI - 0.17, - 0.05, p = 0.0001). Compared with monotherapy, the combination with other hypoglycemic agents can reduce albuminuria levels (SMD - 0.13, 95% CI - 0.19, - 0.06, p < 0.0001). CONCLUSIONS: The effect of SGLT2 inhibitor on eGFR in patients with T2DM was not statistically significant, but it was effective in reducing albuminuria levels.


Assuntos
Albuminúria/urina , Diabetes Mellitus Tipo 2/tratamento farmacológico , Taxa de Filtração Glomerular/efeitos dos fármacos , Hipoglicemiantes/farmacologia , Inibidores do Transportador 2 de Sódio-Glicose/farmacologia , Albuminúria/complicações , Creatinina/urina , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/urina , Humanos , Hipoglicemiantes/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico
10.
PLoS One ; 14(2): e0210522, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30716076

RESUMO

BACKGROUND: Arterial stiffness has been associated with renal dysfunction and its progression, but the pathophysiological relation underlying this association has not been fully established, particularly among individuals without hypertension and diabetes. We investigated the cross-sectional associations between arterial stiffness and renal function in adults without cardiovascular disease, and whether this association remained among subjects without hypertension and diabetes. METHODS: All eligible participants from ELSA-Brasil (2008-2010), aged 35 to 74 years (N = 13,586) were included, of whom 7,979 were free from hypertension and diabetes. The response variables were: 1) low glomerular filtration rate (eGFR<60ml/min/1.73m2) estimated by CKD-EPI; 2) increased albumin/creatinine ratio (ACR ≥30mg/g); and 3) chronic kidney disease (CKD). Arterial stiffness was ascertained by the carotid-femoral pulse wave velocity (PWV). The covariates were sex, age, race/color, level of schooling, smoking, body mass index, total cholesterol/HDL-c glycated hemoglobin, diabetes, systolic blood pressure, heart rate and use of antihypertensive drugs. Logistic regression was used to examine the associations. RESULTS: After all adjustments, 1 m/s increase in PWV was associated with ORs equal to 1.10 (95%CI: 1.04-1.16), 1.10 (95%CI: 1.05-1.16) and 1.12 (95%CI: 1.08-1.17) of low eGFR, high ACR, and CKD, respectively. In subjects without hypertension and diabetes, these ORs were 1.19 (95%CI: 1.07-1.33), 1.20 (95%CI: 1.07-1.32) and 1.21 (95%CI: 1.11-1.30), respectively. CONCLUSION: The increase in PWV was associated with all renal dysfunction markers, even in individuals without hypertension and diabetes, suggesting a relation that is not completely mediated by the presence of these conditions.


Assuntos
Complicações do Diabetes/complicações , Hipertensão/complicações , Insuficiência Renal Crônica/complicações , Rigidez Vascular , Adulto , Idoso , Albuminúria/complicações , Albuminúria/epidemiologia , Albuminúria/fisiopatologia , Brasil/epidemiologia , Estudos de Coortes , Estudos Transversais , Complicações do Diabetes/epidemiologia , Complicações do Diabetes/fisiopatologia , Feminino , Taxa de Filtração Glomerular , Humanos , Hipertensão/epidemiologia , Hipertensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/fisiopatologia
11.
Can J Cardiol ; 35(1): 77-91, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30595186

RESUMO

BACKGROUND: There is ongoing controversy around the surrogacy of proteinuria or albuminuria, particularly for cardiovascular (CV) outcomes, which remain the leading cause of morbidity and mortality among patients with chronic kidney disease. We performed a systematic review and meta-analysis of the literature to assess the surrogacy of changing proteinuria or albuminuria for CV events, end-stage renal disease (ESRD), and all-cause mortality. METHODS: CENTRAL, EMBASE, and MEDLINE were searched (from inception to October 2017). All randomized controlled trials in adults that reported change in proteinuria or albuminuria and ≥ 10 CV, ESRD, or all-cause mortality events were included. We calculated treatment effect ratios (TERs), defined as the ratio of the treatment effect on a clinical outcome and the effect on the change in the surrogate outcome. TERs close to 1 indicate greater agreement between the clinical outcome and changing proteinuria or albuminuria. RESULTS: Thirty-six trials were included in the meta-analysis. We observed inconsistent treatment effects for proteinuria and CV events (20 trials; TER 1.11 [95% confidence interval (CI), 1.01-1.22]) with moderate heterogeneity (I2 = 51%, P = 0.005). Treatment effects on proteinuria or albuminuria were also inconsistent with the effects on all-cause mortality (21 trials; TER 1.17 [95% CI, 1.07-1.28]; I2 = 35%, P for heterogeneity = 0.06), although they were similar with the effects on ESRD (23 trials; TER 0.99 [95% CI, 0.88-1.13]; I2 = 9%, P for heterogeneity = 0.337). CONCLUSIONS: Change in proteinuria or albuminuria might be a suitable surrogate outcome for ESRD. However, overall treatment effects on these potential surrogates are inconsistent and overestimate the treatment effects on CV events and all-cause mortality.


Assuntos
Albuminúria/complicações , Doenças Cardiovasculares/etiologia , Falência Renal Crônica/complicações , Proteinúria/complicações , Medição de Risco/métodos , Albuminúria/metabolismo , Biomarcadores/sangue , Biomarcadores/urina , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/urina , Causas de Morte/tendências , Creatinina/sangue , Progressão da Doença , Saúde Global , Humanos , Incidência , Falência Renal Crônica/metabolismo , Proteinúria/metabolismo , Taxa de Sobrevida/tendências
12.
Nephrol Dial Transplant ; 34(4): 633-641, 2019 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-29788140

RESUMO

BACKGROUND: We aimed to determine if immune-unreactive albumin excretion (IURAE) is associated with cardiovascular (CV) events in a representative sample of a general population from Spain. METHODS: We included 1297 subjects (mean age ± standard error 48.0 ± 0.2 years, 48% females), who participated in the Hortega Follow-Up Study. The primary endpoint was incidence of fatal and non-fatal CV events. Urinary albumin excretion (UAE) was measured in spot voided urine, frozen at -80°C, by immunonephelometry [immune-reactive albumin excretion (IRAE)] and by high-performance liquid chromatography (HPLC) [total albumin excretion (AE)]. IURAE was calculated as the difference between HPLC measurements and IRAE. We estimated fully adjusted hazard ratios (HRs) of CV incidence by Cox regression for IRAE, IURAE and total AE. RESULTS: After an average at-risk follow-up of 13 years, we observed 172 CV events. urinary albumin to creatinine ratio (UACR) of ≥30 mg/g assessed by IRAE, IURAE or total AE concentrations was observed in 74, 273 and 417 participants, respectively. Among discordant pairs, there were 49 events in those classified as micro- and macroalbuminuric by IURAE, but normoalbuminuric by IRAE. Only the IRAE was a significant independent factor for the incidence of CV events [HR (95% confidence interval) 1.15 (1.04-1.27)]. The association of UAE with CV events was mainly driven by heart failure (HF) [HR 1.33 (1.15-1.55) for IRAE; HR 1.38 (1.06-1.79) for IURAE; HR 1.62 (1.22-2.13) for total AE]. Those subjects who were micro- and macroalbuminuric by both IRAE and IURAE had a significant increase in risk for any CV event, and especially for HF. CONCLUSIONS: IRAE, IURAE and AE were associated with an increased risk for CV events, but IRAE offered better prognostic assessment.


Assuntos
Albuminas/análise , Albuminúria/complicações , Biomarcadores/urina , Doenças Cardiovasculares/diagnóstico , Programas de Rastreamento/métodos , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/urina , Estudos de Coortes , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Espanha/epidemiologia , Urinálise
13.
Clin Exp Nephrol ; 23(1): 85-98, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29951723

RESUMO

BACKGROUND: Although left ventricular hypertrophy (LVH) has been established as a predictor of cardiovascular events in chronic kidney disease (CKD), the relationship between the prevalence of LVH and CKD stage during the pre-dialysis period has not been fully examined. METHODS: We measured left ventricular mass index (LVMI) in a cross-sectional cohort of participants in the Chronic Kidney Disease Japan Cohort (CKD-JAC) study to identify factors that are associated with increased LVMI in patients with stage 3-5 CKD. RESULTS: We analyzed the baseline characteristics in 1088 participants (male 63.8%, female 36.2%). Diabetes mellitus was the underlying disease in 41.7% of the patients, and mean age was 61.8 ± 11.1 years. LVH was detected in 23.4% of the patients at baseline. By multivariate logistic analysis, independent risk factors for LVH were past history of cardiovascular disease [odds ratio (OR) 2.364; 95% confidence interval ([CI) 1.463-3.822; P = 0.0004], body mass index (OR 1.108; 95% CI 1.046-1.173; P = 0.0005), systolic blood pressure (OR 1.173; 95% CI 1.005-1.369; P = 0.0433), urinary albumin (OR 1.425; 95% CI 1.028-1.974; P = 0.0333), and serum total cholesterol level (OR 0.994; 95% CI 0.989-0.999; P = 0.0174). CONCLUSION: The cross-sectional baseline data from the CKD-JAC study shed light on the association between LVH and risk factors in patients with decreased renal function. Further longitudinal analyses of the CKD-JAC cohort are needed to evaluate the prognostic value of LVH in CKD patients.


Assuntos
Hipertrofia Ventricular Esquerda/epidemiologia , Hipertrofia Ventricular Esquerda/etiologia , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/epidemiologia , Adulto , Idoso , Albuminúria/complicações , Albuminúria/epidemiologia , Pressão Sanguínea , Índice de Massa Corporal , Estudos de Coortes , Estudos Transversais , Complicações do Diabetes/epidemiologia , Ecocardiografia , Feminino , Taxa de Filtração Glomerular , Humanos , Hipertensão Renal/complicações , Hipertensão Renal/epidemiologia , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores Sexuais , Adulto Jovem
14.
J Am Heart Assoc ; 7(22): e010723, 2018 11 20.
Artigo em Inglês | MEDLINE | ID: mdl-30571489

RESUMO

Background Although hypertension and microalbuminuria are closely interrelated, the magnitude and temporal sequence of the bidirectional association between hypertension and microalbuminuria are largely unknown. We aimed to delineate the bidirectional and temporal relationship between hypertension and microalbuminuria. Methods and Results Leveraging a longitudinal cohort of Chinese adults who had blood pressure and urinary albumin measured twice 4 years apart, we examined the temporal association between hypertension and microalbuminuria by bidirectional and cross-lagged panel analysis. All participants were free of cardiovascular disease and chronic kidney disease at baseline. Bidirectional association analysis found that baseline microalbuminuria predicted the risk of incident hypertension (odds ratio=1.75, P=0.028), and baseline blood pressure also significantly predicted the risk of microalbuminuria (odds ratios=1.27 and 1.21 for a per-SD increase in systolic and diastolic blood pressure, respectively; all P<0.05). Cross-lagged panel analysis demonstrated a bottom-line significant relationship of baseline systolic blood pressure to follow-up urinary albumin ( P=0.079), which is significantly weaker than the other direction of the relationship of baseline urinary albumin to follow-up blood pressures (all P<0.001). Conclusions These findings indicate a significant bidirectional association between microalbuminuria and hypertension in Chinese adults. Elevated urinary albumin excretion is more likely to precede hypertension. The causality between microalbuminuria and hypertension needs further investigation.


Assuntos
Albuminúria/complicações , Hipertensão/complicações , Albuminúria/epidemiologia , Pressão Sanguínea , China/epidemiologia , Feminino , Humanos , Hipertensão/epidemiologia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Fatores de Risco
15.
Diabetes Res Clin Pract ; 146: 191-201, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30389624

RESUMO

AIMS: The aim of the study was to assess whether quantitative-sensory-testing could be used to evaluate prevalence and predictors of diabetic neuropathy (DPNP) in patients with pre-diabetes and type 2 diabetes. METHODS: Twenty-eight pre-diabetics and 108 patients with type 2 diabetes were evaluated using neuropathy-deficit-score (NDS), neuropathy-symptom-score (NSS), nerve-conduction-studies (NCS), short-QST-protocol to examine small fibers and the comprehensive QST-battery (long-QST) according to the German Research Network on Neuropathic Pain protocol. RESULTS: Long-QST revealed a DPNP-prevalence of 71% in pre-diabetics and 95% in patients with type 2 diabetes, while according to NDS it was only 11% and 63%, and NCS missed 58% of patients with DPNP. Small and medium fibers were similarly affected in both groups, while large fiber deficits were significantly more common in type 2 diabetes (p < 0.01). Complete loss of function in all fibers was significantly higher in patients with type 2 diabetes than in pre-diabetics (26% vs. 11%, p < 0.05). Hyperalgesia was slightly increased in pre-diabetes than in type 2 diabetes (57% vs. 43%, p = n.s.). However, NSS only showed significant associations with large fiber deficits. Logistic regression analyses revealed that age (OR 1.14[1.05/1.24]) and albuminuria (OR 12.8[1.52/107.3]) were independent predictors for the presence of DPNP. CONCLUSIONS: DPNP is much more prevalent in patients with pre-diabetes and type 2 diabetes and clinical routine tests may miss the majority of affected patients. Age and albuminuria, but not HbA1c, appear to be significantly associated with DPNP. CLINICAL TRIAL REGISTRATION: NCT03022721.


Assuntos
Albuminúria/complicações , Diabetes Mellitus Tipo 2/complicações , Neuropatias Diabéticas/complicações , Estado Pré-Diabético/complicações , Diabetes Mellitus Tipo 2/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estado Pré-Diabético/patologia
16.
West Afr J Med ; 35(3): 189-194, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30387092

RESUMO

OBJECTIVES: Diabetic nephropathy is a common complication of diabetes mellitus due to microangiopathy leading to end stage renal disease. This study determined the relationship between renal resistivity index and pulsatility index with biochemical indices of renal function in patients with type 2 diabetes mellitus methods: This study involved 80 adults with type 2 diabetes mellitus. Urinary albumin excretion rate (UAER) and serum creatinine levels were measured, and the estimated glomerular filtration rate (eGFR) was calculated. Right renal resistivity index (RI) and pulsatility index (PI) values were determined. RESULTS: Mean renal resistivity index was 0.72±0.06 while the pulsatility index was 1.36 ± 0.24. Resistivity index was positively correlated with albuminuria (r = 0.426; p <0.001) and serum creatinine (r = 0.458; p <0.001), but negatively correlated with eGFR (r = -0.399; p <0.001). There was positive correlation between pulsatility index and albuminuria (r = 0.341; p = 0.002), and serum creatinine (r = 0.478; p = <0.001); and negative correlation between PI and eGFR (r = - 0.359; p = 0.001). CONCLUSIONS: Renal resistivity index and pulsatility index may provide valuable non-invasive estimate of predicting the presence and severity of renal dysfunction in patients with type 2 diabetes.


Assuntos
Creatinina/sangue , Diabetes Mellitus Tipo 2/diagnóstico por imagem , Nefropatias Diabéticas/diagnóstico por imagem , Taxa de Filtração Glomerular/fisiologia , Falência Renal Crônica/diagnóstico por imagem , Rim/diagnóstico por imagem , Ultrassonografia Doppler , Adulto , Albuminúria/complicações , Albuminúria/diagnóstico por imagem , Nefropatias Diabéticas/fisiopatologia , Feminino , Humanos , Rim/irrigação sanguínea , Falência Renal Crônica/sangue , Falência Renal Crônica/fisiopatologia , Masculino , Fluxo Pulsátil/fisiologia
17.
Cell Physiol Biochem ; 51(3): 1119-1133, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30476916

RESUMO

BACKGROUND/AIMS: Diabetic kidney disease (DKD) is a leading cause of end-stage renal disease. However, no effective treatments for this disease are available. Calcium dobesilate (CaD) is widely used to treat diabetic retinopathy. DKD and retinopathy often co-exist and have similar mechanisms of pathogenesis. The aim of the present study was to elucidate the safety and efficacy of CaD in the treatment of DKD. METHODS: In the prospective randomised controlled study, 100 DKD from Type 2 diabetes mellitus (DM) patients with a urinary albumin/ creatinine ratio (ACR) ≥30 mg/g and urinary protein level between 150 mg/24 h and 2 g/24 h with GFR> 90ml/min were enrolled. The patients were randomly divided into the treatment group (500 mg of CaD, administered orally, 3 times per day) and the control group. DKD patients were treated for 3 months. In the case control study, DM patients without proteinuria and healthy individuals were also enrolled. Clinical data and related biochemical parameters were collected. Endothelial function markers (VEGF, ET-1, eNOS, NO) and inflammatory markers (MCP-1, ICAM, PTX3) were detected by ELISA. RESULTS: In the prospective randomised controlled study, the 24 h urinary albumin and 24 h urinary protein levels significantly decreased after three months of treatment with CaD in the patients with DKD, but the cystatin C-based glomerular filtration rate (GFR) remained unchanged. In addition, the levels of inflammatory markers (PTX3, MCP-1, hsCRP, ICAM) and endothelial dysfunction markers (VEGF, ET-1) were significantly reduced compared to pre-treatment levels, NO was signifcantly increased post treatment. In the case control study, we found that PTX3, MCP-1, ICAM, VEGF and ET-1 levels were positively correlated with urinary albumin in DKD patients, while the NO level was negatively correlated. Logistic regression analysis showed that PTX3, NO and HbAlc were influential factors in DKD. After patients with DKD were treated with CaD for three months, the 24 h urinary albumin and 24 h urinary protein levels significantly decreased, but the cystatin C-based glomerular filtration rate (GFR) remained unchanged. In addition, the levels of inflammatory markers (PTX3, MCP-1, hsCRP, ICAM) and endothelial dysfunction markers (VEGF, NO, ET-1) were significantly reduced compared to pre-treatment levels. CONCLUSION: CaD can be safely and effectively used to treatdiabetic nephropathy.


Assuntos
Anti-Inflamatórios/uso terapêutico , Dobesilato de Cálcio/uso terapêutico , Diabetes Mellitus Tipo 2/complicações , Nefropatias Diabéticas/tratamento farmacológico , Inflamação/tratamento farmacológico , Idoso , Albuminúria/complicações , Albuminúria/tratamento farmacológico , Albuminúria/fisiopatologia , Albuminúria/urina , Anti-Inflamatórios/efeitos adversos , Dobesilato de Cálcio/efeitos adversos , Doença Crônica , Creatina/urina , Estudos Transversais , Diabetes Mellitus Tipo 2/fisiopatologia , Diabetes Mellitus Tipo 2/urina , Nefropatias Diabéticas/complicações , Nefropatias Diabéticas/fisiopatologia , Nefropatias Diabéticas/urina , Feminino , Taxa de Filtração Glomerular , Humanos , Inflamação/complicações , Inflamação/fisiopatologia , Inflamação/urina , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
18.
Sci Rep ; 8(1): 15940, 2018 10 29.
Artigo em Inglês | MEDLINE | ID: mdl-30374033

RESUMO

Chronic kidney disease is associated with increased risk of CKD progression and death. Therapeutic approaches to limit progression are limited. Developing tools for the early identification of those individuals most likely to progress will allow enriching clinical trials in high risk early CKD patients. The CKD273 classifier is a panel of 273 urinary peptides that enables early detection of CKD and prognosis of progression. We have generated urine capillary electrophoresis-mass spectrometry-based peptidomics CKD273 subclassifiers specific for CKD stages to allow the early identification of patients at high risk of CKD progression. In the validation cohort, the CKD273 subclassifiers outperformed albuminuria and CKD273 classifier for predicting rapid loss of eGFR in individuals with baseline eGFR > 60 ml/min/1.73 m2. In individuals with eGFR > 60 ml/min/1.73 m2 and albuminuria <30 mg/day, the CKD273 subclassifiers predicted rapid eGFR loss with AUC ranging from 0.797 (0.743-0.844) to 0.736 (0.689-0.780). The association between CKD273 subclassifiers and rapid progression remained significant after adjustment for age, sex, albuminuria, DM, baseline eGFR, and systolic blood pressure. Urinary peptidomics CKD273 subclassifiers outperformed albuminuria and CKD273 classifier for predicting the risk of rapid CKD progression in individuals with eGFR > 60 ml/min/1.73 m2. These CKD273 subclassifiers represented the earliest evidence of rapidly progressive CKD in non-albuminuric individuals with preserved renal function.


Assuntos
Biomarcadores/urina , Taxa de Filtração Glomerular/fisiologia , Insuficiência Renal Crônica/diagnóstico , Adulto , Idoso , Albuminúria/complicações , Albuminúria/diagnóstico , Área Sob a Curva , Progressão da Doença , Diagnóstico Precoce , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Peptídeos/urina , Prognóstico , Curva ROC , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/patologia , Fatores de Risco , Máquina de Vetores de Suporte
19.
J Diabetes Complications ; 32(12): 1160-1168, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30316542

RESUMO

AIMS: To determine among adolescents and young adults with youth-onset type 1 diabetes and type 2 diabetes the rates and risk factors for albuminuria regression and progression. METHODS: Data from SEARCH, a longitudinal observational study of youth-onset type 1 diabetes (N = 1316) and type 2 diabetes (N = 143) were analyzed. Urine albumin:creatinine ratio (UACR) was measured from random urine specimens at baseline and follow-up visits (mean 7 years later). Albuminuria regression was defined as halving of baseline UACR when baseline UACR was ≥30 µg/mg; progression was defined as doubling of baseline UACR when follow-up UACR was ≥30 µg/mg, respectively. Multivariable regression assessed risk factors associated with low-risk albuminuria category (combined persistently-low albuminuria and regression) versus moderate-risk albuminuria category (combined persistently-high albuminuria and progression). RESULTS: Albuminuria progression was more common in type 2 diabetes versus type 1 diabetes (15.4% versus 6.0%, p<0.001). Moderate-risk albuminuria was associated with increasing HbA1c (adjusted OR (aOR) = 1.3, 95% CI 1.1-1.6) and lack of private health insurance (aOR = 2.7, 95%CI 1.1-6.5) in type 1 diabetes; and African American race (OR = 4.6, 95% CI 1.2-14.2), lower estimated insulin sensitivity score (aOR = 2.1, 95% CI 1.4-3.3), baseline UACR (aOR = 3.2, 95% CI 1.7-5.8), and follow-up estimated glomerular filtration rate (eGFR) (10-unit increase aOR = 1.3, 95% CI 1.0, 1.5) in type 2 diabetes. CONCLUSIONS: In the first decade of diabetes duration, kidney complications in type 2 diabetes are significantly more aggressive than in type 1 diabetes and may be associated with less modifiable risk factors including race, insulin sensitivity, and eGFR. Early interventions may help reduce long-term kidney complications.


Assuntos
Albuminúria/epidemiologia , Albuminúria/patologia , Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 1/epidemiologia , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/epidemiologia , Adolescente , Adulto , Idade de Início , Albuminúria/complicações , Albuminúria/diagnóstico , Diabetes Mellitus Tipo 1/patologia , Diabetes Mellitus Tipo 2/patologia , Nefropatias Diabéticas/epidemiologia , Nefropatias Diabéticas/patologia , Progressão da Doença , Feminino , Seguimentos , Humanos , Estudos Longitudinais , Masculino , Prevalência , Sistema de Registros , Fatores de Risco , Estados Unidos/epidemiologia , Adulto Jovem
20.
J Am Heart Assoc ; 7(20): e009995, 2018 10 16.
Artigo em Inglês | MEDLINE | ID: mdl-30371280

RESUMO

Background Chronic kidney disease is a recognized independent risk factor for cardiovascular disease, but whether the risks of ST-segment-elevation myocardial infarction ( STEMI ) and non-ST-segment-elevation myocardial infarction ( NSTEMI ) differ in the chronic kidney disease population is unknown. Methods and Results Using administrative data from Ontario, Canada, we examined patients ≥66 years of age with an outpatient estimated glomerular filtration rate ( eGFR ) and albuminuria measure for incident myocardial infarction from 2002 to 2015. Adjusted Fine and Gray subdistribution hazard models accounting for the competing risk of death were used. In 248 438 patients with 1.2 million person-years of follow-up, STEMI , NSTEMI , and death occurred in 1436 (0.58%), 4431 (1.78%), and 30 015 (12.08%) patients, respectively. The highest level of albumin-to-creatinine ratio (>30 mg/mmol) was associated with a 2-fold higher adjusted risk of both STEMI and NSTEMI among patients with eGFR ≥60 mL/(min·1.73 m2) compared to albumin-to-creatinine ratio <3 mg/mmol. The lowest level of eGFR (<30 mL/[min·1.73 m2]) was not associated with higher STEMI risk but with a 4-fold higher risk of NSTEMI compared to those with eGFR ≥60 mL/(min·1.73 m2). The lowest eGFR (<30 mL/[min·1.73 m2]) and highest albumin-to-creatinine ratio (>30 mg/mmol) were associated with a greater than 4-fold higher risk of both STEMI and NSTEMI (subdistribution hazard models [95% confidence interval] 4.53 [3.30-6.21] and 4.42 [3.67-5.32], respectively) compared to albumin-to-creatinine ratio <3 mg/mmol and eGFR ≥60 mL/(min·1.73 m2). Conclusions Elevations in albuminuria are associated with a higher risk of both NSTEMI and STEMI , regardless of kidney function, whereas reduced kidney function alone is associated with a higher NSTEMI risk.


Assuntos
Albuminúria/complicações , Infarto do Miocárdio sem Supradesnível do Segmento ST/etiologia , Insuficiência Renal Crônica/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/etiologia , Idoso , Albuminúria/fisiopatologia , Feminino , Taxa de Filtração Glomerular/fisiologia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Infarto do Miocárdio sem Supradesnível do Segmento ST/epidemiologia , Ontário/epidemiologia , Insuficiência Renal Crônica/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA