Marcadores de Inflamação, Microalbuminúria e Controle de Pressão Arterial em Cuidados de Saúde Primários / Inflammation Markers, Microalbuminuria and Blood Pressure Control in Primary Health Care

Fundamento: A hipertensão arterial sistêmica (HAS) é uma causa importante de morbidade e mortalidade cardiovascular. Apesar da eficácia do tratamento, um alto número de pacientes não obtém controle de pressão arterial (PA), um fato que implica a necessidade de investigar o papel de outros fatores adicionais, como marcadores de inflamação e microalbuminúria, especialmente em ambientes de saúde. Objetivos: Avaliar a associação entre os níveis de fibrinogênio sérico, Proteína C-reativa ultrassensível (PCR) e microalbuminúria, com medidas de pressão arterial (PA) avaliadas através de monitorização ambulatorial da pressão arterial (MAPA) em pacientes hipertensos, em ambiente de cuidados de saúde primários. Métodos: Foi realizado um estudo transversal com pacientes hipertensos que foram atendidos em centros de cuidados de saúde primários. Uma avaliação de PA foi efetuada pelo médico de cuidados primários, e este procedimento foi seguido por um teste de referência de 24 horas (MAPA), realizado por um profissional independente. Adicionalmente, a coleta de sangue periférico foi realizada para análise futura de marcadores bioquímicos. Resultados: 143 pacientes foram incluídos. Havia uma tendência para associação entre a variável independente (PA alterada por MAPA de 24 horas) e variável dependente (PCR), havia uma associação entre os valores > 3 mg/dL e MAPA alterada de 24 horas. A razão de prevalência (RP) foi de 1,36 (CI 95% 0,90 ­ 2,06); p=0,18. A respeito dos achados de microalbuminúria e fibrinogênio, foi observada RP 1,03 (CI 95% 0,41 ­ 2,57); p=1 e RP 1,19 (CI 95% 0,96 ­ 1,46); p=0,019, respectivamente, e ambas não foram significantes para PA alterada por MAPA de 24 horas. Conclusões: Há uma tendência para a associação entre PCR e a PA avaliada através da MAPA de 24 horas no contexto dos cuidados primários

Background: Systemic arterial hypertension (SAH) is an important cause of cardiovascular morbidity and mortality. In spite of the effectiveness of the treatment, a high number of patients do not obtain blood pressure (BP) control, a fact that implies the need for investigating the role of other additional factors, such as inflammation markers and microalbuminuria, especially in health care environments. Objectives: To evaluate the association between serum fibrinogen levels, ultra-sensitive C-reactive protein (CRP) and microalbuminuria, with blood pressure (BP) averages evaluated by 24-hour ambulatory blood pressure monitoring (ABPM) in hypertensive patients in primary health care setting.Methods: A cross-sectional study with hypertensive patients who were seen in primary health care centers was performed.A BP evaluation was carried out by the primary care doctor, and this procedure was followed by a reference test 24-hour ABPM, performed by an independent professional. Moreover, the peripheral blood collect was performed for future biochemical markers analysis. Results: 143 patients were included. There was a trend for association between the independent variable (altered BP by 24-hour ABPM) and the dependent variable (CRP), there was an association between the values > 3 mg/dL and altered 24-hour ABPM. The prevalence ratio (PR) was of 1.36 (CI 95% 0.90 ­ 2.06); p=0.18. Regarding microalbuminuria and fibrinogen findings, a 1.03 (CI 95% 0.41 ­ 2.57) PR was seen; p=1 and 1.19 (CI 95% 0.96 ­ 1.46) PR; p=0.019, respectively, and both were not significant for altered BP by 24-hour ABPM. Conclusions: It is a trend for association between CRP with BP evaluated by 24-hour ABPM in the primary care setting

Efeito da perda de peso sobre a hemodinâmica renal em portadores da síndrome metabólica / Weight loss improves renal hemodynamics in patients with metabolic syndrome

OBJETIVO: No presente artigo, investigou-se o impacto da redução do peso corporal na excreção urinária de albumina e na depuração da creatinina em indivíduos obesos com síndrome metabólica. MÉTODOS: Trinta e cinco indivíduos foram submetidos à dieta hipocalórica por um período de 12 semanas, visando uma redução mínima de 5% do peso corporal. Os voluntários foram submetidos à avaliação metabólica (teste oral de tolerância à glicose, dosagens de lípides plasmáticos e ácido úrico) e à avaliação de parâmetros hemodinâmicos renais (depuração da creatinina e excreção urinária de albumina), antes (fase 1) e após 12 semanas de dieta hipocalórica (fase 2). RESULTADOS: Após o período de intervenção, os voluntários foram divididos em dois grupos: indivíduos que atingiram o alvo para redução de peso (respondedores: R, n = 14) e pacientes que não atingiram a meta para redução de peso (não-respondedores: NR, n = 21). Indivíduos do Grupo R apresentaram melhora do perfil lipídico, da redução da excreção urinária de albumina (mediana = 162.5 mg/24 horas, variação: 0,8 a 292 mg/24 horas, na fase 1 para 10,4 mg/24 horas, variação: 1,6 a 22,4 mg/24 horas, na fase 2), além de redução significante da depuração da creatinina (121,4 ± 66,5 mL/min. para 92,9 ± 35,6 mL/min., p = 0,001). No Grupo NR, não foram observadas diferenças estatisticamente significantes entre as fases 1 e 2 do estudo. CONCLUSÃO: A redução do peso corporal teve impacto positivo na hemodinâmica renal, reduzindo a excreção urinária de albumina e a hiperfiltração glomerular em indivíduos obesos com síndrome metabólica.

OBJECTIVE: We investigated the impact of weight loss on urinary albumin excretion (UAE) and creatinine clearance in obese patients with metabolic syndrome. METHODS: Thirty-five obese patients undertook a 12-week calorie-restricted diet. The patients underwent a metabolic (oral glucose tolerance test, plasma lipids, and uric acid) and renal hemodynamic evaluations (creatinine clearance and urinary albumin excretion) before (phase 1), and after the 12-week diet (phase 2). RESULTS: After the dietary intervention, the subjects were divided into two groups: patients who achieved the target weight reduction (R: responders, n = 14), and patients who did not (NR: non-responders, n = 21). The patients in Group R showed an improvement in lipid profile, a decrease in UAE (median = 162.5 mg/24 hours, range: 0.8 to 292 mg/24 hours, at phase 1 versus 10.4 mg/24 hours, range: 1.6 to 22.4 mg/24 hours, at phase 2), and a significant reduction in creatinine clearance (121.4 ± 66.5 mL/min. in phase 1 to 92.9 ± 35.6 mL/min. at the end of phase 2, p = 0.001). In Group NR, no statistically significant differences were observed between phases 1 and 2. CONCLUSION: Body weight reduction has a positive impact on renal hemodynamics, decreasing urinary albumin excretion as well as glomerular hyperfiltration in obese patients with metabolic syndrome.

Enfermedad renal crónica: Clasificación, identificación, manejo y complicaciones / Clinical guidelines on identitication, management and complications of chronic kidney disease

The key messages of these guidel ines on chronic kidney disease are: • Chronic kidney disease (CKD) is a public health problem due to its wide distribution, high rate of complications and cost. • CKD is a common condition, its prevalence being about 10 percent, and is treatable if it is detected on time. • A patient with CKD has a higher risk of cardiovascular mortality than of progression of its underlying renal disease. • A new definition of CKD, based on estimated Glomerular Filtration Rate (eGFR) and kidney damage, facilitates its detection and management. • CKD is detected with three simple tests: 1) Blood pressure measurement, 2) Detection of proteinuria or albuminuria in an isolated urine sample, and 3) Estimation of renal function (eGFR), based on serum creatinine, age, gender and race. • The CKD risk groups are individuáis with diabetes, hypertension and a family history of renal disease. • The most cost-effective measures are to detect and treat diabetic and hypertensive patients in the community. • Therapy must emphasize the maximal reduction of cardiovascular risk. • The complications of CKD such as anemia and renal osteodystrophy can be identified and treated on time. • Most patients with chronic kidney disease are detected in the community, therefore their initial care must be organized at the level of primary care, along with programs for hypertension and diabetes.

Frecuencia de microalbuminuría en pacientes diabéticos tipo 2 de la consulta de medicina interna: ambulatorio urbano tipo III Dr. Daniel Camejo Acosta: Barquisimeto-Estado Lara mayo-septiembre 2000 / Frequency of microalbuminuria in diabetic patients type 2 of the consultation of medicine hospitalized ambulatory urban type III Dr. Daniel Camejo Acosta Barquisimeto State Lara: may-september 2000

Determinar la frecuencia de microalbuminuria en pacientes con Diabetes Mellitus tipo 2 que acudieron a la consulta de Medicina Interna del ambulatorio tipo III "Dr. Daniel Camejo Acosta". Se realizó un estudio descriptivo de corte transversal, durante mayo a septiermbre de 2000. La población estuvo constituida por 88 pacientes. La muestra fue de tipo no probabilística constituida por 35 pacientes, los cuales cumplieron con los críterios de inclusión. Para determinar la microalbuminuría se utilizó la técnica del Micral-test II. De 35 pacientes el 28,57 por ciento (n=10) presentó microalbuminuria patológica. De estos pacientes con microalbuminuría patológica: el 40 por ciento (n=4) presentaron 60-69 años. El 60 por ciento (n=6) fueron mujeres. El 50 por ciento (n=5) correspondió a la clase socieconómica III. El 70 por ciento (n=7) cumplían el tratamiento regularmente. El 80 por ciento (n=8) tenían 6-10 años de evolución de la diabetes y 2 (20 por ciento) pacientes tuvieron menos de 5 años de evolución. Estos resultados similares a los de otras investigaciones resaltan en la importancia de la realización de la microalbuminuría, en el control del paciente con diabetes, para la detección precoz de la nefropatía diabética.

Kidney functions in newly diagnosed type 2 diabetic subjects: role of glycemic control.

BACKGROUND: The increased urinary albumin excretion (UAE) found at the diagnosis in type 2 diabetes may at least be functional and, thus reversible, as in type 1 diabetes. Furthermore, a positive correlation has been found between the glycemic control and UAE in type 2 diabetic subjects. MATERIAL AND METHODS: The impact of glycemic control after achieving three months of continuous normo-glycemia was studied in 26 (including 16 males and 10 females) newly diagnosed type 2 diabetic patients to assess renal size/volumes, various renal functions and UAE. RESULTS: A significant reduction was seen in glomerular filtration rate (GFR), UAE and fractional albumin clearance after achieving near normoglycemia (p < 0.01). A decrease in the kidney size/volume, though statistically insignificant, was also observed. Besides a decline in GFR of 4.8% was also noted after three months of stable normoglycemia. UAE normalized in six of these subjects. A statistically significant correlation was also found between the changes in mean fasting plasma glucose and the decline in UAE (r=0.56 and p < 0.01). CONCLUSION: The study emphasizes the necessity to correct the apparently reversible increase in microabuminuria that accompanies hyperglycemia prior to patients recruitment for intervention therapy.

Microalbuminuria in essential hypertensives in treament for hypertension

Foi avaliada a excrecao urinaria de albumina (EUA) em 26 pacientes portadores de hipertensao essencial, nao diabeticos, (5 homens, 21 mulheres, sendo 19 brancos e 7 negros), com clearance de creatinina (Creat) > ou - 75 ml/min/1,73 m2, em tratamento individualizado com drogas anti-hipertensivas diversas, apresentando os seguintes parametros clinico-laboratoriais: idade media, 53 + ou - 2 anos (media + ou - EPM); duracao da hipertensao, 14,9 + ou - 2,2 anos; indice de massa corporea (IMC), 26,8 + ou - 0,7; pressao arterial 142 + ou - 4/89 + ou - 3 mmHg; creatinina serica, 0,8 + ou - 0,03 mg/dL; Creat, 99,3 + ou - 3,8 ml/min/1,73 m2 e excrecao urinaria de albumina, 9,3 + ou - 1,5ug/min...

Impact of captopril on microalbuminuria in diabetics with and without hypertension

Microalbuminuria was determined by RIA in 14 IDD [7normotensive and 7 hypertensive] and 14 NIDD patients [7 normotensive `and 7 hypertensive] before and after one month treatment with captopril [25 mg t.d.s] to evaluate its role in lowering urinary albumin excretion rate [AER]. All diabetic patients showed a significant reduction [P<0.001] of AER after captopril therapy. In normotensive IDD patients, AER decreased from 67 +/- 29.4 micro g/min to 44.8 +/- 23.4 while in hypertensive IDD patients, AER decreased from 148.8 +/- 49.5 to 89 +/- 47.6. In normotensive NIDD patients, AER decreased from 55 +/- 14 to 38.5 +/- 24.4 while in hypertensive, it decreased from 85.7 +/- 20.4 to 51.7 +/- 13.2 micro n/min. IDD, in general, had higher AER than NIDD and hypertension was also associated with higher AER. AER correlated significantly with mean arterial pressure [MAP] and glycosylated haemoglobin [HbA1c] before treatment with captopril, while correlation after treatment was not constant. In conclusion, captorpil decreases AER in microalbuminuric diabetics regardless to the type of diabetes or presence of hypertension