Labile hypertension: characteristics of a referred cohort.

From 88 subjects with labile high blood pressure (LHBP), we collected blood pressure variability (BPV) and assessed relationships with age, medications, and nocturnal pattern via ambulatory blood pressure monitoring. The average age of the subjects was 64 ± 13 years and they were on 1.5 ± 1.3 antihypertensives. BPV did not differ diurnally and was not influenced by medication. Aging associates with increasing daytime systolic but not diastolic BPV, with increasing nighttime systolic BP, and decreasing diastolic BP diurnally. Subjects had widened pulse pressure and abnormal diurnal pattern with age. Further studies are needed to stratify an individual's risk associated with LHBP.

High-dose gadodiamide for catheter angiography and CT in patients with varying degrees of renal insufficiency: Prevalence of subsequent nephrogenic systemic fibrosis and decline in renal function.

OBJECTIVE: The purpose of our study was to evaluate the prevalence of nephrogenic systemic fibrosis (NSF) and nephrotoxicity among patients with differing degrees of renal dysfunction who are exposed to high doses of gadodiamide. MATERIALS AND METHODS: A search of medical records identified patients who received high-dose IV gadodiamide for catheter angiography or CT between January 2002 and December 2005. The cohort was limited to patients who had received a dose of at least 40 mL of gadodiamide during a single imaging session, who underwent at least 1 year of clinical follow-up, and who had moderate to end-stage renal disease (estimated glomerular filtration rate [GFR] < 60 mL/min/1.73 m(2)) established within the previous 48 hours. Any observation suggestive of NSF was recorded, as were all estimated GFR values obtained during the 2 weeks before and the 5 days after gadodiamide administration. RESULTS: Sixty-one patients met the inclusion criteria. The median estimated GFR was 30 mL/min/1.73 m(2) (range, 3-57 mL/min/1.73 m(2)). The median gadodiamide exposure was 80 mL (range, 40-200 mL). NSF eventually developed in one of the 61 patients, yielding a prevalence of 1.6%. Among the 33 patients not undergoing dialysis with estimated GFR documented within 5 days after contrast injection, the change in estimated GFR ranged from -8.8 to 42.9 mL/min/1.73 m(2), with a statistically significant median improvement of 2.4 mL/min/1.73 m(2) (p = 0.007). CONCLUSION: Although gadolinium exposure appears to be a necessary precondition for NSF, gadolinium-based contrast agents alone are not sufficient to cause the disorder, even in very high doses. Clinically relevant nephrotoxicity of gadolinium-based contrast agents was not found.

Characteristics of 100 consecutive patients presenting with orthostatic hypotension.

OBJECTIVE: To elucidate the demographic and clinical characteristics of a consecutive series of patients who presented for evaluation of orthostatic hypotension. PATIENTS AND METHODS: From January 1, 1997, through September 30, 2001, we assessed retrospectively the demographic and clinical characteristics, antihypertensive medication use, and blood pressure variability in 100 consecutive patients with orthostatic hypotension who underwent 24-hour ambulatory blood pressure monitoring (OH group) and in a convenience sample of 100 age-matched patients who underwent 24-hour ambulatory blood pressure monitoring for evaluation of hypertension (HTN group). RESULTS: The OH group had a mean +/- SD age of 71.6 +/- 9.4 years, and 42% were women. The most common symptoms were light-headedness and weakness. Comorbid conditions included neurologic diseases (38%), preexisting hypertension (36%), hyperlipidemia (31%), cardiac arrhythmias and coronary artery disease (45%), and neoplasm (28%). During ambulatory blood pressure monitoring, postprandial decreases in blood pressure were noted in 83% of the OH group, supine or sleep hypertension in 84%, and noncompensatory heart rate variability in 75%. Findings on autonomic testing were abnormal in 99% of patients, serum creatinine value was increased in 30%, proteinuria was present in 27%, and left ventricular hypertrophy was present in 20%. CONCLUSIONS: Orthostatic hypotension is present in a heterogeneous group of disease states, is usually symptomatic, and is often associated with an abnormal blood pressure profile of reversal of circadian pattern, postprandial hypotension, and noncompensatory heart rate variability. Consequent target organ (kidney) damage can be as frequent as in patients who undergo 24-hour ambulatory blood pressure monitoring for evaluation of hypertension.

Acute rapamycin nephrotoxicity in native kidneys of patients with chronic glomerulopathies.

BACKGROUND: Based on its success as a transplant immunosuppressor, there is intense interest in using rapamycin in the treatment of progressive glomerulopathies involving native kidneys. However, we call attention to the potential toxicity associated with the use of rapamycin in this setting. METHODS: We conducted a study to examine the efficacy and safety of rapamycin in patients with progressive chronic renal failure. Eleven patients with either focal segmental glomerulosclerosis, immunoglobulin A nephropathy, membranous nephropathy or membrano-proliferative glomerulonephritis and progressive renal failure (defined as an increase in >25% of baseline serum creatinine over the last year or loss of glomerular filtration rate > or =5 ml/min/year as determined by the Cockcroft-Gault formula), proteinuria > or =1.0 g/24 h and with a creatinine clearance of > or 20 ml/min/1.73 m(2) were entered into a 12 month study. Patients were treated with rapamycin, starting at 5 mg/day, orally, aiming for target blood levels of 7-10 ng/dl. All patients were on treatment with an angiotensin-converting enzyme inhibitor and/or an angiotensin receptor blocker, aiming to control blood pressure < or =145/90 mmHg. RESULTS: Six patients developed acute renal failure, defined as an increase in serum creatinine > or =0.5 mg/dl (baseline: 3.2+/-0.9 mg/dl; peak: 5.6+/-1.6 mg/dl; P<0.01, paired t-test). In four patients, discontinuation of the drug resulted in improvement of renal function close to baseline levels. One patient required haemodialysis and had no subsequent recovery of renal function. In another patient, renal function recovered after discontinuation of the drug and then rapamycin was resumed at a lower dose when creatinine returned to baseline. This resulted in a second acute increase in serum creatinine that failed to return to baseline when the medication was discontinued. Four other patients had the following adverse events: skin rash, severe hypertriglyceridaemia, diarrhoea and hyperkalaemia. In none of the subjects were rapamycin levels >15 ng/dl. CONCLUSIONS: Rapamycin can cause nephrotoxicity in some patients with chronic glomerulopathies. Whether the toxicity is solely related to rapamycin, due to the combination of proteinuria and rapamycin, or other unknown factor use is presently undetermined.