RESUMEN
BACKGROUND: Chronic kidney disease (CKD) is associated with increased cardiovascular risk. Here we evaluate whether strict implementation of guidelines aimed at multiple targets with the aid of nurse practitioners (NP) improves management in patients with CKD. METHODS: MASTER PLAN is a randomised controlled clinical trial, performed in nine Dutch hospitals. Patients with CKD (estimated glomerular filtration rate (eGFR) 20-70 ml÷min) were randomised to receive NP support (intervention group (IG)) or physician care (control group (CG)). Patients were followed for a median of five years. Presented data are an interim analysis on risk factor control at two-year follow-up. RESULTS: We included 788 patients (532 M, 256 F), (393 CG, 395 IG), mean (±SD ) age 59 (±13) years, eGFR 38 (±15) ml÷min÷1.73m(2), blood pressure (BP) 138 (±21)÷80 (±11) mmHg. At two years 698 patients (352 IG, 346 CG) could be analysed. IG as compared with CG had lower systolic (133 vs 135 mmHg; p= 0.04) and diastolic BP (77 vs 80 mmHg; p=0.007), LDL cholesterol (2.30 vs 2.45 mmol(-l); p= 0.03), and increased use of ACE inhibitors, statins, aspirin and vitamin D. The intervention had no effect on smoking cessation, body weight, physical activity or sodium excretion. CONCLUSION: In both groups, risk factor management improved. However, changes in BP control, lipid management and medication use were more pronounced in IG than in CG. Lifestyle interventions were not effective. Coaching by NPs thus benefits everyday care of CKD patients. Whether these changes translate into improvement in clinical endpoints remains to be established.
Asunto(s)
Fallo Renal Crónico/enfermería , Fallo Renal Crónico/terapia , Enfermeras Practicantes , Calidad de la Atención de Salud , Antihipertensivos/uso terapéutico , Enfermedades Cardiovasculares/etiología , Enfermedades Cardiovasculares/prevención & control , Femenino , Tasa de Filtración Glomerular , Humanos , Hipolipemiantes/uso terapéutico , Masculino , Persona de Mediana Edad , Países Bajos , Factores de Riesgo , Conducta de Reducción del Riesgo , Cese del Hábito de FumarRESUMEN
BACKGROUND: Blood pressure (BP) is the most important modifiable risk factor for cardiovascular (CV) disease and progression of kidney dysfunction in patients with chronic kidney disease. Despite extensive antihypertensive treatment possibilities, adequate control is notoriously hard to achieve. Several determinants have been identified which affect BP control. In the current analysis we evaluated differences in achieved BP and achievement of the BP goal between hospitals and explored possible explanations. METHODS: At baseline, BP was measured in a supine position with an oscillometric device in 788 patients participating in the MASTER PLAN study. We also retrieved the last measured office BP from the patient records. Additional baseline characteristics were derived from the study database. Univariate and multivariate analyses were performed with general linear modelling using hospital as a random factor. RESULTS: In univariate analysis, hospital was a determinant of the level of systolic and diastolic BP at baseline. Adjustment for patient, kidney disease, treatment or hospital characteristics affected the relation. Yet, in a fully adjusted model, differences between centres persisted with a range of 15 mmHg for systolic BP and 11 mmHg for diastolic BP. CONCLUSION: Despite extensive adjustments, a clinically relevant, statistically significant difference between hospitals was found in standardised BP measurements at baseline of a randomised controlled study. We hypothesise that differences in the approach towards BP control exist at the physician level and that these explain the differences between hospitals.
Asunto(s)
Antihipertensivos/uso terapéutico , Hospitales , Hipertensión/tratamiento farmacológico , Fallo Renal Crónico/patología , Presión Sanguínea/efectos de los fármacos , Femenino , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Análisis Multivariante , OscilometríaRESUMEN
A 28-year-old young woman was referred to our department of Internal Medicine for analysis of unintentional weight loss. At initial analysis, a persistent proteinuria was found with no evident relation to her weight loss. Anamnestic as well as additional studies showed no evidence of a primary kidney disease. After this exclusion, orthostatic proteinuria was confirmed by simple urine analysis. Since the weight loss had not yet been explained, an analysis followed at the Department of Gastointestinal and Liver Diseases where inflammatory bowel disease (IBD) was found. Literature study shows that proteinuria may be associated with IBD. This concerns mainly selective tubular protein loss, without a distinctive change in protein loss with a change in position. Orthostatic proteinuria, therefore, remained the most likely diagnosis. In this case, the patient was advised to check both urine and kidney function annually.
Asunto(s)
Enfermedades Inflamatorias del Intestino/complicaciones , Proteinuria/etiología , Adulto , Femenino , Humanos , Pérdida de PesoRESUMEN
The portfolio gives the doctor who is undergoing training to become a specialist (Dutch abbreviation aios) a tool to help describe his or her own progress and the future targets in the training programme, and assists the trainer to obtain a more detailed insight into the educational goals that should receive more emphasis. The self-critical attitude of the aios that this helps to develop is a good guarantee for society of the thoroughness of medical specialist training.
Asunto(s)
Documentación/normas , Educación de Postgrado en Medicina/normas , Educación Médica , Cuerpo Médico de Hospitales/normas , Medicina/normas , Especialización , Educación de Postgrado en Medicina/métodos , Humanos , Cuerpo Médico de Hospitales/educación , Países BajosRESUMEN
We describe a patient with thyrotoxic periodic paralysis (TPP) caused by a thyrotropin-secreting pituitary adenoma. The diagnosis TPP was based on the combination of episodes of reversible hypokalaemic paralysis, hyperthyroidism and electrophysiological findings. A thyrotropin-secreting pituitary adenoma was diagnosed on the basis of endocrinological function tests and MRI of the pituitary gland. Before transsphenoidal resection of the adenoma, treatment with octreotide restored euthyroidism both clinically and biochemically. Immunocytochemistry of the pituitary adenoma was positive for TSH exclusively. Incubation with octreotide or quinagolide induced decreased TSH and alpha-subunit production by the cultured adenoma cells, in agreement with the pre-operative in vivo data. This paper is the first to describe in vivo and in vitro characteristics of a thyrotropin-secreting pituitary adenoma in a patient presenting with periodic paralysis.
Asunto(s)
Adenoma/metabolismo , Hipertiroidismo/etiología , Parálisis/etiología , Neoplasias Hipofisarias/metabolismo , Tirotropina/metabolismo , Adenoma/complicaciones , Adenoma/terapia , Adulto , Humanos , Hipopotasemia/etiología , Imagen por Resonancia Magnética , Masculino , Octreótido/uso terapéutico , Neoplasias Hipofisarias/complicaciones , Neoplasias Hipofisarias/terapia , Hormona Liberadora de TirotropinaRESUMEN
Glycohaemoglobin in human blood can be determined by several methods. We investigated three methods used in daily practice, viz. affinity chromatography, HPLC and electrophoresis. We examined the influence of uraemia in diabetic and non-diabetic patients on the results obtained with HPLC and electrophoresis and compared these with the results obtained with affinity chromatography. Our current method (electrophoresis) proved to be very sensitive to uraemia giving falsely elevated levels of HbA1. HPLC was not disturbed by uraemia.
Asunto(s)
Diabetes Mellitus/sangre , Hemoglobina Glucada/análisis , Uremia/sangre , Adolescente , Adulto , Anciano , Cromatografía de Afinidad , Cromatografía Líquida de Alta Presión , Electroforesis en Gel de Poliacrilamida , Humanos , Persona de Mediana Edad , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Urea/sangreRESUMEN
Felodipine induces natriuresis, possibly by renal hemodynamic and/or tubular effects. Theoretically, reversal of the sodium-retaining effect of angiotensin II (Ang II) could be involved. Therefore, we administered felodipine during Ang II infusion and during suppression of endogenous Ang II production in two double-blind studies in healthy volunteers. First, a gradually increasing dose of Ang II was infused during felodipine or solvent infusion. Before starting Ang II, felodipine had lowered renal vascular resistance (RVR) and filtration fraction (FF), and simultaneously increased CNa. The Ang II induced rise of mean arterial pressure (MAP) and renal vasoconstriction was partly antagonized and the falls in glomerular filtration rate (GFR) and CNa completely abolished by felodipine. The combination of felodipine and 3.0 ng/kg/min Ang II even enhanced natriuresis. Second, felodipine or solvent was infused after one week of pretreatment with placebo or the angiotensin converting enzyme (ACE) inhibitor ramipril, which reduced MAP and induced renal vasodilatation. Ramipril pretreatment did not influence significantly the blood pressure reduction, renal vasodilatation, and natriuresis caused by felodipine. In conclusion, it seems unlikely that the natriuretic effect of felodipine is due to interference with renal effects of endogenous Ang II. The fact that felodipine reverses sodium retention on exogenous Ang II may be explained by interference with systemic and renal hemodynamic effects of exogenous Ang II.
Asunto(s)
Angiotensina II/farmacología , Felodipino/farmacología , Natriuresis/efectos de los fármacos , Adulto , Angiotensina II/antagonistas & inhibidores , Angiotensina II/fisiología , Inhibidores de la Enzima Convertidora de Angiotensina/farmacología , Compuestos Bicíclicos con Puentes/farmacología , Método Doble Ciego , Humanos , Riñón/efectos de los fármacos , Riñón/fisiología , Masculino , Natriuresis/fisiología , RamiprilRESUMEN
In contrast to other types of directly acting vasodilators, calcium antagonists promote sodium excretion. It is not well established, however, whether these drugs also induce natriuresis in hypertensive patients with renal disease. Therefore, we studied the acute effects of the dihydropyridine calcium antagonist felodipine in nine such patients (CCr 68 +/- 19 ml/min) and 12 healthy normotensive subjects. In both the hypertensive patients and the normotensive subjects total and fractional sodium excretion rose during the first 40 minutes of intravenous felodipine infusion; in the hypertensive patients this rise of sodium excretion was positively correlated to the initial glomerular filtration rate (GFR) (r = 0.87, P less than 0.01). In the patients, during ongoing felodipine infusion, natriuresis was attenuated in the setting of a large continuing decrease of blood pressure. In contrast, in the normotensive subjects, in whom blood pressure did not fall any further, a steady rise of sodium excretion was observed. In both the hypertensive patients and the normotensive subjects GFR remained unchanged and renal vascular resistance decreased, whereas renal plasma flow increased only in the latter group. Changes in sodium excretion were not correlated to changes in renal hemodynamic parameters. It is concluded, that also in hypertensive patients with diminished renal function felodipine exerts a potentially advantageous natriuretic effect. However, this natriuretic effect is possibly less at lower GFR and seems to be attenuated by blood pressure reduction. The mechanism of this natriuretic effect as well as its contribution to the antihypertensive effect of felodipine still has to be clarified.
Asunto(s)
Felodipino/uso terapéutico , Hipertensión Renal/tratamiento farmacológico , Adulto , Presión Sanguínea/efectos de los fármacos , Felodipino/administración & dosificación , Femenino , Tasa de Filtración Glomerular/efectos de los fármacos , Humanos , Hipertensión Renal/fisiopatología , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Natriuresis/efectos de los fármacos , Circulación Renal/efectos de los fármacos , Resistencia Vascular/efectos de los fármacosRESUMEN
Results from animal experiments have suggested that treatment with recombinant human erythropoietin (rHuEPO) causes changes in renal hemodynamics which are detrimental to renal function. Therefore, the effects of correction of the anemia by rHuEPO on glomerular filtration rate (GFR; inulin clearance) and effective renal plasma flow (ERPF; PAH clearance) were studied in eight pre-dialysis patients. The studies were done before (Hct 0.24 +/- 0.05 liter/liter) and at 89 +/- 19 days after the start of rHuEPO therapy (Hct 0.39 +/- 0.03 liter/liter). To further evaluate the effects of ACE inhibition, 25 mg of captopril was given orally after baseline values had been obtained. Baseline GFR, renal blood flow (RBF) and filtration fraction (FF) did not change during rHuEPO therapy. At low hematocrit (Hct) captopril induced a significant increase in ERPF and RBF, and a decrease in MAP. After correction of the hematocrit the blood pressure lowering effect of captopril remained unchanged. However, captopril no longer induced changes in ERPF and RBF. We conclude that the increase in hematocrit had no adverse effects on GFR. The results suggest that changes in hematocrit may influence the effects of ACE inhibition on efferent vascular resistance. Therefore, the hematocrit should be taken into account when evaluating studies on the effects of ACE inhibition in the progression of chronic renal failure.
Asunto(s)
Anemia/tratamiento farmacológico , Eritropoyetina/uso terapéutico , Circulación Renal , Vasodilatación , Adulto , Anciano , Anemia/fisiopatología , Anemia/terapia , Captopril/uso terapéutico , Diálisis , Femenino , Humanos , Riñón/fisiopatología , Masculino , Persona de Mediana Edad , Proteínas RecombinantesRESUMEN
OBJECTIVE: To compare the antihypertensive, renal haemodynamic and antiproteinuric effect of enalapril and atenolol in patients with proteinuria of non-diabetic origin. DESIGN: Prospective, double blind, randomised 16 week study after a pretreatment period of at least three weeks. SETTING: Outpatient nephrology and hypertension unit. PATIENTS: 27 patients with proteinuria (greater than 300 mg protein/day) of non-diabetic origin, moderately impaired renal function (creatinine clearance 30-90 ml/min), and a pretreatment diastolic blood pressure of greater than 80 mm Hg. INTERVENTIONS: Treatment with enalapril (10 mg/day, adjusted between 5 and 40 mg, if necessary) or atenolol (50 mg/day, adjusted between 25 and 100 mg if necessary) titrated against a target fall in diastolic blood pressure to less than 95 mm Hg or of greater than 10 mm Hg, or both. MAIN OUTCOME MEASURES: Blood pressure, renal haemodynamics, and urinary protein excretion. RESULTS: No differences were detected between the two groups before treatment. The falls in systolic and diastolic blood pressures during treatment were not significantly different between both groups. Proteinuria fell slightly with atenolol but significantly more with enalapril (mean change -0.38 (95% confidence interval -0.78 to 0.03) v -1.2 (-1.70 to -0.69) g/day respectively, p less than 0.02) as did filtration fraction (mean change -1.8 (-2.9 to -0.7) v -3.8 (-4.9 to -2.8)% respectively. Serum potassium concentration increased with enalapril (mean change 0.63 (SD 0.51) v 0.19 (0.47) mmol/l, p less than 0.05). CONCLUSIONS: Enalapril lowers proteinuria more than atenolol in patients with non-diabetic renal disease despite a similar blood pressure lowering effect of both drugs, and its antiproteinuric effect seems to be associated with the characteristic renal haemodynamic effect of angiotensin converting enzyme inhibitors.
Asunto(s)
Atenolol/uso terapéutico , Enalapril/uso terapéutico , Enfermedades Renales/fisiopatología , Proteinuria/tratamiento farmacológico , Adulto , Presión Sanguínea/efectos de los fármacos , Método Doble Ciego , Femenino , Hemodinámica/efectos de los fármacos , Humanos , Riñón/fisiopatología , Enfermedades Renales/orina , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Proteinuria/fisiopatología , Proteinuria/orina , Circulación Renal/efectos de los fármacos , Sodio/orina , Urea/orinaAsunto(s)
Lesión Renal Aguda/terapia , Cuidados Críticos/métodos , Hemofiltración , Lesión Renal Aguda/mortalidad , Anciano , Causas de Muerte , Femenino , Hemofiltración/métodos , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia Multiorgánica/mortalidad , Cuidados Posoperatorios , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Resultado del TratamientoAsunto(s)
Quistes/complicaciones , Hepatopatías/complicaciones , Enfermedades Renales Poliquísticas/complicaciones , Colecistitis/complicaciones , Infecciones por Escherichia coli/complicaciones , Femenino , Humanos , Fallo Renal Crónico/etiología , Persona de Mediana Edad , Enfermedades Renales Poliquísticas/genética , Sepsis/complicacionesAsunto(s)
Eritropoyetina/uso terapéutico , Diálisis Renal , Terapia Combinada , Eritropoyetina/efectos adversos , Hemoglobinas/metabolismo , Humanos , Hipertensión/inducido químicamente , Riñón/efectos de los fármacos , Riñón/fisiopatología , Fallo Renal Crónico/sangre , Fallo Renal Crónico/tratamiento farmacológico , Fallo Renal Crónico/terapiaRESUMEN
1. It has been reported that calcium antagonists lower blood pressure more effectively in salt replete hypertensive patients with a low plasma renin activity (PRA), whereas angiotensin converting enzyme (ACE) inhibitors are more effective in salt depleted patients with a high level of PRA. An inverse relationship between the antihypertensive effects of these two groups of drugs might therefore be expected. 2. Since salt retention and inappropriately high levels of PRA are said to contribute to hypertension in patients with chronic renal failure (CRF), an additive antihypertensive effect with both drugs might also be expected in such patients. 3. To test these hypotheses, we investigated the acute and chronic antihypertensive effects of the calcium antagonist nitrendipine and the new ACE inhibitor cilazapril, given alone, and in combination, in a double-blind, randomized, placebo controlled study of 11 hypertensive patients with chronic renal failure who had a mean pretreatment blood pressure of 149 +/- 3/96 +/- 2 mm Hg. Patients received nitrendipine 10 mg, cilazapril 1.25 or 2.5 mg depending on creatinine clearance, or placebo once daily orally. Nitrendipine and cilazapril were also combined at the same doses. 4. Nitrendipine and cilazapril were equally effective, with a maximal acute reduction of mean arterial pressure (MAP) of 5.3 +/- 1.8% and 8.0 +/- 1.9%, and after 1 week of treatment 5.0 +/- 2.4% and 8.1 +/- 1.8%, respectively. In individual patients no inverse relationship between the blood pressure responses to the two drugs was found.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Bloqueadores de los Canales de Calcio/uso terapéutico , Hipertensión Renal/tratamiento farmacológico , Fallo Renal Crónico/fisiopatología , Nitrendipino/uso terapéutico , Piridazinas/uso terapéutico , Adulto , Peso Corporal/efectos de los fármacos , Cilazapril , Ensayos Clínicos como Asunto , Creatinina/sangre , Método Doble Ciego , Quimioterapia Combinada , Femenino , Hemodinámica/efectos de los fármacos , Humanos , Hipertensión Renal/complicaciones , Hipertensión Renal/fisiopatología , Fallo Renal Crónico/complicaciones , Masculino , Persona de Mediana Edad , Potasio/sangre , Distribución AleatoriaRESUMEN
In patients with a nephrotic syndrome administration of prednisolone causes an increase of proteinuria. To elucidate the mechanism of this effect we have studied the acute proteinuric effect of prednisolone, 125 to 150 mg intravenously, in nine patients (7 M, 2F) with a nephrotic syndrome. Mean age (+/- SD) of the patients was 53 +/- 6 years, mean endogenous creatinine clearance 104 +/- 30 ml/min, and mean proteinuria 7.7 +/- 3.0 g/24 hr. After administration of prednisolone, urinary total protein excretion rose in all patients from a mean (+/- SEM) of 4.89 +/- 0.59 mg/min before to 9.09 +/- 0.99 mg/min at five hours after administration (P less than 0.01). Glomerular filtration rate (inulin clearance), effective renal plasma flow (PAH clearance), and filtration fraction did not change significantly. The increases of urinary excretion of albumin (median %: +92%), IgG (median %: +88%), and transferrin (median %: +76%) were comparable and correlated significantly. Urinary excretion of beta 2-microglobulin did not change significantly however. We conclude that intravenous administration of prednisolone to patients with a nephrotic syndrome causes an increase in urinary protein excretion rate which cannot be explained by changes in renal hemodynamics or tubular protein reabsorption, and which therefore must be the result of a change in glomerular permselectivity characteristics.
Asunto(s)
Síndrome Nefrótico/tratamiento farmacológico , Prednisolona/uso terapéutico , Proteinuria/inducido químicamente , Permeabilidad Capilar/efectos de los fármacos , Femenino , Tasa de Filtración Glomerular , Humanos , Glomérulos Renales/efectos de los fármacos , Masculino , Persona de Mediana Edad , Prednisolona/efectos adversos , Circulación RenalRESUMEN
Dihydropyridines are reported to have a stimulatory effect on vascular smooth muscle Na,K-ATPase activity in vitro. We studied the effects of the dihydropyridine calcium antagonists nimodipine, nitrendipine, nisoldipine, niludipine, nifedipine and felodipine (10(-5) M) on purified Na,K-ATPase isolated from rabbit kidney outer medulla. We were unable to detect an effect of the drugs on the enzyme activity, either under optimal or suboptimal substrate conditions. Likewise, Na,K-ATPase activity, partly inhibited by the addition of ouabain (10(-6) M), Ca2+ (10(-3) M) or arachidonic acid (4 x 10(-5) M), was not influenced by the dihydropyridines. The absence of a stimulatory effect of dihydropyridines on renal Na,K-ATPase is in agreement with the known diuretic and natriuretic effects of the drugs in normotensive and hypertensive men.
Asunto(s)
Bloqueadores de los Canales de Calcio/farmacología , Dihidropiridinas/farmacología , Riñón/enzimología , ATPasa Intercambiadora de Sodio-Potasio/metabolismo , Adenosina Trifosfato/metabolismo , Animales , Técnicas In Vitro , Riñón/efectos de los fármacos , Membranas/efectos de los fármacos , Membranas/enzimología , Músculo Liso Vascular/efectos de los fármacos , ConejosRESUMEN
This case report describes a patient with a pheochromocytoma of the urinary bladder. The patient demonstrated an excessive increase of blood pressure and plasma catecholamines immediately after micturition. Ultrasound and CT-scanning confirmed the localisation of the tumour in the urinary bladder.