Estimated blood pressure trajectories and hypertension patterns among pregnant women living with HIV, Haiti, 2007-2017.

Hypertension in pregnancy is a key driver of mortality and morbidity among Haitian women. HIV infection and treatment may worsen hypertension and increase cardiovascular disease risk. The authors examined blood pressure and hypertension patterns among 1965 women (2306 pregnancies ending in live births) in a prevention of maternal-to-child transmission (PMTCT) program in Port-au-Prince, Haiti, between 2007 and 2017. Hypertension was defined as blood pressure ≥140/90 mm Hg on two consecutive visits. Latent class analysis assessed trajectories of mean arterial pressure (MAP) and multinomial ordinal logistic regression examined factors associated with higher trajectories. Between 2007-2009 and 2013-2016, hypertension at PMTCT entry increased from 1.3% to 3.8% (p = .005), while incidence at any time during PMTCT follow-up increased from 5.0 to 16.1 per 100 person-years (p < .001). Hypertension detected ≤20 weeks and > 20 weeks of gestation (possible gestational hypertension) increased from 1.1% to 3.5% (p = .003) and from 2.3% to 6.9% (p < .001), respectively. Five MAP trajectories ranged from low-stable to high-increasing. In multivariable analysis controlling for history of antiretroviral therapy, age, parity, and weight, program entry in more recent years was associated with greater odds of higher MAP trajectory (adjusted odds ratio for 2013-2016 vs. 2007-2009 = 3.1, 95% confidence interval: 1.7-5.6). The increasing prevalence and incidence of hypertension highlight a need for screening and management prior to PMTCT entry and during follow-up. In a population with limited access to chronic disease care, and where many deliveries occur outside of a clinical setting, the period of PMTCT follow-up represents an opportunity to diagnose and initiate management of preexisting and pregnancy-related hypertension.

Gut commensal microbiota and decreased risk for Enterobacteriaceae bacteriuria and urinary tract infection.

Urinary tract infection (UTI) is a common complication in kidney transplant recipients and can lead to significant morbidity and mortality. Recent evidence supports a role for the gut as a source for UTIs but little is known about the relationship between gut commensal bacteria and UTI development. We hypothesized that the abundance of gut commensal bacteria is associated with a lower risk of developing bacteriuria and UTIs. We performed gut microbiome profiling using 16S rRNA gene sequencing of the V4-V5 hypervariable region on 510 fecal specimens in 168 kidney transplant recipients. Fifty-one kidney transplant recipients (30%) developed Enterobacteriaceae bacteriuria within the first 6 months after transplantation (Enterobacteriaceae Bacteriuria Group) and 117 did not (No Enterobacteriaceae Bacteriuria Group). The relative abundances of Faecalibacterium and Romboutsia were significantly higher in the fecal specimens from the No Enterobacteriaceae Bacteriuria Group than those from the Enterobacteriaceae Bacteriuria Group (Adjusted P value<.01). The combined relative abundance of Faecalibacterium and Romboutsia was inversely correlated with the relative abundance of Enterobacteriaceae (r = -0.13, P = .003). In a multivariable Cox Regression, a top tercile cutoff of the combined relative abundance of Faecalibacterium and Romboutsia of ≥13.7% was independently associated with a decreased risk for Enterobacteriaceae bacteriuria (hazard ratio 0.3, P = .02) and Enterobacteriaceae UTI (hazard ratio 0.4, P = .09). In conclusion, we identify bacterial taxa associated with decreased risk for Enterobacteriaceae bacteriuria and Enterobacteriaceae UTI in kidney transplant recipients, which supports future studies on modulating the gut microbiota as a novel treatment for preventing UTIs.

Obstetrical Complications and Long-Term Cardiovascular Outcomes.

PURPOSE OF REVIEW: Obstetrical complications including indicated preterm birth (PTB), hypertension (HTN), IUGR, and GDM are risk factors for future cardiovascular disease. To identify patients at risk, the American Heart Association recommends obtaining a detailed obstetric history. Our objective was to determine if non-OB-GYN physicians-in-training obtain an obstetric history when assessing a risk profile for cardiovascular disease and to identify differences based on level of training. In 2019, an anonymous survey was distributed to trainees in internal medicine, cardiology, endocrinology, nephrology, and neurology. Subjects were queried about frequency of asking a history of PTB, IUGR, GDM, and HTN in pregnancy. Survey options were always/frequently/sometimes/rarely/never and were categorized into two groups: "ask" (always/frequently/sometimes) vs. "do not ask" (rarely/never). Comparisons between specialties and levels of training were made using chi-square and Fisher's exact test. Comparisons within subjects were made using McNemar's test. RECENT FINDINGS: The response rate was 64% (210 total possible participants), including 98 internal medicine residents and 37 fellows in cardiology (21), endocrinology (3), nephrology (8), and neurology (5). Asking about medical complications (HTN + GDM) was significantly more common than asking about OB complications (PTB + IUGR) (p < 0.001). Internal medicine residents were less likely than subspecialty fellows to ask about HTN (31% vs. 70%; p < 0.001). There were no differences in likelihood of eliciting OB history based on PGY level. An OB history can identify risk factors for cardiovascular morbidity. Our data demonstrates that physicians caring for women lack awareness on the association between complications in pregnancy and cardiovascular health.

Safety of Antihypertensive Medications in Pregnancy: Living With Uncertainty.

See Article by Mito et al.

Blood volume analysis as a guide for dry weight determination in chronic hemodialysis patients: a crossover study.

BACKGROUND: Volume overload and depletion both lead to high morbidity and mortality. Achieving euvolemia is a challenge in patients with end stage kidney disease on hemodialysis (HD). Blood volume analysis (BVA) uses radiolabeled albumin to determine intravascular blood volume (BV). The measured BV is compared to an ideal BV (validated in healthy controls). We hypothesized that BVA could be used in HD to evaluate the adequacy of the current clinically prescribed "estimated dry weight" (EDW) and to titrate EDW in order to improve overall volume status. We were also interested in the reproducibility of BVA results in end stage kidney disease. METHODS: Twelve adults on chronic HD were recruited; 10 completed the study. BVA (Daxor, New York, NY, USA) was used to measure BV at baseline. EDW was kept the same if the patient was deemed to be euvolemic by BVA otherwise, the prescribed EDW was changed with the aim that measured BV would match ideal BV. A second BVA measurement was done 1-3 months later in order to measure BV again. RESULTS: Based on BVA, 6/10 patients were euvolemic at baseline and 5/10 were euvolemic at the second measurement. When comparing patients who had their prescribed EDW changed after the initial BVA to those who did not, both groups had similar differences between measured and ideal BV (P = 0.75). BV values were unchanged at the second measurement (P = 0.34) and there was no linear correlation between BV change and weight change (r2 = 0.08). CONCLUSIONS: This pilot study is the first longitudinal measurement of BVA in HD patients. It revealed that changing weight did not proportionally change intravascular BV. BV remained stable for 1-3 months. BVA may not be helpful in clinically stable HD patients but studies on patients with hemodynamic instability and uncertain volume status are needed. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02717533), first registered February 4, 2015.

Renin-Angiotensin-Aldosterone Profiles in Pregnant Women With Chronic Hypertension.

Pregnant women with chronic hypertension are at risk for increased blood pressure and superimposed preeclampsia (SPE) in late pregnancy. Alterations in the renin-aldosterone system are a feature of normal pregnancy; however, their role in chronic hypertension with and without SPE is less clear. We performed a prospective, longitudinal trial of 108 women with chronic hypertension and measured plasma renin activity (PRA), 24-hour urine sodium, urine potassium, and urine aldosterone (Ualdo) at 12, 20, 28, and 36 weeks and postpartum. SPE developed in 34% of pregnancies. PRA was lower in women who developed SPE at weeks 28 (5.99 versus 6.22 ng/mL per hour; P<0.001) and 36 (5.71 versus 7.74 ng/mL per hour; P=0.002). Ualdo was lower in women with SPE compared with those without SPE at 28 weeks (59.6 versus 81.3 µg/d; P=0.039). Mean arterial pressure was inversely related to both PRA (r=-0.23; P<0.0001) and Ualdo (r=-0.11; P=0.029). PRA and Ualdo were positively associated with each other (r=0.5327; P<0.0001) after adjusting for urine potassium, urine sodium, serum potassium, and mean arterial pressure. PRA and Ualdo were lower in women of black race compared with other racial groups (P<0.001). Our results demonstrate that in women with chronic hypertension PRA and Ualdo increase in early pregnancy and subsequently decrease in women who develop SPE. These findings are consistent with the hypothesis that sodium retention may contribute to the elevation in blood pressure in SPE.

Loop Diuretics in the Treatment of Hypertension.

Loop diuretics are not recommended in current hypertension guidelines largely due to the lack of outcome data. Nevertheless, they have been shown to lower blood pressure and to offer potential advantages over thiazide-type diuretics. Torsemide offers advantages of longer duration of action and once daily dosing (vs. furosemide and bumetanide) and more reliable bioavailability (vs. furosemide). Studies show that the previously employed high doses of thiazide-type diuretics lower BP more than furosemide. Loop diuretics appear to have a preferable side effect profile (less hyponatremia, hypokalemia, and possibly less glucose intolerance). Studies comparing efficacy and side effect profiles of loop diuretics with the lower, currently widely prescribed, thiazide doses are needed. Research is needed to fill gaps in knowledge and common misconceptions about loop diuretic use in hypertension and to determine their rightful place in the antihypertensive arsenal.

Secondary Hypertension in Pregnancy.

Hypertension is a common medical complication of pregnancy. Although 75-80 % of women with preexisting essential hypertension will have uncomplicated pregnancies, the presence of secondary forms of hypertension adds considerably to both maternal and fetal morbidity and mortality. Renovascular hypertension, pheochromocytoma, and Cushing's syndrome in particular are associated with accelerating hypertension, superimposed preeclampsia, preterm delivery, and fetal loss. Primary aldosteronism is a more heterogeneous disorder; there are well-documented cases where blood pressure and hypokalemia are improved during pregnancy due to elevated levels of progesterone. However, superimposed preeclampsia, worsening hypertension, and early delivery are also reported. When possible, secondary forms of hypertension should be diagnosed and treated prior to conception in order to avoid these complications.

Glycemic effects of vildagliptin in patients with type 2 diabetes before, during and after the period of fasting in Ramadan.

OBJECTIVE: To study the incidence of hypoglycemia, glycemic control and body weight changes in patients with type 2 diabetes treated with vildagliptin and metformin versus another group treated with sulphonylureas and metformin during and after the period of fasting in Ramadan. PATIENTS AND METHODS: This is a randomized open-label clinical trial that recruited 69 patients previously treated with a combination therapy of metformin and sulphonylurea. Patients in the control group were maintained on their usual metformin and sulphonylurea regimen with dose adjustment for the fasting period. Patients in the study group were given vildagliptin 50 mg twice daily (at Suhur and at Iftar). One group remained on the previous background therapy unchanged and the other group was switched from sulphonylurea to vildagliptin in combination with metformin. Four visits were scheduled, one before the beginning of Ramadan (baseline), a second visit at mid Ramadan, a third at the end of Ramadan and a final visit 1 month after the end of Ramadan. At every visit, patients were assessed for hypoglycemic events and patient education was given on lifestyle needs and hypoglycemia monitoring and management. RESULTS: The calculated change in hemoglobin A1c from baseline to last visit was similar for both groups. The incidence of hypoglycemia during Ramadan was higher in the control group (26 episodes versus 19 episodes in the study group); this result was not statistically significant (p = 0.334). However, the number of patients who dropped out from the study because of discomfort due to treatment and fear of hypoglycemia was higher in the control group. CONCLUSION: For patients who insist on observing the fast, physicians can allow it only with close follow up and monitoring for hypoglycemic events, and vildagliptin may be a better agent than sulphonylurea.

Management and control of patients with type 2 diabetes mellitus in Lebanon: results from the International Diabetes Management Practices Study (IDMPS).

BACKGROUND: The IDMPS is a study to identify changes in diabetes treatment practice in several developing countries. This paper focuses on diabetes management and compliance with guidelines in a Middle Eastern country like Lebanon. METHODS: The cross-sectional data from the 2006 wave of two weeks duration on the Lebanese population along with the longitudinal data of a 9-month follow-up study were collected. RESULTS: A large proportion of Lebanese patients were not adequately controlled or followed up. A slight proportion was managed by diet and exercise alone while most patients were on two or more oral anti-hyperglycemics. Metformin was the most common monotherapy followed by sulfonylureas. 22.6% of Lebanese patients were on insulin, most commonly basal insulin alone followed by premix insulin alone. Blood glucose self-monitoring was more frequently done by insulinized patients and was associated with better glycemic control. Glycemic control was reached in 29.6% of type 2 patients (HbA1c < 7%) with poorest outcome for patients on insulin and was more frequently achieved in patients who had more frequent monitoring of HbA1c levels. CONCLUSION: For a proper assessment of diabetic control, maintaining adherence to international guidelines needs to be evaluated. Promoting patient education, improving physician knowledge with better implementation of guidelines is recommended.