Enfermedad vascular hipertensiva: evolución de la incidencia en el período 1991-2007 y supervivencia antes de la enfermedad renal terminal / Hypertensive vascular disease: evolution of its incidence in the period 1991-2007 and survival prior to end-stage renal disease

Objetivo: La nefropatía hipertensiva es la segunda causa más común de entrada en tratamiento renal sustitutivo en España, con una incidencia que parece estable desde 1997. Los datos sobre incidencia de nuevos diagnósticos de nefropatía hipertensiva en consulta son escasos al no existir registros similares a los usados en el tratamiento renal sustitutivo. Diseño y métodos: Se ha revisado retrospectivamente la incidencia de este diagnóstico en la base de datos de la Consulta de Nefrología del Hospital Infanta Cristina de Badajoz entre el 1de enero de 1991 y el 31 de diciembre de 2007. El diagnóstico se hizo en la mayor parte de los casos por criterios clínicos. En60 casos se realizó biopsia renal por proteinuria superior a 1g/24 h. Resultados: Durante ese tiempo fueron atendidos en consulta 5.071 pacientes, de los cuales 479 fueron diagnosticados de nefropatía hipertensiva. La incidencia media de nefroangioesclerosis ha sido 44,0 casos pmp, con una edad media de 66,6 ± 12,1 años, siendo el 43,0% mujeres. Se aprecia una tendencia progresiva desde 16,7 pmp en 1991 hasta 89,5pmp en 2007. Las tasas medias fueron 31,8 pmp en el período1991-1995; 32,1 pmp entre 1996 y 2000, y 54,4 en el período2001-2006. La edad media de los pacientes incidentes a lo largo del período estudiado ha seguido una curva en «J»; 53 pacientes (11,6%) han iniciado tratamiento renal sustitutivo durante estos años. La supervivencia estimada antes de llegada a tratamiento renal sustitutivo fue el 96,0% al año, el 85,9%a los 5 años de seguimiento y el 81,6% a los 7 años de seguimiento. Conclusiones: La incidencia de nefropatía hipertensiva parece tender a crecer significativamente en los últimos años a pesar del perfeccionamiento de los tratamientos preventivos utilizados. La mayor permisividad en la edad para la derivación podría influir en estos resultados (AU)

Objective: Hypertensive nephropathy is the second most common cause for starting renal repacement therapy in Spain with a steady incidence since 1997. Data on incidence of hypertensive nephropathy previously to dialysis are scanty because they are not registries similar to those used for renal replacement therapy. Design and methods: It have be enretrospectively studied the records of our hospital Nephrology outpatients clinic from January, 1991 to December, 2007.Diagnosis was commonly made using clinical criteria in most of cases. There were 60 cases whith proteinuria higher than1 g/day and so that renal biopsies were performed. Results: During this time 479 (44.0 pmp) patients were diagnosed of hypertensive nephropathy (mean age 66.6 ± 12.1 years and43.0% were women). Incidence increased from 33.3 pmp(1991) to 76.2 pmp (2006). There was a steady trend to increase incidence since 16.7 pmp in 1991 up to 89.5 pmp in 2007. Mean incidence was 31.8 pmp between 1991 and 1995, 32.1 pmp in the period 1996-2000; and 54.4 pmp from 2001 to 2006.The mean age of incident patients have showed a J curve.53 subjects (11.6%) have started renal replacement therapy. Survival before starting renal replacement therapy was 96.0 at first year, 85.9% at five years and 81.6% after seven years of follow-up. Conclusions: Incidence of hypertensive nephropathy seems to have increased last years specially in spite of therapeutic improvements the prognosis is still unfavourable. Less rectricted age criteria for submitting patients may have influenced these results (AU)

[Hypertensive vascular disease: evolution of its incidence in the period 1991-2007 and survival prior to end-stage renal disease]. / Enfermedad vascular hipertensiva: evolución de la incidencia en el período 1991-2007 y supervivencia antes de la enfermedad renal terminal.

OBJECTIVE: Hypertensive nephropathy is the second most common cause for starting renal replacement therapy in Spain with a steady incidence since 1997. Data on incidence of hypertensive nephropathy previously to dialysis are scanty because there are not registries similar to those used for renal replacement therapy. DESIGN AND METHODS: Retrospectively we studied the records of our hospital Nephrology outpatients clinic from January, 1991 to December, 2007. Diagnosis was commonly made using clinical criteria in most of cases. There were 60 cases with proteinuria higher than 1 g/day and so that renal biopsies were performed. RESULTS: During this time 479 (44.0 pmp) patients were diagnosed of hypertensive nephropathy (mean age 66.6 +/- 12.1 years and 43.0% were women). Incidence increased from 33.3 pmp (1991) to 76.2 pmp (2006). There was a steady trend to increase incidence since 16.7 pmp in 1991 up to 89.5 pmp in 2007. Mean incidence was 31.8 pmp between 1991 and 1995, 32.1 pmp in the period 1996-2000; and 54.4 pmp from 2001 to 2006. The mean age of incident patients showed a J curve. 53 subjects (11.6%) have started renal replacement therapy. Survival before starting renal replacement therapy was 96.0 at first year, 85.9% at five years and 81.6% after seven years of follow-up. CONCLUSIONS: Incidence of hypertensive nephropathy seems to have increased last years specially in spite of therapeutic improvements the prognosis is still unfavourable. Less restricted age criteria for submitting patients may have influenced these results.

Treatment of proteinuria with lercanidipine associated with renin-angiotensin axis-blocking drugs.

OBJECTIVE: Most calcium antagonists do not seem to reduce microalbuminuria or proteinuria. We have tried to assess the antiproteinuric effect of a calcium channel blocker, lercanidipine, in patients previously treated with ACE inhibitors or angiotensin receptor blockers. DESIGN AND METHODS: The study included 68 proteinuric (> 500 mg/day) patients (age 63.1 +/- 12.9 years, 69.1% males and 30.9 females). All patients were receiving ACE inhibitors (51.4%) or angiotensin II receptor blockers (48.6%) therapy but had higher blood pressure than recommended for proteinuric patients (<130/80 mmHg). Patients were clinically evaluated one, three, and six months after starting treatment with lercanidipine (20 mg/day). Samples for urine and blood examination were taken during the examination. When needed, a third drug was added to treatment. Creatinine clearance was measured using 24 h urine collection. RESULTS: BP significantly decreases from 152 +/- 15/86 +/- 11 mmHg to 135 +/- 12/77 +/- 10 mmHg at six months of follow-up (p < 0.001). After six months of treatment, the percentage of normalized patients (BP < 130/80 mmHg) was 42.5%, and the proportion of patients whose BP was below 140/90 mmHg was 58.8%. Plasmatic creatinine did not change nor did creatinine clearance. Plasmatic cholesterol also decreased from 210 +/- 48 to 192 +/- 34 mg/dL (p < 0.001), as did plasma triglycerides (from 151 +/- 77 to 134 +/- 72 mg/dL, p = 0.022). Basal proteinuria was 1.63 +/- 1.34 g/day; it was significantly (p < 0.001) reduced by 23% at the first month, 37% at three months, and 33% at the last visit. CONCLUSIONS: Lercanidipine at 20 mg dose, associated to renin-angiotensin axis-blocking drugs, showed a high antihypertensive and antiproteinuric effect. This antiproteinuric effect seems to be dose-dependent as compared with previous reports and proportionally higher than blood pressure reduction.

[Growing incidence of diabetic nephropathy in the region of Badajoz during the period 1991-2006]. / Incidencia creciente de nefropatía diabética en la provincia de Badajoz durante el período 1991-2006.

OBJECTIVE: Diabetic nephropathy is the most common cause for starting renal repacement therapy in Spain with a steady incidence since 1997. Data on incidence of diabetic nephropathy previously to dialysis are scanty because they are not registries similar to those used for renal replacement therapy. DESIGN AND METHODS: It have been retrospectively studied the records of our hospital Nephrology outward from January, 1991 to December, 2006. Diagnosis was commonly made using clinical criteria (proteinuria plus diabetic retinopathy). There were 21 cases which did not meet theses criteria and so renal biopsy was performed. RESULTS: During this time 478 (49.7 pmp) patients were diagnosed of diabetic nephropathy (mean age 61.2 years, 50.4% women). Incidence increased from 33.3 pmp (1991) to 76.2 pmp (2006). There were not significant changes in the age of patients along the time. Other common diagnosis in diabetic patients were nefroangiosclerosis (129) and glomerulonefritis (n = 103). Survival until renal replacement therapy was 87.5% at one year and 48% at five years of follow up. CONCLUSIONS: Incidence of diabetic nephropathy seems to have increase last years specially in the patients aged 70 or older. In spite of therapeutic improvements the prognosis is still unfavourable. Less rectricted age criteria for submitting patients may have influenced these results.

Incidencia creciente de nefropatía diabética en la provincia de Badajoz durante el período 1991-2006 / No disponible

Objetivo: la nefropatía diabética es la causa más común de entrada en tratamiento renal sustitutivo en España, con una incidencia que parece estable desde 1997. Los datos sobre incidencia de nefropatía diabética en consulta son escasos al no existir registros similares a los usados en el tratamiento renal sustitutivo. Diseño y métodos: se ha revisado retrospectivamente la base de datos de la consulta de Nefrología de nuestro hospital entre enero de 1991 y diciembre de 2006. El diagnóstico se hizo en la mayor parte de los casos por criterios clínicos (proteinuria asociada a retinopatía diabética). En 21 casos se realizó biopsia renal por incumplimiento de estos criterios. Resultados: durante ese tiempo, 478 (49,7 pmp) pacientes fueron diagnosticados de nefropatía diabética (edad media 61,2 años, 50,4% mujeres). Se aprecia una tendencia progresiva de crecimiento desde 33,3 pmp en 1991 hasta 76,2 pmp en 2006. No se han producido variaciones significativas en la edad media de los incidentes. Ciento seis pacientes (22,1%) han iniciado tratamiento renal sustitutivo. En el resto de los casos, el diagnóstico más frecuente fue nefroangiosclerosis (129) y glomerulonefritis (n = 103). La supervivencia estimada antes de llegar a tratamiento renal sustitutivo fue del 87,5% al año y del 48% a los cinco años de seguimiento. Conclusiones: la incidencia de nefropatía diabética parece tender a crecer significativamente en los últimos años, sobre todo en el grupo de edad mayor de 70 años. A pesar del perfeccionamiento de los tratamientos, el pronóstico sigue siendo desfavorable. La mayor permisividad en la edad para la derivación puede haber influido en estos resultados (AU)

Objective: Diabetic nephropathy is the most common cause for starting renal repacement therapy in Spain with a steady incidence since 1997. Data on incidence of diabetic nephropathy previously to dialysis are scanty because they are not registries similar to those used for renal replacement therapy. Design and methods: It have been retrospectively studied the records of our hospital Nephrology outward from January, 1991 to December, 2006. Diagnosis was commonly made using clinical criteria (proteinuria plus diabetic retinopathy). There were 21 cases which did not meet theses criteria and so renal biopsy was performed. Results: During this time 478 (49.7 pmp) patients were diagnosed of diabetic nephropathy (mean age 61.2 years, 50.4% women). Incidence increased from 33.3 pmp (1991) to 76.2 pmp (2006). There were not significant changes in the age of patients along the time. Other common diagnosis in diabetic patients were nefroangiosclerosis (129) and glomerulonefritis (n = 103). Survival until renal replacement therapy was 87.5% at one year and 48% at five years of follow up. Conclusions: Incidence of diabetic nephropathy seems to have increase last years specially in the patients aged 70 or older. In spite of therapeutic improvements the prognosis is still unfavourable. Less rectricted age criteria for submitting patients may have influenced these results (AU)

Long-term antiproteinuric effect of dual renin-angiotensin system blockade.

We evaluated the long-term changes on overt proteinuria induced by dual blockade of the renin-angiotensin system (RAS). Dual blockade was produced by adding an angiotensin II receptor blocker (ARB) to treatment with maximal recommended doses of an angiotensin converting enzyme (ACE) inhibitor in proteinuric patients. A total of 28 patients (19 men and 9 women) with proteinuria higher than 1 g/24 h were enrolled in this trial of treatment with the ARB candesartan (from 4 up to 32 mg daily) added to existing treatment with an ACE inhibitor. At 6, 12, 24, and 36 months, we evaluated proteinuria in 24-h urinary collections, office blood pressure (BP), plasmatic creatinine (Cr), serum potassium (K), and 24 h urine collection creatinine clearance (CrC). During monoblockade of the RAS by ACE inhibitor treatment, albuminuria was 2.94 +/- 1.92 mg/24 h; BP was 137/76 mmHg; K+ was 4.8 +/- 0.5 mmol/l, Cr was 1.76 +/- 0.67 mg/dL, and CrC was 62 +/- 31.9 mL/min. After 6 months, dual blockade of the RAS albuminuria was 2.18 +/- 2.29 mg/24 h (P < 0.01 vs. baseline) and BP was 133/75 mmHg (not significant). At 36 months, albuminuria was 2.21 +/- 2.20 mg/24 h (P < 0.05 vs. baseline); BP was 133/73 mmHg (not significant). CrC was not changed along the follow up. A small increment of Cr was detected at 24 months (2.11 +/- 1.06 mg/mL, P < 0.05). The antiproteinuric effect of dual renin-angiotensin system blockade combining candesartan and ACE inhibitors remain after 36 months without losing its initial effect. Blood pressure changes seem not to explain this long-term antiproteinuric effect.

Dual renin-angiotensin system blockade: in patients with single functioning kidney and proteinuria.

AIM: Dual blockade of renin-angiotensin system (RAS) has increased antiproteinuric effects and it has been increasingly used on patients with proteinuria, but could have secondary effects when this kind of treatment is administered to patients with single functioning kidney. The aim of this study has been to assess the efficacy and safety of dual blockade of RAS in this group of patients. DESIGN AND METHODS: Sixteen patients with a single functioning kidney have been treated in our unit with dual RAS blockade due to proteinuria higher than 1 g/24 h. Mean age was 54.7+/-12.1 years, they were 12 males and 4 females. Analytical data of six months visit and last follow up visit have been retrospectively registered. Several different angiotensin conversor enzyme (ACE) inhibitors and angiotensin receptor blocking (ARB) drugs were used at the maximal dose tolerated by the patient. RESULTS: A small but not significant reduction of SBP and DBP were was observed throughout the study. Mean K+ increase in the second visit (from 4.65+/-0.67 to 5.01+/-1.02 mmol/l, not significant). There were no changes neither in plasmatic creatinine (baseline 1.86+/-0.67, 6 months 1.96+/-0.85) nor in creatinine clearance (baseline 65.2+/-26.9, 6 months 61.6+/-23.8 ml/min). Proteinuria was not reduced by dual RAS blockade (baseline 4.26+/-0.24, 6 months 4.25+/-0.39). CONCLUSIONS: Dual RAS blockade seems to be safe but unhelpful in renal patients with proteinuria associated to single functioning kidney.

Evolution of suboptimal renal transplantations: experience of a single Spanish center.

The increase in patients on dialysis awaiting transplantation has led to the use of grafts from suboptimal donors. The aim of this study was to analyze the function of suboptimal grafts. The secondary objectives were to study vascular and urological complications, as well as delayed renal function and acute rejection episodes. The study included 135 transplantations performed over 4 years with 27% of grafts being from suboptimal donors. Early graft loss was 12%, of which 69% were due to vascular thrombosis. These thromboses were more frequent among grafts from suboptimal donors (30% vs 4%, P < .001). There were no significant differences between the groups in the incidence of acute rejection episodes (17% vs 13%) or delayed graft function (14% vs 13%). A greater incidence of urologic complications was observed among recipients of grafts from older donors. The 1-year creatinine clearance was significantly lower among recipients of grafts from older donors (73 +/- 19 vs 51 +/- 14 mL/min, P < .0001). Sequential immunosuppressive therapy resulted in a lack of significant differences in creatinine clearance at 6 months, 1 year, or 2 years after transplantation between suboptimal grafts with cold ischemia greater or less than 20 hours or in warm ischemia greater or less than 60 minutes. Logistic regression analysis showed that the best determinant of graft loss was donor age older than 60 years. Accordingly, grafts from suboptimal donors were more likely to be lost during the first month after transplantation, particularly because of thrombosis, which was not due to a higher degree of technical complexity of the transplant operation.

Untoward effects of chronic dual renin-angiotensin system blockade: influence of previous chronic renal failure.

Dual blockade of the renin-angiotensin system (RAS) has increased antiproteinuric effects and so a higher incidence of secondary effects can be expected when this kind of treatment is administered. The aim of this study was to assess the safety of dual blockade of RAS. Seventy-five (54 men and 21 women) patients has been treated in our unit with dual RAS blockade due to proteinuria higher than 1 g/24 h. Mean age was 57.1 +/- 14.0 years. Fifty-three patients had chronic renal failure (CRF) at baseline. Analytical data of 6 months visit and last follow-up visit were recorded. A small reduction of systolic blood pressure and diastolic blood pressure was observed in both treatment groups throughout the study. Neither the CRF patients nor those with normal renal function showed any reduction in mean plasma haemoglobin levels, but differences between groups were significant at the second and third visits (anova). No change was detected in haematocrit. Mean K+ significantly increase at the second visit in the CRF group (from 4.80 +/- 0.64 to 5.23 +/- 0.81 mmol/l, p < 0.001, Student's t-test). There were no changes in normal kidney function group (4.58 +/- 0.37 vs. 4.63 +/- 0.44). At baseline plasmatic creatinine was higher in the CRF group (2.09 +/- 0.60 0.20 mg/dl vs. 0.99 +/- 0.20 mg/dl, p < 0.001, Student's t-test) and creatinine clearance was lower (48.6 +/- 20.7 ml/min vs. 107.0 +/- 0.30 ml/min, p < 0.001, Student's t-test). There was a small increase in creatinine along the follow-up when compared with the normal renal function group (p < 0.001, anova). Conversely, creatinine clearance remain unchanged in the normal renal function group, and there was a decrease in creatinine in CRF patients (p < 0.001). Dual RAS blockade seems to be safe in renal patients even when mild to moderate renal failure is present. Severe hyperkalaemia is uncommon. Small increments in plasmatic creatinine can be seen but they are hardly dangerous. Combined treatment does not significantly influence erythropoiesis.

Niveles de ácido úrico y proteína C reactiva en pacientes con insuficiencia renal crónica / Serum uric acid and c-reactive protein levels in patients with chronic kidney disease

Tanto la inflamación como la hiperuricemia se relacionan con un aumento delriesgo cardiovascular y mortalidad en general. Una hipotética relación entre inflamacióne hiperuricemia no ha sido nunca analizada en pacientes con insuficienciarenal crónica (IRC). El objetivo de este estudio fue determinar la prevalenciade un incremento de los niveles de Proteína C Reactiva (PCR), y valorar la hipótesisde una relación entre los niveles de ácido úrico (AU) y PCR.Se estudiaron 337 pacientes (174 hombres, edad media 63 ± 16 años), conIRC prediálisis. Los niveles de PCR de alta sensibilidad fueron analizados comouna variable cualitativa o como una variable continua transformada en logaritmo(log-PCR). Las variables independientes incluidas en los análisis de regresión logísticay lineal fueron: demográficas, características clínicas y bioquímicas, incluyendolos niveles de AU. En un subgrupo de 169 pacientes sin diabetes se realizóel mismo estudio, incluyendo además como variables los niveles basales deinsulina y el parámetro de resistencia a la insulina HOMA-IR.La mediana de PCR fue 3,25 mg/L, y la media de AU de 7,59 ± 1,94 mg/dl.Los pacientes con PCR superior a la mediana tenían una concentración media deAU significativamente mayor a la del resto de los pacientes (7,93 ± 1,79 vs 7,24± 2,03 mg/dl, p = 0,001). Hubo una correlación significativa entre los niveles deAU y log-PCR (r = 0,16, p = 0,0022). La relación entre PCR y AU continuó siendoestadísticamente significativa tras ajuste con la edad, sexo, comorbilidad, obesidad,función renal residual, tratamiento con diuréticos o alopurinol (OR: 1,296,p = 0,0003; y beta: 0,204, p = 0,0002). La asociación significativa entre PCR yAU no cambió cuando se añadieron al modelo el HOMA-IR o los niveles de insulinabasal en el subgrupo de 169 pacientes no diabéticos.En conclusión, los niveles de AU se relacionan de forma independiente con losde PCR en pacientes con IRC

Either inflammation or hyperuricemia has been related with increased cardiovascularrisk and mortality. A hypothetical relationship between serum uric acid levels (SUA) and inflammatory markers has never been tested in chronic kidneydisease (CKD) patients. The purpose of this study was to determine the prevalenceof increased C-reactive protein (CRP) levels in CKD patients, and to test thehypothesis of a relationship between SUA and CRP levels.The study group consisted of 337 patients (174 males, mean age 63 ± 16 years)with advanced chronic renal failure not yet on dialysis. None of them had overtinflammatory or infectious diseases. High sensitivity CRP levels were analyzed asa binary (above or below median value), or continuous variable (log-transformedCRP), by multiple logistic or linear regression analysis, respectively. Demographics,clinical, and biochemical characteristics, including SUA levels, were the variablestested in these analysis. In a subset of 169 patients without diabetes, the sameanalysis were carried out, with the inclusion of fasting insulin levels and HOMAIRas independent variables.Median CRP level was 3.25 mg/L, and mean SUA level was 7.59 ± 1.94 mg/dl.Patients with CRP levels above the median had significantly higher mean SUA levelthan that of the rest of study patients (7.93 ± 1.79 vs 7.24 ± 2.03 mg/dl, p =0.001). SUA levels correlated significantly with log-transformed CRP levels (r =0.16, p = 0.0022). The relationship between SUA and CRP levels remained statisticallysignificant after adjustment for age, sex, comorbid index, obesity, residualrenal function, diuretic and allopurinol treatment, in the multivariate logistic andlinear regression models (OR: 1.296, p = 0.0003; and beta: 0.204, p = 0.0002).The significant association between SUA and CRP levels did not change whenHOMA-IR and fasting insulin levels were included as independent variables in thesubset of 169 patients without diabetes.In conclusion, SUA levels are related with CRP levels in CKD patients

Moxonidina en hipertensión arterial resistente a politerapia antihipertensiva / Moxonidine in antihypertensive polytherapy arterial hypertension

Objetivo. La hipertensión arterial grave que precisa politerapia es la causa de consulta más habitual en las Unidades de Hipertensión Arterial. En muchos casos el enfermo ya está politratado de forma adecuada utilizando las familias clásicas de hipotensores recomendados por las diversas guías terapéuticas. En estos casos los agentes centrales de nueva generación pueden tener una de sus indicaciones como tratamiento. Material y métodos. Se han revisado restrospectivamente las historias de 62 pacientes a los que se indicó tratamiento con moxonidina, de los cuales 47 habían realizado tratamiento durante un período superior a 6 meses (edad: 60,2 ± 11,3; 21 hombres y 35 mujeres). Todos los pacientes fueron tratados con moxonidina en administración única diaria (generalmente nocturna) a dosis entre 0,2 y 0,4 mg inicialmente con elevación máxima hasta 0,6 mg/día. El efecto clínico y bioquímico del tratamiento se ha valorado tras 6 meses de seguimiento. Resultados. La presión arterial sistólica se redujo significativamente (inicial: 161,6 ± 26,3; final: 142,7 ± 18,6 mmHg; p = 0,00004). Lo mismo ocurrió con la presión arterial diastólica (inicial: 93,4 ± 12,6; final: 84,9 ± 12,1 mmHg; p = 0,0002). La reducción final obtenida fue ­18,4/­8,2 mmHg. La reducción final en la presión de pulso fue 10,1 ± 20,6 mmHg. Ocho pacientes presentaron efectos secundarios (el más frecuente, sedación) y uno de ellos interrumpió por esta causa el tratamiento. Alcanzaron una presión arterial < 140/90 mmHg el 34,8 % de los enfermos estudiados, aunque el 67,4 % lograron normalizar su presión arterial diastólica. Conclusiones. La moxonidina demostró ser un fármaco efectivo en las condiciones de trabajo de una Unidad de Hipertensión para reducir la presión arterial en pacientes ya tratados con politerapia

Objective. Serious arterial hypertension that requires polytherapy is the most usual cause in the Arterial Hypertension Units. In many cases, the patient is already adequately polytreated, using the classic families of antihypertensive agents recommended by the different therapeutic guides. In this case, the new generation central agents may have one of their indications as treatment. Material and methods. The clinical records of 62 patients who were prescribed treatment with moxonidine have been retrospectively reviewed. A total of 47 had undergone treatment for a period greater than 6 months (age: 60.2 ± 11.3; 21 men and 35 women). All the patients were treated with moxonidine with single daily administration (generally at night) at a dose between 0.2 and 0.4 mg initially with maximum elevation until 0.6 mg/day. The clinical and biochemical effect of the treatment was assessed after six months follow-up. Results. The SBP was significantly reduced (initial: 161.6 ± 26.3; final: 142.7 ± 18.6 mmHg; p = 0.00004). The same occurred with the DPB (initial: 93.4±12.6; final: 84.9 ± 12.1 mmHg; p = 0.0002). Final reduction obtained was ­18.4/­8.2 mmHg. Final reduction in pulse pressure was 10.1 ± 20.6 mmHg. Eight patients had side effects (the most frequent, sedation) and one of them discontinued treatment for this reason. A total of 34.8 % of the patients studied reached an arterial pressure < 140/90 mmHg, although 67.4 % were able to normalize their DBP. Conclusions. Moxonidine was shown to be an effective drug in the work conditions of the Hypertension Unit to reduce arterial blood pressure in patients already treatment with polytherapy

Hyperhomocysteinemia in patients with mild chronic renal failure.

BACKGROUND: The aim of this study was to evaluate the prevalence of high plasma levels of homocysteine in patients with mild renal failure. METHODS: Forty-six chronic renal failure patients (25 males and 21 females, mean age 55.6+/-14.4 years) were recruited for the study. Mean plasma creatinine was 2.1+/-1.0 mg/dl and mean creatinine clearance was 50.6+/-26.3 ml/min. Patients with severe renal failure were excluded. Patients were compared with a control group with normal renal function (n=35, 22 men and 13 women, mean age 50.0+/-11.5 years). Plasma homocysteine values were measured in both groups at baseline and after an oral overload of methionine. RESULTS: Baseline homocysteine levels of patients were higher than those of controls (16.5+/-7.3 vs. 10.4+/-4.2 micromol/l, p<0.0001). Some 34 patients and 4 controls had increased plasma homocysteine levels at baseline. After the oral overload, 4 more patients had abnormally increased homocysteine levels, meaning that 83% of the patients with chronic renal failure had hyperhomocysteinemia. CONCLUSIONS: Hyperhomocysteinemia is a very common finding among patients with mild renal failure. The need for vitamin supplementation should be evaluated in the first stage of chronic renal failure.

[Serum uric acid and C-reactive protein levels in patients with chronic kidney disease]. / Niveles de ácido úrico y proteína C reactiva en pacientes con insuficiencia renal crónica.

Either inflammation or hyperuricemia has been related with increased cardiovascular risk and mortality. A hypothetical relationship between serum uric acid levels (SUA) and inflammatory markers has never been tested in chronic kidney disease (CKD) patients. The purpose of this study was to determine the prevalence of increased C-reactive protein (CRP) levels in CKD patients, and to test the hypothesis of a relationship between SUA and CRP levels. The study group consisted of 337 patients (174 males, mean age 63 +/- 16 years) with advanced chronic renal failure not yet on dialysis. None of them had overt inflammatory or infectious diseases. High sensitivity CRP levels were analyzed as a binary (above or below median value), or continuous variable (log-transformed CRP), by multiple logistic or linear regression analysis, respectively. Demographics, clinical, and biochemical characteristics, including SUA levels, were the variables tested in these analysis. In a subset of 169 patients without diabetes, the same analysis were carried out, with the inclusion of fasting insulin levels and HOMA-IR as independent variables. Median CRP level was 3.25 mg/L, and mean SUA level was 7.59 +/- 1.94 mg/dl. Patients with CRP levels above the median had significantly higher mean SUA level than that of the rest of study patients (7.93 +/- 1.79 vs 7.24 +/- 2.03 mg/dl, p = 0.001). SUA levels correlated significantly with log-transformed CRP levels (r = 0. 16, p = 0.0022). The relationship between SUA and CRP levels remained statistically significant after adjustment for age, sex, comorbid index, obesity, residual renal function, diuretic and allopurinol treatment, in the multivariate logistic and linear regression models (OR: 1.296, p = 0.0003; and beta: 0.204, p = 0.0002). The significant association between SUA and CRP levels did not change when HOMA-IR and fasting insulin levels were included as independent variables in the subset of 169 patients without diabetes. In conclusion, SUA levels are related with CRP levels in CKD patients.

Obesidad y mortalidad en pacientes con insuficiencia renal avanzada / Obesity and mortality in advanced chronic renal failure patients

Algunos estudios han sugerido que la obesidad podría ser un factor beneficioso para la supervivencia de los pacientes con insuficiencia renal crónica (IRC). La mayoría de estos estudios se han realizado en poblaciones prevalentes en diálisis, sin tener en cuenta la posibilidad de un sesgo de supervivencia. El objetivo del presente estudio fue determinar si la obesidad tiene alguna influencia sobre la supervivencia de los pacientes con IRC avanzada. Se estudiaron 376 pacientes (edad media 63 ñ 15 años) con IRC avanzada prediálisis. La obesidad fue definida como un índice de masa corporal (IMC) >=30 kg/m2. Se cuantificó la comorbilidad por el método de Davies. El tiempo de supervivencia fue computado desde el momento en que los pacientes fueron remitidos a la consulta prediálisis hasta su fallecimiento, censurando el tiempo posterior al trasplante renal. Mediante el análisis de Kaplan-Meier se determinaron las diferencias en la supervivencia de los pacientes distribuidos en cuartiles del IMC, y entre obesos y no obesos. Se realizaron análisis adicionales, estratificando las curvas de supervivencia según edad, sexo, grado de comorbilidad, y porcentaje de masa magra corregida al peso ideal. Para determinar los mejores predictores de mortalidad y el papel de la obesidad ajustada a otras covariables, se utilizó el test de riesgo proporcional de Cox. La mediana del tiempo de supervivencia fue de 1.453 días. Durante el periodo de seguimiento fallecieron 158 pacientes (46 por ciento). La supervivencia fue significativamente diferente en los pacientes distribuidos por cuartiles de IMC (test Breslow = 10,7, p = 0,017). La supervivencia entre obesos y no obesos no fue significativamente diferente. Sin embargo, cuando los pacientes sin comorbilidad fueron estudiados aparte, los obesos tuvieron una peor supervivencia que los no obesos (log-rank = 7,42, p = 0,0064). La obesidad también se asoció con una menor supervivencia en los pacientes con bajo porcentaje de masa magra. Debido a que el efecto de la obesidad sobre la mortalidad no siguió un patrón proporcional de riesgo a lo largo del tiempo de seguimiento, el análisis de Cox fue estratificado por intervalos de 18 meses. Las variables que entraron a formar parte del mejor modelo predictivo de mortalidad fueron: la edad (Relación de Riesgo: 1,04), el índice de comorbilidad (RR: 2,17), la albúmina sérica (RR: 0,62), el filtrado glo- merular al inicio del estudio (RR: 0,91), el sexo masculino (RR: 1,48), y la obesidad (RR: 1,51). En conclusión, la obesidad no fue un factor beneficioso en la supervivencia de los pacientes estudiados. La obesidad tuvo un notable impacto negativo sobre la supervivencia de los pacientes sin comorbilidad (AU)

[Obesity and mortality in advanced chronic renal failure patients]. / Obesidad y mortalidad en pacientes con insuficiencia renal avanzada.

A protective effect of obesity on the mortality of end-stage renal failure patients has been observed in several studies. Most of these studies have been based on prevalent dialysis population. The aim of the present study was to evaluate if obesity has beneficial effects on the survival of advanced chronic renal failure patients. The study group consisted of 376 patients (mean age 63 +/- 15 years) with advanced chronic renal failure not yet on dialysis. Obesity was defined as a body mass index (BMI) > or = 30 kg/m2. Grade of comorbidity was quantified by the method devised by Davies. Survival was analyzed as time from the referral to the predialysis outpatient clinic to patient death, censoring from contributing additional survival data to the analysis following transplantation. Kaplan-Meier analysis was used to test survival differences according to quartiles of BMI, and between obese and nonobese patients. Further analysis were performed, stratifying survival curves by comorbid scores, lean body mass, age, and sex. Cox proportional hazard regression models were used to investigate the best determinants of mortality, and the role of obesity adjusted for other covariates. Median survival time was 1,453 days. During the follow-up time, 158 patients (42%) died. Survival differences among quartiles of BMI were statistically significant (Breslow = 10.7, p = 0.017). Patients within the lowest and the highest quartiles of BMI had higher mortality than the rest of patients. Survival curves between obese and non-obese patients did not differ significantly. However, when patients without comorbidity were studied apart, those with obesity showed worse survival than the rest of patients (log-rank = 7.42, p = 0.0064). Since the effect of obesity on mortality did not follow a proportional hazard pattern throughout the study period, multivariable analysis for mortality was stratified by 18 months intervals. The variables which fitted the best model were: age (Hazard Ratio: 1.04), comorbid score (HR: 2.17), serum albumin (HR: 0.62), GFR at the study entry (HR: 0.91), male gender (HR: 1.48), and obesity (HR: 1.51). In conclusion, obesity had no survival benefit in patients with advanced chronic renal failure. Obesity had a noteworthy impact on early mortality of advanced chronic kidney disease patients without comorbidities.

Progresión de la insuficiencia renal en pacientes con enfermedad renal crónica avanzada / Progression of renal insufficiency in the pre-end-stage renal disease setting

La velocidad de progresión de la insuficiencia renal (VPIR) en pacientes con enfermedad renal crónica avanzada es muy variable. Se han reconocido algunos factores como potenciales modificadores de la VPIR. El objetivo el presente estudio retrospectivo fue determinar cuales fueron los mejores predictores de la VPIR y de la supervivencia sin diálisis en un grupo de pacientes con insuficiencia renal avanzada seguidos en la consulta prediálisis. Se estudiaron 230 pacientes que habían sido remitidos a la consulta prediálisis durante el período comprendido entre enero 1998 y julio 2002. El tiempo medio de seguimiento por paciente fue de 356 días. La diferencia entre la mitad de la suma de los aclaramientos de urea y creatinina (CcrCu) al final y al inicio del seguimiento en la consulta prediálisis, dividido por el tiempo de seguimiento individual fue considerada como medida de la VPIR (DeltaCcr-Cu).Los datos obtenidos al inicio del seguimiento fueron analizados como potenciales predictores de la evolución posterior. Las variables incluidas fueron: datos demográficos, procesos comórbidos, los principales parámetros hematológicos y bioquímicos, tratamiento con antihipertensivos, estatinas y eritropoyetina (EPO), tensión arterial, y el Ccr-Cu al inicio del estudio. Los predictores de DeltaCcr-Cu se determinaron mediante análisis de regresión lineal. Los predictores de la supervivencia sin diálisis se determinaron mediante la regresión de Cox, ajustada a la función renal inicial.El Ccr-Cu medio al inicio del estudio fue 10,98 ñ 2,58 ml/min/1,73 m2, y el DeltaCcrCu medio fue -0,37 ñ 0,46 ml/min/1,73 m2/mes. Los pacientes diagnosticados de nefropatía diabética y glomerulonefritis crónica tuvieron las progresiones más rápidas hacia la insuficiencia renal terminal. Por regresión lineal múltiple, los mejores predictores de DeltaCcr-Cu fueron: la proteinuria de 24 horas (p < 0,0001), y el hematocrito inicial (p = 0,0024). Los mejores predictores de la supervivencia sin diálisis fueron: la proteinuria de 24 horas (g/24 h) (odds ratio: 1,16; p < 0,0001), el hematocrito inicial ( por ciento) (odds ratio: 0,88; p < 0,0001), el tratamiento con EPO (odds ratio: 0,59; p = 0,02) y el diagnóstico de diabetes mellitus (odds ratio: 1,59; p = 0,01).En conclusión, la magnitud de la proteinuria y el grado de severidad de la anemia con el que el paciente es remitido a la consulta prediálisis determinan la velocidad de progresión hacia la insuficiencia renal terminal (AU)

[Progression of renal insufficiency in the pre-end-stage renal disease setting]. / Progresión de la insuficiencia renal en pacientes con enfermedad renal crónica avanzada.

The rate of decline of renal function (RDRF) in the pre-end stage renal disease setting (pre-ESRD) is highly variable. Several factors have been involved as potential modifiers of renal failure progression. This retrospective study attempts to establish which were the main determinants of the RDRF in pre-ESRD patients followed in the predialysis consult. The study group consisted of 230 patients with pre-ESRD not yet on dialysis who were referred to the predialysis consult from January 1998 to July 2002. The mean follow-up time per patient was 356 days. RDRF was assessed as delta of the average of creatinine and urea clearances (CrCl-UCl). Data obtained at time of referral to the predialysis consult were analyzed as potential predictors of the subsequent RDRF. These independent variables included: demographics, comorbid conditions, main hematological and biochemical data, antihypertensive and statin treatment, mean blood pressure, and CrCl-UCl at time of referral. The predictors of delta CrCl-UCl were determined by multiple linear regression analysis. The determinants of the survival without dialysis were established by the Cox regression hazard model, adjusted to renal function at time of referral. Mean CrCl-UCl at time of referral was 10.98 +/- 2.58 ml/min/1.73 m2, and mean delta CrCl-UCl was -0.37 +/- 0.46 ml/min/1.73 m2/month. Patients with diabetic nephropathy and chronic glomerulonephritis had the fastest RDRF, while patients with ischemic nephropathy and chronic interstitial nephritis had the slowest RDRF. Seventy-five patients (46%) required EPO therapy. The best determinants of delta CrCl-UCl were: the 24-hour proteinuria (p < 0.0001), and the hematocrit at time of referral (p = 0.0024). The best determinants of the survival rate without dialysis during the study period were: the proteinuria (in g/24 hours) (R 1, 16; p < 0.0001), the hematocrit at time of referral (OR: 0.88; p < 0.0001), the treatment with EPO (OR: 0.59; p = 0.02), and the diagnosis of diabetes mellitus (OR: 1.59; p = 0.01). In conclusion, apart from the rate of proteinuria, which could represent the best marker of the RDRF in chronic renal diseases, the development of anemia was associated with faster decline in renal function.

[Differences between the glomerular filtration rate estimated by the MDRD equation and the measurement of creatinine and urea clearance in unselected patients with terminal renal insufficiency]. / Diferencias entre la tasa de filtrado glomerular estimada por la ecuación MDRD y la media del aclaramiento de creatinina y urea en pacientes no seleccionados con insuficiencia renal terminal.

From the results of the Modification of Diet in Renal Disease (MDRD) study, a prediction equation for a more accurate estimate of glomerular filtration rate (GFR), was developed. The present study ais to compare the GFR estimated by MDRD formula and that calculated by the average of creatinine and urea clearances in unselected patients with advanced renal failure. The study group consisted of 320 (163 males) with advanced renal failure not yet on dialysis. Their mean age was 63 +/- 14 years. Diabetic nephropathy was the most common etiology of renal failure (25%). Significant comorbidity was observed in 115 patients. Serum creatinine (Cr), urea and albumin were determined in all patients. Creatinine (Ccr) and urea clearance (Cu) were calculated on a 24-hour urine collection. The GFR was estimated by summing Ccr and Cu, and dividing by two (Ccr-Cu). THe clearances were corrected for a body surface area of 1.73 m2. The MDRD formula for the estimation of GFR included the following parameters: serum Cr, BUN, age, gender and serum albumin. Linear regression analysis and Bland-Altmann plot were utilized to establish the degree of correlation and agreement between both estimations of GFR. The percent differences between the two estimations of GFR was especially analyzed in those subgroups of patients which were not included in the MDRD study (patients older than 70 years, diabetics and those with comorbid conditions). The mean GFR estimated by Ccr-Cu and by MDRD formula were 10.04 +/- 3.10 ml/min and 10.55 +/- 3.60 ml/min, respectively (p < 0.0001). The two parameters correlated significantly (R = 0.76, p < 0.0001). GFR by the MDRD formula tended to overestimate the highest values of Ccr-Cu. The mean percent difference between both methods was 6.5 +/- 23.6. MDRD predictive equation overestimated significantly Ccr-Cu in patients older than 70 years (mean overestimation of 15%), males (10%), diabetics (10%), and mainly in patients with comorbidity (17%). In conclusion, the GFR estimated by MDRD formula is very similar to Ccr-Cu in young uremic patients without comorbidity. However, major discrepancies between these two methods could be observed in older patients, and mainly in those with comorbidity.

Diferencias entre la tasa de filtrado glomerular estimada por la ecuación MDRD y la media del aclaramiento de creatinina y urea en pacientes no seleccionados con insuficiencia renal terminal / The glomerular filtration rate estimated by mdrd predictive equation in unselected end-stage renal failure patients: differences from average of creatinine and urea clearances

La determinación del filtrado glomerular mediante I121-thalamato a 1.620 pacientes incluidos en el estudio Modification of Diet in Renal Disease (MDRD), permitió desarrollar una ecuación para estimar el filtrado glomerular sin la necesidad de recogida de orina, en la que la creatinina, nitrógeno ureico, albúmina sérica, edad, sexo y raza son las principales variables. El presente estudio compara el filtrado glomerular estimado por la fórmula MDRD con la media del aclaramiento de creatinina y urea en una población no seleccionada de pacientes con insuficiencia renal avanzada.Fueron incluidos en el estudio 320 pacientes (163 varones) con insuficiencia renal avanzada que no habían iniciado diálisis. La edad media fue 63 ñ 14 años.La nefropatía diabética fue la causa más prevalente de insuficiencia renal (25 por ciento).Se observó una comorbilidad significativa en 115 pacientes. En todos los pacientes se midió creatinina (Cr), urea y albúmina sérica. El aclaramiento de Cr (Ccr) y de urea (Cu) se determinaron mediante la recogida de orina de 24 horas. El filtrado glomerular fue estimado como la media de ambos aclaramientos (Ccr-Cu) corregidos a una superficie corporal de 1,73 m2. La ecuación MDRD para la estimación del filtrado glomerular incluyó como variables la Cr, nitrógeno ureico, edad, sexo, y albúmina sérica. Mediante análisis de regresión lineal y el método de Bland-Altmann se estableció el grado de correlación y similitud entre ambas estimaciones del filtrado glomerular fue analizada en aquellos subgrupos de pacientes que no habían sido incluidos en el estudio MDRD: mayores de 70 años, diabéticos y pacientes con procesos comórbidos. El filtrado glomerular medio estimado por el Ccr-Cu y por la ecuación MDRD fueron respectivamente: 10,04 ñ 3,10 ml/min/1,73 m2 y 10,55 ñ 3,60 ml/min/1,73 m2 (p < 0,0001). Ambos parámetros se correlacionaron significativamente (r = 0,76, p < 0,0001). El filtrado glomerular estimado por la ecuación MDRD tendió a sobreestimar los valores más elevados de Ccr-Cu. La diferencia porcentual media entre ambas estimaciones fue de 6,5 ñ 23,6 por ciento. La ecuación MDRD sobreestimó significativamente el Ccr-Cu en pacientes mayores de 70 años (sobreestimación media 15 por ciento), varones (10 por ciento), diabéticos (10 por ciento), y principalmente en aquellos pacientes con comorbilidad (17 por ciento).En conclusión, el filtrado glomerular estimado por la ecuación MDRD es muy similar al Ccr-Cu en pacientes jóvenes sin comorbilidad. Sin embargo, en ancianos con procesos comórbidos, la ecuación MDRD sobreestima significativamente el Ccr-Cu (AU)

[Ambulatory blood pressure monitoring in young patients]. / Monitorización ambulatoria de presión arterial (MAPA) en enfermos jóvenes.

OBJECTIVE: To defining the criteria for performing ambulatory blood pressure monitoring (ABPM) in young patients. METHOD: It is reported the experience with ABPM on 52 consecutive patients (younger than 30 years old) consulting for hypertension (mean age 23.4 +/- 4.9 years). The ambulatory BP was measured noninvasively for twenty-seven hours by the Spacelabs 90207 device programmed to measure BP every fifteen minutes during daytime and every 20 minutes during nighttime. The definition of daytime and nighttime was made on the basis of wakefulness and sleep or bed rest periods, obtained from a diary kept by the subject, normal nocturnal BP drop was defined as a decrease higher of 10% versus daytime values. It was defined normal BP an 24 hours ambulatory BP < 130/80 mmHg. RESULTS: Thirty seven patients (71%) were normotensives. There were not differences between normotensive and hypertensive patients neither by age (normotensive 23.9 +/- 12.5, hypertensive 23.3 +/- 4.0 years), nor by sex (normotensive, 21 men and 16 women; hypertensive, 10 men and 3 women). Mean 24 h BP of normotensive patients was 119/72 mmHg (p < 0.001 vs. hypertensive, 135/89 mmHg). There were not differences in nocturnal BP drop. White-coat reaction was more intense in normotensive patients (1.17 +/- 0.12, vs. hypertensive 1.04 +/- 0.08, p < 0.001). Four hypertensives showed white-coat reaction (1.11 +/- 0.05). CONCLUSION: ABPM is a helpful diagnostic tool in young patients. It should be routinely performed as first exploration in all patients younger than 30 years consulting for hypertension.