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Balgobin S, Basak S, Teoh CW, Noone D. Hypertension in diabetes. Pediatr Nephrol 2024; 39:1739-1758. [PMID: 37831122 DOI: 10.1007/s00467-023-06163-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/01/2023] [Accepted: 09/01/2023] [Indexed: 10/14/2023]
Abstract
Diabetes mellitus, a disease that affects hundreds of millions of people worldwide, is increasing in prevalence in all age groups, including children and adolescents. Much of the morbidity and mortality associated with diabetes is closely related to hypertension, often coincident with diabetes. Comorbid hypertension and diabetes often worsen the outcomes of each other, likely rooted in some overlapping pathogenic mechanisms. In this educational review, we will discuss the shared pathophysiology of diabetes and hypertension, particularly in regard to inflammation and oxidative stress, the sympathetic nervous system, vascular remodeling, and the renin-angiotensin-aldosterone system (RAAS). We will also review current hypertension diagnosis and management guidelines from many international jurisdictions for both adult and paediatric populations in the setting of diabetes. Many of these guidelines highlight the use and utility of RAAS blockers in this clinical scenario; however, on review of the evidence for their use, several meta-analyses and systematic reviews fail to demonstrate superiority of RAAS blockers over other anti-hypertensive medications. Finally, we discuss several new anti-hypertensive medications, review their mechanisms of action, and highlight some of the evidence for their use in the setting of hypertension and diabetes.
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Affiliation(s)
- Steve Balgobin
- Division of Paediatric Nephrology, The Hospital for Sick Children, 555 University Avenue, Toronto, M5G 1X8, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Sanjukta Basak
- Pediatric Endocrinologist, BC Children's Hospital, Vancouver, BC, Canada
- Division of Endocrinology & Metabolism, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Chia Wei Teoh
- Division of Paediatric Nephrology, The Hospital for Sick Children, 555 University Avenue, Toronto, M5G 1X8, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Damien Noone
- Division of Paediatric Nephrology, The Hospital for Sick Children, 555 University Avenue, Toronto, M5G 1X8, Canada.
- Department of Paediatrics, University of Toronto, Toronto, Canada.
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2
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Verdecchia P, Angeli F, Reboldi G. The lowest well tolerated blood pressure: A personalized target for all? Eur J Intern Med 2024; 123:42-48. [PMID: 38278661 DOI: 10.1016/j.ejim.2024.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/04/2024] [Accepted: 01/17/2024] [Indexed: 01/28/2024]
Abstract
The optimal blood pressure (BP) target for prevention of cardiovascular complications of hypertension remains uncertain. Most Guidelines suggest different targets depending on age, comorbidities and treatment tolerability, but the underlying evidence is not strong. Results of randomized strategy trials comparing lower (i.e., more intensive) versus higher (i.e., less intensive) BP targets should drive the definition. However, these trials tested different BP targets based on systolic BP, diastolic BP or combined systolic and diastolic BP goals. Overall, the more intensive treatment targets reduced the risk of major cardiovascular complications of hypertension when compared with the less intensive targets, despite a higher incidence of unwanted effects including, but not limited to, hypotension, electrolyte abnormalities and renal dysfunction. Consequently, some Guidelines defined low BP thresholds (i.e., 120/70 mmHg) not to exceed downward because of the expectation that unwanted effects may outweigh the outcome benefits. The present review discusses the evidence underlying the choice of BP targets, which remains an important step in the management of hypertensive patients. We conclude that, on the ground of the heterogeneity of available data in support to fixed BP targets, their definition should be personalized in all patients and based on best trade-off between efficacy and safety, i.e., the lowest well tolerated BP.
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Affiliation(s)
- Paolo Verdecchia
- Fondazione Umbra Cuore e Ipertensione-ONLUS, Perugia, Italy; Department of Cardiology, Hospital S. Maria della Misericordia, Perugia, Italy.
| | - Fabio Angeli
- Department of Medicine and Technological Innovation (DiMIT), University of Insubria, Varese, Italy; Department of Medicine and Cardiopulmonary Rehabilitation, IRCCS, Istituti Clinici Scientifici Maugeri, Tradate, Italy
| | - Gianpaolo Reboldi
- Department of Medicine and Surgery, Division of Nephrology, Hospital S. Maria della Misericordia, University of Perugia, Perugia, Italy
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3
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Natale P, Palmer SC, Navaneethan SD, Craig JC, Strippoli GF. Angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers for preventing the progression of diabetic kidney disease. Cochrane Database Syst Rev 2024; 4:CD006257. [PMID: 38682786 PMCID: PMC11057222 DOI: 10.1002/14651858.cd006257.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
BACKGROUND Guidelines suggest that adults with diabetes and kidney disease receive treatment with angiotensin-converting-enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB). This is an update of a Cochrane review published in 2006. OBJECTIVES We compared the efficacy and safety of ACEi and ARB therapy (either as monotherapy or in combination) on cardiovascular and kidney outcomes in adults with diabetes and kidney disease. SEARCH METHODS We searched the Cochrane Kidney and Transplants Register of Studies to 17 March 2024 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included studies evaluating ACEi or ARB alone or in combination, compared to each other, placebo or no treatment in people with diabetes and kidney disease. DATA COLLECTION AND ANALYSIS Two authors independently assessed the risk of bias and extracted data. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS One hundred and nine studies (28,341 randomised participants) were eligible for inclusion. Overall, the risk of bias was high. Compared to placebo or no treatment, ACEi may make little or no difference to all-cause death (24 studies, 7413 participants: RR 0.91, 95% CI 0.73 to 1.15; I2 = 23%; low certainty) and with similar withdrawals from treatment (7 studies, 5306 participants: RR 1.03, 95% CI 0.90 to 1.19; I2 = 0%; low certainty). ACEi may prevent kidney failure (8 studies, 6643 participants: RR 0.61, 95% CI 0.39 to 0.94; I2 = 0%; low certainty). Compared to placebo or no treatment, ARB may make little or no difference to all-cause death (11 studies, 4260 participants: RR 0.99, 95% CI 0.85 to 1.16; I2 = 0%; low certainty). ARB have uncertain effects on withdrawal from treatment (3 studies, 721 participants: RR 0.85, 95% CI 0.58 to 1.26; I2 = 2%; low certainty) and cardiovascular death (6 studies, 878 participants: RR 3.36, 95% CI 0.93 to 12.07; low certainty). ARB may prevent kidney failure (3 studies, 3227 participants: RR 0.82, 95% CI 0.72 to 0.94; I2 = 0%; low certainty), doubling of serum creatinine (SCr) (4 studies, 3280 participants: RR 0.84, 95% CI 0.72 to 0.97; I2 = 32%; low certainty), and the progression from microalbuminuria to macroalbuminuria (5 studies, 815 participants: RR 0.44, 95% CI 0.23 to 0.85; I2 = 74%; low certainty). Compared to ACEi, ARB had uncertain effects on all-cause death (15 studies, 1739 participants: RR 1.13, 95% CI 0.68 to 1.88; I2 = 0%; low certainty), withdrawal from treatment (6 studies, 612 participants: RR 0.91, 95% CI 0.65 to 1.28; I2 = 0%; low certainty), cardiovascular death (13 studies, 1606 participants: RR 1.15, 95% CI 0.45 to 2.98; I2 = 0%; low certainty), kidney failure (3 studies, 837 participants: RR 0.56, 95% CI 0.29 to 1.07; I2 = 0%; low certainty), and doubling of SCr (2 studies, 767 participants: RR 0.88, 95% CI 0.52 to 1.48; I2 = 0%; low certainty). Compared to ACEi plus ARB, ACEi alone has uncertain effects on all-cause death (6 studies, 1166 participants: RR 1.08, 95% CI 0.49 to 2.40; I2 = 20%; low certainty), withdrawal from treatment (2 studies, 172 participants: RR 0.78, 95% CI 0.33 to 1.86; I2 = 0%; low certainty), cardiovascular death (4 studies, 994 participants: RR 3.02, 95% CI 0.61 to 14.85; low certainty), kidney failure (3 studies, 880 participants: RR 1.36, 95% CI 0.79 to 2.32; I2 = 0%; low certainty), and doubling of SCr (2 studies, 813 participants: RR 1.14, 95% CI 0.70 to 1.85; I2 = 0%; low certainty). Compared to ACEi plus ARB, ARB alone has uncertain effects on all-cause death (7 studies, 2607 participants: RR 1.02, 95% CI 0.76 to 1.37; I2 = 0%; low certainty), withdrawn from treatment (3 studies, 1615 participants: RR 0.81, 95% CI 0.53 to 1.24; I2 = 0%; low certainty), cardiovascular death (4 studies, 992 participants: RR 3.03, 95% CI 0.62 to 14.93; low certainty), kidney failure (4 studies, 2321 participants: RR 1.15, 95% CI 0.67 to 1.95; I2 = 29%; low certainty), and doubling of SCr (3 studies, 2252 participants: RR 1.18, 95% CI 0.85 to 1.64; I2 = 0%; low certainty). Comparative effects of different ACEi or ARB and low-dose versus high-dose ARB were rarely evaluated. No study compared different doses of ACEi. Adverse events of ACEi and ARB were rarely reported. AUTHORS' CONCLUSIONS ACEi or ARB may make little or no difference to all-cause and cardiovascular death compared to placebo or no treatment in people with diabetes and kidney disease but may prevent kidney failure. ARB may prevent the doubling of SCr and the progression from microalbuminuria to macroalbuminuria compared with a placebo or no treatment. Despite the international guidelines suggesting not combining ACEi and ARB treatment, the effects of ACEi or ARB monotherapy compared to dual therapy have not been adequately assessed. The limited data availability and the low quality of the included studies prevented the assessment of the benefits and harms of ACEi or ARB in people with diabetes and kidney disease. Low and very low certainty evidence indicates that it is possible that further studies might provide different results.
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Affiliation(s)
- Patrizia Natale
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | | | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Lv Y, Zhai C, Sun G, He Y. Chitosan as a promising materials for the construction of nanocarriers for diabetic retinopathy: an updated review. J Biol Eng 2024; 18:18. [PMID: 38388386 PMCID: PMC10885467 DOI: 10.1186/s13036-024-00414-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
Diabetic retinopathy (DR) is a condition that causes swelling of the blood vessels of the retina and leaks blood and fluids. It is the most severe form of diabetic eye disease. It causes vision loss in its advanced stage. Diabetic retinopathy is responsible for causing 26% of blindness. Very insufficient therapies are accessible for the treatment of DR. As compared to the conventional therapies, there should be enhanced research on the controlled release, shorter duration, and cost-effective therapy of diabetic retinopathy. The expansion of advanced nanocarriers-based drug delivery systems has been now employed to exploit as well as regulate the transport of many therapeutic agents to target sites via the increase in penetration or the extension of the duration of contact employing production by enclosing as well as distributing tiny molecules in nanostructured formulation. Various polymers have been utilized for the manufacturing of these nanostructured formulations. Chitosan possesses incredible biological and chemical properties, that have led to its extensive use in pharmaceutical and biomedical applications. Chitosan has been used in many studies because of its enhanced mucoadhesiveness and non-toxicity. Multiple studies have used chitosan as the best candidate for manufacturing nanocarriers and treating diabetic retinopathy. Numerous nanocarriers have been formulated by using chitosan such as nanostructured lipid carriers, solid lipid nanoparticles, liposomes, and dendrimers for treating diabetic retinopathy. This current review elaborates on the recent advancements of chitosan as a promising approach for the manufacturing of nanocarriers that can be used for treating diabetic retinopathy.
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Affiliation(s)
- Yan Lv
- Department of Ophthalmology, Jilin Province FAW General Hospital, Changchun, 130011, China
| | - Chenglei Zhai
- Department of Orthopaedics, Jilin Province FAW General Hospital, Changchun, 130011, China
| | - Gang Sun
- Department of General Surgery, Jilin Province FAW General Hospital, Changchun, 130011, China.
| | - Yangfang He
- Department of Endocrinology, the Second Hospital of Jilin University, Changchun, 130000, China
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Iwane S, Nemoto W, Miyamoto T, Hayashi T, Tanaka M, Uchitani K, Muranaka T, Fujitani M, Koizumi Y, Hirata A, Tsubota M, Sekiguchi F, Tan-No K, Kawabata A. Clinical and preclinical evidence that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers prevent diabetic peripheral neuropathy. Sci Rep 2024; 14:1039. [PMID: 38200077 PMCID: PMC10781693 DOI: 10.1038/s41598-024-51572-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/06/2024] [Indexed: 01/12/2024] Open
Abstract
Given possible involvement of the central and peripheral angiotensin system in pain processing, we conducted clinical and preclinical studies to test whether pharmacological inhibition of the angiotensin system would prevent diabetic peripheral neuropathy (DPN) accompanying type 2 diabetes mellitus (T2DM). In the preclinical study, the nociceptive sensitivity was determined in leptin-deficient ob/ob mice, a T2DM model. A clinical retrospective cohort study was conducted, using the medical records of T2DM patients receiving antihypertensives at three hospitals for nearly a decade. In the ob/ob mice, daily treatment with perindopril, an angiotensin-converting enzyme inhibitor (ACEI), or telmisartan, an angiotensin receptor blocker (ARB), but not amlodipine, an L-type calcium channel blocker (CaB), significantly inhibited DPN development without affecting the hyperglycemia. In the clinical study, the enrolled 7464 patients were divided into three groups receiving ACEIs, ARBs and the others (non-ACEI, non-ARB antihypertensives). Bonferroni's test indicated significantly later DPN development in the ARB and ACEI groups than the others group. The multivariate Cox proportional analysis detected significant negative association of the prescription of ACEIs or ARBs and β-blockers, but not CaBs or diuretics, with DPN development. Thus, our study suggests that pharmacological inhibition of the angiotensin system is beneficial to prevent DPN accompanying T2DM.
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Affiliation(s)
- Shiori Iwane
- Laboratory of Pharmacology and Pathophysiology, Faculty of Pharmacy, Kindai University, Higashi-Osaka, 577-8502, Japan
- Department of Pharmacy, Kansai Medical University Hospital, Hirakata, 573-1191, Japan
| | - Wataru Nemoto
- Division of Pharmacology, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, 981-8558, Japan
| | - Tomoyoshi Miyamoto
- Laboratory of Pharmacology and Pathophysiology, Faculty of Pharmacy, Kindai University, Higashi-Osaka, 577-8502, Japan
- School of Pharmacy, Hyogo Medical University, Kobe, 650-8530, Japan
| | - Tomonori Hayashi
- Department of Pharmacy, Kindai University Nara Hospital, Ikoma, 630-0293, Japan
| | - Masayuki Tanaka
- Department of Pharmacy, Kansai Medical University Hospital, Hirakata, 573-1191, Japan
| | - Kazuki Uchitani
- Department of Pharmacy, Kansai Medical University Hospital, Hirakata, 573-1191, Japan
| | - Tatsuya Muranaka
- Department of Pharmacy, Kansai Medical University Hospital, Hirakata, 573-1191, Japan
| | - Masanori Fujitani
- Department of Pharmacy, Seichokai Fuchu Hospital, Izumi, 594-0076, Japan
| | - Yuichi Koizumi
- Department of Pharmacy, Seichokai Fuchu Hospital, Izumi, 594-0076, Japan
| | - Atsushi Hirata
- Department of Pharmacy, Kindai University Nara Hospital, Ikoma, 630-0293, Japan
| | - Maho Tsubota
- Laboratory of Pharmacology and Pathophysiology, Faculty of Pharmacy, Kindai University, Higashi-Osaka, 577-8502, Japan
| | - Fumiko Sekiguchi
- Laboratory of Pharmacology and Pathophysiology, Faculty of Pharmacy, Kindai University, Higashi-Osaka, 577-8502, Japan
| | - Koichi Tan-No
- Division of Pharmacology, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, 981-8558, Japan
| | - Atsufumi Kawabata
- Laboratory of Pharmacology and Pathophysiology, Faculty of Pharmacy, Kindai University, Higashi-Osaka, 577-8502, Japan.
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Satarug S, Vesey DA, Gobe GC, Phelps KR. The pathogenesis of albuminuria in cadmium nephropathy. Curr Res Toxicol 2023; 6:100140. [PMID: 38116328 PMCID: PMC10726218 DOI: 10.1016/j.crtox.2023.100140] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 11/16/2023] [Accepted: 11/30/2023] [Indexed: 12/21/2023] Open
Abstract
Background Urinary cadmium excretion (ECd) rises with renal tissue content of the metal. Whereas glomerulopathies are sometimes associated with massive albuminuria, tubular accumulation of Cd typically causes modest albuminuria. Since β2-microglobulinuria (Eβ2M) is an established marker of proximal tubular dysfunction, we hypothesized that a comparison of albuminuria (Ealb) to Eβ2M in Cd-exposed subjects would provide evidence of similar mishandling of both proteins. Methods To depict excretion rates per functional nephron, ECd, Ealb, and Eβ2M were normalized to creatinine clearance (Ccr), a surrogate for the glomerular filtration rate (GFR). Estimation of GFR itself (eGFR) was accomplished with CKD-EPI formulas (2009). Linear and logistic regression analyses were performed to relate Ealb/Ccr, Eβ2M/Ccr, and eGFR to several independent variables. Simple linear regressions of eGFR, Ealb/Ccr, and Eβ2M/Ccr on ECd/Ccr were examined before and after adjustment of dependent variables for age. All regressions were performed after log-transformation of ratios and standardization of all variables. Increments in Ealb/Ccr and Eβ2M/Ccr and decrements in eGFR were quantified through four quartiles of ECd/Ccr. Results As age or ECd/Ccr rose, Ealb/Ccr and Eβ2M/Ccr also rose, and eGFR fell. In linear regressions, slopes relating Ealb/Ccr and Eβ2M/Ccr to ECd/Ccr were similar. After adjustment of dependent variables for age, coefficients of determination (R2) for all regressions rose by a multiple, and slopes approached unity. Ealb/Ccr and Eβ2M/Ccr were similarly associated with each other. Mean Ealb/Ccr and Eβ2M/Ccr rose and mean eGFR fell in stepwise fashion through quartiles of ECd/Ccr. Whereas Eβ2M/Ccr did not vary with blood pressure, Ealb/Ccr rose in association with hypertension in two of the four quartiles. Conclusions Our data indicate that Cd in renal tissue affected tubular reabsorption of albumin and β2M similarly in a large cohort of exposed subjects. The results suggest that Cd reduced receptor-mediated endocytosis and subsequent lysosomal degradation of each protein by a shared mechanism.
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Affiliation(s)
- Soisungwan Satarug
- Centre for Kidney Disease Research, Translational Research Institute, Brisbane, Australia
| | - David A. Vesey
- Centre for Kidney Disease Research, Translational Research Institute, Brisbane, Australia
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, Australia
| | - Glenda C. Gobe
- Centre for Kidney Disease Research, Translational Research Institute, Brisbane, Australia
- School of Biomedical Sciences, The University of Queensland, Brisbane, Australia
- NHMRC Centre of Research Excellence for CKD QLD, UQ Health Sciences, Royal Brisbane and Women’s Hospital, Brisbane, Australia
| | - Kenneth R. Phelps
- Stratton Veterans Affairs Medical Center and Albany Medical College, Albany, NY, USA
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Park CH, Kim HW, Park JT, Chang TI, Yoo TH, Park SK, Kim Y, Jung JY, Jeong JC, Oh KH, Kang SW, Han SH. The 2021 KDIGO blood pressure target and the progression of chronic kidney disease: Findings from KNOW-CKD. J Intern Med 2023; 294:653-664. [PMID: 37538023 DOI: 10.1111/joim.13701] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
BACKGROUND The 2021 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline for the management of blood pressure (BP) in chronic kidney disease (CKD) recommends a target systolic BP of <120 mmHg as this target can provide cardiovascular benefits. However, it remains unclear whether implementing the new BP target could improve kidney outcomes. METHODS The association between the 2021 KDIGO BP target and CKD progression was examined and compared with the 2012 KDIGO BP target among 1724 participants included in the KoreaN Cohort Study for Outcomes in Patients With CKD. The main exposure was the BP status categorized according to the 2012 or 2021 KDIGO guideline: (1) controlled within the 2021 target, (2) controlled within the 2012 target only, and (3) above both targets. The primary outcome was a composite kidney outcome of ≥50% decline in the estimated glomerular filtration rate from baseline or the initiation of kidney replacement therapy during the follow-up period. RESULTS Composite kidney outcomes occurred in 650 (37.7%) participants during the 8078 person-years of follow-up (median, 4.9 years). The incidence rates of this outcome were 55, 66.5, and 116.4 per 1000 person-years in BP controlled within the 2021 and 2012 KDIGO targets, and BP above both targets, respectively. In the multivariable cause-specific hazard model, hazard ratios for the composite outcome were 0.76 (95% confidence interval (CI), 0.60-0.95) for BP controlled within the 2021 target and 1.36 (95% CI, 1.13-1.64) for BP above both targets, compared with BP controlled within 2012 target only. CONCLUSION The newly lowered BP target by the 2021 KDIGO guideline was associated with improved kidney outcome compared with BP target by the 2012 KDIGO guideline.
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Affiliation(s)
- Cheol Ho Park
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Hyung Woo Kim
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Jung Tak Park
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Tae Ik Chang
- Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Sue Kyung Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yaeni Kim
- Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji Yong Jung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Jong Cheol Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Kidney Research Institute, Seoul, Republic of Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
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Rivetti G, Gizzone P, Di Sessa A, Guarino S, Miraglia Del Giudice E, Marzuillo P. Renin angiotensin aldosterone inhibitors in the treatment of proteinuria in children with congenital anomalies of the kidney and urinary tract: more evidence needed. Expert Rev Clin Pharmacol 2023; 16:791-798. [PMID: 37577983 DOI: 10.1080/17512433.2023.2247985] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/31/2023] [Accepted: 08/11/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Congenital anomalies of the kidney and urinary tract (CAKUT) can be associated with proteinuria, possibly leading to a decline in kidney function. The aim of this review is to evaluate evidence on the efficacy of renin-angiotensin-aldosterone system inhibitors (RAASi) in children affected by CAKUT with proteinuria or chronic kidney disease (CKD). AREAS COVERED We conducted a bibliographic search between 1 December 2022 and 20 February 2023, including randomized controlled trials, case-control studies, observational studies, meta-analyses, and systematic reviews dealing with the efficacy of RAASi in reducing proteinuria and slowing the decline of kidney function in children. EXPERT OPINION RAASi are effective in reducing proteinuria and slowing CKD progression in many renal conditions; however, the efficacy of these drugs in patients affected by CAKUT with proteinuria is still unknown. While waiting for more evidence, when facing a child with CAKUT with isolated proteinuria or with proteinuria and CKD, a 6-12-month trial with RAASi with gradual increase to the maximal tolerated dose should be considered. If no improvement of proteinuria is obtained, the RAASi should be discontinued.
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Affiliation(s)
- Giulio Rivetti
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Pietro Gizzone
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Anna Di Sessa
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Stefano Guarino
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Emanuele Miraglia Del Giudice
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Pierluigi Marzuillo
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Napoli, Italy
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9
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Zhang M, Wu J, Wang Y, Wu J, Hu W, Jia H, Sun X. Associations between blood pressure levels and diabetic retinopathy in patients with diabetes mellitus: A population-based study. Heliyon 2023; 9:e16830. [PMID: 37484372 PMCID: PMC10360950 DOI: 10.1016/j.heliyon.2023.e16830] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 05/28/2023] [Accepted: 05/30/2023] [Indexed: 07/25/2023] Open
Abstract
Purpose To evaluate the associations of blood pressure levels with diabetic retinopathy (DR), proliferative diabetic retinopathy (PDR) and diabetic macular edema (DME) in patients with diabetes mellitus. Design A cross-sectional, population-based study. Subjects A total of 152,844 patients with diabetes from 90 major cities in 19 provincial regions of mainland China during 2018-2021 were finally recruited. Methods Blood pressure was graded into 5 levels: normal (without hypertension and <120/80 mmHg), normal high (without hypertension and ≥120/80 mmHg), HT-intensive (hypertension and <120/80 mmHg), HT-moderate (hypertension and blood pressure between 120/80 mmHg and 140/90 mmHg) and HT-high (hypertension and ≥140/90 mmHg). Logistic regression was employed to verify the associations of hypertension and blood pressure levels with DR, PDR and DME. The impacts of blood pressure levels on the outcomes were qualified with nomogram models. Main outcome measures The main outcome was DR. Results There were 16,685 (10.92%) participants having DR, 2841 (1.86%) having PDR, and 1566 (1.02%) having DME. There were 8126 (5.32%) patients without hypertension and 1350 (0.88%) patients with hypertension having blood pressure <120/80 mmHg. When compared to the normal group with covariates adjusted, an increased prevalence of DR was observed in normal high (adjusted odds ratio [OR] = 1.114, 95% confidence interval [CI] = 1.033-1.202), HT-moderate (adjusted OR = 1.163, 95% CI = 1.065-1.271), and HT-high (adjusted OR = 1.203, 95% CI = 1.114-1.300). Conclusions There were associations between hypertension and DR, PDR, and DME in the diabetic population. Increased prevalence of DR was found with blood pressure >120/80 mmHg in both patients with and without hypertension. A nomogram was developed for DR prediction based on blood pressure levels.
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Affiliation(s)
- Min Zhang
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinye Wu
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yimin Wang
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Eye Diseases, Shanghai, China
- Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai, China
- Shanghai Engineering Center for Visual Science and Photomedicine, Shanghai, China
- Shanghai Engineering Center for Precise Diagnosis and Treatment of Eye Diseases, Shanghai, China
| | - Jiali Wu
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Eye Diseases, Shanghai, China
- Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai, China
- Shanghai Engineering Center for Visual Science and Photomedicine, Shanghai, China
- Shanghai Engineering Center for Precise Diagnosis and Treatment of Eye Diseases, Shanghai, China
| | - Weiting Hu
- Shanghai Phoebus Medical Co. Ltd., Shanghai, China
| | - Huixun Jia
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Eye Diseases, Shanghai, China
- Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai, China
- Shanghai Engineering Center for Visual Science and Photomedicine, Shanghai, China
| | - Xiaodong Sun
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Eye Diseases, Shanghai, China
- Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai, China
- Shanghai Engineering Center for Visual Science and Photomedicine, Shanghai, China
- Shanghai Engineering Center for Precise Diagnosis and Treatment of Eye Diseases, Shanghai, China
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10
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Do DV, Han G, Abariga SA, Sleilati G, Vedula SS, Hawkins BS. Blood pressure control for diabetic retinopathy. Cochrane Database Syst Rev 2023; 3:CD006127. [PMID: 36975019 PMCID: PMC10049880 DOI: 10.1002/14651858.cd006127.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND Diabetic retinopathy is a common complication of diabetes and a leading cause of visual impairment and blindness. Research has established the importance of blood glucose control to prevent development and progression of the ocular complications of diabetes. Concurrent blood pressure control has been advocated for this purpose, but individual studies have reported varying conclusions regarding the effects of this intervention. OBJECTIVES To summarize the existing evidence regarding the effect of interventions to control blood pressure levels among diabetics on incidence and progression of diabetic retinopathy, preservation of visual acuity, adverse events, quality of life, and costs. SEARCH METHODS We searched several electronic databases, including CENTRAL, and trial registries. We last searched the electronic databases on 3 September 2021. We also reviewed the reference lists of review articles and trial reports selected for inclusion. SELECTION CRITERIA We included randomized controlled trials (RCTs) in which either type 1 or type 2 diabetic participants, with or without hypertension, were assigned randomly to more intense versus less intense blood pressure control; to blood pressure control versus usual care or no intervention on blood pressure (placebo); or to one class of antihypertensive medication versus another or placebo. DATA COLLECTION AND ANALYSIS Pairs of review authors independently reviewed the titles and abstracts of records identified by the electronic and manual searches and the full-text reports of any records identified as potentially relevant. The included trials were independently assessed for risk of bias with respect to outcomes reported in this review. MAIN RESULTS We included 29 RCTs conducted in North America, Europe, Australia, Asia, Africa, and the Middle East that had enrolled a total of 4620 type 1 and 22,565 type 2 diabetic participants (sample sizes from 16 to 4477 participants). In all 7 RCTs for normotensive type 1 diabetic participants, 8 of 12 RCTs with normotensive type 2 diabetic participants, and 5 of 10 RCTs with hypertensive type 2 diabetic participants, one group was assigned to one or more antihypertensive agents and the control group to placebo. In the remaining 4 RCTs for normotensive participants with type 2 diabetes and 5 RCTs for hypertensive type 2 diabetic participants, methods of intense blood pressure control were compared to usual care. Eight trials were sponsored entirely and 10 trials partially by pharmaceutical companies; nine studies received support from other sources; and two studies did not report funding source. Study designs, populations, interventions, lengths of follow-up (range less than one year to nine years), and blood pressure targets varied among the included trials. For primary review outcomes after five years of treatment and follow-up, one of the seven trials for type 1 diabetics reported incidence of retinopathy and one trial reported progression of retinopathy; one trial reported a combined outcome of incidence and progression (as defined by study authors). Among normotensive type 2 diabetics, four of 12 trials reported incidence of diabetic retinopathy and two trials reported progression of retinopathy; two trials reported combined incidence and progression. Among hypertensive type 2 diabetics, six of the 10 trials reported incidence of diabetic retinopathy and two trials reported progression of retinopathy; five of the 10 trials reported combined incidence and progression. The evidence supports an overall benefit of more intensive blood pressure intervention for five-year incidence of diabetic retinopathy (11 studies; 4940 participants; risk ratio (RR) 0.82, 95% confidence interval (CI) 0.73 to 0.92; I2 = 15%; moderate certainty evidence) and the combined outcome of incidence and progression (8 studies; 6212 participants; RR 0.78, 95% CI 0.68 to 0.89; I2 = 42%; low certainty evidence). The available evidence did not support a benefit regarding five-year progression of diabetic retinopathy (5 studies; 5144 participants; RR 0.94, 95% CI 0.78 to 1.12; I2 = 57%; moderate certainty evidence), incidence of proliferative diabetic retinopathy, clinically significant macular edema, or vitreous hemorrhage (9 studies; 8237 participants; RR 0.92, 95% CI 0.82 to 1.04; I2 = 31%; low certainty evidence), or loss of 3 or more lines on a visual acuity chart with a logMAR scale (2 studies; 2326 participants; RR 1.15, 95% CI 0.63 to 2.08; I2 = 90%; very low certainty evidence). Hypertensive type 2 diabetic participants realized more benefit from intense blood pressure control for three of the four outcomes concerning incidence and progression of diabetic retinopathy. The adverse event reported most often (13 of 29 trials) was death, yielding an estimated RR 0.87 (95% CI 0.76 to 1.00; 13 studies; 13,979 participants; I2 = 0%; moderate certainty evidence). Hypotension was reported in two trials, with an RR of 2.04 (95% CI 1.63 to 2.55; 2 studies; 3323 participants; I2 = 37%; low certainty evidence), indicating an excess of hypotensive events among participants assigned to more intervention on blood pressure. AUTHORS' CONCLUSIONS Hypertension is a well-known risk factor for several chronic conditions for which lowering blood pressure has proven to be beneficial. The available evidence supports a modest beneficial effect of intervention to reduce blood pressure with respect to preventing diabetic retinopathy for up to five years, particularly for hypertensive type 2 diabetics. However, there was a paucity of evidence to support such intervention to slow progression of diabetic retinopathy or to affect other outcomes considered in this review among normotensive diabetics. This weakens any conclusion regarding an overall benefit of intervening on blood pressure in diabetic patients without hypertension for the sole purpose of preventing diabetic retinopathy or avoiding the need for treatment for advanced stages of diabetic retinopathy.
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Affiliation(s)
- Diana V Do
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Genie Han
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Samuel A Abariga
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Barbara S Hawkins
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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11
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Erlendsdottir M, Crawford FW. Randomized controlled trials of biomarker targets. Clin Trials 2023; 20:47-58. [PMID: 36373783 PMCID: PMC9974557 DOI: 10.1177/17407745221131820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Randomized controlled trials are used to estimate the causal effect of a treatment on a health outcome of interest in a patient population. Often the specified treatment in a randomized controlled trial is a medical intervention-such as a drug or procedure-experienced directly by the patient. Sometimes the "treatment" in a randomized controlled trial is a target-such as a goal biomarker measurement-that the patient's physician attempts to reach using available medications or procedures. Large randomized controlled trials of biomarker targets are common in clinical research, and trials have been conducted to compare targets in the management of hypertension, diabetes, anemia, and acute respiratory distress syndrome. However, different randomized controlled trials intended to evaluate the same biomarker targets have produced conflicting recommendations, and meta-analyses that aggregate results of trials of biomarker targets have been inconclusive. METHODS We use causal reasoning to explain why randomized controlled trials of biomarker targets can arrive at conflicting or misleading conclusions. We describe four key threats to the validity of trials of targets: (1) intention-to-treat analysis can be misleading when a direct effect of target assignment on the outcome exists due to lack of blinding; (2) incomparability in results across trials of targets; (3) time-varying adaptive treatment strategies; and (4) Goodhart's law, "when a measure becomes a target, it ceases to be a good measure." RESULTS We illustrate these findings using evidence from 15 randomized controlled trials of blood pressure targets for management of hypertension. Randomized trials of blood pressure targets exhibit substantial variation in the trial patient populations and antihypertensives used to achieve the blood pressure targets assigned in the trials. The trials did not compare or account for time-varying treatment strategies used to reach the randomized targets. Possible "off-target" effects of antihypertensive medications needed to reach lower blood pressure targets may explain the absence of a clear benefit from intensive blood pressure control. DISCUSSION Researchers should critically assess meta-analyses of trials of targets for variation in the types, distributions, and off-target effects of therapies studied. Trial investigators should release detailed information about the biomarker targets compared in new randomized trials, as well as confounders, treatments delivered, and outcomes. New randomized controlled trials should experimentally compare treatment algorithms incorporating biomarkers, rather than targets alone. Causal inference methodology that adjusts for time-varying confounding should be used to compare time-varying treatment strategies in observational settings.
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Affiliation(s)
| | - Forrest W. Crawford
- Department of Biostatistics, Yale School of Public Health,Department of Statistics & Data Science, Yale University,Department of Ecology & Evolutionary Biology, Yale University,Yale School of Management
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12
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Hodson EM, Cooper TE. Altered dietary salt intake for preventing diabetic kidney disease and its progression. Cochrane Database Syst Rev 2023; 1:CD006763. [PMID: 36645291 PMCID: PMC9841968 DOI: 10.1002/14651858.cd006763.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND There is strong evidence that our current consumption of salt is a major factor in the development of increased blood pressure (BP) and that a reduction in our salt intake lowers BP, whether BP levels are normal or raised initially. Effective control of BP in people with diabetes lowers the risk of strokes, heart attacks and heart failure and slows the progression of chronic kidney disease (CKD) in people with diabetes. This is an update of a review first published in 2010. OBJECTIVES To evaluate the effect of altered salt intake on BP and markers of cardiovascular disease and of CKD in people with diabetes. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 31 March 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) of altered salt intake in individuals with type 1 and type 2 diabetes. Studies were included when there was a difference between low and high sodium intakes of at least 34 mmol/day. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies and resolved differences by discussion. We calculated mean effect sizes as mean difference (MD) and 95% confidence intervals (CI) using the random-effects model. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS Thirteen RCTs (313 participants), including 21 comparisons (studies), met our inclusion criteria. One RCT (two studies) was added to this review update. Participants included 99 individuals with type 1 diabetes and 214 individuals with type 2 diabetes. Two RCTs (four studies) included some participants with reduced overall kidney function. The remaining studies either reported that participants with reduced glomerular filtration rate (GFR) were excluded from the study or only included participants with microalbuminuria and normal GFR. Five studies used a parallel study design, and 16 used a cross-over design. Studies were at high risk of bias for most criteria. Random sequence generation and allocation concealment were adequate in only three and two studies, respectively. One study was at low risk of bias for blinding of participants and outcome assessment, but no studies were at low risk for selective reporting. Twelve studies reported non-commercial funding sources, three reported conflicts of interest, and eight reported adequate washout between interventions in cross-over studies. The median net reduction in 24-hour urine sodium excretion (24-hour UNa) in seven long-term studies (treatment duration four to 12 weeks) was 76 mmol (range 51 to 124 mmol), and in 10 short-term studies (treatment duration five to seven days) was 187 mmol (range 86 to 337 mmol). Data were only available graphically in four studies. In long-term studies, reduced sodium intake may lower systolic BP (SBP) by 6.15 mm Hg (7 studies: 95% CI -9.27 to -3.03; I² = 12%), diastolic BP (DBP) by 3.41 mm Hg (7 studies: 95% CI -5.56 to -1.27; I² = 41%) and mean arterial pressure (MAP) by 4.60 mm Hg (4 studies: 95% CI -7.26 to -1.94; I² = 28%). In short-term studies, low sodium intake may reduce SBP by 8.43 mm Hg (5 studies: 95% CI -14.37 to -2.48; I² = 88%), DBP by 2.95 mm Hg (5 studies: 95% CI -4.96 to -0.94; I² = 70%) and MAP by 2.37 mm Hg (9 studies: 95% CI -4.75 to -0.01; I² = 65%). There was considerable heterogeneity in most analyses but particularly among short-term studies. All analyses were considered to be of low certainty evidence. SBP, DBP and MAP reductions may not differ between hypertensive and normotensive participants or between individuals with type 1 or type 2 diabetes. In hypertensive participants, SBP, DBP and MAP may be reduced by 6.45, 3.15 and 4.88 mm Hg, respectively, while in normotensive participants, they may be reduced by 8.43, 2.95 and 2.15 mm Hg, respectively (all low certainty evidence). SBP, DBP and MAP may be reduced by 7.35, 3.04 and 4.30 mm Hg, respectively, in participants with type 2 diabetes and by 7.35, 3.20, and 0.08 mm Hg, respectively, in participants with type 1 diabetes (all low certainty evidence). Eight studies provided measures of urinary protein excretion before and after salt restriction; four reported a reduction in urinary albumin excretion with salt restriction. Pooled analyses showed no changes in GFR (12 studies: MD -1.87 mL/min/1.73 m², 95% CI -5.05 to 1.31; I² = 32%) or HbA1c (6 studies: MD -0.62, 95% CI -1.49 to 0.26; I² = 95%) with salt restriction (low certainty evidence). Body weight was reduced in studies lasting one to two weeks but not in studies lasting for longer periods (low certainty evidence). Adverse effects were reported in only one study; 11% and 21% developed postural hypotension on the low-salt diet and the low-salt diet combined with hydrochlorothiazide, respectively. AUTHORS' CONCLUSIONS This systematic review shows an important reduction in SBP and DBP in people with diabetes with normal GFR during short periods of salt restriction, similar to that obtained with single drug therapy for hypertension. These data support the international recommendations that people with diabetes with or without hypertension or evidence of kidney disease should reduce salt intake to less than 5 g/day (2 g sodium).
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Affiliation(s)
- Elisabeth M Hodson
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Tess E Cooper
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
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13
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Kim Y, Kim W, Kim JK, Moon JY, Park S, Park CW, Park HS, Song SH, Yoo TH, Lee SY, Lee EY, Lee J, Jin K, Cha DR, Cha JJ, Han SY. Blood Pressure Control in Patients with Diabetic Kidney Disease. Electrolyte Blood Press 2022; 20:39-48. [PMID: 36688208 PMCID: PMC9827046 DOI: 10.5049/ebp.2022.20.2.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/21/2022] [Accepted: 12/05/2022] [Indexed: 01/06/2023] Open
Abstract
Diabetic kidney disease (DKD) is the most common cause of end-stage kidney disease. Blood pressure (BP) control can reduce the risks of cardiovascular (CV) morbidity, mortality, and kidney disease progression. Recently, the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines have suggested the implementation of a more intensive BP control with a target systolic BP (SBP) of <120 mmHg based on the evidence that the CV benefits obtained is outweighed by the kidney injury risk associated with a lower BP target. However, an extremely low BP level may paradoxically aggravate renal function and CV outcomes. Herein, we aimed to review the existing literature regarding optimal BP control using medications for DKD.
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Affiliation(s)
- Yaeni Kim
- Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University, Seoul, Republic of Korea
| | - Won Kim
- Department of Internal Medicine, Jeonbuk National University Medical School, Jeonju, Republic of Korea
| | - Jwa-Kyung Kim
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Ju Young Moon
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Samel Park
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Cheol Whee Park
- Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University, Seoul, Republic of Korea
| | - Hoon Suk Park
- Division of Nephrology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, The Catholic University, Seoul, Republic of Korea
| | - Sang Heon Song
- Department of Internal Medicine & Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - So-Young Lee
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Eun Young Lee
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Jeonghwan Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Kyubok Jin
- Department of Internal Medicine, Keimyung University School of Medicine, Keimyung University Kidney Institute, Daegu, Republic of Korea
| | - Dae Ryong Cha
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Jin Joo Cha
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Sang Youb Han
- Department of Internal Medicine, Inje University College of Medicine, Ilsan-Paik Hospital, Goyang, Republic of Korea
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14
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Fu C, Zhang D, Chen H, Zhang H. Timed-averaged blood pressure showed a J-curve association with stroke in elderly chronic kidney disease patients. Ren Fail 2022; 44:1677-1686. [PMID: 36222093 PMCID: PMC9578479 DOI: 10.1080/0886022x.2022.2131574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/30/2022] Open
Abstract
BACKGROUND The risk factors for stroke in elderly patients with chronic kidney disease (CKD) are not well understood. This study aimed to explore the influence of systolic blood pressure (SBP) on the risk of stroke in a large cohort of elderly patients with stage 3-5 CKD. METHODS We retrospectively identified 665 patients hospitalized in Beijing Friendship Hospital from January 2000 to December 2021. Patients were followed up until the occurrence of stroke or death. Multivariate logistic regression analysis and Cox proportional hazard models were used to analyze the risk factors for stroke according to the presence or absence of CKD. The association between CKD and stroke was further evaluated regarding the role of SBP in the hypertensive population. RESULTS In individuals with CKD, a J-shaped relationship was observed between SBP levels and the risk of stroke. Participants with CKD and an SBP less than 125 mmHg had a significantly higher cumulative stroke survival rate than those whose SBP was between 125 and 139 mmHg. The cumulative stroke survival rate increased progressively for those with SBP higher than 140 mmHg. This J-shaped relationship was not found in patients without CKD. CONCLUSION In elderly patients with CKD, those with the lowest BP are at increased risk for incident stroke. This phenomenon could be different from that in the general population.
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Affiliation(s)
- Chen Fu
- Department of Nephrology, Beijing Jishuitan Hospital, Beijing, China
| | - Dongliang Zhang
- Department of Nephrology, Beijing Jishuitan Hospital, Beijing, China
| | - Haiping Chen
- Department of Geriatric Nephrology, Medical and Health Care Center, Beijing Friendship Hospital (affiliated with Capital Medical University), Beijing, China
| | - Hui Zhang
- Department of Nephrology, Tianjin Hospital, Tianjin, China
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15
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Controversies in Hypertension II: The Optimal Target Blood Pressure. Am J Med 2022; 135:1168-1177.e3. [PMID: 35636475 DOI: 10.1016/j.amjmed.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 11/22/2022]
Abstract
The optimal target blood pressure in the treatment of hypertension is undefined. Whether more intense therapy is better than standard, typically <140/90 mm Hg, is controversial. The most recent American guidelines recommend ≤130/80 mm Hg for essentially all adults. There have been at least 28 trials targeting more versus less intensive therapy, including 13 aimed at reducing cardiovascular events and mortality, 11 restricted to patients with chronic kidney disease, and 4 with surrogate endpoints. We review these trials in a narrative fashion due to significant heterogeneity in targets chosen, populations studied, and primary endpoints. Most were negative, although some showed significant benefit to more intense therapy. When determining the optimal pressure for an individual patient, additional factors should be considered, including age, frailty, polypharmacy, baseline blood pressure, and the diastolic blood pressure J-curve. We discuss these modifying factors in detail. Whereas the tenet "lower is better" is generally true, one size does not fit all, and blood pressure control must be individualized.
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16
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Razo C, Welgan CA, Johnson CO, McLaughlin SA, Iannucci V, Rodgers A, Wang N, LeGrand KE, Sorensen RJD, He J, Zheng P, Aravkin AY, Hay SI, Murray CJL, Roth GA. Effects of elevated systolic blood pressure on ischemic heart disease: a Burden of Proof study. Nat Med 2022; 28:2056-2065. [PMID: 36216934 PMCID: PMC9556328 DOI: 10.1038/s41591-022-01974-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 07/27/2022] [Indexed: 12/28/2022]
Abstract
High systolic blood pressure (SBP) is a major risk factor for ischemic heart disease (IHD), the leading cause of death worldwide. Using data from published observational studies and controlled trials, we estimated the mean SBP-IHD dose-response function and burden of proof risk function (BPRF), and we calculated a risk outcome score (ROS) and corresponding star rating (one to five). We found a very strong, significant harmful effect of SBP on IHD, with a mean risk-relative to that at 100 mm Hg SBP-of 1.39 (95% uncertainty interval including between-study heterogeneity 1.34-1.44) at 120 mm Hg, 1.81 (1.70-1.93) at 130 mm Hg and 4.48 (3.81-5.26) at 165 mm Hg. The conservative BPRF measure indicated that SBP exposure between 107.5 and 165.0 mm Hg raised risk by 101.36% on average, yielding a ROS of 0.70 and star rating of five. Our analysis shows that IHD risk was already increasing at 120 mm Hg SBP, rising steadily up to 165 mm Hg and increasing less steeply above that point. Our study endorses the need to prioritize and strengthen strategies for screening, to raise awareness of the need for timely diagnosis and treatment of hypertension and to increase the resources allocated for understanding primordial prevention of elevated blood pressure.
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Affiliation(s)
- Christian Razo
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA.
| | | | - Catherine O Johnson
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Susan A McLaughlin
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Vincent Iannucci
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Anthony Rodgers
- The George Institute for Global Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Nelson Wang
- The George Institute for Global Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Kate E LeGrand
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Reed J D Sorensen
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jiawei He
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Peng Zheng
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Aleksandr Y Aravkin
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
- Department of Applied Mathematics, University of Washington, Seattle, WA, USA
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher J L Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Gregory A Roth
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
- Division of Cardiology, University of Washington, Seattle, WA, USA
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17
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Wang M, Xia M, Yang H, Zhang D, Zhao Y, He Y, Liu J, Zhang L, Yin C, Bai Y. Interaction effect of blood glucose and pressure on the risk of chronic kidney disease: a population-based prospective cohort study. Endocrine 2022; 77:252-261. [PMID: 35778587 DOI: 10.1007/s12020-022-03094-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 05/23/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the interaction effect of blood glucose and blood pressure on the risk of chronic kidney disease (CKD). METHODS 31,165 subjects were selected without CKD at baseline and had completed the first follow-up from "Jinchang cohort". Cox regression model and restricted cubic splines functions were used to evaluate the effects of blood glucose or pressure on the incidence of CKD and dose-response relationship after adjusting for confounding covariates. Synergic effect was assessed by the multiplicative or additive interaction scale. RESULTS Among 31,165 subjects, 1307 new-onset CKD were observed during 68905.78 person-years follow-up, and the incidence density was 18.97 per 1000 person-years. The risk of CKD gradually increased with the increase of blood pressure in diabetes, pre-diabetes and normal groups (Ptrend < 0.05). And, the risk was greatest when SBP/DBP reached ≥150/≥110 mmHg in three groups, and HRs (95% CI) were 1.610 (1.070-2.422), 2.142 (1.396-3.288) and 2.455 (1.941-3.106), respectively. Additionally, among hypertension, pre-hypertension and normal groups, the risk of CKD increased by 16.0%, 14.3% and 25.2% for each 1 mmol/L of FPG. When FPG level was more than 9.0 mmol/L, the risk was greatest and adjusted HRs (95% CI) were 2.856 (2.176-3.748), 2.979 (1.828-4.854) and 7.520 (4.517-12.519). Furthermore, the risk was highest when hypertension was accompanied by diabetes (HR = 4.915, 95% CI: 3.923-6.157). This analysis supported a less than multiplicative effect (HR = 0.634, 95% CI: 0.417-0.964) for the interaction term of diabetes and hypertension, while there was no additive interaction towards CKD in all interaction term. CONCLUSIONS Blood glucose and pressure were independent risk factors in incidence of CKD, but there was only a negative multiplicative interaction between hypertension and diabetes, but no additive interaction effect between them.
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Affiliation(s)
- Minzhen Wang
- Department of Epidemiology and Statistics, School of Public Health, Lanzhou University, Lanzhou, 730000, Gansu, China
| | - Miao Xia
- Department of Epidemiology and Statistics, School of Public Health, Lanzhou University, Lanzhou, 730000, Gansu, China
| | - Hongyan Yang
- Department of Epidemiology and Statistics, School of Public Health, Lanzhou University, Lanzhou, 730000, Gansu, China
| | - Desheng Zhang
- Workers' Hospital of Jinchuan Group Co, Ltd, Jinchang, 737100, Gansu, China
| | - Yanan Zhao
- Department of Epidemiology and Statistics, School of Public Health, Lanzhou University, Lanzhou, 730000, Gansu, China
| | - Yingqian He
- Department of Epidemiology and Statistics, School of Public Health, Lanzhou University, Lanzhou, 730000, Gansu, China
| | - Jing Liu
- Department of Epidemiology and Statistics, School of Public Health, Lanzhou University, Lanzhou, 730000, Gansu, China
| | - Lulu Zhang
- Department of Epidemiology and Statistics, School of Public Health, Lanzhou University, Lanzhou, 730000, Gansu, China
| | - Chun Yin
- Workers' Hospital of Jinchuan Group Co, Ltd, Jinchang, 737100, Gansu, China.
| | - Yana Bai
- Department of Epidemiology and Statistics, School of Public Health, Lanzhou University, Lanzhou, 730000, Gansu, China.
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18
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The Role of Angiotensin Receptor Blockers in the Personalized Management of Diabetic Neuropathy. J Pers Med 2022; 12:jpm12081253. [PMID: 36013202 PMCID: PMC9410471 DOI: 10.3390/jpm12081253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 11/20/2022] Open
Abstract
Neuropathy is a frequent complication of diabetes mellitus (DM) and is associated with the increased risk ofamputation and vascular events. Tight glycemic control is an important component inthe prevention of diabetic neuropathy. However, accumulating data suggest that angiotensin receptor blockers (ARBs) might also be useful in this setting. We discuss the findings of both experimental and clinical studies that evaluated the effects of ARBs on indices of diabetic neuropathy. We also review the implicated mechanisms of the neuroprotective actions of these agents. Overall, it appears that ARBs might be a helpful tool for preventing and delaying the progression of diabetic neuropathy, but more data are needed to clarify their role in the management of this overlooked complication of DM.
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19
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Reboldi G, Angeli F, Gentile G, Verdecchia P. Benefits of more intensive versus less intensive blood pressure control. Updated trial sequential analysis. Eur J Intern Med 2022; 101:49-55. [PMID: 35397950 DOI: 10.1016/j.ejim.2022.03.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/24/2022] [Accepted: 03/30/2022] [Indexed: 01/02/2023]
Abstract
Outcome data from randomized trials which compared different blood pressure (BP) targets grew impressively after publication of recent trials. We conducted a cumulative updated trial sequential analysis of studies which compared a more versus less intensive BP control strategy, for a total of 60,870 randomized patients. The compared BP targets differed across the trials. Outcome measures were stroke, heart failure, myocardial infarction and cardiovascular death. The average duration of follow-up was 3.95 years and achieved systolic BP was 7.69 mmHg lower with the more intensive than the less intensive BP control strategy. The more intensive BP control strategy significantly reduced the risk of stroke (OR 0.79; 95% CI 0.67-0.93), heart failure (OR 0.73; 95% CI 0.55-0.96), myocardial infarction (OR 0.81; 95% CI 0.73-0.91) and cardiovascular death (OR 0.81; 95% CI 0.68-0.98) as compared to the less intensive strategy. In a trial sequential analysis, the more intensive BP control strategy provided conclusive benefits over the less intensive strategy on the risk of stroke, heart failure and myocardial infarction by definitely crossing the efficacy monitoring boundary. For cardiovascular death, the cumulative Z-curve of the sequential analysis touched the efficacy monitoring boundary, but did not cross it. In conclusion, data accrued from randomized trials conclusively demonstrate the superiority of a more intensive over a less intensive BP control strategy for the prevention of stroke, heart failure and myocardial infarction. Results also suggest a significant benefit, albeit not yet conclusive, of a more intensive over a less intensive strategy for prevention of cardiovascular death.
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Affiliation(s)
- Gianpaolo Reboldi
- Department of Medicine, Centro di Ricerca Clinica e Traslazionale (CERICLET), University of Perugia, Perugia, Italy
| | - Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, Varese and Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS Tradate, Italy
| | - Giorgio Gentile
- Royal Cornwall Hospitals, NHS Trust, Truro, Cornwall, United Kingdom; University of Exeter Medical School, Exeter, United Kingdom
| | - Paolo Verdecchia
- Fondazione Umbra Cuore e Ipertensione-ONLUS and Division of Cardiology, Hospital S. Maria della Misericordia, Perugia, Italy.
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20
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Alsalemi N, Sadowski CA, Elftouh N, Louis M, Kilpatrick K, Houle SKD, Lafrance JP. The effect of renin-angiotensin-aldosterone system inhibitors on continuous and binary kidney outcomes in subgroups of patients with diabetes: a meta-analysis of randomized clinical trials. BMC Nephrol 2022; 23:161. [PMID: 35484505 PMCID: PMC9052620 DOI: 10.1186/s12882-022-02763-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 03/29/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction Diabetic nephropathy is the leading cause of kidney failure. Clinical practice guidelines recommend prescribing renin–angiotensin aldosterone system inhibitors (RAASi) to prevent diabetic nephropathy at any stage. We conducted this systematic review and meta-analysis to compare the effects of RAASi with placebo and other antihypertensive agents in adults with diabetes on continuous and binary kidney outcomes to provide a comprehensive review of the class effect of RAASi on several subgroups. Methods A systematic electronic search to identify randomized clinical trials of a duration of ≥ 12 months that recruited ≥ 50 adult participants with type 1 or 2 diabetes with any stage of chronic kidney disease and proteinuria was conducted in MEDLINE, CINAHL, EMBASE, and Cochrane library with no language restriction. Studies were screened against the inclusion and exclusion criteria by two reviewers independently. Results In this meta-analysis, evidence was drawn from 26,551 patients with diabetes from 46 studies. Our analysis shows that RAASi were better than placebo in reducing SrCr (the raw mean difference [RMD] = -13.4 μmol/L; 95%CI: -16.78; -10.01) and albuminuria levels (standardized mean difference [SMD] = -1; 95%CI: -1.57, -0.44, I2 = 96%). When compared to other active treatments, RAASi did not reduce SrCr (RMD = 0.03 μmol/L; 95%CI: -6.4, 6.10, I2 = 76%), caused a non-significant reduction of GFR levels (RMD = -1.21 mL/min; 95%CI: -4.52, 2.09, I2 = 86%), and resulted in modest reduction of albuminuria levels (SMD = -0.55; 95%CI: -0.95, -0.16, I2 = 90%). RAASi were superior to placebo in reducing the risks of kidney failure (OR = 0.74; 95%CI: 0.56, 0.97) and doubling of serum creatinine levels (SrCr; OR = 0.71; 95%CI: 0.55, 0.91), but not in promoting the regression of albuminuria (OR = 3.00; 95%CI: 0.96, 9.37). RAASi, however, were not superior to other antihypertensives in reducing the risks of these outcomes. Patients with type 2 diabetes, macroalbuminuria and longer duration of diabetes had less risk of developing kidney failure in placebo-controlled trials, while longer duration of diabetes, normal kidney function, and hypertension increased the probability of achieving regression of albuminuria in active-controlled trials. Conclusion While our findings revealed the non-superiority of RAASi over other antihypertensives and portrayed a class effect on several subgroups of study participants, it raised a challenging question on whether RAASi deserve their place as first-line therapy in managing diabetic nephropathy. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02763-1.
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Affiliation(s)
- Noor Alsalemi
- Département de Pharmacologie et Physiologie, Université de Montréal, Montreal, Canada.,Centre de Recherche de L'Hôpital Maisonneuve-Rosemont, Montreal, Canada
| | - Cheryl A Sadowski
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
| | - Naoual Elftouh
- Centre de Recherche de L'Hôpital Maisonneuve-Rosemont, Montreal, Canada
| | - Maudeline Louis
- Centre de Recherche de L'Hôpital Maisonneuve-Rosemont, Montreal, Canada
| | - Kelley Kilpatrick
- Centre de Recherche de L'Hôpital Maisonneuve-Rosemont, Montreal, Canada.,Ingram School of Nursing, McGill University, Montreal, Canada
| | | | - Jean-Philippe Lafrance
- Département de Pharmacologie et Physiologie, Université de Montréal, Montreal, Canada. .,Centre de Recherche de L'Hôpital Maisonneuve-Rosemont, Montreal, Canada. .,Service de Néphrologie, CIUSSS de L'Est-de-L'Île-de-Montréal, Montreal, Canada.
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21
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Increased mortality with intensive control in patients with higher baseline SBP and lower Framingham risk. J Hypertens 2022; 40:978-984. [PMID: 35132039 DOI: 10.1097/hjh.0000000000003100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In the Systolic Blood Pressure Intervention Trial (SPRINT), the relative reduction in primary outcome with intensive blood pressure (BP) control was numerically smallest in the highest baseline SBP tertile. In this post hoc analysis of SPRINT, the goal was to explore whether the effects of intensive BP treatment varied among patients with different baseline SBP and cardiovascular risks. METHODS Patient-level data from 9361 randomized participants in SPRINT were used. Heterogeneity between treatment and patient characteristics were examined stratified by different baseline SBP levels. Cumulative incidences of primary outcome and all-cause death were compared between treatment groups for patients with baseline SBP at least 160 mmHg and lower Framingham risk. RESULTS For participants with a baseline SBP of at least 160 mmHg, intensive treatment was associated with a higher rate of all-cause death as compared with standard treatment (1.86 vs. 1.62% per year). After adjustment for age and sex, intensive treatment was associated with significantly increased all-cause death compared with standard treatment [hazard ratio (95% CI) for intensive group: 3.12 (1.00-9.69); P = 0.049] in participants with an SBP of at least 160 mmHg and a Framingham risk score of 31.3% or less (average of median and geometric mean). Patient outcomes were otherwise similar regarding age, use of antihypertensive therapy, cardiovascular disease or chronic kidney disease. CONCLUSION Among the SPRINT participants with a baseline SBP of at least 160 mmHg and a lower Framingham risk score, targeting an SBP of less than 120 mmHg compared with less than 140 mmHg resulted in a significantly higher rate of all-cause death.
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22
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Jaeger BC, Sakhuja S, Hardy ST, Akinyelure OP, Bundy JD, Muntner P, Whelton PK. Predicted cardiovascular risk for United States adults with diabetes, chronic kidney disease, and at least 65 years of age. J Hypertens 2022; 40:94-101. [PMID: 34420013 PMCID: PMC9259065 DOI: 10.1097/hjh.0000000000002982] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline recommends using 10-year predicted atherosclerotic cardiovascular disease (ASCVD) risk to guide decisions to initiate antihypertensive medication. METHODS We included adults aged 40-79 years from the National Health and Nutrition Examination Survey 2013-2018 (n = 8803). We computed 10-year predicted ASCVD risk using the Pooled Cohort risk equations. Clinical CVD was self-reported. Analyses were conducted overall and among those with stage 1 hypertension, defined by a mean SBP of 130-139 mmHg or DBP of 80-89 mmHg. In subgroups defined by diabetes, chronic kidney disease (CKD), and age at least 65 years, we estimated the proportion of United States adults with high ASCVD risk (i.e. 10-year predicted ASCVD risk ≥10% or clinical CVD) and estimated age-adjusted probability of having high ASCVD risk. RESULTS Among United States adults, an estimated 72.3, 64.5, and 83.9 of those with diabetes, CKD, and age at least 65 years had high ASCVD risk, respectively. Among United States adults with stage 1 hypertension, an estimated 55, 36.7, and 72.6% of those with diabetes, CKD, and age at least 65 years had high ASCVD risk, respectively. The probability of having high ASCVD risk increased with age and exceeded 50% for United States adults with diabetes and CKD at ages 52 and 57 years, respectively. For those with stage 1 hypertension, these ages were 55 and 64 years, respectively. CONCLUSION Most United States adults with diabetes, CKD, or age at least 65 years had high ASCVD risk. However, many with stage 1 hypertension did not.
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Affiliation(s)
| | - Swati Sakhuja
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Shakia T Hardy
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Joshua D Bundy
- Department of Epidemiology, Tulane University, New Orleans, Lousiana, USA
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Paul K Whelton
- Department of Epidemiology, Tulane University, New Orleans, Lousiana, USA
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23
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Deng L, Li W, Xu G. Update on pathogenesis and diagnosis flow of normoalbuminuric diabetes with renal insufficiency. Eur J Med Res 2021; 26:144. [PMID: 34895352 PMCID: PMC8665546 DOI: 10.1186/s40001-021-00612-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/16/2021] [Indexed: 12/11/2022] Open
Abstract
In recent decades, the prevalence of diabetic kidney disease has remained stable and appears to be a wide heterogeneity. Normoalbuminuric diabetes with renal insufficiency, which is characterized by a decline in the glomerular filtration rate in the absence of albuminuria, has been identified as an albuminuria-independent phenotype of diabetic kidney disease. Epidemiological data demonstrate that normoalbuminuric phenotype is prevalent. Compared to albuminuric phenotype, normoalbuminuric phenotype has distinct clinical characteristics and a wide heterogeneity of pathological features. Currently, the pathogenesis of normoalbuminuric phenotype remains unclear. Additionally, the flow of diagnosing normoalbuminuric phenotype is not perfect. In this article, we review the latest studies addressing the epidemiology, clinical characteristics, and pathology of normoalbuminuric phenotype. Based on the studies of clinical features and renal histopathologic changes, we attempt to propose an underlying pathogenesis model and a flow chart for diagnosing normoalbuminuric phenotype.
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Affiliation(s)
- Le Deng
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Wenjie Li
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Gaosi Xu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Donghu District, Nanchang, Jiangxi, 330006, People's Republic of China.
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24
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Wang J, Yen F, Lin K, Shin S, Hsu Y, Hsu C. Epidemiological characteristics of diabetic kidney disease in Taiwan. J Diabetes Investig 2021; 12:2112-2123. [PMID: 34529360 PMCID: PMC8668071 DOI: 10.1111/jdi.13668] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/02/2021] [Accepted: 09/12/2021] [Indexed: 12/17/2022] Open
Abstract
Diabetic kidney disease (DKD) is a critical microvascular complication of diabetes. With the continuous increase in the prevalence of diabetes since 2000, the prevalence of DKD has also been increasing in past years. The prevalence of DKD among individuals with type 2 diabetes in Taiwan increased from 13.32% in 2000 to 17.92% in 2014. The cumulative incidence of DKD among individuals with type 1 diabetes in Taiwan was higher than 30% during 1999-2012. DKD is the leading cause of end-stage renal disease (ESRD), with a prevalence of approximately 45% in a population on chronic dialysis in Taiwan. Among individuals with type 2 diabetes, the prevalence of ESRD in the receipt of dialysis also increased from 1.32% in 2005 to 1.47% in 2014. Risk factors for DKD development are age, race, family history, hyperglycemia, hypertension, dyslipidemia, dietary patterns, and lifestyles. Prognostic factors that aggravate DKD progression include age, family history, sex, glycemic control, blood pressure (BP), microvascular complications, and atherosclerosis. This review summarizes updated information on the onset and progression of DKD, particularly in the Taiwanese population. Translating these epidemiological features is essential to optimizing the kidney care and improving the prognosis of DKD in Asian populations.
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Affiliation(s)
- Jun‐Sing Wang
- Division of Endocrinology and MetabolismDepartment of Internal MedicineTaichung Veterans General HospitalTaichungTaiwan
- Faculty of MedicineSchool of MedicineNational Yang‐Ming UniversityTaipeiTaiwan
- Rong Hsing Research Center for Translational MedicineInstitute of Biomedical ScienceNational Chung Hsing UniversityTaichungTaiwan
- PhD Program in Translational MedicineNational Chung Hsing UniversityTaichungTaiwan
| | | | - Kun‐Der Lin
- Department of Internal MedicineKaohsiung Municipal Ta‐Tung HospitalKaohsiung Medical University HospitalKaohsiung Medical UniversityKaohsiungTaiwan
- Division of Endocrinology and MetabolismDepartment of Internal MedicineKaohsiung Medical University Hospital and College of MedicineKaohsiung Medical UniversityKaohsiungTaiwan
| | - Shyi‐Jang Shin
- Division of Endocrinology and MetabolismDepartment of Internal MedicineKaohsiung Medical University Hospital and College of MedicineKaohsiung Medical UniversityKaohsiungTaiwan
- Grander ClinicKaohsiungTaiwan
| | - Yueh‐Han Hsu
- Department of Internal MedicineDitmanson Medical Foundation Chia‐Yi Christian HospitalChia‐Yi CityTaiwan
- Department of NursingMin‐Hwei College of Health Care ManagementTainan CityTaiwan
| | - Chih‐Cheng Hsu
- Institute of Population Health SciencesNational Health Research InstituteZhunan, MiaoliTaiwan
- Department of Health Services AdministrationChina Medical UniversityTaichung CityTaiwan
- Department of Family MedicineMin‐Sheng General HospitalTaoyuanTaiwan
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25
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Filippone EJ, Foy AJ, Naccarelli GV. The diastolic blood pressure J-curve revisited: An update. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2021; 12:100065. [PMID: 38559601 PMCID: PMC10978147 DOI: 10.1016/j.ahjo.2021.100065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/04/2021] [Accepted: 10/15/2021] [Indexed: 04/04/2024]
Abstract
Hypertension remains a leading cause of morbidity and mortality. Recent treatment guidelines stress more strict systolic blood pressure (SBP) targets without regard for abnormally low achieved diastolic blood pressures (DBP). However, as DBP falls below a critical level, adverse events increase, the so-called J-shaped curve. Proponents argue that the low DBP is causative due to reduced coronary perfusion during diastole with obstructive coronary artery disease (CAD), whereas others postulate the J-curve represents reverse causality from underlying comorbidity. Most data are observational, derived from population-based cohorts or post-hoc analyses of randomized controlled trials (RCT) conducted for other reasons. The purpose of this review is to analyze the observational studies performed over the last decade addressing the J-curve, with consideration of earlier data. Overall, a J-curve exists, but it remains uncertain whether low DBP is causative or instead reflects reverse causation from either diseased vasculature (widened pulse pressure) or severe underlying comorbidity. The most convincing data for causation come from studies restricted to patients with documented CAD, with evidence suggesting revascularization may mitigate risk. RCTs are needed to determine if a low DBP should preclude intensification of therapy, especially with documented CAD. Firm recommendations cannot be made with contemporary data.
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Affiliation(s)
- Edward J. Filippone
- Division of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Andrew J. Foy
- Department of Medicine, Penn State University Heart and Vascular Institute, Penn State M.S Hershey Medical Center and College of Medicine, Hershey, PA, USA
| | - Gerald V. Naccarelli
- Department of Medicine, Penn State University Heart and Vascular Institute, Penn State M.S Hershey Medical Center and College of Medicine, Hershey, PA, USA
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26
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Hashemi H, Rezvan F, Pakzad R, Ansaripour A, Heydarian S, Yekta A, Ostadimoghaddam H, Pakbin M, Khabazkhoob M. Global and Regional Prevalence of Diabetic Retinopathy; A Comprehensive Systematic Review and Meta-analysis. Semin Ophthalmol 2021; 37:291-306. [PMID: 34402390 DOI: 10.1080/08820538.2021.1962920] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE We conducted a systematic search to estimate DR prevalence in different age and gender groups, and to evaluate the determinants of heterogeneity in its prevalence. METHODS A systematic and comprehensive search from inception to August 10, 2020, was done in international databases, including Scopus, PubMed, Web of Science, Embase, and other data sources without any restriction to find cross-sectional studies related to the prevalence of DR. RESULTS Of 6399 studies, 90 articles with a sample size of 563460 individuals and 204189 diabetic patients were analyzed. The estimated pooled prevalence of DR in the diabetic population in general; in female and in male was 28.41% (95% CI: 25.98 to 30.84); 25.93% (95% CI: 23.54 to 28.31) and 28.95% (95% CI: 26.57 to 31.32); respectively and the prevalence of DR showed no inter-gender difference. The heterogeneity of the pooled prevalence according to I2 was 99% (p < .001). According to the meta-regression results, the variables of WHO region (Coefficient of AMRO vs SEARO: 15.56; p: 0.002), age (Coefficient of above 60 years vs below 40 year: 18.67; p: 0.001), type of DR (Coefficient: 19.01; p < .001), and publication year (Coefficient: -0.60; p: 0.001) had a significant correlation with heterogeneity. CONCLUSION One third of diabetic patients suffered from DR, mostly NPDR. DR increased markedly after the age of 60 years, which could be due to the longer duration of diabetes. Age, WHO region, type of DR, and publication year affected the heterogeneity in the prevalence of DR.
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Affiliation(s)
- Hassan Hashemi
- Noor Research Center for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran, Iran
| | - Farhad Rezvan
- Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran, Iran
| | - Reza Pakzad
- Department of Epidemiology, Faculty of Health, Ilam University of Medical Sciences, Ilam, Iran
| | | | | | - Abbasali Yekta
- Department of Optometry, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Rehabilitation Science, School of Allied Medical Sciences, Mazandaran University of Medical Sciences, Sari, Iran
| | - Hadi Ostadimoghaddam
- Refractive Errors Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mojgan Pakbin
- Noor Research Center for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran, Iran
| | - Mehdi Khabazkhoob
- Department of Basic Sciences, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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27
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Lee JY, Park JT, Joo YS, Lee C, Yun HR, Yoo TH, Kang SW, Choi KH, Ahn C, Oh KH, Sung S, Kim SW, Lee J, Han SH, Chae DW, Chin HJ, Lee SW, Lee K, Hyun YY, Ma SK, Bae EH, Kim CS, Kim YS, Chung W, Jung JY, Kim YH, Kim TH, Kang SW, Oh YK, Park SK. Association of Blood Pressure With the Progression of CKD: Findings From KNOW-CKD Study. Am J Kidney Dis 2021; 78:236-245. [DOI: 10.1053/j.ajkd.2020.12.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 12/14/2020] [Indexed: 02/08/2023]
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28
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Lee JY, Han SH. Blood pressure control in patients with chronic kidney disease. Korean J Intern Med 2021; 36:780-794. [PMID: 34153181 PMCID: PMC8273817 DOI: 10.3904/kjim.2021.181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/17/2021] [Indexed: 12/26/2022] Open
Abstract
Uncontrolled blood pressure (BP) in patients with chronic kidney disease (CKD) can lead to serious adverse outcomes. To prevent the occurrence of cardiovascular events (CVEs), and end-stage kidney disease, achieving an optimal BP level is important. Recently, there has been a paradigm shift in the management of BP largely as a result of the Systolic Blood Pressure Intervention Trial (SPRINT), which showed a reduction in CVEs by lowering systolic BP to 120 mmHg. A lower systolic blood pressure (SBP) target has been accepted by the Kidney Disease: Improving Global Outcomes (KDIGO) 2021 guidelines. However, whether intensive control of SBP targeting < 120 mmHg is also effective in patients with CKD is controversial. Notably, this lower target SBP is associated with a higher risk of adverse kidney outcomes. Unfortunately, there have been no randomized controlled trials on this issue involving only patients with CKD, particularly those with advanced CKD. In this review, we discuss the optimal control of BP in patients with CKD in terms of reduction in death and CVEs as well as attenuation of CKD progression based on the evidence-based literature.
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Affiliation(s)
| | - Seung Hyeok Han
- Correspondence to Seung Hyeok Han, M.D. Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: +82-2-2228-1984 Fax: +82-2-393-6884 E-mail:
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Cheung AK, Chang TI, Cushman WC, Furth SL, Hou FF, Ix JH, Knoll GA, Muntner P, Pecoits-Filho R, Sarnak MJ, Tobe SW, Tomson CR, Mann JF. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int 2021; 99:S1-S87. [PMID: 33637192 DOI: 10.1016/j.kint.2020.11.003] [Citation(s) in RCA: 380] [Impact Index Per Article: 126.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022]
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Alencherry B, Laffin LJ. Treatment of Hypertension in Patients with Diabetes Mellitus: a Contemporary Approach. Curr Cardiol Rep 2021; 23:14. [PMID: 33486635 DOI: 10.1007/s11886-021-01443-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 01/16/2023]
Abstract
PURPOSE OF REVIEW Blood pressure guidelines worldwide have changed their recommended blood pressure goals multiple times over the past decade due to an evolving understanding of the treatment of hypertension in patients with diabetes mellitus. While it is evident through randomized trials that treatment of hypertension in diabetes mellitus prevents complications, the optimal blood pressure goal is not clear. RECENT FINDINGS Post hoc analyses of the Action to Control Cardiovascular Risk in Diabetes-Blood Pressure (ACCORD-BP) trial, its long-term follow along study ACCORDION, and Systolic Blood Pressure Intervention Trial (SPRINT) suggest that patients with diabetes have a reduced risk of adverse cardiovascular events when aiming for more intensive blood pressure targets. High-quality data support guideline recommendations for more aggressive blood pressure targets in patients with diabetes mellitus. Reasoning for a return to more aggressive blood pressure goals in this at-risk population is discussed, and treatment strategies encompassing contemporary therapeutic options are recommended.
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Affiliation(s)
- Ben Alencherry
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Luke J Laffin
- Section of Preventive Cardiology and Rehabilitation, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Mail Code JB-1, Cleveland, OH, 44195, USA.
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Aboelnasr MS, Shaltout AK, AlSheikh MR, Abdelhameed AH, Elrefaey W. Diabetic kidney disease in patients newly diagnosed with type-2 diabetes mellitus: Incidence and associations. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2021; 31:191-199. [PMID: 32129213 DOI: 10.4103/1319-2442.279940] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The global prevalence of type 2 diabetes mellitus (DM) in adults is increasing all over the world. Diabetic kidney disease (DKD) is one of the most common complications of DM. The aim of the present work is to study chronic kidney disease (CKD) in patients newly diagnosed with type 2 DM as regards incidence and associations. This is a comparative cross-sectional study. The study included 153 patients with newly diagnosed type 2 DM over the past six months. DKD was diagnosed if urinary albumin to creatinine ratio >30 mg/g in two out of three-morning urine samples collected within three to six months and/or estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 using 2009 CKD-Epidemiology Collaboration creatinine equation. DKD was present in 45.75% of patients. In our study, 54.9% of patients had microalbuminuria, 39.2% had macroalbuminuria, and 5.9% had severely increased albuminuria. As regards eGFR, 5.2% of patients had eGFR <60 mL/min/1.73 m2. Regression analysis showed that increased levels of cholesterol, triglyceride, and glycated hemoglobin were associated with an increased likelihood of developing nephropathy while nonsmoking and elevated high-density lipoprotein cholesterol levels were associated with a reduction in that likelihood. DKD was present in a substantial proportion of our patients at diagnosis. Routine screening for DKD is recommended in all patients early at the onset itself of diagnosis with type 2 DM.
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Affiliation(s)
- Mohamed Sabry Aboelnasr
- Department of Internal Medicine, Nephrology Unit, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ahmed Kotb Shaltout
- Department of Internal Medicine, Nephrology Unit, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mabrouk Ramadan AlSheikh
- Department of Internal Medicine, Nephrology Unit, Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | - Waleed Elrefaey
- Department of Internal Medicine, Nephrology Unit, Faculty of Medicine, Tanta University, Tanta, Egypt
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Abstract
BACKGROUND This is the first update of this review first published in 2009. When treating elevated blood pressure, doctors usually try to achieve a blood pressure target. That target is the blood pressure value below which the optimal clinical benefit is supposedly obtained. "The lower the better" approach that guided the treatment of elevated blood pressure for many years was challenged during the last decade due to lack of evidence from randomised trials supporting that strategy. For that reason, the standard blood pressure target in clinical practice during the last years has been less than 140/90 mm Hg for the general population of patients with elevated blood pressure. However, new trials published in recent years have reintroduced the idea of trying to achieve lower blood pressure targets. Therefore, it is important to know whether the benefits outweigh harms when attempting to achieve targets lower than the standard target. OBJECTIVES The primary objective was to determine if lower blood pressure targets (any target less than or equal to 135/85 mm Hg) are associated with reduction in mortality and morbidity as compared with standard blood pressure targets (less than or equal to 140/ 90 mm Hg) for the treatment of patients with chronic arterial hypertension. The secondary objectives were: to determine if there is a change in mean achieved systolic blood pressure (SBP) and diastolic blood pressure (DBP associated with "lower targets" as compared with "standard targets" in patients with chronic arterial hypertension; and to determine if there is a change in withdrawals due to adverse events with "lower targets" as compared with "standard targets", in patients with elevated blood pressure. SEARCH METHODS The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to May 2019: the Cochrane Hypertension Specialised Register, CENTRAL (2019, Issue 4), Ovid MEDLINE, Ovid Embase, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing patients allocated to lower or to standard blood pressure targets (see above). DATA COLLECTION AND ANALYSIS Two review authors (JAA, VL) independently assessed the included trials and extracted data. Primary outcomes were total mortality; total serious adverse events; myocardial infarction, stroke, congestive heart failure, end stage renal disease, and other serious adverse events. Secondary outcomes were achieved mean SBP and DBP, withdrawals due to adverse effects, and mean number of antihypertensive drugs used. We assessed the risk of bias of each trial using the Cochrane risk of bias tool and the certainty of the evidence using the GRADE approach. MAIN RESULTS: This update includes 11 RCTs involving 38,688 participants with a mean follow-up of 3.7 years. This represents 7 new RCTs compared with the original version. At baseline the mean weighted age was 63.1 years and the mean weighted blood pressure was 155/91 mm Hg. Lower targets do not reduce total mortality (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.86 to 1.05; 11 trials, 38,688 participants; high-certainty evidence) and do not reduce total serious adverse events (RR 1.04, 95% CI 0.99 to 1.08; 6 trials, 18,165 participants; moderate-certainty evidence). This means that the benefits of lower targets do not outweigh the harms as compared to standard blood pressure targets. Lower targets may reduce myocardial infarction (RR 0.84, 95% CI 0.73 to 0.96; 6 trials, 18,938 participants, absolute risk reduction (ARR) 0.4%, number needed to treat to benefit (NNTB) 250 over 3.7 years) and congestive heart failure (RR 0.75, 95% CI 0.60 to 0.92; 5 trials, 15,859 participants, ARR 0.6%, NNTB 167 over 3.7 years) (low-certainty for both outcomes). Reduction in myocardial infarction and congestive heart failure was not reflected in total serious adverse events. This may be due to an increase in other serious adverse events (RR 1.44, 95% CI 1.32 to 1.59; 6 trials. 18,938 participants, absolute risk increase (ARI) 3%, number needed to treat to harm (NNTH) 33 over four years) (low-certainty evidence). Participants assigned to a "lower" target received one additional antihypertensive medication and achieved a significantly lower mean SBP (122.8 mm Hg versus 135.0 mm Hg, and a lower mean DBP (82.0 mm Hg versus 85.2 mm Hg, than those assigned to "standard target". AUTHORS' CONCLUSIONS For the general population of persons with elevated blood pressure, the benefits of trying to achieve a lower blood pressure target rather than a standard target (≤ 140/90 mm Hg) do not outweigh the harms associated with that intervention. Further research is needed to see if some groups of patients would benefit or be harmed by lower targets. The results of this review are primarily applicable to older people with moderate to high cardiovascular risk. They may not be applicable to other populations.
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Affiliation(s)
- Jose Agustin Arguedas
- Depto de Farmacologia Clinica, Facultad de Medicina, Universidad de Costa Rica, San Pedro de Montes de Oca, Costa Rica
| | - Viriam Leiva
- Escuela de Enfermeria, Facultad de Medicina, University of Costa Rica, San Jose, Costa Rica
| | - James M Wright
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada
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Liew A, Bavanandan S, Prasad N, Wong MG, Chang JM, Eiam-Ong S, Hao CM, Lim CY, Lim SK, Oh KH, Okada H, Susantitaphong P, Lydia A, Tran HTB, Villanueva R, Yeo SC, Tang SCW. ASIAN PACIFIC SOCIETY OF NEPHROLOGY CLINICAL PRACTICE GUIDELINE ON DIABETIC KIDNEY DISEASE. Nephrology (Carlton) 2020; 25 Suppl 2:12-45. [PMID: 33111477 DOI: 10.1111/nep.13785] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Adrian Liew
- The Kidney & Transplant Practice, Mount Elizabeth Novena Hospital, Singapore
| | | | - Narayan Prasad
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Muh Geot Wong
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia.,Division of Renal and Metabolic, The George Institute for Global Health, Sydney, Australia
| | - Jer Ming Chang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Taiwan
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Chuan-Ming Hao
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | | | - Soo Kun Lim
- Renal Division, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University, Seoul, Republic of Korea
| | - Hirokazu Okada
- Department of Nephrology, Saitama Medical University, Saitama, Japan
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Aida Lydia
- Division of Nephrology and Hypertension, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia-Dr Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Huong Thi Bich Tran
- Renal Division, Department of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | | | - See Cheng Yeo
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore
| | - Sydney C W Tang
- Division of Nephrology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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Choi YJ, Kim SH, Kang SH, Yoon CH, Lee HY, Youn TJ, Chae IH, Kim CH. Reconsidering the cut-off diastolic blood pressure for predicting cardiovascular events: a nationwide population-based study from Korea. Eur Heart J 2020; 40:724-731. [PMID: 30535368 DOI: 10.1093/eurheartj/ehy801] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/15/2018] [Accepted: 11/17/2018] [Indexed: 01/09/2023] Open
Abstract
AIMS It is unclear whether a J-curve association exists in cardiovascular risk prediction and how independently systolic and diastolic blood pressure (BP) predict cardiovascular outcomes. This study evaluated the association of systolic and diastolic BP with major cardiovascular events to clarify these issues. METHODS AND RESULTS Antihypertensive medication-naïve subjects with available BP measurements and no history of cardiovascular events were extracted from the National Health Insurance Services Health Screening Cohort. The study endpoint was a composite of cardiac death, myocardial infarction, stroke, and heart failure. The study population comprised 290 600 subjects (median follow-up duration 6.7 years). The risk for major cardiovascular events was lowest at systolic and diastolic BPs of 90-99 mmHg and 40-49 mmHg, respectively, above which BPs demonstrated a log-linear risk prediction. Systolic and diastolic BPs were highly correlated. The risk prediction of diastolic BP was inconsistent when stratified by systolic BP. A wider pulse pressure rather than a higher diastolic BP was significantly associated with cardiovascular outcomes among men aged ≥55 years. In addition, the difference between diastolic BPs of <80 mmHg and 80-89 mmHg mostly disappeared after statistical adjustment or stratification. CONCLUSION Elevated BP is a strong predictor of future cardiovascular events including cardiac death, myocardial infarction, stroke, and heart failure. This study showed that the log-linear relationship between BP and cardiovascular events extended down to a BP of ≥90/40 mmHg. Although hypertension is defined using a lower systolic BP cut-off of ≥130 mmHg, the diastolic BP component of ≥80 mmHg seems disproportionately low.
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Affiliation(s)
- You-Jung Choi
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, Korea.,Department of Internal Medicine, Seoul National University, 101 Daehak-ro, Chong No Gu, Seoul, Korea
| | - Sun-Hwa Kim
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, Korea
| | - Si-Hyuck Kang
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, Korea.,Department of Internal Medicine, Seoul National University, 101 Daehak-ro, Chong No Gu, Seoul, Korea
| | - Chang-Hwan Yoon
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, Korea.,Department of Internal Medicine, Seoul National University, 101 Daehak-ro, Chong No Gu, Seoul, Korea
| | - Hae-Young Lee
- Department of Internal Medicine, Seoul National University, 101 Daehak-ro, Chong No Gu, Seoul, Korea.,Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Chong No Gu, Seoul, Korea
| | - Tae-Jin Youn
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, Korea.,Department of Internal Medicine, Seoul National University, 101 Daehak-ro, Chong No Gu, Seoul, Korea
| | - In-Ho Chae
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, Korea.,Department of Internal Medicine, Seoul National University, 101 Daehak-ro, Chong No Gu, Seoul, Korea
| | - Cheol-Ho Kim
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, Korea.,Department of Internal Medicine, Seoul National University, 101 Daehak-ro, Chong No Gu, Seoul, Korea
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35
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The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2019). Hypertens Res 2020; 42:1235-1481. [PMID: 31375757 DOI: 10.1038/s41440-019-0284-9] [Citation(s) in RCA: 974] [Impact Index Per Article: 243.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Koh BMQR, Banu R, Nusinovici S, Sabanayagam C. 100 most-cited articles on diabetic retinopathy. Br J Ophthalmol 2020; 105:1329-1336. [PMID: 32855165 DOI: 10.1136/bjophthalmol-2020-316609] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/22/2020] [Accepted: 07/30/2020] [Indexed: 12/27/2022]
Abstract
Diabetic retinopathy (DR) research has had significant advancements over the past decades. We analysed the impact and characteristics of the top 100 (T100) most-cited articles in DR research. The Scopus database was searched for articles published from 1960 to June 2020 by two independent investigators. The T100 DR articles were published between 1961 and 2017 with median citations of 503 (range: 306-20 100); 84% were published after 1990. More than half (59%) were published in general medical/diabetes journals while 37% in ophthalmology journals. The top six journals contributed to 56% of the T100: Ophthalmology (n=13), Archives of Ophthalmology (n=12), Diabetes (n=9), New England Journal of Medicine (n=8), Journal of the American Medical Association (n=7) and The Lancet (n=7). Although observational studies were most popular (33%), randomised controlled trials (RCTs, 24%) published in journals with higher impact factor (IF) and citations (median IF and citations=7.113, 503 vs 21.437, 696.5, both p-value<0.05). 33 of the T100 were cited by several international DR clinical guidelines. The USA contributed to 63% of T100, but 18% of articles published after 2000 came from Asia. More than 80% of both first and last authors were men. Artificial intelligence (AI) to screen for DR ranked 14th and 99th despite recent publications in 2016 and 2017, respectively. To conclude, our T100 analysis showed that RCTs were most-cited and more articles were published in non-ophthalmology than ophthalmology journals. It highlights the impact the T100 DR has in shaping guidelines used to date in DR management, identifies AI for DR screening as an emerging area and shows a contemporary rise of Asian contribution in DR research.
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Affiliation(s)
- Barry Moses Quan Ren Koh
- Duke-NUS Medical School, Singapore.,School of Medical Sciences, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Riswana Banu
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
| | - Simon Nusinovici
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
| | - Charumathi Sabanayagam
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore .,Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
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Dedov II, Shestakova MV, Mayorov AY, Shamkhalova MS, Sukhareva OY, Galstyan GR, Tokmakova AY, Nikonova TV, Surkova EV, Kononenko IV, Egorova DN, Ibragimova LI, Shestakova EA, Klefortova II, Sklyanik IA, Yarek-Martynova IY, Severina AS, Martynov SA, Vikulova OK, Kalashnikov VY, Bondarenko IZ, Gomova IS, Starostina EG, Ametov AS, Antsiferov MB, Bardymova TP, Bondar IA, Valeeva FV, Demidova TY, Mkrtumyan AM, Petunina NA, Ruyatkina LA, Suplotova LA, Ushakova OV, Khalimov YS. Diabetes mellitus type 2 in adults. DIABETES MELLITUS 2020. [DOI: 10.14341/dm12507] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Tatiana P. Bardymova
- Irkutsk State Medical Academy of Postgraduate Education – Branch Campus of the Russian Medical Academy of Continuing Professional Education
| | | | | | | | - Ashot M. Mkrtumyan
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov
| | - Nina A. Petunina
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
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Chang TI, Lim H, Park CH, Rhee CM, Moradi H, Kalantar-Zadeh K, Kang EW, Kang SW, Han SH. Associations of Systolic Blood Pressure With Incident CKD G3-G5: A Cohort Study of South Korean Adults. Am J Kidney Dis 2020; 76:224-232. [PMID: 32305207 DOI: 10.1053/j.ajkd.2020.01.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 01/16/2020] [Indexed: 01/17/2023]
Abstract
RATIONALE & OBJECTIVE Clinical practice guidelines recommend a target blood pressure (BP)<130/80 mm Hg to reduce cardiovascular risk. However, the optimal BP to prevent chronic kidney disease (CKD) is unknown. STUDY DESIGN Population-based retrospective cohort study. SETTING & PARTICIPANTS 10.5 million adults who participated in the National Health Insurance Service National Health Checkup Program in South Korea between 2009 and 2015 and had an estimated glomerular filtration rate (GFR) ≥ 60 mL/min/1.73 m2 at the beginning of follow-up. PREDICTORS Baseline and time-updated systolic BP (SBP) as a continuous variable and categorized as<110, 110 to 119, 120 to 129, 130 to 139, or≥140 mm Hg. OUTCOME Incident CKD GFR categories 3 to 5 (CKD G3-G5), defined as de novo development of estimated GFR<60 mL/min/1.73 m2 for at least 2 consecutive assessments confirmed at least 90 days apart. ANALYTICAL APPROACH Cox proportional hazards regression for baseline BP and marginal structural analysis for time-updated BP. RESULTS During 49,169,311 person-years of follow-up, incident CKD G3-G5 developed in 172,423 (1.64%) individuals with a crude event rate of 3.51 (95% CI, 3.49-3.52) per 1,000 person-years. Compared to a baseline SBP of 120 to 129 mm Hg, HRs for incident CKD G3-G5 for the<110, 110 to 119, 130 to 139, and≥140 mm Hg categories were 0.84 (95% CI, 0.82-0.85), 0.92 (95% CI, 0.91-0.94), 1.11 (95% CI, 1.09-1.12), and 1.30 (95% CI, 1.28-1.31), respectively. For time-updated SBPs, corresponding HRs were 0.57 (95% CI, 0.56-0.59), 0.79 (95% CI, 0.78-0.80), 1.58 (95% CI, 1.55-1.60), and 2.49 (95% CI, 2.45-2.53), respectively. Treated as a continuous exposure, each 10-mm Hg higher SBP was associated with 35% higher risk for incident CKD G3-G5 (95% CI, 1.35-1.36). LIMITATIONS Use of International Classification of Diseases codes to assess comorbid condition burden; residual confounding, and potential selection bias cannot be excluded. CONCLUSIONS In this large national cohort study, higher SBPs were associated with higher risk for incident CKD G3-G5. These findings support evaluation of SBP-lowering strategies to reduce the development of CKD.
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Affiliation(s)
- Tae Ik Chang
- Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyangshi, Gyeonggi-do, Republic of Korea
| | - Hyunsun Lim
- Department of Policy Research Affairs, National Health Insurance Service Medical Center, Ilsan Hospital, Goyangshi, Gyeonggi-do, Republic of Korea
| | - Cheol Ho Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA
| | - Hamid Moradi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Ea Wha Kang
- Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyangshi, Gyeonggi-do, Republic of Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Internal Medicine, College of Medicine, Severance Biomedical Science Institute, Brain Korea 21 PLUS, Yonsei University, Seoul, Republic of Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Yonekawa Y, Modi YS, Kim LA, Skondra D, Kim JE, Wykoff CC. American Society of Retina Specialists Clinical Practice Guidelines on the Management of Nonproliferative and Proliferative Diabetic Retinopathy without Diabetic Macular Edema. JOURNAL OF VITREORETINAL DISEASES 2020; 4:125-135. [PMID: 34308094 DOI: 10.1177/2474126419893829] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Purpose Nonproliferative (NPDR) and proliferative diabetic retinopathy (PDR) without diabetic macular edema (DME) affect millions of individuals living with diabetes throughout the world. There is increasing data on various management strategies for such patients, but there is limited consensus on how the data should be adopted into clinical practice. Methods This literature review and editorial presents and synthesizes the current evidence for various management paradigms for NPDR and PDR without DME. Results Retina specialists are an integral member of the diabetes management team, and should encourage patients on the importance of glycemic and cardiovascular optimization for both systemic and retinopathy risk factor reduction. The diabetic retinopathy severity scale (DRSS) is now an approvable endpoint for clinical trials in the United States, therefore becoming more clinically relevant. For PDR without DME, the Diabetic Retinopathy Study (DRS) and the Early Treatment Diabetic Retinopathy Study (ETDRS) established the standard of care with panretinal photocoagulation (PRP). Laser parameters have since evolved to include less intense and earlier intervention. Studies have recently demonstrated that anti-vascular endothelial growth factor (VEGF) treatment of PDR is effective at regressing neovascularization and improving DRSS levels in many patients. Further evidence is required to determine optimal treatment frequency, duration, and retreatment criteria, in the real world. There are concerns for adverse events in patients being lost to follow up during anti-VEGF treatment. For NPDR without DME, the standard of care has been a wait-and-watch approach. Data within the DRS and the ETDRS suggest that PRP for severe NPDR can be an option for select patients as well. Multiple clinical trials have now demonstrated that anti-VEGF treatment can improve the DRSS score in NPDR. Further studies are required to assess whether this positively affects long-term visual outcomes, and whether the benefits outweigh the risks in the real world for routine use. Conclusions There is cumulative evidence demonstrating the efficacy of various treatment options for NPDR and PDR without DME. Currently, patients would most likely benefit from thoughtful management strategies that are tailored to the individual patient.
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Affiliation(s)
- Yoshihiro Yonekawa
- Mid Atlantic Retina, Wills Eye Hospital, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Yasha S Modi
- Department of Ophthalmology, New York University School of Medicine, New York, NY
| | - Leo A Kim
- Retina Service, Ophthalmology Department, Mass Eye & Ear, Harvard Medical School, Boston, MA
| | - Dimitra Skondra
- Retina Service, Department of Ophthalmology and Visual Science, University of Chicago, IL
| | - Judy E Kim
- Department of Ophthalmology & Visual Sciences, Medical College of Wisconsin, Milwaukee, WI
| | - Charles C Wykoff
- Retina Consultants of Houston, Blanton Eye Institute, Houston Methodist Hospital, Weill Cornell Medical College, Houston, TX
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El Mokadem M, Abd El Hady Y, Aziz A. A Prospective Single-Blind Randomized Trial of Ramipril, Eplerenone and Their Combination in Type 2 Diabetic Nephropathy. Cardiorenal Med 2020; 10:392-401. [DOI: 10.1159/000508670] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Abstract
<b><i>Introduction:</i></b> Angiotensin-converting enzyme inhibitors (ACEI) combined with mineralocorticoid receptor antagonists were found to have a beneficial effect on patients with chronic kidney disease. <b><i>Objective:</i></b> The aim of our clinical trial was to compare the antialbuminuric effect of ramipril monotherapy, eplerenone monotherapy and eplerenone/ramipril combination therapy in patients with stage 1 hypertension and type 2 diabetes mellitus. <b><i>Methods:</i></b> In a single-blind, randomized clinical trial, 75 hypertensive patients (stage 1 hypertension) with type 2 diabetes mellitus and microalbuminuria were randomized in a 1:1:1 ratio to 1 of 3 groups: ramipril 10 mg monotherapy (25 patients), eplerenone 50 mg monotherapy (25 patients) and combination therapy of eplerenone/ramipril 50/10 mg (25 patients) through a randomized clinical trial. Blood pressure, urinary albumin/creatinine ratio (UACR), serum creatinine, estimated glomerular filtration rate (eGFR) and serum K level were measured before randomization and after 24 weeks. <b><i>Results:</i></b> Ramipril and eplerenone monotherapy showed a significant lowering of UACR compared with baseline levels (<i>p</i> ≤ 0.0001). The eplerenone/ramipril combination group showed a more significant reduction of UACR compared with the ramipril and eplerenone monotherapy groups (<i>p</i> = 0.0001). There was a more significant lowering of systolic blood pressure in the combination group (<i>p</i> < 0.0001). A nonsignificant change of serum potassium level, serum creatinine and eGFR was found among the 3 groups. <b><i>Conclusion:</i></b> Addition of eplerenone to ACEI shows an added antialbuminuric effect without significant change of the serum K level compared with eplerenone or ACEI.
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Otani T, Yokoyama H, Hanai K, Miura J, Uchigata Y, Babazono T. Rapid increase in the incidence of end-stage renal disease in patients with type 1 diabetes having HbA1c 10% or higher for 15 years. Clin Pediatr Endocrinol 2019; 28:113-125. [PMID: 31666764 PMCID: PMC6801355 DOI: 10.1297/cpe.28.113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/17/2019] [Indexed: 12/19/2022] Open
Abstract
The incidence of end-stage renal disease (ESRD) in Japanese patients with type 1 diabetes
mellitus (T1DM) was investigated regarding the association between mean HbA1c values
during follow-up and the duration of follow-up/illness. The study includes 988 patients
diagnosed at ages younger than 30 yr. These patients were initially examined between 1962
and 1999, and HbA1 and/or HbA1c measurements were taken for at least 3 yr after 1980. The
follow-up period was from the date of the first HbA1 or HbA1c measurement to the final
measurement day, or HbA1c measurement day immediately before the development of ESRD. The
condition progressed to ESRD in 63 patients (mean duration of illness: 23.6 yr). Cox
regression analysis revealed that patients with HbA1c of ≥ 10% had a significantly
increased higher risk than those with HbA1c under 8% (P < 0.0001). The HbA1c cut-off
point was 10.0%. The HbA1c value was ≥ 10% at baseline and during follow-up in 128
patients. Assuming that HbA1c of ≥ 10% persisted since the time of diagnosis in these
patients, the cumulative incidence of ESRD abruptly increased after 15 yr of illness.
Thus, the incidence of ESRD increased after the persistence of HbA1c of ≥ 10% for 15
yr.
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Affiliation(s)
- Toshika Otani
- Diabetes Center, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Omiya Kyoritsu Hospital, Saitama, Japan
| | | | - Ko Hanai
- Diabetes Center, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Junnosuke Miura
- Diabetes Center, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yasuko Uchigata
- Diabetes Center, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Tetsuya Babazono
- Diabetes Center, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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Raghavan S, Ho YL, Kini V, Rhee MK, Vassy JL, Gagnon DR, Cho K, Wilson PWF, Phillips LS. Association Between Early Hypertension Control and Cardiovascular Disease Incidence in Veterans With Diabetes. Diabetes Care 2019; 42:1995-2003. [PMID: 31515207 PMCID: PMC6754236 DOI: 10.2337/dc19-0686] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 07/26/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Guidelines for hypertension treatment in patients with diabetes diverge regarding the systolic blood pressure (SBP) threshold at which treatment should be initiated and treatment goal. We examined associations of early SBP treatment with atherosclerotic cardiovascular disease (ASCVD) events in U.S. adults with diabetes. RESEARCH DESIGN AND METHODS We studied 43,986 patients with diabetes who newly initiated antihypertensive therapy between 2002 and 2007. Patients were classified into categories based on SBP at treatment initiation (130-139 or ≥140 mmHg) and after 2 years of treatment (100-119, 120-129, 130-139, 140-159, and ≥160 mmHg). The primary outcome was composite ASCVD events (fatal and nonfatal myocardial infarction and stroke), estimated using inverse probability of treatment-weighted Poisson regression and multivariable Cox proportional hazards regression. RESULTS Relative to individuals who initiated treatment when SBP was 130-139 mmHg, those with pretreatment SBP ≥140 mmHg had higher ASCVD risk (hazard ratio 1.10 [95% CI 1.02, 1.19]). Relative to those with pretreatment SBP of 130-139 mmHg and on-treatment SBP of 120-129 mmHg (reference group), ASCVD incidence was higher in those with pretreatment SBP ≥140 mmHg and on-treatment SBP 120-129 mmHg (adjusted incidence rate difference [IRD] 1.0 [-0.2 to 2.1] events/1,000 person-years) and in those who achieved on-treatment SBP 130-139 mmHg (IRD 1.9 [0.6, 3.2] and 1.1 [0.04, 2.2] events/1,000 person-years for those with pretreatment SBP 130-139 mmHg and ≥140 mmHg, respectively). CONCLUSIONS In this observational study, patients with diabetes initiating antihypertensive therapy when SBP was 130-139 mmHg and those achieving on-treatment SBP <130 mmHg had better outcomes than those with higher SBP levels when initiating or after 2 years on treatment.
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Affiliation(s)
- Sridharan Raghavan
- Veterans Affairs Eastern Colorado Healthcare System, Aurora, CO
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO
- Colorado Cardiovascular Outcomes Research Consortium, Aurora, CO
| | - Yuk-Lam Ho
- Veterans Affairs Boston Healthcare System, Boston, MA
| | - Vinay Kini
- Colorado Cardiovascular Outcomes Research Consortium, Aurora, CO
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO
| | - Mary K Rhee
- Atlanta Veterans Affairs Medical Center, Decatur, GA
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Jason L Vassy
- Veterans Affairs Boston Healthcare System, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA
| | - David R Gagnon
- Veterans Affairs Boston Healthcare System, Boston, MA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Kelly Cho
- Veterans Affairs Boston Healthcare System, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Peter W F Wilson
- Atlanta Veterans Affairs Medical Center, Decatur, GA
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Lawrence S Phillips
- Atlanta Veterans Affairs Medical Center, Decatur, GA
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
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Yusufu M, Zhang X, Sun X, Raat H, Wang N. How to perform better intervention to prevent and control diabetic retinopathy among patients with type 2 diabetes: A meta-analysis of randomized controlled trials. Diabetes Res Clin Pract 2019; 156:107834. [PMID: 31550487 DOI: 10.1016/j.diabres.2019.107834] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 08/05/2019] [Accepted: 08/29/2019] [Indexed: 11/26/2022]
Abstract
This meta-analysis of randomized controlled trials (RCTs) aims to investigate how to perform better interventions targeting modifiable risk factors of diabetic retinopathy (DR) to prevent and control DR in patients with type 2 diabetes by comparing different intervention types and follow-up intervals. Literature published before June 1st, 2019 were searched on Pubmed, Embase and ScienceDirect. RCTs targeting modifiable risk factors of DR (including blood glucose, blood pressure, lipid, dietary, physical activity and smoking) were selected by two reviewers and double checked for accuracy. Random effects models were estimated to calculate pooled Odds Ratios (OR). Twenty-two RCTs (n = 22,511) were included. In general, interventions targeting modifiable risk factor of DR reduced the risk of developing DR (I2 = 26.7%; OR = 0.60; 95% CI 0.45 to 0.79) and DR worsening (I2 = 0.0%; OR = 0.62; 95% CI 0.47 to 0.80; P < 0.001). Multifactorial interventions had better effect on reducing the risk of development and progression of DR in comparison with other interventions, while only blood-pressure-control interventions showed significant effect on slowing down DR worsening. Additionally, interventions with follow-up >5 years had better effect on reduction of DR development, and interventions with follow-up >2 years had better effect on reducing the risk of DR worsening.
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Affiliation(s)
- Mayinuer Yusufu
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Xuxi Zhang
- Public Heath School, Health Science Center, Peking University, Beijing, China; Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Xinying Sun
- Public Heath School, Health Science Center, Peking University, Beijing, China
| | - Hein Raat
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ningli Wang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China.
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Almalki Z, Alatawi Y, Alharbi A, Almaklefi B, Alfaiz S, Almohana O, Alsaidan Y, Alanezi A. Cost-Effectiveness of More Intensive Blood Pressure Treatment in Patients with High Risk of Cardiovascular Disease in Saudi Arabia: A Modelling Study of Meta-Analysis. Int J Hypertens 2019; 2019:6019401. [PMID: 31662901 PMCID: PMC6791260 DOI: 10.1155/2019/6019401] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/07/2019] [Accepted: 09/04/2019] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE The current literature suggests that more intensive blood pressure (BP) treatment is clinically more effective than less intensive treatment in patients at high risk for cardiovascular disease (CVD). In this analysis, we evaluated the potential clinical benefit and cost-effectiveness of more intensive BP treatment in patients at high risk of developing CVD over their lifetimes. METHODS A Markov state-transition model was developed for the BP strategies to estimate the lifetime incremental cost-effectiveness ratio (ICER) per quality-adjusted-life-year (QALY) using evidence published from a meta-analysis. The other model inputs were retrieved from previous studies. Estimated costs were collected from five hospitals in Riyadh. The model used a lifetime framework adopting Saudi payer perspective and applied a 3% annual discount rate. Sensitivity analysis was conducted using one-way and probabilistic sensitivity analysis (PSA) to evaluate the robustness and uncertainty of the estimates. RESULTS Treating 10,000 patients with high CVD risk with more intensive BP therapy would avert a total of 873 CV events over their remaining lifetimes as compared with a less intensive strategy. The projections showed that more intensive BP therapy would be cost-effective compared to the less intensive strategy with incremental costs per QALY of $20,358. Probabilistic sensitivity analysis suggested more intensive control would be cost-effective compared with the less intensive control of BP 87.25 % of the time. CONCLUSION The result of this study showed that more intensive BP treatment appears to be a cost-effective choice for patients with a high risk of CVD in Saudi Arabia when compared with a less intensive BP strategy. Thus, this finding provides strong evidence for the adoption of this strategy within the Saudi healthcare system.
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Affiliation(s)
- Ziyad Almalki
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Yasser Alatawi
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Mecca, Riyadh, Saudi Arabia
| | - Adnan Alharbi
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Mecca, Riyadh, Saudi Arabia
| | - Bader Almaklefi
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Suliman Alfaiz
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Omar Almohana
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Yasser Alsaidan
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Abdullah Alanezi
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
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45
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Blood pressure level associated with lowest cardiovascular event in hypertensive diabetic patients. J Hypertens 2019; 36:2434-2443. [PMID: 30015754 DOI: 10.1097/hjh.0000000000001842] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The ACCORD BP trial failed to show the benefit of strict blood pressure (BP) control on cardiovascular events in diabetics with high cardiovascular risk. However, this result cannot be generalized to all diabetics. We investigated whether lower mean BP in diabetic people with hypertension is associated with better prognosis. METHODS Participants from the Korea National Health Insurance Service Health Examinee Cohort who were diagnosed with diabetes and hypertension between 2003 and 2006 were included in the analysis (N = 7926). Mortality and cardiovascular events were compared among three groups according to mean SBP (<130, 130-<140, ≥140 mmHg) and mean DBP (<80, 80-<90, ≥ 90 mmHg) recorded during follow-up health examinations for up to 11 years. RESULTS Significant reductions in the risk of all-cause death, nonfatal myocardial infarction (MI), nonfatal stroke, and end-stage renal disease were observed in patients with a mean SBP of 130 mmHg to less than 140 mmHg, as compared with patients with a mean SBP of at least 140 mmHg. The additional clinical benefit of a mean SBP of less than 130 mmHg was unclear. Lower risk of all-cause death, cardiovascular mortality, and nonfatal strokes was observed in patients with a mean DBP of 80 mmHg to less than 90 mmHg. A mean DBP of less than 80 mmHg was associated with further reduction in all-cause mortality, cardiovascular mortality, ischaemic stroke, and total stroke. CONCLUSION A mean BP of less than 140/80 mmHg was associated with further reduction in the risk of all-cause mortality, cardiovascular mortality, and nonfatal cardiovascular events in diabetic hypertensive patients.
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46
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Ahmed SB, Dumanski SM. Why Do Patients With Well-Controlled Vascular Risk Factors Develop Progressive Chronic Kidney Disease? Can J Cardiol 2019; 35:1170-1180. [DOI: 10.1016/j.cjca.2019.06.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/07/2019] [Accepted: 06/14/2019] [Indexed: 01/17/2023] Open
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47
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Aschmann HE, Boyd CM, Robbins CW, Mularski RA, Chan WV, Sheehan OC, Wilson RF, Bennett WL, Bayliss EA, Yu T, Leff B, Armacost K, Glover C, Maslow K, Mintz S, Puhan MA. Balance of benefits and harms of different blood pressure targets in people with multiple chronic conditions: a quantitative benefit-harm assessment. BMJ Open 2019; 9:e028438. [PMID: 31471435 PMCID: PMC6720326 DOI: 10.1136/bmjopen-2018-028438] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Recent studies suggest that a systolic blood pressure (SBP) target of 120 mm Hg is appropriate for people with hypertension, but this is debated particularly in people with multiple chronic conditions (MCC). We aimed to quantitatively determine whether benefits of a lower SBP target justify increased risks of harm in people with MCC, considering patient-valued outcomes and their relative importance. DESIGN Highly stratified quantitative benefit-harm assessment based on various input data identified as the most valid and applicable from a systematic review of evidence and based on weights from a patient preference survey. SETTING Outpatient care. PARTICIPANTS Hypertensive patients, grouped by age, gender, prior history of stroke, chronic heart failure, chronic kidney disease and type 2 diabetes mellitus. INTERVENTIONS SBP target of 120 versus 140 mm Hg for patients without history of stroke. PRIMARY AND SECONDARY OUTCOME MEASURES Probability that the benefits of a SBP target of 120 mm Hg outweigh the harms compared with 140 mm Hg over 5 years (primary) with thresholds >0.6 (120 mm Hg better), <0.4 (140 mm Hg better) and 0.4 to 0.6 (unclear), number of prevented clinical events (secondary), calculated with the Gail/National Cancer Institute approach. RESULTS Considering individual patient preferences had a substantial impact on the benefit-harm balance. With average preferences, 120 mm Hg was the better target compared with 140 mm Hg for many subgroups of patients without prior stroke, especially in patients over 75. For women below 65 with chronic kidney disease and without diabetes and prior stroke, 140 mm Hg was better. The analyses did not include mild adverse effects, and apply only to patients who tolerate antihypertensive treatment. CONCLUSIONS For most patients, a lower SBP target was beneficial, but this depended also on individual preferences, implying individual decision-making is important. Our modelling allows for individualised treatment targets based on patient preferences, age, gender and co-morbidities.
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Affiliation(s)
- Hélène E Aschmann
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Craig W Robbins
- Center for Clinical Information Services, Kaiser Permanente Care Management Institute, Oakland, California, USA
- Kaiser Permanente National Guideline Program, Oakland, California, USA
- Guidelines International Network, Board of Trustees, Denver, Colorado, USA
- Family Medicine, Colorado Permanente Medical Group, Denver, Colorado, USA
- Clinical Education MOC Portfolio, The Permanente Federation, Oakland, California, USA
| | - Richard A Mularski
- The Center for Health Research, Kaiser Permanente Northwest, Northwest Permanente Research and Evaluation, Portland, Oregon, USA
- Department of Pulmonary & Critical Care Medicine, Northwest Permanente, Portland, Oregon, USA
- Oregon Health & Science University, Portland, Oregon, USA
| | - Wiley V Chan
- Kaiser Permanente Northwest, National Guideline Program, Portland, Oregon, USA
| | - Orla C Sheehan
- Division of Geriatric Medicine and Gerontology, Center on Aging and Health, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Renée F Wilson
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Wendy L Bennett
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente, Denver, Colorado, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tsung Yu
- Department of Public Health College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Bruce Leff
- Division of Geriatric Medicine and Gerontology, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karen Armacost
- Division of Geriatric Medicine and Gerontology, Patient and Caregiver Partner Group, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carol Glover
- Division of Geriatric Medicine and Gerontology, Patient and Caregiver Partner Group, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Katie Maslow
- Division of Geriatric Medicine and Gerontology, Patient and Caregiver Partner Group, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Gerontological Society of America, Washington, District of Columbia, USA
| | - Suzanne Mintz
- Division of Geriatric Medicine and Gerontology, Patient and Caregiver Partner Group, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Family Caregiver Advocacy, Kensington, Maryland, USA
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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Lessey G, Stavropoulos K, Papademetriou V. Mild to moderate chronic kidney disease and cardiovascular events in patients with type 2 diabetes mellitus. Vasc Health Risk Manag 2019; 15:365-373. [PMID: 31686830 PMCID: PMC6709811 DOI: 10.2147/vhrm.s203925] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 05/01/2019] [Indexed: 12/20/2022] Open
Abstract
Chronic kidney disease (CKD) has become a major public health problem in the USA and worldwide. A large majority of patients with CKD have mild to moderate disease and microalbuminuria. It has increasingly been noted that patients with CKD have a significantly higher risk of cardiovascular outcomes compared to patients with normal kidney function. Many studies have shown increased risk beginning at stage 3 CKD but risk has been elevated in patients with milder degrees of kidney dysfunction in some studies. This risk may be better predicted by the degree of albuminuria in the earlier stages of CKD. Data addressing interventions to improve outcomes in patients with mild to moderate CKD are scarce. In this paper, we examined data and post hoc analyses from the ORIGIN and ACCORD trials. Data indicate that intensive treatment of diabetes in patients with CKD actually may result in adverse outcomes. The mechanism by which CKD results in increased cardiovascular risk is not clear. Patients with CKD frequently have the traditional risk factors that cause cardiovascular disease and there are mechanisms that are unique to CKD that promote the development of cardiovascular disease. In this article, we describe in some detail traditional, newer and novel risk factors that play a role in the development of CKD and heart disease.
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Affiliation(s)
- Gayatri Lessey
- Department of Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Konstantinos Stavropoulos
- Department of Medicine, Georgetown University Hospital, Washington, DC, USA.,Department of Medicine, VA Medical Center, Washington, DC, USA
| | - Vasilios Papademetriou
- Department of Medicine, Georgetown University Hospital, Washington, DC, USA.,Department of Medicine, VA Medical Center, Washington, DC, USA
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49
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Does the benefit from treating to lower blood pressure targets vary with age? A systematic review and meta-analysis. J Hypertens 2019; 37:1558-1566. [DOI: 10.1097/hjh.0000000000002079] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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50
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Lee HY, Shin J, Kim GH, Park S, Ihm SH, Kim HC, Kim KI, Kim JH, Lee JH, Park JM, Pyun WB, Chae SC. 2018 Korean Society of Hypertension Guidelines for the management of hypertension: part II-diagnosis and treatment of hypertension. Clin Hypertens 2019; 25:20. [PMID: 31388453 PMCID: PMC6670135 DOI: 10.1186/s40885-019-0124-x] [Citation(s) in RCA: 168] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 06/25/2019] [Indexed: 02/06/2023] Open
Abstract
The standardized techniques of blood pressure (BP) measurement in the clinic are emphasized and it is recommended to replace the mercury sphygmomanometer by a non-mercury sphygmomanometer. Out-of-office BP measurement using home BP monitoring (HBPM) or ambulatory BP monitoring (ABPM) and even automated office BP (AOBP) are recommended to correctly measure the patient’s genuine BP. Hypertension (HTN) treatment should be individualized based on cardiovascular (CV) risk and the level of BP. Based on the recent clinical study data proving benefits of intensive BP lowering in the high risk patients, the revised guideline recommends the more intensive BP lowering in high risk patients including the elderly population. Lifestyle modifications, mostly low salt diet and weight reduction, are strongly recommended in the population with elevated BP and prehypertension and all hypertensive patients. In patients with BP higher than 160/100 mmHg or more than 20/10 mmHg above the target BP, two drugs can be prescribed in combination to maximize the antihypertensive effect and to achieve rapid BP control. Especially, single pill combination drugs have multiple benefits, including maximizing reduction of BP, minimizing adverse effects, increasing adherence, and preventing cardiovascular disease (CVD) and target organ damage.
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Affiliation(s)
- Hae-Young Lee
- 1Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jinho Shin
- 2Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Gheun-Ho Kim
- 2Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sungha Park
- 3Department of Internal Medicine, Yonsei University, Seoul, Korea
| | - Sang-Hyun Ihm
- 4Division of Cardiology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Chang Kim
- 3Department of Internal Medicine, Yonsei University, Seoul, Korea
| | - Kwang-Il Kim
- 5Department of Internal Medicine, Seoul National University, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ju Han Kim
- Department of Internal Medicine, School of Medicine, Chonnam University, GwangJu, Korea
| | - Jang Hoon Lee
- 7Division of Cardiology, Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jong-Moo Park
- 8Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Wook Bum Pyun
- 9Cardiovascular Center, Seoul Hospital, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Shung Chull Chae
- 7Division of Cardiology, Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
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