Validation of the Modification of Diet in Renal Disease formula for estimating GFR with special emphasis on calibration of the serum creatinine assay

Long-term Prolonged-release Tacrolimus-based Immunosuppression in De Novo Kidney Transplant Recipients: 5-Y Prospective Follow-up of Patients in the ADVANCE Study

Although prolonged-release tacrolimus (PR-T) is widely approved for posttransplantation immunosuppression in kidney recipients, large-scale studies are required to assess long-term outcomes. We present follow-up data from the Advagraf-based Immunosuppression Regimen Examining New Onset Diabetes Mellitus in Kidney Transplant Recipients (ADVANCE) trial, in which kidney transplant patients (KTPs) received corticosteroid minimization with PR-T.

Methods

ADVANCE was a 24-wk, randomized, open-label, phase-4 study. De novo KTPs received PR-T with basiliximab and mycophenolate mofetil and were randomized to receive an intraoperative corticosteroid bolus plus tapered corticosteroids until day 10 (arm 1) or an intraoperative corticosteroid bolus (arm 2). In this 5-y, noninterventional follow-up, patients received maintenance immunosuppression according to standard practice. The primary endpoint was graft survival (Kaplan-Meier). Secondary endpoints included patient survival, biopsy-confirmed acute rejection-free survival, and estimated glomerular filtration rate (4-variable modification of diet in renal disease).

Results

Follow-up study included 1125 patients. Overall graft survival at 1 and 5 y posttransplantation was 93.8% and 88.1%, respectively, and was similar between treatment arms. At 1 and 5 y, patient survival was 97.8% and 94.4%, respectively. Five-year graft and patient survival rates in KTPs who remained on PR-T were 91.5% and 98.2%, respectively. Cox proportional hazards analysis demonstrated similar risk of graft loss and death between treatment arms. Five-year biopsy-confirmed acute rejection-free survival was 84.1%. Mean ± standard deviation values of estimated glomerular filtration rate were 52.7 ± 19.5 and 51.1 ± 22.4 mL/min/1.73 m² at 1 and 5 y, respectively. Fifty adverse drug reactions were recorded, probably tacrolimus-related in 12 patients (1.5%).

Conclusions

Graft survival and patient survival (overall and for KTPs who remained on PR-T) were numerically high and similar between treatment arms at 5 y posttransplantation.

Evaluating prediction methods for glomerular filtration to optimise drug doses in obese and nonobese patients

AIMS

The most suitable method for predicting the glomerular filtration rate (GFR) in obesity is currently debated. Therefore, multiple GFR/creatinine clearance prediction methods were applied to (morbidly) obese and nonobese patients ranging from moderate renal impairment to glomerular hyperfiltration and their predictions were rated based on observed fosfomycin pharmacokinetics, as this model drug is exclusively eliminated via glomerular filtration.

METHODS

The GFR/creatinine clearance predictions via the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), Modification of Diet in Renal Disease (MDRD; indexed and de-indexed by body surface area) and creatinine clearance via the Cockcroft-Gault formula (CLCR_CG ) using different body size descriptors were compared to the fosfomycin clearance (CL_FOF ) from 30 surgical patients (body mass index = 20.1-52.0 kg m^-2 ), receiving 8000 mg as intravenous infusion.

RESULTS

The concordance between CL_FOF and creatinine clearance predictions was highest for CLCR_CG employing either ideal body weight or adjusted body weight (if body mass >1.3 ideal body weight; CLCR_{CG_ABW-Schwartz} , concordance-correlation coefficient [95% confidence interval] = 0.474 [0.156; 0.703], CCC) and GFR predictions via the de-indexed MDRD equation (concordance-correlation coefficient = 0.452 [0.137; 0.685]). The proportion of predicted GFR values within ±30% of the observed CL_FOF (P₃₀  = 72.3-76.7%) was only marginally lower than the reported P₃₀ in the original CKD-EPI and MDRD publications (P₃₀  = 84.1-90.0%).

CONCLUSION

This analysis represents a successful proof-of-concept for evaluating GFR/creatinine clearance prediction methods: Across all body mass index classes CLCR_{CG_ABW-Schwartz} or the de-indexed MDRD were most suitable for predicting creatinine clearance/GFR also in (morbidly) obese, CKD stage <3B individuals in therapeutic use. Their application is proposed in optimising doses for vital therapies in obese patients requiring monitoring of renal function (e.g. methotrexate dosing).

Incidence and Predictors of Progression in Asymptomatic Patients With Stable Heart Failure

Data from previous heart failure (HF) trials suggest that patients with mild symptoms (NYHA II) actually have a poor clinical outcome. However, these studies did not assess clinical stability and rarely included patients in NYHA I. We sought to determine the incidence of short-term clinical progression in supposedly stable HF patients in NYHA I. In addition, we aimed to investigate the predictive value of widely available electrocardiographic and echocardiographic parameters for short-term disease progression. This is a retrospective study including 153 consecutive patients with HF with reduced and mid-range ejection fraction (HFrEF: LVEF<40%; HFmrEF: LVEF 40-49%) in NYHA I with no history of decompensation within the previous 6 months. All patients underwent comprehensive baseline echocardiographic and electrocardiographic assessment. The primary endpoint was the composite of cardiovascular death, hospitalization and need for intensification of HF treatment within a 12 month follow-up period. The cumulative incidence of HF progression was 17.8%, with a median time to event of 193 days. Death and hospitalization due to HF accounted for three-quarters of the events. QRS duration ≥120ms and mitral regurgitation grade >1 showed to be significant predictors of HF progression (HR: 8.92, p<0.001; and HR: 4.10, p<0.001, respectively). Patients without these risk factors had a low incidence of clinical events (3.8%). In conclusion, almost one in five supposedly stable HF patients in NYHA I experience clinical progression in short-term follow-up. Simple electrocardiographic and echocardiographic predictors may be useful for risk stratification and could help to improve individual HF patient management and outcomes.

Long-term, Prolonged-release Tacrolimus-based Immunosuppression in De Novo Liver Transplant Recipients: 5-year Prospective Follow-up of Patients in the DIAMOND Study

Background

Immunosuppression with calcineurin inhibitors (CNIs) is reportedly associated with risk of renal impairment in liver transplant recipients. It is believed that this can be mitigated by decreasing initial exposure to CNIs or delaying CNI introduction until 3-4 d posttransplantation. The ADVAGRAF studied in combination with mycophenolate mofetil and basiliximab in liver transplantation (DIAMOND) trial evaluated different administration strategies for prolonged-release tacrolimus (PR-T).

Methods

DIAMOND was a 24-wk, open-label, phase 3b trial in de novo liver transplant recipients randomized to: PR-T 0.2 mg/kg/d (Arm 1); PR-T 0.15-0.175 mg/kg/d plus basiliximab (Arm 2); or PR-T 0.2 mg/kg/d delayed until day 5 posttransplant plus basiliximab (Arm 3). In a 5-y follow-up, patients were maintained on an immunosuppressive regimen according to standard clinical practice (NCT02057484). Primary endpoint: graft survival (Kaplan-Meier analysis).

Results

Follow-up study included 856 patients. Overall graft survival was 84.6% and 73.5% at 1 and 5 y post transplant, respectively. Five-year rates for Arms 1, 2, and 3 were 74.7%, 71.5%, and 74.5%, respectively. At 5 y, death-censored graft survival in the entire cohort was 74.7%. Overall graft survival in patients remaining on PR-T for ≥30 d was 79.1%. Graft survival in patients who remained on PR-T at 5 y was 87.3%. Patient survival was 86.6% at 1 y and 76.3% at 5 y, with survival rates similar in the 3 treatment arms at 5 y. Estimated glomerular filtration rate at the end of the 24-wk initial study and 5 y posttransplant was 62.1 and 61.5 mL/min/1.73 m², respectively, and was similar between the 3 treatment arms at 5 y. Overall, 18 (2.9%) patients had ≥1 adverse drug reaction, considered possibly related to PR-T in 6 patients.

Conclusions

In the DIAMOND study patient cohort, renal function, graft survival, and patient survival were similar between treatment arms at 5 y posttransplant.

Cardio-ankle vascular index represents the best surrogate for 10-year ASCVD risk estimation in patients with primary hypertension

Background: Identification of target organ damage and/or risk-enhancing factors help treatment decisions in hypertensive and hyperlipidaemic patients who reside in borderline to an intermediate risk category based on 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimates.Aim: In the present study, we aimed to investigate the comparative efficacy of certain hypertension-mediated organ damage markers (HMOD) for the prediction of 10-year ASCVD risk ≥10%, in patients with primary hypertension without established CVD.Methods: One-hundred thirty-seven asymptomatic hypertensive patients ≥40 years of age were enrolled in the present study. Ten-year ASCVD risks were estimated by Pooled Cohort Equations. The following HMOD markers; pulse pressure (PP), left ventricular mass index (LVMI), carotid intima-media thickness (CIMT), ankle-brachial index (ABI), cardio-ankle vascular index (CAVI) and estimated glomerular filtration rate (eGFR) were evaluated with respect to efficacy for predicting ≥10% ASCVD risk with ROC analysis.Results: CAVI gave the greatest Area Under Curve (AUC = 0.736, p < .000), and followed by CIMT (AUC = 0.727, p < .000), LVMI (AUC = O.630, p = .01), and PP (AUC = 0.623, p = .02). ABI and eGFR were not found to be predictive. CAVI correlated best with estimated 10-year ASCVD risk (r = 0.460, p < .000). A CAVI value ≥8 was found 71% sensitive and 72% specific for predicting ≥10% risk in 10-year ASCVD risk scale. CAVI gave the best graded response to increments in 10-year ASCVD risk categories.Conclusion: We suggest that CAVI is the best surrogate for 10-year ASCVD risk, among several HMOD markers.

Limited reliability of heart rate as a sympathetic marker in chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is characterized by a pronounced sympathetic overactivity as documented by the marked increase in muscle sympathetic nerve traffic (MSNA) and in plasma norepinephrine reported in this condition. Whether and to what extent in CKD heart rate (HR) reflects the adrenergic overdrive remains undefined. It is also undefined the relative validity of the different adrenergic markers in reflecting renal dysfunction.

MATERIALS AND METHODS

In 82 CKD patients, aged 58.4 ± 1.1 years (mean ± SEM), we measured resting clinic blood pressure, HR (EKG), venous NE (HPLC) and MSNA (microneurography). The same measurements were made in 24 age-matched healthy controls.

RESULTS

HR was significantly greater in CKD than in controls (74.0 ± 1.1 versus 68.2 ± 1.8 bpm, P < 0.02) and significantly directly related to the elevated plasma norepinephrine and MSNA values (r = 0.22 and 0.39, P < 0.05 and <0.0003, respectively). Both MSNA and plasma norepinephrine were significantly and inversely related to the estimated glomerular filtration rate. The correlation did not achieve statistical significance for HR. Similar results were obtained examining the relationships with left ventricular mass index.

CONCLUSION

Our data show that in CKD not only peripheral but also cardiac sympathetic drive is markedly enhanced and HR can be regarded as a marker of the adrenergic overdrive characterizing this condition. The reliability of HR as sympathetic marker appears to be limited, however, this variable being unable to closely reflect, at variance from MSNA and plasma norepinephrine, the interindividual differences in renal dysfunction and the accompanying structural cardiovascular alterations.

Estimation of glomerular filtration rate from skeletal muscle mass. A new equation independent from age, weight, gender, and ethnicity

BACKGROUND AND AIMS

The most used indicator for the renal function is the glomerular filtration rate (GFR). Current used predictive GFR equations were calibrated on patients with chronic kidney disease. Thus, they are not very precise in healthy individuals. The estimation of skeletal muscle mass (SMM) allows the prediction of the daily urinary creatinine excretion (24hUCrE). This study proposes an equation for the estimation of GFR based on SMM (eGFRMuscle) and serum creatinine (SCr).

METHODS AND RESULTS

Four hundred sixty-six free-living men underwent a bioelectrical impedance analysis for the evaluation of SMM (kg), a blood withdrawal for the measurement of SCr (mg/dL), and a 24-h urinary collection for the assessment of 24hUCrE (g/24 h). The linear regression analysis between SMM and 24hUCrE and the measurement of SCr allowed developing a predictive equation of eGFRMuscle. The equation predicting eGFRMuscle (ml/min/1.73 m²) was SMM (kg) × 3.06/SCr (mg/dL). eGFRMuscle was statistically different from eGFR predicted by Cockroft-Gault, MDRD Study, and CKD-EPI equations (p = 0.017, p < 0.001, and p < 0.001, respectively). Pairwise comparison of standard error of the area under the ROC curve (AUC) of eGFRMuscle with all the other AUCs of ROC curves highlighted significant differences.

CONCLUSIONS

The equation presented in this study results in age, weight, gender, and ethnicity independent because it arises directly from SMM estimation. Therefore, the proposed equation could allow evaluating the GFR also in healthy people with low, average, or high weight, and in older people, regardless of GFR and SCr levels.

Clinical risk factors for the prediction of acute kidney injury post cardiac resynchronization therapy in an elderly population

Background

Data on the occurrence of acute kidney injury (AKI) in patients undergoing cardiac resynchronization therapy (CRT) implantation is limited and no previous studies investigated its impact in an elderly population. CRT implantation requires a relatively low quantity of contrast medium. Previous studies, however, focused primarily on contrast medium as etiological factor for AKI, reporting a high incidence (8–14%). The high incidence of AKI in absence of use of substantial amounts of contrast volume, suggests the existence of other factors that contribute to AKI.

Objectives

To determine the predictive value of patient and procedure-related risk factors for the occurrence of AKI post CRT, as well as the AKIs impact on length of in-hospital stay (LOS) and 1-year mortality.

Methods

Retrospective observational study, including consecutive patients that underwent CRT implantation in a single center.

Results

60 patients with a mean age of 77 ± 8.4 years were included in the study and Twelve (20%) developed AKI. Prior renal insufficiency (p = 0.03; OR = 15.4), larger procedure time (p = 0.02; OR = 1.03), intra-operative hypotension (p < 0.01; OR = 1.72) and bleeding (p = 0.01 (OR = 7.86), showed to predict AKI significantly. AKI associated a significantly longer LOS (12 vs 3 days, p < 0.01). No significant differences regarding 1-year mortality were observed (p = 0.19; HR = 2.7 for patients with AKI).

Conclusions

AKI is a frequent complication of CRT implantation with an important impact on in-hospital stay, especially in the elderly. In addition to contrast administration, clinical factors could play a significant role in the occurrence of AKI.

Long-term, prolonged-release tacrolimus-based immunosuppression in de novo kidney transplant recipients: 5-year prospective follow-up of the ADHERE study patients

The objectives of this study were to assess long-term graft survival, patient survival, renal function, and acute rejections in de novo kidney transplant recipients, treated with once-daily prolonged-release tacrolimus-based therapy. The study was a 5-year non-interventional prospective follow-up of patients from the ADHERE study, a Phase IV 12-month open-label assessment of patients randomized to receive prolonged-release tacrolimus in combination with mycophenolate mofetil (MMF) (Arm 1) or sirolimus (Arm 2). From 838 patients in the randomized study, 587 were included in the long-term follow-up, of whom 510 completed the study at year 5. At 1 year post-transplant, graft and patient survival rates were 93.0% and 97.8%, respectively, and at 5 years were 84.0% and 90.8%, respectively. Cox proportional hazards analysis showed no association between graft loss, initial randomized treatment arm, donor age, donor type, or sex. The 5-year acute rejection-free survival rate was 77.4%, and biopsy-confirmed acute rejection-free survival rate was 86.0%. Renal function remained stable over the follow-up period: mean ± SD eGFR 4-variable modification diet in renal disease formula (MDRD4) was 52.3 ± 21.6 ml/min/1.73 m² at 6 months and 52.5 ± 23.0 ml/min/1.73 m² at 5 years post-transplant. These findings support the role of long-term once-daily prolonged-release tacrolimus-based immunosuppression, in combination with sirolimus or MMF, for renal transplant recipients in routine clinical practice.

Admission to the surgical intensive care unit during intensivist coverage is associated with lower incidence of postoperative acute kidney injury and shorter ventilator time

PURPOSE

This study aimed to assess the impact of intensivist coverage on the incidence of acute kidney injury (AKI) and ventilator time among patients postoperatively admitted to the intensive care unit (ICU).

METHODS

Adult patients postoperatively admitted to the ICU between January 2012 and December 2017 were retrospectively enrolled. The incidence of AKI within 72 h of surgery and the postoperative ventilator time were compared between the groups covered by intensivists and non-intensivists.

RESULTS

After propensity score (PS) matching, 5650 patients were included in the final analysis (2825 patients in each group). The incidence rate of AKI was significantly higher in the non-intensivist coverage group than in the intensivist coverage group (22.7% vs. 20.2%; P = 0.023). Moreover, logistic regression analysis in the PS-matched cohort showed that the incidence of postoperative AKI in the non-intensivist coverage group increased by 16% compared to that in the intensivist coverage group (odds ratio 1.16, 95% confidence interval 1.02-1.32; P = 0.023). Additionally, the median time of ventilator use in the non-intensivist coverage group was significantly longer than that in the intensivist coverage group [7.8 (interquartile range, IQR 2.6-13.8) h vs. 5.3 (1.8-8.3) h; P < 0.001].

CONCLUSION

High-intensity intensivist coverage is associated with a lower risk of postoperative AKI and shorter postoperative ventilator times. These findings suggested that in addition to medical trainees, initial management of surgical ICU patients by intensivists may lower the risk of AKI and facilitate early weaning from mechanical ventilation.

Perioperative sedative use is not associated with acute kidney injury after total hip or knee arthroplasty

Background

The use of sedatives (propofol or dexmedetomidine) is common in total knee arthroplasty (TKA) or total hip arthroplasty (THA) under spinal anesthesia. Although propofol and dexmedetomidine have been reported to decrease the risk of acute kidney injury (AKI) after cardiac surgery, their effects on AKI incidence after TKA or THA are still unknown. The purpose of this study was to investigate the associations between sedative dosage (propofol and dexmedetomidine) and AKI incidence after TKA or THA under spinal anesthesia.

Methods

This retrospective observational study analyzed medical records of adult patients aged 18 years or older who underwent unilateral TKA or THA under spinal anesthesia at a single tertiary care hospital between January 2007 and June 2018. Data were analyzed using univariable and multivariable logistic regression analyses.

Results

A total of 5,663 patients were included in the analysis (TKA: 3,570, 63.0%; THA: 2,093, 37.0%), and 147 patients (2.6%) developed AKI in postoperative days 0-3. Multivariable logistic regression analysis showed that propofol dosage (odds ratio: 0.99, 95% confidence interval: 0.94, 1.05; P=0.839) and dexmedetomidine dosage (odds ratio: 0.95, 95% confidence interval: 0.84, 1.09; P=0.461) were not significantly associated with AKI incidence.

Conclusions

This study demonstrated no significant association between sedative uses (propofol, dexmedetomidine) and AKI incidence after THA or TKA under spinal anesthesia, and use of such sedatives does not require extreme caution.

Nitrogen-terminated silicon nanoparticles obtained via chemical etching and passivation are specific fluorescent probes for creatinine

A method is described here to prepare water-dispersible nitrogen-functionalized silicon nanoparticles (N-SiNPs). It consists of two steps, viz. etching of the oxidized shell of SiNPs and nitrogen-passivation of the exposed silicon. The resulting N-SiNPs have an average diameter of 2.6±0.7 nm and show blue fluorescence (with excitation/emission peaks at 340/420 nm). The fluorescence quantum yield is 23% and the decay time is in the nanosecond regime. Compared to etching methods using a plasma or hydrofluoric acid, the process described here (etching and passivation) is mild, continuous, fast, and air-compatible. The N-SiNPs modified with chlorotetracycline are shown to be a viable fluorescent probe for creatinine. Fluorescence drops in the 0 to 20 μM creatinine concentration range, and the limit of detection is 0.14 μM.

Fluctuations in Serum Chloride and Acute Kidney Injury among Critically Ill Patients: A Retrospective Association Study

Exposure to dyschloremia among critically ill patients is associated with an increased risk of acute kidney injury (AKI). We aimed to investigate how fluctuations in serum chloride (Cl⁻) are associated with the development of AKI in critically ill patients. We retrospectively analyzed medical records of adult patients admitted to the intensive care unit (ICU) between January 2012 and December 2017. Positive and negative fluctuations in Cl⁻ were defined as the difference between the baseline Cl- and maximum Cl- levels and the difference between the baseline Cl⁻ and minimum Cl⁻ levels measured within 72 h after ICU admission, respectively. In total, 19,707 patients were included. The odds of developing AKI increased 1.06-fold for every 1 mmol L⁻¹ increase in the positive fluctuations in Cl⁻ (odds ratio: 1.06; 95% confidence interval: 1.04 to 1.08; p < 0.001) and 1.04-fold for every 1 mmol L⁻¹ increase in the negative fluctuations in Cl⁻ (odds ratio: 1.04; 95% confidence interval: 1.02 to 1.06; p < 0.001). Increases in both the positive and negative fluctuations in Cl- after ICU admission were associated with an increased risk of AKI. Furthermore, these associations differed based on the functional status of the kidneys at ICU admission or postoperative ICU admission.

Is endocan a biochemical marker for asymptomatic target organ damage in hypertensive patients?

Objective:

Identification of the asymptomatic target organ damage (AOD) helps to stratify the overall risk of cardiovascular (CV) diseases and guides a treatment decision in hypertensive patients without a symptomatic CV or renal disease. The endothelial-cell-specific molecule 1 (endocan) is regarded as a novel marker of endothelial dysfunction. Its release is increased in hypertensive patients, especially those with symptomatic CV and renal disease. In the present study, we aimed to evaluate the endocan levels in asymptomatic hypertensive patients with or without AOD.

Methods:

The study included 132 asymptomatic hypertensive patients, and 101 of who had at least one AOD.

Results:

Serum endocan levels did not differ between patients with and without AOD (3.81±0.78 vs. 3.83±0.63 ng/mL, p=0.88). An analysis according to the presence of any specific AOD did not show any difference between groups. No significant correlation was found between serum endocan levels and any of the continuous variables related to AOD, such as the pulse pressure, carotid intimae-media thickness, cardio-ankle vascular index, ankle-brachial index, left ventricular mass index, Sokolow–Lyon index, Cornell voltage-duration product, and estimated glomerular filtration rate.

Conclusion:

Endocan may not serve as a useful biomarker at asymptomatic vascular stages of hypertension, despite its role in indicating disease severity and inflammatory activation in advanced symptomatic CV and renal disease.

Preadmission Statin Therapy Is Associated with a Lower Incidence of Acute Kidney Injury in Critically Ill Patients: A Retrospective Observational Study

This study aimed to investigate the association between preadmission statin use and acute kidney injury (AKI) incidence among critically ill patients who needed admission to the intensive care unit (ICU) for medical care. Medical records of patients admitted to the ICU were reviewed. Patients who continuously took statin for >1 month prior to ICU admission were defined as statin users. We investigated whether preadmission statin use was associated with AKI incidence within 72 h after ICU admission and whether the association differs according to preadmission estimated glomerular filtration rate (eGFR; in mL min⁻¹ 1.73 m⁻²). Among 21,236 patients examined, 5756 (27.1%) were preadmission statin users and 15,480 (72.9%) were non-statin users. Total AKI incidence within 72 h after ICU admission was 31% lower in preadmission statin users than in non-statin users [odds ratio (OR), 0.69; 95% confidence interval (CI), 0.61–0.79; p < 0.001]. This association was insignificant among individuals with eGFR <30 mL min⁻¹ 1.73 m⁻² (p > 0.05). Our results suggested that preadmission statin therapy is associated with a lower incidence of AKI among critically ill patients; however, this effect might not be applicable for patients with eGFR <30 mL min⁻¹ 1.73 m⁻².

Early Vascular Aging Risk Assessment From Ambulatory Blood Pressure Monitoring: The Early Vascular Aging Ambulatory Score

BACKGROUND

This study compared the diagnostic accuracy of blood pressure (BP) measurement methods, office BP, ambulatory BP monitoring (ABPM), and home BP, in the identification of early vascular aging (EVA) and developed a score to predict the risk of EVA in hypertensive patients.

METHODS

Two-hundred eighty-two consecutive subjects (39.7% male) aged 56.8  ±  15.8 years were included. Office and out-of-office BP measurements including ABPM on a usual working day and 7 days home BP monitoring were performed. Carotid-femoral pulse wave velocity (c-f PWV) was measured in all patients. EVA was defined as c-f PWV values higher than the expected for age average values according to European population data.

RESULTS

In univariate analysis, EVA was significantly correlated with office systolic BP, average 24-hour systolic and diastolic BP, and average 24-hour and office heart rates. The area under the curve for predicting EVA was 0.624 (95% CI 0.551 to 0.697), 0.559 (95% CI 0.484 to 0.635) and 0.565 (95% CI 0.49 to 0.641), for daytime, home, and office systolic BP, respectively. Ambulatory BP variables, age, sex, body mass index, diabetes mellitus (yes/no), and estimated glomerular filtration rate were used to develop a new score for EVA providing a total accuracy of 0.82, 0.84 sensitivity, and 0.78 specificity.

CONCLUSIONS

In conclusion, the new risk score, Early Vascular Aging Ambulatory score, may accurately identify hypertensive patients with EVA using ABPM values and classic cardiovascular risk factors.

Citrate-capped silver nanoparticles as a probe for sensitive and selective colorimetric and spectrophotometric sensing of creatinine in human urine

Urinary creatinine concentration is a critical physiological parameter that enables reliable assessment of patient renal function and diagnosis of a broad spectrum of diseases. In this study, a simple and inexpensive sensor comprising monodisperse, citrate-capped silver nanoparticles (cc-AgNPs) was developed, which enabled rapid, sensitive and selective quantitation of creatinine directly in unprocessed urine. The mechanism of this sensor entails the creatinine-mediated aggregation of the cc-AgNPs (within 1 min) under alkaline conditions (pH 12). This is attributed to the tautomerization of creatinine to its amino anionic species at alkaline pH, which cross-link the cc-AgNPs via hydrogen bond networks with the negatively charged citrate caps. Creatinine elicited visibly-discernable color changes of the cc-AgNPs colloids in a concentration-dependent manner up to 10 μM. UV-visible spectroscopic analyses of the cc-AgNPs revealed that creatinine elicited a concentration-dependent decrease in intensity of the localized surface plasmon resonance (LSPR) band centered around 403 nm, with a concomitant increase in intensity of the red-shifted LSPR band at 670 nm. This observation denotes a creatinine-mediated increase in cc-AgNP particle size via aggregation, as confirmed by transmission electron microscopy analysis. The cc-AgNP sensor exhibited a linear correlation between the A₆₇₀/A₄₀₃ extinction ratio and creatinine concentration range of 0-4.2 μM in aqueous solutions (R² = 0.996), and a low detection limit of 53.4 nM. Hence, the simplicity, short assay time, and high sensitivity and selectivity of our cc-AgNP sensor affirms its utility as a creatinine monitoring assay for low-resource, point-of-care settings.

Carotid and aortic stiffness in essential hypertension and their relation with target organ damage: the CATOD study

OBJECTIVE

The objective of the study is to investigate in the hypertensive population the possible differential association between increased aortic and/or carotid stiffness and organ damage in multiple districts, such as the kidney, the vessels, and the heart.

METHODS

In 314 essential hypertensive patients, carotid-femoral pulse wave velocity (cfPWV, by applanation tonometry) and carotid stiffness (from ultrasound images analysis), together with left ventricular hypertrophy, carotid intima-media thickness, urinary albumin-creatinin ratio, and glomerular filtration rate were measured. Increased cfPWV and carotid stiffness were defined according to either international reference values or the 90th percentile of a local control group (110 age and sex-matched healthy individuals).

RESULTS

When considering the 90th percentile of a local control group, increased cfPWV was associated with reduced glomerular filtration rate, either when carotid stiffness was increased [odds ratio (OR) 13.27 (confidence limits (CL) 95% 3.86-45.58)] or not [OR 7.39 (CL95% 2.25-24.28)], whereas increased carotid stiffness was associated with left ventricular hypertrophy, either when cfPWV was increased [OR 2.86 (CL95% 1.15-7.09)] or not [OR 2.81 (CL95% 1.13-6.97)]. No association between increased cfPWV or carotid stiffness and target organ damage was found when cutoffs obtained by international reference values were used. The concomitance of both increased cfPWV and carotid stiffness did not have an additive effect on organ damage.

CONCLUSION

Aortic and carotid stiffness are differentially associated with target organ damage in hypertensive patients. Regional arterial stiffness as assessed by cfPWV is associated with renal organ damage and local carotid stiffness with cardiac organ damage.

Perioperative complications and postoperative outcomes of partial nephrectomy for renal cell carcinoma: Does indication matter?

Introduction:

The aim of the study was to determine whether perioperative complications and postoperative outcomes varied with the indication of partial nephrectomy (PN).

Materials and Methods:

We reviewed data of 184 consecutive PN for suspected renal cell carcinoma operated between January 2004 and December 2013. Complications using the Clavien-Dindo classification were compared between surgeries for absolute indications (chronic renal failure, bilateral tumors, or solitary kidney), those for relative indications (comorbid illnesses with the potential to affect renal function) and elective indications (patients without risk factors). Complex tumors were defined as size >7 cm, multiple, hilar, and endophytic tumors.

Results:

Patients with an absolute indication had larger tumors (P = 0.001) and tumors of a higher pathological T-stage (P = 0.03). Minor complications (Clavien 1 and 2) occurred in 25.4% patients in the elective arm versus over 40% in the other arms (P = 0.049). Major complications (Clavien 3+) were less common in the elective arm (3.2% cases vs. 12.7% in the relative arm and 13.8% in the absolute arm) with a trend to significance (P = 0.09). On multivariate analysis, absolute indication (odds ratio [OR] = 2.4, P = 0.04) and surgery for a complex renal mass (OR = 2.5 times, P = 0.03) remained significant predictors of minor complications. Major complications were more common in the relative (OR = 5.5, P = 0.057) and absolute indication arm (OR = 5.231, P = 0.051) with a trend toward significance.

Conclusions:

Elective indication was associated with fewer complications than PN for relative or absolute indications.

Correlations of dietary energy and protein intakes with renal function impairment in chronic kidney disease patients with or without diabetes

Dietary energy and protein intake can affect progression of chronic kidney disease (CKD). CKD complicated with diabetes is often associated with a decline in renal function. We investigated the relative importance of dietary energy intake (DEI) and dietary protein intake (DPI) to renal function indicators in nondiabetic and diabetic CKD patients. A total of 539 Stage 3-5 CKD patients [estimated glomerular filtration rate (eGFR)<60 mL/min/1.73 m² using the Modification of Diet in Renal Disease equation] with or without diabetes were recruited from outpatient clinics of Nephrology and Nutrition in a medical center in Taiwan. Appropriateness of DEI and DPI was used to subcategorize CKD patients into four groups:(1) kidney diet (KD) A (KD-A), the most appropriate diet, was characterized by low DPI and adequate DEI; (2) KD-B, low DPI and inadequate DEI; (3) KD-C, excess DPI and adequate DEI; and (4) KD-D, the least appropriate diet, excess DPI and inadequate DEI. Inadequate DEI was defined as a ratio of actual intake/recommended intake less than 90% and adequate DEI as over 90%. Low DPI was defined as less than 110% of recommended intake and excessive when over 110%. Outcome measured was eGFR. In both groups of CKD patients, DEI was significantly lower (p<0.001) and DPI higher (p=0.002) than recommended levels. However, only in the nondiabetic CKD patients were KD-C and KD-D significantly correlated with reduced eGFR compared with KD-A at increments of -5.63 mL/min/1.73 m² (p = 0.029) and -7.72 mL/min/1.73 m² (p=0.015). In conclusion, inadequate energy and excessive protein intakes appear to correlate with poorer renal function in nondiabetic CKD patients. Patients with advanced CKD are in need of counseling by dietitians to improve adherence to diets.

Application of vancomycin in patients with varying renal function, especially those with augmented renal clearance

CONTEXT

Augmented renal clearance (ARC) refers to enhanced renal elimination of circulating solute, and has attracted wide attention in recent years.

OBJECTIVE

This study evaluates the effects of ARC on serum vancomycin concentration in patients administered vancomycin.

MATERIALS AND METHODS

This was a retrospective study in patients receiving vancomycin treatment at a dose of 1000 mg in every 12 h and undergoing serum monitoring admitted over a 2-year period (May 2013 to May 2015), in order to estimate the influence of ARC on serum vancomycin concentration. In this study, statistical comparisons were made on the results from patients grouped according to creatinine clearance (CL_cr).

RESULTS

One hundred forty-eight patients were enrolled in our study. The results showed that ARC patients were significantly younger, with a significantly lower S_cr and higher GFR. The CL_cr and steady-state trough concentrations of serum vancomycin exhibited a logarithmic correlation (Rs = -0.699, R²=0.488, p < 0.01) in the patients included in our study. The trough vancomycin concentrations of 62.9% patients in high CL_cr group were under 10 μg/mL.

DISCUSSION AND CONCLUSION

Since ARC was significantly associated with subtherapeutic serum vancomycin concentration, it was necessary to devise adjusted dosage regimens for these patients based on their CL_cr.

Diferencias entre MDRD-4 y CG en la prevalencia de la insuficiencia renal y sus variables asociadas en pacientes diabéticos tipo 2

Objetivo

Estimar la prevalencia de insuficiencia renal (IR) oculta en DM2, comparando 2 fórmulas de estimación de filtrado glomerular (EFG): Modification of Diet in Renal Disease 4 (MDRD-4) y Crockcoft-Gault (CG) y las variables clínicas asociadas.

Diseño Analítico transversal multicéntrico.

Emplazamiento

Dos áreas básicas de atención primaria a Terres de l’Ebre.

Participantes

Un total de 493 DM2 con médico asignado en las áreas incluidas y edad > 18 años. Pérdidas de 9 y 11 casos en cada fórmula debido a falta de variables necesarias para EFG.

Mediciones principales

Estimación del filtrado glomerular mediante las 2 fórmulas, valores de creatinina plasmática, clasificación de pacientes con IR establecida, IR oculta y sin IR, posibles variables clinicopatológicas asociadas a la IR.

Resultados

Un 45,2% fueron hombres, con una media de edad 70,4 años y un tiempo de evolución de diabetes de 7,5 años. La prevalencia de IR oculta con MDRD-4 fue del 18%, y del 22,6% con CG. Los casos detectados por CG y no por MDRD-4 fueron mayores y con peso menor. En ambas fórmulas, los pacientes con IR oculta presentaron más patologías crónicas, hipertensión y eventos cardiovasculares (CV) que los sin IR. Los factores de riesgo asociados a IR oculta fueron el ser mujer y el incremento de la edad y del colesterol LDL.

Conclusiones

La prevalencia de IR oculta fue del 20% en DM2 e, independientemente de la fórmula, se observó un peor control de factores CV, lo que les hace ser un grupo de mayor riesgo de sufrir un evento.

Microalbuminuria predicts the recurrence of cardiovascular events in patients with essential hypertension

OBJECTIVES

Microalbuminuria (MAU) is associated with an enhanced risk of cardiovascular events. The prevalence of MAU and its prognostic impact has an important role in the stratification of cardiovascular risk in patients with essential hypertension. This is an observational, prospective study performed by 13 general practitioners aiming at assessing the prevalence and prognostic relevance of MAU in essential hypertension.

METHODS

Patients with essential hypertension and with recent determination of MAU were enrolled into the study by general practitioners, and were followed up for 3 years. Primary end point was the occurrence of major cardiovascular events during the follow-up.

RESULTS

Out of 1024 unselected patients, consecutively enrolled from January 2009 to March 2010, 804 completed the 3-year follow-up. Patients were categorized into two groups according to the absence (n = 523, 65%) or presence (n = 281, 35%) of MAU. During the follow-up, 41 cardiovascular events (1.69 events/100 patient-years) were reported. The presence of MAU was not associated with increased risk of cardiovascular events (adjusted hazard ratio = 1.32; 95% confidence interval 0.290-4.340, P = 0.097). When the analysis was restricted to the patients with previous cardiovascular event, MAU (adjusted hazard ratio = 2.18; 95% confidence interval 0.42-2.43, P = 0.031), together with age, metabolic syndrome, diabetes, and smoking, independently predicted the occurrence of cardiovascular events.

CONCLUSION

Presence of MAU in patients with essential hypertension is not associated with increased risks of cardiovascular events. At the variance, in patients with previous cardiovascular events, MAU was found to predict recurrent events. Thus, the assessment of MAU could be considered a useful tool in secondary prevention.

Atrial Dilatation Development in Hypertensive Treated Patients: The Campania-Salute Network

BACKGROUND

Left atrial (LA) dilatation is associated with unfavorable outcome in hypertension. However, there are few data on clinical, demographic, and echocardiographic findings correlated with LA dilatation development.

METHODS

From the Campania-Salute Network registry, we identified 5,375 hypertensive patients (52±11 years, 38% women) in normal sinus rhythm, with normal LA diameter (parasternal short-axis <24.0 in women and <25.4mm/m in men), with normal left ventricular (LV) ejection fraction, and with at least 12 months of echocardiographic follow-up. We included in the clinic evaluation type of antihypertensive drugs.

RESULTS

Follow-up duration was of 70±48 months. During follow-up, 647 patients (12%) showed LA dilatation. Patients with incident LA dilatation were older, most likely to be women, more obese, more diabetics, with lower Modification of Diet in Renal Disease, higher total cholesterol, lower uric acid, higher pulse pressure, lower heart rate, higher LV mass, concentric geometry and lower E/A ratio at mitral level, longer E deceleration time, and higher intima-media carotid thickness. They take more drugs, and follow-up was longer (overall P < 0.05). In the Cox analysis, age, female gender, obesity, higher LV mass, LA diameter at baseline, and longer E deceleration time were determinants of LA dilatation. Furthermore, the use of diuretics protected against LA dilatation.

CONCLUSIONS

Our data identify a risk profile for LA dilatation, characterized by older age, female sex, obesity, higher LV mass, and worse diastolic function. In this subgroup of patients, the use of diuretics seems to protect against LA dilatation.

Cystatin C and NGAL as Biomarkers for Early Detection of Acute Kidney Injury in Geriatrics

Acute kidney injury (AKI) is associated with cardiovascular mortality and morbidity especially in high-risk patients undergoing cardiac surgery. It ranges from 7.7% to 28.1% in different studies. The aim of this study was to compare cystatin C and neutrophil gelatinase-associated lipocalin (NGAL) with Creatinine as an early marker for acute kidney injury in geriatrics. From 2013 through 2015, 307 consecutive high-risk elderly patients older than 70 years undergoing emergency coronary artery bypass grafting using extracorporeal circulation were studied. All patients underwent diagnostic coronary angiography and the surgical procedure within 1 week in single hospital stay and were randomized according to timing of interval between coronary angiographyand cardiac procedure as follows: group I, less than 2 days; group II, between 2 and 4 days; and group III, higher than 4 days. Renal function was analyzed by serum cystatin C, NGAL, and creatinine. Blood samples were obtained from each patient at five time points: basal value before operation, in the four hours after operation, and on the first, third, and fifth postoperative days. Glomerular filtration rate (GFR) was calculated by Cockcroft-Gault (CG). A total of 56 patients developed postoperative acute kidney failure according to the risk, injury, and failure; and loss; and end-stage kidney disease classification. Perioperative fluid requirements, urine output, and vasopressor need during and after cardiopulmonary bypass were similar. 30-day mortality in groups was higher in group I than group II and group III (P = 0.025). AKI was least prominent in group III compared to group I and group II (P = 0.001) and expectedly, postoperative dialysis requirement was least common in group III (15, 16.66%). Patients in group III had the most favorable clinical outcome with regards to the length of ICU and hospital stay. Overall serum creatinine, cystatin C, and urine NGAL levels changed significantly throughout the entire length of following-up period in group I and group II, but not in group III. Changes in serum levels of cystatin, creatinine, and creatinine clearance were prominent in later than 24 hours. Urinary NGAL was the first variable to rise in the immediate postoperative period. Cystatin GFR was a more rapid marker than serum creatinine GFR to show acute kidney injury in three groups was a significant marker.

Colorimetric Detection of Creatinine Based on Plasmonic Nanoparticles via Synergistic Coordination Chemistry

A simple and portable colorimetric assay for creatinine detection is fabricated based on the synergistic coordination of creatinine and uric acid with Hg(2+) on the surface of gold nanoparticles, which exhibits good selectivity and sensitivity. Point-of-care clinical creatinine monitoring can be supported for monitoring renal function and diagnosing corresponding renal diseases at home.

[Arterial hypertension and sleep apnea hypopnea syndrome in primary care]

INTRODUCTION AND OBJECTIVES

Sleep apnea hypopnea syndrome (SAHS) is frequent in hypertensive patients and plays a role in a greater incidence of cardiovascular morbidity-mortality. This study aims to know the clinical profile of hypertensive patients with SAHS compared to hypertensive patients without SAHS to know which variables should be used to orient their screening from primary care.

METHODOLOGY

An observational, descriptive, retrospective study of cases (hypertensive patients with SAHS) and controls (hypertensive patients without) was performed in an urban health care center. Based on a computerized registry of the site, patients diagnosed of SAHS and hypertension over 30 years of age were selected. For each case, one control case of hypertensive patients without SAHS paired by age and gender was randomly obtained.

RESULTS

A total of 64 cases and 64 controls were selected. Standing out in the bivariate analysis were greater BMI (34.3±12.8 vs. 28.6±3.6), predominance of obesity (70.3 vs. 35.9%), metabolic syndrome (77.3 vs. 42.2%), consumption of psychopharmaceuticals (19.7 vs. 7.8%) and anithypertensive drugs (26.5 vs. 14.0%), ischemic heart disease (20.3 vs. 9.4%) in the case group versus control group (P<.05 for all the variables). The multivariate analysis showed that only the presence of metabolic syndrome was related with the presence of SAHS in hypertensive patients (OR 4.65; 95% CI: 2.03-10.64; P<.001).

CONCLUSIONS

Screening for SAHS should be performed in hypertensive patients seen in primary care if they have metabolic syndrome criteria.

Estimating glomerular filtration rate in kidney transplantation: Still searching for the best marker

Kidney transplantation is the treatment of choice for end-stage renal disease. The evaluation of graft function is mandatory in the management of renal transplant recipients. Glomerular filtration rate (GFR), is generally considered the best index of graft function and also a predictor of graft and patient survival. However GFR measurement using inulin clearance, the gold standard for its measurement and exogenous markers such as radiolabeled isotopes ((51)Cr EDTA, (99m)Tc DTPA or (125)I Iothalamate) and non-radioactive contrast agents (Iothalamate or Iohexol), is laborious as well as expensive, being rarely used in clinical practice. Therefore, endogenous markers, such as serum creatinine or cystatin C, are used to estimate kidney function, and equations using these markers adjusted to other variables, mainly demographic, are an attempt to improve accuracy in estimation of GFR (eGFR). Nevertheless, there is some concern about the inability of the available eGFR equations to accurately identify changes in GFR, in kidney transplant recipients. This article will review and discuss the performance and limitations of these endogenous markers and their equations as estimators of GFR in the kidney transplant recipients, and their ability in predicting significant clinical outcomes.

Individualizing pharmacotherapy in patients with renal impairment: the validity of the Modification of Diet in Renal Disease formula in specific patient populations with a glomerular filtration rate below 60 ml/min. A systematic review

Background

The Modification of Diet in Renal Disease (MDRD) formula is widely used in clinical practice to assess the correct drug dose. This formula is based on serum creatinine levels which might be influenced by chronic diseases itself or the effects of the chronic diseases. We conducted a systematic review to determine the validity of the MDRD formula in specific patient populations with renal impairment: elderly, hospitalized and obese patients, patients with cardiovascular disease, cancer, chronic respiratory diseases, diabetes mellitus, liver cirrhosis and human immunodeficiency virus.

Methods and Findings

We searched for articles in Pubmed published from January 1999 through January 2014. Selection criteria were (1) patients with a glomerular filtration rate (GFR) < 60 ml/min (/1.73m²), (2) MDRD formula compared with a gold standard and (3) statistical analysis focused on bias, precision and/or accuracy. Data extraction was done by the first author and checked by a second author. A bias of 20% or less, a precision of 30% or less and an accuracy expressed as P₃₀% of 80% or higher were indicators of the validity of the MDRD formula. In total we included 27 studies. The number of patients included ranged from 8 to 1831. The gold standard and measurement method used varied across the studies. For none of the specific patient populations the studies provided sufficient evidence of validity of the MDRD formula regarding the three parameters. For patients with diabetes mellitus and liver cirrhosis, hospitalized patients and elderly with moderate to severe renal impairment we concluded that the MDRD formula is not valid. Limitations of the review are the lack of considering the method of measuring serum creatinine levels and the type of gold standard used.

Conclusion

In several specific patient populations with renal impairment the use of the MDRD formula is not valid or has uncertain validity.

Prognostic value of combined target-organ damage in patients with essential hypertension

BACKGROUND

Whether the combination of chronic kidney disease (CKD) and left ventricular hypertrophy (LVH) affects the cardiovascular (CV) risk in patients with uncomplicated hypertension is poorly investigated. The aim of this study was to assess the effects of LVH, CKD, and their combination on CV events in hypertension.

METHODS

This study analyzed 1,078 patients with essential hypertension.

RESULTS

LVH was present in 104 (9.6%) patients, CKD was present in 556 (51.5%) patients, and the combination of LVH and CKD was found in 174 (16.1%) patients. During the follow-up (median = 84 months), 52 CV events were observed (0.64 events/100 patient-years): 6 (2.4%) in patients without target-organ damage (TOD), 6 (5.7%) in patients with LVH, 20 (3.6%) in patients with CKD, and 20 (11.4%) in patients with combined LVH+CKD. Adjusted hazard ratio (HR) for CV events was 1.62 (P = 0.34) for LVH, 0.951 (P = 0.94) for CKD, and 2.45 (P = 0.03) for LVH+CKD. After multivariable Cox proportional hazard analysis, the combination of LVH+CKD was significantly associated with risk of CV events, when the model was adjusted for sex and age (HR = 2.447; P = 0.03) and for the presence of 1 CV risk factor (HR = 3.226; P = 0.02). In contrast, the association of LVH+CKD was no longer significant when the model was adjusted for sex, age, and the presence of ≥ 2 CV risk factors.

CONCLUSIONS

The results of this study highlight the relevance of the interactions between TODs and hemodynamic, anthropometric, and metabolic abnormalities in the CV risk stratification of patients with essential hypertension.

A prospective observational study of all-cause mortality in relation to serum 25-OH vitamin D3 and parathyroid hormone levels in patients with type 2 diabetes

BACKGROUND

Low levels of vitamin D have been related to increased mortality and morbidity in several non-diabetic studies. We aimed to prospectively study relationships between serum 25-OH vitamin D3 (vitamin D) and of serum parathyroid hormone (PTH) to total mortality in type 2 diabetes. We also aimed to compare the levels of these potential risk-factors in patients with and without diabetes.

METHODS

The main study design was prospective and observational. We used baseline data from 472 men and 245 women who participated in the "Cardiovascular Risk factors in Patients with Diabetes-a Prospective study in Primary care" study. Patients were 55-66 years old at recruitment, and an age-matched non-diabetic sample of 129 individuals constituted controls for the baseline data. Carotid-femoral pulse-wave velocity (PWV) was measured with applanation-tonometry and carotid intima-media thickness (IMT) with ultrasound. Patients with diabetes were followed for all-cause mortality using the national Swedish Cause of Death Registry.

RESULTS

Levels of vitamin D were lower in patients with diabetes than in controls, also after correction for age and obesity, while PTH levels did not differ. Nine women and 24 men died during 6 years of median follow up of the final cohort (n = 698). Vitamin D levels were negatively related to all-cause mortality in men independently of age, PTH, HbA1c, waist circumference, 24-h systolic ambulatory-blood pressure (ABP) and serum-apoB (p = 0.049). This finding was also statistically significant when PWV and IMT were added to the analyses (p = 0.028) and was not affected statistically when medications were also included in the regression-analysis (p = 0.01). In the women with type 2 diabetes, levels of PTH were positively related with all-cause mortality in the corresponding calculations (p = 0.016 without PWV and IMT, p = 0.006 with PWV and IMT, p = 0.045 when also adding medications to the analysis), while levels of vitamin D was without statistical significance (p >0.9).

CONCLUSIONS

Serum vitamin D in men and serum PTH in women give prognostic information in terms of total-mortality that are independent of regular risk factors in addition to levels of ABP, IMT and PWV.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01049737.

Correlation between endothelial dysfunction and left ventricular remodeling in patients with chronic kidney disease

BACKGROUND/AIMS

To investigate the role of endothelial dysfunction on left ventricular remodeling in patients with chronic kidney disease and to evaluate the correlation between endothelial dysfunction and left ventricular remodeling.

METHODS

Seventy-three patients with chronic kidney disease as study-group and thirty healthy volunteers as control-group were enrolled in the present study. All patients in both groups had echocardiography examination. The concentration of endothelin-1, nitric oxide, and inducible nitric oxide synthase of serum of all patients and healthy volunteers was measured. The incidence of cardiac structural abnormalities in patients with chronic kidney disease, and the relationship between endothelial dysfunction and cardiac structural abnormalities were analyzed.

RESULTS

The incidence of left ventricular hypertrophy, left ventricular concentric remodeling, and left ventricular systolic dysfunction was 65%, 8.33%, and 16.67%, respectively. The level of endothelin-1 and nitric oxide increased in study-group, and the concentration of inducible nitric oxide synthase decreased. There was significant positively relationship between plasma endothelin-1 and left ventricular mass index, interventricular septal thickness, left ventricular diastolic diameter. There was negatively relationship between the level of serum nitric oxide and the maximum flow velocity at the mitral in left ventricular diastolic stage. There was not any correlation between inducible nitric oxide synthase with left ventricular remodeling.

CONCLUSIONS

The results showed that there was a higher incidence of left ventricular hypertrophy in patients with chronic kidney disease. Endothelin-1 and nitric oxide played an important role on the development of left ventricular hypertrophy.

Determinants of left ventricular hypertrophy in patients with recent diagnosis of essential hypertension

OBJECTIVE

Development of left ventricular hypertrophy (LVH) is a multifactorial phenomenon. We retrospectively assessed the risk factors for LVH in patients with recent diagnosis of essential hypertension.

METHODS

We analysed 1518 participants with recent diagnosis of essential hypertension (≤2 years). The duration of hypertension was established after cross-checking the patients' history and the records of the general practitioners'. The following cardiovascular (CV) risk factors were considered: age (men >55 years, women >65 years), SBP >140  mmHg, DBP >90  mmHg, obesity, diabetes, hypercholesterolemia, low or high-density lipoprotein (HDL)-cholesterol (men <40  m/dl, women <50  mg/dl), and chronic kidney disease (CKD).

RESULTS

Age, prevalence of metabolic diseases, CKD, and the severity of hypertension were higher in patients with LVH. One hundred twenty-two (8%) patients did not have CV risk factors, whereas 288 (19%), 472 (31.1%), 351 (23.1%) and 285 (18.8%) patients had one, two, three and more than three CV risk factors, respectively. At univariate analysis, CV risk factors for LVH where found to be sex, age, SBP, low HDL-cholesterol, obesity, diabetes, CKD, and metabolic syndrome. In the multivariate analysis, the independent predictors of LVH were found to be sex, age, SBP, obesity and diabetes. A significant correlation was found between indexed left ventricular mass and body mass index (r(2) = 0.167), age (r(2) = 0.077) and SBP (r (2)= 0.055).

CONCLUSION

This study reveals that, in patients with recent diagnosis of essential hypertension obesity represents the most important modifiable CV risk factor for LVH.

Prevalence and clinical characteristics of patients with true resistant hypertension in central and Eastern Europe: data from the BP-CARE study

OBJECTIVE

Scanty information is available on the clinical characteristics of resistant hypertension in Central and East European countries. The Blood Pressure (BP) control rate and CArdiovascular Risk profilE (BP-CARE) study allowed us to assess the prevalence and the main clinical features of resistant hypertension in this population.

DESIGN AND METHOD

The study was carried out in 1312 treated hypertensive patients living in nine Central and East European countries.

RESULTS

Four hundred and twenty-three patients had apparent resistant hypertension, of whom 168 had pseudo-resistant hypertension (noncompliant/white-coat) and 255 were true treatment-resistant hypertension patients (TRH). Clinical BP values in TRH amounted to 157.4±16.9/91.8±10.0 mmHg despite the daily use of 3.6±0.7 drugs. Their 24-h BP values were 149.5±16.5/97.5±9.8 mmHg. Compared to controlled hypertensive patients (n=368) and uncontrolled nonresistant hypertensive patients (n=521), TRH were older with a greater prevalence of women. They showed a higher rate of previous cardiovascular events and a very high cardiovascular risk profile. Estimated glomerular filtration rate was significantly lower in TRH as compared to controlled hypertensive patients and uncontrolled nonresistant hypertensive patients. Overall, target organ damage was more frequently detected in TRH than in controlled hypertensive patients and uncontrolled nonresistant hypertensive patients. The factor most frequently associated with TRH was severity of hypertension followed by age, total cholesterol, BMI and history of heart failure.

CONCLUSIONS

The present study provides evidence that the prevalence of TRH in Central and East European countries is similar to that found in Western Europe and USA. It also shows the very high cardiovascular risk of TRH and the elevated association of this condition with obesity, renal failure, organ damage and history of cardiovascular events.

Estimation of renal function in the intensive care unit: the covert concepts brought to light

Frantic efforts have been made up to this date to derive consensus for estimating renal function in critically ill patients, only to open the Pandora's box. This article tries to explore the various methods available to date, the newer concepts, and the uncared issues that may still prove to be useful in estimating renal function in intensive care unit patients. The concept of augmented renal clearance, which is frequently encountered in critically ill patients, should always be taken into account, as correct therapeutic dosage of drugs sounds vital which in turn depends on correctly calculated glomerular filtration rate. Serum creatinine and creatinine-based formulae have their own demerits that are well known and established. While Cockcroft-Gault and 4-variable modification of diet in renal diseases formulae are highly inadequate in the intensive care setup for estimating glomerular filtration rate, employing isotopic methods is impractical and cumbersome. The 6-variable modification of diet in renal diseases formula fairs better as it takes into account the serum albumin and blood urea nitrogen, too. Jelliffe's and modified Jelliffe's equations take into account the rate of creatinine production and volume of distribution which in turn fluctuates heavily in a critically ill patient. Twenty-four-hour and timed creatinine clearances offer values close to reality although not accurate and cannot provide immediate results. Cystatin C is a novel agent that offers a sure promise as it is least influenced by factors that affect serum creatinine to a major extent. Aminoglycoside clearance, although still in the dark area, may prove a simple yet precise way of estimating glomerular filtration rate in those patients in whom these drugs are therapeutically employed. Optic ratiometric method has emerged as the most sophisticated one in glomerular filtration rate estimation in critically ill patients.

Comparison of glomerular filtration rates calculated by different serum cystatin C-based equations in patients with chronic kidney disease

Background

We aimed to evaluate the performance of serum cystatin C-based equations in calculating the glomerular filtration rate (GFR) in patients with varying stages of chronic kidney disease (CKD).

Methods

Serum cystatin C and creatinine levels were measured in 615 CKD patients. The CKD stage was determined by the creatinine-based estimated GFR (eGFR) equation using the four-variable abbreviated Modification of Diet in Renal Disease equation suggested by the Kidney Disease Outcome Quality Initiative with the addition of a coefficient applicable to Korean populations (K-aMDRD). In each CKD stage, the ratio of serum cystatin C to creatinine was calculated and six different cystatin C-based equations were used to estimate GFR. Cystatin C-based eGFR and aMDRD eGFR values were compared using the paired t test, Pearson correlation test, and the Bland–Altman plot.

Results

The mean age of patients was 53.21±14.45 years; of the 615 patients, 346 were male. The serum cystatin C-to-creatinine ratio was inversely correlated with the CKD stage. Compared with the K-aMDRD values, the results of the Hoek, Filler, and Le Bricon’s cystatin C-based eGFR equations were lower in CKD Stages 1–3 and higher in Stages 4 and 5. However, the results of the Orebro-cystatin (Gentian) equation [GFR=100/ScytC (mL/minute/1.73 m²) – 14] were similar to those of the K-aMDRD equation in CKD Stages 4 and 5 (15.44±9.45 vs. 15.17±9.05 mL/minute/1.73 m², respectively; P=0.722; bias=0.27±8.87).

Conclusion

The eGFRs obtained from the six cystatin C-based equations differed widely. Therefore, further studies are required to determine the most accurate equation to estimate GFR in Koreans with CKD.

Impact of renal insufficiency on mortality in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention

BACKGROUND

Chronic kidney disease is associated with increased risk of mortality. We examined the impact of moderate and severe renal insufficiency (RI) on short- and long-term mortality among unselected patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI).

METHODS

From January 1, 2002 to December 31, 2010 all patients with STEMI treated with primary PCI were identified. The hazard ratio (HR) for death was estimated using a Cox regression model, controlling for potential confounders. RI was defined as creatinine clearance (CrCl) < 60 mL/min (moderate RI: CrCl ≤30 < 60 mL/min and severe RI: CrCl < 30 mL/min).

RESULTS

The study cohort consisted of 4,116 patients of whom 898 (21.8%) had RI and 3,218 (78.2%) had a CrCl ≥ 60 mL/min. Compared to patients without RI, patients with RI were older, more often female and more likely to have diabetes mellitus, hypertension and to present with a higher Killip class.Among patients with a preserved kidney function and patients with RI, 30-day all-cause mortality was 3.5% vs. 20.9% (log-rank p < 0.001); 1-year all-cause mortality was 5.7% vs. 29.4% (log-rank p < 0.001); 5-year all-cause mortality was 13.4% vs. 47.4% (log-rank p < 0.001). Moderate and severe RI were associated with higher 1-year mortality compared to patients with a preserved renal function (CrCl ≤30 < 60 mL/min: adjusted HR 2.71 [95% CI 2.09-3.51], p < 0.001), and (CrCl < 30 mL/min: adjusted HR 7.09 [4.82-10.44], p < 0.001).

CONCLUSION

In unselected STEMI patients treated with primary PCI, moderate and severe RI were associated with increased risk of mortality.

Novel electrochemical sensing platform based on magnetic field-induced self-assembly of Fe3O4@Polyaniline nanoparticles for clinical detection of creatinine

A novel electrochemical sensing platform based on magnetic field-induced self-assembly of Fe3O4@Polyaniline nanoparticles (Fe3O4@PANI NPs) has been for the first time fabricated for the sensitive detection of creatinine in biological fluids. The template molecule, creatinine, was self-assembled on the surface of Fe3O4@PANI NPs together with the functional monomer aniline by the formation of N-H hydrogen bonds. After pre-assembled, through the magnetic-induction of the magnetic glassy carbon electrode (MGCE), the ordered structure of molecularly imprinted polymers (MIPs) were established by the electropolymerization and assembled on the surface of MGCE with the help of magnetic fields by a simple one-step approach. The structural controllability of the MIPs film established by magnetic field-induced self-assembly was further studied. The stable and hydrophilic Fe3O4@PANI can not only provide available functionalized sites with which the template molecule creatinine can form hydrogen bond by the abundant amino groups in PANI matrix, but also afford a promoting pathway for electron transfer. The as-prepared molecularly imprinted electrochemical sensor (MIES) shows good stability and reproducibility for the determination of creatinine with the detection limit reached 0.35 nmol L(-1) (S/N=3). In addition, the highly sensitive and selective MIES has been successfully used for the clinical determination of creatinine in human plasma and urine samples. The average recoveries were 90.8-104.9% with RSD lower than 2.7%.