Effects of lisinopril and nitrendipine on urinary albumin excretion and renal function in patients with mild to moderate essential hypertension

Controlled-release nifedipine and candesartan low-dose combination therapy in patients with essential hypertension: the NICE Combi (Nifedipine and Candesartan Combination) Study

OBJECTIVE

To compare the clinical efficacy of low-dose controlled-release (CR) nifedipine (20 mg/day) plus candesartan (8 mg/day) combination therapy with that of up-titrated candesartan (12 mg/day) monotherapy.

DESIGN

Randomized, double-blind study.

SETTING

Outpatient study.

PATIENTS AND PARTICIPANTS

Patients with essential hypertension, who did not achieve their target blood pressure with baseline treatment of candesartan 8 mg/day for 8 weeks.

MAIN OUTCOME MEASURES

Blood pressure, pulse pressure, urinary microalbumin excretion.

RESULTS

Blood pressure was significantly reduced in both groups (P < 0.05), but the reduction was significantly greater in the combination therapy group (12.1 +/- 1.4/8.7 +/- 0.9 mmHg) than in the up-titrated monotherapy group (4.1 +/- 1.4/4.6 +/- 0.9 mmHg) (P < 0.0001). The reduction in pulse pressure was significantly greater in the combination therapy group (3.3 +/- 1.2 mmHg) than in the up-titrated monotherapy group (0.7 +/- 1.2 mmHg) (P = 0.0031). Urinary microalbumin excretion decreased significantly in the combination therapy group (from 61.9 to 40.5 mg/g creatinine; P < 0.05), but not in the up-titrated monotherapy group.

CONCLUSIONS

These findings suggest that the low-dose combination therapy of nifedipine CR and candesartan is superior to the up-titrated monotherapy of candesartan in terms of blood pressure control and renal protection in patients with essential hypertension.

Association between serum C-reactive protein levels and microalbuminuria: a population-based cross-sectional study in northern Iwate, Japan

OBJECTIVE

The presence of microalbuminuria is a renal marker of vascular endothelial damage, and is an independent and strong predictor of increased risk for cardiovascular mortality and morbidity. Elevated circulating C-reactive protein (CRP) levels have recently been reported to be a novel cardiovascular risk factor, and it has been suggested that this acute-phase protein impairs vascular endothelial function. The aim of the present study was to determine whether serum CRP level is a dependent or an independent risk factor of microalbuminuria in the general population.

METHODS

Subjects of this cross-sectional study were apparently healthy individuals drawn from the general Japanese population (mean age, 62; men, 2,236; women, 4,217). Serum CRP levels were determined using a highly sensitive kit and urine albumin-creatinine ratio (UACR) was calculated using a single urine sample. Multivariate logistic regression analysis was used to determine which risk factors (ie, age, hypertension, diabetes, obesity, hypercholesterolemia, smoking, and CRP) might predict the presence of microalbuminuria.

RESULTS

In addition to classical cardiovascular risk factors such as age, hypertension, diabetes and obesity, serum CRP levels are also significantly correlated with microalbuminuria in men (odds ratio = 1.42, 95% CI = 1.13-1.79; p < 0.01) and women (odds ratio = 1.25, 95% CI = 1.05-1.49; p < 0.01). When subjects with diabetes were excluded from the analysis, serum CRP levels continued to be a significant predictor for microalbuminuria (odds ratio = 1.35, 95% CI = 1.06-1.73; p < 0.05 for men: odds ratio = 1.23, 95% CI = 1.03-1.47; p < 0.05 for women).

CONCLUSIONS

The present study has shown that low-grade inflammation as represented by high sensitivity CRP levels may be significantly related to the presence of microalbuminuria. This suggests that microalbuminuria may be a useful marker representing systemic low-grade inflammation as well as being an established cardiovascular risk factor in apparently healthy individuals.

Effect of amlodipine and cilazapril treatment on platelet Ca2+ handling in spontaneously hypertensive rats

Abnormal Ca2+ handling and enhanced aggregation response have been reported in platelets from spontaneously hypertensive rats (SHR) and patients with essential hypertension, and thought to be involved in the progression of target organ damage of hypertension. It is important to examine whether antihypertensive therapy can improve the abnormal platelet response in hypertension. We investigated the effect of antihypertensive treatment such as amlodipine and cilazapril on Ca2+ handling and aggregation response in SHR platelets. Four-week-old male SHR were divided into three groups. Each group was treated with amiodipine (A: 10 mg/kg/day), cilazapril (C: 10 mg/kg/day) or vehicle (V) for 8 weeks by gavage. At 12-week-old, platelet [Ca2+]i was measured with fura-2 in each group of SHR and age-matched Wistar-Kyoto rats (WKY) as normal control. Systolic blood pressure in amlodipine and cilazapril treated groups were similar with WKY and significantly lower than vehicle treated group (A: 124 +/- 9, C: 126 +/- 9, WKY: 122 +/- 10 and V: 180 +/- 9 mmHg, respectively). The basal [Ca2+]i in the three groups of SHR were similar and higher than WKY (A: 47 +/- 1.7, C: 47 +/- 1.2, V: 48 +/- 3.9 and WKY: 40 +/- 4.0 nmol/l, respectively). There were no significant differences in thrombin (0.1 U/ml)-stimulated [Ca2+]i rise in the presence or absence of extracellular Ca2+ among the three groups of SHR and these were higher than WKY. Intracellular Ca2+ discharge capacity, assessed by the ionomycinstimulation was similar in the all groups. Thrombin-induced maximum platelet aggregation responses in the three groups of SHR were similar and higher than WKY. The antihypertensive treatment of Ca2+ antagonist or ACE inhibitor gave no change in intraplatelet Ca2+ metabolism in SHR. These results support the hypothesis that an abnormal Ca2+ handling in SHR platelet is genetically determined and not improved by hypotensive therapy.

A case of nephrotic syndrome associated with renovascular hypertension successfully treated with candesartan

A sixty eight-year-old man was referred to our hospital for evaluation of hypertension and hypokalemia. His chief complaints were fatigability and weakness of the lower extremities. Atrophy of the right kidney was noted on computed tomography. The laboratory findings demonstrated massive proteinuria, markedly elevated plasma renin activity, hypokalemia, and renal insufficiency. Angiography showed total occlusion of the right renal artery. The patient was diagnosed as having nephrotic syndrome associated with renovascular hypertension. Treatment with candesartan, an angiotensin-II-receptor blocker (ARB), controlled both hypertension and proteinuria satisfactorily without worsening of his renal function. This is the first report on the effect of ARB on nephrotic syndrome associated with renovascular hypertension. Based on the results, ARB can be considered a promising agent for the treatment of patients with renovascular hypertension with massive proteinuria and renal insufficiency.

Prevalence and predictors of renal artery stenosis in patients undergoing cardiac catheterization

Renal artery stenosis (RAS) is recognized as a major co-morbid condition for patients with cardiovascular disease. Although the prevalence of RAS in Western countries has been reported as 13.5-18% in patients with suspected coronary artery disease (CAD) undergoing coronary angiography, there is little information available about the prevalence of RAS in Asian populations, which are less susceptible to atherosclerosis. To evaluate the prevalence of RAS in Japanese patients suspected of cardiovascular disease and the relationships among RAS and vascular risk factors, especially hypertension, renal artery angiography was performed in a total of 289 consecutive patients receiving diagnostic cardiac catheterization. RAS with a stenosis diameter greater than 50% was considered significant. The prevalence of RAS was 21/289 (7%) including 18 (6%) cases of unilateral stenosis and 3 (1%) of bilateral stenosis. RAS accompanied 14/220 (6%) cases of CAD, 4/34 (12%) cases of valvular heart disease and 1/14 (7%) cases of cardiomyopathy. In the subgroups of CAD, the prevalence of RAS was 5%, 10%, 9%, and 19% in cases of 0, 1, 2 and 3-vessel disease, respectively. Hypertension was more frequent among patients with than among those without RAS (86% vs. 45%, p=0.0003). The prevalence of RAS was 13% in hypertensives and 2% in normotensives (p = 0.004). Thus RAS was frequent in patients with established CAD, and particularly in those with 3-vessel disease. Together, the results showed that hypertension was closely associated with RAS, appearing as both a risk factor and a possible clinical manifestation of the disease. We conclude that more attention should be paid to RAS in Japanese patients with hypertension and cardiovascular disease.

Microalbuminuria, an integrated marker of cardiovascular risk in essential hypertension

This paper reviews the existing epidemiological and clinical evidence about the relationships of non-diabetic microalbuminuria with cardiovascular risk factors such as elevated blood pressure (BP), systolic particularly, cardiac hypertrophy, adverse metabolic status, smoking habits, elevated angiotensin II levels, endothelial dysfunction, acute and perhaps subclinical inflammation. Because of that unique property of reflecting the influence of so many clinically relevant parameters, microalbuminuria may legitimately be defined as an integrated marker of cardiovascular risk, an unique profile among the several prognostic predictors available to stratify risk in hypertensive patients. Recent cohort studies also showed associations with cardiovascular morbidity and mortality independently from conventional atherogenic factors. This behaviour, whose understanding still needs further elucidation, suggests to measure albuminuria and to screen patients at a higher absolute risk in whom preventive treatment is expected to be more beneficial than in those with a lower absolute risk.

Cilnidipine is as effective as benazepril for control of blood pressure and proteinuria in hypertensive patients with benign nephrosclerosis

To investigate the beneficial effects of cilnidipine, a calcium channel blocker that shows high selectivity for N-type receptors, on the progression of chronic renal insufficiency, we compared the efficacy of cilnidipine to that of benazepril, an angiotensin-converting enzyme (ACE) inhibitor with known renal protective effects, in a one-year trial evaluating hypertensive control, serum creatinine, and albuminuria in a cohort of patients. Given the seeming importance of the etiology of chronic renal insufficiency in determining drug efficacy, we limited our study to 20 patients with a single common condition, benign nephrosclerosis. The average age of the patients was 62+/-4 years old. The changes in systolic and diastolic blood pressure over the course of the study year revealed a similar reduction with cilnidipine and benazepril. Both cilnidipine and benazepril induced similar reductions in systolic and diastolic blood pressure over the course of the study year. The baseline levels of serum creatinine were 1.40+/-0.2 mg/dl and urinary excretion of albumin was 168+/-10 mg daily. The levels of serum creatinine were not significantly changed throughout the study in either group, although the levels of urinary excretion of albumin were significantly decreased in both groups. There were no significant differences in either of these values between the two groups. In conclusion, both cilnidipine and benazepril equally and effectively reduced blood pressure and albuminuria in hypertensive patients with benign nephrosclerosis in a one-year trial.