Antonio Del Giudice

A small randomised trial of low-dose aspirin in women at high risk of pre-eclampsia

OBJECTIVE To determine if aspirin (ASA) therapy reduces the incidence of pre-eclampsia in women at high risk of this condition. STUDY DESIGN Randomised clinical trial. We recruited pregnant women with gestational age at randomisation <14 weeks, who satisfied the following criteria: chronic hypertension, history of severe pre-eclampsia or eclampsia or intrauterine growth retardation (IUGR) or intrauterine foetal death. Nineteen women in the no-treatment group and 16 in the ASA group were successfully followed up. RESULTS The mean birthweight was higher in the ASA group than in the no-treatment group (2790 g (S.D. 340 g) versus 2616 g (S.D. 779 g)), but the difference was not statistically significant. We found no statistically significant differences between the groups in the proportion of infants with birthweight below 2500 g (13.3% versus 29.4%) and the number of cases with pregnancy-induced hypertension (PIH)/pre-eclampsia (31.3% versus 36.8%). CONCLUSION These limited data give some support to the potential favourable effect of early treatment with ASA in pregnant women at risk of PIH and IUGR.

Acute renal failure in the elderly: epidemiology and clinical features

Structural and functional alterations affecting the aging kidney predispose to an increased risk of acute renal failure (ARF) in the elderly. This is a common problem becoming more relevant because of an increase in life expectancy. The epidemiology of ARF in the elderly is far from being well assessed, because of the lack of uniform definition criteria, variable etiology, coexistence of several comorbidities, and the various clinical settings and geographic areas where the condition is managed, with a higher incidence in developed regions where elderly patients predominate. In 2004, the Acute Dialysis Quality Initiative group proposed the RIFLE criteria for diagnosis and stratification of ARF. More recently, the Acute Kidney Injury Network proposed several refinements to the RIFLE criteria, and the use of the term acute kidney injury (AKI) has been suggested to mean any abrupt reduction in kidney function, while restricting use of the term ARF to severe dysfunction requiring renal replacement treatment. Although in elderly patients the more frequent forms of AKI are functional or obstructive, parenchymal AKI, such as acute tubular necrosis and contrast-induced nephropathy, still frequently occur. Elderly patients with chronic renal disease (CKD) who develop AKI are at high risk for mortality, and are prone to non-recovery from AKI and progression to more advanced stages of CKD and even to end-stage renal disease. Panels of AKI biomarkers are likely to improve early diagnosis and treatment, thus reducing morbidity and mortality of older patients from this condition in the future.

Acute Kidney Injury in the Elderly: Epidemiology, Risk Factors and Outcomes

Structural and functional changes affecting the aging kidney predispose to an increased risk of Acute Kidney Injury (AKI) in the elderly, a condition which is becoming more and more relevant with the increase in life expectancy. The epidemiology of AKI in the elderly is not well assessed, because of the variable etiology, the coexistence of several comorbidities, the various clinical settings and geographical areas where the condition is managed, and the lack of uniform definition criteria. Currently, the use of the term AKI is suggested to mean any abrupt reduction in kidney function, while acute renal failure is just meant to indicate severe dysfunctions requiring renal replacement treatment. Comorbidities, common among elderly patients and several age-related conditions are risk factors for AKI. Moreover, also in elderly patients the presence of baseline proteinuria and reduced glomerular filtration rate are both powerful independent risk factors for AKI. Elderly patients with Chronic Kidney Disease (CKD) who develop AKI are at high risk for mortality, non-recovery from AKI and progression to more advanced stages of CKD and even to endstage renal disease. As a consequence, the challenge for nephrologists is to find strategies to either prevent AKI or prevent the transition from AKI to CKD.

Prevalence and control of hypertension by 48-h ambulatory blood pressure monitoring in haemodialysis patients: a study by the European Cardiovascular and Renal Medicine (EURECA-m) working group of the ERA-EDTA

Background Population-specific consensus documents recommend that the diagnosis of hypertension in haemodialysis patients be based on 48-h ambulatory blood pressure (ABP) monitoring. However, until now there is just one study in the USA on the prevalence of hypertension in haemodialysis patients by 44-h recordings. Since there is a knowledge gap on the problem in European countries, we reassessed the problem in the European Cardiovascular and Renal Medicine working group Registry of the European Renal Association-European Dialysis and Transplant Association. Methods A total of 396 haemodialysis patients underwent 48-h ABP monitoring during a regular haemodialysis session and the subsequent interdialytic interval. Hypertension was defined as (i) pre-haemodialysis blood pressure (BP) ≥140/90 mmHg or use of antihypertensive agents and (ii) ABP ≥130/80 mmHg or use of antihypertensive agents. Results The prevalence of hypertension by 48-h ABP monitoring was very high (84.3%) and close to that by pre-haemodialysis BP (89.4%) but the agreement of the two techniques was not of the same magnitude (κ statistics = 0.648; P <0.001). In all, 290 participants were receiving antihypertensive treatment. In all, 9.1% of haemodialysis patients were categorized as normotensives, 12.6% had controlled hypertension confirmed by the two BP techniques, while 46.0% had uncontrolled hypertension with both techniques. The prevalence of white coat hypertension was 18.2% and that of masked hypertension 14.1%. Of note, hypertension was confined only to night-time in 22.2% of patients while just 1% of patients had only daytime hypertension. Pre-dialysis BP ≥140/90 mmHg had 76% sensitivity and 54% specificity for the diagnosis of BP ≥130/80 mmHg by 48-h ABP monitoring. Conclusions The prevalence of hypertension in haemodialysis patients assessed by 48-h ABP monitoring is very high. Pre-haemodialysis BP poorly reflects the 48 h-ABP burden. About a third of the haemodialysis population has white coat or masked hypertension. These findings add weight to consensus documents supporting the use of ABP monitoring for proper hypertension diagnosis and treatment in this population.

823 HYPERTENSION IN THE ELDERLY WITH SUNDRY COMORBIDITIES: A 30-MONTH OBSERVATIONAL STUDY BY A NEPHROLOGY AMBULATORY UNIT DEDICATED TO HYPERTENSION

Objective: The prevalence of hypertension increases with age and in the elderly is 60-80%. Herewith we report an observational study on an outpatient population carried out by a specialized unit of nephrology. Design and methods: The following parameters were recorded from a cohort of 405 consecutive hypertensive patients observed over a period of 30 months (October 2009 - March 2012): age, sex, number of visits, body-mass index, waist circumference, blood pressure (BP), glomerular filtration rate (GFR), lipid profile, comorbidities, antihypertensive drugs prescribed. Concordant with the current guidelines, patients that had a sitting BP ⩽140/90 mmHg and patients with chronic kidney disease (CKD) or diabetes mellitus (DM) that had a sitting BP ⩽130/80 mmHg, were considered as having achieved BP control. Results: 175 hypertensive patients (72 males/103 females, 43.2% of the cohort) were older than 65 years. The following comorbidities, graded as 1+ to 4+ were detected: ischemic/hypertrophic cardiopathy, dyslipidemia, CKD, DM, peripheral arteriopathy, metabolic syndrome, overweight, obesity. BP control was achieved by 63,6% of patients, but only by 43.4% of those with DM and 37.2% of those with CKD. Compared to patients whose BP was not controlled, those achieving BP target were slightly younger (mean age 73.1 vs. 75.4 years) and showed a higher GFR (68.4 vs. 61.5 mL/min); moreover, they were more strictly followed up (2.17 vs. 1.67 visit per patient). There was no significant difference in the number of antihypertensive drugs prescribed. Conclusions: Under proper monitoring and treatment, nearly 2/3 of our hypertensive elderly outpatients achieved BP control.