Keita Sueyoshi

Long-Term Effects of Calcium Antagonists on Augmentation Index in Hypertensive Patients with Chronic Kidney Disease: A Randomized Controlled Study

Background: Our previous retrospective study showed that benidipine was superior to amlodipine (AM) for reducing proteinuria and preserving the augmentation index (AI) in patients with chronic kidney disease (CKD). Methods: The present study enrolled CKD patients whose blood pressure was not well controlled by an angiotensin receptor blocker (ARB) and a calcium channel blocker other than AM or azelnidipine (AZ). Either AM (5 mg) or AZ (16 mg) was prescribed randomly. Clinical parameters, including proteinuria, serum creatinine, and AI, were measured before initiation of AM or AZ and 1 year later to assess the long-term effect on renal function and central blood pressure. Results: Brachial and central blood pressures were similarly reduced in both groups. However, pulse rate increased in the AM group, but decreased in the AZ group (+3 ± 1 vs. –2 ± 1 bpm, p < 0.0001). The reduction of proteinuria was greater in the AZ group (–29 ± 2 vs. –38 ± 3%, p < 0.01). Improvement of AI adjusted for a pulse rate of 75 bpm was larger in the AZ group than in the AM group (–4 ± 1 vs. –9 ± 1%, p < 0.05). In both groups, estimated GFR remained unchanged throughout the observation period. Conclusion: In hypertensive patients with CKD, combined treatment with AZ and an ARB decreases proteinuria and preferentially improves arterial reflection.

Granulomatous interstitial nephritis in chronic lymphocytic leukaemia

We present a case of granulomatous interstitial nephritis (GIN) associated with chronic lymphocytic leukaemia (CLL). GIN is a rare pathological finding noted in renal biopsy specimens. Furthermore, CLL does not usually cause GIN. In this case, acute renal injury probably resulted from GIN, and urgent dialysis was required, despite sufficient chemotherapy. Immunohistochemical analyses of a biopsy specimen revealed invasion of CD20( +) CLL cells, surrounded by reactive T cells, and granuloma formation. Thus, CLL may induce secondary interstitial nephritis as a granulomatous reaction.

Seasonal Variations of Daily Changes in Blood Pressure Among Hypertensive Patients with End-Stage Renal Diseases

Hypertension is a well-known cardiovascular risk. Patients with end-stage renal diseases frequently suffer hypertension, and their blood pressure elevates in winter. However, seasonal changes in daily variations of blood pressure are poorly assessed in patients treated with hemodialysis. Thirty hypertensive patients with end-stage renal diseases were enrolled in the study. Dry weight and antihypertensive medications were altered when they were necessary. Home blood pressure measurements were performed at least for 1 week in each season; April–May 2008, July–August 2008, October–November 2008, and January–February 2009. Both morning and evening systolic blood pressures (SBPs) showed significant seasonal changes ( p < 0.01), with the highest blood pressure in winter (162 ± 18 and 135 ± 22 mmHg in morning and evening). Morning diastolic blood pressure (DBP) also exhibited seasonal changes ( p < 0.05), with the highest blood pressure in fall ( 78 ± 8 mmHg). Evening DBP did not manifest seasonal deviations. Morning-evening differences in SBP and DBP were the greatest in winter (28 ± 21 and 10 ± 9 mmHg in SBP and DBP, p < 0.01), and the smallest in summer (16 ± 12 and 6 ± 5 mmHg). Daily variations of SBP and DBPs in spring (19 ± 12 and 7 ± 6 mmHg) and fall (20 ± 13 and 9 ± 8 mmHg) were between those of summer and winter. Our results indicate that not only averaged blood pressure but also variations of blood pressure in winter are larger than the other seasons, and suggest that these blood pressure variations participate in cardiovascular events in hypertensive patients with end-stage renal diseases.

Aliskiren Reduces Morning Blood Pressure in Hypertensive Patients with Diabetic Nephropathy

Diabetic nephropathy (DN) is a leading disease that requires renal replacement therapy. The progression of renal dysfunction in DN is faster than the other renal diseases. While antihypertensive therapy reduces albuminuria, a good indicator for the progression, hypertension in DN is treatment resistant. Among patients with DN who took angiotensin receptor blockers (ARBs), 27 patients who exhibited poor control of albuminuria were enrolled into the study. Angiotensin receptor blocker was exchanged to aliskiren (150–300 mg/d) and clinical parameters were followed for 6 months. Exchange to aliskiren decreased albuminuria (1.57 ± 0.68 to 0.89 ± 0.45 g/gCr, P < .01) without changes in estimated glomerular filtration rate and office blood pressure (BP). Body weight and hemoglobin A1c were not altered. Aliskiren also reduced plasma renin activity (2.0 ± 0.9 to 1.2 ± 0.6 ng/mL/h, P < .01). While evening BP was unchanged, morning systolic BP (139 ± 8 to 132 ± 7 mm Hg, P < .01) and diastolic BP (81 ± 7 to 76 ± 6 mm Hg, P < .05) were decreased significantly after 6 months. Our results indicated that aliskiren decreased BP, especially morning BP in hypertensive patients with DN. The present data suggest that aliskiren exerts renoprotective actions including reduction in albumin excretion for patients with DN.

Height constitutes an important predictor of mortality in end-stage renal disease.

Aim. Height is an important determinant of augmentation index (AI) that anticipates cardiovascular prognosis. There is a scanty of the data whether short height predicts survival in patients with end-stage renal diseases, a high risk population. Methods. Fifty two hypertensive patients with type 2 diabetic nephropathy receiving hemodialysis and 52 patients with nondiabetic nephropathy were enrolled. In addition to AI estimated with radial artery tonometry, classical cardiovascular risk factors were considered. Patients were followed for 2 years to assess cardiovascular prognosis. Results. Cox hazards regression revealed that both smoking and shortness in height independently contributed to total mortality and indicated that smoking as well as the presence of left ventricular hypertrophy predicted cardiovascular mortality. Our findings implicated that high AI, the presence of diabetes, and low high-density lipoprotein cholesterol were significant contributors to cardiovascular events. Conclusions. Our findings provide new evidence that shortness in height independently contributes to total mortality in hemodialysis patients.

Zigzagged Augmentation Index in Diabetes

Although the patients with diabetic nephropathy suffered high cardiovascular risk, augmentation index (AI) in diabetic nephropathy has been poorly characterized. Cross-sectional studies were performed on 26 diabetic and 27 nondiabetic nephropathic patients. Home blood pressure was examined. In addition, blood pressure, pulse rate, and AI were measured in both supine and sitting positions. Patient backgrounds such as age, sex, sitting blood pressure, and pulse rate were similar between two groups. Circadian variations of home blood pressure were preserved in nondiabetic patients, but disappeared in diabetes. Changing from supine to sitting position induced greater decrements of systolic blood pressure (ΔSBP −9 ± 8 mmHg) and AI (ΔAI −7 ± 10) in the diabetic group than in nondiabetic patients (ΔSBP −4 ± 12 mmHg, ΔAI −2 ± 9). Multivariate regression analysis revealed that AI in a sitting position correlated positively to SBP and inversely to pulse rate. Of interest, AI in supine position related positively to age, the presence of diabetes and SBP, and inversely to pulse rate. The present data indicate autonomic dysfunction in patients with diabetic nephropathy. Furthermore, our findings provide the evidence that autonomic dysfunction elicits an inadequate physiological arterial contraction in response to postural change, thereby reducing AI that results in the fall of SBP. Finally, the present results suggest that AI in supine, but not sitting position, is suited for detecting cardiovascular risk in diabetes.

Calcium channel blockers suppress daily variations of blood pressure in hypertensive patients with end-stage renal diseases.

Abstract Hypertension is a well-known cardiovascular risk. Patients with end-stage renal diseases frequently suffer hypertension. Furthermore, daily variations of blood pressure are relatively large in patients treated with hemodialysis, partly due to ultrafiltration. Twenty hypertensive patients with end-stage renal diseases whose blood pressure was controlled by a single antihypertensive agent, either angiotensin receptor antagonist (ARB) or calcium channel blocker (CCB), were enrolled into the study. Home blood pressure measurements were also performed. Average systolic and diastolic blood pressures were similar between two agents. However, variations of systolic blood pressure during ARB treatment were greater than those of CCB, and maximal differences in daily systolic blood pressure during treatment with ARB (19 ± 7 mmHg) were greater than those with CCB (14 ± 6 mmHg, p < 0.01). Systolic blood pressure measured after hemodialysis under ARB therapy (110 ± 6 mmHg) was lower than that of CCB (118 ± 6 mmHg, p < 0.05). Daily variations of diastolic blood pressure were similar between ARB and CCB periods. Our results indicate that variations of systolic blood pressure during ARB treatment are larger than CCB, and suggest that CCB is useful to obtain the better quality of blood pressure control, improving blood pressure stability by preventing substantial drops in blood pressure in hypertensive patients with end-stage renal diseases.

Aliskiren Reduces Morning Blood Pressure in Hypertensive Patients with Diabetic Nephropathy on Hemodialysis

Our previous study indicated that the exchange from an angiotensin receptor blocker (ARB) to aliskiren reduced morning blood pressure and albuminuria in hypertensive patients with diabetic nephropathy. We extended the above study and assessed the effects of exchanging from an ARB to aliskiren on home blood pressure in hypertensive patients with diabetic nephropathy on chronic hemodialysis. The patients who were persistently hypertensive despite antihypertensive therapy, including ARB, were considered as candidates for the exchange from the ARB to aliskiren. Patients’ age and durations of diabetes and hemodialysis were averaged as 62 ± 9 years old, 15 ± 8 and 7 ± 3 years, respectively. Aliskiren decreased morning systolic blood pressure (149 ± 14 to 144 ± 13 mm Hg, n = 30, P < .01) and plasma renin activity (3.5 ± 1.1 to 1.2 ± 0.6 ng/mL/h, P < .01) without changes in serum potassium. Aliskiren also reduced interdialytic weight gain (2.7 ± 0.6 to 2.5 ± 0.5 kg/interval, P < .05) and attenuated the magnitude of intradialytic declines in systolic (−20 ± 11 to −17 ± 10 mm Hg, P < .05) and diastolic blood pressure (−9 ± 6 to −5 ± 5 mm Hg, P < .01). The exchange from an ARB to aliskiren is safe and useful to control home blood pressure in hypertensive hemodialysis patients with diabetic nephropathy. Aliskiren reduced both intradialytic blood pressure drops and interdialytic weight gain in patients with DN.

Evaluation of the Time to Terminate Continuous Renal Replacement Therapy in Patients with Acute Kidney Injury Following Cardiovascular Surgery in Association with or without a Mechanical Ventilation Support

Acute kidney injury (AKI) is a frequent and severe complication after cardiovascular surgery. Indications for continuous renal replacement therapy (CRRT) in patients with AKI have been proposed. However, there is often less discussion of when to terminate CRRT as well as what conditions are required for transferring patients to intermittent hemodialysis (HD). In this retrospective study of electronic medical records, we examined the role of a mechanical ventilator support in determining when to terminate CRRT in patients with AKI. When CRRT was stopped, 32 patients were supported with a mechanical ventilator while 41 patients had no support. Although there were no differences in age, sex, and pre levels of cardiopulmonary between the two groups, the levels of eGFR before the cardiovascular surgery were lower in the patients without a ventilator. Increases in body weight after cardiac surgery were higher, sequential organ failure assessment (SOFA) score was higher, and central venous pressures were higher in patients supported with a ventilator (all were p<0.05). The rate of re-introduction to CRRT was higher (p=0.016) in patients supported with a ventilator. After multiple regression analysis, successful cessation of CRRT was dependent on support of mechanical ventilation (odds ratio, 5.20 (CI: 1.15-23.4)). These data suggest that successful termination of CRRT is closely associated with removing the support of a mechanical ventilator.

Risk Factors for Acute Kidney Injury Requiring Continuous Renal Replacement Therapy after Off-Pump Coronary Surgery

Background: Recently, off-pump coronary artery bypass (OPCABG) grafting without cardiopulmonary bypass has become a less stressful surgical procedure for coronary artery bypass grafting (CABG). Many reports have discussed the risk factors involved associated with on-pump coronary artery bypass grafting and acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). However, only a few papers have evaluated the risk factors for AKI requiring CRRT after OPCABG. Aim: The purpose of this study was to assess the risk factors for AKI requiring CRRT after OPCAB. Methods: An observational study of 237 consecutive non dialysis patients who underwent isolated CABG using OPCABG was conducted from September 2010 to June 2012. AKI was defined as proposed by the Acute Kidney Injury Network. Variables with P<0.05 in bivariate analysis collected from pre-, intra- and postoperative data were tested in the multivariate and proportional hazards regression analyses for risk factors of AKI requiring CRRT after OPCABG. Results: Among 237 subjects, 33 patients needed CRRT due to AKI. The risk factors that were independently associated with AKI requiring CRRT were: pre-estimated glomerular filtration rate (GFR) (less than 60 ml/min/1.73m2), pre-serum albumin level (less than 3.5 g/dl), pre-hemoglobin level (less than 12g/dL), intra-urine volume (less than 600 mL), use of intra-aortic balloon pump (IABP), and post-PaO2/FiO2 (P/F) (less than 300). Conclusion: In conclusion, it is possible that the risk of developing AKI requiring CRRT after OPCABG depended on the levels of GFR, serum albumin and hemoglobin before surgery, on the levels of urine volume and use of IABP during surgery and the levels of P/F after surgery