P. Dessì-Fulgheri

Massive spontaneous perirenal hematoma and accelerated hypertension in a patient with polyarteritis nodosa

A 43-year-old Albanian man is presented who underwent nephrectomy for a huge right spontaneous perirenal hematoma. The diagnosis of polyarteritis nodosa as the etiology of the hematoma has been made only by histological examination, because of the quick and unforeseeable onset of this complication and the nonspecificity of symptoms. We hypothesize a relationship between reactivation of polyarteritis nodosa and treatment with rifampicin and isoniazid.

Microalbuminuria and Left Ventricular Mass in Overweight and Obese Hypertensive Patients Role of the Metabolic Syndrome

AbstractBackground: Left ventricular hypertrophy (LVH) and microalbuminuria are common in hypertensive patients and are often associated with metabolic syndrome (MetS). However, it is not clear whether MetS could modify the association between cardiac and renal damage.n Objective: The aim of this study was to assess if the relationship of albumin/creatinine ratio (ACR) and left ventricular mass (LVM) could be independent from MetS in hypertensive overweight/obese patients.n Methods: 180 essential hypertensive and overweight/obese (body mass index [BMI] ≥25 kg/m2) patients referred to our Hypertension Centre from January 2006 to April 2009 because of blood pressure (BP) control-related problems were studied. Exclusion criteria were scarce adherence to antihypertensive drug therapy as investigated by the Morisky Medical Adherence Scale (MMAS), heart failure (New York Heart Association III or IV or left ventricular ejection fraction [LVEF] <50%), liver failure, cancer or other systemic severe diseases. MetS was defined according to the National Cholesterol Education Program (USA) Adult Treatment Panel III classification as modified by the American Heart Association. ACR was obtained from first morning urine specimens. Left ventricular dimensions, mass and ejection fraction, were measured by echocardiography following the American Society of Echocardiography recommendations.n Results: Patients with microalbuminuria had a 6-fold higher risk for LVH/h2.7 and 2-fold higher risk for LVH/body surface area (BSA). Univariate linear regression analysis showed a positive relationship between ACR and LVM, expressed both as LVM/h2.7 or LVM/BSA, as well as a direct correlation between logACR and interventricular diameters and ejection fraction. Regression models including logACR, estimated glomerular filtration rate, BMI, age, hypertension duration, smoking and MetS (as a single variable as well as each single component), showed that only logACR, BMI, hypertension duration and systolic blood pressure (SBP) were independently associated with LVM/h2.7.n Conclusion: Along with BP and BMI, albuminuria measured in a morning urine sample as ACR is a valuable low-cost index of cardiac organ damage and increased cardiovascular risk in hypertensive patients independently by MetS. On the other hand, MetS is not an independent risk factor for cardiac damage because it does not seem to add anything more than the sum of each of its components (especially SBP and adiposity indexed by BMI) to the relationship between cardiac and renal subclinical organ damage.

Angiotensin Receptor Blockers and Target-Organ Protection Beyond Blood Pressure Control

The renin-angiotensin-aldosterone system (RAAS) is considered to be the main mediator of the cardiovascular damage associated with high blood pressure. Recent guidelines recognised, both directly and indirectly, the central role of RAAS, reporting the ‘compelling indications’ for the use of drugs that antagonise this system. The results of many large trials with the angiotensin receptor blockers (ARBs) candesartan, losartan, irbesartan and valsartan have been published from the year 2000 to the end of 2003. These trials have been conducted to verify that, beyond blood pressure control, ARBs could offer better organ protection in many different clinical conditions. Despite the favourable premises, some ARB trials not only failed to show superiority, but even equivalence with lower-cost therapies of confirmed efficacy (e.g. captopril 50mg three times daily). On the contrary, other ARB trials (IDNT [Irbesartan Diabetic Nephropathy Trial], IRMA2 [Irbesartan in Patients with Type 2 Diabetes and Microalbuminuria], RENAAL [Reduction of End points in NIDDM with the Angiotensin II Antagonist Losartan], and LIFE [Losartan Intervention for End Point Reduction in Hypertension]) have had such clear-cut outcomes that irbesartan (300mg) and losartan (100mg) are the drugs of choice in type 2 diabetes patients with proteinuria or in hypertensive patients with left ventricular hypertrophy. The key factor for ARBs to succeed in delivering superior organ protection appears to be the high dosages used, dosages uncommonly utilised, with some exceptions, to treat hypertension in clinical practice. The results of the published ARB trials are reviewed, focusing on the dose-efficacy of target-organ protection beyond blood pressure control.