P. Van der Niepen

METHOTRExATE SHOULD NOT BE USED FOR PATIENTS WITH END-STAGE KIDNEY DISEASE

Abstract Methotrexate is a widely used disease-modifying anti-rheumatic drug. Its effectiveness has been proven in placebo-controlled trials and in comparison with other disease-modifying anti-rheumatic drugs. The pharmacokinetics of methotrexate are highly variable and unpredictable. In patients with normal renal function, the recommended dose in rheumatoid arthritis ranges between 7.5 and 15 mg/week, but in recent years, even dosages up to 25 mg weekly are used. Toxicity includes myelosuppression, gastrointestinal adverse effects, hepatotoxicity and pneumonitis. Renal impairment and age are considered major risk factors for developing methotrexate toxicity, but studies show conflicting results. Whether methotrexate can be administered to patients with end-stage kidney disease has not been formally tested. The present case illustrates the severe side effects of low-dose methotrexate treatment in a patient with end-stage kidney disease. Seven other cases have reported similar and even more severe and irreversible consequences after low-dose regimen. In view of these side effects we strongly recommend to monitor toxicity rigorously in patients with stage 3 or stage 4 kidney disease and not to use methotrexate in patients with stage 5 kidney disease.

Gender-specific, multi-level determinants of outcomes of antihypertensive treatment: a sub-analysis of the Belgian PREVIEW study

Gender-specific determinants of blood pressure (BP) values and control have not been the focus of clinical hypertension research. The purpose of this analysis was to identify gender-specific and multi-level (physician and patient) determinants of BP values and predictors of uncontrolled BP. We completed a subgroup analysis comparing men and women who participated in the Belgian PREVIEW study of second-line treatment effectiveness of valsartan, applying two-level hierarchical modelling of 90-day BP values and guideline-defined BP control. In total, 1665 women and 1525 men were treated by 504 general practitioners. Fewer women than men reached systolic BP (SBP) (P=0.015) and combined BP targets at 90 days (P=0.007). More than 26% of the variance in 90-day SBP (intra-class correlation coefficient (ICC)=0.270) and diastolic BP (DBP) (ICC=0.262) was attributable to physician-level factors for men; the physician-level ICCs for SBP and DBP were 0.259 and 0.268, respectively, for women. Determinants of 90-day BP values and predictors of uncontrolled BP varied considerably by gender. Many of the multi-level determinants of BP by gender are amenable to intervention, and the remainder can serve as warning signs to clinicians that patients may remain vulnerable to poor outcomes associated with sub-optimal BP control.

Association of sarcoid like lesions in the bone marrow with an adenocarcinoma of the ovary: report of a case.

SummaryA patient with an adenocarcinoma of the ovary, associated with sarcoid-like granulomas in the bone marrow is reported. These lesions represent a nonspecific inflammatory reaction, secondary to the presence of the tumour, although no tumour cells are (apparently) present in the bone marrow. The frequency, differential diagnosis and possible pathogenesis of this phenomenon arc discussed.

Legionnaires’ Disease And Acute Renal Insufficiency: Report Of A Case And Review Of The Literature

We report the case of a 73-year-old man, who developed acute renal failure in association with a Legionella pneumophila serotype 1 pneumonia. Renal biopsy revealed a tubulointerstitial nephritis. Treatment with erythromycin, rifampicin and haemodialysis resulted in a clinical resolution of the pulmonary and renal syndromes.

Patient- and physician-level determinants of blood pressure response to treatment in normal weight and overweight patients (the PREVIEW study)

BACKGROUND AND AIMS Obesity combined with hypertension places patients at greater risk for target-organ damage and cardiovascular disease. The purpose of this secondary analysis was to identify physician- and patient-levels determinants of blood pressure (BP) values and predictors of uncontrolled BP through subgroup analysis by body mass index (BMI). METHODS AND RESULTS We conducted a subgroup analysis of 3006 patients with High-BMI (BMI >25 kg/m(2); n=2124) and Normal-BMI (BMI<25 kg/m(2); n=882) treated by 504 physicians and enrolled in PREVIEW, a Belgian prospective, multi-center, pharmaco-epidemiological study of 90-day second-line treatment with valsartan. Physician- and patient-level determinants of BP values and BP control were identified by means of hierarchical linear and logistic regression. Blood pressure values and control after 90 days of treatment were consistently lower for the High-BMI group. The 25.5% of variance in 90-day systolic and 28.3% of the variance in 90-day diastolic BP were attributable to physician-level determinants for the High-BMI group; versus 27.3% and 29.8% for the Normal-BMI group (ICC=0.273 and 0.298, respectively). Determinants of 90-day BP values and predictors of uncontrolled BP varied considerably by BMI status. CONCLUSION Several common and unique patient- and physician-level determinants of BP values and control were identified for the High-BMI and Normal-BMI groups. These findings highlight the need for differentiating healthcare interventions to account for patient and physician variables, particularly with respect to effective BP management in vulnerable populations.

Unilateral hydronephrosis and recurrent endometrial stromal sarcoma with review of the literature.

In this case we present a woman with arterial hypertension. Further examination showed an unilateral hydronephrosis caused by extrinsic compression. A tumoral mass, invading the caval inferior vein and the renal vein, is the very origin of the compression. This mass is a recidive of an endometrial stromal sarcoma for which she had a hysterectomy in 1984.

FIbromuscular Dysplasia of the Internal Carotid Artery: an Unusual Cause of Preversible Ischemic Neurologic Disease

SummaryA 51-ycar-old woman developed a right hemiparesis, due to a fibromuscular dysplasia (FMD) of the left internal carotid artery. Diagnosis was made by an intraarterial digital subtraction angiography (IA-DSA). She was successfully treated by the graduated internal dilatation method. The incidence, aetiology, diagnosis and management of FMD are discussed.

[PP.23.08] WHEN BECOMES CHRONIC HYPERTENSION A RISK FACTOR FOR PRE-ECLAMPSIA

Objective: The prevalence of chronic hypertension (CHT) in pregnant women is increasing, complicating 1%-5% of pregnancies. Gestational hypertension, defined as de novo development of hypertension (HTN) after 20 weeks gestation, is usually benign; but can progress to pre-eclampsia (PE) in about 25% of cases. Overall 10%-15% of maternal deaths are directly associated with PE and eclampsia. Since aetiology, risk factors and evolution of PE are not completely understood, more research is needed to optimize management and identify factors to pick up PE early in the process to prevent maternal and fetal death. To characterise a cohort patients referred for HTN during pregnancy (CHT as well as gestational HT) or referred postpartum for PE to a hypertension clinic. Design and method: Retrospective analysis comparing women, hypertensive during pregnancy, with and without CHT. Data of the prospective ongoing study will be presented as well. Results: At the moment 75 patients are included in the analysis, 44 of them are known with CHT. Baseline characteristics and risk factors for PE (age, BMI, way of conception, prior PE, diabetes mellitus, renal disease and weight gain during pregnancy) in the two groups are comparable. Women with CHT had significant higher gravidity and a significant higher gestational age. Delivery and the incidence of PE in both groups are not significantly different. BPs are shown in fig. 1 and 2. The number of antihypertensive drugs significantly increases from the first to the third trimester in all patients. Figure. No caption available. Conclusions: We observed a significant decrease in SBP during the second trimester in women with CHT without PE compared to women with CHT and PE. This may indicate the absence of a decrease of BP during pregnancy as a potential early identifying factor for pre-eclampsia in patients with CHT, suggesting the need for early and more regular follow up. Secondly, mean systolic OBP was significantly higher in women with CHT and PE during the whole pregnancy, without any difference in the number of antihypertensive drugs, suggesting that stricter BP-control is needed aiming a target OBP < 140/90 mmHg.

[PP.11.02] FIBROMUSCULAR DYSPLASIA: RESULTS OF A MULTICENTRE STUDY IN FLANDERS

Objective: Fibromuscular dysplasia (FMD) is an idiopathic, segmental, noninflammatory, nonatherosclerotic vascular disease, which results in arterial narrowing of small and medium-sized vessels. The last years new perspectives of the disease have opened up thanks to the systematically recording of FMD patients data in central databases in the US and France. The main objectives of this multicentre study were to discover the epidemiology, vascular involvement, clinical manifestations and management of FMD patients in Flanders. Later on, these results will be compared to those of the French & US Registry to discover new insights about the disease. Design and method: Multicentre study at 5 different hospitals in Flanders. 123 FMD patients were included in the database. Patients were eligible for enrolment if they were adults (18+ years old), diagnosis of FMD was confirmed using medical imaging and permission was given by written informed consent. Results: Patients were on average 57.3 years (SD 15.8) when FMD was first diagnosed. 83.7% were female. Arterial hypertension (38.5%) was the most frequent symptom leading to diagnosis of FMD. Neurological complaints such as headache (26.4%), vertigo and/or balancing problems (23.1%) and a cervical bruit 17.5%) were also common. Ten patients (8.3%) had no symptoms at the time of diagnosis. Vascular events and complications as a result of FMD occurred in a minority of patients (21.1%). Cerebrovascular involvement (81.8%) was nearly as frequent as renovascular FMD (85.3%). In 25 of 60 (41.7%) patient having two or more vascular beds imaged, co-existent FMD was found in at least two vascular beds. Digital subtraction angiography was the preferred technique for detecting FMD related lesions. The majority of the patients was pharmacologically treated (86.3%), 25.9% of them underwent an endovascular treatment. Conclusions: This study confirmed the finding that FMD is a disorder of mostly middle-aged people, but can be found in any age group. The carotid/vertebral arteries were nearly as frequently involved as the renovascular bed. Symptoms as a result of FMD were highly variable, with FMD incidentally discovered in a minority of all patients.

GENDER DIFFERENCES IN THE EVOLUTION OF BLOOD PRESSURE IN HYPERTENSIVE PATIENTS IN THE PROSPECTIVE BELGICA-STROKE STUDY: RESULTS OF ONE YEAR FOLLOW-UP: PP.7.277

Objective: Cardiovascular (CV) risk management includes use of risk calculation and treatment of modifiable risk factors such as blood pressure (BP). The primary objective of this study was to evaluate the impact of an online risk calculator on the 10-year estimated Framingham stroke risk and the 10-year estimated CV mortality risk (SCORE) on the risk profile of hypertensive patients not at goal for their blood pressure. This sub-analysis reports the evolution of blood pressure in men and women during the first year of the study. Design and Method: Primary care patients > 40 years were recruited by their General Practitioner, an online CV risk management tool being made available to the physician. Goal attainment was as defined as in the ESH/ESC 2003 guidelines. Results: 15744 patients were recruited, of which 8767 had completed data for 4 visits. Fifty-two percent were male. Age differed significantly between male and female patients (65.3 vs. 68.9 years, p < 0.001). There were 2317 diabetic patients (1251 male). Women had significant higher systolic BP at the start of the study. BP improved significantly between each visit (apart for DBP at the last visit for the male diabetic), and the biggest drop was noticed between visit 1 and 2. There was no longer a gender difference in SBP after 4 visits. Goal attainment improved significantly, with no significant differences at the end of one year. The female patient, esp. non-diabetic lagged behind the male patient during the study for BP reduction. An increase in patients treated for their BP was noticed during the study. Figure 1. No caption available. Conclusion: Significant improvement of BP control was noticed in both men and women during the first year. The reduction in BP was noticed later in the study for women than for men, despite a larger increase in percentage of patients treated. Female diabetic patients gained better BP control than male diabetic patients, although overall goal attainment in the diabetic patient was very poor.