Relu Cernes

Arterial Elasticity in Cardiovascular Disease: Focus on Hypertension, Metabolic Syndrome and Diabetes

Arterial stiffness is an independent risk factor for premature cardiovascular morbidity and mortality that can be evaluated by noninvasive methods and can be reduced by good clinical management. The present chapter examines the association between arterial stiffness and cardiovascular risk factors including hypertension, metabolic syndrome, diabetes, advanced renal failure, hypercholesterolemia and obesity. The mechanisms responsible for the structural and functional modifications of the arterial wall are also described. We deal with parameters related to arterial compliance, focusing on two of them, pulse wave velocity and the augmentation index, useful in rapid assessment of arterial compliance by the bedside. Data that highlight the role of aortic pulse wave velocity and the augmentation index as independent factors in predicting fatal and nonfatal cardiovascular events in different populations are briefly presented. A number of lifestyle changes and traditional antihypertensive agents that improve arterial compliance are finally discussed. Novel therapies, such as statins, thiazolidindinediones, phosphodiesterase inhibitors and inhibitors or breakers of advanced glycation end product cross-links between colagen and elastin hold substantial promise.

Differential clinical profile of candesartan compared to other angiotensin receptor blockers.

The advantages of blood pressure (BP) control on the risks of heart failure and stroke are well established. The renin-angiotensin system plays an important role in volume homeostasis and BP regulation and is a target for several groups of antihypertensive drugs. Angiotensin II receptor blockers represent a major class of antihypertensive compounds. Candesartan cilexetil is an angiotensin II type 1 (AT[1]) receptor antagonist (angiotensin receptor blocker [ARB]) that inhibits the actions of angiotensin II on the renin-angiotensin-aldosterone system. Oral candesartan 8–32 mg once daily is recommended for the treatment of adult patients with hypertension. Clinical trials have demonstrated that candesartan cilexetil is an effective agent in reducing the risk of cardiovascular mortality, stroke, heart failure, arterial stiffness, renal failure, retinopathy, and migraine in different populations of adult patients including patients with coexisting type 2 diabetes, metabolic syndrome, or kidney impairment. Clinical evidence confirmed that candesartan cilexetil provides better antihypertensive efficacy than losartan and is at least as effective as telmisartan and valsartan. Candesartan cilexetil, one of the current market leaders in BP treatment, is a highly selective compound with high potency, a long duration of action, and a tolerability profile similar to placebo. The most important and recent data from clinical trials regarding candesartan cilexetil will be reviewed in this article.

Medication Apprehension and Compliance among Dialysis Patients – A Comprehensive Guidance Attitude

Background: Compliance with treatment regimens is a continuing challenge for chronic dialysis patients and their medical caregivers. Poor patient adherence to prescribed medications can adversely affect treatment outcome. Study Design: In this pre- versus post-intervention study, 89 chronic dialysis patients [75 hemodialysis (HD), 14 continuous ambulatory peritoneal dialysis (CAPD); mean age 62.7 ± 12.39 years, 34 females] responded to a written questionnaire designed to assess knowledge about and compliance with 5 groups of prescribed medications: metabolic drugs, antihypertensives, cardiac-supporting agents, peptic disease therapy and hematological replacement therapy. Mode of intake, storage, means of supply and source of information for each class of drug were also assessed. Patients then received both oral and written instructions regarding their prescribed medications (intervention). This information was repeated 3 months later. Six months after the intervention, patients were re-administered the questionnaires. Response to the questionnaires and laboratory data were compared prior to and following the intervention. Results: Overall, compliance with prescribed medications significantly improved following the intervention, from 89 to 95.7%, p = 0.0007. This relative improvement was greater in HD than CAPD patients (27 vs. 2%, p < 0.0001). Improvement in compliance was associated with lower initial scores, fewer years of education, and longer dialysis vintage. Compared to baseline values, post-intervention blood hemoglobin, hematocrit, mean corpuscular volume, ferritin and Ca levels were significantly improved. Conclusions: Dialysis patients appear to benefit from receiving comprehensive guidance about medications, in terms of compliance with medications and blood chemistry and hematology measures.

A Randomized Controlled Clinical Trial Comparing the Efficacy of Dead Sea Mineral-Enriched Body Lotion versus Two Types of Placebo in the Treatment of Cutaneous Dryness, Itching, Peeling and Tightness in Hemodialysis Patients (EDIT)

Background/Aims: The present study was designed to investigate the short-term safety and efficacy of topical application with body lotion enriched with minerals from the Dead Sea versus 2 different placebo treatments in reducing symptoms of uremic pruritus. Methods: In this single-center, randomized, double placebo-controlled clinical trial, 78 hemodialysis patients with self-reported uremic pruritus were randomized to twice-daily topical treatment with body lotion enriched with minerals from the Dead Sea (DS) or to each of 2 types of placebo: (1) lotion with no Dead Sea minerals but otherwise identical to DS (P1) or (2) lotion with no active ingredients (P2). Symptoms of uremic pruritus (itching, dryness, peeling, tightness) were evaluated at baseline and 2 weeks (14 days) after treatment intervention using a 5-point Likert scale. Results: Following treatment, significant differences in symptom severity scores between DS and P1 and, separately, between group DS and P2, were not detected. Additionally, when DS was compared to the combined placebo groups (P1 and P2 together), significant post-treatment differences in symptom severity scores were not observed. Symptoms were less severe post-treatment regardless of treatment assignment. Conclusions: DS was not superior to either of the placebo treatments in the symptomatic relief of uremic pruritus.

Noninvasive skin measurements to monitor chronic renal failure pathogenesis.

BACKGROUND/AIMS Cutaneous manifestations are common in hemodialysis (HD) patients with chronic renal failure (CRF). Associated with uremia, pruritus is a frequently observed symptom in CRF patients and increases with deteriorating renal function. Skin hydrophilic biomarkers (SHB) may be altered in CRF compared to healthy controls. METHODS A noninvasive skin wash sampling technique to detect the expression of SHB, by measuring their secretion on skin surface, was used on HD patients and healthy controls. Hydrophilic antioxidants such as total antioxidant scavenging capacity (TSC) and uric acid (UA) content, and cytokine inflammatory biomarkers such as TNFα and IL-10 levels were estimated. RESULTS Our findings demonstrate significant alterations of the SHB level between HD patients and healthy volunteers. Furthermore, such alterations of secreted SHB correlated markedly with detected changes in blood biochemistry and dermatology severity score. CONCLUSION Skin wash sampling of SHB is a noninvasive technique that distinguishes between HD patients and healthy controls. In HD patients, SHB is associated with biochemical markers in blood and dermatologic symptom severity. This technique is also suggested, as a monitoring tool for diagnosis and treatments of various diseases, in which skin dysfunction is involved.

Role of Paced Breathing for Treatment of Hypertension

Purpose of ReviewHypertension remains to be a major contributor to global morbidity and mortality. Despite a plethora of pharmacological options available, an abundance of patients have uncontrolled blood pressure thus creating the need for additional strategies, including non-pharmacologic approaches. In this review, we discuss the antihypertensive effect of slow and deep respiration by increasing baroreflex sensitivity.Recent FindingsAsking patients to carry out paced breathing sessions unaccompanied by a personal coach or unaided by a device may be unfeasible. Among proposed breathing techniques, RESPeRATE is a US Food and Drug Administration–certified device that assists slow breathing. In this review, we consider the mechanisms through which guided breathing mechanisms may impact on blood pressure control and alternative techniques.SummaryGuided breathing techniques along with lifestyle therapies may be helpful as a first step for patients with mild hypertension and prehypertension who do not suffer from cardiovascular disease, renal disease, or diabetes. Drug therapy must be considered after a couple of months if non-pharmacological therapy was unsuccessful. Device-guided paced breathing (DGB) may be recommended for those who cannot obtain full control of their hypertension with medical therapy alone or cannot tolerate potential side effects of pharmacologic treatment. Also, patients with well-controlled hypertension who may wish to try to reduce medication burden may be candidates for DGB. Patients with white coat or labile hypertension who are interested in biofeedback techniques could also be considered.

Relation of Arterial Properties to Left Ventricular Hypertrophy in Hypertensive Adults: Focus on Gender-Related Differences:

Background: Although gender-related differences in ventricular remodeling and arterial stiffness have been described, the impact of gender on the association between vascular compliance and left ventricular hypertrophy (LVH) has not been investigated. The current study was designed to determine the gender-related differences in the association between echographically determined LVH measures and arterial stiffness in hypertensive men and women. Methods: In the current study, 104 hypertensive participants (61 men and 43 women) were enrolled. Large artery elasticity index (LAEI) and small artery elasticity index (SAEI) were determined using pulse wave contour analysis (HDI CR 2000, Eagan, Minnesota). Left ventricular hypertrophy parameters including intraventricular septum thickness (IVST), posterior wall thickness (PWT), and left ventricular mass index (LVMI) were assessed echographically. Results: Hypertensive male versus female were similar in terms of age, body mass index (BMI), blood pressure, concomitant medications, and cardiovascular risk factors. Left ventricular mass index was significantly, inversely associated with IVST (r = —.32, P = .01), PWT (r = —.32, P = .01), and LVMI (r = —.28, P = .03) in men and significantly, inversely associated with IVST (r = —39, P = .01), PWT (r = —.42, P = .005), LVMI (r = —.54, P < .0001) in women. Small artery elasticity index was significantly, inversely associated with LVMI (r = —0.36, P = .02) in women only. In regression analysis, LAEI explained more variability than SAEI and was an independent predictor of LVH parameters in hypertensive men and women. Conclusions: Compliance of large arteries is potentially an independent predictor of LVH in hypertensive men and women. Therefore, arterial compliance is being considered an important tool in predicting LVH in hypertensive participants.

Diabetes Mellitus Type 2 and Proteinuria

Chronic kidney disease (CKD) is prevalent in people with diabetes; a recent analysis of NHANES data found that 39.6% of people with diagnosed diabetes, 41.7% of those with undiagnosed diabetes and 17.7% of those with prediabetes had CKD [3]. Increased urinary protein excretion may be an early clinical manifestation of diabetic nephropathy. However, when assessing protein excretion, the urine dipstick is a relatively insensitive marker for initial increases in protein excretion, not becoming positive until protein excretion exceeds 300 to 500 mg/day (upper limit of normal less than 150 mg/day, with most individuals excreting less than 100 mg/day) [4]. Microalbuminuria is delimited as an albumin excretion rate of 30-300 mg/24 h or a spot urine albumin to creatinine Ratio (ACR) of 30-300 mg/g (3.5-35 mg/mmol) in males and 20-200 mg/g (2.5-25 mg/mmol) in females. Overt diabetic nephropathy (DN) is settled by proteinuria >500 mg/24 h or albuminuria >300 mg/24 h. Also DN can be defined by an estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m2 [5]. 5097 subjects with type 2 diabetes were followed from 1977 to 1997 to determine the rate of progression of kidney disease. From diagnosis of diabetes, progression to microalbuminuria occurred at 2.0% per year, from microalbuminuria to macroalbuminuria at 2.8% per year, and from macroalbumi‐ nuria to elevated plasma creatinine (>or=175 micromol/L) or renal replacement therapy (RRT) at 2.3% per year. Ten years following diagnosis of diabetes, the prevalence of microalbumi‐ nuria was 24.9%, of macroalbuminuria was 5.3%, and of elevated plasma creatinine or RRT was 0.8% [6]. Renal dysfunction, including proteinuria and microalbuminuria, is predictive of cardiovascular events, and cardiovascular and all-cause mortality [7-11]. Although these cutoffs defining normoalbuminuria, microalbuminuria, and macroalbuminuria facilitate deter‐

Dietary Therapy for Children With Congenital Solitary Functioning Kidney

Background. Renal injury, proteinuria, and hypertension, are consequences of congenital solitary functioning kidney (CSFK). Renal injury appears around 10 years of age and requires dialysis by the age of 30 years. Low protein intake attenuated renal damage in animal experimental models, uninephrectomized patients, and kidney transplant donors and recipients. Low salt intake facilitates blood pressure control. Objective. Relevant data concerning CSFK patients have not been described so far. We decided to examine long-term preventing effects of protein restriction and low-salt diet on proteinuria, kidney function, and hypertension, in this distinct polulation. Methods. Twenty-eight children with CSFK were included in a prospective observational exposure series. Following parents’ agreement, protein and salt restriction—0.85 × recommended daily allowance (RDA)—was started under dietitian supervision. Compliance verification was performed by (a) monitoring urinary urea nitrogen and body weight, (b) measuring ...