Vanja Ivković

[OP.2B.03] GLOMERULAR HYPERFILTRATION AS A RISK FACTOR FOR RENAL IMPAIRMENT AND HYPERTENSION IN APPARENTLY HEALTHY SUBJECTS.

Objective: Chronic kidney disease(CKD) is established CV risk factor, and already early renal impairment(RI) increases risk for hypertension(HT) and loss of renal function. It was reported that blood pressure (BP) and metabolic derangements are associated with glomerular hyperfiltration(GHF), and GHF increases risk of developing microalbuminuria (MA) in HT stage 1. Our aim was to analyze whether GHF predicts progression to HT and RI in apparently healthy subjects. Design and method: Out of 954 subjects enrolled in ENAH follow-up study, 371 (137 m, 234 w; mean age = 46 years) were eligible for further analysis:100 with optimal, 72 with normal BP, 70 with PHT (high normal BP), and 129 with newly diagnosed untreated HT. Follow-up period was 77 ± 12 months. Exclusion criteria were treatment with antihypertensive drugs, diabetes, pregnancy, eGFR<60 ml/min, CV or cerebrovascular incident, chronic terminal diseases, dementia, immobility and missing data. BP and heart rate were measured using Omron 6 device following the ESH guidelines. Uric acid, glucose, lipids, serum creatinine, hsCRP, leptin and adiponektin were determined; HOMA index was used to calculate insulin resistance and MDRD formula to estimate GFR. Albumin to creatinine ratio (ACR) was determined from the first morning spot urine. GHF was defined as eGFR above the cut off value of the 5th quintile of the whole group. Results: In the GHF group eGFR(ml/min/year) decreased significantly more than in others (−3.4 (IQ−5.8 to −1.76 vs. −1.5 (IQ−2.6 to −0.3); total decrease −17.7% vs. −9.8%; per year −2.8% vs. −1.5%; all p < 0.001). ACR was non-significantly higher in GHF group at enter and at the end of follow-up (5.73 (IQ3.35–8.6) vs. 4.5 (IQ3.31–7.25); p = 0.06, 5.93 (IQ4.26–8.64) vs. 5.7 (IQ4.08–9.82; NS, respectively). In the GHF group, at the end of follow-up ACR did not increase significantly. At enter and at the end of follow-up BP was significantly lower in GHF group (p < 0.001). At the end of study we failed to observe difference in increase of BP and new-onset HT between GHF and others. Conclusions: In our group of healthy subjects GHF was associated only with more rapid decrease of GFR. No impact of GHF on ACR increase and development of new-onset HT in healthy subjects was observed. GHF has less prominent effect on HT and kidney function in apparently healthy subjects than in those with HT and metabolic disorder.

Is herbal tea consumption a factor in endemic nephropathy

Endemic (Balkan) nephropathy (EN) is a chronic tubulointerstitial nephropathy frequently associated with upper urothelial cancer exclusively affecting farming villagers [1–3]. Based on our results, EN is considered to be an environmental form of aristolochic acid nephropathy (AAN) [1–3]. AAN was first reported in 1993 in Belgium and subsequently more AAN cases were reported worldwide as AA has been an integral part of traditional herbal medicines [4]. The extent of this problem was recently documented in Taiwan where precise data on prescriptions of herbal products containing AA is available [5]. Aristolochia spp. has been used for more than 2,000 years in the practice of traditional medicine and European physicians were familiar with the use of this plant as well. After its intrinsic toxicity became known, importing Aristolochia herbs was banned in many countries, including Croatia. Nevertheless, products containing AA remain a part of traditional medicine and are sold in many countries that do not have strict control protocols. Recently we reported that AA DNA adducts were present in 95 % of patients with EN who underwent surgery for upper urothelial cancers [2] and affirmed the idea that bread contaminated with AA might be the cause of EN [6, 7]. However, the causative relationship between AA and EN again raised the question whether bread intake is the only route of ingestion or whether AA was ingested also in EN as a part of folkloric medicine. Gluhovschi et al. [8] reported that although therapeutic remedies based on AA products are used in the EN affected area in Romania, no relationship between these remedies and the development of EN or of tumors was observed. However, they used HPLC for detection of AA in plasma, which is less sensitive than the mass spectrometry we recently used in tissue samples [1, 2]. In addition, when re-analyzing their data, it does appear that AA was used more frequently in the endemic area. In our opinion, this leaves the question whether herbal tea may play a role in EN still unanswered. In our preliminary study we failed to find any evidence in the group of 1,041 Croatian farmers that herbal tea or traditional medicine use is related to EN [9]. The observed differences between

Adiponectin is Not Associated With Blood Pressure in Normotensives and Untreated Hypertensives With Normal Kidney Function

AbstractThe role of adiponectin in hypertension is still a matter of debate. Obtained conflicting results could be mostly explained with diversity of subjects included in different studies. Our aim was to analyze association of adiponectin with blood pressure (BP) in a group of normotensive and untreated hypertensive subjects.Participants (N = 257) were selected from a random sample of 2487 subjects enrolled in an observational cross-sectional study. Subjects with diabetes and chronic kidney diseases were excluded. BP was measured using Omron M6 device following ESH/ESC guidelines. Adiponectin concentration was determined by ELISA.There were no differences in adiponectin values (mg/L) between hypertensives and normotensives (median 9.75; iqr: 7.44–17.88 vs 11.35; iqr: 7.43–12.63; P = 0.17). On univariate linear regression adiponectin was not associated with systolic or diastolic BP (P > 0.05). Furthermore, multivariate analysis did not show significant contribution of log-transformed adiponectin either to systolic (&bgr; = −0.040; P = 0.43) or diastolic BP (&bgr; = 0.066; P = 0.33).In our group of normotensives and untreated hypertensives with normal kidney function adiponectin was not associated with BP even after adjustment for other risk factors. Our results and conclusions should not be extrapolated to subjects with other characteristics.

Expression of BMP-2 in Vascular Endothelial Cells of Recipient May Predict Delayed Graft Function After Renal Transplantation

Background/Aims: Delayed graft function (DGF) is associated with adverse outcomes after renal transplantation. Bone morphogenetic protein-2 (BMP-2) is involved in both endothelial function and immunological events. We compared expression of BMP-2 in epigastric artery of renal transplant recipients with immediate graft function (IGF) and DGF. Methods: 79 patients were included in this prospective study. Patients were divided in IGF group (64 patients) and DGF group (15 patients). BMP-2 expression in intima media (BMP2m) and endothelium (BMP2e) of epigastric artery was assessed by immunohistochemistry. Results: Lower intensity of BMP2e staining was recorded in DGF compared to IGF. In DGF patients, 93% had no expression of BMP2e and 7% had 1st grade expression, compared to 45% and 41% in IGF group, respectively (P=0.001) (P<0.001 for no expression and P = 0.015 for 1st grade expression). Patients who had BMP2e staining positive had lower odds for DGF (OR 0.059 [0.007, 0.477]) and this remained significant even after adjustment for donor and recipient variables, cold ischemia time, and immunological matching (OR 0.038 [0.003, 0.492]). Conclusions: Our results demonstrate that BMP-2 expression in endothelial cells of epigastric arteries may predict development of DGF.

[PP.07.18] ASSOCIATION OF ADIPONECTIN GENE POLYMORPHISMS WITH BLOOD PRESSURE AND HYPERTENSION

Objective: The role of adiponectin in hypertension (HT) is still a matter of debate. Obtained conflicting results could be mostly explained with diversity of subjects included in different studies. Our aim was to analyze association of adiponectin and its gene polymorphisms with blood pressure (BP) in a group of normotensive (NT) and untreated HT subjects with normal kidney function. Design and method: Analyses was conducted in 192 subjects (68 m; age 44 (IQR 31–53)). Those with diabetes, treated HT and chronic kidney disease (eGFR < 60 ml/min) were excluded. BP was measured using Omron M6 device following ESH/ESC guidelines. Adiponectin concentration was determined by ELISA. Genotyping was done using PCR-FRET. Genetic association analyses were done with Arlequin and haplotype analysis with Unphased. Results: There were no differences in plasma adiponectin values (mg/L) between HT and NT (9.75; iqr:7.44–17.88 vs.11.35;iqr:7.43–12.63;P = 0.17) and no associations with systolic or diastolic BP (P > 0.05). Ninety-three persons had genotype −11377C/C, 77 had −11377C/G and 18 −11377G/G; minor allele frequency (MAF) 30%,with no difference between NT and HT. Polymorphism −11377C > G was not associated with HT in the dominant, codominant, overdominant, recessive or additive model (all p > 0.05). Polymorphism −11391G > A (164 were dominant homozygots and 22 were heterozygots; MAF 12%, with no difference between NT and HT) also was not associated with HT (OR 2.12 [0.73–6.16]). Haplotype analysis established three haplotypes, C-G (freq. 64%), G-G (30%), C-A (6%) which showed no association with HT well. Conclusions: In our group of NT and untreated HT with normal kidney function adiponectin was not associated with BP even after adjustment for other risk factors. Even more, we did not find an association of two common adiponectin gene polymorphisms with HT. Adiponectin-BP relationship is complex and differs between specific populations. Our conclusions should not be extrapolated to subjects with other characteristics. Studies on larger number are needed.

[PP.30.14] SALT CONSUMPTION IN CROATIAN CONTINENTAL RURAL POPULATION: ENAH STUDY

Objective: Results from our previous survey confirmed that salt consumption (24 h mapping) in Croatia is above 11 g/day. Salt intake was higher in rural than in urban area. Croatian national campaign started in 2008 and our aim was to analyze trends in salt consumption in rural area in the past period. Design and method: Out of 3056 subjects enrolled in ENAH study, 2259 (868m, 1391w) were eligible for further analysis. All inhabitants older than 18 years of age from this rural area were invited to participate and were examined on a door-to-door basis. Pregnant women, patients with terminal illness who were bed-ridden, patients with severe disability or those who have had at least one limb amputated or immobilized and mentally ill or suffering from dementia were considered ineligible. Participation rate was >70%. Salt intake (g/day) was estimated from the first morning spot urine using Intersalt equation. Blood pressure (BP) was measured using Omron 6 device following the ESH guidelines. Villagers were examined in 2008, 2010 and 2015 and trends in salt intake and association with BP were analyzed. There were no differences in age and gender between survey years. Results: In 2008, 2010, 2015 salt intake in the whole group was 10.5(8.7–12.2); 10.2(8.4–12.1); 10.9 (9.5–12.2), respectively; in men 10.4(8.8–12.2); 10.1(8.5–12.1);10.9 (9.3–12.3), respectively; in women 10.6 (8.6–12.3); 10.4(8.4–12.1); 10.9 (9.6–12.1), respectively. We failed to observe trend in decreasing salt intake, without gender difference. Significant correlation between salt intake and systolic and diastolic BP was found in the whole group (r = 0.32; r = 0.18, respectively, both p < 0.001), in men(r = 0.29; r = 0.134, respectively, both p = 0.01) and in women (r = 0.35; r = 0.21, respectively, both p < 0.001). Conclusions: We are fully aware of many drawbacks related to the spot urine sampling. However, using the same method and the same equation in the same population we believe that we can consider our results reliable to estimate the trend of salt consumption in rural area. Significant correlation with BP was observed which confirms prior results. Despite of the Croatian National Program launched 10 years ago, salt consumption in rural area is very high and remains unchanged and further efforts in this field are needed.

[OP.7A.05] TRENDS IN PREVALENCE, TREATMENT AND CONTROL OF HYPERTENSION IN CROATIAN CONTINENTAL RURAL POPULATION - ENAH STUDY

Objective: Overall prevalence of hypertension (HT) in Croatia is high and control of HT is poor. In this study our aim was to analyze trends in prevalence, treatment and control of HT in the same rural population during the 10 years long survey. Design and method: Out of 3056 subjects enrolled in ENAH study, 2361 were eligible for further analysis. All inhabitants older than 18 years of age from this rural area were invited to participate and were examined on a door-to-door basis. Pregnant women, patients with terminal illness who were bed-ridden, patients with severe disability or those who have had at least one limb amputated or immobilized and mentally ill or suffering from dementia were considered ineligible. Participation rate was >70%. Blood pressure (BP) and heart rate (HR) were measured using Omron 6 device following the ESH guidelines. HT was defined as a BP > = 140/90 mmHg, and/or current use of antihypertensive drugs. Treatment of HT was defined as usage of antihypertensive medication at the time of the interview. Control of treated HT was defined as BP < 140/90 mmHg. Villagers were examined in 2005, 2008, 2010 and 2015, and trends of prevalence, treatment and control were analysed. There were no differences in age and gender among various years groups. Results: Prevalence of HT decreased from 2005 to 2010 but still remains very high (64.1% vs. 55.2%; p = 0.04). Prevalence of treated HT significantly increased from 2005 to 2015 (26.8% vs. 68.5%; p = 0.001). Prevalence of controlled HT gradually increased and in 2005, 2008, 2010 and 2015 was 11.%, 14.5%, 15.1% and 17.3%, respectively; p = 0.09). Significant decrease in average systolic BP was observed (p for trend <0.001 for systolic BP). Conclusions: Prevalence of HT in Croatian rural area remains very high. Nowadays, much more HT were treated and there is trend to better control. However, results are still unacceptable. High salt consumption, obesity, poor socioeconomic status and low educational level are the most import causes of such thrashing result.

[OP.5C.04] HEART RATE IS ASSOCIATED WITH GLOMERULAR HYPERFILTRATION IN APPARENTLY HEALTHY SUBJECTS.

Objective: Glomerular hyperfiltration (GHF) was associated with progression of kidney disease and hypertension (HT). It was reported that high metabolic risk is related to increase of GHF. Our aim was to analyze in apparently healthy subjects which factor(s) influence (s) GHF and determine(s) clinical course in long-term prospective study. Design and method: Out of 954 subjects enrolled in ENAH follow-up study, 371 (137 m, 234w; mean age = 46years) were eligible for further analysis:100 with optimal, 72 with normal BP, 70 with PHT (high normal BP), and 129 with newly diagnosed untreated HT. Follow-up period was 77 ± 12 months. Exclusion criteria were treatment with antihypertensive drugs, diabetes, pregnancy, eGFR < 60 ml/min, CV or cerebrovascular incident, chronic terminal diseases, dementia, immobility and missing data. BP and heart rate were measured using Omron 6 device following the ESH guidelines. Uric acid, glucose, lipids, serum creatinine, hsCRP, leptin and adiponectin were determined; HOMA index was used to calculate insulin resistance and MDRD formula to estimate GFR. Albumin to creatinine ratio (ACR) was determined from the first morning spot urine. GHF was defined as eGFR above the cut off value of the 5th quintile of the whole group. Results: Subjects with GHF were younger (38.1 vs. 48 13), had smaller waist circumfernce (87 ± 17 vs. 92 ± 16), lower BP (121/76 vs. 131/81), total cholesterol (5.3 ± 1.1 vs. 5.8 ± 1.1) LDL-cholesterol (3.1 ± 0.9 vs. 3.5 ± 1.0) and leptin (C 5,1 (IQ2.8–10.7) vs. 10.4 (5.4–16.6) compared to others; all p < 0.05. Neither metabolic factors nor BP values were assosiated with GHF. However, GHF was positively associated with HR in a way that every 1 beat/min increases odds for hyperfiltration for 7% (1.07 [1.02, 1.13]) at baseline for 6% at the end of follow up (1.06 [1.01, 1.10]). Conclusions: Contrary to some reports from literature, our group of apparently healthy subjects with GHF did not have increased metabolic risk. Interestingly, according to our results heart rate is positively associated with GFH indicating that increased sympathetic activity might have important role.

[PP.03.05] SERUM URIC ACID IS NOT ASSOCIATED WITH ALBUMINURIA IN PREHYPERTENSION AND NEWLY DIAGNOSED HYPERTENSION

Objective: Elevated serum uric acid(SUA) even asymptomatic was found to be associated with blood pressure(BP), hypertension(HT), cardiovascular and chronic kidney disease. It was reported that xantin oxidase inhibitors(XOi) could in animals reverse glomerular hypertension and hypertrophy caused with hyperuricemia and in hyperuremic humans decrease microalbuminuria(MA). However, the question still remain whether elevated SUA is cause. marker, or just epiphenomen of renal impairment. Our aim was to analyze association of SUA with MA in prehypertensives(PHT) and newly diagnosed, untreated hypertensives(HT). Design and method: Out of 954 subjects enrolled in ENAH follow-up study, 371 (137 m, 234 w) were eligible for further analysis 100 with optimal, 72 with normal BP, 70 with PHT (high normal BP), and 129 with newly diagnosed HT. Exclusion criteria were treatment with antihypertensive drugs and XOi, diabetes, pregnancy, eGFR<60 ml/min, CV or cerebrovascular incident, chronic terminal diseases, dementia, immobility and missing data. BP was measured using Omron 6 device following the ESH guidelines. Fasting blood was analysed for SUA, glucose, lipids, serum creatinine, hsCRP. HOMA index was used to calculate insulin resistance and MDRD formula to estimate GFR. Albumin to creatinine ratio (ACR) was determined from the first morning spot urine. Results: In the whole group there is trend of lower ACR regarding SUA (1st vs. 2nd vs. 3rd tercile 5.78 vs. 5.11 vs. 4.65; p = 0.002). 78.3% subjects in the highest tertile of SUA were in the lowest tertile of ACR. Correlation of SUA and ACR was significantly negative (r = −0.21; p < 0.01), but after adjustment for age, gender, waist circumference, systolic BP, FBG, alpha1/CR significance was lost (beta = −0.09; p = 0.89). In the subgroup of PHT and HT SUA was also negatively correlated (r = −0.14; p = 0.02) but again the association was not significant after adjustment (beta = −0.10; p = 0.28). Trend of ACR across of SUA tertiles was the same as in the whole group (p = 0.02). Conclusions: In PHT and newly diagnosed, untreated HT, SUA is not associated with MA. Even more, our observation on negative association of SUA with MA might rise a provocative question whether in early phase of cardiorenal continuum elevated SUA, having antioxidative properties, might be even protective.

[PP.03.11] PREHYPERTENSION IS ASSOCIATED WITH CHRONIC KIDNEY DISEASE IN EUROPEAN RURAL POPULATION- DATA FROM BRISGHELA HEART STUDY (ITALY) AND ENAH STUDY (CROATIA)

Objective: Chronic kidney disease (CKD) is a silent global epidemic. Hypertension and diabetes are most important risk factors. As prehypertension (PHT) was associated with increased cardiovascular (CV) and renal risk, our aim was to analyze association of PHT with CKD in European rural continental population. Design and method: In this international prospective long-term follow up study data on 5162 subjects (m 2387) from BrEna cohort formed from original cohorts of Brisighella Heart Study (Italy) and ENAH study (Croatia) were analyzed. Them 3389 (m 1456) were eligible for further analyses, and 1335 (m 541) were followed up for average period of 100 months (IQ84–120); 11.337 person years. CKD was defined as eGFR < 60 ml/min (MDRD), HT as BP > = 140/90 mmHg and/or taking antihypertensive drugs, and PHT according to JNC-7 (PHTJ) and ESH stratification (PHTE). At the end of follow-up there were 236 new-onset CKD patients. Results: Prevalence of PHTJ was 25.8% (m vs. w 28.4vs.23.9%;p < 0.05), PHTE 7.8% (m vs.w 8.5vs.7.2; p>0.05). Prevalence of CKD in the whole group was 12.1% (m vs. w. 8.1 vs.15.2; p < 0.01). In the whole group prevalence of CKD increases across BP categories from optimal BP, PHTJ, PHTE and HT (3.2 vs.4.8 vs.5.8 vs.17.8, respectively, p < 0.01), as well in men (0.0 vs.3.3. vs. 2.0 vs.11.7, respectively, p < 0.05) and in women (4.1 vs.6.1 vs.8.9 vs.22.5, respectively, p < 0.01). At baseline, in logistic regression adjusted risk (OR) for CKD was not significant comparing PHT vs. NT, and at the end of follow up PHT was not an independent predictor of new-onset CKD even in obese. In the group of new-onset CKD there was no difference in proportion of PHT at start of follow-up. Conclusions: In European rural population prevalence of CKD increases across BP categories. It is higher in PHT than in NT. PHT was not found to be an independent risk factor for new- onset CKD (3a stage) even in subjects with BMI > 30 kg/m2. Longer period of follow-up, as in HUNT study, is needed this association to become evident. Nevertheless, in PHT, particularly obese, it is prudent to monitor kidney function yearly.