The International Society of Hypertension (ISH) has recently developed practice guidelines for the management of hypertension in adults aged ≥18 years. Conceptually, the 2020 ISH Guidelines are ...closer to the 2018 ESC/ESH Guidelines rather than to the 2017 ACC/AHA Guidelines. The ISH Guidelines have two distinctive features when compared with the 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) Guidelines and the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines. First, they are written in a concise and easy-to-read style; second, they focuses on practical issues related to the management of hypertension in ‘high-income’ as well as in ‘low-income’ countries, where there is limited access to resources for the diagnosis and treatment of hypertension. In our opinion, the 2020 ISH Guidelines share with the 2018 ESC/ESH Guidelines an important limitation which may impair the retention of these key aspects of Guidelines by physicians, with consequent difficult adoption in clinical practice. It consists in the definition of several blood pressure targets in relation to age, target organ damage and concomitant disease. We believe that results of randomized clinical trials and meta-analysis do not support the recommendation of differential BP targets, as well as of rigid ‘safety boundaries’. This review critically examines similarities and differences across the three major Hypertension Guidelines, which include the definition of hypertension, drug treatment, and blood pressure targets, with emphasis on key messages relevant for clinical practice.
Diabetic kidney disease (DKD) is a chronic microvascular complication in patients with diabetes mellitus (DM) and the leading cause of end-stage kidney disease (ESKD). Although glomerulosclerosis, ...tubular injury and interstitial fibrosis are typical damages of DKD, the interplay of different processes (metabolic factors, oxidative stress, inflammatory pathway, fibrotic signaling, and hemodynamic mechanisms) appears to drive the onset and progression of DKD. A growing understanding of the pathogenetic mechanisms, and the development of new therapeutics, is opening the way for a new era of nephroprotection based on precision-medicine approaches. This review summarizes the therapeutic options linked to specific molecular mechanisms of DKD, including renin-angiotensin-aldosterone system blockers, SGLT2 inhibitors, mineralocorticoid receptor antagonists, glucagon-like peptide-1 receptor agonists, endothelin receptor antagonists, and aldosterone synthase inhibitors. In a new era of nephroprotection, these drugs, as pillars of personalized medicine, can improve renal outcomes and enhance the quality of life for individuals with DKD.
OBJECTIVEGuidelines generally recommend intensive lowering of blood pressure (BP) in patients with type 2 diabetes. There is uncertainty about the impact of this strategy on case-specific events. ...Thus, we generated estimates of the effects of BP reduction on the risk of myocardial infarction (MI) and stroke in diabetic patients.
METHODSWe selected studies which compared different BP-lowering agents and different BP intervention strategies in patients with diabetes. Outcome measures were MI and stroke. We abstracted information about study design, intervention, population, outcomes, and methodological quality for a total of 73 913 patients with diabetes (295 652 patient-years of exposure) randomized in 31 intervention trials.
RESULTSOverall, experimental treatment reduced the risk of stroke by 9% (P = 0.0059), and that of MI by 11% (P = 0.0015). Allocation to more-tight, compared with less-tight, BP control reduced the risk of stroke by 31% relative risk (RR) 0.61, 95% confidence interval (CI) 0.48–0.79, whereas the reduction in the risk of MI approached, but did not achieve, significance odds ratio (OR) 0.87, 95% CI 0.74–1.02. In a meta-regression analysis, the risk of stroke decreased by 13% (95% CI 5–20, P = 0.002) for each 5-mmHg reduction in SBP, and by 11.5% (95% CI 5–17, P < 0.001) for each 2-mmHg reduction in DBP. In contrast, the risk of MI did not show any association with the extent of BP reduction (SBPP = 0.793; DBPP = 0.832).
CONCLUSIONIn patients with diabetes, protection from stroke increases with the magnitude of BP reduction. We were unable to detect such a relation for MI.
Background
Between February and April 2020, Italy experienced an overwhelming growth of the COVID-19 pandemic. Little is known, at the country level, where and how patients on renal replacement ...therapy (RRT) have been mostly affected.
Methods
Survey of the network of Nephrology centers using a simplified 17 items electronic questionnaire designed by Italian Society of Nephrology COVID-19 Research Group. We used spatial epidemiology and geographical information systems to map SARS-CoV-2 spread among RRT patients in Italy.
Results
On April 9th 2020, all nephrology centers (n = 454) listed in the DialMap database were invited to complete the electronic questionnaire. Within 11 days on average, 365 centers responded (80.4% response rate; 2.3% margin of error) totaling 60,441 RRT patients. The surveyed RRT population included 30,821 hemodialysis (HD), 4139 peritoneal dialysis (PD), and 25,481 transplanted (Tx) patients respectively. The proportion of SARS-CoV-2 positive RRT patients in Italy was 2.26% (95% CI 2.14–2.39) with significant differences according to treatment modality (p < 0.001). The proportion of patients positive for SARS-CoV-2 was significantly higher in HD (3.55% 95% CI 3.34–3.76) than PD (1.38% 95% CI 1.04–1.78 and Tx (0.86% 95% CI 0.75–0.98) (p < 0.001), with substantial heterogeneity across regions and along the latitude gradient (p < 0.001). In RRT patients the highest rate was in the north-west (4.39% 95% CI 4.11–4.68, followed by the north-east (IR 2.06% 1.79–2.36), the center (0.91% 0.75–1.09), the main islands (0.67% 0.47–0.93), and the south (0.59% 0.45–0.75. During the COVID-19 pandemic, among SARS-Cov-2 positive RRT patients the fatality rate was 32.8%, as compared to 13.3% observed in the Italian population as of April 23rd.
Conclusions
A substantial proportion of the 60,441 surveyed RRT patients in Italy were SARS-Cov-2 positive and subsequently died during the exponential phase of COVID-19 pandemic. Infection risk and rates seems to differ substantially across regions, along geographical latitude, and by treatment modality.
There is large evidence that treatment of hypertension significantly reduces the risk of morbidity and mortality in the elderly. Although it is generally accepted that the benefit of antihypertensive ...treatment is largely explained by the reduction in systolic blood pressure, the optimal blood pressure target in elderly patients is still a topic of debate. Unfortunately, the clinical trials which demonstrated the benefit of antihypertensive treatment in old and very old patients with hypertension included relatively fit patients since frail patients were generally excluded. Available data suggest that when treating older adults, and especially frail older hypertensive adults, extra caution is appropriate in the setting of significant adverse events. Nonetheless, recent observations demonstrated a similar benefit from a more intensive compared with a less intensive blood pressure lowering in both fit and frail older adults. Of note, the rate of serious adverse events appears not dissimilar in the two treatment strategies, and not associated to frailty. Taken together, these findings support the concept that an intensive therapeutic strategy appears reasonable even in elderly hypertensive patients, particularly when the treatment is well tolerated.
Backgrounds: The recent coronavirus disease 2019 (COVID-19) pandemic has placed worldwide health systems and hospitals under pressure, and so are the renal care models. This may be a unique ...opportunity to promote and expand alternative models of health-care delivery in patients undergoing renal replacement therapies. Summary: Despite the high risk of acquiring communicable diseases when undergoing in-centre treatments, only a small proportion of patients are currently being treated with home therapies. Recent data provided by the Italian Society of Nephrology (SIN), the REIN French Registry and the Wuhan Hemodialysis Quality Control Center clearly show that patients receiving hospital-based treatment have a 3- to 4-fold greater risk of infection, and a subsequent fatality proportion between 21 and 34%. On the other hand, home-based therapy can be managed remotely, there is little or no need for transport to and from the hospital, and it is less expensive. Besides, the digital revolution in health care with the development of virtual care systems can make home dialysis with telehealth a cost-effective solution for both patients and health-care providers. Such a transition would require specific training for physicians and health-care professionals and a functional re-organization of dialysis centres to improve the skills and expertise in caring for patients at home. Conclusion: The need for more widespread home treatment is the main lesson learnt by nephrologists by the COVID-19 pandemic.
The association between glomerular hyperfiltration and cardiovascular events is not well known. To investigate whether glomerular hyperfiltration is independently associated with risk of adverse ...outcome we analyzed 8794 participants, average age 52 years enrolled in 8 prospective studies. Of these, 89% had hypertension. Using the 5th and 95th percentiles of the age- and sex-specific quintiles of CKD-EPI-calculated estimated glomerular filtration rate (eGFR), we identified three participant groups with low, high and normal eGFR. The ambulatory pulse pressure interval was wider and nighttime blood pressure fall was smaller in both the low and high than in the normal eGFR participants. During a mean follow-up of 6.2 years, there were 722 cardiovascular events. Crude event rates were significantly higher for both high (1.8 per 100-person-year) and low eGFR groups (2.1 per 100 person-year) as compared with group with normal eGFR (1.2 per 100 person-year). In multivariable Cox models including age, sex, average 24-hour blood pressure, smoking, diabetes, and cholesterol, both high eGFR (hazard ratio 1.5 (95% confidence interval 1.2-2.1) and low eGFR (2.0 1.5-2.6) participants had a significantly higher risk of cardiovascular events as compared to those with normal eGFR. Addition of body mass index to the multivariable survival model did not change the magnitude of hazard estimates. Thus, glomerular hyperfiltration is a strong and independent predictor of cardiovascular events in a large multiethnic population of predominantly hypertensive individuals. Our findings support a U-shaped relationship between eGFR and adverse outcome.
How Low Should We Go With Blood Pressure? Verdecchia, Paolo; Angeli, Fabio; Reboldi, Gianpaolo
Circulation research,
2017-January-6, 2017-01-06, 20170106, Letnik:
120, Številka:
1
Journal Article
Abstract
Background
Randomized controlled trials (RCTs) reported contrasting results about reverse left ventricular remodeling (LVR) after sodium-glucose co-transporter-2 inhibitors (SGLT2i) therapy ...in patients with heart failure (HF).
Methods and results
We performed a metanalysis of RCTs of SGLT2i administration in HF outpatients published until June 2022 searching four electronic databases. The protocol has been published in PROSPERO. Primary LVR outcome was change in absolute LV end-diastolic (LVEDV) and end-systolic volume (LVESV) from baseline to study endpoint. Secondary outcomes included changes in LVEDV and LVESV indexed to body surface area, LV Mass index (LVMi), LV ejection fraction (LVEF), and N-terminal pro-B-type natriuretic peptide (NTproBNP). Mean differences (MDs) with 95% CIs were pooled. A total of 9 RCTs (1385 patients) were analyzed. All of them reported data on LVEF. Six trials reported data on LVESV and LVEDV (n = 951); LVMi was available in 640. SGLT2i treatment significantly reduced LVEDV MD= -10.59 ml (-17.27; -3.91), P = 0.0019, LVESV MD= -8.80 ml (-16.91; -0.694), P = 0.0334, and LVMI MD= -5.34 gr/m2 (-9.76; -0.922), P = 0.0178, while LVEF significantly increased MD = + 1.98% (0.67; 0.306), P = 0.0031. By subgroup analysis, the beneficial effects of SGLT2i on LVEF did not differ by imaging method used, time to follow-up re-evaluation, or HF phenotype. Reduction in LV volumes tended to be greater in HF with reduced EF (HFrEF) than in those with preserved EF (HFpEF), while the opposite was observed for LVMi.
Conclusions
Treatment with SGLT2i significantly reversed cardiac volumes, improving LV systolic function and LV mass, particularly in HFrEF patients.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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