Publications (125) View all
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Article: Long-term visit-to-visit office blood pressure variability increases the risk of adverse cardiovascular outcomes in patients with chronic kidney disease.
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ABSTRACT: Long-term visit-to-visit blood pressure (BP) variability predicts a high risk for cardiovascular events in patients with essential hypertension. Whether long-term visit-to-visit BP variability holds the same predictive power in predialysis patients with chronic kidney disease (CKD) is unknown. Here we tested the relationship between long-term visit-to-visit office BP variability and a composite end point (death and incident cardiovascular events) in a cohort of 1618 patients with stage 2-5 CKD. Visit-to-visit systolic BP variability was significantly and independently related to baseline office, maximal, and average systolic BPs, age, glucose, estimated glomerular filtration rate, and albumin, and to the number of visits during the follow-up. Both the standard deviation of systolic BP (hazard ratio: 1.11, 95% confidence interval: 1.01-1.20) and the coefficient of variation of systolic BP (hazard ratio: 1.15, 95% confidence interval: 1.02-1.29) were significant predictors of the combined end point independent of peak and average systolic BP, cardiovascular comorbidities, Framingham risk factors, and CKD-related risk factors. Antihypertensive treatment (β-blockers and sympatholytic drugs) significantly abrogated the excess risk associated with high systolic BP variability. Thus, large visit-to-visit systolic BP variability in patients with CKD predicts a higher risk of death and nonfatal cardiovascular events independent of underlying BP levels.Kidney International advance online publication, 24 April 2013; doi:10.1038/ki.2013.132.Kidney International 04/2013; · 6.61 Impact Factor -
Article: Prevalence and Prognostic Role of Resistant Hypertension in Chronic Kidney Disease Patients.
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ABSTRACT: OBJECTIVES: To evaluate in CKD prevalence and prognosis of true resistant hypertension (RH), that is, confirmed by ambulatory blood pressure (ABP) monitoring. BACKGROUND: In CKD, uncontrolled hypertension is a major risk factor but no study has properly investigated the role of RH. METHODS: We prospectively studied 436 hypertensive CKD patients under nephrology care. Four groups were constituted by combining 24h-ABP with diagnosis of RH (office BP ≥130/80 mmHg despite adherence to ≥3 full-dose antihypertensive drugs including a diuretic or ≥4 drugs): control (ABP<125/75 without RH), pseudoresistance (ABP<125/75 with RH), sustained hypertension (ABP≥125/75 without RH), true resistance (ABP≥125/75 with RH). Endpoints of survival analysis were renal (end-stage renal disease or death), and cardiovascular events (fatal and non-fatal cardiovascular event). RESULTS: Age was 65±14 years, males 58%, diabetes 36%, cardiovascular disease 30%, median proteinuria 0.24 (interquartile range 0.09-0.83) g/day, eGFR 43±20 mL/min/1.73m(2), office BP 146±19/82±12 mmHg, 24h-ABP 129±17/72±10 mmHg. True resistant patients were 22.9% and pseudoresistant 7.1%, while patients with sustained hypertension were 42.9% and controls 27.1%. Over 57 months of follow up, 109 cardiovascular events and 165 renal events occurred. Compared to controls, cardiovascular risk [Hazard Ratio, (95% Confidence Interval)] was 1.24 (0.55-2.78) in pseudoresistance, 1.11 (0.67-1.84) in sustained hypertension and 1.98 (1.14-3.43) in true resistance. Corresponding hazards for renal events were 1.18 (0.45-3.13), 2.14 (1.35-3.40) and 2.66 (1.62-4.37). CONCLUSIONS: In CKD, pseudoresistance is not associated with an increased cardio-renal risk and sustained hypertension predicts only renal outcome. True resistance is prevalent and identifies patients carrying the highest cardiovascular risk.Journal of the American College of Cardiology 04/2013; · 14.16 Impact Factor -
Article: Letter to the Editor: Comment on the article "Estimating the influence of physicians on the underuse of drugs in diabetic nephropathy in Taiwan" by Huang et al, and author's reply.
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ABSTRACT: Available as pdf only.Journal of nephrology 03/2013; 26(2):417-418. · 1.65 Impact Factor -
Article: Antiproteinuric effect of add-on paricalcitol in CKD patients under maximal tolerated inhibition of renin-angiotensin system: a prospective observational study.
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ABSTRACT: BACKGROUND: Whether paricalcitol (PCT) reduces proteinuria in the presence of intensified inhibition of Renin-Angiotensin-System (RAS) is poorly studied. We evaluated the antiproteinuric effect of PCT in non-dialysis chronic kidney disease (CKD) patients with proteinuria greater than 0.5 g/24 h persisting despite anti-RAS therapy titrated to minimize proteinuria in the absence of adverse effects. METHODS: Forty-eight CKD patients were studied in the first six months of add-on oral PCT (1 mcg/day) and three months after drug withdrawal. RESULTS: Males were 87.5%, age 63 +/- 14 yrs, systolic/diastolic blood pressure (BP) 143 +/- 22/78 +/- 11 mmHg, eGFR 29.7 +/- 14.5 mL/min/1.73 m2, diabetes 40%, and cardiovascular disease 38%. At referral in the center (28 months prior to study baseline), proteinuria was 2.44 (95% CI 1.80-3.04) g/24 h with 6 patients not receiving any anti-RAS and 42 treated with a single agent, at low dosage in most cases. At study baseline, twenty patients were under 2-3 anti- RAS drugs while twenty-eight received 1 agent at full dose and proteinuria resulted to be reduced versus referral to 1.23 g/24 h (95%CI 1.00-1.51). Six months of add-on PCT significantly decreased proteinuria to 0.61 g/24 h (95%CI 0.40-0.93), with levels less than 0.5 g/24 h achieved in 37.5% patients, in the absence of changes of BP and GFR. Proteinuria recovered to basal value after drug withdrawal. The extent of antiproteinuric response to PCT was positively associated with diabetes, eGFR and daily Na excretion (R2 = 0.459, P <0.0001). PTH decreased from 201 (IQR 92-273) to 83 (IQR 50-189) pg/mL. CONCLUSIONS: In CKD patients, add-on PCT induces a significant reduction of proteinuria that is evident despite intensified anti-RAS therapy and larger in the presence of diabetes, higher GFR and unrestricted salt intake.BMC Nephrology 11/2012; 13(1):150. · 2.18 Impact Factor -
Article: The effect of increasing age on the prognosis of non-dialysis patients with chronic kidney disease receiving stable nephrology care.
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ABSTRACT: To define whether age modifies the prognosis of patients with chronic kidney disease (CKD) on nephrology care, we prospectively followed patients with CKD who have been receiving nephrology care in a clinic for 1 year or more. The incidence of end-stage renal disease (ESRD), defined by the occurrence of dialysis or transplant, or death without ESRD was estimated by a competing-risk approach, and interactions between age and risk factors tested in Cox models over a median follow-up period of 62.4 months. Of 1248 patients with stage III–V CKD, 481 were younger than 65, 410 were between 65 and 75, and 357 were over 75 years old. Within each age class, the mean estimated glomerular filtration rate(eGFR) was 31, 32, and 29 ml/min per 1.73 m2, respectively. There were 394 ESRD events and 353 deaths. The risk of ESRD was higher than the risk of death without ESRD for ages <60 years, and independent of eGFR. The ESRD risk diminished with aging but still prevailed for eGFRs of 25–35 in patients between 65 and 75 years and with an eGFR below 15 in those up to 85 years old. Proteinuria significantly increased the risk of ESRD with advancing age. Surprisingly, the unfavorable effects of cardiovascular disease on ESRD and of diabetes on survival significantly decreased with increasing age. Male gender, higher phosphate, lower body mass index, and hemoglobin were age-independent predictors for ESRD, while cardiovascular disease, lower hemoglobin, higher proteinuria and uric acid, and ESRD also predicted death. Thus, in older patients on nephrology care, the risk of ESRD prevailed overmortality even when eGFR was not severely impaired. Proteinuria increases ESRD risk, while the predictive role of other modifiable risk factors was unchanged compared with younger patients.Kidney International 05/2012; 82(4):482-8. · 6.61 Impact Factor
