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[Prevalence of chronic kidney disease in hypertensive patients under treatment at primary care health centres in Spain and the monitoring of their blood pressure: the DISEHTAE Study]
Abstract
To establish what proportion of hypertensive patients being treated in the primary care health centres of Spain have diminished renal function, and to ascertain their level of blood pressure (BP) control.
Descriptive, cross-sectional study, based on an external audit of clinical charts.
Primary care health centres in 14 autonomous regions.
A total of 6,113 charts of hypertensive patients from 107 primary care health centres were checked. The selection of primary care health centres and charts was randomized.
Creatinine and BP figures of the patients included were analyzed. Chronic kidney disease was defined as a glomerular filtration rate (GFR), as calculated by the equation developed by the Modification of Diet in Renal Disease (MDRD) Study, at under 60 mL/min per 1.73 m(2) of body surface area. A good level of BP control was defined as having figures lower than 130/80 mm Hg.
Of all patients, 25.7% (95% CI, 24.3-27.2) had a diminished GFR. Of these, 19.1% (95% CI, 16.6-21.9) had a good level of control of systolic BP, 49.9% (95% CI, 46.6-53.2) had a good level of control of diastolic BP, and 15.2% (95% CI, 12.9-17.8) had a good level of control of both.
A considerable proportion of hypertensive patients under treatment in the primary care health centres of Spain have a diminished GFR. Only 1 in 6 of these have their BP under control.
... Our study finding was also higher than the finding of another study conducted in Spain with an external audit of clinical charts had chronic kidney disease with diminished estimated glomerular filtration rate 25.7% and a study which assessed traditional risk factors of cardiovascular disease chronic kidney disease was found in 42% of patients 17 . This divergence might be due to the different methodology they used (audit of clinical charts), time, race and geographical location dissimilarity. ...
Hypertension speeds up the process of hardening of the arteries which makes vulnerable to atherosclerosis
formation and damages tiny blood vessels within the kidney. As a result, dyslipidemia becomes one of the most
common risk modificator and quantitative risk categorization among hypertensive patients and hypertensive
kidney disease becomes a major cause of morbidity and mortality. Although evidences present these, there is
scarce data in Africa and as far as to our knowledge there is no data in Ethiopia about lipid and Kidney function
test profiles among hypertensive patients. To determine prevalence of dyslipidemia, chronic kidney disease and
each kidney function test profile abnormality and to identify their associated risk factors among hypertensive
patients at Felegehiwot Referral Hospital from March 26- April 25, 2012. A cross-sectional study was
conducted among all hypertensive patients (123) at Felegehiwot Referral Hospital hypertensive clinic from
March 26- April 25, 2012. After getting consent from each study subject data was collected by trained data
collectors and lab tests were performed by lab personnel to determine prevalence of dyslipidemia, chronic
kidney disease and each kidney function test profile abnormality. Then the collected data was cleared and
entered with statistical software Epi Info version 2002 and analyzed for proportion and association using SPSS
version 16 by the principal investigator. While, there was very high dyslipidemia (78.0%) in at least one of the
criteria and chronic kidney disease (96.7%); stage 1-2 46.3% and reduced Estimated glomerular filtration rate
(Estimated glomerular filtration rate<60ml/min/1.73m2) 50.4% among the study subjects according to adult
treatment panel III and united states of national kidney foundation kidney disease outcome quality initiative by
Cockcroft-Gault glomerular filtration rate equation respectively. Lipid alteration due to hypercholesterolemia,
low high density lipoprotein cholesterol, total cholesterol/high density lipoprotein cholesterol > 5, high low
density lipoprotein cholesterol and hypertriglyceridemia was 39.0%, 26.8%, 18.7%, 45.5%, 35.0% while each
kidney function test profile abnormality was 67.5%, 8.1%, 8.9%, 52.9%,14.6% for serum creatinine, serum urea,serum potassium, serum sodium and protein in urine respectively. There was very high burden of complications
related to hypertension. Therefore, care for other risk factors as age increases and urban inhabitants are needed
to reduce chronic kidney disease with reduced estimated glomerular filtration rate and dyslipidemia
respectively.
... In a study from Spain, out of 6,113 charts of hypertensive patients, 25.7% had a diminished GFR. Of these, only 19.1% had a good level of control of systolic BP, 49.9% had a good level of control of diastolic BP (16) . The National Kidney Foundation recommend a target BP for all CKD patients of <130/80 mmHg and this might require more than one antihypertensive drug to be achieved (17,18) . ...
... 6 Vara-Gonzalez et al studied the prevalence of CKD in hypertensive patients on treatment at the PHC centers in Spain and reported that 25.7% patients had a reduced GFR. 7 Sharma et al reported a prevalence of eGFR less than 60 mL/min of 7.3-14% from a study conducted in China, Mongolia and Nepal, which is comparable to our findings; they also reported a prevalence of proteinuria in 2.4-10% of the subjects. 8 Singh reported a lower prevalence of proteinuria (2.25%) in India than our findings. ...
Objectives: To investigate the prevalence of PER-1, PER-2, GES, IMP-1, VIM-2, OXA-23, and OXA-24 type beta-lactamases in carbapenem-resistant Acinetobacter baumannii isolates, in view of the fact that Beta-lactamase production is the most important mechanism of acquired beta-lactam resistance in Gram-negative pathogens. Design: Experimental study Setting: Department of Medical Microbiology, School of Medicine, Pamukkale University, Denizli, Turkey Subjects: From January 2009 to December 2009, a total of 98 carbapenem-resistant A. baumannii bacteria were isolated from patients. Intervention: In-house PCR was performed for the detection of PER-1, PER-2, GES, IMP-1, VIM-2, OXA-23, and OXA-24 beta-lactamase genes in those clinical carbapenem-resistant A. baumannii isolates. Main Outcome Measure: Prevalence rate of beta-lactamase genes in carbapenem-resistant A. baumannii isolates Results: GES beta-lactamase was found in 59 isolates (60.20%). PER-1 was found in eight isolates (8.16%). IMP-1 was found in five isolates (5.10%). OXA-24 was detected in two isolates (2.04%). No isolate possessed VIM-2, PER-2, or OXA-23 beta-lactamase genes. Conclusion: This study indicates that the GES type beta-lactamases are the most prevalent among carbapenem-resistant A. baumannii isolates in our hospital. Screening for beta-lactamases and strict infection control for these isolates will help prevent further spread of resistance.
Objectives: To estimate the prevalence of self-medication with over-the-counter pain relievers (OTCPR, like acetaminophen, ibuprofen, and aspirin) among Kuwaiti citizens above the age of 16 years and describe their patterns of use, perceived awareness of, and concerns about the drugs' potential side effects Design: A descriptive cross-sectional questionnaire-based survey. Setting: Selected population from the six Kuwaiti governorates. Subjects: The data were collected over a four-month period in 2012, from 850 subjects identified as Kuwaiti citizens. These subjects were recruited using stratified random sampling. Results: Overall, a 67% response rate was obtained. In total, 68% (573) of the respondents reported use of OTCPR. Women, middle-aged or singles, and those with higher education used these drugs more than other subgroups (p < 0.05). We found evidence of inappropriate use of these drugs, with 15% (88) of consumers using them almost daily. Not only were 81% of the consumers unaware of the potential side effects, but also more than 61% were not concerned about them. Women were more knowledgeable than men regarding the maximum dose (p = 0.036, OR = 1.49, CI = 1.03-2.17). Consumers with higher levels of education did not show distinct knowledge regarding the maximum allowed dose of the drugs (p = 0.252, OR = 1.71, CI = 0.68-4.25). Conclusion: The results showed a high prevalence of self-medication with OTCPR among Kuwaiti citizens. The subjects showed unawareness and unconcern regarding potential complications. This demonstrates the need for educational interventions.
Objectives: Transmission of hepatitis B virus (HBV), hepatitis C virus (HCV) and human immune deficiency virus (HIV) does take place in dialysis units worldwide at different rates. The aim of this study was to identify the prevalence rates of HBV, HCV and HIV in the dialysis unit, Mubarak Al-Kabeer Hospital (MAKH), Kuwait. Design: Retrospective study. Settings: Dialysis Unit and Virology Unit, MAKH, Kuwait. Subjects: In 2012, a total of 1369 samples from adult patients on dialysis at MAKH were screened. Intervention: HBV, HCV and HIV were screened for HBV surface antigen (HBsAg) (ARCHITECT HBsAg Qualitative II 2011, Abbott), HCV antibodies (Anti-HCV) (ARCHITECT Reagent Kit 2011, Abbott) and HIV antigen and antibody (HIV Ag/Ab) (ARCHITECT HIV Ag/Ab Combo Reagent Kit 2011, Abbott), respectively. Main Outcome Measures: Prevalence rates of HBV, HCV and HIV in the dialysis unit, MAKH, Kuwait. Results: HBV, HCV and HIV prevalence among dialyzed patients in the MAKH dialysis unit was 1.2%, 6.3% and 0.1% respectively. Conclusion: This study, to our knowledge, is the only study providing recent data on blood borne viruses (BBVs) among patients in a dialysis unit in Kuwait. A multicenter study is recommended to determine the national prevalence of BBVs in all the dialysis unit of Kuwait.
Hypertension is a public health problem of first magnitude, because of its high prevalence and the associated increase in cardiovascular and renal complications. For this reason, achieving adequate pressure control in a high percentage of patients is a priority for any health system. In our country there have been numerous studies examining the degree of control of hypertension. The percentage of patients achieving adequate control has increased progressively, but the margin of improvement is still very important. Among the factors that have contributed to this improved control is the use of antihypertensive drugs in combination, free or fixed. This article reviews the progress made in controlling hypertension, in which the combined use of antihypertensive drugs has played a key role and future therapeutic options to further improve the pressure control, with special attention to the fixed combination three antihypertensive drugs.
To audit the documentation of medical care provided to hypertensive patients and to evaluate the management of hypertension in a primary healthcare center, Family Medicine Staff Clinic, Sultan Qaboos University (SQU) in Oman.
An audit of electronic medical records (EMR) was carried out during 2007and 2008 on a representative sample of 150 patients, selected randomly using a simple randomization method. The mean age of the patients was 54.8 +/- 9.9 years. The majority were Omanis; 53.3% were female, 46.7% were male. All patients' records were reviewed for proper recording in a pre designed structured form. Re-auditing was done in 2008. McNemar's test was used to compare data in 2007 with data in 2008.
Age, gender, blood pressure recording, renal function tests, and lipid levels were sufficiently recorded (>75%) in the computer system. Histories of pertinent symptoms and smoking history were poorly recorded (<1%). Fifty-five percent of the hypertensive patients were sufficiently controlled (BP<140/90). There were significant differences between 2007 and 2008 with respect to documentation and recording of pertinent symptoms (p<0.001) and renal function tests (p=0.026).
Conducting an audit of EMR is essential to evaluate clinical performance and to determine what changes should be made to improve quality of care. There was significant improvement in documentation of pertinent symptoms in the second audit.
Hypertension is a leading global risk factor for the burden of cardiovascular disease. Data about changes in hypertension control are important to set intervention priorities. We conducted a systematic review and meta-analysis of epidemiological studies to determine the control of hypertension in Spain over the past decade.
A search of PubMed/MEDLINE, SCOPUS and IME was performed for epidemiological studies conducted in Spain (since 2000) with data on control rates for hypertension. The primary outcome was the prevalence of uncontrolled hypertension defined as the percentage of patients having SBP at least 140 mmHg and/or DBP at least 90 mmHg. For populations at risk (e.g. patients with diabetes), the definition was SBP at least 130 mmHg and/or DBP at least 80-85 mmHg.
Seventy-six studies evaluating 341 632 patients (79% with hypertension) met the inclusion criteria. Among hypertensive patients, the overall pooled prevalence of uncontrolled hypertension (≥140/90 mmHg) was 67.0% [95% confidence interval (CI) 64.1-69.9%], but was 87.6% (95% CI 86.2-89.0%) when the most restricted definition (≥130/80-85 mmHg) was used for patients at risk. The test for heterogeneity was significant (P < 0.001). Using metaregression analyses, we showed that the prevalence of uncontrolled hypertension did not change significantly over time, but the percentage of patients receiving at least two antihypertensive drugs increased (P = 0.032 and 0.001).
In Spain, the control of hypertension is far from optimum and does not appear to have improved in recent years despite the increased intensity of therapy. Patients at risk with comorbidities appear to be controlled worse.
Italy Developing Education and awareness on MicroAlbuminuria in patients with hyperteNsive Disease is an observational, cross-sectional, multicenter study aimed at determining prevalence and correlates of chronic kidney disease (CKD) among Italian hypertensive patients attending out-patient referral clinics. CKD was defined as glomerular filtration rate (GFR) less than 60 ml/min per 1.73 m (Modification of Diet in Renal Disease equation) or urine albumin to creatinine ratio of at least 2.5 mg/mmol in men and of at least 3.5 mg/mmol in women or both.
Among 3534 study patients (mean age 61 years, 54% male patients, 37% diabetic patients), the prevalence of microalbuminuria, reduced GFR, and CKD was 27, 26, and 42%, respectively. Only 11% of patients had concomitant microalbuminuria and reduced GFR. Sex, smoking, systolic blood pressure, glucose, and GFR were the independent predictors of albumin to creatinine ratio, whereas sex, age, history of cardiovascular diseases, uric acid, abdominal obesity, and albumin to creatinine ratio were more closely related to GFR. The presence of CKD was associated with older age, smoking, higher systolic and pulse pressure levels, impaired fasting glucose, hyperuricemia, and previous cardiovascular disease. Furthermore, CKD was not only associated with a greater use of renin-angiotensin system-inhibiting, lipid-lowering and antiplatelet drugs but also with inadequate blood pressure control.
Renal abnormalities are found in a significant number of hypertensive patients. CKD occurs more often in older patients and in those with associated metabolic risk factors or clinical conditions. These results suggest the need to improve awareness of the role of renal damage as a component of global risk and to develop appropriate therapeutic strategies to reduce morbidity and mortality in this specific subgroup of patients.
The National High Blood Pressure Education Program presents the complete Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Like its predecessors, the purpose is to provide an evidence-based approach to the prevention and management of hypertension. The key messages of this report are these: in those older than age 50, systolic blood pressure (BP) of greater than 140 mm Hg is a more important cardiovascular disease (CVD) risk factor than diastolic BP; beginning at 115/75 mm Hg, CVD risk doubles for each increment of 20/10 mm Hg; those who are normotensive at 55 years of age will have a 90% lifetime risk of developing hypertension; prehypertensive individuals (systolic BP 120-139 mm Hg or diastolic BP 80-89 mm Hg) require health-promoting lifestyle modifications to prevent the progressive rise in blood pressure and CVD; for uncomplicated hypertension, thiazide diuretic should be used in drug treatment for most, either alone or combined with drugs from other classes; this report delineates specific high-risk conditions that are compelling indications for the use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers); two or more antihypertensive medications will be required to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg) for patients with diabetes and chronic kidney disease; for patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using two agents, one of which usually will be a thiazide diuretic, should be considered; regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan. Positive experiences, trust in the clinician, and empathy improve patient motivation and satisfaction. This report serves as a guide, and the committee continues to recognize that the responsible physician's judgment remains paramount.
Chronic kidney disease is common in older patients with hypertension.
To compare rates of coronary heart disease (CHD) and end-stage renal disease (ESRD) events; to determine whether glomerular filtration rate (GFR) independently predicts risk for CHD; and to report the efficacy of first-step treatment with a calcium-channel blocker (amlodipine) or an angiotensin-converting enzyme inhibitor (lisinopril), each compared with a diuretic (chlorthalidone), in modifying cardiovascular disease (CVD) outcomes in high-risk patients with hypertension stratified by GFR.
Post hoc subgroup analysis.
Multicenter randomized, double-blind, controlled trial.
Persons with hypertension who were 55 years of age or older with 1 or more risk factors for CHD and who were stratified into 3 baseline GFR groups: normal or increased (> or = 90 mL/min per 1.73 m2; n = 8126 patients), mild reduction (60 to 89 mL/min per 1.73 m2; n = 18,109 patients), and moderate or severe reduction (< 60 mL/min per 1.73 m2; n = 5662 patients).
Random assignment to chlorthalidone, amlodipine, or lisinopril.
Rates of ESRD, CHD, stroke, and combined CVD (CHD, coronary revascularization, angina, stroke, heart failure, and peripheral arterial disease).
In participants with a moderate to severe reduction in GFR, 6-year rates were higher for CHD than for ESRD (15.4% vs. 6.0%, respectively). A baseline GFR of less than 53 mL/min per 1.73 m2 (compared with >104 mL/min per 1.73 m2) was independently associated with a 32% higher risk for CHD. Amlodipine was similar to chlorthalidone in reducing CHD (16.0% vs. 15.2%, respectively; hazard ratio, 1.06 [95% CI, 0.89 to 1.27]), stroke, and combined CVD (CHD, coronary revascularization, angina, stroke, heart failure, and peripheral arterial disease), but less effective in preventing heart failure. Lisinopril was similar to chlorthalidone in preventing CHD (15.1% vs. 15.2%, respectively; hazard ratio, 1.00 [CI, 0.84 to 1.20]), but was less effective in reducing stroke, combined CVD events, and heart failure.
Proteinuria data were not available, and combination therapies were not tested.
Older high-risk patients with hypertension and reduced GFR are more likely to develop CHD than to develop ESRD. A low GFR independently predicts increased risk for CHD. Neither amlodipine nor lisinopril is superior to chlorthalidone in preventing CHD, stroke, or combined CVD, and chlorthalidone is superior to both for preventing heart failure, independent of level of renal function.
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Background
The prevalence and incidence of end-stage renal disease in the United States are increasing, but milder renal disease is much more common and may often go undiagnosed and undertreated.
Methods
A cross-sectional study of a representative sample of the US population was conducted using 16 589 adult participants aged 17 years and older in the Third National Health and Nutrition Examination Survey (NHANES III) conducted from 1988 to 1994. An elevated serum creatinine level was defined as 141 µmol/L or higher (≥1.6 mg/dL) for men and 124 µmol/L or higher (≥1.4 mg/dL) for women (>99th percentile for healthy young adults) and was the main outcome measure.
Results
Higher systolic and diastolic blood pressures, presence of hypertension, antihypertensive medication use, older age, and diabetes mellitus were all associated with higher serum creatinine levels. An estimated 3.0% (5.6 million) of the civilian, noninstitutionalized US population had elevated serum creatinine levels, 70% of whom were hypertensive. Among hypertensive individuals with an elevated serum creatinine level, 75% received treatment. However, only 11% of all individuals with hypertension had their blood pressure reduced to lower than 130/85 mm Hg (the Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure recommendation for hypertensive individuals with renal disease); 27% had a blood pressure lower than 140/90 mm Hg. Treated hypertensive individuals with an elevated creatinine level had a mean blood pressure of 147/77 mm Hg, 48% of whom were prescribed one antihypertensive medication.
Conclusion
Elevated serum creatinine level, an indicator of chronic renal disease, is common and strongly related to inadequate treatment of high blood pressure.
Objective
To establish what proportion of hypertensive patients being treated in the primary care health centres of Spain have diminished renal function, and to ascertain their level of blood pressure (BP) control.
Design
Descriptive, cross-sectional study, based on an external audit of clinical charts.
Setting
Primary care health centres in 14 autonomous regions.
Participants
A total of 6113 charts of hypertensive patients from 107 primary care health centres were checked. The selection of primary care health centres and charts was randomized.
Main measurements
Creatinine and BP figures of the patients included were analyzed. Chronic kidney disease was defined as a glomerular filtration rate (GFR), as calculated by the equation developed by the Modification of Diet in Renal Disease (MDRD) Study, at under 60 mL/min per 1.73 m2 of body surface area. A good level of BP control was defined as having figures lower than 130/80 mm Hg.
Results
Of all patients, 25.7% (95% CI, 24.3-27.2) had a diminished GFR. Of these, 19.1% (95% CI, 16.6-21.9) had a good level of control of systolic BP, 49.9% (95% CI, 46.6-53.2) had a good level of control of diastolic BP, and 15.2% (95% CI, 12.9-17.8) had a good level of control of both.
Conclusions
A considerable proportion of hypertensive patients under treatment in the primary care health centres of Spain have a diminished GFR. Only 1 in 6 of these have their BP under control.
The prevalence and incidence of end-stage renal disease in the United States are increasing, but milder renal disease is much more common and may often go undiagnosed and undertreated.
A cross-sectional study of a representative sample of the US population was conducted using 16 589 adult participants aged 17 years and older in the Third National Health and Nutrition Examination Survey (NHANES III) conducted from 1988 to 1994. An elevated serum creatinine level was defined as 141 micromol/L or higher (>/=1.6 mg/dL) for men and 124 micromol/L or higher (>/=1.4 mg/dL) for women (>99th percentile for healthy young adults) and was the main outcome measure.
Higher systolic and diastolic blood pressures, presence of hypertension, antihypertensive medication use, older age, and diabetes mellitus were all associated with higher serum creatinine levels. An estimated 3.0% (5.6 million) of the civilian, noninstitutionalized US population had elevated serum creatinine levels, 70% of whom were hypertensive. Among hypertensive individuals with an elevated serum creatinine level, 75% received treatment. However, only 11% of all individuals with hypertension had their blood pressure reduced to lower than 130/85 mm Hg (the Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure recommendation for hypertensive individuals with renal disease); 27% had a blood pressure lower than 140/90 mm Hg. Treated hypertensive individuals with an elevated creatinine level had a mean blood pressure of 147/77 mm Hg, 48% of whom were prescribed one antihypertensive medication.
Elevated serum creatinine level, an indicator of chronic renal disease, is common and strongly related to inadequate treatment of high blood pressure.
Timely referral to nephrologists depends on identification of renal failure. Most primary care physicians and specialists rely on serum creatinine as the standard test for determination of renal function. Creatinine clearance requires 24 hours urine collection with many pitfalls and wrong results. We compare serum creatinine and the Cockcroft-Gault (C-G) equation as measure of glomerular filtration rate (GFR). The study included 1,053 outpatients with serum creatinine lower than 2.5 mg/dl referred to our nephrological laboratory for serum creatinine and GFR determination using the C-G formula. Patients were grouped into two groups: normal renal function (serum creatinine < 1.3 mg/dl) and "incipient" abnormal renal function (serum creatinine 1.3-2.5 mg/dl). In the group of females with normal creatinine 22% (60-70 y), 35% (70-80 y) and 57% (> 80 y) had GFR values below 50 ml/min. In the group of males 11.3% (70-80 y) and 33.3% (> 80 y) also had GFR reduction in spite of normal serum creatinine. A severe renal insufficiency with creatinine clearance lower than 30 ml/min was observed in the group with "incipient" renal failure based on serum creatinine: 22.7%, 40% and 82.9% for females and 6%, 22.7% and 57% for male (60-70 y; 70-80 y; and > 80 y respectively). In order to improve management and prevention of renal failure appropriate measurements of renal function other than serum creatinine should be emphasize.
The present study assessed the prevalence, awareness, treatment and control of hypertension among the elderly population of Spain.
Based on a nationally representative sample of 4009 individuals aged 60 years, two sets of six blood pressure measurements were obtained by trained observers at each subject's home, using standardized methods. In each set, three mercury-based measurements were alternated with three automated measurements.
The mean systolic blood pressure (SBP)/diastolic blood pressure (DBP) was 143/79 mmHg, and the pulse pressure was 64 mmHg. The prevalence rate of hypertension (SBP 140 mmHg, DBP 90 mmHg, or current drug treatment) was 68.3%. No result obtained was sensitive to a particular measurement device. Of the hypertensives, 65% were aware of their condition, 55.3% were treated and 16.3% were controlled. Among treated hypertensives, SBP control (32.2%) was much lower than DBP control (82.3%). Control was lower in men than in women, in older than in younger subjects, and in those with lowest than in those with higher educational levels. About 57% of uncontrolled treated hypertensives were on monotherapy. Weight loss was among the least heeded items of advice (39% among overweight hypertensives).
Hypertension is a major public health problem in elderly Spaniards. Most hypertensives had their hypertension uncontrolled. Greater emphasis should be laid on the most disadvantaged (the older, men, and those with lowest education) in terms of hypertension management, and on reinforcing weight loss and combining drugs for enhanced hypertension control.
Chronic kidney disease is a worldwide public health problem with an increasing incidence and prevalence, poor outcomes, and high cost. Outcomes of chronic kidney disease include not only kidney failure but also complications of decreased kidney function and cardiovascular disease. Current evidence suggests that some of these adverse outcomes can be prevented or delayed by early detection and treatment. Unfortunately, chronic kidney disease is underdiagnosed and undertreated, in part as a result of lack of agreement on a definition and classification of its stages of progression. Recent clinical practice guidelines by the National Kidney Foundation 1) define chronic kidney disease and classify its stages, regardless of underlying cause, 2) evaluate laboratory measurements for the clinical assessment of kidney disease, 3) associate the level of kidney function with complications of chronic kidney disease, and 4) stratify the risk for loss of kidney function and development of cardiovascular disease. The guidelines were developed by using an approach based on the procedure outlined by the Agency for Healthcare Research and Quality. This paper presents the definition and five-stage classification system of chronic kidney disease and summarizes the major recommendations on early detection in adults. Recommendations include identifying persons at increased risk (those with diabetes, those with hypertension, those with a family history of chronic kidney disease, those older than 60 years of age, or those with U.S. racial or ethnic minority status), detecting kidney damage by measuring the albumin-creatinine ratio in untimed ("spot") urine specimens, and estimating the glomerular filtration rate from serum creatinine measurements by using prediction equations. Because of the high prevalence of early stages of chronic kidney disease in the general population (approximately 11% of adults), this information is particularly important for general internists and specialists.
End-stage renal disease substantially increases the risks of death, cardiovascular disease, and use of specialized health care, but the effects of less severe kidney dysfunction on these outcomes are less well defined.
We estimated the longitudinal glomerular filtration rate (GFR) among 1,120,295 adults within a large, integrated system of health care delivery in whom serum creatinine had been measured between 1996 and 2000 and who had not undergone dialysis or kidney transplantation. We examined the multivariable association between the estimated GFR and the risks of death, cardiovascular events, and hospitalization.
The median follow-up was 2.84 years, the mean age was 52 years, and 55 percent of the group were women. After adjustment, the risk of death increased as the GFR decreased below 60 ml per minute per 1.73 m2 of body-surface area: the adjusted hazard ratio for death was 1.2 with an estimated GFR of 45 to 59 ml per minute per 1.73 m2 (95 percent confidence interval, 1.1 to 1.2), 1.8 with an estimated GFR of 30 to 44 ml per minute per 1.73 m2 (95 percent confidence interval, 1.7 to 1.9), 3.2 with an estimated GFR of 15 to 29 ml per minute per 1.73 m2 (95 percent confidence interval, 3.1 to 3.4), and 5.9 with an estimated GFR of less than 15 ml per minute per 1.73 m2 (95 percent confidence interval, 5.4 to 6.5). The adjusted hazard ratio for cardiovascular events also increased inversely with the estimated GFR: 1.4 (95 percent confidence interval, 1.4 to 1.5), 2.0 (95 percent confidence interval, 1.9 to 2.1), 2.8 (95 percent confidence interval, 2.6 to 2.9), and 3.4 (95 percent confidence interval, 3.1 to 3.8), respectively. The adjusted risk of hospitalization with a reduced estimated GFR followed a similar pattern.
An independent, graded association was observed between a reduced estimated GFR and the risk of death, cardiovascular events, and hospitalization in a large, community-based population. These findings highlight the clinical and public health importance of chronic renal insufficiency.
Although improved control of hypertension is known to attenuate progression of chronic kidney disease (CKD), little is known about the adequacy of hypertension treatment in adults with CKD in the United States. Using data from the Fourth National Health and Nutrition Survey, we assessed adherence to national hypertension guideline targets for patients with CKD (blood pressure <130/80 mm Hg), we assessed control of systolic (<130 mm Hg) and diastolic (<80 mm Hg) blood pressure, and we evaluated determinants of adequate blood pressure control. Presence of CKD was defined as glomerular filtration rate <60 mL/min per 1.73 m2 or presence of albuminuria (albumin:creatinine ratio >30 microg/mg). Multivariable logistic regression with appropriate weights was used to determine predictors of inadequate hypertension control and related outcomes. Among 3213 participants with CKD, 37% had blood pressure <130/80 mm Hg (95% confidence interval [CI], 34.5% to 41.8%). Of those with inadequate blood pressure control, 59% (95% CI, 54% to 64%) had systolic >130 mm Hg, with diastolic < or =80 mm Hg, whereas only 7% (95% CI, 3.9 to 9.8%) had a diastolic pressure >80 mm Hg, with systolic blood pressure < or =130 mm Hg. Non-Hispanic black race (odds ratio [OR], 2.4; 95% CI, 1.5 to 3.9), age >75 years (OR, 4.7; 95% CI, 2.7 to 8.2), and albuminuria (OR, 2.4; 95% CI, 1.4 to 4.1) were independently associated with inadequate blood pressure control. We conclude that control of hypertension is poor in participants with CKD and that lack of control is primarily attributable to systolic hypertension. Future guidelines and antihypertensive therapies for patients with CKD should target isolated systolic hypertension.
Despite therapeutic advances, strict control of hypertension remains elusive in patients with chronic renal insufficiency (CRI). The present study was designed for assessment of control rates of blood pressure in patients with CRI. Secondary objectives included evaluation of the control rates of proteinuria and cardiovascular comorbidities.
A multicenter and cross-sectional survey of unselected patients with CRI attending outpatient nephrology clinics in Spain between April and September 2003 was performed.
Fifty-two centers recruited 2501 patients with a mean age 64.8 years (65.7% men). The prevalence of previous cardiovascular disease was 55%. The two most prevalent renal diseases were vascular (38.9%) and diabetic nephropathy (20.1%). Blood pressure below 130/80 mmHg was observed in 435 patients (17.4%). A poor blood pressure control was associated with older age, greater proteinuria and higher low-density lipoprotein cholesterol levels. Proteinuria less than 0.5 g/day was observed in 1209 cases (48.3%). A total of 1899 patients (75.9%) were receiving drugs suppressing the activity of the renin-angiotensin system and 1048 patients (41.9%) were being treated with three or more antihypertensive drugs. Lipid-lowering agents and antiplatelet therapy were used in 49.3 and 38.1% of patients, respectively.
The control rate of blood pressure in patients with CRI is inadequate despite frequent use of combination therapy that most commonly included an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Greater emphasis should be made to increase the number and dose of antihypertensive drugs and the need for using a statin as well as antiplatelet therapy in order to improve renal and cardiovascular outcomes.
Epidemiological data on the incidence and prevalence of cardiovascular disease in chronic renal failure are scant The objective of the present study is to assess the relationship between renal function, measured by the estimated glomerular filtration rate, and the presence of early or established cardiovascular disease, in a population of hypertensives from primary care.
Cross-sectional, multicentre study carried out in primary care centres all over Spain. Hypertensive subjects, older than 55 years, were included. In all of them a structured interview including cardiovascular risk factors or disease was performed. Blood pressure was measured following a standard procedure, and serum biochemistry and an electrocardiogram were obtained. Renal function was estimated using the abbreviated MDRD (Modification of Diet in Renal Disease Study Group) equation. For each glomerular filtration rate stratum the odds ratio and 95% confidence interval (CI) of left ventricular hypertrophy or cardiovascular disease were calculated, adjusted by confounding variables.
A total of 13 687 patients (mean age 68.1 years, women 55.4%, diabetics 30.6%, body mass index 28.6 kg/m2) were included. Of these, 26.4% had established cardiovascular diseases and 20.3% electrocardiographic left ventricular hypertrophy. The average serum creatinine was 1.01 mg/dl, creatinine clearance 70.0 ml/min, and glomerular filtration rate 74.0 ml/min per 1.73 m2. Thirty-three patients (0.24%) had glomerular filtration rate < 5 ml/min per 1.73 m2; 89 (0.65%) from 15 to 29; 3745 (27.36%) from 30 to 59; 7798 (56.97%) from 60 to 89; and 2019 (14.75%) higher than 89 ml/min per 1.73 m2. In a multiple regression analysis, after adjusting by age, sex, body mass index, diabetes, systolic and diastolic blood pressure, and smoking, a lower glomerular filtration rate was associated with a higher prevalence of left ventricular hypertrophy. Likewise, a reduction in the glomerular filtration rate was also associated with a higher prevalence of cardiovascular disease.
In hypertensive patients from primary care, the prevalence of cardiovascular disease is inversely proportional to the level of renal function. Estimated glomerular filtration is easy to determine and complements evaluation of the hypertensive patient.
In the past few years there has been a growing amount of information about renal dysfunction and cardiovascular risk. The objectives of this study were to assess the prevalence of renal dysfunction and evaluate the relation between renal function and cardiovascular risk in patients with essential hypertension.
A multicenter, cross-sectional survey of unselected patients with essential hypertension attending primary care settings in Spain was performed between june and november 2004. Renal function was evaluated with the abbreviated equation of the Modification of Diet in Renal Disease study. Renal insufficiency was defined as an estimated glomerular filtration rate <60 ml/min/1.73 m2.
Eighty-eight investigators from 50 centers recruited 2130 patients being mean age 65.6 +/- 11 years and female 53%. Prevalence of diabetes, lipid abnormalities, and previous cardiovascular disease were 30.3%, 45.9%, and 42.1% respectively. Prevalence of renal insufficiency was 32.4% (95% CI 30.4-34.4). Patients suffering from renal insufficiency showed a higher prevalence of cardiovascular disease when comparing with those with an estimated glomerular filtration rate = or >60 ml/min/1.73 m2 (56.2% vs. 35.3%, OR 2.35, 95% CI 1.95-2.82, p < 0.001). A logistic regression analysis showed that the relation of renal dysfunction with cardiovascular disease was independent of other variables or classical cardiovascular risk factors as age, female sex, diabetes, smoking, hypercholesterolemia, and systolic blood pressure.
Renal insufficiency was present in 32.4% of patients with essential hypertension attending primary care settings. Cases with renal dysfunction showed a higher cardiovascular risk. Hypertensive patients with renal insufficiency should be considered as candidates for an aggressive approach of cardiovascular risk management.
Few cohort studies have examined the longitudinal association between change in blood pressure and decline in kidney function among treated hypertensive patients without chronic kidney disease. We conducted a nonconcurrent cohort study to examine the effects of blood pressure on estimated glomerular filtration rate and early kidney function decline (rise in serum creatinine > or =0.6 mg/dL during follow-up) among 504 African-American and 218 white hypertensive patients. Our results showed that each standard deviation higher treated systolic (18 mm Hg) and diastolic (10 mm Hg) blood pressure was associated with an average annual decline (95% confidence interval [CI]) in estimated glomerular filtration rate of -0.92 ([-1.49 to -0.36] P=0.001) and -0.83 ([-1.38 to -0.28] P=0.003) mL x min(-1) x 1.73 m(-2), respectively, after adjustment for race, age, education, income, use of antihypertensive drugs, body mass index, and history of diabetes and dyslipidemia. Likewise, each standard deviation higher systolic and diastolic blood pressure was associated with relative risks (95% CIs) of 1.81 ([1.29 to 2.55] P<0.001) and 1.55 ([1.08 to 2.22] P=0.046), respectively, for early kidney function decline. Compared with patients with a blood pressure level <140/90 mm Hg, those with a blood pressure level > or =160/95 mm Hg had a -2.67 ([-4.01 to -1.32] P<0.001) mL x min(-1) x 1.73 m(-2) greater annual decline in estimated glomerular filtration rate and a 5.21-fold ([2.06 to 13.21] P<0.001) greater risk of early kidney function decline. Our study found that higher levels of treated blood pressure were positively and significantly related to early decline in kidney function among hypertensive men. These results indicate that better blood pressure control might prevent the onset of chronic kidney disease among hypertensives.
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