Morning blood pressure at home predicts erythropoietin-induced hypertension in patients with chronic renal diseases

Background Correction of anemia by erythropoietin (EPO) is often associated with a rise in blood pressure (BP; EPO-induced hypertension). Most studies regarding EPO-induced hypertension have involved evaluation using office/clinic BP (OBP). However, recent investigations suggest that BP measured at home (HBP) may be of more importance for clinical practice in hypertension. In this context, the present study addressed whether or not HBP measured in the morning could be useful to predict EPO-induced hypertension. Methods The study involved patients with mild to moderate renal impairment who had renal anemia requiring EPO treatment. BP control was evaluated based on the relationship between OBP and HBP in the morning. The BP categories used were well-controlled BP, poorly controlled BP, hypertension with a white-coat effect (white-coat hypertension), and masked hypertension. Comparison was made of the BP categories before and after EPO treatment. Results Before EPO treatment, 38% of patients had well-controlled BP, 30% had poorly controlled BP, 20% had masked hypertension, and 12% had white-coat hypertension, revealing a predominance of morning hypertension (poorly controlled BP plus masked hypertension). Following EPO treatment, the prevalence of morning hypertension in patients with masked hypertension and poorly controlled BP increased significantly, by 5% (HBP in those with masked hypertension increased from 152 +/− 18 mmHg to 162 +/− 25 mmHg, and HBP in those with poorly controlled BP increased from 157 +/− 18 mmHg to 168 +/− 25 mmHg; P < 0.05 by paired t-test). And there was a significant decrease in the prevalence of the well-controlled category, by 8%, with an increased level of morning HBP (from 128 +/− 14 mmHg to 137 +/− 16 mmHg; P < 0.05 by paired t-test). In contrast, OBP remained unchanged in all groups. The development of EPO-induced hypertension was effectively predicted by HBP in the morning (from 62% to 72% before and after EPO treatment; P = 0.0031 by Wilcoxon's analysis), but not by OBP (from 42% to 47% before and after treatment; P = 0.1399). Conclusions The present study indicates that, despite receiving concurrent antihypertensive therapy, the majority of patients with renal disease had morning hypertension. Furthermore, HBP in the morning can be more useful than OBP to predict the development of EPO-induced hypertension in patients with renal anemia.     

Long-Term Prognosis in Malignant or Accelerated Hypertension

In 51 consecutive patients with malignant hypertension collectedfrom 1976 to 1981 we have analysed patient and kidney survivalat 5 years and at last follow-up. The patients were 41 men,10 women, mean age 53 years, with a stage III (63%) or stageIV (27%) fundi and a diastolic blood pressure (BP) > 130mmHg. The hypertension was primary in 26, renovascular in 17and secondary to bilateral nephropathy in eight. At 5-yearsfollow-up, the patient and kidney survival rates were respectively72.5% and 47%. At last follow-up, 18 patients had died (35%)and 18 additional patients require dialysis (renal death=70%).The principal causes of death related to terminal renal failureand/or dialysis. Initial involvement of heart (27%) and brain(35%) led to a few more deaths. Blood pressure control reducedconsequences for the heart and brain but not for the kidney.Patients at higher risk are those with serum creatinine greaterthan 200 µmol/l on admission.     

Twenty-four-hour ambulatory blood pressure monitoring in young children

 Twenty-four-hour ambulatory blood pressure monitoring (ABPM) has many advantages for the diagnosis and follow-up of hypertension at all ages. This technique has so far not been documented as applicable to the very young. We studied the feasibility of ABPM in 61 healthy children and in 40 patients with renal diseases and/or hypertension, aged less than 6 years. A satisfactory ABPM profile (recording time = 24 h and >30 good recordings) was obtained in 77% of the healthy children. The mean number of good blood pressure (BP) measurements per 24 h increased with age from 46 (3–4 years) to 58 (6 years). The mean (±SD) systolic and diastolic BPs of healthy 3- to 6-year-old children (n = 47) were 110±5/67±5 mmHg during the day-time and 100±5/58±5 mmHg at night. In addition to the nocturnal decrease in BP, ABPM detected a second, day-time dip in BP during bed rest after lunch. Ninety percent of patients with renal disease and/or hypertension had successful ABPM recordings for 24 h, with an age-dependent increase in the mean number of reliable readings from 34 (< 2 years) to 48 (4 years). In 5 of 10 children with hypertensive results obtained by casual BP measurements, elevated BP was not confirmed by ABPM. We conclude that ABPM is a useful tool for the diagnosis and evaluation of hypertension in children under 6 years of age. Received March 5, 1996; received in revised form and accepted May 6, 1997     

Reno-vascular hypertension in childhood: a nationwide survey

Renovascular disease accounts for 8–10% of all cases of paediatric hypertension, whereas, in adults, its incidence is approximately 1%. The Turkish Paediatric Hypertension Group aimed to create the first registry database for childhood renovascular hypertension in Turkey. Twenty of the 28 paediatric nephrology centres in Turkey responded to the survey and reported 45 patients (27 girls, 18 boys) with renovascular hypertension between 1990 and 2005. The age at presentation ranged from 20 days to 17 years. The mean blood pressure at the diagnosis was 169/110 mmHg. Chief complaints of symptomatic patients were headache (38%), seizure (18%), epistaxis (4%), growth retardation (4%), cognitive dysfunction (4%), polyuria (2%), palpitation (2%), and hemiplegia (2%). Renovascular hypertension was found incidentally in 11 children. The diagnosis of renovascular hypertension was established with conventional angiography in 39 patients, MR angiography in three, CT angiography in two, and captopril diethylene triamine penta-acetic acid (DTPA) scintigraphy in one patient. Twenty-one children had bilateral renal artery stenosis and 24 had unilateral renal artery stenosis. Of these, 14 (31%) had fibromuscular dysplasia; 12 (27%) Takayasu’s arteritis; six (13%) neurofibromatosis; two (5%) Williams syndrome; one (2%) Kawasaki disease; one (2%) mid-aortic syndrome; one (2%) extrinsic compression to the renal artery, and eight (18%) unspecified bilateral renal artery stenosis. Hypertension was controlled with antihypertensive drugs in 17 patients. Percutaneous transluminal angioplasty (PTRA) or surgery had to be performed in 28 patients: PTRA in 16 patients, PTRA + surgery in one patient and surgery in 11 patients (four nephrectomies). The importance of vasculitic disease, especially Takayasu’s arteritis, should not be underestimated in children with renovascular hypertension.     

Masked hypertension in children and young adults

Masked hypertension, a high ambulatory blood pressure (ABP) in the presence of normal office blood pressure (BP), is recognized as a risk factor for cardiovascular complications in the adult population. We evaluated the prevalence of masked hypertension in pediatric patients. We studied 136 patients (59 boys and 77 girls, aged 6–25 years, mean 13.1±4.7 years). In all patients, office BP measurements with auscultatory technique were less than the 95th percentile for sex and age or <140/90 mmHg for those over 18 years. Masked hypertension was diagnosed when either systolic or diastolic daytime ABP values were equal to or greater than the 95th percentile for sex and height of reference values or 135 mmHg systolic or 85 mmHg diastolic BP for those over 15 years. Among 136 patients, 15 (11%) had masked hypertension. The prevalence of masked hypertension was higher in boys (19%) than in girls (5%), but not different between younger (15 years) and older (>15 years) patients (11% vs. 12%). The diagnoses in the group with masked hypertension included 3 patients with diabetic nephropathy, 2 with obesity, and 2 with orthostatic dysregulation. In conclusion, masked hypertension is present in pediatric patients, and is more common in boys. Further study is needed to identify patients who may benefit from recognition of masked hypertension.     

Outcomes of laparoscopic adrenalectomy for hyperaldosteronism

BACKGROUND: Primary hyperaldosteronism is a frequent cause of resistant hypertension and is amenable to surgical intervention when caused by a unilateral aldosterone-producing adenoma. The aim of this study was to investigate the long-term results of laparoscopic adrenalectomy in the control of hypertension caused by primary hyperaldosteronism. METHODS: A prospective case series of patients undergoing laparoscopic adrenalectomy for hyperaldosteronism was studied. Blood pressure (BP), serum aldosterone levels, plasma renin activity, serum potassium and antihypertensive requirement were measured before and after adrenalectomy. RESULTS: Sixty-two patients with hyperaldosteronism underwent laparoscopic adrenalectomy in the period from December 1995 to August 2005. The median follow up was 59 months. There was a significant decrease in both systolic blood pressure and diastolic blood pressure at final follow up compared with that before operation. Systolic blood pressure decreased from 149 mmHg to 129 mmHg at final follow up (P < 0.0001). Diastolic blood pressure decreased from 89 mmHg to 80 mmHg (P < 0.0001). Antihypertensive requirement was decreased from an average of 2.6 separate medications preoperatively to 1.4 medications at final follow up (P < 0.0001). Serum aldosterone levels were significantly lower (698 (confidence interval 534-862) pg/mL vs 181 (confidence interval 139-225) pg/mL, P < 0.0001). Overall, 34% of patients had cure of hypertension and did not require any antihypertensive agent. A further 51% had improvement in BP control, whereas 5% had no change or had worsening hypertension. Multivariate regression analysis showed that age and gland size were independent factors predicting sustained hypertension after surgery. CONCLUSION: In appropriately selected patients with primary hyperaldosteronism, laparoscopic adrenalectomy is effective in improving long-term BP control. Larger adrenal gland size and older age at time of surgery are predictors of persisting hypertension.     

One‐ and five‐year follow‐ups on blood pressure and renal function in kidney donors

It is considered safe to donate a kidney if internationally accepted medical criteria are fulfilled. However, some donors have encountered hypertension, proteinuria and impaired renal function after donation. The study was based on retrospective data on 908 donors, donating in the period 1997–2007. Preoperative and follow‐up data were collected from patient files and the Norwegian Living Donor Registry. Follow‐up data were available for 665 donors at 1 year after donation, and 256 donors at 5 years after donation. We calculated the estimated glomerular filtration rate (eGFR) using the four variable Modification of Diet in Renal Disease equation. At 1 and 5 years after donation, the prevalence of hypertension was 11.7% and 27.1% respectively compared to 2.6% before donation. Proteinuria was present in 3.3% and 1.6% at 1 and 5 years. Mean eGFR was 56.1 ± 10.8 ml/min/1.73 m² at 1 year and 61.0 ± 11.8 ml/min/1.73 m² at 5 years. Mean blood pressure was 122.5 ± 10.6/76.2 ± 7.5 mmHg at donation (n = 908), 124.3 ± 14.2/77.9 ± 8.2 mmHg at 1‐year (n = 649) and 127.2 ± 15.4/78.8 ± 8.3 mmHg at 5‐year follow‐ups (n = 247). We found no evidence of further decline in renal function beyond the initial decrement following nephrectomy.     

Rare normalization of blood pressure after unilateral adrenalectomy in 31 patients with Conn syndrome

Background Adrenal tumor excision in patients with Conn syndrome is not always followed by normalization of blood pressure (BP). The aim of the study was to determine predictors of persistent hypertension during long-term observation after adrenalectomy. Materials and methods Thirty-one patients (23 F and 8 M) with Conn syndrome and adrenal tumor subjected to unilateral adrenalectomy were included. The duration of hypertension ranged from 1 to 30 years and observation time from 1 to 10 years. Results Beneficial impact of adrenalectomy on BP control was found in 25 patients, including only 10 patients with BP normalization. Patients with normalization of BP were significantly younger [41 (36–46) vs 53 (48–57) years; p = 0.002] and had lower pulse BP [72 (56–89) vs 93(80–106) mmHg; p = 0.03]. Significant decline of maximal values of systolic and diastolic BP after surgery was observed [59 (47–72) and 29 (20–37) mmHg, respectively]. The analysis revealed that age over 50 years and pulse BP over 70 mmHg predict the persistence of hypertension after surgery. Conclusion Normalization of BP after adrenalectomy is observed only in 32% of patients with Conn syndrome regardless the normalization of hypokalemia. BP normalization in long period observation was more frequently found in younger patients with lower pulse BP. This study was presented at the 2nd Biennial Congress of the European Society of Endocrine Surgeons, Krakow, Poland, 18–20 May 2006.     

Yield of renal arteriography in the evaluation of pediatric hypertension

The prevalence of renovascular disease is estimated to be 3%–5% in pediatric patients with hypertension. The utility of non-invasive imaging tests has not been evaluated in children, and renal arteriography remains the diagnostic test of choice. However, there are no established guidelines for the application of this test and information is not available about the likelihood of detecting an abnormality if an arteriogram is performed in children with hypertension. Therefore, we reviewed the yield of renal arteriography in pediatric patients if the test was performed based on the following two criteria: (1) severe hypertension exceeding the 99th percentile for age and sex or (2) failure to control high blood pressure with one antihypertensive drug. During the period 1983–1998, 28 children (mean age 11.7 years) who satisfied one of the above criteria underwent renal arteriography to investigate hypertension. None of the patients were renal transplant recipients. The average duration of hypertension was 11 months and the peak blood pressure was 168/107 mmHg. The renal arteriogram was abnormal in 12 patients (43%). Unilateral renal artery stenosis was the most-common abnormality. When the patients were divided into two groups – those with an abnormal or normal test result – they did not differ in age, sex, or racial distribution. The peak systolic blood pressure was higher in children with an abnormal renal arteriogram (P<0.05). Among those undergoing the arteriogram on the basis of the first criterion, i.e., severe hypertension, 11 of 23 (48%) studies were abnormal. Five children had an arteriogram based on the second criterion – failure to control the blood pressure with one medication – and in 1 patient (20%) the test was abnormal. We conclude that the prevalence of renovascular disease in a population of hypertensive children subjected to renal arteriography is around 40%. Two clinical criteria – namely severe hypertension or failure to control hypertension effectively with one drug – are useful to guide the application of renal arteriography in children with hypertension. Received: 12 August 1999 / Revised: 24 November 1999 / Accepted: 28 November 1999     

The effects of an ACE inhibitor and a calcium antagonist on the progression of renal disease: the Nephros Study.

BACKGROUND: The renoprotective effect of ACE inhibition in chronic renal disease is well established but the studies on effects of calcium antagonists on progression of renal disease and on proteinuria have given varying results. METHODS: We conducted an open long-term randomized prospective multi-centre study comparing the combination of ramipril and felodipine ER (F) with either drug alone in non-diabetic renal disease. Included were patients with uncontrolled hypertension (diastolic blood pressure (DBP)) > or =95 mmHg on treatment with a diuretic and a beta-blocker. Fifty-one patients received the combination of R and F, 54 patients R, and 53 patients F. The treatment goal was a DBP <90 mmHg and a similar BP reduction in the three groups. Mean doses at the last visit were 5+5, 10 and 9 mg, respectively, after a mean treatment time of nearly 2 years. The progression of renal impairment was studied by serial measurements of serum creatinine, iohexol clearance, and albuminuria. RESULTS: The reduction in supine systolic (S) BP and DBP expressed as median values were -19.0/-14.5,-14.3/-15.0 and -13.5/-13.3 mmHg in the R+F, R, and F groups, respectively. There was no significant difference between the groups. When correction for the acute drug effect was performed the R+F group had a slower progression rate of the renal disease (loss of glomerular filtration rate (GFR) ml/min/year) compared with the F group (P<0.05) but not to the R group (P>0.20). There was a rise in albuminuria after 2 years in the F group (P<0.05), but no significant change was found in the other groups. CONCLUSIONS: In patients with non-diabetic renal disease the combination of an ACE inhibitor and a calcium antagonist in reduced doses used in addition to baseline therapy with beta-blockers and diuretics, tended to cause a better BP reduction as each drug per se. The R+F treatment also caused a slower progression of the renal disease compared with F alone. The combination treatment seems to afford better BP control and appears to be a favourable therapeutic option in patients with renal disease and hypertension.     

Prevalence and clinical correlates of white coat hypertension in chronic kidney disease.

BACKGROUND: The role of white coat hypertension (WCH) in the poor control of blood pressure (BP) in chronic kidney disease (CKD) is ill defined. METHODS: We measured systolic clinical (CBP) and ambulatory blood pressure (ABP) in 290 consecutive patients with non-dialysis CKD [glomerular filtration rate (GFR) <60 ml/min/1.73 m(2)]. We defined normotension (NOR) if CBP and daytime ABP <130 mmHg, sustained hypertension (SH) when both BP >or=130 mmHg, WCH if only daytime ABP <130 mmHg, and masked hypertension (MH) when only CBP <130 mmHg. RESULTS: NOR patients were 15.5%, WCH 31.7%, SH 46.9% and MH 5.9%. Due to the high prevalence of WCH, achievement of BP target (<130 mmHg) was more than doubled by daytime ABP than CBP (47.2 vs 21.4%). WCH was characterized by prevalence of diabetes (31.5%), left ventricular hypertrophy (LVH; 50.0%) and CBP values (146 +/- 12 mmHg) lower than in SH (41.9%, 71.3% and 158 +/- 18 mmHg) but greater than in NOR (17.8%, 37.8% and 118 +/- 7 mmHg). Among patients with CBP >or=130 mmHg, the independent risk of having SH rather than WCH increased in the presence of higher CBP [Odds ration (OR) 1.61, 95% confidence intervals (CI) 1.29-2.02], LVH (OR 1.94, 95% CI 1.03-3.63) and proteinuria (OR 3.12, 95% CI 1.31-7.43). In the WCH group, 24 h, daytime and nighttime ABP were 118 +/- 7/68 +/- 8, 120 +/- 7/71 +/- 8 and 112 +/- 12/63 +/- 9 mmHg, respectively. CONCLUSIONS: In CKD, WCH is highly prevalent and can be predicted in the absence of higher CBP, LVH and proteinuria. In these patients, pursuing a low BP target may not be safe because of the risk of cardio-renal hypoperfusion especially at nighttime.     

Pulmonary Hypertension among Patients on Dialysis and Kidney Transplant Recipients

Pulmonary arterial hypertension (PAH) is a serious cardiac complication among patients with end-stage renal disease (ESRD). We investigated pulmonary hypertension and its associated factors among patients who were on chronic dialysis and kidney transplant recipients. One hundred-eighty patients in three groups of hemodialysis (HD), peritoneal dialysis (PD), and kidney transplant were studied. Demographic and clinical characteristics and echocardiographic findings were evaluated. A multivariable linear regression model was used to find factors associated with pulmonary artery pressure. The mean age of participants was 50.3 ± 15.5 years and 63.9% were male. We found pulmonary hypertension (mean pulmonary artery pressure >25 mmHg) in 31.6%, 8.3%, and 5% of the patients on HD, PD, and transplant recipients, respectively (p < 0.001). In multivariate analyses, being on HD (B = 5.276, confidence interval [CI] 95%: 1.211–9.341), age (B = –0.319, CI 95%: –0.501 to –0.138), smoking (B = 11.631, CI 95%: 1.847–21.416), systolic cardiac dysfunction (B = 6.313, CI 95%: 3.073–9.554), and diastolic cardiac dysfunction (B = 5.227, CI 95%: 1.176–9.277) were associated with systolic pulmonary artery pressure. These results showed that pulmonary hypertension is a frequent cardiac complication among patients with ESRD, and the type of renal replacement therapy (HD), systolic and diastolic cardiac dysfunction, and smoking are associated with increased pulmonary artery pressure. Further studies with larger sample sizes and also prospective studies are recommended in this regard.     

Renal and haemodynamic effects of amlodipine and nifedipine in hypertensive renal transplant recipients

Background. Immunosuppressive treatment with cyclosporin A (CsA) improves the survival of renal allografts, but is associated with renal vasoconstriction and hypertension. Previous reports suggest that the calcium-channel blockers nifedipine and amlodipine may improve graft function in CsA-treated patients. We have compared the effects of amlodipine (5-10 mg once daily) and nifedipine retard (10-40 mg twice daily) on renal function and blood pressure in renal transplant recipients treated with CsA. Methods. This was a multicentre, two-way, crossover study in 27 evaluable hypertensive patients with renal insufficiency following renal transplantation, who were maintained on a stable dose of CsA. Patients received either amlodipine (5-10 mg once daily) or nifedipine retard (10-40 mg twice daily) for 8 weeks, and were then crossed over to the other treatment for a further 8 weeks. Results. Trends were seen during amlodipine treatment towards larger improvements, in serum creatinine (by 8% of baseline on amlodipine vs 4% on nifedipine), lithium clearance (13% vs 2%), and glomerular filtration rate 11% vs 7%). Effective renal plasma flow was increased by 11% of baseline on nifedipine vs 9% on amlodipine. There were no significant differences between treatments. Amlodipine and nifedipine lowered systolic blood pressure to a similar extent (21 mmHg vs 15 mmHg respectively, P=0.25), but amlodipine was more effective than nifedipine in lowering diastolic blood pressure (13 mmHg vs 8 mmHg, P=0.006). Both treatments were well tolerated. Conclusion. Once-daily amlodipine is at least effective as twice-daily nifedipine retard in controlling blood pressure and does not adversely affect graft function in hypertensive renal allograft recipients.     

An investigation of the effect of advancing uraemia, renal replacement therapy and renal transplantation on blood pressure diurnal variability

Background: Ambulatory blood pressure recordings have been shown to correlate better with target organ damage than have isolated clinic blood pressure readings. There have been some small studies demonstrating that abnormal blood pressure diurnal rhythm is common in uraemia and in patients on renal replacement therapy. Abnormal blood pressure diurnal rhythm itself may be at risk factor for accelerated target organ damage. Methods: We retrospectively studied 480 ambulatory blood pressure recordings in 380 patients with essential hypertension, secondary hypertension, and on renal replacement therapy. We examined diurnal blood pressure rhythm in each group. Results: Abnormal blood pressure diurnal rhythm (non-dipping) is significantly more prevalent in patients with underlying renal disease, even with normal excretory renal function (53%) than in age-, sex-, and race-matched controls with essential hypertension ((30%), P <0.01). In patients with renal disease the prevalence of non-dipping rose with worsening renal function, reaching statistical significance once plasma creatinine was greater than 400 &mgr;mol/l. There was a direct correlation between plasma creatinine and percent decline in blood pressure at night for both systolic (r=0.23) and diastolic (r=0.24) blood pressure in patients with underlying renal disease and impaired excretory renal function. High prevalences of abnormal diurnal BP rhythm are seen in patients on haemodialysis (82%), peritoneal dialysis (78%), patients with plasma creatinine >600 &mgr;mol/l (75%), and in renal transplant recipients (74%). Conclusion: Abnormal blood pressure diurnal rhythm ('non-dipping') is significantly more common in secondary than in primary hypertension, even with normal renal function. Abnormal blood pressure diurnal rhythm becomes increasingly common with advancing uraemia. Once the plasma creatinine is greater than 600 &mgr;mol/l the prevalence of non-dipping is the same as that seen with renal replacement therapy. This phenomenon is not modulated by successful renal transplantation.     

Masked Uncontrolled Hypertension in CKD

Masked uncontrolled hypertension (MUCH) is diagnosed in patients treated for hypertension who are normotensive in the clinic but hypertensive outside. In this study of 333 veterans with CKD, we prospectively evaluated the prevalence of MUCH as determined by ambulatory BP monitoring using three definitions of hypertension (daytime hypertension ≥135/85 mmHg; either nighttime hypertension ≥120/70 mmHg or daytime hypertension; and 24-hour hypertension ≥130/80 mmHg) or by home BP monitoring (hypertension ≥135/85 mmHg). The prevalence of MUCH was 26.7% by daytime ambulatory BP, 32.8% by 24-hour ambulatory BP, 56.1% by daytime or night-time ambulatory BP, and 50.8% by home BP. To assess the reproducibility of the diagnosis, we repeated these measurements after 4 weeks. Agreement in MUCH diagnosis by ambulatory BP was 75–78% (κ coefficient for agreement, 0.44–0.51), depending on the definition used. In contrast, home BP showed an agreement of only 63% and a κ coefficient of 0.25. Prevalence of MUCH increased with increasing clinic systolic BP: 2% in the 90–110 mmHg group, 17% in the 110–119 mmHg group, 34% in the 120–129 mmHg group, and 66% in the 130–139 mmHg group. Clinic BP was a good determinant of MUCH (receiver operating characteristic area under the curve 0.82; 95% confidence interval 0.76–0.87). In diagnosing MUCH, home BP was not different from clinic BP. In conclusion, among people with CKD, MUCH is common and reproducible, and should be suspected when clinic BP is in the prehypertensive range. Confirmation of MUCH diagnosis should rely on ambulatory BP monitoring.     

Renal and aortic localizations in Takayasu's disease

AIM OF THE STUDY: The aim of this work was to study the localizations of Takayasu's disease to the aorta and the renal arteries, the long-term results of their surgical treatment and the evolution of the disease with time. PATIENTS AND METHODS: From 1972 to 2000, 23 patients (16 females, 7 males) with aortic and/or renal lesions were operated on. Mean age was 19.5 +/- 12.4 years. Despite heavy medical treatment, all had severe and uncontrollable hypertension. Eighteen patients had associated lesions of the aorta and renal arteries, 5 had isolated lesions of the renal artery, 10 had lesions of mesenteric arteries, 6 had lesions of supra-aortic trunks. Percutaneous transluminal angioplasty of the renal artery (ies) was attempted in 4 cases and was unsuccessful in all. Due to bilateral lesions in 12 patients, the surgical treatment consisted of 3 nephrectomies and 32 artery repairs of which 23 were performed by conventional in situ surgery and 9 by extracorporeal repair. An aortic bypass was performed in 7 patients and revascularization of other visceral arteries in 3. The follow-up extends from 1 to 18 years (mean: 5). RESULTS: There was no mortality. Three postoperative thromboses of repairs occurred: 2 of renal artery and 1 of mesenteric artery. Immediate results on blood pressure control were as follows: complete cure in 18 patients (78%), improvement in 3 (13%) and failure in 2 (9%). During the follow-up, evolution of the disease was observed in 10 patients (43%): 4 repeat stenoses of renal arteries due to aggravation of aortic lesions requiring reoperation in 2 patients, 3 aggravation of aortic lesions requiring an aortic bypass in 1 patient, 1 coronary insufficiency requiring a coronary bypass at 8.5 years. During the long-term follow up, due to secondary anatomical deteriorations, the results of surgery on blood pressure control were as follow: complete cure in 14 patients (61%), improvement in 4 (17%), failure in 5 (22%). CONCLUSION: Surgical treatment of reno-aortic lesions in Takayasu's disease must be reserved to patients whose arterial hypertension is uncontrollable despite heavy medical treatment. Results are altered by the evolution of the disease either locally or in other territories and that may require several operations. Due to frequently occurring late degeneration of repairs, surgical therapy must be carefully decided and patients' follow-up must be prolonged.     

The role of dietary cations in the blood pressure of renal transplant recipients

BACKGROUND: The role of dietary cations in hypertension has been evaluated in the general population and selected subgroups, but its contribution to blood pressure (BP) elevations in patients with functional renal allografts has not been critically examined. METHODS: After counseling based on Dietary Approaches to Stop Hypertension (DASH) guidelines, we measured timed 24-h urine excretion rates of sodium, potassium, calcium, and magnesium as a surrogate for their dietary intake, in 244 stable adult single-organ renal transplant recipients, correlating these with averaged blinded clinic-measured BP values. Multiple linear regression analysis adjusting for factors affecting BP in transplant recipients was performed. RESULTS: There was no correlation between systolic (SBP) or diastolic pressure (DBP) and 24-h urine excretion rates of each cation. There was no BP difference between patients receiving cyclosporine and tacrolimus (127/77 vs. 129/78 mmHg, p = 0.38), or in cation excretion except for calcium (2.85 +/- 2.0 vs. 2.90 +/- 2.8, p = 0.002). Protein excretion (p < 0.0001), age (p = 0.002), and weight (p = 0.04) were positively associated with SBP, while only weight (p = 0.01) was associated with DBP by multivariate analysis. CONCLUSION: Dietary cation intake is not significantly associated with BP in renal transplant recipients. These data do not support recommendations to alter dietary cation intake as part of the management of post-transplantation hypertension.     

Endovascular revascularization of renal artery stenosis in the solitary functioning kidney

The treatment of renal artery stenosis by angioplasty and stenting is an effective and accepted alternative to surgery for the treatment of renovascular hypertension and preservation of renal function. We report the technical and clinical outcomes of renal artery stenting in patients with a solitary functioning kidney and renal artery stenosis. From October 1993 to November 1999, 30 stents were placed in the renal arteries of 27 patients (mean age 72 ± 8 years) with a solitary functioning kidney and azotemia. The mean diameter renal artery stenosis was 86 ± 14%. The mean preprocedure serum creatinine (Cr) level was 3.0 ± 1.5 mg/dL (range 1.5–7.5 mg/dL), arterial blood pressure was 171 ± 29/85 ± 13 mmHg, and the number of antihypertensive drugs was 2.9 ± 1.1. Indications for stenting were suboptimal balloon dilation (n = 16), intimai dissection (n = 6), and restenosis following angioplasty (n = 5). Atherosclerotic ostial lesions were present in 25 (93%) of 27 renal arteries. This represents the largest series of renal artery stenting in patients with a solitary functioning kidney, and demonstrates this treatment modality to be a relatively safe alternative to conventional surgery in this high-risk patient group. Most (74%) of the patients in this series had improved or stabilized renal function. Further efforts to define preprocedural indicators of success are necessary to identify the patients who may benefit from revascularization of their solitary kidney. Presented at the Twenty-fifth Annual Meeting of the Peripheral Vascular Surgery Society, Toronto, Ontario, Canada, June 10, 2000.     

Effectiveness of a multidisciplinary kidney disease clinic in achieving treatment guideline targets.

BACKGROUND: We have demonstrated previously that at referral most chronic kidney disease (CKD) patients have suboptimal metabolic and hypertension control. Although several studies suggest that CKD clinics improve patient outcome, in fact there are minimal published data describing the actual effect of such clinics on these parameters. METHODS: We performed a historical prospective review of a cohort of 340 CKD patients referred to our multidsciplinary clinic in 1998 or 1999, with estimated creatinine clearance (CCr) <60 ml/min. Data regarding blood pressure (BP) control, metabolic/anaemia parameters, medications, access planning and dialysis starts were collected. RESULTS: The number of patients followed was 234, 144, 100 and 70 at years 1-4 of follow-up, respectively. Twenty-five percent of the patients were diabetic, and 25% were suspected to have ischaemic nephropathy; mean age was 67+/-15 years. Although phosphate control improved from referral, below a CCr of 30 ml/min, 27% of visits showed hyperphosphataemia. Thirty-one percent of patients with CCr <15 ml/min had haemoglobin <100 g/l at follow-up despite the availability of erythropoietin. BP improved from a mean of 151/80 mmHg at referral to 137/75 mmHg in subsequent visits. At follow-up visits, 62% of BPs were still >130 mmHg systolic or 85 mmHg diastolic. For proteinuric patients (>1 g/day), 75% of follow-up visits showed BP >125/75 mmHg, despite angiotensin-converting enzyme inhibitor use increasing from 35% at referral to 79% at follow-up. Twenty-four percent of patients started renal replacement therapy, initially haemodialysis (HD) in 57%, peritoneal dialysis (PD) in 35% and pre-emptive transplant in 8%. Thirty-eight percent of dialysis starts occurred within 6 months of referral, but PD was the modality in half of these. Only half of the HD patients started using an aterio-venous fistula, and of those using a central catheter 11 of 24 had been followed >6 months, but only four of them had attempted fistula creation. CONCLUSIONS: CKD clinic attendance was associated with improvements in metabolic and BP control, and was able to facilitate the use of PD even for late referrals. However, even the multidisciplinary model with nephrologists, nurse educators and dietitians was unable to achieve guideline-recommended metabolic, anaemia, BP and access targets for a significant number of patients.     

Relationship of ambulatory blood pressure monitoring data to echocardiographic findings in haemodialysis patients

BACKGROUND: The present study was performed to assess the value of ambulatoryblood pressure monitoring (ABPM) in determining the adequacyof blood pressure (BP) control, and its relationship to echocardiographicfindings in haemodialysis (HD) patients. METHODS: We studied 40 non-diabetic adult patients who had been on regularHD treatment for a median duration of 43 months. Twenty-four-hourABPM was performed using a non-invasive ABP monitor (Pressurescan,ERKA). Casual BP (cBP) was defined as the average of two measurementsobtained at two HD sessions, one preceding and one followingthe ABP recordings, and was calculated for both the predialysisand postdialysis phases. Two-dimensional and M-mode echocardiographywere performed in each patient to determine interventricularseptal thickness (IVS), left ventricular posterior wall thickness(LVPW), left ventricular fractional shortening (FS), and leftventricular mass index (LVMI) RESULTS: According to average 24-h BP levels, 50% of the patients hadsystolic hypertension (HT) (>139 mmHg), and 72.5% had diastolicHT (>87 mmHg), while only 25% had been diagnosed as HT bycBP measurements (P>0.01 and P>0.0001 respectively). Diurnalvariation in BP was not present in about 80% of the patients.Echocardiography was normal in only four patients (10%). LVMIand LV wall thickness were correlated to ABPM data better thanto cBP measurements. Using stepwise linear regression analysis,LVMI and FVS were positively correlated with systolic BP load(P> 0.0001 and P=0.0001 respectively), and LVPW was positivelycorrelated with night-time systolic BP level (P>0.001). CONCLUSIONS: ABPM is necessary to assess the adequacy of BP control, andis well correlated to end-organ damage of HT in HD patients.