Conclusions. Increased RI is associated with early signs of TOD in EH and could be a marker of intrarenal Background. Increased renal resistance detected by ultrasound ( US) Doppler has been reported in severe atherosclerosis. essential hypertension ( EH ) and recently was shown to correlate with the degree of renal impairment in Key words: atherosclerosis; essential hypertension; michypertensive patients with chronic renal failure. roalbuminuria; renal vascular resistance; target organ However, the pathophysiological significance of this damage finding is still controversial. Methods. In a group of 211 untreated patients with EH, we evaluated renal resistive index (RI ) by US Doppler of interlobar arteries and early signs of target Introduction organ damage ( TOD). Albuminuria was measured as the albumin to creatinine ratio (ACR) in three non- Ultrasound ( US) Doppler of renal vasculature is a consecutive first morning urine samples. Left ventricu- reliable, non-invasive evaluation technique whose clinlar mass was evaluated by M-B mode echocardiogra- ical application has increased steadily in recent years. phy, and carotid wall thickness (IMT ) by high In fact its usefulness varies from the diagnosis of renal resolution US scan. artery stenosis and renovascular disease [1,2] to the Results. RI was positively correlated with age (r= assessment of intrarenal haemodynamics in several 0.25, P=0.003) and systolic blood pressure (SBP) (r= diVerent pathological conditions such as essential 0.2, P=0.02) and with signs of early TOD, namely hypertension [3], acute [4] and chronic renal failure ACR (r=0.22, P=0.01) and IMT (r=0.17, P<0.05), [5,6 ], and graft rejection [7‐9]. and inversely correlated with renal volume (r=’0.22, Several parameters can be calculated during the P=0.01) and diastolic blood pressure (r=’0.23, P= cardiac cycle on the basis of the shape of Doppler 0.006). Multiple linear regression analysis demon- waves at various sites of the renal vasculature both strated that age, gender, ACR and SBP independently extra- and intra-parenchymally. These parameters are influence RI and together account for ~20% of its independent of the angle and the position of the variations (F=8.153, P<0.0001). When clinical data exploring probe, allowing for accurate and reproduwere analysed according to the degree of RI, the cible measurements of downstream vascular impedpatients in the top quartile were found to be older ance. In particular, increased resistive (RI ) and (P<0.05) and with higher SBP (P<0.05) as well as pulsatility (PI ) indexes measured at the level of the early signs of TOD, namely increased ACR (P<0.002) interlobar arteries recently have been associated with and IMT (P<0.005 by ANOVA), despite similar body the severity and duration of essential hypertension [10] mass index, uric acid, fasting blood glucose, lipid and with worse renal function in renal parenchymal profile and duration of hypertension. Furthermore, disease [5], although the pathophysiological significpatients with higher RI showed a significantly higher ance of these findings deserves further investigation. prevalence of microalbuminuria (13 vs 12 vs 3 vs 33% The present study was initiated to investigate the x2=11.72, P=0.008) and left ventricular hypertrophy relationship between US Doppler RI of the intrarenal (40 vs 43 vs 32 vs 60%, x2=9.25, P<0.05). vasculature and early target organ damage such as left ventricular hypertrophy (LVH ), microalbuminuria and

/pdf/increased-renal-resistive-index-in-patients-with-essential-52zwx3k1jl.pdf

Increased renal resistive index in patients with essential hypertension: a marker of target organ damage.

Microalbuminuria is defined as abnormal urinary excretion of albumin between 30 and 300 mg/d. It can be measured accurately by several widely available and sensitive methods. This abnormality can be found in 8 to 15% of nondiabetic patients with primary hypertension, although its prevalence varies greatly in the literature, likely due to differences in the methods used to detect it and to the criteria applied in the selection of patients. The pathogenetic mechanisms leading to the development of microalbuminuria are still not completely known. BP load and increased systemic vascular permeability, possibly due to early endothelial damage, seem to play a major role. Increased urinary albumin excretion has been associated with several unfavorable metabolic and nonmetabolic risk factors and subclinical hypertensive organ damage. In fact, a higher prevalence of concentric left ventricular hypertrophy and subclinical impairment of left ventricular performance, as well as the presence of carotid atherosclerosis, have been reported in patients with microalbuminuria. These associations might per se justify a greater incidence of cardiovascular events. Long-term longitudinal studies have recently confirmed the unfavorable prognostic significance of microalbuminuria in hypertensive patients. It has also been hypothesized that microalbuminuria might be a forerunner of overt renal damage in primary hypertension. Clinical studies, however, have shown conflicting results, and this hypothesis has to be considered tempting but speculative at present. In conclusion, microalbuminuria is a specific, integrated marker of cardiovascular risk and target organ damage in primary hypertension and one that is suitable for identifying patients at higher global risk. A wider use of this test in the diagnostic work-up of hypertensive patients is recommended.

/pdf/microalbuminuria-cardiovascular-and-renal-risk-in-primary-vfsmdvzla8.pdf

Microalbuminuria, Cardiovascular, and Renal Risk in Primary Hypertension

BACKGROUND Microalbuminuria has recently emerged as a strong, independent predictor of cardiovascular mortality in patients with essential hypertension, yet the pathophysiological mechanisms underlying this association remain to be elucidated. OBJECTIVE To study the relationship between microalbuminuria and left ventricular geometry and function and extra-cardiac vascular changes in a group of 211 untreated hypertensive patients. METHODS Albuminuria was evaluated as albumin-to-creatinine ratio in three non-consecutive first morning urine samples. Left ventricular mass index and function were assessed by M-B mode echocardiography and carotid wall thickness by high-resolution ultrasound scan. RESULTS The prevalences of microalbuminuria and left ventricular hypertrophy were 14 and 47% respectively. Patients in the top quartile of albuminuria showed a higher left ventricular mass index (57 +/- 1.8, 55 +/- 2, 47 +/- 1.4 and 48 +/- 1.6 g/m2.7, respectively; P< 0.0001) as well as a higher prevalence of left ventricular hypertrophy (72, 65, 26 and 25%, respectively; P< 0.001) and especially concentric hypertrophy (56, 47, 17 and 21%, respectively; P< 0.0001) in the four quartiles of albuminuria. Microalbuminuric patients showed depressed left ventricular performance as indicated by a reduced midwall fractional shortening (15.7 +/- 0.3, 15.9 +/- 0.3, 16.7 +/- 0.4 and 16.8 +/- 0.3%, respectively; P< 0.02). Furthermore patients in the top quartile of albuminuria showed increased carotid wall thickness as compared to normoalbuminuric patients (0.78 +/- 0.03, 0.7 +/- 0.04, 0.65 +/- 0.03 and 0.6 +/- 0.03 mm, respectively; P < 0.001). CONCLUSIONS Hypertensive patients with microalbuminuria show a higher prevalence of unfavourable left ventricular geometric patterns, depressed left ventricular function and early signs of extra-cardiac vascular damage. These findings strengthen the role of microalbuminuria as an indicator of subclinical cardiovascular disease and may account for the worse outcome that is usually associated with increased urinary albumin excretion in essential hypertension.

Left ventricular geometry and function in patients with essential hypertension and microalbuminuria

Microalbuminuria (MA) is a well recognized marker of cardiovascular complications in hypertension, but whether MA can predict adverse outcome in this clinical condition is still a subject for debate. The fact that in hypertensive cohorts those patients who showed an increase in albumin excretion rate also manifested an increased incidence of morbid events indicates that the presence of MA in hypertension may carry an increased cardiovascular risk. However, the prognostic significance of MA remains controversial because no results of prospective studies performed in hypertensive subjects without diabetes mellitus are available. Several factors can affect the prevalence of MA in hypertension, including severity of the disease, selection procedures, concomitant risk factors, degree of obesity, age, and sex distribution. This accounts for the large differences in the prevalence of MA that can be found in the literature, with prevalence rates going from a low of 4.7% to a high of 40%. There is still conflict over whether MA in hypertension is due to increased intraglomerular pressure or to glomerular damage. The data from the literature suggest that in subjects with mild hypertension the main determinant of albumin excretion rate is the haemodynamic load. In subjects with more severe hypertension and hypertensive complications, the augmented urinary albumin leak is probably the consequence of a systemic microvascular disturbance which involves the glomeruli. In this respect, the insulin resistance state often associated to high blood pressure appears as one of the main pathogenetic factors. Whether management of hypertensive populations may be improved by monitoring of albumin excretion rate and whether antihypertensive drugs which are more effective in decreasing urinary albumin can be more beneficial in patients with MA remains to be determined.

Clinical value of microalbuminuria in hypertension.

Cross-sectional studies have shown that home blood pressure (BP) correlates with hypertensive target organ damage better than clinic BP. However, there have been few longitudinal studies regarding the predictive value of home BP on the changes in organ damage in treated hypertensive patients. Clinic and home BP over a 12-month period, antihypertensive medication use, echocardiographic and electrocardiographic results, and serum creatinine and urinary protein levels were examined in 209 treated hypertensive patients in 1993. These patients were prospectively followed for 5 years. The patients were divided into 4 subgroups according to hypertension control as follows: good control (<140/90 mmHg for clinic BP, <135/85 mmHg for home BP), improved, worsened, and poor control. The average clinic BP was 147.0+/-14.9/87.0+/-7.6 mmHg (mean+/-SD) in 1993 and 146.0+/-13.7/84.1+/-7.5 mmHg in 1998. The average home BP was 136.8+/-10.4/84.3+/-7.6 mmHg in 1993 and 136.1+/-9.7/81.2+/-7.7 mmHg in 1998. The left ventricular mass index (LVMI) positively correlated with both home systolic BP and clinic systolic BP in 1998 but not in 1993. The correlation tended to be closer for home BP than for clinic BP. LVMI did not change in patients with good or improved home systolic BP, while it increased in those with poor or worsened home systolic BP. The relationship between changes in LVMI and clinic BP was not significant. In conclusion, Home BP was more effective than clinic BP as a predictor of changes in left ventricular hypertrophy in treated hypertensive patients. Home BP should be controlled to below 135/85 mmHg to prevent cardiac hypertrophy.

Relationship between Home Blood Pressure and Longitudinal Changes in Target Organ Damage in Treated Hypertensive Patients

Relationship of left ventricular mass with clinic blood pressure measured over a six-month period vs. ambulatory blood pressure: p1.112

Prevalence and Clinical Correlates of Microalbuminuria in Stage I Hypertension: Results From the Hypertension and Ambulatory Recording Venetia Study (HARVEST Study)

According to recent international guidelines the decision on whether to treat young subjects during the early phase of hypertension should be based not only on their office blood pressure but also on their ambulatory blood pressure and whether target organ damage has occurred. Few data on the prevalence of hypertensive complications in young subjects with mild hypertension are available. In the Hypertension and Ambulatory Recording Venetia Study (HARVEST), a multicenter trial conducted in northeast Italy, the percentage of young borderline-to-mild hypertensive subjects with echocardiographic left ventricular hypertrophy was 4.5% and the percentage with concentric remodeling was 4%. Clear differences in cardiac size and geometric adjustment to ambulatory systolic pressure between the two sexes were found. The impact of blood pressure on the walls of the left ventricle and on the left ventricular mass was remarkable in women but weak in men. The assessment of left ventricular systolic function confirmed that many young mild hypertensive subjects have an increased ejective performance. The left ventricular contractility evaluated by midwall measurement was, however, found to be depressed in 9.2% of the HARVEST participants. Their left ventricular diastolic function was similar to that of 50 normotensive controls. The prevalence of microalbuminuria [albumin excretion rate (AER) > 30 mg/24 h) was 6.1%, only slightly higher than that found by other authors among normotensive subjects and much lower than that observed among patients with more severe hypertension. For our stage I hypertensives, however, the AER was correlated to the 24 h blood pressure with high statistical significance, whereas we found no relationship between the AER and left ventricular mass index either for all of the subjects taken together or for the men and women considered separately. The results suggest that renal and cardiac involvement do not occur in parallel during the initial phase of hypertension.

Target organ damage and ambulatory blood pressure in stage I hypertension. The Hypertension and Ambulatory Recording Venetia Study.

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Relationship of left ventricular mass with clinic blood pressure measured over a six-month period vs. ambulatory blood pressure: p1.112

Prevalence and Clinical Correlates of Microalbuminuria in Stage I Hypertension: Results From the Hypertension and Ambulatory Recording Venetia Study (HARVEST Study)

Target organ damage and ambulatory blood pressure in stage I hypertension. The Hypertension and Ambulatory Recording Venetia Study.