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Query: UMLS:C0730345 (microalbuminuria)
 4,018 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Endothelial dysfunction is the initial pathophysiological step in a progression of vascular damage that leads to overt cardiovascular and chronic kidney disease. Angiotensin II, the primary agent of the renin-angiotensin system (RAS), has a central role in endothelial dysfunction. Therefore, RAS blockade with an angiotensin receptor blocker (ARB) and/or angiotensin-converting enzyme (ACE) inhibitor provides a rational approach to reverse endothelial dysfunction, reduce microalbuminuria, and, thus, improves cardiovascular and renal prognosis. ARBs and ACE inhibitors act at different points in the RAS pathway and recent evidence suggests that there are differences regarding their effects on endothelial dysfunction. In addition to blood pressure lowering, studies have shown that ARBs reduce target-organ damage, including improvements in endothelial dysfunction, arterial stiffness, the progression of renal dysfunction in patients with type 2 diabetes, proteinuria, and left ventricular hypertrophy. The ONgoing Telmisartan Alone in combination with Ramipril Global Endpoint Trial (ONTARGET) Programme is expected to provide the ultimate evidence of whether improved endothelial function translates into reduced cardiovascular and renal events in high-risk patients, and to assess possible differential outcomes with telmisartan, the ACE inhibitor ramipril, or a combination of both (dual RAS blockade). Completion of ONTARGET is expected in 2008.
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PMID:Cardiovascular risk reduction by reversing endothelial dysfunction: ARBs, ACE inhibitors, or both? Expectations from the ONTARGET Trial Programme. 1758 70

Metabolic syndrome (MetSyndr), a constellation of abnormalities [obesity, glucose intolerance, insulin resistance (IR), dyslipidemia (low HDL-cholesterol, high LDL-cholesterol and triglycerides (TG)], and elevated blood pressure (BP)], increases the risk of cardiovascular (CV) disease and premature death. From 10% to 30% of the adult population in industrialized countries has MetSyndr, which effectively predicts the development of type 2 diabetes mellitus (T2D) and CV disease. Because of the complex etiology of MetSyndr, a multi-targeted, integrated therapeutic approach is required to simultaneously treat high BP, obesity, lipid disorders and T2D (if present), to fully protect CV, cerebrovascular and renal systems. If lifestyle modification (weight control, diet, exercise, smoking cessation, moderation of alcohol intake) is ineffective, pharmaco-theraphy should be added to treat simultaneously the lipid- and non-lipid CV risk factors. Patients with HTN and MetSyndr should be started on angiotensin-converting enzyme (ACE) inhibitors, unless contraindicated. The ACE inhibitors and angiotensin receptor blockers (ARBs) reduce the odds of developing new onset T2D and also decrease albuminuria. The ACE inhibitors provide cardioprotective and renoprotective benefits beyond their effect on BP; they also improve IR. The ARBs are renoprotective in addition to being cardioprotective. Long-acting calcium channel blockers are also recommended in hypertensive patients with MetSyndr; these drugs also improve IR. Thiazides (at low doses) and selected ss-blockers can be given to patients with HTN and MetSyndr. Celiprolol in combination with diuretics has a favorable effect on glucose tolerance and IR in patients with HTN and MetSyndr, and spironolactone added to ACE inhibitor or ARB therapy provides additional reno- and CV protective benefits in patients with diabetic nephropathy. Carvedilol, a ss-blocker with vasodilating properties, added to ACE inhibitor or ARB therapy, is effective in preventing worsening of microalbuminuria in patients with HTN and MetSyndr; it also improves IR and glycemic control. Most patients eventually require two or more antihypertensive drugs to reach BP goal. It is recommended that therapy in patients whose BP is more than 20/10 mm Hg above target at diagnosis be initiated with a combination of antihypertensive drugs, administered either as individual drugs or as fixed-dose formulations. Treatment with fixed-dose combinations, such as irbesartan + hydrochlorothiazide provides good BP control in more than two-thirds of hypertensive patients with MetSyndr. Lipid and BP targets are reached in a high percent of patients with HTN and CV disease treated with a combination of amlodipine + atorvastatin. In conclusion, hypertensive patients with the MetSyndr be treated aggressively for each component of the syndrome to provide CV, cerebrovascular and renal protection.
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PMID:Metabolic syndrome: treatment of hypertensive patients. 1766 15

The term prehypertension, which first appeared in the Seventh Report of the Joint National Committee (JNC 7) in 2003, has sparked controversy in the field of hypertension. Systolic blood pressure (BP) rises with age in industrialized societies, but an individual's rate of rise of systolic BP and the age at which BP crosses the arbitrary threshold of hypertension depends on prior BP levels (hence "prehypertension"). Obesity, another major factor in prehypertension, activates neurohumoral systems (renin-angiotensin and sympathetic nervous) and contributes to age-related BP increases. The JNC 7 recommendation for prehypertension management with optimal weight control (largely through diet and exercise) remains the mainstay, especially in the elderly. The Trial of Prevention of Hypertension demonstrated that angiotensin receptor blockade (ARB) retards age-related BP increases in prehypertensive patients. Associated elevated risk conditions (prediabetes, hypercholesterolemia, microalbuminuria) may justify early use of ARB therapy (in men and in women without childbearing potential) if weight control fails.
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PMID:Prehypertension: demographics, pathophysiology, and treatment. 1768 75

Recent studies questioned the existence of a specific renoprotective effects of ACE-inhibitors (ACE-i) and angiotensin receptor blockers (ARBs) besides their blood pressure lowering effect. In the ALLHAT study patients were randomly assigned to receive chlorthalidone, amlodipine and lisinopril. Results showed that, even in patients with reduced GFR, neither lisinopril nor amlodipine was superior to chlorthalidone in reducing the rate of development of ESRD or a 50% or greater decrement in GFR. Because of inclusion criteria the ALLHAT population was selected as at low risk for renal outcomes. Moreover, over 50% of the patients who were randomized to lisinopril either never received the medication or received the lower possible dose. Casas et al selected RCT comparing ACE-i and ARBs with other regimens. They concluded that ACE-i and ARBs are not more renoprotective that can be explained by lowering of blood pressure (BP) in diabetic nephropathy, while in non diabetic kidney disease a blood pressure independent renoprotective effect is uncertain. They made a very heterogeneous selection of trials that was dominated by the ALLHAT study; the analysis was not based on individual patient data. The Benedict Study showed that in hypertensive, normoalbuminuric patients with type 2 diabetes, BP reduction and ACE-i therapy both independently may prevent microalbuminuria. ACE-i therapy is particularly effective when BP is poorly controlled. We conclude that the recommendation of the Guidelines to use ACE-i and/or ARBs as first-line antihypertensive drugs for renoprotection in patients with diabetic and non diabetic kidney disease is still valid.
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PMID:[Antihypertensive therapy and renoprotection: do we really need to block the renin-angiotension system?]. 1788 9

Essential hypertensive patients (176 males and 329 females), aged 58.0+/-11.2 years were enrolled in a cross-sectional study conducted from February to March 2006 to investigate the prevalence and risk factors for microalbuminuria in hypertensive patients attending the Outpatient Department of Siriraj Hospital, Bangkok, Thailand. Macroalbuminuria was detected in 11 (2.2%) patients and microalbuminuria in 94 (18.6%) patients. Only male aged>or=45 years or female aged>or=55 years correlated significantly with a high occurrence of microalbuminuria, while calcium channel blocker and statin users were protected against microalbuminuria. The presence of microalbuminuria was not associated with age>or=60 years, male gender, current/previous smokers, hypertension duration>or=10 years, lack of blood pressure normalization, metabolic syndrome, use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and multi-drug use. Risk factor recognition for microalbuminuria will enable physicians to identify cases that should be screened for microalbuminuria.
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PMID:Microalbuminuria in Thai essential hypertensive patients. 1803 97

Diabetes is currently one of the leading causes of end-stage renal failure requiring renal replacement therapy in the Western World. About 15% to 20% of type 1 diabetic patients and 30% to 40% of type 2 diabetic patients will eventually develop end-stage renal failure. To prevent the development or progression of diabetic kidney disease, good glycaemic control remains the cornerstone in the management of diabetic patients. Beyond glycaemic control, other metabolic factors have been shown to be involved in the development of diabetic kidney disease, i.e. advanced glycation endproducts (AGEs) and the aldose reductase pathway. Furthermore, an adequate control of high blood pressure and treatment of microalbuminuria are major therapeutic targes. To achieve adequate blood pressure control, a combination therapy with different classes of antihypertensive agents is often necessary, especially including angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Other vasoactive factors involved in diabetic nephropathy such as endothelin and nitric oxide will be covered briefly. Besides hyperglycaemia and high blood pressure, other risk factors have been identified in the development or progression of diabetic kidney disease: smoking, hyperlipidaemia, obesity and high protein intake. Their impact on renal function will be highlighted. Finally, recent research has also identified intracellular pathways such as the diacylglycerol-protein kinase C pathway and several growth factors, such as growth hormone, insulin-like growth factor, transforming growth factor-beta, vascular endothelial growth factor, and platelet derived growth factor as players in diabetic kidney disease.
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PMID:Novel insights in the treatment of diabetic nephropathy. 1822 60

Treatment with different antihypertensive drug classes has varied effects on glucose metabolism. Thiazide diuretic use in hypertensives has been associated with the development of glucose intolerance and diabetes. Some findings suggest that the probability of worsening glucose metabolism and the development of new diabetes after thiazide initiation is associated with increasing body mass index. Nonselective or beta(1) selective beta-blockers may also lead to decreased insulin sensitivity in hypertensive patients. Newer beta-blockers that cause vasodilatation and beta-blockers that have intrinsic sympathomimetic activity may not have these deleterious effects on insulin sensitivity and glucose metabolism. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers may exert beneficial effects on glycemic control through a variety of mechanisms related to the inhibition of angiotensin II. These agents may be particularly useful in patients with microalbuminuria to slow the progression of renal disease. While there may be some small differences among different classes of calcium channel blockers, there is little net effect of these agents on glucose metabolism. The prevalence of obesity, hypertension, and type 2 diabetes mellitus is increasing in the US. In this setting, it is important to individualize antihypertensive therapy and to monitor its metabolic consequences so that potential adverse effects that would negate some of the benefits of blood-pressure lowering are minimized.
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PMID:Effects of antihypertensives on glucose metabolism. 1837 Jul 75

Risk factors such as hypertension or diabetes result in a continuum of renal damage. Without intervention, initial subclinical endothelial damage progresses to incipient disease, identified by microalbuminuria. Glomerular filtration rate declines, macroalbuminuria develops, and eventually end-stage renal disease (ESRD) emerges. Because of the interrelationship between cardiovascular and renal disease and their common pathophysiologies involving angiotensin II, many patients die of cardiovascular disease before renal replacement therapy is needed. Blood pressure control is key to renoprotection, but blood pressure-independent mechanisms are also implicated. Targeting the renin-angiotensin system (RAS) using angiotensin-converting enzyme (ACE) inhibitors and/or angiotensin receptor blockers (ARBs) is a logical approach to managing all at-risk patients. In advanced nephropathy, therapy aims at retarding progression to ESRD. For incipient nephropathy, ideal therapy should bring about microalbuminuria regression. In patients at risk of renal damage, preventing early target-organ damage is essential. Although evidence of ACE inhibitor benefit is limited, data show that ARBs provide renoprotection throughout the continuum and that this may be related to their cardioprotective effects. More aggressive RAS targeting by combination blockade is under investigation. Telmisartan is an ARB that delays progression of incipient and overt diabetic nephropathy and brings about regression from microalbuminuria to normoalbuminuria in hypertensive and normotensive patients. The ultimate proof of benefit will come from the ONTARGET trial, which will evaluate the cardiovascular and renal protective effects of the combination of telmisartan and ramipril.
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PMID:Prospects for renovascular protection by more aggressive renin-angiotensin system control. 1844 82

Because diabetes mellitus was not being adequately treated according to guidelines in an academic general medicine clinic, 2 of the authors (W.S.A. and A.H.G.) instituted an educational program to see if we could improve the appropriate management of diabetes mellitus in the academic general medicine clinic. Following this educational program, we investigated the appropriate management of 196 unselected patients with diabetes mellitus, mean age 61 years, who were followed up for at least 1 year in an academic general medicine clinic. The blood pressure was reduced to <130/80 mm Hg in 161 of 196 diabetics (82%). The hemoglobin A1c was reduced to <7.0% in 134 of 196 diabetics (68%). Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers were used to treat 50 of 51 diabetics (98%) with coronary artery disease (CAD), ischemic stroke, or peripheral arterial disease; 33 of 35 diabetics (94%) with a glomerular filtration rate <60 mL/min/1.73 m; 54 of 57 diabetics (94%) with microalbuminuria, and 21 of 22 diabetics (96%) with electrocardiographic left ventricular hypertrophy. Aspirin was used to treat 50 of 51 diabetics (98%) with CAD, ischemic stroke, or peripheral arterial disease. beta-Blockers were used to treat 36 of 39 diabetics (92%) with CAD. Statins were used to treat 168 of 196 diabetics (86%). Smoking cessation counseling was documented in 39 of 53 smokers (74%). Of 196 diabetics, 196 (100%) had a neurological examination, 129 (66%) were referred to an ophthalmologist for an eye examination, and 125 (64%) were referred to a podiatrist for foot care. These data show that an educational program on the appropriate management of diabetes mellitus improved the management of diabetes mellitus in an academic general medicine clinic.
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PMID:Prevalence of appropriate management of diabetes mellitus in an academic general medicine clinic. 1926 67

Type 2 diabetes mellitus (T2DM) is a worldwide pandemic that may lead to diabetic kidney disease (DKD), a complication which is the single most important and globally prevalent cause of chronic kidney disease. Microalbuminuria has been shown to be an early indicator of DKD and data suggest that angiotensin receptor blockers (ARBs) reduce urinary albumin excretion and retard the progression of renal disease in hypertensive T2DM patients. However, the effects of ARBs on preventing microalbuminuria and ensuing DKD in normotensive patients with T2DM is yet to be fully established. The objective of this study is to assess the anti-microalbuminuric effects of losar-tan therapy versus placebo in normotensive T2DM patients. This randomized single blinded controlled trial was performed at the Diabetic Clinic, Jinnah Hospital, Lahore over a period of 10 months. A total of 361 normotensive patients with T2DM and microalbuminuria were selected; of them, 171 patients were randomly allocated to the test group and 190 enrolled into the control group. The patients in the test group were started on losartan 50 mg/day for a six month period while those in the control group were put on vitamin B-12 500 mcg/day. The patients as well as the primary attending phy-sicians/lab evaluators were blinded to the study. All study patients were followed up on a monthly basis. Quantitative microalbuminuria was tested at the beginning and at the end of the study. Out of the 171 patients in the test group, 149 (87.1%) had significant reduction of albuminuria by > 30% of their baseline (mean 101.9 +/- 21.7 baseline and, 47.5 +/- 12.9 post-therapy). The corresponding values for albuminuria in the 190 patients in the control group was mean 104.7 +/- 26.3 baseline and post 6-month mean 103.9 +/- 22.9, with P< 0.0001. The anti-albuminuric effect of losartan was reversible as seen on re-checking the urinary albumin two months after discontinuation of treatment. Our study shows that losartan was well tolerated and demonstrated significant anti-proteinuric effects in patients with T2DM with early nephropathy independent of hypertension.
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PMID:Reduction of microalbuminuria by using losartan in normotensive patients with type 2 diabetes mellitus: A randomized controlled trial. 1941 46


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