Publications by authors named "Patricia Van der Niepen"

39 Publications

Prevalence and Disease Spectrum of Extracoronary Arterial Abnormalities in Spontaneous Coronary Artery Dissection.

JAMA Cardiol 2021 Nov 24. Epub 2021 Nov 24.

Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom.

Importance: Spontaneous coronary artery dissection (SCAD) has been associated with fibromuscular dysplasia (FMD) and other extracoronary arterial abnormalities. However, the prevalence, severity, and clinical relevance of these abnormalities remain unclear.

Objective: To assess the prevalence and spectrum of FMD and other extracoronary arterial abnormalities in patients with SCAD vs controls.

Design, Setting, And Participants: This case series included 173 patients with angiographically confirmed SCAD enrolled between January 1, 2015, and December 31, 2019. Imaging of extracoronary arterial beds was performed by magnetic resonance angiography (MRA). Forty-one healthy individuals were recruited to serve as controls for blinded interpretation of MRA findings. Patients were recruited from the UK national SCAD registry, which enrolls throughout the UK by referral from the primary care physician or patient self-referral through an online portal. Participants attended the national SCAD referral center for assessment and MRA.

Exposures: Both patients with SCAD and healthy controls underwent head-to-pelvis MRA (median time between SCAD event and MRA, 1 [IQR, 1-3] year).

Main Outcome And Measures: The diagnosis of FMD, arterial dissections, and aneurysms was established according to the International FMD Consensus. Arterial tortuosity was assessed both qualitatively (presence or absence of an S curve) and quantitatively (number of curves ≥45%; tortuosity index).

Results: Of the 173 patients with SCAD, 167 were women (96.5%); mean (SD) age at diagnosis was 44.5 (7.9) years. The prevalence of FMD was 31.8% (55 patients); 16 patients (29.1% of patients with FMD) had involvement of multiple vascular beds. Thirteen patients (7.5%) had extracoronary aneurysms and 3 patients (1.7%) had dissections. The prevalence and degree of arterial tortuosity were similar in patients and controls. In 43 patients imaged with both computed tomographic angiography and MRA, the identification of clinically significant remote arteriopathies was similar. Over a median 5-year follow-up, there were 2 noncardiovascular-associated deaths and 35 recurrent myocardial infarctions, but there were no primary extracoronary vascular events.

Conclusions And Relevance: In this case series with blinded analysis of patients with SCAD, severe multivessel FMD, aneurysms, and dissections were infrequent. The findings of this study suggest that, although brain-to-pelvis imaging allows detection of remote arteriopathies that may require follow-up, extracoronary vascular events appear to be rare.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamacardio.2021.4690DOI Listing
November 2021

Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension.

Hypertension 2021 Sep 30;78(4):898-911. Epub 2021 Aug 30.

Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., P.D., M.J., A.J.).

Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/HYPERTENSIONAHA.121.17004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8415524PMC
September 2021

Fibromuscular dysplasia: its various phenotypes in everyday practice in 2021.

Kardiol Pol 2021;79(7-8):733-744. Epub 2021 Jun 24.

Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.

Fibromuscular dysplasia (FMD) is a non-atherosclerotic vascular disease that may involve medium-sized muscular arteries throughout the body. The pathogenesis of FMD remains poorly understood, but a combination of genetic and environmental factors may be involved. The majority of FMD patients are women, but men may have a more progressive disease, especially when smoking. Besides the classical phenotype of string of beads or focal stenosis, arterial aneurysms, dissections, and tortuosity are frequent manifestations of the disease. However, the differential diagnosis of FMD is extensive and includes imaging artefacts as well as other arterial diseases. Diagnosis is based on CT-, MR-, or conventional catheter-based angiography during work-up of clinical manifestations, but clinically silent lesions may be found incidentally. Arterial hypertension and neurological symptoms are the most frequent clinical presentations, as renal and cerebrovascular arteries are the most commonly involved. However, involvement of most arteries throughout the body has been reported, resulting in a variety of clinical symptoms. The management of FMD depends on the vascular phenotype as well on the clinical picture. Ongoing FMD-related research will elaborate in depth the current progress in improved understandings of the disease's clinical manifestations, epidemiology, natural history and pathogenesis. This review is focused on the clinical management of adult FMD in daily practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.33963/KP.a2021.0040DOI Listing
September 2021

Current progress in clinical, molecular, and genetic aspects of adult fibromuscular dysplasia.

Cardiovasc Res 2021 Mar 19. Epub 2021 Mar 19.

Department of Hypertension, National Institute of Cardiology, Warsaw, Poland.

Fibromuscular dysplasia (FMD) is a non-atherosclerotic vascular disease that may involve medium-sized muscular arteries throughout the body. The majority of FMD patients are women. Although a variety of genetic, mechanical, and hormonal factors play a role in the pathogenesis of FMD, overall, its cause remains poorly understood. It is probable that the pathogenesis of FMD is linked to a combination of genetic and environmental factors. Extensive studies have correlated the arterial lesions of FMD to histopathological findings of arterial fibrosis, cellular hyperplasia, and distortion of the abnormal architecture of the arterial wall. More recently, the vascular phenotype of lesions associated with FMD has been expanded to include arterial aneurysms, dissections, and tortuosity. However, in the absence of a string of beads or focal stenosis, these lesions do not suffice to establish the diagnosis. While FMD most commonly involves renal and cerebrovascular arteries, involvement of most arteries throughout the body has been reported. Increasing evidence highlights that FMD is a systemic arterial disease and that subclinical alterations can be found in non-affected arterial segments. Recent significant progress in FMD-related research which has led to improved understandings of the disease's clinical manifestations, natural history, epidemiology, and genetics. Ongoing work continues to focus on FMD genetics and proteomics, physiological effects of FMD on cardiovascular structure and function, and novel imaging modalities and blood-based biomarkers that can be used to identify subclinical FMD. It is also hoped that the next decade will bring the development of multi-centred and potentially international clinical trials to provide comparative effectiveness data to inform the optimal management of patients with FMD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/cvr/cvab086DOI Listing
March 2021

Pregnancy-Related Complications in Patients With Fibromuscular Dysplasia: A Report From the European/International Fibromuscular Dysplasia Registry.

Hypertension 2020 08 8;76(2):545-553. Epub 2020 Jul 8.

Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium (M.P., S.D.M., A. Pasquet, A. Persu).

Current literature suggests a higher risk of pregnancy-related complications in patients with renal fibromuscular dysplasia (FMD). The aim of our study was to assess the nature and prevalence of pregnancy-related complications in patients subsequently diagnosed with FMD. A call for participation was sent to centers contributing to the European/International FMD Registry. Patients with at least 1 pregnancy were included. Data on pregnancy were collected through medical files and FMD characteristics through the European/International FMD Registry. Data from 534 pregnancies were obtained in 237 patients. Despite the fact that, in 96% of cases, FMD was not diagnosed before pregnancy, 40% of women (n=93) experienced pregnancy-related complications, mostly gestational hypertension (25%) and preterm birth (20%), while preeclampsia was reported in only 7.5%. Only 1 patient experienced arterial dissection and another patient an aneurysm rupture. When compared with patients without pregnancy-related complications, patients with complicated pregnancies were younger at FMD diagnosis (43 versus 51 years old; <0.001) and had a lower prevalence of cerebrovascular FMD (30% versus 52%; =0.003) but underwent more often renal revascularization (63% versus 40%, <0.001). In conclusion, the prevalence of pregnancy-related complications such as gestational hypertension and preterm birth was high in patients with FMD, probably related to the severity of renal FMD. However, the prevalence of preeclampsia and arterial complications was low/moderate. These findings emphasize the need to screen hypertensive women for FMD to ensure revascularization before pregnancy if indicated and appropriate follow-up during pregnancy, without discouraging patients with FMD from considering pregnancy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/HYPERTENSIONAHA.120.15349DOI Listing
August 2020

Vascular access type and mortality in haemodialysis: a retrospective cohort study.

BMC Nephrol 2020 06 18;21(1):231. Epub 2020 Jun 18.

Department of Nephrology & Hypertension, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium.

Background: Haemodialysis patients have a high mortality rate. Part of this can be attributed to vascular access complications. Large retrospective studies have shown a higher mortality in patients dialysed with a catheter, which is mostly ascribed to infectious complications. Since we observe very little infectious complications in our haemodialysis patients, the aim of our study was to assess if we could still detect a difference in survival according to vascular access type.

Methods: Patients that started chronic haemodialysis treatment between 1/1/2007 and 31/12/2016 at the 'Universitair Ziekenhuis Brussel' were retrospectively studied. The time to death was studied as a function of the two main vascular access types using survival analysis, considering the type of vascular access at the initiation of dialysis or as time varying, and accounting for the available baseline characteristics.

Results: Of 374 patients 309 (82.6%) initiated haemodialysis with a catheter, while 65 patients initiated with an arteriovenous access. Vascular access type during follow-up did not change in 74% of all patients. A Kaplan Meier plot did not suggest a survival dependent on the vascular access type at start. An extended cox proportional hazard analysis showed that vascular access type was not independently correlated with mortality. However, age, history of congestive heart failure and active cancer at initiation of dialysis were independently associated with mortality.

Conclusions: In this retrospective cohort study, haemodialysis vascular access type was not independently correlated with patient survival, even after taking into account change of vascular access over time.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12882-020-01889-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7302381PMC
June 2020

The European/International Fibromuscular Dysplasia Registry and Initiative (FEIRI)-clinical phenotypes and their predictors based on a cohort of 1000 patients.

Cardiovasc Res 2021 02;117(3):950-959

Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.

Aims: Since December 2015, the European/International Fibromuscular Dysplasia (FMD) Registry enrolled 1022 patients from 22 countries. We present their characteristics according to disease subtype, age and gender, as well as predictors of widespread disease, aneurysms and dissections.

Methods And Results: All patients diagnosed with FMD (string-of-beads or focal stenosis in at least one vascular bed) based on computed tomography angiography, magnetic resonance angiography, and/or catheter-based angiography were eligible. Patients were predominantly women (82%) and Caucasians (88%). Age at diagnosis was 46 ± 16 years (12% ≥65 years old), 86% were hypertensive, 72% had multifocal, and 57% multivessel FMD. Compared to patients with multifocal FMD, patients with focal FMD were younger, more often men, had less often multivessel FMD but more revascularizations. Compared to women with FMD, men were younger, had more often focal FMD and arterial dissections. Compared to younger patients with FMD, patients ≥65 years old had more often multifocal FMD, lower estimated glomerular filtration rate and more atherosclerotic lesions. Independent predictors of multivessel FMD were age at FMD diagnosis, stroke, multifocal subtype, presence of aneurysm or dissection, and family history of FMD. Predictors of aneurysms were multivessel and multifocal FMD. Predictors of dissections were age at FMD diagnosis, male gender, stroke, and multivessel FMD.

Conclusions: The European/International FMD Registry allowed large-scale characterization of distinct profiles of patients with FMD and, more importantly, identification of a unique set of independent predictors of widespread disease, aneurysms and dissections, paving the way for targeted screening, management, and follow-up of FMD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/cvr/cvaa102DOI Listing
February 2021

Dissecting visceral fibromuscular dysplasia reveals a new vascular phenotype of the disease: a report from the ARCADIA-POL study.

J Hypertens 2020 04;38(4):737-744

Department of Hypertension, Institute of Cardiology, Warsaw.

Objective: Visceral artery fibromuscular dysplasia (VA FMD) manifestations range from asymptomatic to life-threatening. The aim of the study is to evaluate the prevalence and clinical characteristics of VA FMD.

Methods: A total of 232 FMD patients enrolled into ongoing ARCADIA-POL study were included in this analysis. All patients underwent detailed clinical evaluation including ambulatory blood pressure monitoring, biobanking, duplex Doppler of carotid and abdominal arteries and whole body angio-computed tomography. Three control groups (patients with renal FMD without visceral involvement, healthy normotensive patients and resistant hypertensive patients) matched for age and sex were included.

Results: VA FMD was present in 32 patients (13.8%). Among these patients (women: 84.4%), FMD lesions were more frequent in celiac trunk (83.1%), 62.5% of patients showed at least one visceral aneurysm, and five patients presented with severe complications related to VA FMD. No demographic differences were found between patients with VA FMD and individuals from the three control groups, with the exception of lower weight (P < 0.001) and BMI (P < 0.001) in VA FMD patients. Patients with FMD (with or without visceral artery involvement) showed significantly smaller visceral arterial diameters compared with controls without FMD.

Conclusion: Patients with FMD showed smaller visceral arterial diameters when compared with patients without FMD. This may reflect a new phenotype of FMD, as a generalized arteriopathy, what needs further investigation. Lower BMI in patients with VA FMD might be explained by chronic mesenteric ischemia resulting from FMD lesions. FMD visceral involvement and visceral arterial aneurysms in patients with renal FMD are far to be rare. This strengthens the need for a systematic evaluation of all vascular beds, including visceral arteries, regardless of initial FMD involvement.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/HJH.0000000000002327DOI Listing
April 2020

Long-term cardiovascular outcome after renal revascularization.

Pol Arch Intern Med 2019 11 29;129(11):735-737. Epub 2019 Nov 29.

Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium; Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.20452/pamw.15075DOI Listing
November 2019

First International Consensus on the diagnosis and management of fibromuscular dysplasia.

Vasc Med 2019 04 16;24(2):164-189. Epub 2019 Jan 16.

6 Paris Descartes University, Paris, France.

This article is a comprehensive document on the diagnosis and management of fibromuscular dysplasia (FMD), which was commissioned by the working group 'Hypertension and the Kidney' of the European Society of Hypertension (ESH) and the Society for Vascular Medicine (SVM). This document updates previous consensus documents/scientific statements on FMD published in 2014 with full harmonization of the position of European and US experts. In addition to practical consensus-based clinical recommendations, including a consensus protocol for catheter-based angiography and percutaneous angioplasty for renal FMD, the document also includes the first analysis of the European/International FMD Registry and provides updated data from the US Registry for FMD. Finally, it provides insights on ongoing research programs and proposes future research directions for understanding this multifaceted arterial disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1358863X18821816DOI Listing
April 2019

First international consensus on the diagnosis and management of fibromuscular dysplasia.

J Hypertens 2019 02;37(2):229-252

Paris Descartes University.

This article is a comprehensive document on the diagnosis and management of fibromuscular dysplasia (FMD) which was commissioned by the Working Group 'Hypertension and the Kidney' of the European Society of Hypertension (ESH) and the Society for Vascular Medicine (SVM). This document updates previous consensus documents/scientific statements on FMD published in 2014 with full harmonization of the position of European and US experts. In addition to practical consensus-based clinical recommendations, including a consensus protocol for catheter-based angiography and percutaneous angioplasty for renal FMD, the document also includes the first analysis of the European/International FMD Registry and provides updated data from the US Registry for FMD. Finally, it provides insights on ongoing research programs and proposes future research directions for understanding this multifaceted arterial disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/HJH.0000000000002019DOI Listing
February 2019

Visceral Fibromuscular Dysplasia: From asymptomatic disorder to emergency.

Eur J Clin Invest 2018 Nov 17;48(11):e13023. Epub 2018 Sep 17.

Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.

Fibromuscular dysplasia (FMD) is an idiopathic, segmental, non-atherosclerotic and non-inflammatory disease of the musculature of arterial walls, leading to stenosis of small and medium-sized arteries, mostly involving renal and cervical arteries. As a result of better and more systematic screening, it appears that involvement of the splanchnic vascular bed is more frequent than originally assumed. We review epidemiology, pathogenesis, clinical picture as well as diagnosis and treatment of visceral artery (VA) FMD. The clinical picture is very diverse, and diagnosis is based on CT-, MR- or conventional catheter-based angiography. Involvement of VAs generally occurs among patients with multi-vessel FMD. Therefore, screening for VA FMD is advised especially in renal artery (RA) FMD and in case of aneurysms and/or dissections. Treatment depends on the clinical picture. However, the level of evidence is low, and much of the common practice is extrapolated from visceral atherosclerotic disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/eci.13023DOI Listing
November 2018

Renal blood oxygenation level-dependent magnetic resonance imaging to measure renal tissue oxygenation: a statement paper and systematic review.

Nephrol Dial Transplant 2018 09;33(suppl_2):ii22-ii28

Department of Radiology, NorthShore University HealthSystem, Evanston, IL, USA.

Tissue hypoxia plays a key role in the development and progression of many kidney diseases. Blood oxygenation level-dependent magnetic resonance imaging (BOLD-MRI) is the most promising imaging technique to monitor renal tissue oxygenation in humans. BOLD-MRI measures renal tissue deoxyhaemoglobin levels voxel by voxel. Increases in its outcome measure R2* (transverse relaxation rate expressed as per second) correspond to higher deoxyhaemoglobin concentrations and suggest lower oxygenation, whereas decreases in R2* indicate higher oxygenation. BOLD-MRI has been validated against micropuncture techniques in animals. Its reproducibility has been demonstrated in humans, provided that physiological and technical conditions are standardized. BOLD-MRI has shown that patients suffering from chronic kidney disease (CKD) or kidneys with severe renal artery stenosis have lower tissue oxygenation than controls. Additionally, CKD patients with the lowest cortical oxygenation have the worst renal outcome. Finally, BOLD-MRI has been used to assess the influence of drugs on renal tissue oxygenation, and may offer the possibility to identify drugs with nephroprotective or nephrotoxic effects at an early stage. Unfortunately, different methods are used to prepare patients, acquire MRI data and analyse the BOLD images. International efforts such as the European Cooperation in Science and Technology (COST) action 'Magnetic Resonance Imaging Biomarkers for Chronic Kidney Disease' (PARENCHIMA) are aiming to harmonize this process, to facilitate the introduction of this technique in clinical practice in the near future. This article represents an extensive overview of the studies performed in this field, summarizes the strengths and weaknesses of the technique, provides recommendations about patient preparation, image acquisition and analysis, and suggests clinical applications and future developments.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ndt/gfy243DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6106642PMC
September 2018

[Fibromuscular dysplasia and hypertension : beyond renal arteries].

Rev Med Suisse 2017 Sep;13(574):1580-1583

Service de cardiologie, Cliniques universitaires Saint-Luc ; Pôle de recherche cardiovasculaire, Institut de recherche expérimentale et clinique, Université catholique de Louvain, Avenue Hippocrate 10, 1200 Bruxelles, Belgique.

Fibromuscular dysplasia (FMD) is a disease associated with abnormalities of the arterial wall of medium-sized arteries. These abnormalities can lead to stenosis or less frequently to dissections or aneurysms. FMD is probably more frequent than initially thought. Nowadays, it is often a chance finding during a radiologic exam. In symptomatic cases, poor organ perfusion due to stenosis, dissection or aneurysm rupture may lead to the diagnosis. The aim of this non-systematic review illustrated with a clinical case is to present our current knowledge of FMD and to highlight the necessity of a standardized and multidisciplinary work-up to improve management of affected patients and understanding of the disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
September 2017

Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH).

Nephrol Dial Transplant 2017 Apr;32(4):620-640

CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy.

In patients with end-stage renal disease (ESRD) treated with haemodialysis or peritoneal dialysis, hypertension is common and often poorly controlled. Blood pressure (BP) recordings obtained before or after haemodialysis display a J- or U-shaped association with cardiovascular events and survival, but this most likely reflects the low accuracy of these measurements and the peculiar haemodynamic setting related to dialysis treatment. Elevated BP detected by home or ambulatory BP monitoring is clearly associated with shorter survival. Sodium and volume excess is the prominent mechanism of hypertension in dialysis patients, but other pathways, such as arterial stiffness, activation of the renin-angiotensin-aldosterone and sympathetic nervous systems, endothelial dysfunction, sleep apnoea and the use of erythropoietin-stimulating agents may also be involved. Non-pharmacologic interventions targeting sodium and volume excess are fundamental for hypertension control in this population. If BP remains elevated after appropriate treatment of sodium and volume excess, the use of antihypertensive agents is necessary. Drug treatment in the dialysis population should take into consideration the patient's comorbidities and specific characteristics of each agent, such as dialysability. This document is an overview of the diagnosis, epidemiology, pathogenesis and treatment of hypertension in patients on dialysis, aiming to offer the renal physician practical recommendations based on current knowledge and expert opinion and to highlight areas for future research.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ndt/gfw433DOI Listing
April 2017

Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH).

J Hypertens 2017 04;35(4):657-676

aDepartment of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece bPole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique cDivision of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium dDepartment of Medicine, Indiana University School of Medicine eRichard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana, USA fService of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland gDepartment of Medicine, Maastricht University Medical Center, Maastricht hZuyderland Medical Center, Geleen, The Netherlands iDepartment of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK jService de Néphrologie-Immunologie Clinique, Hôpital Bretonneau, François-Rabelais University, Tours, France kSaarland University Medical Center; Internal Medicine IV - Nephrology and Hypertension, Homburg, Germany lDivision of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium mDepartment of Nephrology, Sfax University Hospital nResearch Unit, Faculty of Medicine, Sfax University, Sfax, Tunisia oDivision of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey pCNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy qInstitute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK rIIS-Fundacion Jimenez Diaz, School of Medicine, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain sDepartment of Cardiovascular, Neural, and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano tDepartment of Medicine and Surgery, University of Milano-Bicocca, Milan uUniversità degli Studi and IRCCS Azienda Ospedaliera Universitaria San Martino IST, Genova, Italy vINSERM, Centre d'Investigations Cliniques Plurithématique 1433, UMR 1116, Université de Lorraine, CHRU de Nancy wF-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, Nancy, France xHypertension Unit & Institute of Research i+12, Hospital Universitario 12 de Octubre, Madrid, Spain yDepartment of Nephrology and Hypertension, Universitair Ziekenhuis Brussel - VUB, Brussels zNephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium aaDepartment of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands bbDepartment of Nephrology, Transplantation and Internal Medicine Medical University of Silesia in Katowice, Katowice, Poland ccManhes Hospital and FCRIN INI-CRCTC, Manhes, France.

In patients with end-stage renal disease treated with hemodialysis or peritoneal dialysis, hypertension is very common and often poorly controlled. Blood pressure (BP) recordings obtained before or after hemodialysis display a J-shaped or U-shaped association with cardiovascular events and survival, but this most likely reflects the low accuracy of these measurements and the peculiar hemodynamic setting related with dialysis treatment. Elevated BP by home or ambulatory BP monitoring is clearly associated with shorter survival. Sodium and volume excess is the prominent mechanism of hypertension in dialysis patients, but other pathways, such as arterial stiffness, activation of the renin-angiotensin-aldosterone and sympathetic nervous systems, endothelial dysfunction, sleep apnea and the use of erythropoietin-stimulating agents may also be involved. Nonpharmacologic interventions targeting sodium and volume excess are fundamental for hypertension control in this population. If BP remains elevated after appropriate treatment of sodium-volume excess, the use of antihypertensive agents is necessary. Drug treatment in the dialysis population should take into consideration the patient's comorbidities and specific characteristics of each agent, such as dialysability. This document is an overview of the diagnosis, epidemiology, pathogenesis and treatment of hypertension in patients on dialysis, aiming to offer the renal physician practical recommendations based on current knowledge and expert opinion and to highlight areas for future research.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/HJH.0000000000001283DOI Listing
April 2017

Fibromuscular dysplasia - results of a multicentre study in Flanders.

Vasa 2017 May 3;46(3):211-218. Epub 2017 Feb 3.

9 Department of Cardiac and Vascular Diseases, Ghent University Hospital, UZ Ghent, Ghent, Belgium.

Background: Fibromuscular dysplasia (FMD) is an idiopathic, non-inflammatory, non-atherosclerotic vascular disease, resulting in focal narrowing of small and medium-sized arteries. Systematic recording of clinical data in central databases as in the US and France provided new insights into FMD. The main objectives of this multicentre study were to explore the epidemiology, pattern of vascular involvement, clinical manifestations, and management of FMD patients in Flanders.

Patients And Methods: Multicentre, retrospective registry of patients diagnosed with FMD based on medical imaging.

Results: Hundred-twenty-three FMD patients (83.7 % female) were included. Mean age at FMD diagnosis was 57.3 years (SD 15.8). More than half of patients (59.5 %) were hypertensive at the time of diagnosis. Neurological complaints such as headache (26.4 %) and dizziness (23.1 %) were also frequently reported. FMD was discovered incidentally in 10 patients (8.3 %). Nearly one quarter (22.8 %) of patients experienced a cerebrovascular event. Aneurysms were found in one-fifth (20.3 %) of patients and 11.4 % had an arterial dissection. FMD affected most frequently the renal (85.3 %), carotid (74.7 %), and vertebral (39.8 %) arteries. Renovascular FMD was more prevalent in men, whereas cerebrovascular FMD was more frequent in women. Multiple affected sites were documented in 25 of 61 (41.0 %) patients, having two or more vascular beds imaged. Digital subtraction angiography was most frequently used for detecting FMD. One third (32.9 %) of patients received an interventional treatment, mainly patients with renovascular FMD (32.8 % underwent percutaneous transluminal angioplasty) and patients with an intracranial carotid aneurysm (36.4 % were treated by means of coiling).

Conclusions: Although differences existed, results of the Flemish registry were broadly in line with the US and French registries. Patient databases help to learn more about the natural history, progression, and management of FMD, based on real life clinical evidence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1024/0301-1526/a000613DOI Listing
May 2017

Renal Artery Stenosis in Patients with Resistant Hypertension: Stent It or Not?

Curr Hypertens Rep 2017 Jan;19(1)

Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.

After three large neutral trials in which renal artery revascularization failed to reduce cardiovascular and renal morbidity and mortality, renal artery stenting became a therapeutic taboo. However, this is probably unjustified as these trials have important limitations and excluded patients most likely to benefit from revascularization. In particular, patients with severe hypertension were often excluded and resistant hypertension was either poorly described or not conform to the current definition. Effective pharmacological combination treatment can control blood pressure in most patients with renovascular hypertension. However, it may also induce further renal hypoperfusion and thus accelerate progressive loss of renal tissue. Furthermore, case reports of patients with resistant hypertension showing substantial blood pressure improvement after successful revascularization are published over again. To identify those patients who would definitely respond to renal artery stenting, properly designed randomized clinical trials are definitely needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11906-017-0703-8DOI Listing
January 2017

Revisiting Fibromuscular Dysplasia: Rationale of the European Fibromuscular Dysplasia Initiative.

Hypertension 2016 10 8;68(4):832-9. Epub 2016 Aug 8.

From the Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique (A.P., E.B.), and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium. (A.P.); Department of Internal Medicine, Division of Nephrology and Hypertension, Universitair Ziekenhuis Brussel (Vrije Universiteit Brussel, VUB), Brussel, Belgium, (P.V.D.N.); Normandie Université, UNICAEN, Inserm U919, CHU Côte de Nacre, Caen, 14000 France (E.T.); Department of Cardiology, Ghent University Hospital, Ghent, Belgium (S.G.); Department of Medical Sciences, Internal Medicine and Hypertension Division, AOU Città della Salute e della Scienza, Turin, Italy (E.B.); Fibromuscular Dysplasia Society of America, Rocky River, OH (P.M.); Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Hypertension Unit, F-75015 Paris, France (P.-F.P.); Université Paris-Descartes, Paris Sorbonne Cité, F-75006 Paris, France (P.-F.P.); and Université Paris-Descartes, Paris Sorbonne Cité; AP-HP, Department of Genetics, Hôpital Europeen Georges Pompidou; INSERM, UMR-S 970, PARCC, Paris, France (X.J.).

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/HYPERTENSIONAHA.116.07543DOI Listing
October 2016

Pulmonary Limited MPO-ANCA Microscopic Polyangiitis and Idiopathic Lung Fibrosis in a Patient with a Diagnosis of IgA Nephropathy.

Case Rep Nephrol 2015 22;2015:378170. Epub 2015 Jul 22.

Departement Interne Geneeskunde/Nefrologie, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.

We present a case of a male patient with chronic renal insufficiency, due to crescentic glomerulonephritis with IgA deposits, who successively developed (idiopathic) thrombocytopenic purpura (ITP) and MPO-ANCA microscopic polyangiitis (MPA) with pulmonary fibrosis. The patient presented with cough, weight loss, and dyspnea on exertion. CT imaging and pulmonary function tests were compatible with interstitial pneumonitis with pulmonary fibrosis. Laboratory results showed high MPO-ANCA titers; the urinary sediment was bland. The patient was treated successfully with cyclophosphamide and methyl-prednisolone. This unique case illustrates the diagnostic and therapeutic challenges of an unusual presentation of microscopic polyangiitis presenting first as isolated kidney disease with recurrence in the form of pneumonitis without renal involvement, in association with renal IgA deposits and ITP as coexisting autoimmune conditions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1155/2015/378170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4525752PMC
August 2015

Belgian global implementation of cardiovascular and stroke risk assessment study: methods and baseline data of the BELGICA-STROKE STUDY.

Eur J Cardiovasc Prev Rehabil 2011 Aug 25;18(4):635-41. Epub 2011 Feb 25.

Department of Nephrology and Hypertension, Universitair Ziekenhuis Brussel, Brussels, Belgium.

Objectives: BELGICA-STROKE is a longitudinal study to enhance the use of online cardiovascular risk prediction scores based on the SCORE 10-year risk estimates for fatal cardiovascular disease (adapted for Belgium) and the Framingham 10-year stroke risk and to evaluate their impact on the cardiovascular risk profile of hypertensive patients. Methods and baseline characteristics are described here.

Design: Prospective, multicenter study in primary care.

Methods: General practitioners (N = 810) recruited consecutive hypertensive patients aged >40 years who were not at blood pressure goal and assessed them every 4 months. The estimated 10-year risks for fatal cardiovascular disease and stroke were available on a secured, specially designed study website. The calculated risk profile of a patient was modifiable by adding treatment goals in order to increase awareness and motivation of both physician and patient. An automated feedback on goal-level attainment and both cardiovascular risk scores was provided.

Results: Mean age of the 15,744 patients was 66.3 years: 51.9% were men, 77.8% had excess weight, 19.4% were smokers, and 25.9% had diabetes. Left ventricle hypertrophy was present in 20.0%, atrial fibrillation in 5.8%. Mean blood pressure was 153.8/88.2 mmHg, mean cholesterol 211.5 mg/dl. Most patients (89.2%) received antihypertensive medication, of which 36.9% was monotherapy. Mean estimated 10-year stroke risk was 19.1%, and mean estimated 10-year fatal cardiovascular disease risk 5.9%.

Conclusions: The 10-year estimated stroke and fatal cardiovascular disease risks were moderate to high in hypertensive patients not at goal blood pressure, emphasizing the importance of global cardiovascular risk factor assessment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1741826710389416DOI Listing
August 2011

Renal replacement therapy is an independent risk factor for mortality in critically ill patients with acute kidney injury.

Crit Care 2010 1;14(6):R221. Epub 2010 Dec 1.

Department of Medicine, University of Antwerpen, Universiteitsplein 1, 2610 Wilrijk, Belgium.

Introduction: Outcome studies in patients with acute kidney injury (AKI) have focused on differences between modalities of renal replacement therapy (RRT). The outcome of conservative treatment, however, has never been compared with RRT.

Methods: Nine Belgian intensive care units (ICUs) included all adult patients consecutively admitted with serum creatinine >2 mg/dl. Included treatment options were conservative treatment and intermittent or continuous RRT. Disease severity was determined using the Stuivenberg Hospital Acute Renal Failure (SHARF) score. Outcome parameters studied were mortality, hospital length of stay and renal recovery at hospital discharge.

Results: Out of 1,303 included patients, 650 required RRT (58% intermittent, 42% continuous RRT). Overall results showed a higher mortality (43% versus 58%) as well as a longer ICU and hospital stay in RRT patients compared to conservative treatment. Using the SHARF score for adjustment of disease severity, an increased risk of death for RRT compared to conservative treatment of RR = 1.75 (95% CI: 1.4 to 2.3) was found. Additional correction for other severity parameters (Acute Physiology And Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA)), age, type of AKI and clinical conditions confirmed the higher mortality in the RRT group.

Conclusions: The SHARF study showed that the higher mortality expected in AKI patients receiving RRT versus conservative treatment can not only be explained by a higher disease severity in the RRT group, even after multiple corrections. A more critical approach to the need for RRT in AKI patients seems to be warranted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/cc9355DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3219996PMC
January 2012

Gender and hypertension management: a sub-analysis of the I-inSYST survey.

Blood Press 2011 Apr 24;20(2):69-76. Epub 2010 Nov 24.

Department of Nephrology and Hypertension, Universitair Ziekenhuis Brussel, Brussels, Belgium.

Hypertension is a major risk factor for cardiovascular disease, which is the leading cause of death in women. Aim. To evaluate blood pressure control, prevalence of concomitant cardiovascular risk factors, subclinical and clinical organ damage, and treatment according to gender. Methods. 11,562 patients (49% women) from the cross-sectional I-inSyst survey in primary care were included. Results. Blood pressure control in women (21.8%) and men (21.2%) was similar, despite a slightly older age (64.9 vs 63 years, p<0.0001). Women had less concomitant cardiovascular risk factors and organ damage, with the exception of diabetes, cerebrovascular and renal disease, than men. They received more antihypertensive drugs than men (1.7 ± 0.9 vs 1.5 ± 0.9, p<0.0001). Diuretics were more (45% vs 36.5%, p<0.0001), calcium-channel blockers (26% vs 29%, p<0.003) and angiotensin-converting enzyme inhibitors (20% vs 22%, p<0.02) were less commonly prescribed in women than in men. Different clinical factors (i.e. age, duration of hypertension, smoking) in women and men were associated with blood pressure control, but gender itself was not. Conclusions. In this group of treated hypertensive patients, blood pressure control in women and men was not different. Women had a lower prevalence of most cardiovascular risk factors, subclinical and clinical organ damage. Antihypertensive drug treatment varied according to gender.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3109/08037051.2010.532304DOI Listing
April 2011

"Later, lazier, and unluckier": a heuristic profile of high vulnerability is an independent predictor of uncontrolled blood pressure (the PREVIEW study).

Int J Gen Med 2010 Jul 21;3:163-6. Epub 2010 Jul 21.

University of Arizona, Tucson, AZ, USA;

Objective: Vulnerability profiling, an alternative to deterministic risk assessment, offers clinicians a more intuitive but empirically-grounded assessment of patient risk. This study aimed to determine whether a heuristic profile of high vulnerability is an independent predictor of uncontrolled hypertension.

Methods: Secondary analysis of prospective observational study data on 2999 hypertensive patients treated with valsartan. Predictive validity of vulnerability profiling for first-line, second-line, and first-or-second-line antihypertensive treatment was inferred from 1) logistic regression models with adequate statistical fit, 2) statistically significant odds ratios for uncontrolled BP for the high-vulnerability cluster exceeding 1.00, and 3) correct classification rates for patients' BP control status.

Results: All models of uncontrolled BP were significant (P < 0.001); all odds ratios for the high-vulnerability cluster were greater than 1.00 and significant (P < 0.001). Correct classification rates for the highly-vulnerability cluster on uncontrolled BP after first-line, second-line, or either treatment were 91.1%, 61.2%, and 93.5% for systolic BP; 74.5%, 65.8%, and 76.7% for diastolic BP; and 92.8%, 65.3%, and 94.6% for combined systolic and diastolic BP.

Conclusion: The heuristic profile of "later, lazier, and unluckier" is an intuitive and valid tool to help identify patients at greater risk for poor BP control seen in general practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2147/ijgm.s11638DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2915526PMC
July 2010

Improved blood pressure control in elderly hypertensive patients: results of the PAPY-65 Survey.

Drugs Aging 2010 Jul;27(7):573-88

Department of Nephrology and Hypertension, Universitair Ziekenhuis Brussel, Brussels, Belgium.

Background: Blood pressure (BP) control is far from optimal. Studies on factors influencing BP control in the elderly are limited, yet identification of factors contributing to the low rate of BP control is a prerequisite to improvement of clinical management.

Objective: To evaluate the rate of BP control and the relationship between different clinical characteristics and BP control in treated hypertensive outpatients aged >or=65 years.

Methods: The PAPY-65 Survey was a prospective cross-sectional survey conducted in primary care in Belgium in 2007. Participating primary-care physicians were required to include consecutive hypertensive patients aged >or=65 years and treated with antihypertensive drugs. Demographic and anthropometric data as well as data on cardiovascular risk factors and history were obtained. BP was measured in accordance with the European Society of Hypertension/European Society of Cardiology guidelines.

Results: The mean +/- standard deviation (SD) age of the 1272 patients enrolled in the survey was 75 +/- 7 years; 702 (55%) patients were women. The mean +/- SD systolic/diastolic BP was 134/79 +/- 13/8 mmHg. BP was normalized (reduced to <140/90 mmHg, or <130/80 mmHg in patients with diabetes mellitus) in 617 (48.5%) patients overall and in 88 (24%) patients with diabetes (n = 371). The majority of patients (921; 72%) were treated with two or more antihypertensive drugs. Both general obesity (body mass index >or=30 vs <25 kg/m2) and abdominal obesity were associated with lack of BP control (unadjusted odds ratio [OR] 2.988, 95% CI 2.200, 4.057 and OR 2.066, 95% CI 1.649, 2.588, respectively). Abdominal obesity was no longer related to BP control when adjusted for the presence of diabetes. Diabetes was strongly associated with lack of BP control only when a stringent definition of BP control (<130/80 mmHg) was used. The combined presence of subclinical organ damage and a history of cardiovascular disease was associated with less uncontrolled BP (OR 0.62, 95% CI 0.48, 0.80).

Conclusion: Compared with previous data in the elderly in Belgium, a clear improvement in BP control was observed, probably related to the use of more antihypertensive agents. The presence of diabetes, excess bodyweight and abdominal obesity were all associated with poor BP control.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2165/11537350-000000000-00000DOI Listing
July 2010

Hierarchical linear and logistic modeling of outcomes of antihypertensive treatment in elderly patients: findings from the PREVIEW study.

Arch Gerontol Geriatr 2010 Jul-Aug;51(1):45-53. Epub 2009 Aug 27.

University of Arizona, College of Nursing, Tucson, AZ 85721, USA.

Achieving guideline-recommended blood pressure targets is difficult in older adults with hypertension. We completed a subgroup analysis of patients 65 years of age or older enrolled in PREVIEW, a prospective, multicenter, pharmacoepidemiological study of the determinants and outcomes of second-line antihypertensive treatment with valsartan in Belgium. Multilevel modeling was used to identify physician- and patient-level determinants of blood pressure values and practice guideline-derived definitions of blood pressure control. Data on 1560 patients and 504 physicians were used in this analysis. Blood pressure control rates for patients age 65 and over were lower for systolic (34.2% vs. 38.6%) and combined systolic/diastolic blood pressure (31.2% vs. 34.4%) compared to the entire PREVIEW sample. Twenty-seven percent of the variability in systolic, and 32% in diastolic pressure after 90 days of treatment were attributable to such variables as physicians' knowledge and adherence to evidence-based guidelines, practice patterns, and experience; with the remaining variance attributable to various demographic, behavioral, and clinical patient-related factors. Several independent predictors of uncontrolled blood pressure after 90 days of treatment were identified, largely confirming factors identified as determinants of blood pressure values. Recommendations for managing hypertension in the elderly are made in view of these findings.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.archger.2009.07.009DOI Listing
September 2010

Effectiveness of valsartan for treatment of hypertension: patient profiling and hierarchical modeling of determinants and outcomes (the PREVIEW study).

Ann Pharmacother 2009 May 7;43(5):849-61. Epub 2009 Apr 7.

Tutor in Internal Medicine, Department of Nephrology and Hypertension, Universitair Ziekenhuis Brussel, Brussel, Belgium.

Background: Patient- and clinician-related factors may explain variability in blood pressure (BP) outcomes and the differences between real-world effectiveness and efficacy seen in randomized trials of antihypertensive agents.

Objective: To examine the effectiveness of 90 days of second-line valsartan treatment and identify patient- and physician-level determinants that impact BP outcomes.

Methods: A prospective, multicenter, multilevel pharmaco-epidemiological study was conducted in 3194 hypertensive patients (systolic BP [SBP] > or =140 mm Hg, diastolic BP [DBP] > or =90 mm Hg; for diabetic patients, > or =130 and > or =80 mm Hg, respectively) treated by 504 general practitioners (GPs). Statistical analysis included heuristic data mining, and hierarchical linear and logistic modeling.

Results: With valsartan treatment, mean +/- SD SBP decreased from 154.4 +/- 15.5 mm Hg to 139.0 +/- 12.0 mm Hg and mean DBP decreased from 91.3 +/- 9.2 mm Hg to 82.6 +/- 7.4 mm Hg. SBP control rates increased from 9.0% to 38.6%, DBP from 25.5% to 65.5%, and combined SBP/DBP from 7.3% to 34.4%. A highly vulnerable cohort (n = 1063; 35.4%) of patients was identified. Twenty-four percent of variability in SBP and 25% of variability in DBP at 90 days were attributable to physician-related variables: guideline-compliant BP management, hypertension, practice patterns, hypertensive patient volume, and years in practice. The remaining 76% and 75% of variability in SBP and DBP, respectively, were due to patient factors, notably diabetes and related complications, vulnerability to uncontrolled BP, nonadherence, cardiovascular risk, and age. Similar factors increased the odds of treatment nonresponse, with diabetes being the single largest determinant of uncontrolled SBP (OR 8.99), DBP (OR 20.35), and combined SBP/DBP (OR = 18.64).

Conclusions: Valsartan is effective and well tolerated in a broad range of patients in whom first-line antihypertensive treatment failed or was not tolerated. Mitigating the impact of BP-elevating variables and optimizing the effect of BP-lowering factors provides therapeutic benefits incremental to valsartan's pharmacologic effect. Improving outcomes in hypertensive patients involves 3 steps: (1) identifying, intuitively rather than formally, patients less likely to achieve BP control; (2) targeting modifiable or manageable patient- and physician-level determinants with BP-elevating or BP-lowering effects; and (3) managing variables that increase the odds and optimizing those that lower the odds of uncontrolled BP.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1345/aph.1L576DOI Listing
May 2009

Effect of short-term rosiglitazone therapy in peritoneal dialysis patients.

Perit Dial Int 2009 Jan-Feb;29(1):108-11

Department of Nephrology, Universitair Ziekenhuis Brussel, Brussels, Belgium.

View Article and Find Full Text PDF

Download full-text PDF

Source
April 2009
-->