다중혈관 관상동맥 환자에서 y-문합을 이용하여 양쪽 내흉동맥만을 사용한 우회술의 조기 성적

The Modification of Diet in Renal Disease (MDRD) Study equation underestimates glomerular filtration rate (GFR) in patients with mild kidney disease. Levey and associates therefore developed and va...

/pdf/a-new-equation-to-estimate-glomerular-filtration-rate-5fqjpsnzwg.pdf

A New Equation to Estimate Glomerular Filtration Rate

http://www.klinikaikozpont.u-szeged.hu/pedia/images/pdf/CME_TEL/Full-Text/25.pdf

The Hallmarks of Aging

Background End-stage renal disease substantially increases the risks of death, cardiovascular disease, and use of specialized health care, but the effects of less severe kidney dysfunction on these outcomes are less well defined. Methods We estimated the longitudinal glomerular filtration rate (GFR) among 1,120,295 adults within a large, integrated system of health care delivery in whom serum creatinine had been measured between 1996 and 2000 and who had not undergone dialysis or kidney transplantation. We examined the multivariable association between the estimated GFR and the risks of death, cardiovascular events, and hospitalization. Results The median follow-up was 2.84 years, the mean age was 52 years, and 55 percent of the group were women. After adjustment, the risk of death increased as the GFR decreased below 60 ml per minute per 1.73 m2 of body-surface area: the adjusted hazard ratio for death was 1.2 with an estimated GFR of 45 to 59 ml per minute per 1.73 m2 (95 percent confidence interval, 1....

https://www.nejm.org/doi/pdf/10.1056/NEJMoa041031

Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization

XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

Hypertension: Principles and Practice

Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, PharmaSmart International, Inc., Rochester, New York, Marshfield Clinic Research Institute, Marshfield, Wisconsin, Welch Allyn, Skaneateles Falls, New York, GE Healthcare, Milwaukee, Wisconsin, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania and Department of Medicine, Columbia University Medical Center, New York, New York, USA Correspondence to Bruce S. Alpert, MD, 1350 Poplar Ridge Dr., Memphis, TN 38120, USA Tel: +1 901 229 3719; fax: +1 901 757 8181; e-mail: bsa2347@gmail.com

Future use of the European Society of Hypertension International Protocol for validation of automated sphygmomanometers.

Renal sympathectomy has been in use since the 1930s to reduce blood pressure (BP) in patients with severe hypertension. Radical surgical sympathectomy and therapeutic splanchnicectomy were used before the advent of modern pharmacologic treatments to treat severe hypertension but these methods were largely abandoned with the availability of newer antihypertensive drugs that were both effective and had minimal side effects in the mid-late 1960s. Despite these newer efficacious drugs there remain patients with severe resistant hypertension. Renal sympathetic nerves contribute to the development and perpetuation of hypertension, and sympathetic outflow to the kidneys is activated in patients with essential hypertension. Efferent sympathetic outflow stimulates renin release, increases tubular sodium reabsorption, and reduces renal blood flow. Afferent signals from the kidney modulate central sympathetic outflow and thereby directly contribute to neurogenic hypertension. This was the basis for the use of nonselective surgical sympathectomy in the past. There has been a recent reemergence of interest in ablation of the renal sympathetic nerves using a catheter-based approach. A newly developed endovascular catheter technology enables selective denervation of the human kidney, with radiofrequency (RF) energy delivered in the renal artery lumen, accessing the renal nerves located in the adventitia of the renal arteries. This percutaneous, catheter-based approach is applied to selectively ablate the renal sympathetic nerves. In this approach, ablation is achieved percutaneously via the lumen of the main renal artery using a catheter connected to an RF generator. After gaining access via the femoral artery and confirmation of anatomic eligibility with renal angiography, the treatment catheter (Simplicity; Medtronic, Inc, Mountain View, CA) is introduced into each renal artery, and discrete RF ablations lasting 2 minutes each are applied to achieve 6 ablations separated both longitudinally and rotationally within each renal artery. Catheter tip temperature and impedance are constantly monitored during ablation, and RF energy delivery is regulated according to a predetermined algorithm. The mean duration of the procedure is less than 40 minutes. Patients often report back pain during the procedure so conscious sedation and narcotics are generally used. Complications have been infrequent and fairly minor but do include pseudoaneurysms at the puncture site and rarely renal artery dissection, which has been managed by stenting. An initial study of this approach showed successful renal denervation with both reductions of sympathetic activity and renin release in conjunction with reductions of central sympathetic outflow. This study showed substantial reductions of BP without substantial procedure-related complications. A larger study (Renal Denervation in Patients With Uncontrolled Hypertension [Symplicity 2]) was then performed using this RF catheter ablation procedure in a randomized trial of 106 patients with resistant hypertension despite treatment with an average of 5 antihypertensive medications including a diuretic. The patients were evaluated at 6 months. RF ablation significantly decreased the office BP from 178 ⁄97 mm Hg to 143 ⁄85 mm Hg compared with no decrease in BP in patients who were maintained on baseline antihypertensive therapy. A systolic BP <140 mm Hg was attained significantly more often with RF ablation (19% vs 4%). There was no significant difference between the groups in kidney function. Complications related to RF ablation included one femoral artery pseudoaneurysm. Long-term data regarding efficacy and safety of this procedure are limited. In a cohort study of 153 patients with resistant hypertension treated with catheter-based RF ablation, medical evaluation was performed in 64 patients at 12 months and 18 patients at 24 months. Compared with baseline, BP was reduced by 23 ⁄11 mm Hg at 12 months and 32 ⁄14 mm Hg at 24 months. The average number of antihypertensive medications used was the same at last follow-up as it was at baseline. Renal artery stenosis was diagnosed and stented in 1 patient 6 months after RF ablation. Another recent substudy assessed the effects of renal sympathetic denervation by RF ablation on BP reduction and sleep apnea severity in 10 patients with severe hypertension and sleep apnea. Antihypertensives were not changed during the study. Three and 6 months after renal denervation, in-office systolic BP and diastolic BP were decreased by 34 ⁄13 mm Hg. Significant decreases were also observed in plasma glucose concentration, glycated hemoglobin levels, and a decrease in apnea-hypopnea index at 6 months after renal denervation. This catheter-based approach to renal denervation presents a novel approach to severe resistant hypertension. Renal denervation has the potential to improve BP control most likely via interference with both From the Department of Medicine, Renal Division, Hypertension Program, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA Address for correspondence: Debbie L. Cohen, MD, Renal Division, Perelman School of Medicine at the University of Pennsylvania, 1 Founders Building, 3400 Spruce Street, Philadelphia, PA 19104 E-mail: debbie.cohen@uphs.upenn.edu DOI: 10.1111/j.1751-7176.2011.00563.x

Renal denervation revisited: promising treatment for resistant hypertension?

I nterest in the nature and velocity of pulse wave travel in the human circulation witnessed an innovative mix of technology and mathematics in the nineteenth and early twentieth centuries. A number of ingenious devices in the mid to late nineteenth century, in particular, were able to reveal graphically (often by a stylus-based indentation on a wax media) the complex nature of the pulse, typically obtained from the radial artery [1]. In the mid-1920s, the first measurements of human pulse wave velocity appeared, with values remarkably similar to those recorded in the past 20 years as noninvasive technologies to measure velocity have become available [2]. The usual unit in which pulse wave velocity is reported is in meters/second. Normal values for carotid-to-femoral pulse wave velocity in adults tend to rise 0.5–1m/s with each decade [3]. A healthy 45-year-old man or woman, for example, would be expected to have a carotid–femoral pulse wave velocity of 7m/s. Pulse wave velocity values tend to be higher in diabetic patients, and tend to rise more quickly with age when hypertension is present. European investigators recommend using carotid–femoral values as these are more representative of the aortic values. Nonetheless, a large body of literature also exists on the role of brachial-to-ankle pulse wave velocity, a method commonly used in Asian cohorts [4]. Because this method includes muscular as well as elastic arteries, the values are typically higher in patients than they would be if only the carotid–femoral beds were included [5]. In addition, cuff-based oscillometric determination of pulse wave velocity is an emerging area [6]. In 2010, the first meta-analysis of the effects of pulse wave velocity on cardiovascular outcomes and death appeared [7]. This analysis included 17 longitudinal studies, and almost 16 000 patients. Four of the cohorts studied were

Raymond R. Townsend

Papers

Hypertension: Principles and Practice

Future use of the European Society of Hypertension International Protocol for validation of automated sphygmomanometers.

Renal denervation revisited: promising treatment for resistant hypertension?

Vascular stiffness as a surrogate measure of mortality in patients with chronic kidney disease.

Renal Denervation: A Review.