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

The letter of Dr Budoff regarding our ASH position article on central blood pressure points out that studies such as those of Williams et al (ASCOT CAF E substudy), Roman et al (Strong Heart), Chirinos et al (MESA), and Mitchell et al (Framingham Study) support a role for central blood pressure and measures of arterial stiffness in predicting the cardiovascular risk from blood pressure. Dr Budoff also noted that ‘‘For individual patients, central pressure cannot be accurately predicted from brachial pressure, therefore direct measure is required to use this prognostic marker’’. Finally, Dr Budoff also notes that medications may differ in their central compared with their peripheral (brachial) blood pressure effects. We agree with his assessments in principle, but there are several caveats that need to be addressed. First, in the ASCOT CAF E trial, there were no central blood pressure baseline measurements because central measurements were not undertaken until the first year of follow-up. Moreover, in ASCOT CAF E, the treatment target was the brachial blood pressure, and the lower central systolic pressure profile was an interesting finding in the subgroup treated with amlodipine/perindopril compared with atenolol/thiazide therapy. However, the central pressures were not the target of therapy. What is missing in CAF E, and in the field in general, is a cardiovascular outcome study whose treatment is based on the central pressure profile in the first place. Such studies are underway, but we exercised caution in this regard. The Strong Heart Study, MESA, and the Framingham Heart Study were longitudinal observational cohort studies, not intervention trials. And while the central pressure profiles did prove useful for endpoint prediction, the brachial blood pressure was predictive in the Strong Heart Study, the MESA study required additional separation of the forward traveling and reflected arterial waveforms that was not typically available outside specialized hemodynamic labs, and most positive findings in Framingham were based on arterial stiffness (aortic pulse wave velocity) not central pressure waveforms. If anything, other Framingham data by Mitchell et al, to date, have not supported the concept that central pressure measures are superior to brachial pressure measurements for outcome prediction. The Framingham findings in particular underscore that central pressure profiles, while somewhat dependent on arterial stiffness,

Response to Budoff and Steigerwalt.

subunit of the GABAA receptor

Renal denervation has emerged as a safe and effective therapy to lower blood pressure in hypertensive patients. In addition to the main renal arteries, branch vessels are also denervated in more contemporary studies. Accurate and reliable imaging in renal denervation patients is critical for long-term safety surveillance due to the small risk of renal artery stenosis that may occur after the procedure. This review summarizes three common non-invasive imaging modalities: Doppler ultrasound (DUS), computed tomography angiography (CTA), and magnetic resonance angiography (MRA). DUS is the most widely used owing to cost considerations, ease of use, and the fact that it is less invasive, avoids ionizing radiation exposure, and requires no contrast media use. Renal angiography is used to determine if renal artery stenosis is present when non-invasive imaging suggests renal artery stenosis. We compiled data from prior renal denervation studies as well as the more recent SPYRAL-HTN OFF MED Study and show that DUS demonstrates both high sensitivity and specificity for detecting renal stenosis de novo and in longitudinal assessment of renal artery patency after interventions. In the context of clinical trials DUS has been shown, together with the use of the baseline angiogram, to be effective in identifying stenosis in branch and accessory arteries and merits consideration as the main screening imaging modality to detect clinically significant renal artery stenosis after renal denervation and this is consistent with guidelines from the recent European Consensus Statement on Renal Denervation.

Imaging strategies for safety surveillance after renal artery denervation

Ambulatory blood-pressure monitoring provides the best confirmation of the presence of hypertension detected in the office setting. A systematic review sponsored by the Agency for Healthcare Resear...

The Value in an Ambulatory Blood-Pressure Registry

Office-based blood pressure monitoring has been the primary way of managing the cardiovascular risk associated with a diagnosis of hypertension. As research unfolds the nature in which the pulse waveform is generated, additional insights beyond standard measures of systolic and diastolic blood pressure have emerged to help reclassify the cardiovascular risk of patients or point out patterns that have, in longitudinal cohort studies, shown promise as predictors of outcomes such as heart failure. In this review, we focus on the pressure profile in the proximal aorta that can be obtained easily and noninvasively from the radial or brachial artery during a clinical office encounter and the potential value of these measures in outcomes such as left ventricular hypertrophy and heart failure.

/pdf/novel-uses-of-office-based-measures-of-arterial-compliance-3k2od56uks.pdf

Raymond R. Townsend

Papers

Response to Budoff and Steigerwalt.

subunit of the GABAA receptor

Imaging strategies for safety surveillance after renal artery denervation

The Value in an Ambulatory Blood-Pressure Registry

Novel Uses of Office-Based Measures of Arterial Compliance.