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...

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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

Adults with chronic kidney disease (CKD) are at increased risk for developing heart failure (HF). However, longitudinal cardiac remodeling in CKD has not been well-characterized and its association with HF outcomes remains unknown. We evaluated the association between change in echocardiographic parameters between baseline and year 4 with the subsequent risk of HF hospitalization and death using Cox proportional hazard models in a landmark analysis of a prospective multicenter CKD cohort. Among 2673 participants, mean ± SD age was 61 ± 11 years, with 45% women, and 56% non-white. A total of 472 hospitalizations for HF and 776 deaths occurred during a median (interquartile range) follow-up duration of 8.0 (6.3-9.1) years. Patients hospitalized for HF experienced larger preceding absolute increases in left ventricular (LV) volumes and decreases in LV ejection fraction. Adverse changes in LV ejection fraction, LV cavity volume, LV mass index, and LV geometry were independently associated with an increased risk of HF hospitalization and death. Among adults with CKD, deleterious cardiac remodeling occurs over a relatively short timeframe and adverse remodeling is associated with increased risk of HF-related morbidity and mortality. 

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The association between changes in echocardiography and risk of heart failure hospitalizations and death in adults with chronic kidney disease

The sodium glucose co-transporter-2 (SGLT2) inhibitors are a new class of agents for the treatment of type 2 diabetes mellitus. SGLT2 inhibitors are based on the structure of phlorizin, which was originally isolated from apple tree bark. Among the 6 sodium glucose transporters, SGLT is a low-affinity, high-capacity transporter expressed exclusively in the S1 and S2 segments of the renal proximal tubule, where 90% of glucose reabsorption occurs. The concept that SGLT2 inhibitors would reduce glucose transport was derived from observations of patients with renal glycosuria caused by mutations in the SLGT2 gene. These patients are generally asymptomatic aside from increased renal glucose excretion. Interestingly, patients with type 2 diabetes show upregulation of SGLT2 with greatly increased renal cell glucose uptake. Therefore, in type 2 diabetics there is the opportunity to increase renal glucose excretion by inhibiting SLGT2. SGLT2 inhibitors work independently of insulin, and could be used in combination with exogenous insulin as an adjunct for therapy in patients with type 1 diabetes. SGLT2 inhibitors reduce glucose reabsorption in the renal proximal tubule resulting in glycosuria without harming renal function. SLGT2 inhibitors also decrease plasma glucose levels and reverse glucotoxicity resulting from insulin resistance. Studies have shown these drugs to be relatively safe with no major side effects including no major hypoglycemic events. Mild or moderate hypoglycemia has only been observed when superimposed on the background of insulin therapy. SGLT2 inhibitors have also been shown in preclinical studies to increase insulin sensitivity. Chronic treatment with an SGLT2 inhibitor sergliflozin has been shown to decrease triglyceride levels and improve fatty liver. These drugs have also been associated with loss of calories and mild weight loss. SGLT2 inhibitors have also been shown to have a beneficial effect on lowering BP. SGLT2 inhibitors have a sodium-dependent co-transport system with concurrent mild diuretic effects, which could lead to sodium loss and decrease blood pressure. There are some studies that have specifically assessed blood pressure changes in type 2 diabetics with the use of SGLT2 inhibitors. One study administered remogliflozin etabonate for 12 days to patients with type 2 diabetes and resulted in a decrease in systolic blood pressure of 6 to 9 mmHg, depending on the dosage used. Another study using dapagliflozin vs placebo in type 2 diabetics showed a more modest decrease in systolic blood pressure of 4.6 1.8 vs 0.9 1.8 mmHgwith placebo, and a decrease in diastolic blood pressure of 2.8 1.1 vs 0.7 1.0 with placebo. There are now a growing number of SGLT2 inhibitors being developed with multiple preclinical and clinical studies being conducted. One agent, canagliflozin, was favorably evaluated by an FDA advisory panel in January 2013. Dapagliflozin was approved in the European Union in 2012. SGLT2 inhibitors represent an exciting new class of drugs with the potential to impact cardiovascular disease risk through improved glycemic control with possible additional benefits of weight loss, improved triglycerides, and lowering of blood pressure. Sweet!

Sweet & Low: New Treatment for Diabetes That May Reduce Blood Pressure

Update on β‐Blockers in Hypertension

Recent experimental interest has centered on the role of the calcium antagonists in the preservation of tissue function due to their ability to inhibit intracellular calcium accumulation as well as their potent vasodilatory properties. Most studies to date have centered primarily on myocardial tissue rendered either ischemic or anoxic by coronary artery ligation or manipulation of perfusing solutions. Assessment of myocardial function has included the quantitation of infarct size,1 ultrastructural histologic changes,2 or the evaluation of cellular biochemical parameters such as measurement of high energy phosphates,3 intracellular pH,4 and pyridine nucleotides.5

Raymond R. Townsend

Papers

The association between changes in echocardiography and risk of heart failure hospitalizations and death in adults with chronic kidney disease

Sweet & Low: New Treatment for Diabetes That May Reduce Blood Pressure

Update on β‐Blockers in Hypertension

Effect of calcium antagonists on vasopressin induced changes in myocardial and renal pyridine nucleotides in the intact rat.

Primary hyperaldosteronism: returning to the limelight?