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We extracted data from the French Speaking Registry of Peritoneal Dialysis and retrospectively studied peritonitis and the outcome of 30 patients with polycystic kidney disease firstly treated with peritoneal dialysis within our dialysis unit since 1997. There were 15 men and 15 women with a mean age of 54 years. Eighty-five per-cent of the patients had hepatic impairment. Ten patients did not suffer from comorbidities. Charlson comorbidity index was greater than or equal to 4 in five patients. Most of the patients was treated with automated peritoneal dialysis during the night. Only one patient was not autonomous with peritoneal dialysis. The whole medical monitoring lasted 836 months, representing an average of 28 months per patient. Eleven patients had a total of 24 peritonitis, 9 with gram negative bacillus. The incidence of peritonitis was one episode every 35 months-patient. Peritonitis was responsible for sudden admission in hemodialysis unit in two cases and death in one case. Fifteen patients (50%) benefited from renal transplantation. Only one patient had to undergo nephrectomy prior to renal transplantation. Seven patients were admitted to hemodialysis unit (the median duration time on peritoneal dialysis was 36 months). Four patients died. Four patients are currently treated with peritoneal dialysis. In conclusion, this retrospective study points out that peritoneal dialysis, especially automated peritoneal dialysis, is a good option for patients with polycystic kidney disease necessitating dialysis.

AIM The aim of this study is to explore the individual and combined effects of obesity and metabolic profile on the impairment of glomerular function among hypertensive subjects. METHODS This is a cross-sectional study enrolling 499 hypertensive subjects. Based on body mass index values and metabolic profile, they were assigned to one of four metabolic phenotype groups: MHNO: metabolically healthy non-obese, MHO: metabolically healthy but obese, MUHNO: metabolically unhealthy but non-obese, and MUHO: metabolically unhealthy and obese. The effect of the interaction between obesity and metabolic profile was tested on an additive scale, for both microalbuminuria and reduced estimated glomerular filtration rate (eGFR). RESULTS After adjustment for confounding factors, the highest risk of both microalbuminuria and decreased eGFR was found among patients of the MUHO group (OR = 6.0 [2.13], p

OBJECTIVES The aim of this study was to assess blood pressure (BP) control in patients with chronic kidney disease (CKD) according to office and home BP and to assess the prevalence of normal BP, white-coat uncontrolled hypertension (WUCH), masked uncontrolled hypertension (MUCH) and elevated BP. METHODS Patients with renal failure with or without proteinuria were included in this multicenter observational study. Office BP was first measured by the physician using a self-monitoring BP device (three automatic readings), then by the patient at home (morning and evening) over 3 consecutive days. WUCH was defined as a systolic BP (SBP)/diastolic BP (DBP) ≥140/90 mmHg in the clinic and SBP/DBP

Erectile dysfunction (ED) is not routinely discussed with patients in cardiology practices whereas it may impact the ability of patients to stay on therapy. Most of the studies about ED and antihypertensive therapies have several methodological limitations. Diuretics and beta-blockers have been shown to have a deleterious effect on ED. ISRA inhibitors, calcium antagonists, vasodilator beta-blockers and alpha-blockers have been shown to have a neutral impact on ED. Angiotensin 2 inhibitors, nebivolol and alpha-blockers use has sometimes beneficial effect on ED. In case of ED due to antihypertensive treatment, drugs can be switched each other but careful attention in patients with a high cardiovascular risk is required.

Resume But de l’etude Evaluer la fiabilite de l’autoquestionnaire ExSel® pour detecter une consommation excessive de sel (≥ 12 g/24 h) chez les patients consultant pour hypertension et/ou insuffisance renale. Methodes Les resultats obtenus par l’autoquestionnaire ExSel® ont ete compares a l’excretion de sodium pendant 24 h a l’aide du test de Kappa de Cohen, et du test du Khi2. La sensibilite, la specificite, les VPP et VPN ont ete calculees. Une courbe ROC a ete realisee pour rechercher un seuil de positivite. Resultats Les caracteristiques moyennes des 101 patients avec des resultats fiables etaient les suivantes : âge de 67 ± 12 ans, indice de masse corporelle 28,4 + 5,6 kg/m2, SBP/DBP 139 ± 23/74 ± 13 mmHg (98 % etaient des hypertendus). La consommation de sel evaluee par la natriurese des 24 h etait de 7,5 ± 3,1 g/24 h. La creatininurie etait de 13,9 + 20,1 mmol/24 h. Une consommation excessive de sel (≥ 12 g/24 h) a ete observee chez 8 % des patients. Le test Kappa a 0,17 et le Khi2 a 0,66 signifient que l’accord entre ExSel® et la natriurese n’etait pas significatif pour depister un exces de consommation sodee. La sensibilite etait de 37 %, la specificite de 90 %, la VPP de 20 % et la VPN de 94 %. L’aire sous la courbe ROC etait trop faible (0,665) pour esperer pouvoir determiner un seuil de positivite d’ExSel® adapte aux patients consultant en nephrologie. Conclusion L’autoquestionnaire ExSel® n’est pas adaptee aux patients ambulatoires suivis en consultation de nephrologie dont 98 % etaient hypertendus pour depister une consommation excessive de sel > 12 g/24 h.

International audience; Hypertension is much less common in children than in adults. The group of experts decided to perform a review of the literature to draw up a position statement that could be used in everyday practice. The group rated recommendations using the GRADE approach. All children over the age of 3 years should have their blood pressure measured annually. Due to the lack of data on cardiovascular morbidity and mortality associated with blood pressure values, the definition of hypertension in children is a statistical value based on the normal distribution of blood pressure in the paediatric population, and children and adolescents are considered as having hypertension when their blood pressure is greater than or equal to the 95th percentile. Nevertheless, it is recommended to use normative blood pressure tables developed according to age, height and gender, to define hypertension. Measuring blood pressure in children can be technically challenging and several measurement methods are listed here. Regardless of the age of the child, it is recommended to carefully check for a secondary cause of hypertension as in 2/3 of cases it has a renal or cardiac origin. The care pathway and principles of the therapeutic strategy are described here.

Background. Clinical decision tools that have been proposed to predict the clinical course of patients admitted to hospital with COVID-19 are poorly presented and are at high risk of selection bias. The aim of the study was to propose a prediction clinical tool to predict an unfavourable outcome at the admission of a SARS-CoV2 infected patient that was carefully developed using a large learning database and that was developed from models derived from artificial intelligence.Methods. The PREDICT-COVID study is a post hoc analysis of the Noso-Cor study, a multicenter prospective, observational study. All patients infected by SARS-CoV2 hospitalized in one of the 11 Lyon-University hospitals since 8-March-2020 have been included. The PREDICT-COVID database was split in two separate datasets: the learning dataset (80%) was used for the development of the model and the validation dataset (20%) for internal validation. The primary composite outcome was the need for mechanical ventilation or admission into an intensive care unit, or death within 21 days of admission.Results. Data from 823 patients were analysed: age 70.6±16·9 years; body mass index 26.7±5·4 kg/m2 and median number of comorbidities was 2. Out of the 44 recorded variables, 11 that were the most linked to the primary outcome criteria were retained to develop the optimised risk prediction tool. At admission the 5 most informative predictors were, in descending order: C-Reactive Protein, neutrophil-to-lymphocyte ratio, aspartate transaminase, shortness of breath, and prothrombin time. The ten-fold cross validation of the optimised model had an area under the ROC curve of 0.76±0.06. The performance of the developed Bayesian model to predict the primary outcome of the validation dataset had a mean area under the ROC curve of 0.78, sensitivity of 60%, and specificity of 77%.Conclusions. The proposed optimised prediction tool that uses 11 routinely determined variables to predict an unfavourable course at admission for COVID-19 had satisfactory performance. For an external validation, the PREDICT-COVID prediction tool is available online at: https://www.hed.cc/?a=covid&n=NETCRIT21J.netaTrial registration: The Noso-Cor study was registered on ClinicalTrials (NCT04290780). The present analysis was registered on ClinicalTrials (NCT04412031) the June 2, 2020.

International audience; Since the publication of the Framingham Heart Study, which suggested that uric acid should no longer be associated with coronary heart disease after additional adjustment for cardiovascular disease risk factors, the number of publications challenging this statement has dramatically increased. The aim of this paper was to review and discuss the most recent studies addressing the possible relation between sustained elevated serum uric acid levels and the onset or worsening of cardiovascular and renal diseases. Original studies involving American teenagers clearly showed that serum uric acid levels were directly correlated with systolic and diastolic pressures, which has been confirmed in adult cohorts revealing a 2.21-fold increased risk of hypertension. Several studies involving patients with coronary artery disease support a role for serum uric acid level as a marker and/or predictor for future cardiovascular mortality and long-term adverse events in patients with coronary artery disease. Retrospective analyses have shown an inverse relationship between serum uric acid levels and renal function, and even a mild hyperuricemia has been shown to be associated with chronic kidney disease in patients with type 2 diabetes. Interventional studies, although of small size, showed that uric acid (UA)-lowering therapies induced a reduction of blood pressure in teenagers and a protective effect on renal function. Taken together, these studies support a role for high serum uric acid levels (>6 mg/dL or 60 mg/L) in hypertension-associated morbidities and should bring awareness to physicians with regards to patients with chronic hyperuricemia.

Summary Severe acute respiratory syndrome coronavirus 2, which is responsible for the current coronavirus disease 2019 pandemic, uses angiotensin-converting enzyme 2 as a gateway into host cells. In this review, we summarize the biology of this enzyme, which plays a key role in cardiovascular homeostasis. Blockers of the renin-angiotensin system modify the expression and activity of angiotensin-converting enzyme 2 in different ways. The effects of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on the expression and enzyme activity of angiotensin-converting enzyme 2 are reviewed, and the consequences of these treatments for the severity of coronavirus disease 2019 infection are discussed.

In patients with chronic kidney disease, serum potassium level is a factor influencing sudden cardiac death (SCD). The aim of our analysis was to study the combined effect of serum potassium level and renal function on the onset of SCD in elderly hypertensive subjects. Data from the 3620 hypertensive patients aged over 70 years were extracted from three randomized clinical trials included in the INDANA database. During a mean follow up of 4.5 years, 81 patients (2.24%) died from SCD. Mean serum potassium levels and prevalence of chronic kidney disease were not different in patients who died from SCD. In addition to serum potassium and creatinine levels, 14 clinical and biological variables linked to cardiovascular diseases recorded at baseline were analyzed using a Bayesian network. The area under the receiver operating characteristic curve of the Bayesian model reached 0.91. Bayesian inference was used to simulate the combined effects of serum potassium and creatinine levels on SCD. Our analysis, using simulated data from Bayesian model, showed that the estimated probabilities of SCD was significantly increased in case of hyperkalemia (>5.0 mmol/l) and in case of hypokalemia (

Background All-cause mortality in haemodialysis (HD) is high, reaching 15.6% in the first year according to the European Renal Association. Methods A new clinical tool to predict all-cause mortality in HD patients is proposed. It uses a post hoc analysis of data from the prospective cohort study Photo-Graph V3. A total of 35 variables related to patient characteristics, laboratory values and treatments were used as predictors of all-cause mortality. The first step was to compare the results obtained using a logistic regression to those obtained by a Bayesian network. The second step aimed to increase the performance of the best prediction model using synthetic data. Finally, a compromise between performance and ergonomics was proposed by reducing the number of variables to be entered in the prediction tool. Results Among the 9010 HD patients included in the Photo-Graph V3 study, 4915 incident patients with known medical status at 2 years were analysed. All-cause mortality at 2 years was 34.1%. The Bayesian network provided the most reliable prediction. The final optimized models that used 14 variables had areas under the receiver operating characteristic curves of 0.78 ± 0.01, sensitivity of 72 ± 2%, specificity of 69 ± 2%, predictive positive value of 70 ± 1% and negative predictive value of 71 ± 2% for the prediction of all-cause mortality. Conclusions Using artificial intelligence methods, a new clinical tool to predict all-cause mortality in incident HD patients is proposed. The latter can be used for research purposes before its external validation at: https://www.hed.cc/? a=twoyearsallcausemortalityhemod&n=2-years%20All-cause%20Mortality%20Hemodialysis.neta.

Background: Among people with diabetes, those with kidney disease have exceptionally high rates of cardiovascular (CV) morbidity and mortality and progression of their underlying kidney disease. Finerenone is a novel, nonsteroidal, selective mineralocorticoid receptor antagonist that has shown to reduce albuminuria in type 2 diabetes (T2D) patients with chronic kidney disease (CKD) while revealing only a low risk of hyperkalemia. However, the effect of finerenone on CV and renal outcomes has not yet been investigated in long-term trials. Patients and Methods: The Finerenone in Reducing CV Mortality and Morbidity in Diabetic Kidney Disease (FIGARO-DKD) trial aims to assess the efficacy and safety of finerenone compared to placebo at reducing clinically important CV and renal outcomes in T2D patients with CKD. FIGARO-DKD is a randomized, double-blind, placebo-controlled, parallel-group, event-driven trial running in 47 countries with an expected duration of approximately 6 years. FIGARO-DKD randomized 7,437 patients with an estimated glomerular filtration rate ≥25 mL/min/1.73 m2 and albuminuria (urinary albumin-to-creatinine ratio ≥30 to ≤5,000 mg/g). The study has at least 90% power to detect a 20% reduction in the risk of the primary outcome (overall two-sided significance level α = 0.05), the composite of time to first occurrence of CV death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure. Conclusions: FIGARO-DKD will determine whether an optimally treated cohort of T2D patients with CKD at high risk of CV and renal events will experience cardiorenal benefits with the addition of finerenone to their treatment regimen. Trial Registration: EudraCT number: 2015-000950-39; ClinicalTrials.gov identifier: NCT02545049.

Il n’y a pas « une » hypertension au cours de la grossesse mais « des » hypertensions, de mecanismes et de consequences differents pour la mere et le fœtus. L’hypertension arterielle (HTA) chronique est definie par une pression arterielle systolique (PAS) ≥ 140 mm Hg ou une pression arterielle diastolique (PAD) ≥ 90 mm Hg avant la grossesse ou avant la 20e semaine d’amenorrhee (SA). L’HTA gestationnelle est definie par une PAS ≥ 140 mm Hg ou une PAD ≥ 90 mm Hg survenant pendant ou apres la 20e SA. La pre-eclampsie (PE) est l’apparition d’une HTA et d’une proteinurie apres la 20e SA. Une PE severe s’accompagne de signes cliniques temoignant d’une souffrance viscerale. Une PE se developpe dans 1 a 2 % des grossesses, mais beaucoup plus frequemment (jusqu’a 34 %) en presence de facteurs de risque. L’HTA au cours de la grossesse reste, par ses complications, la premiere cause de morbidite et mortalite maternelles. Il n’y a pas de traitement curatif specifique de la PE hormis l’interruption de la grossesse. Le traitement de l’HTA au cours des six premiers mois de grossesse cherche a eviter les complications maternelles de l’HTA sans etre deletere sur le developpement fœtal. Toutes les HTA severes doivent etre traitees. Dans l’HTA legere a moderee, un traitement sera discute chez les patientes a haut risque cardiovasculaire (CV). L’objectif tensionnel est, pour toutes, une PAS inferieure a 160 mm Hg et une PAD comprise entre 85 et 100 mm Hg. A plus long terme, les societes savantes, dont la Societe francaise d’hypertension arterielle (SFHTA) et le College des gynecologues et obstetriciens francais (CNGOF), considerent la PE comme un facteur de risque emergeant specifique d’HTA chronique, d’accidents coronaires, d’accidents vasculaires cerebraux, d’insuffisance renale chronique et de mortalite cardio-neuro-vasculaire. Le risque de complications est d’autant plus important quand des accidents a la fois maternels et fœtaux sont survenus, ou encore precocement pendant la grossesse. Paradoxalement, l’information de ces femmes a risque est insuffisante par meconnaissance et par manque de sensibilisation des professionnels de sante. L’education de ces femmes est un enjeu majeur de prevention, en developpant des consultations d’information et d’annonce au decours de l’accouchement, en les incitant a optimiser leur hygiene de vie avec un suivi coordonne. Dans cet objectif, le consensus francais souligne l’opportunite de mettre en place des parcours de soins structures, qui, outre le suivi de ces femmes, visent a ameliorer les pratiques des professionnels de sante.

High blood pressure in pregnancy remains, by its complications, the leading cause of morbidity and maternal and fetal mortality. The frequency (5 to 10% of pregnancies) and the potential severity of this disease, both for mother and child, encourage to standardize and to optimize our medical practices. This is the main objective of this work. If the short-term complications for the mother and child are well known, long-term ones for the mother beginning to be better identified (in particular, the risk of recurrence in a subsequent pregnancy, the risk of chronic hypertension and the increased risk of cardiovascular events). The occurrence of hypertension during pregnancy disturbs the "classic" organization of care. Several health professionals are involved, the general practitioner, obstetrician, gynecologist, midwife, cardiologist, nephrologist… There is not always a care coordinator and decisions are sometimes taken with delay. These data encouraged the French Society of Hypertension to write a consensus offering easy and efficient recommendations. Educate women and all health professionals to hypertension and its management, in line with current scientific data, is one of the major challenges of this consensus.

Points essentiels Il n’y a pas une hypertension au cours de la grossesse mais des hypertensions, de mecanismes et de consequences differents pour la mere et le fœtus. L’hypertension arterielle chronique est definie par une PAS ≥ 140 mm Hg ou une PAD ≥ 90 mm Hg avant la grossesse ou avant la 20 e semaine d’amenorrhee (SA). L’hypertension arterielle gestationnelle est definie par une PAS ≥ 140 mm Hg ou une PAD ≥ 90 mm Hg survenant pendant ou apres la 20 e SA. La pre-eclampsie est l’apparition d’une HTA et d’une proteinurie apres 20 SA. Une pre-eclampsie severe s’accompagne de signes cliniques temoignant d’une souffrance viscerale. Le HELLP syndrome est une pre-eclampsie grave s’accompagnant d’une hemolyse intravasculaire et d’une cytolyse hepatique. L’eclampsie se caracterise par des crises convulsives tonico-cloniques. Une hypertension chronique preexistante est observee dans 1 a 5 % des grossesses. Une hypertension gestationnelle sans proteinurie apparait dans 5 a 6 % des grossesses. Une pre-eclampsie se developpe dans 1 a 2 % des grossesses, mais beaucoup plus frequemment (jusqu’a 34 %) en presence de facteurs de risque. L’hypertension arterielle au cours de la grossesse reste, par ses complications, la premiere cause de morbidite et mortalite maternelles.

Background Hepatitis B vaccination is recommended for chronic kidney disease (CKD) patients before starting dialysis. We performed an analyis aimed to describe the clinical and biological parameters related to the success of vaccination in CKD patients before starting dialysis. Methods We extracted data of 170 non-dialyzed patients who were offered hepatitis B vaccination from a register. They received a first vaccination of 40 μg followed by boosters after one, two and six months. Patients were considered protected if their hepatitis B antibody level was > 10 IU/L, three months apart. A logistic regression and a Bayesian model were used to describe the relationships between variables and the success of vaccination. Results Vaccination protected 50.6% of the patients. Model adjustment to the data was higher using the Bayesian model compared to the logistic regression (with area under the ROC curve of 0.955 ± 0.007 vs 0.775 ± 0.066 respectively). The Bayesian model's robustness studied using a 10 fold cross validation showed a percentage of misclassified subjects of 12.4 ± 1.8%, a sensitivity of 87.7 ± 0.3%, a specificity of 87.5 ± 0.3%, a positive predictive value of 87.8 ± 0.3% and negative predictive value of 87.4 ± 0.2%. As classified by the Bayesian model, the variables most related to successful vaccination were, in descending order: age, eGFR, protidemia, albuminemia, cause of renal failure, gender, previous vaccination and weight. Conclusion The Bayesian network confirmed that both kidney function and nutritional status of patients are important factors to explain the success of vaccination against hepatitis B in CKD patients before dialysis. For research purposes, before an external validation, the network can be used online at www.hed.cc/?s=Bhepatitis&n=ReseauhepatiteBsup10.neta .

To improve the management of resistant hypertension, the French Society of Hypertension, an affiliate of the French Society of Cardiology, has published a set of eleven recommendations. The primary objective is to provide the most up-to-date information based on the strongest scientific rationale and that is easily applicable to daily clinical practice. Resistant hypertension is defined as uncontrolled blood pressure on office measurements and confirmed by out-of-office measurements despite a therapeutic strategy comprising appropriate lifestyle and dietary measures and the concurrent use of three antihypertensive agents including a thiazide diuretic, a renin-angiotensin system blocker (ARB or ACEI) and a calcium channel blocker, for at least 4 weeks, at optimal doses. Treatment compliance must be closely monitored, as must factors that are likely to affect treatment resistance (excessive dietary salt intake, alcohol, depression, drug interactions and vasopressor drugs). If the diagnosis of resistant hypertension is confirmed, the patient should be referred to a hypertension specialist to screen for potential target organ damage and secondary causes of hypertension. The recommended treatment regimen is a combination therapy comprising four treatment classes, including spironolactone (12.5-25 mg per day). In the event of a contraindication or a non-response to spironolactone, or if adverse effects occur, a β-blocker, an α-blocker, or a centrally acting antihypertensive drug should be prescribed. Because renal denervation is still undergoing assessment for the treatment of hypertension, this technique should only be prescribed by a specialist hypertension clinic.

Summary Background Resistant hypertension is common, mainly idiopathic, but sometimes related to primary aldosteronism. Thus, most hypertension specialists recommend screening for primary aldosteronism. Aims To optimize the selection of patients whose aldosterone-to-renin ratio (ARR) is elevated from simple clinical and biological characteristics. Methods Data from consecutive patients referred between 1 June 2008 and 30 May 2009 were collected retrospectively from five French ‘European excellence hypertension centres’ institutional registers. Patients were included if they had at least one of: onset of hypertension before age 40 years, resistant hypertension, history of hypokalaemia, efficient treatment by spironolactone, and potassium supplementation. An ARR > 32 ng/L and aldosterone > 160 ng/L in patients treated without agents altering the renin–angiotensin system was considered as elevated. Bayesian network and stepwise logistic regression were used to predict an elevated ARR. Results Of 334 patients, 89 were excluded (31 for incomplete data, 32 for taking agents that alter the renin–angiotensin system and 26 for other reasons). Among 245 included patients, 110 had an elevated ARR. Sensitivity reached 100% or 63.3% using Bayesian network or logistic regression, respectively, and specificity reached 89.6% or 67.2%, respectively. The area under the receiver-operating-characteristic curve obtained with the Bayesian network was significantly higher than that obtained by stepwise regression (0.93 ± 0.02 vs. 0.70 ± 0.03; P Conclusion In hypertension centres, Bayesian network efficiently detected patients with an elevated ARR. An external validation study is required before use in primary clinical settings.

AIM Primary aldosteronism could exert a negative feedback on prorenin secretion, of possibly different magnitude, whether it is related to an aldosterone-producing adenoma (APA) or an idiopathic hyperaldosteronism (IHA). The objectives of this study were to evaluate the level of prorenin in three subgroups: APA, IHA, and essential hypertension; and the performance of the aldosterone-to-prorenin ratio (APR) for the diagnosis of an APA. METHODS Seven hundred and forty-six hypertensive patients with a standardized work-up, including a prorenin measurement, were considered. Ninety-six patients without neutral treatment and 38 patients with other forms of secondary hypertension were excluded. APA and IHA were categorized according to computed tomography scan, adrenal venous sampling, pathological analysis and improvement of hypertension after surgery. RESULTS Thirty-five patients had a diagnosis of APA, 57 of IHA and 504 of essential hypertension. Prorenin was lower in APA and IHA than in essential hypertension (32.9, 40.4 and 50.3 pg/ml, respectively; P

RésuméPour améliorer la prise en charge de l’HTA résistante, la Société française d’HTA, filiale de la Société française de cardiologie publie onze recommandations dont l’objectif principal est d’apporter des informations actualisées ayant la meilleure justification scientifique et qui soient applicables dans la pratique quotidienne des professionnels de santé travaillant dans le système de santé français.L’HTA résistante est définie par une pression artérielle non contrôlée en consultation et confirmée par des mesures en dehors du cabinet médical, malgré une stratégie thérapeutique comprenant des règles hygiéno-diététiques adaptées et une trithérapie antihypertensive (diurétique thiazidique, bloqueur du SRA [ARA2 ou IEC] et inhibiteur calcique), depuis au moins 4semaines, à dose optimale.Il convient de rechercher une mauvaise observance et les facteurs qui favorisent la résistance (excès de sel, alcool, dépression et interférences médicamenteuses, substances ayant une action vasopressive).Si l’HTA résistante est confirmée, il est recommandé de demander l’avis d’un spécialiste en HTA pour rechercher une atteinte d’organe cible, une HTA secondaire.La stratégie thérapeutique recommandée est la quadrithérapie incluant la spironolactone (12,5 à 25mg/j). En cas de contre-indication ou de non réponse à la spironolactone, ou en présence d’effets indésirables, il est suggéré de prescrire un bêta-bloquant, ou un alpha-bloquant, ou un antihypertenseur central.L’intérêt de la dénervation rénale étant en cours d’évaluation, il est suggéré que l’indication de cette technique soit posée dans un centre spécialisé en HTA.SummaryTo improve the management of resistant hypertension, the French Society of Hypertension, an affiliate of the French Society of Cardiology, has published a set of eleven recommendations. The primary objective is to provide the most up-to-date information, based on the strongest scientific rationale and which is easily applicable to daily clinical practice for health professionals working within the French health system.Resistant hypertension is defined as uncontrolled blood pressure (BP) both on office measurements and confirmed by out-of-office measurements despite a therapeutic strategy comprising appropriate lifestyle and dietary measures and the concurrent use of three antihypertensive agents including a thiazide diuretic, a renin–angiotensin system blocker (ARB or ACEI) and a calcium channel blocker, for at least four weeks, at optimal doses.Treatment compliance must be closely monitored, as most factors that are likely to affect treatment resistance (excessive dietary salt intake, alcohol, depression and drug interactions, or vasopressors).If the diagnosis of resistant hypertension is confirmed, the patient should be referred to a hypertension specialist to screen for potential target organ damage and secondary causes of hypertension.The recommended treatment regimen is a combination therapy comprising four treatment classes, including spironolactone (12.5 to 25mg/day). In the event of a contraindication or a non-response to spironolactone, or if adverse effects occur, a β-blocker, an α-blocker, or a centrally acting antihypertensive drug should be prescribed.Because renal denervation is still undergoing assessment for the treatment of hypertension, this technique should only be prescribed by a specialist hypertension clinic.

Current antihypertensive strategies do not take into account that individual characteristics may influence the magnitude of blood pressure (BP) reduction. Guidelines promote trial-and-error approaches with many different drugs. We conducted the Identification of the Determinants of the Efficacy of Arterial blood pressure Lowering drugs (IDEAL) Trial to identify factors associated with BP responses to perindopril and indapamide. IDEAL was a cross-over, double-blind, placebo-controlled trial, involving four 4-week periods: indapamide, perindopril and two placebo. Eligible patients were untreated, hypertensive and aged 25-70 years. The main outcome was systolic BP (SBP) response to drugs. The 112 participants with good compliance had a mean age of 52. One in every three participants was a woman. In middle-aged women, the SBP reduction from drugs was -11.5 mm Hg (indapamide) and -8.3 mm Hg (perindopril). In men, the response was significantly smaller: -4.8 mm Hg (indapamide) and -4.3 (perindopril) (P for sex differences 0.001 and 0.015, respectively). SBP response to perindopril decreased by 2 mm Hg every 10 years of age in both sexes (P=0.01). The response to indapamide increased by 3 mm Hg every 10 years of age gradient in women (P=0.02). Age and sex were important determinants of BP response for antihypertensive drugs in the IDEAL population. This should be taken into account when choosing drugs a priori.

Adrenal venous sampling (AVS) is a challenging technical procedure and few patients had AVS procedure twice.To evaluate the reproducibility of the AVS, why AVS were repeated and the conclusions drawn from them.From 1997-2012, 12 patients underwent two AVS. A cortisol level in the adrenal vein greater than or equal to 1.1 to inferior vena cava defined a successful catheterization and a lateralization of secretion corresponded to an aldosterone-to-cortisol vein ratio greater than or equal to 2 between the one side to another.The same side of lateralization of secretion was found in 75% of them. The second AVS were due to technical failure (n=4), unproven lateralization (n=2), a lateralization opposite to the main nodule and ipsilateral to hyperplasia (n=4) on first AVS. For two patients, as the CT was normal, AVS was required again. The second AVS was successful in all patients, including those with an initial technical failure but only patient with technical failure underwent surgery, as BP and kaliemia were controlled. Lateralization on the side of hyperplasia or opposite to the biggest nodule was confirmed in two of four cases.When AVS is unsuccessful for technical reasons, it is worth doing it again but after being sure that surgery is still possibly indicated.

Glomerular filtration rate estimates (e-GFR) are often used to evaluate the changes in renal function, but have not been validated for this purpose in kidney transplant recipients (KTRs). The aim of this study was to evaluate the validity of e-GFR for monitoring serial changes in renal function in KTR using directly measured GFR by inulin clearance (I-GFR) as the reference standard.Performances of inverse serum creatinine (1/creat) and Cockcroft and Gault, Modification of Diet in Renal Disease, and Chronic Kidney Disease Epidemiology Collaboration formulas were assessed to estimate the changes in I-GFR.A total of 1935 I-GFR clearance procedures were performed in 631 KTRs who underwent serial measurements between 2003 and 2009. The baseline median I-GFR were 51.0 mL/min/1.73 m(2) (confidence interval 95%: 23-84 mL/min/1.73 m(2)]. The performances of 1/creat and formulas for detecting the I-GFR variations between two consecutive measurements (n = 1304) were similar. To detect the variations of20% (increase or decrease), sensitivities ranged between 50 and 56%, and specificities between 64 and 69%. To detect the variations20% (increase or decrease), sensitivities ranged between 27% and 39%, and specificities between 88 and 97%. Bland-Altman plots confirmed the scattering of values for individual patients.In a population of Caucasian KTRs, the mean changes in GFR are correctly estimated whatever the formula used in the range of 23-84 mL/min/1.73 m(2) and can thus be applied in population studies. However, in clinical practice, individual changes in GFR evaluated by formulas should be interpreted with caution in KTRs.

Background/Aims: Urinary albumin excretion is subject to intra-individual variability. Thus, for research purposes, it is recommended to test three urine samples collected over a short period of time. The objective of our analysis was to check the usefulness of triplicate samples to determine the albuminuric status of diabetic patients. Methods: We present the results of the non-planned retrospective analysis of 246 triplicate morning urine samples obtained from 95 type 2 diabetics included in three multinational, randomized, double-blind studies. Albuminuria was determined by immunoturbidimetry on fresh samples in the same central laboratory. Microalbuminuria was defined by a urine albumin to creatinine ratio (UACR) between 2.5 and 25 mg/mmol in males and between 3.5 and 35 mg/mmol in females. Concordance was obtained when the second and/or third sample (UACR2 and UACR3) confirmed the albuminuric status obtained from the first sample (UACR1). Results: Considering the first samples, 9% were within the normal range, 35% showed microalbuminuria and 56% showed macroalbuminuria. The overall concordance rate was 95%. The log of UACR was highly correlated between samples. Bland-Altman plots expressed in percent variations between two samples confirmed that the mean variation was low (around 8%) but revealed the scattering of values, 95% being between -60 and +77% of variation between samples. Conclusions: There is no benefit in repeating morning UACR determination in diabetic patients to accurately categorize a subject as having normo-, micro- or macroalbuminuria. However, in order to accurately quantify albuminuria, repeated determinations are required.

High blood pressure in pregnancy remains, by its complications, the leading cause of morbidity and maternal and fetal mortality. The frequency (5 to 10% of pregnancies) and the potential severity of this disease, both for mother and child, encourage to standardize and to optimize our medical practices. This is the main objective of this work. If the short-term complications for the mother and child are well known, long-term ones for the mother beginning to be better identified (in particular, the risk of recurrence in a subsequent pregnancy, the risk of chronic hypertension and the increased risk of cardiovascular events). The occurrence of hypertension during pregnancy disturbs the "classic" organization of care. Several health professionals are involved, the general practitioner, obstetrician, gynecologist, midwife, cardiologist, nephrologist… There is not always a care coordinator and decisions are sometimes taken with delay. These data encouraged the French Society of Hypertension to write a consensus offering easy and efficient recommendations. Educate women and all health professionals to hypertension and its management, in line with current scientific data, is one of the major challenges of this consensus.

Summary Background Biological diagnostic criteria for diagnosing aldosterone-producing adenoma (APA) are not well-established. Aim The aim of the study was to establish the best biological predictors of APA. Methods A prospective register was implemented in 17 secondary or tertiary hypertension centres. The inclusion criterion was one of the following: onset of hypertension before 40 years of age; history of hypokalaemia; drug-resistant hypertension (resistant to three drugs); or spironolactone efficiency on BP. Results Among the 338 collected cases, 192 patients had two aldosterone-to-renin ratio (ARR) determinations (after 1 hour supine and at least 1 hour upright) on the same occasion. Twenty-five patients (8.2%) had biological hyperaldosteronism and an adrenal adenoma identified by computed tomography. APA was histologically confirmed in all 12 patients who underwent surgery. Histologically proven APAs were used as the ‘gold standard’ in receiver operating characteristic (ROC) curve analysis. ARRs were computed with a minimum renin value set at 5 ng/L to avoid misclassification of so-called ‘low-renin hypertension’. To predict an APA, the ARR area under the ROC curve was 0.93. A supine ARR cut-off value of 32 ng/ng provided the highest sum of sensitivity (92%) plus specificity (92%). On the basis of an ARR ≥ 32 ng/ng in the supine and/or upright position, sensitivity reached 100%. Conclusion The proposed cut-off value of 32 ng/ng for ARR (minimum renin value set at 5 ng/L) in one of two determinations had 100% sensitivity and 72% specificity with 20% positive and 100% negative predictive values for diagnosing APA.

Background The management of kidney transplant recipients requires accurate estimate of glomerular filtration rate (GFR). This study aims at evaluating the performance of four creatinine-based formulas for estimating the GFR (estimated GFR) in this population. Methods Performances of Cockcroft and Gault formula, Modification of Diet in Renal Disease (MDRD) simplified formula, Chronic Kidney Disease Epidemiology Collaboration formula, and Nankivell formula were assessed compared with inulin clearance taken as the gold standard for measuring GFR (measured GFR). Performances were assessed using the first measurements of GFR obtained in 1249 subjects. How estimated GFR tracks changes in measured GFR over time since transplantation in those patients with repeated measures was also assessed. Results The MDRD formula provided the best estimate of GFR with a mean bias of -0.5 mL/min/1.73 m, a standard deviation of bias of 12 mL/min/1.73 m, and a 30% accuracy at 85%. The MDRD formula also seemed to provide the best performance for estimating GFR, irrespective of age, stage of renal failure, and in people whose body mass index was more than 18.5 kg/m. This robustness is important in clinical practice. The performance of the four formulas was not modified by the posttransplant period. Conclusion Even if 30% accuracy was suboptimal in the Kidney Disease Outcomes Quality Initiative guidelines, our results, obtained in a large number of patients, lead us to recommend using the MDRD formula to monitor GFR in kidney transplant recipients.

Item does not contain fulltext BACKGROUND AND OBJECTIVES: Evaluation of renal function by estimation of the glomerular filtration rate (GFR) is very important for the diagnosis and treatment of patients with chronic kidney disease (CKD). The Cockcroft-Gault (CG) and Modification of Diet in Renal Disease (MDRD) formulas are the most commonly used estimations. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Estimated GFR values by each formula were compared with measured GFR (mGFR) by renal inulin clearance in 2208 European adults (46% women, 1.4% Caribbean blacks), with and without CKD, and mean mGFR 72.4 +/- 39.0 (range 2.2 to 177.2) ml/min/1.73 m(2). RESULTS: Overall, the CG and MDRD formulas showed bias (mean difference) -3.5 ml/min/1.73 m(2) (5.3%), P < 0.001, and -9.8 ml/min/1.73 m(2) (-6.4%), P < 0.001; precision (SD of bias) 21.5 ml/min/1.73 m(2) (43.1%) and 20.0 ml/min/1.73 m(2) (33.0%); limits of agreement (2 SD by Bland-Altman method) 39.5 to -46.5 (range 86.0) ml/min/1.73 m(2) and 30.2 to -49.8 (range 80.0) ml/min/1.73 m(2); and accuracy within +/-30% of mGFR 70.8 and 69.0%, respectively. Both formulas showed a trend for decreasing accuracy with lower mGFR levels. According to the Kidney Disease Outcomes Quality Initiative (K/DOQI)-CKD classification's five GFR groups, the CG and MDRD formulas properly assigned 61.6 and 57.1% of the entire population and had a range of positive predictive values 42.6 to 81.8% and 39.6 to 85.2% and of negative predictive values 81.7 to 96.6% and 76.4 to 97.5%, respectively. CONCLUSIONS: The CG and MDRD formulas had some limitations for proper GFR estimation and K/DOQI-CKD classification by GFR levels alone.

Resume Le dosage de l'excretion urinaire d'albumine (EUA) peut se faire sur un echantillon urinaire sur les premieres urines du matin, sur les urines de 24 heures ou sur prelevement urinaire minute. Les valeurs definissant la microalbuminurie sont : urines de 24 heures : 30–300 mg/24 h ; echantillon urinaire : 20–200 mg/ml ou 30–300 mg/g creatinine urinaire ou 2,5–25 mg/mol (chez l'homme), ou 3,5–35 mg/mol (chez la femme) creatinine urinaire ; echantillon urinaire minute : 20–200 μg/min. La place du dosage semi-quantitatif (bandelettes) n'est pas clairement definie. La microalbuminurie est consideree comme un reflet d'une atteinte generalisee de l'endothelium, mais ce n'est pas demontre. Chez le sujet diabetique La microalbuminurie est un marqueur independant de risque cardiovasculaire (CV), renal et de mortalite totale chez les diabetiques de type 1 et 2. L'augmentation de l'EUA au cours du temps est un marqueur de risque CV et renal chez le diabetique de type 1 ; sa regression est associee a une regression de ces risques. Chez le sujet non diabetique La microalbuminurie est un marqueur independant de risque CV, de risque de diabete, d'alteration de la fonction renale et de mortalite totale. Elle est un marqueur de risque de developper une hypertension arterielle chez le sujet normotendu et un marqueur de risque d'evolution defavorable, ou de deces au cours de cancers et de lymphomes. L'elevation ou la persistance d'une EUA elevee au cours du temps est associee a un pronostic pejoratif chez certains hypertendus. La mesure d'EUA peut etre recommandee chez certains hypertendus ayant un ou deux facteurs de risque CV associes dont le risque CV semble mal evalue ou ayant une hypertension arterielle (HTA) refractaire : la microalbuminurie indique ici un risque CV eleve et incite a assurer un controle tensionnel strict. Il y a peu d'etudes chez les sujets non hypertendus et non diabetiques ; elles suggerent globalement que la microalbuminurie est un facteur de comorbidite et de mauvais pronostic comme chez les sujets hypertendus ou diabetiques. En prevention secondaire, la microalbuminurie est un marqueur de risque independant, mais n'a pas de retombees therapeutiques specifiques. Il n'est pas recommande de rechercher systematiquement une microalbuminurie chez le sujet non hypertendu, non diabetique, sans antecedent de maladie renale. Il est recommande d'effectuer une surveillance de la fonction renale annuelle (excretion urinaire d'albumine creatininemie et estimation du debit de filtration glomerulaire) chez les sujets microalbuminuriques. Therapeutique Chez tout patient ayant une microalbuminurie : reduction ponderale et de l'apport sode excessif ( chez le diabetique , prescription d'un inhibiteur de l'enzyme de conversion (diabete de type 1) ou d'un antagoniste des recepteurs de l'angiotensine 2 (diabete de type 2) a dose suffisante en premiere intention. Les diuretiques thiazidiques ont un effet synergique avec les bloqueurs du systeme renine angiotensine sur la reduction de l'EUA ; chez le non diabetique , les cinq grandes classes d'antihypertenseurs (IEC, ARA2, diuretiques, antagonistes calciques, betabloquants) sont utilisables en premiere intention.

The interindividual age-related decrease in baroreflex sensitivity (BRS) was reported in many cross-sectional studies. However, the long-term intraindividual decrease in BRS has never been confirmed by longitudinal studies. Data obtained from a 5-year prospective study designed to assess the 5-year stress effects on blood pressure (BP) provided the opportunity to assess longitudinal aging process on spectrally determined BRS (S-BRS) using the cross spectral analysis. This analysis was carried out in 205 men aged between 18 and 50 years who had 2 valid beat to beat BP recordings (Finapress) at a mean 5-year interval. At inclusion and at end of follow-up, S-BRS was significantly correlated with age ( r =−0.50, P r =−0.33, P

In view of the enormous quantity of medical information published, critical reading is essential for the rapid selection of information relevant to the physician's practice. Methodological quality is essential. The study design that produces the best evidence of the effects of an intervention is the randomized controlled clinical trial. Valid and reliable metaanalysis can increase the precision of these results. Only studies using clinically relevant outcome measures, analyzed according to intention to treat, deserve attention. Trials of lower methodological quality must be considered as hypothesis-generating trials. The groups receiving the study treatment and the reference treatment must be comparable to avoid sampling bias. The simpler the statistics, the more reliable the results, as a general rule.

Summary Objectives Of the factors so far studied that might explain insufficient blood pressure (BP) control, the principal characteristics involve the treatment (pharmacological activity, drug combinations and adverse effects) or the patient (compliance, tolerance). The original purpose of this observational study was to investigate factors that may influence the BP target set by physicians for patients with uncontrolled hypertension. Methods In this survey, 2024 general practitioners included 6031 patients with uncontrolled hypertension (BP>140/90 mmHg). Results The mean age of the study population (44% women and 42% workers) was 60± 12 years. Mean BP values were 160.8±11.8 mmHg systolic and 93.3±8.4 mmHg diastolic. The systolic BP targets set by the physicians (mean: 136.5±5.6 mmHg) were in accordance with current guidelines. Nevertheless, the steps taken to achieve these goals were barely adequate. Our results suggest that physician-related barriers to achieving BP control are associated with use of a single drug for treatment and BP targets that rise with patients' BP and body mass index. As expected, diabetes mellitus and microalbuminuria prompted physicians to set lower BP targets. Conversely, contrary to guidelines, kidney failure was not taken into account in the therapeutic decision. Conclusion Improving the therapeutic management of hypertension and continuing to decrease its effects on cardiovascular and renal morbidity and mortality require better continuing education for healthcare professionals or the development of incentive plans or both.

International audience; The relationship between blood pressure (BP) and cardiovascular diseases has been extensively documented. However, the benefit of anti-hypertensive drugs differs according to the type of cardiovascular event. Aortic stiffness is tightly intertwined with BP and aorta cross-talk with small arteries. We endeavored to elucidate which BP component and type of vessel remodeling was predictive of the following outcomes: fatal myocardial infarction (MI), fatal stroke, renal -, coronary- or cerebrovascular-related deaths. Large vessel remodeling was estimated by an aortography-based aortic atherosclerosis score (ATS) while small vessel disease was documented by the presence of a hypertensive retinopathy. We included 1031 subjects referred for hypertension workup and assessed outcomes 30 years later. After adjustment for major risk factors, ATS and pulse pressure (PP) were predictive of coronary events while mean BP (MBP) and retinopathy were not. On the contrary, MBP was predictive of cerebrovascular and renal related deaths while ATS and PP were not. Retinopathy was only predictive of cerebrovascular related deaths. Lastly, the aortic atherosclerosis phenotype and increased PP identified patients prone to develop fatal MI whereas the retinopathy phenotype and increased MBP identified patients at higher risk of fatal stroke. These results illustrate the particular feature of the resistive coronary circulation comparatively to the brain and kidneys' low-resistance circulation. Our results advocate for a rational preventive strategy based on the identification of distinct clinical phenotypes. Accordingly, decreasing MBP levels could help preventing stroke in retinopathy phenotypes whereas targeting PP is possibly more efficient in preventing MI in atherosclerotic phenotypes.

Background Pathogenesis of primary hypertension remains unclear, because many heterogeneous factors (diet, physiologic, and psychological factors) are simultaneously involved. We have conducted an original analysis to study the influence of the combination of these factors on BP evolution. Methods Seven homogeneous clusters were constituted from 213 healthy normotensive subjects taking into account 10 variables. Those variables used to cluster homogeneous “risk profiles” are usually considered as potential risk factors for hypertension: age, body mass index, alcohol consumption, sodium/potassium urinary ratio, systolic blood pressure (SBP) and heart rate response to mental stress, baroreflex sensitivity (BRS), job demand, job latitude, and behavioral pattern (personality score). Five-year BP evolution (ΔSBP or Δdiastolic BP [DBP]) was compared between risk profiles. Results Four clusters of subjects representing about 50% of the population had a significantly higher 5-year ΔSBP (≥5 mm Hg) compared to the 5-year ΔSBP of the two clusters in which SBP did not increase. These four clusters had a low BRS. Two profiles that group six unfavorable risk factors had the most detrimental 5-year ΔSBP. Interestingly, perceived high job demand in a cluster of younger subjects with a high personality score and a low BRS had also a detrimental SBP evolution. Conclusions The major interest of this study is to highlight that hypertension development is not univocal between subjects and that different combinations of factors could explain differential BP evolution in groups of subjects sharing the same risk profile. A lower BRS was a consistent predictor for detrimental 5-year BP evolution.

Background The aim of this analysis was to test, in a large sample of normotensive subjects, the short-term influence of job strain on the onset of hypertension. Methods According to the questionnaire of Karasek et al, job strain was divided into four modalities: (high strain, low strain, passive, and active) based on job demand (eg, the need to work hard and quickly) and job latitude (eg, control over skill use, time allocation, and organizational decisions) scores. High strain (HS) was defined by a high demand and a low job decision latitude. Individual data obtained in 926 (age 41 ± 6 years) healthy normotensive or newly diagnosed hypertensive subjects were analyzed. Subjects participated in two prospective work site surveys designed to assess the influence of job strain on hypertension development. Relationships between job strain modalities and work site blood pressure (BP) levels were assessed using a general linear model. A complementary analysis using the the Pearson Φ coefficient (Z analysis) was implemented to explore nonlinear or scattered relationships between job strain and onset of hypertension. Results Systolic BP (SBP) was linearly related significantly to BMI and alcohol consumption, whereas diastolic BP (DBP) was related to age. The linear model did not find any relationship between SBP or DBP and job strain modalities. Using the Z analysis, development of systolic hypertension (SBP >140 mm Hg) was significantly associated with high job strain ( P Conclusions Our results suggest that there is no global relationship between job strain and BP levels. However our methodology revealed a significant association between job strain and work site BP in a predominantly male subgroup of newly diagnosed hypertensive subjects exposed to high job strain.

Hypertension is more frequent and more severe in blacks than in other racial groups. Salt-sensitive and low-renin hypertension are both more frequent in blacks. Cardiovascular morbidity appears to be similar in blacks and whites and depends on the classic cardiovascular risk factors. Kidney damage leading to end-stage renal disease is more frequent in blacks. Reduced salt intake improves drug efficacy. Diuretics and calcium channel blockers are more effective in lowering blood pressure, while angiotensin-converting-enzyme inhibitors may be more effective in preventing organ damage. Specific trials are needed to evaluate therapeutic benefits in blacks.

We have reported that high job strain was associated with a significantly higher diastolic blood pressure (DBP) of 4.5 mm Hg during the working hours, irrespective of BP reactivity to a stress test. We report the final results of the first 5-year follow-up study, which aimed to assess the respective influences of perception of professional strain and cardiovascular reactivity to a mental stress test on BP. A cohort of 292 healthy subjects (mean±SEM age, 38±1 years) was followed up for progression to hypertension outcome, which was defined as an increase in systolic blood pressure (SBP) or DBP >7 mm Hg or a DBP >95 mm Hg during follow-up. None of the subjects was lost to follow-up, and 209 subjects completed the study. The high-strain (HS) group, representing 20.9% of the subjects, was compared with the remaining subjects (non-high-strain [NHS]). Similarly, the subjects with the highest BP stress reactivity (HR; 20.9% of subjects) were compared with the remaining subjects (NHR). Progression to hypertension was reached by 93 subjects (31.8%). Kaplan-Meier survival estimates revealed that neither HS nor HR increased the incidence of progression to hypertension. End-of-follow-up 24-hour ambulatory BPs that were similar in HS and NHS (120±2 vs 120±1 mm Hg, respectively) and in HR and NHR (122±2 vs 120±1 mm Hg, respectively) confirmed our findings. Age, alcohol, salt diet, body mass index, and occupation did not interfere with our results. In conclusion, cardiovascular HR and HS do not appear to be major risk markers for future high BP in healthy, young adults.

Objective To investigate further the relationships between blood pressure and sodium intake, which have been claimed to exist, but have not been clearly established, in epidemiological studies. Design and participants A 2-year follow up study of a cohort of 296 healthy volunteers working in the same company. Results Consistent with previously reported findings, covariance analysis in the entire population, including multivariate analysis to examine the potential influence of confounding variables, failed to identify a significant relationship between blood pressure and sodium intake or between their respective changes within 2 years. To test the hypothesis of a heterogeneous distribution of salt sensitivity, we calculated the statistical dependence between blood pressure and sodium intake using the Z Rho coefficient analysis that quantifies the prevalence of a statistical link between two variables. A significant dependence (P< 0.05) between diastolic (DBP) or systolic (SBP) blood pressure and sodium intake was found in 16 and 5% of the participants, respectively. The analysis of the 2-year changes in blood pressure and sodium intake reinforced our findings. Our finding of a relationship between blood pressure and sodium intake in only a few individuals may explain the lack of a global relationship between these two variables investigated by the covariance analysis in our study. Conclusion Our results suggest that 5-16% of healthy individuals have a 'salt-dependent blood pressure' and might benefit from a reduction in dietary salt intake.

Background/Aims: In hemodialysis patients, there is a marked inter-individual variability in the pharmacokinetics of vancomycin. This retrospective study was carried out to design a model describing the parameters that may influence the trough concentrations of vancomycin (TCV) in hemodialysis patients. Methods: A Bayesian model was constructed from data obtained during 314 hemodialysis sessions performed in 31 hemodialysis patients receiving vancomycin. The model's validity was assessed by goodness of fit. A bootstrap resampling method was used to calculate bias and accuracy for 80 predicted and observed TCV. Results: A total of 31 patients underwent dialysis 3 times a week for a mean duration of 4 h. Their mean age was 69 ± 12 years. The vancomycin infusion was started 30 min before the scheduled end of the dialysis session at a flow rate of 1,000 mg/h. The mean TCV of the study population was 16.1 ± 3.2 mg/l. The area under receiver operating characteristic curve of the constructed model was 95.2%. In the validation sample (80 randomly selected TCV), the observed mean TCV was 15.8 ± 3.6 mg/l, whereas the mean TCV predicted by the model was 15.7 ± 3.0 mg/l. If the mean bias was low between the predicted and observed TCV (-0.1 mg/l), SD was high (3.43 mg/l). The variables most closely linked to TCV were in descending order: weight after dialysis, weight before dialysis, the dose of vancomycin administered during the previous dialysis session and creatinine concentration before dialysis. Conclusion: This simple model describes patient-related and dialysis-related parameters that mainly influence TCV. Before its use in clinical practice, this model should be validated prospectively.

Scarce information is available on stress-induced renal behavior in humans, especially in normotensives offspring of hypertensives (HP) and in hypertensives (HT).Ten HP and 10 HT were compared to 10 normotensives with normotensive parents (NP). Systolic blood pressure (SBP) and renal functional parameters were determined during rest and stress periods.The stress SBP reactivity was significantly (P.05) higher in HP than in NP and HT. At rest, HP were characterized by a significantly (P.05) higher glomerular filtration rate. Stress significantly reduced glomerular filtration rate (-14 +/- 4 mL/min/1.73 m2, P.05) only in HT. Renal plasma flow significantly (P.05) decreased during stress in NP (-35 +/- 16 mL/min/1.73 m2) and in HT (-49 +/- 25 mL/min/1.73 m2), whereas it did not change in HP. The resulting filtration fraction increased significantly during stress only in NP (1.5% +/- 0.6%, P.05). Despite the increase in BP, stress induced a similar decrease in sodium excretion rate in NP (-52 +/- 26 micromol/min) and in HT (-56 +/- 24 micromol/min). The stress-induced sodium reabsorption occurred only in the proximal part of the tubules (lithium clearance). In HP, stress did not alter either sodium excretion rate or plasma renin activity.The stress-induced renal modifications are characterized by an efferent vasoconstriction and a paradoxical increase in sodium reabsorption that occurred in the proximal part of the tubules in NP. In HP, genetically at risk of hypertension, basal renal alterations may explain a different stress-induced renal behavior. In HT, stress-induced increase in sodium reabsorption may be involved in the sustained BP level.

Background and Objective Type 2 diabetes (T2D) and chronic kidney disease (CKD) are closely linked. This study aimed to describe and analyze the relations between renal function and glycemic control in T2D patients with overt nephropathy. Patients and methods Data were collected from a French observational prospective multicenter study. Patients included were adults with T2D, clinical proteinuria and an estimated glomerular filtration rate (eGFR) over 15 mL/min/1.73 m 2 . Baseline data and glycemic control after a one-year follow-up are presented here. Results Data from 986 adult patients were analyzed. Mean age was 70 years. Mean eGFR was 42 mL/min/1.73 m 2 , 66% of patients had proteinuria above 1 g/day. HbA1c was higher in patients with lower eGFR in a model adjusted to age, gender, body mass index, hemoglobin level and erythropoietin use. Statistical significance was lost when stepwise multivariate analysis took into account the type of pharmacological treatment used to treat hyperglycemia.The type of antidiabetic agents differed across eGFR strata. Below 60 mL/min/1.73 m 2 , the use of metformin declined while the use of insulin increased.After one year of follow up, 35% of patients had persistently poor or worsened glycemic control (HbA1c > 8%). The only covariate independently associated with this characteristic was the duration of insulin therapy. Conclusion In patients with T2D and overt nephropathy, the observed correlation of low eGFR with high HbA1c was not predicted by eGFR. Our data rather underscore a different use of antidiabetic treatments in patients with advanced renal dysfunction, and the difficulty to improve glycemic control in patients with long standing insulin therapy.

Resume But de l’etude Nous rapportons l’experience du centre hospitalo-universitaire de Lyon concernant la denervation renale pour le traitement de l’hypertension arterielle resistante. Patients et methodes Sur une periode d’un an, 17 patients (12 hommes/5 femmes) ont ete traites par une procedure de denervation renale. L’âge moyen etait de 56,5 ± 11,5 ans, l’indice de masse corporelle (IMC) de 33 ± 5 kg/m2 et la mesure ambulatoire de la pression arterielle (MAPA) des 24 heures de 157 ± 16/87 ± 13 mmHg avec en moyenne 4,2 ± 1,5 traitements anti-hypertenseurs. Resultats Nous n’avons pas observe de complications peri- ou postoperatoires dans notre cohorte. Apres un suivi median de 3 mois et un nombre de traitements anti-hypertenseurs stable (n = 4,2 ± 1,2), la baisse de pression arterielle obtenue en consultation est en moyenne de 20 ± 15 mmHg (p Conclusion Nos resultats sont en accord avec les donnees observees dans les autres centres. La reponse manometrique est significative, mais la variation interindividuelle est importante. La securite de la technique est acceptable.

The aim of this study was to compare the diagnostic performance of N-terminal pro-brain natriuretic peptide (NT-proBNP), electrocardiographic (ECG) criteria and transthoracic echocardiography (TTE) versus cardiac magnetic resonance imaging in detecting left ventricular hypertrophy (LVH). The study included 42 hypertensive subjects with mean±s.d. age 48.1±12.3 years, 57.1% men, 24-h ambulatory blood pressure 144/89 mm Hg, left ventricular ejection fraction50%, without symptoms of heart failure, and not taking any drugs that interfere with hormonal regulation. The accuracies of the methods in detecting LVH were compared at two diagnostic LVH cutoffs: low, 83 g m(-2) in men and 67 g m(-2) in women; and high, 96 g m(-2) in men and 81 g m(-2) in women. With the low and high LVH cutoffs, the areas under the receiver-operating characteristic curves and the optimal values for NT-proBNP were 0.761, 0.849, 200 and 421 pg ml(-1), respectively. An NT-proBNP level under 30 pg ml(-1) ruled out LVH with 100% sensitivity. The optimal values and literature-based values of NT-proBNP allowed a correct classification of 73-81% of the subjects. In 80-90% of the cases, the diagnostic accuracy of NT-proBNP was close to that of ECG criteria but lower than that of TTE criteria. Interestingly, combining ECG criteria and NT-proBNP level improved the diagnostic performance to be at least comparable to that of TTE: the percentages of correctly classified subjects were 73-95% vs. 67-86%, respectively. Of note, the range considers both diagnostic LVH cutoffs. The simultaneous use of ECG criteria and NT-proBNP plasma levels seemed to be powerful enough to detect LVH in most hypertensive subjects.

Psychological stress has been reported to be related to higher blood pressure (BP) and unfavorable cardiovascular profile. However, because of the complexity of personal stress management, a multilevel stress measurement strategy is needed. The aim of this cross-sectional study was to analyze the respective influences of the subjective perception of professional strain (high demand and low latitude) and cardiovascular reactivity to a stress test (Stroop stress test) on BP. Worksite BP was measured in 303 healthy normotensive subjects, 18 to 55 years of age, who worked in the same chemical company. In a subset of 70 randomly selected subjects, 24-hour ambulatory BP was performed to assess BP during working hours. The 20% of subjects who reported the highest job strain (high-strain group) or the highest BP stress reactivity (high-responder group) were compared with the remaining subjects (80%) (non-high-strain or low-responder groups). Subjects who submitted to the highest job strain had significantly higher ambulatory diastolic BP (4.5 mm Hg, P =0.015) during only working hours, whereas BP was similar during the remaining hours. Worksite BP and stress cardiovascular reactivity were similar between job strain groups. BP stress reactivity did not influence worksite and ambulatory BP. Spontaneous BP variability assessed by standard deviation and spectral analysis was equivalent between complementary groups. Prevalence of microalbuminuria was significantly higher in the high-responder group (8.2% versus 2.5% in low responders) and only slightly higher in the high-strain group (6.2% versus 3.2% in non-high strain). Potential confounding factors, such as age, gender, alcohol consumption, salt intake, body mass index, and occupation, which were equivalent between groups, did not interfere with our results. Our study quantifies high-professional strain effects on BP levels that appear to be higher only during the working period and to be independent from spontaneous BP variability and stress BP reactivity.

Although amikacin is primarily eliminated via glomerular filtration, drug concentrations are not consistently predicted in all patients. To better describe the relationship between amikacin clearance and both age and renal function, we used a new heuristic approach involving statistical analysis of dependence. Retrospective pharmacokinetic study using data from seven centres in France. 634 patients with sepsis aged between 18 and 98 years of age who received intravenous amikacin. Clearance of amikacin was modelled using the NonParametric EM algorithm for a two-compartment model (NPEM2) with intravenous infusion. A total of 2499 serum amikacin determinations was available for analysis. The relationship between the clearance of amikacin and age was weak. Interestingly, the Z method, which filters data based on dependence criteria, selected data that were best fitted by a polynomial function (r = 0.90; p < 0.001). This representation of the polynomial function was similar to a previously proposed theoretical model describing covariations between the clearance of amikacin and age. However, the polynomial function applied to only 33% of the patients that were selected by the Z method. The correlation between the clearance of amikacin and renal function was also relatively low (r = 0.39). The Z method exhibited a continuous and strong dependence pattern between the clearance of amikacin and age for 49% of the patients. The Z methodology, which filters data using dependence criteria, confirms that age, renal function and amikacin clearance are strongly related, but only in less than half of a large sample of patients with sepsis without renal pathology. These results suggest that other variables should be taken into account in order to improve the description of the behaviour of amikacin. The Z methodology improved the classical description of relationships between variables, and should be applied to better select pertinent variables in pharmacokinetic studies.