Assessment of microalbuminuria in hypertensive patients with established coronary artery disease

Open access

Abstract

Objectives. Cardiovascular risk assessment is continuously improving due to a better understanding of the atherosclerotic pathomechanism by investigating new risk factors. Microalbuminuria is known as a predictor of renal, as well as cardiovascular morbidity and mortality in patients with hypertension. The aim of this study was to determine the clinical relevance of microalbuminuria and its relationship with traditional cardiovascular risk factors in hypertensive high-risk patients with established coronary artery disease. Methods. We have collected clinical and laboratory data from 94 hypertensive patients (currently treated or newly diagnosed) with known coronary artery disease (angiographically documented) admitted in the Institute of Cardiovascular Diseases. From January 2012 to April 2013 they were screened for microalbuminuria. For the diagnosis of microalbuminuria, a first-morning urine sample was analyzed by immunoturbidimetry (MAU range: 20-200 mg/l, the microalbuminuric group). Patients with urinary albumin excretion >200 mg/l were excluded. Patients with values <20 mg/l were considered the normoalbuminuric group. Results. A large percentage (53.2%) of the study group was found with microalbuminuria. Patients with microalbuminuria were older, mostly male, with a longer duration of hypertension, and with a higher prevalence of left ventricular hypertrophy (LVH). None of the traditional cardiovascular risk factors - age, male gender, obesity, smoking, diabetes mellitus, dyslipidemia - indicated a statistical significance in relation with MAU. Although left ventricular ejection fraction (LVEF) didn't influence the level of microalbuminuria, a strong correlation was achieved with the presence of LVH (p=0.005) and duration of hypertension (p=0.046). Conclusion. Hypertensive high-risk patients should be routinely screened for microalbuminuria and when confirmed they may need a more aggressive medical therapy to lower the cardiovascular risk.

1. Borch-Johnsen K, Feldt-Rasmussen B, Strandgaard S, Schroll M, Jensen JS. Urinary albumin excretion. An independent predictor of ischemic heart disease. Arterioscler Thromb Vasc Biol. 1999 Aug; 19(8):1992-7

2. Wada T, Shimizu M, Toyama T, Hara A, Kaneko S, Furuichi K. Clinical impact of albuminuria in diabetic nephropathy. Clinical and experimental nephrology 2012; 16: 96-101.

3. Fox CS, Matsushita K, Woodward M, Bilo HJG, Chalmers J, Heerspink HJ, et al. Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without diabetes: a meta-analysis. Lancet 2012; 380: 1662-1673.

4. Böhm M, Thoenes M, Danchin N, Bramlage P, La Puerta P, Volpe M. Association of cardiovascular risk factors with microalbuminuria in hypertensive individuals: the i-SEARCH global study. J Hypertens 2007; 25(11):2317-2324

5. Ibsen H, Olsen MH, Wachtell K, Borch-Johnsen K, Lindholm LH, Mogensen CE, et al. Reduction in albuminuria translates to reduction in cardiovascular events in hypertensive patients: losartan intervention for endpoint reduction in hypertension study. Hypertension 2005; 45(2):198-202

6. Parving HH, Lehnert H, Brochner-Mortensen J, Gomis R, Andersen S, Arner P. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med 2001; 345(12):870-878

7. Agrawal B, Berger A, Wolf K, Luft FC. Microalbuminuria screening by reagent strip predicts cardiovascular risk in hypertension. J Hypertens. 1996; 14:223-228.

8. Jensen JS, Feldt-Rasmussen B, Borch-Johnsen K, Clausen P., Appleyard M, Jensen G. Microalbuminuria in arterial hypertension: relation to cardiovascular disease and antihypertensive agents. J Hum Hypertens. 1997;11:727-732

9. Pontremoli R, Sofia A, Ravera M, Nicolella C, Viazzi F, Tirotta A, et al. Prevalence and clinical correlates of microalbuminuria in essential hypertension: The Magic Study. Hypertension. 1997; 30:1135-1143.

10. Jensen JS, Feldt-Rasmussen B, Strandgaard S, Schroll M, Borch-Johnsen K. Arterial hypertension, microalbuminuria, and risk of ischemic heart disease. Hypertension 2000; 35:898-903.

11. Vaur L, Gueret P, Lievre M, Chabaud S, Passa P. Development of congestive heart failure in type 2 diabetic patients with microalbuminuria or proteinuria: observa- tions from the DIABHYCAR (type 2 DIABetes, Hypertension, CArdiovascular Events and Ramipril) study. Diabetes Care 2003; 26:855-860.

12. Yuyun MF, Khaw KT, Luben R, Welch A, Bingham S, Day NE, et al. Microalbuminuria and stroke in a British population: the European Prospective Investigation into Cancer in Norfolk (EPIC-Norfolk) population study. J Intern Med 2004; 255:247-256.

13. Lakka TA, Salonen R, Kaplan GA, Salonen JT. Blood pressure and the progression of carotid atherosclerosis in middle-aged men. Hypertension 1999; 34:51-56.

14. Schmieder RE, Schrader J, Zidek W, Tebbe U, Paar WD, Bramlage P, et al. Low-grade albuminuria and cardiovascular risk: What is the evidence? Clin Res Cardiol 2007; 96:247-257

15. Garg AX, Kiberd BA, Clark WF, Haynes RB, Clase CM. Albuminuria and renal insufficiency prevalence guides population screening: results from the NHANES III. Kidney Int. 2002; 61(6):2165-75.

16. Hillege HL, Janssen WM, Bak AA, Diercks GF, Grobbee DE, Crijns HJ, et al. Microalbuminuria is common, also in a nondiabetic, nonhypertensive population, and an independent indicator of cardiovascular risk factor and cardiovascular morbidity. J Intern Med. 2001; 249(6):519-26.

17. Mahfoud F, Ukena C, Pöss J, Bramlage P, Volpe M, Thoenes M, et al. Microalbuminuria independently correlates to cardiovascular comorbidity burden in patients with hypertension. Clin Res Cardiol. 2012 Sep; 101(9):761-6

18. Klausen KP, Parving HH, Scharling H, Jensen JS. The association between metabolic syndrome, microalbuminuria and impaired renal function in the general population: impact on cardiovascular disease and mortality. J Intern Med. 2007 Oct; 262(4):470-8.

19. de Simone G, Gottdiener JS, Chinali M, Maurer MS. Left ventricular mass predicts heart failure not related to previous myocardial infarction: the Cardiovascular Health Study. Eur Heart J 2008; 29(6):741-747

20. Gerstein HC, Mann JF, Yi Q, Zinman B, Dinneen SF, Hoogwerf B, et al.; HOPE Study Investigators. Albuminuria and risk of cardiovascular events, death, and heart failure in diabetic and nondiabetic individuals. JAMA. 2001 Jul 25; 286(4):421-6

21. Klausen K, Borch-Johnsen K, Feldt-Rasmussen B, Jensen G, Clausen P, Scharling H, et al. Very low levels of microalbuminuria are associated with increased risk of coronary heart disease and death independently of renal function, hypertension, and diabetes. Circulation. 2004 Jul 6; 110(1):32-5

22. Kannel WB. Risk stratification in hypertension: new insights from the Framingham Study. Am J Hypertens 2000; 13(1 Pt2):3S-10S

23. Deckert T, Kofoed-Enevoldsen A, Nørgaard K, Borch-Johnsen K, Feldt-Rasmussen B, Jensen T. Microalbuminuria. Implications for micro- and macrovascular disease. Diabetes Care. 1992 Sep; 15(9):1181-91

24. Stehouwer CD, Smulders YM. Microalbuminuria and risk for cardiovascular disease: Analysis of potential mechanisms. J Am Soc Nephrol. 2006 Aug; 17(8):2106-11.

25. Deckert T, Feldt-Rasmussen B, Borch-Johnsen K, Jensen T, Kofoed-Enevoldsen A. Albuminuria reflects widespread vascular damage. The Steno hypothesis. Diabetologia 1989; 32:219-26.

26. Stehouwer CD, Gall MA, Twisk JW, Knudsen E, Emeis JJ, Parving HH. Increased urinary albumin excretion, endothelial dysfunction, and chronic low-grade inflammation in type 2 diabetes: progressive, interrelated, and independently associated with risk of death. Diabetes 2002; 51:1157-65.

27. Stehouwer CD, Nauta JJ, Zeldenrust GC, Hackeng WH, Donker AJ, den Ottolander GJ. Urinary albumin excretion, cardiovascular disease, and endothelial dysfunction in non-insulin-dependent diabetes mellitus. Lancet 1992; 340:319-23.

28. Festa A, D’Agostino R, Howard G, Mykkanen L, Tracy RP, Haffner SM. Inflammation and microalbuminuria in nondiabetic and type 2 diabetic subjects: The Insulin Resistance Atherosclerosis Study. Kidney Int 2000; 58:1703-10.

29. Klausen P, Feldt-Rasmussen B, Jensen G, Jensen JS. Endothelial haemostatic factors are associated with progression of urinary albumin excretion in clinically healthy subjects: a 4-year prospective study. Clin Sci (Lond) 1999; 97:37-43.

30. Jensen JS. Renal and systemic transvascular albumin leakage in severe atherosclerosis. Arterioscler Thromb Vasc Biol 1995; 15:1324-9.

31. Jensen JS, Feldt-Rasmussen B, Borch-Johnsen K, Jensen KS, Nordestgaard BG. Increased transvascular lipoprotein transport in diabetes: association with albuminuria and systolic hypertension. J Clin Endocrinol Metab 2005; 90:4441-5.

32. Garg JP, Bakris GL. Microalbuminuria: marker of vascular dysfunction, risk factor for cardiovascular disease. Vasc Med. 2002 Feb; 7(1):35-43

33. Ayerden Ebinç F, Haksun E, Ulver DB, Koç E, Erten Y, Reis Altok K, et al. The relationship between vascular endothelial growth factor (VEGF) and microalbuminuria in patients with essential hypertension. Intern Med. 2008; 47(17):1511-6

34. Mancia G, Laurent S, Agabiti-Rosei E, Ambrosioni E, Burnier M, Caulfield MJ, et al. Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document. J Hypertens 2009; 27(11):2121-2158

35. Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: Executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2010; 122:2748-64

36. Viazzi F, Leoncini G, Pontremoli R. Global cardiovascular risk assessment in the management of primary hypertension: the role of the kidney. Int J Hypertens. 2013; 2013:542646.

37. Leibowitz D, Planer D, Ben-Ibgi F, Rott D, Weiss AT, Bursztyn M. Measurement of wall thickness alone does not accurately assess the presence of left ventricular hypertrophy. Clin Exp Hypertens 2007; 29:119-125.

38. Bauml MA, Underwood DA. Left ventricular hypertrophy: an overlooked cardiovascular risk factor. Cleve Clin J Med. 2010 Jun; 77(6):381-7.

39. Mann JF, Schmieder RE, Dyal L, McQueen MJ, Schumacher H, Pogue J, et al. TRANSCEND® (Telmisartan Randomised Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease) Investigators: Effect of telmisartan on renal outcomes: a randomized trial. Ann Intern Med 2009; 7:1-10.

40. Mann JF, Schmieder RE, McQueen M, Dyal L, Schumacher H, Pogue J, et al. The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET®) Investigators: Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET® study): a multicentre, randomised, double-blind, controlled trial. Lancet 2008; 372:547-53

41. Chatzikyrkou C, Menne J. Update on the ROADMAP clinical trial report: olmesartan for the prevention or delay of microalbuminuria development in type 2 diabetes. Expert Rev Cardiovasc Ther. 2012 Sep;10(9):1087-92.

Revista Romana de Medicina de Laborator

Romanian Journal of Laboratory Medicine

Journal Information


IMPACT FACTOR 2018: 0,800
5-year IMPACT FACTOR: 0,655



CiteScore 2017: 0.31

SCImago Journal Rank (SJR) 2018: 0.194
Source Normalized Impact per Paper (SNIP) 2018: 0.306

Cited By

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 154 114 20
PDF Downloads 57 49 8