Diuretic Research Articles

Comparison of effectiveness and safety of high-dose native vitamin D versus active vitamin D in the treatment of hypoparathyroidism

Objective To investigate the effectiveness and safety of high-dose native vitamin D versus active vitamin D by retrospective analysis of clinical data in patients with non-surgical hypoparathyroidism (ns-HP) in our hospital. Methods ns-HP patients with stable therapeutic schedule in recent three years were included. According to the vitamin D agents used, patients were divided into three groups: active vitamin D group, native vitamin D group, and mixed vitamin D group. The effectiveness was evaluated by analysis of markers including post-treatment serum calcium, incidence of hypocalcemia, hypocalcemic symptoms and signs. The safety was evaluated in various groups by analyzing incidences of hypercalcemia and hypercalciuria, glomerular filtration rate, percentage of thiazide diuretic use, nephrocalcinosis or renal stone. Results Patients in active vitamin D group were more likely to experience episodes of hypocalcemia compared with those in native group (32.94%±21.46% vs 24.86%±10.1%, P 0.05). Conclusions Under the circumstance of regular follow-up, both high-dose native vitamin D and active vitamin D could treat ns-HP effectively and safely. Native vitamin D may be better in maintaining eucalcemia and reducing incidence of hypocalcemia compared with active vitamin D. Key words: Non-surgical hypoparathyroidism; Native vitamin D; Active vitamin D; Treatment

Application effect of metoprolol in the treatment of atrial fibrillation complicated with chronic heart failure

Objective To investigate the application effect of metoprolol in the treatment of atrial fibrillation complicated with chronic heart failure(CHF). Methods From February 2015 to February 2019, 398 elderly patients with atrial fibrillation and CHF in Wangjiangshan Branch of the People's Hospital of Zhejiang Province were selected in the study.The patients were divided into two groups according to the digital table, with 199 case in each group.The control group was treated with rest, digitalis inhalation, diuretics, angiotensin converting enzyme inhibitors, nitrate and enteric-coated aspirin.The observation group was treated with metoprolol on this basis.The effective rate of treatment, heart rate changes before and after treatment, left ventricular ejection fraction and 6-minute walking distance in the two groups were observed and analyzed. Results The effective rate of the observation group was 88.94%(177/199), which was significantly higher than 71.86%(143/199) in the control group, the difference was statistically significant (χ2=18.433, P=0.000). The highest heart rate, the lowest heart rate and the resting heart rate in the observation group after treatment were significantly better than those in the control group[(115.12±0.35)times/min vs.(122.12±16.22)times/min, (90.21±18.12)times/min vs.(94.12±11.11)times/min, (97.00±9.64)times/min vs.(102.03±11.20)times/min], the differences were statistically significant(t=4.246, 4.783, 4.662, all P<0.05). The LVEF and 6-minute walking distance of the observation group after treatment were significantly better than those of the control group[(45.0±2.0)% vs.(41.0±3.0)%, (340.09±31.45)m vs.(302.43±29.45)m], the differences were statistically significant(t=4.246, 7.662, all P<0.05). Conclusion Digitalis combined with metoprolol can effectively control the heart rate of atrial fibrillation combined with CHF, improve ventricular function and increase cardiac endurance.The combined therapy is worthy of promoting in this disease. Key words: Heart failure; Atrial fibrillation; Digitalis; Metoprolol; Heart rate; Stroke volume

P324Impact of impaired right ventricular strain on the prognosis of HFpEF

Abstract Background Right ventricle (RV) strain has emerged as an accurate and sensitive tool for RV function assessment and is a powerful predictor of survival in heart failure with reduced ejection fraction. The impact of impaired RV strain on prognosis of HFpEF patients however, remains unclear. Purpose We sought to analyze RV global longitudinal strain (RV-GLS) by 2D speckle tracking echocardiography (STE) in controls and HFpEF patients and determine its prognostic value. Methods Between January 2015 and June 2017, we prospectively enrolled 163 consecutive patients with HFpEF (78±9 years, 62% women) and 27 age and sex matched controls (76±5 years, 67% women). All patients underwent complete 2D echography. Myocardial deformation was assessed on a dedicated four chambers view, with a speckle tracking software. Due to poor tracking quality, RV-GLS could not be analyzed in 14 patients (7.4%). Impaired RV-GLS was defined as a GLS above −17.5% corresponding to the mean + 2 SD of age and sex matched controls. HFpEF patients were followed up for a combined outcome of all-cause mortality and first HF hospitalization. Results Mean RV-GLS was significantly altered in HFpEF patients compared to controls (−21.7±4.9% vs −25.9±4.2%; p&lt;0.001). 28 HFpEF patients (19%) had an impaired RV-GLS. During a mean follow-up of 19±9months, 73 HFpEF patients (49%) reached the combined outcome (15 all cause deaths and 58 first HF hospitalization). In univariate Cox regression analysis, loop diuretic medication (HR 1.92 [1.10–3.32], p=0.021), low hemoglobin (HR 0.85 [0.75–0.97], p=0.013), low eGFR (HR 0.97 [0.96–0.99], p&lt;0.001), E wave velocity (HR 1.01 [1.00–1.02], p&lt;0.001), septal E/e' (HR 1.03 [1.00–1.05], p=0.011) and impaired RV-GLS (HR 2.01 [1.19–3.40], p=0.009) were significantly associated with worse prognosis. In multivariate Cox analysis, hemoglobin levels (HR 0.83 [0.72–0.96], p=0.01), eGFR (HR 0.98 [0.97–0.99]; p=0.009) and impaired RV-GLS (HR 2.48 [1.38–4.44], p=0.002), were independent predictors of the combined outcome. Kaplan-Meier event free survival curves show that HFpEF patients with RV-GLS above −17.5% had worse prognosis than those with better myocardial deformation (p=0.009, Figure). Conclusions RV-GLS is significantly different between controls and HFpEF patients. In HFpEF, impaired RV-GLS is associated with worse prognosis.

A Pilot Study Embedding Clinical Pharmacists Within an Interprofessional Nephrology Clinic for the Initiation and Monitoring of Empagliflozin in Diabetic Kidney Disease

Background: The American Diabetes Association (ADA) recommends sodium-glucose cotransporter-2 (SGLT2) inhibitors as the second medication to be started, after metformin, for patients with chronic kidney disease (CKD). Sodium-glucose cotransporter-2 inhibitors may cause volume, blood pressure, and electrolyte disturbances; consequently, frequent monitoring and adjustments to other diabetes, blood pressure, and/or diuretic medications may be necessary. Objective: To evaluate the safety and efficacy of an interprofessional clinic model partnering nephrologists and pharmacists for the initiation and monitoring of SGLT2 inhibitors. Methods: A clinical pharmacist was embedded within the nephrology clinic to provide patient education, telephone follow-up, and to work collaboratively with the nephrologists. Diabetes, hypertension, and diuretic regimens were adjusted as needed after empagliflozin initiation. Diabetes regimens were adjusted to adhere to the 2019 ADA guidelines that promote agents with CKD and atherosclerotic cardiovascular disease benefit. Results: Fourteen patients were initiated on empagliflozin during the study period. Urine albumin-to-creatinine ratio (UACR) improved (mean % change −12% ± 61%); the mean percentage change was greater in patients with a higher baseline UACR. The mean change in hemoglobin A1c was 0.3% ± 0.6%. Common adverse reactions were observed and improved over time; no serious adverse drug reactions occurred. Finally, empagliflozin initiation necessitated adjustments to diabetes, hypertension, and diuretic regimens in almost all patients (n = 13, 93%). Conclusion: The implementation of an innovative, interprofessional care model within a nephrology clinic for the initiation and monitoring of empagliflozin in patients with DKD demonstrated clinical benefit with minimal safety concerns.

Antioxidant Mechanism of Xiaojin Pill () for Treatment of Peyronie's Disease in Rats Based on Matrix Metalloproteinases.

To evaluate the effects of Xiaojin Pill () in the treatment of Peyronie's disease (PD) in a rat model. Twenty-four male Sprague-Dawley rats were randomly divided into four groups with 6 in each: sham operation, PD model, vehicle control and Xiaojin Pill groups. The rats in the sham operation group received penile tunica albsginea (TA) injection with 50 μL vehicle, while the rats in the other 3 groups received 50 μL penile TA injection of 50 μg transforming growth factor (TGF)-β1. Forty-two days after the injection, rats in the vehicle control and Xiaojin Pill groups received 0.5 mL water and Xiaojin Pill solution (107 mg/kg of body weight), respectively by gavage for 28 days, while those in the sham operation and PD model groups did not receive any intervention. After intervention, the expressions of matrix metalloproteinase 2/9 (MMP2/9), nitric oxidesynthase (NOS), superoxide dismutase (SOD) and malondialdehyde (MDA) were measured. Rats in the PD model and vehicle control groups presented obvious fibrosis in corpus cavernosum (CC) and demonstrated a significantly increased expressions of MMP2 and MMP9 in the CC compared with the sham operation group (all P<0.01). In contrast, the expressions of MMP2 and MMP9 in the Xiaojin Pill group were significantly down-regulated (both P<0.01). In addition, the levels of NOS and MDA in CC were significantly increased while the activity of SOD was decreased in the PD model and vehicle control groups compared with the sham operation group (all P<0.01). After Xiaojin Pill treatment, the levels of MDA, NOS and SOD appeared to be corrected (all P<0.01). Xiaojin Pill could reduce fibrosis in the CC by decreasing the expressions of MMPs, NOS and MDA, and by increasing the activity of SOD. Therefore, Xiaojin Pill might be a therapeutic option for PD.

Review of mechanism on astragalus membranaceus in two-ways regulation of blood pressure

Astragalus membranaceus is one of the frequently used qi tonifying herbal medicines. It can regulate blood pressure. This paper reviewed the studies on the two-way regulation of blood pressure of Astragalus membranaceus in recent years, even thought the Astragalus membranaceus has been regarded to cure hyperhension due to qi deficiency. It can lower the pressure with large dosage or in liquid-fried form. Astragalus membranaceus, Astragalus membranaceus as the sovereign drug of the formulas or Astragalus membranaceus combined with western medicine can regulate blood pressure. It was found that the effect of reducing blood pressure was mainly related to the decrease of heart rate, dilation of blood vessels, inhibition of oxidative stress, reduction of calcium ion level, diuretics, change the content of growth factor and receptor, lowering uric acid, reduction of cysteine levels, and increase insulin sensitivity.Itelevated the blood pressure, mainly related to the increase of cardiac output and vasoconstriction. Key words: Astragalus membranaceus; Blood pressure; Two-ways regulation; Review

Distinct effects of antihypertensives on depression in the real-world setting: A retrospective cohort study

BackgroundEvidence is increasing that pathways of antihypertensives may have a role in the pathogenesis of depression. However, how the class of antihypertensives affects depression risk remains unclear. MethodsThe effects of different classes of antihypertensives on depression were explored using an insurance database in Beijing, China. Antihypertensives in our study included calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), beta-blockers (BBs), and diuretics (DIUs). Those initially treated with only one class of antihypertensives were included. Stratified analysis was conducted for demographic characteristics, comorbidities, and statin prescriptions. ResultsIn total, 181,709 newly detected hypertension patients were included. The median follow-up period was 4.33 years and 19,030 participants were with depression by the end. After adjusting for covariates, the incidence density (95% confidence interval, CI) of depression in the BB, ACEI, DIU, CCB, and ARB groups was 3.16 (2.98–3.33), 3.10 (2.91–3.29), 2.70 (2.45–2.94), 2.67 (2.53–2.81), and 2.30 (2.16–2.43) per 100 person-years, respectively. Compared with ARB group, the hazard ratio (95% CI) of depression for BB, ACEI, DIU, and CCB group was 1.37 (1.32–1.43), 1.35 (1.28–1.42), 1.17 (1.08–1.27), and 1.16 (1.12–1.21), respectively. Stratified analysis suggested the highest depression ID remained within the BB or ACEI group. LimitationsDetailed clinical information was unavailable, which may introduce bias. Patients on monotherapy as initial treatment were included and caution is needed for extrapolation. ConclusionsCompared with ARBs, there may be a class effect of other antihypertensives on the risk of depression.

Urocortin 2 in patients with hypertension treated with angiotensin converting enzyme inhibitors or angiotensin receptor blockers.

Urocortin 2 (Ucn2) - corticotropin-releasing hormone receptor 2 signalling has favourable effects in the cardiovascular system, including vasodilation, lowering of blood pressure and systemic peripheral resistance, increase in cardiac output and cardiac contractility, as well as cardioprotection against ischemia-reperfusion injury. Vasodilation and lowering of blood pressure seem to be very interesting and important effects, but their mechanism and interaction with the antihypertensive drugs have not been evaluated. The aim of the present study was to assess the relationship between Ucn2 concentration and antihypertensive therapy in patients with primary hypertension. We examined a group of 65 patients with primary hypertension receiving at least 3 antihypertensive drugs. In all of them plasma level of Ucn2, anthropometric measurements, biochemical tests, ambulatory blood pressure monitoring (ABPM), and echocardiography were performed. There were no differences in Ucn2 level related to beta-blockers, calcium channel blockers or diuretics, but we observed that in patients treated with angiotensin converting enzyme inhibitors (ACEI) (n = 52) serum Ucn2 levels were significantly higher than in patients treated with angiotensin-receptor blockers (ARBs) (n = 13) (10.93 versus 5.56 ng/mL; P < 0.05). Moreover, we did not observe any differences in terms of blood pressure on ABPM, biochemical measurements, left ventricular mass index, or presence of diabetes. In addition, in a small subgroup receiving alpha-blockers we also found a lower level of Ucn2, with coexisting higher systolic blood pressure at night, higher left ventricle mass index (LVMI) and more frequent occurrences of diabetes compared to non-alpha-blockers. Our findings suggest that the hypotensive action of renin-angiotensin-aldosterone system blockade may be related to the urocortin system. Ucn2 may be an important element in the mosaic of blood pressure-lowering factors in patients treated for essential hypertension.

A Comparison of Symptoms Among Patients with Head and Neck or Truncal Lymphedema and Normal Controls.

Background: Symptoms associated with midline lymphedema are not fully understood and it is unclear if symptoms associated with swelling in the head and neck are similar to those associated with swelling in the truncal region of the body. Objectives: Describe symptoms experienced by those with head and neck and truncal lymphedema. Compare symptom presence, intensity, and distress among those two groups and participants with no lymphedema. Methods: Cross-sectional descriptive study administered by online survey. Results: Nonlymphedema participants were younger than the lymphedema groups. Those with truncal lymphedema took more diuretic medications than the other groups. Participants with truncal lymphedema experienced a greater number of symptoms than the other groups (p < 0.001). These symptoms were also more severe and intense (p < 0.001). Fourteen symptoms distinguished the truncal group from the other two groups (p < 0.001). Nine symptoms differentiated the head and neck group from the other groups (p < 0.001). Conclusion: These preliminary findings support that symptom profiles differ among those with lymphedema and those without lymphedema. The number, type, severity, and intensity of symptoms vary based upon the location of lymphedema. The need to use two lymphedema anatomical classifications (head and neck and truncal) instead of one classification (midline) when assessing lymphedema-related symptoms is also supported.

Analysis of risk factors for adverse cardiac events in adults with acute myocarditis during hospitalization

Objective To analyze the risk factors of adverse cardiac events in adults with acute myocarditis during hospitalization and provide reference for clinical diagnosis and treatment. Methods A restrospective study was conducted in 80 patients (54 males and 26 females) with acute myocarditis over 18 years old admitted to our hospital between January 2007 and December 2016. Major adverse cardiac events (MACE) were defined as death, cardiac arrest, cardiogenic shock and ventricular fibrillation. According to whether MACE occurred during hospitalization, patients were divided into two groups: the MACE group and the non-MACE group. The differences between the two groups were compared, and the risk factors were analyzed by logistic regression. Results There were 12 patients in the MACE group and 68 patients in the non-MACE group. The age of patients in the two groups was similar. Compared with the non-MACE group, the proportion of female patient in the MACE group was higher (66.7% vs 26.5%, P=0.015), and the systolic pressure (mmHg) was lower at admission (89.75±17.63 vs 112.49±16.35, P 120 ms) was significantly higher in the MACE group (75% vs 17.6%, P<0.01). In the MACE group, the proportion of diuretics and vasoactive drugs (dopamine, norepinephrine, and adrenaline) was higher (66.7% vs 25%, 91.7% vs 4.4%,66.7% vs 0,75% vs 0%, all P<0.01); the proportion of glucocorticoids and immunoglobulin was higher (33.3% vs 8.8%, P=0.038; 33.3% vs 4.4%, P=0.008), and the proportion of ventilator, CRRT, ECMO and IABP were also higher (50% vs 1.5%, 33.3% vs 0, 25% vs 0%, 25% vs 0%, all P<0.01). Logistic regression analysis showed that the OR value of MACE in female patients during hospitalization was 5.56 (95%CI: 1.49-20.71, P=0.011). The OR value of MACE in patients with reduced LVEF at admission was 5.92 (95%CI: 1.62-21.67, P=0.007).The OR value of MACE in patients with prolonged QRS wave was 14.00 (95%CI: 3.29-59.55, P<0.01). Conclusions Female patients, LVEF 120 ms) are independent risk factors for MACE in adult patients with acute myocarditis during hospitalization. Key words: Acute myocarditis; Adult; Major adverse cardiac events; Risk factors

Sex differences in antihypertensive drug use and blood pressure control

BackgroundHypertension is the most important modifiable cardiovascular risk factor. Epidemiological studies have shown the benefits of lowering blood pressure (BP), but BP control is a major challenge. Furthermore, there are...

Heart failure with preserved ejection fraction in the elderly: pathophysiology, diagnostic and therapeutic approach.

Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome characterized by symptoms and sings of heart failure with elevated left ventricular filling pressures at rest or during exercise. It is the most common type of heart failure in the elderly and its prevalence increases with age and is higher in females at any given age. HFpEF is frequently accompanied of comorbid conditions such as diabetes mellitus, obesity, atrial fibrillation and renal dysfunction. The diagnosis relies in the integration of clinical information, laboratory data and interpretation of cardiac imaging and hemodynamic findings at rest and during exercise. Conditions that have a specific treatment such as coronary artery disease, valvular disease, cardiac amyloidosis and constrictive pericarditis should be considered and evaluated as appropriate. Aggressive management of comorbidities, optimization of blood pressure control and volume status using diuretics as needed are among the current treatment recommendations. There are no specific therapies that have shown to decrease mortality in HFpEF. In symptomatic patients with history of hospital admission for decompensated heart failure, the implantation of a wireless pulmonary artery pressure monitor should be considered. Finally, given the high mortality of this condition, goals of care discussion should be initiated early and involvement of palliative care medicine should be considered.

Inspiratory Breath-Hold - A Simple Clinical Intervention to Assess Risk Threshold for Suction Events in Stable LVAD Outpatients

Purpose HeartWare HVAD flow waveforms provide important clinical information on pump function and patient hemodynamics. We assessed changes in flow waveform during inspiratory breath-hold (IBH) maneuver and whether optimization in device speed and medical therapy improved waveform characteristics. Methods We studied HeartWare HVAD patients at consecutive follow-up visits. Characteristic changes in the HVAD monitor flow waveform with IBH were assessed and compared to baseline for reduced flow waveform pulsatility (RWP); flatline (FL); and suction (S). If suction was induced, management was changed by reduction in pump speed, diuretics or anti-hypertensives. Average flow, peak and trough pump flows, flow pulsatility (peak - trough), speed and power were recorded. Baseline pump parameters were compared between patients who required a change (C) vs no change (NC) in management. Patients in the C group were further assessed post-management change (PC) at next visit. Results Sixteen patients were included: 13 male (81.25%), median age 53.7 years (range 38.7-75.6), median support duration 254 days (range 21-2540). Suction was observed with IBH in 6 (37.5%, group C) vs no suction in n=10 (62.5%, group NC). There was no significant difference in any baseline pump parameter between C vs NC (Table). Of the 6 patients in group C who underwent management change, 4 had pump speed reduction and 2 decreased diuretic medications. Pump speed was significantly lower in the PC group (2533 ± 81.6 vs 2600 ± 63.2 respectively, p=0.025) at follow up. No other significant differences in pump parameters were noted (Table). At follow up (PC) there were significantly fewer waveform abnormalities (including RWP, FL, or S) 0.94 ± 0.90 vs 2.4 ± 0.5, p=0.034. Conclusion Pump parameters and flow waveform observation at rest do not reflect suction risk in stable HVAD outpatients. IBH is a simple clinical intervention to assess suction risk threshold and can be utilized to guide changes in management. HeartWare HVAD flow waveforms provide important clinical information on pump function and patient hemodynamics. We assessed changes in flow waveform during inspiratory breath-hold (IBH) maneuver and whether optimization in device speed and medical therapy improved waveform characteristics. We studied HeartWare HVAD patients at consecutive follow-up visits. Characteristic changes in the HVAD monitor flow waveform with IBH were assessed and compared to baseline for reduced flow waveform pulsatility (RWP); flatline (FL); and suction (S). If suction was induced, management was changed by reduction in pump speed, diuretics or anti-hypertensives. Average flow, peak and trough pump flows, flow pulsatility (peak - trough), speed and power were recorded. Baseline pump parameters were compared between patients who required a change (C) vs no change (NC) in management. Patients in the C group were further assessed post-management change (PC) at next visit. Sixteen patients were included: 13 male (81.25%), median age 53.7 years (range 38.7-75.6), median support duration 254 days (range 21-2540). Suction was observed with IBH in 6 (37.5%, group C) vs no suction in n=10 (62.5%, group NC). There was no significant difference in any baseline pump parameter between C vs NC (Table). Of the 6 patients in group C who underwent management change, 4 had pump speed reduction and 2 decreased diuretic medications. Pump speed was significantly lower in the PC group (2533 ± 81.6 vs 2600 ± 63.2 respectively, p=0.025) at follow up. No other significant differences in pump parameters were noted (Table). At follow up (PC) there were significantly fewer waveform abnormalities (including RWP, FL, or S) 0.94 ± 0.90 vs 2.4 ± 0.5, p=0.034. Pump parameters and flow waveform observation at rest do not reflect suction risk in stable HVAD outpatients. IBH is a simple clinical intervention to assess suction risk threshold and can be utilized to guide changes in management.

The Cardiorenal Syndrome

In patients with chronic cardio renal syndrome chronic heart disease coexists with chronic kidney disease and poses the patients to a specifically high risk for cardiovascular events and mortality. Treatment recommendations in this condition with a high level of evidence are sparse. Mainstay of therapy in cardiorenal syndrome is fluid metabolism control and stabilization of renal and cardiac function, which can basically been achieved by substances modifying the renin-angiotensin-aldosterone-system as well as diuretics. Noteworthy, despite inducing short-term decreases in renal function, inhibition of the RAAS and diuretic medication associate with the long-term improvements of outcome (so-called pseudo-worsening of renal function). The chronic cardiorenal syndrome calls for interdisciplinary care by both nephrologists and cardiologists in order to allow high-end patient care with a maximum of beneficial effect and a minimum of treatment-related side effects.

Therapeutic effect of Baccharis anomala DC. extracts on activated hepatic stellate cells.

The therapeutic potential of Baccharis anomala DC. extracts was evaluated through its cytotoxic and antiproliferative effect and their phenotypic reversion property in activated hepatic stellate cells (HSCs). Baccharis anomala is distributed in Brazil (southeastern and south regions) and used for diuretic effect in folk medicine. Four fractions were obtained from the fractionation of the methanolic extract. Fractions III and IV decreased cell proliferation without increasing cell necrosis markers levels and induced cell cycle arrest in G1 phase. Fraction III induced phenotypic reversion through PPAR-γ activation pathway, while fraction IV did not alter PPAR-α/γ expression levels, suggesting that there is an independent PPAR-α/γ pathway involved. Hydroxybenzoic, chlorogenic and coumaric acids were identified. Fractions III and IV showed antiproliferative effect and ability to induce reversion of activated phenotype of HSCs.

Analysis of 24-hour ambulatory blood pressure monitoring in the assessment of high blood pressure medication in elderly patients

Objective To evaluate the value of ambulatory blood pressure monitoring in evaluating hypertension status and the efficacy of antihypertensive medication in hypertension patients. Methods We retrospectively collected data from 236 elderly hypertensive patients at our hospital from July 2016 to June 2017 and analyzed the blood pressure characteristics of patients under 24 h ambulatory blood pressure monitoring and the effects of different types of antihypertensive medication. Results Of 236 patients with high blood pressure, 80.1% had both higher systolic blood pressure and higher diastolic blood pressure; about 90.0% had blood pressure load greater than 40.0%; blood pressure in 57.6% of patients reached its peak both in the morning and in the afternoon; a majority(58.9%)showed a non-dipper circadian pattern.After antihypertensive drug treatment, the blood pressure indicators significantly improved(P<0.05). Common antihypertensive drugs included calcium antagonists, angiotensin converting enzyme inhibitors(ACEI), angiotensin receptor blockers(ARB), diuretics, beta blockers, and combination drugs. Conclusions 24 h ambulatory blood pressure monitoring can provide comprehensive blood pressure data, help achieve accurate assessment of blood pressure status, and may be used in the evaluation of antihypertensive drug treatment. Key words: Blood pressure monitoring; Hypertension

Subcutaneous calcinosis: a rare complication of chronic hypercalcemia.

Subcutaneous calcinosis is a rare entity that may be secondary to either tissue damage, phosphocalcic disturbance or idiopathic origin. In the context of hypercalcemia, subcutaneous calcinosis remains a rare complication with few cases reported in the litterature. We report the case of a 27-year-old patient admitted for chronic hypercalcemia with right femur fracture and renal failure. Clinical examination found hard, painless, non-inflammatory subcutaneous nodules at the 2 elbows and at the lower gum (Panel A), the elbow radiography showed radiopaque structures in favor of subcutaneous calcinosis (Panel B). The etiological investigations of hypercalcemia showed a parathyroid hormon at 2200ng/ml (15-65), with cervical ultrasound showing a right inferior parathyroid nodule of 3cm * 1.6cm, in favor of primary hyperparathyroidism. The evolution was marked by the decrease of the size of the lesions in 15 days after normalization of the phosphocalcic balance after a symptomatic treatment based on intravenous rehydration, diuretics, corticosteroid bolus and bisphosphonate. Although hypercalcemia can reach very high serum levels in primary hyperparathyroidism, it is rarely accompanied by subcutaneous calcinosis. Indeed, it is hyperphosphoremia which represents the main factor involved in the development of cutaneous calcinosis in the context of phosphocalcic disturbances, and this independently of the level of hypercalcemia. Lesions tend to resolve spontaneously when calcium and phosphate levels normalize.

The interplay of renal potassium and sodium handling in blood pressure regulation: critical role of the WNK-SPAK-NCC pathway.

Renal salt handling has a profound effect on body fluid and blood pressure (BP) maintenance as exemplified by the use of diuretic medications to treat states of volume expansion or hypertension. It has recently been proposed that a low potassium (K+) intake turns on a "renal K+ switch" which increases sodium (Na+) and chloride (Cl-) reabsorption, causing salt-retention, and in susceptible individuals, this causes hypertension. A signaling network, involving with-no-lysine (WNK) kinases, underpins the switch activity to coordinate aldosterone's two essential actions (K+ secretion and Na+ retention). A dysfunctional WNK kinase network drives excessive and inappropriate Na+, Cl- and urinary K+ retention in familial hyperkalemic hypertension (FHHt, also known as Gordon's syndrome). Mutations in genes encoding WNK1 and WNK4 or components of an ubiquitin ligase complex, cullin3, and kelch-like family member 3 (KLHL3), cause FHHt by upregulating the thiazide-sensitive sodium chloride cotransporter (NCC). Inhibition of NCC with thiazide diuretics corrects hypertension and hyperkalaemia in FHHt. These observations highlight the critical role of the NCC in the regulation of Na+ and K+ balance and of BP. Here we discuss the physiology of Na+ and K+ handling in the distal renal tubule with respect to BP regulation, with a focus on recent discoveries in the WNK- Ste20-related proline-alanine-rich kinase (SPAK)-NCC pathway.

Effect of target systolic blood pressure on cardiovascular events in patients with hypertension complicated with type 2 diabetes

Objective To compare the effects of target systolic blood pressure on cardiovascular events in patients with hypertension and type 2 diabetes after antihypertensive drugs. Methods This study was a retrospective cohort study. Randomly selected from March 2014 to March 2017, 1 563 patients with hypertension and type 2 diabetes diagnosed in the Department of Cardiology of the Tiemei Group General Hospital. There was no cardiovascular complications at admission. After admission, the population variables of each patient were recorded. Each patient was adjusted for blood pressure and blood glucose according to the doctor's advice after admission. After the hospital was discharged, the patient was followed up for blood pressure every week. The follow-up was 3-4 months. The average systolic blood pressure of each patient was recorded as the target systolic pressure. The patients who were followed up were divided into three groups according to the target systolic pressure value, namely ≤120 mmHg(1 mmHg=0.133 kPa) group, >120-130 mmHg group, >130-140 mmHg group. After that, it was changed to a weekly telephone follow-up of the nurses for a total of 3 years. The cardiovascular disease (CVD) occurred in these patients within 3 years were recorded. The CVD was used as the dependent variable, and the systolic blood pressure of each group was used as the independent variable to do COX. Proportional risk regression analysis, the hazard ratio (HR) of each group of concurrent CVD. Taking CVD as the dependent variable, HR of CVD with >130-140 mmHg group was taken as the reference value, and all population variables were used as independent variables, respectively, ≤120 mmHg group, >120-130 mmHg group and >130-140 mmHg group combined with CVD risk ratio. Results During the 3-year follow-up period, 1 401 patients with blood pressure met: 104 patients with systolic blood pressure ≤120 mmHg, 543 patients with >120-130 mmHg, and 754 patients with >130-140 mmHg. The incidence of CVD in the three groups was 14.4% (15/104), 8.8% (48/543), 7.0% (53/754). HR of CVD were 1.66, 0.96, 0.53 in ≤ 120 mmHg group, >120-130 mmHg group, >130-140 mmHg group. Compared with >130-140 mmHg group, the risk ratio of CVD in all subgroups of ≤120 mmHg group was statistically increased (HR>1, P 130-140 mmHg, >120-130 mmHg group with 65-79 years old, combined with more than 3 groups of antihypertensive drugs, patients with diuretics showed a statistically significant increase in the risk ratio of CVD (HR>1, P <0.05). Conclusions The target systolic blood pressure of patients with hypertension and type 2 diabetes should be >130-140 mmHg. For patients aged 65-79 years, more than 3 groups of antihypertensive drugs are used. Patients with diuretics should have a target systolic blood pressure of >130-140 mmHg. Key words: Hypertension; Diabetes mellitus, type 2; Cardiovascular diseases

The treatment of tumor dissolved syndrome

Tumor lysis syndrome is an oncologic emergency that seriously threatens the lives of patients.Prevention of tumor lysis syndrome is more important than treatment.According to the risk classification, identifying high risk patients and effective preventive measures can improve the prognosis of patients.Patients with tumor lysis syndrome should receive hydration, rasburicase, diuretics, correction of electrolyte imbalances and appropriate renal replacement therapy. Key words: Tumor lysis syndrome; Risk classification; Prevention; Therapy