MD Conference Express EASD 2012 - (Page 33)
out, lifestyle- and medication-related issues have been eliminated, and secondary causes of rHT have been excluded) a pharmacologic approach should be developed. At present the most effective treatment paradigm appears to be triple-combination drug therapy [Calhoun DA et al. Hypertension 2009]. In patients uncontrolled by triple therapy, spironolactone has been shown to be effective in lowering BP [Chapman N et al. Hypertension 2007; AlvarezAlvarez B et al. J Hypertension 2010]. rHT is highly prevalent and frequently accompanied by other cardiovascular risk factors. Prof. Ruilope concluded that, following failed pharmacological therapy, renal denervation should play a role in its treatment. Felix Mahfoud, MD, Universitätsklinikum des Saarlandes, Saarbrücken, Germany, discussed the topics of glucose metabolism, insulin resistance, heart failure, and OSA in relation to renal denervation. In a pilot study in patients with rHT, renal denervation reduced fasting, mean 2-hour glucose and C-peptide levels, and insulin sensitivity, in addition to significantly reducing BP (Figure 2), suggesting that the procedure may provide protection for patients with rHT and metabolic disorders who are at high cardiovascular risk [Mahfoud F et al. Circulation 2011]. Studies have also shown that bilateral renal nerve ablation is associated with substantial improvement in insulin sensitivity, while reducing glomerular hyperfiltration and urinary albumin excretion [Schlaich MP et al. J Hypertens 2011] and improving glucose tolerance [Witkowski A et al. Hypertension 2011]. Figure 2. BP Reduction After Renal Denervation.
Systolic Diastolic 1 month -10 -4 3 months -12 -3 p=0.277
Sympathetic activity correlates to NYHA class and heart failure, while chronic heart failure (CHF) is characterized by increased sympathetic activity, which is proportional to severity of CHF. Cardiac norepinephrine spillover increased 3-fold in mild to moderate CHF patients and 4-fold in severe CHF patients. This indicates increased amounts of transmitter available at neuroeffector junctions that precede the augmented sympathetic outflow to the kidneys and skeletal muscle found in advanced CHF. Because previous research suggests that the kidneys are a major contributor to heart failure, a study of the effects of sympathetic renal denervation in patients with CHF is in progress. OSA is associated with sympathovagal imbalance, atrial fibrillation, and postapneic BP increases. Renal denervation displays antiarrhythmic effects by reducing negative tracheal pressure–induced atrial effective refractory period shortening, and it inhibits postapneic BP increases associated with OSA-associated AF [Linz D et al. Hypertension 2012]. The safety of renal denervation was demonstrated in a study that showed the procedure reduced BP, renal resistive index, and the incidence of albuminuria without adversely affecting glomerular filtration rate or renal artery structure [Mahfoud F et al. Hypertension 2012]. Prof. Mahfoud suggested that patients with the following characteristics are suitable for renal denervation: • SBP ≥160 mm Hg (≥150 mm Hg for type 2 diabetes patients) • ≥3 antihypertensive drugs in adequate dosage and combination (including diuretic) • Completion of life-style modifications (eg, diet)
0
Change in Blood Pressure (mm Hg)
1 month -28 -8
3 months -32 -5
• Exclusion of secondary hypertension • Exclusion of pseudoresistance (eg, via 24-hour ABPM) • Preserved renal function (estimated glomerular filtration rate ≥45 mL/min/1.73 m2) • Eligible renal arteries: no stenosis, no percutaneous transluminal angioplasty/stenting
-5 -10 -15 -20 -25 -30 -35 -40
p<0.001 p<0.001 p=0.192 p=0.494 p=0.154 p<0.001
p<0.001
Renal denervation (n=37) Control (n=13)
Reprinted from Mahfoud F et al. Effect of Renal Sympathetic Denervation on Glucose Metabolism in Patients With Resistant Hypertension: A Pilot Study. Circulation. 2011;123:1940-1946, with permission from Lipincott Williams and Wilkins.
Peer-Reviewed Highlights of the 48th Annual Meeting of the European Association for the Study of Diabetes
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http://en.wikipedia.org/wiki/Saarbr%C3%BCcken
Table of Contents for the Digital Edition of MD Conference Express EASD 2012
MD Conference Express EASD 2012
Contents
Understanding Incretin Hormone Action and the Treatment of Diabetes
New ADA/EASD Guidelines Focus on Patient-Centered Care
ORIGIN Trial: Insulin Glargine and n-3 Fatty Acids Fail to Reduce CV Events in Diabetic Patients
Exenatide Once Weekly Sustained Improvement in Glycemic Control with Weight Loss Through 4 Years
DiaPep277® Shows Promise as a Therapeutic Strategy for T1DM
Linagliptin Proves Safe and Effective as Add-on Therapy to Basal Insulin
12-Week Treatment with LY2409021 Significantly Lowers HbA1C and Is Well Tolerated in Patients with T2DM
Insulin Degludec Is Superior to Sitagliptin in Improving Glycemic Control in Uncontrolled Patients with Type 2 Diabetes on Oral Agents
Dapagliflozin Does Not Impact Renal Function in Patients with T2DM
Population-Based Screening for T2DM:The ADDITION-Cambridge Trial
The Challenges of Pharmaceutical Management of Painful Diabetic Peripheral Neuropathy
Enterovirus Infection
Novel Oral Agents
GLP-1
Genetics
Renal Denervation
Hypertension and Renal Function Are Risk Factors for CAD in T1DM
MD Conference Express EASD 2012
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