17th European Society on Hypertension Meeting Milan, 2007 INGENIOUS HYPERCARE: RENAL PHENOTYPE Josep Redon. MD, PhD, FAHA Hypertension Clinic. Internal Medicine Hospital Clinico. University of Valencia Spain

HOME BP JRP B2: Genetics, genomics and proteomics on chronic kidney disease in hypertension Investigating the genetic, genomic and proteomic basis of susceptibility to renal damage (urinary albumin excretion and renal damage) in HTN patients Creating a large database of several thousand patients in different European countries Cross-sectional and follow-up investigations

HOME BP JRP B2: Genetics, genomics and proteomics on chronic kidney disease in hypertension: Objectives To analyse genetic factors associated with renal phenotypes in hypertensive subjects: elevated urinary albumin excretion (microalbuminuria, proteinuria), reduced GFR, end-stage renal disease To detect novel early markers of renal damage in hypertension by using proteomics and to examine their association with genetic markers

HOME BP JRP B2: Genetics, genomics and proteomics on chronic kidney disease in hypertension: Types of studies Family-based association study of renal phenotypes, conducted simultaneously in the A2, B2 and B3 Case-control studies of renal phenotypes in previously recruited hypertensives Follow-up studies of renal phenotypes in preexisting cohorts and in the family study

HOME BP Phenotypes for renal damage in hypertension: yearsmonths UAE FG ml/min

HOME BP Prevalence of renal damage in hypertension. I-Demand project (927 subjects) 122 (13.2%) 99 (10.7%) 134 (14.5%) renal dysfunction: 38.5% of pts microalbuminuria N=233 (25.3%) eGFR 60 ml/min N=221 (24.0%)

HOME BP Seven-year incidence of ESRD according baseline creatinine clearance and proteinuria in general population Creatinine Clearance (ml/min) Proteinuria (+) Proteinuria (-) Cumulative Incidence of ESRD per screened in 7 yrs From Iseki et al., 2004

HOME BP Phenotypes for renal damage in hypertension: GFR Cockroft-Gault Formula (140- age) x body weight (serum creatinine * 72) * x 0.85 (if female) MDRD Formula 186 * serum creatinine * age * (if female) * (if AA) eGFR

HOME BP Stages of chronic renal disease StageDescriptionGF ml/min/ 1.73 m 2 Prevalence -On risk- 1Renal lesion with GF normal or increased > % 2Renal lesion with GF slightly reduced % 3GF moderately reduced % 4GF severely reduced % 5Renal failure<15 o dialysis 0.1 %

HOME BP Prevalence of chronic renal failure in hypertension Serum Cr eCrCl > mg/dl < 60 ml/min HOT % 12.3% INSIGHT % 29.1% HOPE % 36.4% ** H Clinico % 17.5 % * (n)

HOME BP Creatinine and cardiovascular morbidity and mortality. HOPE study Mann et al. Ann Intern Med 2001

HOME BP Cardiovascular risk and creatinine values >1.5 mg/dl. HOT study Adapted from Ruilope et al, JASN 2001 CV events MI Stroke CV mortality Total mortality

HOME BP Cardiovascular disease and probability of GFR decline. The ARIC study Elsaved et al. Arch Intern Med 2007

HOME BP Relationship between serum levels of creatinine and creatinine clearance Miravalles, Rodicio (data on file)

HOME BP Formulans to estimate the GFR Cockroft-Gault Formula (140- age) x body weight (serum creatinine * 72) * x 0.85 (if female) MDRD Formula 186 * serum creatinine * age * (if female) * (if AA) eGFR

HOME BP Relationship between MDRD and Cockcroft- Gault formulas to estimate renal function Miravalles, Rodicio (data on file) eGFR (ml/min/1.73m2) Creatinine clearance (ml/min)

HOME BP Relationship between two methods to estimate GFR: MDRD formula and I-talamate MDRD Iodo-talamate Rule et al. Ann Intern Med 2004

HOME BP GFR and standarized rates of hospitalization and cardiovascular events Kaiser Permanent Renal Registry Go, A. S. et al. N Engl J Med 2004

HOME BP Association of eGFR, and cystatin C with risk for death in elderly without chronic kidney disease Shlipak et al. Ann Intern Med 2006

HOME BP Relationship between serum cystatin C and creatinine clearance Miravalles, Rodicio (data on file) ROC curves to detect patients with GFR 60 – 90 mL/min Cystatin C (0.576 – 0.756) Creatinine (0.481 – 0.675)

HOME BP Measuring GFR in the JRP A2, B2 and B3 (I) MDRD formula in each of the centres Creatinine will be measured in the coordinating centre with a standarized method and GFR will be recalculated Cystatin C will be measured in the coordinating centre

HOME BP Phenotypes for renal damage in hypertension: Urinary albumin excretion UAE

HOME BP Prevalence of microalbuminuria according BP categories. NAHNES III Prevalence of albuminuria, % optimal normal high normal stage 1 stage 2 stage 3 men women from Jones, et al. 2003

HOME BP Natural history of microalbuminuria Redon et al. Curr Hypertens Rep Time x BP Insulin-resistant Non-insulin resistant Nephrosclerosis Microalbuminuria percentage (%) 60

HOME BP Changes in UAE categories according the UAE level and the presence of treatment at the begining Group of patientsNumber subjects (%)Rate 100 patientes/year Microalbuminurics Regresion untreated Regresion treated Progresion117.3 Proteinurics Regresion untreated Regresion treated from Pascual, et al. J Hypertens 2006

HOME BP UAE and risk of cardiovascular and non- cardiovascular mortality Hillege et al Circulation

HOME BP Urinary albumin excretion and cardiovascular mortality. NAHNES II Muntner et al. JASN 2002 <30 mg/dL, n= mg/dL, n= mg/dL, n= Age (yr) Cumulative CV disease mortality

HOME BP Microalbuminuria and GFR changes overtime. The PREVEND study Microalbuminuria Delta creatinine clearance (ml/min per 4 year) Urinary albumin excretion (mg/24hr) Verhave et al. JASN 2003

HOME BP Passage, metabolization and excretion of albumin in the urine Total albumin (IMRA and non-IMRA), fragments Tubular cells Reabsorption Degradation Back-leak Filtration

HOME BP Methods to measure albumin in urine Antibody recognisable albumin Immunoassays (RIA, nephelometry) Albumin not detected by immunoassays HPLC, precipitation Peptide fragments Spectrophotometry

HOME BP Circadian variability of UAE in essential hypertension Redón et al, Med Clin, 1995

HOME BP Intraindividual variability of UAE measurements Redón et al, Med Clin 1995

HOME BP UAE: samples and units of measurement SpotNight24 hour mg/24 h mg/min mg/mmol Cr mg/g Cr Urine sample Units

HOME BP UAE: samples and units of measurement SpotNight24 hour mg/24 h mg/min mg/mmol Cr 3-29 mg/g Cr Urine sample Units

HOME BP Urinary albumin stability over time in ideal conditions: 4ºC and protected from light Day Percentage of negatives who still negative Percentage of positives who still positive Agreement Correlation coefficient

HOME BP Urinary albumin measurement by using RIA and HPLC

HOME BP Bland-Altman plot of two methods for measuring urinary albumin: RIA and HPLC

HOME BP Measuring UAE in the JRP A2, B2 and B3 (I) First voiding urine in the morning 3 different days Measurements with nephelometrie and simultaneous examination of sediment (or disptick) in each of the centres 5 aliquots to store frozen at -20º at least (maintain at 4º out of light until frozen, recomendable no more than 4 hours) Samples frozen should be sent to the coordinating center (each 3 or 6 months)

HOME BP Measuring UAE in the JRP A2, B2 and B3 (and the others) (II) Measurements of albumin (nephrelometrie, HPLC) and creatinine UAE will be analyzed as qualitative and quantitative traits Measurement of other markers (oxidative stress) Proteomics in a small sample (with special requirements for urine collection and storage)

HOME BP Risk for ESRD according BP categories in the Kaiser Permanent Register (21-year follow-up) men women / / / / / / Age-adjusted ESRD rates per person-yrs Blood pressure category from Hsu, et al aRR 1.62 aRR 1.98 aRR 2.59 aRR 3.86 aRR 3.88 aRR 4.25 <120/80