Domanda facile. Lo stadio G3a corrisponde a una velocità di filtrazione compresa tra 45-59 ml/min. Lo stadio A1 corrisponde a un'albuminuria inferiore a 30 mg/ml. Pertanto, l'opzione corretta è la 1.

Domanda facile. Lo stadio G3a corrisponde a una velocità di filtrazione compresa tra 45-59 ml/min. Lo stadio A1 corrisponde a un'albuminuria inferiore a 30 mg/ml. Pertanto, [HIDDEN].

Una donna di 66 anni con diabete mellito di tipo 2. Al momento della valutazione della funzione renale, ha presentato uno stadio G3a/A1. A quali valori corrisponde questo stadio, il più frequente nei pazienti con nefropatia diabetica?

Velocità di filtrazione glomerulare 45-59 ml/min/1,73 m² e albuminuria <30 mg/ml.

Velocità di filtrazione glomerulare 30-44 ml/min/1,73 m² e albuminuria <30 mg/ml.

Tasso di filtrazione glomerulare 45-59 ml/min/1,73 m² e albuminuria 30-300 mg/ml.

Velocità di filtrazione glomerulare 15-29 ml/min/1,73 m² e albuminuria <30 mg/ml.

[Frequency of chronic kidney disease among ambulatory patients with type 2 diabetes].

Type 2 diabetes mellitus is the main cause of chronic kidney disease in developed countries. To study the prevalence of chronic kidney disease among adults with diabetes mellitus attended at a public primary health care clinic in southern Chile. One hundred patients with type 2 diabetes mellitus, aged more than 15 years participated in this cross sectional study. Chronic kidney disease was defined as the presence of a urine albumin/creatinine ratio over 30 mg/g or an estimated glomerular filtration rate of less than 60 mL/min/1,73 m², detected in at least two opportunities, separated at least by three months. Thirty four percent of participants had chronic kidney disease (17% stage 1 or 2 and 17% stage 3). Thirty percent of participants had an abnormal urinary albumin/creatinine ratio. Halfof the patients with an estimated glomerular filtration rate below 60 mL/min/1,73 m², had a normal urinary albumin/creatinine ratio. The rates of chronic kidney disease in this group of diabetic patients are very similar to those reported elsewhere.

Chronic Kidney Disease -- Introduction

The 6 categories include: G1: GFR 90 ml/min per 1.73 m 2 and above G2: GFR 60 to 89 ml/min per 1.73 m 2 G3a: GFR 45 to 59 ml/min per 1.73 m 2 G3b: GFR 30 to 44 ml/min per 1.73 m 2 G4: GFR 15 to 29 ml/min per 1.73 m 2 G5: GFR less than 15 ml/min per 1.73 m 2 or treatment by dialysis The three levels of albuminuria include an albumin-creatinine ratio (ACR) A1: ACR less than 30 mg/gm (less than 3.4 mg/mmol) A2: ACR 30 to 299 mg/gm (3.4 to 34 mg/mmol) A3: ACR greater than 300 mg/gm (greater than 34 mg/mmol).

Chronic Kidney Disease -- Staging

The 6 categories include: G1: GFR 90 ml/min per 1.73 m 2 and above G2: GFR 60 to 89 ml/min per 1.73 m 2 G3a: GFR 45 to 59 ml/min per 1.73 m 2 G3b: GFR 30 to 44 ml/min per 1.73 m 2 G4: GFR 15 to 29 ml/min per 1.73 m 2 G5: GFR less than 15 ml/min per 1.73 m 2 or treatment by dialysis The 3 levels of albuminuria include albumin-creatinine ratio (ACR): A1: ACR less than 30 mg/gm (less than 3.4 mg/mmol) A2: ACR 30 to 299 mg/gm (3.4 to 34 mg/mmol) A3: ACR greater than 300 mg/gm (greater than 34 mg/mmol)

Glomerular filtration rate

The severity of chronic kidney disease (CKD) is described by six stages; the most severe three are defined by the MDRD-eGFR value, and first three also depend on whether there is other evidence of kidney disease (e.g., proteinuria): 0) Normal kidney function – GFR above 90 mL/min/1.73 m2 and no proteinuria 1) CKD1 – GFR above 90 mL/min/1.73 m2 with evidence of kidney damage 2) CKD2 (mild) – GFR of 60 to 89 mL/min/1.73 m2 with evidence of kidney damage 3) CKD3 (moderate) – GFR of 30 to 59 mL/min/1.73 m2 4) CKD4 (severe) – GFR of 15 to 29 mL/min/1.73 m2 5) CKD5 kidney failure – GFR less than 15 mL/min/1.73 m2 Some people add CKD5D for those stage 5 patients requiring dialysis; many patients in CKD5 are not yet on dialysis. Note: others add a "T" to patients who have had a transplant regardless of stage.

Chronic Kidney Disease (Nursing) -- Introduction

The 6 categories include: G1: GFR 90 ml/min per 1.73 m2 and above G2: GFR 60 to 89 ml/min per 1.73 m2 G3a: GFR 45 to 59 ml/min per 1.73 m2 G3b: GFR 30 to 44 ml/min per 1.73 m2 G4: GFR 15 to 29 ml/min per 1.73 m2 G5: GFR less than 15 ml/min per 1.73 m2 or treatment by dialysis The three levels of albuminuria include albumin-creatinine ratio (ACR) A1: ACR less than 30 mg/gm (less than 3.4 mg/mmol) A2: ACR 30 to 299 mg/gm (3.4 to 34 mg/mmol) A3: ACR greater than 300 mg/gm (greater than 34 mg/mmol).

[Update on Diabetic Nephropathy 2018].

UPDATE ON DIABETIC NEPHROPATHY 2018:  The prevalance of elevated albuminuria in patients with diabetes is decreasing, while that of reduced eGFR is increasing, probably owing to more stringent blood pressure and blood glucose control.Well validated online score calculators for risk for renal replacement therapy, cardiovascular events and death are available online.Clinical variables remain more suited than histology for predicting end stage renal disease. Extracapillary hypercellularity, segmental sclerosis and exsudative lesions could represent a distinct risk phenotype.SGLT-2-inhibitors and GLP-1 analogues provide significant reductions of micro- and macrovascular end points. SGLT-2-inhibitors can only be prescribed at eGFR > 60 ml/min/1,73 m<sup2</sup, GLP-1 analogues and metformin at eGFR > 30 ml/min/1,73 m<sup2</sup.The ACC/AHA guideline 2017 defines arterial hypertension at blood pressure ≥ 130/80 mmHg, the ESC/ESH guideline 2018 at ≥ 140/90 mmHg. The blood pressure goal for patients with diabetes is < 130/80 mmHg, if well tolerated. ESC/ESH 2018 recommend not lowering blood pressure lower than 120/70 mmHg, in persons aged ≥ 65 years, systolic blood pressure 130 - < 140 mmHg is recommended.

Chronic kidney disease

Protein in the urine is regarded as an independent marker for worsening of kidney function and cardiovascular disease. Hence, British guidelines append the letter "P" to the stage of chronic kidney disease if protein loss is significant. Stage 1: Slightly diminished function; kidney damage with normal or relatively high GFR (≥90 ml/min/1.73 m2) and persistent albuminuria. Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. Stage 2: Mild reduction in GFR (60–89 ml/min/1.73 m2) with kidney damage. Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. Stage 3: Moderate reduction in GFR (30–59 ml/min/1.73 m2):. British guidelines distinguish between stage 3A (GFR 45–59) and stage 3B (GFR 30–44) for purposes of screening and referral.

Contrast-induced nephropathy

Roxana Mehran score The Roxana Mehran score is a clinical prediction rule to estimate probability of nephropathy (increase ≥25% and/or ≥0.5 mg/dl in serum creatinine at 48 h): Risk Factors: Systolic blood pressure <80 mm Hg - 5 points (if systolic BP less than 80 mmHg for at least one hour requiring inotropic support) Intra-arterial balloon pump - 5 points Congestive heart failure, counting as NYHA class III (marked limitation in activity due to symptoms, even during less-than-ordinary activity) or worse, or history of pulmonary edema - 5 points Age >75 y - 4 points Hematocrit level <39% for men and <35% for women - 3 points Diabetes mellitus- 3 points Contrast media volume - 1 point for each 100 mL Decreased kidney function: Serum creatinine level >1.5 g/dL - 4 points or Estimated Glomerular filtration rate (online calculator) 2 for 40–60 mL/min/1.73 m2 4 for 20–40 mL/min/1.73 m2 6 for < 20 mL/min/1.73 m2

Renal Function Tests -- Procedures -- Glomerular Filtration Rate

Serum creatinine is also utilized in GFR estimating equations such as the Modified Diet in Renal Disease (MDRD) and the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation. These eGFR equations are superior to serum creatinine alone since they include race, age, and gender variables. GFR is classified into the following stages based on kidney disease. Kidney Disease Improving Global Outcomes (KDIGO) stages of chronic kidney disease (CKD): Stage 1 GFR greater than 90 ml/min/1.73 m² Stage 2 GFR-between 60 to 89 ml/min/1.73 m² Stage 3a  GFR 45 to 59 ml/min/1.73 m² Stage 3b GFR 30 to 44 ml/min/1.73 m² Stage 4 GFR of 15 to 29 ml/min/1.73 m² Stage 5-GFR less than 15 ml/min/1.73 m² (end-stage renal disease)

Glomerular filtration rate

Creatinine clearance CCr One method of determining GFR from creatinine is to collect urine (usually for 24 h) to determine the amount of creatinine that was removed from the blood over a given time interval. If one removes 1440 mg in 24 h, this is equivalent to removing 1 mg/min. If the blood concentration is 0.01 mg/mL (1 mg/dL), then one can say that 100 mL/min of blood is being "cleared" of creatinine, since, to get 1 mg of creatinine, 100 mL of blood containing 0.01 mg/mL would need to have been cleared. Creatinine clearance (CCr) is calculated from the creatinine concentration in the collected urine sample (UCr), urine flow rate (Vdt), and the plasma concentration (PCr). Since the product of urine concentration and urine flow rate yields creatinine excretion rate, which is the rate of removal from the blood, creatinine clearance is calculated as removal rate per min (UCr×Vdt) divided by the plasma creatinine concentration. This is commonly represented mathematically as

[What values should be used to diagnose microalbuminuria in patients with diabetes mellitus?].

Diabetic nephropathy (DN) is a complication of diabetes mellitus (DM) associated with increased morbi-mortality. The identification of individuals at high risk for DN will make its prevention more effective. Urinary albumin excretion rate (UAER) is still the best marker for DN development and progression. It is also a major risk factor for macrovascular disease. High-normal albuminuria (< 20 microg/min) is still associated with development of micro- and macroalbuminuria. UAER has a continuous relationship with the development of renal and cardiovascular disease, without a cutoff point from which there is a highly increased risk. However, in clinical practice we need a reference value in order to guide the patient's treatment. Some evidence indicates values of UAER between 5 and 10 microg/min as a new cutoff point for the diagnosis of microalbuminuria. In conclusion, the association between UAER and the renal and cardiovascular outcomes seems to be continuous and is already present with UAER within the normal range. The adoption of a UAER value around 5 to 10 microg/min as risky could identify patients that should receive earlier and more aggressive treatment of modifiable risk factors.

[Albuminuria and glycemic control. The significance for mortality in non-insulin-dependent diabetes mellitus].

The impact of microalbuminuria and macroalbuminuria on mortality was evaluated prospectively in 328 Caucasian patients with non-insulin-dependent diabetes mellitus (NIDDM) followed for five years. One hundred and ninety-one patients with normoalbuminuria (albumin excretion rate (AER) < 30 mg/24 h), 86 patients with microalbuminuria (AER 30-299 mg/24 h), and 51 patients with macroalbuminuria (AER > or = 300 mg/24 h) all less than 66 years old at start of the study were followed from 1987 until death or until 1 January 1993. Eight percent of patients with normoalbuminuria, 20% of patients with microalbuminuria, and 35% of patients with macroalbuminuria had died, predominantly from cardiovascular disease. Significant predictors of all-cause mortality included preexisting coronary heart disease, AER, HbA1c level and age. Significant predictors of cardiovascular mortality included preexisting coronary heart disease, macroalbuminuria, HbA1c level and systolic blood pressure. Abnormally elevated urinary albumin excretion and poor glycaemic control indicate a substantially increased all-cause, mainly cardiovascular, mortality risk in NIDDM patients.

Razionale. In Italia la pandemia COVID-19 ha determinato importanti riorganizzazioni logistiche nell'erogazione delle cure ospedaliere e di specialistica ambulatoriale. Ciò ha spinto clinici e decisori pubblico-amministrativi della Sanità ad adottare nuovi modelli organizzativi in molteplici scenari clinici. Materiali e metodi. Il registro OIBOH (Optimal Intensification therapy in a Broad Observed High risk patient population with coronary disease) è uno studio osservazionale "cross-sectional" condotto in vari centri italiani di cardiologia ambulatoriale per valutare durante la pandemia COVID-19 la capacità di identificare in breve tempo i pazienti ad altissimo rischio cardiovascolare residuo dopo un evento coronarico recente (<12 mesi). Successivamente alla valutazione clinica iniziale, venivano arruolati i pazienti ritenuti ad altissimo rischio, registrando le caratteristiche cliniche e di trattamento in una scheda di raccolta dati elettronica.Risultati. Al registro hanno partecipato 134 centri di cardiologia ambulatoriale che hanno arruolato 1428 pazienti su 3227 esaminati fra quelli che avevano avuto accesso ad una visita cardiologica durante la pandemia nel periodo ottobre 2020-marzo 2021. Il criterio di arruolamento era costituito dall'aver avuto una diagnosi di coronaropatia confermata angiograficamente negli ultimi 12 mesi, per sindrome coronarica acuta (SCA) o cronica (SCC). La SCA come evento indice era presente nel 93% dei pazienti arruolati mentre la SCC nel 7%. L'età media era 67 ± 10 anni, il 25% era di sesso femminile. Il 96.1% dei pazienti con SCA e il 67.6% dei pazienti con SCC sono stati sottoposti a rivascolarizzazione coronarica. Il 46% e 47% dei pazienti con SCA e SCC, rispettivamente, era diabetico. Oltre il 65% dei pazienti presentava una malattia coronarica multivasale. È stata osservata una importante prevalenza di arteriopatia periferica (17.5% nei pazienti con SCA e 19.6% nei pazienti con SCC). I valori di pressione arteriosa e frequenza cardiaca risultavano ben controllati (128 ± 25.2 mmHg e 65 ± 12.3 b/min nei pazienti con SCA; 127 ± 23.4 mmHg e 67 ± 13.2 b/min nei pazienti con SCC). Viceversa, è stato riportato uno scarso controllo dei livelli di colesterolemia LDL, con un valore medio di 88.8 ± 38.6 mg/dl nei pazienti con SCA e 86 ± 36.6 mg/dl nei pazienti con SCC. Solo il 16.4% dei pazienti con SCA raggiungeva i livelli raccomandati dalle attuali linee guida europee. Nonostante l'estensivo uso di statine (>90%), si è rilevato un utilizzo limitato dell'associazione statina ad alta intensità + ezetimibe (solo il 22.4% dei pazienti). Estremamente basso è stato l'utilizzo di inibitori di PCSK9 (2.5%). La duplice terapia antiaggregante piastrinica (DAPT) è risultata complessivamente ben condotta fin dalla dimissione ospedaliera. Nei pazienti in DAPT, l'inibitore P2Y12 più utilizzato è risultato il ticagrelor alla dose di 90 mg, soprattutto dopo un evento coronarico acuto (in circa l'80% dei pazienti con SCA). Nella stragrande maggioranza dei casi (>90%) i cardiologi ambulatoriali hanno posto indicazione a prosecuzione della DAPT oltre i 12 mesi con aspirina e ticagrelor 60 mg bid. Conclusioni. La gestione del paziente con coronaropatia in fase cronica stabilizzata è molto complessa. Tale complessità logistico-gestionale si è accentuata durante la pandemia COVID-19. Il registro OIBOH ha evidenziato un'ottima capacità di identificare le problematiche clinico-prognostiche delle cardiologie ambulatoriali italiane, specie nei pazienti ad altissimo rischio residuo. Rimangono importanti aree di miglioramento come uno stretto controllo della colesterolemia LDL, mentre altre raccomandazioni delle linee guida, come la prosecuzione della DAPT con ticagrelor 60 mg oltre i 12 mesi, risultano ben applicate. L'implementazione dell'assistenza con la medicina digitale e l'intelligenza artificiale potrebbe migliorare di molto la performance dei clinici.

[Risk and prevention of diabetic nephropathy].

Diabetic nephropathy is one of the most frequent causes of end-stage renal disease (ESRD), and there has been a dramatic increase in the number of patients entering renal replacement therapy in the last few years. Moreover, diabetic nephropathy is associated with elevated cardiovascular morbidity and mortality. Prevention and treatment of diabetic nephropathy is based on optimal metabolic and blood pressure control, proteinuria reduction, and renin-angiotensin-aldosterone system (RAAS) inhibition. In the normoalbuminuric patient, optimal glycemic control (HbA1c below 7.0%) plays a fundamental role in the primary prevention of ESRD. Furthermore, blood pressure levels below 130/80 mmHg are strongly recommended. In the microalbuminuric stage, strict glycemic control (HbA1c below 7.0%) likely reduces the incidence of overt nephropathy, while blood pressure values less than 130/80 mmHg are recommended. Moreover, there is evidence that inhibition of RAAS, either by angiotensin-converting-enzyme inhibitors (ACE-I) or angiotensin-receptor blockers (ARB), reduces the development of overt nephropathy, regardless of the blood pressure levels. ACE-I are recommended as the drugs of choice in type 1 diabetes, while both ACE-I and ARB are considered first-choice drugs in type 2 diabetes. Once overt proteinuria has developed, it is uncertain whether glycemic control affects the progression of nephropathy, which is strongly influenced by blood pressure and proteinuria. Optimal blood pressure levels are < 130/80 mmHg in patients with proteinuria < 1 g/day and < 120/75 mmHg in patients with proteinuria > or =1 g/day. In type 1 diabetes there is consensus on the renoprotective role of ACE-I, while in type 2 diabetes, ARB have been shown to be more effective than conventional therapy or calcium-channel blockers in slowing the progression of nephropathy. Lastly, a multifactorial therapeutic approach based on optimal glycemic control, intensive antihypertensive therapy, inhibition of RAAS, statins and aspirin is pivotal in the prevention and treatment of diabetic nephropathy.

[In-hospital and long-term (to 3 years) results of using bare-metal stents in patients with coronary artery disease and chronic kidney disease].

Patients (n=727) who had been subjected to implantation of one or several standard stents in 2004 were included into this study. These patients were divided into 3 groups according to initial level of glomerular filtration rate (GFR, MDRD equation): group 1 - 466 patients with GFR >60 ml/min/1,73 m(2), group 2 - 233 patients with GFR 30 - 60 ml/min/1,73 m(2), group 3 - 38 patients with GFR <30 ml/min/1,73 m(2). In all group 2 and 3 patients prevention of contrast induced nephropathy (CIN) was implemented: hydration before and after angiography, limitation of intake of nephrotoxic drugs, N acetylcysteine 600 mg/day orally. In all group 2 and 3 patients only contrast preparation iodixanol was used. Total amount of contrast did not exceed 350 ml in patients with GFR 45-59 ml/min/1.73 m(2) and 250 ml - with GFR <45 ml/min/1.73 m(2). In all patients with GFR 60 ml/min/1.73 m(2) low osmolar contrast preparations were used (total amount - less then 600 ml per patient). Immediate success of PCI was similar in all groups (99.4%, 98.2% 97.4%, respectively). Rate of CIN rose significantly in groups 2 and 3 (0.4%, 4.9%, 13.2%, respectively, <0.001). Before 6 months after PCI restenosis developed more frequently with lowering of GFR (group 1 - 11%, group 2 - 22%, group 3 - 34%, <0.001). Myocardial infarction developed by 3 years in 6, 10, and 26% of patients in groups 1, 2, and 3, respectively. Lethality during 3 years was 5, 10, and 24% in groups 1, 2, and 3, respectively. Regression analysis showed that as a whole 3 years rate of myocardial infarction rose 1.57 times in group 2 compared with group 1, and 3.91 times in group 3 compared with group 1. Mortality by 3 years rose 1.93 times in group 2 compared with group 1, and 4.52 times in group 3 compared with group 1. Thus, presence of initially lowered GFR increases risk of CIN after elective implantations of standard stents, leads to rise of restenosis rate by 6 months and increase of mortality and rate of nonfatal myocardial infarction by 3 years.

[How I evaluate...diabetic nephropathy. First part: micro- and macroalbuminuria].

Diabetic nephropathy (DN) appears in about 30% of patients with type 1 diabetes (D1) and 15 to 60% of patients with type 2 diabetes (D2). It is preceded by microalbuminuria. Microalbuminuria is defined as an albumin excretion rate between 30 and 300 mg/24 h (on a 24-hour urine collection) or between 20 and 200 micrograms/min (on an overnight collection) in at least two out of three consecutive collections made within a 6-month period. Alternative screening techniques use either dipstick (Micral-Test II) or the albumin to creatinine ratio on an early morning urine sample (30-300 mg/g creatinine). Once persistent microalbuminuria is confirmed, 80% of type 1 diabetic patients and 20 to 50% of type 2 diabetic patients will progress to DN. In D2, microalbuminuria also represents a powerful predictor of early mortality from cardiovascular disease. Macroalbuminuria (AER > 300 mg/24 h, corresponding to a total protein excretion > 500 mg/24 h) will eventually lead to a end-stage renal insufficiency within 10 to 20 years. In D2, numerous patients will die from cardiovascular disease before reaching end-stage renal failure. Angiotensin-converting enzyme inhibitors can slow down the evolution toward DN when prescribed when microalbuminuria appears. Screening for microalbuminuria should therefore be a part of the annual clinical assessment in every diabetic patient.

Glomerular filtration rate

Normal ranges The normal range of GFR, adjusted for body surface area, is 100–130 average 125 mL/min/1.73m2 in men and 90–120 ml/min/1.73m2 in women younger than the age of 40. In children, GFR measured by inulin clearance is 110 mL/min/1.73 m2 until 2 years of age in both sexes, and then it progressively decreases. After age 40, GFR decreases progressively with age, by 0.4–1.2 mL/min per year. Decreased GFR A decreased renal function can be caused by many types of kidney disease. Upon presentation of decreased renal function, it is recommended to perform a history and physical examination, as well as performing a renal ultrasound and a urinalysis. The most relevant items in the history are medications, edema, nocturia, gross hematuria, family history of kidney disease, diabetes and polyuria. The most important items in a physical examination are signs of vasculitis, lupus erythematosus, diabetes, endocarditis and hypertension.

[Prevalenza di ipotiroidismo nei pazienti sottoposti a emodialisi presso un ospedale generale di Ahvaz.]

Riassunto. Obiettivo. Lo scopo di questo studio trasversale è determinare la prevalenza dell'ipotiroidismo tra i pazienti in emodialisi (ED) e i suoi potenziali fattori di rischio. Metodi. Sono stati raccolti dati demografici e di laboratorio [vale a dire, livelli sierici di tireotropina (TSH), anticorpi anti-perossidasi tiroidea (anti-TPO)] di 117 pazienti con MH. I dati sono stati analizzati da SPSS.V 26, quando necessario. Risultati. I pazienti avevano un'età media (DS) di 59,47±15,08 anni e il 66,7% (n=78) era di genere maschile. I livelli medi (DS) di TSH erano 2,56 (4,01) μIU/mL. L'ipotiroidismo subclinico (SCH) è stato definito come un livello di TSH >4,2 μIU/mL e FT4 normale. Quindici pazienti (12,80%) avevano SCH. Non c'era correlazione significativa tra ipotiroidismo ed età, genere e/o malattie sottostanti (p>0,05). Inoltre, tra i 15 pazienti con SCH, 1 paziente (6,7%) ha mostrato un risultato anti-TPO positivo mentre 14 pazienti (93,3%) hanno avuto un risultato anti-TPO negativo. Conclusione. Data la notevole prevalenza dell'ipotiroidismo nei pazienti con ED, lo screening di routine della funzione tiroidea in questa popolazione di pazienti può aiutare a ridurre i tassi di complicanze e mortalità attraverso una diagnosi precoce e un intervento tempestivo.

[Prevalence of subnormal glomerular filtration rate in patients with diabetes mellitus].

To evaluate prevalence of subnormal glomerular filtration rate (GFR) in diabetes mellitus (DM) patients with reference to albuminuria level. GFR by MDRD and urine excretion of protein/albumin were estimated in 851 diabetic patients (473 with type 1 DM and 378 with type 2 DM). Normoalbuminuria (NAU), microalbuminuria (MAU) and proteinuria were detected in 54, 16 and 30% type 1 diabetics, respectively; 77% had subnormal GFR, in NAU 8.3% had GFR decline (< 60 ml/min) corresponding to stage III-IV chronic disease of the kidneys. In MAU the latter was present in 16.4%, in proteinuria--in 62.8%. Type 2 diabetics had NAU in 33.6% cases, MAU--in 17.7%, proteinuria--in 48.7%. Subnormal GFR < 60 ml/min was found in 40% cases with NAU and MAU. Most patients with proteinuria had chronic disease of the kidneys of stage III-V In a normal creatinine concentration in blood serum subnormal GFR < 60 ml/min was observed in type 1 DM in 7.6, in type 2 DM--in 33% cases. Prevalence of subnormal GFR in diabetic patients with NAU and MAU is rather high. This necessitates wide introduction of this index in screening, follow-up and classification of renal damage severity in DM as well as estimation of albuminuria/proteinuria.

Albuminuria and estimated glomerular filtration rate as predictors of diabetic end-stage renal disease and death.

We investigated predictive value of albuminuria and estimated GFR (eGFR) for ESRD in Pima Indians with type 2 diabetes. Beginning in 1982, 2420 diabetic Pima Indians ≥18 years old were followed until they developed ESRD or died or until December 31, 2005. Individuals were classified at baseline by urinary albumin-to-creatinine ratio (ACR) and by eGFR, calculated by the Chronic Kidney Disease Epidemiology Collaboration equation. Predictors of ESRD and mortality were examined by proportional hazards regression. During a mean follow-up of 10.2 years, 287 individuals developed ESRD. Incidence of ESRD among individuals with macroalbuminuria (ACR ≥ 300 mg/g) was 9.3 times that of those with normoalbuminuria (ACR < 30 mg/g), controlled for age, gender, and duration of diabetes. Incidence among individuals with eGFR 15 to 29 ml/min per 1.73 m(2) was 81.9 times that of those with eGFR 90 to 119 ml/min per 1.73 m(2). Models that combined albuminuria and eGFR added significant predictive information about risk of ESRD or death compared with models containing eGFR or albuminuria alone. The hazard ratio for ESRD associated with a 10-ml/min per 1.73 m(2) lower eGFR was 1.36, whereas that associated with an increase in albuminuria category was 2.69; corresponding hazard ratios for death were 1.15 and 1.37. These results suggest that incorporation of quantitative information about albuminuria into staging systems based on eGFR adds significant prognostic information about risk for diabetic ESRD and death.

[Diabetic nephropathy and cardiovascular risk].

The importance of the early detection of diabetic nephropathy is because it is a cardiovascular risk marker and it indicates the existence of vascular changes associated to an increase risk of having a cardiovascular event in diabetes mellitus type 1 (DM 1), as well as in type 2 (DM 2). Microalbuminuria is a risk factor for overall cardiovascular and coronary mortality in the patients with DM 1. Total mortality is increased in patients with DM 2 and microalbuminuria with a RR of 1.8, and it is related to microalbuminuria levels even below the considered normal range (20 microg/min and/or 30 mg/day). For this reason, the definition of microalbuminuria must be reviewed in the patients with DM 2. More studies are needed to confirm the predictive power of microalbuminuria in cardiovascular and coronary disease.

Albuminuria

Causes of albuminuria can be discriminated between by the amount of protein excreted. The nephrotic syndrome usually results in the excretion of about 3.0 to 3.5 grams per 24 hours. Nephritic syndrome results in far less albuminuria. Microalbuminuria (between 30 and 300 mg/24h, mg/l of urine or μg/mg of creatinine) can be a forerunner of diabetic nephropathy. The term albuminuria is now preferred in Nephrology since there is not a "small albumin" (microalbuminuria) or a "big albumin" (macroalbuminuria). A1 represents normal to mildly increased urinary albumin/creatinine ratio (<30 mg/g or < 3 mg/mmmol); A2 represents moderately increased urinary albumin/creatinine ratio (30–300 mg/g or 3–30 mg/mmmol, previously known as microalbuminuria); and A3 reflects severely increased urinary albumin/creatinine ratio >300 mg/g or > 30 mg/mmol).

[Captopril reduction of albuminuria in type-II diabetics with diabetic nephropathy].

This study was to search if captopril (C) reduces albuminuria in a group of type II diabetics with diabetic nephropathy (DN). Eleven type II diabetics with DN and hypertension, with albuminuria over 0.30 g/L/24th, fasten blood glucose under 250 mg/dL, serum albumin over 3 g/dL, without infection, cardiac failure or diuretic treatment, were treated with C for six months, as the only treatment for hypertension and albuminuria. Every month, albuminuria in a 24h urinary collection, medium arterial pressure (MAP), serum creatinine and fasten blood glucose were measured. Ten women and one man with 60 (50-70) years of average age (0 to 100th percentile), with 18 (8-35) years of diabetic disease, and 4 (1-7) years of clinic hypertension were studied. Before the treatment with C they had albuminuria of 6.9 (0.7 to 12.5) g/L/24h, MAP of 119.7 (93.2 to 139) mmHg, serum creatinine of 2.2 (0.7 to 7.5) mg/dL and glucose of 168 (78 to 250) mg/dL. After 6 months with C, they had albuminuria of 3.5 (0.2 to 9.6) g/L/24h (p less than 0.01), MAP of 113.4 (92.9 to 132.4) mmHg (p = 0.5), serum creatinine of 2.3 (0.5 to 6.4) mg/dL (p = 0.23) and glucose of 133 (87.5 to 239) mg/dL (p = 0.32). The MAP showed a predictive relation over albuminuria (p = less than 0.004). During the six months of study, C reduced albuminuria in type II diabetics with hypertension and diabetic nephropathy.

Norfloxacin

“Absorption of norfloxacin is rapid following single doses of 200 mg, 400 mg and 800 mg. At the respective doses, mean peak serum and plasma concentrations of 0.8, 1.5 and 2.4 μg/mL are attained approximately one hour after dosing. The effective half-life of norfloxacin in serum and plasma is 3–4 hours. Steady-state concentrations of norfloxacin will be attained within two days of dosing. Renal excretion occurs by both glomerular filtration and tubular secretion as evidenced by the high rate of renal clearance (approximately 275 mL/min). Within 24 hours of drug administration, 26 to 32% of the administered dose is recovered in the urine as norfloxacin with an additional 5-8% being recovered in the urine as six active metabolites of lesser antimicrobial potency. Only a small percentage (less than 1%) of the dose is recovered thereafter. Fecal recovery accounts for another 30% of the administered dose. Two to three hours after a single 400-mg dose, urinary concentrations of 200 μg/mL

[Type 2 diabetic nephropathy: clinical course and prevention proposals 2004].

The first clinical evidence of nephropathy is the appearance of low, but abnormal, albumin levels in the urine (>30 mg/day or 20 mg/min), microalbuminuria. Without specific interventions, approximately 80% of type 1 diabetics have their urinary albumin excretion increase at a rate of 10-20%/yr to the stage of overt nephropathy or clinical albuminuria (>300 mg/24h or >200 mg/min) over 10-15 yrs, developing hypertension along the way. Approximately 30% of individuals with type 2 diabetes are found to have microalbuminuria or overt nephropathy shortly after the diagnosis of their illness, because diabetes is actually present for many years previously and because the presence of albuminuria can depend on other concomitant nephropathies, as shown by biopsy studies. Without specific intervention, 20-40% of type 2 diabetic patients with microalbuminuria progress to overt nephropathy, but 20 yrs after onset only 20% progress to end-stage renal failure (ESRD). The rates of decline in glomerular filtration rate (GFR) are highly variable from one individual to another, but they may not be substantially different between patients with type 1 and type 2 diabetes. As therapies and interventions for coronary artery disease continue to improve, more elderly type 2 diabetes patients can be expected to survive long enough to develop renal failure. The recently published Italian Society of Nephrology (SIN) guidelines for diagnosis and therapy of diabetic nephropathy present the route for the best strategies in prevention and therapy, from earlier onset to advanced ESRD.

Al professor Mosca la "Honorary Fellowship" dell'American College of Surgeons.

È la massima onorificenza conferita dalla più grande organizzazione mondiale di chirurghi La più grande organizzazione mondiale di chirurghia ha conferito la sua massima onorificenza al professor Franco Mosca, Emerito di Chirurgia generale dell'Università di Pisa. La "Honorary Fellowship" dell'American College of Surgeons (ACS) è stata assegnata al professor Mosca in occasione del Congresso 2018 che si è svolto a Boston. L'ACS, fondata nel 1913, è la più grande organizzazione di chirurgia generale e specialistica e riunisce più di 82.000 chirurghi di tutto il mondo, con lo scopo di migliorare la qualità della pratica chirurgica. Dalla sua istituzione a oggi sono divenuti membri onorari 470 chirurghi internazionali e tra di loro primo italiano fra tutti Raffaele Bastianelli nel lontano 1918 ed a seguire Roberto Alessandri nel 1926, Mario Dogliotti nel 1951 e Pietro Valdoni nel 1955. Il professor Franco Mosca, Fellow dell'ACS da 25 anni, aggiunge questo massimo riconoscimento ad honorem ad altri ambiti e molto esclusivi, quali il Royal College of Surgeons (2006), l'American Surgical Association (2008) e il Polish Association of Surgeons (2011). Nella Motivazione del riconoscimento si ricorda che "il professor Franco Mosca è divenuto cattedratico nel 1986. Da allora ha creato una Unità Operativa di eccellenza in chirurgia oncologica, vascolare e trapiantologica. Fin dall'inizio della sua carriera si è dedicato a migliorare l'organizzazione ospedaliera introducendo la terapia intensiva post chirurgica, l'endoscopia chirurgica, l'ecografia diagnostica ed operativa nella convinzione che i chirurghi non possono delegare queste attività ad altri se vogliono ottenere i migliori risultati. Queste basi hanno consolidato lo sviluppo di una costellazione di nuovi programmi per il trattamento dell'ipertensione portale, la chirurgia vascolare, i trapianti di organi (rene, pancreas, fegato). Inoltre il professor Mosca ha sviluppato la chirurgia oncologica e in particolare quella pancreatica ed epatobiliare; infine ha, tra i primi in Italia, sviluppato la chirurgia laparoscopica. L'interesse per le nuove tecnologie ha portato il professor Mosca a stabilire legami stretti con i Dipartimenti di Ingegneria delle Università Pisane, mettendo a punto nuovi dispositivi per la chirurgia laparoscopica e l'endoscopica fino alla creazione di un Centro di Eccellenza (Endocas) per ricerca e training in chirurgia assistita dal computer. Questo centro è riconosciuto, primo e unico in Italia, dall'American College of Surgeons quale 'Accredited Education Institute'. Il professor Mosca è un eccezionale leader chirurgico e uno dei più rispettati e influenti chirurghi europei". "Desidero condividere questo riconoscimento - ha dichiarato il professor Franco Mosca - con quanti hanno collaborato con me in tanti anni di impegno e sacrificio rendendo possibile il raggiungimento di risultati importanti a favore dei nostri pazienti e della Sanità Pubblica. Sono molto gratificato per essere stato presentato all'ACS da un illustre allievo della Scuola Medica Pisana: il professor Fabrizio Michelassi chirurgo di fama mondiale".

[Albuminuria in patients with type 2 diabetes mellitus in relation to percentage of HbA1c].

Albuminuria is an early marker of the microvascular and macrovascular complications in patients with type 2 diabetes mellitus. Metabolic complication accompanying the disease, especially hyperglicaemia, have significant influence on the range of albumin excretion. The aim of the study was to evaluate urinary albumin excretion and percentage of glycated hemoglobin (HbA1c), in relation to fasting and postprandial glycaemia. Research was made in two groups of patients with confirmed albuminuria: in the 1st group with good glycemic control with HbA1c > or = 6,1%-< or = 6,5%, and in the 2-nd group with poor glycemic control with HbA1c > 6,5%-< or = 10%. The control group consisted of 21 patients with essential hypertension and coexisted albuminuria, not suffering from diabetes. The average fasting and postprandial glycemic were calculated for each patient on the basis of the last three values of glycaemia from the patient's self-control test. The extent of albuminuria and the percentage of HbA1c were determined by the immunoturbidimetric test. The highest albumin excretion in urine was noticed in the group with poor glycemic control, a slightly lower level of albuminuria was found in the group with good glycemic control, however the lowest level of albumin excretion was noticed in the control group. The differences were not statistically significant. The fasting glycaemia as well as postprandial glycaemia were increased in the group with higher percentage of HbA1c (p < 0,001) with comparison to the group with good glycemic control. The average percentage of HbA1c was 7,54% in the group with poor glycemic control and was significantly connected with larger glycaemia with comparison to the 2nd group with average percentage of HbA1c 6,3%. The excretion of albumin in urine rises with increased glycaemia and percentage of glycosylated hemoglobin. Fasting glycaemia as well as postprandial glycaemia have influence on the percentage of glycated hemoglobin.

Sequence of progression of albuminuria and decreased GFR in persons with type 1 diabetes: a cohort study.

The sensitivity of albuminuria in predicting loss of kidney function has been questioned. We determined the sequence of kidney disease stages (microalbuminuria, macroalbuminuria, low estimated glomerular filtration rate [eGFR], and end-stage renal disease [ESRD]) and characterized those without albuminuria before a low eGFR. The Pittsburgh Epidemiology of Diabetes Complications Study is a prospective cohort investigation of childhood-onset type 1 diabetes. 480 study participants with eGFR greater than 60 mL/min/1.73 m(2) (mean age, 27 years; diabetes duration, 19 years at study entry) were prospectively followed up for 16 years. Low eGFR was defined as creatinine clearance less than 60 mL/min/1.73 m(2) from timed urine collections; microalbuminuria, as albumin excretion rate between 20 to 200 microg/min (30 to 300 mg/24 h); macroalbuminuria, as albumin excretion rate greater than 200 microg/min (>300 mg/24 h); and ESRD, as dialysis or renal transplantation. The 33 of 480 individuals (7%) who developed ESRD had prior albuminuria. 71 of 480 (15%) individuals developed low eGFR. 66 of 71 (93%) had prior/concurrent albuminuria, and 5 of 71 (7%) did not. Incident low eGFR values in the 5 patients were: (1) 54, (2) 58, (3) 59, (4) 59.7, and (5) 59.8 mL/min/1.73 m(2). 3 of 5 (60%; patients 1, 4, and 5) subsequently developed albuminuria. Final eGFRs in the 5 patients were: (1) 94, (2) 86, (3) 60, (4) 65, and (5) 54 mL/min/1.73 m(2), respectively. GFR and insulin sensitivity were not measured, but estimated. Incident decreased eGFR in patients without preceding/concurrent albuminuria may be caused by misclassification or a temporary eGFR decrease. Moderately decreased eGFR may occur rarely in patients with type 1 diabetes without preceding albuminuria.

[Efect of short term glycemic control on microalbuminuria and glomerular filtration rate in type 2 diabetic patients with poor glycemic control].

The intensive glucose control significantly reduces the risk of microvascular complications, including nephropathy. We assess the impact of glycemic control through calculation of weekly mean glycemia (WMG) and glycemic variability (GV) on 24 hours ambulatory blood pressure (ABPM), urinary albumin excretion (UAE) and glomerular filtration rate (GFR). 53 patients with type 2 diabetes mellitus (DM2) were randomly divided into two groups to receive conventional or intensive treatment, which included weekly visits for medication adjustments and implementation of an educational plan for six weeks. We observed glycemic control (WMG < 150 mg/dL and VG < 50) in 75% (n = 21) of the patients on the intervention treatment (IT) (n = 28), and in 24% (n = 6) of the ones on the conventional treatment (CT) (n = 25) (p < 0.001). Considering patients of the two groups, 14 out of the 27 patients who achieved glycemic control showed initial mean systolic blood pressure (SBP) > 120 mmHg which was reduced from 138.4 ± 10.1 to 127.8 ± 11.6 mmHg (p = 0.023) at the end of week six. Reductions in SBP and diastolic BP (DBP) during wakefulness and sleep did not occur in the group (n = 17) without glycemic control and with SBP > 120 mmHg. Initially, 15 patients had GFR > 120 mL/min, and after six weeks, only the subgroup that achieved glycemic control (n = 7) showed a reduction of 137.2 ± 16 to 122.2 ± 25.2 mL/min (p = 0.02). At the beginning of the study, another fifteen patients presented with microalbuminuria. After six weeks, regardless of whether they achieved glycemic control or not, there was reduction in UAE, from 63.0 ± 43.1 to 24.8 ± 19.5 mg/g creatinine (p = 0.02). Thus short term glycemic control resulted in reductions of BP, GFR and the UAE in patients with DM2, which are beneficial for renal protection.

[Microalbuminuria in a population of 653 patients with type 1 and 2 diabetes].

The aim of this retrospective study was to evaluate the prevalence of microalbuminuria in type 1 and 2 diabetic patients with or without high blood pressure levels. 653 patients were involved in the study [type 1: n = 413 (normotensive: n = 298; hypertensive: n = 115); type 2: n = 240 (normotensive: n = 93; hypertensive: n = 147)]. In type 1 diabetic patients, the prevalence of microalbuminuria was of 21 per cent. Microalbuminuria was also found in 28 per cent of type 2 diabetic subjects (p less than 0.10 vs type 1). The prevalence of microalbuminuria was significantly higher in hypertensive than in normotensive diabetic subjects (28 vs 20 per cent; p less than 0.05). Blood pressure in type 1 and 2 normotensive patients was significantly higher in subjects with than without microalbuminuria. We also observed higher HbA1 levels in microalbuminuric type 1 diabetic patients. Finally, we also assessed that the prevalence of diabetic chronic complications was higher in type 1 patients with than without microalbuminuria (p less than 0.05). This relationship was not evidenced in type 2 diabetic patients. In conclusion, the prevalence of microalbuminuria in a population of type 1 and 2 diabetic patients is high. We confirm in this study the relationship between microalbuminuria, blood pressure, and HbA1.

Association between kidney function and albuminuria with cardiovascular events in HIV-infected persons.

Cardiovascular disease (CVD) is now a leading cause of death in HIV-infected persons; however, risk markers for CVD are ill defined in this population. We examined the association between longitudinal measures of kidney function and albuminuria with risk of atherosclerotic CVD and heart failure in a contemporary cohort of HIV-infected individuals. We followed a national sample of 17 264 HIV-infected persons receiving care in the Veterans Health Administration for (1) incident CVD, defined as coronary, cerebrovascular, or peripheral arterial disease, and (2) incident heart failure. Rates of CVD and heart failure were at least 6-fold greater in the highest-risk patients with an estimated glomerular filtration rate (eGFR) <30 mL/min per 1.73 m(2) and albuminuria > or =300 mg/dL versus those with no evidence of kidney disease (eGFR > or =60 mL/min per 1.73 m(2) and no albuminuria). After multivariable adjustment, eGFR levels 45 to 59, 30 to 44, and <30 mL/min per 1.73 m(2) were associated with hazard ratios for incident CVD of 1.46 (95% confidence interval, 1.15 to 1.86), 2.03 (1.47 to 2.82), and 1.99 (1.46 to 2.70) compared with eGFR > or =60 mL/min per 1.73 m(2). Similarly, albuminuria levels 30, 100, and > or =300 mg/dL had hazard ratios for CVD of 1.28 (1.09 to 1.51), 1.48 (1.15 to 1.90), and 1.71 (1.30 to 2.27) compared with absent albuminuria. The associations between eGFR and albuminuria with heart failure were larger in magnitude and followed the same trends. In this national sample of HIV-infected persons, eGFR and albuminuria levels were strongly associated with risk of CVD and heart failure. Kidney function and albuminuria provide complementary prognostic information that may aid CVD risk stratification in HIV-infected persons.

[Diabetic nephropathy: significance of microalbuminuria and proteinuria in Type I and Type II diabetes mellitus].

Diabetic nephropathy is a progressive renal disease and represents a serious late complication of diabetes. There are familial clustering and huge ethnic differences in the occurrence of diabetic nephropathy, which point to a genetic predisposition. Diabetic nephropathy is defined by persistent albuminuria (albumin excretion rate [AER] > 300 mg/day), declining glomerular filtration rate and rising blood pressure. Several years of incipient nephropathy, characterized by worsening microalbuminuria (AER 30 to 300 mg/day or 20 to 200 micrograms/min), which is Albustix-negative and detectable by special assays only, are followed by established nephropathy. The natural history of nephropathy differs between insulin-dependent (IDDM) and non-insulin-dependent (NIDDM) diabetes mellitus. In IDDM, nephropathy develops in 30 to 40% of cases. The incidence peaks after 15 to 16 years of diabetes. In NIDDM, estimates of prevalence range from 15 to 20%, and nephropathy often supervenes after a shorter known duration of diabetes than in IDDM. GFR is often increased above normal (hyperfiltration) from the onset of IDDM due to increased renal blood flow, glomerular capillary hypertension and increased filtration surface. The glomeruli are hypertrophied and the kidneys enlarged. In both IDDM and NIDDM, GFR begins to decline irreversibly, when AER has risen to 100 to 300 mg/day at an average rate of 10 ml/min. per year. This is due to progressive reduction of the filtration surface area through mesangial expansion. Serum creatinine levels begin to rise when GFR falls below 50 ml/min, and then end-stage renal failure follows after an average of five years.(ABSTRACT TRUNCATED AT 250 WORDS)