17th European Society on Hypertension Meeting Milan, 2007

1. 17th European Society on Hypertension MeetingMilan, 2007 INGENIOUS HYPERCARE: RENAL PHENOTYPE Josep Redon. MD, PhD, FAHA Hypertension Clinic. Internal Medicine Hospital Clinico. University of Valencia Spain

2. 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

3. 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

4. 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

5. Phenotypes for renal damage in hypertension: UAE FG ml/min years months

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

7. Seven-year incidence of ESRD according baseline creatinine clearance and proteinuria in general population Proteinuria (+) Proteinuria (-) 1000 100 Cumulative Incidence of ESRD per 1.000 screened in 7 yrs 10 1 0.1 0.01 0 15 30 45 60 75 90 105 120 135 Creatinine Clearance (ml/min) From Iseki et al., 2004

8. Phenotypes for renal damage in hypertension: GFR eGFR • Cockroft-Gault Formula • (140- age) x body weight • (serum creatinine * 72) • * x 0.85 (if female) • MDRD Formula • 186 * serum creatinine -1.154 * age -0.203 • * 0.742 (if female) * 1.210 (if AA)

9. Stages of chronic renal disease

10. Prevalence of chronic renal failure in hypertension Serum Cr eCrCl > 1.4-1.5 mg/dl < 60 ml/min (n) HOT 18790 2.5% 12.3% INSIGHT 6321 3.1 % 29.1% HOPE 9173 10.5 % 36.4% ** H Clinico1539 5.3 % 17.5 % *

11. Creatinine and cardiovascular morbidity and mortality. HOPE study 60 50 40 30 20 10 0 Primary Myocardial CV Total outcome infarction mortality mortality Creatinine <1,4 mg/dl Creatinine >1,4mg/dl Mann et al. Ann Intern Med 2001

12. RR 4 Cardiovascular risk and creatinine values >1.5 mg/dl. HOT study 3 2 1 0 Stroke Total mortality CV events MI CV mortality Adapted from Ruilope et al, JASN 2001

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

14. Relationship between serum levels of creatinine and creatinine clearance Miravalles, Rodicio (data onfile)

15. Formulans to estimate the GFR eGFR • Cockroft-Gault Formula • (140- age) x body weight • (serum creatinine * 72) • * x 0.85 (if female) • MDRD Formula • 186 * serum creatinine -1.154 * age -0.203 • * 0.742 (if female) * 1.210 (if AA)

16. Relationship between MDRD and Cockcroft-Gault formulas to estimate renal function eGFR (ml/min/1.73m2) Creatinine clearance (ml/min) Miravalles, Rodicio (data onfile)

17. Relationship between two methods to estimate GFR: MDRD formula and I-talamate Iodo-talamate MDRD Rule et al. Ann InternMed 2004

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

19. Association of eGFR, and cystatin C with risk for death in elderly without chronic kidney disease Shlipak et al. Ann InternMed 2006

20. Relationship between serum cystatin C and creatinine clearance ROC curves to detect patients with GFR 60 – 90 mL/min Cystatin C 0.671 (0.576 – 0.756) Creatinine 0.578 (0.481 – 0.675) Miravalles, Rodicio (data onfile)

21. Measuring GFR in the JRP A2, B2 and B3 (I) • MDRD formula in each of the centres • Creatininewillbemeasured in thecoordinating centre with a standarizedmethod and GFR willberecalculated • Cystatin C willbemeasured in thecoordinating centre

22. Phenotypes for renal damage in hypertension: Urinary albumin excretion UAE

23. Prevalence of microalbuminuria according BP categories. NAHNES III 80 men women 70 60 56 55 50 Prevalence of albuminuria, % 40 35 31 30 21 20 16 14 12 12 8 10 7 5 0 optimal normal high normal stage 1 stage 2 stage 3 from Jones, et al. 2003

24. Natural history of microalbuminuria Non-insulin resistant 60 60 Nephrosclerosis 50 40 Microalbuminuria percentage (%) 30 Insulin-resistant 20 10 0 Time x BP Redon et al. Curr Hypertens Rep 2007

25. Changes in UAE categories according the UAE level and the presence of treatment at the begining from Pascual, et al. J Hypertens 2006

26. UAE and risk of cardiovascular and non-cardiovascular mortality 60 Hillege et al Circulation 2000

27. Urinary albumin excretion and cardiovascular mortality. NAHNES II 1.00 0.75 0.50 0.25 0.00 50 55 60 65 70 75 80 85 <30 mg/dL, n=8528 30-299 mg/dL, n=196 300 mg/dL, n=62 Cumulative CV disease mortality Age (yr) Muntner et al. JASN 2002

28. Microalbuminuria and GFR changes overtime. The PREVEND study Microalbuminuria 10 5 0 Delta creatinine clearance (ml/min per 4 year) -5 -10 -15 1 10 100 1000 Urinary albumin excretion (mg/24hr) Verhave et al. JASN 2003

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

30. Methods to measure albumin in urine • Antibodyrecognisablealbumin • Immunoassays (RIA, nephelometry) • Albuminnotdetectedbyimmunoassays • HPLC, precipitation • Peptidefragments • Spectrophotometry

31. Circadianvariability of UAE in essentialhypertension 1000 100 Night UAE (µg/min) 10 1 1 10 100 1000 Day UAE (µg/min) Redón et al, MedClin, 1995

32. Intraindividualvariability of UAE measurements 1000 100 First day 24-hours (µg/min) 10 HTA DM tipo 1 1 1 10 100 1000 Second day 24 hours (µg/min) Redón et al, MedClin 1995

33. UAE: samples and units of measurement Urine sample Units

34. UAE: samples and units of measurement Urine sample Units

35. Urinary albumin stability over timein ideal conditions: 4ºC and protected from light Percentage of positives who still positive Percentage of negatives who still negative Correlation coefficient Day Agreement

36. Urinary albumin measurement by using RIA and HPLC

37. Bland-Altman plot of two methods for measuring urinary albumin: RIA and HPLC

38. Measuring UAE in the JRP A2, B2 and B3 (I) • Firstvoidingurine in themorning • 3 differentdays • Measurementswithnephelometrie and simultaneousexamination of sediment (ordisptick) in each of the centres • 5 aliquotstostorefrozen at -20º at least (maintain at 4º out of light untilfrozen , recomendable no more than 4 hours) • Samplesfrozenshouldbesenttothecoordinating center (each 3 or 6 months)

39. Measuring UAE in the JRP A2, B2 and B3 (and the others) (II) • Measurements of albumin (nephrelometrie, HPLC) and creatinine • UAE willbeanalyzed as qualitative and quantitativetraits • Measurement of othermarkers (oxidative stress) • Proteomics in a smallsample (withspecialrequirementsforurinecollection and storage)

40. Risk for ESRD according BP categories in the Kaiser Permanent Register (21-year follow-up) 70 men women aRR 4.25 60 50 aRR 3.88 aRR 3.86 Age-adjusted ESRD rates per 100000 person-yrs 40 30 aRR 2.59 20 aRR 1.98 aRR 1.62 10 0 <120/80 ≥210/120 130-139/85-89 140-159/90-99 120-129/80-84 180-209/110-119 160-179/100-109 Blood pressure category from Hsu, et al. 2005