Dr. Luis Miguel Ruilope Jefe de la Unidad de Hipertensión del Hospital Universitario 12 de Octubre, Madrid CONTINUO CARDIOVASCULAR

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2 Dr. Luis Miguel Ruilope Jefe de la Unidad de Hipertensión del Hospital Universitario 12 de Octubre, Madrid CONTINUO CARDIOVASCULAR

3 Continuo cardiorrenal RETROCESO Target organ damage Asymptomatic CKD New risk factors Atherosclerosis Target organ damage Symptomatic Risk factors ESRD Death

4 Los pesos pesados de los factores de riesgo modificables de las enf. cardiovasculares Colesterol Hipertensión Diabetes Tabaquismo LDL HDL Riesgo global en enfermedades cardiovasculares

5 Prevalencia y causas de la enfermedad renal terminal Number of dialysis patients Diabetes Hypertension Projection 95% CI , , ,

6 Riesgos cardiovasculares Edad, etnia, diabetes/síndrome metabólico/obesidad, hipertensión, hiperlipidemia, tabaquismo

7 CVRF Age, Ethnicity Diabetes/MetSyn/Obesity Hypertension, hyperlipidemia, smoking CVD Atherosclerosis CKD egfr<60ml/min/1.73m 2 Albuminuria

8 Cociente de riesgo e intervalo de confianza del 95% para la mortalidad cardiovascular y para todas las causas según el índice de filtrado glomerular estimado (egfr) y el cociente albúmina-creatinina (ACR) Hazard ratios and 95% CIs (shaded areas) according to egfr (A, C) and ACR (B, D) adjusted for each other, age, sex, ethnic origin, history of cardiovascular disease, systolic blood pressure, diabetes, smoking, and total cholesterol. The reference (diamond) was egfr 95 ml/min/1.73 m2 and ACR 5 mg/g, respectively. Circles represent statistically significant and triangles represent not significant. ACR plotted in mg/g. Lancet May 18, 2010 (Published Online)

9 Cociente de riesgo e intervalo de confianza del 95% para la mortalidad cardiovascular y para todas las causas según el índice de filtrado glomerular estimado (egfr) y la albúmina categórica Shaded areas represent 95% CIs. Models included spline egfr, categorical albuminuria, and their interaction terms as well as adjustment for age, sex, ethnic origin, history of cardiovascular disease, systolic blood pressure, diabetes, smoking, and total cholesterol. The reference (diamond) was egfr 95 ml/min/1.73 m² plus ACR less than 3.4 mg/mmol (30 mg/g) or dipstick test result negative or trace. Circles represent statistically significant and triangles represent not significant. Lancet May 18, 2010 (Published Online)

10 + + + CVD Atherosclerosis + CVRF Age, ethnicity Diabetes/MetSyn/Obesity Hypertension, hyperlipidemia, smoking RRF (Stage 3-5 of CKD) Albuminuria Anemia Vitamin D deficiency Calcium/phosphate alterations ADMA CKD egfr<60ml/min/1.73m 2 Albuminuria +

11 CVD Atherosclerosis + CVRF Age, Ethnicity Diabetes/MetSyn/Obesity Hypertension, hyperlipidemia, smoking CKD egfr<60ml/min/1.73m 2 Albuminuria + + Primary renal diseases Deranged fetal programming with nephron underdosing RRF (Stage 3-5 of CKD) Albuminuria Anemia Vitamin D deficiency Calcium/phosphate alterations ADMA

12 - CVRF Age, Ethnicity Diabetes/MetSyn/Obesity Hypertension, hyperlipidemia, smoking CVD Atherosclerosis CKD egfr<60ml/min/1.73m 2 Albuminuria + RRF + - (Stage 3-5 of CKD) Albuminuria Anemia Vitamin D deficiency Calcium/phosphate alterations ADMA Primary renal diseases Deranged fetal programming with nephron underdosing BP control Lipid control HbA 1 C control Body weight control Antiplatelet therapy Quit smoking Adequate diet Physical activity Stage 3-5 CKD Phosphate control Anemia control Vitamin D deficiency

13 Cumulative incidence Incidencia acumulativa de eventos cardiovasculares 0.15 Primary end point* CKD, placebo No CKD, placebo CKD, rosuvastatin No CKD, rosuvastatin No. at Risk CKD Rosuvastatin Placebo No CKD Rosuvastatin Placebo Follow-up (years) *Primary end point: non-fatal MI, nonfatal stroke, hospital stay for unstable angina, arterial revascularization, or CV death Ridker PM et al. J Am Coll Cardiol. 2010;55(12):

14 Terapia antiplaquetaria Aspirin 81 mg is indicated whenever the risk is high or CV disease is present in patients with stage 4 CKD Abboud & Henrich. N Eng J Med. 2010; 362: 56-65

15 Published online February 18, 2010

16 ACCOMPLISH: Evolución de la enfermedad renal crónica* para la población con intención de tratamiento * Defined as: doubling of serum creatinine concentration, estimated glomerular filtration rate less than 15 ml/min/1,73 m 2, or need for dialysis Published online February 18, 2010

17 ACCOMPLISH: Evolución de la enfermedad renal crónica* y muerte CV para la población con intención de tratamiento * Defined as: doubling of serum creatinine concentration, estimated glomerular filtration rate less than 15 ml/min/1,73 m 2, or need for dialysis Published online February 18, 2010

18 ACCOMPLISH: Cambios en la tensión arterial a lo largo del ensayo en pacientes con enfermedad renal crónica Published online February 18, 2010

19 Riesgos de inhibición del RAAS Hipotensión Fallo renal Hiperpotasemia

20 Categorías de riesgo en las variables renales y de mortalidad por FG y fase de albuminuria y proteinuria (KDIGO 2009) UAE A1 A1 A2 A3 A3 mg/g Optimal <15 High-normal High Very high 300-1,999 Nefrotic >2,000 GFR stage Description (ml/min/ 1.73 m 2 ) G1 High >105 G1 Optimal G2 Mild G3a Mild to moderate G3b Moderate to severe G4 Severe G5 Kidney failure <15 Levey AS et al. Kidney Int, 8 December 2010

21 Límite de FG estimada y riesgo de hiperpotasemia egfr < 30 ml/min/1.73 m 2 Serum potassium limits: > 4 mmol/l and < 5.6 mmol/l

22 Tratamiento de hiperpotasemia Calcium infusion Insulin & glucose Sodium bicarbonate Beta-2-adrenergic agonists Loop or thiazide diuretics Cation exchange resins Dialysis

23 PEARL-HF [1] : Cambios en los niveles de potasio sérico desde el inicio del ensayo

24 PEARL-HF [1] : Cambios en los niveles de potasio sérico por FG

25 PEARL-HF [1] : Pacientes con niveles de potasio sérico > 5,5 meq/l por FG