MINISTRY OF EDUCATION AND TRANING MINISTRY OF NATIONAL DEFENCE VIETNAM MILITARY MEDICAL UNIVERSITY NGUYỄN VĨNH HƯNG STUDY ON HEMODYNAMIC INDEX OF KIDNEY ARTERIES AND GLOMERULAR FILTRATION RATE IN ESSENTIAL HYPERTENSION PATIENTS Specialist: Nephrology-Urology Code: 62.72.01.46 Epitomize of PhD thesis Hanoi - 2014 1 1 Research completed in: VIETNAM MILITARY MEDICAL UNIVERSITY Supervisor I: AssProf. PhD HA HOANG KIEM Supervisor I: AssProf. PhD DINH THI KIM DUNG Scientific reviewer I: Ass.Prof TRAN VAN CHAT Scientific reviewer II: Ass.Prof DOAN VAN DE Scientific reviewer III: AssProf. PhD NGUYEN VAN QUYNH Thesis will be presented in university examiner assembly In Vietnam military medical university At hour min, day month year 2014 Find thesis in 1. National library 2. Vietnam military medical university 2 2 INTRODUCTION Hypertension (HTA) is cause and consequences of CKD. Renal failure is severe of HTA and affects quality of life’s patients and is the heavy burnde of social. USRDS 2005 showed 27% FSRD caused by HTA, HTA is 2 nd caused less than diabetes 51%. WHO warned HTA in Vietnam will be most important cause of ESRD in near future. HTA lead increasing of blood flow of kidney and intragromerular pressure increase. Belong the time, normal structure of gromeruli will be destroyed, sclerosis and kidney function decreased and the end ESRD. HTA destroyed all kinds of kiney arteries by the longtime hype pressure. This procedure is dangerous because it hell is “silent”. Signes appearred late, when loss kidney function. Doppler ultrasound is non-invasive intervention for diagnose follow up kidney arteries disorder. This technique help find out early injury caused by HTA. There are many research about disease caused by HTA. Therefore need more research in hemodynamic kidney arteries and gromerular filtration rate. Information received help diagnose early, prevent kidney complication of HTA. OBJECTIF 1. Study on hemodynamic index (HI)(speed of blood flow, blood flow volume, resistance index, pulsasitive index); Plasma renin concentration (PCR) and gromerular fitration rate (GFR) in essential HTA with negative macroalbuminuria. 2. Relationship of blood flow volume (FV) of kidney arteries, GFR with PRC, and anothers hemodynamics index. NEWCONTRIBUTION OF THESIS 3 3 - Result received reconfirms HI of kidney arteries, GFR depend on HTA situation: Stage of HTA, time of HTA. - Warning clinical physics evaluate completely, systematic, chronology HI, GFR, PCR in essential patients to prevent renal injuries. CONTENT OF THESIS Thesis have 124 pages: Introduction 2 pages, Chapter 1: Background 24 pages, Chapter 2: Subjects and method 15 pages, Chapter 3: Result 33 pages, Chapter 4: Discusion 29 pages. Thesis has 44 tables, 3 schemas, 3 images. References 162: in Vietnamese 26 and 146 in English. Chapter 1 BACKGROUND 1.1. Kidney injuries caused by HTA Early, changing of function passed in the longtime recurred if right treated. Later, sclerosis accelerated and dimension of kidney decreases cause ERSD. GFR in early time maintain with low FV (flow volume) but later GFR decreased and ESRD at the end. All of kidney arteries injured but mostly in afferent arteries. The character of histological injuries’ is intimae artery and endothelia destruction sclerosis, necroses all of the arteries. 1.2. GFR disorder in HTA Theory, changing of pressure lead changing function, later structure destroyed, belong the time abnormal struction decreases function. Actually, most of CKD hypertensions aren’t treated. In early time of HTA, GFR in normal ranger or increase lightly. Late, when MAU appeared, GFR in normal range. If patient aren’t under good HTA controlled; Microalbumin or clinical protein in uria appeared, GFR decrease significally, clinical signs of renal failure more severe. GFR loss in HTA patient caused by renal auto regulation system dysfunction. Auto regulation contraction of afferent arteries and refection 4 4 tubulo-glomerular system disordes. HTA chonic patient from epithelial dysfunction and structural arteries destroyed. Intragromerular pressure decreased with blood pressure higher than 80mmHg and increase with BP higher than 160mmHg. 1.1 . Renal artery interventional method - Direct method: + Ultrasound color Doppler + Digital angiography + MRI - Indirect + Intravenous urography, image nuclear + Biochemical test 1.2 . Researches hemodynamic index and GFR in HTA patients in Vietnam and global. MDRD research showed CKD patient have slower decreased of GFR if volume controlled HTA compared non-controlled. Resumed of 9 clinical researches on the changing of GFR in HTA patients: CKD patient non- controlled HTA (more than 140/90mmHg) – GFR decreased 12ml/min/year. Inversing well control HTA (<130/80mmHg) GFR decreased 2ml/min/year. (similar normal subject). Peterson and al conclude RI and PI of renal arteries have closed relationship with another HI and GFR. In Vietnam, Tran Bui (2002) evaluated HI of renal arteries by Doppler ultrasound. 35 normal subject competed 35 hypertensive’s patients with age 30-79. Blood follow (BF) in subject is 842ml/min. (HTA) (decreased significality patients 262ml/min =24%. Huynh Van Nhuan 2005 studied on 36 CKD compared 22 normal showed RI and PI increased significality (0,79 compared 0,665) 2,13 compared 1,22. Chapter 2 SUBJECT AND METHOD 2.1. Subject: 5 5 - 333 peoples divide 2 groups: 136 normal and 197 HTA patients with age 40-90; among them 91 male and 106 female. - Patients followed up in E hospital with essential HTA diagnosed, proteinuria negative, GFR > 60ml/min. 2.2 Method: - Perspective, controlled, description. - Time of study: Jan/09 – Jan/2012 - Location: E hospital 2.2.2 Steps of study Step 1: Chose study subject Clinical consultation; BP measured, urin test 10 index, ultrasound kidney and urology system. Step 2: - Measured BP; GFR test, MAU test, ultrasound Doppler kidney arteries. - Collect research parameters recorded, and stopped all of HTA treatments possible Step 3: Analyze parameters collected by mathematical statistic SPSS 10.0 - Mean, SD - Relationship under - Compare mean, % - Result statistical signification with p<0,05 - Result presented schema, table, image Chapter 3 RESULT OF RESEARCH 3.1 Character of subjects 6 6 Table 3.1: Mean age Gender Age ( X ± SD) (year) p HTA (n = 197) Control (n = 136) Male (n=165) 59,1 ± 10,2 60,6 ± 9,7 >0,05 Female (n=168) 59,3 ± 9,3 59,3 ± 9,5 >0,05 p >0,05 >0,05 all 59,2 ± 9,7 60,0 ± 9,6 >0,05 Comment: mean age of HTA patients isn’t different normal subject with p≥0,05 the same for gender 7 7 Table 3.2. Stage of HTA Age stage I n (%) Stage II n (%) p all n (%) 40-50 38 (88,4) 5 (10,6) < 0,05 43 (21,8) 51-60 35 (63,6) 20 (36,4) < 0,05 55 (27,9) 61-70 16 (25,8) 46 (74,2) < 0,05 62 (31,5) > 70 2 (5,4) 35 (94,6) < 0,05 37 (18,8) All 91(46,2) 106(53,8) < 0,05 197 (100) Comment: percentage of HTA stage I higher than stage II sihnificaltly. No one stageIII 3.2. Plasma concentration of renin (mg/l) Table 3.3: PCR (mg/l)by age Age Renin ( X ± SD) (mg/l) p HTA(n=197) Control (n=136) 40-50(n=43) 2,70± 0,86 1,16 ± 0,11 < 0,05 51-60(n=55) 2,29 ± 0,71 1,27 ± 0,17 < 0,05 61-70(n=62) 2,24 ± 0,54 1,26 ± 0,17 < 0,05 >70(n=37) 1,75 ± 0,40 1,27 ± 0,17 < 0,05 all 2,26 ± 0,72 1,25 ± 0,16 < 0,05 p < 0,05 >0,05 Comment: PRC mean in HTA group higher than normal significaltly p<0,05. More young more different in normal group PRC don’t change with age but in HTA group PRC decreased with age. Table 3.4: Percentage increased-decreased PRC Age Increased ( >1,57 mg/l) n Normal (0,93 - 1,57mg/l) n Decreased (<0,93 mg/l) n (%) 8 8 (%) (%) 40-50(n=43) 34 (23,6) 9 (17,0) 0 51-60(n=55) 39 (27,1) 16(30,2) 0 61-70(n=62) 48 (33,3) 14 (26,4) 0 >70(n=37) 23 (16,0) 14 (26,4) 0 All 144 (73,1) 53 26,9) 0 Comment: We defined normal range level of PRC 0,93-1,57 from table3.6. In research 144 HTA PRC increased 73,1% and no one decreased different significantly. 3.3. Microalbuminuria Table 3.5: Microalbuminuria Gender Microalbuminuria MAU (+) n (%) Concentration (mg/24h) ( X ± SD) Male (n=91) 32 (56,1) 43,9 ± 64,3 Female (n=106) 25 (43,9) 31,5 ± 60,9 p < 0,05 >0,05 All (n=197) 57 (28,9) 37,9 ± 62,9 Comment: 57 patients with microalbuminuria (+) is 28,9%. among microalbumin (+), male 56,1% female is 43,9%, diferent significalty p<0,05. Table 3.6: microalbuminuria by time of HTA Time (year) Microalbumin (+) n (%) Microalbumin (-) n (%) <1 (n=39) 5 (8,8) 13 (9,3) 1-5 (n=67) 34 (59,6) 109 (77,8) >5 (n=91) 18 (31,6) 18 (12,9) 9 9 p <0,05 <0,05 All 57 (28,9) 140 (71,1) Comment: microalbumin (+) increased by time and diferent significalty p<0,05 compared microalbumin negative. Table 3.7: microalbuminuria by stage of HTA Stage Microalbumin (+) n (%) Microalbumin (-) n (%) p I (n=91) 13 (22,8) 78 (55,7) <0,05 II (n=106) 44 (77,2) 62 (44,3) <0,05 p <0,05 >0,05 OR 4,258 Comment: Microalbuminuria (+) increased by stage HTA significalty p<0,05. Patients HTA stage II risk microalbumin niệu (+) higher 4,258 time stage I. diferent significalty p<0,05 microalbumin (+) and microalbumin niệu (-) by stage. 3.4. Gromerular filtration rate (GFR) Table 3.8: GFR (ml/min) by age Age GFR ( X ± SD ) (ml/min) p HTA (n=197) Control (n=136) 40-50(1) (nb=43)(nc=20) 86,3 ± 8,5 103,9 ± 11,0 <0,05 10 10 [...]... renin concentration constant Thus the concentration in the blood renin hypertension decreased with age, while those without hypertension renin levels stable Fink H.A 2012 study of renal lesions seen in patients with chronic kidney disease, the angiotensin converting enzyme inhibitors and AT1 receptor inhibition reduces the risk of end-stage renal failure, reduced mortality risk of myocardial infarction... hole in the parenchyma and in Patients with higher age of increasing RI Table 4.3 Correlation between renal blood flow and glomerular filtration rate Author Correlation coefficient (r) we 0,279 Makino Y 0,56 Lebkowka U 0,38 4.9 Related glomerular filtration rate and hypertension In the early stages of hypertension increased glomerular vascular pressure response to blood pressure puts increased glomerular. .. hemodynamics and glomerular filtration rate in relation to the status of hypertension in patients with primary hypertension in hypertensive phase, time disease and severity of kidney damage On the basis of the results obtained recommends clinicians a comprehensive assessment, systematic, periodic parameters of renal artery hemodynamics, glomerular filtration rate, blood renin levels to detect injuries kidney. .. of myocardial infarction and sudden stroke, thereby confirming the role of the reninangiotensin system-aldosterone in target organ damage in hypertensive patients 4.4 Change in glomerular filtration rate Glomerular filtration rate decreases with increasing blood pressure stage This may indicate that the glomerular filtration rate depends on the internal blood pressure and glomerular affected by systemic... filtration rate in early stage and mild In contrast to the blood pressure in people with hypertension stage II, the inverse correlation between blood pressure and glomerular filtration rate is a lot 21 22 clearer We thought at the time was new hypertension or hypertension and mild early stage, the glomerular filtration rate seems to increase with events, but then the response time with the number of. .. pressure, increased glomerular filtration rate decreases Initial blood pressure makes the blood flow to the kidneys increases and increased glomerular filtration rate But then over time the response of the kidney is no longer as in the first phase and to a certain time point, the glomerular filtration rate will decrease rather than increase Through research can see clearly the relative influence of blood... reduced glomerular filtration rate and always goes down very fast, whereas the group with hypertension stage I early glomerular filtration rate increased slightly and then decreases with time Hypertension is a major cause of disease on cardiovascular events and kidney damage Lash and his colleagues in 2009 CRIC study results confirmed the correlation between kidney function and risk factors such as hypertension, ... aldosterone-renin-angiotensin system We examined blood parameters renin to learn this association In the present study we found that the concentration of renin in hypertension 197 (2.26 mg / l) significantly greater than the concentration of renin in 136 people in the control group (1,25mg / l) In the subgroup of patients renin concentration decreases with age have statistically significant p . MINISTRY OF EDUCATION AND TRANING MINISTRY OF NATIONAL DEFENCE VIETNAM MILITARY MEDICAL UNIVERSITY NGUYỄN VĨNH HƯNG STUDY ON HEMODYNAMIC INDEX OF KIDNEY ARTERIES AND GLOMERULAR FILTRATION RATE. research in hemodynamic kidney arteries and gromerular filtration rate. Information received help diagnose early, prevent kidney complication of HTA. OBJECTIF 1. Study on hemodynamic index (HI)(speed. filtration rate Glomerular filtration rate decreases with increasing blood pressure stage. This may indicate that the glomerular filtration rate depends on the internal blood pressure and glomerular