1. 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

2. 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

3. 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

4. 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

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

6. 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%)

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

8. 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 -1.154 * age -0.203 * 0.742 (if female) * 1.210 (if AA) eGFR

9. HOME BP Stages of chronic renal disease StageDescriptionGF ml/min/ 1.73 m 2 Prevalence -On risk- 1Renal lesion with GF normal or increased >90 3.3 % 2Renal lesion with GF slightly reduced 60-89 3.0 % 3GF moderately reduced30-59 4.3 % 4GF severely reduced15-29 0.2 % 5Renal failure<15 o dialysis 0.1 %

10. HOME BP Prevalence of chronic renal failure in hypertension Serum Cr eCrCl > 1.4-1.5 mg/dl < 60 ml/min HOT 18790 2.5% 12.3% INSIGHT 6321 3.1 % 29.1% HOPE 9173 10.5 % 36.4% ** H Clinico 1539 5.3 % 17.5 % * (n)

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

12. 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

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

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

15. 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 -1.154 * age -0.203 * 0.742 (if female) * 1.210 (if AA) eGFR

16. 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)

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

18. 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

19. 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

20. 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 0.671 (0.576 – 0.756) Creatinine 0.578 (0.481 – 0.675)

21. 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

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

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

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

25. 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 untreated615927.8 Regresion treated1914018.0 Progresion117.3 Proteinurics Regresion untreated123317.4 Regresion treated465420.7 from Pascual, et al. J Hypertens 2006

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

27. HOME BP Urinary albumin excretion and cardiovascular mortality. NAHNES II Muntner et al. JASN 2002 <30 mg/dL, n=8528 30-299 mg/dL, n=196 300 mg/dL, n=62 1.00 0.75 0.50 0.25 0.00 5055606570758085 Age (yr) Cumulative CV disease mortality

28. HOME BP Microalbuminuria and GFR changes overtime. The PREVEND study Microalbuminuria Delta creatinine clearance (ml/min per 4 year) Urinary albumin excretion (mg/24hr) 1101001000 -15 -10 -5 0 5 10 Verhave et al. JASN 2003

29. 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

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

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

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

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

34. HOME BP UAE: samples and units of measurement SpotNight24 hour mg/24 h30-299 mg/min20-199 mg/mmol Cr 3-29 mg/g Cr30-299 Urine sample Units

35. 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

36. HOME BP Urinary albumin measurement by using RIA and HPLC

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

38. 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)

39. 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)

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