Intensive blood pressure lowering may not induce true kidney disease after all

Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information.

1. Intensive blood pressure lowering may not induce true kidney disease after all

Abstract: http://annals.org/aim/article/doi/10.7326/M18-1037

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Creatinine elevations, commonly seen during intensive blood pressure (BP) lowering, most likely do not represent true kidney disease, but may instead reflect benign reductions in kidney blood flow that occur naturally during treatment. The findings, published in Annals of Internal Medicine, represent a major advancement in the understanding of whether kidney tissue damage accompanies the diagnosis of chronic kidney disease (CKD) during hypertension therapy.

The Systolic Blood Pressure Intervention Trial (SPRINT) clinical trial demonstrated that more intensive systolic blood pressure management (target <120mmHg) reduced rates of major cardiovascular events and mortality. However, intensive BP lowering is associated with a 3-fold incidence of CKD, as measured by serum creatinine levels. Given the lower blood pressure targets in the recently-updated national hypertension guidelines, there has been substantial concern that guideline implementation of BP targets could cause an epidemic of CKD.

Researchers from the University of California San Francisco and the University of California San Diego used a panel of validated urinary biomarkers of kidney damage to compare kidney function between SPRINT participants who developed CKD and matched controls. Where creatinine concentration is an indirect reflection of the kidney's filtering function, urinary biomarkers measure actual kidney damage. As such, the researchers found that the diagnosis of CKD during intensive hypertension treatment was not associated with true kidney tissue damage and thus may not represent real disease. These findings highlight the major limitations of current clinical standards to diagnose and monitor CKD.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Michael Shlipak, MD, MPH, please contact Scott Maier at scott.maier@ucsf.edu.

2. Algorithm safely rules out pulmonary embolism in pregnant women

Abstract: http://annals.org/aim/article/doi/10.7326/M18-1670

Editorial: http://annals.org/aim/article/doi/10.7326/M18-2818

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A diagnostic strategy based on assessment of clinical probability, D-dimer measurement, bilateral lower limb compression ultrasonography (CUS), and computed tomography pulmonary angiography (CTPA) can safely rule out pulmonary embolism (PE) in pregnant women. Findings from a multicenter prospective management outcome study are published in Annals of Internal Medicine.

PE is among the most common causes of maternal death in developed countries and diagnosing PE is particularly challenging during pregnancy. Use of conventional diagnostic algorithms for PE is limited by several factors and guidelines provide inconsistent recommendations on the use of diagnostic tests in pregnant women.

Researchers from Geneva University Hospitals, Geneva, Switzerland studied 395 pregnant women with clinically suspected PE in 11 centers in France and Switzerland between August 2008 and July 2016 to prospectively validate a PE diagnostic strategy. PE was excluded in patients with a low or intermediate pretest clinical probability based on Geneva score and a negative D-dimer result. The remaining women underwent lower limb CUS and, if results were negative, CTPA. The researchers found that their diagnostic algorithm safely ruled out PE in pregnant women with a 3-month thromboembolic rate of 0.0 percent. The algorithm accuracy meets the recently proposed criteria of the International Society of the Thrombosis and Haemostasis for confirming the safety of VTE diagnostic strategies.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Marc Righini, MD, please contact him directly at Marc.Righini@hcuge.ch.

3. Presence of antiphospholipid antibodies found to be an important independent risk factor for MI

Abstract: http://annals.org/aim/article/doi/10.7326/M18-2130

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Researchers found a strong association between antiphospholipid antibodies (aPL) and immunoglobin G (IgG) positivity and first-time myocardial infarction (MI). Findings from a brief research report are published in Annals of Internal Medicine and will be presented at the American College of Rheumatology (Chicago Oct 19-24).

Researchers from Karolinska Institutet, Stockholm, Sweden assessed the frequency of antiphospholipid antibodies and antinuclear antibodies among 805 consecutive patients under the age of 75 who were hospitalized for a first MI at 17 Swedish hospitals between 2010 and 2014 compared to population controls individually matched for age, sex, and region. They found that the antibodies were 10 times more common in patients with MI than in control patients and occurred independently of traditional cardiovascular risk factors.

According to the researchers, these findings may lead to improved management, treatment, and out-comes for many patients with or at high risk for MI.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Elisabet Svenungsson, MD, PhD, please contact the Karolinska Institutet's Press Office at pressinfo@ki.se.

4. Evidence suggests that clinicians may need to rethink how they use buprenorphine to treat opioid use disorder

Abstract: http://annals.org/aim/article/doi/10.7326/M18-1652

Editorial: http://annals.org/aim/article/doi/10.7326/M18-2722

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Clinicians may need to rethink the way they treat opioid use disorder with buprenorphine.

A review of published evidence found that many current practices are too restrictive and conflict with the science. A special article on the next stage of buprenorphine care for opioid use disorder is published in Annals of Internal Medicine.

Researchers from the University of Massachusetts reviewed published research to contrast recent evidence with common, widespread, and outdated practices involving the use of buprenorphine that have the paradoxical effect of potentially harming patients. The research focused on the following seven areas: location of buprenorphine induction; combining buprenorphine with a benzodiazepine; relapse during buprenorphine treatment; requirements for counseling; uses of drug testing; use of other substances during buprenorphine treatment; and duration of buprenorphine treatment.

Based on the evidence, the researchers suggest a more progressive approach to treating opioid use disorder that minimizes barriers in the Opioid Treatment Cascade of Care, including linkage, initiation, and maintenance of buprenorphine therapy. In addition to allowing home induction of buprenorphine, the researchers suggest that the old practice of requiring counseling with buprenorphine use may do more harm than good. The authors also challenge previous practices of discharging patients for relapse or use of other substances.

The researchers note that nearly all evidence guiding current practice was found before the lethality of heroin and illicitly produced fentanyl appeared at scale, making updated, evidence-based treatment all the more critical. Editorialists strongly agree that the magnitude of the opioid epidemic calls for a reexamination of the conservative approaches to buprenorphine use.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Stephen Martin, MD, EdM, please contact him directly at stmartin@gmail.com.

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