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Thyroid (follicular-cell) hyperplasia was observed cholesterol quick fix vytorin 20mg visa, ranging in severity from moderate at 1000 mg/kg of diet to free cholesterol test jacksonville fl 30mg vytorin with mastercard marked at 10 000 mg/kg of diet cholesterol mg per day order 20mg vytorin, but no thyroid tumours were reported (Fitzhugh & Nelson does cholesterol medication make you cough order 30 mg vytorin visa, 1948). Epidermoid carcinomas of the external auditory duct or meibomian glands of the eyelids were diagnosed in 17/19 treated rats in contrast to 0/12 control rats. A subsequent study from the same laboratory, in which the same strain of rat was given 0. Treatment had no effect on the mortality rate, the cumulative rate for the experiment being 65% for males and 60% for females. There was no difference between control and treated groups in tumour incidence at any site examined, including the liver (1/60 in controls and 0/60 in treated rats) (Radomski et al. A control group of 30 males and 30 females fed basal diet was terminated at 25 months. There was no increase in tumour incidence at any of the organ sites examined, including the liver, in which there were no tumours observed in either control or treated groups (Deichmann et al. In the initiating arm, groups of four to six male and female Sprague-Dawley rats, 21?26 days of age, received an oral dose of 200 or 500 mg/kg bw per day thiourea (purity, 99. Another four groups received either thiourea, Clophen A 50 or olive oil alone at the same doses. Thiourea did not enhance the incidence of foci of hepatocellular alteration when given either as an initiator or a promoter (Oesterle & Deml, 1988). Five animals from each group were killed at various intervals up to the end of the study. Groups of 10 or 15 male Fischer 344 rats, 5 weeks of age, received a single subcuta neous injection of 1. The incidences of thyroid follicular cell tumours were increased at both doses of thiourea (p < 0. Thiourea did not promote the induction of hepatocellular tumours to a statistically significant degree (Shimo et al. A group of 15 male Fischer 344 rats, 6 weeks of age, received a single subcutaneous injection of 2. Groups of 10 male Fischer 344 rats, 6 weeks of age, received a single subcutaneous injection of 2. A single oral dose of 100 mg of thiourea was almost completely eliminated from the blood within 24 h; 15% was broken down in the intestine and 30?50% in other tissues and body fluids, the remainder (approximately 30%) being excreted as thiourea in the urine (Williams & Kay, 1947). In rats given 5 mg by intravenous injection, 30% of the thiourea was recovered from the carcasses after 3 h and only traces after 25 h (Williams & Kay, 1947). In homogenized liver preparations from female Holtzman rats, 28?35% of added thiourea was metabolized within 3 h. The pathway for the breakdown of thiourea was suggested to be as follows: uracil;? Dose-dependent decreases were found in the serum concentrations of triiodothyronine [by 60% and 15%, respectively] and thyroxine (T4) [by 85% and 45%, respectively]. Thyroid weights were significantly increased in a treatment duration-dependent manner. Hyperplasia was noted at 2 weeks and adenomas at 4 weeks, both of which increased with length of treatment. Thyroid hyperplasias and neoplasias were induced in both groups; however, the combination of thiourea and vitamin A induced more cell proliferation, as measured by bromodeoxyuridine incorporation (Takegawa et al. Mature (450?500 g) and immature (50?80 g, 21?23 days of age) male Sprague Dawley rats were given an intraperitoneal dose of 0. The immature, but not the mature rats were tolerant to the toxic pulmonary effects of this treatment (Hollinger et al. Vascular permeability, as determined by Evans blue dye injected into a femoral vein, increased with the age of male Sprague-Dawley rats that received an intraperitoneal dose of 10 mg/kg bw thiourea 2 h before sacrifice. The increased vascular permeability concorded with increased concentrations of histamine in lung and plasma (Giri et al. The lethal intraperitoneal dose of thiourea in male Sprague-Dawley rats was 10 mg/kg bw, causing 100% mortality within 24 h. The protection was correlated with histamine concentrations; that is, the histamine concentrations were low when the animals were protected (Giri et al. In an assay for iodination with 2-methoxyphenol (guaiacol) in the presence of iodide and thiourea, thyroid peroxidase oxidized thiourea to formamidine disulfide. While the specific incidences of fetal effects were not provided, the authors noted that growth retardation and malformations of the nervous system and skeleton were present in the treated offspring (Kern et al. It did not induce mutation in Salmonella typhimurium umu and did not induce prophage in E. It was weakly mutagenic in base-pair substitution and frame shift strains of Salmonella in the mouse host-mediated assay after intramuscular admi nistration. Thiourea was mutagenic in Saccharomyces cerevisiae and induced intrachromo somal recombination and petite mutations. Thiourea did not induce homologous or non-homologous recombination in cultured Chinese hamster cells. There is disagreement in the literature about the ability of thiourea to induce muta tion in mouse lymphoma L5178Y (Tk locus) or Chinese hamster V79 (Hprt locus) cells. Mutagenicity in Chinese hamster V79 cells was enhanced by depletion of intra cellular glutathione. Thiourea induced intrachromosomal recombination in transformed human lympho blastoid cells. This is the probable basis of its thyroid tumour-promoting activity in experimental animals; however, no definitive conclusion regarding the mechanism of carcinogenicity of thiourea can be drawn in view of the mixed results obtained in tests for genotoxicity. Thiourea can interfere with thyroid peroxidase-mediated iodination of thyroglobulin. Thiourea was not mutagenic in bacteria, but mixed results were obtained in assays in mammalian cells. In four early studies involving several strains of mice, thyroid hyperplasia but not thyroid tumours was reported after oral administration of thiourea. In several studies in rats given thiourea orally, either a high incidence of thyroid follicular-cell adenomas and carcinomas or increased incidences of hepatocellular adenomas or tumours of the Zymbal or meibomian glands were reported. However, there were deficiencies in each of these studies and no corres pondence between studies with respect to tumour site. In five initiation?promotion studies in rats, thiourea promoted thyroid follicular-cell tumours initiated by N-nitroso bis(2-hydroxypropyl)amine. Thiourea acts by inhibiting thyroid peroxidase, resulting in decreased thyroid hormone production and increased proliferation due to an increase in the secretion of thyroid-stimulating hormone. This is the probable basis of the tumori genic activity of thiourea for the thyroid in experimental animals. No data were available on reproductive or developmental effects of thiourea in humans. One study in rats showed growth retardation and malformations of the skeleton and nervous system in the offspring of thiourea-treated animals. Thiourea did not induce gene mutation in bacteria, but mixed results were obtained in assays in mammalian cells. It consistently induced chromosomal recombination in yeast and insects and induced mammalian cell transformation. There is limited evidence in experimental animals for the carcinogenicity of thiourea. Overall evaluation Thiourea is not classifiable as to its carcinogenicity to humans (Group 3). Tests with Salmonella typhimurium and Escherichia coli using a standardized protocol. Volume 31 Volume 40 Volume 51 Some Food Additives, Feed Some Naturally Occurring and Coffee, Tea, Mate, Methyl Additives and Naturally Synthetic Food Components, xanthines and Methylglyoxal Occurring Substances Furocoumarins and Ultraviolet 1991; 513 pages 1983; 314 pages (out-of-print) Radiation 1986; 444 pages Volume 52 Volume 32 Chlorinated Drinking-water; Polynuclear Aromatic Volume 41 Chlorination By-products; Some Compounds, Part 1: Chemical, Some Halogenated Hydrocarbons Other Halogenated Compounds; Environmental and Experimental and Pesticide Exposures Cobalt and Cobalt Compounds Data 1986; 434 pages 1991; 544 pages 1983; 477 pages (out-of-print) Volume 42 Volume 53 Silica and Some Silicates Occupational Exposures in Volume 33 1987; 289 pages Insecticide Application, and Polynuclear Aromatic Some Pesticides Compounds, Part 2: Carbon Volume 43 1991; 612 pages Blacks, Mineral Oils and Some Man-Made Mineral Fibres and Nitroarenes Radon Volume 54 1984; 245 pages (out-of-print) 1988; 300 pages Occupational Exposures to Mists and Vapours from Strong Volume 34 Volume 44 Inorganic Acids; and Other Polynuclear Aromatic Alcohol Drinking Industrial Chemicals Compounds, Part 3: Industrial 1988; 416 pages 1992; 336 pages Exposures in Aluminium Production, Coal Gasification, Volume 45 Volume 55 Coke Production, and Iron and Occupational Exposures in Solar and Ultraviolet Radiation Steel Founding Petroleum Refining; Crude Oil 1992; 316 pages 1984; 219 pages and Major Petroleum Fuels 1989; 322 pages Volume 56 Volume 35 Some Naturally Occurring Polynuclear Aromatic Volume 46 Substances: Food Items and Compounds, Part 4: Bitumens, Diesel and Gasoline Engine Constituents, Heterocyclic Coal-tars and Derived Products, Exhausts and Some Nitroarenes Aromatic Amines and Mycotoxins Shale-oils and Soots 1989; 458 pages 1993; 599 pages 1985; 271 pages Volume 47 Volume 57 Volume 36 Some Organic Solvents, Resin Occupational Exposures of Allyl Compounds, Aldehydes, Monomers and Related Hairdressers and Barbers and Epoxides and Peroxides Compounds, Pigments and Personal Use of Hair Colourants; 1985; 369 pages Occupational Exposures in Some Hair Dyes, Cosmetic Paint Manufacture and Painting Colourants, Industrial Dyestuffs 1989; 535 pages and Aromatic Amines Volume 37 1993; 428 pages Tobacco Habits Other than Volume 48 Smoking; Betel-Quid and Areca Some Flame Retardants and Volume 58 Nut Chewing; and Some Related Textile Chemicals, and Exposures Beryllium, Cadmium, Mercury, Nitrosamines in the Textile Manufacturing and Exposures in the Glass 1985; 291 pages Industry Manufacturing Industry 1990; 345 pages 1993; 444 pages Volume 38 Tobacco Smoking Volume 49 Volume 59 1986; 421 pages Chromium, Nickel and Welding Hepatitis Viruses 1990; 677 pages 1994; 286 pages Volume 39 Some Chemicals Used in Plastics Volume 50 Volume 60 and Elastomers Pharmaceutical Drugs Some Industrial Chemicals 1986; 403 pages 1990; 415 pages 1994; 560 pages Volume 61 Volume 71 Supplement No. Lips 1 From the Division of Biomedical Genetics, Department of Metabolic and Endocrine Diseases, University Medical Centre Utrecht, Utrecht; 2Department of Endocrinology, University Medical Centre Groningen, University of Groningen, Groningen; 3Division of Internal Medicine and Dermatology, Department of Clinical Endocrinology, University Medical Centre Utrecht, 4 Utrecht; Department of Genetics, University Medical Centre Groningen, University of Groningen, Groningen; and 5Netherlands Metabolomics Centre, location University Medical Centre Utrecht, Utrecht; the Netherlands Abstract. More research is being aimed at the Medical Centre Utrecht, Utrecht; the Netherlands).

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The new england journal of medicine intestinal infections with nematodes may result iron hoe hoog mag cholesterol ratio zijn discount vytorin. Typical findings include a striking micro in severe anemia lowering cholesterol with diet discount 20 mg vytorin free shipping, especially in young children cholesterol levels measurement vytorin 20 mg cheap. However cholesterol levels new guidelines order 30mg vytorin fast delivery, knowledge of this condition with hypermenorrhea may also have concomi is valuable to clinicians, since it clarifies how tant malabsorption of iron. Bariatric surgery, such as inflammation: increased serum levels of hepci laparoscopic Roux-en-Y gastric bypass, which is din have been reported in the early stages of performed in selected obese patients to reduce disease but not during disease progression. The prevalence of celiac disease in more than 50 families38,39 have led to consti and its atypical manifestations, which include tutively high production of hepcidin, which iron-deficiency anemia, are increasingly recog blocks the intestinal absorption of iron. Iron-Deficiency Anemia negligible incidence among iron-replete partici and anemia of chronic diseases) are well estab pants, whereas 2. Similarly, au supply that is insufficient to support normal toimmune atrophic gastritis, another rare cause erythropoiesis. However, in determining iron of iron-refractory deficiency anemia, which re status, it is important to consider the whole pic sults from an immune reaction against gastric ture rather than relying on single test results. High Clinical Findings er cutoff levels for ferritin are used in the diag Iron-deficiency anemia is chronic and frequently nosis of iron deficiency in other conditions. Weakness, fatigue, difficulty in concen chronic kidney disease in the presence of a trating, and poor work productivity are nonspe transferrin saturation level of less than 30%54). The extent to which means of biopsy is an option that is not used these nonhematologic effects of iron deficiency frequently. At present, no reliable test for hepci are manifested before anemia develops is un din levels is available. Signs of iron deficiency in tissue are subtle and may not respond to iron therapy. Iron defi Therapy ciency has been reported to decrease cognitive performance and to delay mental and motor Cautions and General Guidelines development in children. Patients with iron-deficiency anemia should re Severe iron-deficiency anemia in pregnancy is ceive iron supplementation. Caution must be associated with an increased risk of preterm la used in areas in which malaria is endemic be bor, low neonatal weight, and increased new cause supplementation may reverse the poten born and maternal mortality. Iron deficiency tially protective effects of iron deficiency55 or may predispose a person to infections, precipi increase the susceptibility to coinfections. In patients with heart failure, iron defi site Plasmodium falciparum is less efficient in infect ciency has a negative effect on the quality of life, ing iron-deficient erythrocytes than in infecting irrespective of the presence of anemia. A Failure of oral therapy few small studies show that the administration Iron intolerance or with low iron levels that are refractory to treatment. This approach rapidly corrects not lating agents) only hypoxia but also iron deficiency, since one Persistent anemia after use of erythropoiesis-stimulating agents in patients unit of packed red cells provides approximately with cancer who are receiving chemotherapy 200 mg of iron. Anemia of chronic disease unresponsive to treatment with erythropoiesis stimulating agents alone Oral Iron Therapy Potential indication with insufficient supporting data the administration of oral iron is a convenient, Iron deficiency in heart failure inexpensive, and effective means of treating Transfusion-sparing strategy in surgical patients stable patients. Among the myriad preparations on the market, iron sulfate is the most frequent * Celiac disease or H. The recommended daily dose for adults with iron deficiency is 100 to 200 mg of elementary iron and that for children is 3 to 6 such as the eradication of infection with H. The low hepcidin levels in patients There are no known markers that can be used to with iron-deficiency anemia ensure effective predict which patients will or will not have a iron absorption and the rapid recovery of hemo response to oral iron therapy. The oral iron chal globin levels; however, 3 to 6 months of treat lenge test (in which 60 mg of oral iron is admin ment are required for the repletion of iron stores istered and serum iron levels are measured 1 to and the normalization of serum ferritin levels. A pilot study showed fects, including nausea, vomiting, constipation, that measurement of serum hepcidin levels and metallic taste; these side effects are frequent could help to identify patients in whom a re and, although not severe, are often worrisome to sponse to oral iron is probable (those with low patients. Although oral iron may cause dark hepcidin levels) and those in whom it is not stools, it does not produce false positive results probable (those with normal or elevated hepci on tests for occult blood. Assessment termination of treatment, lack of compliance of an early response to oral iron might also be with the regimen or discontinuation by the pa useful in the treatment of iron-deficiency ane tient, or a truly refractory response to treatment. In the latter case, other, specific treatments, One study in patients with rheumatologic dis n engl j med 372;19 nejm. The ad cluding anaphylaxis) to high-molecular-weight dition of iron supplementation may eliminate or iron dextran has traditionally limited the indica delay the need for these agents in some patients tions for the intravenous administration of iron. Be are also used in selected patients with low-risk cause the use of intravenous iron circumvents myelodysplastic syndrome and in patients with the problem of iron absorption, it is more effec cancer who are receiving chemotherapy: in these tive and increases hemoglobin levels more quick circumstances, iron supplementation is usually ly than oral iron. The dose needed is calculated with nous iron is preferred when high hepcidin levels this formula: body weight in kilograms? One hypothesis suggests enteral iron therapy is high, but the number of that increased iron in macrophages leads to the hospital or clinic visits that are required is sig overexpression of ferroportin by means of the nificantly decreased. Intravenous iron4 nous administration is also preferred when a should be avoided in the first trimester of preg rapid increase in hemoglobin level is required or nancy because of the lack of data on safety70; it when iron-deficiency anemia caused by chronic has an acceptable side-effect profile when used blood loss cannot be controlled with the use of later in pregnancy. Active inflam for conditions other than those mentioned are 1840 n engl j med 372;19 nejm. Practical recommen European trial of patients with iron deficiency dations for minimizing risk70 include a slow in and chronic heart failure showed that the use of fusion rate, careful patient observation, and ad intravenous iron supplementation led to im ministration by trained health care personnel in provements in physical performance, New York an environment with access to resuscitation fa Heart Association functional class,50 and quality cilities. Some concern persists with regard to benefit of administering iron to patients with the long-term biologic effects of iron and its heart failure. McLean E, Cogswell M, Egli I, Woj and ferritin index in iron deficiency anae prevalence of total and severe anaemia in dyla D, de Benoist B. N Engl J Med 2005;352: causes-and-diagnosis-of-iron-deficiency binding to ferroportin and inducing its 1011-23. Iron and hepcidin: Detection, evaluation, and management N Engl J Med 2014;371:1324-31. Pavord S, Myers B, Robinson S, Allard ogy Am Soc Hematol Educ Program 2013; 2010;116:4754-61. Blood 2011; in nephrology and oncology: what do we and management of iron deficiency ane 117(25):e218-e225. A systematic analysis of global eters is only in part dependent on serum anemia in older persons. Nat Genet 2014;46: inhibits hepcidin activation by cleaving tients with atypical microcytic anaemia. Blood 2011; preschool children in a high malaria Capsule endoscopy: present status and 118:4459-62. Host iron status and iron supplemen tors and risk of vitamin and mineral defi 43. Emerging causes malaria season, iron deficiency, and in severe anemia and iron deficiency in Ma of iron deficiency anemia refractory to oral flammation determine plasma hepcidin lawian pre-school children. Nutritional iron turned the relationship and potential mecha cological consequences of obesity surgery. Bach V, Schruckmayer G, Sam I, Kem comes of iron deficiency after laparoscopic iron for the treatment of fatigue in non mler G, Stauder R. Prevalence and possi Roux-en-Y gastric bypass: a 10-year analy anemic, premenopausal women with low ble causes of anemia in the elderly: a cross sis. Cohen-Solal A, Damy T, Terbah M, et and iron deficiency in Caucasians, but not 63. Silvestri L, Pagani A, Nai A, De Do 1934 classification to the third millenni adults with iron deficiency anemia previ menico I, Kaplan J, Camaschella C. Safety and efficacy of intravenous iron: administration, effi zation and management. Comin-Colet J, Lainscak M, Dickstein library/Press release/2013/06/ the management of iron deficiency in K, et al. Lancet Diabetes Endocrinol 2014;2: Outcomes and Practice Patterns Study long-term intravenous iron therapy with 513-26. Auerbach M, Strauss W, Auerbach S, Copyright 2015 Massachusetts Medical Society. Radigan Although gastric resections are performed less frequently today, clinicians are still faced with treating patients who have a history of gastric surgery. Nutritional intoler ances and malabsorption can lead to nutrient deficiencies and undesirable clinical con sequences. Intolerances can often be managed with dietary manipulation and close nutrition follow-up. Nutrient deficiencies leading to anemia and metabolic bone disease require ongoing monitoring and supplementation. This article describes the various gastric resections and provides guidelines for the management of both acute and long term nutrition-related side effects. Timely and appropriate oday, gastric resection is reserved for patients nutritional intervention can minimize diet intolerances, with peptic ulcer disease that has failed to weight loss and micronutrient deficiencies that often T respond to medical therapy or those with malig follow.

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Diagonal dashed lines are extrapolations of the regression lines to cholesterol test medicare discount 30 mg vytorin amex earlier and later times worst high cholesterol foods cheap 30mg vytorin overnight delivery. The interval predicted from the first regression line was 30 months (left vertical dashed line) too much cholesterol in shrimp vytorin 20mg generic. The prediction error (difference between the actual and predicted intervals) was 10 months (25% of the actual interval) cholesterol levels change with age buy vytorin 30mg with amex. In that study, the second slope was less steep in 61% of cases and more steep in 39% of cases. The magnitude of the changes in slope was relatively large in comparison to the first slope (mean of 130% of the value of the first slope). Consequently, the mean error in the interval until reaching the final serum creatinine was also relatively large, 27% of the predicted interval (Fig 49). At least three previous measures of kidney function are necessary (more are better) to permit a precise estimate of the slope, especially if the rate of decline is slow. For this review, longitudinal studies were compiled to relate the rate of decline in kidney function with the potential associated factors. The effect of interventions on the rate of progression is summarized in a later section. Duration of follow-up between 1 and 3 years or less than 1 year is noted in the tables. Massy and Hannedouche both reported that glomerular disease was associated with a faster rate of progression than tubulointerstitial nephropathy. However, these two studies showed a conflicting result regarding the rate of progression associated with hypertensive kidney disease. These studies either excluded diabetics, or had a very small proportion of patients with diabetes in the study sample. Stratification 205 kidney function were used, and the effect of interventions or other potential confounders cannot be determined. There was a wide range of rates of decline among patients with nondiabetic kidney disease. Loss of kidney function for transplant recipients is influenced by episodes of rejection, use of immunosuppressive agents, patient gender and size, and quality of the donor kidney, among other factors. Half reported a faster rate of progression among blacks; however, only one study reported a significant association between black race and faster rates of progression in multivariate analysis. The majority of the studies reported a faster rate of progression among individuals with lower baseline kidney function, but about one third reported no association. The data report either a faster rate of progression or no association with male gender, and a single study reported a faster rate of progression among females. The evidence is not conclusive, but suggests a faster rate of progression among men. The studies differed in that they assessed systolic blood pressure, diastolic blood pressure, or mean arterial pressure?two of these or all of these. The studies evalu ated one or more of the following factors: high levels of total cholesterol, triglycerides, or low density lipoprotein, and low levels of high density lipoprotein. The impact of dyslipidemia reported herein is based on whether any one of these factors was associated with a faster rate of progression. There were 7 studies that reported in multivariate analyses a significant association between dyslipidemia and faster rate of progression. There were 7 studies that reported no significant association between dyslipidemia and 214 Part 7. The data are not sufficient to conclude that dyslipidemia is associated with a faster rate of progression. However, most of these studies compared rates of progression before or after treatment with erythropoietin and/or iron, or treated versus untreated, and all performed only univariate analyses. In keeping with the rest of this section the guideline, only this one study was considered for inclusion in an evidence table (Table 122). Of the seven studies, three, including Kuriyama, re ported an increased rate of progression among patients with lower hematocrit levels; the remaining studies reported no association. The data are not sufficient to conclude that anemia is associated with a faster rate of progression. Thus, the goal of this section was to review published guidelines and position statements by reputable national organizations addressing widely accepted interventions. In addi tion, meta-analyses of randomized trials or data from selected large randomized trials were used to formulate this guideline. Details of the sources of information are presented in each of the following sections. Strict glycemic control in diabetes slows the development and progression of chronic kidney disease (R). The reader should refer to the guideline, available on the internet for comprehensive information ( The role of strict glycemic control in slowing the progression of diabetic kidney disease is less certain. Three randomized trials of strict glycemic control in type 2 diabetes also demonstrate a beneficial effect of strict glycemic control on the development and progression of diabetic kidney disease. Fasting blood glucose values rose over time in both groups; the mean HgbA1c was 11% lower in the intervention group. The intervention group had a 25% reduction in ?microvascular? events, a combined endpoint that included both retinal and kidney disease. The data suggested a lower prevalence of microalbuminuria in the intervention group and a re duced incidence of declining kidney function. The results showed a lower incidence of the development and progression of microalbuminuria. The Steno Type 2 Study compared an intensive multifactor intervention to standard therapy in 160 patients with type 2 diabetes and microalbuminuria. There was 73% reduction in the incidence of clinical proteinuria in the intervention group. However, the relative importance of strict glycemic control and any of the other factors cannot be determined from this study. The optimal frequency of self monitoring of blood glucose for patients with type 2 diabetes is not known, but it should be sufficient to facilitate reaching glucose goals. The role of self-monitoring of blood glucose in stable diet-treated patients with type 2 diabetes is not known. Whether treated with insulin or oral glu cose-lowering agents, or a combination, goals remain those outlined in the table. Recommendations for the general population are based on a large body of evidence from observational studies and clinical trials relating blood pressure levels to mortality and cardiovascular disease. There is general agreement that risk stratification should be used in deciding which patients with high blood pressure should be treated and how intensively245 (Table 124). The recommended goal of antihypertensive therapy for pa tients at low or moderate risk for complications is to maintain systolic and diastolic blood pressure less than 140 and 90 mm Hg, respectively. Target blood pressure is lower in younger patients and related to age, weight and height. In the general population, the recommended antihypertensive agents are diuretics and beta-adrenergic blockers, because their efficacy in reducing cardiovascular mortality and morbidity has been proven in clinical trials. These subgroups include, among others, patients with chronic kidney disease, diabetes, and cardiovascular disease. Large-scale epidemiological studies of cardiovascular disease have included few patients with chronic kidney disease, and most clinical trials of antihypertensive agents to prevent cardiovascu lar disease have excluded patients with decreased kidney function. Some of the important randomized trials on the target level of blood pressure in patients with chronic kidney disease due to diabetes and other diseases are summarized below. The Work Group did not find randomized trials on target blood pressure levels in kidney transplant recipients. A total of 840 patients were randomized either to usual target blood pressure (mean arterial pressure 107 mm Hg, equivalent to blood pressure 140/90 mm Hg) versus a lower-than-usual target blood press (mean arterial pressure 92 mm Hg, equiva lent to blood pressure 125/75 mm Hg). Patients with higher levels of proteinuria at baseline had a greater beneficial effect of the low blood pressure goal. The investigators recommended a lower target blood pressure for patients with urine protein excretion less than approxi mately 1. Angiotensin-converting enzyme inhibitors and angiotensin receptor antago nists slow the progression of chronic kidney disease (R). This section presents an overview of the main points of these guidelines and studies. In addition, preliminary results of clinical trials with angiotensin receptor antagonists are briefly discussed.

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