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[email protected] Current Vascular Pharmacology, 2013, 11, 000-000
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Prediabetes, Prehypertension- do we Need PRE-CKD? Jolanta Malyszko1* and Maciej Banach2 1
Department of Nephrology and Transplantology, Medical University, Bialystok Poland; 2Department of Hypertension, Medical University of Lodz, Poland Abstract: Screening is the systematic use of a test for a health problem or risk factor when no recognized signs or symptoms would indicate the presence of that problem or risk factor. Abnormal glucose metabolism can be documented years before the onset of overt diabetes. Nowadays, prediabetes can be subdivided into impaired fasting glucose or impaired glucose tolerance. Substantial number of subjects with either will progress to overt diabetes within years. Prediabetes bears also the increased risk of cardiovascular complications. Prehypertension is much newer term introduced by the seventh report of the Joint National Committee (JNC 7) published in 2003 as systolic blood pressure from 120 to 139 mmHg or diastolic blood pressure from 80 to 89 mmHg in adults (not receiving blood pressure-lowering treatment). Similarly prehypertension also increased the risk of cardiovascular complications and progression to hypertension. Chronic kidney disease is also highly prevalent mainly in the elderly. It is associated with important adverse outcomes such as cardiovascular mortality and morbidity. Factors associated with higher risk of chronic kidney disease include mainly hypertension, diabetes, obesity and older age. Early detection and diagnosis of chronic kidney disease may prevent the full blown disease and its end-stage requiring renal replacement therapy. The review focus on the problem of high risk population for development of diabetes, hypertension and whether time has come to focus also on the conditions predisposing to the development of chronic kidney disease.
Keywords: Blood pressure, chronic kidney disease, hypertension, prediabetes, prehypertension. INTRODUCTION Screening is the systematic use of a test for a health problem or risk factor when no recognized signs or symptoms would indicate the presence of that problem or risk factor. The most important goal of screening is to identify the asymptomatic person to timely introduce either therapeutic or lifestyle intervention to prevent to or to slow the progression to a disease. In the sense when disease is defined as a condition that is symptomatic or perceivably disturbing or disrupting health, then screening should be directed towards “predisease”. This concept of predisease came from oncology and several preventive measures were then introduced such as Papanicolaou smear for cervical cancer. To answer the question whether the term predisease make sense, one should bear in mind the discriminating ability of the predisease category, is there a feasible intervention effectively decreasing the likelihood of disease development or progression, and whether benefits exceed harms. And last but not least problem is whether all these approaches are cost-effective. Additionally, there is the potential psychological harm of the predisease labeling for subjects as being not healthy but bearing a kind of stigma. PREDIABETES AND PREHYPERTENSION The term ”prediabetes” was introduced by Jackson and Woolf in 1956 to refer to what has become known as a *Address correspondence to this author at the Department of Nephrology and Transplantology, Medical University, 15-540 Bialystok, Zurawia 14, Poland; Tel:/Fax: ??????????????????????????; E-mail:
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gestational diabetes [1]. Abnormal glucose metabolism can be documented years before the onset of overt diabetes [2]. Nowadays, prediabetes can be subdivided into impaired fasting glucose or impaired glucose tolerance, depending on which test is used [3]. According to the most current guideline from American Diabetes Associations published in 2011 [4] there are two categories of increased risk for diabetes: impaired fasting glucose (IFG) — fasting plasma glucose between 100 and 125 mg/dL (5.6 to 6.9 mmol/L) and impaired glucose tolerance (IGT) — two-hour plasma glucose value during a 75 g oral glucose tolerance test between 140 and 199 mg/dL (7.8 to 11.0 mmol/L). Additionally persons with HbA1C with a range between 5.7 to 6.4 percent (6.0 to 6.4 percent in the International Expert Committee report [5]) are at highest risk, although there is a continuum of increasing risk across the entire spectrum of A1C levels less than 6.5 percent. The same criteria are used by WHO [6,7], but The European Diabetes Epidemiology Group (EDEG) issued a position statement in 2006 recommending that the original cut-off point for IFG (110 mg/dL or 6.1 mmol/L) be retained [8]. They also recommend that the term "non-diabetic hyperglycemia" be used in preference to "impaired fasting glucose." An International Expert Committee issued a consensus report in June 2009, recommending that an A1C level 6.5 percent be used to diagnose diabetes, and the ADA affirmed this decision [3,5]. The diagnosis should be confirmed with a repeat A1C. However, if an A1C test is either unavailable or uninterpretable, for example owing to rapid red cell turnover with anemia, the previous diagnostic methods and criteria, using glucose testing, should be used. Although the natural history of IFG and IGT is variable, ap© 2013 Bentham Science Publishers
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proximately 25 percent of subjects with either will progress to diabetes over three to five years [8]. Subjects with additional diabetes risk factors, including obesity and family history, are more likely to develop diabetes. Ford et al. [9] reported that relative risk of cardiovascular disease (CVD) is approximately 1.1-1.2 among people with prediabetes when compared to those without prediabetes. In addition, it was showwd in analysis of six prospective studies that the incidence rates of type 2 diabetes among patients with IGT ranged from 36 to 87 per 1000 person-years [10] and were higher among Hispanic, Pima, and Nauruan people than among whites. There is evidence that aggressive lifestyle modifications can prevent diabetes. A meta-analysis of 10 prospective cohort studies of physical activity and type 2 diabetes reported a lower risk of developing diabetes with regular moderate physical activity, including brisk walking, compared with being sedentary (RR 0.69, 95% CI 0.58-0.83) [11]. On the other hand, weight reduction, if sustained, can substantially improve glycemic control in patients with type 2 diabetes. There is also evidence that lifestyle intervention (combined diet and exercise aimed at weight loss and increasing activity levels) can also improve glucose tolerance and prevent progression from IGT to type 2 diabetes [12-16] as shown by the Finnish Diabetes Prevention Study and Diabetes Prevention Program (DPP) [12], the China Da Qing Diabetes Prevention Study (CDQDPS) [14] and Zensharen Study for Prevention of Lifestyle Diseases persisting even after 20 years [16]. In a post hoc analysis of MRFIT trial (a large, randomized primary prevention trial of intervention consisting of advice on diet, exercise, stopping smoking, and more intensive blood pressure treatment versus usual care in men at high risk for coronary heart disease) subjects with normal glucose tolerance at baseline (n = 11,827), the intervention program was associated with a lower risk of type 2 diabetes in the nonsmokers (HR 0.82, 95% CI 0.68-0.98), but not in the smokers [17], probably due to the weight gain after smoking cessation. Prehypertension is much newer term introduced by the seventh report of the Joint National Committee (JNC 7) published in 2003 as systolic blood pressure from 120 to 139 mmHg or diastolic blood pressure from 80 to 89 mmHg in adults (not receiving blood pressurelowering treatment) [18]. According to ESH/ESC guidelines adopted in Europe these values of blood pressure as named high-normal [19]. JNC 7 also included the statement that “prehypertension” is not a disease category. Rather, it is a designation chosen to identify individuals at high risk of developing hypertension so that both patients and clinicians are alerted to this risk and encouraged to intervene and prevent or delay the disease from developing” [18]. In the United States the prevalence of prehypertension among adults is approximately 37% [20]. Patients with prehypertension also appear to have a greater prevalence of traditional cardiovascular risk factors than those with normal blood pressures [21,22]. As shown in the Framingham Heart Study an increased hazard ratio was also observed in those with normal values (120 to 129/80 to 84 mmHg) compared with participants with optimal (called normal in JNC 7) blood pressures (
