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RESEARCH ARTICLE
SA JOURNAL OF DIABETES & VASCULAR DISEASE
60
VOLUME 14 NUMBER 2 • DECEMBER 2017
Microalbuminuria is one of the sensitive markers of increased
capillary permeability and may be useful to study the systemic
inflammatory response after CABG.
6,22,23
According to previous
investigations, urinary microalbuminuria increased significantly in
the early postoperative period and one day after CABG.
In our study, peak increase in microalbuminuria was observed
in both groups but there was no statistically significant difference
(
p
= 0.071). These levels decreased, particularly on the fifth day in
our cases, and the decrease was statistically significantly different
in group T. In both groups, hsCRP increased and peaked on the first
postoperative day in both groups. However, in group T, hsCRP, as
one of the pro-inflammatory agents, decreased significantly on the
fifth day. Therefore, the increase in acute inflammatory response
was similar in both groups on the first postoperative day, and in
group T, both markers had decreased by the fifth day.
Borch-Johnsen
et al.
showed the direct relationship between
proteinuria and cardiovascular mortality rate in insulin-dependent
diabetic patients after open-heart surgery in patients undergoing
CABG.
24
Telmisartan was also shown to reduce or normalise
microalbuminuria in 34%of patients with diabetes, and in a second,
smaller study including 64 hypertensive and 60 normotensive
patients, to reduce the incidence of renal dysfunction. This confirmed
that telmisartan reduced microalbuminuria independently of its
blood pressure-lowering effects. Restoration of normal urine
albumin levels has also been demonstrated by telmisartan.
25
Our study showed that telmisartan reduced microalbuminuria,
not only pre-operatively, but also after open-heart surgery. The return
to baseline levels was also faster than in group N-T. Angiotensin
receptor blocking agents decrease some of the postoperative acute
inflammatory agents in on-pump CABG patients with diabetes
mellitus by lessening the systemic consequences of renal dysfunction,
and may have additional cardiovascular effects by exerting beneficial
effects on endothelial tissue elsewhere in the body and within the
heart in this patients group. The cardiovascular benefits of angiotensin
receptor antagonists have been evaluated, not only in terms of their
ability to lower blood pressure, but also on their ability to prevent
strokes, cardiac events and target-organ damage.
14,16
Limitations of our study are the relatively small size of our series
and the lack of definite criteria for selection of patients for this
study. As most coronary patients are already being treated with
angiotensin receptor blocking agents, the results of our study will
not have a major impact on clinical practice. Furthermore, it would
have been better to test the predictive value of microalbuminuria
on prognosis in this category of patients. However, we hope that
this study will pioneer further studies on this method.
Conclusion
Our results showed that telmisartan decreased systemic
inflammation and urinary albumin excretion in diabetic patients
after CABG surgery, compared to those not taking angiotensin
receptor antagonists. These beneficial effects of telmisartan
treatment on diabetic patients after CABG should be investigated
further in prospective, randomised studies.
References
1. Stehouwer CD, Smulders YM. Microalbuminuria and risk for cardiovascular
disease: analysis of potential mechanisms.
J Am Soc Nephrol
2006;
17
: 2106–
2111.
2. Hillege HL, Fidler V, Diercks GF, van Gilst WH, de Zeeuw D, van Veldhuisen DJ,
et
al
; Prevention of Renal and Vascular End Stage Disease (PREVEND) Study Group.
Urinary albumin excretion predicts cardiovascular and noncardiovascular mortality
in general population.
Circulation
2002;
106
: 1777–1782.
3. Mojiminiyi OA, Abdella N, Moussa MA, Akanji AO, Al Mohammedi H, Zaki M.
Association of C-reactive protein with coronary heart disease risk factors in
patients with type 2 diabetes mellitus.
Diabetes Res Clin Pract
2002;
58
: 37–44.
4. Jie W, Zhiqiang L. An epidemiological cross-sectional survey of microalbuminuria
and risk factors in type 2 diabetic patients.
Clin Med J Chin
2005;
12
: 859–861.
5. Venkat KK. Proteinuria and microalbuminuria in adults: significance, evaluation,
and treatment.
South Med J
2004;
97
: 969–979.
6. Marshall SM. Recent advances in diabetic nephropathy.
Postgrad Med J
2004;
80
:
624–633.
7. Gosling P. Microalbuminuria: a marker of systemic disease.
Br J Hosp Med
1995;
54
: 285–290.
8. Loef BG, Epema AH, Navis G, Ebels T, van Oeveren W, Henning RH. Off-pump
coronary revascularization attenuates transient renal damage compared with
on-pump coronary revascularization.
Chest
2002;
121
: 1190–1194.
9. Abacilar F, Dogan OF, Duman U, Ucar I, Demircin M, Ersoy U,
et al
. Changes and
the effects of the plasma levels of tumor necrosis factor after coronary artery
bypass surgery with cardiopulmonary bypass.
Heart Surgery Forum
2006;
9
:
703–709.
10. Leehey DJ, Singh AK, Alavi N, Singh R. Role of angiotensin II in diabetic
nephropathy.
Kidney Int
2000;
77
: 93–98.
11. Manley HJ. Role of angiotensin-converting-enzyme inhibition in patients with
renal disease.
Am J Health Syst Pharm
2000;
57
: 12–18.
12. Remuzzi A, Perico N, Amuchastegui CS, Malanchini B, Mazerska M, Battaglia C,
et al
. Short- and long-term effect of angiotensin II receptor blockade in rats with
experimental diabetes.
J Am Soc Nephrol
1993;
4
: 40–49.
13. Esmatjes E, Flores L, Inigo P, Lario S, Ruilope LM, Campistol JM. Effect of losartan
on TGF-beta1 and urinary albumin excretion in patients with type 2 diabetes
mellitus and microalbumin-uria.
Nephrol Dial Transplant
2001;
16
: 90–93.
14. Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH,
et
al
; RENAAL Study Investigators. Effects of losartan on renal and cardiovascular
outcomes in patients with type 2 diabetes and nephropathy.
N Engl J Med
2001;
345
: 861–869.
15. Vogt L, Navis G, Koster J, Manolis AJ, Reid JL, de Zeeuw D, on behalf of the
Angiotensin II Receptor Antagonist Telmisartan Micardis in Isolated Systolic
Hypertension (ARAMIS) Study Group. The angiotensin II receptor antagonist
telmisartan reduces urinary albumin excretion in patients with isolated systolic
hypertension: results of a randomized, double-blind, placebo-controlled trial.
J
Hypertens
2005;
23
: 2055–2061.
16. Ribeiro AB, Gavras H. Angiotensin II antagonists: clinical experience in the
treatment of hypertension, prevention of cardiovascular outcomes and renal
protection in diabetic nephropa-thy and proteinuria.
Arq Bras Endocrinol Metabol
2006;
50
: 327–333.
17. Seçici S, Battaloglu B, Uyar IS,
et al
. Rosuvastatin pretreatment does not attenuate
microalbuminuria after coronary artery bypass grafting.
Turk Gogus Kalp Dama
2014;
22
(3): 496–501. Doi: 10.5606/tgkdc. dergisi.2014.8991.
18. Mangano CM, Diamondstone LS, Ramsay JG, Aggarwal A, Herskowitz A,
Mangano DT. Renal dysfunction after myocardial revascularization: risk factors,
adverse outcomes, and hospital resource utilization. The Multicenter Study of
Perioperative Ischemia Research Group.
Ann Intern Med
1998;
128
: 194–203.
19. Ramsay JG. The respiratory, renal, and hepatic systems: effect of cardiac surgery
and cardiopulmonary bypass. In: Mora CT, ed.
Cardiopulmonary Bypass
. New
York: Springer-Verlag, 1995: 147–168.
20. Sener T, Köprülü AS, Karpuzoglu OE,
et al
. The clinical results of off-pump
coronary artery bypass surgery in renal dysfunction patients.
Turk Gogus Kalp
Dama
2013;
21
(4): 918–923. Doi: 10.5606/tgkdc. dergisi.2013.8168.
21. Loef BG, Epema AH, Navis G, Ebels T, van Oeveren W, Henning RH. Off-pump
coronary revascularization attenuates transient renal damage compared with
on-pump coronary revascularization.
Chest
2002;
121
: 1190–1194.
22. Morariu AM, Loef BG, Aarts LP, Rietman GW, Rakhorst G, van Oeveren W,
et al
.
Dexamethasone: benefit and prejudice for patients undergoing on-pump coronary
artery bypass grafting: a study on myocardial, pulmonary, renal, intestinal, and
hepatic injury.
Chest
2005;
128
: 2677–2687.
23. Bugra O, Baysal A, Fedakar A, Erdem K, Sunar H, Daglar B. Does serum neutrophil
gelatinase-associated lipocalin biomarker detect the early deterioration in renal
functions in patients with insulin-dependent diabetes mellitus undergoing
coronary artery bypass graft surgery?
Turk Gogus Kalp Dama
2014;
22
(1): 63–70.
Doi: 10.5606/tgkdc.dergisi.2014.7780.
24. Borch-Johnsen K, Kreiner S. Proteinuria: value as predictor of cardiovascular
mortality in insulin dependent diabetes mellitus.
Br Med J
1987;
294
: 1651–1654.
25. Montalescot G, Collt JP. Preserving cardiac function in the hypertensive patient:
why renal parameters hold the key.
Eur Heart J
2005;
26
: 2616–2622.