Skip to main content
SpringerLink
Log in

Accuracy of retinal changes in predicting microalbuminuria among elderly hypertensive patients: a cross-sectional study from a teaching hospital in South India

  • Nephrology - Original Paper
  • Published:
International Urology and Nephrology Aims and scope Submit manuscript

Abstract

Objective

Microalbuminuria is an important marker of end organ damage in hypertensive patients, but is often not tested for, especially in a resource-poor setting. We studied the accuracy of retinal changes in predicting microalbuminuria among a cohort of geriatric hypertensive patients.

Methods

One hundred and eighty elderly hypertensive patients aged more than 65 years were assessed for their demographic characteristics, smoking status, duration of hypertension, current severity of hypertension, body mass index, left ventricular hypertrophy by electrocardiogram (ECG), and high sensitivity C-reactive protein (HsCRP). Optic fundi were assessed for retinopathy after pupillary dilatation, and were photographed. Microalbuminuria (albumin–creatinine ratio) was measured as an average of two nonconsecutive overnight spot urine samples. Patients with pre-diabetes, diabetes, metabolic syndrome, treatment with angiotensin converting enzyme inhibitors and/or angiotensin receptor blockers, overt nephropathy or proteinuria, and active infection were excluded.

Results

Mean age was 74 ± 6.56 years. One-third were obese and 18.9% had left ventricular hypertrophy. Prevalence of microalbuminuria was 39.4% and prevalence of retinopathy was 40%. Microalbuminuria showed a strong association with retinopathy (P < 0.0001). Logistic regression identified association of microalbuminuria with duration of hypertension (P = 0.001) and elevated high sensitivity C-reactive protein (P = 0.021). Retinopathy was associated with duration of hypertension (P = 0.001) and smoking (P < 0.0001). Tests of accuracy for retinopathy as a predictor of microalbuminuria showed a sensitivity of 72% and specificity of 81%.

Conclusion

Prevalence of microalbuminuria and retinopathy were quite high in our cohort of elderly hypertensive patients. Retinal changes of any grade probably have moderate accuracy in predicting microalbuminuria and hence we can initiate work-up for target organ damage, especially in a resource-poor setting.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J (2005) Global burden of hypertension: analysis of worldwide data. Lancet 365:217–223

    PubMed  Google Scholar 

  2. Blythe WD, Maddux FW (1991) Hypertension as a causative diagnosis of patients entering end-stage renal disease programs in the United States from 1980–1986. Am J Kidney Dis 28:33–37

    Google Scholar 

  3. Wesstuch JM, Dworkin LD (1992) Does essential hypertension cause end-stage renal disease? Kidney Int 41(Suppl 36):S33–S37

    Google Scholar 

  4. Rutkowski B (2000) Changing pattern of end-stage renal disease in central and eastern Europe. Nephrol Dial Transplant 15:156–160. doi:10.1093/ndt/15.2.156

    Article  PubMed  CAS  Google Scholar 

  5. Mani MK (2003) Prevention of chronic renal failure at the community level. Kidney Int 63(Suppl 83):S86–S89. doi:10.1046/j.1523-1755.63.s83.17.x

    Article  Google Scholar 

  6. Prakash J, Hota JK, Singh S, Sharma OP (2006) Clinical spectrum of chronic renal failure in the elderly: a hospital based study from eastern India. Int Urol Nephrol 38(3–4):821–827. doi:10.1007/s11255-006-9003-y

    PubMed  Google Scholar 

  7. Prakash J, Saxena RK, Sharma OP, Usha (2001) Spectrum of renal diseases in the elderly: single center experience from a developing country. Int Urol Nephrol 33(2):227–233. doi:10.1023/A:1015279619491

    Article  PubMed  CAS  Google Scholar 

  8. Tiwari SC, Srivastava S (1998) Geropsychiatric morbidity in rural Uttar Pradesh. Indian J Psychiatry 40:266–273

    Google Scholar 

  9. Ministry of health and family welfare, government of India (2002) Annual report: health plan and policy. Ministry of health and family Welfare, New Delhi, p 15

  10. Mohan V, Deepa M, Farooq S, Datta M, Deepa R (2007) Prevalence, awareness and control of hypertension in Chennai—the Chennai urban rural epidemiology study (CURES-52). JAPI 55:326–332

    PubMed  CAS  Google Scholar 

  11. Yudkin JS, Forrest RD, Jackson C (1988) Microalbuminuria as predictor of vascular disease in nondiabetic subjects. Lancet 2:530–533. doi:10.1016/S0140-6736(88)92657-8

    Article  PubMed  CAS  Google Scholar 

  12. Damsgaard EM, Froland A, Jorgensen OD, Mogensen CE (1990) Microalbuminuria as predictor of increased mortality in elderly people. BMJ 300:297–300

    Article  PubMed  CAS  Google Scholar 

  13. Marcia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G et al (2007) 2007 Guidelines for the management of arterial hypertension. Eur Heart J 28:1462–1536

    Google Scholar 

  14. Positional statement, American Diabetes Association (2006) Diagnosis and classification of diabetes mellitus. Diabetes Care 29:S43–S48

    Google Scholar 

  15. Executive summary of the third report of the national cholesterol education program (NCEP) expert panel (2001) on detection, evaluation and treatment of high blood cholesterol in adults (adult treatment panel III) JAMA 285:2486–2497

    Google Scholar 

  16. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al (2003) The seventh report of the joint national committee on prevention, detection, evaluation and treatment of high blood pressure (JNC-7). JAMA 289:2560–2571. doi:10.1001/jama.289.19.2560

    Article  PubMed  CAS  Google Scholar 

  17. Jeffrey SF, Eleftheria MF (2005) Obesity. In: Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL (eds) Harrison’s principles of internal medicine, vol 1, 16th edn. McGraw Hill Inc, New York, pp 422–423

    Google Scholar 

  18. Poulsen PL, Mogensen C (1998) Clinical evaluation of a test for immediate and quantitative determination of urinary albumin to creatinine ratio. Diabetes Care 21:97–98

    PubMed  CAS  Google Scholar 

  19. Hoy W, SP McDonald (2004) Albuminuria: marker or target in indigenous populations. Kidney Int 66(Suppl 92):S25–S31. doi:10.1111/j.1523-1755.2004.09207.x

    Article  Google Scholar 

  20. Tetsuya B, Chieko T, Yasuhiko I (2004) Definition of microalbuminuria in first-morning and random spot urine in diabetic patients. Diabetes Care 27:1838–1839. doi:10.2337/diacare.27.7.1838

    Article  Google Scholar 

  21. Keith NM, Wagner HP, Barker NW (1939) Some different types of essential hypertension—their course and prognosis. Am J Med Soc 197:332–343

    Article  Google Scholar 

  22. Romhilt DW, Estes EH Jr (1968) A point-score system for the ECG diagnosis of left ventricular hypertrophy. Am Heart J 75:752–758. doi:10.1016/0002-8703(68)90035-5

    Article  PubMed  CAS  Google Scholar 

  23. Greenberg RS, Daniels SR, Dana Flanders W, Eley JW, Boring JR (2005) Diagnostic testing. In: Greenberg RS (ed) Medical epidemiology. McGraw-Hill, New York

    Google Scholar 

  24. Cuspidi C, Salerno M, Salerno DE, Meani S, Valerio C, Esposito A et al (2004) High prevalence of retinal vascular changes in never-treated essential hypertensives: an inter- and intra-observer reproducibility study with non-mydriatic retinography. Blood Press 13(1):25–30. doi:10.1080/08037050310025753

    Article  PubMed  Google Scholar 

  25. Cuspidi C, Macca G, Salerno M, Michev L, Fusi V, Severgnini B et al (2001) Evaluation of target organ damage in arterial hypertension: which role for qualitative funduscopic examination? Ital Heart J 2(9):702–706

    PubMed  CAS  Google Scholar 

  26. Ruilope LM, Salvetti A, Jamerson K, Hansson L, Warnold I, Wedel H et al (2001) Renal function and intensive lowering of blood pressure in hypertensive participants of the hypertension optimal treatment (HOT) study. J Am Soc Nephrol 12:218–225

    PubMed  CAS  Google Scholar 

  27. Mann JF, Gerstein HC, Pogue J, Bosch J, Yusuf S (2001) Renal insufficiency as a predictor of cardiovascular outcomes and the impact of ramipril: the HOPE randomized trial. Ann Intern Med 134:629–636

    PubMed  CAS  Google Scholar 

  28. Pontremoli R, Sofia A, Ravera M, Nicolella C, Viazzi F, Tirotta A et al (1997) Prevalence and clinical correlates of microalbuminuria in essential hypertension. The MAGIC study. Hypertension 30:1135–1143

    PubMed  CAS  Google Scholar 

  29. Hoegholm A, Bang LE, Kristensen KS, Nielsen JW, Holm J (1994) Microalbuminuria in 411 untreated individuals with established hypertension, white coat hypertension, and normotension. Hypertension 24:101–105

    PubMed  CAS  Google Scholar 

  30. Redon J, Rovira E, Miralles A, Julve R, Pascual JM (2002) Factors related to the occurrence of microalbuminuria during antihypertensive treatment in essential hypertension. Hypertension 39:794–798. doi:10.1161/hy0302.105209

    Article  PubMed  CAS  Google Scholar 

  31. Jager A, Kostense PJ, Ruhé HG, Heine RJ, Nijpels G (1999) Microalbuminuria and peripheral arterial disease are independent predictors of cardiovascular and all-cause mortality, especially among hypertensive subjects: five-year follow-up of the Hoorn Study. Arterioscler Thromb Vasc Biol 19:617–624

    PubMed  CAS  Google Scholar 

  32. Levy BI, Ambrosio G, Pries AR, Struijker-Boudier HAJ (2001) Microcirculation in hypertension—a new target for treatment? Circulation 104:735–740. doi:10.1161/hc3101.091158

    Article  PubMed  CAS  Google Scholar 

  33. Agewall S, Wikstrand J, Ljungman S, Fagerberg B (1997) Usefulness of microalbuminuria in predicting cardiovascular mortality in treated hypertensive men with and without diabetes mellitus. Risk factor intervention study group. Am J Cardiol 80:164–169. doi:10.1016/S0002-9149(97)00312-3

    Article  PubMed  CAS  Google Scholar 

  34. Ljungman S, Wikstrand J, Hartford M, Berglund G (1996) Urinary albumin excretion—a predictor of risk of cardiovascular disease. A prospective 10-year follow-up of middle-aged nondiabetic normal and hypertensive men. Am J Hypertens 9:770–778. doi:10.1016/0895-7061(96)00102-1

    Article  PubMed  CAS  Google Scholar 

  35. Redon J, Liao Y, Lozano JV et al (1994) Factors related to the presence of microalbuminuria in essential hypertension. Am J Hypertens 7:801–807

    PubMed  CAS  Google Scholar 

  36. Culleton BF, Larson MG, Wilson PW, Evans JC, Parfrey PS, Levy D (1999) Cardiovascular disease and mortality in a community-based cohort with mild renal insufficiency. Kidney Int 56:2214–2219. doi:10.1046/j.1523-1755.1999.00773.x

    Article  PubMed  CAS  Google Scholar 

  37. Kronenberg F, Kuen E, Ritz E, Junker R, Konig P, Kraatz G et al (2000) Lipoprotein (a) serum concentrations and apolipoprotein (a) phenotypes in mild and moderate renal failure. J Am Soc Nephrol 11:105–115

    PubMed  CAS  Google Scholar 

  38. Fliser D, Pacini G, Engelleiter R, Kautzky-Willer A, Prager R, Franek E et al (1998) Insulin resistance and hyperinsulinemia are already present in patients with incipient renal disease. Kidney Int 53:1343–1347. doi:10.1046/j.1523-1755.1998.00898.x

    Article  PubMed  CAS  Google Scholar 

  39. Jungers P, Joly D, Massy Z, Chauveau P, Nguyen AT, Aupetit J et al (1999) Sustained reduction of hyperhomocysteinaemia with folic acid supplementation in predialysis patients. Nephrol Dial Transplant 14:2903–2906. doi:10.1093/ndt/14.12.2903

    Article  PubMed  CAS  Google Scholar 

  40. Tsioufis C, Dimitriadis K, Taxiarchou E, Vasiliadou C, Chartzoulakis G, Tousoulis D et al (2006) Diverse associations of microalbuminuria with C-reactive protein, interleukin-18 and soluble CD40 ligand in male essential hypertensive subjects. Am J Hypertens 19:462–466. doi:10.1016/j.amjhyper.2005.07.026

    Article  PubMed  CAS  Google Scholar 

  41. Lydakis C, Lip GYH (1998) Microalbuminuria and cardiovascular risk. Q J Med 91:381–391

    CAS  Google Scholar 

  42. van den Born B-JH, Hulsman CAA, Hoekstra JBL, Schlingemann RO, van Montfrans GA (2005) Value of routine funduscopy in patients with hypertension: systematic review. BMJ 331:73–77

    Article  PubMed  Google Scholar 

  43. Cuspidi C, Meani S, Valerio C, Fusi V, Catini E, Sala C et al (2005) Prevalence and correlates of advanced retinopathy in a large selected hypertensive population. The evaluation of target organ damage in hypertension (ETODH) study. Blood Press 14(1):25–31. doi:10.1080/08037050510008805

    Article  PubMed  CAS  Google Scholar 

  44. Ebinc H, Ebinc FA, Ozkurt ZN (2007) Relationship of early hypertensive retinopathy to inflammation markers and microalbuminuria in hypertensive patients with regulated blood pressure. Saudi Med J 28(3):472–473

    PubMed  Google Scholar 

  45. Cuspidi C, Meani S, Salerno M et al (2004) Retinal microvascular changes and target organ damage in untreated essential hypertensives. J Hypertens 22:2095–2102. doi:10.1097/00004872-200411000-00010

    Article  PubMed  CAS  Google Scholar 

  46. Saitoh M, Matsuo K, Nomoto S, Kondoh T, Yanagawa T, Katoh Y et al (1998) Relationship between left ventricular hypertrophy and renal and retinal damage in untreated patients with essential hypertension. Intern Med 37:576–580. doi:10.2169/internalmedicine.37.576

    Article  PubMed  CAS  Google Scholar 

  47. Cerasola G, Cottone S, D’Ignoto G, Grasso L, Mangano MT, Carapelle E et al (1989) Microalbuminuria as a predictor of cardiovascular damage in essential hypertension. J Hypertens 7(Suppl 6):S332–S333

    CAS  Google Scholar 

  48. Pontremoli R, Cheli V, Sofia A, Tirotta A, Ravera M, Nicolella C et al (1995) Prevalence of micro- and macroalbuminuria and their relationship with other cardiovascular risk factors in essential hypertension. Nephrol Dial Transplant 10(Suppl 6):6–9

    PubMed  Google Scholar 

  49. Kozan O, Buyukoz turk K, Ilerigelen B, Kabakci G, Koylan N et al (2007) The impact of plasma high-sensitivity C-reactive protein levels on cardiovascular risk stratification of hypertensive patients: results of the ICEBERG study. J Clin Hypertens 9(7):500–505. doi:10.1111/j.1524-6175.2007.05738.x

    Article  CAS  Google Scholar 

  50. Bakris GL, Ruilope L, Locatelli F, Ptaszynska A, Pieske B, de Champlain J et al (2007) Treatment of microalbuminuria in hypertensive subjects with elevated cardiovascular risk: results of the IMPROVE trial. Kidney Int 72(7):879–885. doi:10.1038/sj.ki.5002455

    Article  PubMed  CAS  Google Scholar 

  51. Skov K, Fenger-Gron J, Mulvany MJ (1996) Effects of an angiotensin converting enzyme inhibitor, a calcium antagonist, and an endothelin receptor antagonist on renal afferent arteriolar structure. Hypertension 28:464–471

    PubMed  CAS  Google Scholar 

  52. Puttinger H, Soleiman A, Oberbauer R (2003) Regression of hypertensive nephropathy during three years of optimal blood pressure control. Wien Klin Wochenschr 115(12):429–431

    PubMed  Google Scholar 

  53. Leatham A et al (1949) The retinal vessels in hypertension. QJM 18:203–204

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Sri Ramachandra University, Porur, Chennai, Tamilnadu, India

    Ghanshyam Palamaner Subash Shantha, Emmanuel Bhaskar, Anita A. Kumar, Varun Sundaram, Arul Senghor, Porchelvan Swaminathan, Manjunath Sundaresan, Yadav Srinivasan & Georgi Abraham

Authors
  1. Ghanshyam Palamaner Subash Shantha
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Emmanuel Bhaskar
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Anita A. Kumar
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Varun Sundaram
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Arul Senghor
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Porchelvan Swaminathan
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Manjunath Sundaresan
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Yadav Srinivasan
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Georgi Abraham
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ghanshyam Palamaner Subash Shantha.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Shantha, G.P.S., Bhaskar, E., Kumar, A.A. et al. Accuracy of retinal changes in predicting microalbuminuria among elderly hypertensive patients: a cross-sectional study from a teaching hospital in South India. Int Urol Nephrol 41, 137–143 (2009). https://doi.org/10.1007/s11255-008-9452-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11255-008-9452-6

Keywords

Search

Navigation