Aim/hypothesis: Microalbuminuria represents the earliest clinical evidence of diabetic nephropathy and is a marker of increased cardiovascular morbidity and mortality. Its early detection allows the implementation of individualised and aggressive intervention programmes to reduce cardiovascular risk factors. There is limited information on the prevalence of microalbuminuria among hypertensive type 2 diabetic patients in Asia. Methods: This cross-sectional epidemiological study aimed to assess the prevalence of microalbuminuria and macroalbuminuria among consecutively screened hypertensive type 2 diabetic adult patients in 103 centres in 10 Asian countries or regions. Predictive factors for microalbuminuria and macroalbuminuria were characterised using a stepwise logistic regression model. Results: A total of 6,801 patients were enrolled and 5,549 patients constituted the per-protocol population (patients with bacteriuria and haematuria were excluded). The prevalence of microalbuminuria was 39.8% (39.2-40.5; 95% CI) and the prevalence of macroalbuminuria was 18.8% (18.2-19.3; 95% CI). Only 11.6% of the patients had systolic and diastolic blood pressure below the 130/80 mm Hg target. In the multivariate analyses, the predictive factors for the presence of microalbuminuria were age, BMI, systolic blood pressure and ethnic origin. The highlighted predictive factors for the presence of macroalbuminuria were age, sex, ethnic origin, BMI, duration of diabetes, presence of diabetic complications, intake of diuretics, intake of calcium channel blockers, diastolic and systolic blood pressure. Conclusions/interpretation: The high prevalence (58.6%) of micro or macroalbuminuria observed in these patients is alarming and indicates an impending pandemic of diabetic cardiovascular and renal diseases in Asia with its potential economic consequences.

The second edition of the MOH clinical practice guidelines on hypertension for Singapore was published in 2005. Since then, more facts about this important condition have emerged, particularly those recommending home blood pressure monitoring (HBPM) and 24-hour ambulatory blood pressure monitoring (ABPM) as key procedures in diagnosing suspected hypertension. Target groupThe main aim of these guidelines is to help physicians make sound clinical decisions about hypertension by presenting up-to-date information about diagnosis, classification, treatment, outcomes and follow-up. These guidelines are developed for all healthcare professionals in Singapore. Guideline developmentThese guidelines have been produced by an MOH-appointed committee of cardiologists, internists, general medicine practitioners, renal physicians, family physicians, and a neurologist. They were developed by adaptation of existing guidelines, critical review of relevant literature and expert clinical consensus taking local practice into consideration. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or his guardian or carer. Review of guidelinesEvidence-based clinical practice guidelines are only as current as the evidence that supports them. Users must keep in mind that new evidence could supersede recommendations in these guidelines. The workgroup advises that these guidelines be scheduled for review five years after publication, or earlier if new evidence appears that requires substantive changes to the recommendations. EXECUTIVE SUMMARY OF RECOMMENDATIONS IntroductionThis is the executive summary of the MOH Clinical Practice Guidelines (CPG) on Hypertension. It is intended to be used with reference to the full version of the CPG, which is freely available on the MOH website at this link: https://www.moh.gov.sg/ content/moh_web/healthprofessionalsportal/doctors/guidelines/ cpg_medical.html.Hypertension is the leading associated risk factor for cardiovascular disease. It is prevalent and increasing in many developing and developed countries. The Singapore National Health Survey (NHS) 2010 showed that the crude prevalence of hypertension (defined as BP of ≥ 140/90 mmHg) among Singapore residents aged 30 to 69 years was 23.5%, compared to 24.9% in 2004 and 27.3% in 1998. However, the age-specific prevalence for hypertension rises markedly from age 40 years onward and, with our ageing population, we continue to face challenges in the prevention and control of hypertension. Target audienceThese guidelines are developed for all healthcare professionals in Singapore as an evidence-based resource to provide up-to date information and guidance on diagnosis, classification, treatment, outcomes and follow-up. CMEArticle Ministry of Health Clinical Practice Guidelines: HypertensionJam Chin Tay, Ashish Anil Sule, Daniel Chew, Jeannie Tey, Titus Lau, Simon Lee, Sze Haur Lee, Choon Kit Leong, Soo Teik L...

The protein selectivity index was measured in 68 patients (53 males, 15 females) with proteinuria due to IgA nephropathy to determine whether it bore any relationship to other clinical and pathological features of known prognostic significance. The mean age of the patients was 25 ± 8 years with a follow-up period of 42 + 35 months. Forty-six presented with asymptomatic haematuria and proteinuria, 17 with macroscopic haematuria and 5 with the nephrotic syndrome. Twenty-three (34%) patients had selective proteinuria and 45 (66%) had non-selective proteinuria. Patients with non-selective proteinuria had more glomerulosclerosis (29% ± 20 vs. 16% ± 20, p < 0.02), higher serum creatinine (1.47 mg/dl ± 0.70 vs. 1.17 mg/dl ± 0.33, p < 0.02), lower creatinine clearance (79 ml/min ± 28 vs. 95 ml/min ± 25, p < 0.02), and higher incidence of hypertension (χ² = 3.84, p < 0.05) when compared to those with selective proteinuria. The protein selectivity was measured at the end of the study. Of the 5 patients with the nephrotic syndrome, 1 had poorly selective proteinuria and failed to remit and 4 had highly selective proteinuria who either remitted spontaneously (1 patient) or with treatment (3 patients). The results suggest that patients with IgA nephropathy and poorly selective proteinuria are more likely to have other features indicating a poor prognosis such as glomerulosclerosis, renal impairment and hypertension.

It is well recognised that Asia is at the epicenter of the global type 2 diabetes epidemic. Driven by socioeconomic changes involving industrialization, urbanization and adoption of Western lifestyles, the unprecedented increases in the prevalence of diabetes are particularly evident in Southeast Asia. The impact of diabetes is immense, and despite evidence of the benefit of optimal glucose control in reducing the risk of disease progression and development of macrovascular and microvascular complications, many individuals in this region remain poorly controlled. Chronic kidney disease (CKD) is an increasingly common diabetes-associated complication in Asian patients. Furthermore, Southeast Asia has one of the highest rates of end-stage renal disease (ESRD) in the world. Consequently, CKD in diabetes is associated with considerable morbidity and cardiovascular-related mortality, highlighting the need to screen and assess patients early in the course of the disease. The management of type 2 diabetes patients with declining renal function represents a significant challenge. Many of the older antidiabetic agents, such as metformin and sulfonylureas, are limited in their utility in CKD as a result of contraindications or hypoglycemic episodes. In contrast, dipeptidyl-peptidase IV inhibitors have provided a welcome addition to the therapeutic armamentarium for achieving glycemic control in these special populations. With comparable efficacy to and more favorable pharmacokinetic and side-effect profiles than traditional therapies, agents in this drug class, such as linagliptin, offer a more tailored approach to disease control in type 2 diabetes patients with declining renal function. (J Diabetes Invest

Beta-blockers have long being used as first-line therapy for hypertension as their use had resulted in a reduction in cardiovascular morbidity and mortality in controlled clinical trials. A recent meta-analysis comparing beta-blockers to all other anti-hypertensive drugs taken together has found that stroke reduction was sub-optimal. Specifically, atenolol was associated with a 26% higher risk of stroke compared with other drugs. Several reasons may explain the less favourable outcomes with beta-blocker therapy. These include some adverse metabolic abnormalities such as dyslipidaemia and new-onset diabetes, and less effective reduction of central aortic compared with brachial blood pressure. Newer beta-blockers such as carvedilol or nebivolol are better tolerated. These beta-blockers have a vasodilating effect, which may beneficially affect systolic blood pressure in the aorta. Their long-term cardiovascular outcome in hypertension is still not known. Further studies would be required to show that stroke is adequately reduced by these newer beta-blockers. In conclusion, beta-blockers should not be the first drugs of choice in the management of uncomplicated hypertension. They may be used in addition to other antihypertensive agents to achieve blood pressure goals. However, in patients with angina pectoris, a previous myocardial infarction, heart failure and certain dysrhythmias, beta-blockers still play an important role. Key words: Central aortic pressure, Stroke