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THE FREQUENCY OF COMORBID CONDITIONS IN PATIENTS WITH HYPERTENSION
1MD Kuzminova N. V.
1Gribenyuk O. V.
1Romanova V. O.
1MD Osovska N. Y.
2MD Knyazkova 1.1.
Ukraine, Vinnitsa, Vinnitsa National Medial University named after M. Pyrogov, Department of
Internal Medicine No1
2Ukraine, Kharkiv, Kharkiv National Medical University, Department of Clinical Pharmacology
Abstract. Today, weight gain is considered to be not only an important factor in the development and progression of hypertension, but also in the development of nonalcoholic fatty liver disease. According to the results of the examination of 170 patients with stage II hypertension, optimal body weight was observed only in 30 patients (17.6%), overweight - in 37 patients (21.7%), first degree obesity - in 58 (34.1%), second degree obesity - in 45 patients (26.5%). Abdominal fat distribution type predominated in more than 80% of patients with hypertension. The signs of nonalcoholic fatty liver disease, such as steatosis, were registered in 109 (64.1%) patients, its incidence progressively increasing together with body weight gain (from 40.0 % of patients with an optimal body weight and 54.1% of patients with overweight to 65.5% ofpatients with the 1st degree obesity and up to 86.7% of the 2nd degree obesity patients (p<0.05 compared to patients with optimal weight and overweight). Thus, this study demonstrated overweight, 1st and 2nd degrees obesity, to occur in the vast majority of patients with stage II essential hypertension. The frequency of hepatic steatosis increased with the increase in body mass index.
Keywords: hepatic steatosis, hypertension, optimal body weight, overweight, obesity.
Introduction. Today, weight gain plays an important role not only in the development and progression of cardiovascular diseases, but also in the development of the nonalcoholic fatty liver disease (NAFLD) [1]. Comorbidity of liver disease and hypertension often occurs as a part of metabolic syndrome (MS). Obesity, especially, abdominal type, insulin resistance and compensatory
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hyperinsulinemia are among the major key factors of this syndrome, which also participate in the development of NAFLD. However, because of the lack of clear clinical picture and precise diagnostic criteria in the early stages of its development, often NAFLD is detected during careful examination of patients with obesity and essential hypertension, a combination of these conditions as well as other diseases [2]. However, data on the presence of concomitant NAFLD in patients with hypertension are limited and inconsistent [3; 4; 5; 6].
This investigation is a part of the research "Dysfunction of endothelium and adipose tissue, their relationship with the functional status of the liver and cardiovascular remodeling and possibilities of their correction in patients with cardiovascular disorders», state registration No 0113U007670 and is a part of the scientific work "Nonalcoholic fatty liver disease as an additional factor of cardiovascular risk in hypertensive patients" at the department of internal medicine № 1 at Vinnitsa National Medial University named after M. Pyrogov .
The aim: to identify and assess the prevalence of NAFLD in patients with stage II essential hypertension and different body weight.
Materials and methods. The screening, taking medical history and complaints, obtaining of an informed consent to participate in the research, coordinated with ethical standards of World Medical Association's Declaration of Helsinki, preceded the initial studies.
The study involved 170 patients with stage II essential hypertension - 98 women (57.6%) and 72 men (42.4%) - with various degrees of hypertension and body weight. The age of the patients ranged from 35 to 69 years (average age was 49.3 ± 0.5 years). The diagnosis of stage II hypertension was established according to ESC and ESH (2013) criteria. The average duration of hypertension was 8.9 ± 0.4 years. The study didn't include patients with secondary hypertension, stage I or III essential hypertension, patients with liver diseases of viral, alcoholic, autoimmune and other etiologies as well as renal dysfunction, diabetes mellitus (DM), disorders of carbohydrate tolerance, heart defects, stage II or III chronic heart failure (CHF) (by classification of M.D. Strazhesko-V.H.Vasylenko), chronic obstructive pulmonary disease, respiratory failure, III and IV degrees obesity.
All patients underwent complete anthropometric, clinical-laboratory and instrumental examination including electrocardiography (ECG "YUKARD" (Hungary), echocardiography (echocardiograph "My Lab 25" (Italy), ambulatory blood pressure monitoring (device AVRM-04, "Mediteh" Hungary). The diagnosis of NAFLD was either confirmed or excluded after ultrasound of the liver with tissue density histograms and after biochemical test« FibroMax » (BioRredictive, France). The study included exclusively the patients with concomitant steatosis with no signs of cytolysis syndrome and structural and biochemical changes characteristic of nonalcoholic steatohepatitis. The control group included 20 pearsons of similar age and sex.
Statistical data analysis was carried out by the methods of variation statistics using the program StatSoft "Statistica" v. 12. The results are presented for quantitative variables as median and interquartile scope (25 and 75 percentile) and relative values in per cent. Significant difference in per cent was calculated by criterion %2.
Results and discussion. The examination included the study of patients with stage II essential hypertension. The first, the second and the third degree hypertension was detected in 50 (29.4%), 63 (37.1%) and 57 patients (33.5 %), respectively.
The analysis by body mass index (BMI) showed optimum body weight (BMI = 20-24.9 kg/m2) in 30 patients (17.6%), overweight (BMI = 25-29.9 kg/m2) - in 37 patients (21.7%).The first degree obesity (BMI = 30-34.9 kg/m2) was established in 58 patients (34.1%) while obesity of the second degree (BMI = 35-39.9 kg/m2) was noted in 45 patients (26.5%) (Fig. 1).
□ Optimal body weight H Overweight 0 First degree obesity a Second degree obesity
Fig. 1. The distribution of patients with stage II essential hypertension by BMI, (%)
Diagnosis of NAFLD was made in 109 patients (64.1%) with concomitant steatosis versus 61 patients (35.9%) without its signs (significant markers of liver impression were not found; SteatoTest's rate in patients with steatosis was 0.41 (0. 37; 0.56) versus 0.17 (0.12; 0.22) in the group without steatosis, significant difference between these two groups being 0.002).
Mean BMI was significantly different between the groups of patients with and without steatosis amounting to 32 (29.37) kg/m2 and 29 (24.32) kg/m2, respectively, p = 0.0001. These data indicate the obese patients to dominate in the group with steatosis. A direct correlation was found between BMI and the presence of steatosis in patients with stage II hypertension (r = 0.48, p <0.000001).
Evaluation of distribution of fat in the body found that waist circumference (W C) exceeded the permissible limits (>94 cm for men; >80 cm for women) regardless the presence of steatosis. WC was 101 (92; 108) cm in the group without steatosis, and it was 110 (100; 119) cm in patients with steatosis with significant increase in concomitant NAFLD (p = 0.0002). The waist to hip circumference (HC) (WC/HC) ratio was > 0.93 and there was no significant difference in this ratio depending on the presence of NAFLD. WC/HC ratio in the group without steatosis was 0.97 (0.92; 1.01) versus 0.99 (0.95; 1.03) in the group with concomitant steatosis, which was significantly higher compared with control for both groups (r<0.0001), but no significant difference between these two groups was found (p = 0.11). However, significant correlations were found between indices of WC, HC and WC/HC ratio and the presence of steatosis being 0.47, 0.44, 0.31, respectively, with significant value p <0.0001.
Our data indicate that, despite significant correlations between anthropometric indicators, showing the predominance of abdominal fat distribution in the body, and the presence of steatosis, formation of abdominal type of obesity was typical also for patients without NAFLD. These data, in its turn, may indicate that the android or "top" type of obesity is not necessarily accompanied by the development of fatty liver disease, and NAFLD can have more complex pathogenetic mechanisms caused not only by the progression of body weight and visceral accumulation of adipose tissue.
The above mentioned results are concordant with those of other researchers demonstrating the development of NAFLD in patients without concomitant obesity [7]. However, according to other authors, the position of visceral fat is an independent risk factor for NAFLD [8; 9] and WC values and WC/HC ratio are considered to be independent predictors of liver necroinflamatory state [10]. One of the hypotheses of this relationship states that adipose tissue can lead to the development of insulin resistance and activation of nonspecific chronic systemic inflammation. However, the role of those markers in the mechanisms of fatty liver disease is still not understood.
There were 12 patients (40.0%) with concomitant steatosis and optimal body weight, and steatosis was detected in 20 patients (54.1%) among the persons with overweight (Figure 4). In body weight increase to the first degree obesity the presence of concomitant steatosis was already found in 38 patients (65.5%), and there were 39 patients (86.7%) with steatosis and the second degree obesity. There was significant difference between the second degree obesity group and the patients without obesity, and the first degree obesity group (p<0.05) (Fig. 2). Significant direct correlation between BMI index and the presence of second degree obesity (r= 0.35, r<0.00001) was observed. The data analysis demonstrated the incidence of concomitant steatosis to increase progressively with BMI increase. 100 90 80 70 60 50 40 30 20 10 0
I Steatosis(+)
□ Steatosis(-)
86,7%* •#
r
40 %*
Optimal body weight (n=30)
Overweight (n=37)
First degree obesity (n=58)
Second degree obesity ( (n=45)
Fig. 2. NAFLD detection rate in patients with stage II essential hypertension by BMI, (%). * - Significant difference between the groups with obesity, overweight and optimal body weight (r<0.05); # - Significant difference between the groups with obesity and overweight (r<0.05); • - Significant difference between the groups with the first and the second degrees of obesity (r<0.05).
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Our data demonstrated the presence of NAFLD among the persons with optimal weight without signs of disorders in tolerance to carbohydrates and type II diabetes. They confirmed the results of other authors that both the SP and SG can develop in individuals with insulin resistance state but without diabetes (DM) who have no excess body weight and do not meet the minimum criteria for MS [11].
Additional routine biochemical methods showed no signs of inflammation, such as increased activity of alanine and aspartate aminotransferase, alkaline phosphatase and hamahlutamiltranspeptydase indicating the absence of steatohepatitis. In particular, the result of the NashTest from the biochemical panel «FibroMax» was 0.12 (0.12; 0.13) in the group without concomitant fatty liver disease and 0.21 (0.17; 0.23) in the group with concomitant NAFLD. There was no significant difference between these two groups (p = 0.002) without exceeding the permissible limit of this index indicating the development of steatohepatitis by the NashTest in patients with concomitant NAFLD.
These data are opposite to the results of recent studies where BMI plays a role in the differential diagnosis between steatosis and steatohepatitis (according to Pasiyeshvili L.M., BMI 28.9 kg / m2 was the threshold for the development of steatohepatitis, and abdominal obesity was directly associated with the severity of the disease). [12] And according to other studies a direct relationship was found between BMI and progression of steatosis to steatohepatitis (correlation coefficient was 0.35 and 0.14, respectively, p <0.001) [1].
Thus, this study showed that the vast majority of patients with stage II essential hypertension had concomitant premorbid obesity (it was found in 103 (60.6%) of 170 patients). Associated steatosis was detected in 109 (64.1%) patients, its incidence increasing in the patients with overweight and especially with concomitant second degree obesity.
Conclusions:
1. Patients with parallel increase of body weight (overweight was noted in 21.7% of patients while the obesity was noted in 60.6% of patients) predominated in the group with stage II hypertension by BMI.
2. The frequency of steatosis increased progressively with BMI increase, reaching 65.5% and 86.7% in the patients with obesity of the first and the second degrees, respectively.
Perspective courses of future researches may be to investigate common pathophysiological mechanism of NAFLD and hypertension, indicating more precise and less invasive diagnostic criteria for syeatosis, determining markers, associated with poor prognosis in these patients.
Conflict of interest: none declared.
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