Cardiovascular Risk Factor or Risk Marker?
Dr. Bakris: That leads me into cardiovascular risk. It is pretty clear from all the epidemiology that the presence of microalbuminuria is a cardiovascular risk marker. You may have a higher risk for cardiovascular events if you have microalbuminuria. Is that simply a reflection of this underlying inflammatory state and perhaps poor diet or whatever you want to say, or is it something unique? Mechanistically, it does not look like anything is going on there. That is why it is a marker and not a risk factor. What are your thoughts?
Dr. Glassock: In my opinion, microalbuminuria is not directly in the causal pathway for the development of cardiovascular disease. In fact, studies have shown that if you take the standard risk factors, say the Framingham risk score, and you determine the 10-year risk for cardiovascular disease and add microalbuminuria to that list, this does not materially change the quantification of risk. I think most of the risk associated with microalbuminuria is its tight linkage to these standard risk factors: age, obesity, diabetes, smoking, high blood pressure, and others.
Dr. Bakris: Do any data from clinical trials show that reducing microalbuminuria independent of blood pressure, glucose, and lipids actually reduces risk?
Dr. Glassock: None that I know of, George. Your ACCOMPLISH study showed that when you use a combination of drugs that is demonstrably effective in reducing both cardiovascular and renal risk, albumin excretion actually goes up.Which is a paradox.
Dr. Bakris: More specifically, albumin excretion probably doesn't change. Those are the main points, because this is hotly debated. Do you want to add anything that I did not cover that is really hot and specific to this issue?