551
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Barrera-Chimal J, Kolkhof P, Lima-Posada I, Joachim A, Rossignol P, Jaisser F. Differentiation between emerging non-steroidal and established steroidal mineralocorticoid receptor antagonists: head-to-head comparisons of pharmacological and clinical characteristics. Expert Opin Investig Drugs 2021; 30:1141-1157. [PMID: 34758679 DOI: 10.1080/13543784.2021.2002844] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Mineralocorticoid receptor (MR) antagonists (MRAs) provide cardiorenal protection. However steroidal MRAs might induce hyperkalemia and sex hormone-related adverse effects. Several novel non-steroidal MRAs are being developed that are highly selective for the MR and may have an improved safety profile. AREAS COVERED This narrative review summarizes data from head-to-head comparisons of emerging non-steroidal MRAs with older steroidal MRAs, including pharmacological characteristics, pharmacokinetic properties, clinical outcomes, and safety, and highlights similarities and differences between emerging agents and established steroidal MRAs. EXPERT OPINION Head-to-head comparisons in phase 2 trials suggest that the new non-steroidal MRAs exhibit at least equivalent efficacy to steroidal MRAs but may have a better safety profile in patients with heart failure and/or kidney disease. When also taking into account data from recent phase 3 placebo-controlled trials, these novel non-steroidal MRAs have the potential to provide a cardiorenal benefit above that of current optimized standard-of-care treatment in a high-risk population with reduced renal function, and with a lower risk of hyperkalemia. To optimize therapy, further research is needed to clarify the molecular differences in the mode of action of non-steroidal MRAs versus steroidal MRAs, and biomarkers that are predictive of MRA response need to be identified and validated.
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Affiliation(s)
- Jonatan Barrera-Chimal
- Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico.,Unidad de Investigación UNAM-INC, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Peter Kolkhof
- Heart and Vascular Diseases, R&D Preclinical Research, Bayer AG, Germany
| | - Ixchel Lima-Posada
- Centre de Recherche Des Cordeliers, Sorbonne Université, Université de Paris, Paris, France
| | - Alexandre Joachim
- Normandy University, University of Caen Normandy, Centre Hospitalier Universitaire (CHU) de Caen Normandie, Department of Pharmacology, Ea 4650, Signalisation, Électrophysiologie Et Imagerie Des Lésions d'Ischémie-Reperfusion Myocardique, Caen, France
| | - Patrick Rossignol
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques Plurithématique - 1433, and Inserm U1116; Chru Nancy; F-crin Ini-crct, Nancy, France
| | - Frederic Jaisser
- Centre de Recherche Des Cordeliers, Sorbonne Université, Université de Paris, Paris, France.,Université de Lorraine, Inserm, Centre d'Investigations Cliniques Plurithématique - 1433, and Inserm U1116; Chru Nancy; F-crin Ini-crct, Nancy, France
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552
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Provenzano M, Jongs N, Vart P, Stefánsson BV, Chertow GM, Langkilde AM, McMurray JJ, Correa-Rotter R, Rossing P, Sjöström CD, Toto RD, Wheeler DC, Heerspink HJ. The Kidney Protective Effects of the Sodium–Glucose Cotransporter-2 Inhibitor, Dapagliflozin, Are Present in Patients With CKD Treated With Mineralocorticoid Receptor Antagonists. Kidney Int Rep 2021; 7:436-443. [PMID: 35257056 PMCID: PMC8897688 DOI: 10.1016/j.ekir.2021.12.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/01/2021] [Accepted: 12/06/2021] [Indexed: 12/20/2022] Open
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553
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Xu Y, Fu EL, Clase CM, Mazhar F, Jardine MJ, Carrero JJ. GLP-1 receptor agonist versus DPP-4 inhibitor and kidney and cardiovascular outcomes in clinical practice in type-2 diabetes. Kidney Int 2021; 101:360-368. [PMID: 34826514 DOI: 10.1016/j.kint.2021.10.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/13/2021] [Accepted: 10/26/2021] [Indexed: 12/16/2022]
Abstract
Whether glucagon-like peptide-1 receptor agonists (GLP1-RA) reduce detrimental kidney outcomes is uncertain. In secondary analyses, trials have shown consistent reductions in macroalbuminuria, but inconclusive results about kidney function decline. To help clarify this, we conducted a cohort study to compare kidney and cardiovascular outcomes in individuals who started GLP1-RA or dipeptidyl peptidase-4 inhibitors (DPP4i) (reduces degradation of endogenous GLP1). The primary outcome was a composite of sustained doubling of creatinine, kidney failure or kidney death. The secondary outcomes were three-point major adverse cardiovascular events (MACE) and its individual components. Propensity score weighted Cox regression was used to balance 53 confounders. A total of 19,766 individuals were included, of whom 5,699 initiated GLP1-RA, and were followed for a median 2.9 years. Mean age was 63 years, 26.2% had atherosclerotic cardiovascular disease and 16.0% had an estimated glomerular filtration rate (eGFR) under 60 ml/min/1.73m2. The adjusted hazard ratio for GLP1-RA vs. DPP4i was 0.72 (95% confidence interval 0.53-0.98) for the composite kidney outcome and 0.85 (0.73-0.99) for MACE, with absolute five-year risk reductions of 0.8% (0.1%-1.5%) and 1.6% (0.2%-2.9%), respectively. Hazard ratios were 0.79 (0.60-1.05) for cardiovascular death, 0.86 (0.68-1.09) for myocardial infarction and 0.74 (0.59-0.93) for stroke. Results were consistent within subgroups, including age, sex, eGFR and baseline metformin use. Thus, in our analysis of patients from routine clinical practice, the use of GLP1-RA was associated with a lower risk of kidney outcomes compared with DPP4i. Reductions in both kidney outcomes and MACE were similar in magnitude to those reported in large cardiovascular outcome trials.
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Affiliation(s)
- Yang Xu
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
| | - Edouard L Fu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Catherine M Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Faizan Mazhar
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Meg J Jardine
- Kidney Health Research, NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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554
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Kintscher U, Bakris GL, Kolkhof P. Novel Non-Steroidal Mineralocorticoid Receptor Antagonists in Cardiorenal Disease. Br J Pharmacol 2021; 179:3220-3234. [PMID: 34811750 DOI: 10.1111/bph.15747] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/26/2021] [Accepted: 11/01/2021] [Indexed: 11/29/2022] Open
Abstract
Mineralocorticoid receptor (MR) antagonists (MRAs) are key agents in guideline-oriented drug therapy for cardiovascular (CV) diseases such as chronic heart failure with reduced ejection fraction (HFrEF) and resistant hypertension. Currently available steroidal MRAs are efficacious in reducing morbidity and mortality, however, they can be associated with intolerable side effects including hyperkalemia in everyday clinical practice. Recently, a new class of non-steroidal MRAs including esaxerenone, AZD9977, apararenone, KBP-5074, and finerenone have been developed with an improved benefit-risk profile and a novel indication for finerenone for diabetic kidney disease. To better understand the non-steroidal MRAs, this review provides information on the molecular pharmacology as well as relevant current preclinical and clinical data on cardiorenal outcomes. A comparative review of all compounds in the class is discussed with regard to clinical efficacy and safety as well as a perspective outlining their future use in clinical practice.
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Affiliation(s)
- Ulrich Kintscher
- Charite - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Pharmacology, Cardiovascular-Metabolic-Renal Research Center, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany
| | - George L Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago, IL, USA
| | - Peter Kolkhof
- Research & Early Development, Cardiovascular Research, Bayer AG, Wuppertal, Germany
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555
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Grossmann C, Almeida-Prieto B, Nolze A, Alvarez de la Rosa D. Structural and molecular determinants of mineralocorticoid receptor signalling. Br J Pharmacol 2021; 179:3103-3118. [PMID: 34811739 DOI: 10.1111/bph.15746] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/19/2021] [Accepted: 11/08/2021] [Indexed: 12/18/2022] Open
Abstract
During the past decades, the mineralocorticoid receptor (MR) has evolved from a much-overlooked member of the steroid hormone receptor family to an important player, not only in volume and electrolyte homeostasis but also in pathological changes occurring in an increasing number of tissues, especially the renal and cardiovascular systems. Simultaneously, a wealth of information about the structure, interaction partners and chromatin requirements for genomic signalling of steroid hormone receptors became available. However, much of the information for the MR has been deduced from studies of other family members and there is still a lack of knowledge about MR-specific features in ligand binding, chromatin remodelling, co-factor interactions and general MR specificity-conferring mechanisms that can completely explain the differences in pathophysiological function between MR and its closest relative, the glucocorticoid receptor. This review aims to give an overview of the current knowledge of MR structure, signalling and co-factors modulating its activity.
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Affiliation(s)
- Claudia Grossmann
- Julius Bernstein Institute of Physiology, Martin Luther University Halle-Wittenberg, Halle, Saale, Germany
| | - Brian Almeida-Prieto
- Departamento de Ciencias Médicas Básicas and Instituto de Tecnologías Biomédicas, Universidad de La Laguna, La Laguna, Tenerife, Spain
| | - Alexander Nolze
- Julius Bernstein Institute of Physiology, Martin Luther University Halle-Wittenberg, Halle, Saale, Germany
| | - Diego Alvarez de la Rosa
- Departamento de Ciencias Médicas Básicas and Instituto de Tecnologías Biomédicas, Universidad de La Laguna, La Laguna, Tenerife, Spain
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556
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Agarwal R, Filippatos G, Pitt B, Anker SD, Rossing P, Joseph A, Kolkhof P, Nowack C, Gebel M, Ruilope LM, Bakris GL. Cardiovascular and kidney outcomes with finerenone in patients with type 2 diabetes and chronic kidney disease: the FIDELITY pooled analysis. Eur Heart J 2021; 43:474-484. [PMID: 35023547 PMCID: PMC8830527 DOI: 10.1093/eurheartj/ehab777] [Citation(s) in RCA: 344] [Impact Index Per Article: 114.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/23/2021] [Accepted: 11/01/2021] [Indexed: 02/06/2023] Open
Abstract
AIMS The complementary studies FIDELIO-DKD and FIGARO-DKD in patients with type 2 diabetes and chronic kidney disease (CKD) examined cardiovascular and kidney outcomes in different, overlapping stages of CKD. The purpose of the FIDELITY analysis was to perform an individual patient-level prespecified pooled efficacy and safety analysis across a broad spectrum of CKD to provide more robust estimates of safety and efficacy of finerenone compared with placebo. METHODS AND RESULTS For this prespecified analysis, two phase III, multicentre, double-blind trials involving patients with CKD and type 2 diabetes, randomized 1:1 to finerenone or placebo, were combined. Main time-to-event efficacy outcomes were a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, or hospitalization for heart failure, and a composite of kidney failure, a sustained ≥57% decrease in estimated glomerular filtration rate from baseline over ≥4 weeks, or renal death. Among 13 026 patients with a median follow-up of 3.0 years (interquartile range 2.3-3.8 years), the composite cardiovascular outcome occurred in 825 (12.7%) patients receiving finerenone and 939 (14.4%) receiving placebo [hazard ratio (HR), 0.86; 95% confidence interval (CI), 0.78-0.95; P = 0.0018]. The composite kidney outcome occurred in 360 (5.5%) patients receiving finerenone and 465 (7.1%) receiving placebo (HR, 0.77; 95% CI, 0.67-0.88; P = 0.0002). Overall safety outcomes were generally similar between treatment arms. Hyperkalaemia leading to permanent treatment discontinuation occurred more frequently in patients receiving finerenone (1.7%) than placebo (0.6%). CONCLUSION Finerenone reduced the risk of clinically important cardiovascular and kidney outcomes vs. placebo across the spectrum of CKD in patients with type 2 diabetes. KEY QUESTION Does finerenone, a novel selective, nonsteroidal mineralocorticoid receptor antagonist, added to maximum tolerated renin-angiotensin system inhibition reduce cardiovascular disease and kidney disease progression over a broad range of chronic kidney disease in patients with type 2 diabetes? KEY FINDING In a prespecified, pooled individual-level analysis from two randomized trials, we found reductions both in cardiovascular events and kidney failure outcomes with finerenone. Because 40% of the patients had an estimated glomerular filtration rate of >60 mL/min/1.73m2 they were identified solely on the basis of albuminuria. TAKE HOME MESSAGE Finerenone reduces the risk of clinical cardiovascular outcomes and kidney disease progression in a broad range of patients with chronic kidney disease and type 2 diabetes. Screening for albuminuria to identify at-risk patients among patients with type 2 diabetes facilitates reduction of both cardiovascular and kidney disease burden.
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Affiliation(s)
- Rajiv Agarwal
- Indiana University School of Medicine and Richard L. Roudebush VA Medical Center, 1481 W. 10th St, Indianapolis, IN 46202, USA
| | - Gerasimos Filippatos
- Department of Cardiology, Attikon University Hospital, Rimini 1, Chaidari 124 62, Athens, Greece
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, 1500 E. Medical Centre Dr #6303, Ann Arbor, MI 48109, USA
| | - Stefan D Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, CharitéUniversitätsmedizin, Charitépl. 1, 10117 Berlin, Germany
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Niels SteensensVej 2-4, 2820 Gentofte, Denmark.,Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3b 33.5, DK-2200 Copenhagen, Denmark
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Müllerstraße 178, 13353 Berlin, Germany
| | - Peter Kolkhof
- Research and Development, Preclinical Research Cardiovascular, Bayer AG, Friedrich-Ebert-Straße 217/333, 42117, Wuppertal, Germany
| | - Christina Nowack
- Research and Development, Clinical Development Operations, Bayer AG, Friedrich-Ebert-Straße 217/333, 42117, Wuppertal, Germany
| | - Martin Gebel
- Research and Development, Integrated Analysis Statistics, Bayer AG, Friedrich-Ebert-Straße 217/333, 42117, Wuppertal, Germany
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Instituto de Investigación Hospital 12 de OctubreCentro de ActividadesAmbulatorias, 6ª Planta Bloque DAvda. de Córdoba, s/n28041 Madrid, Spain.,CIBER-CV, Hospital Universitario 12 de Octubre, Av. de Córdoba, s/n, 28041, Madrid, Spain.,Faculty of Sport Sciences, European University of Madrid, C. Tajo, s/n, 28670 Villaviciosa de Odón, Madrid, Spain
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, 5841 South Maryland Avenue, MC 6092, 60637 Chicago, IL, USA
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557
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Kawanami D, Takashi Y, Muta Y, Oda N, Nagata D, Takahashi H, Tanabe M. Mineralocorticoid Receptor Antagonists in Diabetic Kidney Disease. Front Pharmacol 2021; 12:754239. [PMID: 34790127 PMCID: PMC8591525 DOI: 10.3389/fphar.2021.754239] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023] Open
Abstract
Diabetic kidney disease (DKD) is a major cause of end-stage kidney disease (ESKD) worldwide. Mineralocorticoid receptor (MR) plays an important role in the development of DKD. A series of preclinical studies revealed that MR is overactivated under diabetic conditions, resulting in promoting inflammatory and fibrotic process in the kidney. Clinical studies demonstrated the usefulness of MR antagonists (MRAs), such as spironolactone and eplerenone, on DKD. However, concerns regarding their selectivity for MR and hyperkalemia have remained for these steroidal MRAs. Recently, nonsteroidal MRAs, including finerenone, have been developed. These agents are highly selective and have potent anti-inflammatory and anti-fibrotic properties with a low risk of hyperkalemia. We herein review the current knowledge and future perspectives of MRAs in DKD treatment.
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Affiliation(s)
- Daiji Kawanami
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Yuichi Takashi
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Yoshimi Muta
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Naoki Oda
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Dai Nagata
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Hiroyuki Takahashi
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Makito Tanabe
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
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558
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Goulooze SC, Snelder N, Seelmann A, Horvat-Broecker A, Brinker M, Joseph A, Garmann D, Lippert J, Eissing T. Finerenone Dose-Exposure-Serum Potassium Response Analysis of FIDELIO-DKD Phase III: The Role of Dosing, Titration, and Inclusion Criteria. Clin Pharmacokinet 2021; 61:451-462. [PMID: 34786651 PMCID: PMC8891103 DOI: 10.1007/s40262-021-01083-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 12/15/2022]
Abstract
Background Finerenone is a nonsteroidal selective mineralocorticoid receptor antagonist (MRA) that demonstrated efficacy in delaying the progression of chronic kidney disease (CKD) and reducing cardiovascular events in patients with CKD and type 2 diabetes mellitus in FIDELIO-DKD, where 5734 patients were randomized 1:1 to receive either finerenone or placebo, with a median follow-up of 2.6 years. Doses of finerenone 10 or 20 mg once daily were titrated based on (serum) potassium and estimated glomerular filtration rate. The MRA mode of action increases potassium. Methods Nonlinear mixed-effects population pharmacokinetic/pharmacodynamic models were used to analyze the finerenone dose–exposure–response relationship for potassium in FIDELIO-DKD. Individual time-varying exposures from pharmacokinetic analyses were related to the potassium response via a maximal effect, indirect-response model informed by 148,384 serum potassium measurements. Results Although observed potassium levels decreased with increasing dose (i.e., inverse relation), model-based simulations for a fixed-dose setting (i.e., no dose titration) revealed the intrinsic finerenone dose–exposure–potassium response, with potassium levels increasing in a dose- and exposure-dependent manner, thus explaining the apparent conflict. The potassium limit for inclusion and uptitration from finerenone 10 to 20 mg in FIDELIO-DKD was ≤ 4.8 mmol/L. Modified limits of ≤ 5.0 mmol/L were simulated, resulting in higher hyperkalemia frequencies for both the finerenone and the placebo arms, whereas the relative hyperkalemia risk of a finerenone treatment compared with placebo did not increase. Conclusions The analyses demonstrated the effectiveness of finerenone dose titration in managing serum potassium and provide a quantitative basis to guide safe clinical use. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-021-01083-1.
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Affiliation(s)
| | - Nelleke Snelder
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | - Andreas Seelmann
- Bayer AG, Pharmaceuticals R&D, Pharmacometrics, Leverkusen/Wuppertal/Berlin, Germany
| | | | - Meike Brinker
- Bayer AG, Pharmaceuticals R&D, Clinical Development, Wuppertal/Berlin, Germany
| | - Amer Joseph
- Bayer AG, Pharmaceuticals R&D, Clinical Development, Wuppertal/Berlin, Germany
| | - Dirk Garmann
- Bayer AG, Pharmaceuticals R&D, Pharmacometrics, Leverkusen/Wuppertal/Berlin, Germany
| | - Joerg Lippert
- Bayer AG, Pharmaceuticals R&D, Pharmacometrics, Leverkusen/Wuppertal/Berlin, Germany
| | - Thomas Eissing
- Bayer AG, Pharmaceuticals R&D, Pharmacometrics, Leverkusen/Wuppertal/Berlin, Germany.
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559
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van den Berg P, Ruppert M, Mesic E, Snelder N, Seelmann A, Heinig R, Joseph A, Garmann D, Lippert J, Eissing T. Finerenone Dose-Exposure-Response for the Primary Kidney Outcome in FIDELIO-DKD Phase III: Population Pharmacokinetic and Time-to-Event Analysis. Clin Pharmacokinet 2021; 61:439-450. [PMID: 34773606 PMCID: PMC8891099 DOI: 10.1007/s40262-021-01082-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Finerenone is a nonsteroidal selective mineralocorticoid receptor antagonist that recently demonstrated efficacy in delaying chronic kidney disease progression and reducing cardiovascular events in patients with chronic kidney disease and type 2 diabetes in FIDELIO-DKD, where 5734 patients were randomized 1:1 to receive either titrated finerenone doses of 10 or 20 mg once daily or placebo, with a median follow-up of 2.6 years. METHODS Nonlinear mixed-effects population pharmacokinetic models were used to analyze the pharmacokinetics in FIDELIO-DKD, sparsely sampled in all subjects receiving finerenone. Post-hoc model parameter estimates together with dosing histories allowed the computation of individual exposures used in subsequent parametric time-to-event analyses of the primary kidney outcome. RESULTS The population pharmacokinetic model adequately captured the typical pharmacokinetics of finerenone and its variability. Either covariate effects or multivariate forward-simulations in subgroups of interest were contained within the equivalence range of 80-125% around typical exposure. The exposure-response relationship was characterized by a maximum effect model estimating a low half-maximal effect concentration at 0.166 µg/L and a maximal hazard decrease at 36.1%. Prognostic factors for the treatment-independent chronic kidney disease progression risk included a low estimated glomerular filtration rate and a high urine-to-creatinine ratio increasing the risk, while concomitant sodium-glucose transport protein 2 inhibitor use decreased the risk. Importantly, no sodium-glucose transport protein 2 inhibitor co-medication-related modification of the finerenone treatment effect per se could be identified. CONCLUSIONS None of the tested pharmacokinetic covariates had clinical relevance in FIDELIO-DKD. Finerenone effects on kidney outcomes approached saturation towards 20 mg once daily and sodium-glucose transport protein 2 inhibitor use provided additive benefits.
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Affiliation(s)
- Paul van den Berg
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | - Martijn Ruppert
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | - Emir Mesic
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | - Nelleke Snelder
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | - Andreas Seelmann
- Pharmacometrics, Pharmaceuticals R&D, Bayer AG, Leverkusen, Germany
| | - Roland Heinig
- Clinical Pharmacology, Pharmaceuticals R&D, Bayer AG, Wuppertal, Germany
| | - Amer Joseph
- Clinical Development, Pharmaceuticals R&D, Bayer AG, Berlin, Germany
| | - Dirk Garmann
- Pharmacometrics, Pharmaceuticals R&D, Bayer AG, Leverkusen, Germany
| | - Joerg Lippert
- Pharmacometrics, Pharmaceuticals R&D, Bayer AG, Leverkusen, Germany
| | - Thomas Eissing
- Pharmacometrics, Pharmaceuticals R&D, Bayer AG, Leverkusen, Germany.
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560
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Filippatos G, Anker SD, Agarwal R, Ruilope LM, Rossing P, Bakris GL, Tasto C, Joseph A, Kolkhof P, Lage A, Pitt B. Finerenone Reduces Risk of Incident Heart Failure in Patients With Chronic Kidney Disease and Type 2 Diabetes: Analyses from the FIGARO-DKD Trial. Circulation 2021; 145:437-447. [PMID: 34775784 PMCID: PMC8812430 DOI: 10.1161/circulationaha.121.057983] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: Chronic kidney disease (CKD) and type 2 diabetes (T2D) are independently associated with heart failure (HF), a leading cause of morbidity and mortality. In the FIDELIO-DKD and FIGARO DKD trials, finerenone (a selective, nonsteroidal mineralocorticoid receptor antagonist) improved cardiovascular outcomes in patients with albuminuric CKD and T2D. These prespecified analyses from FIGARO-DKD assessed the impact of finerenone on clinically important HF outcomes. Methods: Patients with T2D and albuminuric CKD (urine albumin-to-creatinine ratio [UACR] ≥30 to <300 mg/g and estimated glomerular filtration rate [eGFR] ≥25 to ≤90 ml/min/1.73 m2, or UACR ≥300 to ≤5000 mg/g and eGFR ≥60 ml/min/1.73 m2,), without symptomatic HF with reduced ejection fraction, were randomized to finerenone or placebo. Time-to-first event outcomes included: new-onset HF (first hospitalization for HF [HHF] in patients without a history of HF at baseline); cardiovascular death or first HHF; HF-related death or first HHF; first HHF; cardiovascular death or total (first or recurrent) HHF; HF-related death or total HHF; and total HHF. Outcomes were evaluated in the overall population and in prespecified subgroups categorized by baseline HF history (as reported by the investigators). Results: Overall, 7352 patients were included in these analyses; 571 (7.8%) had a history of HF at baseline. New-onset HF was significantly reduced with finerenone versus placebo (1.9% versus 2.8%; hazard ratio [HR], 0.68 [95% CI 0.50-0.93]; P=0.0162). In the overall population, the incidences of all HF outcomes analyzed were significantly lower with finerenone than placebo, including a 18% lower risk of cardiovascular death or first HHF (HR, 0.82 [95% CI 0.70-0.95]; P=0.011), a 29% lower risk of first HHF (HR, 0.71 [95% CI 0.56-0.90]; P=0.0043) and a 30% lower rate of total HHF (rate ratio, 0.70 [95% CI, 0.52- 0.94]). The effects of finerenone on improving HF outcomes were not modified by a history of HF. The incidence of treatment-emergent adverse events was balanced between treatment groups. Conclusions: The results from these FIGARO-DKD analyses demonstrate that finerenone reduces new-onset HF and improves other HF outcomes in patients with CKD and T2D, irrespective of a history of HF.
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Affiliation(s)
- Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - Stefan D Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, IN
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain; CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain; Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Christoph Tasto
- Research and Development, Statistics and Data Insights, Bayer AG, Wuppertal, Germany
| | - Amer Joseph
- Research and Development, Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - Peter Kolkhof
- Preclinical Research Cardiovascular, Pharmaceuticals, Research & Development, Bayer AG, Wuppertal, Germany
| | - Andrea Lage
- Cardiology and Nephrology Clinical Development, Bayer SA, São Paulo, Brazil
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor MI
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561
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Tuttle KR. Forecasting therapeutic responses by albuminuria and eGFR slope during the DAPA-CKD trial. Lancet Diabetes Endocrinol 2021; 9:727-728. [PMID: 34619107 DOI: 10.1016/s2213-8587(21)00265-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Katherine R Tuttle
- Providence Medical Research Center, Providence Health Care, Spokane, WA, USA; Nephrology Division, University of Washington School of Medicine, Seattle, WA 99204, USA.
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562
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Rossignol P. A Step Forward Toward a New Treatment Paradigm in the Cardiorenal Continuum. JACC. HEART FAILURE 2021; 9:821-823. [PMID: 34627723 DOI: 10.1016/j.jchf.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 09/14/2021] [Indexed: 06/13/2023]
Affiliation(s)
- Patrick Rossignol
- Université de Lorraine, Institut National de la Santé Et de la Recherche Médicale (INSERM), Centre d'Investigations Cliniques-Plurithématique 14-33, INSERM U1116, Centre Hospitalier Régional Universitaire Nancy, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France.
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563
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Georgianos PI, Roumeliotis S, Eleftheriadis T, Liakopoulos V. Novel therapeutic strategies for cardiorenal protection in patients with type 2 diabetes and chronic kidney disease. Curr Vasc Pharmacol 2021; 20:117-120. [PMID: 34719374 DOI: 10.2174/1570161119666211029111428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/04/2021] [Accepted: 09/09/2021] [Indexed: 11/22/2022]
Abstract
Type 2 diabetes mellitus (T2DM) is the leading cause of end-stage kidney disease (ESKD) worldwide [1]. The development of chronic kidney disease (CKD) in patients with T2DM substantially increases their risk for cardiovascular (CV) morbidity and mortality [2]. In fact, when T2DM and early-stage CKD co-exist, the risk for CV death is several times higher than the risk for progression to ESKD [3]. Therefore, there is a need for the development of novel therapies to improve CV and kidney failure outcomes in this high-risk population. In this brief perspective, we explore the role of sodium-glucose co-transporter type-2 (SGLT-2) inhibitors and the nonsteroidal mineralocorticoid-receptor-antagonist (MRA) finerenone, in the management of diabetic kidney disease (DKD).
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Affiliation(s)
- Panagiotis I Georgianos
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - Stefanos Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | | | - Vassilios Liakopoulos
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki. Greece
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564
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Delanaye P, Scheen AJ. The diuretic effects of SGLT2 inhibitors: A comprehensive review of their specificities and their role in renal protection. DIABETES & METABOLISM 2021; 47:101285. [PMID: 34597788 DOI: 10.1016/j.diabet.2021.101285] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/16/2021] [Indexed: 02/08/2023]
Abstract
Sodium-glucose cotransporter type 2 inhibitors (SGLT2is) are new oral glucose-lowering agents that provide cardiovascular and renal protection in both patients with and without type 2 diabetes. Because of their unique mechanism of action, increased glucosuria is associated with osmotic diuresis and some natriuresis, yet the latter seems mostly transient. The potential role of the diuretic effect in overall cardiovascular and renal protection by SGLT2is remains a matter of debate. Precise evaluation of the diuretic effect is not so easy and most studies relied upon indirect estimations that led to divergent results, presumably also explained by different study designs and population characteristics. Everybody agrees upon the fact that SGLT2is are different from other classical diuretics (thiazides and loop diuretics) as they present some favourable properties, i.e. reduced sympathetic activity, preserved potassium balance, lower risk of acute renal injury, decrease of serum uric acid level. The potential role of the diuretic effect of SGLT2is on renal outcomes is still unclear, yet their ability to reduce albuminuria and dampen the risk of heart failure may contribute to improve renal prognosis besides other complex underlying mechanisms. In this comprehensive review we first critically analyse the results obtained with indirect methods that assess a diuretic effect of SGLT2is, second we describe the specificities of the diuretic activity of SGLT2is compared with other classical diuretics, and third we discuss the potential mechanisms by which the diuretic effect of SGLT2is could contribute to the improvement of renal outcomes consistently reported with this innovative amazing pharmacological class.
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Affiliation(s)
- Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium; Department of Nephrology-Dialysis-Apheresis, Hôpital Universitaire Carémeau, Nimes, France
| | - Andre J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium; Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium.
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565
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Merker L, Bautsch BW, Ebert T, Guthoff M, Isermann B. Nephropathie bei Diabetes. DIABETOL STOFFWECHS 2021. [DOI: 10.1055/a-1515-9133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Bernd-Walter Bautsch
- Innere Medizin, Katholische Kliniken Oberberg, St. Josef-Krankenhaus, Engelskirchen
| | - Thomas Ebert
- Universitätsklinikum Leipzig, Klinik für Endokrinologie, Nephrologie und Rheumatologie, Leipzig
- Karolinska Institutet, Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Stockholm, Schweden
| | - Martina Guthoff
- Medizinische Klinik IV, Diabetologie, Endokrinologie, Nephrologie, Universitätsklinikum Tübingen
| | - Berend Isermann
- Institut für Laboratoriumsmedizin, Klinische Chemie und Molekulare Diagnostik, Universitätsklinikum Leipzig
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566
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CV benefits of finerenone in T2DM and CKD. Nat Rev Cardiol 2021; 18:738. [PMID: 34508230 DOI: 10.1038/s41569-021-00621-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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567
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Kolkhof P, Joseph A, Kintscher U. Nonsteroidal mineralocorticoid receptor antagonism for cardiovascular and renal disorders - New perspectives for combination therapy. Pharmacol Res 2021; 172:105859. [PMID: 34461222 DOI: 10.1016/j.phrs.2021.105859] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/16/2021] [Accepted: 08/25/2021] [Indexed: 02/06/2023]
Abstract
During the recent 30 years, there has been a dramatic increase in knowledge about the role of aldosterone and the mineralocorticoid receptor (MR) in the pathophysiology of cardiovascular (CV) and kidney diseases. The scientific perspective on the aldosterone/MR ensemble extended from a previously renal epithelial-centered focus on sodium-potassium exchange to a broader view as systemic modulators of extracellular matrix, inflammation and fibrosis. Spironolactone was launched as the first antagonist of aldosterone 27 years before the MR was cloned. It was classified as a potassium-sparing diuretic, based on its initial clinical characterization as a diuretic and its preferred activity to compensate for the potassium loss induced by loop diuretics when used in combination. The second steroidal MR antagonist was eplerenone which was discovered at a time when the role of aldosterone and MR in cardiac fibrosis was rediscovered. The constraint of developing potentially life-threatening hyperkalaemia when used in combination with other inhibitors of the renin-angiotensin-system (RAS) in patients with reduced kidney function initiated extensive research and development activities with the goal to identify novel nonsteroidal MR antagonists with an improved benefit-risk ratio. Here we summarize major current clinical trials with MRAs in different CV and renal diseases. Addition of the nonsteroidal MRA finerenone to optimal RAS blockade recently reduced CV and kidney outcomes in two large phase III trials in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D). We provide an outlook on further opportunities for combination therapy of nonsteroidal MRA finerenone with RAS inhibitors and sodium-glucose cotransporter-2 inhibitors (SGLT2i).
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Affiliation(s)
- Peter Kolkhof
- Cardiovascular Research, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany.
| | - Amer Joseph
- Cardiology and Nephrology, Clinical Development, R&D Pharmaceuticals, Bayer AG, Berlin, Germany
| | - Ulrich Kintscher
- Charite - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Pharmacology, Cardiovascular-Metabolic-Renal Research Center, 10115 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany
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568
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Mosenzon O, Schechter M, Leibowitz G. Kidney Outcomes With Glucagon-Like Peptide-1 Receptor Agonists in Patients With Type 2 Diabetes. Adv Chronic Kidney Dis 2021; 28:347-360. [PMID: 34922691 DOI: 10.1053/j.ackd.2021.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/14/2021] [Accepted: 04/23/2021] [Indexed: 01/10/2023]
Abstract
Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are highly effective in reducing glycemia in patients with type 2 diabetes (T2D). These medications effectively reduce cardiovascular (CV) risk in patients with T2D and established CV disease or with multiple risk factors. In addition, treatment with GLP-1 RA may exert protective effects on the diabetic kidney. Herein, we summarize the findings regarding the kidney safety and efficacy of GLP-1 RAs in patients with T2D. We review data from GLP-1 RAs phase 3 kidney studies, CV outcome trials, as well as real-world evidence. The accumulating data show that treatment with GLP-1 RAs is safe, well-tolerated, and effective in patients with different levels of kidney dysfunction. Furthermore, CV outcome trials suggest that GLP-1 RAs reduce albuminuria and may attenuate the decline in kidney function over time. The ongoing FLOW trial studying the effects of semaglutide in patients with diabetic kidney disease is expected to shed light on the effects of GLP-1 RAs on kidney outcomes and clarify their role in the management of patients with T2D and kidney disease.
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569
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Jung HH. Hypertension Management in Patients with Chronic Kidney Disease in the Post-SPRINT Era. Electrolyte Blood Press 2021; 19:19-28. [PMID: 35003282 PMCID: PMC8715225 DOI: 10.5049/ebp.2021.19.2.19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 10/27/2021] [Accepted: 11/15/2021] [Indexed: 12/02/2022] Open
Abstract
The management of high blood pressure (BP) is crucial for improving outcomes in patients with chronic kidney disease (CKD). The updated Kidney Disease: Improving Global Outcomes 2021 BP guideline proposes treating adults with CKD to a target systolic BP (SBP) of <120 mmHg based on the standardized office BP measurement. This suggestion is largely based on the finding of SPRINT (Systolic Blood Pressure Intervention Trial) that targeting an SBP of <120 mmHg versus <140 mmHg is beneficial for cardiovascular and mortality outcomes, regardless of the patient’s kidney disease status. However, extended follow-up studies of CKD trials showed that intensive versus usual BP control was associated with a lower risk of kidney failure in patients with, but not in those without, proteinuria. Similarly, a recent population-based study in Korea demonstrated that the optimal on-treatment BP for composite cardiorenal and mortality outcomes was left-shifted in adults with CKD, particularly in those with albuminuria, relative to that in patients without CKD. Moreover, in meta-analyses of randomized trials, more intensive versus standard BP control was associated with a lower risk of all-cause mortality in patients with CKD and albuminuria but not in those without CKD. Meanwhile, a 2020 Cochrane review reported that lower BP targets (≤135/85 mmHg), compared with standard targets (≤140/90 mmHg), resulted in a small reduction in cardiovascular events, an increase in other serious adverse events, and no reduction in total serious adverse events. Lowering SBP to <120 mmHg can potentially increase the risk of treatment-related adverse events beyond the cardioprotective benefits, and standardized BP measurement increases the burden on patients and resources. Thus, targeting a BP of <130/80 mmHg with appropriate office BP measurement can be an option in patients with CKD. The presence of albuminuria would need to be additionally considered to determine individualized BP targets.
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Affiliation(s)
- Hae Hyuk Jung
- Department of Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Republic of Korea
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