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Ortiz A. The unaccomplished mission of reducing mortality in patients on kidney replacement therapy. Clin Kidney J 2020; 13:948-951. [PMID: 33391738 PMCID: PMC7769530 DOI: 10.1093/ckj/sfaa235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 10/29/2020] [Indexed: 12/21/2022] Open
Abstract
Six years ago, a comprehensive review by the EURECA-m working group of the ERA-EDTA thoroughly addressed the drivers of mortality in patients with end-stage kidney disease. Not unexpectedly, the key global driver of early death in these patients was the lack of access to kidney replacement therapy. However, and contrary to the expectations of non-nephrologists, mortality was still high when kidney replacement therapy was provided. This was due to excess cardiovascular and non-cardiovascular mortality, and the need to further characterize correctable risk factors and eventually test the impact of correcting them was emphasized. In this issue of ckj, seven reports address risk factors for death in non-dialysis chronic kidney disease (CKD), dialysis and kidney transplant patients. They characterize irreversible (e.g. sex; age; genetic variants of the KL gene encoding the anti-ageing protein Klotho) and reversible (obesity; mineral and bone disorder parameters; anti-depressant drugs, especially those that increase the QT; amputation; public health investments) factors associated with mortality of CKD patients on or off kidney replacement therapy.
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Affiliation(s)
- Alberto Ortiz
- IIS-Fundacion Jimenez Diaz UAM and School of Medicine, UAM, Madrid, Spain
- GEENDIAB, Madrid, Spain
- REDINREN, Madrid, Spain
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52
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Ortiz A. Ckj consolidation among Q1 Urology and Nephrology journals. Clin Kidney J 2020; 13:723-727. [PMID: 33123351 PMCID: PMC7577766 DOI: 10.1093/ckj/sfaa197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 12/21/2022] Open
Abstract
The Clinical Kidney Journal (ckj) impact factor from Clarivate’s Web of Science for 2019 was 3.388. This consolidates ckj among journals in the top 25% (first quartile, Q1) in the Urology and Nephrology field according to the journal impact factor. The manuscripts contributing the most to the impact factor focused on chronic kidney disease (CKD) epidemiology and evaluation, CKD complications and their management, cost-efficiency of renal replacement therapy, pathogenesis of CKD, familial kidney disease and the environment–genetics interface, onconephrology, technology, SGLT2 inhibitors and outcome prediction. We provide here an overview of the hottest and most impactful topics for 2017–19.
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Affiliation(s)
- Alberto Ortiz
- IIS-Fundación Jiménez Diaz, Department of Medicine, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain.,Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
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Fernandez-Prado R, Perez-Gomez MV, Ortiz A. Pelacarsen for lowering lipoprotein(a): implications for patients with chronic kidney disease. Clin Kidney J 2020; 13:753-757. [PMID: 33123354 PMCID: PMC7577764 DOI: 10.1093/ckj/sfaa001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/06/2020] [Indexed: 12/24/2022] Open
Abstract
Chronic kidney disease (CKD) patients are at an increased risk of cardiovascular disease (CVD) and statins may not be protective in advanced CKD. The reasons for the limited efficacy of statins in advanced CKD are unclear, but statins may increase plasma levels of the highly atherogenic molecule lipoprotein(a), also termed Lp(a), as well as PCSK9 (protein convertase subtilisin/kexin type 9) levels. Lp(a) has also been linked to calcific aortic stenosis, which is common in CKD. Moreover, circulating Lp(a) levels increase in nephrotic syndrome with declining renal function and are highest in patients on peritoneal dialysis. Thus, the recent publication of the Phase 2 randomized controlled trial of pelacarsen [also termed AKCEA-APO(a)-LRx and TQJ230], a hepatocyte-directed antisense oligonucleotide targeting the LPA gene messenger RNA, in persons with CVD should be good news for nephrologists. Pelacarsen safely and dose-dependently decreased Lp(a) levels by 35-80% and a Phase 3 trial [Lp(a)HORIZON, NCT04023552] is planned to run from 2020 to 2024. Unfortunately, patients with estimated glomerular filtration rate <60 mL/min or urinary albumin:creatinine ratio >100 mg/g were excluded from Phase 2 trials and those with 'significant kidney disease' will be excluded from the Phase 3 trial. Optimized exclusion criteria for Lp(a)HORIZON would provide insights into the role of Lp(a) in CVD in CKD patients.
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Affiliation(s)
- Raul Fernandez-Prado
- IIS-Fundacion Jimenez Diaz-Universidad Autonoma de Madrid and Fundacion Renal Iñigo Alvarez de Toledo-IRSIN, Madrid, Spain
- REDINREN, Madrid, Spain
| | - Maria Vanessa Perez-Gomez
- IIS-Fundacion Jimenez Diaz-Universidad Autonoma de Madrid and Fundacion Renal Iñigo Alvarez de Toledo-IRSIN, Madrid, Spain
- REDINREN, Madrid, Spain
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz-Universidad Autonoma de Madrid and Fundacion Renal Iñigo Alvarez de Toledo-IRSIN, Madrid, Spain
- REDINREN, Madrid, Spain
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Fernandez-Fernandez B, Sarafidis P, Kanbay M, Navarro-González JF, Soler MJ, Górriz JL, Ortiz A. SGLT2 inhibitors for non-diabetic kidney disease: drugs to treat CKD that also improve glycaemia. Clin Kidney J 2020; 13:728-733. [PMID: 33123352 PMCID: PMC7577767 DOI: 10.1093/ckj/sfaa198] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/01/2020] [Indexed: 02/07/2023] Open
Abstract
Sodium-glucose co-transporter-2 (SGLT2) inhibitors decreased cardiovascular (CV) events and improved renal outcomes in CV safety studies in type 2 diabetes melitus (T2DM) patients at high CV risk. Canagliflozin also improved kidney outcomes in diabetic kidney disease in the Canagliflozin and Renal Events in Diabetes and Nephropathy Clinical Evaluationtrial. More recently, the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial showed that dapagliflozin improved CV outcomes in patients with HF with or without diabetes. Protection from HF in non-diabetics was confirmed for empagliflozin in the EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Reduced Ejection Fraction (EMPEROR-Reduced) trial. A meta-analysis of DAPA-HF and EMPEROR-Reduced confirmed reductions in all-cause and CV death and the combined risk of CV death or worsening HF, as well as in the composite renal endpoint {hazard ratio [HR] 0.62 [95% confidence interval (CI) 0.43-0.90]} without differences based on the presence of diabetes or baseline estimated glomerular filtration rate (eGFR). Moreover, the Study to Evaluate the Effect of Dapagliflozin on Renal Outcomes and Cardiovascular Mortality in Patients With Chronic Kidney Disease (DAPA-CKD) showed that dapagliflozin as an add-on over renin-angiotensin system blockade in patients with chronic kidney disease (CKD; with or without T2DM) reduced the HR for the primary endpoint (time to the first occurrence of ≥50% eGFR decline, end-stage kidney disease or renal or CV death) to 0.61 (95% CI 0.51-0.72) and for the secondary endpoints of worsening renal function or death from kidney failure [HR 0.56 (95% CI 0.45-0.68)], hospitalization for HF or CV death [HR 0.71 (95% CI 0.55-0.92)] and all-cause mortality [HR 0.69 (95% CI 0.53-0.88)]. These beneficial effects were consistent in patients with and without T2DM. In conclusion, SGLT2 inhibitors offer CV and kidney protection in both diabetic and non-diabetic CKD and, additionally, improve glycaemic control in T2DM, making them first-line therapy for CKD independent from diabetic status.
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Affiliation(s)
- Beatriz Fernandez-Fernandez
- IIS-Fundacion Jimenez Diaz and School of Medicine, Universidad Autónoma de Madrid, Grupo Español de Estudio de la Nefropatia Diabetica, Madrid, Spain
- Spanish Renal Research Network, Madrid, Spain
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
- Bellvitge University Hospital, Hospitalet, Grupo Español de Estudio de la Nefropatia Diabetica, Barcelona, Spain
| | - Juan F Navarro-González
- Spanish Renal Research Network, Madrid, Spain
- Unidad de Investigación y Servicio de Nefrología, Hospital Universitario Nuestra Señora de Candelaria, Grupo Español de Estudio de la Nefropatia Diabetica, Santa Cruz de Tenerife, Spain
| | - María José Soler
- Spanish Renal Research Network, Madrid, Spain
- Department of Nephrology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Nephrology Research Group, Vall d’Hebron Research Institute , Grupo Español de Estudio de la Nefropatia Diabetica, Barcelona, Spain
| | - Jose Luis Górriz
- Spanish Renal Research Network, Madrid, Spain
- Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Grupo Español de Estudio de la Nefropatia Diabetica, Valencia, Spain
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz and School of Medicine, Universidad Autónoma de Madrid, Grupo Español de Estudio de la Nefropatia Diabetica, Madrid, Spain
- Spanish Renal Research Network, Madrid, Spain
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Gonzalez-Martin G, Cano J, Carriazo S, Kanbay M, Perez-Gomez MV, Fernandez-Prado R, Ortiz A. The dirty little secret of urate-lowering therapy: useless to stop chronic kidney disease progression and may increase mortality. Clin Kidney J 2020; 13:936-947. [PMID: 33391737 PMCID: PMC7769546 DOI: 10.1093/ckj/sfaa236] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Indexed: 02/07/2023] Open
Abstract
Hyperuricaemia is frequent in chronic kidney disease (CKD). Observational studies have shown an association with adverse outcomes and acquired hyperuricaemia (meaning serum urate levels as low as 1.0 mg/dL) in animal models induces kidney injury. This evidence does not justify the widespread use of urate-lowering drugs for asymptomatic hyperuricaemia in CKD. However, promising results from small, open-label studies led some physicians to prescribe urate-lowering drugs to slow CKD progression. Two recent, large, placebo-controlled trials (CKD-FIX and PERL) showed no benefit from urate lowering with allopurinol on the primary endpoint of CKD progression, confirming prior negative results. Despite these negative findings, it was still argued that the study population could be optimized by enrolling younger non-proteinuric CKD patients with better preserved glomerular filtration rate (GFR). However, in these low-risk patients, GFR may be stable under placebo conditions. Additionally, the increased mortality trends already identified in gout trials of urate-lowering therapy were also observed in CKD-FIX and PERL, sending a strong safety signal: 21/449 (4.7%) and 10/444 (2.2%) patients died in the combined allopurinol and placebo groups, respectively [chi-squared P-value 0.048; relative risk 2.07 (95% CI 0.98–4.34); P = 0.06]. Given the absent evidence of benefit in multiple clinical trials and the potentially serious safety issues, the clear message should be that urate-lowering therapy should not be prescribed for the indication of slowing CKD progression. Additionally, regulatory agencies should urgently reassess the safety of chronic prescription of urate-lowering drugs for any indication.
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Affiliation(s)
- Guillermo Gonzalez-Martin
- IIS-Fundacion Jimenez Diaz UAM and School of Medicine, UAM, Madrid, Spain.,GEENDIAB.,REDINREN, Madrid, Spain
| | - Jaime Cano
- IIS-Fundacion Jimenez Diaz UAM and School of Medicine, UAM, Madrid, Spain.,GEENDIAB.,REDINREN, Madrid, Spain
| | - Sol Carriazo
- IIS-Fundacion Jimenez Diaz UAM and School of Medicine, UAM, Madrid, Spain.,GEENDIAB.,REDINREN, Madrid, Spain
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Maria Vanessa Perez-Gomez
- IIS-Fundacion Jimenez Diaz UAM and School of Medicine, UAM, Madrid, Spain.,GEENDIAB.,REDINREN, Madrid, Spain
| | - Raul Fernandez-Prado
- IIS-Fundacion Jimenez Diaz UAM and School of Medicine, UAM, Madrid, Spain.,GEENDIAB.,REDINREN, Madrid, Spain
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz UAM and School of Medicine, UAM, Madrid, Spain.,GEENDIAB.,REDINREN, Madrid, Spain
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56
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Carriazo S, Vanessa Perez-Gomez M, Ortiz A. Hypertensive nephropathy: a major roadblock hindering the advance of precision nephrology. Clin Kidney J 2020; 13:504-509. [PMID: 32897275 PMCID: PMC7467619 DOI: 10.1093/ckj/sfaa162] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Indexed: 12/29/2022] Open
Abstract
In the 2017 Annual Report of the ERA-EDTA Registry, hypertension continues to be the second or third most common cause of renal replacement therapy (RRT) in Europe, tied with glomerulonephritis. There is, however, one little issue: hypertension-induced end-stage renal disease (ESRD) might not exist at all as currently understood, that is, as hypertensive nephrosclerosis. In this regard, the incidence of RRT due to hypertensive nephropathy is related to the incidence of other causes of ESRD but not to the burden of hypertension per country. The current definition of hypertensive nephropathy is non-specific, outdated and only allows a delayed diagnosis by exclusion. It is not helpful that 80% of chronic kidney disease patients develop hypertension and kidney biopsy has no findings specific for hypertensive nephropathy. There is an urgent need to redefine the concept of hypertensive nephropathy with a clear and comprehensive set of criteria that at least should indicate how other nephropathies, including familial nephropathies, should be excluded. Correct causality assessment and aetiology-based therapy is a key to the progress of nephrology and it should no longer be accepted that ‘hypertensive nephropathy’ serves to disguise a suboptimal diagnostic workup. A diagnosis of nephropathy of unknown cause would be more honest when the full range of alternative aetiological diagnoses is not explored.
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Affiliation(s)
- Sol Carriazo
- IIS-Fundación Jiménez Diaz, Department of Medicine, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain and Red de Investigación Renal, Instituto Carlos III-FEDER, Madrid, Spain
| | - Maria Vanessa Perez-Gomez
- IIS-Fundación Jiménez Diaz, Department of Medicine, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain and Red de Investigación Renal, Instituto Carlos III-FEDER, Madrid, Spain
| | - Alberto Ortiz
- IIS-Fundación Jiménez Diaz, Department of Medicine, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain and Red de Investigación Renal, Instituto Carlos III-FEDER, Madrid, Spain
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Martínez-Castelao A, Soler MJ, Górriz Teruel JL, Navarro-González JF, Fernandez-Fernandez B, de Alvaro Moreno F, Ortiz A. Optimizing the timing of nephrology referral for patients with diabetic kidney disease. Clin Kidney J 2020; 14:5-8. [PMID: 33564400 PMCID: PMC7857795 DOI: 10.1093/ckj/sfaa125] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/08/2020] [Indexed: 02/06/2023] Open
Abstract
Age-standardized rates of diabetes mellitus (DM)-related complications, such as acute myocardial infarction, stroke or amputations, have decreased in recent years, but this was not associated with a clear reduction of the incidence of advanced chronic kidney disease (CKD) requiring renal replacement therapy. The early detection of diabetic kidney disease (DKD) is a key to reduce complications, morbidity and mortality. Consensus documents and clinical practice guidelines recommend referral of DM patients to nephrology when the estimated glomerular filtration rate falls below 30 mL/min/1.73 m2 or when albuminuria exceeds 300 mg/g urinary creatinine. Conceptually, it strikes as odd that patients with CKD are referred to the specialist caring for the prevention and treatment of CKD only when >70% of the functioning kidney mass has been lost. The increasing global health burden of CKD, driven in large part by DKD, the suboptimal impact of routine care on DKD outcomes as compared with other DM complications, the realization that successful therapy of CKD requires early diagnosis and intervention, the advances in earlier diagnosis of kidney injury and the recent availability of antidiabetic drugs with a renal mechanism of action and lack of hypoglycaemia risk, which additionally are cardio- and nephroprotective, all point towards a paradigm shift in the care for DM patients in which they should be referred earlier to nephrology as part of a coordinated and integrated care approach.
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Affiliation(s)
- Alberto Martínez-Castelao
- Nephrology department, Bellvitge University Hospital, Barcelona, Spain
- GEENDIAB (Grupo Español de Estudio de la Nefropatía Diabética), Sociedad Española Nefrología (SEN), Santander, Spain
- REDinREN, Instituto Salud Carlos III, Madrid, Spain
- Correspondence to: Alberto Martínez-Castelao; E-mail:
| | - María José Soler
- GEENDIAB (Grupo Español de Estudio de la Nefropatía Diabética), Sociedad Española Nefrología (SEN), Santander, Spain
- REDinREN, Instituto Salud Carlos III, Madrid, Spain
- Nephrology department, Hospital Universitari Vall d’Hebrón, Barcelona, Spain
| | - José Luis Górriz Teruel
- GEENDIAB (Grupo Español de Estudio de la Nefropatía Diabética), Sociedad Española Nefrología (SEN), Santander, Spain
- REDinREN, Instituto Salud Carlos III, Madrid, Spain
- Nephrology department, Hospital Clínico Valencia, INCLIVA, Valencia, Spain
| | - Juan F Navarro-González
- GEENDIAB (Grupo Español de Estudio de la Nefropatía Diabética), Sociedad Española Nefrología (SEN), Santander, Spain
- REDinREN, Instituto Salud Carlos III, Madrid, Spain
- Nephrology department, Unidad Investigación Hospital Nuestra Señora de Candelaria, Tenerife, Spain
| | - Beatriz Fernandez-Fernandez
- REDinREN, Instituto Salud Carlos III, Madrid, Spain
- Nephrology department, IIS-Fundación Jiménez Díaz UAM, Madrid, Spain
| | - Fernando de Alvaro Moreno
- GEENDIAB (Grupo Español de Estudio de la Nefropatía Diabética), Sociedad Española Nefrología (SEN), Santander, Spain
- Nephrology department, Hospitales Madrid, Madrid, Spain
| | - Alberto Ortiz
- GEENDIAB (Grupo Español de Estudio de la Nefropatía Diabética), Sociedad Española Nefrología (SEN), Santander, Spain
- REDinREN, Instituto Salud Carlos III, Madrid, Spain
- Nephrology department, IIS-Fundación Jiménez Díaz UAM, Madrid, Spain
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Kanbay M, Ertuglu LA, Afsar B, Ozdogan E, Siriopol D, Covic A, Basile C, Ortiz A. An update review of intradialytic hypotension: concept, risk factors, clinical implications and management. Clin Kidney J 2020; 13:981-993. [PMID: 33391741 PMCID: PMC7769545 DOI: 10.1093/ckj/sfaa078] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 04/30/2020] [Indexed: 12/13/2022] Open
Abstract
Intradialytic hypotension (IDH) is a frequent and serious complication of chronic haemodialysis, linked to adverse long-term outcomes including increased cardiovascular and all-cause mortality. IDH is the end result of the interaction between ultrafiltration rate (UFR), cardiac output and arteriolar tone. Thus excessive ultrafiltration may decrease the cardiac output, especially when compensatory mechanisms (heart rate, myocardial contractility, vascular tone and splanchnic flow shifts) fail to be optimally recruited. The repeated disruption of end-organ perfusion in IDH may lead to various adverse clinical outcomes affecting the heart, central nervous system, kidney and gastrointestinal system. Potential interventions to decrease the incidence or severity of IDH include optimization of the dialysis prescription (cool dialysate, UFR, sodium profiling and high-flux haemofiltration), interventions during the dialysis session (midodrine, mannitol, food intake, intradialytic exercise and intermittent pneumatic compression of the lower limbs) and interventions in the interdialysis period (lower interdialytic weight gain and blood pressure–lowering drugs). However, the evidence base for many of these interventions is thin and optimal prevention and management of IDH awaits further clinical investigation. Developing a consensus definition of IDH will facilitate clinical research. We review the most recent findings on risk factors, pathophysiology and management of IDH and, based on this, we call for a new consensus definition of IDH based on clinical outcomes and define a roadmap for IDH research.
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Affiliation(s)
- Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Lale A Ertuglu
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Baris Afsar
- Department of Internal Medicine, Division of Nephrology, Suleyman Demirel University School of Medicine, Isparta, Turkey
| | - Elif Ozdogan
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Dimitrie Siriopol
- Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. PARHON' University Hospital, 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. PARHON' University Hospital, 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Carlo Basile
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy.,Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
| | - Alberto Ortiz
- Dialysis Unit, School of Medicine, IIS-Fundacion Jimenez Diaz, Universidad Autónoma de Madrid, Madrid, Spain
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Albuminuria Downregulation of the Anti-Aging Factor Klotho: The Missing Link Potentially Explaining the Association of Pathological Albuminuria with Premature Death. Adv Ther 2020; 37:62-72. [PMID: 32236874 DOI: 10.1007/s12325-019-01180-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Indexed: 12/17/2022]
Abstract
Ten percent of the adult population has chronic kidney disease (CKD), which is diagnosed when the glomerular filtration rate (GFR) is below 60 mL/min per 1.73 m2 or when albuminuria is above 30 mg/day. The numerical thresholds were chosen because they are associated with an increased risk of CKD progression or premature death within a wider scenario of accelerated aging. Indeed, CKD is one of the fastest growing causes of death worldwide. A decreased GFR is associated with the accumulation of uraemic toxins that may promote tissue and organ damage. However, CKD may be diagnosed when the GFR is completely normal, as long as there is pathological albuminuria. A key unanswered question to stem the rise of CKD-associated deaths is whether the association between isolated albuminuria (when the GFR is normal) and premature death is causal. The recent demonstration that albuminuria per se directly suppresses the production of the anti-aging factor Klotho by kidney tubular cells may be one of the first steps to address the causality of the albuminuria-premature death-accelerated aging association. This hypothesis should be tested in interventional studies that should draw from translational science advances. Thus, the observation that albuminuria decreases Klotho production through epigenetic mechanisms implies that Klotho downregulation may persist after the correction of albuminuria, and innovative therapeutic approaches are needed to restore Klotho production. On the basis of recent literature, these may include manipulation of NF-kappaB regulators such as B cell lymphoma 3 protein (BCL-3), and epigenetic regulators such as histone deacetylases, or the repurposing of drugs such as pentoxifylline.
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Martinez-Moreno JM, Fontecha-Barriuso M, Martín-Sánchez D, Sánchez-Niño MD, Ruiz-Ortega M, Sanz AB, Ortiz A. The Contribution of Histone Crotonylation to Tissue Health and Disease: Focus on Kidney Health. Front Pharmacol 2020; 11:393. [PMID: 32308622 PMCID: PMC7145939 DOI: 10.3389/fphar.2020.00393] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 03/16/2020] [Indexed: 12/12/2022] Open
Abstract
Acute kidney injury (AKI) and chronic kidney disease (CKD) are the most severe consequences of kidney injury. They are interconnected syndromes as CKD predisposes to AKI and AKI may accelerate CKD progression. Despite their growing impact on the global burden of disease, there is no satisfactory treatment for AKI and current therapeutic approaches to CKD remain suboptimal. Recent research has focused on the therapeutic target potential of epigenetic regulation of gene expression, including non-coding RNAs and the covalent modifications of histones and DNA. Indeed, several drugs targeting histone modifications are in clinical use or undergoing clinical trials. Acyl-lysine histone modifications (e.g. methylation, acetylation, and crotonylation) have modulated experimental kidney injury. Most recently, increased histone lysine crotonylation (Kcr) was observed during experimental AKI and could be reproduced in cultured tubular cells exposed to inflammatory stress triggered by the cytokine TWEAK. The degree of kidney histone crotonylation was modulated by crotonate availability and crotonate supplementation protected from nephrotoxic AKI. We now review the functional relevance of histone crotonylation in kidney disease and other pathophysiological contexts, as well as the implications for the development of novel therapeutic approaches. These studies provide insights into the overall role of histone crotonylation in health and disease.
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Affiliation(s)
- Julio M Martinez-Moreno
- Research Institute-Fundacion Jimenez Diaz, Autonomous University of Madrid (UAM), Madrid, Spain
| | - Miguel Fontecha-Barriuso
- Research Institute-Fundacion Jimenez Diaz, Autonomous University of Madrid (UAM), Madrid, Spain.,Red de Investigación Renal (REDinREN), Madrid, Spain
| | - Diego Martín-Sánchez
- Research Institute-Fundacion Jimenez Diaz, Autonomous University of Madrid (UAM), Madrid, Spain.,Red de Investigación Renal (REDinREN), Madrid, Spain
| | - Maria D Sánchez-Niño
- Research Institute-Fundacion Jimenez Diaz, Autonomous University of Madrid (UAM), Madrid, Spain.,Red de Investigación Renal (REDinREN), Madrid, Spain
| | - Marta Ruiz-Ortega
- Research Institute-Fundacion Jimenez Diaz, Autonomous University of Madrid (UAM), Madrid, Spain.,Red de Investigación Renal (REDinREN), Madrid, Spain.,School of Medicine, Autonomous University of Madrid (UAM), Madrid, Spain
| | - Ana B Sanz
- Research Institute-Fundacion Jimenez Diaz, Autonomous University of Madrid (UAM), Madrid, Spain.,Red de Investigación Renal (REDinREN), Madrid, Spain
| | - Alberto Ortiz
- Research Institute-Fundacion Jimenez Diaz, Autonomous University of Madrid (UAM), Madrid, Spain.,Red de Investigación Renal (REDinREN), Madrid, Spain.,School of Medicine, Autonomous University of Madrid (UAM), Madrid, Spain.,IRSIN, Madrid, Spain
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Abstract
Chronic kidney disease (CKD) is one of the fastest growing global causes of death, estimated to rank among the top five by 2040 (Foreman et al, 2018). This illustrates current pitfalls in diagnosis and management of CKD. Advanced CKD requires renal function replacement by dialysis or transplantation. However, earlier CKD stages, even when renal function is still normal, are already associated with an increased risk of premature death (Perez‐Gomez et al, 2019). Thus, novel approaches to diagnose and treat CKD are needed. The histopathological hallmark of CKD is kidney fibrosis, which is closely associated with local inflammation and loss of kidney parenchymal cells. Thus, kidney fibrosis is an attractive process to develop tests allowing an earlier diagnosis of CKD and represents a potential therapeutic target to slow CKD progression or promote regression.
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Affiliation(s)
- Alberto Ortiz
- IIS-Fundacion Jimenez Diaz, Department of Medicine, School of Medicine, Universidad Autonoma de Madrid, Madrid, Spain.,Fundacion Renal Iñigo Alvarez de Toledo-IRSIN and REDINREN, Madrid, Spain
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Carriazo S, Ramos AM, Sanz AB, Sanchez-Niño MD, Kanbay M, Ortiz A. Chronodisruption: A Poorly Recognized Feature of CKD. Toxins (Basel) 2020; 12:E151. [PMID: 32121234 PMCID: PMC7150823 DOI: 10.3390/toxins12030151] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 02/17/2020] [Accepted: 02/20/2020] [Indexed: 02/07/2023] Open
Abstract
Multiple physiological variables change over time in a predictable and repetitive manner, guided by molecular clocks that respond to external and internal clues and are coordinated by a central clock. The kidney is the site of one of the most active peripheral clocks. Biological rhythms, of which the best known are circadian rhythms, are required for normal physiology of the kidneys and other organs. Chronodisruption refers to the chronic disruption of circadian rhythms leading to disease. While there is evidence that circadian rhythms may be altered in kidney disease and that altered circadian rhythms may accelerate chronic kidney disease (CKD) progression, there is no comprehensive review on chronodisruption and chronodisruptors in CKD and its manifestations. Indeed, the term chronodisruption has been rarely applied to CKD despite chronodisruptors being potential therapeutic targets in CKD patients. We now discuss evidence for chronodisruption in CKD and the impact of chronodisruption on CKD manifestations, identify potential chronodisruptors, some of them uremic toxins, and their therapeutic implications, and discuss current unanswered questions on this topic.
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Affiliation(s)
- Sol Carriazo
- IIS-Fundacion Jimenez Diaz, Department of Medicine, Universidad Autonoma de Madrid, Fundacion Renal Iñigo Alvarez de Toledo-IRSIN, 28040 Madrid, Spain; (S.C.); (A.MR.); (A.BS.); (M.D.S.-N.)
- Red de Investigación Renal (REDINREN), 28040 Madrid, Spain
| | - Adrián M Ramos
- IIS-Fundacion Jimenez Diaz, Department of Medicine, Universidad Autonoma de Madrid, Fundacion Renal Iñigo Alvarez de Toledo-IRSIN, 28040 Madrid, Spain; (S.C.); (A.MR.); (A.BS.); (M.D.S.-N.)
- Red de Investigación Renal (REDINREN), 28040 Madrid, Spain
| | - Ana B Sanz
- IIS-Fundacion Jimenez Diaz, Department of Medicine, Universidad Autonoma de Madrid, Fundacion Renal Iñigo Alvarez de Toledo-IRSIN, 28040 Madrid, Spain; (S.C.); (A.MR.); (A.BS.); (M.D.S.-N.)
- Red de Investigación Renal (REDINREN), 28040 Madrid, Spain
| | - Maria Dolores Sanchez-Niño
- IIS-Fundacion Jimenez Diaz, Department of Medicine, Universidad Autonoma de Madrid, Fundacion Renal Iñigo Alvarez de Toledo-IRSIN, 28040 Madrid, Spain; (S.C.); (A.MR.); (A.BS.); (M.D.S.-N.)
- Red de Investigación Renal (REDINREN), 28040 Madrid, Spain
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, 34010 Istanbul, Turkey;
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz, Department of Medicine, Universidad Autonoma de Madrid, Fundacion Renal Iñigo Alvarez de Toledo-IRSIN, 28040 Madrid, Spain; (S.C.); (A.MR.); (A.BS.); (M.D.S.-N.)
- Red de Investigación Renal (REDINREN), 28040 Madrid, Spain
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Fontecha-Barriuso M, Martin-Sanchez D, Martinez-Moreno JM, Monsalve M, Ramos AM, Sanchez-Niño MD, Ruiz-Ortega M, Ortiz A, Sanz AB. The Role of PGC-1α and Mitochondrial Biogenesis in Kidney Diseases. Biomolecules 2020; 10:biom10020347. [PMID: 32102312 PMCID: PMC7072614 DOI: 10.3390/biom10020347] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 02/06/2023] Open
Abstract
Chronic kidney disease (CKD) is one of the fastest growing causes of death worldwide, emphasizing the need to develop novel therapeutic approaches. CKD predisposes to acute kidney injury (AKI) and AKI favors CKD progression. Mitochondrial derangements are common features of both AKI and CKD and mitochondria-targeting therapies are under study as nephroprotective agents. PGC-1α is a master regulator of mitochondrial biogenesis and an attractive therapeutic target. Low PGC-1α levels and decreased transcription of its gene targets have been observed in both preclinical AKI (nephrotoxic, endotoxemia, and ischemia-reperfusion) and in experimental and human CKD, most notably diabetic nephropathy. In mice, PGC-1α deficiency was associated with subclinical CKD and predisposition to AKI while PGC-1α overexpression in tubular cells protected from AKI of diverse causes. Several therapeutic strategies may increase kidney PGC-1α activity and have been successfully tested in animal models. These include AMP-activated protein kinase (AMPK) activators, phosphodiesterase (PDE) inhibitors, and anti-TWEAK antibodies. In conclusion, low PGC-1α activity appears to be a common feature of AKI and CKD and recent characterization of nephroprotective approaches that increase PGC-1α activity may pave the way for nephroprotective strategies potentially effective in both AKI and CKD.
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Affiliation(s)
- Miguel Fontecha-Barriuso
- Research Institute-Fundacion Jimenez Diaz, Autonoma University, 28040 Madrid, Spain; (M.F.-B.); (D.M.-S.); (J.M.M.-M.); (A.M.R.); (M.D.S.-N.); (M.R.-O.); (A.O.)
- REDINREN, 28040 Madrid, Spain
| | - Diego Martin-Sanchez
- Research Institute-Fundacion Jimenez Diaz, Autonoma University, 28040 Madrid, Spain; (M.F.-B.); (D.M.-S.); (J.M.M.-M.); (A.M.R.); (M.D.S.-N.); (M.R.-O.); (A.O.)
- REDINREN, 28040 Madrid, Spain
| | - Julio Manuel Martinez-Moreno
- Research Institute-Fundacion Jimenez Diaz, Autonoma University, 28040 Madrid, Spain; (M.F.-B.); (D.M.-S.); (J.M.M.-M.); (A.M.R.); (M.D.S.-N.); (M.R.-O.); (A.O.)
| | - Maria Monsalve
- Instituto de Investigaciones Biomédicas “Alberto Sols” (CSIC-UAM), 28029 Madrid, Spain;
| | - Adrian Mario Ramos
- Research Institute-Fundacion Jimenez Diaz, Autonoma University, 28040 Madrid, Spain; (M.F.-B.); (D.M.-S.); (J.M.M.-M.); (A.M.R.); (M.D.S.-N.); (M.R.-O.); (A.O.)
- REDINREN, 28040 Madrid, Spain
| | - Maria Dolores Sanchez-Niño
- Research Institute-Fundacion Jimenez Diaz, Autonoma University, 28040 Madrid, Spain; (M.F.-B.); (D.M.-S.); (J.M.M.-M.); (A.M.R.); (M.D.S.-N.); (M.R.-O.); (A.O.)
- REDINREN, 28040 Madrid, Spain
| | - Marta Ruiz-Ortega
- Research Institute-Fundacion Jimenez Diaz, Autonoma University, 28040 Madrid, Spain; (M.F.-B.); (D.M.-S.); (J.M.M.-M.); (A.M.R.); (M.D.S.-N.); (M.R.-O.); (A.O.)
- REDINREN, 28040 Madrid, Spain
- School of Medicine, UAM, 28029 Madrid, Spain
| | - Alberto Ortiz
- Research Institute-Fundacion Jimenez Diaz, Autonoma University, 28040 Madrid, Spain; (M.F.-B.); (D.M.-S.); (J.M.M.-M.); (A.M.R.); (M.D.S.-N.); (M.R.-O.); (A.O.)
- REDINREN, 28040 Madrid, Spain
- School of Medicine, UAM, 28029 Madrid, Spain
- IRSIN, 28040 Madrid, Spain
| | - Ana Belen Sanz
- Research Institute-Fundacion Jimenez Diaz, Autonoma University, 28040 Madrid, Spain; (M.F.-B.); (D.M.-S.); (J.M.M.-M.); (A.M.R.); (M.D.S.-N.); (M.R.-O.); (A.O.)
- REDINREN, 28040 Madrid, Spain
- Correspondence: ; Tel.: +34-91-550-48-00
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Ramos AM, Fernández-Fernández B, Pérez-Gómez MV, Carriazo Julio SM, Sanchez-Niño MD, Sanz A, Ruiz-Ortega M, Ortiz A. Design and optimization strategies for the development of new drugs that treat chronic kidney disease. Expert Opin Drug Discov 2019; 15:101-115. [PMID: 31736379 DOI: 10.1080/17460441.2020.1690450] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Chronic kidney disease (CKD) is characterized by increased risks of progression to end-stage kidney disease requiring dialysis and cardiovascular mortality, predicted to be among the five top causes of death by 2040. Only the design and optimization of novel strategies to develop new drugs to treat CKD will contain this trend. Current therapy for CKD includes nonspecific therapy targeting proteinuria and/or hypertension and cause-specific therapies for diabetic kidney disease, autosomal dominant polycystic kidney disease, glomerulonephritides, Fabry nephropathy, hemolytic uremic syndrome and others.Areas covered: Herein, the authors review the literature on new drugs under development for CKD as well as novel design and development strategies.Expert opinion: New therapies for CKD have become a healthcare priority. Emerging therapies undergoing clinical trials are testing expanded renin-angiotensin system blockade with double angiotensin receptor/endothelin receptor blockers, SGLT2 inhibition, and targeting inflammation, the immune response, fibrosis and the Nrf2 transcription factor. Emerging therapeutic targets include cell senescence, complement activation, Klotho expression preservation and microbiota. Novel approaches include novel model systems that can be personalized (e.g. organoids), unbiased systems biology-based identification of new therapeutic targets, drug databases that speed up drug identification and repurposing, nanomedicines that improve drug delivery and RNA targeting to expand the number of targetable proteins.
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Affiliation(s)
- Adrián M Ramos
- Laboratory of Nephrology and Hypertension, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz (IIS-FJD), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain.,Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain
| | - Beatriz Fernández-Fernández
- Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain.,Nephrology, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz (IIS-FJD), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - María Vanessa Pérez-Gómez
- Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain.,Instituto de Investigación Sanitaria-Fundación Jiménez Díaz (IIS-FJD), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Sol María Carriazo Julio
- Nephrology, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz (IIS-FJD), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - María Dolores Sanchez-Niño
- Laboratory of Nephrology and Hypertension, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz (IIS-FJD), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain.,Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain
| | - Ana Sanz
- Laboratory of Nephrology and Hypertension, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz (IIS-FJD), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain.,Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain
| | - Marta Ruiz-Ortega
- Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain.,Laboratory of Renal and Vascular Pathology and Diabetes, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz (IIS-FJD), School of Medicine, Universidad Autónoma de Madrid and Cellular Biology in Renal Diseases Laboratory, Universidad Autónoma de Madrid, Madrid, Spain
| | - Alberto Ortiz
- Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain.,Instituto de Investigación Sanitaria-Fundación Jiménez Díaz (IIS-FJD), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain.,Fundación Renal Iñigo Álvarez de Toledo IRSIN C/José Abascal, Madrid, Spain
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Castillo-Rodriguez E, Fernandez-Fernandez B, Alegre-Bellassai R, Kanbay M, Ortiz A. The chaos of hypertension guidelines for chronic kidney disease patients. Clin Kidney J 2019; 12:771-777. [PMID: 31807290 PMCID: PMC6885687 DOI: 10.1093/ckj/sfz126] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Indexed: 12/19/2022] Open
Abstract
Three major guidelines deal with blood pressure thresholds and targets for antihypertensive drug therapy in chronic kidney disease (CKD) patients: the 2012 Kidney Disease: Improving Global Outcomes Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease; the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults; and the 2018 ESC/ESH Guidelines for the Management of Arterial Hypertension. However, a careful reading of the three guidelines leaves the practicing physician confused about the definition of CKD, how hypertension and secondary hypertension should be diagnosed in CKD patients and what the blood pressure thresholds, targets and compelling indications of antihypertensive drug therapy should be for this population. Current guidelines refer to different CKD populations and propose different definitions of hypertension, different thresholds to initiate antihypertensive therapy in CKD patients and different BP targets compelling antihypertensive drug use. The different bodies producing guidelines should work together towards a unified definition of CKD, a unified concept of hypertension and unified BP thresholds and targets for hypertensive drug therapy for CKD patients. Otherwise they risk promoting confusion and therapeutic nihilism among physicians and patients.
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Affiliation(s)
- Esmeralda Castillo-Rodriguez
- IIS-Fundacion Jimenez Diaz, School of Medicine, Universidad Autonoma de Madrid, Madrid, Spain.,Fundacion Renal Iñigo Alvarez de Toledo-IRSIN, Madrid, Spain.,REDINREN, Madrid, Spain
| | - Beatriz Fernandez-Fernandez
- IIS-Fundacion Jimenez Diaz, School of Medicine, Universidad Autonoma de Madrid, Madrid, Spain.,Fundacion Renal Iñigo Alvarez de Toledo-IRSIN, Madrid, Spain.,REDINREN, Madrid, Spain
| | - Raquel Alegre-Bellassai
- IIS-Fundacion Jimenez Diaz, School of Medicine, Universidad Autonoma de Madrid, Madrid, Spain.,Fundacion Renal Iñigo Alvarez de Toledo-IRSIN, Madrid, Spain.,REDINREN, Madrid, Spain
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz, School of Medicine, Universidad Autonoma de Madrid, Madrid, Spain.,Fundacion Renal Iñigo Alvarez de Toledo-IRSIN, Madrid, Spain.,REDINREN, Madrid, Spain
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66
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Fernandez-Prado R, Kanbay M, Ortiz A, Perez-Gomez MV. Expanding congenital abnormalities of the kidney and urinary tract (CAKUT) genetics: basonuclin 2 (BNC2) and lower urinary tract obstruction. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S226. [PMID: 31656805 DOI: 10.21037/atm.2019.08.73] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Raul Fernandez-Prado
- Division of Nephrology and Hypertension, Dialysis Unit, School of Medicine, IIS-Fundacion Jimenez Diaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Alberto Ortiz
- Division of Nephrology and Hypertension, Dialysis Unit, School of Medicine, IIS-Fundacion Jimenez Diaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Maria Vanessa Perez-Gomez
- Division of Nephrology and Hypertension, Dialysis Unit, School of Medicine, IIS-Fundacion Jimenez Diaz, Universidad Autónoma de Madrid, Madrid, Spain
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Valdivielso JM, Rodríguez-Puyol D, Pascual J, Barrios C, Bermúdez-López M, Sánchez-Niño MD, Pérez-Fernández M, Ortiz A. Atherosclerosis in Chronic Kidney Disease: More, Less, or Just Different? Arterioscler Thromb Vasc Biol 2019; 39:1938-1966. [PMID: 31412740 DOI: 10.1161/atvbaha.119.312705] [Citation(s) in RCA: 152] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patients with chronic kidney disease (CKD) are at an increased risk of premature mortality, mainly from cardiovascular causes. The association between CKD on hemodialysis and accelerated atherosclerosis was described >40 years ago. However, more recently, it has been suggested that the increase in atherosclerosis risk is actually observed in early CKD stages, remaining stable thereafter. In this regard, interventions targeting the pathogenesis of atherosclerosis, such as statins, successful in the general population, have failed to benefit patients with very advanced CKD. This raises the issue of the relative contribution of atherosclerosis versus other forms of cardiovascular injury such as arteriosclerosis or myocardial injury to the increased cardiovascular risk in CKD. In this review, the pathophysiogical contributors to atherosclerosis in CKD that are shared with the general population, or specific to CKD, are discussed. The NEFRONA study (Observatorio Nacional de Atherosclerosis en NEFrologia) prospectively assessed the prevalence and progression of subclinical atherosclerosis (plaque in vascular ultrasound), confirming an increased prevalence of atherosclerosis in patients with moderate CKD. However, the adjusted odds ratio for subclinical atherosclerosis increased with CKD stage, suggesting a contribution of CKD itself to subclinical atherosclerosis. Progression of atherosclerosis was closely related to CKD progression as well as to the baseline presence of atheroma plaque, and to higher phosphate, uric acid, and ferritin and lower 25(OH) vitamin D levels. These insights may help design future clinical trials of stratified personalized medicine targeting atherosclerosis in patients with CKD. Future primary prevention trials should enroll patients with evidence of subclinical atherosclerosis and should provide a comprehensive control of all known risk factors in addition to testing any additional intervention or placebo.
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Affiliation(s)
- José M Valdivielso
- From the Vascular & Renal Translational Research Group and UDETMA, IRBLleida. Spanish Research Network for Renal Diseases (RedInRen. ISCIII), Lleida, Spain (J.M.V., M.B.-L.)
| | - Diego Rodríguez-Puyol
- Nephrology Unit, Fundación para la investigación del Hospital Universitario Príncipe de Asturias, RedInRen, Alcalá de Henares, Madrid, Spain (D.R.-P.)
| | - Julio Pascual
- Department of Nephrology, Institute Mar for Medical Research, Hospital del Mar, RedInRen, Barcelona, Spain (J.P., C.B.)
| | - Clara Barrios
- Department of Nephrology, Institute Mar for Medical Research, Hospital del Mar, RedInRen, Barcelona, Spain (J.P., C.B.)
| | - Marcelino Bermúdez-López
- From the Vascular & Renal Translational Research Group and UDETMA, IRBLleida. Spanish Research Network for Renal Diseases (RedInRen. ISCIII), Lleida, Spain (J.M.V., M.B.-L.)
| | - Maria Dolores Sánchez-Niño
- IIS-Fundacion Jimenez Diaz, School of Medicine, University Autonoma of Madrid, FRIAT and RedInRen, Madrid, Spain (M.D.S.-N., A.O.)
| | | | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz, School of Medicine, University Autonoma of Madrid, FRIAT and RedInRen, Madrid, Spain (M.D.S.-N., A.O.)
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Carriazo S, Perez-Gomez MV, Cordido A, García-González MA, Sanz AB, Ortiz A, Sanchez-Niño MD. Dietary Care for ADPKD Patients: Current Status and Future Directions. Nutrients 2019; 11:nu11071576. [PMID: 31336917 PMCID: PMC6683072 DOI: 10.3390/nu11071576] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/05/2019] [Accepted: 07/09/2019] [Indexed: 02/07/2023] Open
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic nephropathy, and tolvaptan is the only therapy available. However, tolvaptan slows but does not stop disease progression, is marred by polyuria, and most patients worldwide lack access. This and recent preclinical research findings on the glucose-dependency of cyst-lining cells have renewed interest in the dietary management of ADPKD. We now review the current dietary recommendations for ADPKD patients according to clinical guidelines, the evidence base for those, and the potential impact of preclinical studies addressing the impact of diet on ADPKD progression. The clinical efficacy of tolvaptan has put the focus on water intake and solute ingestion as modifiable factors that may impact tolvaptan tolerance and ADPKD progression. By contrast, dietary modifications suggested to ADPKD patients, such as avoiding caffeine, are not well supported and their impact is unknown. Recent studies have identified a chronic shift in energy production from mitochondrial oxidative phosphorylation to aerobic glycolysis (Warburg effect) as a contributor to cyst growth, rendering cyst cells exquisitely sensitive to glucose availability. Therefore, low calorie or ketogenic diets have delayed preclinical ADPKD progression. Additional preclinical data warn of potential negative impact of excess dietary phosphate or oxalate in ADPKD progression.
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Affiliation(s)
- Sol Carriazo
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, 28040 Madrid, Spain
- Red de Investigación Renal (REDINREN), 28029 Madrid, Spain
| | - Maria Vanessa Perez-Gomez
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, 28040 Madrid, Spain
- Red de Investigación Renal (REDINREN), 28029 Madrid, Spain
| | - Adrian Cordido
- Red de Investigación Renal (REDINREN), 28029 Madrid, Spain
- Grupo de Genética y Biología del Desarrollo de las Enfermedades Renales, Laboratorio de Nefrología (n.°11), Instituto de Investigación Sanitaria (IDIS), Complexo Hospitalario de Santiago de Compostela (CHUS), 15706 Santiago de Compostela, Spain
| | - Miguel Angel García-González
- Red de Investigación Renal (REDINREN), 28029 Madrid, Spain
- Grupo de Genética y Biología del Desarrollo de las Enfermedades Renales, Laboratorio de Nefrología (n.°11), Instituto de Investigación Sanitaria (IDIS), Complexo Hospitalario de Santiago de Compostela (CHUS), 15706 Santiago de Compostela, Spain
| | - Ana Belen Sanz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, 28040 Madrid, Spain
- Red de Investigación Renal (REDINREN), 28029 Madrid, Spain
| | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, 28040 Madrid, Spain.
- Red de Investigación Renal (REDINREN), 28029 Madrid, Spain.
| | - Maria Dolores Sanchez-Niño
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, 28040 Madrid, Spain.
- Red de Investigación Renal (REDINREN), 28029 Madrid, Spain.
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Fernandez-Fernandez B, Fernandez-Prado R, Górriz JL, Martinez-Castelao A, Navarro-González JF, Porrini E, Soler MJ, Ortiz A. Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation and Study of Diabetic Nephropathy with Atrasentan: what was learned about the treatment of diabetic kidney disease with canagliflozin and atrasentan? Clin Kidney J 2019; 12:313-321. [PMID: 31198532 PMCID: PMC6543971 DOI: 10.1093/ckj/sfz070] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Indexed: 12/11/2022] Open
Abstract
In April 2019, two major Phase 3 randomized clinical trials were published that assessed primary renal outcomes in diabetic kidney disease (DKD) in type 2 diabetes mellitus (T2DM). The Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE) tested an already available antidiabetic drug, canagliflozin, and the Study of Diabetic Nephropathy with Atrasentan (SONAR) tested a novel molecule, the endothelin-1 receptor blocker atrasentan, both on top of renin-angiotensin system blockade. Both trials demonstrated significant nephroprotection in patients with overt DKD (albuminuria >300 mg/g urinary creatinine) for combined primary endpoints of end-stage kidney disease (ESKD), doubling of serum creatinine or death from renal or cardiovascular causes in CREDENCE {hazard ratio [HR] 0.70 [95% confidence interval (CI) 0.59-0.82]} and ESKD and doubling of serum creatinine in SONAR [HR 0.65 (95% CI 0.49-0.88)]. Canagliflozin also decreased the secondary renal endpoint ESKD, doubling of serum creatinine or renal death [HR 0.66 (95% CI 0.53-0.81)], which was similar in nature and impact to the primary endpoint in SONAR. In addition, canagliflozin decreased a secondary endpoint of cardiovascular death or hospitalization for heart failure [HR 0.69 (95% CI 0.57-0.83)], whereas atrasentan had no significant impact on a secondary cardiovascular composite endpoint or on hospital admissions for heart failure and, despite restrictive exclusion criteria, there was a non-significant trend towards more frequent episodes of heart failure. Based on these results, canagliflozin will likely be approved for the indication of treating DKD in T2DM and the estimated glomerular filtration rate threshold for prescribing it will be lifted, whereas the future and place of atrasentan in the treatment of DKD remain unclear.
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Affiliation(s)
- Beatriz Fernandez-Fernandez
- IIS-Fundacion Jimenez Diaz UAM and School of Medicine, UAM, Madrid, Spain
- REDINREN, Madrid, Spain
- GEENDIAB, Barcelona, Spain
| | - Raul Fernandez-Prado
- IIS-Fundacion Jimenez Diaz UAM and School of Medicine, UAM, Madrid, Spain
- REDINREN, Madrid, Spain
- GEENDIAB, Barcelona, Spain
| | - Jose Luis Górriz
- GEENDIAB, Barcelona, Spain
- Hospital Clínico Universitario, Universitat de Valencia-INCLIVA, Valencia, Spain
| | | | - Juan F Navarro-González
- GEENDIAB, Barcelona, Spain
- Unidad de Investigación y Servicio de Nefrología, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Esteban Porrini
- GEENDIAB, Barcelona, Spain
- Instituto de Tecnologías Biomédicas, Hospital Universitario de Canarias, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - María José Soler
- GEENDIAB, Barcelona, Spain
- Nephrology Department, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Nephrology Research Group, Vall d’Hebron Research Institute, Barcelona, Spain
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz UAM and School of Medicine, UAM, Madrid, Spain
- REDINREN, Madrid, Spain
- GEENDIAB, Barcelona, Spain
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