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Wang Q, Ren D, Li Y, Xu G. Klotho attenuates diabetic nephropathy in db/db mice and ameliorates high glucose-induced injury of human renal glomerular endothelial cells. Cell Cycle 2019; 18:696-707. [PMID: 30784349 DOI: 10.1080/15384101.2019.1580495] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Glomerular endothelial cell injury plays an important role in the development and progression of diabetic nephropathy (DN). The expression and function of klotho in glomerular endothelial cells remain unclear. Thus, this study aimed to investigate the expression and the functional role of klotho in DN progression in mice and in high glucose (HG)-induced cell injury of human renal glomerular endothelial cells (HRGECs) and the underlying mechanism. In this study, HRGECs were cultured with media containing HG to induce endothelial cell injury and db/db mice were used as DN model mice. Klotho was overexpressed or knocked down in HRECs to evaluate its role in HG-induced HRGECs injury. klotho-overexpressing adenovirus (rAAV-klotho) was injected into db/db mice via the tail vein to further validate the protective effect of klotho in DN. Decreased klotho expression was observed in DN patients, DN mice, and HG-exposed HRGECs. Furthermore, klotho overexpression significantly abolished the HG-induced HRGECs injury and activation of Wnt/β-catenin pathway and RAAS. In contrast, klotho knockdown exerted the opposite effects. Moreover, klotho attenuated diabetic nephropathy in db/db mice, which was also associated with inhibition of the Wnt/β-catenin pathway and RAAS. In conclusion, klotho attenuates DN in db/db mice and ameliorates HG-induced injury of HRGECs.
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Affiliation(s)
- Qi Wang
- a Department of Nephrology , the Second Affiliated Hospital of Nanchang University , Nanchang , China
| | - Daijin Ren
- a Department of Nephrology , the Second Affiliated Hospital of Nanchang University , Nanchang , China
| | - Yebei Li
- a Department of Nephrology , the Second Affiliated Hospital of Nanchang University , Nanchang , China
| | - Gaosi Xu
- a Department of Nephrology , the Second Affiliated Hospital of Nanchang University , Nanchang , China
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Trachtman H, Nelson P, Adler S, Campbell KN, Chaudhuri A, Derebail VK, Gambaro G, Gesualdo L, Gipson DS, Hogan J, Lieberman K, Marder B, Meyers KE, Mustafa E, Radhakrishnan J, Srivastava T, Stepanians M, Tesar V, Zhdanova O, Komers R. DUET: A Phase 2 Study Evaluating the Efficacy and Safety of Sparsentan in Patients with FSGS. J Am Soc Nephrol 2018; 29:2745-2754. [PMID: 30361325 PMCID: PMC6218860 DOI: 10.1681/asn.2018010091] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 09/03/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND We evaluated and compared the effects of sparsentan, a dual endothelin type A (ETA) and angiotensin II type 1 receptor antagonist, with those of the angiotensin II type 1 receptor antagonist irbesartan in patients with primary FSGS. METHODS In this phase 2, randomized, double-blind, active-control Efficacy and Safety of Sparsentan (RE-021), a Dual Endothelin Receptor and Angiotensin Receptor Blocker, in Patients with Focal Segmental Glomerulosclerosis (FSGS): A Randomized, Double-blind, Active-Control, Dose-Escalation Study (DUET), patients aged 8-75 years with biopsy-proven FSGS, eGFR>30 ml/min per 1.73 m2, and urinary protein-to-creatinine ratio (UP/C) ≥1.0 g/g received sparsentan (200, 400, or 800 mg/d) or irbesartan (300 mg/d) for 8 weeks, followed by open-label sparsentan only. End points at week 8 were reduction from baseline in UP/C (primary) and proportion of patients achieving FSGS partial remission end point (FPRE) (UP/C: ≤1.5 g/g and >40% reduction [secondary]). RESULTS Of 109 patients randomized, 96 received study drugs and had baseline and week 8 UP/C measurements. Sparsentan-treated patients had greater reductions in UP/C than irbesartan-treated patients did when all doses (45% versus 19%; P=0.006) or the 400 and 800 mg doses (47% versus 19%; P=0.01) were pooled for analysis. The FSGS partial remission end point was achieved in 28% of sparsentan-treated and 9% of irbesartan-treated patients (P=0.04). After 8 weeks of treatment, BP was reduced with sparsentan but not irbesartan, and eGFR was stable with both treatments. Overall, the incidence of adverse events was similar between groups. Hypotension and edema were more common among sparsentan-treated patients but did not result in study withdrawals. CONCLUSIONS Patients with FSGS achieved significantly greater reductions in proteinuria after 8 weeks of sparsentan versus irbesartan. Sparsentan was safe and well tolerated.
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Affiliation(s)
- Howard Trachtman
- Division of Pediatric Nephrology, Department of Pediatrics, New York University School of Medicine, Langone Medical Center, New York, New York;
| | - Peter Nelson
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, Washington
| | - Sharon Adler
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - Kirk N Campbell
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Abanti Chaudhuri
- Division of Pediatric Nephrology, Stanford University, Palo Alto, California
| | - Vimal Kumar Derebail
- Division of Nephrology and Hypertension, University of North Carolina Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Giovanni Gambaro
- Division of Nephrology and Dialysis, Università Cattolica del Sacro Cuore, Fondazione Policlinico A. Gemelli, Rome, Italy
| | - Loreto Gesualdo
- Nephrology Unit, Department of Emergency and Organ Transplantation (DETO), Azienda Ospedaliero Universitaria Policlinico di Bari, Bari, Italy
| | - Debbie S Gipson
- Division of Pediatric Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Jonathan Hogan
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kenneth Lieberman
- Department of Pediatric Nephrology, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack, New Jersey
- Seton Hall-Hackensack Meridian School of Medicine, Hackensack, New Jersey
| | - Brad Marder
- Division of Transplant Research, Colorado Kidney Care, Denver, Colorado
| | - Kevin Edward Meyers
- Division of Nephrology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Esmat Mustafa
- Department of Nephrology and Research Division, Arizona Kidney Disease and Hypertension Center, Phoenix, Arizona
| | | | - Tarak Srivastava
- Children's Mercy Hospital, Kansas City, Missouri
- University of Missouri School of Medicine, Kansas City, Missouri
| | | | - Vladimír Tesar
- Department of Nephrology, Charles University, Prague, Czech Republic
- General University Hospital, Prague, Czech Republic
| | - Olga Zhdanova
- Division of Nephrology, New York University School of Medicine, New York, New York; and
| | - Radko Komers
- Department of Research & Development, Retrophin, Inc., San Diego, California
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Vaněčková I, Hojná S, Kadlecová M, Vernerová Z, Kopkan L, Červenka L, Zicha J. Renoprotective effects of ET(A) receptor antagonists therapy in experimental non-diabetic chronic kidney disease: Is there still hope for the future? Physiol Res 2018; 67:S55-S67. [PMID: 29947528 DOI: 10.33549/physiolres.933898] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Chronic kidney disease (CKD) is a life-threatening disease arising as a frequent complication of diabetes, obesity and hypertension. Since it is typically undetected for long periods, it often progresses to end-stage renal disease. CKD is characterized by the development of progressive glomerulosclerosis, interstitial fibrosis and tubular atrophy along with a decreased glomerular filtration rate. This is associated with podocyte injury and a progressive rise in proteinuria. As endothelin-1 (ET-1) through the activation of endothelin receptor type A (ET(A)) promotes renal cell injury, inflammation, and fibrosis which finally lead to proteinuria, it is not surprising that ET(A) receptors antagonists have been proven to have beneficial renoprotective effects in both experimental and clinical studies in diabetic and non-diabetic CKD. Unfortunately, fluid retention encountered in large clinical trials in diabetic CKD led to the termination of these studies. Therefore, several advances, including the synthesis of new antagonists with enhanced pharmacological activity, the use of lower doses of ET antagonists, the addition of diuretics, plus simply searching for distinct pathological states to be treated, are promising targets for future experimental studies. In support of these approaches, our group demonstrated in adult subtotally nephrectomized Ren-2 transgenic rats that the addition of a diuretic on top of renin-angiotensin and ET(A) blockade led to a further decrease of proteinuria. This effect was independent of blood pressure which was normalized in all treated groups. Recent data in non-diabetic CKD, therefore, indicate a new potential for ET(A) antagonists, at least under certain pathological conditions.
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Affiliation(s)
- I Vaněčková
- Institute of Physiology of the Czech Academy of Sciences, Prague, Czech Republic.
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Synergistic effect of renalase and chronic kidney disease on endothelin-1 in patients with coronary artery disease ‒ a cross-sectional study. Sci Rep 2018; 8:7378. [PMID: 29743680 PMCID: PMC5943599 DOI: 10.1038/s41598-018-25763-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 04/27/2018] [Indexed: 12/30/2022] Open
Abstract
Endothelin-1 (ET-1) is associated with endothelial dysfunction and vasoconstriction. Increased circulating ET-1 levels are associated with long-term cardiovascular mortality. Renalase, released from kidney, metabolizes catecholamines and regulates blood pressure. An increase in circulating renalase levels has been reported in patients with chronic kidney disease (CKD) and is associated with coronary artery disease (CAD). We hypothesized the existence of a synergistic effect of serum renalase levels and CKD on ET-1 levels in patients with CAD. We evaluated 342 non-diabetic patients with established CAD. ET-1 and renalase levels were measured in all patients after an overnight fast. Patients with CKD had higher ET-1 (1.95 ± 0.77 vs. 1.62 ± 0.76 pg/ml, P < 0.001) and renalase levels (46.8 ± 17.1 vs. 33.9 ± 9.9 ng/ml, P < 0.001) than patients without CKD. Patients with both CKD and high renalase levels (>the median of 36.2 ng/ml) exhibited the highest serum ET-1 (P value for the trend <0.001). According to multivariate linear regression analysis, the combination of high serum renalase levels with CKD was a significant risk factor for increased serum ET-1 levels (regression coefficient = 0.297, 95% confidence interval = 0.063‒0.531, P = 0.013). In conclusion, our data suggest a synergistic effect of high serum renalase levels and CKD on increases in ET-1 levels in patients with established CAD.
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Elbarbary NS, Ismail EAR, El-Naggar AR, Hamouda MH, El-Hamamsy M. The effect of 12 weeks carnosine supplementation on renal functional integrity and oxidative stress in pediatric patients with diabetic nephropathy: a randomized placebo-controlled trial. Pediatr Diabetes 2018; 19:470-477. [PMID: 28744992 DOI: 10.1111/pedi.12564] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 06/16/2017] [Accepted: 06/27/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Oxidative stress is a significant contributor to the pathogenesis of diabetic nephropathy. Carnosine is a natural radical oxygen species scavenger. We investigated the effect of carnosine as an adjuvant therapy on urinary albumin excretion (UAE), the tubular damage marker alpha 1-microglobulin (A1M), and oxidative stress in pediatric patients with type 1 diabetes and nephropathy. METHODS This randomized placebo-controlled trial included 90 patients with diabetic nephropathy, despite oral angiotensin-converting enzyme inhibitors (ACE-Is), who were randomly assigned to receive either 12 weeks of carnosine 1 g/day (n = 45), or matching placebo (n = 45). Both groups were followed-up with assessment of hemoglobin A1c (HbA1c), UAE, A1M, total antioxidant capacity (TAC) and malondialdhyde (MDA). RESULTS Baseline clinical and laboratory parameters were consistent between carnosine and placebo groups (P > .05). After 12 weeks, carnosine treatment resulted in significant decrease of HbA1c (8.2 ± 2.1% vs 7.4 ± 1.3%), UAE (91.7 vs 38.5 mg/g creatinine), A1M (16.5 ± 6.8 mg/L vs 9.3 ± 6.6 mg/L), MDA levels (25.5 ± 8.1 vs 18.2 ± 7.7 nmol/mL) while TAC levels were increased compared with baseline levels (P < .001) and compared with placebo (P < .001). No adverse reactions due to carnosine supplementation were reported. Baseline TAC was inversely correlated to HbA1c (r = -0.58, P = .04) and A1M (r = -0.682, P = .015) among carnosine group. CONCLUSIONS Oral supplementation with L-Carnosine for 12 weeks resulted in a significant improvement of oxidative stress, glycemic control and renal function. Thus, carnosine could be a safe and effective strategy for treatment of pediatric patients with diabetic nephropathy.
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Affiliation(s)
| | | | - Abdel Rahman El-Naggar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Modern technology and Information University, Cairo, Egypt
| | - Mahitab Hany Hamouda
- Department of Clinical Pharmacy, Faculty of Pharmacy, Modern technology and Information University, Cairo, Egypt
| | - Manal El-Hamamsy
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
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Yu SMW, Bonventre JV. Acute Kidney Injury and Progression of Diabetic Kidney Disease. Adv Chronic Kidney Dis 2018; 25:166-180. [PMID: 29580581 DOI: 10.1053/j.ackd.2017.12.005] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/15/2017] [Accepted: 12/22/2017] [Indexed: 12/23/2022]
Abstract
Diabetic kidney disease, commonly termed diabetic nephropathy (DN), is the most common cause of end-stage kidney disease (ESKD) worldwide. The characteristic histopathology of DN includes glomerular basement membrane thickening, mesangial expansion, nodular glomerular sclerosis, and tubulointerstitial fibrosis. Diabetes is associated with a number of metabolic derangements, such as reactive oxygen species overproduction, hypoxic state, mitochondrial dysfunction, and inflammation. In the past few decades, our knowledge of DN has advanced considerably although much needs to be learned. The traditional paradigm of glomerulus-centered pathophysiology has expanded to the tubule-interstitium, the immune response and inflammation. Biomarkers of proximal tubule injury have been shown to correlate with DN progression, independent of traditional glomerular injury biomarkers such as albuminuria. In this review, we summarize mechanisms of increased susceptibility to acute kidney injury in diabetes mellitus and the roles played by many kidney cell types to facilitate maladaptive responses leading to chronic and end-stage kidney disease.
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Weng SC, Wu CL, Kor CT, Chiu PF, Wu MJ, Chang CC, Tarng DC. Migraine and subsequent chronic kidney disease risk: a nationwide population-based cohort study. BMJ Open 2017; 7:e018483. [PMID: 29284721 PMCID: PMC5770945 DOI: 10.1136/bmjopen-2017-018483] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE We compared the incidence and risk of chronic kidney disease (CKD) between subjects with new-onset migraine and matched controls without migraine in this large-scale retrospective cohort study. DESIGN Population-based cohort study. SETTING 8880 subjects with migraine and 503 070 subjects without migraine were enrolled between January 1, 2000 and December 31, 2013, all diagnosed to be without kidney disease. All the participants were registered in the National Health Insurance Research Database. PARTICIPANTS Finally, data from 7156 subjects with migraine and 7156 propensity-score-matched control subjects were analysed. PRIMARY OUTCOME MEASURE We used Cox proportional hazards regression to estimate adjusted HRs for incident CKD; subgroup analyses were performed to assess the interactive effects of migraine with demographics, comorbidities and long-term medications. RESULTS The incidence of CKD was higher in the migraine group than in the control group. The risk of developing CKD was significantly higher in subjects with migraine than without migraine (P=0.031). Subjects with migraine aged <65 years (age 40-64 (adjusted HR (aHR) 1.35; 95% CI 1.05 to 1.73); age <40 (aHR 1.55; 95% CI 1.02 to 2.36)), with ≥1 comorbid diseases (1-2 diseases (aHR 1.30; 95% CI 1.01 to 1.68); ≥3 diseases (aHR 1.45; 95% CI 1.01 to 2.07)), and not receiving anti-migraine agents (aHR 1.26; 95% CI 1.04 to 1.54) were at a higher risk of developing CKD compared with the control subjects. The interaction between migraine and comorbidities was not significant; age, male gender and long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) were independent risk factors for CKD in subjects with migraine. CONCLUSION Migraine may be an independent risk factor for CKD. Young subjects with migraine, and those with comorbid conditions or without medical control, are likely to be at higher risk for CKD. Ageing, male sex and NSAIDs tend to have an association with CKD in subjects with migraine.
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Affiliation(s)
- Shuo-Chun Weng
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Internal Medicine, Center for Geriatrics and Gerontology, Division of Nephrology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chia-Lin Wu
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Internal Medicine, Division of Nephrology, Changhua Christian Hospital, Changhua, Taiwan
- School of Medicine, Chung-Shan Medical University, Taichung, Taiwan
- Internal Medicine Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Chew-Teng Kor
- Internal Medicine Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Ping-Fang Chiu
- Department of Internal Medicine, Division of Nephrology, Changhua Christian Hospital, Changhua, Taiwan
- School of Medicine, Chung-Shan Medical University, Taichung, Taiwan
- Internal Medicine Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Ming-Ju Wu
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Internal Medicine, Center for Geriatrics and Gerontology, Division of Nephrology, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, Chung-Shan Medical University, Taichung, Taiwan
| | - Chia-Chu Chang
- Department of Internal Medicine, Division of Nephrology, Changhua Christian Hospital, Changhua, Taiwan
- School of Medicine, Chung-Shan Medical University, Taichung, Taiwan
- Internal Medicine Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Der-Cherng Tarng
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Department and Institute of Physiology, National Yang-Ming University, Taipei, Taiwan
- Department of Medicine, Division of Nephrology, Taipei Veterans General Hospital, Taipei, Taiwan
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Alrashdi SF, Deliyanti D, Talia DM, Wilkinson-Berka JL. Endothelin-2 Injures the Blood-Retinal Barrier and Macroglial Müller Cells: Interactions with Angiotensin II, Aldosterone, and NADPH Oxidase. THE AMERICAN JOURNAL OF PATHOLOGY 2017; 188:805-817. [PMID: 29248456 DOI: 10.1016/j.ajpath.2017.11.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 10/20/2017] [Accepted: 11/07/2017] [Indexed: 02/07/2023]
Abstract
Although increasing evidence indicates that endothelin-2 (Edn2) has distinct roles in tissue pathology, including inflammation, glial cell dysfunction, and angiogenesis, its role in the retina and the factors that regulate its actions are not fully understood. We hypothesized that Edn2 damages the blood-retinal barrier (BRB) and that this is mediated by interactions with the renin-angiotensin-aldosterone system and reactive oxygen species derived from NADPH oxidase (Nox). C57BL/6J mice received an intravitreal injection of Edn2 or control vehicle to examine the blood pressure-independent effects of Edn2. Mice administered Edn2 were randomized to receive by intraperitoneal injection treatments that inhibited the Edn type a receptor, Edn type b receptor, angiotensin type 1 receptor, mineralocorticoid receptor, or Nox isoforms 1 to 4. One month later, mice administered Edn2 exhibited breakdown of the BRB with increased vascular leakage, vascular endothelial growth factor expression, and infiltrating macrophages (Ly6C+CD45highCD11b+). Further, macroglial Müller cells, which influence the integrity of the BRB and prevent retinal edema, became gliotic and expressed increased levels of water (aquaporin-4) and ion (Kir4.1) channels. This Edn2-mediated retinopathy was reduced by all treatments. Complementary in vitro studies in cultured Müller cells supported these findings and demonstrated the importance of reactive oxygen species in mediating these events. In conclusion, Edn2 has detrimental effects on the BRB and Müller cells that involve interactions with the renin-angiotensin aldosterone system and Nox1/4.
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Affiliation(s)
- Saeed F Alrashdi
- Department of Diabetes, Monash University, Melbourne, Victoria, Australia
| | - Devy Deliyanti
- Department of Diabetes, Monash University, Melbourne, Victoria, Australia
| | - Dean M Talia
- Department of Diabetes, Monash University, Melbourne, Victoria, Australia
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Editorial over the Many Faces of Vitamin D in Chronic Kidney Disease: from Mineral to Immune-Inflammatory Modulator. Inflammation 2017; 41:365-367. [PMID: 29177788 DOI: 10.1007/s10753-017-0707-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Egido J, Rojas-Rivera J, Mas S, Ruiz-Ortega M, Sanz AB, Gonzalez Parra E, Gomez-Guerrero C. Atrasentan for the treatment of diabetic nephropathy. Expert Opin Investig Drugs 2017; 26:741-750. [PMID: 28468519 DOI: 10.1080/13543784.2017.1325872] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Endothelin-1 (ET-1) is the most potent vasoconstrictor, and is involved in the renal regulation of salt and water homeostasis. When produced in excess in the kidney, ET-1 promotes proteinuria and tubulointerstitial injury. There is great interest in the clinical use of endothelin receptor antagonists (ERAs) in chronic kidney disease (CKD), mainly in diabetic nephropathy (DN). Areas covered: Physiopathological actions of ET-1 on the kidney. Both dual ETAR/ETBR (bosentan) or ETAR specific endothelin antagonists (avosentan and atrasentan, among others), which have progressed to early clinical development, with particular emphasis on atrasentan. Expert opinion: Different phase I and II clinical trials with ERAs in DN, mostly with atrasentan, have shown that these drugs have a marked anti-proteinuric effect on residual proteinuria when administered as add-on therapy in addition to ACEi or ARAII treatment. In the past few years, a series of randomized controlled trials investigating new approaches to DN have provided negative or inconclusive data, or even were terminated due to safety concerns or lack of efficacy. Therefore, we eagerly but cautiously await the results of the ongoing SONAR trial with atrasentan in more than 4,000 patients including assessment of renal and cardiovascular hard-end points (estimated primary completion date, July 2018).
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Affiliation(s)
- Jesus Egido
- a Division of Nephrology and Hypertension , Madrid , Spain.,b Renal, Vascular and Diabetes Research Laboratory University Hospital Fundacion Jimenez Diaz. Autonoma University (UAM) , Madrid , Spain.,c Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM) , Madrid , Spain.,d FRIAT (Fundacion Renal Iñigo Alvarez de Toledo) , Madrid , Spain
| | | | - Sebastian Mas
- b Renal, Vascular and Diabetes Research Laboratory University Hospital Fundacion Jimenez Diaz. Autonoma University (UAM) , Madrid , Spain.,c Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM) , Madrid , Spain
| | - Marta Ruiz-Ortega
- b Renal, Vascular and Diabetes Research Laboratory University Hospital Fundacion Jimenez Diaz. Autonoma University (UAM) , Madrid , Spain
| | - Ana Belen Sanz
- b Renal, Vascular and Diabetes Research Laboratory University Hospital Fundacion Jimenez Diaz. Autonoma University (UAM) , Madrid , Spain
| | - Emilio Gonzalez Parra
- a Division of Nephrology and Hypertension , Madrid , Spain.,d FRIAT (Fundacion Renal Iñigo Alvarez de Toledo) , Madrid , Spain
| | - Carmen Gomez-Guerrero
- b Renal, Vascular and Diabetes Research Laboratory University Hospital Fundacion Jimenez Diaz. Autonoma University (UAM) , Madrid , Spain.,c Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM) , Madrid , Spain
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George C, Mogueo A, Okpechi I, Echouffo-Tcheugui JB, Kengne AP. Chronic kidney disease in low-income to middle-income countries: the case for increased screening. BMJ Glob Health 2017; 2:e000256. [PMID: 29081996 PMCID: PMC5584488 DOI: 10.1136/bmjgh-2016-000256] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 03/28/2017] [Indexed: 12/23/2022] Open
Abstract
Chronic kidney disease (CKD) is fast becoming a major public health issue, disproportionately burdening low-income to middle-income countries, where detection rates remain low. We critically assessed the extant literature on CKD screening in low-income to middle-income countries. We performed a PubMed search, up to September 2016, for studies on CKD screening in low-income to middle-income countries. Relevant studies were summarised through key questions derived from the Wilson and Jungner criteria. We found that low-income to middle-income countries are ill-equipped to deal with the devastating consequences of CKD, particularly the late stages of the disease. There are acceptable and relatively simple tools that can aid CKD screening in these countries. Screening should primarily include high-risk individuals (those with hypertension, type 2 diabetes, HIV infection or aged >60 years), but also extend to those with suboptimal levels of risk (eg, prediabetes and prehypertension). Since screening for hypertension, type 2 diabetes and HIV infection is already included in clinical practice guidelines in resource-poor settings, it is conceivable to couple this with simple CKD screening tests. Effective implementation of CKD screening remains a challenge, and the cost-effectiveness of such an undertaking largely remains to be explored. In conclusion, for many compelling reasons, screening for CKD should be a policy priority in low-income to middle-income countries, as early intervention is likely to be effective in reducing the high burden of morbidity and mortality from CKD. This will help health systems to achieve cost-effective prevention.
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Affiliation(s)
- Cindy George
- Non-Communicable Disease Research Unit, South African Medical Research Council, Parow, Cape Town, South Africa
| | - Amelie Mogueo
- Department of Management, Assessment and Health Policy, School of Public Health, The University of Montreal, Montreal, Canada
| | - Ikechi Okpechi
- Division of Nephrology and Hypertension, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | | | - Andre Pascal Kengne
- Non-Communicable Disease Research Unit, South African Medical Research Council, Parow, Cape Town, South Africa
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Efficacy and Safety of Sparsentan Compared With Irbesartan in Patients With Primary Focal Segmental Glomerulosclerosis: Randomized, Controlled Trial Design (DUET). Kidney Int Rep 2017; 2:654-664. [PMID: 29142983 PMCID: PMC5678638 DOI: 10.1016/j.ekir.2017.02.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/05/2017] [Accepted: 02/27/2017] [Indexed: 11/25/2022] Open
Abstract
Introduction Primary focal segmental glomerulosclerosis (FSGS) is a leading cause of nephrotic syndrome and end-stage renal disease. There are no US Food and Drug Administration−approved therapies for FSGS, and treatment often fails to reduce proteinuria. Endothelin is an important factor in the pathophysiology of podocyte disorders, including FSGS. Sparsentan is a first-in-class, orally active, dual-acting angiotensin receptor blocker (ARB) and highly selective endothelin Type A receptor antagonist. This study is designed to evaluate whether sparsentan lowers proteinuria compared with an ARB alone and has a favorable safety profile in patients with FSGS. Methods DUET is a phase 2, randomized, active-control, dose-escalation study with an 8-week, fixed-dose, double-blind period followed by 136 weeks of open-label sparsentan treatment. Patients aged 8 to 75 years with primary FSGS will be randomized to treatment with sparsentan or irbesartan for 8 weeks. Results The primary efficacy objective is to test the hypothesis that sparsentan over the dose range (200 mg, 400 mg, or 800 mg daily) is superior to irbesartan (300 mg daily) in decreasing the urinary protein-to-creatinine ratio (UPC) from baseline to 8 weeks postrandomization. As secondary objectives, the trial will evaluate the proportion of patients who achieve prespecified targets of UPC reduction, changes in laboratory and quality-of-life indices, and detailed safety analysis. Analyses will be conducted at the end of the double-blind (week 8) and open-label (week 144) periods. Discussion This study will provide important evidence on whether dual ARB and endothelin blockade may be an effective therapeutic strategy for FSGS and may provide the rationale for next-phase trials.
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Scheen AJ, Delanaye P. Effects of reducing blood pressure on renal outcomes in patients with type 2 diabetes: Focus on SGLT2 inhibitors and EMPA-REG OUTCOME. DIABETES & METABOLISM 2017; 43:99-109. [PMID: 28153377 DOI: 10.1016/j.diabet.2016.12.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/16/2016] [Accepted: 12/19/2016] [Indexed: 12/13/2022]
Abstract
Empagliflozin, a sodium-glucose cotransporter type 2 (SGLT2) inhibitor, has enabled remarkable reductions in cardiovascular and all-cause mortality as well as in renal outcomes in patients with type 2 diabetes (T2D) and a history of cardiovascular disease in the EMPA-REG OUTCOME. These results have been attributed to haemodynamic rather than metabolic effects, in part due to the osmotic/diuretic action of empagliflozin and the reduction in arterial blood pressure (BP). The present narrative review includes the results of meta-analyses of trials evaluating the effects on renal outcomes of lowering BP in patients with T2D, with a special focus on the influence of baseline and achieved systolic BP, and compares the renal outcome results of the EMPA-REG OUTCOME with those of other major trials with inhibitors of the renin-angiotensin system in patients with T2D and the preliminary findings with other SGLT2 inhibitors, and also evaluates post hoc analyses from the EMPA-REG OUTCOME of special interest as regards the BP-lowering hypothesis and renal function. While systemic BP reduction associated to empagliflozin therapy may have contributed to the renal benefits reported in EMPA-REG OUTCOME, other local mechanisms related to kidney homoeostasis most probably also played a role in the overall protection observed in the trial.
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Affiliation(s)
- A J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium; Clinical Pharmacology Unit, CHU Liège, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
| | - P Delanaye
- Division of Nephrology, Dialysis, Transplantation and Hypertension, Department of Medicine, CHU Liège (ULg-CHU), Liège, Belgium
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Yang P, Huang T, Xu G. The novel mineralocorticoid receptor antagonist finerenone in diabetic kidney disease: Progress and challenges. Metabolism 2016; 65:1342-9. [PMID: 27506741 DOI: 10.1016/j.metabol.2016.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 05/24/2016] [Accepted: 06/03/2016] [Indexed: 12/26/2022]
Affiliation(s)
- Pingping Yang
- Medical Center of the Graduate School, Nanchang University, China; Department of Nephrology, the Second Affiliated Hospital of Nanchang University, China
| | - Tianlun Huang
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, China
| | - Gaosi Xu
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, China.
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