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Volpe M, Pontremoli R, Borghi C. Direct renin inhibition: from pharmacological innovation to novel therapeutic opportunities. High Blood Press Cardiovasc Prev 2012; 18:93-105. [PMID: 21950781 DOI: 10.2165/11593540-000000000-00000] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Nowadays, social and economic burden related to cardiovascular and renal diseases still remains extremely high, although there has been a dramatic improvement of diagnostic options and therapeutic strategies reported in the last 30 years. The progressively higher attention towards integrated pharmacological strategies, which are able to interfere with different pathophysiological mechanisms, has certainly led to better control of cardiovascular and renal diseases. In view of the large involvement of the renin-angiotensin system (RAS) in the vast majority of pathophysiological mechanisms leading to the development and progression of cardiovascular and renal diseases, it can be easily understood why it has been long viewed as the 'ideal' target for the pharmacological treatment of several clinical conditions. Recently, besides the well known therapeutic approaches for RAS blockade, based on the use of ACE inhibitors, angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) and aldosterone antagonists, both the scientific and medical community have focused their attention on a novel therapeutic option. In 2007, aliskiren, the first compound of a new drug class, the direct renin inhibitors (DRIs), has become available for clinical use, being a novel and innovative therapeutic option. Aliskiren is able to interfere with the enzymatic activity of renin by blocking the catalytic site of the molecule and inducing an 'upstream' RAS blockade. This leads to a modulation of the biological properties of renin, thus resulting in the missed cleavage of angiotensinogen to angiotensin I. Aliskiren has demonstrated antihypertensive efficacy comparable or even superior to that of other classes of antihypertensive drugs, both in monotherapy and in combination therapies. Its safety and tolerability are comparable with those of other antihypertensive drug classes and almost similar to placebo. In addition, it has been demonstrated to reduce progression of cardiac and renal organ damage in addition to ACE inhibitors or ARBs. An ambitious and large clinical trial programme specifically designed for this innovative antihypertensive drug will evaluate the efficacy of aliskiren in terms of reduced incidence of major cardiovascular and renal outcomes in patients with hypertension and cardiovascular disease, besides the use of optimal (standard) therapeutic strategies, including ACE inhibitors and ARBs.
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Affiliation(s)
- Massimo Volpe
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine, University of Rome "Sapienza", Sant'Andrea Hospital, Italy.
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Drummond W, Sirenko YM, Ramos E, Baek I, Keefe DL. Aliskiren as add-on therapy in the treatment of hypertensive diabetic patients inadequately controlled with valsartan/HCT combination: a placebo-controlled study. Am J Cardiovasc Drugs 2012; 11:327-33. [PMID: 21846154 DOI: 10.2165/11591970-000000000-00000] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Hypertension frequently coexists with diabetes mellitus, resulting in increased cardiovascular risk. Thus, BP control is crucial in decreasing morbidity and mortality in this difficult-to-treat patient population. OBJECTIVE The objective of this study was to evaluate the efficacy and safety of aliskiren in hypertensive patients with diabetes not adequately responsive to the combination of valsartan and hydrochlorothiazide (HCT). METHODS After a 1- to 4-week washout period, patients with a mean sitting diastolic BP (msDBP) ≥95 mmHg were treated with valsartan 160 mg for 2 weeks followed by valsartan/HCT 160 mg/25 mg for an additional 4 weeks (single-blind active run-in period). Patients whose msDBP remained ≥85 mmHg after the active run-in period were randomized (1 : 1) to receive aliskiren 150 mg (n = 184) or placebo (n = 179) as add-on therapy for 6 weeks. Aliskiren was then force-titrated to 300 mg once daily for another 6 weeks. Efficacy variables were: the change in msDBP and mean sitting systolic BP (msSBP) from baseline to week 12 endpoint, diastolic response (msDBP <80 mmHg or reduction of at least 10 mmHg), and BP control rate (<130/80 mmHg). RESULTS Of the 363 patients randomized, 328 (90.4%) completed the study (aliskiren and placebo groups: 89.7% and 91.1%, respectively). At week 12 endpoint, the least squares mean (LSM) changes in msDBP (aliskiren vs placebo: -5.8 vs -4.8 mmHg; p = 0.2767) and msSBP (aliskiren vs placebo: -7.3 vs -4.8 mmHg; p = 0.0725) were numerically greater in patients treated with aliskiren compared with those treated with placebo; however, this difference was not statistically significant. The proportion of diastolic responders (aliskiren and placebo: 68.5% and 72.9%, respectively; p = 0.8482) and patients achieving BP control (aliskiren and placebo: 16.0% and 16.4%, respectively; p = 0.7511) were similar for both groups. Overall, 63 (34%) and 59 (33%) patients in the aliskiren and placebo groups, respectively, experienced adverse events (AEs). The most commonly reported AEs were headache (placebo group: 6.1%) and dizziness (aliskiren group: 4.4%). Aliskiren was well tolerated. CONCLUSION The reductions in BP with aliskiren added to valsartan/HCT in this study were numerically greater compared with placebo added to valsartan/HCT, although not statistically significant.
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Affiliation(s)
- W Drummond
- Renaissance Clinical Research and Hypertension Center, Dallas, TX, USA.
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Zhang Y, Wang Y, Chen Y, K. Deb D, Sun T, Zhao Q, Chun Li Y. Inhibition of renin activity by aliskiren ameliorates diabetic nephropathy in type 1 diabetes mouse model. ACTA ACUST UNITED AC 2012. [DOI: 10.4236/jdm.2012.23055] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Wu Y, Shi C, Sun X, Wu X, Sun H. Synthesis, biological evaluation and docking studies of octane-carboxamide based renin inhibitors with extended segments toward S3′ site of renin. Bioorg Med Chem 2011; 19:4238-49. [DOI: 10.1016/j.bmc.2011.05.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 05/26/2011] [Accepted: 05/27/2011] [Indexed: 10/18/2022]
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De Nicola L, Zamboli P, Bellizzi V, Stanzione G, Russo D, Nappi F, Minco M, Chiodini P, Conte G, Minutolo R. Antiproteinuric response to add-on aliskiren in proteinuric patients treated with dual blockade of the renin-angiotensin system: a 12-month prospective uncontrolled study. Am J Kidney Dis 2011; 57:961-3. [PMID: 21507536 DOI: 10.1053/j.ajkd.2011.02.384] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 02/09/2011] [Indexed: 11/11/2022]
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56
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Ohara I, Tanimoto M, Gohda T, Yamazaki T, Hagiwara S, Murakoshi M, Aoki T, Toyoda H, Ishikawa Y, Funabiki K, Horikoshi S, Tomino Y. Effect of Combination Therapy with Angiotensin Receptor Blocker and 1,25-Dihydroxyvitamin D3 in Type 2 Diabetic Nephropathy in KK-Ay/Ta Mice. ACTA ACUST UNITED AC 2011; 117:e124-32. [DOI: 10.1159/000320284] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Accepted: 08/12/2010] [Indexed: 11/19/2022]
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Identification of a new biaryl scaffold generating potent renin inhibitors. Bioorg Med Chem Lett 2010; 20:5822-6. [DOI: 10.1016/j.bmcl.2010.07.127] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Revised: 07/27/2010] [Accepted: 07/28/2010] [Indexed: 11/23/2022]
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58
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Rabbia F, Testa E, Totaro S, Leotta G, Berra E, Covella M, Milazzo V, Di Stefano C, Veglio F. Effects of Antihypertensive Drugs on the Renin-Angiotensin System in Essential Hypertension. High Blood Press Cardiovasc Prev 2010. [DOI: 10.2165/11311870-000000000-00000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Webb RL, Schiering N, Sedrani R, Maibaum J. Direct Renin Inhibitors as a New Therapy for Hypertension. J Med Chem 2010; 53:7490-520. [DOI: 10.1021/jm901885s] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Randy L. Webb
- Novartis Pharmaceuticals Corp., Institutes for BioMedical Research, East Hanover, New Jersey
| | - Nikolaus Schiering
- Novartis Pharma AG, Institutes for BioMedical Research, Novartis Campus, CH-4056 Basel, Switzerland
| | - Richard Sedrani
- Novartis Pharma AG, Institutes for BioMedical Research, Novartis Campus, CH-4056 Basel, Switzerland
| | - Jürgen Maibaum
- Novartis Pharma AG, Institutes for BioMedical Research, Novartis Campus, CH-4056 Basel, Switzerland
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Cagnoni F, Njwe CAN, Zaninelli A, Ricci AR, Daffra D, D'Ospina A, Preti P, Destro M. Blocking the RAAS at different levels: an update on the use of the direct renin inhibitors alone and in combination. Vasc Health Risk Manag 2010; 6:549-59. [PMID: 20730071 PMCID: PMC2922316 DOI: 10.2147/vhrm.s11816] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2010] [Indexed: 01/13/2023] Open
Abstract
The renin–angiotensin–aldosterone system (RAAS), an important regulator of blood pressure and mediator of hypertension-related complications, is a prime target for cardiovascular drug therapy. Angiotensin-converting enzyme inhibitors (ACEIs) were the first drugs to be used to block the RAAS. Angiotensin II receptor blockers (ARBs) have also been shown to be equally effective for treatment. Although these drugs are highly effective and are widely used in the management of hypertension, current treatment regimens with ACEIs and ARBs are unable to completely suppress the RAAS. Combinations of ACEIs and ARBs have been shown to be superior than to either agent alone for some, but certainly not all, composite cardiovascular and kidney outcomes, but dual RAAS blockade with the combination of an ACEI and an ARB is sometimes associated with an increase in the risk for adverse events, primarily hyperkalemia and worsening renal function. The recent introduction of the direct renin inhibitor, aliskiren, has made available new combination strategies to obtain a more complete blockade of the RAAS with fewer adverse events. Renin system blockade with aliskiren and another RAAS agent has been, and still is, the subject of many large-scale clinical trials and furthermore, is already available in some countries as a fixed combination.
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Affiliation(s)
- Francesca Cagnoni
- Internal Medicine, Ospedale Unificato Broni-Stradella, Stradella (PV), Italy.
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Wu WP, Chang CH, Chiu YT, Ku CL, Wen MC, Shu KH, Wu MJ. A reduction of unilateral ureteral obstruction-induced renal fibrosis by a therapy combining valsartan with aliskiren. Am J Physiol Renal Physiol 2010; 299:F929-41. [PMID: 20685818 DOI: 10.1152/ajprenal.00192.2010] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The protective effect of combination therapy with valsartan and aliskiren against renal fibrosis remains to be defined. This study was undertaken to examine the protective effects of the combination of valsartan and aliskiren against renal fibrosis induced by unilateral ureteral obstruction (UUO). Combination therapy with valsartan (15 mg·kg(-1)·day(-1)) and aliskiren (10 mg·kg(-1)·day(-1)), valsartan monotherapy (30 mg·kg(-1)·day(-1)), and aliskiren monotherapy (20 mg·kg(-1)·day(-1)) all significantly ameliorated the increase in blood urea nitrogen and the degree of hydronephrosis determined by the increase in weight and length of the obstructed kidney. The dose titration study and blood pressure measurement confirmed that the combination therapy provided a greater benefit independent of the vasodilatory effect. There were no significant changes in serum levels of creatinine, sodium, and potassium in UUO rats and any treatment groups. Combination therapy also attenuated UUO-related increases in the scores of tubular dilatation, interstitial volume, interstitial collagen deposition, α-smooth muscle actin, the activation of ERK 1/2, the infiltration of monocytes/macrophages, the mRNA expression of snail-1, and transforming growth factor-β1 to a greater extent compared with aliskiren or valsartan used alone. The mRNA expression of renin and the (pro)renin receptor significantly increased after UUO. Combination therapy and monotherapy of valsartan and aliskiren had a comparable enhancing effect on the mRNA expression of renin, whereas all these treatments did not affect the expression of the (pro)renin receptor. In conclusion, a direct renin inhibitor in conjunction with an angiotensin II receptor blocker exerts increased renal protection against renal fibrosis and inflammation during obstruction over either agent alone.
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Affiliation(s)
- Wen-Pyng Wu
- Graduate Institute of Clinical Medical Science, China Medical University, China
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Kong J, Kim GH, Wei M, Sun T, Li G, Liu SQ, Li X, Bhan I, Zhao Q, Thadhani R, Li YC. Therapeutic effects of vitamin D analogs on cardiac hypertrophy in spontaneously hypertensive rats. THE AMERICAN JOURNAL OF PATHOLOGY 2010; 177:622-31. [PMID: 20616348 DOI: 10.2353/ajpath.2010.091292] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Vitamin D inhibits renin expression and blocks the compensatory induction of renin associated with the use of renin-angiotensin system inhibitors. Here we test the therapeutic effects of two commonly used vitamin D analogs and their combination with losartan on the development of left ventricular hypertrophy. One-month-old male spontaneously hypertensive rats were treated with vehicle, losartan, paricalcitol, doxercalciferol, a combination of losartan and paricalcitol, or a combination of losartan and doxercalciferol for 2 months. Blood pressure was markedly reduced by losartan, but not by paricalcitol or doxercalciferol alone. Echocardiograpy demonstrated a 65 to 80% reduction in left ventricular wall thickness with losartan, paricalcitol, or doxercalciferol monotherapy and almost complete prevention of left ventricular hypertrophy with the combination therapies. Attenuation of cardiac and cardiomyocyte hypertrophy, and suppression of atrial and brain natriuretic peptides, were most marked in the combination therapy groups. These changes were well correlated with left ventricular gene and microRNA expression profiles in the different treatment groups. Renal and cardiac renin expression was markedly increased in losartan-treated animals, but nearly normalized with combination therapy. The same vitamin D analogs suppressed plasma renin activity in patients receiving chronic hemodialysis. These data demonstrate that vitamin D analogs have potent antihypertrophic activity in part via suppression of renin in the kidney and heart, and combination of these analogs with losartan achieves much better therapeutic effects because of the blockade of the compensatory renin increase.
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Affiliation(s)
- Juan Kong
- Laboratory of Metabolic Disease Research and Drug Development, Shengjing Hospital, China Medical University, Shenyang, China
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63
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Combined vitamin D analog and AT1 receptor antagonist synergistically block the development of kidney disease in a model of type 2 diabetes. Kidney Int 2010; 77:1000-9. [DOI: 10.1038/ki.2010.22] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ke CY, Lee CC, Lee CJ, Subeq YM, Lee RP, Hsu BG. Aliskiren ameliorates chlorhexidine digluconate-induced peritoneal fibrosis in rats. Eur J Clin Invest 2010; 40:301-9. [PMID: 20486991 DOI: 10.1111/j.1365-2362.2010.02264.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Peritoneal fibrosis (PF) is a recognized complication of long-term peritoneal dialysis (PD) and can lead to ultrafiltration failure. The present study was designed to investigate the protective effects of aliskiren on chlorhexidine digluconate-induced PF in rats. MATERIALS AND METHODS The PF was induced in Sprague-Dawley rats by daily administration of 0.5 mL 0.1% chlorhexidine digluconate in normal saline via PD tube for 1 week. Rats received daily intravenous injections of low-dose aliskiren (1 mg kg(-1)) or high-dose aliskiren (10 mg kg(-1)) for 1 week. After 7 days, conventional 4.25% Dianeal (30 mL) was administered via a PD catheter with a dwell time of 4 h and assessed of peritoneal function. At the end of dialysis, rats were sacrificed and the liver peritoneum was harvested for microscopically and immunohistochemistry. RESULTS There was no significant difference in mean arterial pressure and heart rate between groups. After 4 h of PD, the D(4)/P(4) urea level was reduced, the D(4)/D(0) glucose level, serum and dialysate transforming growth factor-beta1 (TGF-beta1) level was increased, the liver peritoneum was markedly thicker, and the expression of TGF-beta1, alpha-smooth muscle actin (alpha-SMA), fibronectin, collagen, and vascular endothelial growth factor (VEGF) were elevated in the PS group compared with the vehicle group. Aliskiren decreased the serum and dialysate TGF-beta1 level, decreased the thickness of the liver peritoneum, and decreased the expression of TGF-beta1, alpha-SMA, fibronectin, collagen, and VEGF-positive cells in liver peritoneum. Moreover, high-dose aliskiren had better protective effects against PF than low dose in rats. CONCLUSIONS Aliskiren protected against chlorhexidine digluconate-induced PF in rats by decreasing TGF-beta1 production.
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Abstract
Vitamin D analogs may slow the progression of chronic kidney disease. Tan et al. report that paricalcitol has additive effects with an angiotensin-converting enzyme inhibitor (ACEI) in suppressing extracellular matrix expression, interstitial inflammation, and myofibroblast activation in obstructive nephropathy. Paricalcitol inhibited renin transcription, countering the compensatory ACEI-induced rise in renin, thus achieving a more complete blockade of the renin-angiotensin system (RAS). Vitamin D analogs may enhance the renoprotective effects of RAS inhibitors.
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Affiliation(s)
- Min Li
- Section of Nephrology and Hypertension, Department of Medicine, Tulane University School of Medicine, Section of Nephrology and Hypertension, New Orleans, Louisiana 70112, USA.
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Abstract
Inhibition of the renin-angiotensin-aldosterone system (RAAS) plays a pivotal role in preventing and treating diabetic nephropathy. However, despite documented beneficial effects of RAAS inhibitors in diabetic patients with nephropathy, reversal of the progressive course of this disorder or at least long-term stabilization of renal function are often difficult to achieve, and many patients still progress to end-stage renal disease. Incomplete inhibition of the RAAS has been postulated as one of the reasons for unsatisfactory therapeutic responses to RAAS inhibition in some patients. Inhibition of renin, a rate-limiting step in the RAAS activation cascade, is the logical approach to overcome at least some of the above-mentioned problems associated with the treatment with traditional RAAS inhibitors. This article focuses on experimental and clinical studies evaluating the two principal approaches to renin inhibition: direct renin inhibition with competitive inhibitors (eg, aliskiren) and inhibition of the (pro)renin receptor.
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Affiliation(s)
- Radko Komers
- Division of Nephrology and Hypertension, Oregon Health & Science University, Portland, OR 97239-2940, USA.
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67
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Abstract
PURPOSE OF REVIEW To evaluate the evidence supporting the use of renin inhibitors to control hypertension, limit kidney disease progression, and decrease cardiovascular risk in patients with chronic kidney disease (CKD). RECENT FINDINGS The literature on the subject is still limited. Most of the studies have used aliskiren as the study drug. Animal models show improved survival and decreased renal injury in animals receiving aliskiren. Human studies in patients with normal renal function show effective blood pressure control alone or in combination with different agents. There are no studies focusing on blood pressure control in patients with CKD, though the drug has been safely used in CKD. In a randomized clinical trial, aliskiren decreased albuminuria when added to losartan in patients with early diabetic nephropathy. Ongoing studies are evaluating the role of renin inhibitors in the prevention of cardiovascular events and slowing of kidney disease progression in CKD. SUMMARY Renin inhibitors, specifically aliskiren, effectively decrease albuminuria. Their role in improving hard renal endpoints and decreasing cardiovascular events in CKD still remains to be established.
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Tan X, He W, Liu Y. Combination therapy with paricalcitol and trandolapril reduces renal fibrosis in obstructive nephropathy. Kidney Int 2009; 76:1248-57. [PMID: 19759524 DOI: 10.1038/ki.2009.346] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Growing evidence suggests that active vitamin D slows the progression of chronic kidney diseases. Here we compared the individual renal protective efficacy of paricalcitol and trandolapril (an angiotensin-converting enzyme inhibitor) in obstructive nephropathy, and examined any potential additive effects of their combination on attenuating renal fibrosis and inflammation. Mice underwent unilateral ureteral obstruction and were treated individually with paricalcitol or trandolapril or their combination. Compared to vehicle-treated controls, monotherapy with paricalcitol or trandolapril inhibited the expression and accumulation of fibronectin and type I and type III collagen, suppressed alpha-smooth muscle actin, vimentin, and Snail1 expression, and reduced total collagen content in the obstructed kidney. Combination therapy led to a more profound inhibition of all parameters. Monotherapy also suppressed renal RANTES (regulated on activation, normal T cell expressed and secreted) and tumor necrosis factor (TNF)-alpha expression and inhibited renal infiltration of T cells and macrophages, whereas the combination had additive effects. Renin expression was induced in the fibrotic kidney and was augmented by trandolapril. Paricalcitol blocked renin induction in the absence or presence of trandolapril. Our study indicates that paricalcitol has renal protective effects, comparable to that of trandolapril, in reducing interstitial fibrosis and inflammation. Combination therapy had additive efficacy in retarding renal scar formation during obstructive nephropathy.
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Affiliation(s)
- Xiaoyue Tan
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15261, USA
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Zhang Y, Deb DK, Kong J, Ning G, Wang Y, Li G, Chen Y, Zhang Z, Strugnell S, Sabbagh Y, Arbeeny C, Li YC. Long-term therapeutic effect of vitamin D analog doxercalciferol on diabetic nephropathy: strong synergism with AT1 receptor antagonist. Am J Physiol Renal Physiol 2009; 297:F791-801. [PMID: 19535571 DOI: 10.1152/ajprenal.00247.2009] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The intrarenal renin-angiotensin system (RAS) plays a key role in the development of diabetic nephropathy. Recently, we showed that combination therapy with an AT(1) receptor blocker (ARB) and an activated vitamin D analog produced excellent synergistic effects against diabetic nephropathy, as a result of blockade of the ARB-induced compensatory renin increase. Given the diversity of vitamin D analogs, here we used a pro-drug vitamin D analog, doxercalciferol (1alpha-hydroxyvitamin D(2)), to further test the efficacy of the combination strategy in long-term treatment. Streptozotocin-induced diabetic DBA/2J mice were treated with vehicle, losartan, doxercalciferol (0.4 and 0.6 microg/kg), or losartan and doxercalciferol combinations for 20 wk. Vehicle-treated diabetic mice developed progressive albuminuria and glomerulosclerosis. Losartan alone moderately ameliorated kidney injury, with renin being drastically upregulated. A similar therapeutic effect was seen with doxercalciferol alone, which markedly suppressed renin and angiotensinogen expression. The losartan and doxercalciferol combination most effectively prevented albuminuria, restored glomerular filtration barrier structure, and dramatically reduced glomerulosclerosis in a dose-dependent manner. These effects were accompanied by blockade of intrarenal renin upregulation and ANG II accumulation. These data demonstrate an excellent therapeutic potential for doxercalciferol in diabetic renal disease and confirm the concept that blockade of the compensatory renin increase enhances the efficacy of RAS inhibition and produces synergistic therapeutic effects in combination therapy.
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Affiliation(s)
- Yan Zhang
- Division of Biological Sciences, Department of Medicine, The University of Chicago, Chicago, Illinois 60637, USA
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Abstract
Recent decades have witnessed the revelation of expanding roles of the vitamin D endocrine system beyond calcium and phosphorus metabolism. Along with these non-calcemic or non-classic actions of vitamin D are newly discovered therapeutic actions of vitamin D analogs in a number of pathological conditions, including kidney disease. The kidney is the major organ involved in the synthesis of the hormonal metabolite of vitamin D, and vitamin D deficiency is a common feature of chronic kidney disease even in its early stages. Experimental data suggest that vitamin D deficiency may in turn accelerate the progression of kidney disease. Low-calcemic vitamin D analogs have exhibited impressive therapeutic effects in various kidney disease models, with targets ranging from the NF-kappaB pathway to the renin-angiotensin system. These recent studies demonstrate that vitamin D analogs have potent renoprotective effects. The emerging experimental and clinical evidence has provided a solid foundation for the continuing exploration of vitamin D analogs in prevention and intervention in kidney disease.
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Affiliation(s)
- Yan Chun Li
- Department of Medicine, The University of Chicago, Chicago, Illinois 60637, USA.
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Abstract
Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are thought to possess cardioprotective, cerebroprotective, and nephroprotective properties. Both classes of agents can prevent or reverse endothelial dysfunction and atherosclerosis, thereby potentially reducing the risk of cardiovascular events. Such a reduction has been shown with angiotensin-converting enzyme inhibitors in patients with coronary artery disease, but no such data are scarce with angiotensin receptor blockers (Valsartan in Acute Myocardial Infarction study). Both angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have been shown to reduce damage in target organs, such as the heart and kidney, and to decrease cardiovascular mortality and morbidity in patients with congestive heart failure. These drugs (especially angiotensin receptor blockers) may successfully prevent atrial fibrillation and play a protective role in metabolic syndrome. In some clinical settings, combined therapy angiotensin-converting enzyme inhibitors with angiotensin receptor blocker (double blockade of the renin-angiotensin- aldosterone system) may appear the most effective.
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Takahashi S, Hori K, Shinbo M, Hiwatashi K, Gotoh T, Yamada S. Isolation of human renin inhibitor from soybean: soyasaponin I is the novel human renin inhibitor in soybean. Biosci Biotechnol Biochem 2008; 72:3232-6. [PMID: 19060406 DOI: 10.1271/bbb.80495] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We found human renin inhibitory activity in soybean and isolated the active compound, soybean renin inhibitor (SRI). The physico-chemical data on the isolated SRI were identical with those of soyasaponin I. SRI showed significant inhibition against recombinant human renin, with an IC(50) value of 30 microg/ml. Kinetic studies with SRI indicated partial noncompetitive inhibition, with a K(i) value of 37.5 microM. On the other hand, SRI weakly inhibited pepsin, papain, and bromeline activities, but did not inhibit other proteinases, such as trypsin, kallikrein, angiotensin converting enzyme, and aminopeptidase M. Moreover, a significant (p<0.05) decrease in the systolic blood pressure of spontaneously hypertensive rats was observed when partially purified SRI was orally administrated at 40 mg/kg/d for 7 weeks. This is the first demonstration of a renin inhibitor from soybean, soyasaponin I.
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Affiliation(s)
- Saori Takahashi
- Institute for Food and Brewing, Akita Prefectural Agricultural, Forestry, and Fisheries Research Center, Arayamachi, Akita, Japan.
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Abstract
Diabetic nephropathy (DN) is the most common renal complication of diabetes mellitus and a leading cause of end-stage renal disease. The renin-angiotensin system (RAS) is a major mediator of progressive renal injury in DN, and RAS inhibitors have been used as the mainstay treatment for DN. One major problem limiting the efficacy of the RAS inhibitors is the compensatory renin increase caused by disruption of renin feedback inhibition. Vitamin D negatively regulates the RAS by suppressing renin expression and thus plays a renoprotective role in DN. Diabetic vitamin D receptor-null mutant mice develop more severe renal injuries because of more robust RAS activation. Combination therapy with an RAS inhibitor and a vitamin D analogue markedly ameliorates renal injuries due to blockade of the compensatory renin increase by the analogue. These most recent data demonstrate that vitamin D and its analogues have renoprotective and therapeutic potentials in DN through targeting the RAS.
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Affiliation(s)
- Yan Chun Li
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA.
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Combination therapy with AT1 blocker and vitamin D analog markedly ameliorates diabetic nephropathy: blockade of compensatory renin increase. Proc Natl Acad Sci U S A 2008; 105:15896-901. [PMID: 18838678 DOI: 10.1073/pnas.0803751105] [Citation(s) in RCA: 237] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The renin-angiotensin system (RAS) plays a critical role in the development of diabetic nephropathy, and blockade of the RAS is currently used for treatment of diabetic nephropathy. One major problem for the current RAS inhibitors is the compensatory renin increase, which reduces the efficacy of RAS inhibition. We have shown that vitamin D exerts renoprotective actions by transcriptionally suppressing renin. Here we demonstrated that combination therapy with an AT1 receptor blocker and a vitamin D analog markedly ameliorated renal injury in the streptozotocin (STZ)-induced diabetes model due to the blockade of the compensatory renin rise by the vitamin D analog, leading to more effective RAS inhibition. STZ-treated diabetic DBA/2J mice developed progressive albuminuria and glomerulosclerosis within 13 weeks, accompanied by increased intrarenal production of angiotensin (Ang) II, fibronection, TGF-beta, and MCP-1 and decreased expression of slit diaphragm proteins. Treatment of the diabetic mice with losartan or paricalcitol (19-nor-1,25-dihydroxyvitamin D(2), an activated vitamin D analog) alone moderately ameliorated kidney injury; however, combined treatment with losartan and paricalcitol completely prevented albuminuria, restored glomerular filtration barrier structure, and markedly reduced glomerulosclerosis. The combined treatment suppressed the induction of fibronection, TGF-beta, and MCP-1 and reversed the decline of slit diaphragm proteins nephrin, Neph-1, ZO-1, and alpha-actinin-4. These were accompanied by blockade of intrarenal renin and Ang II accumulation induced by hyperglycemia and losartan. These data demonstrate that inhibition of the RAS with combination of vitamin D analogs and RAS inhibitors effectively prevents renal injury in diabetic nephropathy.
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75
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Danser AJ, Nguyen G. The Renin Academy Summit: advancing the understanding of renin science. J Renin Angiotensin Aldosterone Syst 2008; 9:119-23. [PMID: 18584589 DOI: 10.3317/jraas.2008.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Ah Jan Danser
- Department of Pharmacology, Erasmus MC, Dr Molewaterplein 50, 3015 GE, Rotterdam, The Netherlands
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76
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Panesar M, Damodar A. Aliskiren combined with losartan in diabetes and nephropathy. N Engl J Med 2008; 359:1068; author reply 1069-70. [PMID: 18768954 DOI: 10.1056/nejmc081393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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77
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Inhibition of the renin-angiotensin system and chronic kidney disease. Int Urol Nephrol 2008; 40:1015-25. [PMID: 18704745 DOI: 10.1007/s11255-008-9424-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2008] [Accepted: 06/23/2008] [Indexed: 12/28/2022]
Abstract
Chronic kidney disease (CKD), a major worldwide public-health problem which affects about 10% of the population, has an increased annual incidence rate of about 5-8%. This increased incidence is mainly due to type 2 diabetes and hypertension and the increasing incidence of elderly patients with CKD. Although the progression to end-stage renal failure (ESRF) is mainly based upon the underlying disease, comorbid conditions such as an initial low renal function, severe proteinuria, and high levels of blood pressure also play important roles in the development of ESRF. Since experimental and clinical evidence suggest that angiotensin II plays a central role in the progression of CKD, pharmacological inhibition of the renin-angiotensin-aldosteron system (RAAS) with angiotensin converting enzyme inhibitors or angiotensin II receptor antagonists has been suggested as first-line treatment for hypertension and prevention of ESRF in these patients. Aliskiren, a novel renin inhibitor is also a promising medical intervention. However, independently of the category of the drugs used, low target blood pressure levels seem to be equally or more important for the delay or prevention of CKD. In this review the results of studies with pharmacological inhibition of the RAAS in patients with diabetic and nondiabetic nephropathy is discussed.
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Fisher NDL, Jan Danser AH, Nussberger J, Dole WP, Hollenberg NK. Renal and hormonal responses to direct renin inhibition with aliskiren in healthy humans. Circulation 2008; 117:3199-205. [PMID: 18559696 DOI: 10.1161/circulationaha.108.767202] [Citation(s) in RCA: 136] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Pharmacological interruption of the renin-angiotensin system focuses on optimization of blockade. As a measure of intrarenal renin activity, we have examined renal plasma flow (RPF) responses in a standardized protocol. Compared with responses with angiotensin-converting enzyme inhibition (rise in RPF approximately 95 mL x min(-1) x 1.73 m(-2)), greater renal vasodilation with angiotensin receptor blockers (approximately 145 mL x min(-1) x 1.73 m(-2)) suggested more effective blockade. We predicted that blockade with the direct oral renin inhibitor aliskiren would produce renal vascular responses exceeding those induced by angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. METHODS AND RESULTS Twenty healthy normotensive subjects were studied on a low-sodium (10 mmol/d) diet, receiving separate escalating doses of aliskiren. Six additional subjects received captopril 25 mg as a low-sodium comparison and also received aliskiren on a high-sodium (200 mmol/d) diet. RPF was measured by clearance of para-aminohippurate. Aliskiren induced a remarkable dose-related renal vasodilation in low-sodium balance. The RPF response was maximal at the 600-mg dose (197+/-27 mL x min(-1) x 1.73 m(-2)) and exceeded responses to captopril (92+/-20 mL x min(-1) x 1.73 m(-2); P<0.01). Furthermore, significant residual vasodilation was observed 48 hours after each dose (P<0.01). The RPF response on a high-sodium diet was also higher than expected (47+/-17 mL x min(-1) x 1.73 m(-2)). Plasma renin activity and angiotensin levels were reduced in a dose-related manner. As another functional index of the effect of aliskiren, we found significant natriuresis on both diets. CONCLUSIONS Renal vasodilation in healthy people with the potent renin inhibitor aliskiren exceeded responses seen previously with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. The effects were longer lasting and were associated with significant natriuresis. These results indicate that aliskiren may provide more complete and thus more effective blockade of the renin-angiotensin system.
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Affiliation(s)
- Naomi D L Fisher
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
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79
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80
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Aliskiren—mode of action and preclinical data. J Mol Med (Berl) 2008; 86:659-62. [DOI: 10.1007/s00109-008-0330-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Revised: 02/18/2008] [Accepted: 02/20/2008] [Indexed: 10/22/2022]
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81
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Westermann D, Schmieder R, Schultheiss HP, Tschöpe C. Renin inhibitors, clinical experience. J Mol Med (Berl) 2008; 86:691-5. [PMID: 18437334 DOI: 10.1007/s00109-008-0338-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Revised: 02/21/2008] [Accepted: 02/25/2008] [Indexed: 11/26/2022]
Abstract
The inhibition of the renin-angiotensin system is one of the most commonly utilized ways to lower blood pressure in patients with arterial hypertension. Up till now, angiotensin-converting enzyme inhibitors as well as angiotensin receptor blockers are the established inhibitors of this system, and both classes are used in clinical routine. There is a wealth of information about those classes, which are known not only to lower blood pressure, but also to prevent end-organ damage and, ultimately, reduce mortality in patients. Direct renin inhibition was already targeted 30 years ago to inhibit the renin-angiotensin system, but low bioavailability and short duration of action of the first generations of renin inhibitors withheld their clinical success. With the new generation of non-peptide orally available renin inhibitors, a third substance to inhibit the renin-angiotensin system is on the market, and the prototype of this class, aliskiren, has now been tested in various clinical trials in arterial hypertension. We review the studies of aliskiren and discuss its current role in the contemporary treatment of arterial hypertension as well as the possible new fields of action for aliskiren in treating heart failure and diabetic nephropathy.
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Affiliation(s)
- Dirk Westermann
- Department of Cardiology and Pneumology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, Berlin, Germany
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82
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Establishing a new option for target-organ protection: rationale for ARB plus ACE inhibitor combination therapy. Am J Hypertens 2008; 21:248-56. [PMID: 18219303 DOI: 10.1038/ajh.2007.56] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Activation of the renin-angiotensin system (RAS) plays an important role in the promotion of cardiovascular disease and target-organ damage, mediated in part by hypertension. Combination therapy targeting RAS activation may reduce target-organ damage and provide superior blood pressure (BP) control; combining angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) represents one possible approach. In monotherapy studies, both ACE inhibitors and ARBs have demonstrated similar positive effects on BP and on RAS-related target-organ damage, including nephropathy and congestive heart failure. Studies of combination therapy, most of which involved addition of an ARB to existing ACE inhibitor therapy, have demonstrated benefits among patients with congestive heart failure and renal disease. However, variances in study design and populations, dosing and titration methods, and clinical end points, in addition to inherent differences between agents, limit the ability to reach clinically meaningful conclusions about the value of dual RAS inhibition. Trials designed to document such efficacy are currently underway.
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83
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84
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Renin polymorphisms and haplotypes are associated with blood pressure levels and hypertension risk in postmenopausal women. J Hypertens 2008; 26:230-7. [DOI: 10.1097/hjh.0b013e3282f29865] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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85
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Feldt S, Maschke U, Dechend R, Luft FC, Muller DN. The putative (pro)renin receptor blocker HRP fails to prevent (pro)renin signaling. J Am Soc Nephrol 2008; 19:743-8. [PMID: 18235083 DOI: 10.1681/asn.2007091030] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The prorenin/renin receptor is a recently discovered component of the renin-angiotensin system. The effects of aliskiren, a direct inhibitor of human renin, were compared with the handle region decoy peptide (HRP), which blocks the prorenin/renin receptor, in double-transgenic rats overexpressing the human renin and angiotensinogen genes. After 7 wk, all aliskiren-treated rats were alive, whereas mortality was 40% in vehicle-treated and 58% in HRP-treated rats. Aliskiren but not the HRP reduced BP and normalized albuminuria, cystatin C, and neutrophil gelatinase-associated lipocalin, a marker of renal tubular damage, to the levels of nontransgenic controls. In vitro, human renin and prorenin induced extracellular signal-regulated kinase 1/2 phosphorylation, independent of angiotensin II (AngII), in vascular smooth muscle cells. Preincubation with the HRP or aliskiren did not prevent renin- and prorenin-induced extracellular signal-regulated kinase 1/2 phosphorylation, whereas the MAP kinase kinase (MEK1/2) inhibitor PD98059 prevented both. In conclusion, renin inhibition but not treatment with the HRP protects against AngII-induced renal damage in double-transgenic rats. In addition, the in vitro data do not support the use of the HRP to block AngII-independent prorenin- or renin-mediated effects.
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Affiliation(s)
- Sandra Feldt
- Experimental and Clinical Research Center, Max-Delbruck-Center, Lindenberger Weg 80, 13125 Berlin, Germany
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86
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Hollenberg N. Inhibición de renina. HIPERTENSION Y RIESGO VASCULAR 2008. [DOI: 10.1016/s1889-1837(08)71739-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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87
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Toto R, Palmer BF. Rationale for combination angiotensin receptor blocker and angiotensin-converting enzyme inhibitor treatment and end-organ protection in patients with chronic kidney disease. Am J Nephrol 2007; 28:372-80. [PMID: 18073461 DOI: 10.1159/000112269] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2007] [Accepted: 10/25/2007] [Indexed: 11/19/2022]
Abstract
Chronic kidney disease (CKD) is a major public health problem that has received increasing attention because of the high rate of associated cardiovascular morbidity and mortality. Mounting evidence indicates that angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), drugs that inhibit the renin-angiotensin-aldosterone system (RAAS) safely slow down progression of CKD. There is also growing evidence supporting combination treatment of nephropathies with an ACE inhibitor plus an ARB to more completely block the RAAS and provide greater renoprotection than either an ACE inhibitor-based or ARB-based regimen. The National Kidney Foundation suggests that ACE inhibitors and ARBs may be used in combination to reduce proteinuria in patients with kidney disease; however, larger outcomes trials are needed.
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Affiliation(s)
- Robert Toto
- Patient-Oriented Research - Nephrology, University of Southwestern Medical Center at Dallas, Dallas, TX 75225-8856, USA.
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88
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Weir MR. Renin inhibitors: novel agents for renoprotection or a better angiotensin receptor blocker for blood pressure lowering? Curr Opin Nephrol Hypertens 2007; 16:416-21. [PMID: 17693755 DOI: 10.1097/mnh.0b013e328209fe00] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Direct renin inhibitors are the newest antihypertensive therapeutic class. The review describes their antihypertensive and antiproteinuric effects and possible renoprotective capabilities. RECENT FINDINGS Clinical trials demonstrate direct renin inhibitors reduce systolic and diastolic blood pressure comparable with other commonly used antihypertensive drugs, including angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. They also reduce proteinuria and are renoprotective in experimental models of kidney disease. Direct renin inhibitors, when used with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, offer incremental blood pressure reduction far greater than that observed when an angiotensin-converting enzyme inhibitor and angiotensin receptor blocker are used together. This suggests that renin inhibitors possess a unique and distinct mechanism of action compared with the other two therapeutic classes. SUMMARY Direct renin inhibitors, due to their antihypertensive and antiproteinuric effects, and the unique mechanism of action resulting in reduction in plasma renin activity and suppression of angiotensin II levels, may offer a unique opportunity to facilitate blood pressure reduction with both angiotensin-converting enzyme inhibitors and angiotensin receptor blockers as well as other commonly used therapeutic classes. More effective blood pressure and proteinuria reduction coupled with a unique means of suppressing the renin angiotensin system may offer improved opportunity for renoprotection.
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Affiliation(s)
- Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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89
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Abstract
Evidence that renin system blockade is useful in many patients with hypertension is overwhelming. Two recent lines of investigation have suggested that more complete blockade leads to improved clinical outcomes. One line of investigation involves the use of a combination of an angiotensin-converting enzyme inhibitor with an angiotensin-receptor blocker. The second line of investigation involves the use of very high dose angiotensin-receptor blocker. The interaction of renin with substrate is the rate-limiting step in the renin cascade; thus, the recent development of a powerful renin inhibitor also favors more complete blockade of the system. In many patients, this is likely to lead to improved treatment.
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Affiliation(s)
- Norman K Hollenberg
- Department of Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, MA 02115, USA.
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90
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Abstract
The important role of renin-angiotensin-aldosterone system blockade in the treatment of systemic hypertension, heart failure, diabetic kidney disease, and atherogenesis has been clearly established. The theoretical therapeutic advantages for inhibiting the detrimental effects of the renin-angiotensin system at its most upstream point have served as the impetus for the development of renin inhibitors. The advent of aliskiren, the first in a novel class of orally active, nonpeptide, highly specific, human renin inhibitors, provides a new modality in the armamentarium of renin-angiotensin system antagonists. Studies in marmosets and rats demonstrated that aliskiren reduced blood pressure in a dose-dependent manner and is highly efficacious in blocking plasma renin activity with parallel reductions in the levels of the other downstream constituents of the renin-angiotensin system. Clinical trials in hypertensive patients have confirmed these benefits with aliskiren whose blood pressure-lowering efficacy is similar to or better than those of standard therapeutic doses of enalapril, losartan, irbesartan, and hydrochlorothiazide. Aliskiren is well tolerated, with few reported adverse effects even at the highest doses tested. Given the established beneficial effects of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in the treatment of cardiovascular and renovascular diseases, future studies may further elucidate a similar protective role for aliskiren both as a monotherapy and as part of a combination therapy.
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Affiliation(s)
- Reza Sepehrdad
- Department of Internal Medicine, UC Davis Medical Center, Sacramento, California, USA
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91
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Holsworth DD, Jalaie M, Belliotti T, Cai C, Collard W, Ferreira S, Powell NA, Stier M, Zhang E, McConnell P, Mochalkin I, Ryan MJ, Bryant J, Li T, Kasani A, Subedi R, Maiti SN, Edmunds JJ. Discovery of 6-ethyl-2,4-diaminopyrimidine-based small molecule renin inhibitors. Bioorg Med Chem Lett 2007; 17:3575-80. [DOI: 10.1016/j.bmcl.2007.04.052] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2007] [Revised: 04/17/2007] [Accepted: 04/18/2007] [Indexed: 11/30/2022]
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92
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Abstract
Aliskiren (Tekturna) is an orally active, nonpeptidic inhibitor of renin, the enzyme involved in the initial and rate-limiting step of the renin-angiotensin system (RAS). In the US, aliskiren is approved for the treatment of hypertension and may be used alone or in combination with other antihypertensive agents. Monotherapy with aliskiren 150-300mg once daily was effective in lowering blood pressure (BP) and providing 24-hour BP control; it was generally well tolerated when administered for up to 1 year to patients with mild to moderate hypertension. In the short term (1-3 months), the BP-lowering effect of aliskiren 150-300mg once daily was significantly greater than that of hydrochlorothiazide (HCTZ) 12.5-25mg once daily and noninferior to, or significantly greater than, that of ramipril 5-10mg once daily. It was similar to that of valsartan 160-320mg once daily and losartan 100mg once daily, and similar to, or significantly greater than, that of irbesartan 150mg once daily. Aliskiren provided significant additional BP-lowering effects when combined with HCTZ 12.5-25 mg/day, ramipril 5-10 mg/day, amlodipine 5mg once daily or valsartan 160-320 mg/day; combination therapy was well tolerated. Long-term administration of aliskiren-based therapy was superior to HCTZ- and ramipril-based therapies in lowering BP after 6 months, and was similarly well tolerated. The ultimate role of aliskiren will be determined by the results of target organ protection studies, which are ongoing, and a cardiovascular outcome trial, which is planned. Nonetheless, by offering a new approach to the blockade of the RAS, aliskiren provides a useful addition to the therapeutic options available to treat patients with mild to moderate hypertension.
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Affiliation(s)
- James E Frampton
- Wolters Kluwer Health | Adis, Auckland, New Zealand, an editorial office of Wolters Kluwer Health, Conshohocken, Pennsylvania, USA.
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