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Relationship Between Aldosterone and Parathyroid Hormone, and the Effect of Angiotensin and Aldosterone Inhibition on Bone Health. Clin Rev Bone Miner Metab 2015. [DOI: 10.1007/s12018-015-9182-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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152
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Lantis AC, Ames MK, Werre S, Atkins CE. The effect of enalapril on furosemide-activated renin-angiotensin-aldosterone system in healthy dogs. J Vet Pharmacol Ther 2015; 38:513-7. [PMID: 25771846 DOI: 10.1111/jvp.12216] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 01/29/2015] [Indexed: 11/25/2022]
Abstract
Studies in our laboratory have revealed that furosemide-induced RAAS activation, evaluated via the urine aldosterone-to-creatinine ratio (UAldo:C), was not attenuated by the coadministration of benazepril, while enalapril successfully suppressed amlodipine-induced urinary aldosterone excretion. This study was designed to evaluate the efficacy of enalapril in suppressing ACE activity and furosemide-induced circulating RAAS activation. Failure to do so would suggest that this failure may be a drug class effect. We hypothesized that enalapril would suppress ACE activity and furosemide-induced circulating RAAS activation. Sixteen healthy hound dogs. The effect of furosemide (2 mg/kg PO, q12 h; Group F) and furosemide plus enalapril (0.5 mg/kg PO, q12 h; Group FE) on circulating RAAS was determined by plasma ACE activity, 4-6 h post-treatment, and urinary A:C on days -1, -2, 1, 4, and 7. There was a significant increase in the average urine aldosterone-to-creatinine ratio (UAldo:C) after administration of furosemide (P < 0.05). Enalapril inhibited ACE activity (P < 0.0001) but did not significantly reduce aldosterone excretion. A significant (P < 0.05) increase in the UAldo:C was maintained for the 7 days of the study in both groups. Enalapril decreased plasma ACE activity; however, it did not suppress furosemide-induced RAAS activation, as determined by the UAldo:C. While enalapril blunts ACE activity, the absence of circulating RAAS suppression may be due to angiotensin II reactivation, alternative RAAS pathways, and furosemide overriding concurrent ACE inhibition, all indicating the existence of aldosterone breakthrough (ABT). Along with similar findings with benazepril, it appears that failure to suppress aldosterone suppression with furosemide stimulation may be a drug class effect. The discrepancy between the current data and the documented benefits of enalapril likely reflects the efficacy of this ACE inhibitor in suppressing tissue RAAS, variable population responsiveness to ACE-inhibition, and/or providing additional survival benefits, possibly through as yet unknown mechanisms.
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Affiliation(s)
- A C Lantis
- Department of Small Animal Clinical Sciences, Virginia-Maryland Regional College of Veterinary Medicine, Blacksburg, VA, USA
| | - M K Ames
- Department of Small Animal Clinical Sciences, Virginia-Maryland Regional College of Veterinary Medicine, Blacksburg, VA, USA.,Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
| | - S Werre
- Department of Small Animal Clinical Sciences, Virginia-Maryland Regional College of Veterinary Medicine, Blacksburg, VA, USA
| | - C E Atkins
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
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153
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Franklin SS, Weber MA. Optimum antihypertensive therapy: does adiposity matter? Lancet 2015; 385:834-6. [PMID: 25468165 DOI: 10.1016/s0140-6736(14)61336-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Stanley S Franklin
- Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine, CA 92697, USA.
| | - Michael A Weber
- Division of Cardiovascular Medicine, State University of New York, Downstate College of Medicine, Brooklyn, New York, NY, USA
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154
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Lymperopoulos A, Sturchler E, Bathgate-Siryk A, Dabul S, Garcia D, Walklett K, Rengo G, McDonald P, Koch WJ. Different potencies of angiotensin receptor blockers at suppressing adrenal β-Arrestin1-dependent post-myocardial infarction hyperaldosteronism. J Am Coll Cardiol 2015; 64:2805-6. [PMID: 25541135 DOI: 10.1016/j.jacc.2014.09.070] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 08/08/2014] [Accepted: 09/08/2014] [Indexed: 12/25/2022]
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155
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Maiolino G, Azzolini M, Rossi GP. Mineralocorticoid Receptor Antagonists Therapy in Resistant Hypertension: Time to Implement Guidelines! Front Cardiovasc Med 2015; 2:3. [PMID: 26664875 PMCID: PMC4668865 DOI: 10.3389/fcvm.2015.00003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 01/12/2015] [Indexed: 12/24/2022] Open
Abstract
Despite the availability of anti-hypertensive medications with increasing efficacy up to 50% of hypertensive patients have blood pressure levels (BP) not at the goals set by international societies. Some of these patients are either not optimally treated or are non-adherent to the prescribed drugs. However, a proportion, despite adequate treatment, have resistant hypertension (RH), which represents an important problem in that it is associated to an excess risk of cardiovascular events. Notwithstanding a complex pathogenesis, an abundance of data suggests a key contribution for the mineralocorticoid receptor (MR) in RH, thus fostering a potential role for its antagonists in RH. Based on these premises randomized clinical trials aimed at testing the efficacy of MR antagonists (MRAs) in RH patients have been completed. Overall, they demonstrated the efficacy of MRAs in reducing BP and surrogate markers of target organ damage, such as microalbuminuria, either compared to placebo or to other drugs. In summary, owing to the key role of the MR in the pathogenesis of RH and on the proven efficacy of MRAs we advocate their inclusion as an essential component of therapy in patients with presumed RH. Conversely, we propose that RH should be diagnosed only in patients whose BP values show to be resistant to an up-titrated dose of these drugs.
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Affiliation(s)
- Giuseppe Maiolino
- Department of Medicine (DIMED), Internal Medicine 4, University of Padova , Padova , Italy
| | - Matteo Azzolini
- Department of Medicine (DIMED), Internal Medicine 4, University of Padova , Padova , Italy
| | - Gian Paolo Rossi
- Department of Medicine (DIMED), Internal Medicine 4, University of Padova , Padova , Italy
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156
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Brown J, de Boer IH, Robinson-Cohen C, Siscovick DS, Kestenbaum B, Allison M, Vaidya A. Aldosterone, parathyroid hormone, and the use of renin-angiotensin-aldosterone system inhibitors: the multi-ethnic study of atherosclerosis. J Clin Endocrinol Metab 2015; 100:490-9. [PMID: 25412416 PMCID: PMC4318894 DOI: 10.1210/jc.2014-3949] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
CONTEXT Aldosterone and PTH are implicated in the pathogenesis of cardiovascular and skeletal diseases. An expanding body of evidence supports a bidirectional and positive physiologic relationship between aldosterone and PTH. Large population-based studies confirming this relationship, and whether it may be targeted as a potential method to mitigate the clinical consequences associated with excess aldosterone and PTH, are needed. OBJECTIVE We hypothesized that higher aldosterone levels would associate with higher PTH, and that the use of renin-angiotensin-aldosterone system (RAAS) inhibitors would predict lower PTH in a large, multi-ethnic, community-based cohort. DESIGN, SETTING, PARTICIPANTS We conducted cross-sectional analyses of participants in the Multi-Ethnic Study of Atherosclerosis without apparent primary hyperparathyroidism or chronic kidney disease (n = 5668). We evaluated associations of RAAS inhibitor use with PTH concentration among 1888 treated hypertensive participants. We also tested associations of serum aldosterone concentration with PTH concentration among 1547 participants with these measurements. OUTCOME Serum PTH concentration. RESULTS Higher aldosterone associated with higher PTH (β = 0.19 pg/ml per 1 ng/dl of aldosterone, P < .0001), and this finding was most pronounced among those with a primary hyperaldosteronism-like phenotype. There was a stepwise increment in PTH when comparing untreated normotensives, hypertensives using RAAS inhibitors, untreated hypertensives, and treated hypertensives using non-RAAS inhibitors (40.8, 45.0, 46.2, 47.1 pg/ml, respectively). The use of any RAAS inhibitor independently associated with lower PTH (β = -2.327 pg/ml per use of RAAS inhibitor, P = .006), when compared with the use of any non-RAAS inhibitor medication. CONCLUSIONS Higher serum aldosterone concentration is associated with higher serum PTH concentration, and the use of RAAS inhibitors is associated with lower PTH concentration. These results extend prior evidence from observational and intervention studies suggesting a potentially important and modifiable relationship between the RAAS and PTH in humans.
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Affiliation(s)
- Jenifer Brown
- Division of Endocrinology, Diabetes, and Hypertension (J.B., A.V.), Center for Adrenal Disorders (A.V.), Brigham and Women's Hospital and Harvard Medical School (J.B., A.V.), Boston, Massachusetts 02115; Department of Medicine, Kidney Research Institute (I.H.d.B., C.R.-C., B.K.), University of Washington, Seattle, Washington 98104; Department of Medicine, Division of Nephrology (I.H.d.B., B.K.), University of Washington, Seattle, Washington 98104; The New York Academy of Medicine (D.S.S.), New York, New York 10029; Veterans' Affairs Hospital (M.A.), San Diego, California 92161; and Division of Preventive Medicine (M.A.), Department of Family and Preventive Medicine, University of California San Diego, San Diego, California 92093
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157
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Dabul S, Bathgate-Siryk A, Valero TR, Jafferjee M, Sturchler E, McDonald P, Koch WJ, Lymperopoulos A. Suppression of adrenal βarrestin1-dependent aldosterone production by ARBs: head-to-head comparison. Sci Rep 2015; 5:8116. [PMID: 25631300 PMCID: PMC4309955 DOI: 10.1038/srep08116] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 11/26/2014] [Indexed: 12/22/2022] Open
Abstract
The known angiotensin II (AngII) physiological effect of aldosterone synthesis and secretion is mediated by either Gq/11 proteins or βarrestin1 (βarr1), both of which can couple to its type 1 receptors (AT₁Rs), present in adrenocortical zona glomerulosa (AZG) cell membranes. In the present study, we examined the relative potencies of all the currently used in the clinic AT₁R antagonist drugs (angiotensin receptor blockers, ARBs, or sartans) at preventing activation of these two signaling mediators (G proteins and βarrs) at the AngII-bound AT1R and, consequently, at suppression of aldosterone in vitro. All ARBs were found to be potent inhibitors of G protein activation at the AT₁R. However, candesartan and valsartan were the most potent at blocking AngII-induced βarr activation at this receptor, among the tetrazolo-biphenyl-methyl derivatives, translating into excellent efficacies at aldosterone suppression in H295R cells. Conversely, irbesartan and losartan were largely G protein-selective inhibitors at the AT₁R, with very low potency towards βarr inhibition. As a result, they were very weak suppressors of βarr1-dependent aldosterone production in H295R cells. These findings provide important pharmacological insights into the drug class of ARBs and medicinal chemistry insights for future drug development in the field of AngII antagonism.
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Affiliation(s)
- Samalia Dabul
- Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, Fort Lauderdale, FL 33328, USA
| | - Ashley Bathgate-Siryk
- Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, Fort Lauderdale, FL 33328, USA
| | - Thairy Reyes Valero
- Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, Fort Lauderdale, FL 33328, USA
| | - Malika Jafferjee
- Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, Fort Lauderdale, FL 33328, USA
| | - Emmanuel Sturchler
- Translational Research Institute, Scripps Florida, Jupiter, FL 33458, USA
| | - Patricia McDonald
- Translational Research Institute, Scripps Florida, Jupiter, FL 33458, USA
| | - Walter J Koch
- Center for Translational Medicine, Temple University, Philadelphia, PA 19140, USA
| | - Anastasios Lymperopoulos
- Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, Fort Lauderdale, FL 33328, USA
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158
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Ruilope LM, Agarwal R, Chan JC, Cooper ME, Gansevoort RT, Haller H, Remuzzi G, Rossing P, Schmieder RE, Nowack C, Ferreira AC, Pieper A, Kimmeskamp-Kirschbaum N, Bakris GL. Rationale, design, and baseline characteristics of ARTS-DN: a randomized study to assess the safety and efficacy of finerenone in patients with type 2 diabetes mellitus and a clinical diagnosis of diabetic nephropathy. Am J Nephrol 2015; 40:572-81. [PMID: 25591469 DOI: 10.1159/000371497] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 11/20/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND/AIMS Finerenone decreases albuminuria in patients having heart failure with reduced ejection fraction and mild-to-moderate (stage 2-3) chronic kidney disease. The MinerAlocorticoid Receptor Antagonist Tolerability Study-Diabetic Nephropathy (ARTS-DN; NCT01874431) is a multicenter, randomized, double-blind, placebo-controlled, parallel-group, phase 2b study. ARTS-DN investigated whether the mineralocorticoid receptor antagonist finerenone reduces albuminuria without causing major alterations in serum potassium levels in patients with type 2 diabetes mellitus and a clinical diagnosis of DN who were receiving a renin-angiotensin-system (RAS) inhibitor. METHODS Patients were randomized to oral finerenone 1.25-20 mg or placebo once daily. The primary objectives were to assess the ratio of the urinary albumin-to-creatinine ratio at day 90 to that at baseline in patients receiving finerenone, and to compare it with that in the placebo group. Additional exploratory analyses included evaluating changes from baseline in serum potassium levels, efficacy and safety biomarkers, and health-related quality of life. RESULTS Of 1,501 patients screened, 821 (the sample population) received at least one dose of finerenone/placebo. Baseline characteristics included: male, 77.8%; white, 84.2%; very high albuminuria (formerly macroalbuminuria), 38.4%; high albuminuria (formerly microalbuminuria), 60.3%; median (range) estimated glomerular filtration rate, 66.3 (24.5-130.7) ml/min/1.73 m(2); and systolic blood pressure (mean ± standard deviation), 138.1 ± 14.4 mm Hg. There was a history of cardiovascular disease in 39.6%, diabetic neuropathy in 20.0%, and diabetic retinopathy in 19.9% of patients. CONCLUSION ARTS-DN is the first phase 2b trial of finerenone in combination with a RAS inhibitor in patients with type 2 diabetes mellitus and a clinical diagnosis of DN.
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Affiliation(s)
- Luis M Ruilope
- Institute of Investigation and Hypertension Unit, Hospital 12 de Octubre, Madrid, Spain
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159
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Gwoo S, Kim YN, Shin HS, Jung YS, Rim H. Predictors of hyperkalemia risk after hypertension control with aldosterone blockade according to the presence or absence of chronic kidney disease. Nephron Clin Pract 2015; 128:381-6. [PMID: 25572273 DOI: 10.1159/000369138] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 10/16/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Aldosterone antagonists have been proven to be efficient in the management of hypertension and the reduction of proteinuria; however, they are not widely used because of the risk of hyperkalemia. We assessed the predictors of hyperkalemia risk following hypertension control using aldosterone blockade in the presence or absence of chronic kidney disease (CKD). METHODS A total of 6,575 patients with hypertension treated between January 1, 2000, and November 30, 2012, were evaluated for the safety of an aldosterone-blocking agent (spironolactone) added to preexisting blood pressure-lowering regimens. Hyperkalemia was defined as a serum potassium level ≥5.0 mEq/l. All patients used 3 mechanistically complementary antihypertensive agents, including a diuretic and a RAAS blocker. Patients were evaluated after 4 and 8 weeks of treatment. The incidence of hyperkalemia, significant renal dysfunction [a reduction of the estimated glomerular filtration rate (eGFR) ≥30%], and adverse effects was assessed. RESULTS The incidence of hyperkalemia in the presence or absence of CKD was 50.4 and 42.6% after 4 weeks (p = 0.001) and 3.8 and 3.0% after 8 weeks, respectively (p = 0.371). A logistic regression analysis revealed that medication, CKD, basal hyperkalemia, reduction in eGFR, and diabetes were all predictive of a hyperkalemia risk following spironolactone use. CONCLUSION Spironolactone was well tolerated by selected CKD patients. The risk of serious hyperkalemia or a significant reduction of eGFR appears to be low. Strict monitoring over the first month of treatment followed by standard surveillance for angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers is suggested.
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Affiliation(s)
- Sangeon Gwoo
- Department of Internal Medicine, Kosin University College of Medicine, Busan, South Korea
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160
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Miura SI, Nakayama A, Tomita S, Matsuo Y, Suematsu Y, Saku K. Comparison of aldosterone synthesis in adrenal cells, effect of various AT1 receptor blockers with or without atrial natriuretic peptide. Clin Exp Hypertens 2014; 37:353-7. [PMID: 25496380 DOI: 10.3109/10641963.2014.987391] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Bifunctional angiotensin II (Ang II) type 1 (AT1) receptor blockers (ARBs) that can block the activation of not only AT1 receptor, but also neprilysin, which metabolizes vasoactive peptides including atrial natriuretic peptide (ANP), are currently being developed. However, the usefulness of the inactivation of ANP in addition to the AT1 receptor with regard to aldosterone (Ald) synthesis is not yet clear. We evaluated the inhibitory effects of various ARBs combined with or without ANP on Ang II-induced adrenal Ald synthesis using a human adrenocortical cell line (NCI-H295R). Ang II increased Ald synthesis in a dose- and time-dependent manner. Ald synthesis induced by Ang II was completely blocked by azilsartan, but not PD123319 (AT2 receptor antagonist). CGP42112 AT2 receptor agonist did not affect Ald synthesis. While most ARBs block Ang II-induced Ald synthesis to different extents, azilsartan and olmesartan have similar blocking effects on Ald synthesis. The different effects of ARBs were particularly observed at 10(-7) and 10(-8 )M. ANP attenuated Ang II-induced Ald synthesis, and ANP-mediated attenuation of Ang II-induced Ald synthesis were blocked by inhibitors of G-protein signaling subtype 4 and protein kinase G. ANP (10(-8) and 10(-7 )M) without ARBs inhibited Ald synthesis, and the combination of ANP (10(-7 )M) and ARB (10(-8 )M) had an additive effect with respect to the inhibition of Ald synthesis. In conclusions, ARBs had differential effects on Ang II-induced Ald synthesis, and ANP may help to block Ald synthesis when the dose of ARB is not sufficient to block its secretion.
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161
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Ando K, Ohtsu H, Uchida S, Kaname S, Arakawa Y, Fujita T. Anti-albuminuric effect of the aldosterone blocker eplerenone in non-diabetic hypertensive patients with albuminuria: a double-blind, randomised, placebo-controlled trial. Lancet Diabetes Endocrinol 2014; 2:944-53. [PMID: 25466242 DOI: 10.1016/s2213-8587(14)70194-9] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Renin-angiotensin system inhibitors have renoprotective effects in patients with chronic kidney disease, but most patients treated with these drugs have residual urinary albumin excretion. Some small clinical studies show that mineralocorticoid receptor blockade reduces albuminuria. Our study aimed to examine the beneficial effects of addition of a selective aldosterone antagonist, eplerenone, to renin-angiotensin system inhibitors in hypertensive patients with non-diabetic chronic kidney disease. METHODS In this double-blind, randomised, placebo-controlled trial, we enrolled hypertensive patients, aged 20–79 years, with albuminuria (urinary albumin-to-creatinine ratio [UACR] in the first morning void urine of 30–599 mg/g), an estimated glomerular filtration rate of 50 mL/min per 1·73 m2 or more, and who had received an angiotensin-converting enzyme inhibitor, an angiotensin receptor blocker, or both, for at least 8 weeks. Participants were from 59 clinics and hospitals in Japan. Eligible patients were randomly assigned (1:1), stratified by baseline characteristics, to either low-dose eplerenone (50 mg/day) or placebo, with continuation of standard antihypertensive treatment to attain therapeutic goals (<130/80 mm Hg) for 52 weeks. We assessed efficacy in all patients who received allocated treatment, provided a baseline and post-treatment urine sample, and remained in follow-up. We assessed safety in all patients who received allocated treatment. The primary efficacy measure was percent change in UACR in the first morning void urine at week 52 from baseline. The trial is registered at the clinical trials registry of University Hospital Medical Information Network (UMIN), trial identification number UMIN000001803. FINDINGS Between April 1, 2009, and March 31, 2012, we randomly allocated 170 patients to the eplerenone group and 166 patients to the placebo group. In the primary efficacy analysis, mean percent change in UACR from baseline was −17·3% (95% CI −33·65 to −0·94) for 158 patients in the eplerenone group compared with 10·3% (−6·75 to 22·3) for 146 patients in the placebo group (absolute difference −27·6% [–51·15 to −3·96]; p=0·0222). In the safety analyses, 53 (31%) of 169 patients in the eplerenone group had adverse events (five serious), as did 49 (30%) of 163 in the placebo group (seven serious). Although mean serum potassium concentration was higher in the eplerenone group than the placebo group, severe hyperkalaemia (>5·5 mmol/L) was not recorded in either group. INTERPRETATION Addition of low-dose eplerenone to renin-angiotensin system inhibitors might have renoprotective effects through reduction of albuminuria in hypertensive patients with non-diabetic chronic kidney disease, without serious safety concerns. FUNDING Pfizer.
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162
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Sato Y, Sato W, Maruyama S, Wilcox CS, Falck JR, Masuda T, Kosugi T, Kojima H, Maeda K, Furuhashi K, Ando M, Imai E, Matsuo S, Kadomatsu K. Midkine Regulates BP through Cytochrome P450-Derived Eicosanoids. J Am Soc Nephrol 2014; 26:1806-15. [PMID: 25377079 DOI: 10.1681/asn.2013121259] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 09/22/2014] [Indexed: 01/25/2023] Open
Abstract
The effects of endothelium-derived hyperpolarizing factors have been attributed to cytochrome P450-derived epoxyeicosatrienoic acids (EETs), but the regulation and role of EETs in endothelial dysfunction remain largely unexplored. Hypertension is a primary risk factor for renal dysfunction, which is frequently accompanied by various systemic diseases induced by endothelial dysfunction in the microcirculation. We previously reported that the endothelial growth factor midkine (MK) enhances hypertension in a model of CKD. Here, we investigated the hypothesis that MK regulates EET activity and thereby BP. MK gene-deleted mice were resistant to hypertension and developed less glomerulosclerosis and proteinuria after administration of a nitric oxide synthase (NOS) inhibitor in the setting of uninephrectomy. The hypertension observed in uninephrectomized wild-type mice after NOS inhibition was ameliorated by anti-MK antibody. MK-deficient mice produced higher amounts of EETs, and EETs dominantly regulated BP in these mice. Furthermore, MK administration to MK-deficient mice recapitulated the BP control observed in wild-type mice. EETs also dominantly regulated renal blood flow, which may influence renal function, in MK-deficient mice. Taken together, these results suggest that the MK/EET pathway is physiologically engaged in BP control and could be a target for the treatment of hypertension complicated by endothelial dysfunction.
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Affiliation(s)
- Yuka Sato
- Departments of Biochemistry and Nephrology
| | | | | | - Christopher S Wilcox
- Hypertension, Kidney and Vascular Research Center, Georgetown University, Washington, DC; and
| | - John R Falck
- Department of Biochemistry, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | | | | | - Masahiko Ando
- Center for Advanced Medicine and Clinical Research, Nagoya University Graduate School of Medicine, Nagoya, Japan
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163
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Buglioni A, Cannone V, Cataliotti A, Sangaralingham SJ, Heublein DM, Scott CG, Bailey KR, Rodeheffer RJ, Dessì-Fulgheri P, Sarzani R, Burnett JC. Circulating aldosterone and natriuretic peptides in the general community: relationship to cardiorenal and metabolic disease. Hypertension 2014; 65:45-53. [PMID: 25368032 DOI: 10.1161/hypertensionaha.114.03936] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We sought to investigate the role of aldosterone as a mediator of disease and its relationship with the counter-regulatory natriuretic peptide (NP) system. We measured plasma aldosterone (n=1674; aged≥45 years old) in a random sample of the general population from Olmsted County, MN. In a multivariate logistic regression model, aldosterone analyzed as a continuous variable was associated with hypertension (odds ratio [OR]=1.75; 95% confidence interval [CI]=1.57-1.96; P<0.0001), obesity (OR=1.34; 95% CI=1.21-1.48; P<0.0001), chronic kidney disease (OR=1.39; 95% CI=1.22-1.60; P<0.0001), central obesity (OR=1.47; 95% CI=1.32-1.63; P<0.0001), metabolic syndrome (OR=1.41; 95% CI=1.26-1.58; P<0.0001), high triglycerides (OR=1.23; 95% CI=1.11-1.36; P<0.0001), concentric left ventricular hypertrophy (OR=1.22; 95% CI=1.09-1.38; P=0.0007), and atrial fibrillation (OR=1.24; 95% CI=1.01-1.53; P=0.04), after adjusting for age and sex. The associations with hypertension, central obesity, metabolic syndrome, triglycerides, and concentric left ventricular hypertrophy remained significant after further adjustment for body mass index, NPs, and renal function. Furthermore, aldosterone in the highest tertile correlated with lower NP levels and increased mortality. Importantly, most of these associations remained significant even after excluding subjects with aldosterone levels above the normal range. In conclusion, we report that aldosterone is associated with hypertension, chronic kidney disease, obesity, metabolic syndrome, concentric left ventricular hypertrophy, and lower NPs in the general community. Our data suggest that aldosterone, even within the normal range, may be a biomarker of cardiorenal and metabolic disease. Further studies are warranted to evaluate a therapeutic and preventive strategy to delay the onset and progression of disease, using mineralocorticoid antagonists or chronic NP administration in high-risk subjects identified by plasma aldosterone.
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Affiliation(s)
- Alessia Buglioni
- From the Cardiorenal Research Laboratory, Division of Cardiovascular Diseases, Departments of Medicine and Health Sciences Research, College of Medicine Mayo Clinic, Rochester, MN (A.B., V.C., A.C., S.J.S., D.M.H., C.G.S., K.R.B., R.J.R., J.C.B.); and Internal Medicine and Geriatrics, Department of Clinical and Molecular Science, University "Politecnica delle Marche" and Italian National Research Centre on Aging, IRCCS/INRCA, Ancona, Italy (A.B., P.D.-F., R.S.).
| | - Valentina Cannone
- From the Cardiorenal Research Laboratory, Division of Cardiovascular Diseases, Departments of Medicine and Health Sciences Research, College of Medicine Mayo Clinic, Rochester, MN (A.B., V.C., A.C., S.J.S., D.M.H., C.G.S., K.R.B., R.J.R., J.C.B.); and Internal Medicine and Geriatrics, Department of Clinical and Molecular Science, University "Politecnica delle Marche" and Italian National Research Centre on Aging, IRCCS/INRCA, Ancona, Italy (A.B., P.D.-F., R.S.)
| | - Alessandro Cataliotti
- From the Cardiorenal Research Laboratory, Division of Cardiovascular Diseases, Departments of Medicine and Health Sciences Research, College of Medicine Mayo Clinic, Rochester, MN (A.B., V.C., A.C., S.J.S., D.M.H., C.G.S., K.R.B., R.J.R., J.C.B.); and Internal Medicine and Geriatrics, Department of Clinical and Molecular Science, University "Politecnica delle Marche" and Italian National Research Centre on Aging, IRCCS/INRCA, Ancona, Italy (A.B., P.D.-F., R.S.)
| | - S Jeson Sangaralingham
- From the Cardiorenal Research Laboratory, Division of Cardiovascular Diseases, Departments of Medicine and Health Sciences Research, College of Medicine Mayo Clinic, Rochester, MN (A.B., V.C., A.C., S.J.S., D.M.H., C.G.S., K.R.B., R.J.R., J.C.B.); and Internal Medicine and Geriatrics, Department of Clinical and Molecular Science, University "Politecnica delle Marche" and Italian National Research Centre on Aging, IRCCS/INRCA, Ancona, Italy (A.B., P.D.-F., R.S.)
| | - Denise M Heublein
- From the Cardiorenal Research Laboratory, Division of Cardiovascular Diseases, Departments of Medicine and Health Sciences Research, College of Medicine Mayo Clinic, Rochester, MN (A.B., V.C., A.C., S.J.S., D.M.H., C.G.S., K.R.B., R.J.R., J.C.B.); and Internal Medicine and Geriatrics, Department of Clinical and Molecular Science, University "Politecnica delle Marche" and Italian National Research Centre on Aging, IRCCS/INRCA, Ancona, Italy (A.B., P.D.-F., R.S.)
| | - Christopher G Scott
- From the Cardiorenal Research Laboratory, Division of Cardiovascular Diseases, Departments of Medicine and Health Sciences Research, College of Medicine Mayo Clinic, Rochester, MN (A.B., V.C., A.C., S.J.S., D.M.H., C.G.S., K.R.B., R.J.R., J.C.B.); and Internal Medicine and Geriatrics, Department of Clinical and Molecular Science, University "Politecnica delle Marche" and Italian National Research Centre on Aging, IRCCS/INRCA, Ancona, Italy (A.B., P.D.-F., R.S.)
| | - Kent R Bailey
- From the Cardiorenal Research Laboratory, Division of Cardiovascular Diseases, Departments of Medicine and Health Sciences Research, College of Medicine Mayo Clinic, Rochester, MN (A.B., V.C., A.C., S.J.S., D.M.H., C.G.S., K.R.B., R.J.R., J.C.B.); and Internal Medicine and Geriatrics, Department of Clinical and Molecular Science, University "Politecnica delle Marche" and Italian National Research Centre on Aging, IRCCS/INRCA, Ancona, Italy (A.B., P.D.-F., R.S.)
| | - Richard J Rodeheffer
- From the Cardiorenal Research Laboratory, Division of Cardiovascular Diseases, Departments of Medicine and Health Sciences Research, College of Medicine Mayo Clinic, Rochester, MN (A.B., V.C., A.C., S.J.S., D.M.H., C.G.S., K.R.B., R.J.R., J.C.B.); and Internal Medicine and Geriatrics, Department of Clinical and Molecular Science, University "Politecnica delle Marche" and Italian National Research Centre on Aging, IRCCS/INRCA, Ancona, Italy (A.B., P.D.-F., R.S.)
| | - Paolo Dessì-Fulgheri
- From the Cardiorenal Research Laboratory, Division of Cardiovascular Diseases, Departments of Medicine and Health Sciences Research, College of Medicine Mayo Clinic, Rochester, MN (A.B., V.C., A.C., S.J.S., D.M.H., C.G.S., K.R.B., R.J.R., J.C.B.); and Internal Medicine and Geriatrics, Department of Clinical and Molecular Science, University "Politecnica delle Marche" and Italian National Research Centre on Aging, IRCCS/INRCA, Ancona, Italy (A.B., P.D.-F., R.S.)
| | - Riccardo Sarzani
- From the Cardiorenal Research Laboratory, Division of Cardiovascular Diseases, Departments of Medicine and Health Sciences Research, College of Medicine Mayo Clinic, Rochester, MN (A.B., V.C., A.C., S.J.S., D.M.H., C.G.S., K.R.B., R.J.R., J.C.B.); and Internal Medicine and Geriatrics, Department of Clinical and Molecular Science, University "Politecnica delle Marche" and Italian National Research Centre on Aging, IRCCS/INRCA, Ancona, Italy (A.B., P.D.-F., R.S.)
| | - John C Burnett
- From the Cardiorenal Research Laboratory, Division of Cardiovascular Diseases, Departments of Medicine and Health Sciences Research, College of Medicine Mayo Clinic, Rochester, MN (A.B., V.C., A.C., S.J.S., D.M.H., C.G.S., K.R.B., R.J.R., J.C.B.); and Internal Medicine and Geriatrics, Department of Clinical and Molecular Science, University "Politecnica delle Marche" and Italian National Research Centre on Aging, IRCCS/INRCA, Ancona, Italy (A.B., P.D.-F., R.S.)
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Lantis AC, Ames MK, Atkins CE, DeFrancesco TC, Keene BW, Werre SR. Aldosterone breakthrough with benazepril in furosemide-activated renin-angiotensin-aldosterone system in normal dogs. J Vet Pharmacol Ther 2014; 38:65-73. [PMID: 25224804 DOI: 10.1111/jvp.12154] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 06/28/2014] [Indexed: 11/29/2022]
Abstract
Pilot studies in our laboratory revealed that furosemide-induced renin-angiotensin-aldosterone system (RAAS) activation was not attenuated by the subsequent co-administration of benazepril. This study was designed to evaluate the effect of benazepril on angiotensin-converting enzyme (ACE) activity and furosemide-induced circulating RAAS activation. Our hypothesis was that benazepril suppression of ACE activity would not suppress furosemide-induced circulating RAAS activation, indicated by urinary aldosterone concentration. Ten healthy hound dogs were used in this study. The effect of furosemide (2 mg/kg p.o., q12h; Group F; n = 5) and furosemide plus benazepril (1 mg/kg p.o., q24h; Group FB; n = 5) on circulating RAAS was determined by plasma ACE activity, 4-6 h posttreatment, and urinary aldosterone to creatinine ratio (UAldo:C) on days -1, -2, 1, 3, and 7. There was a significant increase in the average UAldo:C (μg/g) after the administration of furosemide (Group F baseline [average of days -1 and -2] UAldo:C = 0.41, SD 0.15; day 1 UAldo:C = 1.1, SD 0.56; day 3 UAldo:C = 0.85, SD 0.50; day 7 UAldo:C = 1.1, SD 0.80, P < 0.05). Benazepril suppressed ACE activity (U/L) in Group FB (Group FB baseline ACE = 16.4, SD 4.2; day 1 ACE = 3.5, SD 1.4; day 3 ACE = 1.6, SD 1.3; day 7 ACE = 1.4, SD 1.4, P < 0.05) but did not significantly reduce aldosterone excretion (Group FB baseline UAldo:C = 0.35, SD 0.16; day 1 UAldo:C = 0.79, SD 0.39; day 3 UAldo:C 0.92, SD 0.48, day 7 UAldo:C = 0.99, SD 0.48, P < 0.05). Benazepril decreased plasma ACE activity but did not prevent furosemide-induced RAAS activation, indicating aldosterone breakthrough (escape). This is particularly noteworthy in that breakthrough is observed at the time of initiation of RAAS suppression, as opposed to developing after months of therapy.
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Affiliation(s)
- A C Lantis
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
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165
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de Faria AP, Modolo R, Fontana V, Moreno H. Adipokines: novel players in resistant hypertension. J Clin Hypertens (Greenwich) 2014; 16:754-9. [PMID: 25186286 DOI: 10.1111/jch.12399] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 05/08/2014] [Accepted: 05/12/2014] [Indexed: 12/27/2022]
Abstract
Resistant hypertension (RH) is a multifactorial disease, frequently associated with obesity and characterized by blood pressure above goal (140/90 mm Hg) despite the concurrent use of ≥3 antihypertensive drugs of different classes. The mechanisms of obesity-related hypertension include, among others, aldosterone excess and inflammatory adipokines, which have demonstrated a significant role in the pathogenesis of metabolic syndrome and RH. This review aims to summarize recent studies on the role of the adipokines leptin, resistin, and adiponectin in the pathophysiology of RH and target-organ damage associated with this condition. The deregulation of adipokine levels has been associated with clinical characteristics frequently recognized in RH such as diabetes, hyperactivity of sympathetic and renin-angiotensin-aldosterone systems, and vascular and renal damage. Strategies to regulate adipokines may be promising for the management of RH and some clinical implications must be considered when managing controlled and uncontrolled patients with RH.
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Affiliation(s)
- Ana Paula de Faria
- Department of Pharmacology, Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
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166
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Sinnakirouchenan R, Kotchen TA. Role of Sodium Restriction and Diuretic Therapy for “Resistant” Hypertension in Chronic Kidney Disease. Semin Nephrol 2014; 34:514-9. [DOI: 10.1016/j.semnephrol.2014.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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167
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Reed BN, Street SE, Jensen BC. Time and technology will tell: the pathophysiologic basis of neurohormonal modulation in heart failure. Heart Fail Clin 2014; 10:543-57. [PMID: 25217430 DOI: 10.1016/j.hfc.2014.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The central roles of neurohormonal abnormalities in the pathobiology of heart failure have been defined in recent decades. Experiments have revealed both systemic involvement and intricate subcellular regulation by circulating effectors of the sympathetic nervous system, the renin-angiotensin-aldosterone system, and others. Randomized clinical trials substantiated these findings, establishing neurohormonal antagonists as cornerstones of heart failure pharmacotherapy, and occasionally offering further insight on mode of benefit. This review discusses the use of β-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and aldosterone receptor antagonists in the treatment of heart failure, with particular attention to the pathophysiologic basis and mechanisms of action.
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Affiliation(s)
- Brent N Reed
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, 20 North Pine Street, Baltimore, MD 21201, USA
| | - Sarah E Street
- Department of Cell Biology and Physiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Brian C Jensen
- Division of Cardiology and McAllister Heart Institute, University of North Carolina School of Medicine, 160 Dental Circle, Chapel Hill, NC 27599-7075, USA.
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168
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Dorrance AM. Interfering with mineralocorticoid receptor activation: the past, present, and future. F1000PRIME REPORTS 2014; 6:61. [PMID: 25165560 PMCID: PMC4126546 DOI: 10.12703/p6-61] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Aldosterone is a potent mineralocorticoid produced by the adrenal gland. Aldosterone binds to and activates the mineralocorticoid receptor (MR) in a plethora of tissues, but the cardiovascular actions of aldosterone are of primary interest clinically. Although MR antagonists were developed as antihypertensive agents, they are now considered to be important therapeutic options for patients with heart failure. Specifically, blocking only the MR has proven to be a difficult task because of its similarity to other steroid receptors, including the androgen and progesterone receptors. This lack of specificity caused the use of the first-generation mineralocorticoid receptor antagonists to be fraught with difficulty because of the side effects produced by drug administration. However, in recent years, several advances have been made that could potentially increase the clinical use of agents that inhibit the actions of aldosterone. These will be discussed here along with some examples of the beneficial effects of these new therapeutic agents.
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Kawada N, Isaka Y, Kitamura H, Rakugi H, Moriyama T. A pilot study of the effects of eplerenone add-on therapy in patients taking renin-angiotensin system blockers. J Renin Angiotensin Aldosterone Syst 2014; 16:360-5. [PMID: 24961502 DOI: 10.1177/1470320314532509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
HYPOTHESIS This study determined the parameters for predicting the clinical effects of eplerenone (Ep) add-on therapy on blood pressure (BP) and proteinuria in patients taking angiotensin-converting enzyme inhibitors (ACEis) or angiotensin II type I receptor blockers (ARBs). MATERIALS AND METHODS Patients were treated with a gradual increase of Ep to a final dose of 50 mg/day for 2 months. In 35 patients, the efficacy of Ep was evaluated by peripheral BP, proteinuria, and the transtubular K gradient (TTKG). Fifteen patients had additional analysis for central BP, plasma renin activity (PRA) and plasma aldosterone concentration (PAC), measured in the supine position, and 24-hour urine collection before and after receiving Ep. RESULTS Ep add-on therapy reduced the mean arterial pressure (p=0.0005) and central BP (p=0.009) independently to the baseline PAC. Ep induced PRA, but failed to show effects on PAC, TTKG, or albuminuria. Correlation analysis showed inverse relationships between the percent reduction in albuminuria and baseline PAC. CONCLUSIONS Ep add-on therapy in patients taking renin-angiotensin system blockers is expected to reduce BP, even in patients with low PAC. In contrast, the anti-proteinuric action of Ep is dependent on baseline plasma aldosterone levels. TTKG is not appropriate for evaluating the efficacy of Ep.
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Affiliation(s)
| | - Yoshitaka Isaka
- Division of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Japan
| | - Harumi Kitamura
- Division of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Japan
| | - Hiromi Rakugi
- Division of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Japan
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170
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Maliha G, Townsend RR. An Update on Treatment Options for Drug Resistant Hypertension. CURRENT CARDIOVASCULAR RISK REPORTS 2014. [DOI: 10.1007/s12170-014-0394-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Hypertension is an established risk factor for stroke, premature coronary artery disease and heart failure. Control of elevated blood pressure has been shown to result in significant reduction of cardiovascular risk. Aldosterone, the final product of the renin-angiotensin-aldosterone system (RAAS), not only causes salt and water reabsorbtion in the kidneys through its effect on the mineralocorticoid hormone receptor (MR), but also an MR-independent effect, not regulated by conventional MR blockade. Although many pharmacological agents target different levels of the RAAS cascade, these generally result in elevated renin concentration and plasma renin activity. This upstream feedback response subsequently results in elevated levels of angiotensin II, a potent vasoconstrictor and stimulus to aldosterone release. This aldosterone breakthrough counteracts the long-term blood pressure-lowering effect of these agents. Therefore the development of a new class of pharmacologic agents that directly inhibit the production of aldosterone may prove clinically useful in reducing aldosterone and thereby controlling elevated blood pressure.
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Affiliation(s)
- Karl Andersen
- Cardiovascular Research Center, Landspitali the University Hospital of Iceland, IS-101, Reykjavik, Iceland,
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172
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Abstract
Although blockade of the renin-angiotensin-aldosterone system with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers has become standard therapy for chronic kidney disease (CKD), renewed interest in the role of aldosterone in mediating the injuries and progressive insults of CKD has highlighted the potential role of treatments targeting the mineralocorticoid receptor (MR). Although salt restriction is an important component of mitigating the profibrotic effects of MR activation, a growing body of literature has shown that MR antagonists, spironolactone and eplerenone, can reduce proteinuria and blood pressure in patients at all stages of CKD. These agents carry a risk of hyperkalemia, but this risk likely can be predicted based on baseline renal function and mitigated using dietary modifications and adjustments of concomitant medications. Data on hard outcomes, such as progression to end-stage renal disease and overall mortality, still are lacking in patients with CKD.
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Affiliation(s)
- Jamie S Hirsch
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Yelena Drexler
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Andrew S Bomback
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, NY.
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Derad I, Sayk F, Lehnert H, Marshall L, Born J, Nitschke M. Intranasal Angiotensin II in Humans Reduces Blood Pressure When Angiotensin II Type 1 Receptors Are Blocked. Hypertension 2014; 63:762-7. [DOI: 10.1161/hypertensionaha.113.02860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intranasal administration of angiotensin II (ANGII) affects blood pressure in a mode different from intravenously administered ANGII via a direct access to the brain bypassing the blood–brain barrier. This clinical study investigated blood pressure regulation after intranasal ANGII administration in healthy humans, whereas systemic, blood-mediated effects of ANGII were specifically blocked. In a balanced crossover design, men (n=8) and women (n=8) were intranasally administered ANGII (400 μg) or placebo after ANGII type 1 receptors had been blocked by pretreatment with valsartan (80 mg; 12 and 6 hours before intranasal administration). Plasma levels of ANGII, aldosterone, renin, vasopressin, and norepinephrine were measured; blood pressure and heart rate were recorded continuously. Intranasal ANGII acutely decreased blood pressure without altering the heart rate. Plasma levels of vasopressin and norepinephrine remained unaffected. Plasma ANGII levels were increased throughout the recording period. Aldosterone levels increased despite the peripheral ANGII type 1 receptor blockade, indicating an aldosterone escape phenomenon. In conclusion, intranasal ANGII reduces blood pressure in the presence of selective ANGII type 1 receptor blockade. Intranasal ANGII administration represents a useful approach for unraveling the role of this peptide in blood pressure regulation in humans.
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Affiliation(s)
- Inge Derad
- From the Department of Internal Medicine (I.D., F.S., H.L., M.N.) and Department of Neuroendocrinology (L.M.), University of Lübeck, Lübeck, Germany; and Institute of Medical Psychology and Behavioural Neurobiology, University of Tübingen, Tübingen, Germany (J.B.)
| | - Friedhelm Sayk
- From the Department of Internal Medicine (I.D., F.S., H.L., M.N.) and Department of Neuroendocrinology (L.M.), University of Lübeck, Lübeck, Germany; and Institute of Medical Psychology and Behavioural Neurobiology, University of Tübingen, Tübingen, Germany (J.B.)
| | - Hendrik Lehnert
- From the Department of Internal Medicine (I.D., F.S., H.L., M.N.) and Department of Neuroendocrinology (L.M.), University of Lübeck, Lübeck, Germany; and Institute of Medical Psychology and Behavioural Neurobiology, University of Tübingen, Tübingen, Germany (J.B.)
| | - Lisa Marshall
- From the Department of Internal Medicine (I.D., F.S., H.L., M.N.) and Department of Neuroendocrinology (L.M.), University of Lübeck, Lübeck, Germany; and Institute of Medical Psychology and Behavioural Neurobiology, University of Tübingen, Tübingen, Germany (J.B.)
| | - Jan Born
- From the Department of Internal Medicine (I.D., F.S., H.L., M.N.) and Department of Neuroendocrinology (L.M.), University of Lübeck, Lübeck, Germany; and Institute of Medical Psychology and Behavioural Neurobiology, University of Tübingen, Tübingen, Germany (J.B.)
| | - Martin Nitschke
- From the Department of Internal Medicine (I.D., F.S., H.L., M.N.) and Department of Neuroendocrinology (L.M.), University of Lübeck, Lübeck, Germany; and Institute of Medical Psychology and Behavioural Neurobiology, University of Tübingen, Tübingen, Germany (J.B.)
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174
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Treatment Strategies to Prevent Renal Damage in Hypertensive Children. Curr Hypertens Rep 2014; 16:423. [PMID: 24522942 PMCID: PMC3960483 DOI: 10.1007/s11906-014-0423-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hypertension secondary to chronic kidney disease prevails in earlier childhood and obesity-related primary hypertension in adolescence. Both are associated with a high risk of renal and cardiovascular morbidity. In children with chronic kidney disease, uncontrolled hypertension may accelerate progression to end-stage renal disease before adulthood is reached and increase a child’s risk of cardiac death a thousand-fold. Obesity-related hypertension is a slow and silent killer, and though early markers of renal damage are recognized during childhood, end-stage renal disease is a risk in later life. Renal damage will be a formidable multiplier of cardiovascular risk for adults in whom obesity and hypertension tracks from childhood. Management options to prevent renal damage will vary for these different target groups. This review provides a summary of the available renoprotective strategies in order to aid physicians involved in the care of this challenging group of children.
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175
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Elnagar N, Satoh M, Hosaka M, Asayama K, Ishikura K, Obara T, Mano N, Ohkubo T, Imai Y. The velocity of home blood pressure reduction in response to low-dose eplerenone combined with other antihypertensive drugs determined by exponential decay function analysis. Clin Exp Hypertens 2014; 36:83-91. [DOI: 10.3109/10641963.2014.892117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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176
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Liver-specific angiotensinogen suppression: an old yet novel target for blood pressure control through RAS inhibition? Hypertens Res 2014; 37:393-4. [PMID: 24621472 DOI: 10.1038/hr.2014.54] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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177
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Measurement of plasma renin concentration instead of plasma renin activity decreases the positive aldosterone-to-renin ratio tests in treated patients with essential hypertension. J Hypertens 2014; 32:627-34. [DOI: 10.1097/hjh.0000000000000076] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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178
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Anil Kumar KV, Nagwar S, Thyloor R, Satyanarayana S. Anti-stress and nootropic activity of drugs affecting the renin-angiotensin system in rats based on indirect biochemical evidence. J Renin Angiotensin Aldosterone Syst 2014; 16:801-12. [PMID: 24496517 DOI: 10.1177/1470320313516173] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Various stress hormones are responsible for bringing out stress-related changes and are implicated in learning and memory processes. The extensive clinical experience of angiotensin receptor blockers (ARBs) and direct renin inhibitor as antihypertensive agents provides anecdotal evidence of improvements in cognition. The neurochemical basis underlying the anti-stress and nootropic effects are unclear. This study was aimed to determine the effects of aliskiren, valsartan and their combination on the neuromediators of the central nervous system (CNS) and periphery as well as on cognitive function. MATERIALS AND METHODS Groups of rats were subjected to a forced swim stress for one hour after daily treatment with aliskiren, valsartan and their combination. The 24 h urinary excretion of vanillylmandellic acid (VMA), 5-hydroxyindoleacetic acid (5-HIAA), 6-β-hydroxycortisol (6-β-OH) cortisol and homovanillic acid (HVA) was determined in all groups under normal and stressed conditions. Nootropic activity was studied using cook's pole climbing apparatus and acetylcholinesterase (AChE) inhibitory activity by Ellman's method. RESULTS Administration of aliskiren (10 mg/kg), valsartan (20 mg/kg) and their combination at a dose of 5 and 10 mg/kg respectively reduced the urinary metabolite levels. Further, all drugs showed significant improvement in scopolamine-impaired performance and produced inhibition of the AChE enzyme. CONCLUSIONS The present study provides scientific support for the anti-stress and nootropic activities of aliskiren, valsartan and their combination.
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Affiliation(s)
- K V Anil Kumar
- Department of Pharmacology, Visveswarapura Institute of Pharmaceutical Sciences, India
| | - Shrasti Nagwar
- Department of Pharmacology, Visveswarapura Institute of Pharmaceutical Sciences, India
| | - Rama Thyloor
- Department of Biotechnology, Government Science College, India
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179
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Tomey MI, Winston JA. Cardiovascular pathophysiology in chronic kidney disease: opportunities to transition from disease to health. Ann Glob Health 2013; 80:69-76. [PMID: 24751567 DOI: 10.1016/j.aogh.2013.12.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 05/01/2013] [Accepted: 12/19/2013] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is common, and is associated with a high burden of cardiovascular disease. This cardiovascular risk is incompletely explained by traditional risk factors, calling attention to a need to better understand the pathways in CKD contributing to adverse cardiovascular outcomes. FINDINGS Pathophysiological derangements associated with CKD, including disordered sodium, potassium, and water homeostasis, renin-angiotensin-aldosterone and sympathetic activity, anemia, bone and mineral metabolism, uremia, and toxin accumulation may contribute directly to progression of cardiovascular disease and adverse outcomes. CONCLUSION Improving cardiovascular health in patients with CKD requires improved understanding of renocardiac pathophysiology. Ultimately, the most successful strategy may be prevention of incident CKD itself.
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Affiliation(s)
- Matthew I Tomey
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Jonathan A Winston
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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180
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Modulation of aldosterone levels by -344 C/T CYP11B2 polymorphism and spironolactone use in resistant hypertension. ACTA ACUST UNITED AC 2013; 8:146-51. [PMID: 24388430 DOI: 10.1016/j.jash.2013.12.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 10/07/2013] [Accepted: 12/01/2013] [Indexed: 01/12/2023]
Abstract
Interindividual variability in plasma aldosterone levels comprises environmental and genetic sources. Increased aldosterone levels have been associated with higher risk of hypertension and target-organ damage related to hypertension. Aldosterone excess and intravascular volume expansion are implicated in pathophysiology of resistant hypertension (RH). We sought to investigate whether -344 C/T polymorphism (rs1799998) in aldosterone synthase gene (CYP11B2) is associated with plasma aldosterone levels in patients with resistant hypertension. Sixty-two patients with resistant hypertension were enrolled in this cross-sectional study. Genotypes were obtained by allelic discrimination assay using real time polymerase chain reaction. Multivariable linear regression was used to identify whether TT genotype was a predictor of aldosterone levels. No differences in clinical and laboratorial parameters were found among genotype groups. We found an additive effect of the T allele on plasma aldosterone concentration in RH. Also, there was higher aldosterone levels in TT homozygous under use of spironolactone compared with C carriers and compared with TT subjects who was not under use of spironolactone. TT genotype and the use of spironolactone were significant predictors of aldosterone levels in RH subjects. Plasma aldosterone concentration is significantly associated with -344 C/T CYP11B2 polymorphism and with the treatment with spironolactone in resistant hypertensive subjects.
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181
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Roscioni SS, Heerspink HJL, de Zeeuw D. The effect of RAAS blockade on the progression of diabetic nephropathy. Nat Rev Nephrol 2013; 10:77-87. [PMID: 24296623 DOI: 10.1038/nrneph.2013.251] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The renin-angiotensin-aldosterone system (RAAS) has a key role in the regulation of blood pressure, sodium and water balance, and cardiovascular and renal homeostasis. In diabetic nephropathy, excessive activation of the RAAS results in progressive renal damage. RAAS blockade using angiotensin-converting-enzyme inhibitors or angiotensin-receptor blockers is the cornerstone of treatment of diabetic renal disease. Alternative RAAS-blockade strategies include renin inhibition and aldosterone blockade. Data from small initial studies of these agents are promising. However, single-agent interventions do not fully block the RAAS and patients treated with these therapies remain at high residual renal risk. Approaches to optimize drug responses include dietary changes and increasing dosages. The theoretically attractive option of combining different RAAS interventions has also been tested in clinical trials but long-term outcomes were disappointing. However, dual RAAS blockade might represent a good therapeutic option for specific patients. A better knowledge of the pathophysiology of the RAAS is crucial to fully understand the mechanisms of action of RAAS blockers and to exploit their renoprotective effects. Moreover, lifestyle interventions or diagnostic tools might be used to optimize RAAS blockade and identify those patients who are most likely to benefit from the therapy.
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Affiliation(s)
- Sara S Roscioni
- Department of Clinical Pharmacology, University Medical Center Groningen, Antonius Deusinglaan 1, Groningen, 9713 AV, Netherlands
| | - Hiddo J Lambers Heerspink
- Department of Clinical Pharmacology, University Medical Center Groningen, Antonius Deusinglaan 1, Groningen, 9713 AV, Netherlands
| | - Dick de Zeeuw
- Department of Clinical Pharmacology, University Medical Center Groningen, Antonius Deusinglaan 1, Groningen, 9713 AV, Netherlands
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182
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Drexler YR, Bomback AS. Definition, identification and treatment of resistant hypertension in chronic kidney disease patients. Nephrol Dial Transplant 2013; 29:1327-35. [PMID: 24046194 DOI: 10.1093/ndt/gft346] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Resistant hypertension, the inability to achieve goal blood pressure despite the use of three or more appropriately dosed antihypertensive drugs (including a diuretic), remains a common clinical problem, especially in patients with chronic kidney disease (CKD). While the exact prevalence and prognosis of resistant hypertension in CKD patients remain unknown, resistant hypertension likely contributes significantly to increased cardiovascular risk and progression of kidney disease in this population. We review the identification and evaluation of patients with resistant hypertension, including the importance of 24-h ambulatory blood pressure monitoring in the identification of 'white-coat', 'masked' and 'non-dipper' hypertension, the latter of which has particular clinical and therapeutic importance in patients with resistant hypertension and CKD. We then discuss treatment strategies for resistant hypertension that target the pathophysiologic mechanisms underlying resistance to treatment, including persistent volume excess, incomplete renin-angiotensin-aldosterone system blockade and inadequate nocturnal blood pressure control. Finally, we propose a treatment algorithm for evaluation and treatment of resistant hypertension in patients with CKD.
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Affiliation(s)
- Yelena R Drexler
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Andrew S Bomback
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, NY, USA
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183
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Navaneethan SD, Bravo EL. Aldosterone breakthrough during angiotensin receptor blocker use: more questions than answers? Clin J Am Soc Nephrol 2013; 8:1637-9. [PMID: 23929926 DOI: 10.2215/cjn.07370713] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Sankar D Navaneethan
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, †Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
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Moranne O, Bakris G, Fafin C, Favre G, Pradier C, Esnault VLM. Determinants and changes associated with aldosterone breakthrough after angiotensin II receptor blockade in patients with type 2 diabetes with overt nephropathy. Clin J Am Soc Nephrol 2013; 8:1694-701. [PMID: 23929924 DOI: 10.2215/cjn.06960712] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Inhibition of the renin-angiotensin-aldosterone system decreases proteinuria and slows estimated GFR decline in patients with type 2 diabetes mellitus with overt nephropathy. Serum aldosterone levels may increase during renin-angiotensin-aldosterone system blockade. The determinants and consequences of this aldosterone breakthrough remain unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This study examined the incidence, determinants, and changes associated with aldosterone breakthrough in a posthoc analysis of a randomized study that compared the effect of two angiotensin II receptor blockers in patients with type 2 diabetes mellitus with overt nephropathy. RESULTS Of 567 of 860 participants included in this posthoc analysis, 28% of participants developed aldosterone breakthrough, which was defined by an increase greater than 10% over baseline values of serum aldosterone levels after 1 year of angiotensin II receptor blocker treatment. Factors independently associated with aldosterone breakthrough at 1 year were lower serum aldosterone and potassium levels at baseline, higher decreases in sodium intake, systolic BP, and estimated GFR from baseline to 1 year, and use of losartan versus telmisartan. Aldosterone breakthrough at 6 months was not sustained at 1 year in 69% of cases, and it did not predict estimated GFR decrease and proteinuria increase between 6 months and 1 year. CONCLUSIONS Aldosterone breakthrough is a frequent event 1 year after initiating renin-angiotensin-aldosterone system blockade, particularly in participants exposed to intensive lowering of BP with sodium depletion and short-acting angiotensin II receptor blockers. Short-term serum aldosterone level increases at 6 months are not associated with negative kidney outcomes between 6 months and 1 year.
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Affiliation(s)
- Olivier Moranne
- Nephrology and, †Epidemiology Departments, Nice University Hospital, Nice, France;, ‡ASH Comprehensive Hypertension Center, University of Chicago, Chicago, Illinois, §Institut National de la Santé et de la Recherche Médicale U1081, Nice Sophia-Antipolis University, Nice, France
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185
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Sato A, Fukuda S. Effect of aldosterone breakthrough on albuminuria during treatment with a direct renin inhibitor and combined effect with a mineralocorticoid receptor antagonist. Hypertens Res 2013; 36:879-84. [PMID: 23864056 DOI: 10.1038/hr.2013.74] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 02/28/2013] [Accepted: 03/13/2013] [Indexed: 11/09/2022]
Abstract
We have reported observing aldosterone breakthrough in the course of relatively long-term treatment with renin-angiotensin (RA) system inhibitors, where the plasma aldosterone concentration (PAC) increased following an initial decrease. Aldosterone breakthrough has the potential to eliminate the organ-protective effects of RA system inhibitors. We therefore conducted a study in essential hypertensive patients to determine whether aldosterone breakthrough occurred during treatment with the direct renin inhibitor (DRI) aliskiren and to ascertain its clinical significance. The study included 40 essential hypertensive patients (18 men and 22 women) who had been treated for 12 months with aliskiren. Aliskiren significantly decreased blood pressure and plasma renin activity (PRA). The PAC was also decreased significantly at 3 and 6 months; however, the significant difference disappeared after 12 months. Aldosterone breakthrough was observed in 22 of the subjects (55%). Urinary albumin excretion differed depending on whether breakthrough occurred. For the subjects in whom aldosterone breakthrough was observed, eplerenone was added. A significant decrease in urinary albumin excretion was observed after 1 month, independent of changes in blood pressure. In conclusion, this study demonstrated that aldosterone breakthrough occurs in some patients undergoing DRI therapy. Aldosterone breakthrough affects the drug's ability to improve urinary albumin excretion, and combining a mineralocorticoid receptor antagonist with the DRI may be useful for decreasing urinary albumin excretion. When the objective is organ protection in hypertensive patients, a two-pronged approach using combination therapy to inhibit both the RA system and aldosterone may be highly effective.
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Affiliation(s)
- Atsuhisa Sato
- Department of Internal Medicine, International University of Health and Welfare Mita Hospital, Tokyo, Japan
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186
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Girerd N, Pang PS, Swedberg K, Fought A, Kwasny MJ, Subacius H, Konstam MA, Maggioni A, Gheorghiade M, Zannad F. Serum aldosterone is associated with mortality and re-hospitalization in patients with reduced ejection fraction hospitalized for acute heart failure: analysis from the EVEREST trial. Eur J Heart Fail 2013; 15:1228-35. [PMID: 23787720 DOI: 10.1093/eurjhf/hft100] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Post-discharge morbidity and mortality for acute heart failure (AHF) patients remains high. Although the adverse effects of neurohormonal activation are well known in chronic HF, the prognostic significance of serum aldosterone in patients hospitalized for AHF has not been well studied. METHODS AND RESULTS A secondary analysis was carried out of the placebo arm (n = 1850) from the EVEREST trial which had aldosterone measured at baseline. All patients were hospitalized for worsening HF and had an LVEF <40%. The median follow-up was 9.9 months. The association between serum aldosterone levels at baseline and the independently adjudicated outcomes [all-cause mortality (ACM) and the combined outcome of cardiovascular mortality (CVM) and HF re-hospitalization] were explored with multivariable Cox models. Median aldosterone levels increased during the hospital stay from 11 ng/dL at baseline to 15 ng/dL at discharge (P < 0.001) and remained increased after discharge (16 ng/dL at 24 weeks, P < 0.001). After adjusting for potential confounders, higher baseline aldosterone levels were associated with an increased risk for ACM and CVM or HF re-hospitalization [hazard ratio (HR) 1.49, 95% confidence intrerval (CI) 1.11-1.99; and HR 1.40, 95% CI 1.11-1.78, respectively, in the highest quartile when compared with the lowest]. CONCLUSION In patients with LVEF <40% hospitalized for AHF and receiving standard therapy, serum aldosterone levels correlated with worse post-discharge outcomes. Aldosterone levels increase during AHF hospitalization and remain increased long after discharge. These results suggest that further modulation of the renin-angiotensin-aldosterone system in patients admitted with worsening HF might favourably improve post-discharge outcomes.
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Affiliation(s)
- Nicolas Girerd
- INSERM, Centre d'Investigations Cliniques 9501, Université de Lorraine, CHU de Nancy, Institut Lorrain du cœur et des vaisseaux, Nancy, France
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187
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Hovater MB, Jaimes EA. Optimizing combination therapy in the management of hypertension: the role of the aliskiren, amlodipine, and hydrochlorothiazide fixed combination. Integr Blood Press Control 2013; 6:59-67. [PMID: 23837008 PMCID: PMC3699292 DOI: 10.2147/ibpc.s32649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
High blood pressure is the leading risk factor for death and disability worldwide, and the prevalence is increasing. Effective treatment decreases the risk of adverse events in proportion to blood pressure reduction. Combination antihypertensive therapy reduces blood pressure promptly and effectively. Single-pill combinations reduce the pill burden and improve adherence, efficacy, and tolerability of treatment compared with single drug pills. A significant portion of the hypertensive population will require three drugs for adequate control. The single-pill combination of aliskiren, amlodipine, and hydrochlorothiazide is based on complementary mechanisms of action. Clinical trials have shown it to be a safe and effective treatment for hypertension. This combination is a reasonable choice in clinical practice for patients with hypertension that requires three drugs for effective treatment.
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Affiliation(s)
- Michael B Hovater
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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188
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Whaley-Connell A, Habibi J, Rehmer N, Ardhanari S, Hayden MR, Pulakat L, Krueger C, Ferrario CM, DeMarco VG, Sowers JR. Renin inhibition and AT(1)R blockade improve metabolic signaling, oxidant stress and myocardial tissue remodeling. Metabolism 2013; 62:861-72. [PMID: 23352204 PMCID: PMC3640616 DOI: 10.1016/j.metabol.2012.12.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 11/30/2012] [Accepted: 12/19/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Strategies that block angiotensin II actions on its angiotensin type 1 receptor or inhibit actions of aldosterone have been shown to reduce myocardial hypertrophy and interstitial fibrosis in states of insulin resistance. Thereby, we sought to determine if combination of direct renin inhibition with angiotensin type 1 receptor blockade in vivo, through greater reductions in systolic blood pressure (SBP) and aldosterone would attenuate left ventricular hypertrophy and interstitial fibrosis to a greater extent than either intervention alone. MATERIALS/METHODS We utilized the transgenic Ren2 rat which manifests increased tissue expression of murine renin which, in turn, results in increased renin-angiotensin system activity, aldosterone secretion and insulin resistance. Ren2 rats were treated with aliskiren, valsartan, the combination (aliskiren+valsartan), or vehicle for 21 days. RESULTS Compared to Sprague-Dawley controls, Ren2 rats displayed increased systolic blood pressure, elevated serum aldosterone levels, cardiac tissue hypertrophy, interstitial fibrosis and ultrastructural remodeling. These biochemical and functional alterations were accompanied by increases in the NADPH oxidase subunit Nox2 and 3-nitrotyrosine content along with increases in mammalian target of rapamycin and reductions in protein kinase B phosphorylation. Combination therapy contributed to greater reductions in systolic blood pressure and serum aldosterone but did not result in greater improvement in metabolic signaling or markers of oxidative stress, fibrosis or hypertrophy beyond either intervention alone. CONCLUSIONS Thereby, our data suggest that the greater impact of combination therapy on reductions in aldosterone does not translate into greater reductions in myocardial fibrosis or hypertrophy in this transgenic model of tissue renin overexpression.
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Affiliation(s)
- Adam Whaley-Connell
- Research Service, Harry S. Truman Memorial Veterans Hospital, 800 Hospital Drive, Columbia, MO 65201, USA.
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189
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Boesby L, Elung-Jensen T, Strandgaard S, Kamper AL. Eplerenone attenuates pulse wave reflection in chronic kidney disease stage 3-4--a randomized controlled study. PLoS One 2013; 8:e64549. [PMID: 23704994 PMCID: PMC3660355 DOI: 10.1371/journal.pone.0064549] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2012] [Accepted: 04/16/2013] [Indexed: 11/18/2022] Open
Abstract
Background Patients with chronic kidney disease (CKD) have high cardiovascular mortality and morbidity associated with increased arterial stiffness. Plasma aldosterone levels are increased in CKD, and aldosterone has been found to increase vascular inflammation and fibrosis. It was hypothesized that aldosterone receptor inhibition with eplerenone could reduce arterial stiffness in CKD stage 3–4. Study Design The design was randomized, open, parallel group. Measurements of arterial stiffness markers were undertaken at weeks 1 and 24. Intervention 24 weeks of add-on treatment with 25–50 mg eplerenone or standard medication. Outcomes Primary outcome parameter was carotid-femoral pulse wave velocity (cfPWV). Secondary outcomes were augmentation index (AIx), ambulatory arterial stiffness index (AASI) and urinary albumin excretion. Results Fifty-four CKD patients (mean eGFR 36 mL/min/1.73 m2, SD 11) were randomized. Forty-six patients completed the trial. The mean difference in cfPWV changes between groups was 0.1 m/s (95%CI: −1.0, 1.3), P = 0.8. The mean difference in AIx changes between groups was 4.4% (0.1, 8.6), P = 0.04. AASI was unchanged in both groups. The ratio of change in urinary albumin excretion in the eplerenone group compared to the control was 0.61 (0.37, 1.01), P = 0.05. Four patients were withdrawn from the eplerenone group including three because of possible side effects; one was withdrawn from the control group. Mild hyperkalemia was seen on three occasions and was easily managed. Limitations The full planned number of patients was not attained. The duration of the trial may have been too short to obtain full effect of eplerenone on the arteries. Conclusions Add-on treatment with eplerenone in CKD stage 3–4 did not significantly reduce cfPWV. There may be beneficial vascular effects leading to attenuated pulse wave reflection. Treatment was well-tolerated. Trial Registration ClinicalTrials.govNCT01100203
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Affiliation(s)
- Lene Boesby
- Department of Nephrology, Herlev Hospital, University of Copenhagen, Herlev, Denmark.
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190
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von Lueder TG, Sangaralingham SJ, Wang BH, Kompa AR, Atar D, Burnett JC, Krum H. Renin-angiotensin blockade combined with natriuretic peptide system augmentation: novel therapeutic concepts to combat heart failure. Circ Heart Fail 2013; 6:594-605. [PMID: 23694773 PMCID: PMC3981104 DOI: 10.1161/circheartfailure.112.000289] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Thomas G. von Lueder
- Monash Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC 3004, Australia
- Department of Cardiology B, Oslo University Hospital Ullevål, 0407 Oslo and Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Norway
| | - S. Jeson Sangaralingham
- Cardiorenal Research Laboratory, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA
| | - Bing H. Wang
- Monash Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC 3004, Australia
| | - Andrew R. Kompa
- Monash Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC 3004, Australia
| | - Dan Atar
- Department of Cardiology B, Oslo University Hospital Ullevål, 0407 Oslo and Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Norway
| | - John C. Burnett
- Cardiorenal Research Laboratory, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA
| | - Henry Krum
- Monash Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC 3004, Australia
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191
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Circulating aldosterone and mortality in female nursing home residents. Exp Gerontol 2013; 48:313-8. [DOI: 10.1016/j.exger.2013.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Revised: 12/11/2012] [Accepted: 01/07/2013] [Indexed: 11/19/2022]
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192
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Ishimitsu T, Ohta S, Ohno E, Takahashi T, Numabe A, Okamura A, Ohba S, Hashimoto A, Matsuoka H. Long-term antihypertensive effects of aliskiren, a direct renin inhibitor, in chronic hemodialysis patients. Ther Apher Dial 2013; 17:524-31. [PMID: 24107281 DOI: 10.1111/1744-9987.12017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The renin-angiotensin-aldosterone system is not necessarily suppressed in end-stage renal disease patients undergoing dialysis. Of all the inhibitors of this system, the clinical efficacy of the renin inhibitor, aliskiren, has not been well demonstrated in dialysis patients. We evaluated the antihypertensive effect of aliskiren, administered as a single daily dose of 150 mg for 24 weeks, in 23 chronic hemodialysis patients (age 65 ± 12 years, 15 men and eight women) with blood pressure ≥140/90 mm Hg, and assessed the factors relating to blood pressure reduction. At 4 weeks, the average systolic blood pressure before the dialysis session was insignificantly reduced from 163 ± 10 mm Hg to 160 ± 15 mm Hg, while it was significantly lowered at 12 (154 ± 13 mm Hg) and 24 weeks (155 ± 10 mm Hg), although the pulse rate was not significantly altered. Serum K increased at 24 weeks from 4.9 ± 0.6 mEq/L to 5.2 ± 0.8 mEq/L. Only 10 out of 23 patients showed systolic blood pressure reduction by ≥10 mm Hg. Naturally, plasma renin immunoreactivity increased, while plasma renin activity, along with angiotensin II and aldosterone levels decreased. Basal levels of the components of the renin-angiotensin-aldosterone system were not significantly different in patients showing systolic blood pressure reduction by ≥10 mm Hg (n = 10) vs. those with <10 mm Hg changes (n = 13). The reduction in systolic blood pressure in all 23 patients taken as a whole correlated with changes in plasma renin activity (r = -0.432, P < 0.05) and angiotensin II (r = 0.467, P < 0.05). In chronic hemodialysis patients, aliskiren modestly lowers blood pressure over the long term, although the antihypertensive effect seems dependent on the changes, but not on the basal levels of plasma renin activity and angiotensin II.
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Affiliation(s)
- Toshihiko Ishimitsu
- Department of Cardiology and Nephrology, Dokkyo Medical University, Mibu, Japan
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193
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Atkins CE, Lantis AC, Ames MK, Gardner SY. Utility of urinary aldosterone measurement in quantitating RAAS activation. J Vet Pharmacol Ther 2013; 35:512-5; author reply 516-8. [PMID: 22966900 DOI: 10.1111/jvp.12011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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194
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Thomas MC. Emerging drugs for managing kidney disease in patients with diabetes. Expert Opin Emerg Drugs 2013; 18:55-70. [PMID: 23330907 DOI: 10.1517/14728214.2013.762356] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION The need for new approaches to manage the increasing numbers of patients with diabetes and their burden of complications is urgent. Of these, chronic kidney disease imposes some of the highest costs, both in dollars and in terms of human suffering. In individuals with diabetes, the presence and severity of kidney disease adversely affects their well-being, contributes to disease morbidity and increases their risk of a premature death. AREAS COVERED To collect information for the strategies previously or currently under investigation for managing kidney disease in patients with diabetes, a literature search was performed through the search engines PubMed and ClinicalTrials.gov. EXPERT OPINION Despite advancing knowledge on the pathogenesis of diabetic kidney disease, and promising effects in experimental models, at present there are no new drugs that come close to providing the solutions we desire for our patients. Even when used in combination with standard care, renal complications are at best only modestly reduced, at the considerable expense of additional pill burden and exposure to serious off-target effects. Some of the most exciting advances over the last decade, including thiazolidinediones, direct renin inhibitors, endothelin antagonists and most recently bardoxolone methyl have all fallen at this last hurdle. Better targeted ('smarter') drugs appear to be the best hope for renoprotective therapy.
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Affiliation(s)
- Merlin C Thomas
- Baker IDI Heart and Diabetes Institute, St Kilda Rd Central, PO Box 6492, Melbourne, VIC 8008, Australia.
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195
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Abstract
Inhibition of the RAAS (renin–angiotensin–aldosterone system) plays a pivotal role in the prevention and treatment of diabetic nephropathy and a spectrum of other proteinuric kidney diseases. 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 reasons for unsatisfactory therapeutic responses to RAAS inhibition in some patients. Inhibition of renin, a rate-limiting step in the RAAS activation cascade, could overcome at least some of the abovementioned problems associated with the treatment with traditional RAAS inhibitors. The present review focuses on experimental and clinical studies evaluating the two principal approaches to renin inhibition, namely direct renin inhibition with aliskiren and inhibition of the (pro)renin receptor. Moreover, the possibilities of renin inhibition and nephroprotection by interventions primarily aiming at non-RAAS targets, such as vitamin D, urocortins or inhibition of the succinate receptor GPR91 and cyclo-oxygenase-2, are also discussed.
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196
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Chapter 2: Lifestyle and pharmacological treatments for lowering blood pressure in CKD ND patients. Kidney Int Suppl (2011) 2012; 2:347-356. [PMID: 25018961 PMCID: PMC4089631 DOI: 10.1038/kisup.2012.52] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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198
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Chapter 8: Future directions and controversies. Kidney Int Suppl (2011) 2012; 2:382-387. [PMID: 25018966 PMCID: PMC4089610 DOI: 10.1038/kisup.2012.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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199
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Educational paper: Progression in chronic kidney disease and prevention strategies. Eur J Pediatr 2012; 171:1579-88. [PMID: 22968936 DOI: 10.1007/s00431-012-1814-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 07/31/2012] [Indexed: 12/17/2022]
Abstract
Chronic kidney disease (CKD) in children is a rare but devastating condition. Once a critical amount of nephron mass has been lost, progression of CKD is irreversible and results in end-stage renal disease (ESRD) and need of renal replacement therapy. The time course of childhood CKD is highly variable. While in children suffering from congenital anomalies of the kidneys and the urinary tract, progression of CKD in general is slow, in children with acquired glomerulopathies, disease progression can be accelerated resulting in ESRD within months. However, irrespective of the underlying kidney disease, hypertension and proteinuria are independent risk factors for progression. Thus, in order to prevent progression, the primary objective of treatment should always aim for efficient control of blood pressure and reduction of urinary protein excretion. Blockade of the renin-angiotensin-aldosterone system preserves kidney function not only by lowering blood pressure, but also by reducing proteinuria and exerting additional anti-proteinuric, anti-fibrotic, and anti-inflammatory effects. Besides, intensified blood pressure control, aiming for a target blood pressure below the 50th percentile, may exert additive renoprotective effects. Additionally, other modifiable risk factors, such as anemia, metabolic acidosis, dyslipidemia, and altered bone-mineral homeostasis may also contribute to CKD progression. In conclusion, beyond strict blood pressure control and reduction of urinary protein excretion, identification and treatment of both, renal disease-related and conventional risk factors are mandatory in children with CKD in order to prevent deterioration of kidney function.
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200
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Management of hyperkalaemia consequent to mineralocorticoid-receptor antagonist therapy. Nat Rev Nephrol 2012; 8:691-9. [DOI: 10.1038/nrneph.2012.217] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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