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Dey S, Garg J, Wang A, Holzner E, Frishman WH, Aronow WS. Finerenone: Efficacy of a New Nonsteroidal Mineralocorticoid Receptor Antagonist in Treatment of Patients With Chronic Kidney Disease and Type 2 Diabetes. Cardiol Rev 2024; 32:285-288. [PMID: 36946916 DOI: 10.1097/crd.0000000000000548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Mineralocorticoid receptor stimulation by aldosterone can cause various cardiovascular and renal disease complications. Finerenone is a new oral nonsteroidal mineralocorticoid receptor antagonist that has been approved for clinical use by the Federal Drug Aministration, and has been shown in clinical trials to reduce the risk of sustained estimated glomerular filtration rate decline, end-stage renal disease, nonfatal myocardial infarction, hospitalization for heart failure and cardiovascular death in adult patients with chronic kidney disease associated with type 2 diabetes. The drug has also been shown to have fewer side effects than the steroidal mineralocorticoid receptor antagonists like spironolactone and eplerenone. In this review article, the authors will discuss the clinical pharmacology of finerenone, its clinical application and the additional studies that are now underway to further assess the efficacy of the drug in diabetic patients having cardiac and renal disease.
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Affiliation(s)
- Subo Dey
- From the Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Jasmine Garg
- From the Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Andy Wang
- From the Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Eva Holzner
- Department of Family Medicine, SUNY Downstate, Brooklyn, NY
| | - William H Frishman
- From the Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- From the Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
- Departments of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
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Quiroz-Aldave JE, Gamarra-Osorio ER, Durand-Vásquez MDC, Rafael-Robles LDP, Gonzáles-Yovera JG, Quispe-Flores MA, Concepción-Urteaga LA, Román-González A, Paz-Ibarra J, Concepción-Zavaleta MJ. From liver to hormones: The endocrine consequences of cirrhosis. World J Gastroenterol 2024; 30:1073-1095. [PMID: 38577191 PMCID: PMC10989500 DOI: 10.3748/wjg.v30.i9.1073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 01/02/2024] [Accepted: 02/06/2024] [Indexed: 03/06/2024] Open
Abstract
Hepatocrinology explores the intricate relationship between liver function and the endocrine system. Chronic liver diseases such as liver cirrhosis can cause endocrine disorders due to toxin accumulation and protein synthesis disruption. Despite its importance, assessing endocrine issues in cirrhotic patients is frequently neglected. This article provides a comprehensive review of the epidemiology, pathophysiology, diagnosis, and treatment of endocrine disturbances in liver cirrhosis. The review was conducted using the PubMed/Medline, EMBASE, and Scielo databases, encompassing 172 articles. Liver cirrhosis is associated with endocrine disturbances, including diabetes, hypoglycemia, sarcopenia, thyroid dysfunction, hypogonadotropic hypogonadism, bone disease, adrenal insufficiency, growth hormone dysfunction, and secondary hyperaldosteronism. The optimal tools for diagnosing diabetes and detecting hypoglycemia are the oral glucose tolerance test and continuous glucose monitoring system, respectively. Sarcopenia can be assessed through imaging and functional tests, while other endocrine disorders are evaluated using hormonal assays and imaging studies. Treatment options include metformin, glucagon-like peptide-1 analogs, sodium-glucose co-transporter-2 inhibitors, and insulin, which are effective and safe for diabetes control. Established standards are followed for managing hypoglycemia, and hormone replacement therapy is often necessary for other endocrine dysfunctions. Liver transplantation can address some of these problems.
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Affiliation(s)
| | | | | | | | | | | | | | - Alejandro Román-González
- Department of Endocrinology, Hospital Universitario de San Vicente Fundación, Medellin 050010, Colombia
- Internal Medicine, Universidad de Antioquia, Medellín 050010, Colombia
| | - José Paz-Ibarra
- School of Medicine, Universidad Nacional Mayor de San Marcos, Lima 15081, Peru
- Department of Endocrinology, Hospital Nacional Edgardo Rebagliati Martins, Lima 15072, Peru
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Natalia B, Tomasz M, Ewa C, Anna GP. Sex-dependent effects of finerenone on hemostasis in normoglycemic and streptozotocin-induced diabetic mice. Biomed Pharmacother 2023; 169:115910. [PMID: 38006618 DOI: 10.1016/j.biopha.2023.115910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 11/27/2023] Open
Abstract
Diabetes is associated with aldosterone excess and the overactivation of its mineralocorticoid receptor (MR) which leads to the development of many cardiovascular dysfunctions. Therefore, MR antagonists have been found to exert favorable effects on the cardiovascular system. Finerenone is a new nonsteroidal MR antagonist approved for the treatment of chronic kidney disease associated with type 2 diabetes. Clinical studies have demonstrated that finerenone improves cardiovascular outcomes. However, its influence on hemostasis in the cardioprotective effect is unknown. Therefore, the main aim of our study was to evaluate the effects of finerenone (10 mg/kg, p.o.) on selected hemostasis parameters in streptozotocin (180 mg/kg, i.p.)-induced diabetes. Since regulation of the MR activity is sex-dependent, the study was conducted in both female and male mice. The most beneficial effects of finerenone were observed in diabetic female mice which included a decrease in thrombus formation, attenuation of platelet activity, inhibition of the coagulation system, and activation of fibrinolysis. In contrast, in male diabetic mice only an attenuation of the coagulation system was observed. Furthermore, finerenone also exerted unfavorable effects, but only in normoglycemic mice, manifested as a slight increase in platelet activity in males and an enhancement of the coagulation system activity in females. Our study is the first to show the sex-dependent and glycemia-dependent effects of finerenone on hemostasis in diabetes. The occurrence of beneficial effects only in female diabetic mice requires in-depth study.
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Affiliation(s)
- Bielicka Natalia
- Department of Biopharmacy and Radiopharmacy, Medical University of Bialystok, ul. Mickiewicza 2C, 15-222 Bialystok, Poland.
| | - Misztal Tomasz
- Department of Physical Chemistry, Medical University of Bialystok, ul. Mickiewicza 2A, 15-089 Bialystok, Poland
| | - Chabielska Ewa
- Department of Biopharmacy and Radiopharmacy, Medical University of Bialystok, ul. Mickiewicza 2C, 15-222 Bialystok, Poland
| | - Gromotowicz-Popławska Anna
- Department of Biopharmacy and Radiopharmacy, Medical University of Bialystok, ul. Mickiewicza 2C, 15-222 Bialystok, Poland
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Feldman RD, Sanjanwala R, Padwal R, Leung AA. Revising the Roles of Aldosterone in Vascular Physiology and Pathophysiology: From Electocortin to Baxdrostat. Can J Cardiol 2023; 39:1808-1815. [PMID: 37734710 DOI: 10.1016/j.cjca.2023.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/23/2023] Open
Abstract
Aldosterone was initially identified as a hormone primarily related to regulation of fluid and electrolyte homeostasis. However, over the past 20 years there has been an increasing appreciation of its role in regulation of vascular function and pathophysiology in the setting of hypertension, atherosclerosis, and heart failure. This review highlights recent advances in our understanding the biology of aldosterone as it relates to the pathophysiology and the management of vascular disease-especially related to hypertension. The review focuses on 3 key areas: 1) advances in our understanding of the cellular mechanisms by which aldosterone mediates its cellular effects, 2) identification of the hidden epidemic of aldosteronism as a mediator of hypertension, and 3) appreciating new therapeutic advances in the clinical pharmacology of aldosterone inhibition in cardiovascular and renal disease.
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Affiliation(s)
- Ross D Feldman
- Robarts Research Institute, Western University, London, Ontario, Canada.
| | - Rohan Sanjanwala
- Department of Internal Medicine, Max Rady School of Medicine, Winnipeg, Manitoba, Canada
| | - Raj Padwal
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Alexander A Leung
- Division of Endocrinology and Metabolism, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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Xu C, Ha X, Yang S, Tian X, Jiang H. Advances in understanding and treating diabetic kidney disease: focus on tubulointerstitial inflammation mechanisms. Front Endocrinol (Lausanne) 2023; 14:1232790. [PMID: 37859992 PMCID: PMC10583558 DOI: 10.3389/fendo.2023.1232790] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/19/2023] [Indexed: 10/21/2023] Open
Abstract
Diabetic kidney disease (DKD) is a serious complication of diabetes that can lead to end-stage kidney disease. Despite its significant impact, most research has concentrated on the glomerulus, with little attention paid to the tubulointerstitial region, which accounts for the majority of the kidney volume. DKD's tubulointerstitial lesions are characterized by inflammation, fibrosis, and loss of kidney function, and recent studies indicate that these lesions may occur earlier than glomerular lesions. Evidence has shown that inflammatory mechanisms in the tubulointerstitium play a critical role in the development and progression of these lesions. Apart from the renin-angiotensin-aldosterone blockade, Sodium-Glucose Linked Transporter-2(SGLT-2) inhibitors and new types of mineralocorticoid receptor antagonists have emerged as effective ways to treat DKD. Moreover, researchers have proposed potential targeted therapies, such as inhibiting pro-inflammatory cytokines and modulating T cells and macrophages, among others. These therapies have demonstrated promising results in preclinical studies and clinical trials, suggesting their potential to treat DKD-induced tubulointerstitial lesions effectively. Understanding the immune-inflammatory mechanisms underlying DKD-induced tubulointerstitial lesions and developing targeted therapies could significantly improve the treatment and management of DKD. This review summarizes the latest advances in this field, highlighting the importance of focusing on tubulointerstitial inflammation mechanisms to improve DKD outcomes.
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Affiliation(s)
- Chengren Xu
- Division of Nephrology, Department of Internal Medicine, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Xiaowen Ha
- Division of Nephrology, Department of Internal Medicine, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Shufen Yang
- Division of Nephrology, Department of Internal Medicine, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Xuefei Tian
- Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Hong Jiang
- Division of Nephrology, Department of Internal Medicine, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
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Leon SJ, Carrero JJ. Adverse effects during treatment with renin-angiotensin-aldosterone system inhibitors; should we stay or should we stop? Curr Opin Nephrol Hypertens 2023; 32:290-296. [PMID: 36811640 DOI: 10.1097/mnh.0000000000000878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
PURPOSE OF REVIEW To discuss recent evidence on the benefits and harms of stopping therapy with renin-angiotensin-aldosterone system inhibitors (RAASi) after the occurrence of adverse events or in patients with advanced chronic kidney disease (CKD). RECENT FINDINGS RAASi may result hyperkalemia or acute kidney injury (AKI), particularly in persons with CKD. Guidelines recommend to temporarily stop RAASi until the problem is resolved. However permanent discontinuation of RAASi is common in clinical practice with the potential to heighten subsequent cardiovascular disease (CVD) risk. A series of studies evaluating the consequences of stopping RAASi (vs. continuing) after an episode of hyperkalemia or AKI consistently report worse clinical outcomes, both higher risk of death and cardiovascular events. The STOP-angiotensin converting enzyme inhibitors (ACEi) trial and two large observational studies also favor the decision to continue ACEi/ angiotensin receptor blockers in advanced CKD, refuting old observations that use of these medications can accelerate the risk of kidney replacement therapy. SUMMARY Available evidence suggests continuing with RAASi after the occurrence of adverse events or in patients with advanced CKD, primarily attributed to sustained cardioprotection. This is in line with current guideline recommendations.
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Affiliation(s)
- Silvia J Leon
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
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Figueroa SM, Bertocchio JP, Nakamura T, El-Moghrabi S, Jaisser F, Amador CA. The Mineralocorticoid Receptor on Smooth Muscle Cells Promotes Tacrolimus-Induced Renal Injury in Mice. Pharmaceutics 2023; 15:pharmaceutics15051373. [PMID: 37242615 DOI: 10.3390/pharmaceutics15051373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023] Open
Abstract
Tacrolimus (Tac) is a calcineurin inhibitor commonly used as an immunosuppressor after solid organ transplantation. However, Tac may induce hypertension, nephrotoxicity, and an increase in aldosterone levels. The activation of the mineralocorticoid receptor (MR) is related to the proinflammatory status at the renal level. It modulates the vasoactive response as they are expressed on vascular smooth muscle cells (SMC). In this study, we investigated whether MR is involved in the renal damage generated by Tac and if the MR expressed in SMC is involved. Littermate control mice and mice with targeted deletion of the MR in SMC (SMC-MR-KO) were administered Tac (10 mg/Kg/d) for 10 days. Tac increased the blood pressure, plasma creatinine, expression of the renal induction of the interleukin (IL)-6 mRNA, and expression of neutrophil gelatinase-associated lipocalin (NGAL) protein, a marker of tubular damage (p < 0.05). Our study revealed that co-administration of spironolactone, an MR antagonist, or the absence of MR in SMC-MR-KO mice mitigated most of the unwanted effects of Tac. These results enhance our understanding of the involvement of MR in SMC during the adverse reactions of Tac treatment. Our findings provided an opportunity to design future studies considering the MR antagonism in transplanted subjects.
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Affiliation(s)
- Stefanny M Figueroa
- Institute of Biomedical Sciences, Universidad Autónoma de Chile, Santiago 8910060, Chile
| | - Jean-Philippe Bertocchio
- INSERM UMRS1138, Sorbonne Université, Université de Paris, Centre de Recherche des Cordeliers, 75006 Paris, France
| | - Toshifumi Nakamura
- INSERM UMRS1138, Sorbonne Université, Université de Paris, Centre de Recherche des Cordeliers, 75006 Paris, France
| | - Soumaya El-Moghrabi
- INSERM UMRS1138, Sorbonne Université, Université de Paris, Centre de Recherche des Cordeliers, 75006 Paris, France
| | - Frédéric Jaisser
- INSERM UMRS1138, Sorbonne Université, Université de Paris, Centre de Recherche des Cordeliers, 75006 Paris, France
| | - Cristián A Amador
- Faculty of Medicine and Science, Universidad San Sebastián, Santiago 7510156, Chile
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Yu MK, Chang TI. Role of Finerenone in Contemporary Clinical Care for Diabetic Kidney Disease. Clin J Am Soc Nephrol 2023; 18:01277230-990000000-00120. [PMID: 37027509 PMCID: PMC10278837 DOI: 10.2215/cjn.0000000000000150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
Affiliation(s)
- Margaret K Yu
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California
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Lv R, Xu L, Che L, Liu S, Wang Y, Dong B. Cardiovascular-renal protective effect and molecular mechanism of finerenone in type 2 diabetic mellitus. Front Endocrinol (Lausanne) 2023; 14:1125693. [PMID: 36860374 PMCID: PMC9968798 DOI: 10.3389/fendo.2023.1125693] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 01/26/2023] [Indexed: 02/17/2023] Open
Abstract
Chronic kidney diseases (CKD) and cardiovascular diseases (CVD) are the main complications in type 2 diabetic mellitus (T2DM), increasing the risk of cardiovascular and all-cause mortality. Current therapeutic strategies that delay the progression of CKD and the development of CVD include angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB), sodium-glucose co-transporter 2 inhibitors (SGLT-2i) and GLP-1 receptor agonists (GLP-1RA). In the progression of CKD and CVD, mineralocorticoid receptor (MR) overactivation leads to inflammation and fibrosis in the heart, kidney and vascular system, making mineralocorticoid receptor antagonists (MRAs) as a promising therapeutic option in T2DM with CKD and CVD. Finerenone is the third generation highly selective non-steroidal MRAs. It significantly reduces the risk of cardiovascular and renal complications. Finerenone also improves the cardiovascular-renal outcomes in T2DM patients with CKD and/or chronic heart failure (CHF). It is safer and more effective than the first- and second-generation MRAs due to its higher selectivity and specificity, resulting in a lower incidence of adverse effects including hyperkalemia, renal insufficiency and androgen-like effects. Finerenone shows potent effect on improving the outcomes of CHF, refractory hypertension, and diabetic nephropathy. Recently studies have shown that finerenone may have potential therapeutic effect on diabetic retinopathy, primary aldosteronism, atrial fibrillation, pulmonary hypertension and so on. In this review, we discuss the characteristics of finerenone, the new third-generation MRA, and compared with the first- and second-generation steroidal MRAs and other nonsteroidal MRAs. We also focus on its safety and efficacy of clinical application on CKD with T2DM patients. We hope to provide new insights for the clinical application and therapeutic prospect.
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Affiliation(s)
- Ruolin Lv
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lili Xu
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Qingdao University, Qingdao, China
- *Correspondence: Bingzi Dong, ; Lili Xu,
| | - Lin Che
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Song Liu
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yangang Wang
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Bingzi Dong
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Qingdao University, Qingdao, China
- *Correspondence: Bingzi Dong, ; Lili Xu,
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Wolter NL, Jaffe IZ. Emerging vascular cell-specific roles for mineralocorticoid receptor: implications for understanding sex differences in cardiovascular disease. Am J Physiol Cell Physiol 2023; 324:C193-C204. [PMID: 36440858 PMCID: PMC9902217 DOI: 10.1152/ajpcell.00372.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/04/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022]
Abstract
As growing evidence implicates extrarenal mineralocorticoid receptor (MR) in cardiovascular disease (CVD), recent studies have defined both cell- and sex-specific roles. MR is expressed in vascular smooth muscle (SMC) and endothelial cells (ECs). This review integrates published data from the past 5 years to identify novel roles for vascular MR in CVD, with a focus on understanding sex differences. Four areas are reviewed in which there is recently expanded understanding of the cell type- or sex-specific role of MR in 1) obesity-induced microvascular endothelial dysfunction, 2) vascular inflammation in atherosclerosis, 3) pulmonary hypertension, and 4) chronic kidney disease (CKD)-related CVD. The review focuses on preclinical data on each topic describing new mechanistic paradigms, cell type-specific mechanisms, sexual dimorphism if addressed, and clinical implications are then considered. New data support that MR drives vascular dysfunction induced by cardiovascular risk factors via sexually dimorphic mechanisms. In females, EC-MR contributes to obesity-induced endothelial dysfunction by regulating epithelial sodium channel expression and by inhibiting estrogen-induced nitric oxide production. In males with hyperlipidemia, EC-MR promotes large vessel inflammation by genomic regulation of leukocyte adhesion molecules, which is inhibited by the estrogen receptor. In pulmonary hypertension models, MRs in EC and SMC contribute to distinct components of disease pathologies including pulmonary vessel remodeling and RV dysfunction. Despite a female predominance in pulmonary hypertension, sex-specific roles for MR have not been explored. Vascular MR has also been directly implicated in CKD-related vascular dysfunction, independent of blood pressure. Despite these advances, sex differences in MR function remain understudied.
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Affiliation(s)
- Nicole L Wolter
- Molecular Cardiology Research Institute, https://ror.org/002hsbm82Tufts Medical Center, Boston, Massachusetts
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, Massachusetts
| | - Iris Z Jaffe
- Molecular Cardiology Research Institute, https://ror.org/002hsbm82Tufts Medical Center, Boston, Massachusetts
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Griesler B, Schuelke C, Uhlig C, Gadasheva Y, Grossmann C. Importance of Micromilieu for Pathophysiologic Mineralocorticoid Receptor Activity—When the Mineralocorticoid Receptor Resides in the Wrong Neighborhood. Int J Mol Sci 2022; 23:ijms232012592. [PMID: 36293446 PMCID: PMC9603863 DOI: 10.3390/ijms232012592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/06/2022] [Accepted: 10/14/2022] [Indexed: 11/17/2022] Open
Abstract
The mineralocorticoid receptor (MR) is a member of the steroid receptor family and acts as a ligand-dependent transcription factor. In addition to its classical effects on water and electrolyte balance, its involvement in the pathogenesis of cardiovascular and renal diseases has been the subject of research for several years. The molecular basis of the latter has not been fully elucidated, but an isolated increase in the concentration of the MR ligand aldosterone or MR expression does not suffice to explain long-term pathologic actions of the receptor. Several studies suggest that MR activity and signal transduction are modulated by the surrounding microenvironment, which therefore plays an important role in MR pathophysiological effects. Local changes in micromilieu, including hypoxia, ischemia/reperfusion, inflammation, radical stress, and aberrant salt or glucose concentrations affect MR activation and therefore may influence the probability of unphysiological MR actions. The surrounding micromilieu may modulate genomic MR activity either by causing changes in MR expression or MR activity; for example, by inducing posttranslational modifications of the MR or novel interaction with coregulators, DNA-binding sites, or non-classical pathways. This should be considered when developing treatment options and strategies for prevention of MR-associated diseases.
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