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Saha AK, Padhi P, Hota D, Rathore V. Neonatal Acute Kidney Injury due to Maternal Olmesartan Intake. Indian J Pediatr 2024; 91:869. [PMID: 38289434 DOI: 10.1007/s12098-024-05037-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/11/2024] [Indexed: 07/16/2024]
Affiliation(s)
- Anish Kumar Saha
- Department of Nephrology, All India Institute of Medical Sciences (AIIMS), Raipur, Chhattisgarh, India
| | - Phalguni Padhi
- Department of Neonatology, All India Institute of Medical Sciences (AIIMS), Raipur, Chhattisgarh, India
| | - Dayanand Hota
- Department of Neonatology, All India Institute of Medical Sciences (AIIMS), Raipur, Chhattisgarh, India
| | - Vinay Rathore
- Department of Nephrology, All India Institute of Medical Sciences (AIIMS), Raipur, Chhattisgarh, India.
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2
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Sinkey RG, Ogunsile FJ, Kanter J, Bean C, Greenberg M. Society for Maternal-Fetal Medicine Consult Series #68: Sickle cell disease in pregnancy. Am J Obstet Gynecol 2024; 230:B17-B40. [PMID: 37866731 PMCID: PMC10961101 DOI: 10.1016/j.ajog.2023.10.031] [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] [Indexed: 10/24/2023]
Abstract
Pregnant individuals with sickle cell disease have an increased risk of maternal and perinatal morbidity and mortality. However, prepregnancy counseling and multidisciplinary care can lead to favorable maternal and neonatal outcomes. In this consult series, we summarize what is known about sickle cell disease and provide guidance for sickle cell disease management during pregnancy. The following are Society for Maternal-Fetal Medicine recommendations.
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Queiroz KA, Vale EP, Martín-Pastor M, Sólon LGS, Sousa FFO. Metabolomic Profile, Plasmatic Levels of Losartan and EXP3174, Blood Pressure Control in Hypertensive Patients and Their Correlation with COVID-19. Pharmaceuticals (Basel) 2023; 16:1290. [PMID: 37765098 PMCID: PMC10535928 DOI: 10.3390/ph16091290] [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: 06/20/2023] [Revised: 07/21/2023] [Accepted: 07/27/2023] [Indexed: 09/29/2023] Open
Abstract
Systemic arterial hypertension (SAH) is one of the most prevalent chronic diseases worldwide and is related to serious health complications. It has been pointed out as a major risk factor for COVID-19. This study aimed to determine the impact of COVID-19 on the metabolomic profile, the correlation with the plasmatic levels of losartan and its active metabolite (EXP3174), biochemical markers, and blood pressure (BP) control in hypertensive patients. 1H NMR metabolomic profiles of hypertensive and normotensive patients with and without previous COVID-19 diagnosis were identified. Plasmatic levels of LOS and EXP3174 were correlated with BP, biochemical markers, and the metabolomic fingerprint of the groups. Biomarkers linked to important aspects of SAH and COVID-19 were identified, such as glucose, glutamine, arginine, creatinine, alanine, choline, erythritol, homogentisate, 0-tyrosine, and 2-hydroxybutyrate. Those metabolites are indicative of metabolic alterations, kidney damage, pulmonary dysfunction, and persistent inflammation, which can be found in both diseases. Some hypertensive patients did not reach the therapeutic levels of LOS and EXP3174, while the BP control was also limited among the normotensive patients with previous COVID-19 diagnoses. Metabolomics proved to be an important tool for assessing the effectiveness of losartan pharmacotherapy and the damage caused by SAH and COVID-19 in hypertensive patients.
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Affiliation(s)
- Kamila A. Queiroz
- Graduate Program on Pharmaceutical Sciences, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil; (K.A.Q.); (L.G.S.S.)
- Laboratory of Quality Control, Bromatology and Microbiology, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil;
| | - Everton P. Vale
- Laboratory of Quality Control, Bromatology and Microbiology, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil;
- Graduate Program on Pharmaceutical Innovation, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil
| | - Manuel Martín-Pastor
- Unidade de Resonancia Magnetica, Área de Infraestruturas de Investigación, Campus Vida, Universidad de Santiago de Compostela, 15782 Santiago de Compostela, Spain;
| | - Lílian G. S. Sólon
- Graduate Program on Pharmaceutical Sciences, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil; (K.A.Q.); (L.G.S.S.)
- Laboratory of Quality Control, Bromatology and Microbiology, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil;
| | - Francisco F. O. Sousa
- Graduate Program on Pharmaceutical Sciences, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil; (K.A.Q.); (L.G.S.S.)
- Laboratory of Quality Control, Bromatology and Microbiology, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil;
- Graduate Program on Pharmaceutical Innovation, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil
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Santos ISR, Martin-Pastor M, Tavares Júnior AG, Queiroz KA, da Silva Sólon LG, Sousa FFOD. Metabolomic Profile and Its Correlation with the Plasmatic Levels of Losartan, EXP3174 and Blood Pressure Control in Hypertensive and Chronic Kidney Disease Patients. Int J Mol Sci 2023; 24:9832. [PMID: 37372980 DOI: 10.3390/ijms24129832] [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: 12/16/2022] [Revised: 04/19/2023] [Accepted: 04/22/2023] [Indexed: 06/29/2023] Open
Abstract
Systemic arterial hypertension (SAH) is one of the most prevalent chronic diseases worldwide and, when dysregulated, may cause serious complications. Losartan (LOS) blocks relevant physiological aspects of hypertension, acting mainly on the reduction of peripheral vascular resistance. Complications of hypertension include nephropathy, in which diagnosis is based on the observation of functional or structural renal dysfunction. Therefore, blood pressure control is essential to attenuate the progression of chronic kidney disease (CKD). In this study, 1H NMR metabolomics were used to differentiate hypertensive and chronic renal patients. Plasmatic levels of LOS and EXP3174, obtained by liquid chromatography coupled with mass-mass spectroscopy, were correlated with blood pressure control, biochemical markers and the metabolomic fingerprint of the groups. Some biomarkers have been correlated with key aspects of hypertension and CKD progression. For instance, higher levels of trigonelline, urea and fumaric acid were found as characteristic markers of kidney failure. In the hypertensive group, the urea levels found could indicate the onset of kidney damage when associated with uncontrolled blood pressure. In this sense, the results point to a new approach to identify CKD in early stages and may contribute to improving pharmacotherapy and reducing morbidity and mortality associated with hypertension and CKD.
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Affiliation(s)
- Ingrid Souza Reis Santos
- Graduate Program on Pharmaceutical Sciences, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil
- Laboratory of Quality Control, Bromatology and Microbiology, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil
| | - Manuel Martin-Pastor
- Unidade de Resonancia Magnetica, Área de Infraestruturas de Investigación, Campus Vida, Universidad de Santiago de Compostela, 15072 Santiago de Compostela, Spain
| | - Alberto Gomes Tavares Júnior
- Graduate Program on Pharmaceutical Sciences, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil
- Laboratory of Quality Control, Bromatology and Microbiology, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil
| | - Kamila Ayres Queiroz
- Graduate Program on Pharmaceutical Sciences, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil
- Laboratory of Quality Control, Bromatology and Microbiology, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil
| | - Lílian Grace da Silva Sólon
- Graduate Program on Pharmaceutical Sciences, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil
- Laboratory of Quality Control, Bromatology and Microbiology, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil
| | - Francisco Fábio Oliveira de Sousa
- Graduate Program on Pharmaceutical Sciences, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil
- Laboratory of Quality Control, Bromatology and Microbiology, Department of Biological & Health Sciences, Federal University of Amapa, Macapa 68903-419, Brazil
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Pruett JE, Romero DG, Yanes Cardozo LL. Obesity-associated cardiometabolic complications in polycystic ovary syndrome: The potential role of sodium-glucose cotransporter-2 inhibitors. Front Endocrinol (Lausanne) 2023; 14:951099. [PMID: 36875461 PMCID: PMC9974663 DOI: 10.3389/fendo.2023.951099] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 01/26/2023] [Indexed: 02/17/2023] Open
Abstract
Polycystic Ovary Syndrome (PCOS) is the most common endocrine disorder in reproductive-age women. PCOS is characterized by androgen excess, oligo/anovulation, and polycystic appearance of the ovaries. Women with PCOS have an increased prevalence of multiple cardiovascular risk factors such as insulin resistance, hypertension, renal injury, and obesity. Unfortunately, there is a lack of effective, evidence-based pharmacotherapeutics to target these cardiometabolic complications. Sodium-glucose cotransporter-2 (SGLT2) inhibitors provide cardiovascular protection in patients with and without type 2 diabetes mellitus. Although the exact mechanisms of how SGLT2 inhibitors confer cardiovascular protection remains unclear, numerous mechanistic hypotheses for this protection include modulation of the renin-angiotensin system and/or the sympathetic nervous system and improvement in mitochondrial function. Data from recent clinical trials and basic research show a potential role for SGLT2 inhibitors in treating obesity-associated cardiometabolic complications in PCOS. This narrative review discusses the mechanisms of the beneficial effect of SGLT2 inhibitors in cardiometabolic diseases in PCOS.
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Affiliation(s)
- Jacob E. Pruett
- Department of Cell and Molecular Biology, University of Mississippi Medical Center, Jackson, MS, United States
| | - Damian G. Romero
- Department of Cell and Molecular Biology, University of Mississippi Medical Center, Jackson, MS, United States
- Mississippi Center of Excellence in Perinatal Research, University of Mississippi Medical Center, Jackson, MS, United States
- Women’s Health Research Center, University of Mississippi Medical Center, Jackson, MS, United States
- Cardiovascular-Renal Research Center, University of Mississippi Medical Center, Jackson, MS, United States
| | - Licy L. Yanes Cardozo
- Department of Cell and Molecular Biology, University of Mississippi Medical Center, Jackson, MS, United States
- Mississippi Center of Excellence in Perinatal Research, University of Mississippi Medical Center, Jackson, MS, United States
- Women’s Health Research Center, University of Mississippi Medical Center, Jackson, MS, United States
- Cardiovascular-Renal Research Center, University of Mississippi Medical Center, Jackson, MS, United States
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, United States
- *Correspondence: Licy L. Yanes Cardozo,
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Petch S, O'Connor E, McGrath A, Daly S. Valsartan exposure in pregnancy with resultant anhydramnios and chronic kidney disease in a late preterm infant. BMJ Case Rep 2021; 14:e240810. [PMID: 34011666 PMCID: PMC8137155 DOI: 10.1136/bcr-2020-240810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 11/04/2022] Open
Abstract
In utero exposure to angiotensin II receptor blockers (ARBs) has fetotoxic effects including renal failure, oligohydramnios and lung hypoplasia. We present the case of a 24-year-old woman who presented to the maternity services in the 34th week of her first pregnancy. She was taking valsartan for hypertension. Ultrasound showed a structurally normal fetus with anhydramnios. The patient was admitted and valsartan was discontinued. She had spontaneous preterm delivery at 35 weeks' gestation of a baby girl. The baby's urine output was minimal in the first week of life and she was transferred to a paediatric hospital for specialist nephrology input. At 6 months of age, she requires ongoing nephrology follow-up and she remains on treatment for hypertension and anaemia. This case demonstrates the serious adverse effects resulting from ARB exposure in utero, and highlights the importance of avoiding fetotoxic medications in women of childbearing age.
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Affiliation(s)
- Sarah Petch
- Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Emily O'Connor
- Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Ailbhe McGrath
- Molecular, Genetic and Population Health Science, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
- General Paediatrics, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Sean Daly
- Maternal Fetal Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland
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Fetotoxic risk of AT1 blockers exceeds that of angiotensin-converting enzyme inhibitors: an observational study. J Hypertens 2020; 38:133-141. [PMID: 31568057 DOI: 10.1097/hjh.0000000000002233] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The fetotoxic potential of prenatal exposure to angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin II receptor blockers (ARBs) has been known for many years. Symptoms range from transient oligohydramnios to neonatal anuria and permanent renal damage, joint contractures, hypocalvaria, lung hypoplasia and intrauterine or neonatal death. This study aims to investigate the critical gestational time for renin-angiotensin system inhibitor (RAS-I)-induced fetopathy, to quantify the fetopathy risk and to evaluate factors associated with the occurrence and severity of fetopathy. METHODS Prospectively and retrospectively ascertained RAS-I exposed pregnancies from the databases of six teratology information services were analyzed. RESULTS Eighty-nine pregnancies with ACE-I and 101 with ARB exposure beyond the first trimester were identified. Fifty-nine of these 190 pregnancies were classified as having evidence of RAS-I fetopathy. All pregnancies affected with fetopathy were exposed after 20 0/7 gestational weeks. Limited to prospectively enrolled cases with exposure at least 20 0/7 gestational weeks, the rate of fetopathy was 3.2% for ACE-I and 29.2% for ARB. The chance of recovery of amniotic fluid volume was higher with RAS-I discontinuation before 30 gestational weeks and with a longer exposure-free interval before delivery. CONCLUSION Exposure to ARBs is associated with a higher fetopathy risk than exposure to ACE-Is. RAS-I should ideally be discontinued prior to pregnancy or immediately after recognition of pregnancy. Because symptoms may improve in cases of RAS-I-induced oligohydramnios, pregnancy should be maintained as long as there is fetal well being. Physicians and patients need to be alerted to the fetotoxic risks of RAS-I.
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Barrett JS. Risk assessment of therapeutic agents under consideration to treat COVID-19 in paediatric patients and pregnant women. Br J Clin Pharmacol 2020; 87:3462-3480. [PMID: 33125791 DOI: 10.1111/bcp.14630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/22/2020] [Accepted: 10/22/2020] [Indexed: 01/08/2023] Open
Abstract
AIM Repurposing strategies to address the COVID-19 pandemic have been accelerated. As both pregnant and paediatric patients are likely to be excluded from most planned investigations, the list of repurposed options and the available data on these drugs and vaccines provide a baseline risk assessment and identify gaps for targeted investigation. METHODS Clinical trials have been searched and reviewed; 23 repurposed drugs and drug combinations and nine candidate vaccines have been assessed regarding the availability of relevant data in paediatrics and pregnant women and to evaluate expected or unanticipated risk. RESULTS Thirteen of the repurposed drugs or drug combinations are indicated for use in paediatrics in some age category albeit for indications other than COVID-19; 10 of these are indicated for use in pregnant women. Even in cases where these drugs are indicated in the populations, source data from which safety and or dosing could be extrapolated for use in COVID-19 is sparse. Vaccine trials are ongoing and generally exclude pregnant women; only in a few instances have paediatric subgroups been planned for enrolment. Data from individual case studies and RWD may suggest that subpopulations of both paediatric patients and pregnant women may be more at risk, particularly those in an increased inflammatory state. CONCLUSION In conjunction with more prospective collaboration, plans are evolving to ensure that we will be better prepared to address similar situations especially in paediatrics and pregnant women where experience is limited and actual practice relies heavily on leveraging data from other populations and indications.
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Affiliation(s)
- Jeffrey S Barrett
- Critical Path Institute, 1730 East River Road, Tucson, Arizona, 85718-5893, USA
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9
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Prenatal Diagnosis of Autosomal Recessive Renal Tubular Dysgenesis with Anhydramnios Caused by a Mutation in the AGT Gene. Diagnostics (Basel) 2019; 9:diagnostics9040185. [PMID: 31718018 PMCID: PMC6963964 DOI: 10.3390/diagnostics9040185] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 11/06/2019] [Accepted: 11/11/2019] [Indexed: 11/16/2022] Open
Abstract
Autosomal recessive renal tubular dysgenesis (ARRTD) is a rare and lethal disorder that causes stillbirth or early neonatal death. Most of the reported cases are diagnosed postnatally by a histopathological hallmark of the absence or paucity of differentiated proximal tubules in kidneys. Prenatal diagnosis of ARRTD is challenging because only a few fetal features (e.g., oligohydramnios/anhydramnios, anuria) are associated with this condition. In this study, we report a fetus with ARRTD, which showed anhydramnios and invisible urinary bladder since the second trimester, followed by growth restriction and reversed end diastolic flow in the middle cerebral artery (MCA-REDF). No morphological anomaly was detected on the fetal kidneys during an ultrasound scan. The baby died of refractory hypotension the day after their birth. Genetic analysis of genes that are involved in the renin-angiotensin-aldosterone system (RAAS), which are the known genetic causes of ARRTD, identified a novel, biparental-origin homozygous c.857-619_1269+243delinsTTGCCTTGC mutation in the AGT gene. The mutation is considered as pathogenic because it is cosegregated with ARRTD and detected in other unrelated ARRTD families. Our findings link the fetal ultrasound manifestations to the ARRTD, highlighting clues that are useful for prenatal diagnosis, which warrants confirmatory genotyping of the RAAS genes including oligohydramnios/anhydramnios, anuria (absent filling of a fetal urinary bladder), MCA-REDF, and a morphologically normal kidney.
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Campbell N, LaMarca B, Cunningham MW. The Role of Agonistic Autoantibodies to the Angiotensin II Type 1 Receptor (AT1-AA) in Pathophysiology of Preeclampsia. Curr Pharm Biotechnol 2019; 19:781-785. [PMID: 30255752 DOI: 10.2174/1389201019666180925121254] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 07/20/2018] [Accepted: 08/15/2018] [Indexed: 12/31/2022]
Abstract
Preeclampsia is the leading cause of death and morbidity worldwide for the mother and fetus during pregnancy. Preeclampsia does not only affect the mother and the baby during pregnancy, but can also have long-term effects, such as the increased risk of hypertension and cardiovascular disease on the offspring and the postpartum mother later in life. The exact cause of preeclampsia is unknown, but women with preeclampsia have elevated concentrations of agonistic autoantibodies against the angiotensin II type 1 receptor (AT1-AA). These AT1-AA's through multiple studies have shown to play a significant role in the pathology and possible genesis of preeclampsia. This review will discuss the discovery of AT1-AAs and the role of AT1-AAs in the pathophysiology of preeclampsia. This review will also discuss future therapeutic approaches towards the AT1-AA to prevent adverse pregnancy outcomes. Furthermore, we will examine the relationship between AT1-AA induced hypertension associated with increased oxidative stress, antiangiogenic factors (such as soluble fms-related tyrosine kinase-1 (sFlt-1), endothelin-1 (ET-1), inflammation, endothelial dysfunction, and reduced renal function. Understanding the pathological role of AT1-AAs in hypertensive pregnancies is important as we search for novel therapies to manage preeclampsia.
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Affiliation(s)
- Nathan Campbell
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, United States
| | - Babbette LaMarca
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, United States.,Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS 39216, United States
| | - Mark W Cunningham
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, United States
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Lallemant M, Prévost S, Nobili F, Riethmuller D, Ramanah R, Seronde MF, Mottet N. Prenatal hypocalvaria after prolonged intrauterine exposure to angiotensin II receptor antagonists. J Renin Angiotensin Aldosterone Syst 2019; 19:1470320318810940. [PMID: 30394825 PMCID: PMC6243420 DOI: 10.1177/1470320318810940] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We report a case of prenatal exposure to angiotensin II receptor antagonists (ARA
II) from the beginning of pregnancy in a patient with a hypokinetic dilated
cardiomyopathy. This case report emphasizes the fetal renal impact of prolonged
intrauterine exposure to renin-angiotensin system (RAS) blockers, and highlights
that this exposure can cause severe prenatal hypocalvaria. This delayed
ossification can be reversible after birth, but the presence of anhydramnios
indicates an early and irreversible block of RAS blockers in the fetus that is
responsible for fetal kidney development abnormalities. This association carries
a high risk of neonatal death. Prolonged exposure to ARA II or other RAS
blockers remains prohibited throughout pregnancy.
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Affiliation(s)
- Marine Lallemant
- 1 Obstetrics and Gynaecology Department, Besançon University Medical Centre, Franche-Comté University, France
| | - Sarah Prévost
- 1 Obstetrics and Gynaecology Department, Besançon University Medical Centre, Franche-Comté University, France
| | - François Nobili
- 2 Paediatric Nephrology Department, Besançon University Medical Centre, Franche-Comté University, France
| | - Didier Riethmuller
- 1 Obstetrics and Gynaecology Department, Besançon University Medical Centre, Franche-Comté University, France
| | - Rajeev Ramanah
- 1 Obstetrics and Gynaecology Department, Besançon University Medical Centre, Franche-Comté University, France
| | - Marie-France Seronde
- 3 Cardiology Department, Besançon University Medical Centre, Franche-Comté University, France
| | - Nicolas Mottet
- 1 Obstetrics and Gynaecology Department, Besançon University Medical Centre, Franche-Comté University, France
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Abstract
Diabetes is a common chronic condition in women of reproductive age. Preconception care is crucial to reducing the risk of adverse maternal and fetal outcomes, such as hypertensive disorders, abnormal fetal growth, traumatic delivery and stillbirth, associated with poor glycemic control. Insulin is the preferred medication to optimize glucose control in women with pregestational diabetes. Frequent dose adjustments are needed during pregnancy to achieve glycemic goals, and team-based multidisciplinary care may help. Postpartum care should include lactation support, counseling on contraceptive options, and transition to primary care.
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Affiliation(s)
- Ronan Sugrue
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Chloe Zera
- Division of Maternal Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Uncoupling proteins as a therapeutic target to protect the diabetic heart. Pharmacol Res 2018; 137:11-24. [PMID: 30223086 DOI: 10.1016/j.phrs.2018.09.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/07/2018] [Accepted: 09/13/2018] [Indexed: 12/16/2022]
Abstract
Myocardial remodeling and dysfunction caused by accelerated oxidative damage is a widely reported phenomenon within a diabetic state. Altered myocardial substrate preference appears to be the major cause of enhanced oxidative stress-mediated cell injury within a diabetic heart. During this process, exacerbated free fatty acid flux causes an abnormal increase in mitochondrial membrane potential leading to the overproduction of free radical species and subsequent cell damage. Uncoupling proteins (UCPs) are expressed within the myocardium and can protect against free radical damage by modulating mitochondrial respiration, leading to reduced production of reactive oxygen species. Moreover, transgenic animals lacking UCPs have been shown to be more susceptible to oxidative damage and display reduced cardiac function when compared to wild type animals. This suggests that tight regulation of UCPs is necessary for normal cardiac function and in the prevention of diabetes-induced oxidative damage. This review aims to enhance our understanding of the pathophysiological mechanisms relating to the role of UCPs in a diabetic heart, and further discuss known pharmacological compounds and hormones that can protect a diabetic heart through the modulation of UCPs.
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He C, Liu Y, Wang Y, Tang J, Tan Z, Li X, Chen Y, Huang Y, Chen X, Ouyang D, Zhou H, Peng J. 1H NMR based pharmacometabolomics analysis of metabolic phenotype on predicting metabolism characteristics of losartan in healthy volunteers. J Chromatogr B Analyt Technol Biomed Life Sci 2018; 1095:15-23. [DOI: 10.1016/j.jchromb.2018.07.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/19/2018] [Accepted: 07/14/2018] [Indexed: 02/06/2023]
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15
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Moroni G, Ponticelli C. Important considerations in pregnant patients with lupus nephritis. Expert Rev Clin Immunol 2018; 14:489-498. [PMID: 29764231 DOI: 10.1080/1744666x.2018.1476139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION In the last few decades, identification of predictors of pregnancy outcome and appropriate pregnancy planning have significantly reduced the maternal and fetal risks in pregnant women with lupus nephritis. Areas covered: Successful pregnancies have been reported even in women with chronic renal disease and renal insufficiency. However, refractory hypertension and severe renal or cardiac chronic dysfunction are still considered contraindications to pregnancy. Pre-term delivery and fetal growth restriction may still occur in SLE patients more frequently than in healthy women, even in pregnancies regularly planned and monitored by a team of nephrologists and gynaecologists. Expert commentary: Stable disease remission is the most important factor for a successful pregnancy. In case of flare-ups of lupus, timely diagnosis and appropriate management may ensure a successful outcome in the majority of pregnant women. The negative role of anti-phospholipid antibodies and of chronic arterial hypertension may be countered with appropriate anticoagulation and anti-hypertensive therapy. Further studies are needed to better assess the possible impact of pregnancy on the long-term outcome of lupus nephritis.
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Affiliation(s)
- Gabriella Moroni
- a Nephrology Unit , Fondazione Ca' Granda IRCCS Ospdale Maggiore Policlinico Milano , Milano , Italy
| | - Claudio Ponticelli
- a Nephrology Unit , Fondazione Ca' Granda IRCCS Ospdale Maggiore Policlinico Milano , Milano , Italy
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16
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Marchetto L, Sordino D, De Bernardo G, Trevisanuto D. Postnatal acute renal failure after fetal exposure to angiotensin receptor blockers. BMJ Case Rep 2015; 2015:bcr-2014-207450. [PMID: 26139648 DOI: 10.1136/bcr-2014-207450] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Maternal hypertensive treatment with angiotensin receptor blockers (ARBs) during the second and third trimester of pregnancy is associated with several fetal and neonatal complications, and potential adverse outcomes. We report a neonate presenting with transient renal acute failure during the first days of life after maternal treatment with ARBs. Women who became pregnant while taking one of these drugs must modify antihypertensive therapy with a different class drug as soon as pregnancy is recognised.
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Affiliation(s)
- Luca Marchetto
- Children and Women's Health Department, Medical School University of Padua, Padua, Italy
| | | | | | - Daniele Trevisanuto
- Children and Women's Health Department, Medical School University of Padua, Padua, Italy
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Yamada A, Tsuji Y, Kato Y, Ueda N. Renal tubular dysgenesis and reversible hypocalvaria after intrauterine exposure to an angiotensin receptor blocker. NDT Plus 2015; 4:141-2. [PMID: 25984140 PMCID: PMC4421588 DOI: 10.1093/ndtplus/sfq209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Yoshikazu Tsuji
- Department of Urology, Social Insurance Chukyo Hospital, Nagoya, Aichi, Japan
| | - Yuich Kato
- Department of Pediatrics, Anjo Kosei Hospital, Anjo, Aichi, Japan
| | - Norishi Ueda
- Department of Developmental Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Richer J, Daoud H, Geier P, Jarinova O, Carson N, Feberova J, Ben Fadel N, Unrau J, Bareke E, Khatchadourian K, Bulman DE, Majewski J, Boycott KM, Dyment DA. Resolution of refractory hypotension and anuria in a premature newborn with loss-of-function of ACE. Am J Med Genet A 2015; 167:1654-8. [PMID: 25899979 DOI: 10.1002/ajmg.a.37067] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 03/05/2015] [Indexed: 11/07/2022]
Abstract
We present the investigation and management of a premature, hypotensive neonate born after a pregnancy complicated by anhydramnios to highlight the impact of early and informed management for rare kidney disease. Vasopressin was used to successfully treat refractory hypotension and anuria in the neonate born at 27 weeks of gestation. Next generation sequencing of a targeted panel of genes was then performed in the neonate and parents. Subsequently, two compound heterozygous deletions leading to frameshift mutations were identified in the angiotensin 1-converting enzyme gene ACE; exon 5:c.820_821delAG (p.Arg274Glyfs*117) and exon24: c.3521delG (p.Gly1174Alafs*12), consistent with a diagnosis of renal tubular dysgenesis. In light of the molecular diagnosis, identification, and treatment of associated low aldosterone level resulted in further improvement in renal function and only mild residual chronic renal failure is present at 14 months of age. Truncating alterations in ACE most often result in fetal demise during gestation or in the first days of life and typically as a result of the Potter sequence. The premature delivery, and serendipitous early treatment with vasopressin, and then later fludrocortisone, resulted in an optimal outcome in an otherwise lethal condition.
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Affiliation(s)
- Julie Richer
- Department of Genetics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Hussein Daoud
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Pavel Geier
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Olga Jarinova
- Department of Genetics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nancy Carson
- Department of Genetics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Jana Feberova
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - Jennifer Unrau
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Eric Bareke
- McGill University and Genome Quebec Innovation Centre, Montréal, Québec, Canada
| | - Karine Khatchadourian
- Division of Endocrinology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Dennis E Bulman
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Jacek Majewski
- McGill University and Genome Quebec Innovation Centre, Montréal, Québec, Canada
| | - Kym M Boycott
- Department of Genetics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - David A Dyment
- Department of Genetics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Odutayo A, Cherney D, Miller J, Ahmed SB, Lai V, Dunn S, Pun N, Moineddin R, Hladunewich MA. Transdermal contraception and the renin-angiotensin-aldosterone system in premenopausal women. Am J Physiol Renal Physiol 2015; 308:F535-40. [DOI: 10.1152/ajprenal.00602.2014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The oral contraceptive pill (OCP) activates the renin-angiotensin-aldosterone system (RAAS) through first-pass hepatic metabolism. Although usually benign, RAAS activation may have detrimental effects on renal and hemodynamic function in some women. Since combined hormonal contraception with the transdermal patch (EVRA) does not undergo first-pass hepatic metabolism, we hypothesized that the RAAS response would be different from that of OCP subjects. Thirty-five nonsmoking, premenopausal women (15 control subjects, 10 OCP subjects, and 10 contraceptive patch subjects) without evidence of cardiovascular disease, renal disease, or diabetes were studied. Baseline angiotensinogen, renin, angiotensin II, aldosterone, and plasma renin activity were assessed along with hormonal and hemodynamic responses to simulated orthostatic stress using incremental lower body negative pressure (LBNP; −15, −25, and −40 mmHg). Baseline levels of angiotensinogen, angiotensin II, and plasma renin activity were significantly higher in OCP subjects compared with normotensive control and contraceptive patch subjects ( P < 0.05), whereas aldosterone was significantly higher in OCP versus control subjects only ( P < 0.05). Plasma renin levels were significantly lower at baseline in contraceptive patch subjects compared with normotensive control and OCP subjects ( P < 0.05). In response to LBNP, increases in renin, angiotensin II, and aldosterone were attenuated in contraceptive patch subjects in conjunction with an exaggerated decline in mean arterial pressure ( P < 0.05 vs. control and OCP subjects). The contraceptive patch in healthy premenopausal women is associated with an impaired ability to maintain blood pressure in response to LBNP, possibly due to insensitivity of the endogenous RAAS. Further evaluation may be beneficial in women with kidney disease.
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Affiliation(s)
- Ayodele Odutayo
- Division of Nephrology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - David Cherney
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Judith Miller
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Vesta Lai
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sheila Dunn
- Department of Family and Community Medicine, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada; and
| | - Nicole Pun
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rahim Moineddin
- The Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Michelle A. Hladunewich
- Division of Nephrology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- University Health Network, University of Toronto, Toronto, Ontario, Canada
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20
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Shimada C, Akaishi R, Cho K, Morikawa M, Kaneshi Y, Yamda T, Minakami H. Outcomes of 83 fetuses exposed to angiotensin receptor blockers during the second or third trimesters: a literature review. Hypertens Res 2015; 38:308-13. [DOI: 10.1038/hr.2015.12] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 10/29/2014] [Accepted: 11/01/2014] [Indexed: 11/09/2022]
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Oppermann M, Padberg S, Kayser A, Weber-Schoendorfer C, Schaefer C. Angiotensin-II receptor 1 antagonist fetopathy--risk assessment, critical time period and vena cava thrombosis as a possible new feature. Br J Clin Pharmacol 2013; 75:822-30. [PMID: 22816796 DOI: 10.1111/j.1365-2125.2012.04388.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 07/16/2012] [Indexed: 11/26/2022] Open
Abstract
AIMS Angiotensin-II receptor 1 antagonists (AT₁-antagonists) may cause severe and even lethal fetopathy in late pregnancy. However, exposure still occurs in spite of warnings in package leaflets. This study aimed to assess the risk of fetopathy, the sensitive time window, and possible new symptoms in prospective as well as retrospective cases with AT₁-antagonist treatment during the second or third trimester of pregnancy. METHODS Patients were enrolled by the Berlin Institute for Clinical Teratology and Drug Risk Assessment in Pregnancy between 1999 and 2011 through risk consultation. Symptoms defined as indicative of AT₁-antagonist fetopathy were: oligo-/anhydramnios, renal insufficiency, lung hypoplasia, joint contractures, skull hypoplasia and fetal/neonatal death. RESULTS In 5/29 (17%) prospectively enrolled cases with AT₁-antagonist exposure beyond the first trimester oligo-/anhydramnios was diagnosed. Two infants showed additional symptoms of fetopathy. The risk is more than 30% if treatment continues beyond the 20th week of pregnancy. Oligo-/anhydramnios was reversible after AT₁-antagonist withdrawal. Among 16 retrospective case reports, three infants presented with a thrombosis of the inferior vena cava in the vicinity of the renal veins. Four out of 13 live births did not survive. CONCLUSIONS Our survey suggests that the risk increases with duration of AT₁-antagonist treatment into late pregnancy and oligo-/anhydramnios may be reversible after AT₁-antagonist discontinuation. Thrombosis of inferior vena cava may be a new feature of AT₁-antagonist fetopathy. AT₁-antagonist medication during pregnancy constitutes a considerable risk and must be discontinued immediately. In case of indicative diagnostic findings in either the fetus or newborn, previous maternal AT₁-antagonist exposure should be considered.
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Affiliation(s)
- Marc Oppermann
- Institute for Clinical Teratology and Drug Risk Assessment in Pregnancy, Charité-Universitätsmedizin Berlin, 14050 Berlin, Germany
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22
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Nelson SM, Greer IA. Hypertensive disorders of pregnancy: preventative-, immediate- and long-term management. Expert Rev Pharmacoecon Outcomes Res 2012; 6:541-54. [PMID: 20528501 DOI: 10.1586/14737167.6.5.541] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The hypertensive disorders of pregnancy are common and continue to be significant contributors to maternal and perinatal mortality and morbidity, both globally and in the UK. This review aims to describe the recent developments in the understanding of the pathophysiology of the disease processes, potential strategies for identification of women at high risk, and current and future therapeutic strategies for the treatment and prevention of hypertension in pregnancy. Women who experience adverse pregnancy outcomes are also at increased risk of premature cardiovascular disease, and potential therapeutic strategies to minimize their risk profile are discussed.
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Affiliation(s)
- Scott M Nelson
- Clinician Scientist, University of Glasgow, Reproductive and Maternal Medicine, and Division of Developmental Medicine, Glasgow Royal Infirmary, 10 Alexandra Parade, Glasgow, G31 ER, UK.
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23
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Bullo M, Tschumi S, Bucher BS, Bianchetti MG, Simonetti GD. Pregnancy Outcome Following Exposure to Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Antagonists. Hypertension 2012; 60:444-50. [DOI: 10.1161/hypertensionaha.112.196352] [Citation(s) in RCA: 206] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marina Bullo
- From the Department of Pediatrics and Division of Pediatric Nephrology, University Hospital (Inselspital), Berne, Switzerland (M.B., S.T., B.S.B., G.D.S.); Division of Pediatrics, Hospitals Bellinzona and Mendrisio, Bellinzona, Switzerland (M.G.B.)
| | - Sibylle Tschumi
- From the Department of Pediatrics and Division of Pediatric Nephrology, University Hospital (Inselspital), Berne, Switzerland (M.B., S.T., B.S.B., G.D.S.); Division of Pediatrics, Hospitals Bellinzona and Mendrisio, Bellinzona, Switzerland (M.G.B.)
| | - Barbara S. Bucher
- From the Department of Pediatrics and Division of Pediatric Nephrology, University Hospital (Inselspital), Berne, Switzerland (M.B., S.T., B.S.B., G.D.S.); Division of Pediatrics, Hospitals Bellinzona and Mendrisio, Bellinzona, Switzerland (M.G.B.)
| | - Mario G. Bianchetti
- From the Department of Pediatrics and Division of Pediatric Nephrology, University Hospital (Inselspital), Berne, Switzerland (M.B., S.T., B.S.B., G.D.S.); Division of Pediatrics, Hospitals Bellinzona and Mendrisio, Bellinzona, Switzerland (M.G.B.)
| | - Giacomo D. Simonetti
- From the Department of Pediatrics and Division of Pediatric Nephrology, University Hospital (Inselspital), Berne, Switzerland (M.B., S.T., B.S.B., G.D.S.); Division of Pediatrics, Hospitals Bellinzona and Mendrisio, Bellinzona, Switzerland (M.G.B.)
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24
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Polifka JE. Is there an embryopathy associated with first-trimester exposure to angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists? A critical review of the evidence. ACTA ACUST UNITED AC 2012; 94:576-98. [PMID: 22807387 DOI: 10.1002/bdra.23027] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 03/23/2012] [Accepted: 04/11/2012] [Indexed: 11/06/2022]
Abstract
Drugs that interfere with the renin-angiotensin system, such as angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), are widely used to manage hypertension and heart failure. Adequate functioning of the RAS is essential for normal fetal kidney development. The potential for ACEIs and ARBs to impair fetal and neonatal renal function if taken after the first trimester of pregnancy has been well documented. Although these drugs were not found to be teratogenic in animals, until recently little was known about the teratogenic effects of ACEIs and ARBs in humans when exposure was limited to the first trimester of pregnancy. New evidence from epidemiologic studies indicates that there may be an elevated teratogenic risk when these drugs are taken during the first trimester of pregnancy. However, this elevated risk does not appear to be specific to ACEIs and ARBs, but is instead related to maternal factors and diseases that typically coexist with hypertension in pregnancy, such as diabetes, advanced maternal age, and obesity. Women who become pregnant while being treated with an ACEI or ARB should be advised to avoid exposure to these drugs during the second and third trimesters of pregnancy by switching to a different class of antihypertensive drugs between weeks 8 and 10 after conception.
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Affiliation(s)
- Janine E Polifka
- Department of Pediatrics, University of Washington, Seattle, Washington, USA.
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25
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Gribouval O, Morinière V, Pawtowski A, Arrondel C, Sallinen SL, Saloranta C, Clericuzio C, Viot G, Tantau J, Blesson S, Cloarec S, Machet MC, Chitayat D, Thauvin C, Laurent N, Sampson JR, Bernstein JA, Clemenson A, Prieur F, Daniel L, Levy-Mozziconacci A, Lachlan K, Alessandri JL, Cartault F, Rivière JP, Picard N, Baumann C, Delezoide AL, Belar Ortega M, Chassaing N, Labrune P, Yu S, Firth H, Wellesley D, Bitzan M, Alfares A, Braverman N, Krogh L, Tolmie J, Gaspar H, Doray B, Majore S, Bonneau D, Triau S, Loirat C, David A, Bartholdi D, Peleg A, Brackman D, Stone R, DeBerardinis R, Corvol P, Michaud A, Antignac C, Gubler MC. Spectrum of mutations in the renin-angiotensin system genes in autosomal recessive renal tubular dysgenesis. Hum Mutat 2011; 33:316-26. [PMID: 22095942 DOI: 10.1002/humu.21661] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 11/08/2011] [Indexed: 11/11/2022]
Abstract
Autosomal recessive renal tubular dysgenesis (RTD) is a severe disorder of renal tubular development characterized by early onset and persistent fetal anuria leading to oligohydramnios and the Potter sequence, associated with skull ossification defects. Early death occurs in most cases from anuria, pulmonary hypoplasia, and refractory arterial hypotension. The disease is linked to mutations in the genes encoding several components of the renin-angiotensin system (RAS): AGT (angiotensinogen), REN (renin), ACE (angiotensin-converting enzyme), and AGTR1 (angiotensin II receptor type 1). Here, we review the series of 54 distinct mutations identified in 48 unrelated families. Most of them are novel and ACE mutations are the most frequent, observed in two-thirds of families (64.6%). The severity of the clinical course was similar whatever the mutated gene, which underlines the importance of a functional RAS in the maintenance of blood pressure and renal blood flow during the life of a human fetus. Renal hypoperfusion, whether genetic or secondary to a variety of diseases, precludes the normal development/ differentiation of proximal tubules. The identification of the disease on the basis of precise clinical and histological analyses and the characterization of the genetic defects allow genetic counseling and early prenatal diagnosis.
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Affiliation(s)
- Olivier Gribouval
- Inserm U983, Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France.
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26
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Baker WL, White WB. Azilsartan medoxomil: a new angiotensin II receptor antagonist for treatment of hypertension. Ann Pharmacother 2011; 45:1506-15. [PMID: 22116996 DOI: 10.1345/aph.1q468] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy, safety, and clinical role of azilsartan medoxomil, an angiotensin II receptor blocker (ARB) that recently gained Food and Drug Administration approval for lowering of blood pressure (BP) in patients with hypertension. DATA SOURCES A systematic review of the literature was performed through August 2011 using MEDLINE, Web of Science, and International Pharmaceutical Abstracts and the key words and MeSH terms azilsartan, azilsartan medoxomil, TAK-491, TAK-536, and Edarbi. Abstracts presented in the last 2 years from the annual meetings of appropriate medical societies were reviewed in addition to a search of clinicaltrials.gov. STUDY SELECTION AND DATA EXTRACTION Studies eligible for inclusion were in vitro or in vivo evaluations of azilsartan medoxomil, with no restrictions on patient population or indication. Data related to the patient populations and outcomes of interest were extracted from each publication. DATA SYNTHESIS Three trials are available in full publication form with others available only as abstracts. Azilsartan medoxomil 40 mg and 80 mg daily significantly improves both systolic and diastolic BP from baseline compared with placebo, and the 80-mg dose has greater efficacy than other ARBs, including olmesartan 40 mg daily and valsartan 320 mg daily. Improvements in both 24-hour BP using ambulatory monitoring and clinic monitoring have been seen with azilsartan medoxomil as well as a higher proportion of patients reaching the goal level. Additional information shows added BP lowering when azilsartan medoxomil is combined with chlorthalidone. Adverse events are similar with azilsartan medoxomil versus other ARBs and include headache, dizziness, urinary tract infections, and fatigue. CONCLUSIONS Azilsartan medoxomil is a safe and effective ARB with a unique pharmacologic profile versus other agents, including slowed angiotensin II type 1 receptor dissociation rates and improved receptor specificity. Studies have shown azilsartan medoxomil 80 mg once daily to reduce BP to a greater extent than valsartan and olmesartan, with similar safety and tolerability.
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Affiliation(s)
- William L Baker
- School of Pharmacy, University of Connecticut, Farmington, CT, USA.
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Običan S, Scialli AR. Teratogenic exposures. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2011; 157C:150-69. [PMID: 21766437 DOI: 10.1002/ajmg.c.30310] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A consideration of teratogenic exposures includes not only an agent (chemical, radiation, biologic) but an exposure level and timing of exposure. There are criteria by which exposures are evaluated for a causal connection with an abnormal outcome. We here review some teratogenic exposures and discuss how they were initially described and confirmed. We have limited our discussion to some of the exposures for which a connection to structural malformations has been accepted in some quarters, and we indicate some exposures for which a causal association awaits confirmation. We recommend that counselors find a reliable and updatable source of information on exposures during pregnancy.
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Affiliation(s)
- Sarah Običan
- Obstetrics and Gynecology, George Washington University School of Medicine and Health Sciences.
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Abstract
Blood pressure targets and medications that are safe differ in pregnant women compared with nonpregnant individuals. The principles of treatment for mild, moderate, and severe hypertension in pregnancy, chronic versus gestational versus preeclampsia, and women hypertensive at term versus remote from term are reviewed. The choice of antihypertensive drugs also is discussed; methyldopa, labetalol, and nifedipine, among others, appear safe for use in pregnancy, whereas angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be avoided. The management of increased blood pressure in the postpartum period, and agents to use in lactation, are also discussed.
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Affiliation(s)
- Tiina Podymow
- Division of Nephrology, McGill University Health Center, Royal Victoria Hospital, 687 Pine Avenue West, Montreal, Quebec, Canada.
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Are angiotensin-converting enzyme inhibitors and angiotensin receptor blockers safe in pregnancy: a report of ninety-one pregnancies. J Hypertens 2011; 29:396-9. [DOI: 10.1097/hjh.0b013e328341885d] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
Hypertensive disorders of pregnancies remain a central public health concern throughout the world, and are a major cause of maternal mortality in the developing world. Although treatment options have not significantly changed in recent years, insight on the pathogenesis of preeclampsia/eclampsia has been remarkable. With improved animal models of preeclampsia and large-scale human trials, we have embarked upon a new era where angiogenic biomarkers based on mechanism of disease can be designed to assist in early diagnosis and treatment. There is also a growing recognition of how elusive the diagnosis of eclampsia can be, especially in the postpartum period. Proper treatment of these patients depends heavily on the correct diagnosis, especially by the emergency physician. Finally, large epidemiologic studies have revealed that preeclampsia, once thought to be a self-limited entity, now appears to portend real damage to the cardiovascular and other organ systems in the long term. This review will present the latest update on our understanding of the various hypertensive disorders of pregnancies and their treatment options.
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Efficacy and safety of angiotensin II receptor type 1 antagonists in children and adolescents. Pediatr Nephrol 2010; 25:801-11. [PMID: 19936798 DOI: 10.1007/s00467-009-1346-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Revised: 08/07/2009] [Accepted: 09/02/2009] [Indexed: 12/30/2022]
Abstract
Our purpose was to evaluate the effects of angiotensin II receptor type 1 antagonists (ARAs) in children and adolescents with hypertension or/and several kinds of nephropathies on blood pressure (BP) and proteinuria and to evaluate related safety issues. Data sources were Medline, Embase, The Cochrane Library, BIOSIS Previews, contact with investigators and manufacturers, personal bibliography of the lead author, and manual searches. We selected randomized controlled trials (RCTs), uncontrolled trials, and case series investigating ARAs in children and adolescents, as well as case reports about adverse events and the embryotoxic effects of ARAs in children. In four RCTs with 698 individuals, mean systolic blood pressure (BP) decreased by 10.5 mmHg [95% confidence interval (CI) 9.8-11.2] and mean diastolic BP by 6.4 mmHg (95% CI 5.8-7.0). Proteinuria decreased by 30-64% (range) in two RCTs and four case series. Safety data were comparable with adult safety data. ARAs can be considered effective and safe in lowering BP and proteinuria in the pediatric age group. The correlation between the surrogate parameters BP and proteinuria with clinical endpoints is documented to a large degree. The evidence is based on RCTs and also on lower evidence levels, such as case series. In some conditions, RCTs in children are not feasible. Registers could provide more evidence in the future.
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32
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Irani RA, Zhang Y, Blackwell SC, Zhou CC, Ramin SM, Kellems RE, Xia Y. The detrimental role of angiotensin receptor agonistic autoantibodies in intrauterine growth restriction seen in preeclampsia. ACTA ACUST UNITED AC 2009; 206:2809-22. [PMID: 19887397 PMCID: PMC2806612 DOI: 10.1084/jem.20090872] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Growth-restricted fetuses are at risk for a variety of lifelong medical conditions. Preeclampsia, a life-threatening hypertensive disorder of pregnancy, is associated with fetuses who suffer from intrauterine growth restriction (IUGR). Recently, emerging evidence indicates that preeclamptic women harbor AT1 receptor agonistic autoantibodies (AT1-AAs) that contribute to the disease features. However, the exact role of AT1-AAs in IUGR and the underlying mechanisms have not been identified. We report that these autoantibodies are present in the cord blood of women with preeclampsia and retain the ability to activate AT1 receptors. Using an autoantibody-induced animal model of preeclampsia, we show that AT1-AAs cross the mouse placenta, enter fetal circulation, and lead to small fetuses with organ growth retardation. AT1-AAs also induce apoptosis in the placentas of pregnant mice, human villous explants, and human trophoblast cells. Finally, autoantibody-induced IUGR and placental apoptosis are diminished by either losartan or an autoantibody-neutralizing peptide. Thus, these studies identify AT1-AA as a novel causative factor of preeclampsia-associated IUGR and offer two possible underlying mechanisms: a direct detrimental effect on fetal development by crossing the placenta and entering fetal circulation, and indirectly through AT1-AA–induced placental damage. Our findings highlight AT1-AAs as important therapeutic targets.
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Affiliation(s)
- Roxanna A Irani
- Department of Biochemistry and Molecular Biology, University of Texas Medical School at Houston, Houston, TX, 77030, USA
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Vendemmia M, Garcia-Méric P, Rizzotti A, Boubred F, Lacroze V, Liprandi A, Simeoni U. Fetal and neonatal consequences of antenatal exposure to type 1 angiotensin II receptor-antagonists. J Matern Fetal Neonatal Med 2009; 18:137-40. [PMID: 16203601 DOI: 10.1080/14767050500217244] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Sartans are selective type 1 angiotensin II receptor-antagonists that are used in the treatment of arterial hypertension. Few reports are available concerning the use of sartans during pregnancy. We report two cases of adverse fetal outcome in hypertensive pregnancies exposed to sartans. In the first case, anamnios and fetal renal failure due to severe tubular dysgenesia led to termination of pregnancy in the 27th week. The second patient presented with hypocalvaria and developed fetal renal failure. The use of sartans during the two last trimesters of pregnancy should be strictly avoided.
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Affiliation(s)
- Maria Vendemmia
- Department of Neonatology, Hôpital de la Timone-Enfants, Marseille, France
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Velázquez-Armenta EY, Han JY, Choi JS, Yang KM, Nava-Ocampo AA. Angiotensin II Receptor Blockers in Pregnancy: A Case Report and Systematic Review of the Literature. Hypertens Pregnancy 2009; 26:51-66. [PMID: 17454218 DOI: 10.1080/10641950601147937] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To describe the case of a woman exposed to angiotensin-II receptor blockers (ARBs) in the preconceptional period and to systematically review the literature on the safety of these drugs when used by pregnant women. METHODS The case was identified at the Korean Motherisk Program (Seoul). For the systematic review, we searched the PubMed for case reports, case series, and post-marketing surveys. RESULTS A hypertensive woman was exposed to irbesartan prior to conception. The embryo had delayed development of upper and lower extremities and decreased digital groove. A karyotype identified a 45,XO Turner syndrome. The patient had a spontaneous abortion. Including the case reported here, 64 published cases were identified in total; 57.8% had favorable and 42.2% had unfavorable outcomes. Duration of treatment during pregnancy among women who had adverse fetal outcomes was 26.3 +/- 10.5 weeks (mean +/- SD), compared with 17.3 +/- 11.6 weeks in those who had favorable outcomes (p = 0.04). CONCLUSIONS Exposure to ARBs for a period longer than the first trimester of pregnancy appears to be associated with a high risk for adverse fetal outcomes.
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Georgaki-Angelaki E, Stergiou N, Naoum E, Papassotiriou I, Anagnostakou M. Olmesartan medoxomil-induced acute renal failure in a premature newborn following maternal exposure during pregnancy: a case report and review of the literature. NDT Plus 2009; 2:295-7. [PMID: 25984019 PMCID: PMC4421235 DOI: 10.1093/ndtplus/sfp045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Accepted: 04/03/2009] [Indexed: 11/14/2022] Open
Abstract
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II (AT II) receptor blockers (ARBs) are widely used antihypertensives with well-recognized renoprotective and cardioprotective effects. Although treatment with these agents generally does not result in adverse metabolic consequences, their use during human pregnancy has been associated with negative reactions. Here we report a premature baby with a history of oligohydramnios and maternal exposure to the ARB olmesartan medoxomil who was transferred to our institution with acute renal failure. Conservative treatment with diuretics and meticulous management of fluids and electrolytes resulted in an improvement in renal function in the patient. We conclude that olmesartan medoxomil may cause reversible renal failure in premature neonates.
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Affiliation(s)
| | | | | | - Ioannis Papassotiriou
- Department of Clinical Biochemistry , 'Aghia Sophia' Children's Hospital , Athens 11527 , Greece
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Congenital unilateral renal tubular dysgenesis and severe neonatal hypertension. Pediatr Nephrol 2009; 24:863-7. [PMID: 18982358 DOI: 10.1007/s00467-008-1035-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2008] [Revised: 09/30/2008] [Accepted: 10/02/2008] [Indexed: 11/27/2022]
Abstract
Severe arterial hypertension rarely occurs in the neonatal period but may have life-threatening consequences. It is most often caused by renal parenchymal or vascular abnormality, which, to be accurately diagnosed, may require a combination of imaging modalities. We report on a case of neonatal hypertension presenting as cardiac failure. Initial imaging suggested unilateral renal artery stenosis, but this was not corroborated by magnetic resonance angiography. Surgical nephrectomy was curative for the hypertension and also allowed diagnosis of renal tubular dysgenesis. Unilateral congenital tubular dysgenesis without renal infarction has not been previously reported. We speculate that the condition was secondary to a period of localised hypoperfusion during early foetal life.
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Arend LJ, Nadasdy T. Emerging therapy-related kidney disease. Arch Pathol Lab Med 2009; 133:268-78. [PMID: 19195969 DOI: 10.5858/133.2.268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2008] [Indexed: 11/06/2022]
Abstract
CONTEXT Many new therapies have emerged within the last 5 to 10 years to treat a variety of conditions. Several of these have direct or indirect renal toxicities that may go undiagnosed without careful attention of the pathologist to a patient's clinical history, particularly the addition of new medications or treatments. OBJECTIVE To discuss patterns of renal injury resulting from medications or therapeutic regimens that have been introduced within the last 10 years. Recognition of these patterns may allow the pathologist to alert the attending clinician to a possible drug-induced renal injury and prevent further deterioration of renal function and possible chronic kidney disease. DATA SOURCES A review of recent literature and unpublished observations of case-derived material. CONCLUSIONS A number of newer therapies have emerged as agents of renal toxicity, producing a variety of pathologic changes in the kidney. The outcome can be acute or chronic glomerular, tubular, interstitial, and/or vascular injury. Some drugs will result in irreversible changes and end-stage renal disease, whereas many of the alterations can be reversed with removal of the offending agent, avoiding potential long-term kidney injury.
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Affiliation(s)
- Lois J Arend
- Department of Pathology and Laboratory Medicine, University of Cincinnati Academic Health Center, Cincinnati, Ohio, USA
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Martin U, Foreman MA, Travis JC, Casson D, Coleman JJ. Use of ACE inhibitors and ARBs in hypertensive women of childbearing age. J Clin Pharm Ther 2008; 33:507-11. [DOI: 10.1111/j.1365-2710.2008.00938.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kato K, Okuda M, Ishikawa H, Takahashi T, Hirahara F. Oligohydramnios and pulmonary hypoplasia: A case in which involvement of an angiotensin II receptor antagonist was suspected. J Obstet Gynaecol Res 2008; 34:242-6. [DOI: 10.1111/j.1447-0756.2008.00762.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- Tiina Podymow
- Division of Nephrology, McGill University Health Center, Royal Victoria Hospital, 687 Pine Ave West, Ross 2.38, Montreal, Quebec, Canada H3A 1A1.
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Celentano C, Prefumo F, di Vera E, Iannicco A, Gallo DP, Liberati M. Reversible acute fetal renal failure due to maternal exposure to angiotensin receptor blocker. Pediatr Nephrol 2008; 23:333-4. [PMID: 17899204 DOI: 10.1007/s00467-007-0618-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Revised: 08/12/2007] [Accepted: 08/13/2007] [Indexed: 10/22/2022]
Abstract
We report on a case of fetal toxicity due to maternal treatment with olmesartan medoxomil. At 29 weeks' gestation, oligohydramnios was found, although the fetus had normal kidneys on ultrasound evaluation. Withdrawal of olmesartan medoxomil, maternal rehydration, and a single dose of furosemide reversed the renal impairment. After term delivery, the neonate was confirmed to have normal renal function. The case suggested that fetal renal impairment due to olmesartan medoxomil may be reversible.
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Affiliation(s)
- Claudio Celentano
- Department of Obstetrics and Gynecology, University of Chieti, Via Sandro Pertini, 4, 65129, Pescara, Italy.
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Roger N, Popovic I, Madelenat P, Mahieu-Caputo D. Toxicité fœtale des antagonistes des récepteurs de l'angiotensine II. À propos d'un cas. ACTA ACUST UNITED AC 2007; 35:556-60. [PMID: 17544313 DOI: 10.1016/j.gyobfe.2007.03.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2006] [Accepted: 03/15/2007] [Indexed: 11/15/2022]
Abstract
The fetal toxicity of angiotensin-converting enzyme inhibitors (ACEI) is now well known. Sartans which are angiotensin II inhibitors, are supposed to have the same side effects on the fetus as ACEI because of their similar mechanism of action. This is supported by experimental and clinical data. Clinical presentation of fetal exposition to sartans varies from transient oligamnios to permanent renal failure, potentially complicated by Potter syndrome. According to previously reported cases, we report a case of transitory fetal oliguria secondary to the exposure to an angiotensin-II-receptor inhibitor (valsartan) between 19 and 21 weeks' gestation. We discuss the management of pregnancies exposed to angiotensin II inhibitors.
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Affiliation(s)
- N Roger
- Service de Gynécologie-Obstétrique, Maternité Aline-de-Crépy, Hôpital Bichat-Claude-Bernard, APHP, Université Paris-VII, 75018 Paris, France
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Bakkum JN, Brost BC, Johansen KL, Johnston BW, Watson WJ. In utero losartan withdrawal and subsequent development of fetal inferior vena cava thrombosis. Obstet Gynecol 2006; 108:739-40. [PMID: 17018485 DOI: 10.1097/01.aog.0000187942.09107.08] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Angiotensin receptor blockers are antihypertensive medications prescribed by a wide variety of physicians, especially for patients with coexistent diabetes mellitus. Angiotensin receptor blockers, as well as angiotensin-converting enzyme inhibitors, are contraindicated in pregnancy. CASE We describe the reversal of losartan-induced oligohydramnios at 27 weeks of gestation with subsequent development of fetal thrombosis and possible mechanism of action for this extremely rare in utero complication. CONCLUSION This theory may help explain the fetal stillbirths in women taking this class of medications during the second and third trimester of pregnancy.
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Affiliation(s)
- Jamie N Bakkum
- Section of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
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Boubred F, Vendemmia M, Garcia-Meric P, Buffat C, Millet V, Simeoni U. Effects of maternally administered drugs on the fetal and neonatal kidney. Drug Saf 2006; 29:397-419. [PMID: 16689556 DOI: 10.2165/00002018-200629050-00004] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The number of pregnant women and women of childbearing age who are receiving drugs is increasing. A variety of drugs are prescribed for either complications of pregnancy or maternal diseases that existed prior to the pregnancy. Such drugs cross the placental barrier, enter the fetal circulation and potentially alter fetal development, particularly the development of the kidneys. Increased incidences of intrauterine growth retardation and adverse renal effects have been reported. The fetus and the newborn infant may thus experience renal failure, varying from transient oligohydramnios to severe neonatal renal insufficiency leading to death. Such adverse effects may particularly occur when fetuses are exposed to NSAIDs, ACE inhibitors and specific angiotensin II receptor type 1 antagonists. In addition to functional adverse effects, in utero exposure to drugs may affect renal structure itself and produce renal congenital abnormalities, including cystic dysplasia, tubular dysgenesis, ischaemic damage and a reduced nephron number. Experimental studies raise the question of potential long-term adverse effects, including renal dysfunction and arterial hypertension in adulthood. Although neonatal data for many drugs are reassuring, such findings stress the importance of long-term follow-up of infants exposed in utero to certain drugs that have been administered to the mother.
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Affiliation(s)
- Farid Boubred
- Faculté de Médecine, Université de la Méditerrannée and Assistance Publique Hôpitaux de Marseille, Hôpital de la Conception, Service de Néonatologie, Marseille, France
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Cooper WO, Hernandez-Diaz S, Arbogast PG, Dudley JA, Dyer S, Gideon PS, Hall K, Ray WA. Major congenital malformations after first-trimester exposure to ACE inhibitors. N Engl J Med 2006; 354:2443-51. [PMID: 16760444 DOI: 10.1056/nejmoa055202] [Citation(s) in RCA: 613] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Use of angiotensin-converting-enzyme (ACE) inhibitors during the second and third trimesters of pregnancy is contraindicated because of their association with an increased risk of fetopathy. In contrast, first-trimester use of ACE inhibitors has not been linked to adverse fetal outcomes. We conducted a study to assess the association between exposure to ACE inhibitors during the first trimester of pregnancy only and the risk of congenital malformations. METHODS We studied a cohort of 29,507 infants enrolled in Tennessee Medicaid and born between 1985 and 2000 for whom there was no evidence of maternal diabetes. We identified 209 infants with exposure to ACE inhibitors in the first trimester alone, 202 infants with exposure to other antihypertensive medications in the first trimester alone, and 29,096 infants with no exposure to antihypertensive drugs at any time during gestation. Major congenital malformations were identified from linked vital records and hospitalization claims during the first year of life and confirmed by review of medical records. RESULTS Infants with only first-trimester exposure to ACE inhibitors had an increased risk of major congenital malformations (risk ratio, 2.71; 95 percent confidence interval, 1.72 to 4.27) as compared with infants who had no exposure to antihypertensive medications. In contrast, fetal exposure to other antihypertensive medications during only the first trimester did not confer an increased risk (risk ratio, 0.66; 95 percent confidence interval, 0.25 to 1.75). Infants exposed to ACE inhibitors were at increased risk for malformations of the cardiovascular system (risk ratio, 3.72; 95 percent confidence interval, 1.89 to 7.30) and the central nervous system (risk ratio, 4.39; 95 percent confidence interval, 1.37 to 14.02). CONCLUSIONS Exposure to ACE inhibitors during the first trimester cannot be considered safe and should be avoided.
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Affiliation(s)
- William O Cooper
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
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Daïkha-Dahmane F, Levy-Beff E, Jugie M, Lenclen R. Foetal kidney maldevelopment in maternal use of angiotensin II type I receptor antagonists. Pediatr Nephrol 2006; 21:729-32. [PMID: 16565869 DOI: 10.1007/s00467-006-0070-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2004] [Revised: 12/12/2005] [Accepted: 12/15/2005] [Indexed: 01/27/2023]
Abstract
We report renal lesions observed in a foetus exposed throughout pregnancy to angiotensin II type I (AT 1) receptor antagonists. The mother suffered from essential hypertension and was treated with Cozaar (losartan 50 mg). Autopsy examination of the foetus revealed severe renal lesions, including tubular dysgenesis, hypertrophy of the endothelial and medial cells lining the arterial and arteriolar walls, hyperplasia of the juxtaglomerular apparatus and poorly developed vasa recta. Similar lesions have already been observed in foetuses of women treated with angiotensin-converting enzyme antagonists and also in foetuses and neonates of animals undergoing experimental blockade of the renin-angiotensin system. The purpose of this report is to describe structural lesions observed in the kidneys, and, particularly, vascular lesions. Our results suggest that the use of AT 1 receptor antagonists during pregnancy may have a severe deleterious effect on kidney development in the foetus.
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Affiliation(s)
- Farida Daïkha-Dahmane
- Service d'Anatomie Pathologique/Unité de Foetopathologie, Centre Hospitalier de Poissy-Saint Germain en Laye, 10, rue du Champ Gaillard, 78303, Poissy Cedex, France.
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Niimura F, Kon V, Ichikawa I. The renin-angiotensin system in the development of the congenital anomalies of the kidney and urinary tract. Curr Opin Pediatr 2006; 18:161-6. [PMID: 16601496 DOI: 10.1097/01.mop.0000193288.56528.40] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW Recognition of the dramatically expanded functional repertoire of the renin-angiotensin system now includes a role in morphogenesis of the kidney and urinary tract. On the basis of published data, the article presents formulations of mechanisms through which the system operates. RECENT FINDINGS Studies in humans and animals carrying defective angiotensin-related genes have provided unequivocal evidence that the renin-angiotensin system is involved in the normal development of both the kidney and the urinary tract. Angiotensin exerts its function through at least two different types of receptors, AT1 and AT2. AT1 mediates establishment of the ureteral peristaltic machinery, while AT2 mediates the early kidney and urinary tract morphogenesis. Disruption in receptor functions promotes development of congenital anomalies of the kidney and urinary tract. SUMMARY Angiotensin is involved in multiple steps of normal development of the kidney and urinary tract through two types of receptors. This takes place in concert with other functionally overlapping genes.
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Affiliation(s)
- Fumio Niimura
- Department of Pediatrics, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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Abstract
Losartan is the first orally available angiotensin-receptor antagonist without agonist properties. Following oral administration, losartan is rapidly absorbed, reaching maximum concentrations 1-2 hours post-administration. After oral administration approximately 14% of a losartan dose is converted to the pharmacologically active E 3174 metabolite. E 3174 is 10- to 40-fold more potent than its parent compound and its estimated terminal half-life ranges from 6 to 9 hours. The pharmacokinetics of losartan and E 3174 are linear, dose-proportional and do not substantially change with repetitive administration. The recommended dosage of losartan 50 mg/day can be administered without regard to food. There are no clinically significant effects of age, sex or race on the pharmacokinetics of losartan, and no dosage adjustment is necessary in patients with mild hepatic impairment or various degrees of renal insufficiency. Losartan, or its E 3174 metabolite, is not removed during haemodialysis. The major metabolic pathway for losartan is by the cytochrome P450 (CYP) 3A4, 2C9 and 2C10 isoenzymes. Overall, losartan has a favorable drug-drug interaction profile, as evidenced by the lack of clinically relevant interactions between this drug and a range of inhibitors and stimulators of the CYP450 system. Losartan does not have a drug-drug interaction with hydrochlorothiazide, warfarin or digoxin. Losartan should be avoided in pregnancy, as is the case with all other angiotensin-receptor antagonists. When given in the second and third trimester of pregnancy, losartan is often associated with serious fetal toxicity. Losartan is a competitive antagonist that causes a parallel rightward shift of the concentration-contractile response curve to angiotensin-II, while E 3174 is a noncompetitive "insurmountable" antagonist of angiotensin-II. The maximum recommended daily dose of losartan is 100mg, which can be given as a once-daily dose or by splitting the same total daily dose into two doses. Losartan reduces blood pressure comparably to other angiotensin-receptor antagonists. Losartan has been extensively studied relative to end-organ protection, with studies having been conducted in diabetic nephropathy, heart failure, post-myocardial infarction and hypertensive patients with left ventricular hypertrophy. The results of these studies have been sufficiently positive to support a more widespread use of angiotensin-receptor antagonists in the setting of various end-organ diseases. Losartan, like other angiotensin-receptor antagonists, is devoid of significant adverse effects.
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Affiliation(s)
- Domenic A Sica
- Division of Nephrology, Medical College of Virginia, Virginia Commonwealth University, PO Box 980160, Richmond, VA 23298, USA.
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Quan A. Fetopathy associated with exposure to angiotensin converting enzyme inhibitors and angiotensin receptor antagonists. Early Hum Dev 2006; 82:23-8. [PMID: 16427219 DOI: 10.1016/j.earlhumdev.2005.11.001] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2005] [Indexed: 10/25/2022]
Abstract
The renin-angiotensin system plays an important role in the regulation of blood pressure. The use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers both control hypertension by interruption of the production or action of angiotensin II, the major end-product of the renin-angiotensin system. The use of angiotensin converting enzyme inhibitors in pregnant women revealed serious and deleterious effects on fetal development including renal failure, renal dysplasia, hypotension, oligohydramnios, pulmonary hypoplasia, and hypocalvaria. The fetal effects of angiotensin converting enzyme inhibitors seem to be greatest during the 2nd and 3rd trimesters of pregnancy. The fetal effect of angiotensin converting enzyme inhibitors during the 1st trimester is controversial. These effects may represent the effect of hypoperfusion in the fetus and not a teratogenic effect. The effect of angiotensin receptor blockers is similar to converting enzyme inhibitors. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be avoided in all pregnant women. Alternative antihypertensive medications should be considered for use in women of childbearing years.
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Affiliation(s)
- Albert Quan
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9063, USA.
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