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Massolini BD, Contieri SSG, Lazarini GS, Bellacosa PA, Dobre M, Petroianu G, Brateanu A, Campos LA, Baltatu OC. Therapeutic Renin Inhibition in Diabetic Nephropathy-A Review of the Physiological Evidence. Front Physiol 2020; 11:190. [PMID: 32231590 PMCID: PMC7082742 DOI: 10.3389/fphys.2020.00190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/19/2020] [Indexed: 11/13/2022] Open
Abstract
The purpose of this systematic review was to investigate the scientific evidence to support the use of direct renin inhibitors (DRIs) in diabetic nephropathy (DN). MEDLINE was searched for articles reported until 2018. A standardized dataset was extracted from articles describing the effects of DRIs on plasma renin activity (PRA) in DN. A total of three clinical articles studying PRA as an outcome measure for DRIs use in DN were identified. These clinical studies were randomized controlled trials (RCTs): one double-blind crossover, one post hoc of a double-blind and placebo-controlled study, and one open-label and parallel-controlled study. Two studies reported a significant decrease of albuminuria associated with PRA reduction. One study had a DRI as monotherapy compared with placebo, and two studies had DRI as add-in to an angiotensin II (Ang II) receptor blocker (ARB). Of 10,393 patients with DN enrolled in five studies with DRI, 370 (3.6%) patients had PRA measured. Only one preclinical study was identified that determined PRA when investigating the effects of aliskiren in DN. Moreover, most of observational preclinical and clinical studies identified report on a low PRA or hyporeninemic hypoaldosteronism in DM. Renin inhibition has been suggested for DN, but proof-of-concept studies for this are scant. A small number of clinical and preclinical studies assessed the PRA effects of DRIs in DN. For a more successful translational research for DRIs, specific patient population responsive to the treatment should be identified, and PRA may remain a biomarker of choice for patient stratification.
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Affiliation(s)
- Bianca Domingues Massolini
- Center of Innovation, Technology and Education-CITÉ, São José dos Campos Technology Park, São José dos Campos, São Paulo, Brazil.,Institute of Biomedical Engineering, Anhembi Morumbi University, Laureate International Universities, São José dos Campos, São Paulo, Brazil
| | - Stephanie San Gregorio Contieri
- Center of Innovation, Technology and Education-CITÉ, São José dos Campos Technology Park, São José dos Campos, São Paulo, Brazil.,Institute of Biomedical Engineering, Anhembi Morumbi University, Laureate International Universities, São José dos Campos, São Paulo, Brazil
| | - Giulia Severini Lazarini
- Center of Innovation, Technology and Education-CITÉ, São José dos Campos Technology Park, São José dos Campos, São Paulo, Brazil.,Institute of Biomedical Engineering, Anhembi Morumbi University, Laureate International Universities, São José dos Campos, São Paulo, Brazil
| | - Paula Antoun Bellacosa
- Center of Innovation, Technology and Education-CITÉ, São José dos Campos Technology Park, São José dos Campos, São Paulo, Brazil.,Institute of Biomedical Engineering, Anhembi Morumbi University, Laureate International Universities, São José dos Campos, São Paulo, Brazil
| | - Mirela Dobre
- Division of Nephrology and Hypertension, University Hospitals, Cleveland, OH, United States
| | - Georg Petroianu
- College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Andrei Brateanu
- Medicine Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Luciana Aparecida Campos
- Center of Innovation, Technology and Education-CITÉ, São José dos Campos Technology Park, São José dos Campos, São Paulo, Brazil.,Institute of Biomedical Engineering, Anhembi Morumbi University, Laureate International Universities, São José dos Campos, São Paulo, Brazil.,College of Health Sciences, Abu Dhabi University, Abu Dhabi, United Arab Emirates
| | - Ovidiu Constantin Baltatu
- Center of Innovation, Technology and Education-CITÉ, São José dos Campos Technology Park, São José dos Campos, São Paulo, Brazil.,Institute of Biomedical Engineering, Anhembi Morumbi University, Laureate International Universities, São José dos Campos, São Paulo, Brazil.,College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates
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2
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Inam R, Gandhi J, Joshi G, Smith NL, Khan SA. Juxtaglomerular Cell Tumor: Reviewing a Cryptic Cause of Surgically Correctable Hypertension. Curr Urol 2019; 13:7-12. [PMID: 31579192 DOI: 10.1159/000499301] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 07/22/2018] [Indexed: 12/16/2022] Open
Abstract
Juxtaglomerular cell tumor (JGCT), or reninoma, is a typically benign neoplasm generally affecting adolescents and young adults due to modified smooth muscle cells from the afferent arteriole of the juxtaglomerular apparatus. Patients experience symptoms related to hypertension and hypoka-lemia due to renin-secretion by the tumor. MRI, PET, CT, and renal vein catheterizations can be used to capture JGCTs, with laparoscopic ultrasonography being most cost-efective. Surgical removal is the best option for management; electrolyte imbalances are a potential complication which may be assuaged via pre-surgical administration of aliskiren, a renin inhibitor. Considering the vast etiology for hypertension and rarity of JGCT, the diagnosing physician must have a high index of suspicion for JGCT. Early recognition and management can help prevent cardiovascular or pregnancy complications and fatalities, vascular invasion and metastasis, improve quality of life, and limit socioeconomic liabilities. Herein we review the epidemiology, genetics, histopathol-ogy, clinical presentation, and management of this rare condition. The impact of genetics on prognosis warrant further research.
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Affiliation(s)
- Rafid Inam
- Department of Physiology and Biophysics, Stony Brook Renaissance University School of Medicine, Stony Brook, NY, USA
| | - Jason Gandhi
- Department of Physiology and Biophysics, Stony Brook Renaissance University School of Medicine, Stony Brook, NY, USA.,Medical Student Research Institute, St. George's University School of Medicine, Grenada, West Indies
| | - Gunjan Joshi
- Department of Internal Medicine, Stony Brook Southampton Hospital, Southampton, NY
| | | | - Sardar Ali Khan
- Department of Physiology and Biophysics, Stony Brook Renaissance University School of Medicine, Stony Brook, NY, USA.,Department of Urology, Stony Brook Renaissance University School of Medicine, Stony Brook, NY, USA
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Rationale for nebivolol/valsartan combination for hypertension: review of preclinical and clinical data. J Hypertens 2018; 35:1758-1767. [PMID: 28509722 PMCID: PMC5548499 DOI: 10.1097/hjh.0000000000001412] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
To treat hypertension, combining two or more antihypertensive drugs from different classes is often necessary. β-Blockers and renin–angiotensin–aldosterone system inhibitors, when combined, have been deemed ‘less effective’ based on partially overlapping mechanisms of action and limited evidence. Recently, the single-pill combination (SPC) of nebivolol (Neb) 5 mg – a vasodilatory β1-selective antagonist/β3 agonist – and valsartan 80 mg, an angiotensin II receptor blocker, was US Food and Drug Administration-approved for hypertension. Pharmacological profiles of Neb and valsartan, alone and combined, are well characterized. In addition, a large 8-week randomized trial in stages I–II hypertensive patients (N = 4161) demonstrated greater blood pressure-reducing efficacy for Neb/valsartan SPCs than component monotherapies with comparable tolerability. In a biomarkers substudy (N = 805), Neb/valsartan SPCs prevented valsartan-induced increases in plasma renin, and a greater reduction in plasma aldosterone was observed with the highest SPC dose vs. valsartan 320 mg/day. This review summarizes preclinical and clinical evidence supporting Neb/valsartan as an efficacious and well tolerated combination treatment for hypertension.
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Kline GA, Prebtani APH, Leung AA, Schiffrin EL. The Potential Role of Primary Care in Case Detection/Screening of Primary Aldosteronism. Am J Hypertens 2017; 30:1147-1150. [PMID: 28992276 DOI: 10.1093/ajh/hpx064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 03/23/2017] [Indexed: 11/13/2022] Open
Abstract
Endocrine hypertension, particularly primary aldosteronism (PA), was previously considered to account for less than 1% of all hypertension and was suspected only when patients presented with spontaneous hypokalemia. However, the last 20 years of PA research has now clearly shown that PA is not a rarity, but rather, may account for up to 13% of unselected hypertensive individuals and between 10% and 20% of those with resistant hypertension. Most of these patients do not have spontaneous hypokalemia. The population prevalence of PA likely far exceeds actual detection rates in routine clinical care. As PA represents one of the most common, potentially reversible causes of hypertension, and is associated with significant cardiovascular complications over the long term, it is clear that a pragmatic strategy for targeted case detection in primary care is needed.
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Affiliation(s)
- Gregory A Kline
- Division of Endocrinology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ally P H Prebtani
- Department of Medicine, Internal Medicine, Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada
| | - Alexander A Leung
- Division of Endocrinology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ernesto L Schiffrin
- Department of Medicine, Jewish General Hospital and Lady Davis Research Institute, McGill University, Montreal, Quebec, Canada
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Ghazi L, Drawz P. Advances in understanding the renin-angiotensin-aldosterone system (RAAS) in blood pressure control and recent pivotal trials of RAAS blockade in heart failure and diabetic nephropathy. F1000Res 2017; 6. [PMID: 28413612 PMCID: PMC5365219 DOI: 10.12688/f1000research.9692.1] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2017] [Indexed: 12/11/2022] Open
Abstract
The renin-angiotensin-aldosterone system (RAAS) plays a fundamental role in the physiology of blood pressure control and the pathophysiology of hypertension (HTN) with effects on vascular tone, sodium retention, oxidative stress, fibrosis, sympathetic tone, and inflammation. Fortunately, RAAS blocking agents have been available to treat HTN since the 1970s and newer medications are being developed. In this review, we will (1) examine new anti-hypertensive medications affecting the RAAS, (2) evaluate recent studies that help provide a better understanding of which patients may be more likely to benefit from RAAS blockade, and (3) review three recent pivotal randomized trials that involve newer RAAS blocking agents and inform clinical practice.
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Affiliation(s)
- Lama Ghazi
- Division of Renal Disease and Hypertension, Department of Medicine, University of Minnesota, Minnesota, MN, USA
| | - Paul Drawz
- Division of Renal Disease and Hypertension, Department of Medicine, University of Minnesota, Minnesota, MN, USA
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Giles TD, Bakris G, Oparil S, Weber MA, Li H, Mallick M, Bharucha DB, Chen C, Ferguson WG. Correlations of plasma renin activity and aldosterone concentration with ambulatory blood pressure responses to nebivolol and valsartan, alone and in combination, in hypertension. ACTA ACUST UNITED AC 2015; 9:845-54. [PMID: 26362831 DOI: 10.1016/j.jash.2015.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 08/03/2015] [Accepted: 08/04/2015] [Indexed: 11/26/2022]
Abstract
After demonstration of the antihypertensive efficacy of the combination of the beta-blocker nebivolol and the angiotensin receptor blocker valsartan in an 8-week, randomized, placebo-controlled trial (N = 4161), we now report the effects of this treatment on the renin-angiotensin-aldosterone system in a substudy (n = 805). Plasma renin activity increased with valsartan (54%-73%) and decreased with nebivolol (51%-65%) and the combination treatment (17%-39%). Plasma aldosterone decreased with individual treatments (valsartan, 11%-22%; nebivolol, 20%-26%), with the largest reduction (35%) observed with maximum combination dose (20 mg nebivolol/320 mg valsartan). Baseline ln(plasma renin activity) correlated with the 8-week reductions in 24-hour systolic and diastolic BP following treatments with the combination (all doses combined, P = .003 and P < .001) and nebivolol (both, P < .001), but not with valsartan. Baseline ln(aldosterone) correlated with 24-hour systolic and diastolic BP reductions following combination treatment only (P < .001 and P = .005). The implications of the renin-angiotensin-aldosterone system effects of this beta blocker-angiotensin receptor blocker combination should be explored further.
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Affiliation(s)
- Thomas D Giles
- Department of Medicine, Tulane University, New Orleans, LA, USA.
| | - George Bakris
- Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Suzanne Oparil
- Division of Cardiovascular Disease, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Michael A Weber
- Division of Cardiovascular Medicine, Downstate College of Medicine, State University of New York, Brooklyn, NY, USA
| | - Huiling Li
- Department of Biostatistics, Forest Research Institute, Inc, an affiliate of Actavis, Inc (now: Allergan), Harborside Financial Center, Jersey City, NJ, USA
| | - Madhuja Mallick
- Department of Biostatistics, Forest Research Institute, Inc, an affiliate of Actavis, Inc (now: Allergan), Harborside Financial Center, Jersey City, NJ, USA
| | - David B Bharucha
- Department of Clinical Development, Forest Research Institute, Inc, an affiliate of Actavis, Inc (now: Allergan), Harborside Financial Center, Jersey City, NJ, USA
| | - ChunLin Chen
- Department of Clinical Development, Forest Research Institute, Inc, an affiliate of Actavis, Inc (now: Allergan), Harborside Financial Center, Jersey City, NJ, USA
| | - William G Ferguson
- Department of Clinical Development, Forest Research Institute, Inc, an affiliate of Actavis, Inc (now: Allergan), Harborside Financial Center, Jersey City, NJ, USA
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Gonzalez MC, Cohen HW, Alderman MH. Pressor response to initial blood pressure monotherapy is associated with cardiovascular mortality. Am J Hypertens 2015; 28:232-8. [PMID: 25227515 DOI: 10.1093/ajh/hpu133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND A paradoxical pressor systolic response to initial antihypertensive monotherapy has been observed in 8% of hypertensive patients. The long-term consequences of this finding are unknown. METHODS We included 945 hypertensive patients with baseline systolic blood pressure (SBP) ≥140mm Hg. A 4-week washout period free of antihypertensive drugs was allowed for those already on treatment at entry. Mortality outcomes were ascertained from the National Death Index. Subjects were categorized by SBP response into depressor (≥10mm Hg fall), nonresponder, and pressor (≥10mm Hg rise) categories. RESULTS There were 268 fatalities. Of these, 100 (37%) were from cardiovascular disease (CVD), of which 70 (70%) were due to coronary artery disease (CAD). A pressor response was associated with higher SBP at 1 year compared with the nonresponder or depressor response (141 vs. 136 vs. 136mm Hg). CVD mortality was greater in pressors than depressors (hazard ratio (HR) = 3.0; 95% confidence interval (CI) = 1.4-6.4; P = 0.004], as was CAD (HR = 3.1; 95% CI = 1.4-6.8; P < 0.01) and all-cause mortality (HR = 1.7; 95% CI = 1.1-2.6; P = 0.02), after adjusting for 1-year SBP and other possible confounders. CONCLUSIONS We found the incidence of a pressor response to monotherapy at 3 months was significantly, specifically, and independently associated with higher subsequent cardiovascular mortality.
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Affiliation(s)
- Maday C Gonzalez
- New York Presbyterian-Weill Cornell Medical Center, New York, New York;
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Zion AS, Izzo JL. Combination therapy with aliskiren and amlodipine in hypertension: treatment rationale and clinical results. Expert Rev Cardiovasc Ther 2014; 9:421-7. [DOI: 10.1586/erc.11.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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9
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Epstein BJ, Smith SM, Choksi R. Recent changes in the landscape of combination RAS blockade. Expert Rev Cardiovasc Ther 2014; 7:1373-84. [DOI: 10.1586/erc.09.127] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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10
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Rajagopalan S, Bakris GL, Abraham WT, Pitt B, Brook RD. Complete renin-angiotensin-aldosterone system (RAAS) blockade in high-risk patients: recent insights from renin blockade studies. Hypertension 2013; 62:444-9. [PMID: 23876474 DOI: 10.1161/hypertensionaha.113.01504] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Sanjay Rajagopalan
- Division of Cardiovascular Medicine, Davis Heart and Lung Research Institute, 460 W, 12th Ave, Room 390, BRT, Columbus, OH 43210, USA.
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Abstract
The renin–angiotensin system (RAS) affects vascular tone, cardiac output and kidney function. By these means the RAS plays a key role in the pathogenesis of arterial hypertension. As a result, RAS inhibition is highly effective not only in lowering blood pressure but also in reducing kidney disease progression (particularly when associated with proteinuria) and cardiovascular events. Among RAS blocking agents, direct renin inhibitors have shown not only excellent efficacy in hypertension control but also pharmacologic tolerance that is comparable with other renin–angiotensin suppressors. Indeed, aliskiren, the only direct renin inhibitor available is effective in controlling blood pressure as monotherapy or in combination with other antihypertensive drugs, irrespective of patient’s age, ethnicity or sex. It is also effective in patients with metabolic syndrome, obesity and diabetes. Long-term studies comparing ‘hard endpoints’ of aliskiren therapy versus treatment with other RAS inhibitors, including cardiac and kidney protection, are currently ongoing. Combined with other antihypertensive agents, aliskiren not only improves their hypotensive response but may also lessen the adverse effects of other drugs. In high-risk patients, however, precautions should be taken when combining two or more renin–angiotensin inhibiting agents, as tissue perfusion may be highly renin-dependent in these patients and serious adverse side effects could take place.
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Affiliation(s)
- Luis Juncos
- Fundación Robert Cade, Pedro de Oñate 253, Cordoba 5003, Argentina
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12
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Jagadeesh G, Balakumar P, Stockbridge N. How well do aliskiren's purported mechanisms track its effects on cardiovascular and renal disorders? Cell Signal 2012; 24:1583-91. [DOI: 10.1016/j.cellsig.2012.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 04/04/2012] [Indexed: 01/27/2023]
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Kanaoka T, Tamura K, Ohsawa M, Wakui H, Maeda A, Dejima T, Azushima K, Haku S, Mitsuhashi H, Yanagi M, Oshikawa J, Uneda K, Aoki K, Fujikawa T, Toya Y, Uchino K, Umemura S. Effects of Aliskiren-Based Therapy on Ambulatory Blood Pressure Profile, Central Hemodynamics, and Arterial Stiffness in Nondiabetic Mild to Moderate Hypertensive Patients. J Clin Hypertens (Greenwich) 2012; 14:522-9. [DOI: 10.1111/j.1751-7176.2012.00640.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Laragh JH, Sealey JE. The plasma renin test reveals the contribution of body sodium-volume content (V) and renin-angiotensin (R) vasoconstriction to long-term blood pressure. Am J Hypertens 2011; 24:1164-80. [PMID: 21938070 DOI: 10.1038/ajh.2011.171] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Body sodium works together with the plasma renin-angiotensin system to ensure adequate blood flow to the tissues. Body sodium content determines the extracellular fluid (ECF) volume ensuring that, with each heart beat, a sufficient volume of fluid is delivered into the arterial space. At the same time the kidneys monitor ECF volume and blood pressure (BP), so that the juxtaglomerular cells can adjust their net secretion rate of renin to maintain an appropriate plasma renin activity (PRA) level. Plasma renin produces angiotensin II (Ang II) to constrict the arterioles and thereby ensure sufficient BP to deliver an appropriate rate of flow for cardiovascular homeostasis. The low renin, sodium-volume dependent (V) form of essential hypertension occurs whenever body sodium content increases beyond the point where plasma renin-angiotensin vasoconstrictor activity is turned off. In contrast, medium to high renin (R) hypertension occurs when too much renin is secreted relative to the body sodium content. Thus, BP = V × R. This volume-vasoconstriction dual support of long-term hypertension is validated by the fact that all effective long-term antihypertensive drug types are either (i) natriuretic to reduce body salt and volume content (anti-V), or (ii) antirenin to reduce or block the activity of the circulating renin-angiotensin system (anti-R). The PRA test defines the relative participation of the concurrent volume and vasoconstrictor factors. In the hypertensive patient PRA testing can guide initiation, addition or subtraction of anti-V or anti-R antihypertensive drug types to thereby improve BP control and prognosis while reducing drug type usage and cost.
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Furberg CD. Renin test-guided drug treatment of hypertension: the need for clinical trials. Am J Hypertens 2011; 24:1158-63. [PMID: 22008966 DOI: 10.1038/ajh.2011.170] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Izzo JL, Zion AS. Combined aliskiren-amlodipine treatment for hypertension in African Americans: clinical science and management issues. Ther Adv Cardiovasc Dis 2011; 5:169-78. [PMID: 21606125 DOI: 10.1177/1753944711409615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
While it may seem at first that antihypertensive drug combinations run counter to the desire to 'personalize' the management of hypertension, the best combinations have predictable efficacy in different individuals and subpopulations. Race is probably not a valid surrogate for clinically meaningful genetic variation or guide to therapy. Most guidelines suggest similar blood pressure goals for different races but drug treatment recommendations have diverged. In the United States, race is not considered to be a major factor in drug choice, but in England and other countries, initial therapy with renin-angiotensin system blocking drugs is not recommended in Blacks. In this review we: (1) examine new trends in race-based research; (2) emphasize the weaknesses of race-based treatment recommendations; and (3) explore the effects of a new combination, renin inhibition (aliskiren) and amlodipine, in African Americans.
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Affiliation(s)
- Joseph L Izzo
- Department of Medicine, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, 462 Grider Street, Buffalo, NY 14215, USA.
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Kobori H, Fu Q, Crowley SD, Gonzalez-Villalobos RA, Campos RR. Comments on Point:Counterpoint: The dominant contributor to systemic hypertension: Chronic activation of the sympathetic nervous system vs. Activation of the intrarenal renin-angiotensin system. Activated intrarenal renin-angiotensin system is correlated with high blood pressure in humans. J Appl Physiol (1985) 2010; 109:2003. [PMID: 21148352 PMCID: PMC3774210 DOI: 10.1152/japplphysiol.01160.2010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Hiroyuki Kobori
- Department of Medicine, Tulane University Health Sciences Center, LA, USA
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Reboldi G, Gentile G, Angeli F, Verdecchia P. Pharmacokinetic, pharmacodynamic and clinical evaluation of aliskiren for hypertension treatment. Expert Opin Drug Metab Toxicol 2010; 7:115-28. [DOI: 10.1517/17425255.2011.538681] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Cardiovascular and Renal Pathologic Implications of Prorenin, Renin, and the (Pro)renin Receptor: Promising Young Players From the Old Renin-Angiotensin-Aldosterone System. J Cardiovasc Pharmacol 2010; 56:570-9. [DOI: 10.1097/fjc.0b013e3181f21576] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Do TH, Chen Y, Nguyen VT, Phisitkul S. Vaccines in the management of hypertension. Expert Opin Biol Ther 2010; 10:1077-87. [PMID: 20455790 DOI: 10.1517/14712598.2010.487060] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD In the USA only 35% of patients with hypertension achieve adequate blood pressure control. Non-compliance is one of the main barriers to treatment. Vaccine against hypertension is an innovative treatment, injected every 4 - 6 months, to combat non-compliance. AREAS COVERED IN THIS REVIEW Pathogenesis of hypertension and progress towards developing a hypertension vaccine, including the virus-like-particle-based approach, new adjuvant molecules and the potential toxicity of hypertension vaccine. WHAT THE READER WILL GAIN The pathogenesis of hypertension is multifactorial. The most common cause is disruption of the Renin-angiotensin-aldosterone system (RAAS), and the first vaccine study was carried out against renin. While the vaccine reduced blood pressure in animal models, it also caused autoimmune disease. In the last decade, vaccines against angiotensin I, angiotensin II, and angiotensin II-type 1 receptors have demonstrated acceptable safety profiles in animal and human studies. TAKE HOME MESSAGE Reduction in blood pressure can be achieved by inducing immunity against targets in the RAAS. The target antigen and selection of adjuvant are crucial factors determining effectiveness and safety of the vaccine. CYT006-AngQb (angiotensin II vaccine) reduced blood pressure in humans but the results were not reproducible with more frequent dosing. Vaccines for hypertension are still in the early phase. We hope for an effective vaccine for hypertension in the years to come.
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Affiliation(s)
- Thong Huy Do
- Texas Tech University Health Sciences Center, Nephrology, Lubbock, TX 79430, USA
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Rabbia F, Testa E, Totaro S, Leotta G, Berra E, Covella M, Milazzo V, Di Stefano C, Veglio F. Effects of Antihypertensive Drugs on the Renin-Angiotensin System in Essential Hypertension. High Blood Press Cardiovasc Prev 2010. [DOI: 10.2165/11311870-000000000-00000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Alderman MH, Cohen HW, Sealey JE, Laragh JH. Pressor responses to antihypertensive drug types. Am J Hypertens 2010; 23:1031-7. [PMID: 20725055 DOI: 10.1038/ajh.2010.114] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Pressor responses to antihypertensive drugs are not addressed in treatment guidelines although they have been described in various clinical situations. We now report the incidence of pressor responses to initiation of monotherapy using four antihypertensive drug types, and the influence of plasma renin activity (PRA) status, among participants in a worksite-based antihypertensive treatment program. METHODS Systolic blood pressure (SBP) response was evaluated among 945 participants with no prior treatment who were given either a diuretic or calcium-channel blocker (natriuretic antivolume V drugs, n = 537) or a beta-blocker or angiotensin-converting enzyme (ACE) inhibitor (antirenin R drugs n = 408). PRA was categorized by low, middle, and high tertiles (L, M, and H). SBP rise > or =10 mm Hg was considered pressor. RESULTS More pressor responses occurred with R than V drugs (11% vs. 5%, P = 0.001). L, M, and H renin tertiles had similar frequencies with V drugs (6, 4, and 6%), but low and middle tertiles given R had greater pressor frequencies (17% P = 0.003 vs. V and 10% P = 0.02 vs. V). Treatment SBP > or =160 mm Hg occurred more frequently with R than V drugs (19% vs. 13%; P = 0.007); moreover, in the lowest renin tertile 35% R vs. 13% V (P = 0.001) had SBP > or =160 mm Hg. Treatment SBP <130 mm Hg was more frequent in V patients in the lowest tertile (18% vs. 5%; P = 0.003), and in R patients in the highest tertile (26% vs. 12%, P = 0.002). CONCLUSIONS Pressor responses to antihypertensive monotherapy occur sufficiently frequently to be of concern, especially in lower renin patients given a beta-blocker or ACE inhibitor (ACEI).
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Jones-Burton C, Rubino J, Roy S, Mai Y, Meehan A, Bellet M, Feig P. Effects of the renin inhibitor MK-8141 (ACT-077825) in patients with hypertension. ACTA ACUST UNITED AC 2010; 4:219-26. [DOI: 10.1016/j.jash.2010.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 06/15/2010] [Accepted: 06/24/2010] [Indexed: 11/17/2022]
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Abstract
Hypertension, a serious disease affecting almost a billion people (25% of adults) worldwide, is a major modifiable risk factor for cardiovascular (CV) and renal disease. Despite numerous advances in the pharmacologic treatment of high blood pressure (BP) and availability of several antihypertensive drugs to treat hypertension, a significant proportion of treated hypertensive patients still have uncontrolled high BP, and thus, face serious morbidity and mortality. Furthermore, it is not sufficient to aim for optimum BP control, but to treat all CV risk factors, protect end-organ damage, prevent progression of disease, and prevent long-range adverse effects of the drugs. Therefore, new therapeutic modalities have to be developed to achieve the above objectives. Some years ago, investigators identified renin inhibition as the preferred pharmacologic approach to blockade of the renin-angiotensin system. Renin is a monospecific enzyme that catalyzes the rate-limiting step in the synthesis of angiotensin II. Amplified enzymatic activity and additional physiologic effects occur when renin and prorenin bind to the (pro)renin receptor. Until very recently, development of clinically effective renin inhibitors remained elusive but molecular modeling was used to develop aliskiren and other renin inhibitors that produce sustained suppression of plasma renin activity after oral administration with a dose-dependent BP. Additional studies will ultimately determine the place of renin inhibition in the treatment of hypertension and related CV disorders.
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Ichihara A, Sakoda M, Kurauchi-Mito A, Narita T, Kinouchi K, Bokuda K, Itoh H. New approaches to blockade of the renin-angiotensin-aldosterone system: characteristics and usefulness of the direct renin inhibitor aliskiren. J Pharmacol Sci 2010; 113:296-300. [PMID: 20675959 DOI: 10.1254/jphs.10r04fm] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Since renin inhibition interferes with the first and rate-limiting steps in the renin-angiotensin system, the renin step is a very attractive target for lowering blood pressure and minimizing target-organ damage. The newly developed direct renin inhibitor aliskiren has several attractive characteristics: it definitively reduces plasma renin activity among inhibitors of the renin-angiotensin system, is remarkably specific for human renin, exhibits a long half-life in plasma comparable to that of amlodipine, and has a high affinity for renal glomeruli and vasculature. Although these characteristics suggest the clinical usefulness and safety of aliskiren, several problems remain unsolved. Why does aliskiren have beneficial effects on the heart and kidneys of patients treated with angiotensin-converting enzyme (ACE) inhibitors and/or angiotensin II type 1-receptor blockers (ARBs)? Is the blood-pressure-lowering effect of aliskiren dependent on the plasma renin activity? Does aliskiren exert a possible adverse effect via (pro)renin receptor-dependent intracellular signals? Here, we review the characteristics and usefulness of aliskiren and discuss the current issues associated with this direct renin inhibitor.
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Affiliation(s)
- Atsuhiro Ichihara
- Department of Anti-Aging Medicine, Keio University School of Medicine, Tokyo, Japan.
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Ruddy MC. Unmet needs in managing hypertension: potential role of direct renin inhibition. Postgrad Med 2010; 122:203-12. [PMID: 20463431 DOI: 10.3810/pgm.2010.05.2159] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Hypertension is the most prevalent and important risk factor for cardiovascular and renal disease worldwide. Despite the large armamentarium of available blood pressure-lowering agents, the need remains for safer and more effective antihypertensive treatment. Based on current target levels of < 140/90 mm Hg, only one-third of hypertensive Americans have achieved goal blood pressure. Several strategies can help address these challenges, including increasing public awareness, and improving physician awareness of evidence-based therapeutic guidelines. There also remains a need for new therapeutic options. This review examines new developments among those agents having inhibitory activity on the renin-angiotensin-aldosterone system (RAAS). All currently available RAAS blockers cause a reactive increase in plasma renin concentration. However, the direct renin inhibitors are the only class that diminishes plasma renin activity, an effect that may provide additional cardiovascular and/or renoprotective benefit. Aliskiren is the first clinically available direct renin inhibitor that has been shown to be effective and well tolerated both as monotherapy and in combination with other established agents in hypertensive patients. Randomized clinical trials are underway to explore the extent to which direct renin inhibition provides additive protection against cardiovascular and renal disease events.
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Pimenta E. Is There a Place on the Shelf for Aliskiren? CURRENT CARDIOVASCULAR RISK REPORTS 2010. [DOI: 10.1007/s12170-010-0108-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Chaudhary K, Nistala R, Whaley-Connell A. Is there a future for direct renin inhibitors? Expert Opin Investig Drugs 2010; 19:653-61. [DOI: 10.1517/13543781003781906] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Funke-Kaiser H, Zollmann FS, Schefe JH, Unger T. Signal transduction of the (pro)renin receptor as a novel therapeutic target for preventing end-organ damage. Hypertens Res 2009; 33:98-104. [PMID: 20010781 DOI: 10.1038/hr.2009.206] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The (pro)renin receptor ((P)RR) not only represents a novel component of the renin-angiotensin system but is also a promising novel drug target because of its crucial involvement in the pathogenesis of renal and cardiac end-organ damage. This review discusses the signal transduction of the (P)RR with its adapter protein promyelocytic zinc-finger protein, the impact of this receptor, especially on cardiovascular disease, and its putative interaction with renin inhibitors such as aliskiren. Furthermore, the increasing complexity regarding the cellular function of the (P)RR is addressed, which arises by the intimate link with proton pumps and the phosphatase PRL-1, as well as by the presence of different subcellular localizations and of a soluble isoform of the (P)RR. Finally, the rationale and strategy for the development of small-molecule antagonists of the (P)RR, called renin/prorenin receptor blockers, are presented.
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Affiliation(s)
- Heiko Funke-Kaiser
- Center for Cardiovascular Research/Institute of Pharmacology, Charité-University Medicine Berlin, Berlin, Germany.
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Stanton AV, Gradman AH, Schmieder RE, Nussberger J, Sarangapani R, Prescott MF. Aliskiren monotherapy does not cause paradoxical blood pressure rises: meta-analysis of data from 8 clinical trials. Hypertension 2009; 55:54-60. [PMID: 19917876 DOI: 10.1161/hypertensionaha.109.135772] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and diuretics all cause reactive rises in plasma renin concentration, but particularly high levels have been reported with aliskiren. This prompted speculation that blockade of plasma renin activity with aliskiren could be overwhelmed, leading to paradoxical increases in blood pressure. This meta-analysis of data from 4877 patients from 8 randomized, double-blind, placebo- and/or active-controlled trials examined this hypothesis. The analysis focused on the incidence of paradoxical blood pressure increases above predefined thresholds, after > or =4 weeks of treatment with 300 mg of aliskiren, angiotensin receptor blockers (300 mg of irbesartan, 100 mg of losartan, or 320 mg of valsartan), 10 mg of ramipril, 25 mg of hydrochlorothiazide, or placebo. There were no significant differences in the frequency of increases in systolic (>10 mm Hg; P=0.30) or diastolic (>5 mm Hg; P=0.65) pressure among those treated with aliskiren (3.9% and 3.1%, respectively), angiotensin receptor blockers (4.0% and 3.7%), ramipril (5.7% and 2.6%), or hydrochlorothiazide (4.4% and 2.7%). Increases in blood pressure were considerably more frequent in the placebo group (12.6% and 11.4%; P<0.001). None of the 536 patients with plasma renin activity data who received 300 mg of aliskiren exhibited an increase in systolic pressure >10 mm Hg that was associated with an increase in plasma renin activity >0.1 ng/mL per hour. In conclusion, the incidence of blood pressure increases with aliskiren was similar to that during treatment with other antihypertensive drugs. Blood pressure rises on aliskiren treatment were not associated with increases in plasma renin activity. This meta-analysis found no evidence that aliskiren uniquely causes paradoxical rises in blood pressure.
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Affiliation(s)
- Alice V Stanton
- Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin 2, Ireland.
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Danser AHJ. The increase in renin during renin inhibition: does it result in harmful effects by the (pro)renin receptor? Hypertens Res 2009; 33:4-10. [PMID: 19893565 DOI: 10.1038/hr.2009.186] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Renin inhibitors, similar to all renin-angiotensin system (RAS) blockers, increase the plasma concentration of renin because they attenuate the negative feedback effect of angiotensin (Ang) II on renin release. The increase in renin has been suggested to be higher than that during other types of RAS blockade. This could potentially limit the effectiveness of renin inhibition, either because Ang II generation might occur again ('Ang II escape'), possibly even at the levels above baseline, as has been described before for angiotensin-converting enzyme inhibitors, or because high levels of renin will stimulate the recently discovered (pro)renin receptor, and thus induce effects in an Ang-independent manner. This review shows first that the cause(s) of the renin increase during treatment with the renin inhibitor aliskiren is the consequence of a combination of factors, including an assay artifact, allowing the detection of prorenin as renin, and a change in renin half-life. When correcting for these phenomena the increase is unlikely to be as excessive as originally thought. The review then critically describes the consequence(s) of such a increase, concluding (i) that an Ang II escape is highly unlikely, given the [aliskiren]/[renin] stoichiometry, and (ii) that renin and prorenin downregulate their receptor (similar to many agonists). On the basis of the latter, one could even speculate that this will be more substantial when the renin and prorenin levels are higher. Thus, from this point of view the larger increase in renin during renin inhibition will cause a stronger reduction in (pro)renin receptor expression, and a greater suppression of (pro)renin receptor-mediated effects than other renin-Ang blockers.
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Affiliation(s)
- A H Jan Danser
- Division of Pharmacology, Vascular and Metabolic Diseases, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands.
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Abstract
PURPOSE OF REVIEW To evaluate the evidence supporting the use of renin inhibitors to control hypertension, limit kidney disease progression, and decrease cardiovascular risk in patients with chronic kidney disease (CKD). RECENT FINDINGS The literature on the subject is still limited. Most of the studies have used aliskiren as the study drug. Animal models show improved survival and decreased renal injury in animals receiving aliskiren. Human studies in patients with normal renal function show effective blood pressure control alone or in combination with different agents. There are no studies focusing on blood pressure control in patients with CKD, though the drug has been safely used in CKD. In a randomized clinical trial, aliskiren decreased albuminuria when added to losartan in patients with early diabetic nephropathy. Ongoing studies are evaluating the role of renin inhibitors in the prevention of cardiovascular events and slowing of kidney disease progression in CKD. SUMMARY Renin inhibitors, specifically aliskiren, effectively decrease albuminuria. Their role in improving hard renal endpoints and decreasing cardiovascular events in CKD still remains to be established.
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Dual blockade of the renin-angiotensin-aldosterone system: beyond the ACE inhibitor and angiotensin-II receptor blocker combination. Am J Hypertens 2009; 22:1032-40. [PMID: 19661925 DOI: 10.1038/ajh.2009.138] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The renin-angiotensin-aldosterone system (RAAS), an important regulator of blood pressure as well as fluid and electrolyte balance, plays an important role in the pathophysiology of cardiovascular and kidney diseases. Blockade of the RAAS with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-II (ANG-II) receptor blockers (ARBs) lowers blood pressure, decreases morbidity and mortality in patients with chronic heart failure, and decreases proteinuria and the rate of decline in renal function in patients with chronic kidney disease. Although these drugs are highly effective and are widely used in the management of cardiovascular and kidney diseases, current treatment regimens with ACEIs and ARBs may not completely suppress the RAAS. Combinations of ACEIs and ARBs have been shown to be superior to either agent alone for some, but certainly not all, composite cardiovascular and kidney outcomes. With the growing appreciation of the role of aldosterone in the pathogenesis of cardiorenal diseases and the recent approval of the direct renin inhibitor (DRI), aliskiren, additional combination strategies have emerged that may offer novel ways to more fully suppress the RAAS. This review examines what is presently known about ACEI/ARB combination therapy and explores alternative combination strategies that include DRIs and mineralocorticoid receptor blockers (MRBs).
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Funke-Kaiser H, Reinemund J, Steckelings UM, Unger T. Adapter proteins and promoter regulation of the angiotensin AT2 receptor — implications for cardiac pathophysiology. J Renin Angiotensin Aldosterone Syst 2009; 11:7-17. [DOI: 10.1177/1470320309343652] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The angiotensin AT 2 receptor (AT2R) represents an important component of the renin-angiotensin system since it is involved in the (patho) physiology of different cardiovascular and neuronal diseases. Furthermore, AT2 receptors can partly mediate beneficial effects of angiotensin AT 1 receptor (AT1R) blockers, and direct pharmacological AT 2 receptor agonism emerges as a novel therapeutic strategy. This review discusses the constitutive and ligand-mediated activity as well as the signal transduction of the AT2 receptor, focusing on adapter proteins which directly bind to this receptor. Direct protein-protein interaction partners of the AT2 receptor described so far include the transcription factor promyelocytic zinc finger protein, AT2 receptor binding protein and the AT1 receptor. In addition, the putative crosstalk of the AT2 receptor with the renin/ prorenin receptor (RER) via the promyelocytic zinc finger protein (PLZF) and the role of oestrogens on the regulation of the AT2 receptor are presented. Conceiving the coupling of the AT2 receptor to different adapter proteins with distinct and partly opposing cellular effects and the implications of its constitutive activity might help to overcome the current controversies on the (patho)physiological role of the AT2 receptor.
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Affiliation(s)
- Heiko Funke-Kaiser
- Center for Cardiovascular Research (CCR)/Institute of Pharmacology, Charité - Universitätsmedizin Berlin, Berlin, Germany,
| | - Jana Reinemund
- Center for Cardiovascular Research (CCR)/Institute of Pharmacology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrike M Steckelings
- Center for Cardiovascular Research (CCR)/Institute of Pharmacology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Unger
- Center for Cardiovascular Research (CCR)/Institute of Pharmacology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Aliskiren monotherapy results in the greatest and the least blood pressure lowering in patients with high- and low-baseline PRA levels, respectively. Am J Hypertens 2009; 22:954-7. [PMID: 19556972 DOI: 10.1038/ajh.2009.114] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Hypertensive patients with low-baseline plasma renin activity (PRA) are known to respond best to natriuretic drugs, and those with high PRA respond best to renin-angiotensin system (RAS) blockade. However, there has been recent speculation that blood pressure (BP)-lowering responses to the renin inhibitor, aliskiren, might also be blunted in some patients with medium-to-high baseline PRA. It has been suggested that treatment resistance in these patients may result from excessive reactive increases in renin secretion, such that aliskiren's blockade of PRA is overwhelmed. In order to test for evidence in support of this hypothesis, we conducted a reanalysis of original data from three published clinical trials of aliskiren. When aliskiren was administered as a monotherapy, or in combination with other blockers of the RAS, changes in PRA were closely correlated with baseline PRA. Patients with low-baseline PRA demonstrated small reductions or rises in PRA, rather than patients with medium-to-high baseline PRA. We confirmed that ambulatory BP-lowering responses to full dose aliskiren monotherapy were greatest and least among patients with high- and low-baseline PRA, respectively. However no such association was demonstrated during aliskiren combination therapy. With either monotherapy or combination therapy, no patient with a baseline PRA >0.65 ng/ml/h was observed to have a rise in both PRA and BP. We conclude, therefore, that there is only evidence for one type of resistance to aliskiren--as with all blockers of the RAS, lesser BP-lowering responses to aliskiren occur in those with the least renin to block.
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Sealey JE, Laragh JH. Using plasma renin (PRA) testing to design follow-up drug treatment strategies in hypertensive patients already taking antirenin system drugs. Am J Hypertens 2009; 22:950. [PMID: 19701164 DOI: 10.1038/ajh.2009.123] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Vanholder R, Argilés A, Beige J, Brunet P, Drüeke TB, Fliser D, Herget-Rosenthal S, Hörl WH, Jörres A, Perna A, Rodriguez-Portillo M, Spasovski G, Stegmayr B, Stenvinkel P, Wanner C, Wiecek A, Massy ZA. Conservative Treatment of the Uremic Syndrome. Semin Dial 2009; 22:449-53. [DOI: 10.1111/j.1525-139x.2009.00600.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Egan BM, Basile JN, Rehman SU, Davis PB, Grob CH, Riehle JF, Walters CA, Lackland DT, Merali C, Sealey JE, Laragh JH. Plasma Renin test-guided drug treatment algorithm for correcting patients with treated but uncontrolled hypertension: a randomized controlled trial. Am J Hypertens 2009; 22:792-801. [PMID: 19373213 DOI: 10.1038/ajh.2009.63] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Undefined pathophysiologic mechanisms likely contribute to unsuccessful antihypertensive drug therapy. The renin test-guided therapeutic (RTGT) algorithm is based on the concept that, irrespective of current drug treatments, subnormal plasma renin activity (PRA) (<0.65 ng/ml/h) indicates sodium-volume excess "V" hypertension, whereas values >or=0.65 indicate renin-angiotensin vasoconstriction excess "R" hypertension. METHODS The RTGT algorithm was applied to treated, uncontrolled hypertensives and compared to clinical hypertension specialists' care (CHSC) without access to PRA. RTGT protocol: "V" patients received natriuretic anti-"V" drugs (diuretics, spironolactone, calcium antagonists, or alpha(1)-blockers) while withdrawing antirenin "R" drugs (converting enzyme inhibitors, angiotensin receptor antagonists, or beta-blockers). Converse strategies were applied to "R" patients. Eighty-four ambulatory hypertensives were randomized and 77 qualified for the intention-to-treat analysis including 38 in RTGT (63.9 +/- 1.8 years; baseline blood pressure (BP) 157.0 +/- 2.6/87.1 +/- 2.0 mm Hg; PRA 5.8 +/- 1.6; 3.1 +/- 0.3 antihypertensive drugs) and 39 in CHSC (58.0 +/- 2.0 years; BP 153.6 +/- 2.3/91.9 +/- 2.0; PRA 4.6 +/- 1.1; 2.7 +/- 0.2 drugs). RESULTS BP was controlled in 28/38 (74% (RTGT)) vs. 23/39 (59% (CHSC)), P = 0.17, falling to 127.9 +/- 2.3/73.1 +/- 1.8 vs. 134.0 +/- 2.8/79.8 +/- 1.9 mm Hg, respectively. Systolic BP (SBP) fell more with RTGT (-29.1 +/- 3.2 vs. -19.2 +/- 3.2 mm Hg, P = 0.03), whereas diastolic BP (DBP) declined similarly (P = 0.32). Although final antihypertensive drug numbers were similar (3.1 +/- 0.2 (RTGT) vs. 3.0 +/- 0.3 (CHSC), P = 0.73) in "V" patients, 60% (RTGT) vs. 11% (CHSC) of "R" drugs were withdrawn and BP medications were reduced (-0.5 +/- 0.3 vs. +0.7 +/- 0.3, P = 0.01). CONCLUSIONS In treated but uncontrolled hypertension, RTGT improves control and lowers BP equally well or better than CHSC, indicating that RTGT provides a reasonable strategy for correcting treated but uncontrolled hypertension.
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Pimenta E, Oparil S. Role of aliskiren in cardio-renal protection and use in hypertensives with multiple risk factors. Ther Clin Risk Manag 2009; 5:459-64. [PMID: 19707255 PMCID: PMC2701487 DOI: 10.2147/tcrm.s5702] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Indexed: 12/15/2022] Open
Abstract
The renin–angiotensin–aldosterone system (RAAS) is a key mediator of blood pressure (BP) and volume regulation in both normotensive and hypertensive persons. Stimulation of RAAS also contributes to hypertension-related target organ damage. The renin–angiotensinogen reaction is the first and rate-limiting step in the generation of angiotensin II (Ang II) and has been a target of antihypertensive drug development for decades. Aliskiren is the first in a new class of orally effective direct renin inhibitors (DRIs) and is approved for the treatment of hypertension in humans. It effectively reduces BP in the general population of hypertensive patients and has a tolerability and safety profile similar to placebo. Aliskiren has favorable effects on vascular inflammation and remodeling, on neurohumoral mediators of various forms of cardiovascular disease, including heart failure, and on proteinuria in diabetic patients. Additional outcome trials are needed to establish the role of this novel class of antihypertensive medication in preventing cardiovascular disease morbidity and mortality.
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Affiliation(s)
- Eduardo Pimenta
- Endocrine Hypertension Research Centre and Clinical Centre of Research Excellence in Cardiovascular Disease and Metabolic Disorders, University of Queensland School of Medicine, Greenslopes Princess Alexandra Hospitals, Brisbane, QLD, Australia
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Pimenta E, Oparil S. Role of aliskiren in cardio-renal protection and use in hypertensives with multiple risk factors. Vasc Health Risk Manag 2009; 5:453-63. [PMID: 19475781 PMCID: PMC2686262 DOI: 10.2147/vhrm.s4291] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The renin-angiotensin-aldosterone system (RAAS) is an important mediator of blood pressure (BP) and volume regulation in both normotensive and hypertensive persons and is a major contributor to hypertension-related target organ damage. The concept of renin inhibition for managing hypertension by blocking the RAAS pathway at its point of activation is very attractive since the renin-angiotensinogen reaction is the first and rate-limiting step in the generation of angiotensin II (Ang II). Aliskiren, the first in a new class of orally effective direct renin inhibitors (DRIs), is approved for the treatment of hypertension. It is effective in reducing BP in the general population of hypertensive patients and in special patient groups such as obese persons, and has a tolerability and safety profile similar to placebo. Aliskiren has renoprotective, cardioprotective and anti-atherosclerotic effects in animal models that appear to be independent of BP lowering. It reduces proteinuria in diabetic patients and has favorable neurohumoral effects in patients with symptomatic heart failure. Additional outcome trials are needed to establish the role of this novel class of antihypertensive medication in the therapeutic armamentarium.
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Affiliation(s)
- Eduardo Pimenta
- Endocrine Hypertension Research Center and Clinical Center of Research Excellence in Cardiovascular Disease and Metabolic Disorders, University of Queensland School of Medicine, Princess Alexandra Hospital, Brisbane, QLD, Australia.
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Minami J, Ohno E, Furukata S, Ishimitsu T, Matsuoka H. Pretreatment levels of plasma renin activity predict ambulatory blood pressure response to valsartan in essential hypertension. J Hum Hypertens 2009; 23:683-6. [DOI: 10.1038/jhh.2009.31] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Frohlich ED, Re RN. Newer Insights into the Biochemical Physiology of the Renin–Angiotensin System: Role of Angiotensin-(1-7), Angiotensin Converting Enzyme 2, and Angiotensin-(1-12). THE LOCAL CARDIAC RENIN-ANGIOTENSIN ALDOSTERONE SYSTEM 2009. [PMCID: PMC7114999 DOI: 10.1007/978-1-4419-0528-4_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Knowledge of the mechanisms by which the rennin–angiotensin system contributes to cardiovascular pathology continues to advance at a rapid pace as newer methods and therapies uncover the nature of this complex system and its fundamental role in the regulation of blood pressure and tissue function. The characterization of the biochemical pathways and functions mediated by angiotensin-(1-7) [Ang-(1-7)], angiotensin converting enzyme 2 (ACE2), and the mas receptor has revealed a vasodepressor and antiproliferative axis that within the rennin–angiotensin system opposes the biological actions of angiotensin II (Ang II). In addition, new research expands on this knowledge by demonstrating additional mechanisms for the formation of Ang II and Ang-(1-7) through the existence of an alternate form of the angiotensinogen substrate [angiotensin-(1-12)] which generates Ang II and even Ang-(1-7) through a non-renin dependent action. Altogether, this research paves the way for a better understanding of the intracellular mechanisms involved in the synthesis of angiotensin peptides and its consequences in terms of cell function in both physiology and pathology.
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Affiliation(s)
- Edward D. Frohlich
- Ochsner Clinic Foundation, Jefferson Highway 1514 , New Orleans, 70121 U.S.A
| | - Richard N. Re
- Ochsner Clinic Foundation, Jefferson Highway 1514 , New Orleans, 70121 U.S.A
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