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Spahia N, Rroji M, Idrizi A, Spasovski G, Barbullushi M. Sodium and water dynamics in the progression of chronic kidney disease: mechanisms and clinical significance. Int Urol Nephrol 2024; 56:1953-1963. [PMID: 38200365 DOI: 10.1007/s11255-023-03903-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/01/2023] [Indexed: 01/12/2024]
Abstract
AIM Lifestyle modifications can postpone the progression of chronic kidney disease toward its terminal stage. This mini-review aims to explore the impact of salt and water intake on the progression of chronic kidney disease (CKD) and provide insights into the optimal consumption levels to preserve the glomerular filtration rate. METHODS We reviewed relevant literature to examine the association between salt and water consumption and CKD progression. Our analysis includes discussions on the pathophysiology, findings from clinical trials, and recommended intake guidelines. RESULTS Sodium intake, often linked to cardiovascular risk and CKD progression, has shown a complex J-shaped association in some studies, leading to uncertainty about the ideal salt intake level. Sodium and fluid retention are key factors contributing to hypertension, a well-established risk factor for CKD progression. Low-sodium diets have demonstrated promise in reducing blood pressure and enhancing the effects of renin-angiotensin-aldosterone system inhibitors in non-dialysis CKD patients. However, a debate persists regarding the independent effect of salt restriction on CKD progression. Despite medical recommendations, salt consumption remains high among CKD patients. Additionally, the role of water consumption in CKD remains controversial despite its established benefits for CKD prevention in the general population. CONCLUSION Lifestyle modifications involving salt and water intake can influence the progression of CKD. While low-sodium diets have shown potential for mitigating hypertension and proteinuria in non-dialysis CKD patients, their independent impact on CKD progression warrants further investigation. The role of water consumption in CKD remains uncertain, and there is a need for additional research in this area. Clinicians should consider individualized dietary recommendations for CKD patients to help preserve the glomerular filtration rate and improve overall outcomes.
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Affiliation(s)
- Nereida Spahia
- Department of Nephrology, University Hospital Center "Mother Teresa", Tirana, Albania.
| | - Merita Rroji
- Department of Nephrology, University Hospital Center "Mother Teresa", Tirana, Albania
| | - Alma Idrizi
- Department of Nephrology, University Hospital Center "Mother Teresa", Tirana, Albania
| | - Goce Spasovski
- Department of Nephrology, Medical Faculty, University Sts. Cyril and Methodius, Skopje, North Macedonia
| | - Myftar Barbullushi
- Department of Nephrology, University Hospital Center "Mother Teresa", Tirana, Albania
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Giannese D, D'Alessandro C, Panichi V, Pellegrino N, Cupisti A. Nutritional Treatment as a Synergic Intervention to Pharmacological Therapy in CKD Patients. Nutrients 2023; 15:2715. [PMID: 37375619 DOI: 10.3390/nu15122715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
Nutritional and pharmacological therapies represent the basis for non-dialysis management of CKD patients. Both kinds of treatments have specific and unchangeable features and, in certain cases, they also have a synergic action. For instance, dietary sodium restriction enhances the anti-proteinuric and anti-hypertensive effects of RAAS inhibitors, low protein intake reduces insulin resistance and enhances responsiveness to epoetin therapy, and phosphate restriction cooperates with phosphate binders to reduce the net phosphate intake and its consequences on mineral metabolism. It can also be speculated that a reduction in either protein or salt intake can potentially amplify the anti-proteinuric and reno-protective effects of SGLT2 inhibitors. Therefore, the synergic use of nutritional therapy and medications optimizes CKD treatment. Quality of care management is improved and becomes more effective when compared to either treatment alone, with lower costs and fewer risks of unwanted side effects. This narrative review summarizes the established evidence of the synergistic action carried out by the combination of nutritional and pharmacological treatments, underlying how they are not alternative but complementary in CKD patient care.
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Affiliation(s)
- Domenico Giannese
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Claudia D'Alessandro
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Vincenzo Panichi
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Nicola Pellegrino
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
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Sokooti S, Klont F, Tye SC, Kremer D, Douwes RM, Hopfgartner G, Dullaart RPF, Heerspink HJL, Bakker SJL. Association of diuretic use with increased risk for long-term post-transplantation diabetes mellitus in kidney transplant recipients. Nephrol Dial Transplant 2022; 37:1375-1383. [PMID: 35092430 PMCID: PMC9217635 DOI: 10.1093/ndt/gfac012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Indexed: 11/30/2022] Open
Abstract
Background Post-transplantation diabetes mellitus (PTDM) is a major clinical problem in kidney transplant recipients (KTRs). Diuretic-induced hyperglycaemia and diabetes have been described in the general population. We aimed to investigate whether diuretics also increase PTDM risk in KTRs. Methods We included 486 stable outpatient KTRs (with a functioning graft ≥1 year) without diabetes from a prospective cohort study. Participants were classified as diuretic users and non-users based on their medication use verified by medical records. Results At the baseline study, 168 (35%) KTRs used a diuretic (thiazide, n = 74; loop diuretic, n = 76; others, n = 18) and 318 KTRs did not use a diuretic. After 5.2 years [interquartile range (IQR) 4.0‒5.9] of follow up, 54 (11%) KTRs developed PTDM. In Cox regression analyses, diuretic use was associated with incident PTDM, independent of age, sex, fasting plasma glucose (FPG) and haemoglobin A1c (HbA1c) {hazard ratio [HR] 3.28 [95% confidence interval (CI) 1.84–5.83]; P <0.001}. Further adjustment for potential confounders, including lifestyle, family history of cardiovascular disease, use of other medication, kidney function, transplantation-specific parameters, BMI, lipids and blood pressure did not materially change the association. Moreover, in Cox regression analyses, both thiazide and loop diuretics associated with the development of PTDM, independent of age, sex, FPG and HbA1c [HR 2.70 (95% CI 1.24–5.29); P = 0.012 and HR 5.08 (95% CI 2.49–10.34); P <0.001), respectively]. Conclusions This study demonstrates that diuretics overall are associated with an increased risk of developing PTDM in KTRs, independent of established risk factors for PTDM development. The association was present for both thiazide and loop diuretics.
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Affiliation(s)
- Sara Sokooti
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frank Klont
- Life Sciences Mass Spectrometry, Department of Inorganic and Analytical Chemistry, University of Geneva, Geneva, Switzerland
| | - Sok Cin Tye
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Daan Kremer
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rianne M Douwes
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gérard Hopfgartner
- Life Sciences Mass Spectrometry, Department of Inorganic and Analytical Chemistry, University of Geneva, Geneva, Switzerland
| | - Robin P F Dullaart
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Stephan J L Bakker
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Abstract
OBJECTIVE The benefits of a low-salt diet for patients with chronic kidney disease (CKD) are controversial. We conducted a systematic review and meta-analysis of the effect of a low-salt diet on major clinical outcomes. DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE by Ovid, EMBASE and the Cochrane Library databases. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included randomised controlled trials (RCTs) and cohort studies that assessed the effect of a low-salt diet on the renal composite outcomes (more than 50% decline in estimated glomerular filtration rate (eGFR) during follow-up, doubling of serum creatinine or end-stage renal disease), rate of eGFR decline, change in proteinuria, all-cause mortality events, cardiovascular (CV) events, and changes in systolic blood pressure and diastolic blood pressure. DATA EXTRACTION AND SYNTHESIS Two independent researchers extracted data and evaluated their quality. Relative risks (RRs) with 95% CIs were used for dichotomous data. Differences in means (MDs) or standardised mean differences (SMDs) with 95% CIs were used to pool continuous data. We used the Cochrane Collaboration risk-of-bias tool to evaluate the quality of RCTs, and Newcastle-Ottawa Scale to evaluate the quality of cohort studies. RESULTS We found 9948 potential research records. After removing duplicates, we reviewed the titles and abstracts, and screened the full text of 230 publications. Thirty-three studies with 101 077 participants were included. A low-salt diet produced a 28% reduction in renal composite outcome events (RR: 0.72; 95% CI: 0.58 to 0.89). No significant effects were found in terms of changes in proteinuria (SMD: -0.71; 95% CI: -1.66 to 0.24), rate of eGFR (decline MD: 1.16; 95% CI: -2.02 to 4.33), risk of all-cause mortality (RR: 0.92; 95% CI: 0.58 to 1.46) and CV events (RR: 1.01; 95% CI: 0.46 to 2.22). CONCLUSION A low-salt diet seems to reduce the risk for renal composite outcome events in patients with CKD. However, no compelling evidence indicated that such a diet would reduce the eGFR decline rate, proteinuria, incidence of all-cause mortality and CV events. Further, more definitive studies are needed. PROSPERO REGISTRATION NUMBER CRD42017072395.
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Affiliation(s)
- Honghong Shi
- Renal Division, Shanxi Medical University Second Affiliated Hospital, Taiyuan, Shanxi, China
| | - Xiaole Su
- Renal Division, Shanxi Medical University Second Affiliated Hospital, Taiyuan, Shanxi, China
| | - Chunfang Li
- Renal Divison, Shanxi Cardiovascular Hospital, Taiyuan, Shanxi, China
| | - Wenjuan Guo
- Renal Division, Shanxi Medical University Second Affiliated Hospital, Taiyuan, Shanxi, China
| | - Lihua Wang
- Renal Division, Shanxi Medical University Second Affiliated Hospital, Taiyuan, Shanxi, China
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Kwakernaak AJ, Roksnoer LC, Lambers Heerspink HJ, van den Berg-Garrelds I, Lochorn GA, van Embden Andres JH, Klijn MA, Kobori H, Danser AHJ, Laverman GD, Navis GJ. Effects of Direct Renin Blockade on Renal & Systemic Hemodynamics and on RAAS Activity, in Weight Excess and Hypertension: A Randomized Clinical Trial. PLoS One 2017; 12:e0169258. [PMID: 28118402 PMCID: PMC5261569 DOI: 10.1371/journal.pone.0169258] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 12/11/2016] [Indexed: 02/07/2023] Open
Abstract
Aim The combination of weight excess and hypertension significantly contributes to cardiovascular risk and progressive kidney damage. An unfavorable renal hemodynamic profile is thought to contribute to this increased risk and may be ameliorated by direct renin inhibition (DRI). The aim of this trial was to assess the effect of DRI on renal and systemic hemodynamics and on RAAS activity, in men with weight excess and hypertension. Methods A randomized, double-blind, cross-over clinical trial to determine the effect of DRI (aliskiren 300 mg/day), with angiotensin converting enzyme inhibition (ACEi; ramipril 10 mg/day) as a positive control, on renal and systemic hemodynamics, and on RAAS activity (n = 15). Results Mean (SEM) Glomerular filtration rate (101 (5) mL/min/1.73m2) remained unaffected by DRI or ACEi. Effective renal plasma flow (ERPF; 301 (14) mL/min/1.73m2) was increased in response to DRI (320 (14) mL/min/1.73m2, P = 0.012) and ACEi (317 (15) mL/min/1.73m2, P = 0.045). Filtration fraction (FF; 34 (0.8)%) was reduced by DRI only (32 (0.7)%, P = 0.044). Mean arterial pressure (109 (2) mmHg) was reduced by DRI (101 (2) mmHg, P = 0.008) and ACEi (103 (3) mmHg, P = 0.037). RAAS activity was reduced by DRI and ACEi. Albuminuria (20 [9–42] mg/d) was reduced by DRI only (12 [5–28] mg/d, P = 0.030). Conclusions In men with weight excess and hypertension, DRI and ACEi improved renal and systemic hemodynamics. Both DRI and ACEi reduced RAAS activity. Thus, DRI provides effective treatment in weight excess and hypertension. Trial Registration Dutch trial register, registration number: 2532 www.trialregister.nl
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Affiliation(s)
- A. J. Kwakernaak
- Department of Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, The Netherlands
- * E-mail:
| | - L. C. Roksnoer
- Department of Medicine, Division of Vascular Medicine and Pharmacology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - H. J. Lambers Heerspink
- Department of Clinical Pharmacology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - I. van den Berg-Garrelds
- Department of Medicine, Division of Vascular Medicine and Pharmacology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - G. A. Lochorn
- General Practitioner Practice Gorecht, Hoogezand, The Netherlands
| | | | - M. A. Klijn
- General Practitioner Practice Boterdiep, Groningen, The Netherlands
| | - H. Kobori
- Department of Pharmacology, Kagawa University, School of Medicine, Miki, Kita District, Kagawa, Japan
| | - A. H. J. Danser
- Department of Medicine, Division of Vascular Medicine and Pharmacology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - G. D. Laverman
- Department of Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, The Netherlands
- Department of Internal Medicine, Division of Nephrology, ZGT Hospital Almelo, Netherlands
| | - G. J. Navis
- Department of Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, The Netherlands
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de Vries LV, Dobrowolski LC, van den Bosch JJ, Riphagen IJ, Krediet CP, Bemelman FJ, Bakker SJ, Navis G. Effects of Dietary Sodium Restriction in Kidney Transplant Recipients Treated With Renin-Angiotensin-Aldosterone System Blockade: A Randomized Clinical Trial. Am J Kidney Dis 2016; 67:936-44. [DOI: 10.1053/j.ajkd.2015.11.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 11/30/2015] [Indexed: 01/13/2023]
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8
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Wasser WG, Gil A, Skorecki KL. The Envy of Scholars: Applying the Lessons of the Framingham Heart Study to the Prevention of Chronic Kidney Disease. Rambam Maimonides Med J 2015; 6:RMMJ.10214. [PMID: 26241225 PMCID: PMC4524402 DOI: 10.5041/rmmj.10214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
During the past 50 years, a dramatic reduction in the mortality rate associated with cardiovascular disease has occurred in the US and other countries. Statistical modeling has revealed that approximately half of this reduction is the result of risk factor mitigation. The successful identification of such risk factors was pioneered and has continued with the Framingham Heart Study, which began in 1949 as a project of the US National Heart Institute (now part of the National Heart, Lung, and Blood Institute). Decreases in total cholesterol, blood pressure, smoking, and physical inactivity account for 24%, 20%, 12%, and 5% reductions in the mortality rate, respectively. Nephrology was designated as a recognized medical professional specialty a few years later. Hemodialysis was first performed in 1943. The US Medicare End-Stage Renal Disease (ESRD) Program was established in 1972. The number of patients in the program increased from 5,000 in the first year to more than 500,000 in recent years. Only recently have efforts for risk factor identification, early diagnosis, and prevention of chronic kidney disease (CKD) been undertaken. By applying the approach of the Framingham Heart Study to address CKD risk factors, we hope to mirror the success of cardiology; we aim to prevent progression to ESRD and to avoid the cardiovascular complications associated with CKD. In this paper, we present conceptual examples of risk factor modification for CKD, in the setting of this historical framework.
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Affiliation(s)
- Walter G. Wasser
- Division of Nephrology, Mayanei HaYeshua Medical Center, Bnei Brak, Israel
- Division of Nephrology, Rambam Health Care Campus, Haifa, Israel
- To whom correspondence should be addressed. E-mail:
| | - Amnon Gil
- Division of Nephrology, Carmel Medical Center, Haifa, Israel
| | - Karl L. Skorecki
- Division of Nephrology, Rambam Health Care Campus, Haifa, Israel
- Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Director of Medical and Research Development, Rambam Health Care Campus, Haifa, Israel
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Toering TJ, van der Graaf AM, Visser FW, Groen H, Faas MM, Navis G, Lely AT. Higher filtration fraction in formerly early-onset preeclamptic women without comorbidity. Am J Physiol Renal Physiol 2015; 308:F824-31. [PMID: 25694481 DOI: 10.1152/ajprenal.00536.2014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 02/08/2015] [Indexed: 11/22/2022] Open
Abstract
Formerly preeclamptic women have an increased risk for developing end-stage renal disease, which has been attributed to altered renal hemodynamics and abnormalities in the renin-angiotensin-aldosterone system. Whether this is due to preeclampsia itself or to comorbid conditions is unknown. Renal hemodynamics and responsiveness to ANG II during low Na(+) intake (7 days, 50 mmol Na(+)/24 h) and high Na(+) (HS) intake (7 days, 200 mmol Na(+)/24 h) were studied in 18 healthy normotensive formerly early-onset preeclamptic women (fPE women) and 18 healthy control subjects (fHP women), all selected for absence of comorbidity. At the end of each diet, renal hemodynamics and blood pressure were measured before and during graded ANG II infusion. Both HS intake and former preeclampsia increased filtration fraction (FF) without an interaction between the two. FF was highest during HS intake in fPE women [0.31 ± 0.12 vs. 0.29 ± 0.11 in fHP women, generalized estimating equation analysis (body mass index corrected), P = 0.03]. The renal response to ANG II infusion was not different between groups. In conclusion, fPE women have a higher FF compared with fHP women. As this was observed in the absence of comorbidity, preeclampsia itself might exert long-term effects on renal hemodynamics. However, we cannot exclude the presence of prepregnancy alterations in renal function, which, in itself, lead to an increased risk for preeclampsia. In experimental studies, an elevated FF has been shown to play a pathogenic role in the development of hypertension and renal damage. Future studies, however, should evaluate whether the subtle differences in renal hemodynamics after preeclampsia contribute to the increased long-term renal risk after preeclampsia.
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Affiliation(s)
- Tsjitske J Toering
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Anne Marijn van der Graaf
- Department of Pathology and Medical Biology, Division of Medical Biology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Folkert W Visser
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Henk Groen
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands; and
| | - Marijke M Faas
- Department of Pathology and Medical Biology, Division of Medical Biology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Gerjan Navis
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - A Titia Lely
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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Humalda JK, Navis G. Dietary sodium restriction: a neglected therapeutic opportunity in chronic kidney disease. Curr Opin Nephrol Hypertens 2014; 23:533-40. [PMID: 25222815 PMCID: PMC4189688 DOI: 10.1097/mnh.0000000000000073] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Restriction of dietary sodium is recommended at a population level as well as for groups at high cardiovascular risk, and chronic kidney disease (CKD). This review addresses recent evidence for the protective effect of dietary sodium restriction in CKD patients specifically. RECENT FINDINGS Sodium intake in CKD populations is generally high, and often above population average. Recent data demonstrated that moderately lower sodium intake in CKD patients is associated with substantially better long-term outcome of renin-angiotensin-aldosterone system (RAAS)-blockade, in diabetic and nondiabetic CKD, related to better effects of RAAS-blockade on proteinuria, independent of blood pressure. This is in line with better short-term efficacy of RAAS-blockade during moderate sodium restriction in diabetic and nondiabetic CKD. This effect of sodium restriction is likely mediated by its effects on volume status. Sustainable sodium restriction can be achieved by approaches on the basis of behavioral sciences. SUMMARY Moderate restriction of dietary sodium can substantially improve the protective effects of RAAS-blockade in CKD, by specific renal effects apparent from proteinuria reduction. The latter precludes straightforward extrapolation of data from nonrenal populations to CKD. Concerns regarding the adverse effects of a very low sodium intake should not distract from the protective effects of moderate sodium restriction. Prospective studies should assess the efficacy and sustainability of different strategies to target high sodium intake in CKD, along with measures at population level. VIDEO ABSTRACT http://links.lww.com/CONH/A14.
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Affiliation(s)
- Jelmer K Humalda
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Lambers Heerspink HJ, Navis G, Ritz E. Salt intake in kidney disease--a missed therapeutic opportunity? Nephrol Dial Transplant 2013; 27:3435-42. [PMID: 22942175 DOI: 10.1093/ndt/gfs354] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Although significant progress has been made in the treatment of chronic kidney disease (CKD), treatment is not yet satisfactory, particularly when it is started in the late stages of the disease. Novel modes of intervention to mitigate the burden of disease are required. The reduction of dietary salt intake (which is high in the industrialized world) is one such option. Better understanding of the deleterious effects of salt on renal and cardiovascular health is necessary to raise awareness of the importance of reduction of the salt content in food products. Therefore, we (i) review pathways through which high salt intake exerts damaging effects, (ii) provide an assessment of recent observational studies linking dietary salt intake to the progression of renal and cardiovascular disease and (iii) discuss the interaction between salt intake and rennin-angiotensin-aldosterone-system inhibitors, i.e. the first choice antihypertensive agents for the treatment of CKD.
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Lambers Heerspink HJ, de Borst MH, Bakker SJL, Navis GJ. Improving the efficacy of RAAS blockade in patients with chronic kidney disease. Nat Rev Nephrol 2012; 9:112-21. [PMID: 23247573 DOI: 10.1038/nrneph.2012.281] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Reduction of blood pressure and proteinuria by blockade of the renin-angiotensin-aldosterone system (RAAS) has been the cornerstone of renoprotective intervention for patients with chronic kidney disease (CKD) for many years. Despite the proven efficacy of RAAS blockade, however, the reduction in proteinuria is insufficient in many patients, and does not prevent further deterioration of renal function. Short-term studies have shown that a variety of treatment intensification strategies have a beneficial effect on blood pressure and proteinuria, including RAAS blockade using either dose escalation or multiple drugs, and restriction of dietary sodium. Large clinical trials have shown that RAAS blockade with multiple drugs does not improve patients' long-term renal or cardiovascular outcome. By contrast, two post-hoc analyses of landmark trials in nephrology show beneficial renal and cardiovascular effects from avoiding excessive dietary sodium intake during single-agent RAAS blockade therapy. The effects of dietary sodium restriction on renal or cardiovascular outcome still require prospective confirmation. However, current data support the implementation of lifestyle changes to reduce dietary sodium intake in combination with single-agent RAAS blockade, rather than dual-agent RAAS blockade, as a potent and feasible strategy to mitigate the burden of renal and cardiovascular disease in patients with CKD.
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Affiliation(s)
- Hiddo J Lambers Heerspink
- Department of Clinical Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 9700 AD, Groningen, The Netherlands
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van den Berg E, Geleijnse JM, Brink EJ, van Baak MA, Homan van der Heide JJ, Gans ROB, Navis G, Bakker SJL. Sodium intake and blood pressure in renal transplant recipients. Nephrol Dial Transplant 2012; 27:3352-9. [PMID: 22499024 DOI: 10.1093/ndt/gfs069] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Hypertension is common among renal transplant recipients (RTR) and a risk factor for graft failure and mortality. Sodium intake is a well-established determinant of blood pressure (BP) in the general population. However, data in RTR are limited. International guidelines recommend a maximum daily sodium intake of 70 mmol. We investigated sodium intake in RTR as compared to healthy controls and its association with BP. METHODS We included 660 RTR (age 53 ± 13 years, 58% male) and 201 healthy controls (age 54 ± 11 years, 46% male). Sodium intake was assessed from 24-h urine collections. The morning after completion of urine collection, BP was measured according to a strict protocol. RESULTS Urinary sodium excretion was 156 ± 62 mmol/24 h in RTR and 195 ± 75 in controls (difference: P < 0.001), and 95% of RTR had a urinary sodium excretion >70 mmol/24 h. Systolic BP (SBP) and diastolic BP (DBP) were 136 ± 18 and 82 ± 11 mmHg, respectively. Sodium intake was positively associated with SBP (β = 0.042 mmHg/mmol/24 h, P = 0.002) and DBP (β = 0.023 mmHg/mmol/24 h, P = 0.007), independent of potential confounders. CONCLUSIONS Although RTR had a lower sodium intake than healthy controls, their intake still exceeded current guidelines. Reduction of sodium intake to recommended amounts could reduce SBP by 4-5 mmHg. Better control of sodium intake may help to prevent graft failure and mortality due to hypertension among RTR.
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Vegter S, Perna A, Postma MJ, Navis G, Remuzzi G, Ruggenenti P. Sodium intake, ACE inhibition, and progression to ESRD. J Am Soc Nephrol 2011; 23:165-73. [PMID: 22135311 DOI: 10.1681/asn.2011040430] [Citation(s) in RCA: 219] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
High sodium intake limits the antihypertensive and antiproteinuric effects of angiotensin-converting enzyme (ACE) inhibitors in patients with CKD; however, whether dietary sodium also associates with progression to ESRD is unknown. We conducted a post hoc analysis of the first and second Ramipril Efficacy in Nephropathy trials to evaluate the association of sodium intake with proteinuria and progression to ESRD among 500 CKD patients without diabetes who were treated with ramipril (5 mg/d) and monitored with serial 24-hour urinary sodium and creatinine measurements. Urinary sodium/creatinine excretion defined low (<100 mEq/g), medium (100 to <200 mEq/g), and high (≥200 mEq/g) sodium intake. During a follow-up of >4.25 years, 92 individuals (18.4%) developed ESRD. Among those with low, medium, and high sodium intakes, the incidence of ESRD was 6.1 (95% confidence interval [95% CI], 3.8-9.7), 7.9 (95% CI, 6.1-10.2), and 18.2 (95% CI, 11.3-29.3) per 100 patient-years, respectively (P<0.001). Patients with high dietary sodium exhibited a blunted antiproteinuric effect of ACE inhibition despite similar BP among groups. Each 100-mEq/g increase in urinary sodium/creatinine excretion associated with a 1.61-fold (95% CI, 1.15-2.24) higher risk for ESRD; adjusting for baseline proteinuria attenuated this association to 1.38-fold (95% CI, 0.95-2.00). This association was independent from BP but was lost after adjusting for changes in proteinuria. In summary, among patients with CKD but without diabetes, high dietary salt (>14 g daily) seems to blunt the antiproteinuric effect of ACE inhibitor therapy and increase the risk for ESRD, independent of BP control.
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Affiliation(s)
- Stefan Vegter
- Mario Negri Institute for Pharmacological Research, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano, 87 - 24126 Bergamo, Italy
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15
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Cravedi P, Ruggenenti P, Remuzzi G. Which antihypertensive drugs are the most nephroprotective and why? Expert Opin Pharmacother 2010; 11:2651-63. [DOI: 10.1517/14656566.2010.521742] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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16
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Influence of dietary modifications on the blood pressure response to antihypertensive medication. Br J Nutr 2010; 105:248-55. [DOI: 10.1017/s0007114510003223] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Identifying dietary modifications that potentiate the blood pressure (BP)-lowering effects of antihypertensive medications and that are practical for free-living people may assist in achieving BP reduction goals. We assessed whether two dietary patterns were effective in lowering BP in persons on antihypertensive therapy and in those not on therapy. Ninety-four participants (38/56 females/males), aged 55·6 (sd 9·9) years, consumed two 4-week dietary regimens in random order (Dietary Approaches to Stop Hypertension (DASH)-type diet and low-Na high-K (LNAHK) diet) with a control diet before each phase. Seated home BP was measured daily for the last 2 weeks in each phase. Participants were grouped based on antihypertensive drug therapy. The LNAHK diet produced a greater fall in systolic BP (SBP) in those on antihypertensive therapy ( − 6·2 (sd 6·0) mmHg) than in those not on antihypertensive therapy ( − 2·8 (sd 4·0) mmHg) (P = 0·036), and this was greatest for those on renin–angiotensin system (RAS) blocker therapy ( − 9·5 (sd 6·4) mmHg) (interaction P = 0·007). The fall in SBP on the DASH-type diet, in those on therapy (overall − 1·1 (sd 6·2) mmHg; renin–angiotensin blocker therapy − 4·2 (sd 4·7) mmHg), was not as marked as that observed on the LNAHK diet. Dietary modifications are an important part of all hypertension management regimens, and a low-Na and high-K diet enhances the BP-lowering effect of antihypertensive medications, particularly those targeting the RAS.
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Yamasue K, Morikawa N, Mizushima S, Tochikubo O. The Blood Pressure Lowering Effect of Lactotoripeptides and Salt Intake in 24-H Ambulatory Blood Pressure Measurements. Clin Exp Hypertens 2010; 32:214-20. [DOI: 10.3109/10641963.2010.491885] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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18
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Meijer E, Rook M, Tent H, Navis G, van der Jagt EJ, de Jong PE, Gansevoort RT. Early renal abnormalities in autosomal dominant polycystic kidney disease. Clin J Am Soc Nephrol 2010; 5:1091-8. [PMID: 20413443 PMCID: PMC2879311 DOI: 10.2215/cjn.00360110] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Accepted: 03/10/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Potential therapeutic interventions are being developed for autosomal dominant polycystic kidney disease (ADPKD). A pivotal question will be when to initiate such treatment, and monitoring disease progression will thus become more important. Therefore, the prevalence of renal abnormalities in ADPKD at different ages was evaluated. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Included were 103 prevalent ADPKD patients (Ravine criteria). Measured were mean arterial pressure (MAP), total renal volume (TRV), GFR, effective renal plasma flow (ERPF), renal vascular resistance (RVR), and filtration fraction (FF). Twenty-four-hour urine was collected. ADPKD patients were compared with age- and gender-matched healthy controls. RESULTS Patients and controls were subdivided into quartiles of age (median ages 28, 37, 42, and 52 years). Patients in the first quartile of age had almost the same GFR when compared with controls, but already a markedly decreased ERPF and an increased FF (GFR 117 +/- 32 versus 129 +/- 17 ml/min, ERPF 374 +/- 119 versus 527 +/- 83 ml/min, FF 32% +/- 4% versus 25% +/- 2%, and RVR 12 (10 to 16) versus 8 (7 to 8) dynes/cm(2), respectively). Young adult ADPKD patients also had higher 24-hour urinary volumes, lower 24-hour urinary osmolarity, and higher urinary albumin excretion (UAE) than healthy controls, although TRV in these young adult patients was modestly enlarged (median 1.0 L). CONCLUSIONS Already at young adult age, ADPKD patients have marked renal abnormalities, including a decreased ERPF and increased FF and UAE, despite modestly enlarged TRV and near-normal GFR. ERPF, FF, and UAE may thus be better markers for disease severity than GFR.
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Affiliation(s)
- Esther Meijer
- Division of Nephrology, Department of Internal Medicine and
| | - Mieneke Rook
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hilde Tent
- Division of Nephrology, Department of Internal Medicine and
| | - Gerjan Navis
- Division of Nephrology, Department of Internal Medicine and
| | - Eric J. van der Jagt
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Dual blockade of the renin-angiotensin-aldosterone system in cardiac and renal disease. Curr Opin Nephrol Hypertens 2010; 19:140-52. [PMID: 20051849 DOI: 10.1097/mnh.0b013e3283361887] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Renin-angiotensin-aldosterone system (RAAS) blockade improves outcome in cardiovascular disease (CVD) and chronic kidney disease (CKD), but the residual risk during monotherapy RAAS blockade remains very high. This review discusses the place of dual RAAS blockade in improving these outcomes. RECENT FINDINGS The combination of angiotensin-converting enzyme inhibitor (ACEI) with angiotensin II type 1 receptor blocker (ARB) generally had a better antihypertensive and antiproteinuric effect than monotherapy in many studies, but is also associated with more adverse effects. Unfortunately, the effect on hard renal and cardiovascular endpoints is not unequivocal. The combination of ACEI (or ARB) with aldosterone blockade has long-term benefits in heart failure, and an added effect on proteinuria in CKD, but data on hard renal endpoints are lacking. Dual blockade including renin inhibition has added antiproteinuric effects, but studies to gather long-term data are still under way. Available strategies to optimize the effect of monotherapy RAAS blockade include dose titration and correction of volume excess. Whether dual blockade has better efficacy and/or fewer adverse effects than optimized monotherapy has not been investigated. SUMMARY Several options are available to increase the effect of monotherapy RAAS blockade. For proteinuric CKD, these can be combined in a stepwise approach aimed at maximal proteinuria reduction; this includes dual blockade for patients with persistent proteinuria during optimized monotherapy RAAS blockade. Long-term randomized studies, however, are needed to support the benefits of dual blockade for long-term renal and cardiovascular outcome in CKD.
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20
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Benefits of dietary sodium restriction in the management of chronic kidney disease. Curr Opin Nephrol Hypertens 2009; 18:531-8. [DOI: 10.1097/mnh.0b013e3283312fc8] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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21
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Bellizzi V, Di Iorio BR, De Nicola L, Minutolo R, Zamboli P, Trucillo P, Catapano F, Cristofano C, Scalfi L, Conte G. Very low protein diet supplemented with ketoanalogs improves blood pressure control in chronic kidney disease. Kidney Int 2007; 71:245-51. [PMID: 17035939 DOI: 10.1038/sj.ki.5001955] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Blood pressure (BP) is hardly controlled in chronic kidney disease (CKD). We compared the effect of very low protein diet (VLPD) supplemented with ketoanalogs of essential amino acids (0.35 g/kg/day), low protein diet (LPD, 0.60 g/kg/day), and free diet (FD) on BP in patients with CKD stages 4 and 5. Vegetable proteins were higher in VLPD (66%) than in LPD (48%). LPD was prescribed to 110 consecutive patients; after run-in, they were invited to start VLPD. Thirty subjects accepted; 57 decided to continue LPD; 23 refused either diet (FD group). At baseline, protein intake (g/kg/day) was 0.79+/-0.09 in VLPD, 0.78+/-0.11 in LPD, and 1.11+/-0.18 in FD (P<0.0001). After 6 months, protein intake was lower in VLPD than LPD and FD (0.54+/-0.11, 0.78+/-0.10, and 1.04+/-0.21 g/kg/day, respectively; P<0.0001). BP diminished only in VLPD, from 143+/-19/84+/-10 to 128+/-16/78+/-7 mm Hg (P<0.0001), despite reduction of antihypertensive drugs (from 2.6+/-1.1 to 1.8+/-1.2; P<0.001). Urinary urea excretion directly correlated with urinary sodium excretion, which diminished in VLPD (from 181+/-32 to 131+/-36 mEq/day; P<0.001). At multiple regression analysis (R2=0.270, P<0.0001), BP results independently related to urinary sodium excretion (P=0.023) and VLPD prescription (P=0.003), but not to the level of protein intake. Thus, in moderate to advanced CKD, VLPD has an antihypertensive effect likely due to reduction of salt intake, type of proteins, and ketoanalogs supplementation, independent of actual protein intake.
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Affiliation(s)
- V Bellizzi
- Nephrology Unit, A Landolfi Hospital, Solofra, Italy.
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22
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Zamboli P, De Nicola L, Minutolo R, Bertino V, Catapano F, Conte G. Management of hypertension in chronic kidney disease. Curr Hypertens Rep 2007; 8:497-501. [PMID: 17139806 DOI: 10.1007/s11906-006-0029-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Optimal blood pressure control (<130/80 mm Hg) in patients with chronic kidney disease (CKD), despite being the main objective of conservative therapy, is rarely achieved in clinical practice. A major area of improvement is the correction of the extracellular volume expansion. This goal can be reached by means of dietary salt restriction (100 mEq/d of NaCl). If this intervention fails, hypertension can be treated by thiazide diuretics in patients with mild CKD, whereas loop diuretics at adequate doses are indicated in patients with more advanced CKD. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are more effective than other drugs in slowing progression of proteinuric diabetic and nondiabetic CKD. However, the control rates of blood pressure are usually inadequate with antihypertensive therapy including only these drugs; therefore, addition of other classes of antihypertensive drugs is often required.
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23
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Hamming I, Navis G, Kocks MJA, van Goor H. ACE inhibition has adverse renal effects during dietary sodium restriction in proteinuric and healthy rats. J Pathol 2006; 209:129-39. [PMID: 16532430 DOI: 10.1002/path.1956] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Angiotensin-converting enzyme inhibitors (ACEi) provide renoprotection. A low sodium diet enhances their efficacy. However, the added effect of sodium restriction on proteinuria and blood pressure is not invariably associated with better preservation of renal morphology, suggesting that the combination of ACEi with a low sodium diet can elicit renal structural abnormalities. To test this hypothesis, the effects of ACEi in combination with a control (CS) or a low sodium (LS) diet were investigated in healthy rats and in adriamycin nephrotic rats. After 3 weeks of treatment, rats were sacrificed and kidneys examined for renal structural abnormalities. In healthy rats, ACEi reduced blood pressure: the fall in blood pressure was significantly greater in the ACEi/LS group. Renal morphology was normal in the ACEi/CS group but severe interstitial damage was found in the ACEi/LS group. This was associated with increased interstitial macrophage influx and up-regulation of osteopontin, alpha-smooth muscle actin, and collagen III expression. In addition, ACEi/LS induced an increase in the total medial area of afferent arterioles. In nephrotic rats, ACEi/LS reduced both blood pressure and proteinuria, whereas only blood pressure was reduced in the ACEi/CS group. Mild interstitial damage was present in the ACEi/CS group but, strikingly, pronounced tubulo-interstitial abnormalities occurred in the ACEi/LS group, similar to those seen in ACEi/LS healthy rats, with similar changes in afferent arteriolar walls. In conclusion, the combination of ACEi/LS elicits pronounced renal interstitial abnormalities in healthy and nephrotic rats, despite a significant reduction of proteinuria in the latter. Considering their occurrence in healthy rats, these renal adverse effects cannot be due to specific characteristics of adriamycin nephrosis. Further studies should elucidate the mechanisms underlying these observations and their impact on long-term renoprotection.
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Affiliation(s)
- I Hamming
- Department of Pathology and Laboratory Medicine, University Medical Center Groningen and University of Groningen, The Netherlands.
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24
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Renal Protection in Chronic Kidney Disease. Hypertension 2005. [DOI: 10.1016/b978-0-7216-0258-5.50115-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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25
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Verhave JC, Hillege HL, Burgerhof JGM, Janssen WMT, Gansevoort RT, Navis GJ, de Zeeuw D, de Jong PE. Sodium intake affects urinary albumin excretion especially in overweight subjects. J Intern Med 2004; 256:324-30. [PMID: 15367175 DOI: 10.1111/j.1365-2796.2004.01390.x] [Citation(s) in RCA: 162] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To examine the relationship between sodium intake and urinary albumin excretion, being an established risk marker for later cardiovascular morbidity and mortality. DESIGN Cross-sectional cohort study using linear regression analysis. Setting. University hospital outpatient clinic. SUBJECTS A cohort drawn from the general population, consisting of 7850 subjects 28-75 years of age, all inhabitants of the city of Groningen, the Netherlands. The cohort is enriched for the presence of subjects with elevated urinary albumin concentration. RESULTS The results show a positive relationship between dietary sodium intake and urinary albumin excretion. The association was independent of other cardiovascular risk factors (such as sex, age, blood pressure, body mass index (BMI), waist-to-hip ratio, serum cholesterol, plasma glucose and smoking) and other food constituents (calcium, potassium and protein). The relationship between sodium intake and urinary albumin excretion was steeper in subjects with a higher BMI compared with a lower BMI. CONCLUSIONS Sodium intake is positively related to urinary albumin excretion. This relation is more pronounced in subjects with a higher BMI. These results suggest that high sodium intake may unfavourably influences cardiovascular prognosis especially in overweight and obese subjects.
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Affiliation(s)
- J C Verhave
- Division of Nephrology, Department of Medicine, University Medical Center Groningen, Groningen University Institute of Drug Exploration (GUIDE), Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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26
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Kocks MJA, Gschwend S, de Zeeuw D, Navis G, Buikema H. Low Sodium Modifies the Vascular Effects of Angiotensin-Converting Enzyme Inhibitor Therapy in Healthy Rats. J Pharmacol Exp Ther 2004; 310:1183-9. [PMID: 15175418 DOI: 10.1124/jpet.104.067272] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Low dietary sodium (LS) increases the effect of angiotensin-converting enzyme (ACE) inhibitor therapy in patients and experimental models, but mechanisms underlying this enhanced efficacy are largely unknown. Because the benefits of ACE inhibition are mediated to a considerable extent by their effect on the vasculature, we studied whether low sodium alters the vascular effects of ACE inhibition. Baseline functional and morphological characteristics, and endothelium-dependent and -independent dilatory responses were studied in isolated perfused small intrarenal and mesenteric arteries obtained from control rats (CON), rats on LS, lisinopril-treated rats (CON-LIS), or rats treated with lisinopril during LS (LS-LIS). We found, first, that LS-LIS compared with CON-LIS enhances blood pressure reduction. Second, interlobar renal arteries had increased lumen diameter and reduced adrenergic contractility in CON-LIS compared with CON, without additional effects of LS. In contrast, mesenteric arteries were not altered in CON-LIS compared with CON, but became triggered for increased myogenic and adrenergic constriction in LS-LIS. Third, LS-LIS decreased acetylcholine (ACh)-induced vasodilation in both mesenteric and renal arteries compared with CON-LIS. During the latter condition, opposite prostaglandins are involved in the endothelial function of the two different vascular beds, i.e., increased involvement of contractile prostaglandins in ACh-induced vasodilatation in renal arteries, versus dilatory prostaglandins in mesenteric arteries. Whether cause or consequence of the enhanced blood pressure response, our data demonstrate a modifying effect of dietary sodium on vascular effects of ACE inhibition. These findings provide a rationale for further studies addressing the mechanism-of-actions of our therapies to find additional strategies to improve therapy response.
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Affiliation(s)
- Menno J A Kocks
- Department of Clinical Pharmacology, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands.
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De Nicola L, Minutolo R, Bellizzi V, Zoccali C, Cianciaruso B, Andreucci VE, Fuiano G, Conte G. Achievement of target blood pressure levels in chronic kidney disease: a salty question? Am J Kidney Dis 2004; 43:782-95. [PMID: 15112168 DOI: 10.1053/j.ajkd.2004.01.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A large body of evidence supports the validity of lowering blood pressure (BP) to prevent cardiovascular (CV) disease in the general population. This issue becomes even more critical in renal patients because they carry a greater CV risk across the entire spectrum of chronic kidney disease (CKD). In these patients, achievement of lower BP levels also is fundamental to limit the progression of renal damage, especially in the presence of significant proteinuria. Although expert panels have strongly recommended to intensively decrease BP in patients with CKD, management of hypertension in these patients remains inadequate. Armed with the knowledge of the extreme salt-sensitivity of BP in patients with CKD, it is reasonable to hypothesize that more aggressive treatment of volume expansion can be helpful. Nevertheless, although abundant literature has evidenced that dietary sodium restriction decreases BP levels in patients with essential hypertension, no large and prospective study has been conducted to date on this issue in patients with CKD. A potential reason is the low compliance of patients with CKD to dietary prescriptions; however, this problem can be overcome by specific counseling. Alternatively, loop diuretics administered at a high dose should represent the cornerstone of therapy, but, again, well-designed studies verifying the effectiveness of these agents in a large CKD population are still awaited. Nephrologists seem to be reluctant to adequately administer diuretics because of the fear of adverse events. Conversely, the major detrimental effect, that is, excessive hypovolemia, can be prevented if daily body weight loss is limited to 0.3 to 0.5 kg during the initial period of treatment.
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Affiliation(s)
- Luca De Nicola
- Division of Nephrology, Second University of Naples, Naples, Italy.
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28
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Laverman GD, de Zeeuw D, Navis G. Between-patient differences in the renal response to renin-angiotensin system intervention: clue to optimising renoprotective therapy? J Renin Angiotensin Aldosterone Syst 2002; 3:205-13. [PMID: 12584664 DOI: 10.3317/jraas.2002.042] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Renin-angiotensin-aldosterone system (RAAS) blockade with angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin II (Ang II), AT(1)-receptor blockers (ARB) is the cornerstone of renoprotective therapy. Still, the number of patients with end-stage renal disease is increasing worldwide, prompting the search for improved renoprotective strategies. In spite of proven efficacy at group level, the long-term renoprotective effect of RAAS blockade displays a marked between-patient heterogeneity, which is closely linked to between-patient differences in the intermediate parameters of blood pressure, proteinuria and renal haemodynamics. Of note, the between-patient differences by far exceed the between-regimen differences, and thus may provide a novel target for exploration and intervention. The responsiveness to RAAS blockade appears to be an individual characteristic as demonstrated by studies applying a rotation-schedule design. The type and severity of renal disease, obesity, insulin-resistance, glycaemic control, and genetic factors may all be involved in individual differences in responsiveness, as well as dietary factors, such as dietary sodium and protein intake. Several strategies, such as dietary sodium restriction and diuretic therapy, dose-titration for proteinuria, and dual RAAS blockade with ACE-I and ARB, can improve the response to therapy at a group level. However, when analysed for their effect in individuals, it appears that these measures do not allow poor responders to catch up with the good responders, i.e. in spite of their efficacy at group level, the available measures are usually not sufficient to overcome individual resistance to RAAS blockade. We conclude that between-patient differences in responsiveness to renoprotective intervention should get specific attention as a target for intervention. Unravelling of the underlying mechanisms may allow development of specific intervention. Based on the currently available data, we propose that response-based treatment schedules, with a multidrug approach titrated and adapted at individual responses rather than fixed treatment schedules, may provide a fruitful strategy for more effective renoprotection.
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Affiliation(s)
- Gozewijn D Laverman
- Division of Nephrology, University Hospital Groningen, Groningen, 9713, The Netherlands.
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29
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Paassen PVAN, Zeeuw DDE, Jong PEDE, Navis G. Renin inhibition improves pressure natriuresis in essential hypertension. J Am Soc Nephrol 2000; 11:1813-1818. [PMID: 11004211 DOI: 10.1681/asn.v11101813] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Pressure natriuresis (PN), i.e., a rise in renal sodium excretion in response to a higher BP, is involved in long-term BP regulation. PN is blunted in essential hypertension, but the mechanism is unknown. This study assessed the role of the renin-angiotensin-aldosterone system (RAAS) in PN in eight essential hypertensive men from the individual correlations between spontaneous fluctuations in BP and time corresponding changes in sodium excretion (collected at 2- and 4-h intervals for 48 h), during strict sodium balance, without treatment, and during renin inhibition (remikiren, 600 mg oral compound). Without treatment, daily values for mean arterial pressure were 109.5 +/- 1.9 and 107 +/- 1.9 mmHg, for urinary sodium excretion were 37.2 +/- 2.8 and 42.0 +/- 2.8 mmol/24 h, and for plasma renin activity were 2.34 +/- 0.48 and 2.23 +/- 0.44 nmol/L per h, respectively, for two consecutive days. During remikiren treatment, mean arterial pressure was 101.9 +/- 1.7 and 100.8 +/- 1. 7 mmHg (P: < 0.05, versus baseline). Urinary sodium excretion was 39. 3 +/- 3.7 and 45.2 +/- 5.3 mmol/24 h (not significant versus baseline), and plasma renin activity was 0.79 +/- 0.11 and 0.82 +/- 0.13 nmol/L per h (P: < 0.05 versus baseline). During remikiren treatment, BP correlated positively with sodium excretion in all patients but in only three of eight patients without treatment. The slope of the regression equation was steeper during remikiren treatment in seven of eight patients. Thus, the relationship between BP and natriuresis was more readily apparent during RAAS blockade, suggesting that RAAS activity blunts PN in hypertensive patients. Improved PN may contribute to the hypotensive effect of RAAS blockade and to maintenance of sodium balance at a lower BP level without volume expansion.
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Affiliation(s)
- Pieter VAN Paassen
- Department of Medicine, Division of Nephrology, University Hospital Groningen and Groningen University Institute for Drug Exploration (GUIDE), The Netherlands
| | - Dick DE Zeeuw
- Department of Medicine, Division of Nephrology, University Hospital Groningen and Groningen University Institute for Drug Exploration (GUIDE), The Netherlands
- Department of Clinical Pharmacology, University Hospital Groningen and Groningen University Institute for Drug Exploration (GUIDE), The Netherlands
| | - Paul E DE Jong
- Department of Medicine, Division of Nephrology, University Hospital Groningen and Groningen University Institute for Drug Exploration (GUIDE), The Netherlands
| | - Gerjan Navis
- Department of Medicine, Division of Nephrology, University Hospital Groningen and Groningen University Institute for Drug Exploration (GUIDE), The Netherlands
- Department of Clinical Pharmacology, University Hospital Groningen and Groningen University Institute for Drug Exploration (GUIDE), The Netherlands
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30
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Keane WF, Eknoyan G. Proteinuria, albuminuria, risk, assessment, detection, elimination (PARADE): a position paper of the National Kidney Foundation. Am J Kidney Dis 1999; 33:1004-10. [PMID: 10213663 DOI: 10.1016/s0272-6386(99)70442-7] [Citation(s) in RCA: 368] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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31
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Wapstra FH, van Goor H, de Jong PE, Navis G, de Zeeuw D. Dose of doxorubicin determines severity of renal damage and responsiveness to ACE-inhibition in experimental nephrosis. J Pharmacol Toxicol Methods 1999; 41:69-73. [PMID: 10598677 DOI: 10.1016/s1056-8719(99)00015-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Nephrosis induced by doxorubicin (adriamycin) is an experimental model of glomerulosclerosis with relative stable proteinuria which is commonly used for pharmacological intervention studies. It is induced by a single or a double dose of doxorubicin, with doses that vary considerably among investigators from 2 to 7.5 mg/kg. Intervention studies with ACE-inhibitors in this model have provided conflicting results. We hypothesized that these discrepancies might be due to different properties of the doxorubicin model, related to the dose of doxorubicin used to induce proteinuria. We tested this hypothesis by inducing doxorubicin nephrosis with 1, 2 and 3 mg/kg, and evaluating the response to intervention with lisinopril. The 1-mg/kg doxorubicin dose did not induce significant proteinuria. The 2- and the 3-mg/ kg dose resulted in a proteinuria of 684+/-215 mg/24 h and 736+/-277 mg/24 h 6 weeks after induction, respectively (Mean+/-SD). Treatment with lisinopril 2 mg/kg/day reduced proteinuria to 160+/-170 mg/24 h(p<0.01) in the 2-mg/kg doxorubicin group, whereas in the 3-mg/kg doxorubicin group, proteinuria did not respond to lisinopril (529+/-264 mg/24 h). In time control rats, proteinuria remained stable. Renal damage developed in both time control groups, with a glomerulosclerosis score of 29+/-22 in the 2-mg/kg group and 84+/-41 in the 3-mg/kg doxorubicin group. Lisinopril resulted in a significantly lower glomerulosclerosis score in the 2-mg/kg doxorubicin group only (16+/-15, p<0.05), whereas the 3-mg/kg group showed no significant reduction (56+/-29, NS). In conclusion, the dose of doxorubicin used to induce nephrosis is an important determinant not only of the severity of the ensuring renal damage, but also of the response to intervention by ACE-inhibition. These findings have an impact on the interpretation of intervention studies in this model.
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Affiliation(s)
- F H Wapstra
- Groningen Institute of Drug Studies (GIDS), Department of Medicine, State University, University Hospital, The Netherlands
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Wing LM, Arnolda LF, Harvey PJ, Upton J, Molloy D, Gabb GM, Bune AJ, Chalmers JP. Low-dose diuretic and/or dietary sodium restriction when blood pressure is resistant to ACE inhibitor. Blood Press 1998; 7:299-307. [PMID: 10321443 DOI: 10.1080/080370598437169] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
AIM To compare the efficacy of indapamide (1.25 mg daily) and low-salt diet (<100 mmol/day) separately and in combination in essential hypertensive patients with inadequate BP response to perindopril. DESIGN AND METHODS Randomized double-blind, double-dummy, crossover design. The randomized treatments were indapamide 1.25 mg daily, sodium chloride 80 mmol daily, the combination of indapamide and sodium chloride and placebo. All patients received perindopril 4 mg daily and maintained a low-sodium diet. RESULTS 19 patients entered and 17 completed the study. Prior to randomization, average clinic sitting blood pressure was 162/101 mm Hg and average 24-h urine sodium excretion was 157 mmol/day. Compared to the phase in which patients received perindopril with sodium repletion, clinic and ambulatory BPs were significantly reduced (p<0.01) in all the other phases. Indapamide had a greater effect on BP than dietary sodium restriction, and in combination their effects were additive. The effect of indapamide on ambulatory BP persisted throughout 24 h, but the effect of the low-salt diet was predominantly observed during waking hours. CONCLUSIONS In hypertensives with BP resistant to the angiotensin converting enzyme (ACE) inhibitor perindopril, the diuretic indapamide had greater additional efficacy and longer duration of action than dietary sodium restriction. In combination they had additive effects on BP.
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Affiliation(s)
- L M Wing
- Department of Clinical Pharmacology, Flinders University and Flinders Medical Centre, Adelaide, South Australia.
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McCarron DA, Bennett WM, Reusser ME. Adverse effects of sodium restriction with concurrent medication use. J Ren Nutr 1995. [DOI: 10.1016/1051-2276(95)90039-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Singer DR, Markandu ND, Cappuccio FP, Miller MA, Sagnella GA, MacGregor GA. Reduction of salt intake during converting enzyme inhibitor treatment compared with addition of a thiazide. Hypertension 1995; 25:1042-4. [PMID: 7737713 DOI: 10.1161/01.hyp.25.5.1042] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A moderate reduction in salt intake lowers blood pressure in individuals with hypertension and improves blood pressure control in those taking a converting enzyme inhibitor. However, it is unclear how effective reduction of salt intake is compared with addition of other drugs, in particular, thiazide diuretics. We directly compared the separate effects on blood pressure of reducing sodium intake or adding a thiazide diuretic in the pressure of a converting enzyme inhibitor in a double-blind, randomized, crossover study. We studied 11 subjects with essential hypertension who had been taking 25 mg captopril twice daily for at least 1 month. In the double-blind study, after 1 month of captopril alone, supine blood pressure was 151 +/- 5/95 +/- 4 (SEM) mm Hg. With the addition of 25 mg hydrochlorothiazide once daily for 1 month, blood pressure fell to 137 +/- 5/87 +/- 3 mm Hg. When a moderate reduction in salt intake (from 206 +/- 26 to 109 +/- 20 mmol urinary sodium/24 h) was added to captopril for 1 month, blood pressure was reduced by a similar amount (to 137 +/- 4/90 +/- 3 mm Hg). Plasma potassium fell during the diuretic treatment (3.9 +/- 0.1 to 3.7 +/- 0.1 mmol/L, P < .05) but increased nonsignificantly during salt reduction (3.9 +/- 0.1 to 4.1 +/- 0.2 mmol/L). These results clearly demonstrate that moderate salt reduction, which can be easily achieved, is as effective as a thiazide diuretic in lowering blood pressure in the presence of a converting enzyme inhibitor and has the particular advantage that plasma potassium does not decrease.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- D R Singer
- Department of Medicine, St George's Hospital Medical School, London, UK
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MacFadyen RJ, Lees KR, Reid JL. Responses to low dose intravenous perindoprilat infusion in salt deplete/salt replete normotensive volunteers. Br J Clin Pharmacol 1994; 38:329-34. [PMID: 7833222 PMCID: PMC1364776 DOI: 10.1111/j.1365-2125.1994.tb04362.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
1. Intravenous ACE inhibitor therapy appears to have a role in the treatment of acute heart failure and early after myocardial infarction. Practical experience with intravenous administration with activation of renin is limited. We report responses to perindoprilat (Pt, 0.67 mg) or placebo (P) infused over 4 h in normotensive male volunteers (n = 12, 19-28 years, 53-77 kg) with double-blind, placebo controlled salt depletion (SD) or salt repletion (SR) as a model of the activated renin system. 2. Salt depletion caused no significant fall in serum sodium (P, 139.4 +/- 2.4; Pt, 138.3 +/- 1.9) compared with salt replete preparation (P, 139.9 +/- 1.2; Pt, 139.7 +/- 0.9) but elevation of plasma renin activity 2-3-fold. Pretreatment baseline systolic blood pressure following salt depletion (P, 121 +/- 9.3/71 +/- 7.9; Pt, 121.5 +/- 9.6/69 +/- 8.1) was higher than following salt replete preparation (P, 114 +/- 9.5/61 +/- 7.2; Pt, 116.9 +/- 6.9/67 +/- 7.2). 3. Baseline corrected supine SBP fell significantly and to a similar extent following active treatment regardless of activation of the renin system (SD, -14.6 +/- 9.5/-9.4 +/- 6.4; SR, -12 +/- 14/-10.1 +/- 6.6) compared with placebo (SD, -6.1 +/- 6/-3.7 +/- 5.6; SR, -4.7 +/- 10/-1.3 +/- 6.5). Heart rate was unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R J MacFadyen
- University Department of Medicine and Therapeutics, Gardiner Institute, Western Infirmary, Glasgow
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Affiliation(s)
- P M ter Wee
- Department of Medicine, Free University Hospital, Amsterdam, The Netherlands
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Jerums G, Allen TJ, Tsalamandris C, Cooper ME. Angiotensin converting enzyme inhibition and calcium channel blockade in incipient diabetic nephropathy. The Melbourne Diabetic Nephropathy Study Group. Kidney Int 1992; 41:904-11. [PMID: 1513112 DOI: 10.1038/ki.1992.138] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Small increases in blood pressure are a feature of incipient diabetic nephropathy, and mean blood pressure often correlates with the degree of albuminuria in such patients. Antihypertensive therapy with angiotensin converting enzyme inhibitors (CEI) or calcium channel blockers (CCB) has been assessed in several studies to determine if either form of treatment modifies incipient diabetic nephropathy and its evolution to established nephropathy. The acute renal hemodynamic effects of CEI differ from those of CCB under certain circumstances. In incipient diabetic nephropathy, therapy with CEI but not CCB tends to reduce filtration fraction, especially in hyperfiltering patients. In hypertensive patients with incipient diabetic nephropathy, both treatments result in a decrease in albuminuria and the responses are mainly dependent on the lowering of systemic blood pressure. In normotensive patients with incipient diabetic nephropathy, a lowering of mean blood pressure with CEI or CCB is not found consistently while effects on albuminuria are difficult to interpret. Short- and long-term therapy with CEI lowers or stabilizes albuminuria. Short-term administration of CCB has at times been associated with increases in albuminuria, but a comparison of CEI and CCB over 12 months in the Melbourne Diabetic Nephropathy Study (MDNS) has shown that both drugs stabilize albuminuria with no significant differences in their effects. Serial analysis of urinary sodium excretion in the MDNS shows that the hypotensive response to CEI in incipient nephropathy is highly dependent on sodium intake, and that sodium intake may modulate albuminuria during both CEI and CCB therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- G Jerums
- Endocrine Unit, Austin Hospital, Heidelberg, Victoria, Australia
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Abstract
Recent experimental studies suggest that the resistance state of the preglomerular and postglomerular capillary arterioles may determine if a particular class of antihypertensive agents will protect the kidney from hemodynamically mediated glomerular injury. This review discusses (1) the effects of angiotensin II on the renal microcirculation, (2) the pathophysiology of essential hypertensive renal disease, (3) the renal pharmacology of angiotensin-converting enzyme (ACE) inhibitors, and (4) the hypothesis that renal protection is dependent on control of systemic and glomerular hypertension.
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Affiliation(s)
- J H Bauer
- Department of Medicine, University of Missouri, Columbia 65212
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Singer DR, Markandu ND, Sugden AL, Miller MA, MacGregor GA. Sodium restriction in hypertensive patients treated with a converting enzyme inhibitor and a thiazide. Hypertension 1991; 17:798-803. [PMID: 2045142 DOI: 10.1161/01.hyp.17.6.798] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
When the function of the renin system is inhibited, blood pressure becomes more dependent on changes in sodium and water balance. Diuretics alone and sodium restriction alone are additive to converting enzyme inhibitor therapy. However, it is not known if these two ways of reducing sodium balance are additive in the presence of established converting enzyme inhibition. We therefore performed a double-blind crossover study of the effects of moderate sodium restriction in 21 patients with essential hypertension who were already being treated with the combination of a converting enzyme inhibitor and a diuretic. After 1 month of captopril (50 mg twice daily) and hydrochlorothiazide (25 mg once daily) therapy, with their usual sodium intake, average supine blood pressure was 147/96 +/- 5/3 (SEM) mm Hg 2 hours after treatment. Patients then reduced their sodium intake to around 80-100 mmol/day for the remainder of the study. After 2 weeks of sodium restriction, they entered a double-blind, randomized, crossover study of Slow Sodium (100 mmol sodium/day) compared with Slow Sodium placebo, while continuing sodium restriction and the above treatment. During the double-blind study, after 1 month of treatment with captopril (50 mg twice daily), hydrochlorothiazide (25 mg once daily), and Slow Sodium placebo, supine blood pressure 2 hours after treatment was 138/88 +/- 4/2 mm Hg (24-hour urinary sodium 104 +/- 11 mmol). After 1 month of captopril (50 mg twice daily), hydrochlorothiazide (25 mg once daily), and Slow Sodium tablets, supine blood pressure 2 hours after treatment was 147/91 +/- 5/2 mm Hg (p less than 0.05; 24-hour urinary sodium 195 +/- 14 mmol).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- D R Singer
- Department of Medicine I, St. George's Hospital Medical School, London, UK
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Reams GP, Bauer JH. Acute and chronic effects of angiotensin converting enzyme inhibitors on the essential hypertensive kidney. Cardiovasc Drugs Ther 1990; 4:207-19. [PMID: 2285613 DOI: 10.1007/bf01857635] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The natural course of essential hypertensive renal disease is characterized by a slowly progressive impairment of renal function. Initially, the changes are functional and reversible; however, structural changes gradually occur, leading to hypertensive nephrosclerosis. Similarities exist between the early functional hemodynamic changes observed in the essential hypertensive kidney and the physiologic renal effects of angiotensin II. To the degree that the initial functional changes are the result of excessive endogenous production of angiotensin II, interruption of the integrity of this humoral system could be expected to reverse the pathophysiologic sequence of events leading to hypertensive nephrosclerosis. This review focuses on the pathophysiology of the essential hypertensive kidney, the intrarenal effects of angiotensin II, and the acute and chronic effects of angiotensin converting enzyme (ACE) inhibition therapy on the essential hypertensive kidney. The data reviewed suggest that ACE inhibition therapy does reverse the initial functional hemodynamic changes observed in the essential hypertensive kidney and may protect the glomerulus from hemodynamically mediated injury.
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Affiliation(s)
- G P Reams
- Department of Medicine, University of Missouri, Columbia
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Heeg JE, de Jong PE, van der Hem GK, de Zeeuw D. Efficacy and variability of the antiproteinuric effect of ACE inhibition by lisinopril. Kidney Int 1989; 36:272-9. [PMID: 2550696 DOI: 10.1038/ki.1989.190] [Citation(s) in RCA: 264] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
We studied the efficacy of the ACE inhibitor lisinopril in treating overt proteinuria in comparison with the NSAID indomethacin, and evaluated some of the conditions that could influence this antiproteinuric effect. In 12 patients with a proteinuria varying from 3.2 to 10.5 g/24 hr, a diastolic BP ranging from 64 to 105 mm Hg, and a GFR varying from 34 to 127 ml/min, the effect of different lisinopril doses and of changing dietary sodium intake was evaluated. Proteinuria fell by 27 +/- 20% from 6.1 +/- 2.1 to 4.5 +/- 1.9 g/24 hr on a low dose (median 5 mg/day) lisinopril and by 50 +/- 17% to 3.1 +/- 1.4 g/24 hr on a higher dose (median 10 mg/day), irrespective of initial proteinuria, BP, or GFR. This antiproteinuric effect was abolished by increasing salt intake from 50 to 200 mmol/day, and was recovered again by re-instituting the sodium restricted diet. The antiproteinuric effect of 10 mg/day lisinopril was comparable to the reduction in proteinuria (by 57 +/- 21% to 2.8 +/- 2.0 g/24 hr) on 150 mg/day indomethacin, while adverse effects were less and renal hemodynamic effects were more favorable during lisinopril. In some patients it took several weeks before the effect of the ACE inhibitor on proteinuria was stabilized. Thus, the antiproteinuric effect of the ACE inhibitor lisinopril appears to be dose and time related, and is strongly dependent on dietary sodium restriction, whereas it does not depend on initial proteinuria, BP, or GFR. The effect is comparable to that of indomethacin, while adverse effects are less.
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Affiliation(s)
- J E Heeg
- Department of Medicine, State University Hospital Groningen, The Netherlands
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Campese VM. Effect of antihypertensive agents on renal function and on sodium-volume status. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1989; 252:331-46. [PMID: 2675558 DOI: 10.1007/978-1-4684-8953-8_34] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- V M Campese
- University of Southern California, Department of Medicine, Los Angeles 90033
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Jonker GJ, de Zeeuw D, Huisman RM, Piers DB, Beekhuis H, van der Hem GK. Angiotensin converting enzyme inhibition improves diagnostic procedures for renovascular hypertension in dogs. Hypertension 1988; 12:411-9. [PMID: 3169950 DOI: 10.1161/01.hyp.12.4.411] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
In renovascular hypertension adaptive mechanisms in the poststenotic kidney are a probable cause of the 20 to 25% false-negative findings during rapid sequence urography or [123I]o-iodohippurate renography. We blocked the renin-angiotensin system in an effort to increase the yield of these diagnostic procedures. Chronically instrumented, salt-depleted conscious dogs were used in which a light (n = 5), moderate (n = 4), or severe (n = 2) renal artery stenosis was induced. Before stenosis 10 of the dogs showed no left-right differences with either diagnostic procedure, and angiotensin converting enzyme (ACE) inhibition did not change this result. Two to 3 weeks after induction of a renal artery stenosis, all dogs showed signs of renovascular hypertension. However, only 50% of the renograms and 22% of the urograms showed differences between the two kidneys indicative of the presence of stenosis. After ACE inhibition, all previously negative test results became positive (abnormal) and previously existing left-right differences became more evidence. Electromagnetically measured renal blood flow on the stenotic side did not change during ACE inhibition (146 +/- 13 vs 145 +/- 21 ml/min), whereas contralateral blood flow showed a distinct increase (207 +/- 18 vs 282 +/- 20 ml/min, p less than 0.01). In conclusion, ACE inhibition markedly improves the sensitivity of rapid sequence urography and hippurate renography in the diagnosis of renovascular hypertension in the two-kidney, one clip Goldblatt hypertensive dog. The effects of ACE inhibition on the handling of the different tracers do not appear to be related to its effects on renal blood flow or systemic blood pressure.
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Affiliation(s)
- G J Jonker
- Department of Internal Medicine, State University Hospital, Groningen, The Netherlands
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