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Wu L, Rodriguez M, El Hachem K, Krittanawong C. Diuretic Treatment in Heart Failure: A Practical Guide for Clinicians. J Clin Med 2024; 13:4470. [PMID: 39124738 PMCID: PMC11313642 DOI: 10.3390/jcm13154470] [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: 07/09/2024] [Revised: 07/25/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
Congestion and fluid retention are the hallmarks of decompensated heart failure and the major reason for the hospitalization of patients with heart failure. Diuretics have been used in heart failure for decades, and they remain the backbone of the contemporary management of heart failure. Loop diuretics is the preferred diuretic, and it has been given a class I recommendation by clinical guidelines for the relief of congestion symptoms. Although loop diuretics have been used virtually among all patients with acute decompensated heart failure, there is still very limited clinical evidence to guide the optimized diuretics use. This is a sharp contrast to the rapidly growing evidence of the rest of the guideline-directed medical therapy of heart failure and calls for further studies. The loop diuretics possess a unique pharmacology and pharmacokinetics that lay the ground for different strategies to increase diuretic efficiency. However, many of these approaches have not been evaluated in randomized clinical trials. In recent years, a stepped and protocolized diuretics dosing has been suggested to have superior benefits over an individual clinician-based strategy. Diuretic resistance has been a major challenge to decongestion therapy for patients with heart failure and is associated with a poor clinical prognosis. Recently, therapy options have emerged to help overcome diuretic resistance to loop diuretics and have been evaluated in randomized clinical trials. In this review, we aim to provide a comprehensive review of the pharmacology and clinical use of loop diuretics in the context of heart failure, with attention to its side effects, and adjuncts, as well as the challenges and future direction.
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Affiliation(s)
- Lingling Wu
- Cardiovascular Division, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Mario Rodriguez
- John T. Milliken Department of Medicine, Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplant, Barnes-Jewish Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Karim El Hachem
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY 10029, USA
| | - Chayakrit Krittanawong
- Section of Cardiology, Cardiology Division, NYU Langone Health and NYU School of Medicine, 550 First Avenue, New York, NY 10016, USA
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Tabibzadeh N, Wang D, Karaboyas A, Schaeffner E, Jacobson SH, Vega A, Nitta K, Bieber B, Pecoits-Filho R, Torres PAU. Diuretic prescriptions in the first year of haemodialysis: international practice patterns and associations with outcomes. Clin Kidney J 2024; 17:sfae141. [PMID: 38989279 PMCID: PMC11233991 DOI: 10.1093/ckj/sfae141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Indexed: 07/12/2024] Open
Abstract
Background The use of diuretics in patients on haemodialysis (HD) is thought to maintain diuresis. However, this assumption and the optimal dose are based on little scientific evidence, and associations with clinical outcomes are unclear. Methods We reported international variations in diuretic use and loop diuretic dose across 27 759 HD patients with dialysis vintage <1 year in the Dialysis Outcomes and Practice Patterns Study phases 2-5 (2002-2015), a prospective cohort study. Doses of torsemide (4:1) and bumetanide (80:1) were converted to oral furosemide-equivalent doses. Adjusted Cox, logistic and linear regressions were used to investigate the association of diuretic use and dose with outcomes. Results Diuretic utilization varied widely by country at vintage <3 months, ranging from >80% in Germany and Sweden to <35% in the USA, at a median dose ranging from 400-500 mg/day in Germany and Sweden to <100 mg/day in Japan and the USA. Neither diuretic use nor higher doses were associated with a lower risk of all-cause mortality, a higher risk of hospitalization for fracture or elevated parathyroid hormone levels, but the prescription of higher doses (>200 mg/day) was associated with a higher risk of all-cause hospitalization. Conclusions Substantial international differences exist in diuretic prescriptions, with use and doses much higher in some European countries than the USA. The prescription and higher doses of loop diuretics was not associated with improved outcomes.
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Affiliation(s)
- Nahid Tabibzadeh
- Nephrology Division, Massachusetts General Hospital, Boston, MA, USA
| | - Dongyu Wang
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Elke Schaeffner
- Department of Nephrology, Institute of Public Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan H Jacobson
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Almudena Vega
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Pablo Antonio Ureña Torres
- Department of Dialysis, AURA Nord Saint Ouen, Saint-Ouen, France
- Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
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Ow CPC, Okazaki N, Iguchi N, Peiris RM, Evans RG, Hood SG, May CN, Bellomo R, Lankadeva YR. Effects of furosemide, acetazolamide and amiloride on renal cortical and medullary tissue oxygenation in non-anaesthetised healthy sheep. Exp Physiol 2024; 109:766-778. [PMID: 38551893 PMCID: PMC11061632 DOI: 10.1113/ep091479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/13/2024] [Indexed: 05/02/2024]
Abstract
It has been proposed that diuretics can improve renal tissue oxygenation through inhibition of tubular sodium reabsorption and reduced metabolic demand. However, the impact of clinically used diuretic drugs on the renal cortical and medullary microcirculation is unclear. Therefore, we examined the effects of three commonly used diuretics, at clinically relevant doses, on renal cortical and medullary perfusion and oxygenation in non-anaesthetised healthy sheep. Merino ewes received acetazolamide (250 mg; n = 9), furosemide (20 mg; n = 10) or amiloride (10 mg; n = 7) intravenously. Systemic and renal haemodynamics, renal cortical and medullary tissue perfusion andP O 2 ${P_{{{\mathrm{O}}_{\mathrm{2}}}}}$ , and renal function were then monitored for up to 8 h post-treatment. The peak diuretic response occurred 2 h (99.4 ± 14.8 mL/h) after acetazolamide, at which stage cortical and medullary tissue perfusion andP O 2 ${P_{{{\mathrm{O}}_{\mathrm{2}}}}}$ were not significantly different from their baseline levels. The peak diuretic response to furosemide occurred at 1 h (196.5 ± 12.3 mL/h) post-treatment but there were no significant changes in cortical and medullary tissue oxygenation during this period. However, cortical tissueP O 2 ${P_{{{\mathrm{O}}_{\mathrm{2}}}}}$ fell from 40.1 ± 3.8 mmHg at baseline to 17.2 ± 4.4 mmHg at 3 h and to 20.5 ± 5.3 mmHg at 6 h after furosemide administration. Amiloride did not produce a diuretic response and was not associated with significant changes in cortical or medullary tissue oxygenation. In conclusion, clinically relevant doses of diuretic agents did not improve regional renal tissue oxygenation in healthy animals during the 8 h experimentation period. On the contrary, rebound renal cortical hypoxia may develop after dissipation of furosemide-induced diuresis.
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Affiliation(s)
- Connie P. C. Ow
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental HealthUniversity of MelbourneMelbourneVictoriaAustralia
| | - Nobuki Okazaki
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental HealthUniversity of MelbourneMelbourneVictoriaAustralia
- Department of Anesthesiology and ResuscitologyOkayama UniversityOkayamaJapan
| | - Naoya Iguchi
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental HealthUniversity of MelbourneMelbourneVictoriaAustralia
- Department of Anesthesiology and Intensive Care MedicineGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Rachel M. Peiris
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental HealthUniversity of MelbourneMelbourneVictoriaAustralia
| | - Roger G. Evans
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental HealthUniversity of MelbourneMelbourneVictoriaAustralia
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of PhysiologyMonash UniversityMelbourneVictoriaAustralia
| | - Sally G. Hood
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental HealthUniversity of MelbourneMelbourneVictoriaAustralia
| | - Clive N. May
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental HealthUniversity of MelbourneMelbourneVictoriaAustralia
- Department of Critical Care, Melbourne Medical SchoolUniversity of MelbourneMelbourneVictoriaAustralia
| | - Rinaldo Bellomo
- Department of Critical Care, Melbourne Medical SchoolUniversity of MelbourneMelbourneVictoriaAustralia
- Australian and New Zealand Intensive Care Research Centre (ANZIC‐RC), School of Public Health and Preventive MedicineMonash UniversityMelbourneAustralia
- Department of Intensive CareAustin HospitalMelbourneAustralia
- Department of Intensive CareRoyal Melbourne HospitalMelbourneAustralia
- Data Analytics Research and Evaluation CentreAustin HospitalMelbourneAustralia
| | - Yugeesh R. Lankadeva
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental HealthUniversity of MelbourneMelbourneVictoriaAustralia
- Department of Critical Care, Melbourne Medical SchoolUniversity of MelbourneMelbourneVictoriaAustralia
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Ye XF, Wang WYY, Wang XY, Huang QF, Li Y, Wang JG. Alcohol Consumption and Antihypertensive Treatment Effect in Male Patients With Hypertension. Am J Hypertens 2024; 37:112-119. [PMID: 37769181 DOI: 10.1093/ajh/hpad091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 07/03/2023] [Accepted: 09/25/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Alcohol consumption is a proven risk factor of hypertension. In the present analysis, we investigated the use of antihypertensive medications and blood pressure control in male alcohol drinkers and non-drinkers with hypertension (systolic/diastolic blood pressure 160-199/100-119 mm Hg). METHODS The study participants were patients enrolled in a 12-week therapeutic study and treated with the irbesartan/hydrochlorothiazide combination 150/12.5 mg once daily, with the possible up-titration to 300/12.5 mg/day and 300/25 mg/day at 4 and 8 weeks of follow-up, respectively, for blood pressure control of <140/90 mm Hg or <130/80 mm Hg in patients with diabetes mellitus. Alcohol consumption was classified as non-drinkers and drinkers. RESULTS The 68 alcohol drinkers and 168 non-drinkers had similar systolic/diastolic blood pressure at baseline (160.8 ± 12.1/99.8 ± 8.6 vs. 161.8 ± 11.0/99.2 ± 8.6, P ≥ 0.55) and other characteristics except for current smoking (80.9% vs. 47.6%, P < 0.0001). In patients who completed the 12-week follow-up (n = 215), the use of higher dosages of antihypertensive drugs was similar at 4 weeks of follow-up in drinkers and non-drinkers (10.6% vs. 12.4%, P = 0.70), but increased to a significantly higher proportion in drinkers than non-drinkers at 12 weeks of follow-up (54.7% vs. 36.6%, P = 0.01). The control rate of hypertension tended to be lower in alcohol drinkers, compared with non-drinkers, at 4 weeks of follow-up (45.6% vs. 58.9%, P = 0.06), but became similar at 12 weeks of follow-up (51.5% vs. 54.8%, P = 0.65). CONCLUSION Alcohol drinkers compared with non-drinkers required a higher dosage of antihypertensive drug treatment to achieve similar blood pressure control. CLINICAL TRIAL REGISTRY NUMBER NCT00670566 at www.clinicaltrials.gov.
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Affiliation(s)
- Xiao-Fei Ye
- Department of Epidemiology and Statistics, School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wen-Yuan-Yue Wang
- Department of Epidemiology and Statistics, School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin-Yu Wang
- Department of Epidemiology and Statistics, School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qi-Fang Huang
- Department of Cardiovascular Medicine, Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Li
- Department of Cardiovascular Medicine, Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ji-Guang Wang
- Department of Epidemiology and Statistics, School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Cardiovascular Medicine, Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Ali S, Navaneethan SD, Virani SS, Gregg LP. Revisiting diuretic choice in chronic kidney disease. Curr Opin Nephrol Hypertens 2022; 31:406-413. [PMID: 35894274 PMCID: PMC9455225 DOI: 10.1097/mnh.0000000000000814] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Existing guidelines offer little direction about the use of thiazide and loop diuretics in patients with chronic kidney disease (CKD). This review summarizes recent studies impacting indications and safety considerations for these agents in patients with CKD. RECENT FINDINGS Chlorthalidone reduces blood pressure compared to placebo in patients with advanced CKD, challenging the belief that thiazide diuretics lose efficacy at lower glomerular filtration rates (GFR). Existing studies show no clear impact of thiazide or loop diuretic use on kidney or cardiovascular outcomes in patients with CKD. Sodium-glucose co-transporter type 2 (SGLT2) inhibitors have diuretic effects, but concomitant use of a diuretic does not diminish the preventive benefits of these agents against acute kidney injury (AKI). Despite theoretical concerns, thiazide diuretics likely do not worsen circulating vasopressin levels or cyst progression in polycystic kidney disease and may be useful for alleviating polyuria from tolvaptan. Diuretics cause multiple adverse effects, including electrolyte abnormalities, hemodynamic-mediated decrease in estimated GFR, and AKI. SUMMARY Recent evidence supports expanded indications for diuretics in patients with kidney disease, including chlorthalidone for hypertension in advanced CKD. Monitoring electrolytes and estimated GFR is critical to ensure patient safety when prescribing these agents for patients with CKD.
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Affiliation(s)
- Sehrish Ali
- Selzman Institute for Kidney Health, Section of Nephrology,
Department of Medicine, Baylor College of Medicine, Houston, TX
- Section of Nephrology, Michael E. DeBakey Veterans Affairs
Medical Center, Houston, TX
| | - Sankar D. Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology,
Department of Medicine, Baylor College of Medicine, Houston, TX
- Section of Nephrology, Michael E. DeBakey Veterans Affairs
Medical Center, Houston, TX
- Veterans Affairs Health Services Research and Development
Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
- Institute of Clinical and Translational Research, Baylor
College of Medicine, Houston, TX
| | - Salim S. Virani
- Veterans Affairs Health Services Research and Development
Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
- Division of Cardiology, Baylor College of Medicine,
Houston, TX
- Division of Cardiology, Department of Medicine, Michael E.
DeBakey VA Medical Center, Houston, TX
| | - L. Parker Gregg
- Selzman Institute for Kidney Health, Section of Nephrology,
Department of Medicine, Baylor College of Medicine, Houston, TX
- Section of Nephrology, Michael E. DeBakey Veterans Affairs
Medical Center, Houston, TX
- Veterans Affairs Health Services Research and Development
Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
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Mariano LNB, Pontioli DA, Aline da Silva A, Niero R, Cechinel-Filho V, de Souza P. Diuretic and antiurolithic effect of Garcinia humilis (Vahl) C.D.Adams leaves, a medicinal plant native to South American countries. Chem Biodivers 2022; 19:e202200022. [PMID: 35997661 DOI: 10.1002/cbdv.202200022] [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: 01/08/2022] [Accepted: 08/23/2022] [Indexed: 11/06/2022]
Abstract
This study evaluated the diuretic and antiurolithic effect of methanolic extract (MEGHL), dichloromethane (DCM), and ethyl acetate (EtA) fractions obtained from the leaves of Garcinia humilis , a medicinal plant known as achachairu and native to South American countries such as Bolivia, Peru, and Brazil. For the analysis of diuretic effect, the female rats received the treatment with MEGHL (3, 10, and 30 mg/kg), DCM (1, 3 and 10 mg/kg), EtA (1, 3, and 10 mg/kg), hydrochlorothiazide (HCTZ; 10 mg/kg), or vehicle (VEH) after an overload of saline solution. At the end 8-h of the experiment, the urinary parameters were measured . Additionally, the antiurolithic effect was analyzed, in which sodium oxalate was added in synthetic urine in the presence or absence of MEGHL, DCM, and EtA in different concentrations (0.1, 0.3, and 1 mg/mL). MEGHL, DCM, and EtA were able to promote 8-h diuresis in rats. MEGHL treatment at dose 30 mg/kg was accompanied by increased urinary Na + , K + and Cl - excretion. Moreover, the DCM and EtA fractions treatment increased K + and Cl - excretion in the urine, although it does not cause any change in Na + elimination. All the preparations were able to exert an antiurolithic effect in vitro , decreasing the number of calcium oxalate crystals of the monohydrate and dihydrate types. Taking together, the results presented herein showed that the preparations of G. humilis leaves are promising strategies to induce diuresis and antiurolithic effects.
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Affiliation(s)
| | - Daiane Aline Pontioli
- UNIVALI: Universidade do Vale do Itajai, Curso de Nutrição, Rua Uruguai, 458, Itajai, BRAZIL
| | - Ana Aline da Silva
- UNIVALI: Universidade do Vale do Itajai, Curso de Nutrição, Rua Uruguai, 458, Itajai, BRAZIL
| | - Rivaldo Niero
- UNIVALI: Universidade do Vale do Itajai, Ciencias Farmaceuticas, Rua Uruguai, 458, Itajai, BRAZIL
| | - Valdir Cechinel-Filho
- UNIVALI: Universidade do Vale do Itajai, Ciencias Farmaceuticas, Rua Uruguai, 458, Itajai, BRAZIL
| | - Priscila de Souza
- Universidade do Vale do Itajai, Ciencias Farmaceuticas, Rua Uruguai, 458, 88302901, Itajai, BRAZIL
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Adão JR, de Souza P, Boeing T, Mariano LN, Brandt AM, Hemmer JV, Bazani HA, de Andrade SF, Corrêa R, Klein-Júnior LC, Niero R. Synthesis and characterization of Schiff base derivatives and its effect on urinary parameters of Wistar rats: A comparative analysis with different classes of diuretics. J Mol Struct 2022. [DOI: 10.1016/j.molstruc.2022.132849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Diuretics and the kidney. BJA Educ 2022; 22:216-223. [DOI: 10.1016/j.bjae.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 11/22/2022] Open
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Lee TH, Kuo G, Chang CH, Huang YT, Yen CL, Lee CC, Fan PC, Chen JJ. Diuretic effect of co-administration of furosemide and albumin in comparison to furosemide therapy alone: An updated systematic review and meta-analysis. PLoS One 2021; 16:e0260312. [PMID: 34851962 PMCID: PMC8635380 DOI: 10.1371/journal.pone.0260312] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 11/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It has been a matter of much debate whether the co-administration of furosemide and albumin can achieve better diuresis and natriuresis than furosemide treatment alone. There is inconsistency in published trials regarding the effect of this combination therapy. We, therefore, conducted this meta-analysis to explore the efficacy of furosemide and albumin co-administration and the factors potentially influencing the diuretic effect of such co-administration. METHODS In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched the PubMed, Embase, Medline, and Cochrane databases. Prospective studies with adult populations which comparing the effect of furosemide and albumin co-administration with furosemide alone were included. The outcomes including diuretic effect and natriuresis effect measured by hourly urine output and hourly urine sodium excretion from both groups were extracted. Random effect model was applied for conducting meta-analysis. Subgroup analysis and sensitivity analysis were performed to explore potential sources of heterogeneity of treatment effects. RESULTS By including 13 studies with 422 participants, the meta-analysis revealed that furosemide with albumin co-administration increased urine output by 31.45 ml/hour and increased urine excretion by 1.76 mEq/hour in comparison to furosemide treatment alone. The diuretic effect of albumin and furosemide co-administration was better in participants with low baseline serum albumin levels (< 2.5 g/dL) and high prescribed albumin infusion doses (> 30 g), and the effect was more significant within 12 hours after administration. Diuretic effect of co-administration was better in those with baseline Cr > 1.2 mg/dL and natriuresis effect of co-administration was better in those with baseline eGFR < 60 ml/min/1.73m2. CONCLUSION Co-administration of furosemide with albumin might enhance diuresis and natriuresis effects than furosemide treatment alone but with high heterogeneity in treatment response. According to the present meta-analysis, combination therapy might provide advantages compared to the furosemide therapy alone in patients with baseline albumin levels lower than 2.5 g/dL or in patients receiving higher albumin infusion doses or in patients with impaired renal function. Owing to high heterogeneity and limited enrolled participants, further parallel randomized controlled trials are warranted to examine our outcome. REGISTRATION PROSEPRO ID: CRD42020211002; https://clinicaltrials.gov/.
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Affiliation(s)
- Tao Han Lee
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - George Kuo
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- * E-mail: (GK); (J-JC)
| | - Chih-Hsiang Chang
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yen Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chieh Li Yen
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cheng-Chia Lee
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pei Chun Fan
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jia-Jin Chen
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- * E-mail: (GK); (J-JC)
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Mayes-Hopfinger L, Enache A, Xie J, Huang CL, Köchl R, Tybulewicz VLJ, Fernandes-Alnemri T, Alnemri ES. Chloride sensing by WNK1 regulates NLRP3 inflammasome activation and pyroptosis. Nat Commun 2021; 12:4546. [PMID: 34315884 PMCID: PMC8316491 DOI: 10.1038/s41467-021-24784-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 06/30/2021] [Indexed: 01/05/2023] Open
Abstract
The NLRP3 inflammasome mediates the production of proinflammatory cytokines and initiates inflammatory cell death. Although NLRP3 is essential for innate immunity, aberrant NLRP3 inflammasome activation contributes to a wide variety of inflammatory diseases. Understanding the pathways that control NLRP3 activation will help develop strategies to treat these diseases. Here we identify WNK1 as a negative regulator of the NLRP3 inflammasome. Macrophages deficient in WNK1 protein or kinase activity have increased NLRP3 activation and pyroptosis compared with control macrophages. Mice with conditional knockout of WNK1 in macrophages have increased IL-1β production in response to NLRP3 stimulation compared with control mice. Mechanistically, WNK1 tempers NLRP3 activation by balancing intracellular Cl- and K+ concentrations during NLRP3 activation. Collectively, this work shows that the WNK1 pathway has a critical function in suppressing NLRP3 activation and suggests that pharmacological inhibition of this pathway to treat hypertension might have negative clinical implications.
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Affiliation(s)
- Lindsey Mayes-Hopfinger
- Department of Biochemistry and Molecular Biology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Aura Enache
- Department of Biochemistry and Molecular Biology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jian Xie
- Department of Medicine, Division of Nephrology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Chou-Long Huang
- Department of Medicine, Division of Nephrology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Robert Köchl
- The Francis Crick Institute, London, UK
- Kings College London, London, UK
| | | | - Teresa Fernandes-Alnemri
- Department of Biochemistry and Molecular Biology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Emad S Alnemri
- Department of Biochemistry and Molecular Biology, Thomas Jefferson University, Philadelphia, PA, USA.
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA.
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Ogata H, Shimofurutani N, Okada T, Nagamoto H, Akizawa T. Efficacy and safety of oral tolvaptan in patients undergoing hemodialysis: a Phase 2, double-blind, randomized, placebo-controlled trial. Nephrol Dial Transplant 2021; 36:1088-1097. [PMID: 32901255 PMCID: PMC8160953 DOI: 10.1093/ndt/gfaa148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 04/14/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Loop diuretics are used to manage fluid retention in patients with end-stage kidney disease undergoing hemodialysis (HD). This randomized, double-blind, placebo-controlled, Phase 2 trial evaluated the efficacy and safety of tolvaptan, a vasopressin V2 receptor antagonist, in Japanese HD patients. METHODS A total of 124 patients (24-h urine volume ≥500 mL) on thrice-weekly HD were randomized to receive oral tolvaptan 15 mg/day (n = 40), tolvaptan 30 mg/day (n = 40) or placebo (n = 44) for 24 weeks. Efficacy endpoints were change from baseline in 24-h urine volume, total fluid removal by HD per week and interdialytic weight gain (IDWG). Safety was assessed via the incidence of treatment-emergent adverse events (TEAEs). RESULTS At treatment end, the difference (95% confidence interval) from the placebo group in the mean change from baseline in 24-h urine volume was significant in the tolvaptan 15 mg {429.1 mL [95% confidence interval (CI) 231.0, 627.2]; P < 0.0001} and 30 mg [371.6 mL (95% CI 144.1, 599.2); P = 0.0017] groups. The mean changes from baseline in total fluid removal by HD and IDWG were not significantly different in the tolvaptan groups versus the placebo group. Although the proportion of patients with TEAEs was lower in the placebo group (77.3%) than in the tolvaptan groups (92.3%), tolvaptan was safe and well-tolerated during the study period. CONCLUSIONS Tolvaptan significantly sustained diuretic action for 24 weeks in HD patients but did not reduce total fluid removal by HD per week and IDWG to the same extent.
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Affiliation(s)
- Hiroaki Ogata
- Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Naoko Shimofurutani
- Headquarters of Clinical Development, Otsuka Pharmaceutical Co. Ltd, Osaka, Japan
| | - Tadashi Okada
- Headquarters of Clinical Development, Otsuka Pharmaceutical Co. Ltd, Osaka, Japan
| | - Hisashi Nagamoto
- Medical Affairs, Otsuka Pharmaceutical Co. Ltd, Tokushima, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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12
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Chapa R, Li CY, Basit A, Thakur A, Ladumor MK, Sharma S, Singh S, Selen A, Prasad B. Contribution of Uptake and Efflux Transporters to Oral Pharmacokinetics of Furosemide. ACS OMEGA 2020; 5:32939-32950. [PMID: 33403255 PMCID: PMC7774078 DOI: 10.1021/acsomega.0c03930] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/03/2020] [Indexed: 05/17/2023]
Abstract
Furosemide is a widely used diuretic for treating excessive fluid accumulation caused by disease conditions like heart failure and liver cirrhosis. Furosemide tablet formulation exhibits variable pharmacokinetics (PK) with bioavailability ranging from 10 to almost 100%. To explain the variable absorption, we integrated the physicochemical, in vitro dissolution, permeability, distribution, and the elimination parameters of furosemide in a physiologically-based pharmacokinetic (PBPK) model. Although the intravenous PBPK model reasonably described the observed in vivo PK data, the reported low passive permeability failed to capture the observed data after oral administration. To mechanistically justify this discrepancy, we hypothesized that transporter-mediated uptake contributes to the oral absorption of furosemide in conjunction with passive permeability. Our in vitro results confirmed that furosemide is a substrate of intestinal breast cancer resistance protein (BCRP), multidrug resistance-associated protein 4 (MRP4), and organic anion transporting polypeptide 2B1 (OATP2B1), but it is not a substrate of P-glycoprotein (P-gp) and MRP2. We then estimated the net transporter-mediated intestinal uptake and integrated it into the PBPK model under both fasting and fed conditions. Our in vitro data and PBPK model suggest that the absorption of furosemide is permeability-limited, and OATP2B1 and MRP4 are important for its permeability across intestinal membrane. Further, as furosemide has been proposed as a probe substrate of renal organic anion transporters (OATs) for assessing clinical drug-drug interactions (DDIs) during drug development, the confounding effects of intestinal transporters identified in this study on furosemide PK should be considered in the clinical transporter DDI studies.
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Affiliation(s)
- Revathi Chapa
- Department
of Pharmaceutics, University of Washington, Seattle, Washington 98195-0005, United States
| | - Cindy Yanfei Li
- Department
of Pharmaceutics, University of Washington, Seattle, Washington 98195-0005, United States
| | - Abdul Basit
- College
of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington 99202, United States
| | - Aarzoo Thakur
- National
Institute of Pharmaceutical
Education and Research (NIPER), SAS Nagar, Punjab 160062, India
| | - Mayur K Ladumor
- Department
of Pharmaceutics, University of Washington, Seattle, Washington 98195-0005, United States
- National
Institute of Pharmaceutical
Education and Research (NIPER), SAS Nagar, Punjab 160062, India
| | - Sheena Sharma
- College
of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington 99202, United States
- National
Institute of Pharmaceutical
Education and Research (NIPER), SAS Nagar, Punjab 160062, India
| | - Saranjit Singh
- National
Institute of Pharmaceutical
Education and Research (NIPER), SAS Nagar, Punjab 160062, India
| | - Arzu Selen
- Office
of Testing and Research, Office of Pharmaceutical Quality, CDER/ FDA, Silver
Spring, Maryland 20903-1058, United States
| | - Bhagwat Prasad
- College
of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington 99202, United States
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13
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Secora AM, Shin JI, Qiao Y, Alexander GC, Chang AR, Inker LA, Coresh J, Grams ME. Hyperkalemia and Acute Kidney Injury with Spironolactone Use Among Patients with Heart Failure. Mayo Clin Proc 2020; 95:2408-2419. [PMID: 33153631 PMCID: PMC8005315 DOI: 10.1016/j.mayocp.2020.03.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/03/2020] [Accepted: 03/12/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To quantify the risk of hyperkalemia and acute kidney injury (AKI) when spironolactone use is added on to loop diuretic use among patients with heart failure, and to evaluate whether the risk is modified by level of kidney function. METHODS We identified 17,110 patients with heart failure treated with loop diuretics between January 1, 2004, and December 31, 2016 within the Geisinger Health System. We estimated the incidence of hyperkalemia and AKI associated with spironolactone initiation, and used target trial emulation methods to minimize confounding by indication. RESULTS During a mean follow-up of 134 mo, 3229 of 17,110 patients (18.9%) initiated spironolactone. Incidence rates of hyperkalemia and AKI in patients using spironolactone with a loop diuretic were 2.9 and 10.1 events per 1000 person-months, respectively. In propensity score-matched analyses, spironolactone initiation was associated with higher hyperkalemia and AKI risk compared with loop alone (hazard ratio, 1.69; 95% CI, 1.35 to 2.10; P<.001, and hazard ratio, 1.12; 95% CI, 1.00 to 1.26; P=.04, respectively). There were no differences in the relative risk of either outcome associated with spironolactone by level of kidney function. CONCLUSION The addition of spironolactone to loop diuretics in patients with heart failure was associated with higher risk of hyperkalemia and AKI; these risks must be weighed against the potential benefits of spironolactone.
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Affiliation(s)
- Alex M Secora
- Johns Hopkins University Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD.
| | - Jung-Im Shin
- Johns Hopkins University Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD
| | - Yao Qiao
- Johns Hopkins University Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD
| | - G Caleb Alexander
- Johns Hopkins University Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Division of General Internal Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore, MD
| | - Alex R Chang
- Division of Nephrology, Geisinger Health System, Danville, PA
| | - Leslie A Inker
- Tufts Medical Center, Department of Internal Medicine, Division of Nephrology, Boston, MA
| | - Josef Coresh
- Johns Hopkins University Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD
| | - Morgan E Grams
- Johns Hopkins University Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD; Division of Nephrology, Department of Medicine, Johns Hopkins Medicine, Baltimore, MD
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14
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Bolda Mariano LN, Boeing T, Cechinel-Filho V, Niero R, Mota da Silva L, de Souza P. The acute diuretic effects with low-doses of natural prenylated xanthones in rats. Eur J Pharmacol 2020; 884:173432. [PMID: 32745607 DOI: 10.1016/j.ejphar.2020.173432] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 07/26/2020] [Accepted: 07/26/2020] [Indexed: 11/28/2022]
Abstract
The diuretic effect of 3-demethyl-2-geranyl-4-prenylbellidypholine xanthone (DGP) and 1,5,8-trihydroxy-4',5'-dimethyl-2H-pyrano(2,3:3,2)-4-(3-methylbut-2-enyl) xanthone (TDP), two natural prenylated xanthones, was investigated in female normotensive (NTR) and spontaneously hypertensive rats (SHR). The rats received a single treatment with DGP, TDP, hydrochlorothiazide (HCTZ), or vehicle (VEH) after an oral load of physiological saline. The effects of DGP and TDP in combination with diuretics of clinical use, as well as with L-NAME, atropine and indomethacin were also explored. The urinary parameters were measured at the end of the 8-h experiment. When orally given to rats, DGP was able to increase the urine volume, at doses of 0.03-0.3 mg/kg, associated with a K+-sparing effect. TDP, in turn, at doses of 0.03-0.3 mg/kg, induced diuresis and saluresis (i.e. augmented urinary levels of Na+ and Cl-) in NTR, while decreased the urinary content of Ca2+ in both NTR and SHR. The combination with HCTZ, but not with furosemide or amiloride, significantly enhanced DGP and TDP induced diuresis, which was accompanied by an increase of the electrolytes content in the urine. Instead, amiloride in combination with DGP or TDP enhanced urinary Na+ and Cl- and decreased K+ elimination. Furthermore, the effect of DGP and TDP were heightened after pretreatment with L-NAME. While atropine was able to prevent DGP-induced diuresis, the pretreatment with indomethacin precluded TDP-induced diuresis. Besides, TDP exerted protective effects against urinary calcium oxalate crystals formation. Taken together, our data revealed the diuretic effect of two xanthones in rats and their possible underlying mode of action.
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Affiliation(s)
- Luísa Nathália Bolda Mariano
- Programa de Pós-graduação em Ciências Farmacêuticas (PPGCF), Núcleo de Investigações Químico-Farmacêuticas (NIQFAR), Universidade do Vale do Itajaí (UNIVALI), Rua Uruguai, 458, Centro, 88302-901, Itajaí, Brazil
| | - Thaise Boeing
- Programa de Pós-graduação em Ciências Farmacêuticas (PPGCF), Núcleo de Investigações Químico-Farmacêuticas (NIQFAR), Universidade do Vale do Itajaí (UNIVALI), Rua Uruguai, 458, Centro, 88302-901, Itajaí, Brazil
| | - Valdir Cechinel-Filho
- Programa de Pós-graduação em Ciências Farmacêuticas (PPGCF), Núcleo de Investigações Químico-Farmacêuticas (NIQFAR), Universidade do Vale do Itajaí (UNIVALI), Rua Uruguai, 458, Centro, 88302-901, Itajaí, Brazil
| | - Rivaldo Niero
- Programa de Pós-graduação em Ciências Farmacêuticas (PPGCF), Núcleo de Investigações Químico-Farmacêuticas (NIQFAR), Universidade do Vale do Itajaí (UNIVALI), Rua Uruguai, 458, Centro, 88302-901, Itajaí, Brazil
| | - Luisa Mota da Silva
- Programa de Pós-graduação em Ciências Farmacêuticas (PPGCF), Núcleo de Investigações Químico-Farmacêuticas (NIQFAR), Universidade do Vale do Itajaí (UNIVALI), Rua Uruguai, 458, Centro, 88302-901, Itajaí, Brazil
| | - Priscila de Souza
- Programa de Pós-graduação em Ciências Farmacêuticas (PPGCF), Núcleo de Investigações Químico-Farmacêuticas (NIQFAR), Universidade do Vale do Itajaí (UNIVALI), Rua Uruguai, 458, Centro, 88302-901, Itajaí, Brazil.
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15
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Takagi K, Sato N, Ishihara S, Iha H, Kobayashi N, Ito Y, Nohara T, Ohkuma S, Mitsuishi T, Ishizuka A, Shigihara S, Sone M, Nakama K, Tokuyama H, Omote T, Kikuchi A, Nakamura S, Yamamoto E, Ishikawa M, Amitani K, Takahashi N, Maruyama Y, Imura H, Shimizu W. Differences in pharmacological property between combined therapy of the vasopressin V2-receptor antagonist tolvaptan plus furosemide and monotherapy of furosemide in patients with hospitalized heart failure. J Cardiol 2020; 76:499-505. [PMID: 32665162 DOI: 10.1016/j.jjcc.2020.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/07/2020] [Accepted: 05/07/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Tolvaptan has been shown to improve congestion in heart failure patients. The purpose of this study was to evaluate the pharmacology and clinical efficacy of combined tolvaptan and furosemide therapy. METHODS This study included 40 patients with systemic volume overload who were hospitalized for heart failure. Patients who showed no improvement in the condition after receiving 20 mg intravenous furosemide were included and were randomly selected to receive tolvaptan as an add-on to furosemide or to receive an increased dose of furosemide. We evaluated the bioelectrical impedance analyzer parameters, the parameters of the inferior vena cava using echocardiography, vital signs, body weight, urine output, and laboratory data for 5 days. RESULTS In the changes from baseline between intracellular water volume (ICW) and extracellular water volume (ECW) after additional use of tolvaptan or furosemide from Day 1 to Day 5, there were no significant differences observed between ICW and ECW over 5 days in the tolvaptan + furosemide group, although differences were found in the furosemide group from Day 2 onward. Changes in the respiratory collapse of inferior vena cava increased significantly, and systolic blood pressure decreased significantly only in the furosemide group. CONCLUSIONS The present study clearly demonstrates that combined therapy with tolvaptan and furosemide removed excess ICW and ECW to an equal extent, while furosemide alone primarily removed ECW, including intravascular water.
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Affiliation(s)
- Koji Takagi
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Naoki Sato
- Department of Cardiovascular Medicine, Kawaguchi Cardiovascular and Respiratory Hospital, Kawaguchi, Japan.
| | - Shiro Ishihara
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Hayano Iha
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Noriyuki Kobayashi
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Yusuke Ito
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Tsuyoshi Nohara
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Satoru Ohkuma
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Tatsuya Mitsuishi
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Atsushi Ishizuka
- Department of Cardiovascular Medicine, Kawaguchi Cardiovascular and Respiratory Hospital, Kawaguchi, Japan
| | - Shota Shigihara
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Michiko Sone
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Kenji Nakama
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Hideo Tokuyama
- Department of Cardiovascular Medicine, Kawaguchi Cardiovascular and Respiratory Hospital, Kawaguchi, Japan
| | - Toshiya Omote
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Arifumi Kikuchi
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Shunichi Nakamura
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Eisei Yamamoto
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Masahiro Ishikawa
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Kenichi Amitani
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Naoto Takahashi
- Cardiology and Intensive Care Unit, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Yuji Maruyama
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Hajime Imura
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
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16
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Mihaila SM, Faria J, Stefens MFJ, Stamatialis D, Verhaar MC, Gerritsen KGF, Masereeuw R. Drugs Commonly Applied to Kidney Patients May Compromise Renal Tubular Uremic Toxins Excretion. Toxins (Basel) 2020; 12:toxins12060391. [PMID: 32545617 PMCID: PMC7354492 DOI: 10.3390/toxins12060391] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/05/2020] [Accepted: 06/09/2020] [Indexed: 02/07/2023] Open
Abstract
In chronic kidney disease (CKD), the secretion of uremic toxins is compromised leading to their accumulation in blood, which contributes to uremic complications, in particular cardiovascular disease. Organic anion transporters (OATs) are involved in the tubular secretion of protein-bound uremic toxins (PBUTs). However, OATs also handle a wide range of drugs, including those used for treatment of cardiovascular complications and their interaction with PBUTs is unknown. The aim of this study was to investigate the interaction between commonly prescribed drugs in CKD and endogenous PBUTs with respect to OAT1-mediated uptake. We exposed a unique conditionally immortalized proximal tubule cell line (ciPTEC) equipped with OAT1 to a panel of selected drugs, including angiotensin-converting enzyme inhibitors (ACEIs: captopril, enalaprilate, lisinopril), angiotensin receptor blockers (ARBs: losartan and valsartan), furosemide and statins (pravastatin and simvastatin), and evaluated the drug-interactions using an OAT1-mediated fluorescein assay. We show that selected ARBs and furosemide significantly reduced fluorescein uptake, with the highest potency for ARBs. This was exaggerated in presence of some PBUTs. Selected ACEIs and statins had either no or a slight effect at supratherapeutic concentrations on OAT1-mediated fluorescein uptake. In conclusion, we demonstrate that PBUTs may compete with co-administrated drugs commonly used in CKD management for renal OAT1 mediated secretion, thus potentially compromising the residual renal function.
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Affiliation(s)
- Silvia M. Mihaila
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, 3854 CG Utrecht, The Netherlands; (S.M.M.); (M.C.V.); (K.G.F.G.)
- Department of Nephrology and Hypertension, University Medical Center Utrecht, 3582 CX Utrecht, The Netherlands; (J.F.); (M.F.J.S.)
| | - João Faria
- Department of Nephrology and Hypertension, University Medical Center Utrecht, 3582 CX Utrecht, The Netherlands; (J.F.); (M.F.J.S.)
| | - Maurice F. J. Stefens
- Department of Nephrology and Hypertension, University Medical Center Utrecht, 3582 CX Utrecht, The Netherlands; (J.F.); (M.F.J.S.)
| | - Dimitrios Stamatialis
- (Bio)artificial Organs, Department of Biomaterials Science and Technology, University of Twente, 7522 LW Enschede, The Netherlands;
| | - Marianne C. Verhaar
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, 3854 CG Utrecht, The Netherlands; (S.M.M.); (M.C.V.); (K.G.F.G.)
| | - Karin G. F. Gerritsen
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, 3854 CG Utrecht, The Netherlands; (S.M.M.); (M.C.V.); (K.G.F.G.)
| | - Rosalinde Masereeuw
- Department of Nephrology and Hypertension, University Medical Center Utrecht, 3582 CX Utrecht, The Netherlands; (J.F.); (M.F.J.S.)
- Correspondence:
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17
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Walther CP, Nambi V, Hanania NA, Navaneethan SD. Diagnosis and Management of Pulmonary Hypertension in Patients With CKD. Am J Kidney Dis 2020; 75:935-945. [PMID: 32199709 DOI: 10.1053/j.ajkd.2019.12.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 12/07/2019] [Indexed: 12/12/2022]
Abstract
Pulmonary hypertension (PH) is a highly prevalent and important condition in adults with chronic kidney disease (CKD). In this review, we summarize the definition of PH, discuss its pathophysiology and classifications, and describe diagnostic and management strategies in patients with CKD, including those with kidney failure treated by kidney replacement therapy. In the general population, PH is classified into 5 groups based on clinical presentation, pathology, hemodynamics, and management strategies. In this classification system, PH in CKD is placed in a diverse group with unclear or multifactorial mechanisms, although underlying cardiovascular disease may account for most cases. CKD may itself directly incite pulmonary circulatory dysfunction and remodeling through uremic toxins, inflammation, endothelial dysfunction, and altered vasoregulation. Despite several studies describing the higher prevalence of PH in CKD and kidney failure, along with an association with poor outcomes, high-quality evidence is not available for its diagnostic and management strategies in those with CKD. In CKD not requiring kidney replacement therapy, volume management along with treatment of underlying risk factors for PH are critical. In those receiving hemodialysis, options are limited and transition to peritoneal dialysis may be considered if recurrent hypotension precludes optimal volume control.
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Affiliation(s)
- Carl P Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX.
| | - Vijay Nambi
- Micheal E DeBakey Veterans Affairs Medical Center, Department of Medicine, Baylor College of Medicine, Houston, TX; Sections of Atherosclerosis and Vascular Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Nicola A Hanania
- Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX; Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.
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18
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Furusho T, Sohara E, Mandai S, Kikuchi H, Takahashi N, Fujimaru T, Hashimoto H, Arai Y, Ando F, Zeniya M, Mori T, Susa K, Isobe K, Nomura N, Yamamoto K, Okado T, Rai T, Uchida S. Renal TNFα activates the WNK phosphorylation cascade and contributes to salt-sensitive hypertension in chronic kidney disease. Kidney Int 2020; 97:713-727. [PMID: 32059997 DOI: 10.1016/j.kint.2019.11.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 11/19/2019] [Accepted: 11/22/2019] [Indexed: 12/13/2022]
Abstract
The inappropriate over-activation of the with-no-lysine kinase (WNK)-STE20/SPS1-related proline/alanine-rich kinase (SPAK)-sodium chloride cotransporter (NCC) phosphorylation cascade increases sodium reabsorption in distal kidney nephrons, resulting in salt-sensitive hypertension. Although chronic kidney disease (CKD) is a common cause of salt-sensitive hypertension, the involvement of the WNK phosphorylation cascade is unknown. Moreover, the effect of immune systems on WNK kinases has not been investigated despite the fact that immune systems are important for salt sensitivity. Here we demonstrate that the protein abundance of WNK1, but not of WNK4, was increased at the distal convoluted tubules in the aristolochic acid nephropathy mouse model of CKD. Accordingly, the phosphorylation of both SPAK and NCC was also increased. Moreover, a high-salt diet did not adequately suppress activation of the WNK1-SPAK-NCC phosphorylation cascade in this model, leading to salt-sensitive hypertension. WNK1 also was increased in adenine nephropathy, but not in subtotal nephrectomy, models of CKD. By comparing the transcripts of these three models focusing on immune systems, we hypothesized that tumor necrosis factor (TNF)-α regulates WNK1 protein expression. In fact, TNF-α increased WNK1 protein expression in cultured renal tubular cells by reducing the transcription and protein levels of NEDD4-2 E3-ligase, which degrades WNK1 protein. Furthermore, the TNF-α inhibitor etanercept reversed the reduction of NEDD4-2 expression and upregulation of the WNK1-SPAK-NCC phosphorylation cascade in distal convoluted tubules in vivo in the aristolochic acid nephropathy model. Thus, salt-sensitive hypertension is induced in CKD via activation of the renal WNK1- SPAK-NCC phosphorylation cascade by TNF-α, reflecting a link with the immune system.
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Affiliation(s)
- Taisuke Furusho
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Eisei Sohara
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Shintaro Mandai
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroaki Kikuchi
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Naohiro Takahashi
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takuya Fujimaru
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroko Hashimoto
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yohei Arai
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Fumiaki Ando
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Moko Zeniya
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takayasu Mori
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Koichiro Susa
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kiyoshi Isobe
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Naohiro Nomura
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohei Yamamoto
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomokazu Okado
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tatemitsu Rai
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shinichi Uchida
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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19
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Vollmer T, Ljungberg B, Jankowski V, Jankowski J, Glorieux G, Stegmayr BG. An in-vitro assay using human spermatozoa to detect toxicity of biologically active substances. Sci Rep 2019; 9:14525. [PMID: 31601841 PMCID: PMC6787250 DOI: 10.1038/s41598-019-50929-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 09/05/2019] [Indexed: 12/24/2022] Open
Abstract
Identifying the key toxic players within an in-vivo toxic syndrome is crucial to develop targeted therapies. Here, we established a novel method that characterizes the effect of single substances by means of an ex-vivo incubation set-up. We found that primary human spermatozoa elicit a distinct motile response on a (uremic) toxic milieu. Specifically, this approach describes the influence of a bulk toxic environment (uremia) as well as single substances (uremic toxins) by real-time analyzing motile cellular behavior. We established the human spermatozoa-based toxicity testing (HSTT) for detecting single substance-induced toxicity to be used as a screening tool to identify in-vivo toxins. Further, we propose an application of the HSTT as a method of clinical use to evaluate toxin-removing interventions (hemodialysis).
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Affiliation(s)
- Tino Vollmer
- Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden. .,Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany. .,Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin-Brandenburg School for Regenerative Therapies (BSRT) & Berlin Center for Advanced Therapies (BeCAT), Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Börje Ljungberg
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umea University, Umea, Sweden
| | - Vera Jankowski
- Institute for Cardiovascular Research, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Joachim Jankowski
- Institute for Cardiovascular Research, University Hospital, RWTH Aachen University, Aachen, Germany.,School for Cardiovascular Diseases, University of Maastricht, Maastricht, The Netherlands
| | - Griet Glorieux
- Nephrology Section, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - Bernd G Stegmayr
- Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden
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Zuo C, Xu G. Efficacy and safety of mineralocorticoid receptor antagonists with ACEI/ARB treatment for diabetic nephropathy: A meta-analysis. Int J Clin Pract 2019; 73:e13413. [PMID: 31464019 DOI: 10.1111/ijcp.13413] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 08/24/2019] [Accepted: 08/26/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND To explore the efficacy and safety of adding mineralocorticoid receptor antagonists (MRAs) to the treatment in diabetic nephropathy (DN) with ACEI/ARB. METHODS We systematically searched the PubMed, Embase and Cochrane Library databases for randomised controlled trials up to November 1st 2018 that evaluated the effects of MRAs with ACEI/ARB treatment. RESULTS The combination treatment of MRAs and ACEI/ARB further reduced urinary protein/albumin excretion compared with ACEI/ARB monotherapy (mean difference [MD], -44.17 [95% CIs, -61.73 to -26.61], P < .00001). Although no statistically significant changes in glomerular filtration rate were observed, the combination group significantly increased serum/plasma creatinine (MD, 7.40 [95% CIs, 4.69-10.11], P < .00001). Subgroup analysis based on generations of MRAs suggested a lower relative risk of hyperkalaemia with finerenone (relative risk, 2.22 [95% CIs, 0.13-38.13], P = .58) than eplerenone (relative risk, 2.81 [95% CIs, 1.03-7.69], P = .04) or spironolactone (relative risk, 4.58 [95% CIs, 2.60-8.08], P < .00001). CONCLUSION MRAs can significantly reduce proteinuria and increase blood creatinine in DN patients under blockade of the renin-angiotensin system. The combination treatment of finerenone and ACEI/ARB runs a lower risk of hyperkalaemia than eplerenone or spironolactone.
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Affiliation(s)
- Chao Zuo
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- Grade 2016, The Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Gaosi Xu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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21
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Castro MCM. Conservative management for patients with chronic kidney disease refusing dialysis. J Bras Nefrol 2019; 41:95-102. [PMID: 30048562 PMCID: PMC6534024 DOI: 10.1590/2175-8239-jbn-2018-0028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/14/2018] [Indexed: 12/24/2022] Open
Abstract
Estimates suggest that 20-30% of the deaths of patients with chronic kidney disease with indication to undergo dialysis occur after refusal to continue dialysis, discontinuation of dialysis or inability to offer dialysis on account of local conditions. Contributing factors include aging, increased comorbidity associated with chronic kidney disease, and socioeconomic status. In several occasions nephrologists will intervene, but at times general practitioners or family physicians are on their own. Knowledge of the main etiologies of chronic kidney disease and the metabolic alterations and symptoms associated to end-stage renal disease is an important element in providing patients with good palliative care. This review aimed to familiarize members of multidisciplinary care teams with the metabolic alterations and symptoms arising from chronic kidney disease treated clinically without the aid of dialysis.
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Luo B, Li J, Yang T, Li W, Zhang J, Wang C, Zhao A, Wang R. Evaluation of renal excretion and pharmacokinetics of furosemide in rats after acute exposure to high altitude at 4300 m. Biopharm Drug Dispos 2018; 39:378-387. [PMID: 30120768 DOI: 10.1002/bdd.2154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 06/09/2018] [Accepted: 06/20/2018] [Indexed: 01/11/2023]
Abstract
With studies indicative of altered renal excretion under high altitude-induced hypobaric hypoxia, the consideration of better therapeutic approaches has long been the aim of research on the management of high altitude related illness. The pharmacokinetics of drugs such as furosemide might be altered under hypoxic conditions, making it essential to establish different dose-regimens to maintain therapeutic efficacy or to avoid toxic side effects at high altitude. Simultaneously, drug-drug interactions (DDIs) mediated by OAT1 occur at high altitude, severely affecting furosemide pharmacokinetics. This study investigated the influence of acute exposure to high altitude at 4300 m on the renal excretion of furosemide in rats. Significant changes in physiological parameters and kidney histopathology were found after acute high altitude exposure. Compared with low altitude, the pharmacokinetics of furosemide and the expression level of OAT1 in kidney were significantly changed after rapid ascent to high altitude. Additionally, the down-regulated OAT1 expression further sustained the potential mechanism for the decreased renal excretion of furosemide, resulting in extended residence of the drug in the human body. The elevation of AUC, Cmax , MRT, t1/2 of furosemide, and decreased CL at high altitude further reinforced the current findings. Moreover, the absorption of furosemide was markedly increased and renal excretion significantly declined after co-administration of captopril, resulting in local drug interaction at high altitude. In conclusion, acute exposure to high altitude may significantly affect the renal excretion of furosemide and the pharmacokinetic parameters of furosemide were altered after co-administration of captopril, which may then impact the conventional therapeutic dosage.
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Affiliation(s)
- Bingfeng Luo
- Key Laboratory of the Plateau Environmental Damage Control, Lanzhou General Hospital of Lanzhou Military Command, PLA, Lanzhou, China.,College of Pharmacy, Lanzhou University, Lanzhou, China
| | - Jing Li
- Key Laboratory of the Plateau Environmental Damage Control, Lanzhou General Hospital of Lanzhou Military Command, PLA, Lanzhou, China
| | - Tao Yang
- Department of Pharmacy, Gansu Provincial Maternity and Child Care Hospital, Lanzhou, China
| | - Wenbin Li
- Key Laboratory of the Plateau Environmental Damage Control, Lanzhou General Hospital of Lanzhou Military Command, PLA, Lanzhou, China
| | - Juanhong Zhang
- Key Laboratory of the Plateau Environmental Damage Control, Lanzhou General Hospital of Lanzhou Military Command, PLA, Lanzhou, China
| | - Chang Wang
- Key Laboratory of the Plateau Environmental Damage Control, Lanzhou General Hospital of Lanzhou Military Command, PLA, Lanzhou, China
| | - Anpeng Zhao
- Key Laboratory of the Plateau Environmental Damage Control, Lanzhou General Hospital of Lanzhou Military Command, PLA, Lanzhou, China
| | - Rong Wang
- Key Laboratory of the Plateau Environmental Damage Control, Lanzhou General Hospital of Lanzhou Military Command, PLA, Lanzhou, China.,College of Pharmacy, Lanzhou University, Lanzhou, China
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Abstract
PURPOSE OF REVIEW Despite the benefits of surgical coronary revascularization, patients continue to be at risk for ischemic events in the years that follow coronary artery bypass graft surgery (CABG), mandating the role for postoperative secondary preventive therapy. The purpose of this review was to present a summary on the subject of secondary prevention after CABG, including an overview of a recently published scientific statement, and highlight the newest studies in the field. RECENT FINDINGS Aspirin and statin therapy continue to be the mainstay of secondary prevention after CABG, although newer antiplatelet and lipid-lowering medicines are being actively studied for their potential benefits. Other important elements to secondary prevention after CABG include the aggressive management of hypertension, smoking cessation, and the initiation of cardiac rehabilitation. SUMMARY Secondary prevention is an essential component of postoperative care after CABG. Instituting preventive therapies after surgery optimizes graft patency and helps patients achieve the highest level of physical health and quality of life following CABG.
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Inanobe A, Itamochi H, Kurachi Y. Kir Channel Blockages by Proflavine Derivatives via Multiple Modes of Interaction. Mol Pharmacol 2018; 93:592-600. [PMID: 29650538 DOI: 10.1124/mol.117.111377] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/06/2018] [Indexed: 11/22/2022] Open
Abstract
Many compounds inhibit tetrameric and pseudo-tetrameric cation channels by associating with the central cavity located in the middle of the membrane plane. They traverse the ion conduction pathway from the intracellular side and through access to the cavity. Previously, we reported that the bacteriostatic agent, proflavine, preferentially blocked a subset of inward rectifier K+ (Kir) channels. However, the development of the inhibition of Kir1.1 by the compound was obviously different from that operating in Kir3.2 as a pore blocker. To gain mechanistic insights into the compound-channel interaction, we analyzed its chemical specificity, subunit selectivity, and voltage dependency using 13 different combinations of Kir-channel family members and 11 proflavine derivatives. The Kir-channel family members were classified into three groups: 1) Kir2.2, Kir3.x, Kir4.2, and Kir6.2Δ36, which exhibited Kir3.2-type inhibition (slow onset and recovery, irreversible, and voltage-dependent blockage); 2) Kir1.1 and Kir4.1/Kir5.1 (prompt onset and recovery, reversible, and voltage-independent blockage); and 3) Kir2.1, Kir2.3, Kir4.1, and Kir7.1 (no response). The degree of current inhibition depended on the combination of compounds and channels. Chimera between proflavine-sensitive Kir1.1 and -insensitive Kir4.1 revealed that the extracellular portion of Kir1.1 is crucial for the recognition of the proflavine derivative acrinol. In conclusion, preferential blockage of Kir-channel family members by proflavine derivatives is based on multiple modes of action. This raises the possibility of designing subunit-specific inhibitors.
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Affiliation(s)
- Atsushi Inanobe
- Department of Pharmacology, Graduate School of Medicine (A.I., H.I., Y.K.), and Center for Advanced Medical Engineering and Informatics (A.I., Y.K.), Osaka University, Suita, Osaka, Japan
| | - Hideaki Itamochi
- Department of Pharmacology, Graduate School of Medicine (A.I., H.I., Y.K.), and Center for Advanced Medical Engineering and Informatics (A.I., Y.K.), Osaka University, Suita, Osaka, Japan
| | - Yoshihisa Kurachi
- Department of Pharmacology, Graduate School of Medicine (A.I., H.I., Y.K.), and Center for Advanced Medical Engineering and Informatics (A.I., Y.K.), Osaka University, Suita, Osaka, Japan
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25
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Wu W, Zhang K, Jiang S, Liu D, Zhou H, Zhong R, Zeng Q, Cheng L, Miao X, Tong Y, Lu Q. Association of co-exposure to heavy metals with renal function in a hypertensive population. ENVIRONMENT INTERNATIONAL 2018; 112:198-206. [PMID: 29275245 DOI: 10.1016/j.envint.2017.12.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 12/15/2017] [Accepted: 12/15/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is an increasing health problem worldwide. Recent studies have suggested the potential associations between exposure to metals and CKD events, particularly in participants with hypertension. However, relevant studies are limited. OBJECTIVES We aimed to explore the associations of metal exposure with renal function in participants with essential hypertension. METHODS Nine hundred and thirty-four participants with essential hypertension were recruited at the Department of Cardiology, Union Hospital, Wuhan, China. We measured the levels of chromium, cadmium, thallium and uranium in urine and calculated the estimated glomerular filtration rate (eGFR) for renal function. Multivariable linear regression models adjusted for potential confounders were applied. RESULTS After adjusting for potential confounders and other metals, doubling of urinary chromium or uranium levels decreased eGFR by 2.90 (95% confidence interval, 2.04 to 3.76) and 1.87 (0.58 to 3.15) mL/min per 1.73m2, respectively. Co-exposure to chromium and uranium was found to greatly decrease eGFR, particularly in women. Compared with those in the low exposure group, women with high exposure to chromium and uranium had a 11.36 (3.66 to 19.07) mL/min per 1.73m2 adjusted decline in eGFR. Higher urinary thallium levels were positively related to elevated eGFR in men. The adjusted increase in eGFR with doubling of thallium levels was 3.12 (1.14 to 5.10) mL/min per 1.73m2. Sex-difference in the associations of exposure to heavy metals with eGFR was also suggested. CONCLUSIONS Our findings suggest that environmental exposure to chromium and uranium might contribute to a decline in eGFR in individuals with hypertension. The associations of exposure to heavy metals with eGFR might be sex-different. Further studies are warranted to confirm our findings and clarify the underlying mechanisms.
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Affiliation(s)
- Weixiang Wu
- State Key Laboratory of Environment Health (Incubation), Key Laboratory of Environment and Health, Ministry of Education, Key Laboratory of Environment and Health (Wuhan), Ministry of Environmental Protection, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, #13 Hangkong Road, Wuhan, Hubei 430030, China
| | - Ke Zhang
- State Key Laboratory of Environment Health (Incubation), Key Laboratory of Environment and Health, Ministry of Education, Key Laboratory of Environment and Health (Wuhan), Ministry of Environmental Protection, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, #13 Hangkong Road, Wuhan, Hubei 430030, China; Department of Clinical Laboratory, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, #1277 Jiefang Road, Wuhan, Hubei 430022, China
| | - Shunli Jiang
- State Key Laboratory of Environment Health (Incubation), Key Laboratory of Environment and Health, Ministry of Education, Key Laboratory of Environment and Health (Wuhan), Ministry of Environmental Protection, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, #13 Hangkong Road, Wuhan, Hubei 430030, China
| | - Dayang Liu
- State Key Laboratory of Environment Health (Incubation), Key Laboratory of Environment and Health, Ministry of Education, Key Laboratory of Environment and Health (Wuhan), Ministry of Environmental Protection, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, #13 Hangkong Road, Wuhan, Hubei 430030, China
| | - Hao Zhou
- State Key Laboratory of Environment Health (Incubation), Key Laboratory of Environment and Health, Ministry of Education, Key Laboratory of Environment and Health (Wuhan), Ministry of Environmental Protection, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, #13 Hangkong Road, Wuhan, Hubei 430030, China
| | - Rong Zhong
- State Key Laboratory of Environment Health (Incubation), Key Laboratory of Environment and Health, Ministry of Education, Key Laboratory of Environment and Health (Wuhan), Ministry of Environmental Protection, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, #13 Hangkong Road, Wuhan, Hubei 430030, China
| | - Qiang Zeng
- State Key Laboratory of Environment Health (Incubation), Key Laboratory of Environment and Health, Ministry of Education, Key Laboratory of Environment and Health (Wuhan), Ministry of Environmental Protection, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, #13 Hangkong Road, Wuhan, Hubei 430030, China
| | - Liming Cheng
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoping Miao
- State Key Laboratory of Environment Health (Incubation), Key Laboratory of Environment and Health, Ministry of Education, Key Laboratory of Environment and Health (Wuhan), Ministry of Environmental Protection, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, #13 Hangkong Road, Wuhan, Hubei 430030, China
| | - Yeqing Tong
- Hubei Provincial Center for Disease Control and Prevention, Wuhan 430079, China
| | - Qing Lu
- State Key Laboratory of Environment Health (Incubation), Key Laboratory of Environment and Health, Ministry of Education, Key Laboratory of Environment and Health (Wuhan), Ministry of Environmental Protection, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, #13 Hangkong Road, Wuhan, Hubei 430030, China.
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Abstract
PURPOSE OF REVIEW In patients with prediabetes or type 2 diabetes, the use of thiazides as antihypertensive agents has been challenged because associated metabolic adverse events, including new-onset diabetes. RECENT FINDINGS These metabolic disturbances are less marked with low-dose thiazides and, in most but not all studies, with thiazide-like diuretics (chlorthalidone, indapamide) than with thiazide-type diuretics (hydrochlorothiazide). In post hoc analyses of subgroups of patients with hypertension and type 2 diabetes, thiazides resulted in a significant reduction in cardiovascular events, all-cause mortality, and hospitalization for heart failure compared to placebo and generally were shown to be non-inferior to other antihypertensive agents. Benefits attributed to thiazide diuretics in terms of cardiovascular event reduction outweigh the risk of worsening glucose control in type 2 diabetes and of new-onset diabetes in non-diabetic patients. Thiazides still play a key role in the management of patients with type 2 diabetes and hypertension.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, University of Liège, CHU Sart Tilman (B35), B-4000, Liege, Belgium.
- Clinical Pharmacology Unit, CHU Liège, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
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Clemmer JS, Hester RL, Pruett WA. Simulating a virtual population's sensitivity to salt and uninephrectomy. Interface Focus 2017; 8:20160134. [PMID: 29285341 DOI: 10.1098/rsfs.2016.0134] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Salt sensitivity, with or without concomitant hypertension, is associated with increased mortality. Reduced functional renal mass plays an important role in causing salt-sensitive hypertension for many individuals. Factors that are important in the condition of decreased renal mass and how they affect blood pressure (BP) or salt sensitivity are unclear. We used HumMod, an integrative mathematical model of human physiology, to create a heterogeneous population of 1000 virtual patients by randomly varying physiological parameters. We examined potential physiological mechanisms responsible for the change in BP in response to high-salt diet (8× change in salt intake for three weeks) with full kidney mass and again after the removal of one kidney in the same group of virtual patients. We used topological data analysis (TDA), a clustering algorithm tool, to analyse the large dataset and separate patient subpopulations. TDA distinguished five unique clusters of salt-sensitive individuals (more than 15 mmHg change in BP with increased salt). While these clusters had similar BP responses to salt, different collections of variables were responsible for their salt sensitivity, e.g. greater reductions in glomerular filtration rate (GFR) or impairments in the renin-angiotensin system. After simulating uninephrectomy in these virtual patients, the three most salt-sensitive clusters were associated with a blunted increase in renal blood flow (RBF) and higher increase in loop and distal sodium reabsorption when compared with the salt-resistant population. These data suggest that the suppression of sodium reabsorption and renin-angiotensin system is key for salt resistance, and RBF in addition to GFR may be an important factor when considering criteria for kidney donors. Here, we show that in our model of human physiology, different derangements result in the same phenotype. While these concepts are known in the experimental community, they were derived here by considering only the data obtained from our virtual experiments. These methodologies could potentially be used to discover patterns in patient sensitivity to dietary change or interventions and could be a revolutionary tool in personalizing medicine.
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Affiliation(s)
- John S Clemmer
- Department of Physiology and Biophysics, Center for Computational Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Robert L Hester
- Department of Physiology and Biophysics, Center for Computational Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - W Andrew Pruett
- Department of Physiology and Biophysics, Center for Computational Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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McIntyre C, McQuillan R, Bell C, Battistella M. Targeted Deprescribing in an Outpatient Hemodialysis Unit: A Quality Improvement Study to Decrease Polypharmacy. Am J Kidney Dis 2017; 70:611-618. [DOI: 10.1053/j.ajkd.2017.02.374] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 02/24/2017] [Indexed: 11/11/2022]
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29
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Ellison DH. Treatment of Disorders of Sodium Balance in Chronic Kidney Disease. Adv Chronic Kidney Dis 2017; 24:332-341. [PMID: 29031361 DOI: 10.1053/j.ackd.2017.07.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/25/2017] [Indexed: 12/23/2022]
Abstract
Extracellular fluid volume expansion is nearly universal in patients with CKD. Such volume expansion has features similar to the syndrome of heart failure with preserved ejection fraction, which not only leads to symptoms but can also lead to further organ damage. Unique treatment challenges are present in this patient population, including low glomerular filtration, which limits sodium chloride filtration, intrinsic tubule predisposition to sodium chloride retention, and proteinuria. In addition, pharmacokinetic considerations alter the disposition of diuretics in patients with CKD and nephrotic syndrome. Maintaining extracellular fluid volume near to normal is often necessary for hypertension treatment in this population, but it may also help prevent progressive cardiovascular and kidney damage. Although powerful diuretics can often accomplish this goal, this often comes at a cost of competing adverse effects. An approach to reduce extracellular fluid volume while avoiding adverse effects, therefore, requires a nuanced yet aggressive therapeutic approach.
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30
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de Boer IH, Bangalore S, Benetos A, Davis AM, Michos ED, Muntner P, Rossing P, Zoungas S, Bakris G. Diabetes and Hypertension: A Position Statement by the American Diabetes Association. Diabetes Care 2017; 40:1273-1284. [PMID: 28830958 DOI: 10.2337/dci17-0026] [Citation(s) in RCA: 370] [Impact Index Per Article: 52.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
| | | | | | | | - Erin D Michos
- The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Paul Muntner
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Sophia Zoungas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Fujimura Y, Yamauchi Y, Murase T, Nakamura T, Fujita SI, Fujisaka T, Ito T, Sohmiya K, Hoshiga M, Ishizaka N. Relationship between plasma xanthine oxidoreductase activity and left ventricular ejection fraction and hypertrophy among cardiac patients. PLoS One 2017; 12:e0182699. [PMID: 28797123 PMCID: PMC5552329 DOI: 10.1371/journal.pone.0182699] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 07/21/2017] [Indexed: 12/15/2022] Open
Abstract
Background and purpose Xanthine oxidoreductase (XOR), which catalyzes purine catabolism, has two interconvertible forms, xanthine dehydrogenase and xanthine oxidase, the latter of which produces superoxide during uric acid (UA) synthesis. An association between plasma XOR activity and cardiovascular and renal outcomes has been previously suggested. We investigated the potential association between cardiac parameters and plasma XOR activity among cardiology patients. Methods and results Plasma XOR activity was measured by [13C2,15N2]xanthine coupled with liquid chromatography/triplequadrupole mass spectrometry. Among 270 patients who were not taking UA-lowering drugs, XOR activity was associated with body mass index (BMI), alanine aminotransferase (ALT), HbA1c and renal function. Although XOR activity was not associated with serum UA overall, patients with chronic kidney disease (CKD), those with higher XOR activity had higher serum UA among patients without CKD. Compared with patients with the lowest XOR activity quartile, those with higher three XOR activity quartiles more frequently had left ventricular hypertrophy. In addition, plasma XOR activity showed a U-shaped association with low left ventricular ejection fraction (LVEF) and increased plasma B-type natriuretic peptide (BNP) levels, and these associations were independent of age, gender, BMI, ALT, HbA1C, serum UA, and CKD stages. Conclusions Among cardiac patients, left ventricular hypertrophy, low LVEF, and increased BNP were significantly associated with plasma XOR activity independent of various confounding factors. Whether pharmaceutical modification of plasma XOR activity might inhibit cardiac remodeling and improve cardiovascular outcome should be investigated in future studies.
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Affiliation(s)
- Yuki Fujimura
- Department of Cardiology, Osaka Medical College, Osaka, Japan
| | - Yohei Yamauchi
- Department of Cardiology, Osaka Medical College, Osaka, Japan
| | - Takayo Murase
- Mie Research Laboratories, Sanwa Kagaku Kenkyusho Co., Mie, Japan
| | - Takashi Nakamura
- Mie Research Laboratories, Sanwa Kagaku Kenkyusho Co., Mie, Japan
| | - Shu-ichi Fujita
- Department of Cardiology, Osaka Medical College, Osaka, Japan
| | | | - Takahide Ito
- Department of Cardiology, Osaka Medical College, Osaka, Japan
| | - Koichi Sohmiya
- Department of Cardiology, Osaka Medical College, Osaka, Japan
| | - Masaaki Hoshiga
- Department of Cardiology, Osaka Medical College, Osaka, Japan
| | - Nobukazu Ishizaka
- Department of Cardiology, Osaka Medical College, Osaka, Japan
- * E-mail:
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32
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Abstract
Hyperkalemia is a potentially life-threatening electrolyte disorder appreciated with greater frequency in patients with renal disease, heart failure, and with use of certain medications such as renin angiotensin aldosterone inhibitors. The traditional views that hyperkalemia can be reliably diagnosed by electrocardiogram and that particular levels of hyperkalemia confer cardiotoxic risk have been challenged by several reports of patients with atypic presentations. Epidemiologic data demonstrate strong associations of morbidity and mortality in patients with hyperkalemia but these associations appear disconnected in certain patient populations and in differing clinical presentations. Physiologic adaptation, structural cardiac disease, medication use, and degree of concurrent illness might predispose certain patients presenting with hyperkalemia to a lower or higher threshold for toxicity. These factors are often overlooked; yet data suggest that the clinical context in which hyperkalemia develops is at least as important as the degree of hyperkalemia is in determining patient outcome. This review summarizes the clinical data linking hyperkalemia with poor outcomes and discusses how the efficacy of certain treatments might depend on the clinical presentation.
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Affiliation(s)
- John R Montford
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; .,Renal Section, Medicine Service, Veterans Affairs Eastern Colorado Health System, Denver, Colorado; and
| | - Stuart Linas
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Division of Nephrology, Department of Medicine, Denver Health and Hospitals, Denver, Colorado
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Severin MJ, Hazelhoff MH, Bulacio RP, Mamprin ME, Brandoni A, Torres AM. Impact of the induced organic anion transporter 1 (Oat1) renal expression by furosemide on the pharmacokinetics of organic anions. Nephrology (Carlton) 2017; 22:642-648. [DOI: 10.1111/nep.12838] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/22/2016] [Accepted: 05/27/2016] [Indexed: 11/28/2022]
Affiliation(s)
- María Julia Severin
- Pharmacology, Faculty of Biochemical and Pharmaceutical Sciences; Rosario National University, CONICET; Rosario Argentina
| | - María Herminia Hazelhoff
- Pharmacology, Faculty of Biochemical and Pharmaceutical Sciences; Rosario National University, CONICET; Rosario Argentina
| | - Romina Paula Bulacio
- Pharmacology, Faculty of Biochemical and Pharmaceutical Sciences; Rosario National University, CONICET; Rosario Argentina
| | - María Eugenia Mamprin
- Pharmacology, Faculty of Biochemical and Pharmaceutical Sciences; Rosario National University, CONICET; Rosario Argentina
| | - Anabel Brandoni
- Pharmacology, Faculty of Biochemical and Pharmaceutical Sciences; Rosario National University, CONICET; Rosario Argentina
| | - Adriana Mónica Torres
- Pharmacology, Faculty of Biochemical and Pharmaceutical Sciences; Rosario National University, CONICET; Rosario Argentina
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Bartoli E, Rossi L, Sola D, Castello L, Sainaghi PP, Smirne C. Use, misuse and abuse of diuretics. Eur J Intern Med 2017; 39:9-17. [PMID: 28233622 DOI: 10.1016/j.ejim.2017.01.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 12/24/2016] [Accepted: 01/17/2017] [Indexed: 12/18/2022]
Abstract
Resolution of edema requires a correct interpretation of body fluids-related renal function, to excrete the excess volume while restoring systemic hemodynamics and avoiding renal failure. In heart failure, the intensive diuresis should be matched by continuous fluids refeeding from interstitium to plasma, avoiding central volume depletion. The slowly reabsorbed ascites cannot refeed this contracted volume in cirrhosis: the ensuing activation of intrathoracic receptors, attended by increased adrenergic and Renin release, causes more avid sodium retention, producing a positive fluid and Na balance in the face of continuous treatment. High-dose-furosemide creates a defect in tubular Na causing diuresis adequate to excrete the daily water and electrolyte load in Chronic Renal Failure. Diuretic treatment requires care, caution and bedside "tricks" aimed at minimizing volume contraction by correctly assessing the homeostatic system of body fluids and related renal hemodynamics.
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Affiliation(s)
- Ettore Bartoli
- Università del Piemonte Orientale, Medicina Interna, Novara, Italy.
| | - Luca Rossi
- Università del Piemonte Orientale, Medicina Interna, Novara, Italy
| | - Daniele Sola
- Università del Piemonte Orientale, Medicina Interna, Novara, Italy
| | - Luigi Castello
- Università del Piemonte Orientale, Medicina Interna, Novara, Italy
| | | | - Carlo Smirne
- Università del Piemonte Orientale, Medicina Interna, Novara, Italy
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Khan YH, Sarriff A, Adnan AS, Khan AH, Mallhi TH. Outcomes of diuretic use in pre-dialysis CKD patients with moderate renal deterioration attending tertiary care referral center. Clin Exp Nephrol 2017; 21:1011-1023. [PMID: 28271257 DOI: 10.1007/s10157-017-1397-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 02/19/2017] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Diuretic therapy has been the mainstay of treatment in chronic kidney disease (CKD) patients, primarily for hypertension and fluid overload. Apart from their beneficial effects, diuretic use is associated with adverse renal outcomes. The current study is aimed to determine the outcomes of diuretic therapy. METHODOLOGY A prospective observational study was conducted by inviting pre-dialysis CKD patients. Fluid overload was assessed by Bioimpedance analysis (BIA). RESULTS A total 312 patients (mean age 64.5 ± 6.43) were enrolled. Among 144 (46.1%) diuretic users, furosemide and hydrochlorothiazide (HCTZ) were prescribed in 69 (48%) and 39 (27%) patients, respectively, while 36 (25%) were prescribed with combination therapy (furosemide plus HCTZ). Changes in BP, fluid compartments, eGFR decline and progression to RRT were assessed over a follow-up period of 1 year. Maximum BP control was observed with combination therapy (-19.3 mmHg, p < 0.001) followed by furosemide [-10.6 mmHg with 80 mg thrice daily (p < 0.001)], -9.3 mmHg with 40-60 mg (p < 0.001) and -5.9 mmHg with 20-40 mg (p = 0.02) while HCTZ offered minimal SBP control [-3.7 mmHg with 12.5-25 mg (p = 0.04)]. Decline in extracellular water (ECW) ranged from -1.5 L(p = 0.01) with thiazide diuretics to -3.8 L(p < 0.001) with combination diuretics. Decline in eGFR was maximum (-3.4 ml/min/1.73 m2, p = 0.01) with combination diuretics and least with thiazide diuretics (-1.6 ml/min/1.73 m2, p = 0.04). Progression to RRT was observed in 36 patients. CONCLUSION It is cautiously suggested to discourage the use of diuretic combination therapy and high doses of single diuretic therapy. Prescribing of diuretics should be done by keeping in view benefit versus harm for each patient.
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Affiliation(s)
- Yusra Habib Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, University Sains Malaysia, 11800,, Gelugor, Penang, Malaysia. .,Chronic Kidney Disease Resource Centre, School of Medical Sciences, Health Campus, University Sains Malaysia, 16150, Kubang Kerain, Kelantan, Malaysia.
| | - Azmi Sarriff
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, University Sains Malaysia, 11800,, Gelugor, Penang, Malaysia
| | - Azreen Syazril Adnan
- Chronic Kidney Disease Resource Centre, School of Medical Sciences, Health Campus, University Sains Malaysia, 16150, Kubang Kerain, Kelantan, Malaysia
| | - Amer Hayat Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, University Sains Malaysia, 11800,, Gelugor, Penang, Malaysia
| | - Tauqeer Hussain Mallhi
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, University Sains Malaysia, 11800,, Gelugor, Penang, Malaysia.,Chronic Kidney Disease Resource Centre, School of Medical Sciences, Health Campus, University Sains Malaysia, 16150, Kubang Kerain, Kelantan, Malaysia
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Araujo M, Welch WJ, Zhou X, Sullivan K, Walsh S, Pasternak A, Wilcox CS. Inhibition of ROMK blocks macula densa tubuloglomerular feedback yet causes renal vasoconstriction in anesthetized rats. Am J Physiol Renal Physiol 2017; 312:F1120-F1127. [PMID: 28228405 DOI: 10.1152/ajprenal.00662.2016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/15/2017] [Accepted: 02/16/2017] [Indexed: 11/22/2022] Open
Abstract
The Na+-K+-2Cl- cotransporter (NKCC2) on the loop of Henle is the site of action of furosemide. Because outer medullary potassium channel (ROMK) inhibitors prevent reabsorption by NKCC2, we tested the hypothesis that ROMK inhibition with a novel selective ROMK inhibitor (compound C) blocks tubuloglomerular feedback (TGF) and reduces vascular resistance. Loop perfusion of either ROMK inhibitor or furosemide caused dose-dependent blunting of TGF, but the response to furosemide was 10-fold more sensitive (IC50 = 10-6 M for furosemide and IC50 = 10-5 M for compound C). During systemic infusion, both diuretics inhibited TGF, but ROMK inhibitor was 10-fold more sensitive (compound C: 63% inhibition; furosemide: 32% inhibition). Despite blockade of TGF, 1 h of constant systemic infusion of both diuretics reduced the glomerular filtration rate (GFR) and renal blood flow (RBF) by 40-60% and increased renal vascular resistance (RVR) by 100-200%. Neither diuretic altered blood pressure or hematocrit. Proximal tubule hydrostatic pressures (PPT) increased transiently with both diuretics (compound C: 56% increase; furosemide: 70% increase) but returned to baseline. ROMK inhibitor caused more natriuresis (3,400 vs. 1,600% increase) and calciuresis (1,200 vs. 800% increase) but less kaliuresis (33 vs. 167% increase) than furosemide. In conclusion, blockade of ROMK or Na+-K+-2Cl- transport inhibits TGF yet increases renal vascular resistance. The renal vasoconstriction was independent of volume depletion, blood pressure, TGF, or PPT.
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Affiliation(s)
- Magali Araujo
- Hypertension Research Center and Division of Nephrology and Hypertension, Georgetown University, Washington, District of Columbia; and
| | - William J Welch
- Hypertension Research Center and Division of Nephrology and Hypertension, Georgetown University, Washington, District of Columbia; and
| | - Xiaoyan Zhou
- Department of Cardiometabolic Diseases, Merck & Company, Incorporated, Kenilworth, New Jersey
| | - Kathleen Sullivan
- Department of Cardiometabolic Diseases, Merck & Company, Incorporated, Kenilworth, New Jersey
| | - Shawn Walsh
- Department of Cardiometabolic Diseases, Merck & Company, Incorporated, Kenilworth, New Jersey
| | - Alexander Pasternak
- Department of Cardiometabolic Diseases, Merck & Company, Incorporated, Kenilworth, New Jersey
| | - Christopher S Wilcox
- Hypertension Research Center and Division of Nephrology and Hypertension, Georgetown University, Washington, District of Columbia; and
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Abstract
We present the case of a patient with heart failure and severe congestion who was responding poorly to diuretic therapy. We discuss the key problems concerning the pathophysiology and bedside therapeutic approach to congestion and fluid overload in this clinical setting, and we give practical suggestions to overcome congestion, especially in the setting of diuretic resistance and worsening renal function. We conclude that the application of key pharmacokinetic and pharmacodynamic principles of diuretic therapy, along with in-depth knowledge of the pathophysiology of heart failure, still represent the cornerstones for a correct approach to decongestive therapy in these patients.
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Khan S, Floris M, Pani A, Rosner MH. Sodium and Volume Disorders in Advanced Chronic Kidney Disease. Adv Chronic Kidney Dis 2016; 23:240-6. [PMID: 27324677 DOI: 10.1053/j.ackd.2015.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 05/01/2015] [Accepted: 12/29/2015] [Indexed: 11/11/2022]
Abstract
The kidney has a remarkable ability to modulate sodium and water excretion to maintain homeostasis despite a widely varying dietary intake. However, as glomerular filtration rate falls to less than 30 mL/min, this ability can be compromised leading to an increased risk for disorders of serum sodium and extracellular volume. In all cases, these disorders are associated with an increased rate of morbidity and mortality. Management strategies to both prevent and treat these conditions are available but requiring special attention to the unique circumstance of advanced CKD to maximize therapeutic response and prevent complications.
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Abstract
While oral diuretics are commonly used in patients with chronic kidney disease for the management of volume and blood pressure, they are often discontinued upon initiation of dialysis. We suggest that diuretics are considerably underutilized in peritoneal dialysis and haemodialysis patients despite numerous potential benefits and few side effects. Moreover, when diuretics are used, optimal doses are not always prescribed. In peritoneal dialysis, the use of diuretics can improve volume status and minimize the need for higher glucose-containing solutions. In patients on haemodialysis, diuretics can help lessen interdialytic weight gain, resulting in decreased ultrafiltration rates and fewer episodes of intradialytic hypotension. This paper will review the mechanism of action of diuretics in patients with renal insufficiency, quantify the risk of side effects and elaborate on the potential advantages of diuretic use in peritoneal dialysis and hemodialysis patients with residual kidney function.
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Affiliation(s)
- Emilie Trinh
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Joanne M Bargman
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada.
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Li Q, Zhang Y, Ding D, Yang Y, Chen Q, Liu C, Li X, Hong C, Ling W. Association between Serum Uric Acid and Mortality among Chinese Patients with Coronary Artery Disease. Cardiology 2016; 134:347-56. [PMID: 26985667 DOI: 10.1159/000443518] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 12/17/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Several studies have investigated the association between serum uric acid (SUA) and the risks of coronary artery disease (CAD) but have yielded inconsistent results. The aim of this study was to assess whether there is an independent association of SUA with all-cause and cardiovascular disease (CVD) mortality in Chinese patients with CAD. METHODS A prospective cohort study of 1,799 patients was conducted. Cox regression models were used to estimate the association of SUA with the risk of death. RESULTS During a median follow-up of 3.9 years, 177 deaths were recorded and 126 of these were due to CVD. Patients in the highest SUA quartile had a 2.43-fold risk of all-cause mortality and a 2.44-fold risk of CVD mortality compared with those in the lowest quartile. In the subpopulation analysis, the association between SUA and mortality remained similar when participants were stratified by age, gender, body mass index and type of CAD. In contrast, we found a significant interaction with estimated glomerular filtration rate (eGFR). There was a stronger association between SUA and the risk of all-cause and CVD mortality among patients with an eGFR ≥60 ml/min/1.73 m2, but no significant association was found in the population with an eGFR <60 ml/min/1.73 m2. CONCLUSIONS Elevated SUA levels were positively associated with an increased risk of all-cause and CVD mortality among CAD patients.
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Affiliation(s)
- Qing Li
- Department of Nutrition, School of Public Health, Sun Yat-sen University, Guangzhou, China
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Briguori C, Visconti G, Donahue M, De Micco F, Focaccio A, Golia B, Signoriello G, Ciardiello C, Donnarumma E, Condorelli G. RenalGuard system in high-risk patients for contrast-induced acute kidney injury. Am Heart J 2016; 173:67-76. [PMID: 26920598 DOI: 10.1016/j.ahj.2015.12.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 12/04/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND High urine flow rate (UFR) has been suggested as a target for effective prevention of contrast-induced acute kidney injury (CI-AKI). The RenalGuard therapy (saline infusion plus furosemide controlled by the RenalGuard system) facilitates the achievement of this target. METHODS Four hundred consecutive patients with an estimated glomerular filtration rate ≤30 mL/min per 1.73 m(2) and/or a high predicted risk (according to the Mehran score ≥11 and/or the Gurm score >7%) treated by the RenalGuard therapy were analyzed. The primary end points were (1) the relationship between CI-AKI and UFR during preprocedural, intraprocedural, and postprocedural phases of the RenalGuard therapy and (2) the rate of acute pulmonary edema and impairment in electrolytes balance. RESULTS Urine flow rate was significantly lower in the patients with CI-AKI in the preprocedural phase (208 ± 117 vs 283 ± 160 mL/h, P < .001) and in the intraprocedural phase (389 ± 198 vs 483 ± 225 mL/h, P = .009). The best threshold for CI-AKI prevention was a mean intraprocedural phase UFR ≥450 mL/h (area under curve 0.62, P = .009, sensitivity 80%, specificity 46%). Performance of percutaneous coronary intervention (hazard ratio [HR] 4.13, 95% CI 1.81-9.10, P < .001), the intraprocedural phase UFR <450 mL/h (HR 2.27, 95% CI 1.05-2.01, P = .012), and total furosemide dose >0.32 mg/kg (HR 5.03, 95% CI 2.33-10.87, P < .001) were independent predictors of CI-AKI. Pulmonary edema occurred in 4 patients (1%). Potassium replacement was required in 16 patients (4%). No patients developed severe hypomagnesemia, hyponatremia, or hypernatremia. CONCLUSIONS RenalGuard therapy is safe and effective in reaching high UFR. Mean intraprocedural UFR ≥450 mL/h should be the target for optimal CI-AKI prevention.
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Affiliation(s)
- Carlo Briguori
- Laboratory of Interventional Cardiology and Department of Cardiology, Clinica Mediterranea, Naples, Italy.
| | - Gabriella Visconti
- Laboratory of Interventional Cardiology and Department of Cardiology, Clinica Mediterranea, Naples, Italy
| | - Michael Donahue
- Laboratory of Interventional Cardiology and Department of Cardiology, Clinica Mediterranea, Naples, Italy
| | - Francesca De Micco
- Laboratory of Interventional Cardiology and Department of Cardiology, Clinica Mediterranea, Naples, Italy
| | - Amelia Focaccio
- Laboratory of Interventional Cardiology and Department of Cardiology, Clinica Mediterranea, Naples, Italy
| | - Bruno Golia
- Laboratory of Interventional Cardiology and Department of Cardiology, Clinica Mediterranea, Naples, Italy
| | - Giuseppe Signoriello
- Department of Mental Health and Preventive Medicine, Second University of Naples, Naples, Italy
| | | | | | - Gerolama Condorelli
- Department of Cellular and Molecular Biology and Pathology, "Federico II" University of Naples, Naples, Italy
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Oh SW, Han SY. Loop Diuretics in Clinical Practice. Electrolyte Blood Press 2015; 13:17-21. [PMID: 26240596 PMCID: PMC4520883 DOI: 10.5049/ebp.2015.13.1.17] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 06/30/2015] [Indexed: 11/05/2022] Open
Abstract
Diuretics are commonly used to control edema across various clinical fields. Diuretics inhibit sodium reabsorption in specific renal tubules, resulting in increased urinary sodium and water excretion. Loop diuretics are the most potent diuretics. In this article, we review five important aspects of loop diuretics, in particular furosemide, which must be considered when prescribing this medicine: (1) oral versus intravenous treatment, (2) dosage, (3) continuous versus bolus infusion, (4) application in chronic kidney disease patients, and (5) side effects. The bioavailability of furosemide differs between oral and intravenous therapy. Additionally, the threshold and ceiling doses of furosemide differ according to the particular clinical condition of the patient, for example in patients with severe edema or chronic kidney disease. To maximize the efficiency of furosemide, a clear understanding of how the mode of delivery will impact bioavailability and the required dosage is necessary.
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Affiliation(s)
- Se Won Oh
- Department of Internal Medicine, Inje University College of Medicine, Goyang, Korea
| | - Sang Youb Han
- Department of Internal Medicine, Inje University College of Medicine, Goyang, Korea
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Kulik A, Ruel M, Jneid H, Ferguson TB, Hiratzka LF, Ikonomidis JS, Lopez-Jimenez F, McNallan SM, Patel M, Roger VL, Sellke FW, Sica DA, Zimmerman L. Secondary Prevention After Coronary Artery Bypass Graft Surgery. Circulation 2015; 131:927-64. [DOI: 10.1161/cir.0000000000000182] [Citation(s) in RCA: 260] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Lachance K, White M, Carrier M, Mansour A, Racine N, Liszkowski M, Ducharme A, de Denus S. Long-term evolution, secular trends, and risk factors of renal dysfunction following cardiac transplantation. Transpl Int 2014; 27:824-37. [DOI: 10.1111/tri.12340] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/03/2014] [Accepted: 04/13/2014] [Indexed: 01/20/2023]
Affiliation(s)
- Kim Lachance
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Pharmacy; Université de Montréal; Montreal QC Canada
| | - Michel White
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Medicine; Université de Montréal; Montreal QC Canada
| | - Michel Carrier
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Medicine; Université de Montréal; Montreal QC Canada
| | - Asmaa Mansour
- Montreal Health Innovations Coordinating Center; a Division of the Montreal Heart Institute; Montreal QC Canada
| | - Normand Racine
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Medicine; Université de Montréal; Montreal QC Canada
| | - Mark Liszkowski
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Medicine; Université de Montréal; Montreal QC Canada
| | - Anique Ducharme
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Medicine; Université de Montréal; Montreal QC Canada
| | - Simon de Denus
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Pharmacy; Université de Montréal; Montreal QC Canada
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McDonald E, Freedman DM, Alexander BH, Doody MM, Tucker MA, Linet MS, Cahoon EK. Prescription diuretic use and risk of basal cell carcinoma in the nationwide U.S. radiologic technologists cohort. Cancer Epidemiol Biomarkers Prev 2014; 23:1539-45. [PMID: 24812037 DOI: 10.1158/1055-9965.epi-14-0251] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND UV radiation (UVR) exposure is the primary risk factor for basal cell carcinoma (BCC). Although prescription diuretics have photosensitizing properties, the relationship between diuretic use and BCC remains unclear. METHODS Using data from the United States Radiologic Technologists Study, a large, nationwide prospective cohort, we assessed the relationship between diuretic use and first primary BCC while accounting for sun exposure history, constitutional characteristics, lifestyle factors, and anthropometric measurements for geographically dispersed individuals exposed to a wide range of ambient UVR. RESULTS After adjustment for potential confounders, we found a significantly increased risk of BCC associated with diuretic use [HR, 1.22; 95% confidence interval (CI), 1.07-1.38]. This relationship was modified by body mass index (P = 0.019), such that BCC risk was increased with diuretic use in overweight (HR, 1.43; 95% CI, 1.16-1.76) and obese individuals (HR, 1.43; 95% CI, 1.09-1.88), but not in normal weight individuals (HR, 0.99; 95% CI, 0.81-1.21). CONCLUSIONS Increased risk of BCC associated with diuretic use in overweight and obese participants may be related to higher dosages, longer duration of medication use, reduced drug metabolism, or drug interactions. IMPACT Future cohort studies should obtain more detailed information on medication use, consider factors that affect drug metabolism, and measure intermediate endpoints such as photosensitivity reactions.
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Affiliation(s)
- Emily McDonald
- Department of Epidemiology and Biostatistics, Indiana University, School of Public Health, Bloomington, Indiana; Division of Cancer Epidemiology and Genetics, Department of Health and Human Services, National Cancer Institute, NIH, Bethesda, Maryland; and
| | - D Michal Freedman
- Division of Cancer Epidemiology and Genetics, Department of Health and Human Services, National Cancer Institute, NIH, Bethesda, Maryland; and
| | - Bruce H Alexander
- Division of Environmental Health Sciences, University of Minnesota, School of Public Health, Minneapolis, Minnesota
| | - Michele M Doody
- Division of Cancer Epidemiology and Genetics, Department of Health and Human Services, National Cancer Institute, NIH, Bethesda, Maryland; and
| | - Margaret A Tucker
- Division of Cancer Epidemiology and Genetics, Department of Health and Human Services, National Cancer Institute, NIH, Bethesda, Maryland; and
| | - Martha S Linet
- Division of Cancer Epidemiology and Genetics, Department of Health and Human Services, National Cancer Institute, NIH, Bethesda, Maryland; and
| | - Elizabeth K Cahoon
- Division of Cancer Epidemiology and Genetics, Department of Health and Human Services, National Cancer Institute, NIH, Bethesda, Maryland; and
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Heramb L, Hallan S, Aasarød K. Bruk av diuretika ved nyresykdom. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2014; 134:840-4. [DOI: 10.4045/tidsskr.13.0721] [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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Management of hyperkalaemia consequent to mineralocorticoid-receptor antagonist therapy. Nat Rev Nephrol 2012; 8:691-9. [DOI: 10.1038/nrneph.2012.217] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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49
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Approach to Cardiovascular Disease Prevention in Patients With Chronic Kidney Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2012; 14:391-413. [DOI: 10.1007/s11936-012-0189-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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