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Blazek O, Bakris GL. A review of novel endothelin antagonists and overview of non-steroidal mineralocorticoid antagonists for treating resistant hypertension: An update. Eur J Pharmacol 2024; 979:176752. [PMID: 39047966 DOI: 10.1016/j.ejphar.2024.176752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/11/2024] [Accepted: 06/16/2024] [Indexed: 07/27/2024]
Abstract
Several agents are emerging from five different novel classes of antihypertensive medications. We will focus on endothelin antagonists and non-steroidal mineralocorticoid receptor antagonists. While several agents exist in this later class, only a couple have demonstrated superior efficacy in resistant hypertension management. Endothelin receptor antagonists are effective therapy for primary and resistant hypertension, but they are not widely used. This is due to side effects demonstrated in large clinical trials, specifically increased peripheral edema and worsening heart failure in some cases, as well as the availability of many alternative agents to manage blood pressure effectively. However, the relationship between endothelin and its close ties to hypertension is evolving. Recent pre-clinical work explores new applications of more selective endothelin receptor antagonists. They suggest that specific subtypes of hypertension may benefit more from endothelin receptor blockade than simply those with primary hypertension. We review this topic and other related data. Lastly, we also provide a brief overview of non-steroidal mineralocorticoid receptor antagonists as some in the class show promise as antihypertensive agents.
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Affiliation(s)
- Olivia Blazek
- Department of Medicine, Am Heart Assoc. Comprehensive Hypertension Center, The University of Chicago Medicine, Chicago, IL, USA.
| | - George L Bakris
- Department of Medicine, Am Heart Assoc. Comprehensive Hypertension Center, The University of Chicago Medicine, Chicago, IL, USA.
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2
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Varda L, Ekart R, Lainscak M, Maver U, Bevc S. Clinical Properties and Non-Clinical Testing of Mineralocorticoid Receptor Antagonists in In Vitro Cell Models. Int J Mol Sci 2024; 25:9088. [PMID: 39201774 PMCID: PMC11354261 DOI: 10.3390/ijms25169088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 08/16/2024] [Accepted: 08/20/2024] [Indexed: 09/03/2024] Open
Abstract
Mineralocorticoid receptor antagonists (MRAs) are one of the renin-angiotensin-aldosterone system inhibitors widely used in clinical practice. While spironolactone and eplerenone have a long-standing profile in clinical medicine, finerenone is a novel agent within the MRA class. It has a higher specificity for mineralocorticoid receptors, eliciting less pronounced adverse effects. Although approved for clinical use in patients with chronic kidney disease and heart failure, intensive non-clinical research aims to further elucidate its mechanism of action, including dose-related selectivity. Within the field, animal models remain the gold standard for non-clinical testing of drug pharmacological and toxicological properties. Their role, however, has been challenged by recent advances in in vitro models, mainly through sophisticated analytical tools and developments in data analysis. Currently, in vitro models are gaining momentum as possible platforms for advanced pharmacological and pathophysiological studies. This article focuses on past, current, and possibly future in vitro cell models research with clinically relevant MRAs.
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Affiliation(s)
- Luka Varda
- Department of Dialysis, Clinic for Internal Medicine, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia; (L.V.); (R.E.)
| | - Robert Ekart
- Department of Dialysis, Clinic for Internal Medicine, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia; (L.V.); (R.E.)
- Department of Pharmacology, Faculty of Medicine, University of Maribor, Taborska ulica 5, 2000 Maribor, Slovenia;
| | - Mitja Lainscak
- Division of Cardiology, Murska Sobota General Hospital, Ulica Dr. Vrbnjaka 6, 9000 Murska Sobota, Slovenia;
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
| | - Uroš Maver
- Department of Pharmacology, Faculty of Medicine, University of Maribor, Taborska ulica 5, 2000 Maribor, Slovenia;
- Institute of Biomedical Sciences, Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia
| | - Sebastjan Bevc
- Department of Pharmacology, Faculty of Medicine, University of Maribor, Taborska ulica 5, 2000 Maribor, Slovenia;
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia
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3
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Palacios-Ramirez R, Soulié M, Fernandez-Celis A, Nakamura T, Boujardine N, Bonnard B, Bamberg K, Lopez-Andres N, Jaisser F. Mineralocorticoid receptor (MR) antagonist eplerenone and MR modulator balcinrenone prevent renal extracellular matrix remodeling and inflammation via the MR/proteoglycan/TLR4 pathway. Clin Sci (Lond) 2024; 138:1025-1038. [PMID: 39092535 DOI: 10.1042/cs20240302] [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: 02/25/2024] [Revised: 08/01/2024] [Accepted: 08/01/2024] [Indexed: 08/04/2024]
Abstract
Excessive activation of the mineralocorticoid receptor (MR) is implicated in cardiovascular and renal disease. Decreasing MR activation with MR antagonists (MRA) is effective to slow chronic kidney disease (CKD) progression and its cardiovascular comorbidities in animal models and patients. The present study evaluates the effects of the MR modulator balcinrenone and the MRA eplerenone on kidney damage in a metabolic CKD mouse model combining nephron reduction and a 60% high-fat diet. Balcinrenone and eplerenone prevented the progression of renal damages, extracellular matrix remodeling and inflammation to a similar extent. We identified a novel mechanism linking MR activation to the renal proteoglycan deposition and inflammation via the TLR4 pathway activation. Balcinrenone and eplerenone similarly blunted this pathway activation.
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Affiliation(s)
- Roberto Palacios-Ramirez
- Centre de Recherche des Cordeliers, Team Diabetes, Metabolic Diseases and Comorbidities, Sorbonne Université, Inserm, Université de Paris, Paris, France
| | - Matthieu Soulié
- Centre de Recherche des Cordeliers, Team Diabetes, Metabolic Diseases and Comorbidities, Sorbonne Université, Inserm, Université de Paris, Paris, France
| | - Amaya Fernandez-Celis
- Cardiovascular Translational Research, Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - Toshifumi Nakamura
- Centre de Recherche des Cordeliers, Team Diabetes, Metabolic Diseases and Comorbidities, Sorbonne Université, Inserm, Université de Paris, Paris, France
| | - Nabiha Boujardine
- Centre de Recherche des Cordeliers, Team Diabetes, Metabolic Diseases and Comorbidities, Sorbonne Université, Inserm, Université de Paris, Paris, France
| | - Benjamin Bonnard
- Centre de Recherche des Cordeliers, Team Diabetes, Metabolic Diseases and Comorbidities, Sorbonne Université, Inserm, Université de Paris, Paris, France
| | - Krister Bamberg
- Early Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Natalia Lopez-Andres
- Cardiovascular Translational Research, Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - Frederic Jaisser
- Centre de Recherche des Cordeliers, Team Diabetes, Metabolic Diseases and Comorbidities, Sorbonne Université, Inserm, Université de Paris, Paris, France
- Université de Lorraine, INSERM Centre d'Investigations Cliniques-Plurithématique 1433, UMR 1116, CHRU de Nancy, French-Clinical Research Infrastructure Network (F-CRIN) INI-CRCT, Nancy, France
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4
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Xian Y, Wang X, Chang Y, Qiang P, Han Y, Hao J, Gao X, Shimosawa T, Xu Q, Yang F. Esaxerenone Attenuates Aldosterone-Induced Mitochondrial Damage-Mediated Pyroptosis in Mouse Aorta and Rat Vascular Smooth Muscle Cells. Life (Basel) 2024; 14:967. [PMID: 39202709 PMCID: PMC11355590 DOI: 10.3390/life14080967] [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: 06/30/2024] [Revised: 07/24/2024] [Accepted: 07/28/2024] [Indexed: 09/03/2024] Open
Abstract
BACKGROUND Vascular smooth muscle cell (VSMC) injury caused by the inflammatory response plays a key role in cardiovascular disease (CVD), and the vasoprotective effects of mineralocorticoid receptor blockers (MRBs) support the role of mineralocorticoid receptor (MR) activation. METHODS C57BL/6 mice and VSMCs isolated from rats were treated with aldosterone and esaxerenone. Caspase-1, GSDMD-N, IL-1β, and NR3C2 expression and DNA damage in aortic VSMCs were detected using immunohistochemistry, Western blotting, and TUNEL staining. Mitochondrial changes were detected by transmission electron microscopy (TEM). Reactive oxygen species (ROS), MitoTracker, JC-I, mitochondrial respiratory chain complexes I-V, and NR3C2 were detected using immunofluorescence and flow cytometry. Pyroptosis was detected with scanning electron microscopy (SEM). RESULTS After aldosterone treatment, the number of TUNEL-positive cells increased significantly, and the expression of caspase-1, GSDMD-N, and IL-1β increased. TEM revealed mitochondrial damage, and SEM revealed specific pyroptotic changes, such as cell membrane pore changes and cytoplasmic extravasation. Increased ROS levels and nuclear translocation of NR3C2 were also observed. These pyroptosis-related changes were reversed by esaxerenone. CONCLUSIONS Aldosterone activates the MR and mediates mitochondrial damage, thereby inducing pyroptosis in VSMCs via the NLRP3/caspase-1 pathway. Esaxerenone inhibits MR activation and reduces mitochondrial damage and oxidative stress, thereby inhibiting pyroptosis.
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Affiliation(s)
- Yunqian Xian
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang 050200, China; (Y.X.); (X.W.); (P.Q.); (Y.H.); (X.G.)
- Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns, Hebei University of Chinese Medicine, Shijiazhuang 050200, China; (Y.C.); (J.H.)
| | - Xuan Wang
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang 050200, China; (Y.X.); (X.W.); (P.Q.); (Y.H.); (X.G.)
- Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns, Hebei University of Chinese Medicine, Shijiazhuang 050200, China; (Y.C.); (J.H.)
| | - Yi Chang
- Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns, Hebei University of Chinese Medicine, Shijiazhuang 050200, China; (Y.C.); (J.H.)
- Institute of Integrative Medicine, College of Integrative Medicine, Hebei University of Chinese Medicine, Shijiazhuang 050200, China
| | - Panpan Qiang
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang 050200, China; (Y.X.); (X.W.); (P.Q.); (Y.H.); (X.G.)
- Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns, Hebei University of Chinese Medicine, Shijiazhuang 050200, China; (Y.C.); (J.H.)
| | - Yutong Han
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang 050200, China; (Y.X.); (X.W.); (P.Q.); (Y.H.); (X.G.)
- Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns, Hebei University of Chinese Medicine, Shijiazhuang 050200, China; (Y.C.); (J.H.)
| | - Juan Hao
- Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns, Hebei University of Chinese Medicine, Shijiazhuang 050200, China; (Y.C.); (J.H.)
| | - Xiaomeng Gao
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang 050200, China; (Y.X.); (X.W.); (P.Q.); (Y.H.); (X.G.)
- Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns, Hebei University of Chinese Medicine, Shijiazhuang 050200, China; (Y.C.); (J.H.)
| | - Tatsuo Shimosawa
- Department of Clinical Laboratory, School of Medicine, International University of Health and Welfare, Narita 286-8686, Chiba, Japan;
| | - Qingyou Xu
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang 050200, China; (Y.X.); (X.W.); (P.Q.); (Y.H.); (X.G.)
- Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns, Hebei University of Chinese Medicine, Shijiazhuang 050200, China; (Y.C.); (J.H.)
- Institute of Integrative Medicine, College of Integrative Medicine, Hebei University of Chinese Medicine, Shijiazhuang 050200, China
| | - Fan Yang
- Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns, Hebei University of Chinese Medicine, Shijiazhuang 050200, China; (Y.C.); (J.H.)
- Institute of Integrative Medicine, College of Integrative Medicine, Hebei University of Chinese Medicine, Shijiazhuang 050200, China
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Raikou VD. Renoprotective strategies. World J Nephrol 2024; 13:89637. [PMID: 38596266 PMCID: PMC11000037 DOI: 10.5527/wjn.v13.i1.89637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/01/2023] [Accepted: 12/26/2023] [Indexed: 03/22/2024] Open
Abstract
Kidney disease remains a condition with an increasing incidence, high morbidity and mortality associated with cardiovascular events. The incidence of end-stage renal disease is expected to increase. Despite of the technical improvement, dialysis never achieved a full clearance of the blood dialysis. Therefore, the demand for new renoprotective measures has never been greater. Here, we report new strategies for preventing renal damage.
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Affiliation(s)
- Vaia D Raikou
- Department of Nephrology, Doctors’General Clinic, Athens 11257, Greece
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Yamamoto E, Usuku H, Sueta D, Suzuki S, Nakamura T, Matsui K, Matsushita K, Iwasaki T, Sakaino N, Sakanashi T, Hirayama K, Kurokawa H, Kikuta K, Yamamoto N, Sato K, Tokitsu T, Taguchi T, Shiosakai K, Sugimoto K, Tsujita K. Efficacy and Safety of Esaxerenone in Hypertensive Patients with Left Ventricular Hypertrophy (ESES-LVH) Study: A Multicenter, Open-Label, Prospective, Interventional Study. Adv Ther 2024; 41:1284-1303. [PMID: 38310194 PMCID: PMC10879332 DOI: 10.1007/s12325-024-02780-6] [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: 09/12/2023] [Accepted: 01/03/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION In contrast to the antihypertensive effect of esaxerenone, there is little evidence of its cardioprotective effect. We investigated the efficacy and safety of esaxerenone in patients with uncontrolled hypertension and left ventricular hypertrophy taking a renin-angiotensin system inhibitor (RASi) or calcium-channel blocker (CCB). METHODS This was a multicenter, open-label, exploratory study with a 24-week treatment period. Esaxerenone was orally administered at an initial dose of 2.5 mg/day (maximum dose: 5 mg/day). The primary endpoints were the change in morning home systolic blood pressure (BP)/diastolic BP and change and percentage change in left ventricular mass index (LVMI) from baseline to end of treatment (EOT). Key secondary endpoints included change from baseline in bedtime home and office BP, achievement rate of target BP, and safety. RESULTS In total, 60 patients were enrolled. Morning home systolic/diastolic BP was significantly decreased from baseline to EOT in the total population (- 11.5/ - 4.7 mmHg, p < 0.001) and in both the RASi and CCB subcohorts (all p < 0.01). Significant reductions in bedtime home and office BP were shown in the total population and both subcohorts. LVMI was also significantly decreased from baseline to EOT in the total population (- 9.9 g/m2, - 8.5%, both p < 0.001) and both subcohorts (all p < 0.05). The incidences of treatment-emergent adverse events (TEAEs) and drug-related TEAEs were 35.0% and 3.3%, respectively; most were mild or moderate. No new safety concerns were identified. CONCLUSION Esaxerenone showed favorable antihypertensive and cardioprotective effects and safety in hypertensive patients with cardiac hypertrophy. TRIAL REGISTRATION Japan Registry of Clinical Trials (jRCTs071190043).
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Affiliation(s)
- Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
- Center for Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Hiroki Usuku
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
- Center for Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
- Department of Laboratory Medicine, Kumamoto University, Kumamoto, Japan
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
- Center for Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Satoru Suzuki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Taishi Nakamura
- Department of Medical Information Science, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kunihiko Matsui
- Department of General Medicine and Primary Care, Kumamoto University Hospital, Kumamoto, Japan
| | - Kenichi Matsushita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
- Center for Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | | | | | | | | | - Hirofumi Kurokawa
- Division of Cardiology, Japan Community Health Care Organization, Hitoyoshi Medical Center, Hitoyoshi, Japan
| | - Koichi Kikuta
- Division of Cardiology, Shinbeppu Hospital, Beppu, Japan
| | - Nobuyasu Yamamoto
- Department of Cardiovascular Medicine, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Japan
| | - Koji Sato
- Department of Cardiology, Kumamoto City Hospital, Kumamoto, Japan
| | - Takanori Tokitsu
- Division of Cardiology, Kumamoto Kenhoku Hospital, Tamana, Japan
| | - Takashi Taguchi
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | | | - Kotaro Sugimoto
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan.
- Center for Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan.
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Hayes AG, Stowasser M, Umapathysivam MM, Falhammar H, Torpy DJ. Approach to the Patient: Reninoma. J Clin Endocrinol Metab 2024; 109:e809-e816. [PMID: 37647894 PMCID: PMC10795928 DOI: 10.1210/clinem/dgad516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/02/2023] [Accepted: 08/28/2023] [Indexed: 09/01/2023]
Abstract
A reninoma is a functional tumor of afferent arteriolar juxtaglomerular cells that secretes the enzyme renin, leading to hyperactivation of the renin-angiotensin-aldosterone system. Reninoma is a potentially curable cause of pathological secondary hyperaldosteronism that results in often severe hypertension and hypokalemia. The lack of suppression of plasma renin contrasts sharply with the much more common primary aldosteronism, but diagnosis is often prompted by screening for that condition. The major differential diagnosis of reninoma is renovascular hypertension. Fewer than 200 cases of reninoma have been described. Reninomas have been reported across a broad demographic but have a 2:1 predilection for women, often of childbearing age. Aldosterone receptor blockade, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers offer effective medical management but are contraindicated in pregnancy, so surgical curative resection is ideal. The current optimal imaging and biochemical workup of reninoma and management approach (ideally, tumor excision with subtotal renal resection) are described.
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Affiliation(s)
- Annabelle G Hayes
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia 5000, Australia
- Faculty of Medicine, University of Adelaide, Adelaide, South Autralia 5000, Australia
| | - Michael Stowasser
- Endocrine Hypertension Research Centre, University of Queensland Diamantina Institute, Brisbane, Queensland 4102, Australia
- Endocrine Hypertension Unit, Greenslopes and Princess Alexandra Hospitals, Brisbane, Queensland 4102, Australia
| | - Mahesh M Umapathysivam
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia 5000, Australia
- Faculty of Medicine, University of Adelaide, Adelaide, South Autralia 5000, Australia
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm SE-171 76, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm SE-171 76, Sweden
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia 5000, Australia
- Faculty of Medicine, University of Adelaide, Adelaide, South Autralia 5000, Australia
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Shah M, Awad AS, Abdel-Rahman EM. Nonsteroidal Mineralocorticoid Receptor Antagonist (Finerenone) in Cardiorenal Disease. J Clin Med 2023; 12:6285. [PMID: 37834929 PMCID: PMC10573495 DOI: 10.3390/jcm12196285] [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: 08/11/2023] [Revised: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
Nonsteroidal mineralocorticoid receptor antagonists (MRAs) present a promising therapeutic option in cardiorenal diseases, mitigating the limitations of steroidal MRAs. Finerenone, a third-generation nonsteroidal MRA, has demonstrated beneficial effects in heart failure (HF) and chronic kidney disease (CKD). Clinical trials, including FIDELIO-DKD and FIGARO-DKD, revealed finerenone's efficacy in improving kidney and cardiovascular (CV) outcomes. Patients with CKD and type 2 diabetes (T2DM) on finerenone experienced reduced rates of cardiovascular events, including hospitalization for HF. However, these trials excluded symptomatic HF patients, focusing on asymptomatic or early-stage HF. The ongoing FINEARTS-HF trial evaluates finerenone in HF with preserved ejection fraction (HFpEF). Additionally, studies exploring finerenone and sodium-glucose cotransporter 2 (SGLT2) inhibitors' (Empagliflozin) combination effects in CKD and T2DM (CONFIDENCE) and the selective MR modulator AZD9977 with another SGLT2 inhibitor (dapagliflozin) in HF and CKD (MIRACLE) aim to expand treatment options. While SGLT-2 inhibitors were shown to reduce hyperkalemia risk in FIDELIO-DKD and potentially lower new-onset HF incidence in FIGARO-DKD, further research is essential. So far, the evidence for the beneficial effect of finerenone in the spectrum of cardiorenal diseases is based only on the results of studies conducted in patients with T2DM, and clinical trials of finerenone in patients with nondiabetic kidney disease are ongoing. Nonsteroidal MRAs hold significant potential as pivotal treatment targets across the cardiorenal disease spectrum. This review will focus on the effects of finerenone on cardiorenal disease.
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Affiliation(s)
- Monarch Shah
- Division of Nephrology, University of Virginia, Charlottesville, VA 22902, USA;
| | - Alaa S. Awad
- Division of Nephrology, University of Florida, Jacksonville, FL 32209, USA;
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9
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Lu TL, Wu SN. Investigating the Impact of Selective Modulators on the Renin-Angiotensin-Aldosterone System: Unraveling Their Off-Target Perturbations of Transmembrane Ionic Currents. Int J Mol Sci 2023; 24:14007. [PMID: 37762309 PMCID: PMC10530685 DOI: 10.3390/ijms241814007] [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: 08/15/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
The renin-angiotensin-aldosterone system (RAAS) plays a crucial role in maintaining various physiological processes in the body, including blood pressure regulation, electrolyte balance, and overall cardiovascular health. However, any compounds or drugs known to perturb the RAAS might have an additional impact on transmembrane ionic currents. In this retrospective review article, we aimed to present a selection of chemical compounds or medications that have long been recognized as interfering with the RAAS. It is noteworthy that these substances may also exhibit regulatory effects in different types of ionic currents. Apocynin, known to attenuate the angiotensin II-induced activation of epithelial Na+ channels, was shown to stimulate peak and late components of voltage-gated Na+ current (INa). Esaxerenone, an antagonist of the mineralocorticoid receptor, can exert an inhibitory effect on peak and late INa directly. Dexamethasone, a synthetic glucocorticoid, can directly enhance the open probability of large-conductance Ca2+-activated K+ channels. Sparsentan, a dual-acting antagonist of the angiotensin II receptor and endothelin type A receptors, was found to suppress the amplitude of peak and late INa effectively. However, telmisartan, a blocker of the angiotensin II receptor, was effective in stimulating the peak and late INa along with a slowing of the inactivation time course of the current. However, telmisartan's presence can also suppress the erg-mediated K+ current. Moreover, tolvaptan, recognized as an aquaretic agent that can block the vasopressin receptor, was noted to suppress the amplitude of the delayed-rectifier K+ current and the M-type K+ current directly. The above results indicate that these substances not only have an interference effect on the RAAS but also exert regulatory effects on different types of ionic currents. Therefore, to determine their mechanisms of action, it is necessary to gain a deeper understanding.
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Affiliation(s)
- Te-Ling Lu
- School of Pharmacy, China Medical University, Taichung 406040, Taiwan;
| | - Sheng-Nan Wu
- Department of Research and Education, An Nan Hospital, China Medical University, Tainan 709040, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung 804201, Taiwan
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10
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Kario K, Ohishi M, Katsuya T, Taguchi T, Tanabe A, Sugimoto K, Shimosawa T. Rationale and design of a multicenter randomized study comparing the efficacy and safety of esaxerenone versus trichlormethiazide in patients with uncontrolled essential hypertension: EXCITE-HT study. J Clin Hypertens (Greenwich) 2023; 25:861-867. [PMID: 37551054 PMCID: PMC10497029 DOI: 10.1111/jch.14705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 08/09/2023]
Abstract
The next-generation mineralocorticoid receptor blocker (MRB) esaxerenone has favorable antihypertensive effects in patients who do not respond to treatment with first-line antihypertensive agents and may be beneficial as a second-line treatment. However, MRBs are currently considered a fourth-line treatment as there is no clinical evidence comparing the efficacy of esaxerenone with other classes of antihypertensive agents. The multicenter, randomized, open-label, parallel-group EXCITE-HT study will evaluate the efficacy and safety of esaxerenone as a second-line agent in the treatment of Japanese patients with uncontrolled essential hypertension. After a 4-week run-in period, patients will receive either esaxerenone or trichlormethiazide for 12 weeks per the package insert and the Japanese Society of Hypertension Guidelines for the Management of Hypertension. At Weeks 4 and 8, the dose of esaxerenone or trichlormethiazide may be increased. Blood pressure (home [morning and bedtime] and office), serum biomarkers, and urinary biomarkers will be measured. The primary efficacy endpoint is the change from baseline in morning home systolic blood pressure/diastolic blood pressure to the end of treatment. The EXCITE-HT study is expected to validate the non-inferiority of esaxerenone to trichlormethiazide and provide the first evidence for the early use of esaxerenone as a second-line agent in the treatment of Japanese patients with uncontrolled essential hypertension instead of its current use as a fourth-line agent.
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Affiliation(s)
- Kazuomi Kario
- Division of Cardiovascular MedicineDepartment of MedicineJichi Medical University School of MedicineTochigiJapan
| | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and HypertensionGraduate School of Medical and Dental SciencesKagoshima UniversityKagoshimaJapan
| | - Tomohiro Katsuya
- Katsuya ClinicHyogoJapan
- Department of Clinical Gene TherapyOsaka University Graduate School of MedicineOsakaJapan
| | - Takashi Taguchi
- Primary Medical Science DepartmentDaiichi Sankyo Co., LtdTokyoJapan
| | - Ayumi Tanabe
- Data Intelligence DepartmentDaiichi Sankyo Co., Ltd.TokyoJapan
| | - Kotaro Sugimoto
- Primary Medical Science DepartmentDaiichi Sankyo Co., LtdTokyoJapan
| | - Tatsuo Shimosawa
- Department of Clinical LaboratorySchool of MedicineInternational University of Health and WelfareChibaJapan
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11
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Kario K, Nishizawa M, Kato M, Ishii H, Uchiyama K, Nagai M, Takahashi N, Asakura T, Shiraiwa T, Yoshida T, Kaneshiro M, Taguchi T, Shiosakai K, Sugimoto K. Nighttime home blood pressure lowering effect of esaxerenone in patients with uncontrolled nocturnal hypertension: the EARLY-NH study. Hypertens Res 2023; 46:1782-1794. [PMID: 37173430 PMCID: PMC10319630 DOI: 10.1038/s41440-023-01292-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 05/15/2023]
Abstract
There is limited evidence on the blood pressure (BP)-lowering effect of esaxerenone on home BP, including nighttime BP. Using two newly developed nocturnal home BP monitoring devices (brachial and wrist), this multicenter, open-label, prospective study investigated the nighttime home BP-lowering effect of esaxerenone in patients with uncontrolled nocturnal hypertension being treated with an angiotensin receptor blocker (ARB) or calcium-channel blocker (CCB). In total, 101 patients were enrolled. During the 12-week study period, change in nighttime home systolic/diastolic BP from baseline to end of treatment measured by the brachial device was -12.9/-5.4 mmHg in the total population and -16.2/-6.6 and -10.0/-4.4 mmHg in the ARB and CCB subcohorts, respectively (all p < 0.001). For the wrist device, the change was -11.7/-5.4 mmHg in the total population and -14.6/-6.2 and -8.3/-4.5 mmHg in each subcohort, respectively (all p < 0.001). Similar significant reductions were shown for morning and bedtime home BP and office BP. Urinary albumin-to-creatinine ratio, N-terminal pro-brain natriuretic peptide, and cardio-ankle vascular index improved in the total population and each subcohort. Incidences of treatment-emergent adverse events (TEAEs) and drug-related TEAEs were 38.6% and 16.8%, respectively; most were mild or moderate. The most frequent drug-related TEAEs were associated with serum potassium elevation (hyperkalemia, 9.9%; blood potassium increased, 3.0%); however, no new safety concerns were raised. Esaxerenone was effective in lowering nighttime home BP as well as morning and bedtime home BP and office BP, safe, and showed organ-protective effects in patients with uncontrolled nocturnal hypertension. Caution is warranted regarding elevated serum potassium levels. This study investigated the effect of esaxerenone on nighttime home BP and organ damage (UACR and NT-proBNP) in patients with uncontrolled nocturnal hypertension despite treatment with an ARB or CCB. Our results show that safe 24-h BP control and organ protection are possible with esaxerenone.
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Affiliation(s)
- Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan.
| | | | | | | | | | - Michiaki Nagai
- Department of Cardiology, Hiroshima City Asa Hospital, Hiroshima, Japan
| | | | - Taro Asakura
- Tsuruma Kaneshiro Diabetes Clinic, Yamato, Japan
| | | | - Tetsuro Yoshida
- Department of Cardiovascular Medicine, Onga Nakama Medical Association Onga Hospital, Onga, Japan
| | | | - Takashi Taguchi
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | | | - Kotaro Sugimoto
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
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12
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Yuan PP, Li M, Zhang Q, Zeng MN, Ke YY, Wei YX, Fu Y, Zheng XK, Feng WS. 2-phenylacetamide Separated from the seed of Lepidium apetalum Willd. inhibited renal fibrosis via MAPK pathway mediated RAAS and oxidative stress in SHR Rats. BMC Complement Med Ther 2023; 23:207. [PMID: 37353787 DOI: 10.1186/s12906-023-04012-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 05/25/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Renal fibrosis with Renin-angiotensin-aldosterone system (RAAS) activation and oxidative stress are one of the major complications in hypertension. 2-phenylacetamide (PA), a major active component of Lepidium apetalum Willd. (L.A), has numerous pharmacological effects. Its analogues have the effect of anti-renal fibrosis and alleviating renal injury. This study aims to explore the underlying mechanism of PA for regulating the renal fibrosis in SHR based on the MAPK pathway mediated RAAS and oxidative stress. METHODS The SHR rats were used as the hypertension model, and the WKY rats were used as the control group. The blood pressure (BP), urine volume were detected every week. After PA treatment for 4 weeks, the levels of RAAS, inflammation and cytokines were measured by Enzyme-Linked Immunosorbnent Assay (ELISA). Hematoxylin-Eosin staining (HE), Masson and Immunohistochemistry (IHC) were used to observe the renal pathology, collagen deposition and fibrosis. Western blot was used to examine the MAPK pathway in renal. Finally, the SB203580 (p38 MAPK inhibitor) antagonism assay in the high NaCl-induced NRK52e cells was used, together with In-Cell Western (ICW), Flow Cytometry (FCM), High Content Screening (HCS) and ELISA to confirm the potential pharmacological mechanism. RESULTS PA reduced the BP, RAAS, inflammation and cytokines, promoted the urine, and relieved renal pathological injury and collagen deposition, repaired renal fibrosis, decreased the expression of NADPH Oxidase 4 (NOX4), transforming growth factor-β (TGF-β), SMAD3 and MAPK signaling pathway in SHR rats. Meanwhile,,the role of PA could be blocked by p38 antagonist SB203580 effectively in the high NaCl-induced NRK52e cells. Moreover, molecular docking indicated that PA occupied the ligand binding sites of p38 MAPK. CONCLUSION PA inhibited renal fibrosis via MAPK signalling pathway mediated RAAS and oxidative stress in SHR Rats.
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Affiliation(s)
- Pei-Pei Yuan
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou, 450046, China
- The Engineering and Technology Center for Chinese Medicine Development of Henan Province, 156 Jinshui East Road, Zhengzhou, 450046, China
| | - Meng Li
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou, 450046, China
- The Engineering and Technology Center for Chinese Medicine Development of Henan Province, 156 Jinshui East Road, Zhengzhou, 450046, China
| | - Qi Zhang
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou, 450046, China
| | - Meng-Nan Zeng
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou, 450046, China
- The Engineering and Technology Center for Chinese Medicine Development of Henan Province, 156 Jinshui East Road, Zhengzhou, 450046, China
| | - Ying-Ying Ke
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou, 450046, China
- The Engineering and Technology Center for Chinese Medicine Development of Henan Province, 156 Jinshui East Road, Zhengzhou, 450046, China
| | - Ya-Xin Wei
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou, 450046, China
| | - Yang Fu
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou, 450046, China
| | - Xiao-Ke Zheng
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou, 450046, China.
- The Engineering and Technology Center for Chinese Medicine Development of Henan Province, 156 Jinshui East Road, Zhengzhou, 450046, China.
| | - Wei-Sheng Feng
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou, 450046, China.
- The Engineering and Technology Center for Chinese Medicine Development of Henan Province, 156 Jinshui East Road, Zhengzhou, 450046, China.
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13
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Lerma E, White WB, Bakris G. Effectiveness of nonsteroidal mineralocorticoid receptor antagonists in patients with diabetic kidney disease. Postgrad Med 2023; 135:224-233. [PMID: 35392754 DOI: 10.1080/00325481.2022.2060598] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Nonsteroidal mineralocorticoid receptor antagonists (MRAs) are a new class of drugs developed to address the medical need for effective and safer treatment to protect the kidney and the heart in patients with diabetic kidney disease (DKD). There are several drugs within this class at varying stages of clinical development. Finerenone is the first nonsteroidal MRA approved in the US for treating patients with chronic kidney disease (CKD) associated with type 2 diabetes (T2D). In clinical studies, finerenone slowed CKD progression without inducing marked antihypertensive effects. Esaxerenone is a nonsteroidal MRA with proven blood pressure-lowering efficacy that is currently licensed in Japan for treating hypertension. There are also three other nonsteroidal MRAs in mid-to-late stages of clinical development. Here we overview evidence addressing pharmacological and clinical differences between the nonsteroidal MRAs and the steroidal MRAs spironolactone and eplerenone. First, we describe a framework that highlights the role of aldosterone-mediated pathological overactivation of the mineralocorticoid receptor and inflammation as important drivers of CKD progression. Second, we discuss the benefits and adverse events profile of steroidal MRAs, the latter of which are often a limiting factor to their use in routine clinical practice. Finally, we show that nonsteroidal MRAs differ from steroidal MRAs based on pharmacology and clinical effects, giving the potential to expand the therapeutic options for patients with DKD. In the recently completed DKD outcome program comprising two randomized clinical trials - FIDELIO-DKD and FIGARO-DKD - and the FIDELITY analysis of both trials evaluating more than 13,000 patients, the nonsteroidal MRA finerenone demonstrated beneficial effects on the kidney and the heart across a broad spectrum of patients with CKD and T2D. The long-term efficacy of finerenone on cardiac and renal morbidity and mortality endpoints, along with the anti-hypertensive efficacy of esaxerenone, widens the scope of available therapies for patients with DKD.
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Affiliation(s)
- Edgar Lerma
- Section of Nephrology, University of Illinois at Chicago/Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - William B White
- Cardiology Center, University of Connecticut School of Medicine, Farmington, CT, USA
| | - George Bakris
- American Heart Association Comprehensive Hypertension Center, Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
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14
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Johnston JG, Welch AK, Cain BD, Sayeski PP, Gumz ML, Wingo CS. Aldosterone: Renal Action and Physiological Effects. Compr Physiol 2023; 13:4409-4491. [PMID: 36994769 DOI: 10.1002/cphy.c190043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Aldosterone exerts profound effects on renal and cardiovascular physiology. In the kidney, aldosterone acts to preserve electrolyte and acid-base balance in response to changes in dietary sodium (Na+ ) or potassium (K+ ) intake. These physiological actions, principally through activation of mineralocorticoid receptors (MRs), have important effects particularly in patients with renal and cardiovascular disease as demonstrated by multiple clinical trials. Multiple factors, be they genetic, humoral, dietary, or otherwise, can play a role in influencing the rate of aldosterone synthesis and secretion from the adrenal cortex. Normally, aldosterone secretion and action respond to dietary Na+ intake. In the kidney, the distal nephron and collecting duct are the main targets of aldosterone and MR action, which stimulates Na+ absorption in part via the epithelial Na+ channel (ENaC), the principal channel responsible for the fine-tuning of Na+ balance. Our understanding of the regulatory factors that allow aldosterone, via multiple signaling pathways, to function properly clearly implicates this hormone as central to many pathophysiological effects that become dysfunctional in disease states. Numerous pathologies that affect blood pressure (BP), electrolyte balance, and overall cardiovascular health are due to abnormal secretion of aldosterone, mutations in MR, ENaC, or effectors and modulators of their action. Study of the mechanisms of these pathologies has allowed researchers and clinicians to create novel dietary and pharmacological targets to improve human health. This article covers the regulation of aldosterone synthesis and secretion, receptors, effector molecules, and signaling pathways that modulate its action in the kidney. We also consider the role of aldosterone in disease and the benefit of mineralocorticoid antagonists. © 2023 American Physiological Society. Compr Physiol 13:4409-4491, 2023.
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Affiliation(s)
- Jermaine G Johnston
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida, USA
- Nephrology Section, Veteran Administration Medical Center, North Florida/South Georgia Malcom Randall Department of Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - Amanda K Welch
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
- Nephrology Section, Veteran Administration Medical Center, North Florida/South Georgia Malcom Randall Department of Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - Brian D Cain
- Department of Biochemistry and Molecular Biology, University of Florida, Gainesville, Florida, USA
| | - Peter P Sayeski
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida, USA
| | - Michelle L Gumz
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida, USA
- Department of Biochemistry and Molecular Biology, University of Florida, Gainesville, Florida, USA
- Nephrology Section, Veteran Administration Medical Center, North Florida/South Georgia Malcom Randall Department of Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - Charles S Wingo
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida, USA
- Nephrology Section, Veteran Administration Medical Center, North Florida/South Georgia Malcom Randall Department of Veterans Affairs Medical Center, Gainesville, Florida, USA
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15
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Factors Associated with the Antihypertensive Effect of Esaxerenone and Serum Potassium Elevation: A Pooled Analysis of Seven Phase III Studies. Adv Ther 2023; 40:1242-1266. [PMID: 36662393 PMCID: PMC9988784 DOI: 10.1007/s12325-022-02393-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 11/29/2022] [Indexed: 01/21/2023]
Abstract
INTRODUCTION This study investigated factors associated with the antihypertensive effects of esaxerenone and the incidence of serum potassium elevation in patients with hypertension. METHODS Using pooled data from seven phase III studies, the study analyzed factors associated with changes in office systolic (SBP) and diastolic (DBP) blood pressure from baseline to 12 weeks, and factors associated with incidence of serum potassium levels ≥ 5.5 mEq/L in esaxerenone-treated patients. RESULTS Overall, 1466 and 1472 patients were included in the full analysis and safety analysis sets, respectively. Male sex (4.02/2.40 mmHg), weight ≥ 78.4 kg (4.62/2.09 mmHg), hypertension duration ≥ 10 years (2.66/1.71 mmHg), prior antihypertensive treatment (2.38/1.40 mmHg), plasma aldosterone concentration ≥ 120 pg/mL (1.66/1.17 mmHg), urinary albumin-to-creatinine ratio (UACR) ≥ 300 mg/gCr (8.94/4.85 mmHg) or 30-299 mg/gCr (5.17/4.15 mmHg), and smoking (2.62/1.27 mmHg) were associated with mean changes in SBP and DBP. Fasting blood glucose ≥ 126 mg/dL (- 2.73 mmHg) was associated with the mean change in SBP only, and older age (65-74 years, - 2.12 mmHg; and ≥ 75 years, - 3.06 mmHg) with mean change in DBP only. Factors significantly associated with incidence of serum potassium levels ≥ 5.5 mEq/L were higher baseline serum potassium (≥ 4.5 mEq/L, odds ratio [OR] 6.702); lower estimated glomerular filtration rate (≥ 90 mL/min/1.73 m2, OR 0.148; 60-89 mL/min/1.73 m2, OR 0.331 vs 30-59 mL/min/1.73 m2, respectively); higher UACR (30-299 mg/gCr, OR 7.317); higher DBP (≥ 100 mmHg, OR 3.248); and grade I hypertension (OR 2.168). CONCLUSION Esaxerenone is effective in patients with a broad range of backgrounds, though some factors may predict increased benefit. Regarding elevated serum potassium, careful therapeutic management is recommended for patients with higher baseline serum potassium and reduced renal function. CLINICAL TRIAL REGISTRATION UMIN000047026.
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16
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Blazek O, Bakris GL. Novel Therapies on the Horizon of Hypertension Management. Am J Hypertens 2023; 36:73-81. [PMID: 36201204 DOI: 10.1093/ajh/hpac111] [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: 09/20/2022] [Revised: 09/23/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The rates of uncontrolled hypertension, along with downstream cardiovascular outcomes, has been worsening in this country. Despite the plethora of antihypertensive medications on the market, the prevalence of resistant hypertension (RH) is estimated to be 13.7%. Therefore in addition to increased clinical education and focus on lifestyle management of hypertension and medication compliance, new therapies are needed to address this rise in hypertension. METHODS A systematic review of the available medical literature was performed to identify emerging treatment options for RH. RESULTS Six different pharmacologic classes and 2 procedural interventions were identified as being appropriate for review in this paper. The pharmacologic classes to be explored are non-steroidal mineralocorticoid receptor antagonists, aminopeptidase A inhibitors, dual endothelin antagonists, aldosterone synthetase inhibitors, atrial natriuretic peptide inhibitors, and attenuators of hepatic angiotensinogen. Discussion of procedural interventions to lower blood pressure will focus on renal denervation and devices that increase carotid baroreceptor activity. CONCLUSIONS Promising medication and procedural interventions are being developed and studied to expand our treatment arsenal for patients with uncontrolled essential hypertension and RH.
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Affiliation(s)
- Olivia Blazek
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago, IL 60637, USA
| | - George L Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago, IL 60637, USA
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17
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Ortiz A, Ferro CJ, Balafa O, Burnier M, Ekart R, Halimi JM, Kreutz R, Mark PB, Persu A, Rossignol P, Ruilope LM, Schmieder RE, Valdivielso JM, Del Vecchio L, Zoccali C, Mallamaci F, Sarafidis P. Mineralocorticoid receptor antagonists for nephroprotection and cardioprotection in patients with diabetes mellitus and chronic kidney disease. Nephrol Dial Transplant 2023; 38:10-25. [PMID: 33944938 DOI: 10.1093/ndt/gfab167] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Indexed: 01/26/2023] Open
Abstract
Diabetic kidney disease (DKD) develops in ∼40% of patients with diabetes and is the most common cause of chronic kidney disease (CKD) worldwide. Patients with CKD, especially those with diabetes mellitus, are at high risk of both developing kidney failure and cardiovascular (CV) death. The use of renin-angiotensin system (RAS) blockers to reduce the incidence of kidney failure in patients with DKD dates back to studies that are now ≥20 years old. During the last few years, sodium-glucose co-transporter-2 inhibitors (SGLT2is) have shown beneficial renal effects in randomized trials. However, even in response to combined treatment with RAS blockers and SGLT2is, the renal residual risk remains high with kidney failure only deferred, but not avoided. The risk of CV death also remains high even with optimal current treatment. Steroidal mineralocorticoid receptor antagonists (MRAs) reduce albuminuria and surrogate markers of CV disease in patients already on optimal therapy. However, their use has been curtailed by the significant risk of hyperkalaemia. In the FInerenone in reducing kiDnEy faiLure and dIsease prOgression in DKD (FIDELIO-DKD) study comparing the actions of the non-steroidal MRA finerenone with placebo, finerenone reduced the progression of DKD and the incidence of CV events, with a relatively safe adverse event profile. This document presents in detail the available evidence on the cardioprotective and nephroprotective effects of MRAs, analyses the potential mechanisms involved and discusses their potential future place in the treatment of patients with diabetic CKD.
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Affiliation(s)
- Alberto Ortiz
- IIS-Fundacion Jimenez Diaz UAM and School of Medicine, GEENDIAB, UAM, Madrid, Spain
| | - Charles J Ferro
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham,UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Michel Burnier
- Service of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland
| | - Robert Ekart
- Department of Dialysis, Clinic for Internal Medicine, University Clinical Center Maribor, Maribor, Slovenia
| | - Jean-Michel Halimi
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Hôpital Bretonneau, Tours University, Tours, France.,F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Reinhold Kreutz
- Department of Clinical Pharmacology and Toxicology, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Brussels, Belgium.,Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Patrick Rossignol
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, UMR 1116, CHRU de Nancy, Université de Lorraine, F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, Nancy, France.,Association Lorraine de Traitement de l'Insuffisance Rénale, Nancy, France
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain.,CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain.,Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital of the Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Jose M Valdivielso
- Vascular and Renal Translational Research Group and UDETMA, IRBLleida, Lleida, Spain
| | | | - Carmine Zoccali
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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18
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Wu Y, Lin H, Tao Y, Xu Y, Chen J, Jia Y, Zheng Z. Network meta-analysis of mineralocorticoid receptor antagonists for diabetic kidney disease. Front Pharmacol 2022; 13:967317. [PMID: 36188560 PMCID: PMC9523214 DOI: 10.3389/fphar.2022.967317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 08/24/2022] [Indexed: 12/19/2022] Open
Abstract
Diabetic kidney disease (DKD) is one of the major causes of end-stage renal disease (ESRD). To evaluate the efficacy and safety of different types of mineralocorticoid receptor antagonists (MRAs) in diabetic kidney disease patients, we conducted this network meta-analysis by performing a systematic search in PubMed, MEDLINE, EMBASE, Web of Science, the Cochrane Library, and Clinicaltrials.gov. A total of 12 randomized clinical trials with 15,492 patients applying various types of MRAs covering spironolactone, eplerenone, finerenone, esaxerenone, and apararenone were included. The efficacy outcomes were the ratio of urine albumin creatine ratio (UACR) at posttreatment vs. at baseline, change in posttreatment estimated glomerular filtration (eGFR) vs. at baseline, and change in posttreatment systolic blood pressure (SBP) vs. at baseline. The safety outcome was the number of patients suffering from hyperkalemia. High-dose finerenone (MD −0.31, 95% CI: −0.52, −0.11), esaxerenone (MD −0.54, 95% CI: −0.72, −0.30), and apararenone (MD −0.63, 95% CI: −0.90, −0.35) were associated with a superior reduction in proteinuria in patients with DKD. Regarding the change in eGFR, the results of all drugs were similar, and finerenone may have potential superiority in protecting the kidney. Compared with placebo, none of the treatments was associated with a higher probability of controlling systolic blood pressure during treatment. Moreover, spironolactone, esaxerenone, and 20 mg of finerenone presented a higher risk of hyperkalemia. This Bayesian network meta-analysis was the first to explore the optimal alternative among MRAs in the treatment of DKD and revealed the superiority of 20 mg of finerenone among MRAs in treating DKD. Systematic Review Registration: PROSPERO, identifier (CRD42022313826)
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Affiliation(s)
- Yichuan Wu
- Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
- De Feng Academy, Southern Medical University, Guangzhou, China
| | - Huanjia Lin
- Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
- De Feng Academy, Southern Medical University, Guangzhou, China
| | - Yuan Tao
- Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
- De Feng Academy, Southern Medical University, Guangzhou, China
| | - Ying Xu
- Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
- De Feng Academy, Southern Medical University, Guangzhou, China
| | - Jiaqi Chen
- Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
- De Feng Academy, Southern Medical University, Guangzhou, China
| | - Yijie Jia
- Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
- De Feng Academy, Southern Medical University, Guangzhou, China
- *Correspondence: Zongji Zheng, ; Yijie Jia,
| | - Zongji Zheng
- Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
- De Feng Academy, Southern Medical University, Guangzhou, China
- *Correspondence: Zongji Zheng, ; Yijie Jia,
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19
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Turana Y, Shen R, Nathaniel M, Chia Y, Li Y, Kario K. Neurodegenerative diseases and blood pressure variability: A comprehensive review from HOPE Asia. J Clin Hypertens (Greenwich) 2022; 24:1204-1217. [PMID: 36196471 PMCID: PMC9532897 DOI: 10.1111/jch.14559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/25/2022] [Accepted: 07/31/2022] [Indexed: 11/19/2022]
Abstract
Asia has an enormous number of older people and is the primary contributor to the rise in neurodegenerative diseases such as Alzheimer's and Parkinson's disease. The therapy of many neurodegenerative diseases has not yet progressed to the point where it is possible to alter the course of the disease. Mid-life hypertension is an important predictor of later-life cognitive impairment and brain neurodegenerative conditions. These findings highlight the pivotal role of preventing and managing hypertension as a risk factor for neurodegenerative disease. Autonomic dysfunction, neuropsychiatric and sleep disturbances can arise in neurodegenerative diseases, resulting in blood pressure variability (BPV). The BPV itself can worsen the progression of the disease. In older people with neurodegenerative disease and hypertension, it is critical to consider 24-h blood pressure monitoring and personalized blood pressure therapy.
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Affiliation(s)
- Yuda Turana
- School of Medicine and Health SciencesAtma Jaya Catholic University of IndonesiaNorth JakartaJakartaIndonesia
- Master Study Program in Biomedical SciencesSchool of Medicine and Health SciencesAtma Jaya Catholic University of IndonesiaNorth JakartaJakartaIndonesia
| | - Robert Shen
- School of Medicine and Health SciencesAtma Jaya Catholic University of IndonesiaNorth JakartaJakartaIndonesia
- Master Study Program in Biomedical SciencesSchool of Medicine and Health SciencesAtma Jaya Catholic University of IndonesiaNorth JakartaJakartaIndonesia
| | - Michael Nathaniel
- School of Medicine and Health SciencesAtma Jaya Catholic University of IndonesiaNorth JakartaJakartaIndonesia
| | - Yook‐Chin Chia
- Department of Medical SciencesSchool of Medical and Life SciencesSunway UniversityBandar SunwayMalaysia
- Department of Primary Care MedicineFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Yan Li
- Department of Cardiovascular MedicineShanghai Key Lab of HypertensionShanghai Institute of HypertensionNational Research Centre for Translational MedicineRuijin HospitalShanghai Jiaotong University School of MedicineShanghaiChina
| | - Kazuomi Kario
- Division of Cardiovascular MedicineDepartment of MedicineJichi Medical University School of MedicineTochigiJapan
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20
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Abstract
Besides the physiological regulation of water, sodium, and potassium homeostasis, aldosterone modulates several physiological and pathological processes in the cardiovascular system. At the vascular level, aldosterone excess stimulates endothelial dysfunction and infiltration of inflammatory cells, enhances the development of the atherosclerotic plaque, and favors plaque instability, arterial stiffness, and calcification. At the cardiac level, aldosterone increases cardiac inflammation, fibrosis, and myocardial hypertrophy. As a clinical consequence, high aldosterone levels are associated with enhanced risk of cardiovascular events and mortality, especially when aldosterone secretion is inappropriate for renin levels and sodium intake, as in primary aldosteronism. Several clinical trials showed that mineralocorticoid receptor antagonists reduce cardiovascular mortality in patients with heart failure and reduced ejection fraction, but inconclusive results were reported for other cardiovascular conditions, such as heart failure with preserved ejection fraction, myocardial infarction, and atrial fibrillation. In patients with primary aldosteronism, adrenalectomy or treatment with mineralocorticoid receptor antagonists significantly mitigate adverse aldosterone effects, reducing the risk of cardiovascular events, mortality, and incident atrial fibrillation. In this review, we will summarize the major preclinical and clinical studies investigating the cardiovascular damage mediated by aldosterone and the protective effect of mineralocorticoid receptor antagonists for the reduction of cardiovascular risk in patients with cardiovascular diseases and primary aldosteronism.
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Affiliation(s)
- Fabrizio Buffolo
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy
| | - Martina Tetti
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy
| | - Paolo Mulatero
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy
| | - Silvia Monticone
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy
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21
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Hattori M, Rahman A, Kidoguchi S, Jahan N, Fujisawa Y, Morisawa N, Ohsaki H, Kobara H, Masaki T, Hossain A, Steeve A, Nishiyama A. Association of Antihypertensive Effects of Esaxerenone with the Internal Sodium Balance in Dahl Salt-Sensitive Hypertensive Rats. Int J Mol Sci 2022; 23:ijms23168915. [PMID: 36012182 PMCID: PMC9408866 DOI: 10.3390/ijms23168915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 11/18/2022] Open
Abstract
Background: The nonsteroidal mineralocorticoid receptor blocker esaxerenone is effective in reducing blood pressure (BP). Objective: In this study, we investigated esaxerenone-driven sodium homeostasis and its association with changes in BP in Dahl salt-sensitive (DSS) hypertensive rats. Methods: In the different experimental setups, we evaluated BP by a radiotelemetry system, and sodium homeostasis was determined by an approach of sodium intake (food intake) and excretion (urinary excretion) in DSS rats with a low-salt diet (0.3% NaCl), high-salt diet (HSD, 8% NaCl), HSD plus 0.001% esaxerenone (w/w), and HSD plus 0.05% furosemide. Results: HSD-fed DSS rats showed a dramatic increase in BP with a non-dipper pattern, while esaxerenone treatment, but not furosemide, significantly reduced BP with a dipper pattern. The cumulative sodium excretion in the active period was significantly elevated in esaxerenone- and furosemide-treated rats compared with their HSD-fed counterparts. Sodium content in the skin, skinned carcass, and total body tended to be lower in esaxerenone-treated rats than in their HSD-fed counterparts, while these values were unchanged in furosemide-treated rats. Consistently, sodium balance tended to be reduced in esaxerenone-treated rats during the active period. Histological evaluation showed that esaxerenone, but not furosemide, treatment attenuated glomerulosclerosis, tubulointerstitial fibrosis, and urinary protein excretion induced by high salt loading. Conclusions: Collectively, these findings suggest that an esaxerenone treatment-induced reduction in BP and renoprotection are associated with body sodium homeostasis in salt-loaded DSS rats.
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Affiliation(s)
- Mai Hattori
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Asadur Rahman
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
- Correspondence: (A.R.); (A.N.); Tel.: +81-87-891-2125 (A.R. & A.N.); Fax: +81-87-891-2126 (A.R. & A.N.)
| | - Satoshi Kidoguchi
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Nourin Jahan
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Yoshihide Fujisawa
- Life Science Research Center, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Norihiko Morisawa
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Hiroyuki Ohsaki
- Department of Medical Biophysics, Kobe University Graduate School of Health Sciences, 7-10-2, Tomogaoka, Suma-ku, Kobe 654-0142, Hyogo, Japan
| | - Hideki Kobara
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Tsutomu Masaki
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Akram Hossain
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Akumwami Steeve
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
- Department of Anesthesiology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Akira Nishiyama
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
- Correspondence: (A.R.); (A.N.); Tel.: +81-87-891-2125 (A.R. & A.N.); Fax: +81-87-891-2126 (A.R. & A.N.)
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22
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Bavuu O, Fukuda D, Ganbaatar B, Matsuura T, Ise T, Kusunose K, Yamaguchi K, Yagi S, Yamada H, Soeki T, Wakatsuki T, Sata M. Esaxerenone, a selective mineralocorticoid receptor blocker, improves insulin sensitivity in mice consuming high-fat diet. Eur J Pharmacol 2022; 931:175190. [PMID: 35961594 DOI: 10.1016/j.ejphar.2022.175190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/03/2022] [Accepted: 08/03/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Esaxerenone is a novel, non-steroidal selective mineralocorticoid receptor (MR) blocker. MR activation plays a crucial role in the development of cardiovascular and metabolic diseases. In this study, we investigated the effects of esaxerenone on various metabolic parameters in mice. MATERIALS AND METHODS Esaxerenone (3 mg/kg/day) was orally administered to high-fat diet (HFD)-fed male C57BL/6 mice. Mice fed a normal diet (ND) served as controls. Glucose and insulin tolerance, plasma lipid levels, and transaminase levels were assessed as metabolic parameters. Macrophage accumulation in the adipose tissue was evaluated using histological analysis. 3T3-L1 adipocytes, HepG2 cells, and C2C12 myotubes were used for in vitro experiments. Gene expression and insulin signaling were examined using quantitative RT-PCR and western blotting, respectively. RESULTS HFD successfully induced insulin resistance compared with that in ND. Esaxerenone ameliorated insulin resistance (P < 0.05) without altering other metabolic parameters, such as the lipid profile. Esaxerenone administration tended to decrease plasma transaminase levels compared with those in the non-treated group. In the adipose tissue, esaxerenone decreased macrophage accumulation (P < 0.05) and increased the expression levels of adiponectin and PPARγ. Aldosterone significantly decreased the expression levels of PPARγ and adiponectin in 3T3-L1 adipocytes. Furthermore, aldosterone attenuated insulin-induced Akt phosphorylation in 3T3-L1 adipocytes, HepG2 cells, and C2C12 myotubes in a dose-dependent manner (P < 0.01). These effects were ameliorated by pretreatment with esaxerenone. CONCLUSION Esaxerenone ameliorated insulin resistance in HFD-fed mice. Reduction of inflammation and improvement in insulin signaling may underlie the beneficial effects of esaxerenone.
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Affiliation(s)
- Oyunbileg Bavuu
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, 770-8503, Japan
| | - Daiju Fukuda
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, 770-8503, Japan; Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, 545-8585, Japan.
| | - Byambasuren Ganbaatar
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, 770-8503, Japan
| | - Tomomi Matsuura
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, 770-8503, Japan
| | - Takayuki Ise
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, 770-8503, Japan
| | - Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, 770-8503, Japan
| | - Koji Yamaguchi
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, 770-8503, Japan
| | - Shusuke Yagi
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, 770-8503, Japan
| | - Hirotsugu Yamada
- Department of Community Medicine for Cardiology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, 770-8503, Japan
| | - Takeshi Soeki
- Department of Community Medicine and Medical Science, Tokushima University Graduate School of Biomedical Sciences, Tokushima, 770-8503, Japan
| | - Tetsuzo Wakatsuki
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, 770-8503, Japan
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, 770-8503, Japan
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23
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Alexandrou ME, Theodorakopoulou MP, Kanbay M, Sarafidis PA. Mineralocorticoid receptor antagonists for cardioprotection in chronic kidney disease: a step into the future. J Hum Hypertens 2022; 36:695-704. [PMID: 34980878 DOI: 10.1038/s41371-021-00641-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 11/12/2021] [Accepted: 11/19/2021] [Indexed: 11/09/2022]
Abstract
Chronic kidney disease (CKD) and cardiovascular disease (CVD) share major risk factors and mechanistic pathways for progression. Furthermore, either decreased glomerular filtration rate or increased albuminuria are major risk factors for cardiovascular events. Evidence from previous renal outcome trials in patients with proteinuric CKD showed that angiotensin-converting-enzyme inhibitors (ACEIs) and angiotensin-II receptor blockers (ARBs) effectively slow CKD progression, establishing these agents as fundamental CKD pharmacologic treatments. However, in all these trials and subsequent meta-analyses, ACEIs and ARBs did not significantly reduce cardiovascular events or mortality, indicating a high residual risk for CVD progression in individuals with CKD. In contrast to the above, several outcome trials with old and novel mineralocorticoid receptor-antagonists (MRAs) clearly suggest that these agents, apart from nephroprotection, offer important cardioprotection in this population. This article is an overview of previous and recent evidence on the effects of MRAs on cardiovascular outcomes in patients with CKD attempting to highlight a pathway able to improve both cardiovascular and renal prognosis in this population.
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Affiliation(s)
- Maria-Eleni Alexandrou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Marieta P Theodorakopoulou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Pantelis A Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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24
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Hypertension and Type 2 Diabetes-The Novel Treatment Possibilities. Int J Mol Sci 2022; 23:ijms23126500. [PMID: 35742943 PMCID: PMC9224227 DOI: 10.3390/ijms23126500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/04/2022] [Accepted: 06/08/2022] [Indexed: 02/04/2023] Open
Abstract
Elevated blood pressure and hyperglycaemia frequently coexist and are both components of metabolic syndrome. Enhanced cardiovascular risk is strongly associated with diabetes and the occurrence of hypertension. Both hypertension and type 2 diabetes, if treated inappropriately, lead to serious complications, increasing the mortality of patients and generating much higher costs of health systems. This is why it is of great importance to find the missing link between hypertension and diabetes development and to simultaneously search for drugs influencing these two disorders or even drugs aimed at their pathological bases. Standard antihypertensive therapy mainly focuses on blood pressure reduction, while novel drugs also possess a wide range of pleiotropic modes of actions, such as cardio- and nephroprotective properties or body weight reduction. These properties are especially desirable in a situation when type 2 diabetes coexists with hypertension. This review describes the connections between diabetes and hypertension development and briefly summarises the current knowledge regarding attempts to define targets for the treatment of high blood pressure in diabetic patients. It also describes the standard hypotensive drugs preferred in patients with type 2 diabetes, as well as novel drugs, such as finerenone, esaxerenone, sodium-glucose co-transporter-2 inhibitors, glucagon-like peptide-1 analogues and sacubitril/valsartan.
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25
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Donate-Correa J, Sanchez-Niño MD, González-Luis A, Ferri C, Martín-Olivera A, Martín-Núñez E, Fernandez-Fernandez B, Tagua VG, Mora-Fernández C, Ortiz A, Navarro-González JF. Repurposing drugs for highly prevalent diseases: pentoxifylline, an old drug and a new opportunity for diabetic kidney disease. Clin Kidney J 2022; 15:2200-2213. [PMID: 36381364 PMCID: PMC9664582 DOI: 10.1093/ckj/sfac143] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Indexed: 11/30/2022] Open
Abstract
Diabetic kidney disease is one of the most frequent complications in patients with diabetes and constitutes a major cause of end-stage kidney disease. The prevalence of diabetic kidney disease continues to increase as a result of the growing epidemic of diabetes and obesity. Therefore, there is mounting urgency to design and optimize novel strategies and drugs that delay the progression of this pathology and contain this trend. The new approaches should go beyond the current therapy focussed on the control of traditional risk factors such as hyperglycaemia and hypertension. In this scenario, drug repurposing constitutes an economic and feasible approach based on the discovery of useful activities for old drugs. Pentoxifylline is a nonselective phosphodiesterase inhibitor currently indicated for peripheral artery disease. Clinical trials and meta-analyses have shown renoprotection secondary to anti-inflammatory and antifibrotic effects in diabetic patients treated with this old known drug, which makes pentoxifylline a candidate for repurposing in diabetic kidney disease.
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Affiliation(s)
- Javier Donate-Correa
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
- GEENDIAB (Grupo Español para el estudio de la Nefropatía Diabética), Sociedad Española de Nefrología, Santander, Spain
- RICORS2040 (RD21/0005/0013), Instituto de Salud Carlos III, Madrid, Spain
| | - María Dolores Sanchez-Niño
- Departamento de Nefrología e Hipertensión, IIS-Fundación Jiménez Díaz y Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
| | - Ainhoa González-Luis
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
- Escuela de doctorado, Universidad de La Laguna
| | - Carla Ferri
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
- Escuela de doctorado, Universidad de La Laguna
| | - Alberto Martín-Olivera
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
- Escuela de doctorado, Universidad de La Laguna
| | - Ernesto Martín-Núñez
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
- RICORS2040 (RD21/0005/0013), Instituto de Salud Carlos III, Madrid, Spain
| | - Beatriz Fernandez-Fernandez
- Departamento de Nefrología e Hipertensión, IIS-Fundación Jiménez Díaz y Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
- RICORS2040 (RD21/0005/0001), Instituto de Salud Carlos III, Madrid, Spain
| | - Víctor G Tagua
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Carmen Mora-Fernández
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
- GEENDIAB (Grupo Español para el estudio de la Nefropatía Diabética), Sociedad Española de Nefrología, Santander, Spain
- RICORS2040 (RD21/0005/0013), Instituto de Salud Carlos III, Madrid, Spain
| | - Alberto Ortiz
- Departamento de Nefrología e Hipertensión, IIS-Fundación Jiménez Díaz y Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
- RICORS2040 (RD21/0005/0001), Instituto de Salud Carlos III, Madrid, Spain
| | - Juan F Navarro-González
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
- GEENDIAB (Grupo Español para el estudio de la Nefropatía Diabética), Sociedad Española de Nefrología, Santander, Spain
- RICORS2040 (RD21/0005/0013), Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Nefrología, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
- Instituto de Tecnologías Biomédicas, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
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26
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Raj R. Finerenone: a new mineralocorticoid receptor antagonist to beat chronic kidney disease. Curr Opin Nephrol Hypertens 2022; 31:265-271. [PMID: 35165249 DOI: 10.1097/mnh.0000000000000785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Clinical trials of the mineralocorticoid receptor antagonist (MRA) finerenone published recently suggest that they improve outcomes in patients with diabetic kidney disease (DKD). This review summarises key research from the last two years to provide clinicians with a synopsis of recent findings. RECENT FINDINGS Large international trials, such as Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease (5674 participants) and Finerenone in Reducing Cardiovascular Mortality and Morbidity in Diabetic Kidney Disease (7437 participants), suggest that in proteinuric patients with DKD and estimated glomerular filtration rate >25 ml/min/1.73 m2, already on renin-angiotensin-aldosterone system inhibitors, addition of finerenone provided modest further improvement in composite renal and cardiovascular outcomes. Proteinuria was reduced; there was also a small drop in systolic blood pressure. Hyperkalaemia remained a concern, although the incidence is lower with finerenone. Emerging data suggest that newer potassium binding agents may mitigate this risk. Preclinical studies suggest additive benefits when MRA and sodium-glucose co-transporter 2 (SGLT-2) inhibitors are used in combination. SUMMARY The nonsteroidal MRA finerenone could improve renal and cardiac outcomes further in diabetics with kidney disease when added to renin-angiotensin system inhibitors. Hyperkalaemia is probably less worrisome, but real-world data is needed. Combinations with other new nephroprotective agents (such as SGLT2i inhibitors) has the potential to provide increasing benefit. Benefits of finerenone in chronic kidney disease without diabetes remains to be seen.
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Affiliation(s)
- Rajesh Raj
- Clinical Associate Professor, University of Tasmania, Consultant Nephrol-ogist, Launceston General Hospital, Launceston, Australia
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27
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Sueta D, Yamamoto E, Usuku H, Suzuki S, Nakamura T, Matsui K, Akasaka T, Shiosakai K, Sugimoto K, Tsujita K. Rationale and Design of the Efficacy and Safety of Esaxerenone in Hypertensive Patients With Left Ventricular Hypertrophy (ESES-LVH) Study ― Protocol for a Multicenter, Open-Label, Exploratory Interventional Study ―. Circ Rep 2022; 4:99-104. [PMID: 35178486 PMCID: PMC8811229 DOI: 10.1253/circrep.cr-21-0122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/07/2021] [Accepted: 01/01/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University
| | - Hiroki Usuku
- Center for Metabolic Regulation of Healthy Aging, Graduate School of Medical Science, Kumamoto University
| | - Satoru Suzuki
- Center for Metabolic Regulation of Healthy Aging, Graduate School of Medical Science, Kumamoto University
| | - Taishi Nakamura
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University
| | - Kunihiko Matsui
- Community, Family, and General Medicine, Faculty of Life Sciences, Graduate School of Medical Science, Kumamoto University
| | | | | | | | - Kenichi Tsujita
- Center for Metabolic Regulation of Healthy Aging, Graduate School of Medical Science, Kumamoto University
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28
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Ishikawa T, Morimoto S, Ichihara A. Effects of mineralocorticoid receptor antagonists on sex hormones and body composition in patients with primary aldosteronism. Hypertens Res 2021; 45:496-506. [PMID: 34961793 DOI: 10.1038/s41440-021-00836-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/17/2021] [Accepted: 12/04/2021] [Indexed: 11/10/2022]
Abstract
Mineralocorticoid receptor antagonists are frequently used for the treatment of primary aldosteronism. Steroidal mineralocorticoid receptor antagonists may have antagonistic actions on androgen receptors, agonistic actions on progesterone receptors, and antagonistic actions on mineralocorticoid receptors. Because anti-androgen effects may cause body fat accumulation and skeletal muscle atrophy, there are concerns that this drug may have adverse effects on body composition. Therefore, in this randomized prospective study, we compared the adverse effects of spironolactone, a steroidal mineralocorticoid receptor antagonist, and esaxerenone, a nonsteroidal mineralocorticoid receptor antagonist, on sex hormone levels and body composition in patients with primary aldosteronism without severe renal dysfunction. The serum concentration of free testosterone was significantly higher in the spironolactone group than in the esaxerenone group in both males and females. However, the levels of estradiol, progesterone, luteinizing hormone, and follicle stimulating hormone did not significantly increase. Changes in body fat percentage and muscle mass rate were not significantly different between the two groups. No patient showed a serum potassium level ≥6.0 mEq/L; however, serum potassium levels were significantly higher in the spironolactone group than in the esaxerenone group. These data indicate that spironolactone may have antagonistic effects on androgen receptors. Esaxerenone did not show any apparent adverse effects, suggesting that it can be safely used in patients with primary aldosteronism.
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Affiliation(s)
- Toru Ishikawa
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, Tokyo, Japan
| | - Satoshi Morimoto
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, Tokyo, Japan.
| | - Atsuhiro Ichihara
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, Tokyo, Japan
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29
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Kawanami D, Takashi Y, Muta Y, Oda N, Nagata D, Takahashi H, Tanabe M. Mineralocorticoid Receptor Antagonists in Diabetic Kidney Disease. Front Pharmacol 2021; 12:754239. [PMID: 34790127 PMCID: PMC8591525 DOI: 10.3389/fphar.2021.754239] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023] Open
Abstract
Diabetic kidney disease (DKD) is a major cause of end-stage kidney disease (ESKD) worldwide. Mineralocorticoid receptor (MR) plays an important role in the development of DKD. A series of preclinical studies revealed that MR is overactivated under diabetic conditions, resulting in promoting inflammatory and fibrotic process in the kidney. Clinical studies demonstrated the usefulness of MR antagonists (MRAs), such as spironolactone and eplerenone, on DKD. However, concerns regarding their selectivity for MR and hyperkalemia have remained for these steroidal MRAs. Recently, nonsteroidal MRAs, including finerenone, have been developed. These agents are highly selective and have potent anti-inflammatory and anti-fibrotic properties with a low risk of hyperkalemia. We herein review the current knowledge and future perspectives of MRAs in DKD treatment.
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Affiliation(s)
- Daiji Kawanami
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Yuichi Takashi
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Yoshimi Muta
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Naoki Oda
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Dai Nagata
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Hiroyuki Takahashi
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Makito Tanabe
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
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Imamura T, Oshima A, Narang N, Kinugawa K. Implication of Mineralocorticoid Receptor Antagonist Esaxerenone in Patients With Heart Failure With Preserved Ejection Fraction. Circ Rep 2021; 3:660-665. [PMID: 34805606 PMCID: PMC8578130 DOI: 10.1253/circrep.cr-21-0115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/05/2021] [Accepted: 09/08/2021] [Indexed: 11/17/2022] Open
Abstract
Background: The implications of mineralocorticoid receptor antagonists, including the newly introduced esaxerenone, on cardiac reverse remodeling in patients with heart failure with preserved ejection fraction (HFpEF) remain uncertain. Methods and Results: We included patients with HFpEF who received esaxerenone for hypertension between November 2019 and July 2021 in this retrospective study. Changes in left ventricular mass index (LVMI) were compared between the 6-month pretreatment period (without esaxerenone) and the 6-month treatment period (on esaxerenone). Thirty-three patients (median age 74 years [interquartile range {IQR} 70-81 years]; 33% male, median systolic blood pressure [SBP] 135 mmHg [IQR 123-148 mmHg]) were included in the study and completed 6-month esaxerenone therapy without any adverse events. During the pretreatment period, SBP decreased significantly (P=0.009), whereas LVMI remained unchanged (P=0.30). During the esaxerenone treatment period, both SBP and LVMI decreased significantly (P=0.003 and P=0.001, respectively). Conclusions: Esaxerenone may have beneficial effects of reverse remodeling in patients with HFpEF when used to treat hypertension. Further studies are needed to understand which patient populations may see greater benefits with esaxerenone.
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Affiliation(s)
- Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama Toyama Japan
| | - Akira Oshima
- Second Department of Internal Medicine, University of Toyama Toyama Japan
| | | | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama Toyama Japan
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Young MJ, Kanki M, Karthigan N, Konstandopoulos P. The Role of the Mineralocorticoid Receptor and Mineralocorticoid Receptor-Directed Therapies in Heart Failure. Endocrinology 2021; 162:6288445. [PMID: 34050730 DOI: 10.1210/endocr/bqab105] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Mineralocorticoid receptor (MR) antagonists (MRA), also referred to as aldosterone blockers, are now well-recognized for their clinical benefit in patients who have heart failure (HF) with reduced ejection fraction (HFrEF). Recent studies have also shown MRA can improve outcomes in patients with HFpEF, where the ejection fraction is preserved but left ventricular filling is reduced. While the MR is a steroid hormone receptor best known for antinatriuretic actions on electrolyte homeostasis in the distal nephron, it is now established that the MR has many physiological and pathophysiological roles in the heart, vasculature, and other nonepithelial tissue types. It is the impact of MR activation on these tissues that underpins the use of MRA in cardiovascular disease, in particular HF. This mini-review will discuss the origins and the development of MRA and highlight how their use has evolved from the "potassium-sparing diuretics" spironolactone and canrenone over 60 years ago, to the more receptor-selective eplerenone and most recently the emergence of new nonsteroidal receptor antagonists esaxerenone and finerenone.
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Affiliation(s)
- Morag J Young
- Baker Heart and Diabetes Institute, Cardiovascular Endocrinology Laboratory, Prahran 3181, Australia
| | - Monica Kanki
- Baker Heart and Diabetes Institute, Cardiovascular Endocrinology Laboratory, Prahran 3181, Australia
- Hudson Institute of Medical Research, Victoria 3168, Australia
| | - Nikshay Karthigan
- Baker Heart and Diabetes Institute, Cardiovascular Endocrinology Laboratory, Prahran 3181, Australia
- Hudson Institute of Medical Research, Victoria 3168, Australia
| | - Penny Konstandopoulos
- Baker Heart and Diabetes Institute, Cardiovascular Endocrinology Laboratory, Prahran 3181, Australia
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Kolkhof P, Joseph A, Kintscher U. Nonsteroidal mineralocorticoid receptor antagonism for cardiovascular and renal disorders - New perspectives for combination therapy. Pharmacol Res 2021; 172:105859. [PMID: 34461222 DOI: 10.1016/j.phrs.2021.105859] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/16/2021] [Accepted: 08/25/2021] [Indexed: 02/06/2023]
Abstract
During the recent 30 years, there has been a dramatic increase in knowledge about the role of aldosterone and the mineralocorticoid receptor (MR) in the pathophysiology of cardiovascular (CV) and kidney diseases. The scientific perspective on the aldosterone/MR ensemble extended from a previously renal epithelial-centered focus on sodium-potassium exchange to a broader view as systemic modulators of extracellular matrix, inflammation and fibrosis. Spironolactone was launched as the first antagonist of aldosterone 27 years before the MR was cloned. It was classified as a potassium-sparing diuretic, based on its initial clinical characterization as a diuretic and its preferred activity to compensate for the potassium loss induced by loop diuretics when used in combination. The second steroidal MR antagonist was eplerenone which was discovered at a time when the role of aldosterone and MR in cardiac fibrosis was rediscovered. The constraint of developing potentially life-threatening hyperkalaemia when used in combination with other inhibitors of the renin-angiotensin-system (RAS) in patients with reduced kidney function initiated extensive research and development activities with the goal to identify novel nonsteroidal MR antagonists with an improved benefit-risk ratio. Here we summarize major current clinical trials with MRAs in different CV and renal diseases. Addition of the nonsteroidal MRA finerenone to optimal RAS blockade recently reduced CV and kidney outcomes in two large phase III trials in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D). We provide an outlook on further opportunities for combination therapy of nonsteroidal MRA finerenone with RAS inhibitors and sodium-glucose cotransporter-2 inhibitors (SGLT2i).
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Affiliation(s)
- Peter Kolkhof
- Cardiovascular Research, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany.
| | - Amer Joseph
- Cardiology and Nephrology, Clinical Development, R&D Pharmaceuticals, Bayer AG, Berlin, Germany
| | - Ulrich Kintscher
- Charite - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Pharmacology, Cardiovascular-Metabolic-Renal Research Center, 10115 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany
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Amatruda M, Gembillo G, Giuffrida AE, Santoro D, Conti G. The Aggressive Diabetic Kidney Disease in Youth-Onset Type 2 Diabetes: Pathogenetic Mechanisms and Potential Therapies. ACTA ACUST UNITED AC 2021; 57:medicina57090868. [PMID: 34577791 PMCID: PMC8467670 DOI: 10.3390/medicina57090868] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 08/21/2021] [Accepted: 08/22/2021] [Indexed: 02/07/2023]
Abstract
Youth-onset Type 2 Diabetes Mellitus (T2DM) represents a major burden worldwide. In the last decades, the prevalence of T2DM became higher than that of Type 1 Diabetes Mellitus (T1DM), helped by the increasing rate of childhood obesity. The highest prevalence rates of youth-onset T2DM are recorded in China (520 cases/100,000) and in the United States (212 cases/100,000), and the numbers are still increasing. T2DM young people present a strong hereditary component, often unmasked by social and environmental risk factors. These patients are affected by multiple coexisting risk factors, including obesity, hyperglycemia, dyslipidemia, insulin resistance, hypertension, and inflammation. Juvenile T2DM nephropathy occurs earlier in life compared to T1DM-related nephropathy in children or T2DM-related nephropathy in adult. Diabetic kidney disease (DKD) is T2DM major long term microvascular complication. This review summarizes the main mechanisms involved in the pathogenesis of the DKD in young population and the recent evolution of treatment, in order to reduce the risk of DKD progression.
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Affiliation(s)
- Michela Amatruda
- Unit of Pediatric Nephrology with Dialysis, AOU Policlinic G Martino, University of Messina, 98125 Messina, Italy;
| | - Guido Gembillo
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (G.G.); (A.E.G.); (D.S.)
- Department of Biomedical and Dental Sciences and Morpho-functional Imaging, University of Messina, 98125 Messina, Italy
| | - Alfio Edoardo Giuffrida
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (G.G.); (A.E.G.); (D.S.)
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (G.G.); (A.E.G.); (D.S.)
| | - Giovanni Conti
- Unit of Pediatric Nephrology with Dialysis, AOU Policlinic G Martino, University of Messina, 98125 Messina, Italy;
- Correspondence:
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Zhu H, Liu M, Li H, Guan T, Zhang Q, Chen Y, Liu Y, Hartmann RR, Yin L, Hu Q. Design, synthesis and biological evaluation of pyridyl substituted benzoxazepinones as potent and selective inhibitors of aldosterone synthase. CHINESE CHEM LETT 2021. [DOI: 10.1016/j.cclet.2020.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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35
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Chang WT, Wu SN. Characterization of Direct Perturbations on Voltage-Gated Sodium Current by Esaxerenone, a Nonsteroidal Mineralocorticoid Receptor Blocker. Biomedicines 2021; 9:biomedicines9050549. [PMID: 34068333 PMCID: PMC8153305 DOI: 10.3390/biomedicines9050549] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/07/2021] [Accepted: 05/11/2021] [Indexed: 02/07/2023] Open
Abstract
Esaxerenone (ESAX; CS-3150, Minnebro®) is known to be a newly non-steroidal mineralocorticoid receptor (MR) antagonist. However, its modulatory actions on different types of ionic currents in electrically excitable cells remain largely unanswered. The present investigations were undertaken to explore the possible perturbations of ESAX on the transient, late and persistent components of voltage-gated Na+ current (INa) identified from pituitary GH3 or MMQ cells. GH3-cell exposure to ESAX depressed the transient and late components of INa with varying potencies. The IC50 value of ESAX required for its differential reduction in peak or late INa in GH3 cells was estimated to be 13.2 or 3.2 μM, respectively. The steady-state activation curve of peak INa remained unchanged during exposure to ESAX; however, recovery of peak INa block was prolonged in the presence 3 μM ESAX. In continued presence of aldosterone (10 μM), further addition of 3 μM ESAX remained effective at inhibiting INa. ESAX (3 μM) potently reversed Tef-induced augmentation of INa. By using isosceles-triangular ramp pulse with varying durations, the amplitude of persistent INa measured at high or low threshold was enhanced by the presence of tefluthrin (Tef), in combination with the appearance of the figure-of-eight hysteretic loop; moreover, hysteretic strength of the current was attenuated by subsequent addition of ESAX. Likewise, in MMQ lactotrophs, the addition of ESAX also effectively decreased the peak amplitude of INa along with the increased current inactivation rate. Taken together, the present results provide a noticeable yet unidentified finding disclosing that, apart from its antagonistic effect on MR receptor, ESAX may directly and concertedly modify the amplitude, gating properties and hysteresis of INa in electrically excitable cells.
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Affiliation(s)
- Wei-Ting Chang
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan 71005, Taiwan;
- Division of Cardiovascular Medicine, Chi-Mei Medical Center, Tainan 71004, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
| | - Sheng-Nan Wu
- Department of Physiology, National Cheng Kung University Medical College, Tainan 70101, Taiwan
- Institute of Basic Medical Sciences, National Cheng Kung University Medical College, Tainan 70101, Taiwan
- Correspondence: ; Tel.: +886-6-2353535 (ext. 5334); Fax: +886-6-2362780
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Doggrell SA. Finerenone - are we there yet with a non-steroidal mineralocorticoid receptor antagonist for the treatment of diabetic chronic kidney disease? Expert Opin Pharmacother 2021; 22:1253-1256. [PMID: 33764251 DOI: 10.1080/14656566.2021.1904892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Chronic kidney disease occurs in 40% of subjects with diabetes and increases the risk of cardiovascular death three-fold, compared to having diabetes alone. The non-steroidal mineralocorticoid receptor antagonist finerenone protects against chronic kidney disease in animal models.Areas covered: This evaluation is of a phase 3 trial of finerenone; Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease (FIDELIO-DKD). In FIDELIO-DKD, finerenone reduced the primary composite outcome of kidney failure, a sustained decrease of at least 40% in eGFR over four weeks, or death from renal causes, from 21.1% to 17.8%, with a good safety profile.Expert opinion: Finerenone is an effective mineralocorticoid receptor antagonist for the treatment of diabetic chronic kidney disease. Recently, glucagon-like peptide 1 (GLP-1) receptor agonists and sodium-glucose cotransporters 2 (SGLT-2) inhibitors have been added to the list of medicines for use in subjects with this condition. Although finerenone has a different mechanism of action to these medicines, it will need to be tested and shown to be effective in presence of these medicines in diabetic kidney disease, prior to widespread use.
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Affiliation(s)
- Sheila A Doggrell
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
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37
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Rahman A, Sawano T, Sen A, Hossain A, Jahan N, Kobara H, Masaki T, Kosaka S, Kitada K, Nakano D, Imamura T, Ohsaki H, Nishiyama A. Cardioprotective Effects of a Nonsteroidal Mineralocorticoid Receptor Blocker, Esaxerenone, in Dahl Salt-Sensitive Hypertensive Rats. Int J Mol Sci 2021; 22:2069. [PMID: 33669786 PMCID: PMC7922950 DOI: 10.3390/ijms22042069] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/09/2021] [Accepted: 02/17/2021] [Indexed: 01/13/2023] Open
Abstract
We investigated the effects of esaxerenone, a novel, nonsteroidal, and selective mineralocorticoid receptor blocker, on cardiac function in Dahl salt-sensitive (DSS) rats. We provided 6-week-old DSS rats a high-salt diet (HSD, 8% NaCl). Following six weeks of HSD feeding (establishment of cardiac hypertrophy), we divided the animals into the following two groups: HSD or HSD + esaxerenone (0.001%, w/w). In survival study, all HSD-fed animals died by 24 weeks of age, whereas the esaxerenone-treated HSD-fed animals showed significantly improved survival. We used the same protocol with a separate set of animals to evaluate the cardiac function by echocardiography after four weeks of treatment. The results showed that HSD-fed animals developed cardiac dysfunction as evidenced by reduced stroke volume, ejection fraction, and cardiac output. Importantly, esaxerenone treatment decreased the worsening of cardiac dysfunction concomitant with a significantly reduced level of systolic blood pressure. In addition, treatment with esaxerenone in HSD-fed DSS rats caused a reduced level of cardiac remodeling as well as fibrosis. Furthermore, inflammation and oxidative stress were significantly reduced. These data indicate that esaxerenone has the potential to mitigate cardiac dysfunction in salt-induced myocardial injury in rats.
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Affiliation(s)
- Asadur Rahman
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (A.R.); (A.S.); (A.H.); (N.J.); (K.K.); (D.N.)
| | - Tatsuya Sawano
- Division of Pharmacology, Faculty of Medicine, Tottori University, 86 Nishi-cho, Yonago, Tottori 683-8503, Japan; (T.S.); (T.I.)
| | - Anupoma Sen
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (A.R.); (A.S.); (A.H.); (N.J.); (K.K.); (D.N.)
| | - Akram Hossain
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (A.R.); (A.S.); (A.H.); (N.J.); (K.K.); (D.N.)
| | - Nourin Jahan
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (A.R.); (A.S.); (A.H.); (N.J.); (K.K.); (D.N.)
| | - Hideki Kobara
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (H.K.); (T.M.)
| | - Tsutomu Masaki
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (H.K.); (T.M.)
| | - Shinji Kosaka
- Department of Pharmacy, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan;
| | - Kento Kitada
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (A.R.); (A.S.); (A.H.); (N.J.); (K.K.); (D.N.)
| | - Daisuke Nakano
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (A.R.); (A.S.); (A.H.); (N.J.); (K.K.); (D.N.)
| | - Takeshi Imamura
- Division of Pharmacology, Faculty of Medicine, Tottori University, 86 Nishi-cho, Yonago, Tottori 683-8503, Japan; (T.S.); (T.I.)
| | - Hiroyuki Ohsaki
- Department of Medical Biophysics, Kobe University Graduate School of Health Sciences, 7-10-2, Tomogaoka, Suma-ku, Kobe, Hyogo 654-0142, Japan;
| | - Akira Nishiyama
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (A.R.); (A.S.); (A.H.); (N.J.); (K.K.); (D.N.)
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Gao X, Yamazaki Y, Tezuka Y, Omata K, Ono Y, Morimoto R, Nakamura Y, Suzuki T, Satoh F, Sasano H. Pathology of Aldosterone Biosynthesis and its Action. TOHOKU J EXP MED 2021; 254:1-15. [PMID: 34011803 DOI: 10.1620/tjem.254.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Aldosterone plays pivotal roles in renin-angiotensin-aldosterone system in order to maintain the equilibrium of liquid volume and electrolyte metabolism. Aldosterone action is mediated by both mineralocorticoid receptor and 11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2). Its excessive actions directly induced tissue injuries in its target organs such as myocardial and vascular fibrosis in addition to chronic kidney diseases. Excessive aldosterone actions were also reported to be involved in unbalanced electrolyte metabolism in inflammatory bowel disease and development of pulmonary diseases. Hyperaldosteronism is tentatively classified into primary and secondary types. Primary aldosteronism is more frequent and has been well known to result in secondary hypertension with subsequent cardiovascular damages. Primary aldosteronism is also further classified into distinctive subtypes and among those, aldosterone-producing adenoma is the most frequent one accounting for the great majority of unilateral primary aldosteronism cases. In bilateral hyperaldosteronism, aldosterone-producing diffuse hyperplasia and aldosterone-producing micronodules or nodules are the major subtypes. All these aldosterone-producing lesions were reported to harbor somatic mutations including KCNJ5, CACNA1D, ATP1A1 and ATP2B3, which were all related to excessive aldosterone production. Among those mutations above, somatic mutation of KCNJ5 is the most frequent in aldosterone-producing adenoma and mostly composed of clear cells harboring abundant aldosterone synthase expression. In contrast, CACNA1D-mutated aldosterone-producing micronodules or aldosterone-producing nodules were frequently detected not only in primary aldosteronism patients but also in the zona glomerulosa of normal adrenal glands, which could eventually lead to an autonomous aldosterone production resulting in normotensive or overt primary aldosteronism, but their details have remained unknown.
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Affiliation(s)
- Xin Gao
- Department of Pathology, Tohoku University, Graduate School of Medicine
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University, Graduate School of Medicine
| | - Yuta Tezuka
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine.,Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital
| | - Kei Omata
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine.,Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital
| | - Yoshikiyo Ono
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital
| | - Ryo Morimoto
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital
| | - Yasuhiro Nakamura
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University
| | - Takashi Suzuki
- Department of Pathology and Histotechnology, Tohoku University Graduate School of Medicine
| | - Fumitoshi Satoh
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine.,Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital
| | - Hironobu Sasano
- Department of Pathology, Tohoku University, Graduate School of Medicine
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Yamazaki T, Mimura I, Tanaka T, Nangaku M. Treatment of Diabetic Kidney Disease: Current and Future. Diabetes Metab J 2021; 45:11-26. [PMID: 33508907 PMCID: PMC7850867 DOI: 10.4093/dmj.2020.0217] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/13/2020] [Indexed: 12/11/2022] Open
Abstract
Diabetic kidney disease (DKD) is the major cause of end-stage kidney disease. However, only renin-angiotensin system inhibitor with multidisciplinary treatments is effective for DKD. In 2019, sodium-glucose cotransporter 2 (SGLT2) inhibitor showed efficacy against DKD in Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE) trial, adding a new treatment option. However, the progression of DKD has not been completely controlled. The patients with transient exposure to hyperglycemia develop diabetic complications, including DKD, even after normalization of their blood glucose. Temporary hyperglycemia causes advanced glycation end product (AGE) accumulations and epigenetic changes as metabolic memory. The drugs that improve metabolic memory are awaited, and AGE inhibitors and histone modification inhibitors are the focus of clinical and basic research. In addition, incretin-related drugs showed a renoprotective ability in many clinical trials, and these trials with renal outcome as their primary endpoint are currently ongoing. Hypoxia-inducible factor prolyl hydroxylase inhibitors recently approved for renal anemia may be renoprotective since they improve tubulointerstitial hypoxia. Furthermore, NF-E2-related factor 2 activators improved the glomerular filtration rate of DKD patients in Bardoxolone Methyl Treatment: Renal Function in chronic kidney disease/Type 2 Diabetes (BEAM) trial and Phase II Study of Bardoxolone Methyl in Patients with Chronic Kidney Disease and Type 2 Diabetes (TSUBAKI) trial. Thus, following SGLT2 inhibitor, numerous novel drugs could be utilized in treating DKD. Future studies are expected to provide new insights.
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Affiliation(s)
- Tomotaka Yamazaki
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Imari Mimura
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Tetsuhiro Tanaka
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
- Corresponding author: Tetsuhiro Tanaka https://orcid.org/0000-0002-2238-4215 Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan E-mail:
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
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40
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Lin Y, Zhang Z, Wang S, Cai J, Guo J. Hypothalamus-pituitary-adrenal Axis in Glucolipid metabolic disorders. Rev Endocr Metab Disord 2020; 21:421-429. [PMID: 32889666 DOI: 10.1007/s11154-020-09586-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2020] [Indexed: 02/07/2023]
Abstract
With the change of life style, glucolipid metabolic disorders (GLMD) has become one of the major chronic disorders causing public health and clinical problems worldwide. Previous studies on GLMD pay more attention to peripheral tissues. In fact, the central nervous system (CNS) plays an important role in controlling the overall metabolic balance. With the development of technology and the in-depth understanding of the CNS, the relationship between neuro-endocrine-immunoregulatory (NEI) network and metabolism had been gradually illustrated. As the hub of NEI network, hypothalamus-pituitary-adrenal (HPA) axis is important for maintaining the balance of internal environment in the body. The relationship between HPA axis and GLMD needs to be further studied. This review focuses on the role of HPA axis in GLMD and reviews the research progress on drugs for GLMD, with the hope to provide the direction for exploring new drugs to treat GLMD by taking the HPA axis as the target and improve the level of prevention and control of GLMD.
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Affiliation(s)
- Yanduan Lin
- Guangdong Metabolic Diseases Research Centre of Integrated Chinese and Western Medicine, Guangdong Pharmaceutical University, Guangzhou, 510006, People's Republic of China
| | - Ziwei Zhang
- Guangdong Metabolic Diseases Research Centre of Integrated Chinese and Western Medicine, Guangdong Pharmaceutical University, Guangzhou, 510006, People's Republic of China
| | - Siyu Wang
- Center for Drug Research and Development, Guangdong Pharmaceutical University, Guangzhou, 510006, People's Republic of China
| | - Jinyan Cai
- Center for Drug Research and Development, Guangdong Pharmaceutical University, Guangzhou, 510006, People's Republic of China.
| | - Jiao Guo
- Guangdong Metabolic Diseases Research Centre of Integrated Chinese and Western Medicine, Guangdong Pharmaceutical University, Guangzhou, 510006, People's Republic of China.
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