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Ames MK, Adin DB, Wood J. Beyond Angiotensin-Converting Enzyme Inhibitors: Modulation of the Renin-Angiotensin-Aldosterone System to Delay or Manage Congestive Heart Failure. Vet Clin North Am Small Anim Pract 2023; 53:1353-1366. [PMID: 37423846 DOI: 10.1016/j.cvsm.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
The renin-angiotensin-aldosterone system (RAAS) consists of bioactive angiotensin peptides, enzymatic pathways, receptors, and the steroid hormone aldosterone. The RAAS regulates blood pressure, sodium, and electrolyte homeostasis and mediates pathologic disease processes. Within this system is an alternative arm that counterbalances the vasoconstrictive, sodium and water retentive, and pro-fibrotic and inflammatory effects of the classical arm. Improved biochemical methodologies in RAAS quantification are elucidating how this complex system changes in health and disease. Future treatments for cardiovascular and kidney disease will likely involve a more nuanced manipulation of this system rather than simple blockade.
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Affiliation(s)
- Marisa K Ames
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California - Davis, 1 Shields Avenue, Davis, CA 95616, USA.
| | - Darcy B Adin
- University of Florida, College of Veterinary Medicine, 2015 Southwest 16th Avenue, Gainesville, FL 32608, USA
| | - James Wood
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California - Davis, 1 Shields Avenue, Davis, CA 95616, USA
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Alexandrou ME, Ferro CJ, Boletis I, Papagianni A, Sarafidis P. Hypertension in kidney transplant recipients. World J Transplant 2022; 12:211-222. [PMID: 36159073 PMCID: PMC9453294 DOI: 10.5500/wjt.v12.i8.211] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/07/2022] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
Kidney transplantation is considered the treatment of choice for end-stage kidney disease patients. However, the residual cardiovascular risk remains significantly higher in kidney transplant recipients (KTRs) than in the general population. Hypertension is highly prevalent in KTRs and represents a major modifiable risk factor associated with adverse cardiovascular outcomes and reduced patient and graft survival. Proper definition of hypertension and recognition of special phenotypes and abnormal diurnal blood pressure (BP) patterns is crucial for adequate BP control. Misclassification by office BP is commonly encountered in these patients, and a high proportion of masked and uncontrolled hypertension, as well as of white-coat hypertension, has been revealed in these patients with the use of ambulatory BP monitoring. The pathophysiology of hypertension in KTRs is multifactorial, involving traditional risk factors, factors related to chronic kidney disease and factors related to the transplantation procedure. In the absence of evidence from large-scale randomized controlled trials in this population, BP targets for hypertension management in KTR have been extrapolated from chronic kidney disease populations. The most recent Kidney Disease Improving Global Outcomes 2021 guidelines recommend lowering BP to less than 130/80 mmHg using standardized BP office measurements. Dihydropyridine calcium channel blockers and angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers have been established as the preferred first-line agents, on the basis of emphasis placed on their favorable outcomes on graft survival. The aim of this review is to provide previous and recent evidence on prevalence, accurate diagnosis, pathophysiology and treatment of hypertension in KTRs.
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Affiliation(s)
- Maria-Eleni Alexandrou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WB, United Kingdom
| | - Ioannis Boletis
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens 11527, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
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Nakagawa H, Kumazawa T, Onoue K, Nakada Y, Nakano T, Ishihara S, Minamino N, Hosoda H, Iwata N, Ueda T, Seno A, Nishida T, Soeda T, Okayama S, Watanabe M, Kawakami R, Saito Y. Local Action of Neprilysin Exacerbates Pressure Overload Induced Cardiac Remodeling. Hypertension 2021; 77:1931-1939. [PMID: 33840200 DOI: 10.1161/hypertensionaha.120.16445] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Hitoshi Nakagawa
- Cardiovascular Medicine, Nara Medical University, Nara, Japan (H.N., T.K., K.O., Y.N., T. Nakano, S.I., T.U., A.S., T. Nishida, T.S., S.O., M.W., R.K., Y.S.)
| | - Takuya Kumazawa
- Cardiovascular Medicine, Nara Medical University, Nara, Japan (H.N., T.K., K.O., Y.N., T. Nakano, S.I., T.U., A.S., T. Nishida, T.S., S.O., M.W., R.K., Y.S.)
| | - Kenji Onoue
- Cardiovascular Medicine, Nara Medical University, Nara, Japan (H.N., T.K., K.O., Y.N., T. Nakano, S.I., T.U., A.S., T. Nishida, T.S., S.O., M.W., R.K., Y.S.)
| | - Yasuki Nakada
- Cardiovascular Medicine, Nara Medical University, Nara, Japan (H.N., T.K., K.O., Y.N., T. Nakano, S.I., T.U., A.S., T. Nishida, T.S., S.O., M.W., R.K., Y.S.)
| | - Tomoya Nakano
- Cardiovascular Medicine, Nara Medical University, Nara, Japan (H.N., T.K., K.O., Y.N., T. Nakano, S.I., T.U., A.S., T. Nishida, T.S., S.O., M.W., R.K., Y.S.)
| | - Satomi Ishihara
- Cardiovascular Medicine, Nara Medical University, Nara, Japan (H.N., T.K., K.O., Y.N., T. Nakano, S.I., T.U., A.S., T. Nishida, T.S., S.O., M.W., R.K., Y.S.)
| | - Naoto Minamino
- Omics Research Center (N.M.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroshi Hosoda
- Departments of Regenerative Medicine and Tissue Engineering (H.H.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nobuhisa Iwata
- Department of Genome-based Drug Discovery, Nagasaki University, Japan (N.I.)
| | - Tomoya Ueda
- Cardiovascular Medicine, Nara Medical University, Nara, Japan (H.N., T.K., K.O., Y.N., T. Nakano, S.I., T.U., A.S., T. Nishida, T.S., S.O., M.W., R.K., Y.S.)
| | - Ayako Seno
- Cardiovascular Medicine, Nara Medical University, Nara, Japan (H.N., T.K., K.O., Y.N., T. Nakano, S.I., T.U., A.S., T. Nishida, T.S., S.O., M.W., R.K., Y.S.)
| | - Taku Nishida
- Cardiovascular Medicine, Nara Medical University, Nara, Japan (H.N., T.K., K.O., Y.N., T. Nakano, S.I., T.U., A.S., T. Nishida, T.S., S.O., M.W., R.K., Y.S.)
| | - Tsunenari Soeda
- Cardiovascular Medicine, Nara Medical University, Nara, Japan (H.N., T.K., K.O., Y.N., T. Nakano, S.I., T.U., A.S., T. Nishida, T.S., S.O., M.W., R.K., Y.S.)
| | - Satoshi Okayama
- Cardiovascular Medicine, Nara Medical University, Nara, Japan (H.N., T.K., K.O., Y.N., T. Nakano, S.I., T.U., A.S., T. Nishida, T.S., S.O., M.W., R.K., Y.S.)
| | - Makoto Watanabe
- Cardiovascular Medicine, Nara Medical University, Nara, Japan (H.N., T.K., K.O., Y.N., T. Nakano, S.I., T.U., A.S., T. Nishida, T.S., S.O., M.W., R.K., Y.S.)
| | - Rika Kawakami
- Cardiovascular Medicine, Nara Medical University, Nara, Japan (H.N., T.K., K.O., Y.N., T. Nakano, S.I., T.U., A.S., T. Nishida, T.S., S.O., M.W., R.K., Y.S.)
| | - Yoshihiko Saito
- Cardiovascular Medicine, Nara Medical University, Nara, Japan (H.N., T.K., K.O., Y.N., T. Nakano, S.I., T.U., A.S., T. Nishida, T.S., S.O., M.W., R.K., Y.S.)
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Kaltenecker CC, Domenig O, Kopecky C, Antlanger M, Poglitsch M, Berlakovich G, Kain R, Stegbauer J, Rahman M, Hellinger R, Gruber C, Grobe N, Fajkovic H, Eskandary F, Böhmig GA, Säemann MD, Kovarik JJ. Critical Role of Neprilysin in Kidney Angiotensin Metabolism. Circ Res 2020; 127:593-606. [PMID: 32418507 DOI: 10.1161/circresaha.119.316151] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
RATIONALE Kidney homeostasis is critically determined by the coordinated activity of the renin-angiotensin system (RAS), including the balanced synthesis of its main effector peptides Ang (angiotensin) II and Ang (1-7). The condition of enzymatic overproduction of Ang II relative to Ang (1-7) is termed RAS dysregulation and leads to cellular signals, which promote hypertension and organ damage, and ultimately progressive kidney failure. ACE2 (angiotensin-converting enzyme 2) and NEP (neprilysin) induce the alternative, and potentially reno-protective axis by enhancing Ang (1-7) production. However, their individual contribution to baseline RAS balance and whether their activities change in chronic kidney disease (CKD) has not yet been elucidated. OBJECTIVE To examine whether NEP-mediated Ang (1-7) generation exceeds Ang II formation in the healthy kidney compared with diseased kidney. METHODS AND RESULTS In this exploratory study, we used liquid chromatography-tandem mass spectrometry to measure Ang II and Ang (1-7) synthesis rates of ACE, chymase and NEP, ACE2, PEP (prolyl-endopeptidase), PCP (prolyl-carboxypeptidase) in kidney biopsy homogenates in 11 healthy living kidney donors, and 12 patients with CKD. The spatial expression of RAS enzymes was determined by immunohistochemistry. Healthy kidneys showed higher NEP-mediated Ang (1-7) synthesis than Ang II formation, thus displaying a strong preference towards the reno-protective alternative RAS axis. In contrast, in CKD kidneys higher levels of Ang II were recorded, which originated from mast cell chymase activity. CONCLUSIONS Ang (1-7) is the dominant RAS peptide in healthy human kidneys with NEP rather than ACE2 being essential for its generation. Severe RAS dysregulation is present in CKD dictated by high chymase-mediated Ang II formation. Kidney RAS enzyme analysis might lead to novel therapeutic approaches for CKD.
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Affiliation(s)
- Christopher C Kaltenecker
- From the Division of Nephrology and Dialysis, Department of Internal Medicine III (C.C.K., F.E., G.A.B., J.J.K.), Medical University of Vienna, Austria
| | - Oliver Domenig
- Attoquant Diagnostics GmbH, Vienna, Austria (O.D., M.P.)
| | - Chantal Kopecky
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia (C.K.)
| | - Marlies Antlanger
- 2nd Department of Internal Medicine, Kepler University Hospital, Med Campus III, Linz, Austria (M.A.)
| | | | - Gabriela Berlakovich
- Division of Transplantation, Department of Surgery (G.B.), Medical University of Vienna, Austria
| | - Renate Kain
- Department of Pathology (R.K.), Medical University of Vienna, Austria
| | - Johannes Stegbauer
- Department of Nephrology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Germany (J.S., M.R.)
| | - Masudur Rahman
- Department of Nephrology, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Germany (J.S., M.R.)
| | - Roland Hellinger
- Center for Physiology and Pharmacology (R.H., C.G.), Medical University of Vienna, Austria
| | - Christian Gruber
- Center for Physiology and Pharmacology (R.H., C.G.), Medical University of Vienna, Austria
| | - Nadja Grobe
- Renal Research Institute, New York, NY (N.G.)
| | - Harun Fajkovic
- Department of Urology (H.F.), Medical University of Vienna, Austria
| | - Farsad Eskandary
- From the Division of Nephrology and Dialysis, Department of Internal Medicine III (C.C.K., F.E., G.A.B., J.J.K.), Medical University of Vienna, Austria
| | - Georg A Böhmig
- From the Division of Nephrology and Dialysis, Department of Internal Medicine III (C.C.K., F.E., G.A.B., J.J.K.), Medical University of Vienna, Austria
| | - Marcus D Säemann
- 6th Medical Department with Nephrology and Dialysis, Wilhelminenhospital, Vienna, Austria (M.D.S.).,Sigmund-Freud University, Vienna, Austria (M.D.S.)
| | - Johannes J Kovarik
- From the Division of Nephrology and Dialysis, Department of Internal Medicine III (C.C.K., F.E., G.A.B., J.J.K.), Medical University of Vienna, Austria
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