1
|
Scholtes RA, van Baar MJB, Kok MD, Bjornstad P, Cherney DZI, Joles JA, van Raalte DH. Renal haemodynamic and protective effects of renoactive drugs in type 2 diabetes: Interaction with SGLT2 inhibitors. Nephrology (Carlton) 2021; 26:377-390. [PMID: 33283420 PMCID: PMC8026736 DOI: 10.1111/nep.13839] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/05/2020] [Accepted: 11/24/2020] [Indexed: 12/25/2022]
Abstract
Diabetic kidney disease remains the leading cause of end‐stage kidney disease and a major risk factor for cardiovascular disease. Large cardiovascular outcome trials and dedicated kidney trials have shown that sodium‐glucose cotransporter (SGLT)2 inhibitors reduce cardiovascular morbidity and mortality and attenuate hard renal outcomes in patients with type 2 diabetes (T2D). Underlying mechanisms explaining these renal benefits may be mediated by decreased glomerular hypertension, possibly by vasodilation of the post‐glomerular arteriole. People with T2D often receive several different drugs, some of which could also impact the renal vasculature, and could therefore modify both renal efficacy and safety of SGLT2 inhibition. The most commonly prescribed drugs that could interact with SGLT2 inhibitors on renal haemodynamic function include renin‐angiotensin system inhibitors, calcium channel blockers and diuretics. Herein, we review the effects of these drugs on renal haemodynamic function in people with T2D and focus on studies that measured glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) with gold‐standard techniques. In addition, we posit, based on these observations, potential interactions with SGLT2 inhibitors with an emphasis on efficacy and safety. This invited review describes the renal haemodynamic and protective effects of commonly prescribed drugs in people with type 2 diabetes and their interaction with SGLT2 inhibitors.
Collapse
Affiliation(s)
- Rosalie A Scholtes
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Michaël J B van Baar
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Megan D Kok
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Petter Bjornstad
- Department of Pediatrics, Division of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, USA.,Department of Medicine, Division of Nephrology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - David Z I Cherney
- Department of Medicine and Department of Physiology, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center, Utrecht, The Netherlands
| | - Daniël H van Raalte
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical Center, VU University Medical Center, Amsterdam, The Netherlands.,Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
2
|
Wang J, McDonagh DL, Meng L. Calcium Channel Blockers in Acute Care: The Links and Missing Links Between Hemodynamic Effects and Outcome Evidence. Am J Cardiovasc Drugs 2021; 21:35-49. [PMID: 32410171 DOI: 10.1007/s40256-020-00410-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Calcium channel blockers (CCBs) exert profound hemodynamic effects via blockage of calcium flux through voltage-gated calcium channels. CCBs are widely used in acute care to treat concerning, debilitating, or life-threatening hemodynamic changes in many patients. The overall literature suggests that, for systemic hemodynamics, although CCBs decrease blood pressure, they normally increase cardiac output; for regional hemodynamics, although they impair pressure autoregulation, they normally increase organ blood flow and tissue oxygenation. In acute care, CCBs exert therapeutic efficacy or improve outcomes in patients with aneurysmal subarachnoid hemorrhage, acute myocardial infarction and unstable angina, hypertensive crisis, perioperative hypertension, and atrial tachyarrhythmia. However, despite the clear links, there are missing links between the known hemodynamic effects and the reported outcome evidence, suggesting that further studies are needed for clarification. In this narrative review, we aim to discuss the hemodynamic effects and outcome evidence for CCBs, the links and missing links between these two domains, and the directions that merit future investigations.
Collapse
Affiliation(s)
- Jin Wang
- Department of Anesthesiology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - David L McDonagh
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lingzhong Meng
- Department of Anesthesiology, Yale University School of Medicine, 330 Cedar Street, TMP 3, New Haven, CT, 06520, USA.
| |
Collapse
|
3
|
Lin YC, Wang JC, Wu MS, Lin YF, Chen CR, Chen CY, Chen KC, Peng CC. Nifedipine Exacerbates Lipogenesis in the Kidney via KIM-1, CD36, and SREBP Upregulation: Implications from an Animal Model for Human Study. Int J Mol Sci 2020; 21:ijms21124359. [PMID: 32575412 PMCID: PMC7352626 DOI: 10.3390/ijms21124359] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 12/15/2022] Open
Abstract
Dysregulation of fatty acid oxidation and accumulation of fatty acids can cause kidney injury. Nifedipine modulates lipogenesis-related transcriptional factor SREBP-1/2 in proximal tubular cells by inhibiting the Adenosine 5‘-monophosphate (AMP)-activated protein kinase (AMPK) pathway in vitro. However, the mechanisms by which nifedipine (NF) modulates lipotoxicity in vivo are unclear. Here, we examined the effect of NF in a doxorubicin (DR)-induced kidney injury rat model. Twenty-four Sprague–Dawley rats were divided into control, DR, DR+NF, and high-fat diet (HFD) groups. The DR, DR+NF, and HFD groups showed hypertension and proteinuria. Western blotting and immunohistochemical analysis showed that NF significantly induced TNF-α, CD36, SREBP-1/2, and acetyl-CoA carboxylase expression and renal fibrosis, and reduced fatty acid synthase and AMPK compared to other groups (p < 0.05). Additionally, 18 patients with chronic kidney disease (CKD) who received renal transplants were enrolled to examine their graft fibrosis and lipid contents via transient elastography. Low-density lipoprotein levels in patients with CKD strongly correlated with lipid contents and fibrosis in grafted kidneys (p < 0.05). Thus, NF may initiate lipogenesis through the SREBP-1/2/AMPK pathway and lipid uptake by CD36 upregulation and aggravate renal fibrosis in vivo. Higher low-density lipoprotein levels may correlate with renal fibrosis and lipid accumulation in grafted kidneys of patients with CKD.
Collapse
Affiliation(s)
- Yen-Chung Lin
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan;
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (M.-S.W.); (Y.-F.L.)
- TMU-Research Center of Urology and Kidney, Taipei Medical University, Taipei 11031, Taiwan
| | - Jhih-Cheng Wang
- Division of Urology, Department of Surgery, Chi-Mei Medical Center, Tainan City 71004, Taiwan;
- Department of Electric Engineering, Southern Taiwan University of Science and Technology, Tainan City 71005, Taiwan
| | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (M.-S.W.); (Y.-F.L.)
- TMU-Research Center of Urology and Kidney, Taipei Medical University, Taipei 11031, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei City 23561, Taiwan
| | - Yuh-Feng Lin
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (M.-S.W.); (Y.-F.L.)
- TMU-Research Center of Urology and Kidney, Taipei Medical University, Taipei 11031, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei City 23561, Taiwan
| | - Chang-Rong Chen
- International Medical Doctor Program, Vita-Salute San Raffaele University, 20132 Milan, Italy;
| | - Chang-Yu Chen
- Program of Biomedical Sciences, College of Arts and Sciences, California Baptist University, Riverside, CA 92504, USA;
| | - Kuan-Chou Chen
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan;
- TMU-Research Center of Urology and Kidney, Taipei Medical University, Taipei 11031, Taiwan
- Department of Urology, Taipei Medical University-Shuang Ho Hospital, New Taipei City 23561, Taiwan
- Department of Urology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Correspondence: (K.-C.C.); (C.-C.P.); Tel.: +886-02-22490088 (K.-C.C.); +886-02-27361661 (C.-C.P.)
| | - Chiung-Chi Peng
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan;
- Correspondence: (K.-C.C.); (C.-C.P.); Tel.: +886-02-22490088 (K.-C.C.); +886-02-27361661 (C.-C.P.)
| |
Collapse
|
4
|
Siddiqi N, Shatat IF. Antihypertensive agents: a long way to safe drug prescribing in children. Pediatr Nephrol 2020; 35:2049-2065. [PMID: 31676933 PMCID: PMC7515858 DOI: 10.1007/s00467-019-04314-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/12/2019] [Accepted: 07/23/2019] [Indexed: 01/07/2023]
Abstract
Recently updated clinical guidelines have highlighted the gaps in our understanding and management of pediatric hypertension. With increased recognition and diagnosis of pediatric hypertension, the use of antihypertensive agents is also likely to increase. Drug selection to treat hypertension in the pediatric patient population remains challenging. This is primarily due to a lack of large, well-designed pediatric safety and efficacy trials, limited understanding of pharmacokinetics in children, and unknown risk of prolonged exposure to antihypertensive therapies. With newer legislation providing financial incentives for conducting clinical trials in children, along with publication of pediatric-focused guidelines, literature available for antihypertensive agents in pediatrics has increased over the last 20 years. The objective of this article is to review the literature for safety and efficacy of commonly prescribed antihypertensive agents in pediatrics. Thus far, the most data to support use in children was found for angiotensin-converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB), and calcium channel blockers (CCB). Several gaps were noted in the literature, particularly for beta blockers, vasodilators, and the long-term safety profile of antihypertensive agents in children. Further clinical trials are needed to guide safe and effective prescribing in the pediatric population.
Collapse
Affiliation(s)
- Nida Siddiqi
- Department of Pharmacy, Sidra Medicine, Doha, Qatar
| | - Ibrahim F. Shatat
- Pediatric Nephrology and Hypertension, Sidra Medicine, HB. 7A. 106A, PO Box 26999, Doha, Qatar ,Weill Cornell College of Medicine-Qatar, Ar-Rayyan, Qatar ,grid.259828.c0000 0001 2189 3475Medical University of South Carolina, Charleston, SC USA
| |
Collapse
|
5
|
Nifedipine Modulates Renal Lipogenesis via the AMPK-SREBP Transcriptional Pathway. Int J Mol Sci 2019; 20:ijms20071570. [PMID: 30934807 PMCID: PMC6480582 DOI: 10.3390/ijms20071570] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 03/16/2019] [Accepted: 03/27/2019] [Indexed: 12/13/2022] Open
Abstract
Lipid accumulation in renal cells has been implicated in the pathogenesis of obesity-related kidney disease, and lipotoxicity in the kidney can be a surrogate marker for renal failure or renal fibrosis. Fatty acid oxidation provides energy to renal tubular cells. Ca2+ is required for mitochondrial ATP production and to decrease reactive oxygen species (ROS). However, how nifedipine (a calcium channel blocker) affects lipogenesis is unknown. We utilized rat NRK52E cells pre-treated with varying concentrations of nifedipine to examine the activity of lipogenesis enzymes and lipotoxicity. A positive control exposed to oleic acid was used for comparison. Nifedipine was found to activate acetyl Coenzyme A (CoA) synthetase, acetyl CoA carboxylase, long chain fatty acyl CoA elongase, ATP-citrate lyase, and 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG CoA) reductase, suggesting elevated production of cholesterol and phospholipids. Nifedipine exposure induced a vast accumulation of cytosolic free fatty acids (FFA) and stimulated the production of reactive oxygen species, upregulated CD36 and KIM-1 (kidney injury molecule-1) expression, inhibited p-AMPK activity, and triggered the expression of SREBP-1/2 and lipin-1, underscoring the potential of nifedipine to induce lipotoxicity with renal damage. To our knowledge, this is the first report demonstrating nifedipine-induced lipid accumulation in the kidney.
Collapse
|
6
|
Shatat IF, Becton LJ, Woroniecki RP. Hypertension in Childhood Nephrotic Syndrome. Front Pediatr 2019; 7:287. [PMID: 31380323 PMCID: PMC6646680 DOI: 10.3389/fped.2019.00287] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 06/26/2019] [Indexed: 11/20/2022] Open
Abstract
Arterial hypertension (HTN) is commonly encountered by clinicians treating children with steroid sensitive (SSNS) and steroid resistant nephrotic syndrome (SRNS). Although the prevalence of HTN in SSNS is less documented than in SRNS, recent studies reported high prevalence in both. Studies have estimated the prevalence of HTN in different patient populations with NS to range from 8 to 59.1%. Ambulatory HTN, abnormalities in BP circadian rhythm, and measures of BP variability are prevalent in patients with NS. Multiple mechanisms and co-morbidities contribute to the pathophysiology of HTN in children with NS. Some contributing factors are known to cause acute and episodic elevations in blood pressure such as fluid shifts, sodium retention, and medication side effects (steroids, CNIs). Others are associated with chronic and more sustained HTN such as renal fibrosis, decreased GFR, and progression of chronic kidney disease. Children with NS are more likely to suffer from other cardiovascular disease risk factors, such as obesity, increased measures of arterial stiffness [increased carotid intima-media thickness (cIMT), endothelial dysfunction, increased pulse wave velocity (PWV)], impaired glucose metabolism, dyslipidemia, left ventricular hypertrophy (LVH), left ventricular dysfunction, and atherosclerosis. Those risk factors have been associated with premature death in adults. In this review on HTN in patients with NS, we will discuss the epidemiology and pathophysiology of hypertension in patients with NS, as well as management aspects of HTN in children with NS.
Collapse
Affiliation(s)
- Ibrahim F Shatat
- Pediatric Nephrology and Hypertension, Sidra Medicine, Doha, Qatar.,Department of Pediatrics, Weill Cornell College of Medicine-Qatar, Doha, Qatar.,College of Nursing, Medical University of South Carolina, Charleston, SC, United States
| | - Lauren J Becton
- Private Practice Practitioner, Pediatric Nephrology, Seattle, WA, United States
| | - Robert P Woroniecki
- Pediatric Nephrology and Hypertension, Stony Brook Children's Hospital, Stony Brook, NY, United States
| |
Collapse
|
7
|
Hammoud SH, Alkhansa S, Mahjoub N, Omar AG, El-Mas MM, Eid AA. Molecular basis of the counteraction by calcium channel blockers of cyclosporine nephrotoxicity. Am J Physiol Renal Physiol 2018; 315:F572-F582. [PMID: 29767558 DOI: 10.1152/ajprenal.00275.2017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Nephrotoxicity is a serious side effect for the immunosuppressant drug cyclosporine A(CSA). In this study, we tested the hypothesis that administration of calcium channel blockers such as verapamil or nifedipine ameliorates renal CSA-induced renal dysfunction. Furthermore, our study investigates the roles of inflammatory, oxidative, and fibrotic pathways in CSA-induced renal dysfunction. Six groups of male rats ( n = 6/group) were used and received one of the following treatments for seven consecutive days: vehicle (Cremophor EL ip), CSA (25 mg·kg-1·day-1 ip), verapamil (2 mg·kg-1·day-1 ip), nifedipine (3 mg·kg-1·day-1 ip), CSA in the presence or absence of either verapamil, or nifedipine. Biochemical and histomorphometric analyses showed that rats treated with CSA exhibited clear signs of nephrotoxicity that included 1) proteinuria and elevations in serum creatinine and blood urea nitrogen, 2) mesangial expansion, 3) increases in glomerular and tubular type IV collagen expression, and 4) increases in the glomerulosclerosis and tubulointerstitial fibrosis indices. Although the single administration of nifedipine or verapamil had no significant effect on renal pathology, or its biochemical and physiological function, the concurrent use of either calcium channel blockers significantly and equipotently ameliorated the biochemical, morphological, and functional derangements caused by CSA. More importantly, we report that the oxidative (reactive oxygen species production, NADPH-oxidase activity, and dual oxidase 1/2 levels), fibrotic (transforming growth factor-β1 expression), and inflammatory (NF-κB expression) manifestations of renal toxicity induced by CSA were significantly reversed upon administration of nifedipine or verapamil. Together, these results highlight the efficacy of calcium channel-blocking agents in attenuating CSA-induced nephrotoxicity and predisposing biochemical and molecular machineries.
Collapse
Affiliation(s)
- Safaa H Hammoud
- Department of Pharmacology and Therapeutics, Faculty of Pharmacy, Beirut Arab University , Beirut , Lebanon
| | - Sahar Alkhansa
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut , Beirut , Lebanon
| | - Neamah Mahjoub
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut , Beirut , Lebanon
| | - Amal G Omar
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Alexandria University , Alexandria , Egypt
| | - Mahmoud M El-Mas
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Alexandria University , Alexandria , Egypt
| | - Assaad A Eid
- Department of Anatomy, Cell Biology and Physiological Sciences, Faculty of Medicine, American University of Beirut , Beirut , Lebanon
| |
Collapse
|
8
|
An Update on Hypertension in Children With Type 1 Diabetes. Can J Diabetes 2018; 42:199-204. [DOI: 10.1016/j.jcjd.2018.02.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 02/21/2018] [Indexed: 12/21/2022]
|
9
|
Chopra A, Brasher P, Chaudhry H, Zheng R, Asif A, Judson MA. Proteinuria in sarcoidosis: Prevalence and risk factors in a consecutive outpatient cohort. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2017; 34:142-148. [PMID: 32476835 DOI: 10.36141/svdld.v34i2.5297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 12/22/2016] [Indexed: 11/02/2022]
Abstract
Introduction: While sarcoidosis has been recognized as a potential cause of proteinuria, no study has systematically evaluated the prevalence and risk factors for proteinuria in sarcoid patients. Methods: Consecutive sarcoid patients followed in a university clinic were identified prospectively. All patients with spot urine protein-to-creatinine ratio (UPCR) between 11-2012 and 07-2015 were included in the analysis. Proteinuria was defined as a spot UPCR equal to or exceeding 0.3 mg/mg. The primary goal of the study was to determine the prevalence of proteinuria in this sarcoidosis cohort. Results: Our study cohort consisted of 190 sarcoidosis patients (65% female, 82% white, mean age of 53 years (range 24-88)). Proteinuria was present in 14/190 (7%) of this cohort. Only5/190 patients (2.5%) had proteinuria who did not have a risk factor for proteinuria. Estimating the 24-hour urine protein excretion by extrapolating from the spot UPCR, proteinuria was moderate in amount (mean 1.60, range 0.32-5.06 mg/mg). Proteinuric patients received a lower mean daily dose of corticosteroids compared to those without proteinuria (0 mg vs 4.7 mg of prednisone); however, this difference did not reach statistical significance (p = 0.20). Conclusion: Our study found proteinuria in 7% of the 190 sarcoid patients. More than half of the patients with proteinuria had a known risk factor for proteinuria other than sarcoidosis. Proteinuria is uncommon in sarcoidosis, and, when it occurs, it should not be assumed that sarcoidosis is the cause without investigating alternative causes of proteinuria. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 142-148).
Collapse
Affiliation(s)
- Amit Chopra
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center, NY
| | - Paul Brasher
- Department of Medicine, Albany Medical College, Albany, NY
| | - Haroon Chaudhry
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center, NY
| | - Robert Zheng
- Department of Medicine, Albany Medical College, Albany, NY
| | - Arif Asif
- Department of Medicine, Nephrology, Albany Medical Center, NY
| | - Marc A Judson
- Department of Medicine, Pulmonary and Critical Care Medicine, Albany Medical Center, NY
| |
Collapse
|
10
|
Xue C, Zhou C, Yang B, Lv J, Dai B, Yu S, Wang Y, Zhao G, Mei C. Comparison of efficacy and safety between benidipine and hydrochlorothiazide in fosinopril-treated hypertensive patients with chronic kidney disease: protocol for a randomised controlled trial. BMJ Open 2017; 7:e013672. [PMID: 28237959 PMCID: PMC5337719 DOI: 10.1136/bmjopen-2016-013672] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Co-administration of a diuretic or calcium channel blocker with an ACE inhibitor are both preferred combinations in patients with hypertensive chronic kidney disease (CKD). According to the available evidence, it is still unknown which combination plays a more active role in renal protection. We hypothesised that a combination of fosinopril and benidipine may delay the progression of CKD more effectively than a combination of fosinopril and hydrochlorothiazide (HCTZ). METHODS AND ANALYSIS This study will be a multicentred, prospective, double-blind, randomised parallel controlled trial for hypertensive CKD patients in China. Patients will be randomised to one of two treatment groups: a combination of benidipine 4-8 mg/day and fosinopril 20 mg/day; or a combination of HCTZ 12.5-25 mg/day and fosinopril 20 mg/day. Patients will be followed up for 24 months after a month's fosinopril run-in. There will be dose-titration after 1 and 2 months. The primary endpoint is changes in estimated glomerular filtration rate (eGFR) from baseline to month 24. Secondary endpoints include changes in home blood pressure (BP), ambulatory BP, proteinuria, urinary albumin/creatinine ratio, and composite renal events in 24 months. Inclusion criteria are: age 18-80 years, non-dialysis CKD patients with eGFR >30 mL/min/1.73 m2, home BP >130 mm Hg systolic or BP >80 mm Hg diastolic at the screening and randomisation, and 24 hour proteinuria <3.5 g. Principal exclusions are hypertensive crisis, transplantation, cancer, severe diabetes complications, hyperkalaemia and severe allergy. The required sample size was 511 patients for detecting a difference in the change of eGFR (one sided α=0.025, power 1-β=0.90). ETHICS AND DISSEMINATION BEAHIT (Benidipine and Hydrochlorothiazide in Fosinopril Treated Chronic Kidney Disease Patients with Hypertension) was approved by Changzheng Hospital Ethics Committee (CZ-20160504-16). The outcomes will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02646397.
Collapse
Affiliation(s)
- Cheng Xue
- Division of Nephrology, Kidney Institute of CPLA, Changzheng Hospital, Second Military Medical University, Shanghai, China
- Department of Pharmacy, 309 Hospital of PLA, Beijing, China
| | - Chenchen Zhou
- Department of Nephrology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Bo Yang
- Division of Nephrology, Kidney Institute of CPLA, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jiayi Lv
- Division of Nephrology, Kidney Institute of CPLA, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Bing Dai
- Division of Nephrology, Kidney Institute of CPLA, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Shengqiang Yu
- Division of Nephrology, Kidney Institute of CPLA, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Yi Wang
- Department of Nephrology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Guanren Zhao
- Department of Pharmacy, 309 Hospital of PLA, Beijing, China
| | - Changlin Mei
- Division of Nephrology, Kidney Institute of CPLA, Changzheng Hospital, Second Military Medical University, Shanghai, China
| |
Collapse
|
11
|
Jensen LJ, Nielsen MS, Salomonsson M, Sørensen CM. T-type Ca 2+ channels and autoregulation of local blood flow. Channels (Austin) 2017; 11:183-195. [PMID: 28055302 DOI: 10.1080/19336950.2016.1273997] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
L-type voltage gated Ca2+ channels are considered to be the primary source of calcium influx during the myogenic response. However, many vascular beds also express T-type voltage gated Ca2+ channels. Recent studies suggest that these channels may also play a role in autoregulation. At low pressures (40-80 mmHg) T-type channels affect myogenic responses in cerebral and mesenteric vascular beds. T-type channels also seem to be involved in skeletal muscle autoregulation. This review discusses the expression and role of T-type voltage gated Ca2+ channels in the autoregulation of several different vascular beds. Lack of specific pharmacological inhibitors has been a huge challenge in the field. Now the research has been strengthened by genetically modified models such as mice lacking expression of T-type voltage gated Ca2+ channels (CaV3.1 and CaV3.2). Hopefully, these new tools will help further elucidate the role of voltage gated T-type Ca2+ channels in autoregulation and vascular function.
Collapse
Affiliation(s)
- Lars Jørn Jensen
- a Departments of Veterinary Clinical and Animal Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Morten Schak Nielsen
- b Department of Biomedical Sciences, Faculty of Health and Medical Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Max Salomonsson
- b Department of Biomedical Sciences, Faculty of Health and Medical Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Charlotte Mehlin Sørensen
- b Department of Biomedical Sciences, Faculty of Health and Medical Sciences , University of Copenhagen , Copenhagen , Denmark
| |
Collapse
|
12
|
Zhao HJ, Li Y, Liu SM, Sun XG, Li M, Hao Y, Cui LQ, Wang AH. Effect of calcium channels blockers and inhibitors of the renin-angiotensin system on renal outcomes and mortality in patients suffering from chronic kidney disease: systematic review and meta-analysis. Ren Fail 2016; 38:849-56. [PMID: 27055479 DOI: 10.3109/0886022x.2016.1165065] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The renoprotective effect of inhibitors of renin-angiotensin system (RAS) has been identified through placebo-controlled trials. However, the effect of calcium-channel blockers (CCBs) on renal system is still controversial. Our current meta-analysis includes available evidences to compare the effect of dihydropyridine CCBs and ACEIs or ARBs on renal outcomes and mortality. We also further investigate whether CCBs can be used in combination with inhibitors of RAS to improve the prognosis of patients with chronic kidney disease (CKD). METHODS AND RESULTS Electronic databases were searched up to July 2012, for clinical randomized controlled trials, assessing the effect of dihydropyridine CCBs on the incidence of end-stage renal disease (ESRD) and all-cause mortality in contrast to ACEIs or ARBs. Eight clinical trials were included containing 25,647 participants. ESRD showed significantly higher frequency with CCBs therapy compared with ACEIs or ARBs therapy, though blood pressure was decreased similarly in both groups in every trial (OR, 1.25; 95% CI, 1.05-1.48; p = 0.01). In contrast, there was no significant difference in the incidence of all-cause mortality between these two groups, though ACEIs or ARBs exhibited better renoprotective effect compared to CCBs (OR, 0.96; 95% CI, 0.89-1.03; p = 0.24). CONCLUSIONS CCBs did not increase all-cause mortality incidence in patients with CKD though they displayed weaker renoprotective, compared to ACEIs or ARBs therapy. Our results suggest the combination of a CCB and an ACEI or ARB should be a preferable antihypertensive therapy in patients with CKD, considering their higher effect in decreasing blood pressure and fewer adverse metabolic problems caused.
Collapse
Affiliation(s)
- Hong-Jin Zhao
- a Department of Cardiology , Provincial Hospital affiliated to Shandong University , Ji'nan , P.R.China ;,b Department of Obstetrics and Gynecology , Child & Family Research Institute, University of British Columbia , Vancouver , British Columbia , Canada
| | - Yan Li
- b Department of Obstetrics and Gynecology , Child & Family Research Institute, University of British Columbia , Vancouver , British Columbia , Canada ;,c Department of Obstetrics and Gynecology , Peking University Third Hospital , Beijing , P.R. China
| | - Shan-Mei Liu
- d Department of Nephrology , Linyi City Yishui Central Hospital, Yishui , Linyi , Shandong , P.R. China
| | - Xiang-Guo Sun
- e Department of Pediatrics , Linyi City Yishui Central Hospital, Yishui , Linyi , Shandong , P.R. China
| | - Min Li
- a Department of Cardiology , Provincial Hospital affiliated to Shandong University , Ji'nan , P.R.China
| | - Yan Hao
- a Department of Cardiology , Provincial Hospital affiliated to Shandong University , Ji'nan , P.R.China
| | - Lian-Qun Cui
- a Department of Cardiology , Provincial Hospital affiliated to Shandong University , Ji'nan , P.R.China
| | - Ai-Hong Wang
- a Department of Cardiology , Provincial Hospital affiliated to Shandong University , Ji'nan , P.R.China
| |
Collapse
|
13
|
Maranta F, Spoladore R, Fragasso G. Pathophysiological Mechanisms and Correlates of Therapeutic Pharmacological Interventions in Essential Arterial Hypertension. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 956:37-59. [PMID: 27864806 DOI: 10.1007/5584_2016_169] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Treating arterial hypertension (HT) remains a hard task. The hypertensive patient is often a subject with several comorbidities and metabolic abnormalities. Clinicians everyday have to choose the right drug for the single patient among the different classes of antihypertensives. Apart from lowering blood pressure, a main therapeutic target should be that of counteracting all the possible pathophysiological mechanisms involved in HT itself and in existing/potential comorbidities. All the ancillary positive and negative effects of the administered drugs should be considered: in particular, since hypertensive patients are often glucose intolerant/diabetic, carrier of serum lipids disorder, have already developed atherosclerotic diseases and endothelial dysfunction, they should not be treated with drugs negatively interfering with these conditions but with molecules that, if possible, improve them. The main pathophysiological mechanisms and correlates of therapeutic pharmacological interventions in essential HT are reviewed here.
Collapse
Affiliation(s)
- Francesco Maranta
- Clinical Cardiology, Heart Failure Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Spoladore
- Clinical Cardiology, Heart Failure Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Fragasso
- Clinical Cardiology, Heart Failure Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| |
Collapse
|
14
|
Chu PY, Campbell MJ, Miller SG, Hill KD. Anti-hypertensive drugs in children and adolescents. World J Cardiol 2014; 6:234-244. [PMID: 24944754 PMCID: PMC4062129 DOI: 10.4330/wjc.v6.i5.234] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 01/28/2014] [Accepted: 04/16/2014] [Indexed: 02/07/2023] Open
Abstract
Worldwide the prevalence of essential hypertension in children and adolescents continues to increase. Traditionally providers have used “off-label” drugs to treat pediatric hypertension, meaning that rigorous clinical trials of these drugs have not been specifically performed in pediatric patient populations. Consequently providers have extrapolated dosing, safety and efficacy from trials in adults. This practice is sub-optimal as children demonstrate unique differences in drug metabolism and response. Use of unstudied or understudied drugs increases risk of adverse events and/or can lead to sub-optimal efficacy. Recognizing these concerns, regulatory agencies have created financial incentives for industry to conduct pediatric clinical trials. These incentives, coupled with the emerging pediatric hypertension epidemic, have spurred over 30 clinical trials of anti-hypertensive drugs over the past 15 years and have resulted in labeling of 10 new drugs by the United States Food and Drug Administration for treatment of hypertension in children and adolescents. Unfortunately the financial incentive structures focus on newer drugs and drug classes. Consequently there is now a relative dearth of trial data for older but sometimes commonly prescribed pediatric antihypertensive drugs. This article reviews recent pediatric antihypertensive drug trials with a focus on trial design and endpoints, drug dosing, safety, efficacy and specific drug indications. We also review the available data and experience for some of the more commonly prescribed, but less well studied “older” pediatric antihypertensive drugs.
Collapse
|
15
|
Coca A, Mazón P, Aranda P, Redón J, Divisón JA, Martínez J, Calvo C, Galcerán JM, Barrios V, Coll ARCI. Role of dihydropyridinic calcium channel blockers in the management of hypertension. Expert Rev Cardiovasc Ther 2014; 11:91-105. [DOI: 10.1586/erc.12.155] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
|
16
|
Ando K, Nitta K, Rakugi H, Nishizawa Y, Yokoyama H, Nakanishi T, Kashihara N, Tomita K, Nangaku M, Takahashi K, Isshiki M, Shimosawa T, Fujita T. Comparison of the antialbuminuric effects of benidipine and hydrochlorothiazide in Renin-Angiotensin System (RAS) inhibitor-treated hypertensive patients with albuminuria: the COSMO-CKD (COmbination Strategy on Renal Function of Benidipine or Diuretics TreatMent with RAS inhibitOrs in a Chronic Kidney Disease Hypertensive Population) study. Int J Med Sci 2014; 11:897-904. [PMID: 25013370 PMCID: PMC4081312 DOI: 10.7150/ijms.9026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 05/14/2014] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE This study evaluated the non-inferiority of renoprotection afforded by benidipine versus hydrochlorothiazide in hypertensive patients with chronic kidney disease (CKD). METHODS In this prospective, multicenter, open-labeled, randomized trial, the antialbuminuric effects of benidipine and hydrochlorothiazide were examined in renin-angiotensin system (RAS) inhibitor-treated patients with blood pressure (BP) readings of ≥ 130/80 mmHg and ≤ 180/110 mmHg, a urinary albumin to creatinine ratio (UACR) of ≥ 300 mg/g, and an estimated glomerular filtration rate (eGFR) of ≥ 30 ml/min/1.73m(2). Patients received benidipine (n = 176, final dose: 4.8 mg/day) or hydrochlorothiazide (n = 170, 8.2 mg/day) for 12 months. RESULTS Benidipine and hydrochlorothiazide exerted similar BP- and eGFR-decreasing actions. The UACR values for benidipine and hydrochlorothiazide were 930.8 (95% confidence interval: 826.1, 1048.7) and 883.1 (781.7, 997.7) mg/g at baseline, respectively. These values were reduced to 790.0 (668.1, 934.2) and 448.5 (372.9, 539.4) mg/g at last observation carried forward (LOCF) visits. The non-inferiority of benidipine versus hydrochlorothiazide was not demonstrated (benidipine/hydrochlorothiazide ratio of LOCF value adjusted for baseline: 1.67 (1.40, 1.99)). CONCLUSIONS The present study failed to demonstrate the non-inferiority of the antialbuminuric effect of benidipine relative to that of hydrochlorothiazide in RAS inhibitor-treated hypertensive patients with macroalbuminuria.
Collapse
Affiliation(s)
- Katsuyuki Ando
- 1. Division of Molecular Cardiovascular Metabolism, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Kosaku Nitta
- 2. Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Hiromi Rakugi
- 3. Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yoshiki Nishizawa
- 4. Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hitoshi Yokoyama
- 5. Division of Nephrology, Kanazawa Medical University School of Medicine, Ishikawa, Japan
| | - Takeshi Nakanishi
- 6. Department of Internal Medicine, Division of Kidney and Dialysis, Hyogo College of Medicine, Nishinomiya, Japan
| | - Naoki Kashihara
- 7. Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Kimio Tomita
- 8. Department of Nephrology, Graduate School of Faculty of Life Science, Kumamoto University, Kumamoto, Japan
| | - Masaomi Nangaku
- 9. Department of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Katsutoshi Takahashi
- 9. Department of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Masashi Isshiki
- 9. Department of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Tatsuo Shimosawa
- 10. Department of Clinical Laboratory, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Toshiro Fujita
- 11. Division of Clinical Epigenetics, Research Center for Advanced Science and Technology, University of Tokyo, Tokyo, Japan
| |
Collapse
|
17
|
Gómez-Pliego R, Gómez-Zamudio J, Velasco-Bejarano B, Ibarra-Barajas M, Villalobos-Molina R. Effect of bis-1,4-dihydropyridine in the kidney of diabetic rats. J Pharmacol Sci 2013; 122:184-92. [PMID: 23823933 DOI: 10.1254/jphs.12248fp] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
The in vivo effectiveness of 4-dihydropyridine (bis-1,4-DHP), a new calcium-channel blocker, as a nephroprotector in isolated perfused kidney was evaluated by determining its effects on parameters associated with renal injury in diabetic rats. Diabetes in male Wistar rats, control, diabetic, control + bis-1,4-DHP, and diabetic + bis-1,4-DHP, was induced by a single administration of STZ (55 mg·kg(-1), i.p.). In the drug-treated groups, treatment with bis-1,4-DHP (10 mg·kg(-1)·day(-1)) started one week before diabetes induction; bis-1,4-DHP was dissolved in DMSO (0.3%) and suspended in drinking water with carboxymethyl cellulose (3%). Parameters evaluated were body weight, blood glucose, albuminuria, proteinuria, creatinine, urea excretion, kidney's weight / body weight ratio, and kidney perfusion pressure in all rat groups at different times of diabetes (2, 4, 6, and 10 weeks). Kidney weight of diabetic rats significantly increased vs. control, control + bis-1,4-DHP, and diabetic + bis-1,4-DHP rats at different times of diabetes. The ratios % kidney weight / 100 g body weight were different between control, control + bis-1,4-DHP, and diabetic + bis-1,4-DHP rats vs. diabetic rats (P < 0.05). Kidney perfusion pressure was decreased by diabetes, while it was partially recovered by bis-1,4-DHP treatment in response to phenylephrine. Bis-1,4-DHP had a tendency to decrease hyperglycemia vs. diabetic rats, even though glycemia was too high as compared with controls, and it ameliorated albuminuria, creatinine, and urea excretion, suggesting a favorable effect on renal haemodynamics. Bis-1,4-DHP, by inhibiting Ca(2+) entrance, induced vasodilation in renal vascular bed and thus may have a nephroprotective effect against diabetes-induced renal dysfunction, but does not have significant impact on hyperglycemia.
Collapse
Affiliation(s)
- Raquel Gómez-Pliego
- Biological Sciences and Human Health Section, Department of Biological Sciences, Faculty of Higher Studies Cuautitlan, National Autonomous University of México, México.
| | | | | | | | | |
Collapse
|
18
|
Geng DF, Sun WF, Yang L, En G, Wang JF. Antiproteinuric effect of angiotensin receptor blockers in normotensive patients with proteinuria: a meta-analysis of randomized controlled trials. J Renin Angiotensin Aldosterone Syst 2013; 15:44-51. [PMID: 23378528 DOI: 10.1177/1470320312474054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION The objective of this article is to evaluate the antiproteinuric effect of angiotensin receptor blockers (ARBs) in normotensive patients with proteinuria. MATERIALS AND METHODS We reviewed randomized controlled trials assessing ARBs treatment in patients with normotension and proteinuria. Data concerning the study design, patient characteristics, and outcomes were extracted. Ratio of means was calculated by using the generalized inverse variance method. RESULTS Eight trials involving 866 patients were included in this study. Compared with a control group, ARBs group was associated with a significant reduction in urinary protein excretion (ratio of means 0.53, 95% CI 0.44-0.64). Subgroup analysis shows that ARBs therapy resulted in a significant decrease in urinary protein excretion in diabetic patients with microalbuminuria or nondiabetic nephropathy with overt proteinuria (ratio of means 0.57, 95% CI 0.47-0.69 and 0.46, 95% CI 0.26-0.83, respectively), in a Western population or an Asian population (ratio of means 0.61, 95% CI 0.54-0.69 and 0.49, 95% CI 0.37-0.64, respectively), and in patients followed up for one to three months or three to 12 months (ratio of means 0.62, 95% CI 0.54-0.70 and 0.49, 95% CI 0.38-0.63, respectively). CONCLUSIONS The data suggest that ARBs may have beneficial effects in preventing the progression of proteinuria in normotensive patients with renal disease.
Collapse
|
19
|
Ando K, Ueshima K, Tanaka S, Kosugi S, Sato T, Matsuoka H, Nakao K, Fujita T. Comparison of the antialbuminuric effects of L-/N-type and L-type calcium channel blockers in hypertensive patients with diabetes and microalbuminuria: the study of assessment for kidney function by urinary microalbumin in randomized (SAKURA) trial. Int J Med Sci 2013; 10:1209-16. [PMID: 23935398 PMCID: PMC3739020 DOI: 10.7150/ijms.5508] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 05/13/2013] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To clarify whether the L-/N-type calcium channel blocker (CCB) cilnidipine is more renoprotective than the L-type CCB amlodipine in patients with early-stage diabetic nephropathy. METHODS In this prospective, multicenter, open-labeled, randomized trial, the antialbuminuric effects of cilnidipine and amlodipine were examined in renin-angiotensin system (RAS) inhibitor-treated patients with hypertension (blood pressure [BP]: 130-180/80-110 mmHg), type 2 diabetes, and microalbuminuria (urinary albumin to creatinine [Cr] ratio [UACR]: 30-300 mg/g). RESULTS Patients received cilnidipine (n = 179, final dose: 10.27 ± 4.13 mg/day) or amlodipine (n = 186, 4.87 ± 2.08 mg/day) for 12 months. Cilnidipine and amlodipine equally decreased BP. The UACR values for the cilnidipine and amlodipine groups were 111.50 ± 138.97 and 88.29 ± 63.45 mg/g, respectively, before treatment and 107.93 ± 130.23 and 89.07 ± 97.55 mg/g, respectively, after treatment. The groups showed similar changes for the natural logarithm of the UACR, serum Cr, and estimated glomerular filtration rate. CONCLUSIONS Cilnidipine did not offer greater renoprotection than amlodipine in RAS inhibitor-treated hypertensive patients with type 2 diabetes and microalbuminuria.
Collapse
Affiliation(s)
- Katsuayuki Ando
- Department of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan.
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Hypertension and chronic kidney disease progression: why the suboptimal outcomes? Am J Med 2012; 125:1057-62. [PMID: 22906957 PMCID: PMC3943135 DOI: 10.1016/j.amjmed.2012.04.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 04/04/2012] [Accepted: 04/07/2012] [Indexed: 01/13/2023]
Abstract
Current therapeutic interventions to retard the progression of chronic kidney disease have yielded disappointing outcomes despite adequate renin-angiotensin system blockade. The parameters to gauge the adequacy of blood pressure control need to be reassessed because clinic blood pressure constitutes a poor gauge of such control. The biologically relevant parameter for hypertensive target organ damage is total blood pressure burden, and reliance on isolated clinic blood pressure measurements per se does not accurately reflect the total blood pressure burden. This is particularly relevant to the population with chronic kidney disease in whom masked daytime or nocturnal hypertension and blood pressure lability are both widely prevalent and more difficult to control. Consequently, it is possible that the limited success currently being achieved in preventing or attenuating chronic kidney disease progression may be attributable in part to suboptimal 24-hour blood pressure control. Recent data and analyses also indicate that blood pressure variability, instability, episodic and nocturnal blood pressure elevations, and maximum systolic blood pressure may constitute additional strong predictors of the risk of target organ damage independently of mean systolic blood pressure. Accordingly, we suggest that future research should include the development of safe and effective strategies to achieve around-the-clock blood pressure control in addition to targeting mechanisms that reduce intrarenal blood pressure transmission or interrupt subsequent downstream pathways. Meanwhile, more aggressive use of patient education and home blood pressure monitoring with selection of longer-acting antihypertensive agents or nocturnal dosing should be considered to improve the current suboptimal results.
Collapse
|
21
|
Akbar DH, Hagras MM, Amin HA, Khorshid OA. Comparison between the effect of glibenclamide and captopril on experimentally induced diabetic nephropathy in rats. J Renin Angiotensin Aldosterone Syst 2012; 14:103-15. [PMID: 23077081 DOI: 10.1177/1470320312460881] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
HYPOTHESIS This study aimed to elucidate the role of glibenclamide in the prevention of diabetic nephropathy and to compare it with a reference drug captopril in rats. MATERIALS AND METHODS There were two main groups of rats. Control group (I) was subdivided into four subgroups which received distilled water, vehicle of streptozotocin, glibenclamide or captopril. The streptozotocin-diabetic Group (II) was subdivided into three subgroups: untreated, glibenclamide or captopril treated. Measurement of arterial blood pressure, serum glucose and creatinine levels, 24 h urinary protein and albumin/creatinine ratio, kidney weight and its histological examination were done after 1, 2, 4, 8, 12 and 16 weeks of treatment. RESULTS In treated diabetic rats captopril reduced blood pressure significantly, while no significant change in the mean arterial blood pressure or blood glucose level was recorded with glibenclamide treatment. Glibenclamide and captopril-treated diabetic rats showed significant decrease in serum creatinine level, urine volume, urinary protein excretion, albumin:creatinine ratio and kidney:body weight ratio compared with the diabetic non-treated group. Histological examination of diabetic kidneys treated with either glibenclamide or captopril showed reduced glomerular hypertrophy, glomerulosclerosis, tubular degeneration and interstitial fibrosis compared with untreated diabetic rats. CONCLUSION Glibenclamide attenuated some biochemical and histological changes produced by diabetic nephropathy, despite persistent hyperglycemia and hypertension.
Collapse
Affiliation(s)
- Daad H Akbar
- Internal Medicine Department, Faculty of Medicine, King Abdulaziz, University, Saudi Arabia
| | | | | | | |
Collapse
|
22
|
Reeves WB, Rawal BB, Abdel-Rahman EM, Awad AS. Therapeutic Modalities in Diabetic Nephropathy: Future Approaches. OPEN JOURNAL OF NEPHROLOGY 2012; 2:5-18. [PMID: 23293752 PMCID: PMC3534956 DOI: 10.4236/ojneph.2012.22002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Diabetes mellitus is the leading cause of end stage renal disease and is responsible for more than 40% of all cases in the United States. Several therapeutic interventions for the treatment of diabetic nephropathy have been developed and implemented over the past few decades with some degree of success. However, the renal protection provided by these therapeutic modalities is incomplete. More effective approaches are therefore urgently needed. Recently, several novel therapeutic strategies have been explored in treating DN patients including Islet cell transplant, Aldose reductase inhibitors, Sulodexide (GAC), Protein Kinase C (PKC) inhibitors, Connective tissue growth factor (CTGF) inhibitors, Transforming growth factor-beta (TGF-β) inhibitors and bardoxolone. The benefits and risks of these agents are still under investigation. This review aims to summarize the utility of these novel therapeutic approaches.
Collapse
Affiliation(s)
- William Brian Reeves
- Department of Medicine, Division of Nephrology, Penn State Hershey Medical Center, Hershey, USA
| | - Bishal B. Rawal
- Department of Medicine, Division of Nephrology, Penn State Hershey Medical Center, Hershey, USA
| | - Emaad M. Abdel-Rahman
- Department of Medicine, Division of Nephrology, University of Virginia, Charlottesville, USA
| | - Alaa S. Awad
- Department of Medicine, Division of Nephrology, Penn State Hershey Medical Center, Hershey, USA
| |
Collapse
|
23
|
Abdel-Rahman EM, Saadulla L, Reeves WB, Awad AS. Therapeutic modalities in diabetic nephropathy: standard and emerging approaches. J Gen Intern Med 2012; 27:458-68. [PMID: 22005942 PMCID: PMC3304033 DOI: 10.1007/s11606-011-1912-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Revised: 08/09/2011] [Accepted: 09/21/2011] [Indexed: 02/06/2023]
Abstract
Diabetes mellitus is the leading cause of end stage renal disease and is responsible for more than 40% of all cases in the United States. Current therapy directed at delaying the progression of diabetic nephropathy includes intensive glycemic and optimal blood pressure control, proteinuria/albuminuria reduction, interruption of the renin-angiotensin-aldosterone system through the use of angiotensin converting enzyme inhibitors and angiotensin type-1 receptor blockers, along with dietary modification and cholesterol lowering agents. However, the renal protection provided by these therapeutic modalities is incomplete. More effective approaches are urgently needed. This review highlights the available standard therapeutic approaches to manage progressive diabetic nephropathy, including markers for early diagnosis of diabetic nephropathy. Furthermore, we will discuss emerging strategies such as PPAR-gamma agonists, Endothelin blockers, vitamin D activation and inflammation modulation. Finally, we will summarize the recommendations of these interventions for the primary care practitioner.
Collapse
Affiliation(s)
- Emaad M. Abdel-Rahman
- Department of Medicine, Division of Nephrology, University of Virginia, Charlottesville, VA USA
| | - Lawand Saadulla
- Department of Medicine, Division of Nephrology, Penn State Hershey Medical Center, College of Medicine, Hershey, PA USA
| | - W. Brian Reeves
- Department of Medicine, Division of Nephrology, Penn State Hershey Medical Center, College of Medicine, Hershey, PA USA
| | - Alaa S. Awad
- Department of Medicine, Division of Nephrology, Penn State Hershey Medical Center, College of Medicine, Hershey, PA USA
| |
Collapse
|
24
|
Fragasso G, Maranta F, Montanaro C, Salerno A, Torlasco C, Margonato A. Pathophysiologic therapeutic targets in hypertension: a cardiological point of view. Expert Opin Ther Targets 2012; 16:179-93. [DOI: 10.1517/14728222.2012.655724] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
|
25
|
Matsuoka H, Ando K, Ueshima K, Babazono T, Kario K, Tanaka S, Nakao K, Fujita T. Design and rationale of the study of assessment for kidney function by urinary microalbumin in randomized (SAKURA) trial. Clin Exp Hypertens 2011; 33:455-62. [PMID: 21649534 DOI: 10.3109/10641963.2010.549271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Recently, it has been demonstrated that L-/N-type calcium channel blockers (CCBs), cilnidipine, but not L-type CCB, decreased urinary protein in renin-angiotensin system (RAS), inhibitor-treated hypertensive patients with macroproteinuria. However, the antiproteinuric effect of cilnidipine was weaker in diabetic patients than in nondiabetic patients with macroproteinuria. This may be due to the fact that diabetic neuropathy was also developed in patients with advanced diabetic nephropathy because L-/N-type CCB has been considered to exert its renoprotetive effects through sympatholytic action. If so, the antiproteinuric effect of cilnidipine may be potent in patients with early stages of diabetic nephropathy. To elucidate our hypothesis, we designed a multi-center, open-labeled, randomized trial to compare the antialbuminuric effect between cilnidipine and amlodipine in RAS inhibitor-treated hypertensive (blood pressure [BP]: 130-180/80-110 mmHg) patients with type 2 diabetes and microalbuminuria (urinary albumin/creatinine [Cr] ratio: 30-300 mg/g). The primary study endpoint is the change in the urinary albumin/Cr ratio after a 1-year treatment. Enrollment began in April 2008 and was completed in March 2010. A total of 367 patients were randomly allocated to receive cilnidipine or amlodipine. At baseline, study subjects had 63.3± 8.5 years of age, 145.9 ± 12.2/80.8 ± 10.0 mmHg of BP, 101.0 ± 111.6 mg/g of urinary albumin/Cr. The trial is expected to show whether cilnidipine can exert an antialbuminuric effect in RAS inhibitor-treated hypertensive patients with early stages of diabetic nephropathy.
Collapse
|
26
|
Effects of up-titration of candesartan versus candesartan plus amlodipine on kidney function in type 2 diabetic patients with albuminuria. J Hum Hypertens 2011; 26:214-9. [DOI: 10.1038/jhh.2011.22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
27
|
MICHELL AR. Diet and Chronic Renal Failure: Is 'Self-Sustaining Progression' in Terminal Decline? ACTA ACUST UNITED AC 2009. [DOI: 10.1080/13590849961852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- A. R. MICHELL
- Centre for Small Animal Studies, Animal Health Trust, Lanwades Park, Kentford, Newmarket, Suffolk CB8 7UU, UK
| |
Collapse
|
28
|
Ziakka S, Kaperonis N, Ferentinou E, Karakasis F, Ntatsis G, Kourvelou C, Papagalanis N. Calcium Channels Blockers and Progression of Kidney Disease. Ren Fail 2009; 29:1003-12. [DOI: 10.1080/08860220701643559] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
|
29
|
Bidani AK, Griffin KA, Williamson G, Wang X, Loutzenhiser R. Protective importance of the myogenic response in the renal circulation. Hypertension 2009; 54:393-8. [PMID: 19546375 DOI: 10.1161/hypertensionaha.109.133777] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Anil K Bidani
- Loyola University Medical Center, 2160 South First Ave, Maywood, IL 60153, USA.
| | | | | | | | | |
Collapse
|
30
|
Abstract
Antihypertensive therapy remains the most effective strategy for slowing the progression of chronic kidney disease (CKD). However, in proteinuric nephropathies, calcium channel blockers (CCBs) are less effective than other antihypertensives unless normotension is achieved. This is because the glomerular capillaries, rather than larger vessels, are the primary site of hypertensive injury in proteinuric nephropathies. CCBs impair renal autoregulation, which protects glomerular capillaries against the transmission of systemic pressures. CCBs' renoprotective inferiority in the comparator group likely accounts for the greater renoprotection observed with renin-angiotensin system blockade rather than blood pressure (BP)-independent renoprotective superiority. Nevertheless, CKD patients are at greater absolute risk for cardiovascular events rather than end-stage renal disease. Therefore, if the needed BP reductions cannot be achieved with other agents, it may be appropriate to use CCBs because of their antihypertensive effectiveness, provided care is taken to ensure normotension and to closely monitor proteinuria and renal disease progression.
Collapse
|
31
|
Wang X, Cupples WA. Brown Norway rats show impaired nNOS-mediated information transfer in renal autoregulationThis article is part of a Special Issue on Information Transfer in the Microcirculation. Can J Physiol Pharmacol 2009; 87:29-36. [DOI: 10.1139/y08-102] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Nonselective inhibition of NO synthase (NOS) augments myogenic autoregulation of renal blood flow (RBF) and profoundly reduces RBF. Previously in Wistar rats, we showed that augmented autoregulation, but not vasoconstriction, is duplicated by intrarenal inhibition of neuronal NOS (nNOS), whereas intrarenal inhibition of inducible NOS (iNOS) has no effect on RBF or on RBF dynamics. Thus macula densa nNOS transfers information from tubuloglomerular feedback to the afferent arteriole. This information flow requires that macula densa nNOS can sufficiently alter ambient NO concentration, that is, that endothelial NOS (eNOS) and iNOS do not alter local NO concentration. Because the Brown Norway rat often shows exaggerated responses to NOS inhibition and has peculiarities of renal autoregulation that are related to NO, we used this strain to study systemic and renal vascular responses to NOS inhibition. The first experiment showed transient blood pressure reduction by bolus i.v. acetylcholine that was dose-dependent in both strains and substantially prolonged in Brown Norway rats. The depressor response decayed more rapidly after nonselective NOS inhibition and the difference between strains was lost, indicating a greater activity of eNOS in Brown Norway rats. In Brown Norway rats, selective inhibition of iNOS reduced RBF (–16% ± 7%) and augmented myogenic autoregulation, whereas nNOS inhibition reduced RBF (–25% ± 4%) and did not augment myogenic autoregulation. The significant responses to intrarenal iNOS inhibition, the reduced modulation of autoregulation by nNOS inhibition, and the enhanced endothelial depressor response suggest that physiological signalling by NO within the kidney is impaired in Brown Norway rats because of irrelevant or inappropriate input of NO by eNOS and iNOS.
Collapse
Affiliation(s)
- Xuemei Wang
- Lady Davis Institute for Medical Research, SMBD-Jewish General Hospital, Montreal, Quebec
- Smooth Muscle Research Group, Faculty of Medicine, University of Calgary, Calgary, Alberta
- Centre for Biomedical Research and Biology Department, University of Victoria, PO Box 3020, Stn. CSC, Victoria, BC V8W 3N5, Canada
| | - William A. Cupples
- Lady Davis Institute for Medical Research, SMBD-Jewish General Hospital, Montreal, Quebec
- Smooth Muscle Research Group, Faculty of Medicine, University of Calgary, Calgary, Alberta
- Centre for Biomedical Research and Biology Department, University of Victoria, PO Box 3020, Stn. CSC, Victoria, BC V8W 3N5, Canada
| |
Collapse
|
32
|
Abstract
Chronic kidney disease is both a cause and a consequence of hypertension. Extracellular volume expansion is an important, if not the most important, contributing factor to hypertension seen in chronic kidney disease. Beyond volume expansion, chronic kidney disease-related hypertension is without truly defining characteristics. Consequently, the sequencing of antihypertensive medications for the patient with chronic kidney disease and hypertension becomes arbitrary. Prescription practice in such patients should be mindful of the need for multiple drug classes with at least one of them being a diuretic. Blood pressure goals in the patient with chronic kidney disease and hypertension are set at lower levels than those for patients with essential hypertension alone. It remains to be determined to what level blood pressure should be lowered in the patient with chronic kidney disease, however.
Collapse
Affiliation(s)
- Domenic A Sica
- Section of Clinical Pharmacology and Hypertension, Division of Nephrology, Virginia Commonwealth University Health System, Richmond, VA 23298-0160, USA.
| |
Collapse
|
33
|
Simonetti GD, Santoro L, Ferrarini A, Crosazzo-Franscini L, Fossali E, Bianchetti MG. Systemic hypertension and proteinuria in childhood chronic renal parenchymal disease: role of antihypertensive drug management. Paediatr Drugs 2008; 9:413-8. [PMID: 18052411 DOI: 10.2165/00148581-200709060-00008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
A variety of chronic kidney diseases tend to progress towards end-stage kidney disease. Progression is largely due to factors unrelated to the initial disease, including systemic hypertension and proteinuria. Drugs that block the renin-angiotensin II-aldosterone system, either ACE inhibitors or angiotensin II receptor antagonists, reduce both BP and proteinuria and appear superior to a more conventional antihypertensive treatment regimen in preventing progression to end-stage kidney disease. The most recent recommendations state that the BP goal in children with chronic kidney disease is the corresponding 90th centile for body height, age, and gender. Since satisfactory BP control is often not achieved, the mnemonic acronym DELTAREPROSI was generated to recall the following tips for the practical management of hypertension and proteinuria in childhood chronic renal parenchymal disease: DEfinition of hypertension and Low blood pressure TArget in REnal disease (90th centile calculated by means of simple formulas), potential of drugs inhibiting the REnin-angiotensin II-aldosterone system in hypertension and PROteinuria, advantages of SImplified treatment regimens and escalating the doses every SIx weeks.
Collapse
|
34
|
Fujita T, Ando K, Nishimura H, Ideura T, Yasuda G, Isshiki M, Takahashi K. Antiproteinuric effect of the calcium channel blocker cilnidipine added to renin-angiotensin inhibition in hypertensive patients with chronic renal disease. Kidney Int 2007; 72:1543-9. [DOI: 10.1038/sj.ki.5002623] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
|
35
|
Rajput RK. Systemic Hypertension – Newer Guidelines. APOLLO MEDICINE 2007. [DOI: 10.1016/s0976-0016(11)60447-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
|
36
|
Segura J, García-Donaire JA, Ruilope LM. Are differences in calcium antagonists relevant across all stages of nephropathy or only proteinuric nephropathy? Curr Opin Nephrol Hypertens 2007; 16:422-6. [PMID: 17693756 DOI: 10.1097/mnh.0b013e328285dfc4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW The main effects of classic calcium antagonists are mediated by the inhibition of L-type calcium channels broadly distributed within the renal vascular bed. Calcium antagonists act predominantly on the afferent arterioles, and dihydropyridines can favour the increase in glomerular hypertension and progression of kidney diseases, in particular when systemic blood pressure remains uncontrolled. RECENT FINDINGS Calcium antagonists have been widely used in clinical practice because of their antihypertensive capacity. The prevention of renal damage is a very important aim of antihypertensive therapy. This is particularly so taking into account the high prevalence of chronic kidney disease in the general population. Non-dihydropyridines such as verapamil have been shown to possess an antiproteinuric effect that could be particularly relevant. SUMMARY Recent data from clinical trials have confirmed that, in hypertensive patients with preserved renal function or with chronic kidney disease, calcium antagonists are effective antihypertensive drugs to be considered alone or in combination with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. In those patients presenting with proteinuric kidney disease, non-dihydropyridines could reduce proteinuria to a greater degree than dihydropyridines.
Collapse
Affiliation(s)
- Julián Segura
- Hypertension Unit, Hospital 12 de Octubre, Madrid, Spain
| | | | | |
Collapse
|
37
|
Abstract
The incidence of chronic kidney disease is steadily increasing in the United States. The magnitude of this problem is such that virtually all health care providers are being called upon to manage these patients. The interplay between chronic kidney disease and drug therapy is complex in that the kidney is both a target for drug effect as well as a moderator of drug elimination. Renal drug elimination occurs by filtration, secretion, and/or metabolism. For renally-cleared compounds, drug clearance typically falls in tandem with the loss of renal function. This process is noteworthy for drug accumulation when the glomerular filtration rate approaches the 30-cc/min range. The kidney is a target for drug effect in relationship to blood pressure and protein excretion. Angiotensin-converting enzyme inhibitor and angiotensin receptor blocker therapy (usually given along with a diuretic) are the drug classes that have been shown to be effective for reduction in both blood pressure and protein excretion in the chronic kidney disease patient. A number of questions still remain unanswered in the pharmacotherapy of chronic kidney disease, including the optimal dose for these drugs as well as what represents the most favorable achieved blood pressure.
Collapse
Affiliation(s)
- Domenic A Sica
- Section of Clinical Pharmacology and Hypertension, Division of Nephrology, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA 23298-0160, USA.
| |
Collapse
|
38
|
Abstract
All children aged > or = 3 years should have an annual blood pressure (BP) measurement taken during a routine physical examination. Physicians should become familiar with recommended pediatric normative BP tables. BP above the 95th percentile may require drug therapy. There are several categories of antihypertensives available to the clinician. Calcium channel antagonists (CCAs) are a class of drugs that exert their antihypertensive effect by inhibiting the influx of calcium ions across the cell membranes. This results in dilatation of peripheral arterioles. When given orally, CCAs are metabolised in the liver by cytochrome P450 (CYP) enzyme CYP3A4; hence, some CCAs will affect the half-life of drugs that share this enzyme system for their metabolism. CCAs can be safely used in children with renal insufficiency or failure and as a general rule there is no need to modify drug dosage in this population. CCAs are generally well tolerated; most adverse effects appear to be dose related. Headache, flushing, gastrointestinal upset, and edema of the lower extremities are the most common symptoms reported with the use of CCAs. Pediatric data regarding safety and efficacy of CCAs have mostly been obtained from retrospective analyses. Extended-release nifedipine and amlodipine are the two most commonly used oral CCAs in the management of pediatric hypertension. These drugs can be given once a day, although many children require twice-daily administration. Extended-release nifedipine has to be swallowed whole; hence, its use in younger children who cannot swallow pills is limited. Amlodipine can be made into a solution without compromising its long duration of action; therefore, it is the CCA of choice for very young children. Oral short-acting nifedipine and intravenous nicardipine are safe and effective CCAs for the management of hypertensive crisis in children. Short-acting nifedipine can cause unpredictable changes in BP; hence, it should be used cautiously and in low doses. Intravenous nicardipine has a rapid onset of action and a short half-life. Intravenous infusion of nicardipine can be titrated for effective control of BP. Intravenous nicardipine has been used safely in hospitalized children and newborns for the management of hypertensive crisis, and for controlled hypotension during surgery. CCAs are a class of antihypertensives that are safe and effective in pediatric patients. They have relatively few adverse effects and are well tolerated by children. This article reviews CCAs as antihypertensives in the management of pediatric hypertension.
Collapse
Affiliation(s)
- Shobha Sahney
- Division of Pediatric Nephrology, Loma Linda Children's Hospital, Loma Linda, California 92354, USA.
| |
Collapse
|
39
|
Yamagishi S, Nakamura K. Revival of nifedipine, a dihydropyridine-based calcium blocker. Med Hypotheses 2007; 68:565-7. [PMID: 17011717 DOI: 10.1016/j.mehy.2006.05.070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2006] [Accepted: 05/16/2006] [Indexed: 11/23/2022]
Abstract
A recent analysis by the Blood Pressure Lowering Treatment Trialists' Collaboration revealed that any commonly-used blood pressure (BP)-lowering regimen reduced the risk of total major cardiovascular events, and larger reductions in BP produced larger reductions in the risk. These observations suggest that most of the differences among treatment regimens in their effects on cardiovascular outcomes could be explained by the differences in achieved BP level. However, it may also be true that some treatment regimen is superior or inferior to others with regard to the risk reduction of cardiovascular events. Indeed, the data from dihydropyridine-based calcium antagonist (DHP) trails are consistent in that they could not protect against new-onset heart failure or progression of renal disease in patients with left-ventricular systolic dysfunction or overt proteinuria, respectively. However, a multicenter, randomized, placebo-controlled, double-blind ACTION trial, which compared the effect of long-acting nifedipine or placebo on mortality and cardiovascular morbidity in patients with stable angina, revealed that nifedipine reduced the risk for new-onset overt heart failure by 29%. Further, an open-label, randomized prospective J-MIND trial, which compared the effect of long-acting nifedipine or enalapril, an angiotensin-converting enzyme inhibitor on onset and progression of nephropathy in hypertensive patients with type 2 diabetes, showed that long-acting nifedipine had an equipotent reoprotective effect on diabetic nephropathy. In this paper, we would like to propose our hypothesis that nifedipine may be unique and superior in its effects on heart failure and proteinuria compared with various DHPs. For ensuring our hypothesis, the following clinical issues would be addressed. Does nifedipine treatment alone decrease the progression of renal disease with overt proteinuria? If these answers are yes, are these beneficial effects of nifedipine superior to that of other DHPs with equihypotensive properties? Does nifedipine treatment also reduce oxidative stress markers? Are these unique effects of nifedipine correlated with its anti-oxidative properties? These prospective studies will provide further valuable information whether nifedipine may be a preferred DHP to achieve BP goals in hypertensive patients with systolic dysfunction or overt proteinuria.
Collapse
Affiliation(s)
- S Yamagishi
- Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan.
| | | |
Collapse
|
40
|
Griffin KA, Bidani AK. Progression of renal disease: renoprotective specificity of renin-angiotensin system blockade. Clin J Am Soc Nephrol 2006; 1:1054-65. [PMID: 17699327 DOI: 10.2215/cjn.02231205] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Recent guidelines for management of patients with chronic kidney disease recommend both lower optimal BP targets and agents that block the renin-angiotensin system (RAS) for specific additional BP-independent renoprotection. Although there are other compelling rationales to use RAS blockade in patients with chronic kidney disease, including its antihypertensive effectiveness and ability to counteract the adverse effects of diuretics, a critical review of the available scientific evidence suggests that the specificity of renoprotection that is provided by RAS blockade has been greatly overemphasized. Little evidence of truly BP-independent renoprotection is observed in experimental animal models when ambient BP is assessed adequately by chronic continuous BP radiotelemetry. Although the clinical trial evidence is somewhat stronger, nevertheless, even when interpreted favorably, the absolute magnitude of the BP-independent component of the renoprotection that is observed with RAS blockade is much smaller than what is due to its antihypertensive effects.
Collapse
Affiliation(s)
- Karen A Griffin
- Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA.
| | | |
Collapse
|
41
|
Loutzenhiser R, Griffin K, Williamson G, Bidani A. Renal autoregulation: new perspectives regarding the protective and regulatory roles of the underlying mechanisms. Am J Physiol Regul Integr Comp Physiol 2006; 290:R1153-67. [PMID: 16603656 PMCID: PMC1578723 DOI: 10.1152/ajpregu.00402.2005] [Citation(s) in RCA: 183] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
When the kidney is subjected to acute increases in blood pressure (BP), renal blood flow (RBF) and glomerular filtration rate (GFR) are observed to remain relatively constant. Two mechanisms, tubuloglomerular feedback (TGF) and the myogenic response, are thought to act in concert to achieve a precise moment-by-moment regulation of GFR and distal salt delivery. The current view is that this mechanism insulates renal excretory function from fluctuations in BP. Indeed, the concept that renal autoregulation is necessary for normal renal function and volume homeostasis has long been a cornerstone of renal physiology. This article presents a very different view, at least regarding the myogenic component of this response. We suggest that its primary purpose is to protect the kidney against the damaging effects of hypertension. The arguments advanced take into consideration the unique properties of the afferent arteriolar myogenic response that allow it to protect against the oscillating systolic pressure and the accruing evidence that when this response is impaired, the primary consequence is not a disturbed volume homeostasis but rather an increased susceptibility to hypertensive injury. It is suggested that redundant and compensatory mechanisms achieve volume regulation, despite considerable fluctuations in distal delivery, and the assumed moment-by-moment regulation of renal hemodynamics is questioned. Evidence is presented suggesting that additional mechanisms exist to maintain ambient levels of RBF and GFR within normal range, despite chronic alterations in BP and severely impaired acute responses to pressure. Finally, the implications of this new perspective on the divergent roles of the myogenic response to pressure vs. the TGF response to changes in distal delivery are considered, and it is proposed that in addition to TGF-induced vasoconstriction, vasodepressor responses to reduced distal delivery may play a critical role in modulating afferent arteriolar reactivity to integrate the regulatory and protective functions of the renal microvasculature.
Collapse
|
42
|
Loutzenhiser R, Griffin KA, Bidani AK. Systolic blood pressure as the trigger for the renal myogenic response: protective or autoregulatory? Curr Opin Nephrol Hypertens 2006; 15:41-9. [PMID: 16340665 DOI: 10.1097/01.mnh.0000199011.41552.de] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The ability of the kidney to autoregulate renal blood flow and glomerular filtration rate has long been viewed as existing to prevent fluctuations in blood pressure from causing parallel fluctuations in renal function and distal delivery of filtrate. This review, however, points out that the primary consequence of the loss of this autoregulatory capacity is not a disturbance in volume regulation, but rather an increased susceptibility to hypertensive injury. Moreover, the kinetic requirements for renal protection indicate that current views of dynamic autoregulation cannot explain how the kidney is normally protected against acute elevations in systolic blood pressure. RECENT FINDINGS Recent findings suggest that the kinetics of the myogenic mechanism of the afferent arteriole are uniquely suited to protect against acute elevations in the systolic blood pressure, in that this vessel not only senses this rapidly oscillating blood pressure component, but that its response is exclusively dependent on this signal. SUMMARY These new findings are consistent with recent data indicating that it is the systolic blood pressure elevations that most closely correlate with target organ damage. The fact that the myogenic mechanism is also a necessary component of renal autoregulation may explain the strong linkage between autoregulatory impairment and increased susceptibility to hypertensive injury.
Collapse
Affiliation(s)
- Rodger Loutzenhiser
- Smooth Muscle Research Group, Department of Pharmacology and Therapeutics, University of Calgary Faculty of Medicine, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada.
| | | | | |
Collapse
|
43
|
Abstract
Calcium antagonists comprise 2 main subclasses, dihydropyridines and nondihydropyridines, and have been studied extensively in hypertensive patients. Early meta-analyses suggested that short-acting calcium antagonists were associated with higher mortality rates resulting from cardiovascular events and other etiologies. Recent meta-analyses failed to show any substantive difference between long acting calcium antagonists and other antihypertensive drug classes with regard to cardiovascular outcomes in those with low to moderate cardiovascular risk or kidney disease progression among those with stage 2 or 3 nonproteinuric kidney diseases. The data from calcium antagonist trials are consistent in that they decrease stroke incidence but fail to protect against new-onset heart failure. In people with proteinuric kidney disease, that is > 300 mg protein/gram creatinine, use of dihydropyridine calcium antagonists to lower blood pressure without the use of agents that block the renin angiotensin aldosterone system does not provide optimal slowing of nephropathy progression. This relates directly to lack of antiproteinuric effects with this subclass and not seen with nondihydropyridine agents that reduce proteinuria to a greater degree than dihydropyridines. Thus, calcium antagonists are safe and as efficacious as other antihypertensive agents to reduce cardiovascular risk. They should be avoided in people with systolic dysfunction but may be used for blood pressure lowering in people with preserved systolic function. Dihydropyridine calcium antagonists should only be used in conjunction with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in proteinuric kidney disease because they will not optimally slow kidney function loss in their absence.
Collapse
Affiliation(s)
- Sandeep Nathan
- Department of Preventive Medicine, Hypertension/Clinical Research Center, Rush University Medical Center, Chicago, IL 60612, USA
| | | | | |
Collapse
|
44
|
Jacob F, Polzin DJ, Osborne CA, Neaton JD, Kirk CA, Allen TA, Swanson LL. Evaluation of the association between initial proteinuria and morbidity rate or death in dogs with naturally occurring chronic renal failure. J Am Vet Med Assoc 2005; 226:393-400. [PMID: 15702689 DOI: 10.2460/javma.2005.226.393] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether urine protein-to-creatinine ratio (UP:C) > or = 1.0 at initial diagnosis of chronic renal failure (CRF) is associated with greater risk of development of uremic crises, death, and progression of renal failure in dogs. DESIGN Prospective cohort study. ANIMALS 45 dogs with CRF PROCEDURE: Dogs were prospectively assigned to 2 groups on the basis of initial UP:C < 1.0 or 2 > or = 1.0. The association between magnitude of proteinuria and development of uremic crises and death was determined before and after dogs with initial UP:C > or =1.0 were assigned to 3 subgroups and compared with dogs with initial UP:C < 1.0. Changes in reciprocal serum creatinine concentration were used to estimate decrease in renal function. RESULTS Initially, dogs had similar clinical characteristics with the exception of systolic blood pressure and UP:C. Relative risks of development of uremic crises and death were approximately 3 times higher in dogs with UP:C > or =1.0, compared with dogs with UP:C < 1.0. Relative risk of adverse outcome was approximately 1.5 times higher for every 1-unit increment in UP:C. The decrease in renal function was of greater magnitude in dogs with UP:C > or =1.0, compared with dogs with UP:C < 1.0. CONCLUSIONS AND CLINICAL RELEVANCE Initial UP:C > or =1.0 in dogs with CRF was associated with greater risk of development of uremic crises and death, compared with dogs with UP:C < 1.0. Initial determinations of UP:C in dogs with naturally occurring CRF may be of value in refining prognoses.
Collapse
Affiliation(s)
- Frédéric Jacob
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Minnesota, Saint Paul, MN 55108, USA
| | | | | | | | | | | | | |
Collapse
|
45
|
Toto RD. Management of Hypertensive Chronic Kidney Disease: Role of Calcium Channel Blockers. J Clin Hypertens (Greenwich) 2005; 7:15-20. [PMID: 15858398 PMCID: PMC8109449 DOI: 10.1111/j.1524-6175.2004.4471.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Both the prevalence and incidence of end-stage renal disease have been increasing in the United States over the past two decades. Diabetes and hypertension are the attributable causes for more than three fourths of all new cases of end-stage renal disease. The overwhelming majority of diabetics with nephropathy are hypertensive, and lowering blood pressure is indicated in all patients with chronic kidney disease because of the increased risk for cardiovascular morbidity and mortality. Multiple studies indicate that reaching goal systolic blood pressure in patients with chronic kidney disease generally requires three to four antihypertensive agents. A number of medication combinations can effectively reduce blood pressure in the chronic kidney disease patient. In this regard, adding a calcium channel blocker to an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker helps in reaching goal blood pressure while preserving renal function in both diabetics and nondiabetics with proteinuria.
Collapse
Affiliation(s)
- Robert D Toto
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
| |
Collapse
|
46
|
Ruggenenti P, Perna A, Loriga G, Ganeva M, Ene-Iordache B, Turturro M, Lesti M, Perticucci E, Chakarski IN, Leonardis D, Garini G, Sessa A, Basile C, Alpa M, Scanziani R, Sorba G, Zoccali C, Remuzzi G. Blood-pressure control for renoprotection in patients with non-diabetic chronic renal disease (REIN-2): multicentre, randomised controlled trial. Lancet 2005; 365:939-46. [PMID: 15766995 DOI: 10.1016/s0140-6736(05)71082-5] [Citation(s) in RCA: 427] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND In chronic nephropathies, inhibition of angiotensin-converting enzyme (ACE) is renoprotective, but can further renoprotection be achieved by reduction of blood pressure to lower than usual targets? We aimed to assess the effect of intensified versus conventional blood-pressure control on progression to end-stage renal disease. METHODS We undertook a multicentre, randomised controlled trial of patients with non-diabetic proteinuric nephropathies receiving background treatment with the ACE inhibitor ramipril (2.5-5 mg/day). We randomly assigned participants either conventional (diastolic <90 mm Hg; n=169) or intensified (systolic/diastolic <130/80 mm Hg; n=169) blood-pressure control. To achieve the intensified blood-pressure level, patients received add-on therapy with the dihydropyridine calcium-channel blocker felodipine (5-10 mg/day). The primary outcome measure was time to end-stage renal disease over 36 months' follow-up, and analysis was by intention to treat. FINDINGS Of 338 patients who were randomised, three (two assigned intensified and one allocated conventional blood-pressure control) never took study drugs and they were excluded. Over a median follow-up of 19 months (IQR 12-35), 38/167 (23%) patients assigned to intensified blood-pressure control and 34/168 (20%) allocated conventional control progressed to end-stage renal disease (hazard ratio 1.00 [95% CI 0.61-1.64]; p=0.99). INTERPRETATION In patients with non-diabetic proteinuric nephropathies receiving background ACE-inhibitor therapy, no additional benefit from further blood-pressure reduction by felodipine could be shown.
Collapse
Affiliation(s)
- Piero Ruggenenti
- Clinical Research Centre for Rare Diseases Aldo e Cele Daccò, Mario Negri Institute for Pharmacological Research, Villa Camozzi, Ranica, Bergamo, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Abstract
Microalbuminuria is an independent marker of cardiovascular risk, irrespective of kidney disease. Recent pharmacologic interventions have resulted in a significant delay and even an arrest in the progression of microalbuminuria to macroalbuminuria or to chronic kidney disease. Focus should be placed on agents that not only lower blood pressure but also improve albuminuria levels. Current guidelines recommend that hypertensive patients with renal disease should be started on agents that block the renin-angiotensin-aldosterone system, such as angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). The use of three to four different agents is frequently necessary to reach the guideline goal blood pressure of 130/80 mm Hg.
Collapse
Affiliation(s)
- Dave C Y Chua
- Rush University Hypertension Center, Rush University Medical Center, 1700 W. Van Buren Street, Suite 470, Chicago, IL 60612, USA
| | | |
Collapse
|
48
|
Abstract
Unlike the majority of patients with uncomplicated hypertension in whom minimal renal damage develops in the absence of severe blood pressure (BP) elevations, patients with diabetic and nondiabetic chronic kidney disease (CKD) exhibit an increased vulnerability to even moderate BP elevations. Investigations in experimental animal models have revealed that this enhanced susceptibility is a consequence of an impairment of the renal autoregulatory mechanisms that normally attenuate the transmission of elevated systemic pressures to the glomeruli in uncomplicated hypertension. The markedly lower BP threshold for renal damage and the steeper slope of relationship between BP and renal damage in such states necessitates that BP be lowered into the normotensive range to prevent progressive renal damage. When BP is accurately measured using radiotelemetry in animal models, the renal protection provided by renin-angiotensin system (RAS) blockade is proportional to the BP reduction with little evidence of BP-independent protection. A critical evaluation of the clinical data also suggests that the BP-independent renoprotection by RAS blockade has been overemphasized and that achieving lower BP targets is more important than the selection of antihypertensive regimens. However, achievement of such BP goals is difficult in CKD patients without aggressive diuresis, because of their proclivity for salt retention. The effectiveness of RAS blockers in lowering BP in patients who have been adequately treated with diuretics, along with their potassium-sparing and magnesium-sparing effects, provides a more compelling rationale for the use of RAS blockade in the treatment of CKD patients than any putative BP-independent renoprotective superiority.
Collapse
Affiliation(s)
- Anil K Bidani
- Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA.
| | | |
Collapse
|
49
|
Abstract
Management of hypertension in diabetic nephropathy is challenging and generally requires a minimum of three different and complementary antihypertensive agents to achieve the recently recommended blood pressure (BP) goal of <130/80 mm Hg in order to reduce cardiovascular (CV) risk and preserve kidney function. Commonly used antihypertensive combinations include an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker, agents that have compelling indications for use in diabetic renal disease, added to a diuretic, generally a thiazide-type agent. If additional therapy is required, either a beta-blocker or calcium antagonist may be added. Beta-blockers are particularly effective in people with a high sympathetic drive, i.e. high pulse rates, to lower BP and reduce CV risk while reducing proteinuria and slowing decline of kidney function. In light of this information, it is disturbing that a recent analysis of the NHANES III database indicates that only about 11% of people with diabetic kidney disease have achieved the target BP of <130/80 mm Hg. Recent data from Denmark demonstrate that focusing on total CV risk reduction among people with diabetes, including achievement of recommended BP and lipid goals along with the use of aspirin, exercise and a proper diet, can reduce the absolute risk of a CV event by 20% over less intensive treatment.
Collapse
Affiliation(s)
- Dave Y Chua
- Department of Preventive Medicine, Rush University Hypertension/Clinical Research Center, Rush Presbyterian/St. Luke's Medical Center, Chicago, IL 60612, USA
| | | |
Collapse
|
50
|
Abstract
Achievement of recommended levels of blood pressure as prescribed by guidelines (i.e., systolic blood pressure of < 130 mmHg in people with nephropathy secondary to type 2 diabetes) generally requires three or more different antihypertensive agents that have complementary modes of action. This systolic goal blood pressure, recommended by generally all international guideline committees, was derived from largely observational studies demonstrating a greater reduction of cardiovascular risk and preservation of kidney function at these levels. Commonly used antihypertensive combinations include angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers, which have compelling indications for use in people with kidney disease and/or diabetes, combined with a diuretic, generally a thiazide-type agent. If additional therapy is required, either a beta-blocker or a calcium antagonist may be added to this antihypertensive "cocktail." Beta-blockers are particularly effective in people with a high sympathetic drive (i.e., high pulse rates) to lower blood pressure and reduce cardiovascular risk. Moreover, in recent studies, their benefits on kidney function, both by reducing macroalbuminuria and slowing the decline of kidney function, make them good agents to add in the appropriate clinical setting. With all these potential benefits of achieving blood pressure goals, it is unfortunate that only 11% of people being treated for hypertension with diabetic kidney disease achieve the blood pressure goal of < 130 mmHg, likely contributing to the climbing incidence of people starting dialysis. Physicians need to work harder and educate patients on the importance of achieving these lower blood pressure guidelines.
Collapse
Affiliation(s)
- Kevin Abbott
- Walter Reed Army Hospital, Department of Medicine, Division of Nephrology, Bethesda, Maryland, USA
| | | | | |
Collapse
|