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Wu L, Rodriguez M, El Hachem K, Krittanawong C. Diuretic Treatment in Heart Failure: A Practical Guide for Clinicians. J Clin Med 2024; 13:4470. [PMID: 39124738 PMCID: PMC11313642 DOI: 10.3390/jcm13154470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 07/25/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
Congestion and fluid retention are the hallmarks of decompensated heart failure and the major reason for the hospitalization of patients with heart failure. Diuretics have been used in heart failure for decades, and they remain the backbone of the contemporary management of heart failure. Loop diuretics is the preferred diuretic, and it has been given a class I recommendation by clinical guidelines for the relief of congestion symptoms. Although loop diuretics have been used virtually among all patients with acute decompensated heart failure, there is still very limited clinical evidence to guide the optimized diuretics use. This is a sharp contrast to the rapidly growing evidence of the rest of the guideline-directed medical therapy of heart failure and calls for further studies. The loop diuretics possess a unique pharmacology and pharmacokinetics that lay the ground for different strategies to increase diuretic efficiency. However, many of these approaches have not been evaluated in randomized clinical trials. In recent years, a stepped and protocolized diuretics dosing has been suggested to have superior benefits over an individual clinician-based strategy. Diuretic resistance has been a major challenge to decongestion therapy for patients with heart failure and is associated with a poor clinical prognosis. Recently, therapy options have emerged to help overcome diuretic resistance to loop diuretics and have been evaluated in randomized clinical trials. In this review, we aim to provide a comprehensive review of the pharmacology and clinical use of loop diuretics in the context of heart failure, with attention to its side effects, and adjuncts, as well as the challenges and future direction.
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Affiliation(s)
- Lingling Wu
- Cardiovascular Division, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Mario Rodriguez
- John T. Milliken Department of Medicine, Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplant, Barnes-Jewish Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Karim El Hachem
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY 10029, USA
| | - Chayakrit Krittanawong
- Section of Cardiology, Cardiology Division, NYU Langone Health and NYU School of Medicine, 550 First Avenue, New York, NY 10016, USA
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2
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Tantisattamo E, Molnar MZ, Ho BT, Reddy UG, Dafoe DC, Ichii H, Ferrey AJ, Hanna RM, Kalantar-Zadeh K, Amin A. Approach and Management of Hypertension After Kidney Transplantation. Front Med (Lausanne) 2020; 7:229. [PMID: 32613001 PMCID: PMC7310511 DOI: 10.3389/fmed.2020.00229] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/04/2020] [Indexed: 12/14/2022] Open
Abstract
Hypertension is one of the most common cardiovascular co-morbidities after successful kidney transplantation. It commonly occurs in patients with other metabolic diseases, such as diabetes mellitus, hyperlipidemia, and obesity. The pathogenesis of post-transplant hypertension is complex and is a result of the interplay between immunological and non-immunological factors. Post-transplant hypertension can be divided into immediate, early, and late post-transplant periods. This classification can help clinicians determine the etiology and provide the appropriate management for these complex patients. Volume overload from intravenous fluid administration is common during the immediate post-transplant period and commonly contributes to hypertension seen early after transplantation. Immunosuppressive medications and donor kidneys are associated with post-transplant hypertension occurring at any time point after transplantation. Transplant renal artery stenosis (TRAS) and obstructive sleep apnea (OSA) are recognized but common and treatable causes of resistant hypertension post-transplantation. During late post-transplant period, chronic renal allograft dysfunction becomes an additional cause of hypertension. As these patients develop more substantial chronic kidney disease affecting their allografts, fibroblast growth factor 23 (FGF23) increases and is associated with increased cardiovascular and all-cause mortality in kidney transplant recipients. The exact relationship between increased FGF23 and post-transplant hypertension remains poorly understood. Blood pressure (BP) targets and management involve both non-pharmacologic and pharmacologic treatment and should be individualized. Until strong evidence in the kidney transplant population exists, a BP of <130/80 mmHg is a reasonable target. Similar to complete renal denervation in non-transplant patients, bilateral native nephrectomy is another treatment option for resistant post-transplant hypertension. Native renal denervation offers promising outcomes for controlling resistant hypertension with no significant procedure-related complications. This review addresses the epidemiology, pathogenesis, and specific etiologies of post-transplant hypertension including TRAS, calcineurin inhibitor effects, OSA, and failed native kidney. The cardiovascular and survival outcomes related to post-transplant hypertension and the utility of 24-h blood pressure monitoring will be briefly discussed. Antihypertensive medications and their mechanism of actions relevant to kidney transplantation will be highlighted. A summary of guidelines from different professional societies for BP targets and antihypertensive medications as well as non-pharmacological interventions, including bilateral native nephrectomy and native renal denervation, will be reviewed.
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Affiliation(s)
- Ekamol Tantisattamo
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States.,Section of Nephrology, Department of Internal Medicine, Multi-Organ Transplant Center, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI, United States
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, United States.,Methodist University Hospital Transplant Institute, Memphis, TN, United States.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Bing T Ho
- Division of Nephrology and Hypertension, Department of Medicine, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Uttam G Reddy
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States
| | - Donald C Dafoe
- Division of Transplantation, Department of Surgery, University of California Irvine School of Medicine, Orange, CA, United States
| | - Hirohito Ichii
- Division of Transplantation, Department of Surgery, University of California Irvine School of Medicine, Orange, CA, United States
| | - Antoney J Ferrey
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States
| | - Ramy M Hanna
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States
| | - Alpesh Amin
- Department of Medicine, University of California Irvine School of Medicine, Orange, CA, United States
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3
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Oliveira B, Cunningham J, Walsh SB. Magnesium Balance in Chronic and End-Stage Kidney Disease. Adv Chronic Kidney Dis 2018; 25:291-295. [PMID: 29793669 DOI: 10.1053/j.ackd.2018.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/05/2018] [Accepted: 01/22/2018] [Indexed: 11/11/2022]
Abstract
This article explores the effects of CKD and end-stage kidney disease on magnesium balance. In CKD, there is decreased glomerular filtration of magnesium. Decreased tubular reabsorption can compensate to a degree, but once CKD stage 4 is reached there is a tendency toward hypermagnesemia. In dialysis, magnesium balance is dependent on the constituents of the dialysate that the blood is exposed to. The concentration of dialysate magnesium is just one of the factors that need to be considered. During transplantation, there are particular effects of immunosuppressants that can affect the magnesium balance and need to be considered by the clinician.
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Dieterlen MT, John K, Haase S, Garbade J, Tarnok A, Mohr FW, Bittner HB, Barten MJ. Effect of confounding factors on a phospho-flow assay of ribosomal S6 protein for therapeutic drug monitoring of the mTOR-inhibitor everolimus in heart transplanted patients. Biomarkers 2016; 22:86-92. [DOI: 10.1080/1354750x.2016.1210676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Shao K, Lu Y, Wang J, Chen X, Zhang Z, Wang X, Wang X, Yang H, Liu G. Different Effects of Tacrolimus on Innate and Adaptive Immune Cells in the Allograft Transplantation. Scand J Immunol 2016; 83:119-27. [PMID: 26524694 DOI: 10.1111/sji.12398] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 10/22/2015] [Indexed: 01/14/2023]
Abstract
While tacrolimus (FK506) is currently used as immunosuppression therapy in transplant recipient, the immunological mechanism remains unknown. Herein, the immunoregulatory effects of FK506 were investigated in the physiological status and allogeneic skin transplantation. FK506 cannot significantly alter the functions of innate immune cells (macrophages and neutrophils) and adaptive immune cells (T cells) in the physiological status. However, it can effectively delay allogeneic skin-graft rejection through ameliorating the T cell responses, but not myeloid-derived innate immune cell responses. Importantly, it did not affect the allograft recipient macrophage innate immune defence capacity to bacteria. In clinics, FK506 treatment can significantly control the cytokine production in T cells, but not non-T cells. This study shows targeting calcineurin signalling, FK506, to be essential in inducing allograft tolerance, but not to damage the innate defence capacity, validating the immune cell phenotypes as a potential marker in transplantation following FK506 treatment.
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Affiliation(s)
- K Shao
- Ruijin Hospital and Medical School of Shanghai Jiao Tong University, Shanghai, China.,Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, Department of Immunology, School of Basic Medical Sciences, Fudan University, Shanghai, China.,Biotherapy Research Center, Institute of Immunobiology, Fudan University, Shanghai, China
| | - Y Lu
- Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, Department of Immunology, School of Basic Medical Sciences, Fudan University, Shanghai, China.,Biotherapy Research Center, Institute of Immunobiology, Fudan University, Shanghai, China.,Key Laboratory of Cell Proliferation and Regulation Biology, Ministry of Education, Institute of Cell Biology, College of Life Sciences, Beijing Normal University, Beijing, China
| | - J Wang
- Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, Department of Immunology, School of Basic Medical Sciences, Fudan University, Shanghai, China.,Biotherapy Research Center, Institute of Immunobiology, Fudan University, Shanghai, China.,Key Laboratory of Cell Proliferation and Regulation Biology, Ministry of Education, Institute of Cell Biology, College of Life Sciences, Beijing Normal University, Beijing, China
| | - X Chen
- Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, Department of Immunology, School of Basic Medical Sciences, Fudan University, Shanghai, China.,Biotherapy Research Center, Institute of Immunobiology, Fudan University, Shanghai, China.,Key Laboratory of Cell Proliferation and Regulation Biology, Ministry of Education, Institute of Cell Biology, College of Life Sciences, Beijing Normal University, Beijing, China
| | - Z Zhang
- Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, Department of Immunology, School of Basic Medical Sciences, Fudan University, Shanghai, China.,Biotherapy Research Center, Institute of Immunobiology, Fudan University, Shanghai, China.,Key Laboratory of Cell Proliferation and Regulation Biology, Ministry of Education, Institute of Cell Biology, College of Life Sciences, Beijing Normal University, Beijing, China
| | - X Wang
- Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, Department of Immunology, School of Basic Medical Sciences, Fudan University, Shanghai, China.,Biotherapy Research Center, Institute of Immunobiology, Fudan University, Shanghai, China
| | - X Wang
- Ruijin Hospital and Medical School of Shanghai Jiao Tong University, Shanghai, China
| | - H Yang
- Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, Department of Immunology, School of Basic Medical Sciences, Fudan University, Shanghai, China.,Biotherapy Research Center, Institute of Immunobiology, Fudan University, Shanghai, China
| | - G Liu
- Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, Department of Immunology, School of Basic Medical Sciences, Fudan University, Shanghai, China.,Biotherapy Research Center, Institute of Immunobiology, Fudan University, Shanghai, China.,Key Laboratory of Cell Proliferation and Regulation Biology, Ministry of Education, Institute of Cell Biology, College of Life Sciences, Beijing Normal University, Beijing, China
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6
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Snyder M, Shillingburg A, Newton M, Hamadani M, Kanate AS, Craig M, Cumpston A. Impact of intravenous magnesium infusion rate during ambulatory replacements on serum magnesium concentrations after allogeneic stem cell transplant. Support Care Cancer 2016; 24:4237-40. [PMID: 27137211 DOI: 10.1007/s00520-016-3252-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 04/25/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE For an outpatient cancer center to operate efficiently, optimizing the use of chair time is essential. Allogeneic hematopoietic cell transplant (allo-HCT) recipients are seen frequently in this setting after hospital discharge and regularly for several months thereafter. Aggressive electrolyte replacement is commonly required in these patients, primarily due to renal wasting with calcineurin inhibitor use. Frequent intravenous (IV) magnesium repletion, requiring several hours of infusion time, is often needed in these patients to adequately manage their magnesium deficiencies. The purpose of this study is to explore the impact of extending the infusion rate of intravenous magnesium sulfate on the frequency and degree of IV magnesium replacements required in allo-HCT recipients. METHODS We conducted a retrospective study to compare two cohorts of patients administered IV magnesium sulfate at a rate of 4 g/1 h versus 4 g/2 h. RESULTS A total of 103 continuous patients were assessed in two groups as cohort 1 at the 4 g/1 h rate and cohort 2 at the 4 g/2 h rate. Cohort 1 required less IV magnesium per outpatient visit (median 2.2 vs. 2.9 g/visit, P = 0.0211) and less total IV magnesium replacement through day +100 (median 68 vs. 85 g, P = 0.0479) than cohort 2. CONCLUSION These data suggest that there is no apparent benefit of prolonging magnesium infusion from 1 to 2 h in our outpatient allo-HCT population.
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Affiliation(s)
- Matthew Snyder
- Department of Pharmacy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Alexandra Shillingburg
- Department of Pharmacy, West Virginia University Medicine, Medical Center Drive, P.O. Box 8045, Morgantown, WV, 26506, USA. .,Osborn Hematopoietic Malignancy and Transplantation Program, Mary Babb Randolph Cancer Center
- West Virginia University, Morgantown, WV, USA.
| | - Michael Newton
- Department of Pharmacy, West Virginia University Medicine, Medical Center Drive, P.O. Box 8045, Morgantown, WV, 26506, USA
| | - Mehdi Hamadani
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Abraham S Kanate
- Osborn Hematopoietic Malignancy and Transplantation Program, Mary Babb Randolph Cancer Center
- West Virginia University, Morgantown, WV, USA
| | - Michael Craig
- Osborn Hematopoietic Malignancy and Transplantation Program, Mary Babb Randolph Cancer Center
- West Virginia University, Morgantown, WV, USA
| | - Aaron Cumpston
- Department of Pharmacy, West Virginia University Medicine, Medical Center Drive, P.O. Box 8045, Morgantown, WV, 26506, USA.,Osborn Hematopoietic Malignancy and Transplantation Program, Mary Babb Randolph Cancer Center
- West Virginia University, Morgantown, WV, USA
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Van Ende C, Van Laecke S, Marechal C, Verbeke F, Kanaan N, Goffin E, Vanholder R, Jadoul M. Proton-pump inhibitors do not influence serum magnesium levels in renal transplant recipients. J Nephrol 2014; 27:707-11. [PMID: 24816563 DOI: 10.1007/s40620-014-0105-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 04/23/2014] [Indexed: 12/19/2022]
Abstract
Severe hypomagnesemia has been reported with use of proton-pump inhibitors (PPIs). We assessed the effect, if any, of PPI use on serum magnesium level in a cross-sectional analysis of a large published cohort of renal transplant recipients (RTRs). Between February 2004 and February 2006, 512 consecutive prevalent RTRs were enrolled at two university hospitals in Belgium (Brussels and Ghent). Serum creatinine was 1.5 ± 0.7 mg/dl, and estimated glomerular filtration rate (eGFR) 53 ± 19 ml/min/1.73 m(2). Mean (and median) magnesium level was 1.91 ± 0.23 mg/dl. PPIs were prescribed in 20 % (n = 101) of cases. At multivariable analysis, PPI use was not an independent predictor of serum magnesium level or hypomagnesemia. The independent predictors of a lower serum magnesium level were the use of tacrolimus, cyclosporin and sirolimus, the absence of use of mycophenolate mofetil, lower levels of parathyroid hormone and higher eGFR. This study is the first to analyze the potential impact of PPIs on magnesium level in a large, representative cohort of RTR patients. Our results suggest that PPIs may be used without particular fear of favoring hypomagnesemia-related side effects in RTRs, an important finding in a population at high risk of hypomagnesemia.
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Affiliation(s)
- Charlotte Van Ende
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain Medical School, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | | | - Celine Marechal
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain Medical School, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | | | - Nada Kanaan
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain Medical School, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Eric Goffin
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain Medical School, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | | | - Michel Jadoul
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain Medical School, Avenue Hippocrate 10, 1200, Brussels, Belgium.
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8
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Ledeganck KJ, De Winter BY, Van den Driessche A, Jürgens A, Bosmans JL, Couttenye MM, Verpooten GA. Magnesium loss in cyclosporine-treated patients is related to renal epidermal growth factor downregulation. Nephrol Dial Transplant 2013; 29:1097-102. [PMID: 24353324 DOI: 10.1093/ndt/gft498] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cyclosporine (CsA) treatment is associated with hypomagnesaemia due to a renal Mg(2+) leak. In animal studies a role for the Mg(2+) channel TRPM6 localized in the distal convoluted tubule and stimulated by epidermal growth factor (EGF) is suggested. We hypothesize that CsA-induced hypomagnesaemia is due to a renal magnesium leak, also in patients, resulting from a downregulation of the renal EGF production, thereby inhibiting the activation of TRPM6. METHODS Renal transplant patients treated with CsA (n = 55) and 35 chronic kidney disease (CKD) patients were included. At three time points, with an interval of at least 1 month, blood and urine samples were taken to determine creatinine, Mg(2+), sodium and EGF. RESULTS Serum Mg(2+) was significantly lower in the CsA group versus the CKD group with significantly more CsA-treated patients developing hypomagnesaemia. Although the fractional excretion (FE) Mg(2+) did not differ significantly between the two groups, subanalysis of the patients with hypomagnesaemia showed a significantly higher FE Mg(2+) in CsA-treated patients compared with CKD patients (P = 0.05). The urinary EGF excretion was significantly decreased in the CsA group and was a predictor of the FE Mg(2+) in the two groups. Serum sodium was significantly decreased in the CsA group simultaneously with an increased FE Na(+). CONCLUSIONS In CsA-treated patients, the association of a low urinary EGF excretion and a decreased renal Mg(2+) reabsorption is in accordance with in vitro and animal studies. In the whole study population, log urinary EGF excretion is an independent predictor of the FE Mg(2+), supporting the role of EGF in magnesium reabsorption.
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Affiliation(s)
- Kristien J Ledeganck
- Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium
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Taber DJ, Srinivas TM, Pilch NA, Meadows HB, Fleming JN, McGillicuddy JW, Bratton CF, Thomas B, Chavin KD, Baliga PK, Egede LE. Are thiazide diuretics safe and effective antihypertensive therapy in kidney transplant recipients? Am J Nephrol 2013; 38:285-91. [PMID: 24061145 DOI: 10.1159/000355135] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 08/20/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND/AIMS There are no published studies assessing the safety and efficacy of thiazides as antihypertensives in kidney transplantation (KTX). METHODS This was a longitudinal retrospective cohort study conducted in adult KTX recipients. Patients were grouped based on receiving thiazides following KTX. Safety and efficacy comparisons were made between thiazide recipients and unexposed patients, as well as change in blood pressure (BP) within thiazide patients. RESULTS 1,093 patients were included (thiazide group: 108, unexposed group: 985). Mean follow-up was 7.3 ± 4.5 years. Thiazide recipients were older (53 ± 11 vs. 48 ± 13 years, p < 0.001) and more likely to be female (52 vs. 41%, p = 0.023) and have pre-KTX hypertension (97 vs. 88%, p = 0.004) or diabetes (36 vs. 27%, p = 0.035). After controlling for baseline differences, safety analysis revealed thiazide recipients were not more likely to be readmitted to the hospital, but were at higher risk to develop hyperkalemia (56 vs. 38%, p < 0.001) or hypokalemia (28 vs. 18%, p = 0.010), with similar rates of hypotension, decreased estimated glomerular filtration rate, graft loss and death. Efficacy analysis demonstrated systolic (147 ± 17 to 139 ± 18 mm Hg, p < 0.001) and diastolic (79 ± 9 to 77 ± 11 mm Hg, p < 0.001) BPs were significantly reduced after thiazide initiation. Compared to unexposed patients, thiazide recipients had higher mean BPs during the entire follow-up (142/78 vs. 136/77, p < 0.001), with similar BPs while on thiazides and comparable rates of goal BPs (<130/80 mm Hg, 32 vs. 36%, p = 0.219). CONCLUSIONS In KTX, based on long-term outcomes, thiazides appear to be safe and effective antihypertensives; in the short-term, thiazides may increase the risk of developing potassium disturbances.
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Affiliation(s)
- David J Taber
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, S.C., USA
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10
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Nicaise D, Chaillou E, Willot S, Bridoux L, Cardona J, Jobert A, Pelatan C, Giniès JL. [Hypomagnesemia after liver transplantation in children]. Arch Pediatr 2013; 20:903-4. [PMID: 23827375 DOI: 10.1016/j.arcped.2013.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 05/28/2013] [Accepted: 05/29/2013] [Indexed: 11/16/2022]
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11
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Kamińska J, Sobiak J, Suliburska JM, Duda G, Głyda M, Krejpcio Z, Chrzanowska M. Effect of mycophenolate mofetil on plasma bioelements in renal transplant recipients. Biol Trace Elem Res 2012; 145:136-43. [PMID: 21870152 PMCID: PMC3272225 DOI: 10.1007/s12011-011-9178-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Accepted: 08/12/2011] [Indexed: 11/25/2022]
Abstract
The proper concentrations of plasma bioelements may favorably reduce the incidence of metabolic disorders, which often occur during immunosuppressive therapy. Mycophenolate mofetil (MMF) is currently one of the most frequently administered immunosuppressive agents; however, MMF treatment is often related to gastrointestinal side effects. The aim of this study was thus to verify whether the MMF treatment itself, or its metabolite pharmacokinetics, has an effect on the concentrations of plasma bioelements. To determine this, the effect of MMF on the levels of both major (sodium [Na], potassium [K], calcium [Ca], magnesium [Mg]), and trace (iron [Fe], zinc [Zn], copper [Cu]) plasma bioelements in 61 renal transplant recipients was assessed in comparison to a control group (n = 45). The pharmacokinetic parameters of mycophenolic acid were determined by the high-performance liquid chromatography method. All patients filled out a 24-h diet history questionnaire. The results showed high plasma concentrations of Fe and low plasma concentrations of Mg and Zn as compared with diagnostic norms. The patients treated with MMF had significantly lower plasma Na (P < 0.001) and significantly higher plasma Zn (P = 0.030) and Cu concentrations (P < 0.001). In conclusion, MMF treatment was found to affect plasma Fe, Zn, and Cu levels by increasing their concentrations while decreasing the plasma Na concentration. Mg and Zn deficiencies, as well as excessive Fe levels, are frequently observed irrespective of the immunosuppressive regimen applied, which suggests that monitoring of these bioelements may be favorable.
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Affiliation(s)
- Jolanta Kamińska
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6, Święcickiego Street, 60-781 Poznań, Poland
| | - Joanna Sobiak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6, Święcickiego Street, 60-781 Poznań, Poland
| | - Joanna Maria Suliburska
- Department of Human Nutrition and Hygiene, Poznań University of Life Sciences, 31, Wojska Polskiego Street, 60-624 Poznań, Poland
| | - Grażyna Duda
- Department of Bromatology, Poznan University of Medical Sciences, 42, Marcelińska Street, 61-354 Poznań, Poland
| | - Maciej Głyda
- Department of Transplantology, District Hospital, 7/19, Juraszów Street, 60-479 Poznań, Poland
| | - Zbigniew Krejpcio
- Department of Human Nutrition and Hygiene, Poznań University of Life Sciences, 31, Wojska Polskiego Street, 60-624 Poznań, Poland
| | - Maria Chrzanowska
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6, Święcickiego Street, 60-781 Poznań, Poland
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12
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The calcineurin inhibitor tacrolimus activates the renal sodium chloride cotransporter to cause hypertension. Nat Med 2011; 17:1304-9. [PMID: 21963515 PMCID: PMC3192268 DOI: 10.1038/nm.2497] [Citation(s) in RCA: 257] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Accepted: 07/15/2011] [Indexed: 12/19/2022]
Abstract
Calcineurin inhibitors (CNIs) are immunosuppressive drugs, which are used widely to prevent rejection of transplanted organs and treat autoimmune disease. Hypertension and renal tubule dysfunction, including hyperkalemia, hypercalciuria, and acidosis often complicate their use1,2. These side effects resemble familial hyperkalemic hypertension (FHHt), a genetic disease characterized by overactivity of the renal sodium chloride co-transporter (NCC), and caused by mutations in WNK kinases. We hypothesized that CNIs induce hypertension by stimulating NCC. In wild-type mice, the CNI tacrolimus caused salt-sensitive hypertension and increased the abundance of phosphorylated NCC, and the NCC regulatory kinases WNK3, WNK4, and SPAK. The functional importance of NCC in this response was demonstrated by showing that tacrolimus did not affect blood pressure in NCC knockout mice, whereas the hypertensive response to tacrolimus was exaggerated in mice over-expressing NCC. Moreover, hydrochlorothiazide reversed tacrolimus-induced hypertension. In kidney transplant recipients treated with tacrolimus, fractional chloride excretion in response to bendroflumethiazide was greater than in controls, and renal NCC abundance was also greater, extending these observations to humans. Together, these findings indicate that tacrolimus-induced hypertension is mediated largely by NCC activation, and suggest that inexpensive and well-tolerated thiazide diuretics may be especially effective in preventing the complications of CNI treatment.
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Lightner AL, Lau J, Obayashi P, Birge K, Melcher ML. Potential Nutritional Conflicts in Bariatric and Renal Transplant Patients. Obes Surg 2011; 21:1965-70. [DOI: 10.1007/s11695-011-0423-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rubin MF. Hypertension following kidney transplantation. Adv Chronic Kidney Dis 2011; 18:17-22. [PMID: 21224026 DOI: 10.1053/j.ackd.2010.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 10/11/2010] [Accepted: 10/19/2010] [Indexed: 12/31/2022]
Abstract
The majority of patients become hypertensive following kidney transplantation. Its occurrence is associated not only with increased fatal and nonfatal cardiovascular events but also with decreased allograft survival. This review summarizes the current knowledge of the epidemiology, etiology, pathophysiology, and management of post-transplant hypertension.
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Bia M, Adey DB, Bloom RD, Chan L, Kulkarni S, Tomlanovich S. KDOQI US commentary on the 2009 KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Kidney Dis 2010; 56:189-218. [PMID: 20598411 DOI: 10.1053/j.ajkd.2010.04.010] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Accepted: 04/26/2010] [Indexed: 12/14/2022]
Abstract
In response to recently published KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for the care of kidney transplant recipients (KTRs), the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) organized a working group of transplant nephrologists and surgeons to review these guidelines and comment on their relevance and applicability for US KTRs. The following commentaries on the KDIGO guidelines represent the consensus of our work group. The KDIGO transplant guidelines concentrated on aspects of transplant care most important to this population in the posttransplant period, such as immunosuppression, infection, malignancy, and cardiovascular care. Our KDOQI work group concurred with many of the KDIGO recommendations except in some important areas related to immunosuppression, in which decisions in the United States are largely made by transplant centers and are dependent in part on the specific patient population served. Most, but not all, KDIGO guidelines are relevant to US patients. However, implementation of many may remain a major challenge because of issues of limitation in resources needed to assist in the tasks of educating, counseling, and implementing and maintaining lifestyle changes. Although very few of the guidelines are based on evidence that is strong enough to justify their being used as the basis of policy or performance measures, they offer an excellent road map to navigate the complex care of KTRs.
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Affiliation(s)
- Margaret Bia
- Yale School of Medicine, New Haven, CT 06520-8029, USA
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Roche SL, O'Sullivan JJ, Kantor PF. Hypertension after pediatric cardiac transplantation: detection, etiology, implications and management. Pediatr Transplant 2010; 14:159-68. [PMID: 19624603 DOI: 10.1111/j.1399-3046.2009.01205.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
While it may rescue children with end-stage heart failure from impending catastrophe, cardiac transplantation leaves 50-70% of pediatric recipients with new-onset hypertension. Given the unique vulnerability of the heart and kidneys in these children, we can expect long-term uncontrolled hypertension to shorten both graft and patient survival. In this review we discuss the multi-factorial etiology of post-transplant hypertension, highlighting current uncertainties and emphasizing mechanisms specific to cardiac recipients. We consider the optimal means of monitoring BP and in particular, the advantages of 24 h-ABP over intermittent clinic measurements. We also review BP treatment after cardiac transplantation, drawing attention to specific cautions appropriate when prescribing antihypertensive agents in these circumstances.
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Affiliation(s)
- S Lucy Roche
- Department of Pediatric Cardiology, The Hospital for Sick Children, Toronto, ON, Canada
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Abstract
Nearly 50 medications have been implicated as inducing hypomagnesaemia, sometimes based on insufficient data regarding clinical significance and frequency of occurrence. In fact, clinical effects attributed to hypomagnaesemia have been reported in only 17 of these drugs. A considerable amount of literature relating to individual drugs has been published, yet a comprehensive overview of this issue is not available and the hypomagnesaemic effect of a drug could be either overemphasised or under-rated. In addition, there are neither guidelines regarding treatment, prevention and monitoring of drug-induced hypomagnesaemia nor agreement as to what serum level of magnesium may actually be defined as 'hypomagnesaemia'. By compiling data from published papers, electronic databases, textbooks and product information leaflets, we attempted to assess the clinical significance of hypomagnesaemia induced by each drug. A practical approach for managing drug-induced hypomagnesaemia, incorporating both published literature and personal experience of the physician, is proposed. When drugs classified as inducing 'significant' hypomagnesaemia (cisplatin, amphotericin B, ciclosporin) are administered, routine magnesium monitoring is warranted, preventive treatment should be considered and treatment of hypomagnesaemia should be initiated with or without overt clinical manifestations. In drugs belonging to the 'potentially significant' category, among which are amikacin, gentamicin, laxatives, pentamidine, tobramycin, tacrolimus and carboplatin, magnesium monitoring is justified when either of the following occurs: clinical manifestations are apparent; persistent hypokalaemia, hypocalcaemia or alkalosis are present; other precipitating factors for hypomagnesaemia coexist; or treatment is with more than one potentially hypomagnesaemic drug. No preventive treatment is required and treatment should be initiated only if hypomagnesaemia is accompanied by symptoms or clinically significant relevant laboratory findings. In those drugs whose hypomagnesaemic effect is labelled as 'questionable', including furosemide and hydrochlorothiazide, routine monitoring and treatment are not required.
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Affiliation(s)
- Jacob Atsmon
- Clinical Pharmacology Unit, Tel Aviv Sourasky Medical Center, Te Aviv, Israel.
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Aisa Y, Mori T, Nakazato T, Shimizu T, Yamazaki R, Ikeda Y, Okamoto S. Effects of Immunosuppressive Agents on Magnesium Metabolism Early after Allogeneic Hematopoietic Stem Cell Transplantation. Transplantation 2005; 80:1046-50. [PMID: 16278584 DOI: 10.1097/01.tp.0000174340.40585.d4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The calcineurin inhibitors, cyclosporine A (CSA) and tacrolimus, cause hypomagnesemia by suppressing reabsorption of magnesium (Mg) from renal tubules. To assess whether the effect on Mg metabolism after allogeneic hematopoietic stem cell transplantation (HSCT) differs among calcineurin inhibitors, we prospectively evaluated the Mg metabolism in recipients of allogeneic HSCT who received CSA or tacrolimus METHODS Patients who underwent allogeneic HSCT were enrolled. CSA and tacrolimus were given by continuous infusion starting from day -1. Serum Mg and the total amount of urinary Mg excretion were measured once before starting of CSA or tacrolimus, and once weekly after HSCT for 4 weeks. Mg was supplemented with magnesium l-aspartate by continuous infusion to maintain the serum Mg level >1.4 mEq/L. RESULTS Thirty-six patients were evaluated (12 in the CSA group, 24 in the tacrolimus group). The serum Mg level began to decrease in both groups at the first week after HSCT, and the mean serum Mg levels were significantly lower in the tacrolimus group than in the CSA group from the first to the third week. The total amount of urinary Mg excretion and Mg supplementation began to increase in both groups at the second week after HSCT, and the amounts in the tacrolimus group were significantly higher than those in the CSA group. CONCLUSIONS Although both calcineurin inhibitors increased urinary Mg excretion and caused hypomagnesemia shortly after HSCT, the effect was more significant with tacrolimus than with CSA. This observation may explain the higher incidence of renal impairment and encephalopathy in patients receiving tacrolimus.
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Affiliation(s)
- Yoshinobu Aisa
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
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Mazzola BL, Vannini SD, Truttmann AC, Vigier RO, Wermuth B, Ferrari P, Bianchetti MG. Long-term calcineurin inhibition and magnesium balance after renal transplantation. Transpl Int 2003. [DOI: 10.1111/j.1432-2277.2003.tb00267.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Christians U, Jacobsen W, Benet LZ, Lampen A. Mechanisms of clinically relevant drug interactions associated with tacrolimus. Clin Pharmacokinet 2002; 41:813-51. [PMID: 12190331 DOI: 10.2165/00003088-200241110-00003] [Citation(s) in RCA: 223] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The clinical management of tacrolimus, a macrolide used as immunosuppressant after transplantation, is complicated by its narrow therapeutic index in combination with inter- and intraindividually variable pharmacokinetics. As a substrate of cytochrome P450 (CYP) 3A enzymes and P-glycoprotein, tacrolimus interacts with several other drugs used in transplantation medicine, which also are known CYP3A and/or P-glycoprotein inhibitors and/or inducers. In clinical studies, CYP3A/P-glycoprotein inhibitors and inducers primarily affect oral bioavailability of tacrolimus rather than its clearance, indicating a key role of intestinal P-glycoprotein and CYP3A. There is an almost complete overlap between the reported clinical drug interactions of tacrolimus and those of cyclosporin. However, in comparison with cyclosporin, only few controlled drug interaction studies have been carried out, but tacrolimus drug interactions have been extensively studied in vitro. These results are inconsistent and are of poor predictive value for clinical drug interactions because of false negative results. P-glycoprotein regulates distribution of tacrolimus through the blood-brain barrier into the brain as well as distribution into lymphocytes. Interaction of other drugs with P-glycoprotein may change tacrolimus tissue distribution and modify its toxicity and immunosuppressive activity. There is evidence that ethnic and gender differences exist for tacrolimus drug interactions. Therapeutic drug monitoring to guide dosage adjustments of tacrolimus is an efficient tool to manage drug interactions. In the near future, progress can be expected from studies evaluating potential pharmacokinetic interactions caused by herbal preparations and food components, the exact biochemical mechanism underlying tacrolimus toxicity, and the potential of inhibition of CYP3A and P-glycoprotein to improve oral bioavailability and to decrease intraindividual variability of tacrolimus pharmacokinetics.
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Affiliation(s)
- Uwe Christians
- Department of Anesthesiology, University of Colorado Health Sciences Center, Denver, Colorado, USA.
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