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Hameed K, Chinnam S, Khan KS, Mushtaq S, Ahmad N, Jaber AAS, Anwar Z, Ur-Rehman I, Khan A. Evaluation of hypertension control among hemodialysis patients in Pakistan: a prospective follow-up study. Blood Press Monit 2023; 28:253-259. [PMID: 37409474 DOI: 10.1097/mbp.0000000000000656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
BACKGROUND Hypertension is highly prevalent and uncontrolled among hemodialysis patients. In Pakistan published data does not provide enough information about the management and factors associated with uncontrolled hypertension in hemodialysis patients. OBJECTIVE This study was conducted to evaluate the factors influencing the pharmacotherapeutic management and control of hypertension in hemodialysis patients. METHODS A prospective follow-up study was conducted on hemodialysis patients who were enrolled at study sites between 1 June 2020 and 31 December 2020. The predialysis blood pressure (BP) readings were recorded as mean SBP and DBP at baseline and for each of 6 months. Multivariate analyses were applied to analyze the factors associated with uncontrolled hypertension in hemodialysis patients. RESULTS The average predialysis BP (SBP and DBP) of study participants at baseline visit was 158.41 and 87.22 mmHg respectively. After 6 months the study participants have 150.27 mmHg and 80.03 mmHg average predialysis SBP and DBP respectively. Only 28.1% of hemodialysis patients were on target BP after 6 months. Results of multivariate analysis have shown that the use of beta-blockers and calcium channel blockers (CCBs) were significantly associated with hypertension control at baseline [odds ratio (OR) = 1.432, P value = 0.034] (OR = 1.499, P value = 0.045) and at after 6 months (OR = 2.824, P value = 0.015) (OR = 1.883, P value = 0.032). CONCLUSION This study revealed that among the antihypertensive drugs, CCBs and beta-blockers provided better management in controlling hypertension among hemodialysis patients.
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Affiliation(s)
- Kiran Hameed
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Sampath Chinnam
- Department of Chemistry, M.S. Ramaiah Institute of Technology (affiliated to Visvesvaraya Technological University, Belgaum), Bengaluru, Karnataka, India
| | | | - Saima Mushtaq
- Department of Healthcare Biotechnology, Atta-ur-Rahman School of Applied Biosciences, National University of Sciences and Technology, Islamabad
| | - Nafees Ahmad
- Department of Pharmacy Practice, Faculty of Pharmacy and Health Sciences, University of Balochistan, Quetta, Pakistan
| | - Ammar Ali Saleh Jaber
- Department of Clinical Pharmacy & Pharmacotherapeutics, Dubai Pharmacy College for Girls, AlMuhaisanah 1, Al mizhar Dubai, UAE
| | - Zeeshan Anwar
- Department of Pharmacy, Abdul Wali Khan University, Mardan, Pakistan
| | - Inayat Ur-Rehman
- Department of Pharmacy, Abdul Wali Khan University, Mardan, Pakistan
| | - Amjad Khan
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
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Liu Q, Dong S, Zhou X, Zhao Y, Dong B, Shen J, Yang K, Li L, Zhu D. Effects of Long-Term Intervention with Losartan, Aspirin and Atorvastatin on Vascular Remodeling in Juvenile Spontaneously Hypertensive Rats. Molecules 2023; 28:molecules28041844. [PMID: 36838830 PMCID: PMC9965824 DOI: 10.3390/molecules28041844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/04/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
Hypertension in adolescents is associated with adverse cardiac and vascular events. In addition to lowering blood pressure, it is not clear whether pharmacological therapy in early life can improve vascular remodeling. This study aimed to evaluate the effects of long-term administration of losartan, aspirin, and atorvastatin on vascular remodeling in juvenile spontaneously hypertensive rats (SHRs). Losartan, aspirin, and atorvastatin were administered via gavage at doses of 20, 10, and 10 mg/kg/day, respectively, on SHRs aged 6-22 weeks. Paraffin sections of the blood vessels were stained with hematoxylin-eosin (H&E) and Sirius Red to evaluate the changes in the vascular structure and the accumulation of different types of collagen. The plasma levels of renin, angiotensin II (Ang II), aldosterone (ALD), endothelin-1 (ET-1), interleukin-6 (IL-6), and neutrophil elastase (NE) were determined using ELISA kits. After the 16-week treatment with losartan, aspirin, and atorvastatin, the wall thickness of the thoracic aorta and carotid artery decreased. The integrity of the elastic fibers in the tunica media was maintained in an orderly manner, and collagen deposition in the adventitia was retarded. The plasma levels of renin, ALD, ET-1, IL-6, and NE in the SHRs also decreased. These findings suggest that losartan, aspirin, and atorvastatin could improve vascular remodeling beyond their antihypertensive, anti-inflammatory, and lipid-lowering effects. Many aspects of the protection provided by pharmacological therapy are important for the prevention of cardiovascular diseases in adults and older adults.
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Affiliation(s)
- Qi Liu
- School of Pharmacy, Minzu University of China, Beijing 100081, China
| | - Shuai Dong
- School of Pharmacy, Minzu University of China, Beijing 100081, China
| | - Xue Zhou
- Chengdu Institute of Biology, Chinese Academy of Sciences, Chengdu 610041, China
| | - Yubo Zhao
- School of Pharmacy, Minzu University of China, Beijing 100081, China
| | - Bin Dong
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Core Laboratory, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jing Shen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Core Laboratory, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Kang Yang
- School of Pharmacy, Minzu University of China, Beijing 100081, China
| | - Linsen Li
- School of Pharmacy, Minzu University of China, Beijing 100081, China
- Correspondence: (L.L.); (D.Z.); Tel.: +86-158-1089-2058 (D.Z.)
| | - Dan Zhu
- School of Pharmacy, Minzu University of China, Beijing 100081, China
- Correspondence: (L.L.); (D.Z.); Tel.: +86-158-1089-2058 (D.Z.)
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Awad K, Zaki MM, Mohammed M, Lewek J, Lavie CJ, Banach M. Effect of the Renin-Angiotensin System Inhibitors on Inflammatory Markers: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Mayo Clin Proc 2022; 97:1808-1823. [PMID: 36202494 DOI: 10.1016/j.mayocp.2022.06.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 05/01/2022] [Accepted: 06/30/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To synthesize more conclusive evidence on the anti-inflammatory effects of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs). METHODS PubMed, Scopus, and Embase were searched from inception until March 1, 2021. We included randomized controlled trials (RCTs) that assessed the effect of ACEIs or ARBs, compared with placebo, on any of the following markers: C-reactive protein (CRP), interleukin 6 (IL-6), or tumor necrosis factor α (TNF-α). Mean changes in the levels of these markers were pooled as a weighted mean difference (WMD) with a 95% CI. RESULTS Thirty-two RCTs (n=3489 patients) were included in the final analysis. Overall pooled analysis suggested that ACEIs significantly reduced plasma levels of CRP (WMD, -0.54 [95% CI, -0.88 to -0.21]; P=.002; I2=96%), IL-6 (WMD, -0.84 [95% CI, -1.03 to -0.64]; P<.001; I2=0%), and TNF-α (WMD, -12.75 [95% CI, -17.20 to -8.29]; P<.001; I2=99%). Moreover, ARBs showed a significant reduction only in IL-6 (WMD, -1.34 [95% CI, -2.65 to -0.04]; P=.04; I2=85%) and did not significantly affect CRP (P=.15) or TNF-α (P=.97) levels. The lowering effect of ACEIs on CRP levels remained significant with enalapril (P=.006) and perindopril (P=.01) as well as with a treatment duration of less than 24 weeks (WMD, -0.67 [95% CI, -1.07 to -0.27]; P=.001; I2=94%) and in patients with coronary artery disease (WMD, -0.75 [95% CI, -1.17 to -0.33]; P<.001; I2=96%). CONCLUSION Based on this meta-analysis, ACEIs showed a beneficial lowering effect on CRP, IL-6, and TNF-α, whereas ARBs were effective as a class in reduction of IL-6 only.
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Affiliation(s)
- Kamal Awad
- Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt; Zagazig University Hospitals, Zagazig, El-Sharkia, Egypt.
| | - Mahmoud Mohamed Zaki
- Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt; Zagazig University Hospitals, Zagazig, El-Sharkia, Egypt
| | - Maged Mohammed
- Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt; Zagazig University Hospitals, Zagazig, El-Sharkia, Egypt
| | - Joanna Lewek
- Department of Preventive Cardiology and Lipidology, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland; Department of Cardiology and Adult Congenital Heart Diseases, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, Louisiana
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland; Department of Cardiology and Adult Congenital Heart Diseases, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland; Cardiovascular Research Centre, University of Zielona Gora, Zielona Gora, Poland
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Choi SR, Lee YK, Cho Park H, Kim DH, Cho A, Kang MK, Choi S. Clinical significance of central systolic blood pressure in LV diastolic dysfunction and CV mortality. PLoS One 2021; 16:e0250653. [PMID: 33951046 PMCID: PMC8099078 DOI: 10.1371/journal.pone.0250653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/08/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND AIMS Cardiovascular (CV) disease is the major cause of death in patients with end-stage kidney disease (ESKD). Left ventricular (LV) diastolic dysfunction reflects LV pressure overload and is common in patients with ESKD. Recently, there have been studies on the usefulness of central blood pressure (BP); however, the relationship between central BP and LV diastolic dysfunction is not clear in dialysis patients with preserved systolic function. The purpose of this study was to investigate the clinical implication of central BP on LV diastolic dysfunction and CV mortality in the ESKD patients with preserved LV systolic function. METHODS This prospective observational cohort study investigated the effect of LV diastolic dysfunction on CV mortality in the ESKD patients with preserved systolic function using echocardiography. Vascular calcification was evaluated using the abdominal aortic calcification score, and aortic stiffness was determined by measuring pulse wave velocity (PWV). The predictors of CV mortality were analyzed using Cox proportional hazard analysis. RESULTS The subjects were comprised of 61 patients, with an average age of 54 years, 20 males (32.8%), and 25 diabetics (41.0%). There were 39 patients on hemodialysis and 22 patients receiving peritoneal dialysis treatment. During the mean follow-up period of 79.3 months, 16 patients (26.2%) died, and 7 patients (11.4%) died of CV events. The central systolic BP and diabetes were independent risk factors for LV diastolic dysfunction. In addition, patients with LV diastolic dysfunction had an increased CV mortality. When left atrial volume index and PWV were adjusted, the E/E' ratio was found to be a predictor of CV mortality. CONCLUSIONS Central systolic BP and diabetes were found to be significant risk factors for LV diastolic dysfunction. LV diastolic dysfunction can independently predict CV mortality in dialysis patients with preserved LV systolic function.
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Affiliation(s)
- Sun Ryoung Choi
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Dongtan, Korea
- Hallym University, Kidney Research Institute, Seoul, Korea
| | - Young-Ki Lee
- Hallym University, Kidney Research Institute, Seoul, Korea
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Hayne Cho Park
- Hallym University, Kidney Research Institute, Seoul, Korea
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Do Hyoung Kim
- Hallym University, Kidney Research Institute, Seoul, Korea
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Ajin Cho
- Hallym University, Kidney Research Institute, Seoul, Korea
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Min-Kyung Kang
- Division of Cardiology, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Seonghoon Choi
- Division of Cardiology, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
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Maruyama T, Takashima H, Abe M. Blood pressure targets and pharmacotherapy for hypertensive patients on hemodialysis. Expert Opin Pharmacother 2020; 21:1219-1240. [PMID: 32281890 DOI: 10.1080/14656566.2020.1746272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Hypertension is highly prevalent in patients with end-stage kidney disease on hemodialysis and is often not well controlled. Blood pressure (BP) levels before and after hemodialysis have a U-shaped relationship with cardiovascular and all-cause mortality. Although antihypertensive drugs are recommended for patients in whom BP cannot be controlled appropriately by non-pharmacological interventions, large-scale randomized controlled clinical trials are lacking. AREAS COVERED The authors review the pharmacotherapy used in hypertensive patients on dialysis, primarily focusing on reports published since 2000. An electronic search of MEDLINE was conducted using relevant key search terms, including 'hypertension', 'pharmacotherapy', 'dialysis', 'kidney disease', and 'antihypertensive drug'. Systematic and narrative reviews and original investigations were retrieved in our research. EXPERT OPINION When a drug is administered to patients on dialysis, the comorbidities and characteristics of each drug, including its dialyzability, should be considered. Pharmacological lowering of BP in hypertensive patients on hemodialysis is associated with improvements in mortality. β-blockers should be considered first-line agents and calcium channel blockers as second-line therapy. Renin-angiotensin-aldosterone system inhibitors have not shown superiority to other antihypertensive drugs for patients on hemodialysis.
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Affiliation(s)
- Takashi Maruyama
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine , Tokyo, Japan
| | - Hiroyuki Takashima
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine , Tokyo, Japan
| | - Masanori Abe
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine , Tokyo, Japan
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Khan A, Khan AH, Adnan AS, Sulaiman SAS, Mushtaq S, Ahmad N, Khan I. Hypertension control among euvolemic hypertensive hemodialysis patients in Malaysia: a prospective follow-up study. J Pharm Policy Pract 2019; 12:10. [PMID: 31114693 PMCID: PMC6515627 DOI: 10.1186/s40545-019-0169-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 03/15/2019] [Indexed: 01/18/2023] Open
Abstract
Objectives Existing literature does not provide enough information on evaluation of factors associated with pre-dialysis controlled hypertension among euvolemic hemodialysis (HD) patients. We conducted a study to evaluate the rate and factors influencing pre-dialysis controlled hypertension among euvolemic HD patients. Design A multicenter prospective follow-up study. Setting Tertiary care teaching hospital and its associated private dialysis centers. Participants This study included 145 euvolemic eligible hypertensive patients. Various sociodemographic, clinical factors and drugs were investigated and analyzed by using appropriate statistical methods to determine the factors influencing hypertension control among the study participants. Results On baseline visit, the mean pre-dialysis systolic and diastolic BP (mmHg) of study participants was 161.2 ± 24. and 79.21 ± 11.8 retrospectively, and 30 (20.6%) patients were on pre-dialysis goal BP. At the end of the 6-months follow-up, the mean pre-dialysis systolic BP and diastolic BP (mmHg) of the patients was 154.6 ± 18.3 and 79.2 ± 11.8 respectively, and 42 (28.9%) were on pre-dialysis goal BP. In multivariate analysis, the use of calcium channel blockers (CCBs) was the only variable which had statistically significant association with pre-dialysis controlled hypertension at baseline (OR = 7.530, p-value = 0.001) and final (OR = 8.988, p-value < 0.001) visits. Conclusions In present study, the positive association observed between CCBs and controlled hypertension suggests that CCBs are effective antihypertensive drugs in the management of hypertension among euvolemic HD patients. Strengths and limitations of this study This study involved a group of patients from tertiary-level teaching hospital and its associated private dialysis centers of Malaysia.To the best of the authors' knowledge, this is the first study to assess the factors influencing pre-dialysis controlled hypertension in a cohort of 145 euvolemic HD patients in a Malaysian setting.For determining the factors influencing hypertenion control multivariate analysis was conducted.Being a prospective follow-up study, the findings of the present study need to be interpreted with caution since it is limited to only 6 months follow up.Nevertheless, a multicenter study with a large sample size and longer follow up time is needed to confirm the findings of the current study.
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Affiliation(s)
- Amjad Khan
- 1Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia.,2Chronic Kidney Disease Resource Centre, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan Malaysia.,3Department of Pharmacy, Quaid-i-Azam University, Islamabad, 45320 Pakistan
| | - Amer Hayat Khan
- 1Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia.,2Chronic Kidney Disease Resource Centre, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan Malaysia
| | - Azreen Syazril Adnan
- 2Chronic Kidney Disease Resource Centre, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan Malaysia
| | - Syed Azhar Syed Sulaiman
- 1Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia
| | - Saima Mushtaq
- 4Health Care Biotechnology Department, Atta ur Rahman School of Applied Biosciences, National University of Sciences & Technology, Islamabad, 44000 Pakistan
| | - Nafees Ahmad
- 5Faculty of Pharmacy and Health Sciences, University of Balochistan, Quetta, 87300 Pakistan
| | - Irfanullah Khan
- 1Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia.,2Chronic Kidney Disease Resource Centre, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan Malaysia
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van 't Erve TJ. Strategies to decrease oxidative stress biomarker levels in human medical conditions: A meta-analysis on 8-iso-prostaglandin F 2α. Redox Biol 2018; 17:284-296. [PMID: 29775960 PMCID: PMC6007822 DOI: 10.1016/j.redox.2018.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 02/07/2023] Open
Abstract
The widespread detection of elevated oxidative stress levels in many medical conditions has led to numerous efforts to design interventions to reduce its effects. Efforts have been wide-ranging, from dietary changes to administration of antioxidants, supplements, e.g., omega-3-fatty acids, and many medications. However, there is still no systemic assessment of the efficacy of treatments for oxidative stress reduction across a variety of medical conditions. The goal of this meta-analysis is, by combining multiple studies, to quantitate the change in the levels of the popular oxidative stress biomarker 8-iso-prostaglandin F2α (8-iso-PGF2α) after a variety of treatment strategies in human populations. Nearly 350 unique publications with 180 distinct strategies were included in the analysis. For each strategy, the difference between pre- or placebo and post-treatment levels calculated using Hedges' g value of effect. In general, administration of antibiotics, antihyperlipidemic agents, or changes in lifestyle (g = - 0.63, - 0.54, and 0.56) had the largest effect. Administration of supplements, antioxidants, or changes in diet (g = - 0.09, - 0.28, - 0.12) had small quantitative effects. To fully interpret the effectiveness of these treatments, comparisons to the increase in g value for each medical condition is required. For example, antioxidants in populations with coronary artery disease (CAD) reduce the 8-iso-PGF2α levels by g = - 0.34 ± 0.1, which is quantitatively considered a small effect. However, CAD populations, in comparison to healthy populations, have an increase in 8-iso-PGF2α levels by g = 0.38 ± 0.04; therefore, the overall reduction of 8-iso-PGF2α levels is ≈ 90% by this treatment in this specific medical condition. In conclusion, 8-iso-PGF2α levels can be reduced not only by antioxidants but by many other strategies. Not all strategies are equally effective at reducing 8-iso-PGF2α levels. In addition, the effectiveness of any strategy can be assessed only in relation to the medical condition investigated.
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Affiliation(s)
- Thomas J van 't Erve
- Immunity, Inflammation and Disease Laboratory, National Institute of Environmental Health Sciences, Research Triangle Park, 27709 NC, USA; Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, 27709 NC, USA.
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Georgianos PI, Pikilidou MI, Liakopoulos V, Balaskas EV, Zebekakis PE. Arterial stiffness in end-stage renal disease-pathogenesis, clinical epidemiology, and therapeutic potentials. Hypertens Res 2018. [PMID: 29531291 DOI: 10.1038/s41440-018-0025-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Arterial stiffness is an important risk factor for cardiovascular morbidity and mortality in patients with end-stage renal disease (ESRD). Arterial stiffness aggravates cardiovascular risk via multiple pathways, such as augmentation of aortic systolic pressure, subendocardial hypoperfusion, and excess pulsatile energy transmission from macro- to microcirculation. Pathogenesis of the arteriosclerotic process in ESRD is complex and not yet fully understood. Several factors unique to ESRD, such as mineral metabolism disturbances, vascular calcifications, formation of advanced glycation end-products, and acute and chronic volume overload, are proposed to play a particular role in the progression of arteriosclerosis in ESRD. As these and other mechanistic pathways of arterial stiffening in ESRD are elucidated, there is hope that this knowledge will be translated into novel therapeutic interventions targeting arterial stiffness. In the meantime, blood pressure (BP) lowering via strict volume control and appropriate use of antihypertensive drugs is a fundamental step in reversing accelerated arterial stiffening and modifying the cardiovascular risk profile of ESRD patients. In this article, we review the pathogenesis, clinical epidemiology, and therapies targeting arterial stiffness in ESRD, discussing recent advances and high-priority goals of future research in these important areas.
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Affiliation(s)
- Panagiotis I Georgianos
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Maria I Pikilidou
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vassilios Liakopoulos
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Elias V Balaskas
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pantelis E Zebekakis
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Chan DT, Watts GF, Irish AB, Dogra GK. Insulin resistance and vascular dysfunction in chronic kidney disease: mechanisms and therapeutic interventions. Nephrol Dial Transplant 2018; 32:1274-1281. [PMID: 26374599 DOI: 10.1093/ndt/gfv326] [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] [Received: 03/16/2015] [Accepted: 08/11/2015] [Indexed: 12/19/2022] Open
Abstract
Insulin resistance (IR) is a novel cardiovascular risk factor that has been implicated in the pathogenesis of cardiovascular disease (CVD) in patients with chronic kidney disease (CKD). Beyond its metabolic effects, insulin can potentially mediate the increased risk for CVD through its vasoactive properties. This review examines key clinical data and potential mechanisms linking IR and cardiovascular risk in CKD. While lifestyle interventions and pharmacotherapies with known insulin-sensitizing properties are promising therapeutic targets to reduce the CVD burden in this population, clinical trial data on the effect of insulin sensitization on vascular function in CKD are either lacking or conflicting and are limited by small sample size and short duration of intervention. Affirming the role of IR in lowering CVD risk in CKD will require prospective randomized controlled studies with sufficient sample size and hard clinical outcomes. Future research efforts should be directed at assessing the efficacy, safety and mechanisms by which novel insulin sensitizers such as bile acid sequestrant, selective and dual peroxisome proliferator-activated receptor modulators and modulators of gut microbiota and uraemic toxins alter vascular function in patients with CKD.
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Affiliation(s)
- Doris T Chan
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Gerald F Watts
- Lipid Disorders Clinic, Cardiovascular Medicine, Royal Perth Hospital, Perth, WA, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | - Ashley B Irish
- Department of Nephrology, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Gursharan K Dogra
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
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Ramirez-Sandoval JC, Sanchez-Lozada LG, Madero M. Uric Acid, Vascular Stiffness, and Chronic Kidney Disease: Is There a Link? Blood Purif 2017; 43:189-195. [PMID: 28114139 DOI: 10.1159/000452726] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Controversy exists with regard to the causal role of hyperuricemia in chronic kidney disease. Vascular stiffness may be the link that explains the relation between hyperuricemia and kidney disease. Hyperuricemia is associated with a number of effects on the vascular endothelium and vascular smooth muscle cells, including an increase in oxidative stress, production of vasoconstrictors, and changes on the structural properties of the large artery wall. Observational evidence in large epidemiological cross-sectional studies suggests that there is an independent association between uric acid and arterial stiffness. The limited evidence from cohort studies or clinical trials does not support treatment of hyperuricemia to reduce vascular stiffness in order to prevent kidney disease. Nevertheless, vascular stiffness may be a valid, reproducible, and useful surrogate endpoint. At this point there seems to be sufficient evidence to warrant larger clinical trials to determine whether lowering uric acid concentrations would be useful for prevention or treatment of vascular stiffness and, subsequently, of cardiovascular and kidney diseases. Video Journal Club 'Cappuccino with Claudio Ronco' at http://www.karger.com/?doi=452726.
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Affiliation(s)
- Juan C Ramirez-Sandoval
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (National Institute of Medical Sciences and Nutrition Salvador Zubirán (INCMNSZ)), Mexico City, Mexico
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Abstract
Among patients on dialysis, hypertension is highly prevalent and contributes to the high burden of cardiovascular morbidity and mortality. Strict volume control via sodium restriction and probing of dry weight are first-line approaches for the treatment of hypertension in this population; however, antihypertensive drug therapy is often needed to control BP. Few trials compare head-to-head the superiority of one antihypertensive drug class over another with respect to improving BP control or altering cardiovascular outcomes; accordingly, selection of the appropriate antihypertensive regimen should be individualized. To individualize therapy, consideration should be given to intra- and interdialytic pharmacokinetics, effect on cardiovascular reflexes, ability to treat comorbid illnesses, and adverse effect profile. β-Blockers followed by dihydropyridine calcium-channel blockers are our first- and second-line choices for antihypertensive drug use. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers seem to be reasonable third-line choices, because the evidence base to support their use in patients on dialysis is sparse. Add-on therapy with mineralocorticoid receptor antagonists in specific subgroups of patients on dialysis (i.e., those with severe congestive heart failure) seems to be another promising option in anticipation of the ongoing trials evaluating their efficacy and safety. Adequately powered, multicenter, randomized trials evaluating hard cardiovascular end points are urgently warranted to elucidate the comparative effectiveness of antihypertensive drug classes in patients on dialysis. In this review, we provide an overview of the randomized evidence on pharmacotherapy of hypertension in patients on dialysis, and we conclude with suggestions for future research to address critical gaps in this important area.
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Affiliation(s)
- Panagiotis I. Georgianos
- Division of Nephrology and Hypertension, First Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indianapolis; and
- Division of Nephrology, Department of Medicine, Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indianapolis
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12
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Peters CD, Kjaergaard KD, Nielsen CH, Christensen KL, Bibby BM, Jensen JD, Jespersen B. Long-term effects of angiotensin II blockade with irbesartan on inflammatory markers in hemodialysis patients: A randomized double blind placebo controlled trial (SAFIR study). Hemodial Int 2016; 21:47-62. [PMID: 27346437 DOI: 10.1111/hdi.12436] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Low-grade chronic inflammation is common in hemodialysis (HD) patients. Previous studies suggest an anti-inflammatory effect of angiotensin II receptor blocker (ARB) treatment. The aim of this study was to compare the effect of ARB vs. placebo on plasma concentrations of inflammatory markers in HD patients. METHODS Adult HD patients were randomized for double-blind treatment with the ARB irbesartan 150-300 mg/day or placebo. At baseline, 1 week, 3, 6, 9, and 12 months plasma high sensitivity C-reactive protein (hsCRP), interleukin (IL)-1β, IL-6, IL-8, IL-18, and transforming growth factor-β (TGF-β) were measured using Luminex and enzyme-linked immunosorbent assay (ELISA) technology. FINDINGS Eighty-two patients were randomized (placebo/ARB: 41/41). The groups did not differ in initial levels of any of the inflammatory markers (placebo/ARB median(range)): hsCRP 3.3(0.2-23.4)/2.7(0.2-29.6) μg/mL; IL-1β 1.1(0.0-45.9)/1.1(0.0-7.2) pg/mL; IL-6 10(1-90)/12(1-84) pg/mL; IL-8 31(9-134)/34(5-192) pg/mL; IL-18 364(188-1343)/377(213-832) pg/mL; TGF-β 3.2(0.8-13.9)/3.6(1.3-3.8) ng/mL. Overall, there was no significant difference in hsCRP, IL-6, IL-8, and TGF-β between placebo and ARB-treated patients during the study period, and hsCRP, IL-6, IL-8, and TGF-β were relatively stable during the study period (P ≥ 0.18 in all tests for parallel curves, equal levels, and constant levels). The IL-1β level was slightly different in the two groups over time, but not significantly (P = 0.09 in test for parallel curves) and it was also relatively stable during the study period (P ≥ 0.49 in tests for equal levels and constant level). IL-18 was the only inflammatory marker which was not constant during the study period (P = 0.001 in test for constant level), but there was no significant difference between placebo and ARB-treated (P ≥ 0.51 in tests for parallel curves and equal levels). DISCUSSION Inflammatory biomarkers were neither acutely, nor in the long-term significantly affected by the ARB irbesartan. Our findings suggest that ARB treatment in HD patients does not offer protective anti-inflammatory effects.
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Affiliation(s)
- Christian D Peters
- Department of Renal Medicine, Aarhus University Hospital, Denmark.,Institute of Clinical Medicine, Aarhus University, Denmark
| | - Krista D Kjaergaard
- Department of Renal Medicine, Aarhus University Hospital, Denmark.,Institute of Clinical Medicine, Aarhus University, Denmark
| | - Claus H Nielsen
- Institute for Inflammation Research, Rigshospitalet, Copenhagen, Denmark
| | | | - Bo M Bibby
- Department of Biostatistics, Aarhus University, Denmark
| | - Jens D Jensen
- Department of Renal Medicine, Aarhus University Hospital, Denmark.,Institute of Clinical Medicine, Aarhus University, Denmark
| | - Bente Jespersen
- Department of Renal Medicine, Aarhus University Hospital, Denmark.,Institute of Clinical Medicine, Aarhus University, Denmark
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13
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Abstract
Hypertension is the most common complication of end-stage renal disease and chronic hemodialysis and yet, only a third of these patients have adequately controlled blood pressures. Pathogenesis of hypertension in this population is complex and multifactorial and therefore poses numerous treatment challenges. Furthermore, it is common practice among nephrologists to withhold antihypertensives prior to a hemodialysis procedure due to concerns for intradialytic hypotension (IDH). Intradialytic hypertension (ID-HTN) is an increasingly recognized phenomenon and although less common than IDH, portends poor cardiovascular prognosis as well as reflects higher hypertension burden in the dialysis population. Withholding antihypertensives prior to dialysis routinely in patients may worsen interdialytic blood pressure control as well as increase the prevalence of euvolemic ID-HTN. It may also increase the risk of cardiac arrhythmias and further compromise hemodynamic stability during dialysis. In such situations, predialysis administration of antihypertensive is appropriate and necessary and drug choice should be based on the patient's comorbidities, pharmacokinetics of the drug and its dialyzability.
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Affiliation(s)
- Namrata Krishnan
- Renal Section and Medical Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut.,Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Aldo J Peixoto
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
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14
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Wang Y, Yang Y, Wang A, An S, Li Z, Zhang W, Liu X, Ruan C, Liu X, Guo X, Zhao X, Wu S. Association of long-term blood pressure variability and brachial-ankle pulse wave velocity: a retrospective study from the APAC cohort. Sci Rep 2016; 6:21303. [PMID: 26892486 PMCID: PMC4759569 DOI: 10.1038/srep21303] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 01/21/2016] [Indexed: 11/09/2022] Open
Abstract
We investigated associations between long-term blood pressure variability (BPV) and brachial-ankle pulse wave velocity (baPWV). Within the Asymptomatic Polyvascular Abnormalities Community (APAC) study, we retrospectively collected long-term BPV and baPWV measures. Long-term BPV was calculated using the mean and standard deviation of systolic blood pressure (SBP) across 4 years based on annual values of SBP. In total, 3,994 subjects (2,284 men) were eligible for inclusion in this study. We stratified the study population into four SBP quartiles. Left and right baPWV was higher in participants with long-term SBPV in the fourth quartile compared with the first quartile (left: 1,725 ± 488 vs. 1,461 ± 340 [p < 0.001]; right: 1,722 ± 471 vs. 1,455 ± 341 [p < 0.001], respectively). We obtained the same result for total baPWV (fourth vs. first quartile: 1,772 ± 429 vs. 1,492 ± 350 [p < 0.001]). Furthermore, there was a trend for gradually increased baPWV (≥1,400 cm/s) with increased SBPV (p < 0.001). After multivariable adjustment, baPWV was positively correlated with long-term BPV (p < 0.001). In conclusion, long-term BPV is significantly associated with arterial stiffness as assessed by baPWV.
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Affiliation(s)
- Yang Wang
- Graduate School, North China University of Science and Technology, Tangshan, China
| | - Yuling Yang
- Graduate School, North China University of Science and Technology, Tangshan, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Shasha An
- Graduate School, North China University of Science and Technology, Tangshan, China
| | - Zhifang Li
- Graduate School, North China University of Science and Technology, Tangshan, China
| | - Wenyan Zhang
- Graduate School, North China University of Science and Technology, Tangshan, China
| | - Xuemei Liu
- Graduate School, North China University of Science and Technology, Tangshan, China
| | - Chunyu Ruan
- Graduate School, North China University of Science and Technology, Tangshan, China
| | - Xiaoxue Liu
- Department of Cardiology,Tangshan People's Hospital, Tangshan, China
| | - Xiuhua Guo
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shouling Wu
- Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan, China
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15
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Aftab RA, Khan AH, Adnan AS, Jannah N. A systematic review on randomized control trials on rennin angiotensin aldosterone system inhibitors role in managing hypertension among hemodialysis patients. Ren Fail 2016; 38:474-80. [PMID: 26853680 DOI: 10.3109/0886022x.2016.1138833] [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] [Indexed: 11/13/2022] Open
Abstract
Randomized control trials (RCTs) are considered as most rigors way of determining the cause-effect relationship of a treatment and outcome. Activation of rennin angiotensin aldosterone system (RAAS) is an important contributor to hypertension in hemodialysis patients. The prevalence of hypertension in hemodialysis patients varies from 60% to 80% and hypertension management alone with conventional hemodialysis is insufficient. Hence, the current review was aimed to investigate the effect of RAAS inhibitors in managing hypertension among hemodialysis patients in a randomized control trial. Using PUBMED and EMBASE databases, randomized control trial with primary or secondary outcomes related to the effect of RAAS inhibitors on blood pressure among hemodialysis patients were included for analysis. The current review also assessed the quality of reporting of RCT. A total of eight RCT met inclusion criteria for current review. According to modified jaded scale, one (12.5%) study scored four points for quality reporting, whereas two (25%) studies scored one point that was the least score. The mean score for all included studies was 2.25. Six (75%) of the eight RCT included, involved ARB in hypertension management among hemodialysis patients, whereas two (25%) studies involved angiotensin-converting enzyme (ACE) inhibitors. Of the siz RCT involving ARB, two (33.3%) RCT also included ACE inhibitors comparison group. Altogether six (75%) studies report a reduction in blood pressure with the use of RAAS inhibitors compared to control group; however, of the six studies, two (33.3%) reported that the reduction in blood pressure was not significant. Whereas, two (25%) studies reported no reduction in blood pressure compared to the control group. The findings from current review do not indicate a clear pattern for a role of RAAS inhibitors for hypertension control among hemodialysis patients.
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Affiliation(s)
- Raja Ahsan Aftab
- a Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences , University Sains Malaysia , Penang , Malaysia ;,b Chronic Kidney Disease Resource Centre, School of Medical Sciences , Health Campus, University Sains Malaysia , KubangKerain , Kelantan , Malaysia
| | - Amer Hayat Khan
- a Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences , University Sains Malaysia , Penang , Malaysia
| | - Azreen Syazril Adnan
- b Chronic Kidney Disease Resource Centre, School of Medical Sciences , Health Campus, University Sains Malaysia , KubangKerain , Kelantan , Malaysia
| | - Nurul Jannah
- b Chronic Kidney Disease Resource Centre, School of Medical Sciences , Health Campus, University Sains Malaysia , KubangKerain , Kelantan , Malaysia
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16
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Peters CD, Kjaergaard KD, Jensen JD, Christensen KL, Strandhave C, Tietze IN, Novosel MK, Bibby BM, Jensen LT, Sloth E, Jespersen B. The Authors Reply. Kidney Int 2015; 88:193-4. [PMID: 26126092 DOI: 10.1038/ki.2015.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Christian D Peters
- 1] Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark [2] Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Krista D Kjaergaard
- 1] Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark [2] Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens D Jensen
- 1] Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark [2] Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | - Ida N Tietze
- Department of Medicine, Viborg Regional Hospital, Viborg, Denmark
| | - Marija K Novosel
- Department of Medicine, Fredericia Hospital, Fredericia, Denmark
| | - Bo M Bibby
- Department of Biostatistics, Aarhus University, Aarhus, Denmark
| | - Lars T Jensen
- Department of Clinical Physiology and Nuclear Medicine, Herlev Hospital, Herlev, Denmark
| | - Erik Sloth
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Bente Jespersen
- 1] Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark [2] Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
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17
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Sun F, Song Y, Liu J, Ma LJ, Shen Y, Huang J, Zhou YL. Efficacy of losartan for improving insulin resistance and vascular remodeling in hemodialysis patients. Hemodial Int 2015; 20:22-30. [PMID: 26104969 DOI: 10.1111/hdi.12327] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Insulin resistance and vascular remodeling are prevalent and predict cardiovascular mortality in hemodialysis patients. Angiotensin II (Ang II) may be involved in both pathogenesis. In the present study, we investigated the effects of the Ang II receptor blocker losartan on insulin resistance, arterial stiffness, and carotid artery structure in hemodialysis patients. Seventy-two hemodialysis patients were randomly assigned to receive either losartan 50 mg qd (n = 36) or β-blocker bisoprolol 5 mg qd (n = 36). At the start and at month 12, ambulatory blood pressure (BP) monitoring, aortic pulse wave velocity (PWV) measurements, and carotid artery ultrasound were performed, and homeostasis model assessment index of insulin resistance (HOMA-IR) was determined. During the study period, bioimpedance method was used to evaluate volume status every 3 months. Home-monitored BPs were measured at least monthly. Ambulatory BP decreased significantly and similarly by either losartan or bisoprolol. Decreases in PWVs in losartan group at the end of month 12 were significantly greater than changes in PWV in bisoprolol group (0.9 ± 0.3 vs. 0.4 ± 0.5 m/s, P = 0.021). Common carotid artery intima-media cross-sectional area decreased significantly only in patients treated with losartan (20.3 ± 4.9 vs. 19.1 ± 5.1 mm(2) , P = 0.001), and HOMA-IR was also reduced in losartan group only (1.9 ± 1.0 vs. 1.7 ± 0.8, P = 0.003). Multiple regression analysis showed significant correlations between changes in PWV and changes in HOMA-IR. With comparable BP-lowering efficacy, losartan achieved better improvement in insulin sensitivity, arterial stiffness, and carotid artery hypertrophy in hemodialysis patients. The regression of arterial stiffness may be in part through attenuation in insulin resistance.
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Affiliation(s)
- Fang Sun
- Department of Nephrology, Institute of Uro-nephrology, Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yan Song
- Department of Nephrology, The First Affiliated Hospital, Chinese PLA General Hospital, Beijing, China
| | - Jing Liu
- Department of Nephrology, Institute of Uro-nephrology, Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Li-Jie Ma
- Department of Nephrology, Institute of Uro-nephrology, Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yang Shen
- Department of Nephrology, Institute of Uro-nephrology, Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jing Huang
- Department of Nephrology, Institute of Uro-nephrology, Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yi-Lun Zhou
- Department of Nephrology, Institute of Uro-nephrology, Chao-Yang Hospital, Capital Medical University, Beijing, China
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18
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Abstract
Hypertension is almost universal in end-stage renal disease (ESRD) and contributes to the substantial cardiovascular (CV) morbidity and mortality observed in these patients. The management of blood pressure (BP) in ESRD is complicated by a number of factors, including missed dialysis treatments, intradialytic changes in BP, medication removal with dialysis, and poor correlation of BPs obtained in the dialysis unit with those at home and with CV outcomes. Control of extracellular volume with ultrafiltration and dietary sodium restriction represents the principal strategy to manage hypertension in ESRD, and antihypertensive medications are subsequently added if this strategy is inadequate. While reduction in BP with medication improves CV outcomes, few head-to-head clinical trials have been performed to firmly establish the superiority of one antihypertensive medication class over another. Therefore, individualization of therapy is necessary, and patient comorbidities must be considered. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and beta-blockers are reasonable first-line agents for most patients. ACE inhibitors and ARBs exert cardioprotective effects that are independent of BP reduction. Medications that are removed with dialysis may be preferred in patients who are prone to develop intradialytic hypotension. Intradialytic hypertension can be managed with challenging the patient's dry weight and using nondialyzable medications. Within a class of antihypertensive medications, there may be large variability in drug removal with dialysis, which must be considered upon medication selection. Studies demonstrate that even thrice-weekly dosing of medication after dialysis has robust BP-lowering effects, which may be a useful regimen in nonadherent patients.
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Affiliation(s)
- Matthew G Denker
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Debbie L Cohen
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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19
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The impact of angiotensin receptor blockers on arterial stiffness: a meta-analysis. Hypertens Res 2015; 38:613-20. [PMID: 25854987 DOI: 10.1038/hr.2015.51] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 02/04/2015] [Accepted: 02/20/2015] [Indexed: 12/30/2022]
Abstract
Some studies reported a protective role of angiotensin receptor blockers (ARBs) against arterial stiffness. Therefore, we performed a meta-analysis of published clinical trials to systematically assess the impact of ARBs on arterial stiffness as measured by using pulse wave velocity (PWV). Eligible articles were identified by searching PubMed, EMBASE, Cochrane, Wanfang and CNKI databanks before 31 July 2014. The data were extracted independently and in duplicate. Forty articles including 53 clinical trials qualified, including 1650 and 1659 subjects in ARB treatment and control groups, respectively. Overall reductions in carotid-femoral PWV (cfPWV) and brachial-ankle PWV (baPWV) were statistically significant, with an average of -42.52 cm s(-1) (95% CI: -81.82 to -3.21; P=0.034) and -107.08 cm s(-1) (95% CI: -133.98 to -80.18; P<0.0005), respectively, after receiving ARBs. Subgroup analysis by ARB type revealed that telmisartan (weighted mean difference or WMD=-100.82 cm s(-1); P<0.0005) and valsartan (WMD=-104.59 cm s(-1); P<0.0005) significantly reduced baPWV, but only valsartan reduced cfPWV (WMD=-65.58; P=0.030). cfPWV was significantly reduced in comparisons of ARBs with placebo (WMD=-79.65 cm s(-1); P=0.001), and baPWV was significantly reduced with calcium channel blockers (WMD=-130.74 cm s(-1); P<0.0005). There were low probabilities of publication bias. Taken together, our findings support the important role of ARB treatment in improving arterial stiffness.
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20
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A low-dose combination of fluvastatin and valsartan: a new "drug" and a new approach for decreasing the arterial age. BIOMED RESEARCH INTERNATIONAL 2015; 2015:235709. [PMID: 25821790 PMCID: PMC4363554 DOI: 10.1155/2015/235709] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 10/27/2014] [Indexed: 12/20/2022]
Abstract
We have developed a new “drug” and approach that appear to be effective in reducing arterial age. This “drug” represents a low, subtherapeutic dose of statin and sartan and particularly their low-dose combination. The improvement of arterial wall characteristics, also reflecting in a decrease of arterial age, was achieved after a short period of treatment (one month) with the above-mentioned drugs. In addition, we have also implemented a new, innovative therapeutic approach, consisting of intermittent (cyclic) treatment—alternating short “treatment” periods and much longer “rest” periods (when the beneficial effects are still present but gradually decline). This new “drug” and approach both merit further investigation in order to confirm their antiaging efficacy.
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21
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No significant effect of angiotensin II receptor blockade on intermediate cardiovascular end points in hemodialysis patients. Kidney Int 2014; 86:625-37. [DOI: 10.1038/ki.2014.69] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 01/29/2014] [Accepted: 01/30/2014] [Indexed: 01/21/2023]
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22
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Li ECK, Heran BS, Wright JM. Angiotensin converting enzyme (ACE) inhibitors versus angiotensin receptor blockers for primary hypertension. Cochrane Database Syst Rev 2014; 2014:CD009096. [PMID: 25148386 PMCID: PMC6486121 DOI: 10.1002/14651858.cd009096.pub2] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Angiotensin converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs) are widely prescribed for primary hypertension (systolic blood pressure > 140 mmHg or diastolic blood pressure > 90 mmHg). However, while ACE inhibitors have been shown to reduce mortality and morbidity in placebo-controlled trials, ARBs have not. Therefore, a comparison of the efficacies of these two drug classes in primary hypertension for preventing total mortality and cardiovascular events is important. OBJECTIVES To compare the effects of ACE inhibitors and ARBs on total mortality and cardiovascular events, and their rates of withdrawals due to adverse effects (WDAEs), in people with primary hypertension. SEARCH METHODS We searched the Cochrane Hypertension Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the World Health Organization (WHO) International Clinical Trials Registry Platform, and the ISI Web of Science up to July 2014. We contacted study authors for missing and unpublished information, and also searched the reference lists of relevant reviews for eligible studies. SELECTION CRITERIA We included randomized controlled trials enrolling people with uncontrolled or controlled primary hypertension with or without other risk factors. Included trials must have compared an ACE inhibitor and an ARB in a head-to-head manner, and lasted for a duration of at least one year. If background blood pressure lowering agents were continued or added during the study, the protocol to do so must have been the same in both study arms. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS Nine studies with 11,007 participants were included. Of the included studies, five reported data on total mortality, three reported data on total cardiovascular events, and four reported data on cardiovascular mortality. No study separately reported cardiovascular morbidity. In contrast, eight studies contributed data on WDAE. Included studies were of good to moderate quality. There was no evidence of a difference between ACE inhibitors and ARBs for total mortality (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.88 to 1.10), total cardiovascular events (RR 1.07; 95% CI 0.96 to 1.19), or cardiovascular mortality (RR 0.98; 95% CI 0.85 to 1.13). Conversely, a high level of evidence indicated a slightly lower incidence of WDAE for ARBs as compared with ACE inhibitors (RR 0.83; 95% CI 0.74 to 0.93; absolute risk reduction (ARR) 1.8%, number needed to treat for an additional beneficial outcome (NNTB) 55 over 4.1 years), mainly attributable to a higher incidence of dry cough with ACE inhibitors. The quality of the evidence for mortality and cardiovascular outcomes was limited by possible publication bias, in that several studies were initially eligible for inclusion in this review, but had no extractable data available for the hypertension subgroup. To this end, the evidence for total mortality was judged to be moderate, while the evidence for total cardiovascular events was judged to be low by the GRADE approach. AUTHORS' CONCLUSIONS Our analyses found no evidence of a difference in total mortality or cardiovascular outcomes for ARBs as compared with ACE inhibitors, while ARBs caused slightly fewer WDAEs than ACE inhibitors. Although ACE inhibitors have shown efficacy in these outcomes over placebo, our results cannot be used to extrapolate the same conclusion for ARBs directly, which have not been studied in placebo-controlled trials for hypertension. Thus, the substitution of an ARB for an ACE inhibitor, while supported by evidence on grounds of tolerability, must be made in consideration of the weaker evidence for the efficacy of ARBs regarding mortality and morbidity outcomes compared with ACE inhibitors. Additionally, our data mostly derives from participants with existing clinical sequelae of hypertension, and it would be useful to have data from asymptomatic people to increase the generalizability of this review. Unpublished subgroup data of hypertensive participants in existing trials comparing ACE inhibitors and ARBs needs to be made available for this purpose.
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Affiliation(s)
- Edmond CK Li
- University of SaskatchewanAnesthesiology, Perioperative Medicine and Pain ManagementRoyal University Hospital103 Hospital Dr.SaskatoonCanadaS7N 0W8
| | - Balraj S Heran
- University of British ColumbiaDepartment of Anesthesiology, Pharmacology and Therapeutics2176 Health Sciences MallVancouverCanadaV6T 1Z3
| | - James M Wright
- University of British ColumbiaDepartment of Anesthesiology, Pharmacology and Therapeutics2176 Health Sciences MallVancouverCanadaV6T 1Z3
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23
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Chow KM, Szeto CC, Kwan BCH, Cheng PMS, Pang WF, Leung CB, Li PKT. Effect of cinacalcet treatment on vascular arterial stiffness among peritoneal dialysis patients with secondary hyperparathyroidism. Nephrology (Carlton) 2014; 19:339-44. [DOI: 10.1111/nep.12223] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2014] [Indexed: 01/26/2023]
Affiliation(s)
- Kai Ming Chow
- Department of Medicine and Therapeutics; The Chinese University of Hong Kong; Prince of Wales Hospital; Hong Kong
| | - Cheuk Chun Szeto
- Department of Medicine and Therapeutics; The Chinese University of Hong Kong; Prince of Wales Hospital; Hong Kong
| | - Bonnie Ching-Ha Kwan
- Department of Medicine and Therapeutics; The Chinese University of Hong Kong; Prince of Wales Hospital; Hong Kong
| | - Phyllis Mei-Shan Cheng
- Department of Medicine and Therapeutics; The Chinese University of Hong Kong; Prince of Wales Hospital; Hong Kong
| | - Wing Fai Pang
- Department of Medicine and Therapeutics; The Chinese University of Hong Kong; Prince of Wales Hospital; Hong Kong
| | - Chi Bon Leung
- Department of Medicine and Therapeutics; The Chinese University of Hong Kong; Prince of Wales Hospital; Hong Kong
| | - Philip Kam-Tao Li
- Department of Medicine and Therapeutics; The Chinese University of Hong Kong; Prince of Wales Hospital; Hong Kong
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24
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Liu M, Li GL, Li Y, Wang JG. Effects of Various Antihypertensive Drugs on Arterial Stiffness and Wave Reflections. ACTA ACUST UNITED AC 2013; 1:97-107. [PMID: 26587429 PMCID: PMC4315340 DOI: 10.1159/000354108] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We reviewed trials that tested the efficacy of antihypertensive drugs in reducing arterial stiffness and wave reflections as assessed by pulse wave velocity and augmentation index, respectively. Regardless of cross-over or parallel-group comparison design, placebo-controlled trials demonstrated that antihypertensive drugs were effective in reducing pulse wave velocity. In actively-controlled parallel-group comparison studies, this effect on arterial stiffness was more evident for angiotensin-converting enzyme inhibitors or angiotensin receptor blockers than other classes of antihypertensive drugs, particularly when brachial-ankle pulse wave velocity was measured. Regardless of cross-over or parallel-group comparison or placebo- or actively-controlled design, the reviewed trials showed that β-blockers were inferior to all the other classes of antihypertensive drugs in reducing augmentation index. However, these studies had a small sample size and a short follow-up time and did not link the changes in measurements of arterial function with cardiovascular events. Whether the superiority or inferiority is clinically relevant for cardiovascular protection and prevention remains to be investigated.
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Affiliation(s)
- Ming Liu
- Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ge-Le Li
- Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yan Li
- Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ji-Guang Wang
- Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Radchenko GD, Sirenko YM, Kushnir SM, Torbas OO, Dobrokhod AS. Comparative effectiveness of a fixed-dose combination of losartan + HCTZ versus bisoprolol + HCTZ in patients with moderate-to-severe hypertension: results of the 6-month ELIZA trial. Vasc Health Risk Manag 2013; 9:535-49. [PMID: 24109189 PMCID: PMC3792946 DOI: 10.2147/vhrm.s44568] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background The aim of this study was to compare the antihypertensive efficacy of losartan 100 mg + hydrochlorothiazide (HCTZ) 25 mg versus bisoprolol 10 mg + HCTZ 25 mg and their influence on arterial stiffness and central blood pressure (BP). Methods Of 60 patients with a mean BP of 173.3 ± 1.7/98.4 ± 1.2 mmHg, 59 were random-ized to losartan + HCTZ (n = 32) or bisoprolol + HCTZ (n = 27). Amlodipine was added if target BP was not achieved at 1 month, and doxazosin was added if target BP was not achieved after 3 months. Body mass index, office and 24-hour ambulatory BP, pulse wave velocity (carotid-femoral [PWVE] and radial [PWVM]), noninvasive central systolic BP, augmentation index (AIx), laboratory investigations, and electrocardiography were done at baseline and after 6 months of treatment. Results Losartan + HCTZ was as effective as bisoprolol + HCTZ, with target office BP achieved in 96.9% and 92.6% of patients and target 24-hour BP in 75% and 66.7% of patients, respectively, after 6 months. Effective treatment of BP led to significant lowering of central systolic BP, but this was decreased to a significantly (P < 0.05) greater extent by losartan + HCTZ (−23.0 ± 2.3 mmHg) than by bisoprolol + HCTZ (−15.4 ± 2.9 mmHg) despite equal lowering of brachial BP. Factors correlated with central systolic BP and its lowering differed between the treatment groups. Losartan + HCTZ did not alter arterial stiffness patterns significantly, but bisoprolol + HCTZ significantly increased AIx. We noted differences in ΔPWVE, ΔPWVM, and ΔAIx between the groups in favor of losartan + HCTZ. Decreased heart rate was associated with higher central systolic BP and AIx in the bisoprolol + HCTZ group, but was not associated with increased AIx in the losartan + HCTZ group. Conclusion Although both treatments decreased both office and 24-hour BP, losartan + HCTZ significantly decreased central systolic BP and had a more positive influence on pulse wave velocity, with a less negative effect of decreased heart rate on AIx and central systolic BP.
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Affiliation(s)
- G D Radchenko
- Secondary Hypertension Department, National Scientific Center, Strazhesko Institute of Cardiology, Kiev, Ukraine
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Zhou YL, Liu J, Ma L, Sun F, Shen Y, Huang J, Cui T. Impact of dry weight determined by calf bioimpedance ratio on carotid stiffness and left ventricular hypertrophy in hemodialysis patients. Artif Organs 2013; 38:327-34. [PMID: 23981096 DOI: 10.1111/aor.12156] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Our previous study has shown that modification of bioimpedance technique by the measurement of bioimpedance ratio in the calf (calf-BR) was a simple and practical method in assessing fluid status in hemodialysis patients. However, the consequences of periodical dry weight (DW) adjustment under the guidance of calf-BR on target organ damage have not been investigated. One hundred fifteen hemodialysis patients were enrolled in this pilot trial. Patients were divided into bioimpedance group and control group according to their dialysis schedule. In the bioimpedance group, DW was routinely adjusted under the guidance of calf-BR every 3 months. In the control group, the assessment of DW remained a clinical judgment. Carotid stiffness, left ventricular mass index (LVMI), and calf-BR were measured at baseline and at the 12th month in both groups. Home blood pressure (BP) was monitored monthly. Episodes of dialysis-related adverse events were recorded. No significant differences were observed in parameters between the two groups at baseline. Compared with the control group, the bioimpedance group had significantly lower values in terms of the annual averages of systolic home BP (147.4 ± 15.3 mm Hg vs. 152.6 ± 16.9 mm Hg, P = 0.019), carotid stiffness index β (10.7 ± 3.3 vs. 12.2 ± 3.1, P = 0.003), LVMI (155.21 ± 15.64 g/m(2) vs. 165.17 ± 16.76 g/m(2) , P < 0.001), and the percentage of individuals with calf-BR over target range (P = 0.040) at month 12, with less annual averages of antihypertensive medications used and lower frequency of intradialytic hypotension, muscle cramps, or clotted angioaccess. Continued DW control achieved by periodical calf-BR measurement improved arterial stiffness and left ventricular hypertrophy with good tolerability in hemodialysis patients.
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Affiliation(s)
- Yi-Lun Zhou
- Department of Nephrology, ChaoYang Hospital, Capital Medical University, Beijing, China
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Arkouche W, Giaime P, Mercadal L. [Fluid overload and arterial hypertension in hemodialysis patients]. Nephrol Ther 2013; 9:408-15. [PMID: 23953783 DOI: 10.1016/j.nephro.2013.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 04/24/2013] [Indexed: 10/26/2022]
Abstract
The water sodium overload is a factor of morbi-mortality and its treatment is one of the markers of adequacy of the hemodialysis treatment. Its first clinical assessment was improved by tools such as echocardiography and ultrasonography of the inferior vena cava, the per-dialytic curve of plasma volume, measuring BNP or proBNP and by impedancemetry. The combination of the evaluation of these parameters and of the clinical situation allows one to assess the extracellular overload, the state of the blood volume and the potential of plasma refilling. The latter is a key factor of the per-dialytic hemodynamic tolerance. It is itself a determining factor in weight can be achieved at the end of the session. Getting the "dry" weight can require modifications of the prescriptions of the hemodialysis sessions, a filling by albumin even a drugs support. Finally, the overload treatment is the central part of the treatment of arterial hypertension, which has to benefit however often from antihypertensive treatment the profit of which is demonstrated.
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Affiliation(s)
- Walid Arkouche
- Association pour l'utilisation du rein artificiel dans la région lyonnaise (AURAL), 69008 Lyon, France
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Janić M, Lunder M, Sabovič M. A new anti-ageing strategy focused on prevention of arterial ageing in the middle-aged population. Med Hypotheses 2013; 80:837-40. [PMID: 23587479 DOI: 10.1016/j.mehy.2013.03.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 01/09/2013] [Accepted: 03/17/2013] [Indexed: 11/17/2022]
Abstract
Ageing is a progressive process that according to available knowledge cannot be effectively reversed, slowed or stopped. Here we propose a new anti-ageing approach that may lead to the design of effective therapeutic intervention. First, we hypothesize that the "organ system" oriented anti-ageing approach represents a better anti-ageing target than the "whole body" or "cellular ageing" concepts. The arterial system is the most suitable target, as it interconnects all the organs in the body, thus influencing them all. Second, we propose that an anti-ageing approach could be more successful in early than late ageing stages; middle-aged people seem to be the most appropriate candidates. Third, we believe that instead of searching for new medication, we should rely on already established medications with beneficial effects on the arterial wall. Renin-angiotensin system inhibitors and statins fulfill these criteria and are potential cornerstones of the new approach. The fourth hypothesis is based on the concept that in the early stages of arterial ageing only slight injury is present and therefore subtherapeutic, low-dose treatment would be effective. Fifth, we hypothesize that slight initial age-related arterial wall changes are reversible and could be corrected by a short-term (one month) treatment. Sixth, we hypothesize that the effects would be present for a certain period of time even after treatment termination. The listed assumptions combined represent the basis for a new, original anti-ageing approach - a subtherapeutic low-dose combination of a renin-angiotensin system inhibitor and a statin for one month (followed by approximately 6-12 months without treatment) could delay or even reverse the arterial ageing process and consequently decrease the incidence of cardiovascular disorders.
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Affiliation(s)
- Miodrag Janić
- Department of Vascular Diseases, University of Ljubljana Medical Centre, Zaloška cesta 7, 1000 Ljubljana, Slovenia.
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Ishimitsu T, Ohta S, Ohno E, Takahashi T, Numabe A, Okamura A, Ohba S, Hashimoto A, Matsuoka H. Long-term antihypertensive effects of aliskiren, a direct renin inhibitor, in chronic hemodialysis patients. Ther Apher Dial 2013; 17:524-31. [PMID: 24107281 DOI: 10.1111/1744-9987.12017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The renin-angiotensin-aldosterone system is not necessarily suppressed in end-stage renal disease patients undergoing dialysis. Of all the inhibitors of this system, the clinical efficacy of the renin inhibitor, aliskiren, has not been well demonstrated in dialysis patients. We evaluated the antihypertensive effect of aliskiren, administered as a single daily dose of 150 mg for 24 weeks, in 23 chronic hemodialysis patients (age 65 ± 12 years, 15 men and eight women) with blood pressure ≥140/90 mm Hg, and assessed the factors relating to blood pressure reduction. At 4 weeks, the average systolic blood pressure before the dialysis session was insignificantly reduced from 163 ± 10 mm Hg to 160 ± 15 mm Hg, while it was significantly lowered at 12 (154 ± 13 mm Hg) and 24 weeks (155 ± 10 mm Hg), although the pulse rate was not significantly altered. Serum K increased at 24 weeks from 4.9 ± 0.6 mEq/L to 5.2 ± 0.8 mEq/L. Only 10 out of 23 patients showed systolic blood pressure reduction by ≥10 mm Hg. Naturally, plasma renin immunoreactivity increased, while plasma renin activity, along with angiotensin II and aldosterone levels decreased. Basal levels of the components of the renin-angiotensin-aldosterone system were not significantly different in patients showing systolic blood pressure reduction by ≥10 mm Hg (n = 10) vs. those with <10 mm Hg changes (n = 13). The reduction in systolic blood pressure in all 23 patients taken as a whole correlated with changes in plasma renin activity (r = -0.432, P < 0.05) and angiotensin II (r = 0.467, P < 0.05). In chronic hemodialysis patients, aliskiren modestly lowers blood pressure over the long term, although the antihypertensive effect seems dependent on the changes, but not on the basal levels of plasma renin activity and angiotensin II.
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Affiliation(s)
- Toshihiko Ishimitsu
- Department of Cardiology and Nephrology, Dokkyo Medical University, Mibu, Japan
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Lin CJ, Pan CF, Liu HL, Chuang CK, Jayakumar T, Wang TJ, Chen HH, Wu CJ. The role of protein-bound uremic toxins on peripheral artery disease and vascular access failure in patients on hemodialysis. Atherosclerosis 2012; 225:173-9. [PMID: 22981405 DOI: 10.1016/j.atherosclerosis.2012.07.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 06/18/2012] [Accepted: 07/04/2012] [Indexed: 11/15/2022]
Abstract
OBJECTIVE p-Cresyl sulfate (PCS) and indoxyl sulfate (IS) have been reported to predict poor clinical outcomes in hemodialysis (HD) patients. However, little is known about the effect of the two toxins on peripheral arterial disease (PAD) and vascular access dysfunction. Our objective was to explore the association between the two toxins and PAD and vascular access failure (VAF) in a hemodialysis-based cohort. METHODS We enrolled 100 stable and eligible HD patients from a single medical center. These patients were screened for PAD by machine and recorded as ABI (ankle brachial index) and brachial-ankle PWV (pulse wave velocity). Serum levels of PCS, IS and biochemical data were also collected concurrently. In addition, we also recorded the first event of VAF and frequency of PTA and thrombectomy during 3-year follow-up. RESULTS Total and free PCS were correlated to right and left ABI and PWV (p < 0.01), and total IS was associated with right and left ABI (p < 0.01) by Pearson's analysis. Repeated measuring by mixed model analysis revealed that serum albumin (p = 0.003), cholesterol (p = 0.01) and total PCS (p = 0.031) had significant correlation with ABI after adjusting other confounding factors. As for brachial-ankle PWV, serum triglyceride (p = 0.002), total IS (p = 0.04) and total PCS (p = 0.050) reached significance finally. In addition, multivariate Cox regression analysis revealed dialysis length and total PCS were related to AV-shunt failure event (Hazard Ratio: 1.14, p = 0.01, and Hazard Ratio: 1.04, p = 0.04, respectively). Both of total and free PCS and IS were also positively linked to numbers of PTA and thrombectomy. Further, the Kaplan-Meier analysis showed only total PCS was significantly associated with vascular access failure event (log rank P = 0.02). CONCLUSION This study shows that the serum levels of PCS and IS were associated with PAD and total PCS could be a valuable determinant of access viability other than traditional or nontraditional risk factors in HD patients.
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Affiliation(s)
- Cheng-Jui Lin
- Division of Nephrology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan, ROC
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31
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Chronic kidney disease and vascular remodelling: molecular mechanisms and clinical implications. Clin Sci (Lond) 2012; 123:399-416. [PMID: 22671427 DOI: 10.1042/cs20120074] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
CKD (chronic kidney disease) is a severe and complex disease with a very high prevalence of CV (cardiovascular) complications. CKD patients are exposed to haemodynamic disturbances in addition to severe metabolic abnormalities that lead to a specific form of arterial remodelling, which contributes to the development of CV disease. Arterial calcification is a major event in the arterial remodelling process and is strongly linked to mineral metabolism abnormalities associated with CKD. Arterial remodelling is not limited to arterial calcification and modifications in arterial wall composition are also observed. Activation of the RAS (renin-angiotensin system), ET-1 (endothelin-1), endothelial dysfunction, oxidative stress and ADMA (asymmetric ω-NG,NG-dimethylarginine), as well as the anti-aging molecule Klotho, are implicated in this process. The present review details the mechanisms involved in arterial calcification and arterial remodelling associated with CKD, and provides the clinical consequences of large and small artery stiffness and remodelling in CKD patients.
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Watanabe Y, Kikuchi T, Mitsuhashi T, Kimura H, Tsuchida Y, Otsuka K. Administration of angiotensin receptor II blockade improves vascular function, urinary albumin excretion, and left ventricular hypertrophy in low-risk essential hypertensive patients receiving antihypertensive treatment with calcium channel blockers. Clin Exp Hypertens 2012; 35:87-94. [PMID: 22679900 DOI: 10.3109/10641963.2012.690472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We examined calcium channel blockers (CCBs) and angiotensin receptor II blockers in low-risk hypertensives to evaluate renal, vascular function and left ventricular mass (LVM) from the viewpoint of salt intake (SI). Low-risk hypertensives who had not met blood pressure (BP) goals with CCB were administered telmisaltan. Office and home BP, urinary albumin excretion (uAE), brachial ankle pulse wave velocity (baPWV) and LVM were significantly reduced. uAE and baPWV correlated with SI. It is therefore necessary to evaluate the organ-protecting effects from the viewpoint of SI. In low-risk hypertensives, telmisartan with CCB improves renal, vascular function and LVM.
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Affiliation(s)
- Yoshihiko Watanabe
- Department of Medicine, Tokyo Women's Medical University, Medical Center East, Tokyo, Japan.
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Lee SY, Kim HY, Gu SW, Kim HJ, Yang DH. 25-hydroxyvitamin D levels and vascular calcification in predialysis and dialysis patients with chronic kidney disease. Kidney Blood Press Res 2012; 35:349-54. [PMID: 22487876 DOI: 10.1159/000335952] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 12/15/2011] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND/AIMS The role of vitamin D in the process of vascular calcification is unclear in patients with chronic kidney disease. We investigated whether serum 25-hydroxyvitamin D [25(OH)D] is associated with vascular calcification in predialysis and dialysis patients. METHODS We included 86 predialysis and 139 dialysis patients. The simple vascular calcification score (SVCS) was evaluated by examining plain X-rays of the pelvis and hands as described previously. The carotid-to-femoral pulse wave velocity (CF-PWV) was assessed with a commercially available device. RESULTS We found a high prevalence of vitamin D deficiency in our population (78.2%). Vascular calcification was present in 46.2% of all patients. Higher calcification (SVCS >3) was significantly associated with lower 25(OH)D levels in predialysis and dialysis patients. Multiple logistic regression analysis for SVCS >3 showed that 25(OH)D levels were negative independent predictors in predialysis (OR: 0.781; 95% CI: 0.623-0.908, p = 0.019) and dialysis patients (OR: 0.805; 95% CI: 0.749-0.853, p = 0.009). Lower 25(OH)D levels were associated with higher CF-PWV in predialysis patients, but this inverse relationship was no longer present in multivariate analysis. CONCLUSION We showed an independent relationship between low serum 25(OH)D levels and vascular calcification in both predialysis and dialysis patients.
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Affiliation(s)
- So-Young Lee
- Department of Internal Medicine, and Bundang CHA General Hospital, CHA University, Seongnam, South Korea
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Hypertension and hemodialysis: pathophysiology and outcomes in adult and pediatric populations. Pediatr Nephrol 2012; 27:339-50. [PMID: 21286758 PMCID: PMC3204338 DOI: 10.1007/s00467-011-1775-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 01/07/2011] [Accepted: 01/12/2011] [Indexed: 01/13/2023]
Abstract
Hypertension is prevalent in adult and pediatric end-stage renal disease patients on hemodialysis. Volume overload is a primary factor contributing to hypertension, and attaining true dry weight remains a priority for nephrologists. Other contributing factors to hypertension include activation of the sympathetic and renin-angiotensin-aldosterone systems, endothelial cell dysfunction, arterial stiffness, exposure to hypertensinogenic drugs, and electrolyte imbalances during hemodialysis. Epidemiologic studies in adults show that uncontrolled hypertension results in cardiovascular morbidity, but reveal increased mortality risk at low blood pressure, so that it remains unclear what the target blood pressure should be. Despite the lack of a definitive BP target, gradual dry weight reduction should be the first intervention for BP control. Renin-angiotensin-aldosterone system inhibitors have been shown to improve cardiovascular morbidity and mortality and are recommended as the initial pharmacologic therapy for hypertensive hemodialysis patients. Short-daily or nocturnal hemodialysis are also good therapeutic options for these patients. It is already established that hypertension in pediatric hemodialysis patients is associated with adverse cardiovascular outcomes, and there is emerging evidence that the mechanisms causing hypertension are similar to adults. Hypertension in adult and pediatric hemodialysis patients warrants aggressive management, although clinical trial evidence of a target BP that improves mortality does not currently exist.
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Effects of thrice weekly nocturnal hemodialysis on arterial stiffness. Atherosclerosis 2012; 220:477-85. [DOI: 10.1016/j.atherosclerosis.2011.11.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 11/04/2011] [Accepted: 11/10/2011] [Indexed: 11/20/2022]
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Han SH, Kang EW, Yoon SJ, Yoon HS, Lee HC, Yoo TH, Choi KH, Han DS, Kang SW. Combined vascular effects of HMG-CoA reductase inhibitor and angiotensin receptor blocker in non-diabetic patients undergoing peritoneal dialysis. Nephrol Dial Transplant 2011; 26:3722-8. [DOI: 10.1093/ndt/gfr108] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lee SY, Kim HY, Park KM, Lee SYG, Hong SG, Kim HJ, Yang DH. MTHFR C677T polymorphism as a risk factor for vascular calcification in chronic hemodialysis patients. J Korean Med Sci 2011; 26:461-5. [PMID: 21394321 PMCID: PMC3051100 DOI: 10.3346/jkms.2011.26.3.461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 12/13/2010] [Indexed: 12/02/2022] Open
Abstract
Polymorphism of 5,10-methylenetetrahydrofolate reductase (MTHFR) C677T is one of the suggested risk factors for atherosclerosis. However, few studies have reported on the relationship between MTHFR C677T polymorphism and vascular calcification (VC) in chronic hemodialysis patients. We investigated the relationship between the MTHFR C677T polymorphism and VC in 152 chronic hemodialysis patients. Patients with a TT genotype exhibited significantly higher VC scores than patients expressing CC and CT (P = 0.002). The prevalence of peripheral vascular disease increased with the incidence of MTHFR C677T mutations for all patients, and the incidence of cerebrovascular accidents also increased with the presence of mutations for young patients (≤ 60 yr) (P < 0.05). Patients with CT and TT genotypes had adjusted odds ratios for VC of 1.39 and 1.58, respectively (P < 0.05). In summary, these data suggest that the MTHFR C677T polymorphism affects the degree of VC in chronic hemodialysis patients.
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Affiliation(s)
- So-Young Lee
- Department of Internal Medicine, Bundang CHA General Hospital, College of Medicine, CHA University, Seongnam, Korea
| | - Hoe-Young Kim
- Department of Internal Medicine, Bundang CHA General Hospital, College of Medicine, CHA University, Seongnam, Korea
| | - Kyung Mi Park
- Department of Internal Medicine, Bundang CHA General Hospital, College of Medicine, CHA University, Seongnam, Korea
| | - Stephen Yon Gu Lee
- Department of Internal Medicine, Bundang CHA General Hospital, College of Medicine, CHA University, Seongnam, Korea
| | - Seong Geun Hong
- Department of Laboratory Medicine, Bundang CHA General Hospital, College of Medicine, CHA University, Seongnam, Korea
| | - Hyung-Jong Kim
- Department of Internal Medicine, Bundang CHA General Hospital, College of Medicine, CHA University, Seongnam, Korea
| | - Dong Ho Yang
- Department of Internal Medicine, Bundang CHA General Hospital, College of Medicine, CHA University, Seongnam, Korea
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Wang AYM, Sanderson JE. Treatment of heart failure in long-term dialysis patients: a reappraisal. Am J Kidney Dis 2011; 57:760-72. [PMID: 21349619 DOI: 10.1053/j.ajkd.2011.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Accepted: 01/11/2011] [Indexed: 12/24/2022]
Abstract
Heart failure is one of the most frequent cardiac complications in patients with end-stage renal disease receiving long-term hemodialysis or peritoneal dialysis and is associated strongly with a poor prognosis. Despite the significant morbidity and mortality associated with heart failure, there are very limited therapeutic options proved to prevent and treat heart failure in dialysis patients. This limitation largely reflects the paucity of adequately powered prospective randomized clinical trials that have examined the efficacy of different therapeutic options in long-term dialysis patients with heart failure. In this article, the second in a series discussing the management of heart failure in dialysis patients, current therapeutic options for heart failure in the maintenance dialysis population are reviewed and potential novel therapeutic options are discussed.
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Affiliation(s)
- Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong.
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Nakano N, Ishimitsu T, Takahashi T, Inada H, Okamura A, Ohba S, Matsuoka H. Effects of efonidipine, an L- and T-type calcium channel blocker, on the renin-angiotensin-aldosterone system in chronic hemodialysis patients. Int Heart J 2010; 51:188-92. [PMID: 20558909 DOI: 10.1536/ihj.51.188] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Components of the renin-angiotensin-aldosterone system such as angiotensin II and aldosterone are believed to contribute to the development and progression of cardiovascular tissue and organ injuries. We compared the effects of two calcium channel blockers, efonidipine and amlodipine, on the renin-angiotensin-aldosterone system in patients with end-stage renal diseases on maintenance hemodialysis. Twenty hypertensive patients on chronic hemodialysis were given efonidipine 20-60 mg twice daily and amlodipine 2.5-7.5 mg once daily for 12 weeks each in a random crossover manner. The average blood pressure was comparable between the efonidipine and amlodipine periods (151 + or - 15/77 + or - 8 versus 153 + or - 15/76 + or - 8 mmHg). The pulse rate did not change significantly during the administration periods. Although the plasma renin activity and plasma angiotensin II were not significantly different between the efonidipine and amlodipine periods, plasma aldosterone was significantly lower in the efonidipine period than in the amlodipine period (123 + or - 118 versus 146 + or - 150 pg/mL, P = 0.027). The findings suggest that efonidipine reduces plasma aldosterone levels in patients on maintenance hemodialysis, and this seems to be an additional benefit to the cardiovascular protection by antihypertensive therapy with efonidipine in patients with end-stage renal disease.
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Affiliation(s)
- Nobuyuki Nakano
- Department of Hypertension and Cardiorenal Medicine, Dokkyo Medical University, Tochigi, Japan
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40
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Sinha AD, Agarwal R. Should All Hypertensive Dialysis Patients Receive a Blocker of the Renin-Angiotensin System? Curr Hypertens Rep 2010; 12:356-63. [DOI: 10.1007/s11906-010-0137-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Siragy HM. Comparing angiotensin II receptor blockers on benefits beyond blood pressure. Adv Ther 2010; 27:257-84. [PMID: 20524096 DOI: 10.1007/s12325-010-0028-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 06/01/2010] [Indexed: 01/13/2023]
Abstract
The renin-angiotensin-aldosterone system (RAAS) is one of the main regulators of blood pressure, renal hemodynamics, and volume homeostasis in normal physiology, and contributes to the development of renal and cardiovascular (CV) diseases. Therefore, pharmacologic blockade of RAAS constitutes an attractive strategy in preventing the progression of renal and CV diseases. This concept has been supported by clinical trials involving patients with hypertension, diabetic nephropathy, and heart failure, and those after myocardial infarction. The use of angiotensin II receptor blockers (ARBs) in clinical practice has increased over the last decade. Since their introduction in 1995, seven ARBs have been made available, with approved indications for hypertension and some with additional indications beyond blood pressure reduction. Considering that ARBs share a similar mechanism of action and exhibit similar tolerability profiles, it is assumed that a class effect exists and that they can be used interchangeably. However, pharmacologic and dosing differences exist among the various ARBs, and these differences can potentially influence their individual effectiveness. Understanding these differences has important implications when choosing an ARB for any particular condition in an individual patient, such as heart failure, stroke, and CV risk reduction (prevention of myocardial infarction). A review of the literature for existing randomized controlled trials across various ARBs clearly indicates differences within this class of agents. Ongoing clinical trials are evaluating the role of ARBs in the prevention and reduction of CV rates of morbidity and mortality in high-risk patients.
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Affiliation(s)
- Helmy M Siragy
- Department of Medicine, Hypertension Center, University of Virginia, Charlottesville, VA 22908, USA.
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Abstract
Hypertension affects most hemodialysis patients and is often poorly controlled. Adequate control of blood pressure is difficult with conventional hemodialysis alone but is important to improve cardiovascular outcomes. Nonpharmacologic interventions to improve blood pressure include educating patients about limiting sodium intake, ensuring adequate sodium solute removal during hemodialysis, and achieving target "dry weight." However, most patients require a number of antihypertensive medications to achieve an appropriate blood pressure. First-line antihypertensive agents include angiotensin converting enzyme inhibitors and angiotensin receptor blockers given their safety profile and demonstrated benefit on cardiovascular outcomes in clinical trials. beta-blockers and combined alpha- and beta-blockers should also be used in patients with cardiovascular disease or congestive heart failure and may improve outcomes in these populations. Calcium channel blockers and direct vasodilators are also effective for controlling blood pressure. Many blood pressure agents can be dosed once daily and should preferentially be administered at night to control nocturnal blood pressure and minimize intradialytic hypotension. In patients who are noncompliant with therapy, renally eliminated agents (such as lisinopril and atenolol) can be given thrice weekly following hemodialysis. Older antihypertensive agents which require thrice daily dosing ought to be avoided given the high pill burden with these regimens and the concern for noncompliance resulting in rebound hypertension. Newer antihypertensive agents, such as direct renin inhibitors, may provide alternative options to improve blood pressure but require testing for efficacy and safety in hemodialysis patients.
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Affiliation(s)
- Jula K Inrig
- University of Texas Southwestern Medical Center at Dallas, Dallas, Texas 75390-852, USA.
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What factors accelerate aortic stiffening in hemodialysis patients? An observational study. Hypertens Res 2010; 33:243-9. [DOI: 10.1038/hr.2009.219] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Ozawa M, Tamura K, Okano Y, Matsushita K, Ikeya Y, Masuda S, Wakui H, Dejima T, Shigenaga AI, Azuma K, Ishigami T, Toya Y, Ishikawa T, Umemura S. Blood Pressure Variability As Well As Blood Pressure Level is Important for Left Ventricular Hypertrophy and Brachial-Ankle Pulse Wave Velocity in Hypertensives. Clin Exp Hypertens 2009; 31:669-79. [DOI: 10.3109/10641960903407033] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Inrig JK, Patel UD, Toto RD, Reddan DN, Himmelfarb J, Lindsay RM, Stivelman J, Winchester JF, Szczech LA. Decreased pulse pressure during hemodialysis is associated with improved 6-month outcomes. Kidney Int 2009; 76:1098-107. [PMID: 19727063 PMCID: PMC2872933 DOI: 10.1038/ki.2009.340] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Pulse pressure is a well established marker of vascular stiffness and is associated with increased mortality in hemodialysis patients. Here we sought to determine if a decrease in pulse pressure during hemodialysis was associated with improved outcomes using data from 438 hemodialysis patients enrolled in the 6-month Crit-Line Intradialytic Monitoring Benefit Study. The relationship between changes in pulse pressure during dialysis (2-week average) and the primary end point of non-access-related hospitalization and death were adjusted for demographics, comorbidities, medications, and laboratory variables. In the analyses that included both pre- and post-dialysis pulse pressure, higher pre-dialysis and lower post-dialysis pulse pressure were associated with a decreased hazard of the primary end point. Further, every 10 mm Hg decrease in pulse pressure during dialysis was associated with a 20% lower hazard of the primary end point. In separate models that included pulse pressure and the change in pulse pressure during dialysis, neither pre- nor post-dialysis pulse pressure were associated with the primary end point, but each 10 mm Hg decrease in pulse pressure during dialysis was associated with about a 20% lower hazard of the primary end point. Our study found that in prevalent dialysis subjects, a decrease in pulse pressure during dialysis was associated with improved outcomes. Further study is needed to identify how to control pulse pressure to improve outcomes.
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Affiliation(s)
- Jula K Inrig
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas 75390-8523, USA.
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Sengstock D, Sands RL, Gillespie BW, Zhang X, Kiser M, Eisele G, Vaitkevicius P, Kuhlmann M, Levin NW, Hinderliter A, Rajagopalan S, Saran R. Dominance of traditional cardiovascular risk factors over renal function in predicting arterial stiffness in subjects with chronic kidney disease. Nephrol Dial Transplant 2009; 25:853-61. [DOI: 10.1093/ndt/gfp559] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Huang WH, Hsu CW, Chen YC, Hung CC, Huang JY, Lin JL, Yang CW. Angiotensin II Receptor Antagonists Supplementation is Associated with Arterial Stiffness: Insight from a Retrospective Study in 116 Peritoneal Dialysis Patients. Ren Fail 2009; 29:843-8. [DOI: 10.1080/08860220701573558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Abstract
The purpose of this study was to evaluate the validity of brachial-ankle pulse wave velocity (baPWV) and the cardio-ankle vascular index (CAVI) as measures of arterial stiffness in hemodialysis (HD) patients. We studied 160 consecutively enrolled HD patients (mean age: 59+/-13 years; 91 male patients). We measured baPWV and CAVI using a VaSera VS-1000, maximum intima-media thickness (max IMT) of the carotid artery by ultrasonography and blood renal and lipid parameters. As a control, baPWV and CAVI were also measured in age- and gender-matched healthy volunteers. Both baPWV and CAVI were significantly higher in HD patients than in controls (baPWV: 1698+/-355 vs. 1454+/-263 cm s(-1), P<0.0001; CAVI: 9.3+/-1.4 vs. 8.9+/-1.2, P<0.01). BaPWV correlated positively with age (r=0.549, P<0.0001), systolic blood pressure (SBP) (r=0.510, P<0.0001), diastolic blood pressure (r=0.203, P<0.0001), pulse pressure (PP) (r=0.499, P<0.0001), Kt V(-1) (r=0.221, P<0.01), Brinkman index (r=0.186, P<0.05) and max IMT (r=0.285, P<0.001). CAVI also correlated positively with age (r=0.562, P<0.0001), SBP (r=0.395, P<0.0001), PP (r=0.490, P<0.0001), Kt V(-1) (r=0.216, P<0.01), Brinkman index (r=0.238, P<0.01) and max IMT (r=0.280, P<0.001). Multiple regression analysis demonstrated baPWV and CAVI correlated independently with age and SBP. Receiver operating characteristics (ROC) curve analysis demonstrated that baPWV and CAVI had similar power to predict increases in max IMT. We also measured baPWV and CAVI immediately before and after HD, and showed CAVI was influenced by changes in water volume. Both baPWV and CAVI are therefore useful indices of arterial stiffness in HD patients.
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Suzuki H. Therapeutic efficacy of renin—angiotensin blockade in patients receiving dialysis. Ther Adv Cardiovasc Dis 2009; 3:397-405. [DOI: 10.1177/1753944709338339] [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: 11/15/2022] Open
Abstract
Observational data in dialysis patients has indicated an increased cardiovascular mortality. One pathophysiological cause of this cardiovascular mortality in these patients is volume overload. In addition, an inappropriately activated renin—angiotensin system (RAS) has been proposed as another possible mechanism for the increased cardiovascular mortality. With these possible causes in mind, blockade of the RAS with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) have both emerged as means of preventing cardiovascular events in this population. This review focuses on clinical evidence of the beneficial effects of ACE inhibitors and ARBs in dialysis patients with regard to the improvement of cardiovascular events as well as blood pressure control and maintenance of dialysis therapy.
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Affiliation(s)
- Hiromichi Suzuki
- Correspondence to: Hiromichi Suzuki, MD, PhD Department of Nephrology, Saitama Medical University, Saitama, Japan,
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Lieb W, Larson MG, Benjamin EJ, Yin X, Tofler GH, Selhub J, Jacques PF, Wang TJ, Vita JA, Levy D, Vasan RS, Mitchell GF. Multimarker approach to evaluate correlates of vascular stiffness: the Framingham Heart Study. Circulation 2008; 119:37-43. [PMID: 19103986 DOI: 10.1161/circulationaha.108.816108] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Arterial stiffness increases with age and contributes to the pathogenesis of systolic hypertension and cardiovascular disease in the elderly. Knowledge about the pathophysiological processes that determine arterial stiffness may help guide therapeutic approaches. METHODS AND RESULTS We related 7 circulating biomarkers representing distinct biological pathways (C-reactive protein, aldosterone-to-renin ratio, N-terminal proatrial natriuretic peptide and B-type natriuretic peptide, plasminogen activator inhibitor-1, fibrinogen, and homocysteine) to 5 vascular function measures (central pulse pressure, carotid-femoral pulse-wave velocity, mean arterial pressure, forward pressure wave amplitude [all measures of conduit artery stiffness], and augmented pressure, an indicator of wave reflection) in 2000 Framingham Offspring Study participants (mean age, 61 years; 55% women). Tonometry measures were obtained on average 3 years after the biomarkers were measured. In multivariable linear regression models adjusting for covariates, the biomarker panel was significantly associated with all 5 vascular measures (P<0.003 for all). On backward elimination, the aldosterone-to-renin ratio was positively associated with each stiffness measure (P< or =0.002 for all). In addition, C-reactive protein was positively related to augmented pressure (P=0.0003), whereas plasminogen activator inhibitor-1 was positively associated with mean arterial pressure (P=0.003), central pulse pressure (P=0.001), and forward pressure wave (P=0.01). CONCLUSIONS Our cross-sectional data on a community-based sample suggest a distinctive pattern of positive associations of biomarkers of renin-angiotensin-aldosterone system activation with pan-arterial vascular stiffness, plasminogen activator inhibitor-1 with central vascular stiffness indices, and C-reactive protein with wave reflection. These observations support the notion of differential influences of biological pathways on vascular stiffness measures.
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