1
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Redon J, Carmena R. Present and future of drug therapy in hypertension: an overview. Blood Press 2024; 33:2320401. [PMID: 38444381 DOI: 10.1080/08037051.2024.2320401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 02/12/2024] [Indexed: 03/07/2024]
Abstract
Purpose: High blood pressure (HBP) is the leading cause of mortality and years of disability, and its prevalence is increasing. Therefore, diagnosis and effective treatment of HBP is one of the main goals to prevent and reduce its complications, and pharmacological treatment is the cornerstone of hypertension management.Materials and Methods: The gradual introduction of different drug families has led to the development of new molecules that have improved efficacy and reduced adverse effects. Results: Current drugs include a large number that target key mechanisms of blood pressure regulation as well as those that contribute to hypertension-induced organ damage. Recently, new antihypertensive drugs have been introduced that not only aim to lower blood pressure but also provide additional protection against organ damage and metabolic disorders. Some of them were introduced for specific indications other than hypertension and other are based in a pharmacogenomic approach. Other routes of administration, such subcutaneous injection, are also being explored to improve protection and compliance.Conclusions: The main characteristics of each class of antihypertensive drug are summarised.
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Affiliation(s)
- Josep Redon
- INCLIVA Research Institute, University of Valencia, Valencia, Spain
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2
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Wu L, Rodriguez M, Hachem KE, Tang WHW, Krittanawong C. Management of patients with heart failure and chronic kidney disease. Heart Fail Rev 2024; 29:989-1023. [PMID: 39073666 DOI: 10.1007/s10741-024-10415-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2024] [Indexed: 07/30/2024]
Abstract
Chronic kidney disease (CKD) and heart failure are often co-existing conditions due to a shared pathophysiological process involving neurohormonal activation and hemodynamic maladaptation. A wide range of pharmaceutical and interventional tools are available to patients with CKD, consisting of traditional ones with decades of experience and newer emerging therapies that are rapidly reshaping the landscape of medical care for this population. Management of patients with heart failure and CKD requires a stepwise approach based on renal function and the clinical phenotype of heart failure. This is often challenging due to altered drug pharmacokinetics interactions with various degrees of kidney function and frequent adverse effects from the therapy that lead to poor patient tolerance. Despite a great body of clinical evidence and guidelines that have offered various treatment options for patients with heart failure and CKD, respectively, patients with CKD are still underrepresented in heart failure clinical trials, especially for those with advanced CKD and end-stage renal disease (ESRD). Future studies are needed to better understand the generalizability of these therapeutic options among heart failures with different stages of CKD.
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Affiliation(s)
- Lingling Wu
- Cardiovascular Division, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mario Rodriguez
- John T Milliken Department of Medicine, Division of Cardiovascular disease, Section of Advanced Heart Failure and Transplant, Barnes-Jewish Hospital, Washington University in St. Louis School of Medicine, St. Louis, USA
| | - Karim El Hachem
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland, Clinic, Cleveland, OH, USA
| | - Chayakrit Krittanawong
- Cardiology Division, Section of Cardiology, NYU Langone Health and NYU School of Medicine, 550 First Avenue, New York, NY, 10016, USA.
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3
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Karreci ES, Jacas S, Donovan O, Pintye D, Wiley N, Zsengeller ZK, Schlondorff J, Alper SL, Friedman DJ, Pollak MR. Differing sensitivities to angiotensin converting enzyme inhibition of kidney disease mediated by APOL1 high-risk variants G1 and G2. Kidney Int 2024:S0085-2538(24)00564-7. [PMID: 39181397 DOI: 10.1016/j.kint.2024.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 07/10/2024] [Accepted: 07/26/2024] [Indexed: 08/27/2024]
Abstract
Apolipoprotein L1 (APOL1) variants G1 and G2 contribute to the excess risk of kidney disease in individuals of recent African ancestry. Since disease mechanisms and optimal treatments remain controversial, we study the effect of current standard-of-care drugs in mouse models of APOL1 kidney disease. Experiments were performed in APOL1 BAC-transgenic mice, which develop proteinuria and glomerulosclerosis following injection with a pCpG-free IFNɤ plasmid. Proteinuric, plasmid injected G1/G1 and G2/G2 mice were randomized to drug treatment or no treatment. Lisinopril, dapagliflozin, and hydralazine were administered in drinking water starting day seven. The urine albumin/creatinine ratio was measured twice weekly, and the kidneys examined histologically with the focal segmental glomerulosclerosis score computed from periodic acid-Shiff-stained sections. The angiotensin converting enzyme inhibitor lisinopril, at standard dose, reduced proteinuria by approximately 90-fold and reduced glomerulosclerosis in the APOL1 G1/G1 BAC-transgenic mice. These effects were independent of blood pressure. Dapagliflozin did not alter disease progression in either G1/G1 or G2/G2 mice. Proteinuria reduction and glomerulosclerosis in G2/G2 BAC-transgenic mice required lisinopril doses two times higher than were effective in G1/G1 mice but achieved a much smaller benefit. Therefore, in these BAC-transgenic mouse models of APOL1 disease, the anti-proteinuric and anti-glomerulosclerotic effects of standard dose lisinopril were markedly effective in G1/G1 compared with G2/G2 APOL1 mice. Comparable reduction in blood pressure by hydralazine treatment provided no such protection. Neither G1/G1 or G2/G2 mice showed improvement with the sodium-glucose cotransporter-2 inhibition dapagliflozin. Thus, it remains to be determined if similar differences in ACE inhibitor responsiveness are observed in patients.
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Affiliation(s)
- Esilida Sula Karreci
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215; Department of Medicine, Harvard Medical School, Boston MA 02115.
| | - Sonako Jacas
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - Olivia Donovan
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - Diana Pintye
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - Nicholas Wiley
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - Zsuzsanna K Zsengeller
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - Johannes Schlondorff
- Division of Nephrology, Department of Medicine, The Ohio State University, Wexner School of Medicine, Columbus, OH 43229
| | - Seth L Alper
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215; Department of Medicine, Harvard Medical School, Boston MA 02115
| | - David J Friedman
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215; Department of Medicine, Harvard Medical School, Boston MA 02115
| | - Martin R Pollak
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215; Department of Medicine, Harvard Medical School, Boston MA 02115
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4
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Takeuchi S, Kohno T, Goda A, Shiraishi Y, Kitamura M, Nagatomo Y, Takei M, Nomoto M, Soejima K, Kohsaka S, Yoshikawa T. Renin-angiotensin system inhibitors for patients with mild or moderate chronic kidney disease and heart failure with mildly reduced or preserved ejection fraction. Int J Cardiol 2024; 409:132190. [PMID: 38761975 DOI: 10.1016/j.ijcard.2024.132190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 05/04/2024] [Accepted: 05/15/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Renin-angiotensin system inhibitors (RASI) reduce adverse cardiovascular events in patients with heart failure (HF) with left ventricular ejection fraction (LVEF) ≤40% and mild or moderate chronic kidney disease (CKD). However, RASI administration rate and its association with long-term outcomes in patients with CKD complicated by HF with LVEF >40% remain unclear. METHODS We analyzed 1923 consecutive patients with LVEF >40% registered within the multicenter database for hospitalized HF. We assessed RASI administration rate and its association with all-cause mortality among patients with mild or moderate CKD (estimated glomerular filtration rate [eGFR]: 30-60 mL/min/1.73 m2). Exploratory subgroups included patients grouped by age (<80, ≥80 years), sex, previous HF hospitalization, B-type natriuretic peptide (higher, lower than median), eGFR (30-44, 45-59 mL/min/1.73 m2), systolic blood pressure (<120, ≥120 mmHg), LVEF (41-49, ≥50%), and mineralocorticoid receptor antagonists (MRA) use. RESULTS Among patients with LVEF >40%, 980 (51.0%) had mild or moderate CKD (age: 81 [74-86] years; male, 52.6%; hypertension, 69.7%; diabetes, 25.9%), and 370 (37.8%) did not receive RASI. RASI use was associated with hypertension, absence of atrial fibrillation, and MRA use. After multivariable adjustments, RASI use was independently associated with lower all-cause mortality over a 2-year median follow-up (hazard ratio: 0.58, 95% confidence interval: 0.43-0.79, P = 0.001), and the mortality rate difference was predominantly due to cardiac death, consistent in all subgroups. CONCLUSIONS Approximately one-third of HF patients with mild or moderate CKD and LVEF >40% were discharged without RASI administration and demonstrated relatively guarded outcomes.
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Affiliation(s)
- Shinsuke Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan.
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | | | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College, Saitama, Japan
| | - Makoto Takei
- Department of Cardiology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Michiru Nomoto
- Department of Cardiology, Saitama Medical University, International Medical Center, Saitama, Japan
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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5
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Correa-Rotter R, Wheeler DC, McEwan P. The Broader Effects of Delayed Progression to End-Stage Kidney Disease: Delaying the Inevitable or a Meaningful Change? Adv Ther 2024:10.1007/s12325-024-02950-6. [PMID: 39141281 DOI: 10.1007/s12325-024-02950-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 07/16/2024] [Indexed: 08/15/2024]
Abstract
A global rise in the prevalence of patients with chronic kidney disease (CKD) with end-stage kidney disease (ESKD) has led to a considerable and increasing burden to health systems, patients, and society. Sodium-glucose cotransporter 2 (SGLT2) inhibitors are proven to reduce incidence of cardio-renal outcomes, including onset of ESKD. Recent post hoc analyses of SGLT2 inhibitor trials extrapolate substantial delays in the average time to ESKD over a patient's lifetime. In this article, we explore the possible real-world effects of such a delay by considering the available evidence reporting outcomes following onset of ESKD. From the patient perspective, a delay in reaching ESKD could substantially improve health-related quality of life and result in additional life years without the need for kidney replacement therapies, a target relevant to all CKD subpopulations. Furthermore, should a patient initiate dialysis at an older age as a result of CKD progression, the time spent in receipt of dialysis, and therefore associated healthcare costs, may also be reduced. A delay in progression may also lead to changes in the management of ESKD, such as increased election of conservative care in preference to dialysis, particularly in elderly populations. For younger patients with CKD, those who reach ESKD while employed face considerable work impairment and productivity loss, as may families and care partners of working age. Therefore, a delay to the onset of ESKD will reduce the proportion of their working lives affected by productivity losses or unemployment due to medical reasons. In conclusion, optimised treatment of CKD may lead to a shift in treatment options, but proper and timely implementation is essential for the realisation of improved outcomes.
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Affiliation(s)
- Ricardo Correa-Rotter
- Department of Nephrology and Mineral Metabolism, National Medical Science and Nutrition Institute Salvador Zubiran, Mexico City, Mexico
| | | | - Phil McEwan
- Health Economics and Outcomes Research Ltd, Unit A, Cardiff Gate Business Park, Copse Walk, Pontprennau, Cardiff, CF23 8RB, UK.
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6
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Nielsen SK, Lamberts M, Nouhravesh N, Jensen MH, Strange JE, Gislason G, Mcgettigan P, Holt A. Temporal trend of first-line drug choice and treatment continuity for hypertension among citizens 75 years or over - a register-based, cohort study. Int J Cardiol 2024; 408:132137. [PMID: 38705205 DOI: 10.1016/j.ijcard.2024.132137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 04/08/2024] [Accepted: 05/02/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Limited knowledge of antihypertensive treatment of the elderly potentially impedes effective strategies for hypertension management in this growing patient group. We aimed to investigate temporal trends for first-line drug choice for antihypertensive treatment and treatment continuity among patients ≥75 years from 2000 to 2021. METHODS Using nationwide Danish registers, patients ≥75 years initiated for the first time on antihypertensive drugs: Angiotensin converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB), beta blockers (BB), calcium channel blockers (CCB), thiazides, or combinations, were identified. Patients with other indications than hypertension were excluded. Treatment continuity was described using claimed prescriptions the first 180 days following study entry. RESULTS From 2000 to 2021, 170,769 patients (median age 80 years [interquartile range:77-84], 60.3% female) were included. From 2000 to 2003 to 2015-2021 the proportion of first-line drug choice increased for ACEi (8.7% to 14.9%), ARB (4.1% to 23.9%), and CCB (10.7% to 27.6%), decreased for thiazides (60.6% to 15.9%) and remained stable for BB (12.9% to 14.1%) and combinations (2.9% to 3.6%). For 157,457 patients alive after 180 days, discontinuation was highest among patients initiated on thiazides (28.3%) whereas most patients continued the same single drug regimen if they started on ACEi (55.2%), ARB (65.0%), BB (57.2%) or CCB (59.3%). CONCLUSIONS From 2000 to 2021 thiazides have been replaced by ACEi, ARB and CCB. Thiazides had the lowest treatment continuity while ARB appeared preferred slightly over ACEi. Differences in adherence in relation to first-line drug choice may warrant scrutiny regarding recommendations for the elderly.
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Affiliation(s)
- Sebastian K Nielsen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 6, DK-2900 Hellerup, Denmark.
| | - Morten Lamberts
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 6, DK-2900 Hellerup, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, DK-2200 Copenhagen, Denmark
| | - Nina Nouhravesh
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 6, DK-2900 Hellerup, Denmark
| | - Mads H Jensen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 6, DK-2900 Hellerup, Denmark
| | - Jarl E Strange
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 6, DK-2900 Hellerup, Denmark; Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 6, DK-2900 Hellerup, Denmark; The Danish Heart Foundation, Vognmagergade 7, DK-1120 Copenhagen, Denmark
| | - Patricia Mcgettigan
- William Harvey Research Institute, Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Anders Holt
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 6, DK-2900 Hellerup, Denmark; Department of Epidemiology and Biostatistics, School of Population Health, University of Auckland, 85 Park Road, Grafton, Auckland 1142, New Zealand
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7
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Ku E, Inker LA, Tighiouart H, McCulloch CE, Adingwupu OM, Greene T, Estacio RO, Woodward M, de Zeeuw D, Lewis JB, Hannedouche T, Jafar TH, Imai E, Remuzzi G, Heerspink HJL, Hou FF, Toto RD, Li PK, Sarnak MJ. Angiotensin-Converting Enzyme Inhibitors or Angiotensin-Receptor Blockers for Advanced Chronic Kidney Disease : A Systematic Review and Retrospective Individual Participant-Level Meta-analysis of Clinical Trials. Ann Intern Med 2024; 177:953-963. [PMID: 38950402 DOI: 10.7326/m23-3236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND In patients with advanced chronic kidney disease (CKD), the effects of initiating treatment with an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin-receptor blocker (ARB) on the risk for kidney failure with replacement therapy (KFRT) and death remain unclear. PURPOSE To examine the association of ACEi or ARB treatment initiation, relative to a non-ACEi or ARB comparator, with rates of KFRT and death. DATA SOURCES Ovid Medline and the Chronic Kidney Disease Epidemiology Collaboration Clinical Trials Consortium from 1946 through 31 December 2023. STUDY SELECTION Completed randomized controlled trials testing either an ACEi or an ARB versus a comparator (placebo or antihypertensive drugs other than ACEi or ARB) that included patients with a baseline estimated glomerular filtration rate (eGFR) below 30 mL/min/1.73 m2. DATA EXTRACTION The primary outcome was KFRT, and the secondary outcome was death before KFRT. Analyses were done using Cox proportional hazards models according to the intention-to-treat principle. Prespecified subgroup analyses were done according to baseline age (<65 vs. ≥65 years), eGFR (<20 vs. ≥20 mL/min/1.73 m2), albuminuria (urine albumin-creatinine ratio <300 vs. ≥300 mg/g), and history of diabetes. DATA SYNTHESIS A total of 1739 participants from 18 trials were included, with a mean age of 54.9 years and mean eGFR of 22.2 mL/min/1.73 m2, of whom 624 (35.9%) developed KFRT and 133 (7.6%) died during a median follow-up of 34 months (IQR, 19 to 40 months). Overall, ACEi or ARB treatment initiation led to lower risk for KFRT (adjusted hazard ratio, 0.66 [95% CI, 0.55 to 0.79]) but not death (hazard ratio, 0.86 [CI, 0.58 to 1.28]). There was no statistically significant interaction between ACEi or ARB treatment and age, eGFR, albuminuria, or diabetes (P for interaction > 0.05 for all). LIMITATION Individual participant-level data for hyperkalemia or acute kidney injury were not available. CONCLUSION Initiation of ACEi or ARB therapy protects against KFRT, but not death, in people with advanced CKD. PRIMARY FUNDING SOURCE National Institutes of Health. (PROSPERO: CRD42022307589).
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Affiliation(s)
- Elaine Ku
- Departments of Medicine and Pediatrics, Division of Nephrology, and Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California (E.K.)
| | - Lesley A Inker
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts (L.A.I., O.M.A., M.J.S.)
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, and Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts (H.T.)
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California (C.E.M.)
| | - Ogechi M Adingwupu
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts (L.A.I., O.M.A., M.J.S.)
| | - Tom Greene
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah (T.G.)
| | - Raymond O Estacio
- Ambulatory Care Services, Denver Health, and Department of General Internal Medicine, University of Colorado at Denver, Health Sciences Center, Denver, Colorado (R.O.E.)
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia, and The George Institute for Global Health, School of Public Health, Imperial College London, London, United Kingdom (M.W.)
| | - Dick de Zeeuw
- Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, the Netherlands (D.deZ.)
| | - Julia B Lewis
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, Tennessee (J.B.L.)
| | | | - Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore (T.H.J.)
| | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan (E.I.)
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy (G.R.)
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands (H.J.L.H.)
| | - Fan Fan Hou
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, Guangzhou, China (F.F.H.)
| | - Robert D Toto
- University of Texas Southwestern Medical Center, Dallas, Texas (R.D.T.)
| | - Philip K Li
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China (P.K.L.)
| | - Mark J Sarnak
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts (L.A.I., O.M.A., M.J.S.)
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8
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Ku E, Tighiouart H, McCulloch CE, Inker LA, Adingwupu OM, Greene T, Estacio RO, Woodward M, de Zeeuw D, Lewis JB, Hannedouche T, Hou FF, Jafar TH, Imai E, Remuzzi G, Heerspink HJL, Toto RD, Sarnak MJ. Association between Acute Declines in eGFR during Renin-Angiotensin System Inhibition and Risk of Adverse Outcomes. J Am Soc Nephrol 2024:00001751-990000000-00354. [PMID: 38889197 DOI: 10.1681/asn.0000000000000426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 06/12/2024] [Indexed: 06/20/2024] Open
Abstract
Key Points
Renin-angiotensin system inhibition was favorable for risk of kidney failure (compared with 0% decline with use of placebo or other agents) up to declines in eGFR of 13% over a 3-month period.Relation between eGFR decline after renin-angiotensin system inhibitor initiation and risk of outcomes was stronger in the first 2 years of follow-up and waned over time.
Background
Declines in GFR occur commonly when renin-angiotensin system (RAS) inhibitors are started. Our objective was to determine the relation between declines in eGFR during trials of RAS inhibition and kidney outcomes.
Methods
We included participants with CKD (eGFR <60 ml/min per 1.73 m2) from 17 trials of RAS inhibition. The exposure was subacute declines in eGFR expressed as % change between randomization and month 3, and in the subset of trials with data available, we also examined % change in eGFR between randomization and month 1. The primary outcome was kidney failure with replacement therapy. Cox proportional hazards models were used to examine the association between subacute declines in eGFR and risk of kidney failure. We used spline models to identify the threshold of change in eGFR below which RAS inhibition was favorable (conservatively comparing a given decline in eGFR with RAS inhibition to no decline in the comparator).
Results
A total of 11,800 individuals with mean eGFR 43 (SD 11) ml/min per 1.73 m2 and median urine albumin-to-creatinine ratio of 362 mg/g (interquartile range, 50–1367) were included, and 1162 (10%) developed kidney failure. The threshold of decline in eGFR that favored the use of RAS inhibitors for kidney failure was estimated to be up to 13% (95% confidence interval, 8% to 17%) over a 3-month interval and up to 21% (95% confidence interval, 15% to 27%) over a 1-month interval after starting RAS inhibitors.
Conclusions
In patients treated with RAS inhibitors, ≤13% decline in eGFR over a 3-month period or ≤21% decline over a 1-month period was associated with lower risk of kidney failure compared with no decline in those assigned to placebo or other agents.
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Affiliation(s)
- Elaine Ku
- Division of Nephrology, Departments of Medicine and Pediatrics, University of California San Francisco, San Francisco, CA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Hocine Tighiouart
- Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Lesley A Inker
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Ogechi M Adingwupu
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Tom Greene
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Raymond O Estacio
- Ambulatory Care Services, Denver Health, Department of General Internal Medicine, University of Colorado at Anschutz Medical Center, Aurora, CO
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- The George Institute for Global Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Julia B Lewis
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Fan Fan Hou
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, Guangzhou, China
| | - Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert D Toto
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mark J Sarnak
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
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9
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Hattori K, Sakaguchi Y, Oka T, Asahina Y, Kawaoka T, Doi Y, Hashimoto N, Kusunoki Y, Yamamoto S, Yamato M, Yamamoto R, Matsui I, Mizui M, Kaimori JY, Isaka Y. Estimated Effect of Restarting Renin-Angiotensin System Inhibitors after Discontinuation on Kidney Outcomes and Mortality. J Am Soc Nephrol 2024:00001751-990000000-00355. [PMID: 38889205 DOI: 10.1681/asn.0000000000000425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 06/12/2024] [Indexed: 06/20/2024] Open
Abstract
Key Points
Restarting renin-angiotensin system inhibitor after discontinuation was associated with a lower risk of kidney outcomes and mortality but not related to hyperkalemia.Our findings support a proactive approach to restarting renin-angiotensin system inhibitor among patients with CKD.
Background
While renin-angiotensin system inhibitors (RASi) have been the mainstream treatment for patients with CKD, they are often discontinued because of adverse effects such as hyperkalemia and AKI. It is unknown whether restarting RASi after discontinuation improves clinical outcomes.
Methods
Using the Osaka Consortium for Kidney disease Research database, we performed a target trial emulation study including 6065 patients with an eGFR of 10–60 ml/min per 1.73 m2 who were followed up by nephrologists and discontinued RASi between 2005 and 2021. With a clone-censor-weight approach, we compared a treatment strategy for restarting RASi within a year after discontinuation with that for not restarting RASi. Patients were followed up for 5 years at maximum after RASi discontinuation. The primary outcome was a composite kidney outcome (initiation of KRT, a ≥50% decline in eGFR, or kidney failure [eGFR <5 ml/min per 1.73 m2]). Secondary outcomes were all-cause death and incidence of hyperkalemia (serum potassium levels ≥5.5 mEq/L).
Results
Among those who discontinued RASi (mean [SD] age 66 [15] years, 62% male, mean [SD] eGFR 40 [26] ml/min per 1.73 m2), 2262 (37%) restarted RASi within a year. Restarting RASi was associated with a lower hazard of the composite kidney outcome (hazard ratio [HR], 0.85; 95% confidence intervals [CIs], 0.78 to 0.93]) and all-cause death (HR, 0.70; 95% CI, 0.61 to 0.80) compared with not restarting RASi. The incidence of hyperkalemia did not differ significantly between the two strategies (HR, 1.11; 95% CI, 0.96 to 1.27).
Conclusions
Restarting RASi after discontinuation was associated with a lower risk of kidney outcomes and mortality but not related to the incidence of hyperkalemia.
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Affiliation(s)
- Koki Hattori
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yusuke Sakaguchi
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tatsufumi Oka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuta Asahina
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takayuki Kawaoka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yohei Doi
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Nobuhiro Hashimoto
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, Osaka, Japan
| | - Yasuo Kusunoki
- Department of Nephrology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | | | - Masafumi Yamato
- Department of Nephrology, Sakai City Medical Center, Sakai, Japan
| | - Ryohei Yamamoto
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
- Health and Counseling Center, Osaka University, Toyonaka, Japan
| | - Isao Matsui
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masayuki Mizui
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Jun-Ya Kaimori
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
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10
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Samuel S, Craver K, Miller C, Pelsue B, Gonzalez C, Allison TA, Gulbis B, Choi HA, Kim S. Reviving Decades-Old Wisdom: Longitudinal Analysis of Renin-Angiotensin System Inhibitors and Its Effects on Acute Ischemic Stroke to Improve Outcomes. Am J Hypertens 2024; 37:531-539. [PMID: 38501167 DOI: 10.1093/ajh/hpae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/08/2024] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND While renin-angiotensin system (RAS) inhibitors have a longstanding history in blood pressure control, their suitability as first-line in-patient treatment may be limited due to prolonged half-life and kidney failure concerns. METHODS Using a cohort design, we assessed the impact of RAS inhibitors, either alone or in combination with beta-blockers, on mortality, while exploring interactions, including those related to end-stage renal disease and serum creatinine levels. Eligible subjects were Acute Ischemic Stroke (AIS) patients aged 18 or older with specific subtypes who received in-patient antihypertensive treatment. The primary outcome was mortality rates. Statistical analyses included cross-sectional and longitudinal approaches, employing generalized linear models, G-computation, and discrete-time survival analysis over a 20-day follow-up period. RESULTS In our study of 3,058 AIS patients, those using RAS inhibitors had significantly lower in-hospital mortality (2.2%) compared to non-users (12.1%), resulting in a relative risk (RR) of 0.18 (95% CI: 0.12-0.26). Further analysis using G-computation revealed a marked reduction in mortality risk associated with RAS inhibitors (0.0281 vs. 0.0913, risk difference [RD] of 6.31% or 0.0631, 95% CI: 0.046-0.079). Subgroup analysis demonstrated notable benefits, with individuals having creatinine levels below and above 1.3 mg/dl exhibiting statistically significant RD (RD -0.0510 vs. -0.0895), and a significant difference in paired comparison (-0.0385 or 3.85%, CI 0.023-0.054). Additionally, longitudinal analysis confirmed a consistent daily reduction of 0.93% in mortality risk associated with the intake of RAS inhibitors. CONCLUSIONS RAS inhibitors are associated with a significant reduction in in-hospital mortality in AIS patients, suggesting potential clinical benefits in improving patient outcomes.
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Affiliation(s)
- Sophie Samuel
- Department of Pharmacy, Memorial Hermann Hospital, Houston, Texas, USA
| | - Kyndol Craver
- Department of Pharmacy, Memorial Hermann Hospital, Houston, Texas, USA
| | - Charles Miller
- Institute of Clinical Research and Learning Health Care, UT Health Houston, Houston, Texas, USA
| | - Brittany Pelsue
- Department of Pharmacy, Memorial Hermann Hospital, Houston, Texas, USA
| | - Catherine Gonzalez
- Department of Neurology, McGovern Medical School, UT Health Houston, Houston, Texas, USA
| | - Teresa A Allison
- Department of Pharmacy, Memorial Hermann Hospital, Houston, Texas, USA
| | - Brian Gulbis
- Department of Pharmacy, Memorial Hermann Hospital, Houston, Texas, USA
| | - Huimahn Alex Choi
- Department of Neurosurgery, McGovern Medical School, UT Health Houston, Houston, Texas, USA
| | - Seokhun Kim
- Institute of Clinical Research and Learning Health Care, UT Health Houston, Houston, Texas, USA
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11
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Bauer AC, Elias RM, Abensur H, Batista MC, Jansen AM, Riella MC. Chronic Kidney Disease in Brazil: Current Status and Recommended Improvements. KIDNEY DISEASES (BASEL, SWITZERLAND) 2024; 10:213-223. [PMID: 38835403 PMCID: PMC11149994 DOI: 10.1159/000538068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 02/26/2024] [Indexed: 06/06/2024]
Abstract
Background Over the last 3 decades, over 700 million individuals worldwide have been diagnosed with chronic kidney disease (CKD). In a 2017 survey in southern Brazil, 11.4% of those surveyed had CKD. Early identification and effective therapy in Brazil may reduce CKD's impact. This panel discusses the early diagnosis and treatment of CKD and the barriers and actions needed to improve the management of CKD in Brazil. A panel of Brazilian nephrologists was provided with relevant questions to address before a multiday conference. During this meeting, each narrative was discussed and edited through several rounds until agreement on the relevant topics and recommendations was achieved. Summary Panelists highlighted hurdles to early diagnosis and treatment of CKD. These include, but are not limited to, a lack of public and patient education, updated recommendations, multidisciplinary CKD treatment, and a national CKD database. People-centered, physician-centered, and healthcare institution-centered actions can be taken to improve outcomes. Patient empowerment is needed via multiple channels of CKD education and access to health-monitoring wearables and apps. Primary care clinicians and nonspecialists must be trained to screen and manage CKD-causing illnesses, including diabetes and hypertension. The healthcare system may implement a national health data gathering system, more screening tests, automated test result reporting, and telehealth. Key Messages Increasing access to early diagnosis can provide a path to improving care for patients with CKD. Concerted efforts from all stakeholders are needed to overcome the barriers.
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Affiliation(s)
- Andrea Carla Bauer
- Department of Internal Medicine- Nephrology Division, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Rosilene M Elias
- Nephrology Division, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
- Nephrology Division, Universidade Nove de Julho (UNINOVE), São Paulo, Brazil
| | - Hugo Abensur
- Nephrology Division, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
- Nephrology Division, BP-Beneficência Portuguesa, São Paulo, Brazil
| | - Marcelo Costa Batista
- Nephrology Division, Universidade Federal de São Paulo and Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Miguel Carlos Riella
- Nephrology Division, Department of Medicine, Hospital Universitário Evangélico Mackenzie, Curitiba, Brazil
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12
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Sarafidis P, Schmieder R, Burnier M, Persu A, Januszewicz A, Halimi JM, Arici M, Ortiz A, Wanner C, Mancia G, Kreutz R. A European Renal Association (ERA) synopsis for nephrology practice of the 2023 European Society of Hypertension (ESH) Guidelines for the Management of Arterial Hypertension. Nephrol Dial Transplant 2024; 39:929-943. [PMID: 38365947 PMCID: PMC11139525 DOI: 10.1093/ndt/gfae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Indexed: 02/18/2024] Open
Abstract
In June 2023, the European Society of Hypertension (ESH) presented and published the new 2023 ESH Guidelines for the Management of Arterial Hypertension, a document that was endorsed by the European Renal Association (ERA). Following the evolution of evidence in recent years, several novel recommendations relevant to the management of hypertension in patients with chronic kidney disease (CKD) appeared in these Guidelines. These include recommendations for target office blood pressure (BP) <130/80 mmHg in most and against target office BP <120/70 mmHg in all patients with CKD; recommendations for use of spironolactone or chlorthalidone for patients with resistant hypertension with estimated glomerular filtration rate (eGFR) higher or lower than 30 mL/min/1.73 m2, respectively; use of a sodium-glucose cotransporter 2 inhibitor for patients with CKD and estimated eGFR ≥20 mL/min/1.73 m2; use of finerenone for patients with CKD, type 2 diabetes mellitus, albuminuria, eGFR ≥25 mL/min/1.73 m2 and serum potassium <5.0 mmol/L; and revascularization in patients with atherosclerotic renovascular disease and secondary hypertension or high-risk phenotypes if stenosis ≥70% is present. The present report is a synopsis of sections of the ESH Guidelines that are relevant to the daily clinical practice of nephrologists, prepared by experts from ESH and ERA. The sections summarized are those referring to the role of CKD in hypertension staging and cardiovascular risk stratification, the evaluation of hypertension-mediated kidney damage and the overall management of hypertension in patients with CKD.
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Affiliation(s)
- Pantelis Sarafidis
- 1st Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Roland Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Germany
| | - Michel Burnier
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Jean-Michel Halimi
- Service de Néphrologie-Hypertension, Dialyses, Transplantation rénale, CHRU Tours, Tours, France and INSERM SPHERE U1246, Université Tours, Université de Nantes, Tours, France
| | - Mustafa Arici
- Department of Nephrology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
| | | | | | - Reinhold Kreutz
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany
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13
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Hurtado K, Scholpa NE, Schnellmann JG, Schnellmann RG. Serotonin regulation of mitochondria in kidney diseases. Pharmacol Res 2024; 203:107154. [PMID: 38521286 DOI: 10.1016/j.phrs.2024.107154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 03/12/2024] [Accepted: 03/21/2024] [Indexed: 03/25/2024]
Abstract
Serotonin, while conventionally recognized as a neurotransmitter in the CNS, has recently gained attention for its role in the kidney. Specifically, serotonin is not only synthesized in the kidney, but it also regulates glomerular function, vascular resistance, and mitochondrial homeostasis. Because of serotonin's importance to mitochondrial health, this review is focused on the role of serotonin and its receptors in mitochondrial function in the context of acute kidney injury, chronic kidney disease, and diabetic kidney disease, all of which are characterized by mitochondrial dysfunction and none of which has approved pharmacological treatments. Evidence indicates that activation of certain serotonin receptors can stimulate mitochondrial biogenesis (MB) and restore mitochondrial homeostasis, resulting in improved renal function. Serotonin receptor agonists that induce MB are therefore of interest as potential therapeutic strategies for renal injury and disease. SIGNIFICANCE STATEMENT: Mitochondrial dysfunction is associated with many human renal diseases such as acute kidney injury, chronic kidney disease, and diabetic kidney disease, which are associated with increased morbidity and mortality. Unfortunately, none of these pathologies has an FDA-approved pharmacological intervention, underscoring the urgency of identifying new therapeutics for such disorders. Studies show that induction of mitochondrial biogenesis via serotonin (5-hydroxytryptamine, 5-HT) receptors reduces kidney injury markers, restores mitochondrial and renal function after kidney injury, and decreases mortality, suggesting that targeting 5-HT receptors may be a promising therapeutic avenue for mitochondrial dysfunction in kidney diseases. While numerous reviews describe the importance of mitochondria and mitochondrial quality control mechanisms in kidney disease, the relevance of 5-HT receptor-mediated mitochondrial metabolic modulation in the kidney has yet to be thoroughly explored.
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Affiliation(s)
- Kevin Hurtado
- Pharmacology and Toxicology, University of Arizona, Tucson, AZ, United States
| | - Natalie E Scholpa
- Pharmacology and Toxicology, University of Arizona, Tucson, AZ, United States; Southern VA Healthcare System, Tucson, AZ, United States
| | | | - Rick G Schnellmann
- Pharmacology and Toxicology, University of Arizona, Tucson, AZ, United States; Southern VA Healthcare System, Tucson, AZ, United States; Department of Neuroscience, College of Medicine, University of Arizona, Tucson, AZ, United States; Southwest Environmental Health Science Center, University of Arizona, Tucson, AZ, United States; Center for Innovation in Brain Science, University of Arizona, Tucson, AZ, United States.
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14
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Hu L, Zhang J, Li M, Feng Y, Lu F. Electrochemical oxidative radical cascade cyclization of dienes and diselenides towards the synthesis of seleno-benzazepines. RSC Adv 2024; 14:12556-12560. [PMID: 38638814 PMCID: PMC11024674 DOI: 10.1039/d4ra01914h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/09/2024] [Indexed: 04/20/2024] Open
Abstract
Selenium-containing compounds are important scaffolds owing to their value in medicinal chemistry, biochemistry and material chemistry. Herein, we report an electrochemical approach to access seleno-benzazepines through an oxidative radical cascade cyclization of dienes with diselenides under metal-free, external oxidant-free and base-free conditions. In a simple undivided cell, various dienes and diselenides were suitable for this transformation, generating the desired products in up to 84% yields. This method provides a green and convenient route for the synthesis of valuable selenium-containing seven-membered N-heterocycles from simple starting materials.
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Affiliation(s)
- Ling Hu
- The National Pharmaceutical Engineering Center for Solid Preparation in Chinese Herbal Medicine, Jiangxi University of Chinese Medicine 56 Yangming Road Jiangxi Nanchang 330006 P. R. China
| | - Jingyi Zhang
- The National Pharmaceutical Engineering Center for Solid Preparation in Chinese Herbal Medicine, Jiangxi University of Chinese Medicine 56 Yangming Road Jiangxi Nanchang 330006 P. R. China
| | - Minghan Li
- The National Pharmaceutical Engineering Center for Solid Preparation in Chinese Herbal Medicine, Jiangxi University of Chinese Medicine 56 Yangming Road Jiangxi Nanchang 330006 P. R. China
| | - Yulin Feng
- The National Pharmaceutical Engineering Center for Solid Preparation in Chinese Herbal Medicine, Jiangxi University of Chinese Medicine 56 Yangming Road Jiangxi Nanchang 330006 P. R. China
| | - Fangling Lu
- The National Pharmaceutical Engineering Center for Solid Preparation in Chinese Herbal Medicine, Jiangxi University of Chinese Medicine 56 Yangming Road Jiangxi Nanchang 330006 P. R. China
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15
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Pollock C, Moon JY, Ngoc Ha LP, Gojaseni P, Ching CH, Gomez L, Chan TM, Wu MJ, Yeo SC, Nugroho P, Bhalla AK. Framework of Guidelines for Management of CKD in Asia. Kidney Int Rep 2024; 9:752-790. [PMID: 38765566 PMCID: PMC11101746 DOI: 10.1016/j.ekir.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/29/2023] [Accepted: 12/11/2023] [Indexed: 05/22/2024] Open
Affiliation(s)
- Carol Pollock
- Kolling Institute of Medical Research, University of Sydney, St Leonards, New South Wales, Australia
| | - Ju-young Moon
- Kyung Hee University School of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Le Pham Ngoc Ha
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | | | | | - Lynn Gomez
- Asian Hospital and Medical Center, Muntinlupa City, Metro Manila, Philippines
| | - Tak Mao Chan
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Ming-Ju Wu
- Taichung Veterans General Hospital, Taichung City, Taiwan
| | | | | | - Anil Kumar Bhalla
- Department of Nephrology-Sir Ganga Ram Hospital Marg, New Delhi, Delhi, India
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16
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Vendeville N, Lepage MA, Festa MC, Mavrakanas TA. Clinical Outcomes of Renin-Angiotensin-Aldosterone Blockade in Patients With Advanced Chronic Kidney Disease: A Systematic Review and Meta-analysis. Can J Cardiol 2024:S0828-282X(24)00192-2. [PMID: 38458564 DOI: 10.1016/j.cjca.2024.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 02/09/2024] [Accepted: 02/13/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND The cardiovascular and renal benefits of renin-angiotensin aldosterone system (RAAS) blockade are not well established in patients with advanced chronic kidney disease (CKD). We conducted a systematic review and meta-analysis to identify potential risks and benefits from RAAS blockade in patients with CKD stage 4-5. METHODS A Medline search from inception to November 2022 was conducted to identify randomised controlled trials (RCTs) in patients with CKD stage 4-5 (estimated glomerular filtration rate ≤ 30 mL/min/1.73 m2) comparing RAAS blockade vs placebo or alternative antihypertensive therapy. Different intervention strategies were assessed (RAAS use vs nonuse, initiation vs placebo/alternative therapy, or discontinuation vs continuation). The primary outcome was progression to end-stage kidney disease (ESKD). Secondary outcomes were all-cause mortality and major adverse cardiovascular events (MACE). The risk ratio (RR) was estimated with the use of a random-effects model. RESULTS Nine RCTs (1150 patients) were included. RAAS blockade was associated with a significant reduction in progression to ESKD: RR 0.84 (95% confidence interval [CI] 0.74-0.96; P = 0.01). There was no benefit from RAAS blockade on all-cause mortality or MACE: RR 1.02 (95% CI 0.63-1.65; P = 0.93) and RR 0.87 (95% CI 0.49-1.57; P = 0.65), respectively. CONCLUSIONS RAAS blockade may be considered in selected patients with CKD stage 4-5 to delay progression to ESKD.
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Affiliation(s)
- Nicolas Vendeville
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada; Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada.
| | - Marc-Antoine Lepage
- Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - M Carolina Festa
- Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Thomas A Mavrakanas
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada; Research Institute, McGill University Health Centre, Montréal, Québec, Canada
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17
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Zhou N, Zhao F, Wang L, Gao X, Zhao X, Zhang M. Visible-Light-Induced Regioselective Cascade Radical Cyclization of α-Bromocarbonyls: Access to Benzazepine Derivatives. J Org Chem 2024; 89:2238-2246. [PMID: 38296256 DOI: 10.1021/acs.joc.3c02184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Visible-light-induced regioselective cascade radical cyclization of α-bromocarbonyls for the synthesis of benzazepine derivatives is described. In the presence of fac-Ir(ppy)3 (2.0 mol %) as a photocatalyst, 2,6-lutidine as a base, and dichloromethane as a solvent, the reactions proceed smoothly to afford seven-membered rings in good yields. This protocol features a broad substrate scope, excellent functional group tolerance, and mild reaction conditions. Preliminary mechanistic studies reveal that the generation of the α-carbon radical is more prone to react with the 1,1-diphenylethylene tethered acrylamide to generate the stable seven-membered heterocycle.
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Affiliation(s)
- Nengneng Zhou
- Key Laboratory of Functionalized Molecular Solids, Ministry of Education, Anhui Key Laboratory of Molecule-Based Materials, College of Chemistry and Materials Science, Anhui Normal University, Wuhu, Anhui 241000, China
| | - Fangli Zhao
- Key Laboratory of Functionalized Molecular Solids, Ministry of Education, Anhui Key Laboratory of Molecule-Based Materials, College of Chemistry and Materials Science, Anhui Normal University, Wuhu, Anhui 241000, China
| | - Lei Wang
- Key Laboratory of Functionalized Molecular Solids, Ministry of Education, Anhui Key Laboratory of Molecule-Based Materials, College of Chemistry and Materials Science, Anhui Normal University, Wuhu, Anhui 241000, China
| | - Xiang Gao
- Key Laboratory of Functionalized Molecular Solids, Ministry of Education, Anhui Key Laboratory of Molecule-Based Materials, College of Chemistry and Materials Science, Anhui Normal University, Wuhu, Anhui 241000, China
| | - Xiaowei Zhao
- Key Laboratory of Functionalized Molecular Solids, Ministry of Education, Anhui Key Laboratory of Molecule-Based Materials, College of Chemistry and Materials Science, Anhui Normal University, Wuhu, Anhui 241000, China
| | - Man Zhang
- Key Laboratory of Functionalized Molecular Solids, Ministry of Education, Anhui Key Laboratory of Molecule-Based Materials, College of Chemistry and Materials Science, Anhui Normal University, Wuhu, Anhui 241000, China
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18
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Shirai Y, Miura K, Hamada R, Ishikura K, Kunishima S, Hattori M. A nationwide survey of MYH9-related disease in Japan. Clin Exp Nephrol 2024; 28:40-49. [PMID: 37733142 DOI: 10.1007/s10157-023-02404-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/04/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND MYH9-related disease (MYH9-RD) is characterized by congenital macrothrombocytopenia, Döhle body-like granulocyte inclusions, and nephropathy, which may progress to end-stage kidney disease (ESKD). However, information on the effects of renin-angiotensin system (RAS) inhibitors on kidney survival is currently lacking and the outcomes of kidney replacement therapy (KRT) in MYH9-RD are largely unknown. METHODS We conducted a cross-sectional nationwide survey by sending questionnaires to 145 institutions in Japan and analyzed data for 49 patients. RESULTS The median patient age was 27 years. Genetic analysis was performed in 37 (76%) patients. Twenty-four patients (65%) had MYH9 variants affecting the motor domain of non-muscle myosin heavy chain-IIA, and these patients had poorer kidney survival than those with variants affecting the tail domain (P = 0.02). There was no significant difference in kidney survival between patients treated with and without RAS inhibitors. Hemodialysis and peritoneal dialysis were performed in 16 and 7 patients, respectively. There were no major bleeding complications during the perioperative period or during follow-up, except for one patient. Most of the 11 patients who underwent kidney transplantation required perioperative red cell concentrate transfusions, but there was no graft loss during the median posttransplant observational period of 2.0 (interquartile range, 1.3-6.8) years. CONCLUSION Our study demonstrated no beneficial effect of RAS inhibitors on kidney function in patients with MYH9-RD, indicating the need for further studies with more patients. All modalities of KRT are feasible options for MYH9-RD patients who progress to ESKD, with adequate attention to bleeding complications.
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Affiliation(s)
- Yoko Shirai
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1, Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
| | - Kenichiro Miura
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1, Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
| | - Riku Hamada
- Department of Nephrology and Rheumatology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Kenji Ishikura
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Shinji Kunishima
- School of Health Science, Gifu University of Medical Science, Seki, Japan
| | - Motoshi Hattori
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1, Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan.
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19
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Song L, Zhang W, Tang SY, Luo SM, Xiong PY, Liu JY, Hu HC, Chen YQ, Jia B, Yan QH, Tang SQ, Huang W. Natural products in traditional Chinese medicine: molecular mechanisms and therapeutic targets of renal fibrosis and state-of-the-art drug delivery systems. Biomed Pharmacother 2024; 170:116039. [PMID: 38157643 DOI: 10.1016/j.biopha.2023.116039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/04/2023] [Accepted: 12/14/2023] [Indexed: 01/03/2024] Open
Abstract
Renal fibrosis (RF) is the end stage of several chronic kidney diseases. Its series of changes include excessive accumulation of extracellular matrix, epithelial-mesenchymal transition (EMT) of renal tubular cells, fibroblast activation, immune cell infiltration, and renal cell apoptosis. RF can eventually lead to renal dysfunction or even renal failure. A large body of evidence suggests that natural products in traditional Chinese medicine (TCM) have great potential for treating RF. In this article, we first describe the recent advances in RF treatment by several natural products and clarify their mechanisms of action. They can ameliorate the RF disease phenotype, which includes apoptosis, endoplasmic reticulum stress, and EMT, by affecting relevant signaling pathways and molecular targets, thereby delaying or reversing fibrosis. We also present the roles of nanodrug delivery systems, which have been explored to address the drawback of low oral bioavailability of natural products. This may provide new ideas for using natural products for RF treatment. Finally, we provide new insights into the clinical prospects of herbal natural products.
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Affiliation(s)
- Li Song
- College of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Wei Zhang
- College of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Shi-Yun Tang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu 610032, China
| | - Si-Min Luo
- College of Traditional Chinese Medicine, Hainan Medical University, Haikou 571199, China
| | - Pei-Yu Xiong
- College of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Jun-Yu Liu
- College of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Heng-Chang Hu
- College of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Ying-Qi Chen
- College of Traditional Chinese Medicine, Hainan Medical University, Haikou 571199, China
| | - Bo Jia
- College of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Qian-Hua Yan
- Department of Endocrinology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210000, China.
| | - Song-Qi Tang
- College of Traditional Chinese Medicine, Hainan Medical University, Haikou 571199, China.
| | - Wei Huang
- College of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China.
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20
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Speedtsberg ES, Tepel M. Narrative review investigating the nephroprotective mechanisms of sodium glucose cotransporter type 2 inhibitors in diabetic and nondiabetic patients with chronic kidney disease. Front Endocrinol (Lausanne) 2023; 14:1281107. [PMID: 38174341 PMCID: PMC10761498 DOI: 10.3389/fendo.2023.1281107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/16/2023] [Indexed: 01/05/2024] Open
Abstract
Background and aims Outcome trials using sodium glucose cotransporter type 2 inhibitors have consistently shown their potential to preserve kidney function in diabetic and nondiabetic patients. Several mechanisms have been introduced which may explain the nephroprotective effect of sodium glucose cotransporter type 2 inhibitors beyond lowering blood glucose. This current narrative review has the objective to describe main underlying mechanisms causing a nephroprotective effect and to show similarities as well as differences between proposed mechanisms which can be observed in patients with diabetic and nondiabetic chronic kidney disease. Methods We performed a narrative review of the literature on Pubmed and Embase. The research string comprised various combinations of items including "chronic kidney disease", "sodium glucose cotransporter 2 inhibitor" and "mechanisms". We searched for original research and review articles published until march, 2022. The databases were searched independently and the agreements by two authors were jointly obtained. Results Sodium glucose cotransporter type 2 inhibitors show systemic, hemodynamic, and metabolic effects. Systemic effects include reduction of blood pressure without compensatory activation of the sympathetic nervous system. Hemodynamic effects include restoration of tubuloglomerular feedback which may improve pathologic hyperfiltration observed in most cases with chronic kidney disease. Current literature indicates that SGLT2i may not improve cortical oxygenation and may reduce medullar oxygenation. Conclusion Sodium glucose cotransporter type 2 inhibitors cause nephroprotective effects by several mechanisms. However, several mediators which are involved in the underlying pathophysiology may be different between diabetic and nondiabetic patients.
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Affiliation(s)
- Emma S Speedtsberg
- Institute of Molecular Medicine, Cardiovascular and Renal Research, University of Southern Denmark, Odense, Denmark
- Institute of Clinical Medicine, University of Southern Denmark, Odense, Denmark
- Department of Nephrology, Odense University Hospital, Odense, Denmark
| | - Martin Tepel
- Institute of Molecular Medicine, Cardiovascular and Renal Research, University of Southern Denmark, Odense, Denmark
- Institute of Clinical Medicine, University of Southern Denmark, Odense, Denmark
- Department of Nephrology, Odense University Hospital, Odense, Denmark
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21
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Takkavatakarn K, Oh W, Cheng E, Nadkarni GN, Chan L. Machine learning models to predict end-stage kidney disease in chronic kidney disease stage 4. BMC Nephrol 2023; 24:376. [PMID: 38114923 PMCID: PMC10731874 DOI: 10.1186/s12882-023-03424-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/05/2023] [Indexed: 12/21/2023] Open
Abstract
INTRODUCTION End-stage kidney disease (ESKD) is associated with increased morbidity and mortality. Identifying patients with stage 4 CKD (CKD4) at risk of rapid progression to ESKD remains challenging. Accurate prediction of CKD4 progression can improve patient outcomes by improving advanced care planning and optimizing healthcare resource allocation. METHODS We obtained electronic health record data from patients with CKD4 in a large health system between January 1, 2006, and December 31, 2016. We developed and validated four models, including Least Absolute Shrinkage and Selection Operator (LASSO) regression, random forest, eXtreme Gradient Boosting (XGBoost), and artificial neural network (ANN), to predict ESKD at 3 years. We utilized area under the receiver operating characteristic curve (AUROC) to evaluate model performances and utilized Shapley additive explanation (SHAP) values and plots to define feature dependence of the best performance model. RESULTS We included 3,160 patients with CKD4. ESKD was observed in 538 patients (21%). All approaches had similar AUROCs; ANN yielded the highest AUROC (0.77; 95%CI 0.75 to 0.79) and LASSO regression (0.77; 95%CI 0.75 to 0.79), followed by random forest (0.76; 95% CI 0.74 to 0.79), and XGBoost (0.76; 95% CI 0.74 to 0.78). CONCLUSIONS We developed and validated several models for near-term prediction of kidney failure in CKD4. ANN, random forest, and XGBoost demonstrated similar predictive performances. Using this suite of models, interventions can be customized based on risk, and population health and resources appropriately allocated.
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Affiliation(s)
- Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Wonsuk Oh
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ella Cheng
- The Cooper Union for the Advancement of Science and Art, New York, NY, USA
| | - Girish N Nadkarni
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Lili Chan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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22
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Chen TK, Hoenig MP, Nitsch D, Grams ME. Advances in the management of chronic kidney disease. BMJ 2023; 383:e074216. [PMID: 38052474 DOI: 10.1136/bmj-2022-074216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
Chronic kidney disease (CKD) represents a global public health crisis, but awareness by patients and providers is poor. Defined as persistent abnormalities in kidney structure or function for more than three months, manifested as either low glomerular filtration rate or presence of a marker of kidney damage such as albuminuria, CKD can be identified through readily available blood and urine tests. Early recognition of CKD is crucial for harnessing major advances in staging, prognosis, and treatment. This review discusses the evidence behind the general principles of CKD management, such as blood pressure and glucose control, renin-angiotensin-aldosterone system blockade, statin therapy, and dietary management. It additionally describes individualized approaches to treatment based on risk of kidney failure and cause of CKD. Finally, it reviews novel classes of kidney protective agents including sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists, non-steroidal selective mineralocorticoid receptor antagonists, and endothelin receptor antagonists. Appropriate, widespread implementation of these highly effective therapies should improve the lives of people with CKD and decrease the worldwide incidence of kidney failure.
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Affiliation(s)
- Teresa K Chen
- Kidney Health Research Collaborative and Division of Nephrology, Department of Medicine, University of California San Francisco; and San Francisco VA Health Care System, San Francisco, CA, USA
| | - Melanie P Hoenig
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Morgan E Grams
- Department of Medicine, New York University Langone School of Medicine, New York, NY, USA
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23
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Fletcher RA, Jongs N, Chertow GM, McMurray JJ, Arnott C, Jardine MJ, Mahaffey KW, Perkovic V, Rockenschaub P, Rossing P, Correa-Rotter R, Toto RD, Vaduganathan M, Wheeler DC, Heerspink HJ, Neuen BL. Effect of SGLT2 Inhibitors on Discontinuation of Renin-angiotensin System Blockade: A Joint Analysis of the CREDENCE and DAPA-CKD Trials. J Am Soc Nephrol 2023; 34:1965-1975. [PMID: 37876229 PMCID: PMC10703073 DOI: 10.1681/asn.0000000000000248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 09/25/2023] [Indexed: 10/26/2023] Open
Abstract
SIGNIFICANCE STATEMENT Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are foundational therapy for CKD but are underused, in part because they are frequently withheld and not restarted due to hyperkalemia, AKI, or hospitalization. Consequently, ensuring persistent use of ACE inhibitors and ARBs in CKD has long been a major clinical priority. In this joint analysis of the CREDENCE and DAPA-CKD trials, the relative risk of discontinuation of ACE inhibitors and ARBs was reduced by 15% in patients randomized to sodium-glucose cotransporter 2 (SGLT2) inhibitors. This effect was more pronounced in patients with urine albumin:creatinine ratio ≥1000 mg/g, for whom the absolute benefits of these medications are the greatest. These findings indicate that SGLT2 inhibitors may enable better use of ACE inhibitors and ARBs in patients with CKD. BACKGROUND Strategies to enable persistent use of renin-angiotensin system (RAS) blockade to improve outcomes in CKD have long been sought. The effect of SGLT2 inhibitors on discontinuation of RAS blockade has yet to be evaluated. METHODS We conducted a joint analysis of canagliflozin and renal events in diabetes with established nephropathy clinical evaluation (CREDENCE) and dapagliflozin and prevention of adverse outcomes in CKD (DAPA-CKD), two randomized, double-blind, placebo-controlled, event-driven trials of SGLT2 inhibitors in patients with albuminuric CKD. The main outcome was time to incident temporary or permanent discontinuation of RAS blockade, defined as interruption of an ACE inhibitor or ARB for at least 4 weeks or complete cessation during the double-blind on-treatment period. Cox regression analyses were used to estimate the treatment effects from each trial. Hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) were pooled with fixed effects meta-analysis to obtain summary treatment effects, overall and across key subgroups. RESULTS During median follow-up of 2.2 years across both trials, 740 of 8483 (8.7%) patients discontinued RAS blockade. The relative risk for discontinuation of RAS blockade was 15% lower in patients randomized to receiving SGLT2 inhibitors (HR, 0.85; 95% CI, 0.74 to 0.99), with consistent effects across trials ( P -heterogeneity = 0.92). The relative effect on RAS blockade discontinuation was more pronounced among patients with baseline urinary albumin:creatinine ratio ≥1000 mg/g (pooled HR, 0.77; 95% CI, 0.63 to 0.94; P -heterogeneity = 0.009). CONCLUSIONS In patients with albuminuric CKD with and without type 2 diabetes, SGLT2 inhibitors facilitate the use of RAS blockade. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER ClinicalTrials.gov, NCT02065791 and NCT03036150 . PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_11_21_JASN0000000000000248.mp3.
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Affiliation(s)
- Robert A. Fletcher
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Glenn M. Chertow
- Departments of Medicine, Epidemiology and Population Health, and Health Policy, Stanford University School of Medicine, Stanford, California
| | - John J.V. McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Clare Arnott
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Meg J. Jardine
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- NHMRC Clinical Trials Centre, University of Sydney, New South Wales, Australia
| | - Kenneth W. Mahaffey
- Department of Medicine, Stanford Center for Clinical Research, Stanford University School of Medicine, Stanford, California
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, UNSW, Sydney, New South Wales, Australia
| | - Patrick Rockenschaub
- Charité Lab for Artificial Intelligence in Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
- QUEST Center for Transforming Biomedical Research, Berlin Institute of Health (BIH), Berlin, Germany
| | - Peter Rossing
- Complications Research, Steno Diabetes Center Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ricardo Correa-Rotter
- National Medical Science and Nutrition Institute Salvador Zubirán, Mexico City, Mexico
| | - Robert D. Toto
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | | | - David C. Wheeler
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Department of Renal Medicine, University College London, London, United Kingdom
| | - Hiddo J.L. Heerspink
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Brendon L. Neuen
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
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24
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Clemmer JS, Yen TE, Obi Y. Modeling the renoprotective mechanisms of SGLT2 inhibition in hypertensive chronic kidney disease. Physiol Rep 2023; 11:e15836. [PMID: 37957121 PMCID: PMC10643202 DOI: 10.14814/phy2.15836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 11/15/2023] Open
Abstract
Sodium-glucose cotransporter (SGLT)-2 inhibitors have recently been approved for chronic kidney disease (CKD) based on their ability to lower proteinuria and slow CKD progression independent of diabetes status. In diabetic renal disease, modulation of tubuloglomerular feedback (TGF) leading to lower intraglomerular pressure has been postulated as one of the mechanisms of renal protection with SGLT2 inhibition; however, this mechanism has not been sufficiently explored in non-diabetic CKD. We hypothesized that SGLT2 inhibition exerts renoprotection in CKD through increasing TGF despite normoglycemia. To test this hypothesis, we used an integrative mathematical model of human physiology, HumMod. Stage 3 CKD conditions were simulated by reducing nephron mass which was associated with hypertension, low glomerular filtration rate (GFR) (55 mL/min), hyperfiltration of remnant nephrons, elevated albuminuria (500 mg/day), and minimal levels of urinary glucose (0.02 mmol/L). SGLT2 inhibition was associated with acute reductions in GFR associated with afferent arteriolar vasoconstriction due to TGF. After 12 months, glomerular pressure, nephron damage, and chronic GFR decline were reduced with SGLT2 inhibition with additional SGLT1 inhibitory effects further enhancing these effects. This model supports the use of SGLT2 inhibitors to reduce hyperfiltration in CKD and mitigate renal disease progression, even in the absence of diabetes.
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Affiliation(s)
- John S. Clemmer
- Department of Physiology and BiophysicsUniversity of Mississippi Medical CenterJacksonMississippiUSA
| | - Timothy E. Yen
- Department of Medicine, Division of NephrologyUniversity of Mississippi Medical CenterJacksonMississippiUSA
| | - Yoshitsugu Obi
- Department of Medicine, Division of NephrologyUniversity of Mississippi Medical CenterJacksonMississippiUSA
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25
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Su L, Li Y, Chen R, Zhang X, Cao Y, Luo F, Pi M, Xu R, Gao Q, Zhou S, Hu Y, Li H, Yang Q, Wan Q, Liu B, Xu H, Li G, Weng J, Xu G, Chen C, Liu H, Shi Y, Zha Y, Kong Y, Su G, Tang Y, Zhou Y, Gong M, Xu X, Nie S. Epidemiology and outcomes of post-AKI proteinuria. Clin Kidney J 2023; 16:2262-2270. [PMID: 37915920 PMCID: PMC10616502 DOI: 10.1093/ckj/sfad129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Indexed: 11/03/2023] Open
Abstract
Background Acute kidney injury (AKI) has been associated with increased risks of new-onset and worsening proteinuria. However, epidemiologic data for post-AKI proteinuria was still lacking. This study aimed to determine the incidence, risk factors and clinical correlations of post-AKI proteinuria among hospitalized patients. Methods This study was conducted in a multicenter cohort including patients aged 18-100 years with hospital-acquired AKI (HA-AKI) hospitalized at 19 medical centers throughout China. The primary outcome was the incidence of post-AKI proteinuria. Secondary outcomes included AKI recovery and kidney disease progression. The results of both quantitative and qualitative urinary protein tests were used to define post-AKI proteinuria. Cox proportional hazard model with stepwise regression was used to determine the risk factors for post-AKI proteinuria. Results Of 6206 HA-AKI patients without proteinuria at baseline, 2102 (33.9%) had new-onset proteinuria, whereas of 5137 HA-AKI with baseline proteinuria, 894 (17.4%) had worsening proteinuria after AKI. Higher AKI stage and preexisting CKD diagnosis were risk factors for new-onset proteinuria and worsening proteinuria, whereas treatment with renin-angiotensin system inhibitors was associated with an 11% lower risk of incident proteinuria. About 60% and 75% of patients with post-AKI new-onset and worsening proteinuria, respectively, recovered within 3 months. Worsening proteinuria was associated with a lower incidence of AKI recovery and a higher risk of kidney disease progression. Conclusions Post-AKI proteinuria is common and usually transient among hospitalized patients. The risk profiles for new-onset and worsening post-AKI proteinuria differed markedly. Worsening proteinuria after AKI was associated with adverse kidney outcomes, which emphasized the need for close monitoring of proteinuria after AKI.
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Affiliation(s)
- Licong Su
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yanqin Li
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ruixuan Chen
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaodong Zhang
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yue Cao
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fan Luo
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Mingjing Pi
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guizhou Provincial People's Hospital, Guizhou University, Guiyang, China
| | - Ruqi Xu
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qi Gao
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shiyu Zhou
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ying Hu
- The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Hua Li
- Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiongqiong Yang
- Department of Nephrology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Qijun Wan
- The Second People's Hospital of Shenzhen, Shenzhen University, Shenzhen, China
| | - Bicheng Liu
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing, China
| | - Hong Xu
- Children's Hospital of Fudan University, Shanghai, China
| | - Guisen Li
- Renal Department and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Sichuan Clinical Research Center for Kidney Diseases, Chengdu, China
| | - Jianping Weng
- Department of Endocrinology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Gang Xu
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunbo Chen
- Department of Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Huafeng Liu
- Key Laboratory of Prevention and Management of Chronic Kidney Disease of Zhanjiang City, Institute of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Yongjun Shi
- Huizhou Municipal Central Hospital, Sun Yat-Sen University, Huizhou, China
| | - Yan Zha
- Guizhou Provincial People's Hospital, Guizhou University, Guiyang, China
| | - Yaozhong Kong
- Department of Nephrology, the First People's Hospital of Foshan, Foshan, Guangdong, China
| | - Guobin Su
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital, The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ying Tang
- The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Yilun Zhou
- Department of Nephrology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mengchun Gong
- Institute of Health Management, Southern Medical University, Guangzhou, China
- Digital China Health Technologies Corporation Limited, Beijing, China
| | - Xin Xu
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Sheng Nie
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
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26
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Lo R, Narasaki Y, Lei S, Rhee CM. Management of traditional risk factors for the development and progression of chronic kidney disease. Clin Kidney J 2023; 16:1737-1750. [PMID: 37915906 PMCID: PMC10616454 DOI: 10.1093/ckj/sfad101] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Indexed: 11/03/2023] Open
Abstract
Chronic kidney disease (CKD) and its downstream complications (i.e. cardiovascular) are a major source of morbidity worldwide. Additionally, deaths due to CKD or CKD-attributable cardiovascular disease account for a sizeable proportion of global mortality. However, the advent of new pharmacotherapies, diagnostic tools, and global initiatives are directing greater attention to kidney health in the public health agenda, including the implementation of effective strategies that (i) prevent kidney disease, (ii) provide early CKD detection, and (iii) ameliorate CKD progression and its related complications. In this Review, we discuss major risk factors for incident CKD and CKD progression categorized across cardiovascular (i.e. hypertension, dyslipidemia, cardiorenal syndrome), endocrine (i.e. diabetes mellitus, hypothyroidism, testosterone), lifestyle (i.e. obesity, dietary factors, smoking), and genetic/environmental (i.e. CKDu/Mesoamerican nephropathy, APOL1, herbal nephropathy) domains, as well as scope, mechanistic underpinnings, and management.
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Affiliation(s)
- Robin Lo
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Yoko Narasaki
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Sean Lei
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
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27
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Taal MW, Lucas B, Roderick P, Cockwell P, Wheeler DC, Saleem MA, Fraser SDS, Banks RE, Johnson T, Hale LJ, Andag U, Skroblin P, Bayerlova M, Unwin R, Vuilleumier N, Dusaulcy R, Robertson F, Colby E, Pitcher D, Braddon F, Benavente M, Davies E, Nation M, Kalra PA. Associations with age and glomerular filtration rate in a referred population with chronic kidney disease: methods and baseline data from a UK multicentre cohort study (NURTuRE-CKD). Nephrol Dial Transplant 2023; 38:2617-2626. [PMID: 37230953 PMCID: PMC10615633 DOI: 10.1093/ndt/gfad110] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is common but heterogenous and is associated with multiple adverse outcomes. The National Unified Renal Translational Research Enterprise (NURTuRE)-CKD cohort was established to investigate risk factors for clinically important outcomes in persons with CKD referred to secondary care. METHODS Eligible participants with CKD stages G3-4 or stages G1-2 plus albuminuria >30 mg/mmol were enrolled from 16 nephrology centres in England, Scotland and Wales from 2017 to 2019. Baseline assessment included demographic data, routine laboratory data and research samples. Clinical outcomes are being collected over 15 years by the UK Renal Registry using established data linkage. Baseline data are presented with subgroup analysis by age, sex and estimated glomerular filtration rate (eGFR). RESULTS A total of 2996 participants was enrolled. Median (interquartile range) age was 66 (54-74) years, eGFR 33.8 (24.0-46.6) mL/min/1.73 m2 and urine albumin to creatinine ratio 209 (33-926) mg/g; 58.5% were male. Of these participants, 1883 (69.1%) were in high-risk CKD categories. Primary renal diagnosis was CKD of unknown cause in 32.3%, glomerular disease in 23.4% and diabetic kidney disease in 11.5%. Older participants and those with lower eGFR had higher systolic blood pressure and were less likely to be treated with renin-angiotensin system inhibitors (RASi) but were more likely to receive a statin. Female participants were less likely to receive a RASi or statin. CONCLUSIONS NURTuRE-CKD is a prospective cohort of persons who are at relatively high risk of adverse outcomes. Long-term follow-up and a large biorepository create opportunities for research to improve risk prediction and to investigate underlying mechanisms to inform new treatment development.
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Affiliation(s)
- Maarten W Taal
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
- Department of Renal Medicine, Royal Derby Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Bethany Lucas
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
- Department of Renal Medicine, Royal Derby Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Paul Roderick
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Paul Cockwell
- Department of Renal Medicine, Queen Elizabeth Hospital, University Hospitals of Birmingham, Birmingham, UK
| | | | - Moin A Saleem
- Bristol Renal and Children's Renal Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Simon D S Fraser
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Rosamonde E Banks
- Leeds Institute of Medical Research at St James's, School of Medicine, University of Leeds, Leeds, UK
| | - Tim Johnson
- Experimental Renal Medicine, Human Metabolism and Oncology, The Medical School, University of Sheffield, Sheffield, UK
| | | | - Uwe Andag
- Evotec International GmbH, Göttingen, Germany
| | | | | | - Robert Unwin
- AstraZeneca BioPharmaceuticals, Cambridge Biomedical Campus, Cambridge, UK
| | - Nicolas Vuilleumier
- Diagnostics Department, Laboratory Medicine Division, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Rodolphe Dusaulcy
- Diagnostics Department, Laboratory Medicine Division, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Fiona Robertson
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Elizabeth Colby
- Bristol Renal and Children's Renal Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Melissa Benavente
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | | | | | - Philip A Kalra
- Renal Services, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
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Zhao Q, Chen Y, Huang W, Zhou H, Zhang W. Drug-microbiota interactions: an emerging priority for precision medicine. Signal Transduct Target Ther 2023; 8:386. [PMID: 37806986 PMCID: PMC10560686 DOI: 10.1038/s41392-023-01619-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 07/20/2023] [Accepted: 08/24/2023] [Indexed: 10/10/2023] Open
Abstract
Individual variability in drug response (IVDR) can be a major cause of adverse drug reactions (ADRs) and prolonged therapy, resulting in a substantial health and economic burden. Despite extensive research in pharmacogenomics regarding the impact of individual genetic background on pharmacokinetics (PK) and pharmacodynamics (PD), genetic diversity explains only a limited proportion of IVDR. The role of gut microbiota, also known as the second genome, and its metabolites in modulating therapeutic outcomes in human diseases have been highlighted by recent studies. Consequently, the burgeoning field of pharmacomicrobiomics aims to explore the correlation between microbiota variation and IVDR or ADRs. This review presents an up-to-date overview of the intricate interactions between gut microbiota and classical therapeutic agents for human systemic diseases, including cancer, cardiovascular diseases (CVDs), endocrine diseases, and others. We summarise how microbiota, directly and indirectly, modify the absorption, distribution, metabolism, and excretion (ADME) of drugs. Conversely, drugs can also modulate the composition and function of gut microbiota, leading to changes in microbial metabolism and immune response. We also discuss the practical challenges, strategies, and opportunities in this field, emphasizing the critical need to develop an innovative approach to multi-omics, integrate various data types, including human and microbiota genomic data, as well as translate lab data into clinical practice. To sum up, pharmacomicrobiomics represents a promising avenue to address IVDR and improve patient outcomes, and further research in this field is imperative to unlock its full potential for precision medicine.
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Affiliation(s)
- Qing Zhao
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, PR China
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha, 410078, PR China
- Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, 110 Xiangya Road, Changsha, 410078, PR China
- National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha, 410008, PR China
| | - Yao Chen
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, PR China
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha, 410078, PR China
- Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, 110 Xiangya Road, Changsha, 410078, PR China
- National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha, 410008, PR China
| | - Weihua Huang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, PR China
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha, 410078, PR China
- Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, 110 Xiangya Road, Changsha, 410078, PR China
- National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha, 410008, PR China
| | - Honghao Zhou
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, PR China
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha, 410078, PR China
- Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, 110 Xiangya Road, Changsha, 410078, PR China
- National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha, 410008, PR China
| | - Wei Zhang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, PR China.
- The First Affiliated Hospital of Shantou University Medical College, Shantou, 515041, PR China.
- The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, 510080, PR China.
- Central Laboratory of Hunan Cancer Hospital, Central South University, 283 Tongzipo Road, Changsha, 410013, PR China.
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Palmer BF, Clegg DJ. Pathophysiology and clinical management of hyperkalemia in chronic kidney disease. Minerva Med 2023; 114:719-735. [PMID: 36912858 DOI: 10.23736/s0026-4806.23.08465-3] [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: 03/14/2023]
Abstract
Adaptive increases in kidney and gastrointestinal excretion of K+ help to prevent hyperkalemia in patients with chronic kidney disease (CKD) as long as the glomerular filtration rate (GFR) remains >15-20 mL/min. K+ balance is maintained by increased secretion per functioning nephron, which is mediated by elevated plasma K+ concentration, aldosterone, increased flow rate, and enhanced Na+-K+-ATPase activity. Fecal losses of potassium also increase in CKD. These mechanisms are effective in preventing hyperkalemia if urine output is in excess of 600 mL/day and the GFR exceeds 15 mL/min. Development of hyperkalemia with only mild to moderate reductions in GFR should prompt a search for intrinsic disease of the collecting duct, disturbances in mineralocorticoid activity, and/or decreased delivery of sodium to the distal nephron. The initial approach to treatment is to review the patient's medication profile and whenever possible discontinue drugs that impair kidney K+ excretion. Patients should be educated on sources of K+ in the diet and should be strongly encouraged to avoid the use of K+ containing salt substitutes as well as herbal remedies since herbs may be a hidden source of dietary K+. Effective diuretic therapy and correction of metabolic acidosis are effective strategies to minimize the potential for hyperkalemia. Discontinuation or use of submaximal doses of renin-angiotensin blockers should be discouraged given the cardiovascular protective effect these drugs provide. Potassium binding drugs can be useful to enable use of these drugs and potentially allow liberalization of the diet in CKD patients.
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Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA -
| | - Deborah J Clegg
- Department of Internal Medicine, Texas Tech Health Sciences Center, El Paso, TX, USA
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Chinnadurai R, Rengarajan S, Budden JJ, Quinn CM, Kalra PA. Maintaining Renin-Angiotensin-Aldosterone System Inhibitor Treatment with Patiromer in Hyperkalaemic Chronic Kidney Disease Patients: Comparison of a Propensity-Matched Real-World Population with AMETHYST-DN. Am J Nephrol 2023; 54:408-415. [PMID: 37725919 DOI: 10.1159/000533753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/18/2023] [Indexed: 09/21/2023]
Abstract
INTRODUCTION Guideline-directed renin-angiotensin-aldosterone system inhibitor (RAASi) therapy is rarely achieved in clinical settings, often due to hyperkalaemia. We assessed the potassium binder, patiromer, on continuation of RAASi therapy in hyperkalaemic patients with chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM) in the AMETHYST-DN trial, propensity score-matched to a real-world cohort not receiving patiromer (Salford Kidney Study). METHODS The phase 2, open-label AMETHYST-DN trial (NCT01371747) randomized 304 adults with CKD on RAASi, T2DM, hyperkalaemia (serum potassium [sK+] >5.0 mEq/L), and hypertension to receive patiromer, 8.4-33.6 g/day for 12 months. Patients underwent propensity score matching for systolic blood pressure (BP), heart failure status, and estimated glomerular filtration rate (eGFR), with 321 patients with CKD, T2DM, hyperkalaemia, and on RAASi from a prospective CKD cohort (Salford Kidney Study). Changes in RAASi utilization, sK+, BP, proteinuria, and eGFR during 12-month follow-up were assessed by Mann-Whitney U or χ2 tests. RESULTS Matching produced 135:135 patients with no significant differences in age, sex, systolic BP, sK+, eGFR, or heart failure status, although differences in diastolic BP remained (p < 0.001). After 12 months, 100% of AMETHYST-DN patients receiving patiromer remained on RAASi therapy, whereas 38.5% of the Salford Kidney Cohort discontinued RAASi (p < 0.001); hyperkalaemia contributed in 16% of patients (42% of RAASi discontinuations). Significantly greater reductions in sK+ and BP, but not proteinuria or eGFR, were observed in AMETHYST-DN, compared with Salford Kidney Study patients (p < 0.05). CONCLUSIONS These results demonstrate the benefit of patiromer for sK+ management to enable RAASi use while revealing beneficial effects on BP.
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Affiliation(s)
- Rajkumar Chinnadurai
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Sharmilee Rengarajan
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | | | | | - Philip A Kalra
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Zhou N, Zhao F, Wang L, Gao X, Zhao X, Zhang M. NHC-Catalyzed Regioselective Intramolecular Radical Cyclization Reaction for the Synthesis of Benzazepine Derivatives. Org Lett 2023; 25:6072-6076. [PMID: 37550857 DOI: 10.1021/acs.orglett.3c02323] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
A novel and efficient strategy for the synthesis of a series of structurally interesting benzazepine derivatives via an N-heterocyclic carbene-catalyzed regioselective intramolecular radical cyclization has been developed. This protocol features good regioselectivity, good functional-group compatibility, and wide substrate scope, providing a transition-metal- and oxidant-free pathway to access the seven-membered rings under mild reaction conditions. Additionally, further transformation of benzazepines and a large-scale experiment were also conducted.
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Affiliation(s)
- Nengneng Zhou
- Key Laboratory of Functionalized Molecular Solids, Ministry of Education, Anhui Key Laboratory of Molecule-Based Materials, College of Chemistry and Materials Science, Anhui Normal University, Wuhu, Anhui 241000, China
| | - Fangli Zhao
- Key Laboratory of Functionalized Molecular Solids, Ministry of Education, Anhui Key Laboratory of Molecule-Based Materials, College of Chemistry and Materials Science, Anhui Normal University, Wuhu, Anhui 241000, China
| | - Lei Wang
- Key Laboratory of Functionalized Molecular Solids, Ministry of Education, Anhui Key Laboratory of Molecule-Based Materials, College of Chemistry and Materials Science, Anhui Normal University, Wuhu, Anhui 241000, China
| | - Xiang Gao
- Key Laboratory of Functionalized Molecular Solids, Ministry of Education, Anhui Key Laboratory of Molecule-Based Materials, College of Chemistry and Materials Science, Anhui Normal University, Wuhu, Anhui 241000, China
| | - Xiaowei Zhao
- Key Laboratory of Functionalized Molecular Solids, Ministry of Education, Anhui Key Laboratory of Molecule-Based Materials, College of Chemistry and Materials Science, Anhui Normal University, Wuhu, Anhui 241000, China
| | - Man Zhang
- Key Laboratory of Functionalized Molecular Solids, Ministry of Education, Anhui Key Laboratory of Molecule-Based Materials, College of Chemistry and Materials Science, Anhui Normal University, Wuhu, Anhui 241000, China
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Stompór T, Adamczak M, Kurnatowska I, Naumnik B, Nowicki M, Tylicki L, Winiarska A, Krajewska M. Pharmacological Nephroprotection in Non-Diabetic Chronic Kidney Disease-Clinical Practice Position Statement of the Polish Society of Nephrology. J Clin Med 2023; 12:5184. [PMID: 37629226 PMCID: PMC10455736 DOI: 10.3390/jcm12165184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/03/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Chronic kidney disease (CKD) is a modern epidemic worldwide. Introducing renin-angiotensin system (RAS) inhibitors (i.e., ACEi or ARB) not only as blood-pressure-lowering agents, but also as nephroprotective drugs with antiproteinuric potential was a milestone in the therapy of CKD. For decades, this treatment remained the only proven strategy to slow down CKD progression. This situation changed some years ago primarily due to the introduction of drugs designed to treat diabetes that turned into nephroprotective strategies not only in diabetic kidney disease, but also in CKD unrelated to diabetes. In addition, several drugs emerged that precisely target the pathogenetic mechanisms of particular kidney diseases. Finally, the role of metabolic acidosis in CKD progression (and not only the sequelae of CKD) came to light. In this review, we aim to comprehensively discuss all relevant therapies that slow down the progression of non-diabetic kidney disease, including the lowering of blood pressure, through the nephroprotective effects of ACEi/ARB and spironolactone independent from BP lowering, as well as the role of sodium-glucose co-transporter type 2 inhibitors, acidosis correction and disease-specific treatment strategies. We also briefly address the therapies that attempt to slow down the progression of CKD, which did not confirm this effect. We are convinced that our in-depth review with practical statements on multiple aspects of treatment offered to non-diabetic CKD fills the existing gap in the available literature. We believe that it may help clinicians who take care of CKD patients in their practice. Finally, we propose the strategy that should be implemented in most non-diabetic CKD patients to prevent disease progression.
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Affiliation(s)
- Tomasz Stompór
- Department of Nephrology, Hypertension and Internal Medicine, University of Warmia and Mazury in Olsztyn, 10-516 Olsztyn, Poland
| | - Marcin Adamczak
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, 40-027 Katowice, Poland
| | - Ilona Kurnatowska
- Department of Internal Diseases and Transplant Nephrology, Medical University of Lodz, 90-419 Lodz, Poland
| | - Beata Naumnik
- Ist Department of Nephrology and Transplantation with Dialysis Unit, Medical University of Bialystok, Zurawia 14 St., 15-540 Bialystok, Poland
| | - Michał Nowicki
- Department of Nephrology, Hypertension and Kidney Transplantation, Central University Hospital, Medical University of Lodz, 92-213 Lodz, Poland
| | - Leszek Tylicki
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdansk, 80-952 Gdansk, Poland
| | - Agata Winiarska
- Department of Nephrology, Hypertension and Internal Medicine, University of Warmia and Mazury in Olsztyn, 10-516 Olsztyn, Poland
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland;
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Hu Y, Liang L, Liu S, Kung JY, Banh HL. Angiotensin-converting enzyme inhibitor induced cough compared with placebo, and other antihypertensives: A systematic review, and network meta-analysis. J Clin Hypertens (Greenwich) 2023; 25:661-688. [PMID: 37417783 PMCID: PMC10423763 DOI: 10.1111/jch.14695] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/08/2023]
Abstract
Studies have shown that angiotensin converting enzyme inhibitors (ACEIs) are superior in primary and secondary prevention for cardiac mortality and morbidity to angiotensin receptor blocker (ARBs). One of the common side effects from ACEI is dry cough. The aims of this systematic review, and network meta-analysis are to rank the risk of cough induced by different ACEIs and between ACEI and placebo, ARB or calcium channel blockers (CCB). We performed a systematic review, and network meta-analysis of randomized controlled trials to rank the risk of cough induced by each ACEI and between ACEI and placebo, ARB or CCB. A total of 135 RCTs with 45,420 patients treated with eleven ACEIs were included in the analyses. The pooled estimated relative risk (RR) between ACEI and placebo was 2.21 (95% CI: 2.05-2.39). ACEI had more incidences of cough than ARB (RR 3.2; 95% CI: 2.91, 3.51), and pooled estimated of RR between ACEI and CCB was 5.30 (95% CI: 4.32-6.50) Moexipril ranked as number one for inducing cough (SUCRA 80.4%) and spirapril ranked the least (SUCRA 12.3%). The order for the rest of the ACEIs are as follows: ramipril (SUCRA 76.4%), fosinopril (SUCRA 72.5%), lisinopril (SUCRA 64.7%), benazepril (SUCRA 58.6%), quinapril (SUCRA 56.5%), perindopril (SUCRA 54.1%), enalapril (SUCRA 49.7%), trandolapril (SUCRA 44.6%) and, captopril (SUCRA 13.7%). All ACEI has the similar risk of developing a cough. ACEI should be avoided in patients who have risk of developing cough, and an ARB or CCB is an alternative based on the patient's comorbidity.
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Affiliation(s)
- Yiyun Hu
- Department of PharmacySecond Xiangya Hospital of Central South UniversityChangshaChina
| | - Ling Liang
- Department of CardiologyThe Third Clinical Medical College, Fujian Medical UniversityFuzhouChina
- Department of CardiologyThe First Affiliated Hospital of Xiamen UniversityXiamenChina
| | - Shuang Liu
- Medical Affairs Management DepartmentSecond Xiangya Hospital of Central South UniversityChangshaChina
| | - Janice Y. Kung
- University of Alberta, John W. Scott Health Sciences LibraryEdmontonCanada
| | - Hoan Linh Banh
- Faculty of Medicine and DentistryDepartment of Family MedicineUniversity of AlbertaEdmontonCanada
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Cooper TE, Teng C, Tunnicliffe DJ, Cashmore BA, Strippoli GF. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for adults with early (stage 1 to 3) non-diabetic chronic kidney disease. Cochrane Database Syst Rev 2023; 7:CD007751. [PMID: 37466151 PMCID: PMC10355090 DOI: 10.1002/14651858.cd007751.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a long-term condition that occurs as a result of damage to the kidneys. Early recognition of CKD is becoming increasingly common due to widespread laboratory estimated glomerular filtration rate (eGFR) reporting, raised clinical awareness, and international adoption of the Kidney Disease Improving Global Outcomes (KDIGO) classifications. Early recognition and management of CKD affords the opportunity to prepare for progressive kidney impairment and impending kidney replacement therapy and for intervention to reduce the risk of progression and cardiovascular disease. Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) are two classes of antihypertensive drugs that act on the renin-angiotensin-aldosterone system. Beneficial effects of ACEi and ARB on kidney outcomes and survival in people with a wide range of severity of kidney impairment have been reported; however, their effectiveness in the subgroup of people with early CKD (stage 1 to 3) is less certain. This is an update of a review that was last published in 2011. OBJECTIVES To evaluate the benefits and harms of ACEi and ARB or both in the management of people with early (stage 1 to 3) CKD who do not have diabetes mellitus (DM). SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 6 July 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and Embase, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) reporting the effect of ACEi or ARB in people with early (stage 1 to 3) CKD who did not have DM were selected for inclusion. Only studies of at least four weeks duration were selected. Authors independently assessed the retrieved titles and abstracts and, where necessary, the full text to determine which satisfied the inclusion criteria. DATA COLLECTION AND ANALYSIS Data extraction was carried out by two authors independently, using a standard data extraction form. The methodological quality of included studies was assessed using the Cochrane risk of bias tool. Data entry was carried out by one author and cross-checked by another. When more than one study reported similar outcomes, data were pooled using the random-effects model. Heterogeneity was analysed using a Chi² test and the I² test. Results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach MAIN RESULTS: Six studies randomising 9379 participants with CKD stages 1 to 3 (without DM) met our inclusion criteria. Participants were adults with hypertension; 79% were male from China, Europe, Japan, and the USA. Treatment periods ranged from 12 weeks to three years. Overall, studies were judged to be at unclear or high risk of bias across all domains, and the quality of the evidence was poor, with GRADE rated as low or very low certainty. In low certainty evidence, ACEi (benazepril 10 mg or trandolapril 2 mg) compared to placebo may make little or no difference to death (any cause) (2 studies, 8873 participants): RR 2.00, 95% CI 0.26 to 15.37; I² = 76%), total cardiovascular events (2 studies, 8873 participants): RR 0.97, 95% CI 0.90 to 1.05; I² = 0%), cardiovascular-related death (2 studies, 8873 participants): RR 1.73, 95% CI 0.26 to 11.66; I² = 54%), stroke (2 studies, 8873 participants): RR 0.76, 95% CI 0.56 to 1.03; I² = 0%), myocardial infarction (2 studies, 8873 participants): RR 1.00, 95% CI 0.84 to 1.20; I² = 0%), and adverse events (2 studies, 8873 participants): RR 1.33, 95% CI 1.26 to 1.41; I² = 0%). It is uncertain whether ACEi (benazepril 10 mg or trandolapril 2 mg) compared to placebo reduces congestive heart failure (1 study, 8290 participants): RR 0.75, 95% CI 0.59 to 0.95) or transient ischaemic attack (1 study, 583 participants): RR 0.94, 95% CI 0.06 to 15.01; I² = 0%) because the certainty of the evidence is very low. It is uncertain whether ARB (losartan 50 mg) compared to placebo (1 study, 226 participants) reduces: death (any-cause) (no events), adverse events (RR 19.34, 95% CI 1.14 to 328.30), eGFR rate of decline (MD 5.00 mL/min/1.73 m2, 95% CI 3.03 to 6.97), presence of proteinuria (MD -0.65 g/24 hours, 95% CI -0.78 to -0.52), systolic blood pressure (MD -0.80 mm Hg, 95% CI -3.89 to 2.29), or diastolic blood pressure (MD -1.10 mm Hg, 95% CI -3.29 to 1.09) because the certainty of the evidence is very low. It is uncertain whether ACEi (enalapril 20 mg, perindopril 2 mg or trandolapril 1 mg) compared to ARB (olmesartan 20 mg, losartan 25 mg or candesartan 4 mg) (1 study, 26 participants) reduces: proteinuria (MD -0.40, 95% CI -0.60 to -0.20), systolic blood pressure (MD -3.00 mm Hg, 95% CI -6.08 to 0.08) or diastolic blood pressure (MD -1.00 mm Hg, 95% CI -3.31 to 1.31) because the certainty of the evidence is very low. AUTHORS' CONCLUSIONS There is currently insufficient evidence to determine the effectiveness of ACEi or ARB in patients with stage 1 to 3 CKD who do not have DM. The available evidence is overall of very low certainty and high risk of bias. We have identified an area of large uncertainty for a group of patients who account for most of those diagnosed as having CKD.
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Affiliation(s)
- Tess E Cooper
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Claris Teng
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | | | - Brydee A Cashmore
- Centre for Kidney Research, The University of Sydney and The Children's Hospital at Westmead, Sydney, Australia
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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White CM, Zorigt N, Deng T, Driver TG. Iodine(III)-Mediated Oxidation of Anilines to Construct Dibenzazepines. Chemistry 2023; 29:e202301141. [PMID: 37053500 PMCID: PMC10330268 DOI: 10.1002/chem.202301141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 04/15/2023]
Abstract
The development of an efficient process that produces bioactive medium-sized N-heterocyclic scaffolds from 2-substituted anilines using either iodosobenzene or (bis(trifluoroacetoxy)iodo)-benzene is reported. The tether between the sulfonamide and the aryl group can be varied to access dihydroacridine-, dibenzazepine-, or dibenzazocine scaffolds. While substitution on the aniline portion is limited to electron-neutral- or electron-poor groups, a broader range of functional groups are tolerated on the ortho-aryl substituent and site selective C-NAr bond formation can be achieved. Preliminary mechanistic investigations suggest that medium-ring formation occurs via radical reactive intermediates.
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Affiliation(s)
- Carmen Margaret White
- Department of Chemistry, University of Illinois Chicago, 845 W Taylor St. MC 111, Chicago, IL, 60607, USA
| | - Naranchimeg Zorigt
- Department of Chemistry, University of Illinois Chicago, 845 W Taylor St. MC 111, Chicago, IL, 60607, USA
| | - Tianning Deng
- Department of Chemistry, University of Illinois Chicago, 845 W Taylor St. MC 111, Chicago, IL, 60607, USA
| | - Tom G Driver
- Department of Chemistry, University of Illinois Chicago, 845 W Taylor St. MC 111, Chicago, IL, 60607, USA
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Patel S, Lam PH, Kanonidis E, Ahmed AA, Raman VK, Wu WC, Rossignol P, Arundel C, Faselis C, Kanonidis IE, Deedwania P, Allman RM, Sheikh FH, Fonarow GC, Pitt B, Ahmed A. Renin-Angiotensin Inhibition and Outcomes in HFrEF and Advanced Kidney Disease. Am J Med 2023; 136:677-686. [PMID: 37019372 PMCID: PMC10466279 DOI: 10.1016/j.amjmed.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 01/18/2023] [Accepted: 03/08/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Renin-angiotensin system inhibitors improve outcomes in patients with heart failure with reduced ejection fraction (HFrEF). However, less is known about their effectiveness in patients with HFrEF and advanced kidney disease. METHODS In the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF), 1582 patients with HFrEF (ejection fraction ≤40%) had advanced kidney disease (estimated glomerular filtration rate <30 mL/min/1.73 m2). Of these, 829 were not receiving angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) prior to admission, of whom 214 were initiated on these drugs prior to discharge. We calculated propensity scores for receipt of these drugs for each of the 829 patients and assembled a matched cohort of 388 patients, balanced on 47 baseline characteristics (mean age 78 years; 52% women; 10% African American; 73% receiving beta-blockers). Hazard ratios (HR) and 95% confidence intervals (CI) were estimated comparing 2-year outcomes in 194 patients initiated on ACE inhibitors or ARBs to 194 patients not initiated on those drugs. RESULTS The combined endpoint of heart failure readmission or all-cause mortality occurred in 79% and 84% of patients initiated and not initiated on ACE inhibitors or ARBs, respectively (HR associated with initiation, 0.79; 95% CI, 0.63-0.98). Respective HRs (95% CI) for the individual endpoints of - Respective HRs (95% CI) for the individual endpoints of all-cause mortality and heart failure readmission were 0.81 (0.63-1.03) and 0.63 (0.47-0.85). CONCLUSIONS The findings from our study add new information to the body of cumulative evidence that suggest that renin-angiotensin system inhibitors may improve clinical outcomes in patients with HFrEF and advanced kidney disease. These hypothesis-generating findings need to be replicated in contemporary patients.
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Affiliation(s)
- Samir Patel
- Veterans Affairs Medical Center, Washington, DC
- George Washington University, Washington, DC
| | - Phillip H. Lam
- Veterans Affairs Medical Center, Washington, DC
- Georgetown University, Washington, DC
- MedStar Washington Hospital Center, Washington, DC
| | | | - Amiya A. Ahmed
- University of Maryland, Baltimore, MD
- Yale University, New Haven, CT
| | - Venkatesh K. Raman
- Veterans Affairs Medical Center, Washington, DC
- Georgetown University, Washington, DC
| | - Wen-Chih Wu
- Veterans Affairs Medical Center, Providence, RI
- Brown University, Providence, RI
| | | | - Cherinne Arundel
- Veterans Affairs Medical Center, Washington, DC
- George Washington University, Washington, DC
- Georgetown University, Washington, DC
| | - Charles Faselis
- Veterans Affairs Medical Center, Washington, DC
- George Washington University, Washington, DC
- Uniformed Services University, Washington, DC
| | | | - Prakash Deedwania
- Veterans Affairs Medical Center, Washington, DC
- University of California, San Francisco, CA
| | - Richard M. Allman
- George Washington University, Washington, DC
- University of Alabama at Birmingham, Birmingham, AL
| | - Farooq H. Sheikh
- Veterans Affairs Medical Center, Washington, DC
- Georgetown University, Washington, DC
- MedStar Washington Hospital Center, Washington, DC
| | | | | | - Ali Ahmed
- Veterans Affairs Medical Center, Washington, DC
- George Washington University, Washington, DC
- Georgetown University, Washington, DC
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Tachikart A, Vachey C, Vauchy C, Savet C, Ducloux D, Courivaud C. Determinants of urgent start dialysis in a chronic kidney disease cohort followed by nephrologists. BMC Nephrol 2023; 24:190. [PMID: 37370038 DOI: 10.1186/s12882-023-03222-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 05/30/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The French Renal Epidemiology and Information Network (REIN) registry collect dialysis initiation context for each patient starting dialysis with a flawed definition of urgent start dialysis (USD). The main objective of this study was to identify factors associated with USD in patients regularly followed-up by a nephrologist using a classification of USD considering the preparation to renal replacement therapy. METHODS This retrospective cohort study included adult patients who started dialysis between 2012 and 2018 in the Franche-Comté region of France after a minimum of two nephrology consultations. We classified dialysis initiation context as follows: USD for patients with no dialysis access (DA) created or planned, unplanned non urgent start dialysis (UNUSD) for patients starting with a recent or non-functional DA and planned start dialysis (PSD) for those starting with a functional and mature DA. RESULTS Four hundred and sixty-five patients met inclusion criteria. According to REIN registry, 94 (20.3%) patients were urgent starters (US) whereas with our classification 80 (17.2%) and 73 (15.7%) where respectively US and unplanned non urgent starters (UNUS). The factors independently associated with USD in our classification were: stroke (odds ratio(OR) = 2.76, 95% confidence interval (95%CI)=[1.41-5.43]), cardiac failure (OR = 1.78, 95%CI=[1.07-2.96]) and the number of nephrology consultations prior dialysis onset (OR = 0.73, 95%CI=[0.64-0.83]). Thirty-one patients died during the first year after dialysis start. According to our classification, we observed significantly different survival probabilities: 95.7%, 89.5% and 83.4% respectively for planned starters, UNUS and US (p = 0.001). CONCLUSION The two factors independently associated with USD were cardiac failure and stroke.
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Affiliation(s)
- Amin Tachikart
- Department of Nephrology, Dialysis and Renal Transplantation, Univ Hospital of Besançon, Besançon, France.
| | - Clément Vachey
- Department of Nephrology, Dialysis and Renal Transplantation, Univ Hospital of Besançon, Besançon, France
| | - Charline Vauchy
- Department of Nephrology, Dialysis and Renal Transplantation, Univ Hospital of Besançon, Besançon, France
| | - Caroline Savet
- Agence de la Biomédecine, REIN Registry, Saint Denis La Plaine Cedex, Paris, France
| | - Didier Ducloux
- Department of Nephrology, Dialysis and Renal Transplantation, Univ Hospital of Besançon, Besançon, France
| | - Cécile Courivaud
- Department of Nephrology, Dialysis and Renal Transplantation, Univ Hospital of Besançon, Besançon, France
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Cusick MM, Tisdale RL, Chertow GM, Owens DK, Goldhaber-Fiebert JD. Population-Wide Screening for Chronic Kidney Disease : A Cost-Effectiveness Analysis. Ann Intern Med 2023; 176:788-797. [PMID: 37216661 PMCID: PMC11091494 DOI: 10.7326/m22-3228] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 (SGLT2) inhibitors have the potential to alter the natural history of chronic kidney disease (CKD), and they should be included in cost-effectiveness analyses of screening for CKD. OBJECTIVE To determine the cost-effectiveness of adding population-wide screening for CKD. DESIGN Markov cohort model. DATA SOURCES NHANES (National Health and Nutrition Examination Survey), U.S. Centers for Medicare & Medicaid Services data, cohort studies, and randomized clinical trials, including the DAPA-CKD (Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease) trial. TARGET POPULATION Adults. TIME HORIZON Lifetime. PERSPECTIVE Health care sector. INTERVENTION Screening for albuminuria with and without adding SGLT2 inhibitors to the current standard of care for CKD. OUTCOME MEASURES Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs), all discounted at 3% annually. RESULTS OF BASE-CASE ANALYSIS One-time CKD screening at age 55 years had an ICER of $86 300 per QALY gained by increasing costs from $249 800 to $259 000 and increasing QALYs from 12.61 to 12.72; this was accompanied by a decrease in the incidence of kidney failure requiring dialysis or kidney transplant of 0.29 percentage points and an increase in life expectancy from 17.29 to 17.45 years. Other options were also cost-effective. During ages 35 to 75 years, screening once prevented dialysis or transplant in 398 000 people and screening every 10 years until age 75 years cost less than $100 000 per QALY gained. RESULTS OF SENSITIVITY ANALYSIS When SGLT2 inhibitors were 30% less effective, screening every 10 years during ages 35 to 75 years cost between $145 400 and $182 600 per QALY gained, and price reductions would be required for screening to be cost-effective. LIMITATION The efficacy of SGLT2 inhibitors was derived from a single randomized controlled trial. CONCLUSION Screening adults for albuminuria to identify CKD could be cost-effective in the United States. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality, Veterans Affairs Office of Academic Affiliations, and National Institute of Diabetes and Digestive and Kidney Diseases.
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Affiliation(s)
- Marika M. Cusick
- Department of Health Policy, School of Medicine, and
Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford
University, Stanford, CA, USA
| | - Rebecca L. Tisdale
- VA Palo Alto Health Care System, Center for Innovation to
Implementation (Ci2i), Menlo Park, CA, USA
| | - Glenn M. Chertow
- Department of Health Policy, School of Medicine, and
Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford
University, Stanford, CA, USA
- Department of Epidemiology and Population Health, Stanford
University School of Medicine, Stanford, CA, USA
- Division of Nephrology, Department of Medicine, Stanford
University School of Medicine, Stanford, CA, USA
| | - Douglas K. Owens
- Department of Health Policy, School of Medicine, and
Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford
University, Stanford, CA, USA
| | - Jeremy D. Goldhaber-Fiebert
- Department of Health Policy, School of Medicine, and
Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford
University, Stanford, CA, USA
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Mark PB, Carrero JJ, Matsushita K, Sang Y, Ballew SH, Grams ME, Coresh J, Surapaneni A, Brunskill NJ, Chalmers J, Chan L, Chang AR, Chinnadurai R, Chodick G, Cirillo M, de Zeeuw D, Evans M, Garg AX, Gutierrez OM, Heerspink HJL, Heine GH, Herrington WG, Ishigami J, Kronenberg F, Lee JY, Levin A, Major RW, Marks A, Nadkarni GN, Naimark DMJ, Nowak C, Rahman M, Sabanayagam C, Sarnak M, Sawhney S, Schneider MP, Shalev V, Shin JI, Siddiqui MK, Stempniewicz N, Sumida K, Valdivielso JM, van den Brand J, Yee-Moon Wang A, Wheeler DC, Zhang L, Visseren FLJ, Stengel B. Major cardiovascular events and subsequent risk of kidney failure with replacement therapy: a CKD Prognosis Consortium study. Eur Heart J 2023; 44:1157-1166. [PMID: 36691956 PMCID: PMC10319959 DOI: 10.1093/eurheartj/ehac825] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 12/14/2022] [Accepted: 12/23/2022] [Indexed: 01/25/2023] Open
Abstract
AIMS Chronic kidney disease (CKD) increases risk of cardiovascular disease (CVD). Less is known about how CVD associates with future risk of kidney failure with replacement therapy (KFRT). METHODS AND RESULTS The study included 25 903 761 individuals from the CKD Prognosis Consortium with known baseline estimated glomerular filtration rate (eGFR) and evaluated the impact of prevalent and incident coronary heart disease (CHD), stroke, heart failure (HF), and atrial fibrillation (AF) events as time-varying exposures on KFRT outcomes. Mean age was 53 (standard deviation 17) years and mean eGFR was 89 mL/min/1.73 m2, 15% had diabetes and 8.4% had urinary albumin-to-creatinine ratio (ACR) available (median 13 mg/g); 9.5% had prevalent CHD, 3.2% prior stroke, 3.3% HF, and 4.4% prior AF. During follow-up, there were 269 142 CHD, 311 021 stroke, 712 556 HF, and 605 596 AF incident events and 101 044 (0.4%) patients experienced KFRT. Both prevalent and incident CVD were associated with subsequent KFRT with adjusted hazard ratios (HRs) of 3.1 [95% confidence interval (CI): 2.9-3.3], 2.0 (1.9-2.1), 4.5 (4.2-4.9), 2.8 (2.7-3.1) after incident CHD, stroke, HF and AF, respectively. HRs were highest in first 3 months post-CVD incidence declining to baseline after 3 years. Incident HF hospitalizations showed the strongest association with KFRT [HR 46 (95% CI: 43-50) within 3 months] after adjustment for other CVD subtype incidence. CONCLUSION Incident CVD events strongly and independently associate with future KFRT risk, most notably after HF, then CHD, stroke, and AF. Optimal strategies for addressing the dramatic risk of KFRT following CVD events are needed.
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Affiliation(s)
- Patrick B Mark
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Huddinge, Sweden
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD 21205, USA
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD 21205, USA
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD 21205, USA
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD 21205, USA
- Department of Medicine, New York University Grossman School of Medicine, 227 East 30th Street, #825 New York, NY 10016, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD 21205, USA
| | - Aditya Surapaneni
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD 21205, USA
| | - Nigel J Brunskill
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Lili Chan
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alex R Chang
- Departments of Nephrology and Population Health Sciences, Geisinger Health, 100 N Academy Ave, Danville, PA 17822, USA
| | - Rajkumar Chinnadurai
- Department of Renal Medicine, Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Gabriel Chodick
- Medical Division, Maccabi Healthcare Services, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Massimo Cirillo
- Dept. "Scuola Medica Salernitana" University of Salerno Fisciano (SA), Italy
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center, Hanzeplein 1, 9713 GZ, Groningen, Netherlands
| | - Marie Evans
- Department of Clinical Intervention, and Technology (CLINTEC), Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Amit X Garg
- ICES, London, Ontario, Canada
- Division of Nephrology, Western University, London, Ontario, Canada
| | - Orlando M Gutierrez
- Departments of Epidemiology and Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center, Hanzeplein 1, 9713 GZ, Groningen, Netherlands
| | - Gunnar H Heine
- Saarland University Medical Center, Internal Medicine IV, Nephrology and Hypertension, Medizinische Klinik IIWilhelm-Epstein-Straße 4 60431 Frankfurt am Main, Germany
| | - William G Herrington
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health (NDPH), and Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH, University of Oxford, Richard Doll Building Old Road Campus Oxford, Oxfordshire, OX3 7LF, United Kingdom
| | - Junichi Ishigami
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD 21205, USA
| | - Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Jun Young Lee
- Transplantation Center, Department of Nephrology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju 26426, Korea
| | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - Rupert W Major
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Angharad Marks
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Girish N Nadkarni
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David M J Naimark
- Sunnybrook Hospital, University of Toronto, Rm 3861929 Bayview Ave. Toronto, Ontario M4G 3E8, Canada
| | - Christoph Nowak
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Mahboob Rahman
- Division of Nephrology, Department of Medicine, Case Western Reserve University, Cleveland, OH
| | - Charumathi Sabanayagam
- Ocular Epidemiology Research Group, Singapore Eye Research Institute, Singapore National Eye Centre, The Academia, 20 College Road, Discovery Tower Level 6, Singapore (169856), Singapore
- Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road Level 11, Singapore (119228), Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program (EYE-ACP), Duke-NUS Medical School, 8 College Road, Singapore (169857), Singapore
| | - Mark Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | | | - Markus P Schneider
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Varda Shalev
- Institute for Health and Research and Innovation, Maccabi Healthcare Services and Tel Aviv University, Tel Aviv, Israel
| | - Jung-Im Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD 21205, USA
| | - Moneeza K Siddiqui
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom
| | | | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - José M Valdivielso
- Vascular & Renal Translational Research Group, IRBLleida, Spain and Spanish Research Network for Renal Diseases (RedInRen. ISCIII), Lleida, Spain
| | - Jan van den Brand
- Department of Nephrology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Pok Fu Lam, Hong Kong SAR, Hong Kong
| | - David C Wheeler
- Centre for Nephrology, University College London, London, United Kingdom
| | - Lihua Zhang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, P.R. China
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Benedicte Stengel
- Clinical Epidemiology team, Centre for Research in Epidemiology and Population Health (CESP), University Paris-Saclay, UVSQ, Inserm, Villejuif, France
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Huang R, Fu P, Ma L. Kidney fibrosis: from mechanisms to therapeutic medicines. Signal Transduct Target Ther 2023; 8:129. [PMID: 36932062 PMCID: PMC10023808 DOI: 10.1038/s41392-023-01379-7] [Citation(s) in RCA: 91] [Impact Index Per Article: 91.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 02/12/2023] [Accepted: 02/20/2023] [Indexed: 03/19/2023] Open
Abstract
Chronic kidney disease (CKD) is estimated to affect 10-14% of global population. Kidney fibrosis, characterized by excessive extracellular matrix deposition leading to scarring, is a hallmark manifestation in different progressive CKD; However, at present no antifibrotic therapies against CKD exist. Kidney fibrosis is identified by tubule atrophy, interstitial chronic inflammation and fibrogenesis, glomerulosclerosis, and vascular rarefaction. Fibrotic niche, where organ fibrosis initiates, is a complex interplay between injured parenchyma (like tubular cells) and multiple non-parenchymal cell lineages (immune and mesenchymal cells) located spatially within scarring areas. Although the mechanisms of kidney fibrosis are complicated due to the kinds of cells involved, with the help of single-cell technology, many key questions have been explored, such as what kind of renal tubules are profibrotic, where myofibroblasts originate, which immune cells are involved, and how cells communicate with each other. In addition, genetics and epigenetics are deeper mechanisms that regulate kidney fibrosis. And the reversible nature of epigenetic changes including DNA methylation, RNA interference, and chromatin remodeling, gives an opportunity to stop or reverse kidney fibrosis by therapeutic strategies. More marketed (e.g., RAS blockage, SGLT2 inhibitors) have been developed to delay CKD progression in recent years. Furthermore, a better understanding of renal fibrosis is also favored to discover biomarkers of fibrotic injury. In the review, we update recent advances in the mechanism of renal fibrosis and summarize novel biomarkers and antifibrotic treatment for CKD.
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Affiliation(s)
- Rongshuang Huang
- Kidney Research Institute, Division of Nephrology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ping Fu
- Kidney Research Institute, Division of Nephrology, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - Liang Ma
- Kidney Research Institute, Division of Nephrology, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Cao H, Rao X, Jia J, Yan T, Li D. Effects of sodium-glucose co-transporter-2 inhibitors on kidney, cardiovascular, and safety outcomes in patients with advanced chronic kidney disease: a systematic review and meta-analysis of randomized controlled trials. Acta Diabetol 2023; 60:325-335. [PMID: 36316605 DOI: 10.1007/s00592-022-01989-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/25/2022] [Indexed: 02/17/2023]
Abstract
AIMS The overall effects of sodium-glucose co-transporter 2 (SGLT2) inhibitors in patients with advanced chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR), 15-30 ml/min per 1.73 m2) remain unclear, and we thus conducted a systematic review and meta-analysis to evaluate the effects of SGLT2 inhibitors on kidney, cardiovascular (CV), and safety outcomes in patients with advanced CKD. METHODS The Medline, Embase, and Cochrane Library databases were systematically searched for randomized controlled trials (RCTs) published up to March 3, 2022, and reporting effects of SGLT2 inhibitors on kidney, CV, or safety outcomes in patients with advanced CKD. RESULTS From 2675 records, six RCTs with 2167 participants were included in the quantitative analyses. In patients with advanced CKD, SGLT2 inhibitors reduced the risk of the primary kidney outcome (a composite of worsening kidney function, end-stage kidney disease (ESKD), or kidney death) by 23% (RR 0.77, 95% CI 0.61-0.98, p = 0.04, I2 = 0 for the heterogeneity) and slowed the annual decline in eGFR slope, with the difference between SGLT2 inhibitor group and placebo group being 1.24 mL/min/1.73m2 per year (95% CI 0.06-2.42, p = 0.04). SGLT2 inhibitors were also associated with a decreased risk of primary CV outcome (a composite of CV death or hospitalization for heart failure) (HR 0.71, 95% CI 0.53-0.96, p = 0.03, I2 = 0 for the heterogeneity) and with similar risks of adverse events (such as acute kidney injury, fracture, amputation, and urinary tract infection). CONCLUSIONS Among patients with advanced CKD, SGLT2 inhibitors reduced the risks of primary kidney and CV outcomes and attenuated the progressive decrease in eGFR compared with placebo, with no evidence of additional safety concerns. These observed benefits may support continuing the use of SGLT2 inhibitors in patients with advanced CKD before initiating maintenance dialysis or kidney transplantation. Future large-scale RCTs are needed to confirm the robustness of these results.
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Affiliation(s)
- Haiyan Cao
- Department of Nephrology, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Xiaosheng Rao
- Department of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
| | - Junya Jia
- Department of Nephrology, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Tiekun Yan
- Department of Nephrology, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Dong Li
- Department of Nephrology, Tianjin Medical University General Hospital, Tianjin, 300052, China.
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Mohan A, Majd Z, Johnson ML, Essien EJ, Barner J, Serna O, Gallardo E, Fleming ML, Ordonez N, Holstad MM, Abughosh SM. A Motivational Interviewing Intervention to Improve Adherence to ACEIs/ARBs among Nonadherent Older Adults with Comorbid Hypertension and Diabetes. Drugs Aging 2023; 40:377-390. [PMID: 36847995 PMCID: PMC9969383 DOI: 10.1007/s40266-023-01008-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Hypertension and diabetes mellitus are independent risk factors for cardiovascular diseases. Due to the cardioprotective nature of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs), they are recommended for patients with comorbid hypertension and diabetes. However, poor adherence to ACEIs/ARBs among older adults is a major public health concern. This study aimed to assess the effectiveness of a telephonic motivational interviewing (MI) intervention conducted by pharmacy students among a nonadherent older population (≥ 65 years old) with diabetes and hypertension. METHODS Patients continuously enrolled in a Medicare Advantage Plan who received an ACEI/ARB prescription between July 2017 and December 2017 were identified. Group-based trajectory modeling (GBTM) was used to identify distinct patterns of ACEI/ARB adherence during the 1-year baseline period: adherent, gaps in adherence, gradual decline, and rapid decline in adherence. Patients from the three nonadherent trajectories were randomized into MI intervention or control group. The intervention consisted of an initial call and five follow-up calls administered by MI-trained pharmacy students and tailored to the baseline ACEI/ARB adherence trajectories. The primary outcome was adherence to ACEI/ARB during the 6- and 12-month periods post-MI implementation. The secondary outcome was discontinuation, defined as no refills for ACEI/ARB during the 6- and 12-month periods post-MI implementation. Multivariable regression analyses examined the impact of MI intervention on ACEI/ARB adherence and discontinuation while adjusting for baseline covariates. RESULTS A total of 240 patients in the intervention group and 480 patients as randomly selected controls were included in this study. At 6 months, patients receiving the MI intervention had significantly better adherence (β = 0.06; p = 0.03) compared with the controls. Linear and logistic regression models also showed patients in the intervention group were more likely to be adherent than controls within 12 months of intervention implementation (β = 0.06; p = 0.02 and OR: 1.46; 95% CI 1.05-2.04, respectively). MI intervention did not have any significant impact on the ACEI/ARB discontinuation. CONCLUSION Patients who received the MI intervention were more likely to be adherent at 6 and 12 months following the intervention initiation, despite gaps in the follow-up calls due to COVID-19. Pharmacist-led MI intervention is an effective behavioral strategy to improve medication adherence among older adults and tailoring the intervention to past adherence patterns may enhance the intervention effectiveness. This study was registered with the United States National Institutes of Health (ClinicalTrials.gov identifier NCT03985098).
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Affiliation(s)
- Anjana Mohan
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Boulevard, Houston, TX, 77204-5047, USA
| | - Zahra Majd
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Boulevard, Houston, TX, 77204-5047, USA
| | - Michael L Johnson
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Boulevard, Houston, TX, 77204-5047, USA
| | - Ekere J Essien
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Boulevard, Houston, TX, 77204-5047, USA
| | - Jamie Barner
- Health Outcomes Division, The University of Texas at Austin, Austin, TX, USA
| | | | | | - Marc L Fleming
- Pharmaceutical Economics and Policy, Chapman University School of Pharmacy, Irvine, CA, USA
| | - Nancy Ordonez
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Marcia M Holstad
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Susan M Abughosh
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Boulevard, Houston, TX, 77204-5047, USA.
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Mandal M, Pradhan R, Lourderaj U, Balamurugan R. Dodging the Conventional Reactivity of o-Alkynylanilines under Gold Catalysis for Distal 7- endo- dig Cyclization. J Org Chem 2023; 88:2260-2287. [PMID: 36744758 DOI: 10.1021/acs.joc.2c02668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A direct ring-closing strategy involving a less facile 7-endo-dig carbacyclization of o-alkynylaniline derivatives for the synthesis of benzo[b]azepines has been presented. The trivial well-documented 5-endo-dig cyclization in o-alkynylaniline derivatives due to high nucleophilicity of nitrogen has been overcome by using their vinylogous amides under gold catalysis to access a wide array of benzo[b]azepines in an atom economical way with excellent functional group compatibility. Deuterium scrambling experiments and DFT studies favor a mechanism involving stabilizing conformational change of the initially formed seven-membered vinyl gold intermediate through a key cyclopropyl gold carbene intermediate and its subsequent protodeauration mediated by the counter anion.
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Affiliation(s)
- Mou Mandal
- School of Chemistry, University of Hyderabad, Hyderabad, Telangana-500046, India
| | - Renuka Pradhan
- School of Chemical Sciences, National Institute of Science Education and Research (NISER) Bhubaneswar, HBNI, P.O. Jatni, Khurda, Odisha-752050, India
| | - Upakarasamy Lourderaj
- School of Chemical Sciences, National Institute of Science Education and Research (NISER) Bhubaneswar, HBNI, P.O. Jatni, Khurda, Odisha-752050, India
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Mohandes S, Doke T, Hu H, Mukhi D, Dhillon P, Susztak K. Molecular pathways that drive diabetic kidney disease. J Clin Invest 2023; 133:165654. [PMID: 36787250 PMCID: PMC9927939 DOI: 10.1172/jci165654] [Citation(s) in RCA: 91] [Impact Index Per Article: 91.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
Kidney disease is a major driver of mortality among patients with diabetes and diabetic kidney disease (DKD) is responsible for close to half of all chronic kidney disease cases. DKD usually develops in a genetically susceptible individual as a result of poor metabolic (glycemic) control. Molecular and genetic studies indicate the key role of podocytes and endothelial cells in driving albuminuria and early kidney disease in diabetes. Proximal tubule changes show a strong association with the glomerular filtration rate. Hyperglycemia represents a key cellular stress in the kidney by altering cellular metabolism in endothelial cells and podocytes and by imposing an excess workload requiring energy and oxygen for proximal tubule cells. Changes in metabolism induce early adaptive cellular hypertrophy and reorganization of the actin cytoskeleton. Later, mitochondrial defects contribute to increased oxidative stress and activation of inflammatory pathways, causing progressive kidney function decline and fibrosis. Blockade of the renin-angiotensin system or the sodium-glucose cotransporter is associated with cellular protection and slowing kidney function decline. Newly identified molecular pathways could provide the basis for the development of much-needed novel therapeutics.
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Affiliation(s)
- Samer Mohandes
- Renal, Electrolyte, and Hypertension Division, Department of Medicine;,Institute for Diabetes, Obesity, and Metabolism;,Department of Genetics; and,Kidney Innovation Center; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tomohito Doke
- Renal, Electrolyte, and Hypertension Division, Department of Medicine;,Institute for Diabetes, Obesity, and Metabolism;,Department of Genetics; and,Kidney Innovation Center; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hailong Hu
- Renal, Electrolyte, and Hypertension Division, Department of Medicine;,Institute for Diabetes, Obesity, and Metabolism;,Department of Genetics; and,Kidney Innovation Center; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dhanunjay Mukhi
- Renal, Electrolyte, and Hypertension Division, Department of Medicine;,Institute for Diabetes, Obesity, and Metabolism;,Department of Genetics; and,Kidney Innovation Center; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Poonam Dhillon
- Renal, Electrolyte, and Hypertension Division, Department of Medicine;,Institute for Diabetes, Obesity, and Metabolism;,Department of Genetics; and,Kidney Innovation Center; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katalin Susztak
- Renal, Electrolyte, and Hypertension Division, Department of Medicine;,Institute for Diabetes, Obesity, and Metabolism;,Department of Genetics; and,Kidney Innovation Center; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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The Growing Challenge of Chronic Kidney Disease: An Overview of Current Knowledge. Int J Nephrol 2023; 2023:9609266. [PMID: 36908289 PMCID: PMC9995188 DOI: 10.1155/2023/9609266] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 02/02/2023] [Accepted: 02/17/2023] [Indexed: 03/05/2023] Open
Abstract
Chronic kidney disease (CKD) is becoming one of the world's most prevalent noncommunicable chronic diseases. The World Health Organization projects CKD to become the 5th most common chronic disease in 2040. Causes of CKD are multifactorial and diverse, but early-stage symptoms are often few and silent. Progression rates are highly variable, but patients encounter both an increased risk for end-stage kidney disease (ESKD) as well as increased cardiovascular risk. End-stage kidney disease incidence is generally low, but every single case carries a significant burden of illness and healthcare costs, making prevention by early intervention both desirable and worthwhile. This review focuses on the prevalence, diagnosis, and causes of CKD. In addition, we discuss the developments in the general treatment of CKD, with particular attention to what can be initiated in general practice. With the addition of recent landmark findings and the expansion of the indication for using sodium-glucose cotransporter 2 inhibitors, there are now new effective treatments to add to standard therapy. This will also be relevant for primary care physicians as many patients with CKD have their family physician as their primary health care professional handling kidney function preservation. In the future, more precise and less invasive diagnostic methods may not only improve the determination of the underlying cause of CKD but may also carry information regarding which treatment to use (i.e. personalized medicine). This could lead to a reduced number of preventive treatments per individual, while at the same time improving the prognosis. This review summarizes ongoing efforts in this area.
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Dos Anjos AA, de Paiva IT, Simões Lima GL, da Silva Filha R, Fróes BPE, Brant Pinheiro SV, Silva ACSE. Nephrotic Syndrome and Renin-angiotensin System: Pathophysiological Role and Therapeutic Potential. Curr Mol Pharmacol 2023; 16:465-474. [PMID: 35713131 DOI: 10.2174/1874467215666220616152312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/14/2022] [Accepted: 05/19/2022] [Indexed: 11/22/2022]
Abstract
Idiopathic Nephrotic Syndrome (INS) is the most frequent etiology of glomerulopathy in pediatric patients and one of the most common causes of chronic kidney disease (CKD) and end-stage renal disease (ESRD) in this population. In this review, we aimed to summarize evidence on the pathophysiological role and therapeutic potential of the Renin-Angiotensin System (RAS) molecules for the control of proteinuria and for delaying the onset of CKD in patients with INS. This is a narrative review in which the databases PubMed, Web of Science, and Sci- ELO were searched for articles about INS and RAS. We selected articles that evaluated the pathophysiological role of RAS and the effects of the alternative RAS axis as a potential therapy for INS. Several studies using rodent models of nephropathies showed that the treatment with activators of the Angiotensin-Converting Enzyme 2 (ACE2) and with Mas receptor agonists reduces proteinuria and improves kidney tissue damage. Another recent paper showed that the reduction of urinary ACE2 levels in children with INS correlates with proteinuria and higher concentrations of inflammatory cytokines, although data with pediatric patients are still limited. The molecules of the alternative RAS axis comprise a wide spectrum, not yet fully explored, of potential pharmacological targets for kidney diseases. The effects of ACE2 activators and receptor Mas agonists show promising results that can be useful for nephropathies including INS.
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Affiliation(s)
- Alessandra Aguiar Dos Anjos
- Departamento de Pediatria, Faculdade de Medicina, Unidade de Nefrologia Pediátrica, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| | - Isadora Tucci de Paiva
- Departamento de Pediatria, Faculdade de Medicina, Unidade de Nefrologia Pediátrica, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| | - Giovanna Letícia Simões Lima
- Faculdade de Medicina, Laboratório Interdisciplinar de Investigação Médica, UFMG, Belo Horizonte, Minas Gerais, Brazil
| | - Roberta da Silva Filha
- Faculdade de Medicina, Laboratório Interdisciplinar de Investigação Médica, UFMG, Belo Horizonte, Minas Gerais, Brazil
| | - Brunna Pinto E Fróes
- Departamento de Pediatria, Faculdade de Medicina, Unidade de Nefrologia Pediátrica, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| | - Sérgio Veloso Brant Pinheiro
- Departamento de Pediatria, Faculdade de Medicina, Unidade de Nefrologia Pediátrica, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| | - Ana Cristina Simões E Silva
- Departamento de Pediatria, Faculdade de Medicina, Unidade de Nefrologia Pediátrica, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
- Faculdade de Medicina, Laboratório Interdisciplinar de Investigação Médica, UFMG, Belo Horizonte, Minas Gerais, Brazil
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Tanpure SD, Kardile RD, Liu RS. Relay Zn( ii)- and Au( i)-catalyzed aziridination/cyclization/ring expansion sequence to form 3-benzazepine derivatives. Org Chem Front 2023. [DOI: 10.1039/d3qo00134b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
The synthesis of 3H-benzo[d]azepine-2-carboxylates from 2-alkynylphenyl aldimines and α-diazo esters using Zn(ii) and Au(i) catalysts is described.
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IgA Nephropathy with Macroproteinuria and a GFR of 20-30 ml/min/1.73 m 2 May Still Benefit from RAS Inhibition. J Renin Angiotensin Aldosterone Syst 2022; 2022:9162427. [PMID: 36660420 PMCID: PMC9822756 DOI: 10.1155/2022/9162427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 12/31/2022] Open
Abstract
Introduction There has been controversy about renin-angiotensin system (RAS) inhibition in IgAN patients with advanced (stage 4) chronic kidney disease (CKD). Therefore, we investigated the effect of RAS blockade in these patients. Methods Renal specimens of 50 IgAN patients who underwent renal biopsy during stage 4 CKD between 2010 and 2020, were stained using immunohistochemistry to detect the expression of RAS receptors (AT1R, AT2R, MasR, and MrgD). The primary endpoint was a composite of end-stage renal disease (ESRD) and death. Main baseline information and the administration of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) were collected. Results During a median follow-up time of 25.5 months, 21 (42.0%) patients reached ESRD and none died. Six patients had a baseline eGFR of 15-20 ml/min/1.73m2, and reached ESRD with a median renal survival time of 7.0 (range 6.0-23.0) months. Among patients with a baseline eGFR of 20-30 ml/min/1.73m2, the percentage of patients using ACEI/ARB in progressive group was much lower than that in stable group (33.3% vs. 62.1%, P = 0.045), together with a shorter renal survival time in progressive group (26.0 vs. 30.5 months, P = 0.033). Macroproteinuria (24 h - UP ≥ 2.5 g) was also associated with a shorter renal survival time, as well as a significant decline in eGFR of stable group (24.4 vs. 26.4 ml/min/1.73 m2, P = 0.026). Lower eGFR [hazards ratio (HR), 0.829, 95% confidence interval (CI), 0.724-0.950; P = 0.007] and use of ACEI/ARB (HR, 0.356, 95% CI, 0.133-0.953; P = 0.040) were predictive of time to ESRD in this stage. No differences were found in the expression of AT1R, AT2R, MasR, and MrgD of renal tissues at the time of biopsy between stable and progressive groups. Conclusion Contingent on monitoring serum creatinine and potassium levels, IgAN with macroproteinuria and a GFR of 20-30 ml/min/1.73m2 may still benefits from intrarenal RAS inhibition.
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Haller H, Bianchi S, McCafferty K, Arthur S, Quinn CM, Budden J, Weir MR. Safety and Efficacy of Patiromer in Hyperkalemic Patients with CKD: A Pooled Analysis of Three Randomized Trials. KIDNEY360 2022; 3:2019-2026. [PMID: 36591361 PMCID: PMC9802546 DOI: 10.34067/kid.0001562022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 07/25/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Hyperkalemia is a common electrolyte abnormality in patients with CKD, which is associated with worse outcomes and limits use of renin-angiotensin-aldosterone system inhibitors (RAASi). This post hoc subgroup analysis of three clinical trials evaluated the efficacy and safety of the sodium-free, potassium-binding polymer, patiromer, for the treatment of hyperkalemia in adults with nondialysis CKD. METHODS Data from the 4-week treatment periods of AMETHYST-DN, OPAL-HK, and TOURMALINE studies were combined. Patients had baseline diagnosis of CKD, hyperkalemia (serum potassium >5.0 mEq/L), and received patiromer 8.4-33.6 g/day. Patients were stratified by baseline eGFR into two subgroups: severe/end-stage CKD (stage 3b-5; eGFR <45 ml/min per 1.73 m2) and mild/moderate CKD (stage 1-3a; eGFR ≥45 ml/min per 1.73 m2). Efficacy was assessed by the change in serum potassium (mean±SE) from baseline to week 4. Safety assessments included incidence and severity of adverse events (AEs). RESULTS Efficacy analyses (n=626; 62% male, mean age 66 years) included 417 (67%) patients with severe/end-stage CKD and 209 (33%) with mild/moderate CKD. Most patients were receiving RAASi therapy at baseline (severe/end-stage CKD 92%; mild/moderate CKD 98%). The mean±SE change in serum potassium (baseline to week 4) was -0.84±0.03 in the severe/end-stage CKD subgroup, and -0.60±0.04 mEq/L in the mild/moderate CKD subgroup. AEs were reported for 40% and 27% patients in the severe/end-stage and mild/moderate CKD subgroups, respectively, with 16% and 12% reporting AEs considered related to patiromer. The most frequent AEs were mild-to-moderate constipation (8% and 3%) and diarrhea (4% and 2%). AEs leading to patiromer discontinuation occurred in 6% and 2% of patients with severe/end-stage CKD, and mild/moderate CKD, respectively. CONCLUSIONS Patiromer was effective for treatment of hyperkalemia and well tolerated in patients across stages of CKD, most of whom were receiving guideline-recommended RAASi therapy.
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Affiliation(s)
- Hermann Haller
- Department of Nephrology and Hypertension, Hannover Medical School, Hanover, Germany
| | - Stefano Bianchi
- Department of Internal Medicine, Nephrology and Dialysis Complex Operative Unit, Livorno, Italy
| | - Kieran McCafferty
- Department of Nephrology, Barts Health NHS Trust, London, United Kingdom
| | - Susan Arthur
- Biostatistics, Vifor Pharma Group, Redwood City, California
| | | | - Jeffery Budden
- Medical Affairs, Vifor Pharma Group, Redwood City, California
| | - Matthew R. Weir
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland
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Zeitler EM, Mottl AK. Toward Guideline-Directed Medical Therapy in Nephrology: Lifetime Benefit of RAAS and SGLT2 Inhibition in Nondiabetic Kidney Disease. Clin J Am Soc Nephrol 2022; 17:1710-1712. [PMID: 36414317 PMCID: PMC9718011 DOI: 10.2215/cjn.12401022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Evan M. Zeitler
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Amy K. Mottl
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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