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Halimi JM, Sarafidis P, Azizi M, Bilo G, Burkard T, Bursztyn M, Camafort M, Chapman N, Cottone S, de Backer T, Deinum J, Delmotte P, Dorobantu M, Doumas M, Dusing R, Duly-Bouhanick B, Fauvel JP, Fesler P, Gaciong Z, Gkaliagkousi E, Gordin D, Grassi G, Grassos C, Guerrot D, Huart J, Izzo R, Jaén Águila F, Járai Z, Kahan T, Kantola I, Kociánová E, Limbourg F, Lopez-Sublet M, Mallamaci F, Manolis A, Marketou M, Mayer G, Mazza A, MacIntyre I, Mourad JJ, Muiesan ML, Nasr E, Nilsson P, Oliveras A, Ormezzano O, Paixão-Dias V, Papadakis I, Papadopoulos D, Perl S, Polónia J, Pontremoli R, Pucci G, Robles NR, Rubin S, Ruilope LM, Rump LC, Saeed S, Sanidas E, Sarzani R, Schmieder R, Silhol F, Sokolovic S, Solbu M, Soucek M, Stergiou G, Sudano I, Tabbalat R, Tengiz I, Triantafyllidi H, Tsioufis K, Václavík J, van der Giet M, der Niepen PV, Veglio F, Venzin R, Viigimaa M, Weber T, Widimsky J, Wuerzner G, Zelveian P, Zebekakis P, Lueders S, Persu A, Kreutz R, Vogt L. Management of patients with hypertension and chronic kidney disease referred to Hypertension Excellence Centres among 27 countries. On behalf of the European Society of Hypertension Working Group on Hypertension and the Kidney. Blood Press 2024; 33:2368800. [PMID: 38910347 DOI: 10.1080/08037051.2024.2368800] [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: 05/08/2024] [Accepted: 06/05/2024] [Indexed: 06/25/2024]
Abstract
Objective Real-life management of patients with hypertension and chronic kidney disease (CKD) among European Society of Hypertension Excellence Centres (ESH-ECs) is unclear : we aimed to investigate it. Methods A survey was conducted in 2023. The questionnaire contained 64 questions asking ESH-ECs representatives to estimate how patients with CKD are managed. Results Overall, 88 ESH-ECS representatives from 27 countries participated. According to the responders, renin-angiotensin system (RAS) blockers, calcium-channel blockers and thiazides were often added when these medications were lacking in CKD patients, but physicians were more prone to initiate RAS blockers (90% [interquartile range: 70-95%]) than MRA (20% [10-30%]), SGLT2i (30% [20-50%]) or (GLP1-RA (10% [5-15%]). Despite treatment optimisation, 30% of responders indicated that hypertension remained uncontrolled (30% (15-40%) vs 18% [10%-25%]) in CKD and CKD patients, respectively). Hyperkalemia was the most frequent barrier to initiate RAS blockers, and dosage reduction was considered in 45% of responders when kalaemia was 5.5-5.9 mmol/L. Conclusions RAS blockers are initiated in most ESH-ECS in CKD patients, but MRA and SGLT2i initiations are less frequent. Hyperkalemia was the main barrier for initiation or adequate dosing of RAS blockade, and RAS blockers' dosage reduction was the usual management.
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Affiliation(s)
- Jean-Michel Halimi
- Service de Néphrologie-Hypertension, Dialyses, Transplantation rénale, Hôpital Bretonneau, Tours, France
| | | | - Michel Azizi
- Université Paris Cité Department of Cardiology, Paris, France
- APHP, Service d'Hypertension Artérielle, Hôpital Européen Georges Pompidou, Paris, France
| | - Grzegorz Bilo
- Grzegorz Bilo, Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Thilo Burkard
- Medical Outpatient Department and Hypertension Clinic, University Hospital Basel, Basel, Switzerland
| | - Michael Bursztyn
- Hypertension Clinic, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem
- Faculty of Medicine, School of Medicine, Hadassah-Hebrew University, Jerusalem, Israel
| | - Miguel Camafort
- Hypertension Unit, Department of Internal Medicine, Hospital Clinic, University of Barcelona, Spain
| | - Neil Chapman
- Peart-Rose Clinic, Hammersmith Hospital, Imperial College Healthcare Trust, London, UK
| | - Santina Cottone
- PROMISE Department, Nephrology and Dialisys Unit with Hypertension ESH Excellence Centre, University Hospital P.Giaccone, Palermo, Italy
- University of Palermo Department of Nephrology, Palermo, Italy
| | - Tine de Backer
- Department of Cardiovascular Diseases, Internal Medicine, University Hospital Ghent, Ghent, Belgium
| | - Jaap Deinum
- Department of Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Philippe Delmotte
- Hypertension Unit (European Society of Hypertension Excellence Centre), Department of Cardiology, HELORA University Hospitals, Mons, Belgium
| | - Maria Dorobantu
- Emergency Clinical Hospital of Bucharest Department of Emergency Medicineap: Department of Cardiology, Bucharest, Romania
| | - Michalis Doumas
- 2nd Prop Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | - Rainer Dusing
- Hypertoniezentrum Bonn, Schwerpunktpraxis Kardiologie, Angiologie, Prävention, Rehabilitation, Bonn, Germany
| | | | - Jean-Pierre Fauvel
- Department of Nephrology and Hypertension, Hôpital Ed Herriot, Lyon, France
| | - Pierre Fesler
- Department of Internal Medicine, Montpellier University Hospital, Montpellier, France
- PhyMedExp, INSERM U1046, CNRS UMR 9214, University of Montpellier, Montpellier, France
| | - Zbigniew Gaciong
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Eugenia Gkaliagkousi
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Greece
| | - Daniel Gordin
- Department of Nephrology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Guido Grassi
- Clinica Medica, University Milano Bicocca, Milan, Italy
| | | | - Dominique Guerrot
- Service de Néphrologie, CIC-CRB 1404, INSERM EnVi U1096, CHU Rouen, France
| | - Justine Huart
- Division of Nephrology, University of Liège Hospital (ULg CHU), University of Liège, and Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA), Cardiovascular Sciences, University of Liège, Liège, Belgium
| | - Raffaele Izzo
- Department of Advanced Medical Sciences, Federico II University of Naples, Italy
| | - Fernando Jaén Águila
- Vascular Risk Unit, Internal Medicine, Virgen de las Nieves University Hospital, Granada, Spain
| | - Zoltán Járai
- South-Buda Center Hospital, St. Imre University Teaching Hospital, Budapest, Hungary
| | - Thomas Kahan
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Karolinska Institute, Stockholm, Sweden
- Department of Cardiology, Danderyd University Hospital Corp, Stockholm, Sweden
| | - Ilkka Kantola
- Division of Medicine, Turku University Hospital, Turku University, Turku, Finland
| | - Eva Kociánová
- First Department of Internal Medicine - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - FlorianP Limbourg
- Dept. of Nephrology and Hypertension, Hypertension Center, Hannover Medical School, Hannover, Germany
| | - Marilucy Lopez-Sublet
- AP-HP, Unité d'hypertension artérielle, service de médecine interne, Hôpital Avicenne, Bobigny, France
- INSERM UMR 942 MASCOT, Paris 13-Université Paris Nord, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Bobigny, France
| | - Francesca Mallamaci
- Grande Ospedale Metropolitano, UOC di Nefrologia abilitata al trapianto renale, CNR Epidemiologia Clinica e Fisiopatologia delle Malattie Renali e dell'Ipertensione Arteriosa, Reggio Calabria, Italy
| | | | - Maria Marketou
- Hypertension Outpatient Clinic, Cardiology Department, Heraklion University General Hospital, Heraklion, Greece
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck Anichstrasse, Innsbruck, Austria
| | - Alberto Mazza
- Internal Medicine Unit, Department of Medicine, ESH Excellence Center Unit, Italy
| | - IainM MacIntyre
- Cardiovascular Risk Clinic, Western General Hospital, Edinburgh, UK
| | - Jean-Jacques Mourad
- Service de Médecine Interne, Hôpital Franco-Britannique, Levallois-Perret, France
| | - Maria Lorenza Muiesan
- Centro Studi Diagnosi e Cura dell'Ipertensione Arteriosa e del Rischio Cardiovascolare (IARC), University of Brescia and ASST Spedali Civili, Italy
| | - Edgar Nasr
- St George University Medical Center Achrafieh-Beirut, Lebanon
| | - Peter Nilsson
- Department of Clinical Sciences, Lund University, Skane University Hospital, Malmö, Sweden
| | - Anna Oliveras
- Hypertension and Vascular Risk Unit, Department of Nephrology, Hospital del Mar, IMIM (Hospital del Mar Medical Research Institute), Universitat Pompeu Fabra, Barcelona, Spain
| | - Olivier Ormezzano
- UF Hypertension et Athérothrombose, Centre Européen d'Excellence en Hypertension Artérielle, Service de Cardiologie, CHU Michallon, Grenoble, France
| | - Vitor Paixão-Dias
- Internal Medicine Department, Hospital Centre of Vila Nova de Gaia/Espinho, Portugal
| | - Ioannis Papadakis
- Hypertension Unit, Dept. of Internal Medicine, University Hospital of Heraklion, Heraklion, Greece
| | | | - Sabine Perl
- Department of Cardiology, Medical University of Graz, Graz, Austria
| | - Jorge Polónia
- Department of Medicine CINTESIS RISE, Faculty of Medicine of Porto, Portugal
| | - Roberto Pontremoli
- Università degli Studi e IRCCS Ospedale Policlinico San Martino di Genova, Italy
| | - Giacomo Pucci
- Department of Medicine and Surgery, University of Perugia, Unit of Internal Medicine - Santa Maria Terni Hospital, Terni, Italy
| | | | - Sébastien Rubin
- Service de Néphrologie-transplantation-dialyse-aphérèses, CHU Bordeaux, France
| | | | - Lars Christian Rump
- Department of Internal Medicine/Nephrology, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Sahrai Saeed
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Elias Sanidas
- Department of Cardiology, LAIKO General Hospital, Athens, Greece
| | - Riccardo Sarzani
- Università Politecnica delle Marche and IRCCS-INRCA Department of Clinical and Molecular Sciences, Ancona, Italy
| | - Roland Schmieder
- Department of Nephrology, Hypertension University Hospital Erlangen, Friedrich Alexander University Erlangen/Nürnberg, Germany
| | - François Silhol
- Service de Médecine Vasculaire et Hypertension Artérielle, Centre de compétence régional des maladies artérielles rares, Centre d'excellence Européen en Hypertension Artérielle 264, rue Saint Pierre, CHU Timone, Marseille, France
| | | | - Marit Solbu
- University Hospital of North Norway Department of Nephrology cb: Department of Internal Medicine and Cardiology, Tromsø, Norway
| | - Miroslav Soucek
- 2nd Department of Internal Medicine, St. Anne's University Hospital, Brno, Czech Republic
- Fakulty of Medicine, Masaryk University Brno, Czech Republic
| | - George Stergiou
- School of Medicine, Third Department of Medicine, Sotiria Hospital, Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, Athens, Greece
| | - Isabella Sudano
- University Hospital Zurich University Heart Center, Cardiology and University of Zurich, Zurich, Switzerland
| | - Ramzi Tabbalat
- Department of Cardiology, Abdali Hospital, Amman, Jordan
| | - Istemihan Tengiz
- Division of Cardiology, Izmir Medicana International Hospital, Yenisehir, Turkey
| | - Helen Triantafyllidi
- 2nd Department of Cardiology, Medical School, University of Athens, ATTIKON Hospital, Athens, Greece
| | - Konstontinos Tsioufis
- 1st Department of Cardiology, National and Kapodistrian University of Athens, Hippocratio Hospital, Greece
| | - Jan Václavík
- Department of Internal Medicine and Cardiology, University Hospital Ostrava, Czech Republic
- Faculty of Medicine, University of Ostrava, Czech Republic
| | - Markus van der Giet
- Medinische Klinik für Nephrologie und internistische Intensivtherapie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Patricia Van der Niepen
- Departement of Nephrology & Hypertension, Universitair Ziekenhuis Brussel Department of Nephrology and Hypertension, VUB, Belgium
| | - Franco Veglio
- Department of Medical Sciences, University of Turin, Italy
| | - RetoM Venzin
- Department of Nephrology, Cantonal Hospital Graubuenden, Chur, Switzerland
| | - Margus Viigimaa
- Centre of Cardiology, North Estonia Medical Centre, Tallinn University of Technology, Tallinn, Estonia
| | - Thomas Weber
- Cardiology Department, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Jiri Widimsky
- IIIrd Internal Department, Centre for Hypertension, General Faculty Hospital, Charles University, Prague, Czech Republic
| | - Gregoire Wuerzner
- Service de néphrologie et d'hypertension, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Parounak Zelveian
- Center of Preventive Cardiology, Armenia Parounak Zelveian, Hospital N2 CJSC, Yerevan, Armenia
| | - Pantelis Zebekakis
- Hypertension Unit of the First Department of Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | | | - Alexandre Persu
- Department of Cardiovascular Diseases, Division of Cardiology, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Reinhold Kreutz
- Institute of Clinical Pharmacology and Toxicology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Liffert Vogt
- Department of Internal Medicine, Section of Nephrology, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, the Netherlands
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Karakasis P, Patoulias D, Popovic DS, Pamporis K, Theofilis P, Nasoufidou A, Stachteas P, Samaras A, Tzikas A, Giannakoulas G, Stavropoulos G, Kassimis G, Karamitsos T, Fragakis N. Effects of mineralocorticoid receptor antagonists on new-onset or recurrent atrial fibrillation: a Bayesian and frequentist network meta-analysis of randomized trials. Curr Probl Cardiol 2024; 49:102742. [PMID: 39002620 DOI: 10.1016/j.cpcardiol.2024.102742] [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: 07/05/2024] [Accepted: 07/10/2024] [Indexed: 07/15/2024]
Abstract
Background Clinical and translational research suggests that mineralocorticoid receptor antagonists (MRAs) may prevent atrial fibrosis and electrical remodeling associated with atrial fibrillation (AF). This study aimed to consolidate existing evidence from randomized controlled trials (RCTs) evaluating the effect of MRAs on incident or recurrent AF. Methods Medline, Cochrane Library and Scopus were searched until February 12, 2024. Triple-independent study selection, data extraction and quality assessment were performed. Evidence was pooled using both pairwise and Bayesian and frequentist network meta-analyses. Results Twenty-three RCTs (13,358 participants) were identified. Based on the pairwise random effects meta-analysis, MRAs were associated with a significant reduction in AF events compared to placebo or usual care (risk ratio {RR}= 0.75; 95% confidence interval {CI}= [0.66, 0.87]; P< 0.001; I2= 3%). This protective effect was robust both for new-onset and recurrent AF episodes (subgroup p-value= 0.69), while the baseline HF status was not a significant effect modifier (subgroup p-value= 0.58). MRAs demonstrated a significantly higher reduction in AF events for patients with chronic renal disease compared to placebo (RR= 0.78; 95% CI= [0.62, 0.98]; P= 0.03; I2= 0%). The network meta-analyses revealed that only spironolactone was associated with a significant reduction in AF events (Bayesian RR= 0.76; 95% CI= [0.65, 0.89]; P< 0.001; level of evidence moderate; SUCRA 0.731), while eplerenone and finerenone showed a neutral effect. Conclusion MRAs confer a significant benefit in terms of reducing incident or recurrent AF episodes, irrespective of HF status. In this context, spironolactone may be preferable compared to eplerenone or finerenone.
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Affiliation(s)
- Paschalis Karakasis
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece.
| | - Dimitrios Patoulias
- Outpatient Department of Cardiometabolic Medicine, Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Djordje S Popovic
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Centre of Vojvodina, Medical Faculty, University of Novi Sad, Novi Sad, Serbia
| | - Konstantinos Pamporis
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Panagiotis Theofilis
- First Cardiology Department, General Hospital of Athens "Hippocratio", University of Athens Medical School, Athens, Greece
| | - Athina Nasoufidou
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Panagiotis Stachteas
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Athanasios Samaras
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Apostolos Tzikas
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece; European Interbalkan Medical Center, Department of Cardiology, Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, Aristotle University Medical School, Thessaloniki, AHEPA University General Hospital, Greece
| | - George Stavropoulos
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - George Kassimis
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Theodoros Karamitsos
- First Department of Cardiology, Aristotle University Medical School, Thessaloniki, AHEPA University General Hospital, Greece
| | - Nikolaos Fragakis
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
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Chang S, Liu H. Effects of combined resistance training and Tai Chi on oxidative stress, blood glucose and lipid metabolism and quality of life in elderly patients with type 2 diabetes mellitus. Res Sports Med 2024; 32:871-884. [PMID: 38715371 DOI: 10.1080/15438627.2024.2349521] [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: 08/16/2023] [Accepted: 04/16/2024] [Indexed: 08/06/2024]
Abstract
This study examined the effects of resistance training (RT), Tai Chi (TC) and combination intervention (RT & TC) on the oxidative stress, blood glucose and lipid metabolism and quality of life of elderly patients with type 2 diabetes mellitus (T2DM). Ninety-four elderly patients with T2DM were randomly divided into an RT group (RTG, n = 23), TC group (TCG, n = 24), combination intervention group (CIG, n = 24) and control group (CG, n = 23). All participants were given nutrition and medication. On this basis, RTG, TCG and CIG were administered for 24 weeks (3 times/week, 40 minutes/time). Observation indicators were malondialdehyde (MDA), superoxide dismutase (SOD), 8-hydroxy-2 deoxyguanosine (8-OHdG), fasting plasma glucose (FPG), postprandial plasma glucose (PPG), haemoglobin A1c (HbA1c) and diabetes specific quality of life (DSQL). RT, TC and joint intervention can reduce the oxidative stress damage on elderly patients with T2DM to different degrees, control the levels of blood sugar and blood lipid and improve the quality of life. Compared with single intervention, combination intervention can further reduce the level of oxidative stress but has no additional benefits on blood glucose and lipid control and quality of life.
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Affiliation(s)
- Shuwan Chang
- School of Sports Medicine and Health, Chengdu Sport University, Chengdu, China
- Department of Sports Human Science, Sichuan Sports College, Chengdu, China
| | - Heng Liu
- College of Physical Education, Chongqing University, Chongqing, China
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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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Thomsen HF, Lausvig NL, Pipper CB, Andersen S, Damgaard LH, Emerson SS, Ravn H. Familywise error for multiple time-to-event endpoints in a group sequential design. Stat Med 2024; 43:3417-3431. [PMID: 38852994 DOI: 10.1002/sim.10132] [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: 08/16/2023] [Revised: 05/15/2024] [Accepted: 05/22/2024] [Indexed: 06/11/2024]
Abstract
We investigate the familywise error rate (FWER) for time-to-event endpoints evaluated using a group sequential design with a hierarchical testing procedure for secondary endpoints. We show that, in this setup, the correlation between the log-rank test statistics at interim and at end of study is not congruent with the canonical correlation derived for normal-distributed endpoints. We show, both theoretically and by simulation, that the correlation also depends on the level of censoring, the hazard rates of the endpoints, and the hazard ratio. To optimize operating characteristics in this complex scenario, we propose a simulation-based method to assess the FWER which, better than the alpha-spending approach, can inform the choice of critical values for testing secondary endpoints.
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Affiliation(s)
| | - Nanna L Lausvig
- Department of Biostatistics, Novo Nordisk A/S, Søborg, Denmark
| | - Christian B Pipper
- Department of Biostatistics, Novo Nordisk A/S, Søborg, Denmark
- Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Søren Andersen
- Department of Biostatistics, Novo Nordisk A/S, Søborg, Denmark
| | - Lars H Damgaard
- Department of Biostatistics, Novo Nordisk A/S, Søborg, Denmark
| | - Scott S Emerson
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Henrik Ravn
- Department of Biostatistics, Novo Nordisk A/S, Søborg, Denmark
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Bilal A, Yi F, Gonzalez GR, Ali M, Im K, Ruff CT, Thethi TK, Pratley RE. Effects of newer anti-hyperglycemic agents on cardiovascular outcomes in older adults: Systematic review and meta-analysis. J Diabetes Complications 2024; 38:108783. [PMID: 38870731 DOI: 10.1016/j.jdiacomp.2024.108783] [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: 03/09/2024] [Revised: 05/07/2024] [Accepted: 06/01/2024] [Indexed: 06/15/2024]
Abstract
AIM To demonstrate cardiovascular safety of dipeptidyl peptidase-4 inhibitors (DPP-4i), glucagon-like peptide-1 receptor agonists (GLP-1RA), and sodium/glucose cotransporter 2 inhibitors (SGLT-2i) across age-groups. METHODS PubMed, Embase and Cochrane were searched for cardiovascular outcome trials (CVOTs) testing newer agents until August 31, 2022 (PROSPERO ID CRD42021260167). Studies with ≥1000 T2D participants enrolled for ≥12 months were included. Random effect models were used to report relative-risk (RR) for three-point major adverse cardiovascular events (3P-MACE) and its components by age subgroups (65 years; 75 years). RESULTS For SGLT-2is, five CVOTs (46,969 patients, 45-50 % ≥65 years) were included. SGLT-2is reduced risk of MACE (RR; 0.91 [CI, 0.85-0.98]); cardiovascular death (CV-death) (RR; 0.84 [CI, 0.73-0.96]); and all-cause mortality (ACM) (RR; 0.86 [CI, 0.79-0.93]) with no difference in subgroups <65 or ≥65 years. For GLP-1RAs, nine CVOTs (n = 64,236, 34-75 % ≥65 years) were included. GLP-1RAs reduced risk of MACE (RR; 0.89 [CI, 0.83-0.95]), stroke (RR; 0.86 [CI, 0.76-0.97]) and ACM (RR; 0.90 [CI, 0.83-0.97]) with no significant difference in subgroups <65 or ≥65 years. Additionally, GLP-1RAs reduced risk of MACE (10 %), ACM (12 %) and CV-death (12 %) with no significant difference in subgroups <75 or ≥75 years. Four CVOTs (n = 33,063; 35-58 % ≥65 years) with DPP-4is were included. There were no significant differences in risk for CV outcomes with DPP-4is compared to placebo in any of the age subgroups. CONCLUSION The overall cardiovascular safety profile of newer anti-hyperglycemic agents is consistent in older and younger individuals.
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Affiliation(s)
- Anika Bilal
- AdventHealth Translational Research Institute, Orlando, FL, USA.
| | - Fanchao Yi
- AdventHealth Translational Research Institute, Orlando, FL, USA
| | | | | | - KyungAh Im
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christian T Ruff
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tina K Thethi
- AdventHealth Translational Research Institute, Orlando, FL, USA; AdventHealth Diabetes Institute, Orlando, FL, USA
| | - Richard E Pratley
- AdventHealth Translational Research Institute, Orlando, FL, USA; AdventHealth Diabetes Institute, Orlando, FL, USA
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7
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Ming J, Hong G, Xu Y, Mernagh P, Pochopień M, Li H. Cost-effectiveness of Finerenone in Addition to Standard of Care for Patients with Chronic Kidney Disease and Type 2 Diabetes in China. Adv Ther 2024; 41:3138-3158. [PMID: 38880821 DOI: 10.1007/s12325-024-02906-w] [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: 04/06/2024] [Accepted: 05/17/2024] [Indexed: 06/18/2024]
Abstract
INTRODUCTION Adding finerenone to current standard of care (SoC), as recommended by Chinese guidelines, has shown substantial benefit in delaying chronic kidney disease (CKD) progression and reducing cardiovascular risk in patients with CKD and type 2 diabetes (T2D) in the landmark FIDELIO-DKD trial. This study aimed to evaluate the cost-effectiveness of finerenone + SoC versus SoC alone among Chinese patients with T2D and CKD from a healthcare system perspective. METHODS A cost-effectiveness model (FINE-CKD) has been developed and published, with health states defined for CKD stages (CKD 1/2, CKD 3, CKD 4, and CKD 5 without renal replacement therapy (RRT), dialysis, or transplant) and cardiovascular event history. Additionally, the model also considered adverse events. Transition probabilities and event risks were derived using patient-level data from Asian population analysis of FIDELIO-DKD. Since the price of finerenone after the national reimbursement drug list (NRDL) inclusion was confidential, the cost of finerenone in the model was assumed to be the same as that of SoC. Other health resource costs were gathered from literature and supplemented by physician interviews. Measured by the EQ-5D-5L questionnaire, quality of life was translated into utilities based on the Chinese EQ-5D-5L value set. RESULTS Discounted at 5.0% annually, over a lifetime horizon, finerenone + SoC resulted in a quality-adjusted life years (QALYs) gain of 0.321 versus SoC alone (8.660 vs. 8.338 QALYs), due to a reduction in the incidence of cardiovascular events and dialysis. Total costs per patient were lower under finerenone + SoC than SoC alone (381,130 CNY vs. 392,390 CNY). As a result, finerenone + SoC was a dominant treatment strategy compared with SoC alone. Sensitivity analysis has confirmed the robustness of this study. CONCLUSION Adding finerenone to SoC was likely to be either a dominant or cost-effective treatment option compared with SoC alone in Chinese patients with CKD and T2D.
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Affiliation(s)
- Jian Ming
- Real World Solutions, IQVIA China, Shanghai, China
- School of Public Health, Fudan University, Shanghai, 200032, China
| | - Guanqi Hong
- Real World Solutions, IQVIA China, Shanghai, China
| | - Yingrui Xu
- Medical Affairs, Pharmaceuticals, Bayer Healthcare Company Ltd, Beijing, China
| | | | | | - Hongchao Li
- School of International Pharmaceutical Business, Centre for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China.
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8
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Jo R, Itoh H, Shibata H. Mineralocorticoid receptor overactivation in diabetes mellitus: role of O-GlcNAc modification. Hypertens Res 2024; 47:2126-2132. [PMID: 38789539 DOI: 10.1038/s41440-024-01734-3] [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: 04/09/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024]
Abstract
Hypertension is a significant risk factor for microangiopathy and cardiovascular complications in diabetic patients. The efficacy of mineralocorticoid receptor (MR) antagonists in impeding the advancement of diabetic nephropathy, along with the reduction in active renin concentration observed in diabetic retinopathy, strongly implies the involvement of MR overactivation in diabetic complications. This review provides a comprehensive review of various mechanisms proposed for MR overactivation in diabetes mellitus. In particular, it focuses on post-translational MR modifications, including O-linked N-acetylglucosamine modification and phosphorylation, which have been implicated in MR protein stabilization and overactivation under conditions of high glucose. Given the role of MR overactivation in hyperglycemia, it emerges as a promising therapeutic target for preventing diabetic complications. Post-translational modifications (PTMs), such as O-GlcNAcylation and phosphorylation, are related to MR overactivation in diabetes and metabolic syndrome. Aldosterone binding promotes the proteasomal degradation of MR. Under conditions of high glucose, O-GlcNAcylation, and PKCβ-mediated MR phosphorylation are increased. Salt loading and oxidative stress also increase MR phosphorylation through the EGER/ERK pathway. PTMs inhibit ubiquitin attachment to the MR and interfere with the receptor's aldosterone-induced proteasomal degradation. Consequently, they increase the sensitivity of the MR to aldosterone and exacerbate aldosterone-associated complications.
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Affiliation(s)
- Rie Jo
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Keiyu Hospital, Kanagawa, Japan
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Hiroshi Itoh
- Center for Preventive Medicine, Keio University, Tokyo, Japan
| | - Hirotaka Shibata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Oita, Japan.
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9
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Khan MS, Lea JP. Kidney and cardiovascular-protective benefits of combination drug therapies in chronic kidney disease associated with type 2 diabetes. BMC Nephrol 2024; 25:248. [PMID: 39090593 PMCID: PMC11293206 DOI: 10.1186/s12882-024-03652-5] [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: 02/08/2024] [Accepted: 06/24/2024] [Indexed: 08/04/2024] Open
Abstract
Given the substantial burden of chronic kidney disease associated with type 2 diabetes, an aggressive approach to treatment is required. Despite the benefits of guideline-directed therapy, there remains a high residual risk of continuing progression of chronic kidney disease and of cardiovascular events. Historically, a linear approach to pharmacologic management of chronic kidney disease has been used, in which drugs are added, then adjusted, optimized, or stopped in a stepwise manner based on their efficacy, toxicity, effects on a patient's quality of life, and cost. However, there are disadvantages to this approach, which may result in missing a window of opportunity to slow chronic kidney disease progression. Instead, a pillar approach has been proposed to enable earlier treatment that simultaneously targets multiple pathways involved in disease progression. Combination therapy in patients with chronic kidney disease associated with type 2 diabetes is being investigated in several clinical trials. In this article, we discuss current treatment options for patients with chronic kidney disease associated with type 2 diabetes and provide a rationale for tailored combinations of therapies with complementary mechanisms of action to optimize therapy using a pillar-based treatment strategy. [This article includes a plain language summary as an additional file].
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Affiliation(s)
| | - Janice P Lea
- Division of Renal Medicine, Department of Internal Medicine, Emory School of Medicine, Atlanta, GA, USA
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10
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Yi Z, Yang B, Wan F, Lu J, Liu D, Lin L, Xu Y, Cen Z, Fan M, Liu W, Lu Q, Jiang G, Zhang Y, Song E, Gao J, Ye D. Chinese Medicine Linggui Zhugan Formula Protects against Diabetic Kidney Disease in Close Association with Inhibition of Proteinase 3-mediated Podocyte Apoptosis in Mice. JOURNAL OF ETHNOPHARMACOLOGY 2024:118650. [PMID: 39094755 DOI: 10.1016/j.jep.2024.118650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/24/2024] [Accepted: 07/30/2024] [Indexed: 08/04/2024]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Linggui-Zhugan (LGZG) comprises four herbs and is a classic formula in traditional Chinese medicine. There is strong clinical evidence of its pleiotropic effects in the prevention of diabetes and its related complications. Although several classes of drugs are currently available for clinical management of diabetic kidney disease (DKD), tight glycemic and/or hypertension control may not prevent disease progression. This study evaluated the therapeutic effect of the ethnopharmacological agent LGZG on DKD. AIM OF THE STUDY This study aimed to investigate the effects of LGZG formula with standard quality control on experimental DKD and its related metabolic disorders in animal model. Meanwhile, the present study aimed to investigate regulatory effects of LGZG on renal proteinase 3 (PR3) to reveal mechanisms underlying renoprotection benefits of LGZG. MATERIALS AND METHODS LGZG decoction was fingerprinted by high-performance liquid chromatography for quality control. An experimental model of DKD was induced in C57 BL/6J mice by a combination of high-fat diet feeding, uninephrectomy, and intraperitoneal injection of streptozocin. The LGZG decoction was administrated by daily oral gavage. RESULTS Treatment with LGZG formula significantly attenuated DKD-like traits (including severe albuminuria, mesangial matrix expansion, and podocyte loss) and metabolic dysfunction (disordered body composition and dyslipidemia) in mice. RNA sequencing data revealed a close association of LGZG treatment with marked modulation of signaling pathways related to podocyte injury and cell apoptosis. Mechanistically, LGZG suppressed the DKD-triggered increase in renal PR3 and podocyte apoptosis. In-vitro incubation of mouse immortalized podocytes with LGZG-medicated serum attenuated PR3-mediated apoptosis. CONCLUSION Our data demonstrated that the LGZG formula protected against DKD in mice and was closely associated with its inhibitory effects on PR3-mediated podocyte apoptosis.
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Affiliation(s)
- Zixuan Yi
- Key Laboratory of Metabolic Phenotyping in Model Animals, Guangdong Pharmaceutical University, Guangzhou, China; Guangdong Metabolic Disease Research Center of Integrated Chinese and Western Medicine, Guangdong Pharmaceutical University, Guangzhou, China
| | - Bei Yang
- Key Laboratory of Metabolic Phenotyping in Model Animals, Guangdong Pharmaceutical University, Guangzhou, China; Guangdong Metabolic Disease Research Center of Integrated Chinese and Western Medicine, Guangdong Pharmaceutical University, Guangzhou, China
| | - Fangyu Wan
- Key Laboratory of Metabolic Phenotyping in Model Animals, Guangdong Pharmaceutical University, Guangzhou, China; Guangdong Metabolic Disease Research Center of Integrated Chinese and Western Medicine, Guangdong Pharmaceutical University, Guangzhou, China
| | - Jing Lu
- Key Laboratory of Metabolic Phenotyping in Model Animals, Guangdong Pharmaceutical University, Guangzhou, China; Guangdong Metabolic Disease Research Center of Integrated Chinese and Western Medicine, Guangdong Pharmaceutical University, Guangzhou, China
| | - Dongyang Liu
- Key Laboratory of Metabolic Phenotyping in Model Animals, Guangdong Pharmaceutical University, Guangzhou, China; Guangdong Metabolic Disease Research Center of Integrated Chinese and Western Medicine, Guangdong Pharmaceutical University, Guangzhou, China
| | - Lin Lin
- Key Laboratory of Metabolic Phenotyping in Model Animals, Guangdong Pharmaceutical University, Guangzhou, China; Guangdong Metabolic Disease Research Center of Integrated Chinese and Western Medicine, Guangdong Pharmaceutical University, Guangzhou, China
| | - Ying Xu
- School of Chinese Medicine, Guangdong Pharmaceutical University, Guangzhou, China
| | - Zhikang Cen
- Key Laboratory of Metabolic Phenotyping in Model Animals, Guangdong Pharmaceutical University, Guangzhou, China; Guangdong Metabolic Disease Research Center of Integrated Chinese and Western Medicine, Guangdong Pharmaceutical University, Guangzhou, China
| | - Mengqi Fan
- Key Laboratory of Metabolic Phenotyping in Model Animals, Guangdong Pharmaceutical University, Guangzhou, China; Guangdong Metabolic Disease Research Center of Integrated Chinese and Western Medicine, Guangdong Pharmaceutical University, Guangzhou, China
| | - Wei Liu
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qiuhan Lu
- School of Public Health (Shenzhen), Shenzhen Campus of Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Guozhi Jiang
- School of Public Health (Shenzhen), Shenzhen Campus of Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Yuying Zhang
- Department of Obstetrics, Shenzhen Longhua Maternity and Child Healthcare Hospital, Shenzhen, China
| | - Erfei Song
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou 510630, Guangdong Province, China; Guangdong-Hong Kong-Macao Joint University Laboratory of Metabolic and Molecular Medicine, The University of Hong Kong and Jinan University, Guangzhou 510630, Guangdong Province, China
| | - Jie Gao
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
| | - Dewei Ye
- Key Laboratory of Metabolic Phenotyping in Model Animals, Guangdong Pharmaceutical University, Guangzhou, China; Guangdong Metabolic Disease Research Center of Integrated Chinese and Western Medicine, Guangdong Pharmaceutical University, Guangzhou, China.
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11
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Singh AK, Farag YMK, Zheng Z, Bakris GL. Clinical trial designs of emerging therapies for diabetic kidney disease (DKD). Postgrad Med 2024:1-9. [PMID: 39045637 DOI: 10.1080/00325481.2024.2377529] [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: 06/01/2024] [Revised: 07/01/2024] [Accepted: 07/04/2024] [Indexed: 07/25/2024]
Abstract
Current evidence for medical therapies for diabetic kidney disease (DKD) is largely based on large-scale clinical trials. These trials, however, often exhibit heterogeneity in participant characteristics and baseline kidney function. These differences may lead to misinterpretation in clinical practice, such that treatment effects from different trials are directly compared and generalized to broader populations beyond the population in which each trial was conducted. This is particularly relevant if comparisons on efficacy and safety are made when the underlying study populations are distinctly different. Indeed, key clinical trials evaluating sodium-glucose transport protein-2 inhibitors (SGLT2i), non-steroidal mineralocorticoid receptor antagonist (nsMRA), and glucagon-like peptide-1 receptor agonist (GLP-1RA) differed in recruitment requirements (inclusion/exclusion criteria), resulting in differences in the severity of the underlying kidney disease as well as risk factor profiles. Moreover, these trials defined their primary and secondary outcomes differently. Collectively, these factors lead to distinct study populations with different baseline risks for DKD progression in the placebo arm in each clinical trial. Consequently, a direct head-to-head comparison of the treatment effect between treatments using relative risk measures from placebo-controlled clinical trials alone is not recommended. In addition, healthcare professionals should be equipped to understand the specific target population of clinical trials to avoid over-generalization when drawing conclusions from these trials.
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Affiliation(s)
- Ajay K Singh
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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12
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Blazek O, Bakris GL. A review of novel endothelin antagonists and overview of non-steroidal mineralocorticoid antagonists for treating resistant hypertension: An update. Eur J Pharmacol 2024; 979:176752. [PMID: 39047966 DOI: 10.1016/j.ejphar.2024.176752] [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: 04/04/2024] [Revised: 06/11/2024] [Accepted: 06/16/2024] [Indexed: 07/27/2024]
Abstract
Several agents are emerging from five different novel classes of antihypertensive medications. We will focus on endothelin antagonists and non-steroidal mineralocorticoid receptor antagonists. While several agents exist in this later class, only a couple have demonstrated superior efficacy in resistant hypertension management. Endothelin receptor antagonists are effective therapy for primary and resistant hypertension, but they are not widely used. This is due to side effects demonstrated in large clinical trials, specifically increased peripheral edema and worsening heart failure in some cases, as well as the availability of many alternative agents to manage blood pressure effectively. However, the relationship between endothelin and its close ties to hypertension is evolving. Recent pre-clinical work explores new applications of more selective endothelin receptor antagonists. They suggest that specific subtypes of hypertension may benefit more from endothelin receptor blockade than simply those with primary hypertension. We review this topic and other related data. Lastly, we also provide a brief overview of non-steroidal mineralocorticoid receptor antagonists as some in the class show promise as antihypertensive agents.
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Affiliation(s)
- Olivia Blazek
- Department of Medicine, Am Heart Assoc. Comprehensive Hypertension Center, The University of Chicago Medicine, Chicago, IL, USA.
| | - George L Bakris
- Department of Medicine, Am Heart Assoc. Comprehensive Hypertension Center, The University of Chicago Medicine, Chicago, IL, USA.
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13
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Chesnaye NC, Ortiz A, Zoccali C, Stel VS, Jager KJ. The impact of population ageing on the burden of chronic kidney disease. Nat Rev Nephrol 2024:10.1038/s41581-024-00863-9. [PMID: 39025992 DOI: 10.1038/s41581-024-00863-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2024] [Indexed: 07/20/2024]
Abstract
The burden of chronic kidney disease (CKD) and its risk factors are projected to rise in parallel with the rapidly ageing global population. By 2050, the prevalence of CKD category G3-G5 may exceed 10% in some regions, resulting in substantial health and economic burdens that will disproportionately affect lower-income countries. The extent to which the CKD epidemic can be mitigated depends largely on the uptake of prevention efforts to address modifiable risk factors, the implementation of cost-effective screening programmes for early detection of CKD in high-risk individuals and widespread access and affordability of new-generation kidney-protective drugs to prevent the development and delay the progression of CKD. Older patients require a multidisciplinary integrated approach to manage their multimorbidity, polypharmacy, high rates of adverse outcomes, mental health, fatigue and other age-related symptoms. In those who progress to kidney failure, comprehensive conservative management should be offered as a viable option during the shared decision-making process to collaboratively determine a treatment approach that respects the values and wishes of the patient. Interventions that maintain or improve quality of life, including pain management and palliative care services when appropriate, should also be made available.
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Affiliation(s)
- Nicholas C Chesnaye
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands
| | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
- RICORS2040, Madrid, Spain
| | - Carmine Zoccali
- Associazione Ipertensione Nefrologia Trapianto Renale (IPNET), c/o Nefrologia, Grande Ospedale Metropolitano, Reggio Calabria, Italy
- Institute of Molecular Biology and Genetics (Biogem), Ariano Irpino, Italy
- Renal Research Institute, New York, NY, USA
| | - Vianda S Stel
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands
| | - Kitty J Jager
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Amsterdam, Netherlands.
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands.
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14
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Escobar Vasco MA, Fantaye SH, Raghunathan S, Solis-Herrera C. The potential role of finerenone in patients with type 1 diabetes and chronic kidney disease. Diabetes Obes Metab 2024. [PMID: 39021345 DOI: 10.1111/dom.15773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 06/20/2024] [Accepted: 06/22/2024] [Indexed: 07/20/2024]
Abstract
Chronic kidney disease (CKD) represents a global health concern, associated with an increased risk of cardiovascular morbidity and mortality and decreased quality of life. Many patients with type 1 diabetes (T1D) will develop CKD over their lifetime. Uncontrolled glucose levels, which occur in patients with T1D as well as type 2 diabetes (T2D), are associated with substantial mortality and cardiovascular disease burden. T2D and T1D share common pathological features of CKD, which is thought to be driven by haemodynamic dysfunction, metabolic disturbances, and subsequently an influx of inflammatory and profibrotic mediators, both of which are major interrelated contributors to CKD progression. The mineralocorticoid receptor is also involved, and, under conditions of oxidative stress, salt loading and hyperglycaemia, it switches from homeostatic regulator to pathophysiological mediator by promoting oxidative stress, inflammation and fibrosis. Progressive glomerular and tubular injury leads to macroalbuminuria a progressive reduction in the glomerular filtration rate and eventually end-stage renal disease. Finerenone, a non-steroidal, selective mineralocorticoid receptor antagonist, is approved for treatment of patients with CKD associated with T2D; however, the benefit of finerenone in patients with T1D has yet to be determined. This narrative review will discuss treatment of CKD in T1D and the potential future role of finerenone in this setting.
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Affiliation(s)
| | - Samuel H Fantaye
- Division of Endocrinology, University of Texas Health, San Antonio, Texas, USA
| | - Sapna Raghunathan
- Division of Endocrinology, University of Texas Health, San Antonio, Texas, USA
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Li X, Zhou X, Gao L. Diabetes and Heart Failure: A Literature Review, Reflection and Outlook. Biomedicines 2024; 12:1572. [PMID: 39062145 PMCID: PMC11274420 DOI: 10.3390/biomedicines12071572] [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: 06/11/2024] [Revised: 07/08/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024] Open
Abstract
Heart failure (HF) is a complex clinical syndrome caused by structural or functional dysfunction of the ventricular filling or blood supply. Diabetes mellitus (DM) is an independent predictor of mortality for HF. The increase in prevalence, co-morbidity and hospitalization rates of both DM and HF has further fueled the possibility of overlapping disease pathology between the two. For decades, antidiabetic drugs that are known to definitively increase the risk of HF are the thiazolidinediones (TZDs) and saxagliptin in the dipeptidyl peptidase-4 (DPP-4) inhibitor, and insulin, which causes sodium and water retention, and whether metformin is effective or safe for HF is not clear. Notably, sodium-glucose transporter 2 (SGLT2) inhibitors and partial glucagon-like peptide-1 receptor agonists (GLP-1 RA) all achieved positive results for HF endpoints, with SGLT2 inhibitors in particular significantly reducing the composite endpoint of cardiovascular mortality and hospitalization for heart failure (HHF). Further understanding of the mutual pathophysiological mechanisms between HF and DM may facilitate the detection of novel therapeutic targets to improve the clinical outcome. This review focuses on the association between HF and DM, emphasizing the efficacy and safety of antidiabetic drugs and HF treatment. In addition, recent therapeutic advances in HF and the important mechanisms by which SGLT2 inhibitors/mineralocorticoid receptor antagonist (MRA)/vericiguat contribute to the benefits of HF are summarized.
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Affiliation(s)
| | | | - Ling Gao
- Department of Endocrinology, Renmin Hospital, Wuhan University, Wuhan 430060, China; (X.L.); (X.Z.)
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Perkovic V, Tuttle KR, Rossing P, Mahaffey KW, Mann JFE, Bakris G, Baeres FMM, Idorn T, Bosch-Traberg H, Lausvig NL, Pratley R. Effects of Semaglutide on Chronic Kidney Disease in Patients with Type 2 Diabetes. N Engl J Med 2024; 391:109-121. [PMID: 38785209 DOI: 10.1056/nejmoa2403347] [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: 05/25/2024]
Abstract
BACKGROUND Patients with type 2 diabetes and chronic kidney disease are at high risk for kidney failure, cardiovascular events, and death. Whether treatment with semaglutide would mitigate these risks is unknown. METHODS We randomly assigned patients with type 2 diabetes and chronic kidney disease (defined by an estimated glomerular filtration rate [eGFR] of 50 to 75 ml per minute per 1.73 m2 of body-surface area and a urinary albumin-to-creatinine ratio [with albumin measured in milligrams and creatinine measured in grams] of >300 and <5000 or an eGFR of 25 to <50 ml per minute per 1.73 m2 and a urinary albumin-to-creatinine ratio of >100 and <5000) to receive subcutaneous semaglutide at a dose of 1.0 mg weekly or placebo. The primary outcome was major kidney disease events, a composite of the onset of kidney failure (dialysis, transplantation, or an eGFR of <15 ml per minute per 1.73 m2), at least a 50% reduction in the eGFR from baseline, or death from kidney-related or cardiovascular causes. Prespecified confirmatory secondary outcomes were tested hierarchically. RESULTS Among the 3533 participants who underwent randomization (1767 in the semaglutide group and 1766 in the placebo group), median follow-up was 3.4 years, after early trial cessation was recommended at a prespecified interim analysis. The risk of a primary-outcome event was 24% lower in the semaglutide group than in the placebo group (331 vs. 410 first events; hazard ratio, 0.76; 95% confidence interval [CI], 0.66 to 0.88; P = 0.0003). Results were similar for a composite of the kidney-specific components of the primary outcome (hazard ratio, 0.79; 95% CI, 0.66 to 0.94) and for death from cardiovascular causes (hazard ratio, 0.71; 95% CI, 0.56 to 0.89). The results for all confirmatory secondary outcomes favored semaglutide: the mean annual eGFR slope was less steep (indicating a slower decrease) by 1.16 ml per minute per 1.73 m2 in the semaglutide group (P<0.001), the risk of major cardiovascular events 18% lower (hazard ratio, 0.82; 95% CI, 0.68 to 0.98; P = 0.029), and the risk of death from any cause 20% lower (hazard ratio, 0.80; 95% CI, 0.67 to 0.95, P = 0.01). Serious adverse events were reported in a lower percentage of participants in the semaglutide group than in the placebo group (49.6% vs. 53.8%). CONCLUSIONS Semaglutide reduced the risk of clinically important kidney outcomes and death from cardiovascular causes in patients with type 2 diabetes and chronic kidney disease. (Funded by Novo Nordisk; FLOW ClinicalTrials.gov number, NCT03819153.).
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Affiliation(s)
- Vlado Perkovic
- From the University of New South Wales, Sydney (V.P.); the Division of Nephrology, University of Washington School of Medicine, Seattle, and Providence Medical Research Center, Providence Inland Northwest Health, Spokane - both in Washington (K.R.T.); Steno Diabetes Center Copenhagen, Herlev (P.R.), the Department of Clinical Medicine, University of Copenhagen, Copenhagen (P.R.), and Novo Nordisk, Søborg (F.M.M.B., T.I., H.B.-T., N.L.L.) - all in Denmark; Stanford Center for Clinical Research, Department of Medicine, Stanford School of Medicine, Palo Alto, CA (K.W.M.); KfH Kidney Center, Munich, and University Hospital, Friedrich-Alexander University, Erlangen - both in Germany (J.F.E.M.); the Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago (G.B.); and AdventHealth Translational Research Institute, Orlando, FL (R.P.)
| | - Katherine R Tuttle
- From the University of New South Wales, Sydney (V.P.); the Division of Nephrology, University of Washington School of Medicine, Seattle, and Providence Medical Research Center, Providence Inland Northwest Health, Spokane - both in Washington (K.R.T.); Steno Diabetes Center Copenhagen, Herlev (P.R.), the Department of Clinical Medicine, University of Copenhagen, Copenhagen (P.R.), and Novo Nordisk, Søborg (F.M.M.B., T.I., H.B.-T., N.L.L.) - all in Denmark; Stanford Center for Clinical Research, Department of Medicine, Stanford School of Medicine, Palo Alto, CA (K.W.M.); KfH Kidney Center, Munich, and University Hospital, Friedrich-Alexander University, Erlangen - both in Germany (J.F.E.M.); the Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago (G.B.); and AdventHealth Translational Research Institute, Orlando, FL (R.P.)
| | - Peter Rossing
- From the University of New South Wales, Sydney (V.P.); the Division of Nephrology, University of Washington School of Medicine, Seattle, and Providence Medical Research Center, Providence Inland Northwest Health, Spokane - both in Washington (K.R.T.); Steno Diabetes Center Copenhagen, Herlev (P.R.), the Department of Clinical Medicine, University of Copenhagen, Copenhagen (P.R.), and Novo Nordisk, Søborg (F.M.M.B., T.I., H.B.-T., N.L.L.) - all in Denmark; Stanford Center for Clinical Research, Department of Medicine, Stanford School of Medicine, Palo Alto, CA (K.W.M.); KfH Kidney Center, Munich, and University Hospital, Friedrich-Alexander University, Erlangen - both in Germany (J.F.E.M.); the Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago (G.B.); and AdventHealth Translational Research Institute, Orlando, FL (R.P.)
| | - Kenneth W Mahaffey
- From the University of New South Wales, Sydney (V.P.); the Division of Nephrology, University of Washington School of Medicine, Seattle, and Providence Medical Research Center, Providence Inland Northwest Health, Spokane - both in Washington (K.R.T.); Steno Diabetes Center Copenhagen, Herlev (P.R.), the Department of Clinical Medicine, University of Copenhagen, Copenhagen (P.R.), and Novo Nordisk, Søborg (F.M.M.B., T.I., H.B.-T., N.L.L.) - all in Denmark; Stanford Center for Clinical Research, Department of Medicine, Stanford School of Medicine, Palo Alto, CA (K.W.M.); KfH Kidney Center, Munich, and University Hospital, Friedrich-Alexander University, Erlangen - both in Germany (J.F.E.M.); the Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago (G.B.); and AdventHealth Translational Research Institute, Orlando, FL (R.P.)
| | - Johannes F E Mann
- From the University of New South Wales, Sydney (V.P.); the Division of Nephrology, University of Washington School of Medicine, Seattle, and Providence Medical Research Center, Providence Inland Northwest Health, Spokane - both in Washington (K.R.T.); Steno Diabetes Center Copenhagen, Herlev (P.R.), the Department of Clinical Medicine, University of Copenhagen, Copenhagen (P.R.), and Novo Nordisk, Søborg (F.M.M.B., T.I., H.B.-T., N.L.L.) - all in Denmark; Stanford Center for Clinical Research, Department of Medicine, Stanford School of Medicine, Palo Alto, CA (K.W.M.); KfH Kidney Center, Munich, and University Hospital, Friedrich-Alexander University, Erlangen - both in Germany (J.F.E.M.); the Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago (G.B.); and AdventHealth Translational Research Institute, Orlando, FL (R.P.)
| | - George Bakris
- From the University of New South Wales, Sydney (V.P.); the Division of Nephrology, University of Washington School of Medicine, Seattle, and Providence Medical Research Center, Providence Inland Northwest Health, Spokane - both in Washington (K.R.T.); Steno Diabetes Center Copenhagen, Herlev (P.R.), the Department of Clinical Medicine, University of Copenhagen, Copenhagen (P.R.), and Novo Nordisk, Søborg (F.M.M.B., T.I., H.B.-T., N.L.L.) - all in Denmark; Stanford Center for Clinical Research, Department of Medicine, Stanford School of Medicine, Palo Alto, CA (K.W.M.); KfH Kidney Center, Munich, and University Hospital, Friedrich-Alexander University, Erlangen - both in Germany (J.F.E.M.); the Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago (G.B.); and AdventHealth Translational Research Institute, Orlando, FL (R.P.)
| | - Florian M M Baeres
- From the University of New South Wales, Sydney (V.P.); the Division of Nephrology, University of Washington School of Medicine, Seattle, and Providence Medical Research Center, Providence Inland Northwest Health, Spokane - both in Washington (K.R.T.); Steno Diabetes Center Copenhagen, Herlev (P.R.), the Department of Clinical Medicine, University of Copenhagen, Copenhagen (P.R.), and Novo Nordisk, Søborg (F.M.M.B., T.I., H.B.-T., N.L.L.) - all in Denmark; Stanford Center for Clinical Research, Department of Medicine, Stanford School of Medicine, Palo Alto, CA (K.W.M.); KfH Kidney Center, Munich, and University Hospital, Friedrich-Alexander University, Erlangen - both in Germany (J.F.E.M.); the Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago (G.B.); and AdventHealth Translational Research Institute, Orlando, FL (R.P.)
| | - Thomas Idorn
- From the University of New South Wales, Sydney (V.P.); the Division of Nephrology, University of Washington School of Medicine, Seattle, and Providence Medical Research Center, Providence Inland Northwest Health, Spokane - both in Washington (K.R.T.); Steno Diabetes Center Copenhagen, Herlev (P.R.), the Department of Clinical Medicine, University of Copenhagen, Copenhagen (P.R.), and Novo Nordisk, Søborg (F.M.M.B., T.I., H.B.-T., N.L.L.) - all in Denmark; Stanford Center for Clinical Research, Department of Medicine, Stanford School of Medicine, Palo Alto, CA (K.W.M.); KfH Kidney Center, Munich, and University Hospital, Friedrich-Alexander University, Erlangen - both in Germany (J.F.E.M.); the Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago (G.B.); and AdventHealth Translational Research Institute, Orlando, FL (R.P.)
| | - Heidrun Bosch-Traberg
- From the University of New South Wales, Sydney (V.P.); the Division of Nephrology, University of Washington School of Medicine, Seattle, and Providence Medical Research Center, Providence Inland Northwest Health, Spokane - both in Washington (K.R.T.); Steno Diabetes Center Copenhagen, Herlev (P.R.), the Department of Clinical Medicine, University of Copenhagen, Copenhagen (P.R.), and Novo Nordisk, Søborg (F.M.M.B., T.I., H.B.-T., N.L.L.) - all in Denmark; Stanford Center for Clinical Research, Department of Medicine, Stanford School of Medicine, Palo Alto, CA (K.W.M.); KfH Kidney Center, Munich, and University Hospital, Friedrich-Alexander University, Erlangen - both in Germany (J.F.E.M.); the Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago (G.B.); and AdventHealth Translational Research Institute, Orlando, FL (R.P.)
| | - Nanna Leonora Lausvig
- From the University of New South Wales, Sydney (V.P.); the Division of Nephrology, University of Washington School of Medicine, Seattle, and Providence Medical Research Center, Providence Inland Northwest Health, Spokane - both in Washington (K.R.T.); Steno Diabetes Center Copenhagen, Herlev (P.R.), the Department of Clinical Medicine, University of Copenhagen, Copenhagen (P.R.), and Novo Nordisk, Søborg (F.M.M.B., T.I., H.B.-T., N.L.L.) - all in Denmark; Stanford Center for Clinical Research, Department of Medicine, Stanford School of Medicine, Palo Alto, CA (K.W.M.); KfH Kidney Center, Munich, and University Hospital, Friedrich-Alexander University, Erlangen - both in Germany (J.F.E.M.); the Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago (G.B.); and AdventHealth Translational Research Institute, Orlando, FL (R.P.)
| | - Richard Pratley
- From the University of New South Wales, Sydney (V.P.); the Division of Nephrology, University of Washington School of Medicine, Seattle, and Providence Medical Research Center, Providence Inland Northwest Health, Spokane - both in Washington (K.R.T.); Steno Diabetes Center Copenhagen, Herlev (P.R.), the Department of Clinical Medicine, University of Copenhagen, Copenhagen (P.R.), and Novo Nordisk, Søborg (F.M.M.B., T.I., H.B.-T., N.L.L.) - all in Denmark; Stanford Center for Clinical Research, Department of Medicine, Stanford School of Medicine, Palo Alto, CA (K.W.M.); KfH Kidney Center, Munich, and University Hospital, Friedrich-Alexander University, Erlangen - both in Germany (J.F.E.M.); the Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago (G.B.); and AdventHealth Translational Research Institute, Orlando, FL (R.P.)
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17
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Zhou L, Li W. Effectiveness and safety of finerenone in Chinese CKD patients without diabetes: a retrospective, real-world study. Int Urol Nephrol 2024:10.1007/s11255-024-04142-1. [PMID: 38985246 DOI: 10.1007/s11255-024-04142-1] [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: 05/15/2024] [Accepted: 06/30/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Finerenone, a non-steroidal mineralocorticoid receptor antagonist, has previously demonstrated its efficacy and safety in chronic kidney disease (CKD) associated with diabetes mellitus. Given its therapeutic potential, finerenone has been preliminarily explored in clinical practice for non-diabetic CKD patients. The effectiveness and safety in this population require further investigation in a real-world setting. METHODS This retrospective, real-world analysis included non-diabetic CKD patients receiving finerenone. The main clinical outcomes assessed were changes in urinary albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR). Serum potassium (sK+) levels were also monitored. Data were collected at baseline, and then at 1 month and 3 months following treatment initiation. RESULTS Totally, 16 patients were included. There was a notable decrease in UACR from 1-month post-treatment, with a further reduction at 3 months, resulting in a median reduction of 200.41 mg/g (IQR, 84.04-1057.10 mg/g; P = 0.028; percent change, 44.52% [IQR, 31.79-65.42%]). The average eGFR at baseline was 80.16 ml/min/1.73m2, with no significant change after 1 month (80.72 ml/min/1.73m2, P = 0.594) and a slight numerical increase to 83.45 ml/min/1.73m2 (P = 0.484) after 3 months. During the 3-month follow-up, sK+ levels showed only minor fluctuations, with no significant differences compared to baseline, and remained within the normal range throughout the treatment period. No treatment discontinuation or hospitalization due to hyperkalemia was observed. CONCLUSION In non-diabetic CKD patients, finerenone showed good effectiveness and safety within a 3-month follow-up period. This study provides valuable real-world evidence supporting the use of finerenone in non-diabetic CKD and highlights the need for future large-scale prospective research to further validate its efficacy.
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Affiliation(s)
- Li Zhou
- Department of Nephropathy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Wenge Li
- Department of Nephropathy, China-Japan Friendship Hospital, Beijing, 100029, China.
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18
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Al-Chalabi S, Sinha S, Kalra PA. Enhancing clinical service design for multimorbidity management: A comprehensive approach to joined-up care for diabetes, chronic kidney disease, and heart failure. Diabet Med 2024:e15403. [PMID: 38978167 DOI: 10.1111/dme.15403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/10/2024] [Accepted: 06/26/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND AND AIMS Multimorbidity is becoming the norm rather than the exception, especially among the ageing population and people with lower socio-economic status. In addition to the rising healthcare cost, multimorbidity poses considerable difficulty in the delivery of adequate holistic care for affected patients. METHODS This review presents a discussion of the current barriers to delivering holistic care to people with multimorbidity and proposes a model of clinical care for people living with cardiovascular-kidney-metabolic (CKM) syndrome as an exemplar of a multimorbidity cluster. RESULTS Single organ/disease services may not be able to provide optimum care to people with multimorbidity due to the potential complex interactions between multiple disease symptoms and management. In addition, people with multimorbidity may be required to attend multiple appointments in different healthcare centres. This may negatively impact access to services due to time and financial burden. Other barriers include co-ordinating communication between healthcare professionals and reduced continuity of care. Optimising CKM health requires patient-centred care led by an interdisciplinary care team who ideally should possess CKM competencies utilising a shared care protocol to coordinate evidence-based care and use of telehealth to empower patients. Stakeholders and policymakers need to adapt new policy models to establish and enhance CKM care models by allocating funds and implementing frameworks for educational reforms. CONCLUSIONS A CKM service has the potential to increase the uptake of cardiac and renal protective medications as well as optimising metabolic care, increase capacity in both primary and secondary care, improve quality of life and clinical outcomes, reduce patient inconvenience, and importantly allow rapid translation of advances in cardiorenal metabolic diseases into clinical practice.
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Affiliation(s)
- Saif Al-Chalabi
- Donal O'Donoghue Renal Research Centre, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Smeeta Sinha
- Donal O'Donoghue Renal Research Centre, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Philip A Kalra
- Donal O'Donoghue Renal Research Centre, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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19
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Yang SQ, Zhao X, Zhang J, Liu H, Wang YH, Wang YG. Comparative efficacy and safety of SGLT2is and ns-MRAs in patients with diabetic kidney disease: a systematic review and network meta-analysis. Front Endocrinol (Lausanne) 2024; 15:1429261. [PMID: 39027482 PMCID: PMC11256196 DOI: 10.3389/fendo.2024.1429261] [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: 05/07/2024] [Accepted: 06/17/2024] [Indexed: 07/20/2024] Open
Abstract
Objectives To evaluate the efficacy and safety of non-steroid mineralocorticoid receptor antagonists (ns-MRAs) and sodium-glucose cotransporter 2 inhibitors (SGLT2is) in patients with diabetic kidney disease (DKD). Methods Systematic literature searches were performed using PubMed, Embase and Web of Science encompassing inception until January 20, 2024. Randomized control trials (RCTs) comparing ns-MRAs and SGLT2is in DKD were selected. The efficacy outcomes of interest included kidney-specific composite outcome, cardiovascular (CV)-specific composite outcome, end-stage kidney disease (ESKD), and overall mortality. We also investigated safety outcomes, including acute kidney injury (AKI) and hyperkalemia. Results A total of 10 randomized clinical trials with 35,786 patients applying various treatments were included. SGLT2is (SUCRA 99.84%) have potential superiority in kidney protection. SGLT2is (RR 1.41, 95%CI 1.26 to 1.57) and ns-MRAs (RR 1.17, 95% CI 1.08 to 1.27) were associated with significantly lower kidney-specific composite outcome than the placebo. Regarding the reduction in CV-specific composite outcome and ESKD, SGLT2is (SUCRA 91.61%; 91.38%) have potential superiority in playing cardiorenal protection. Concerning the CV-specific composite outcome (RR 1.27, 95%CI 1.09 to 1.43) and ESKD (RR 1.43, 95%CI 1.20 to 1.72), SGLT2is significantly reduced the risks compared to placebo. Regarding the reduction in overall mortality, SGLT2is (SUCRA 83.03%) have potential superiority in postponing mortality. Concerning the overall mortality, SGLT2is have comparable effects (RR 1.27, 95%CI 1.09 to 1.43) with placebo to reduce the risk of overall mortality compared to placebo. For AKI reduction, ns-MRAs (SUCRA 63.58%) have potential superiority. SGLT2is have comparable effects (RR 1.24, 95%CI 1.05 to 1.46) with placebo to reduce the risk of AKI. For hyperkalemia reduction, SGLT2is (SUCRA 93.12%) have potential superiority. SGLT2is have comparable effects (RR 1.24, 95%CI 1.05 to 1.46) with placebo to reduce the risk of AKI. Concerning hyperkalemia reduction, nsMRAs (RR 1.24 95%CI 0.39 to 3.72) and SGLT2is (RR 1.01 95%CI 0.40 to 3.02) did not show significant benefit compared to placebo. Conclusion Concerning the efficacy and safety outcomes, SGLT2is may be recommended as a treatment regimen for maximizing kidney and cardiovascular protection, with a minimal risk of hyperkalemia in DKD. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42023458613.
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Affiliation(s)
- Si-Qi Yang
- Department of Nephrology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Department of Nephrology, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xi Zhao
- Department of Nephrology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Department of Nephrology, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Jing Zhang
- Department of Nephrology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Department of Nephrology, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Huan Liu
- Department of Nephrology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Department of Nephrology, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yu-Han Wang
- Department of Nephrology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Department of Nephrology, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yao-Guang Wang
- Department of Nephrology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Department of Nephrology, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
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20
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Fazzini L, Ghirardi A, Limonta R, Calabrese A, D'Elia E, Canova P, Fontana A, Grosu A, Iacovoni A, Ferrari P, De Maria R, Gavazzi A, Montisci R, Senni M, Gori M. Long-term outcomes of phenoclusters in preclinical heart failure with preserved and mildly reduced ejection fraction. ESC Heart Fail 2024. [PMID: 38965689 DOI: 10.1002/ehf2.14913] [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: 03/15/2024] [Revised: 05/30/2024] [Accepted: 06/07/2024] [Indexed: 07/06/2024] Open
Abstract
AIMS The identification of subjects at higher risk for incident heart failure (HF) with preserved ejection fraction (EF) suitable for more intensive preventive programmes remains challenging. We applied phenomapping to the DAVID-Berg population, comprising subjects with preclinical HF, aiming to refine HF risk stratification. METHODS The DAVID-Berg study prospectively enrolled 596 asymptomatic outpatients with EF > 40% with hypertension, diabetes mellitus or known cardiovascular disease. In this cohort, we performed an unsupervised cluster analysis on 591 patients, including clinical, laboratory, electrocardiographic and echocardiographic parameters. We tested the association between each cluster and a composite outcome of HF/death. RESULTS The median age was 70 years, 55.5% were males and the median EF was 61.0%. Phenomapping provided three different clusters. Subjects in Cluster 3 were the oldest and had the highest prevalence of atrial fibrillation, the lowest estimated glomerular filtration rate (eGFR), the highest N-terminal pro-brain natriuretic peptide (NT-proBNP) and the largest left atrium. During a median follow-up of 5.7 years, 13.4% of subjects experienced HF/death events (N = 79). Compared with Clusters 1 and 2, Cluster 3 had the worst prognosis (log-rank test: Cluster 3 vs. 1 P < 0.001; Cluster 3 vs. 2 P = 0.008). Cluster 3 was associated with a risk of HF/death 2.5 times higher than Cluster 1 [adjusted hazard ratio (HR) = 2.46, 95% confidence interval (CI) 1.24-4.90]. CONCLUSIONS Based on phenomapping, older patients with lower kidney function and worse diastolic function might represent a subset of preclinical HF with EF > 40% who deserve more efforts to prevent clinical HF.
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Affiliation(s)
- Luca Fazzini
- Clinical Cardiology Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Arianna Ghirardi
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Raul Limonta
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Alice Calabrese
- Division of Cardiology, Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Emilia D'Elia
- Division of Cardiology, Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Paolo Canova
- Division of Cardiology, Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Aurelia Grosu
- Division of Cardiology, Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Attilio Iacovoni
- Division of Cardiology, Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Paola Ferrari
- Division of Cardiology, Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Renata De Maria
- National Research Council Clinical Physiology Institute, Pisa, Italy
| | - Antonello Gavazzi
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Roberta Montisci
- Clinical Cardiology Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Michele Senni
- Division of Cardiology, Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Mauro Gori
- Division of Cardiology, Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
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Ness BM, Webb H. Finerenone: Who should prescribe it for CKD? The physician associate's perspective. J Nephrol 2024:10.1007/s40620-024-02015-5. [PMID: 38958872 DOI: 10.1007/s40620-024-02015-5] [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: 03/14/2024] [Accepted: 06/15/2024] [Indexed: 07/04/2024]
Abstract
Diabetic kidney disease (DKD) affects 30-40% of all patients with diabetes and contributes significantly to the cardiovascular burden of chronic kidney disease (CKD). Despite the availability of evidence-based medications like finerenone and simple screening tests such as Urinary Albumin-to-Creatinine Ratio (UACR), more resources are still needed to care for DKD patients. Physician Associates (PAs) play a crucial role in the multidisciplinary team responsible for DKD diagnosis, monitoring, and management. A nonsteroidal mineralocorticoid receptor antagonist, namely finerenone, was approved by the FDA in adults with CKD associated with type 2 diabetes to reduce the risk of renal and cardiovascular outcomes. Finerenone is considered among the pillars of care for DKD, furthermore, the addition of finerenone in combination with renin-angiotensin system inhibitors and/or other renal protective medications may offer additional benefits. Primary care providers prescribe finerenone less frequently than specialized care providers, indicating a need to empower physician associates in medication prescription and other renal protection strategies. As part of a multidisciplinary team, physician associates can play an important role in evaluating risk factors that contribute to heart disease and metabolic health. They can also monitor not only kidney function by ordering tests, such as serum creatinine and urinary albumin-to-creatinine ratio every 3-12 months, but also serum potassium levels. Additionally, physician associates can encourage patients to take responsibility for their health by regularly monitoring their blood pressure, blood glucose levels, and body weight. With early detection and management, kidney failure and cardiovascular events may be preventable. Specialized physician associates also play a significant role in the comprehensive care of DKD patients, especially in the later stages. DKD care can be hindered by numerous factors such as lack of patient engagement during counseling, cost disparities, and a complex referral system that requires multidisciplinary guidelines to improve professional communication. It is necessary to re-envision the physician associates' role in primary care and empower them in goal-directed therapies.
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Affiliation(s)
- Becky M Ness
- Department of Nephrology, Mayo Clinic College of Medicine, Rochester, MN, USA.
| | - Heidi Webb
- Bahl & Bahl Medical Associates, Pittsburgh, PA, USA
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22
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van Raalte DH, Bjornstad P, Cherney DZI, de Boer IH, Fioretto P, Gordin D, Persson F, Rosas SE, Rossing P, Schaub JA, Tuttle K, Waikar SS, Heerspink HJL. Combination therapy for kidney disease in people with diabetes mellitus. Nat Rev Nephrol 2024; 20:433-446. [PMID: 38570632 DOI: 10.1038/s41581-024-00827-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/05/2024]
Abstract
Diabetic kidney disease (DKD), defined as co-existing diabetes and chronic kidney disease in the absence of other clear causes of kidney injury, occurs in approximately 20-40% of patients with diabetes mellitus. As the global prevalence of diabetes has increased, DKD has become highly prevalent and a leading cause of kidney failure, accelerated cardiovascular disease, premature mortality and global health care expenditure. Multiple pathophysiological mechanisms contribute to DKD, and single lifestyle or pharmacological interventions have shown limited efficacy at preserving kidney function. For nearly two decades, renin-angiotensin system inhibitors were the only available kidney-protective drugs. However, several new drug classes, including sodium glucose cotransporter-2 inhibitors, a non-steroidal mineralocorticoid antagonist and a selective endothelin receptor antagonist, have now been demonstrated to improve kidney outcomes in people with type 2 diabetes mellitus. In addition, emerging preclinical and clinical evidence of the kidney-protective effects of glucagon-like-peptide-1 receptor agonists has led to the prospective testing of these agents for DKD. Research and clinical efforts are geared towards using therapies with potentially complementary efficacy in combination to safely halt kidney disease progression. As more kidney-protective drugs become available, the outlook for people living with DKD should improve in the next few decades.
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Affiliation(s)
- Daniël H van Raalte
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, VUMC, Amsterdam, The Netherlands.
- Diabetes Center, Amsterdam University Medical Centers, VUMC, Amsterdam, The Netherlands.
- Research Institute for Cardiovascular Sciences, VU University, Amsterdam, The Netherlands.
| | - Petter Bjornstad
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ian H de Boer
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Paola Fioretto
- Department of Medicine, University of Padua, Unit of Medical Clinic 3, Padua, Italy
| | - Daniel Gordin
- Minerva Foundation Institute for Medical Research, Helsinki, Finland
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Sylvia E Rosas
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jennifer A Schaub
- Nephrology Division, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Katherine Tuttle
- Providence Medical Research Center, Providence Inland Northwest Health, Spokane, Washington, USA
- Department of Medicine, University of Washington School of Medicine, Spokane and Seattle, Washington, USA
- Nephrology Division, Kidney Research Institute and Institute of Translational Health Sciences, University of Washington, Spokane and Seattle, Washington, USA
| | - Sushrut S Waikar
- Section of Nephrology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- The George Institute for Global Health, Sydney, New South Wales, Australia
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23
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Tungsanga S, Bello AK. Prevention of Chronic Kidney Disease and Its Complications in Older Adults. Drugs Aging 2024; 41:565-576. [PMID: 38926293 DOI: 10.1007/s40266-024-01128-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2024] [Indexed: 06/28/2024]
Abstract
In an era marked by a global demographic shift towards an aging society, there is a heightened prevalence of chronic kidney disease (CKD) among older adults. The burden of CKD spans from kidney-related complications to impacting psychological well-being, giving rise to depressive symptoms and caregiver burnout. This article delves into CKD prevention strategies within the context of aging, contributing to the discourse by exploring its multifaceted aspects. The prevention of CKD in the older adults necessitates a comprehensive approach. Primary prevention is centered on the modification of risk factors, acknowledging the intricate interplay of various comorbidities. Secondary prevention focuses on early CKD identification. Tertiary prevention aims to address factors contributing to CKD progression and complications, emphasizing the importance of timely interventions. This comprehensive strategy aims to enhance the quality of life for individuals affected by CKD, decelerating the deterioration of functional status. By addressing CKD at multiple levels, this approach seeks to effectively and compassionately care for the aging population.
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Affiliation(s)
- Somkanya Tungsanga
- Division of Nephrology and Immunology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Division of General Internal Medicine-Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Aminu K Bello
- Division of Nephrology and Immunology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
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Wilson JA, Pitman J, Marin J, Wazny LD, Battistella M. Review of the top nephrology studies of 2020-2023. Can Pharm J (Ott) 2024; 157:174-180. [PMID: 39092086 PMCID: PMC11290582 DOI: 10.1177/17151635241250028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/16/2024] [Indexed: 08/04/2024]
Affiliation(s)
- Jo-Anne Wilson
- College of Pharmacy, Faculty of Health, Dalhousie University and Nova Scotia Health Research and Innovation, Halifax, Nova Scotia
| | - Jennifer Pitman
- Pharmacy Department, Nova Scotia Health, Halifax, Nova Scotia
| | - Judith Marin
- St. Paul’s Hospital, Kidney Care Clinic, Vancouver, British Columbia
| | | | - Marisa Battistella
- Leslie Dan Faculty of Pharmacy, University of Toronto and University Health Network, Toronto, Ontario
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Kobayashi M, Girerd N, Zannad F. When to use spironolactone, eplerenone or finerenone in the spectrum of cardiorenal diseases. Nephrol Dial Transplant 2024; 39:1063-1072. [PMID: 38192033 DOI: 10.1093/ndt/gfae004] [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: 11/23/2023] [Indexed: 01/10/2024] Open
Abstract
Kidney disease frequently coexists with cardiovascular (CV) diseases, and this dual presence significantly amplifies the risk of adverse clinical outcomes. Shared pathophysiological mechanisms and common CV risk factors contribute to the increased expression of mineralocorticoid receptors, which in turn can drive the progression of chronic CV-kidney disorders. The steroidal mineralocorticoid receptor antagonists (MRAs) spironolactone and eplerenone have demonstrated efficacy in improving patient outcomes in cases of heart failure with reduced ejection fraction or after a myocardial infarction, but have limited value in patients with chronic kidney disease. The non-steroidal MRA finerenone has now established itself as a foundational guideline-recommended therapy in patients with diabetic kidney disease. To date, these pharmacological agents have been developed in distinct patient populations. The consequences of their distinct pharmacological profiles necessitate further consideration. They have not undergone testing across the entire spectrum of cardiorenal scenarios, and the evidence base is currently being complemented with ongoing trials. In this review, we aim to synthesize the existing body of evidence and chart the future trajectory for the use of spironolactone, eplerenone and finerenone in improving clinical outcomes across the diverse spectrum of cardiorenal diseases. By consolidating the current state of knowledge, we seek to provide valuable insights for informed decision making in the management of patients with these complex and interconnected conditions.
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Affiliation(s)
- Masatake Kobayashi
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques 1433, CHRU de Nancy, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Nicolas Girerd
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques 1433, CHRU de Nancy, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
| | - Faiez Zannad
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques 1433, CHRU de Nancy, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
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Hanouneh M, Le D, Jaar BG, Tamargo C, Cervantes CE. Real-Life Experience on the Effect of SGLT2 Inhibitors vs. Finerenone vs. Combination on Albuminuria in Chronic Kidney Disease. Diagnostics (Basel) 2024; 14:1357. [PMID: 39001247 PMCID: PMC11241372 DOI: 10.3390/diagnostics14131357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 06/24/2024] [Accepted: 06/24/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND There have been several recent advances in the care of patients with chronic kidney disease (CKD), including the use of sodium glucose cotransporter 2 (SGLT2) inhibitors and selective mineralocorticoid receptor antagonists (MRAs). There are very few data reporting the outcomes of these treatments in real-world experience. The aim of this retrospective study is to report the effects of SGLT2 inhibitors, finerenone, and their combination in CKD patients in our community-based setting. METHODS Ninety-eight patients with CKD with an estimated glomerular filtration rate (eGFR) between 25 and 90 mL/min per 1.73 m2 and a urine albumin-to-creatinine ratio (UACR) ≥ 30 mg/g were included. Patients were divided into three groups: two monotherapy groups of SGLT2 inhibitors or finerenone and a third combination group of therapy with SGLT2 inhibitors for the first 4 months and SGLT2 inhibitors and finerenone subsequently. The primary outcomes were the timing and percentage of patients achieving a >50% reduction in UACR from baseline. RESULTS Group 1 comprised 52 patients on SGLT2i, group 2 had 22 patients on finerenone, and group 3 had 24 patients on combination therapy. The baseline median UACR and mean eGFR were 513 mg/g and 47.9 mL/min per 1.73 m2 in group 1, 548.0 mg/g and 50.5 mL/min per 1.73 m2 in group 2, and 800 mg/g and 60 mL/min per 1.73 m2 in group 3. At baseline, 71 (72.4%) patients were on the angiotensin-converting enzyme inhibitor (ACEi) or the angiotensin receptor blocker (ARB), and 78 (79.5%) patients had type 2 diabetes. After 8 months of follow-up, a >50% decrease in albuminuria was achieved in 96% of patients in group 3, compared to 50% in group 1 and 59% in group 2 (p-values were <0.01 and <0.01, respectively). There was a statistically but not clinically significant change in mean potassium levels in group 2 (+0.4 mmol/L) compared to either group 1 (0.0 mmol/L with p-value: <0.01) or group 3 (-0.01 mmol/L with p-value: <0.01). However, there was no difference in potassium levels when comparing groups 1 and 3. At the end of the follow-up, the average difference in eGFR was -3.4 (8.8), -5.3(10.1), and -7.8 (11.2) mL/min per 1.73 m2 in groups 1, 2, and 3, respectively, without a statistically significant difference between groups. CONCLUSIONS In this real-world experience in our community setting, the combination of SGLT2 inhibitors and finerenone in our adult patients with CKD was associated with a very significant and clinically relevant reduction in UACR, without an increased risk of hyperkalemia. Combination therapy of SGLT2 inhibitor and finerenone regarding background use of ACEi/ARB is feasible and should be encouraged for further albuminuria reductions in CKD patients.
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Affiliation(s)
- Mohamad Hanouneh
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (B.G.J.); (C.T.); (C.E.C.)
- Nephrology Center of Maryland, Baltimore, MD 21239, USA
| | - Dustin Le
- Division of Nephrology, Thomas Jefferson University, Philadelphia, PA 19130, USA;
| | - Bernard G. Jaar
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (B.G.J.); (C.T.); (C.E.C.)
- Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, MD 21287, USA
| | - Christina Tamargo
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (B.G.J.); (C.T.); (C.E.C.)
| | - C. Elena Cervantes
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (B.G.J.); (C.T.); (C.E.C.)
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Gomez KA, Tromp J, Figarska SM, Beldhuis IE, Cotter G, Davison BA, Felker GM, Gimpelewicz C, Greenberg BH, Lam CSP, Voors AA, Metra M, Teerlink JR, van der Meer P. Distinct Comorbidity Clusters in Patients With Acute Heart Failure: Data From RELAX-AHF-2. JACC. HEART FAILURE 2024:S2213-1779(24)00418-9. [PMID: 38970586 DOI: 10.1016/j.jchf.2024.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 04/26/2024] [Accepted: 04/30/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Multimorbidity frequently occurs in patients with acute heart failure (AHF). The co-occurrence of comorbidities often follows specific patterns. OBJECTIVES This study investigated multimorbidity subtypes and their associations with clinical outcomes. METHODS From the prospective RELAX-AHF-2 (Relaxin for the Treatment of Acute Heart Failure-2) trial, 6,545 patients (26% with HF with preserved ejection fraction, defined as LVEF ≥50%) were classified into multimorbidity groups using latent class analysis. The association between subgroups and clinical outcomes was examined. Validation of these findings was conducted in the RELAX-AHF trial, which comprised 1,161 patients. RESULTS Five distinct multimorbidity groups emerged: 1) diabetes and chronic kidney disease (CKD) (often male, high prevalence of CKD and diabetes mellitus); 2) ischemic (ischemic HF); 3) elderly/atrial fibrillation (AF) (oldest, high prevalence of AF); 4) metabolic (obese, hypertensive, more often HF with preserved ejection fraction); and 5) young (fewest comorbidities). After adjusting for confounders, patients in the diabetes and CKD (HR: 1.80; 95% CI: 1.50-2.20), elderly/AF (HR: 1.42; 95% CI: 1.20-1.70), and metabolic (HR: 1.40; 95% CI: 1.20-1.80) groups had higher rates of the composite outcome than patients in the young group, primarily driven by differences in rehospitalization. Treatment allocation (placebo or serelaxin) modified these associations (Pinteraction <0.001). Serelaxin-treated patients in the young group were associated with a lower risk for all-cause mortality (HR: 0.59; 95% CI: 0.40-0.90). Similarly, patients from the RELAX-AHF trial clustered in 5 multimorbidity groups. The clinical characteristics and associations with outcomes could also be validated. CONCLUSIONS Comorbidities naturally clustered into 5 mutually exclusive groups in RELAX-AHF-2, showing variations in clinical outcomes. These data emphasize that the specific combination of comorbidities can influence adverse outcomes and treatment responses in patients with AHF.
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Affiliation(s)
- Karla Arevalo Gomez
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, the Netherlands
| | - Jasper Tromp
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, the Netherlands; Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore; Duke-NUS Medical School, Singapore
| | - Sylwia M Figarska
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, the Netherlands
| | - Iris E Beldhuis
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, the Netherlands
| | - Gad Cotter
- Momentum Research, Inc, Durham, North Carolina, USA; Inserm U 942 (Cardiovascular Markers in Stress Conditions), Hopital Lariboisière, Paris, France
| | - Beth A Davison
- Momentum Research, Inc, Durham, North Carolina, USA; Inserm U 942 (Cardiovascular Markers in Stress Conditions), Hopital Lariboisière, Paris, France
| | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Barry H Greenberg
- Division of Cardiology, University of California-San Diego, San Diego, California, USA
| | - Carolyn S P Lam
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, the Netherlands; National Heart Centre Singapore and Duke-National University of Singapore
| | - Adriaan A Voors
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, the Netherlands
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California-San Francisco, San Franscisco, California, USA
| | - Peter van der Meer
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, the Netherlands.
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Schiffrin EL, Fisher NDL. Diagnosis and management of resistant hypertension. BMJ 2024; 385:e079108. [PMID: 38897628 DOI: 10.1136/bmj-2023-079108] [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: 06/21/2024]
Abstract
Resistant hypertension is defined as blood pressure that remains above the therapeutic goal despite concurrent use of at least three antihypertensive agents of different classes, including a diuretic, with all agents administered at maximum or maximally tolerated doses. Resistant hypertension is also diagnosed if blood pressure control requires four or more antihypertensive drugs. Assessment requires the exclusion of apparent treatment resistant hypertension, which is most often the result of non-adherence to treatment. Resistant hypertension is associated with major cardiovascular events in the short and long term, including heart failure, ischemic heart disease, stroke, and renal failure. Guidelines from several professional organizations recommend lifestyle modification and antihypertensive drugs. Medications typically include an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, a calcium channel blocker, and a long acting thiazide-type/like diuretic; if a fourth drug is needed, evidence supports addition of a mineralocorticoid receptor antagonist. After a long pause since 2007 when the last antihypertensive class was approved, several novel agents are now under active development. Some of these may provide potent blood pressure lowering in broad groups of patients, such as aldosterone synthase inhibitors and dual endothelin receptor antagonists, whereas others may provide benefit by allowing treatment of resistant hypertension in special populations, such as non-steroidal mineralocorticoid receptor antagonists in patients with chronic kidney disease. Several device based approaches have been tested, with renal denervation being the best supported and only approved interventional device treatment for resistant hypertension.
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Affiliation(s)
- Ernesto L Schiffrin
- Lady Davis Institute for Medical Research and Department of Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - Naomi D L Fisher
- Department of Medicine, Brigham and Women's Hospital, Harvard University, Boston, MA, USA
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Seferović PM, Paulus WJ, Rosano G, Polovina M, Petrie MC, Jhund PS, Tschöpe C, Sattar N, Piepoli M, Papp Z, Standl E, Mamas MA, Valensi P, Linhart A, Lalić N, Ceriello A, Döhner W, Ristić A, Milinković I, Seferović J, Cosentino F, Metra M, Coats AJS. Diabetic myocardial disorder. A clinical consensus statement of the Heart Failure Association of the ESC and the ESC Working Group on Myocardial & Pericardial Diseases. Eur J Heart Fail 2024. [PMID: 38896048 DOI: 10.1002/ejhf.3347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/31/2024] [Accepted: 06/06/2024] [Indexed: 06/21/2024] Open
Abstract
The association between type 2 diabetes mellitus (T2DM) and heart failure (HF) has been firmly established; however, the entity of diabetic myocardial disorder (previously called diabetic cardiomyopathy) remains a matter of debate. Diabetic myocardial disorder was originally described as the occurrence of myocardial structural/functional abnormalities associated with T2DM in the absence of coronary heart disease, hypertension and/or obesity. However, supporting evidence has been derived from experimental and small clinical studies. Only a minority of T2DM patients are recognized as having this condition in the absence of contributing factors, thereby limiting its clinical utility. Therefore, this concept is increasingly being viewed along the evolving HF trajectory, where patients with T2DM and asymptomatic structural/functional cardiac abnormalities could be considered as having pre-HF. The importance of recognizing this stage has gained interest due to the potential for current treatments to halt or delay the progression to overt HF in some patients. This document is an expert consensus statement of the Heart Failure Association of the ESC and the ESC Working Group on Myocardial & Pericardial Diseases. It summarizes contemporary understanding of the association between T2DM and HF and discuses current knowledge and uncertainties about diabetic myocardial disorder that deserve future research. It also proposes a new definition, whereby diabetic myocardial disorder is defined as systolic and/or diastolic myocardial dysfunction in the presence of diabetes. Diabetes is rarely exclusively responsible for myocardial dysfunction, but usually acts in association with obesity, arterial hypertension, chronic kidney disease and/or coronary artery disease, causing additive myocardial impairment.
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Affiliation(s)
- Petar M Seferović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Walter J Paulus
- Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Giuseppe Rosano
- Department of Human Sciences and Promotion of Quality of Life, San Raffaele Open University of Rome, Rome, Italy
- Cardiology, San Raffaele Cassino Hospital, Cassino, Italy
| | - Marija Polovina
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Mark C Petrie
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Pardeep S Jhund
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Carsten Tschöpe
- Berlin Institute of Health at Charité - Center for Regenerative Therapies, Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Herzzentrum der Charité, Department of Cardiology (CVK) and German Centre for Cardiovascular Research (DZHK)- Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Massimo Piepoli
- Cardiology University Department, RCCS Policlinico San Donato, San Donato Milanese, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Zoltán Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Eberhard Standl
- Diabetes Research Group e.V. at Munich Helmholtz Center, Munich, Germany
| | - Mamas A Mamas
- Cardiovascular Research Group, Keele University, Keele, UK
| | - Paul Valensi
- Polyclinique d'Aubervilliers, Aubervilliers, and Paris Nord University, Bobigny, France
| | - Ales Linhart
- Department of Internal Medicine, School of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Nebojša Lalić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
- Department of Endocrinology, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Wolfram Döhner
- Berlin Institute of Health at Charité - Center for Regenerative Therapies, Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Herzzentrum der Charité, Department of Cardiology (CVK) and German Centre for Cardiovascular Research (DZHK)- Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Arsen Ristić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Ivan Milinković
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Jelena Seferović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Endocrinology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Francesco Cosentino
- Unit of Cardiology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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Ji C, Zhang J, Shi H, Chen B, Xu W, Jin J, Qian H. Single-cell RNA transcriptomic reveal the mechanism of MSC derived small extracellular vesicles against DKD fibrosis. J Nanobiotechnology 2024; 22:339. [PMID: 38890734 PMCID: PMC11184851 DOI: 10.1186/s12951-024-02613-2] [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: 07/21/2023] [Accepted: 06/03/2024] [Indexed: 06/20/2024] Open
Abstract
Diabetic kidney disease (DKD), a chronic kidney disease, is characterized by progressive fibrosis caused due to persistent hyperglycemia. The development of fibrosis in DKD determines the patient prognosis, but no particularly effective treatment. Here, small extracellular vesicles derived from mesenchymal stem cells (MSC-sEV) have been used to treat DKD fibrosis. Single-cell RNA sequencing was used to analyze 27,424 cells of the kidney, we have found that a novel fibrosis-associated TGF-β1+Arg1+ macrophage subpopulation, which expanded and polarized in DKD and was noted to be profibrogenic. Additionally, Actin+Col4a5+ mesangial cells in DKD differentiated into myofibroblasts. Multilineage ligand-receptor and cell-communication analysis showed that fibrosis-associated macrophages activated the TGF-β1/Smad2/3/YAP signal axis, which promotes mesangial fibrosis-like change and accelerates renal fibrosis niche. Subsequently, the transcriptome sequencing and LC-MS/MS analysis indicated that MSC-sEV intervention could restore the levels of the kinase ubiquitin system in DKD and attenuate renal interstitial fibrosis via delivering CK1δ/β-TRCP to mediate YAP ubiquitination degradation in mesangial cells. Our findings demonstrate the unique cellular and molecular mechanisms of MSC-sEV in treating the DKD fibrosis niche at a single-cell level and provide a novel therapeutic strategy for renal fibrosis.
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Affiliation(s)
- Cheng Ji
- Wujin Institute of Molecular Diagnostics and Precision Cancer Medicine of Jiangsu University, Wujin Hospital Affiliated with Jiangsu University, Chang Zhou, Jiangsu, 213004, China
- Jiangsu Key Laboratory of Medical Science and Laboratory Medicine, Department of Laboratory Medicine, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu, 212013, China
| | - Jiahui Zhang
- Jiangsu Key Laboratory of Medical Science and Laboratory Medicine, Department of Laboratory Medicine, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu, 212013, China
| | - Hui Shi
- Jiangsu Key Laboratory of Medical Science and Laboratory Medicine, Department of Laboratory Medicine, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu, 212013, China
| | - Binghai Chen
- Institute of Translational Medicine, Department of Urology, Jiangsu University, Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, 212001, China
| | - Wenrong Xu
- Jiangsu Key Laboratory of Medical Science and Laboratory Medicine, Department of Laboratory Medicine, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu, 212013, China
| | - Jianhua Jin
- Wujin Institute of Molecular Diagnostics and Precision Cancer Medicine of Jiangsu University, Wujin Hospital Affiliated with Jiangsu University, Chang Zhou, Jiangsu, 213004, China.
| | - Hui Qian
- Wujin Institute of Molecular Diagnostics and Precision Cancer Medicine of Jiangsu University, Wujin Hospital Affiliated with Jiangsu University, Chang Zhou, Jiangsu, 213004, China.
- Jiangsu Key Laboratory of Medical Science and Laboratory Medicine, Department of Laboratory Medicine, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu, 212013, China.
- NHC Key Laboratory of Medical Embryogenesis and Developmental Molecular Biology, Shanghai Key Laboratory of Embryo and Reproduction Engineering, ShangHai, 200040, China.
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Gami A, Blumenthal RS, McGuire DK, Sarkar S, Kohli P. New Perspectives in Management of Cardiovascular Risk Among People With Diabetes. J Am Heart Assoc 2024; 13:e034053. [PMID: 38879449 PMCID: PMC11255726 DOI: 10.1161/jaha.123.034053] [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: 06/19/2024]
Abstract
Following the publication of results from multiple landmark cardiovascular outcome trials of antihyperglycemic medications over the past 8 years, there has been a major shift in the focus of care for people with type 2 diabetes, from control of hyperglycemia to managing cardiovascular risk. Multiple international cardiology and diabetes society guidelines and recommendations now endorse sodium-glucose cotransporter-2 inhibitors and glucagon-like protein-1 receptor agonists as first-line therapies to mitigate cardiovascular risk. The most recent publication is the 2023 European Society of Cardiology guideline on the management of cardiovascular disease in those with type 2 diabetes that, for the first time, recommends use of both classes of medications for the mitigation of cardiovascular risk for those with or at high risk for atherosclerotic cardiovascular disease, heart failure, and chronic kidney disease. Here, we review the evidence behind contemporary society guidelines and recommendations for the management of type 2 diabetes and cardiovascular risk.
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Affiliation(s)
- Abhishek Gami
- Department of Internal MedicineJohns Hopkins University School of MedicineBaltimoreMD
| | - Roger S. Blumenthal
- Division of CardiologyJohns Hopkins University School of MedicineBaltimoreMD
| | - Darren K. McGuire
- Division of Cardiology, Department of Internal MedicineUniversity of Texas Southwestern Medical Center and Parkland HealthDallasTX
| | - Sudipa Sarkar
- Division of Endocrinology, Diabetes, and MetabolismJohns Hopkins University School of MedicineBaltimoreMD
| | - Payal Kohli
- Department of CardiologyUniversity of Colorado AnschutzAuroraCO
- Department of CardiologyVeterans Affairs HospitalAuroraCO
- Cherry Creek HeartAuroraCO
- Tegna BroadcastingAuroraCO
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Matsumoto S, Henderson AD, Shen L, Yang M, Swedberg K, Vaduganathan M, van Veldhuisen DJ, Solomon SD, Pitt B, Zannad F, Jhund PS, McMurray JJV. Mineralocorticoid Receptor Antagonists in Patients With Heart Failure and Impaired Renal Function. J Am Coll Cardiol 2024; 83:2426-2436. [PMID: 38739064 DOI: 10.1016/j.jacc.2024.03.426] [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: 02/20/2024] [Revised: 03/22/2024] [Accepted: 03/27/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Kidney dysfunction often leads to reluctance to start or continue life-saving heart failure (HF) therapy. OBJECTIVES This study sought to examine the efficacy and safety of mineralocorticoid receptor antagonists (MRAs) in patients with HF with reduced ejection fraction experiencing significant kidney dysfunction. METHODS We pooled individual patient data from the RALES (Randomized Aldactone Evaluation Study) and EMPHASIS-HF (Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure) trials. The association between MRA treatment and outcomes was assessed according to whether the estimated glomerular filtration rate (eGFR) declined to <30 mL/min/1.73 m2 or not. The primary outcome was cardiovascular death or HF hospitalization. RESULTS Among 4,355 patients included, 295 (6.8%) experienced a deterioration of eGFR after randomization to <30 mL/min/1.73 m2. These patients had more impaired baseline cardiac and kidney function (eGFR 47.3 ± 13.4 mL/min/1.73 m2 vs 70.5 ± 21.8 mL/min/1.73 m2) and had a higher risk of the primary outcome than patients without eGFR deterioration (HR: 2.49; 95% CI: 2.01-3.08; P < 0.001). However, the risk reduction in the primary outcome with MRA therapy was similar in those who experienced a decrease in eGFR to <30 mL/min/1.73 m2 (HR: 0.65; 95% CI: 0.43-0.99) compared with those who did not (HR: 0.63; 95% CI: 0.56-0.71) (Pinteraction = 0.87). In patients with a decrease in eGFR to <30 mL/min/1.73 m2, 21 fewer individuals (per 100 person-years) experienced the primary outcome with MRA treatment, vs placebo, compared with an excess of 3 more patients with severe hyperkalemia (>6.0 mmol/L). CONCLUSIONS Because patients experiencing a decrease in eGFR to <30 mL/min/1.73 m2 are at very high risk, the absolute risk reduction with an MRA in these patients is large and this decline in eGFR should not automatically lead to treatment discontinuation.
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Affiliation(s)
- Shingo Matsumoto
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Alasdair D Henderson
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Li Shen
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Mingming Yang
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Karl Swedberg
- Department of Emergency and Cardiovascular Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dirk J van Veldhuisen
- Department of Cardiology, Thorax Center, University Medical Center Groningen, Groningen, the Netherlands
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 1433, French Institute of Health and Medical Research U1116, French Clinical Research Infrastructure Network-Investigation Network Initiative-Cardiovascular and Renal Clinical Trials, Centre Hospitalier Régional Universitaire de Nancy, Université de Lorraine, Nancy, France
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
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Lima Posada I, Soulié M, Stephan Y, Palacios Ramirez R, Bonnard B, Nicol L, Pitt B, Kolkhof P, Mulder P, Jaisser F. Nonsteroidal Mineralocorticoid Receptor Antagonist Finerenone Improves Diastolic Dysfunction in Preclinical Nondiabetic Chronic Kidney Disease. J Am Heart Assoc 2024; 13:e032971. [PMID: 38842271 PMCID: PMC11255738 DOI: 10.1161/jaha.123.032971] [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: 11/22/2023] [Accepted: 03/15/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND The mineralocorticoid receptor plays a significant role in the development of chronic kidney disease (CKD) and associated cardiovascular complications. Classic steroidal mineralocorticoid receptor antagonists are a therapeutic option, but their use in the clinic is limited due to the associated risk of hyperkalemia in patients with CKD. Finerenone is a nonsteroidal mineralocorticoid receptor antagonist that has been recently investigated in 2 large phase III clinical trials (FIDELIO-DKD [Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease] and FIGARO-DKD [Finerenone in Reducing Cardiovascular Mortality and Morbidity in Diabetic Kidney Disease]), showing reductions in kidney and cardiovascular outcomes. METHODS AND RESULTS We tested whether finerenone improves renal and cardiac function in a preclinical nondiabetic CKD model. Twelve weeks after 5/6 nephrectomy, the rats showed classic signs of CKD characterized by a reduced glomerular filtration rate and increased kidney weight, associated with left ventricular (LV) diastolic dysfunction and decreased LV perfusion. These changes were associated with increased cardiac fibrosis and reduced endothelial nitric oxide synthase activating phosphorylation (ser 1177). Treatment with finerenone prevented LV diastolic dysfunction and increased LV tissue perfusion associated with a reduction in cardiac fibrosis and increased endothelial nitric oxide synthase phosphorylation. Curative treatment with finerenone improves nondiabetic CKD-related LV diastolic function associated with a reduction in cardiac fibrosis and increased cardiac phosphorylated endothelial nitric oxide synthase independently from changes in kidney function. Short-term finerenone treatment decreased LV end-diastolic pressure volume relationship and increased phosphorylated endothelial nitric oxide synthase and nitric oxide synthase activity. CONCLUSIONS We showed that the nonsteroidal mineralocorticoid receptor antagonist finerenone reduces renal hypertrophy and albuminuria, attenuates cardiac diastolic dysfunction and cardiac fibrosis, and improves cardiac perfusion in a preclinical nondiabetic CKD model.
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MESH Headings
- Animals
- Mineralocorticoid Receptor Antagonists/pharmacology
- Mineralocorticoid Receptor Antagonists/therapeutic use
- Renal Insufficiency, Chronic/drug therapy
- Renal Insufficiency, Chronic/physiopathology
- Renal Insufficiency, Chronic/complications
- Renal Insufficiency, Chronic/metabolism
- Naphthyridines/pharmacology
- Naphthyridines/therapeutic use
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Left/drug therapy
- Ventricular Dysfunction, Left/etiology
- Ventricular Dysfunction, Left/metabolism
- Male
- Disease Models, Animal
- Fibrosis
- Nitric Oxide Synthase Type III/metabolism
- Glomerular Filtration Rate/drug effects
- Ventricular Function, Left/drug effects
- Diastole/drug effects
- Kidney/drug effects
- Kidney/physiopathology
- Kidney/metabolism
- Phosphorylation
- Myocardium/metabolism
- Myocardium/pathology
- Rats, Sprague-Dawley
- Rats
- Nephrectomy
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Affiliation(s)
- Ixchel Lima Posada
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris CitéParisFrance
| | - Matthieu Soulié
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris CitéParisFrance
- Univ Rouen Normandie, INSERM EnVI UMR 1096RouenFrance
| | - Yohan Stephan
- Univ Rouen Normandie, INSERM EnVI UMR 1096RouenFrance
| | - Roberto Palacios Ramirez
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris CitéParisFrance
| | - Benjamin Bonnard
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris CitéParisFrance
| | - Lionel Nicol
- Univ Rouen Normandie, INSERM EnVI UMR 1096RouenFrance
| | - Bertram Pitt
- Department of MedicineUniversity of Michigan MedicineAnn ArborMI
| | - Peter Kolkhof
- Cardiovascular Precision Medicines, Research and Early Development, Pharmaceuticals, Bayer AGWuppertalGermany
| | - Paul Mulder
- Univ Rouen Normandie, INSERM EnVI UMR 1096RouenFrance
| | - Frederic Jaisser
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris CitéParisFrance
- Université de Lorraine, INSERM Centre d’Investigations Cliniques‐Plurithématique 1433, UMR 1116, CHRU de Nancy, French‐Clinical Research Infrastructure Network (F‐CRIN) INI‐CRCTNancyFrance
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34
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Gallo G, Savoia C. Hypertension and Heart Failure: From Pathophysiology to Treatment. Int J Mol Sci 2024; 25:6661. [PMID: 38928371 PMCID: PMC11203528 DOI: 10.3390/ijms25126661] [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: 05/30/2024] [Revised: 06/11/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024] Open
Abstract
Hypertension represents one of the primary and most common risk factors leading to the development of heart failure (HF) across the entire spectrum of left ventricular ejection fraction. A large body of evidence has demonstrated that adequate blood pressure (BP) control can reduce cardiovascular events, including the development of HF. Although the pathophysiological and epidemiological role of hypertension in the development of HF is well and largely known, some critical issues still deserve to be clarified, including BP targets, particularly in HF patients. Indeed, the management of hypertension in HF relies on the extrapolation of findings from high-risk hypertensive patients in the general population and not from specifically designed studies in HF populations. In patients with hypertension and HF with reduced ejection fraction (HFrEF), it is recommended to combine drugs with documented outcome benefits and BP-lowering effects. In patients with HF with preserved EF (HFpEF), a therapeutic strategy with all major antihypertensive drug classes is recommended. Besides commonly used antihypertensive drugs, different evidence suggests that other drugs recommended in HF for the beneficial effect on cardiovascular outcomes exert advantageous blood pressure-lowering actions. In this regard, type 2 sodium glucose transporter inhibitors (SGLT2i) have been shown to induce BP-lowering actions that favorably affect cardiac afterload, ventricular arterial coupling, cardiac efficiency, and cardiac reverse remodeling. More recently, it has been demonstrated that finerenone, a non-steroidal mineralocorticoid receptor antagonist, reduces new-onset HF and improves other HF outcomes in patients with chronic kidney disease and type 2 diabetes, irrespective of a history of HF. Other proposed agents, such as endothelin receptor antagonists, have provided contrasting results in the management of hypertension and HF. A novel, promising strategy could be represented by small interfering RNA, whose actions are under investigation in ongoing clinical trials.
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Affiliation(s)
| | - Carmine Savoia
- Clinical and Molecular Medicine Department, Faculty of Medicine and Psychology, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy;
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35
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Johnson HN, Prasad-Reddy L. Updates in Chronic Kidney Disease. J Pharm Pract 2024:8971900241262381. [PMID: 38877746 DOI: 10.1177/08971900241262381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024]
Abstract
Chronic kidney disease (CKD) affects approximately 14% of adults in the United States and is present in at least 10% of the population worldwide. Blood glucose and blood pressure control are imperative to adequately manage CKD as they are the only primary prevention measures for the condition. Recent changes in CKD evaluation and medication therapies that modify disease progression and aid in managing complications such as anemia of CKD have emerged, including a newly approved mineralocorticoid receptor antagonist and hypoxia-inducible factor-prolyl hydroxylase inhibitor, respectively. This focused update on CKD evaluation and management will review the most recent evidence and approved agents to support patients with CKD, including a review of glomerular filtration rate measurement methods such as CKD-EPI 2021 and utilization of cystatin C, Kidney Disease Improving Global Outcomes (KDIGO) guidelines, American Diabetes Association (ADA) guidelines, and primary literature supporting the use of newer agents in CKD. Checklists for managing blood pressure and blood glucose, CKD-mineral bone disorder, and anemia of CKD targeted for pharmacists are also provided. Additionally, a discussion of Centers for Medicare & Medicaid (CMS) coverage of agents approved for managing complications of CKD is included.
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Affiliation(s)
- Haley N Johnson
- Pharmacy Practice, St. Louis College of Pharmacy at University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Lalita Prasad-Reddy
- Office of Medical Education, Chicago Medical School, Rosalind Franklin University of Medicine & Science, North Chicago, IL, USA
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36
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Arici M, Altun B, Araz M, Atmaca A, Demir T, Ecder T, Guz G, Gogas Yavuz D, Yildiz A, Yilmaz T. The significance of finerenone as a novel therapeutic option in diabetic kidney disease: a scoping review with emphasis on cardiorenal outcomes of the finerenone phase 3 trials. Front Med (Lausanne) 2024; 11:1384454. [PMID: 38947237 PMCID: PMC11214281 DOI: 10.3389/fmed.2024.1384454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/22/2024] [Indexed: 07/02/2024] Open
Abstract
This scoping review prepared by endocrinology and nephrology experts aimed to address the significance of finerenone, as a novel therapeutic option, in diabetic kidney disease (DKD), based on the biological prospect of cardiorenal benefit due to non-steroidal mineralocorticoid receptor antagonist (MRA) properties, and the recent evidence from the finerenone phase 3 program clinical trials. The importance of finerenone in slowing DKD progression was critically reviewed in relation to the role of MR overactivation in the pathogenesis of cardiorenal disease and unmet needs in the current practice patterns. The efficacy and safety outcomes of finerenone phase III study program including FIDELIO-DKD, FIGARO-DKD and FIDELITY were presented. Specifically, perspectives on inclusion of patients with preserved estimated glomerular filtration rate (eGFR) or high albuminuria, concomitant use of sodium-glucose co-transporter-2 inhibitor (SGLT2i) or glucagon-like peptide 1 receptor agonist (GLP-1 RA), baseline glycated hemoglobin (HbA1c) level and insulin treatment, clinically meaningful heart failure outcomes and treatment-induced hyperkalemia were addressed. Finerenone has emerged as a new therapeutic agent that slows DKD progression, reduces albuminuria and risk of cardiovascular complications, regardless of the baseline HbA1c levels and concomitant treatments (SGLT2i, GLP-1 RA, or insulin) and with a favorable benefit-risk profile. The evolving data on the benefit of SGLT2is and non-steroidal MRAs in slowing or reducing cardiorenal risk seem to provide the opportunity to use these pillars of therapy in the management of DKD, after a long-period of treatment scarcity in this field. Along with recognition of the albuminuria as a powerful marker to detect those patients at high risk of cardiorenal disease, these important developments would likely to impact standard-of-care options in the setting of DKD.
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Affiliation(s)
- Mustafa Arici
- Department of Nephrology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
| | - Bulent Altun
- Department of Nephrology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
| | - Mustafa Araz
- Department of Endocrinology and Metabolic Diseases, Gaziantep University Faculty of Medicine, Gaziantep, Türkiye
| | - Aysegul Atmaca
- Department of Endocrinology and Metabolic Diseases, Ondokuz Mayis University Faculty of Medicine, Samsun, Türkiye
| | - Tevfik Demir
- Department of Endocrinology and Metabolic Diseases, Dokuz Eylul University Faculty of Medicine, Izmir, Türkiye
| | - Tevfik Ecder
- Department of Nephrology, Istinye University Faculty of Medicine, Istanbul, Türkiye
| | - Galip Guz
- Department of Nephrology, Gazi University Faculty of Medicine, Ankara, Türkiye
| | - Dilek Gogas Yavuz
- Section of Endocrinology and Metabolism, Marmara University School of Medicine, Istanbul, Türkiye
| | - Alaattin Yildiz
- Department of Nephrology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - Temel Yilmaz
- Clinics of Endocrinology and Metabolic Diseases, Florence Nightingale Hospital, Istanbul, Türkiye
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Fatemi Y, Nikfar M, Oladazimi A, Zheng J, Hoy H, Ali H. Machine Learning Approach for Cardiovascular Death Prediction among Nonalcoholic Steatohepatitis (NASH) Liver Transplant Recipients. Healthcare (Basel) 2024; 12:1165. [PMID: 38921280 PMCID: PMC11202858 DOI: 10.3390/healthcare12121165] [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: 04/14/2024] [Revised: 05/30/2024] [Accepted: 06/06/2024] [Indexed: 06/27/2024] Open
Abstract
Cardiovascular disease is the leading cause of mortality among nonalcoholic steatohepatitis (NASH) patients who undergo liver transplants. In the present study, machine learning algorithms were used to identify important risk factors for cardiovascular death and to develop a prediction model. The Standard Transplant Analysis and Research data were gathered from the Organ Procurement and Transplantation Network. After cleaning and preprocessing, the dataset comprised 10,871 patients and 92 features. Recursive feature elimination (RFE) and select from model (SFM) were applied to select relevant features from the dataset and avoid overfitting. Multiple machine learning algorithms, including logistic regression, random forest, decision tree, and XGBoost, were used with RFE and SFM. Additionally, prediction models were developed using a support vector machine, Gaussian naïve Bayes, K-nearest neighbors, random forest, and XGBoost algorithms. Finally, SHapley Additive exPlanations (SHAP) were used to increase interpretability. The findings showed that the best feature selection method was RFE with a random forest estimator, and the most critical features were recipient and donor blood type, body mass index, recipient and donor state of residence, serum creatinine, and year of transplantation. Furthermore, among all the outcomes, the XGBoost model had the highest performance, with an accuracy value of 0.6909 and an area under the curve value of 0.86. The findings also revealed a predictive relationship between features and cardiovascular death after liver transplant among NASH patients. These insights may assist clinical decision-makers in devising strategies to prevent cardiovascular complications in post-liver transplant NASH patients.
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Affiliation(s)
- Yasin Fatemi
- Department of Industrial and Systems Engineering, Auburn University, Auburn, AL 36849, USA; (Y.F.); (M.N.); (A.O.)
| | - Mohsen Nikfar
- Department of Industrial and Systems Engineering, Auburn University, Auburn, AL 36849, USA; (Y.F.); (M.N.); (A.O.)
| | - Amir Oladazimi
- Department of Industrial and Systems Engineering, Auburn University, Auburn, AL 36849, USA; (Y.F.); (M.N.); (A.O.)
| | - Jingyi Zheng
- Department of Mathematics and Statistics, Auburn University, Auburn, AL 36849, USA;
| | - Haley Hoy
- College of Nursing, The University of Alabama in Huntsville, Huntsville, AL 35805, USA;
| | - Haneen Ali
- Department of Industrial and Systems Engineering, Auburn University, Auburn, AL 36849, USA; (Y.F.); (M.N.); (A.O.)
- Health Services Administration Program, Auburn University, Auburn, AL 36849, USA
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38
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Chertow GM. Revisiting a "Paradigm" in Cardiovascular and Kidney Disease. J Am Coll Cardiol 2024; 83:2160-2162. [PMID: 38811093 DOI: 10.1016/j.jacc.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 05/31/2024]
Affiliation(s)
- Glenn M Chertow
- Departments of Medicine, Epidemiology and Population Health, and Health Policy, Stanford University School of Medicine, Palo Alto, California, USA.
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39
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Handelsman Y, Anderson JE, Bakris GL, Ballantyne CM, Bhatt DL, Bloomgarden ZT, Bozkurt B, Budoff MJ, Butler J, Cherney DZI, DeFronzo RA, Del Prato S, Eckel RH, Filippatos G, Fonarow GC, Fonseca VA, Garvey WT, Giorgino F, Grant PJ, Green JB, Greene SJ, Groop PH, Grunberger G, Jastreboff AM, Jellinger PS, Khunti K, Klein S, Kosiborod MN, Kushner P, Leiter LA, Lepor NE, Mantzoros CS, Mathieu C, Mende CW, Michos ED, Morales J, Plutzky J, Pratley RE, Ray KK, Rossing P, Sattar N, Schwarz PEH, Standl E, Steg PG, Tokgözoğlu L, Tuomilehto J, Umpierrez GE, Valensi P, Weir MR, Wilding J, Wright EE. DCRM 2.0: Multispecialty practice recommendations for the management of diabetes, cardiorenal, and metabolic diseases. Metabolism 2024:155931. [PMID: 38852020 DOI: 10.1016/j.metabol.2024.155931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 04/30/2024] [Indexed: 06/10/2024]
Abstract
The spectrum of cardiorenal and metabolic diseases comprises many disorders, including obesity, type 2 diabetes (T2D), chronic kidney disease (CKD), atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), dyslipidemias, hypertension, and associated comorbidities such as pulmonary diseases and metabolism dysfunction-associated steatotic liver disease and metabolism dysfunction-associated steatohepatitis (MASLD and MASH, respectively, formerly known as nonalcoholic fatty liver disease and nonalcoholic steatohepatitis [NAFLD and NASH]). Because cardiorenal and metabolic diseases share pathophysiologic pathways, two or more are often present in the same individual. Findings from recent outcome trials have demonstrated benefits of various treatments across a range of conditions, suggesting a need for practice recommendations that will guide clinicians to better manage complex conditions involving diabetes, cardiorenal, and/or metabolic (DCRM) diseases. To meet this need, we formed an international volunteer task force comprising leading cardiologists, nephrologists, endocrinologists, and primary care physicians to develop the DCRM 2.0 Practice Recommendations, an updated and expanded revision of a previously published multispecialty consensus on the comprehensive management of persons living with DCRM. The recommendations are presented as 22 separate graphics covering the essentials of management to improve general health, control cardiorenal risk factors, and manage cardiorenal and metabolic comorbidities, leading to improved patient outcomes.
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Affiliation(s)
| | | | | | - Christie M Ballantyne
- Department of Medicine, Baylor College of Medicine, Texas Heart Institute, Houston, TX, USA
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Zachary T Bloomgarden
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Biykem Bozkurt
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | | | - Javed Butler
- University of Mississippi Medical Center, Jackson, MS, USA
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | | | - Stefano Del Prato
- Interdisciplinary Research Center "Health Science", Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Robert H Eckel
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Gerasimos Filippatos
- Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | - Francesco Giorgino
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
| | | | - Jennifer B Green
- Division of Endocrinology, Metabolism, and Nutrition, Duke University School of Medicine, Durham, NC, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Per-Henrik Groop
- Department of Nephrology, University of Helsinki, Finnish Institute for Health and Helsinki University HospitalWelfare, Folkhälsan Research Center, Helsinki, Finland; Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia
| | - George Grunberger
- Grunberger Diabetes Institute, Bloomfield Hills, MI, USA; Wayne State University School of Medicine, Detroit, MI, USA; Oakland University William Beaumont School of Medicine, Rochester, MI, USA; Charles University, Prague, Czech Republic
| | | | - Paul S Jellinger
- The Center for Diabetes & Endocrine Care, University of Miami Miller School of Medicine, Hollywood, FL, USA
| | | | - Samuel Klein
- Washington University School of Medicine, Saint Louis, MO, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
| | | | | | - Norman E Lepor
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Chantal Mathieu
- Department of Endocrinology, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Christian W Mende
- University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Erin D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Javier Morales
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, Advanced Internal Medicine Group, PC, East Hills, NY, USA
| | - Jorge Plutzky
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | | | - Peter E H Schwarz
- Department for Prevention and Care of Diabetes, Faculty of Medicine Carl Gustav Carus at the Technische Universität/TU Dresden, Dresden, Germany
| | - Eberhard Standl
- Munich Diabetes Research Group e.V. at Helmholtz Centre, Munich, Germany
| | - P Gabriel Steg
- Université Paris-Cité, Institut Universitaire de France, AP-HP, Hôpital Bichat, Cardiology, Paris, France
| | | | - Jaakko Tuomilehto
- University of Helsinki, Finnish Institute for Health and Welfare, Helsinki, Finland
| | | | - Paul Valensi
- Polyclinique d'Aubervilliers, Aubervilliers and Paris-Nord University, Paris, France
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - John Wilding
- University of Liverpool, Liverpool, United Kingdom
| | - Eugene E Wright
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Hsu CY, Yeh CY, Yen TY, Chen CC, Chen JF, Chu CH, Huang CN, Lin CL, Lin SY, Liu FH, Ou HY, Wang CY. The expert consensus on care and education for patients with diabetic kidney disease in Taiwan. Prim Care Diabetes 2024; 18:284-290. [PMID: 38423826 DOI: 10.1016/j.pcd.2024.02.003] [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: 12/03/2023] [Revised: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 03/02/2024]
Abstract
Increasing prevalence of type 2 DM (T2DM) and diabetic kidney disease (DKD) has posed a great impact in Taiwan. However, guidelines focusing on multidisciplinary patient care and patient education remain scarce. By literature review and expert discussion, we propose a consensus on care and education for patients with DKD, including general principles, specifics for different stages of chronic kidney disease (CKD), and special populations. (i.e. young ages, patients with atherosclerotic cardiovascular disease or heart failure, patients after acute kidney injury, and kidney transplant recipients). Generally, we suggest performing multidisciplinary patient care and education in alignment with the government-led Diabetes Shared Care Network to improve the patients' outcomes for all patients with DKD. Also, close monitoring of renal function with early intervention, control of comorbidities in early stages of CKD, and nutrition adjustment in advanced CKD should be emphasized.
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Affiliation(s)
- Chih-Yao Hsu
- Endocrinology and Metabolism Division, National Taiwan University Hospital Bei-Hu Branch, Taipei, Taiwan
| | | | - Tsung-Yi Yen
- Family Medicine Department, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan
| | - Ching-Chu Chen
- Endocrinology and Metabolism Division, China Medical University Hospital, Taichung, Taiwan
| | - Jung-Fu Chen
- Endocrinology and Metabolism Division, Chang Gung Memorial Hospital Kaohsiung Branch, Kaohsiung, Taiwan
| | - Chih-Hsun Chu
- Endocrinology and Metabolism Division, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chien-Ning Huang
- Endocrinology and Metabolism Division, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Ching-Ling Lin
- Endocrinology and Metabolism Division, Cathay General Hospital, Taipei, Taiwan
| | - Shih-Yi Lin
- Endocrinology and Metabolism Division, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Feng-Hsuan Liu
- Endocrinology and Metabolism Division, Chang Gung Memorial Hospital, Taipei Branch, Taipei, Taiwan
| | - Horng-Yih Ou
- Endocrinology and Metabolism Division, National Cheng Kung University Hospital, Tainan, Taiwan.
| | - Chih-Yuan Wang
- Endocrinology and Metabolism Division, National Taiwan University Hospital, Taipei, Taiwan.
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41
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Xu X, Feng J, Cui Y, Li P, Dong J, Liao L. Renal effects and safety between Asian and non-Asian chronic kidney disease and type 2 diabetes treated with nonsteroidal mineralocorticoid antagonists. J Diabetes 2024; 16:e13566. [PMID: 38753662 PMCID: PMC11098447 DOI: 10.1111/1753-0407.13566] [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: 11/25/2023] [Revised: 03/01/2024] [Accepted: 03/26/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Asians bear a heavier burden of chronic kidney disease (CKD), a common comorbidity of type 2 diabetes mellitus (T2DM), than non-Asians. Nonsteroidal mineralocorticoid receptor antagonists (MRAs) have garnered attention for their potential advantages in renal outcomes. Nevertheless, the impact on diverse ethnic groups remains unknown. METHODS The PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang database, and clinical trial registries were searched through August 2023 with the following keywords: nonsteroidal MRAs (finerenone, apararenone, esaxerenone, AZD9977, KBP-5074), CKD, T2DM, and randomized controlled trial (RCT). A random effects model was used to calculate overall effect sizes. RESULTS Seven RCTs with 14 997 participants were enrolled. Nonsteroidal MRAs reduced urinary albumin to creatinine ratio (UACR) significantly more in Asians than non-Asians: (weighted mean difference [WMD], -0.59, 95% CI, -0.73 to -0.45, p < .01) vs (WMD, -0.29, 95% CI, -0.32 to -0.27, p < .01), respectively. The average decline of estimated glomerular filtration rate (eGFR) was similar in Asians and non-Asians (p > .05). Regarding systolic blood pressure (SBP), nonsteroidal MRAs had a better antihypertension performance in Asians (WMD, -5.12, 95% CI, -5.84 to -4.41, p < .01) compared to non-Asians (WMD, -3.64, 95% CI, -4.38 to -2.89, p < .01). A higher incidence of hyperkalemia and eGFR decrease ≥30% was found in Asians than non-Asians (p < .01). CONCLUSIONS Nonsteroidal MRAs exhibited significant renal benefits by decreasing UACR and lowering SBP in Asian than that of non-Asian patients with CKD and T2DM, without increase of adverse events except hyperkalemia and eGFR decrease ≥30%.
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Affiliation(s)
- Xiaoming Xu
- Department of Endocrinology and Metabology, Shandong Provincial Qianfoshan HospitalShandong UniversityJinanChina
- Department of Endocrinology and MetabologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
| | - Jing Feng
- Department of Endocrinology and Metabology, Shandong Provincial Qianfoshan HospitalShandong UniversityJinanChina
- Department of Endocrinology and MetabologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
| | - Yuying Cui
- Department of Endocrinology and MetabologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- First Clinical Medical CollegeShandong University of Traditional Chinese MedicineJinanChina
| | - Pingjiang Li
- Department of Endocrinology and MetabologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Jianjun Dong
- Department of EndocrinologyQilu Hospital of Shandong UniversityJinanChina
| | - Lin Liao
- Department of Endocrinology and Metabology, Shandong Provincial Qianfoshan HospitalShandong UniversityJinanChina
- Department of Endocrinology and MetabologyThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
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Jain P, Guha S, Kumar S, Sawhney JPS, Sharma K, Sureshkumar KP, Mehta A, Dhediya R, Gaurav K, Mittal R, Kotak B. Management of Heart Failure in a Resource-Limited Setting: Expert Opinion from India. Cardiol Ther 2024; 13:243-266. [PMID: 38687432 PMCID: PMC11093928 DOI: 10.1007/s40119-024-00367-4] [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: 10/12/2023] [Accepted: 04/04/2024] [Indexed: 05/02/2024] Open
Abstract
Heart failure poses a global health challenge affecting millions of individuals, and access to guideline-directed medical therapy is often limited. This limitation is frequently attributed to factors such as drug availability, slow adoption, clinical inertia, and delayed diagnosis. Despite international recommendations promoting the use of guideline-directed medical therapy for heart failure management, personalized approaches are essential in settings with resource constraints. In India, crucial treatments like angiotensin II receptor blocker neprilysin inhibitors and sodium-glucose co-transporter 2 inhibitors are not fully utilized despite their established safety and efficacy. To address this issue, an expert consensus involving 150 specialists, including cardiologists, nephrologists, and endocrinologists, was convened. They deliberated on patient profiles, monitoring, and adverse side effects and provided tailored recommendations for guideline-directed medical therapy in heart failure management. Stressing the significance of early initiation of guideline-directed medical therapy in patients with heart failure, especially with sodium-glucose co-transporter 2 inhibitors, the consensus also explored innovative therapies like vericiguat. To improve heart failure outcomes in resource-limited settings, the experts proposed several measures, including enhanced patient education, cardiac rehabilitation, improved drug access, and reforms in healthcare policies.
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Affiliation(s)
- Peeyush Jain
- Fortis Escorts Heart Institute, New Delhi, India
| | | | | | | | - Kamal Sharma
- Apollo Hospitals, U N Mehta Institute of Cardiology, Ahmedabad, India
| | | | | | | | - Kumar Gaurav
- Dr Reddy's Laboratories Ltd, Hyderabad, Telangana, India
| | - Rajan Mittal
- Dr Reddy's Laboratories Ltd, Hyderabad, Telangana, India
| | - Bhavesh Kotak
- Dr Reddy's Laboratories Ltd, Hyderabad, Telangana, India
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Xu X, Cai L, Zhu X, Wang H, Chen T, Zhu H, Lin K. The impact of urinary albumin-creatinine ratio and glomerular filtration rate on long-term mortality in patients with heart failure: The National Health and Nutrition Examination Survey 1999-2018. Nutr Metab Cardiovasc Dis 2024; 34:1477-1487. [PMID: 38418348 DOI: 10.1016/j.numecd.2024.01.016] [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: 10/08/2023] [Revised: 12/15/2023] [Accepted: 01/10/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND AND AIMS The urinary albumin‒creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR) are important markers of renal dysfunction, but few studies have simultaneously examined their impact on long-term mortality in patients with heart failure (HF). METHODS AND RESULTS This study included patients with HF from the National Health and Nutrition Survey from 1999 to 2018. The fully adjusted Cox proportional risk model was adopted, and propensity score matching (PSM) was also used for risk adjustment. Among 988 patients, a median follow-up of 7.75 years was recorded. A higher UACR corresponded to a higher risk of cardiovascular death (P < 0.001 for trend). No statistically significant difference was found in the trend of eGFR risk stratification on the risk of cardiovascular death (P = 0.09 for trend). After PSM, the results showed that when grouped by UACR, the high-risk group had a higher risk of cardiovascular death regardless of a cutoff value of 30 or 300 mg/g (all P < 0.05). When grouped by eGFR, regardless of a cutoff value of 45 or 30 mL/min/1.73 m2, compared to the low-risk group, the high-risk group did not have a statistically significant increase in cardiovascular death (P = 0.086 and P = 0.093, respectively). The subgroup analysis of the main outcome showed an interaction between the UACR and eGFR (P = 0.044). CONCLUSIONS Both the UACR and eGFR are markers for predicting the progression of HF, but the UACR may be a more important indicator than the eGFR, and they synergistically and complementarily reflect the long-term cardiovascular risk of HF patients.
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Affiliation(s)
- Xiaoqun Xu
- Centre of Laboratory Medicine, Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Long Cai
- Centre of Laboratory Medicine, Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Xinyu Zhu
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Hanxin Wang
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Tielong Chen
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Houyong Zhu
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Kaiqing Lin
- Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China.
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Bornstein SR, de Zeeuw D, Heerspink HJL, Schulze F, Cronin L, Wenz A, Tuttle KR, Hadjadj S, Rossing P. Aldosterone synthase inhibitor (BI 690517) therapy for people with diabetes and albuminuric chronic kidney disease: A multicentre, randomized, double-blind, placebo-controlled, Phase I trial. Diabetes Obes Metab 2024; 26:2128-2138. [PMID: 38497241 DOI: 10.1111/dom.15518] [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: 10/27/2023] [Revised: 01/16/2024] [Accepted: 01/24/2024] [Indexed: 03/19/2024]
Abstract
AIM This Phase I study evaluated the safety and early efficacy of an aldosterone synthase inhibitor (BI 690517) in people with diabetes and albuminuric chronic kidney disease. METHODS Double-blind, placebo-controlled study (NCT03165240) at 40 sites across Europe. Eligible participants [estimated glomerular filtration rate ≥20 and <75 ml/min/1.73 m2; urine albumin/creatinine ratio (UACR) ≥200 and <3500 mg/g] were randomized 6:1 to receive once-daily oral BI 690517 3, 10 or 40 mg, or eplerenone 25-50 mg, or placebo, for 28 days. The primary endpoint was the proportion of participants with drug-related adverse events (AEs). Secondary endpoints included changes from baseline in the UACR. RESULTS Fifty-eight participants were randomized and treated from 27 November 2017 to 16 April 2020 (BI 690517: 3 mg, n = 18; 10 mg, n = 13; 40 mg, n = 14; eplerenone, n = 4; placebo, n = 9) for 28 days. Eight (13.8%) participants experienced drug-related AEs [BI 690517: 3 mg (two of 18); 10 mg (four of 13); 40 mg (two of 14)], most frequently constipation [10 mg (one of 13); 40 mg (one of 14)] and hyperkalaemia [3 mg (one of 18); 10 mg (one of 13)]. Most AEs were mild to moderate; one participant experienced severe hyperkalaemia (serum potassium 6.9 mmol/L; BI 690517 10 mg). UACR responses [≥20% decrease from baseline (first morning void urine) after 28 days] were observed for 80.0% receiving BI 690517 40 mg (eight of 10) versus 37.5% receiving placebo (three of eight). Aldosterone levels were suppressed by BI 690517, but not eplerenone or placebo. CONCLUSIONS BI 690517 was generally well tolerated, reduced plasma aldosterone and may decrease albuminuria in participants with diabetes and albuminuric chronic kidney disease.
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Affiliation(s)
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Friedrich Schulze
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Lisa Cronin
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut, USA
| | - Arne Wenz
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Katherine R Tuttle
- Providence Health Care, University of Washington, Spokane, Washington, USA
| | - Samy Hadjadj
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Copenhagen, Denmark
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45
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Mima A, Saito Y, Matsumoto K, Nakamoto T, Lee S. Effect of finerenone on nephrotic syndrome in patients with diabetic kidney disease. Metabol Open 2024; 22:100294. [PMID: 38952893 PMCID: PMC11215105 DOI: 10.1016/j.metop.2024.100294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/25/2024] [Accepted: 06/04/2024] [Indexed: 07/03/2024] Open
Abstract
Introduction Diabetic kidney disease (DKD) is an important complication of diabetes as it results in end-stage renal disease; hence, several drugs have been developed for its treatment. However, even with treatment with renin-angiotensin system inhibitors and sodium-glucose cotransporter-2 inhibitors, the residual risk of DKD remains. While this risk is an issue, the renoprotective effects of finerenone, a novel non-steroidal mineralocorticoid receptor antagonist, are becoming evident. High proteinuria increases the risk of cardiovascular death as well as renal failure. Hence, it is especially important to address cases of urine protein to nephrotic levels in DKD, however, no previous studies have assessed the safety and efficacy of finerenone in patients with DKD and nephrotic syndrome. Therefore, this study aimed to assess whether finerenone has a renoprotective effect in advanced DKD complicated by nephrotic syndrome. Methods Nine patients with DKD and nephrotic syndrome who received 10-20 mg/day of finerenone were retrospectively analyzed. The average observation period was 9.7 ± 3.4 months. Patients with serum potassium levels greater than 5.0 mEq/L at the start of finelenone were excluded. Changes in urinary protein levels, estimated glomerular filtration rate (eGFR), and serum potassium levels were studied before and after finerenone administration. Results The mean changes in the urinary protein creatinine ratio (UPCR) at baseline were 6.6 ± 2.0. After finerenone treatment, the mean UPCR decreased to -0.6 ± 3.9; however, this change was not statistically significant.The eGFR decline slope also tended to decrease with finerenone treatment (before vs. after: 3.1 ± 4.9 vs. -1.7 ± 3.2 mL/min/1.73 m2. Furthermore, finerenone did not increase serum potassium levels. Conclusions Patients treated with finerenone showed decreased UPCR; hence, it is suggested that finerenone may be effective in treating nephrotic syndrome in patients with DKD. These findings may be applicable to real-world clinical settings. Nonetheless, it is important to note that this study was a retrospective analysis of a single-center cohort and had a limited sample size, highlighting the need for additional large-scale investigations.
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Affiliation(s)
- Akira Mima
- Department of Nephrology, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Yuta Saito
- Department of Nephrology, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Keishi Matsumoto
- Department of Nephrology, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Takahiro Nakamoto
- Department of Nephrology, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Shinji Lee
- Department of Nephrology, Osaka Medical and Pharmaceutical University, Osaka, Japan
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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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Balgobin S, Basak S, Teoh CW, Noone D. Hypertension in diabetes. Pediatr Nephrol 2024; 39:1739-1758. [PMID: 37831122 DOI: 10.1007/s00467-023-06163-x] [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: 06/01/2023] [Revised: 09/01/2023] [Accepted: 09/01/2023] [Indexed: 10/14/2023]
Abstract
Diabetes mellitus, a disease that affects hundreds of millions of people worldwide, is increasing in prevalence in all age groups, including children and adolescents. Much of the morbidity and mortality associated with diabetes is closely related to hypertension, often coincident with diabetes. Comorbid hypertension and diabetes often worsen the outcomes of each other, likely rooted in some overlapping pathogenic mechanisms. In this educational review, we will discuss the shared pathophysiology of diabetes and hypertension, particularly in regard to inflammation and oxidative stress, the sympathetic nervous system, vascular remodeling, and the renin-angiotensin-aldosterone system (RAAS). We will also review current hypertension diagnosis and management guidelines from many international jurisdictions for both adult and paediatric populations in the setting of diabetes. Many of these guidelines highlight the use and utility of RAAS blockers in this clinical scenario; however, on review of the evidence for their use, several meta-analyses and systematic reviews fail to demonstrate superiority of RAAS blockers over other anti-hypertensive medications. Finally, we discuss several new anti-hypertensive medications, review their mechanisms of action, and highlight some of the evidence for their use in the setting of hypertension and diabetes.
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Affiliation(s)
- Steve Balgobin
- Division of Paediatric Nephrology, The Hospital for Sick Children, 555 University Avenue, Toronto, M5G 1X8, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Sanjukta Basak
- Pediatric Endocrinologist, BC Children's Hospital, Vancouver, BC, Canada
- Division of Endocrinology & Metabolism, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Chia Wei Teoh
- Division of Paediatric Nephrology, The Hospital for Sick Children, 555 University Avenue, Toronto, M5G 1X8, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Damien Noone
- Division of Paediatric Nephrology, The Hospital for Sick Children, 555 University Avenue, Toronto, M5G 1X8, Canada.
- Department of Paediatrics, University of Toronto, Toronto, Canada.
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Kodur N, Tang WHW. Non-cardiac comorbidities in heart failure: an update on diagnostic and management strategies. Minerva Med 2024; 115:337-353. [PMID: 38899946 DOI: 10.23736/s0026-4806.24.09070-0] [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: 06/21/2024]
Abstract
Managing non-cardiac comorbidities in heart failure (HF) requires a tailored approach that addresses each patient's specific conditions and needs. Regular communication and coordination among healthcare providers is crucial to providing the best possible care for these patients. Poorly controlled hypertension contributes to left ventricular remodeling and diastolic dysfunction, emphasizing the importance of optimal blood pressure control while avoiding adverse effects. Among HF patients with diabetes, SGLT2 inhibitors and mineralocorticoid receptor antagonists have shown promise in reducing HF-related morbidity and mortality. Chronic kidney disease exacerbates HF and vice versa, forming the vicious cardiorenal syndrome, so disease-modifying therapies should be maintained in HF patients with comorbid CKD, even with transient changes in kidney function. Anemia in HF patients may be multifactorial, and there is growing evidence for the benefit of intravenous iron supplementation in HF patients with iron deficiency with or without anemia. Obesity, although a risk factor for HF, paradoxically offers a better prognosis once HF is established, though developing treatment strategies may improve symptoms and cardiac performance. In HF patients with stroke and atrial fibrillation, anticoagulation therapy is recommended. Among HF patients with sleep-disordered breathing, continuous positive airway pressure may improve sleep quality. Chronic obstructive pulmonary disease often coexists with HF, and many patients can tolerate cardioselective beta-blockers. Cancer patients with comorbid HF require careful consideration of cardiotoxicity risks associated with cancer therapies. Depression is underdiagnosed in HF patients and significantly impacts prognosis. Cognitive impairment is prevalent in HF patients and impacts their self-care and overall quality of life.
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Affiliation(s)
- Nandan Kodur
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - W H Wilson Tang
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA -
- Center for Microbiome and Human Health, Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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Vaduganathan M, Claggett BL, Lam CSP, Pitt B, Senni M, Shah SJ, Voors AA, Zannad F, Desai AS, Jhund PS, Viswanathan P, Bomfim Wirtz A, Schloemer P, Lay-Flurrie J, McMurray JJV, Solomon SD. Finerenone in patients with heart failure with mildly reduced or preserved ejection fraction: Rationale and design of the FINEARTS-HF trial. Eur J Heart Fail 2024; 26:1324-1333. [PMID: 38742248 DOI: 10.1002/ejhf.3253] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/04/2024] [Accepted: 04/09/2024] [Indexed: 05/16/2024] Open
Abstract
AIM Steroidal mineralocorticoid receptor antagonists (MRAs), spironolactone and eplerenone, are strongly recommended in the treatment of patients with chronic heart failure (HF) with reduced left ventricular ejection fraction (LVEF), but the balance of efficacy and safety in those with higher LVEF has not been well established. Broad use of steroidal MRAs has further been limited in part due to safety concerns around risks of hyperkalaemia, gynecomastia, and kidney dysfunction. These risks may be mitigated by the unique pharmacological properties of the non-steroidal MRA finerenone. The FINEARTS-HF trial is designed to evaluate the long-term efficacy and safety of the selective non-steroidal MRA finerenone among patients with HF with mildly reduced or preserved ejection fraction. METHODS FINEARTS-HF is a global, multicentre, event-driven randomized trial evaluating oral finerenone versus matching placebo in symptomatic patients with HF with LVEF ≥40%. Adults (≥40 years) with HF with New York Heart Association class II-IV symptoms, LVEF ≥40%, evidence of structural heart disease, and diuretic use for at least the previous 30 days were eligible. All patients required elevated natriuretic peptide levels: for patients in sinus rhythm, N-terminal pro-B-type natriuretic peptide (NT-proBNP) ≥300 pg/ml (or B-type natriuretic peptide [BNP] ≥100 pg/ml) were required, measured within 30 days (in those without a recent worsening HF event) or within 90 days (in those with a recent worsening HF event). Qualifying levels of NT-proBNP or BNP were tripled if a patient was in atrial fibrillation at screening. Estimated glomerular filtration rate <25 ml/min/1.73 m2 or serum potassium >5.0 mmol/L were key exclusion criteria. Patients were enrolled irrespective of clinical care setting (whether hospitalized, recently hospitalized, or ambulatory). The primary endpoint is the composite of cardiovascular death and total (first and recurrent) HF events. The trial started on 14 September 2020 and has validly randomized 6001 participants across 37 countries. Approximately 2375 total primary composite events are targeted. CONCLUSIONS The FINEARTS-HF trial will determine the efficacy and safety of the non-steroidal MRA finerenone in a broad population of hospitalized and ambulatory patients with HF with mildly reduced or preserved ejection fraction. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT04435626 and EudraCT 2020-000306-29.
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Affiliation(s)
- Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | - Bertram Pitt
- University of Michigan, School of Medicine, Ann Arbor, MI, USA
| | - Michele Senni
- University Bicocca Milan, Milan, Italy
- Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Adriaan A Voors
- University Medical Center Groningen, Groningen, The Netherlands
| | - Faiez Zannad
- Université de Lorraine, Inserm Clinical Investigation Centre, CHU, Nancy, France
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | | | | | | | | | - John J V McMurray
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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50
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Solomon SD, Ostrominski JW, Vaduganathan M, Claggett B, Jhund PS, Desai AS, Lam CSP, Pitt B, Senni M, Shah SJ, Voors AA, Zannad F, Abidin IZ, Alcocer-Gamba MA, Atherton JJ, Bauersachs J, Ma CS, Chiang CE, Chioncel O, Chopra V, Comin-Colet J, Filippatos G, Fonseca C, Gajos G, Goland S, Goncalvesová E, Kang SM, Katova T, Kosiborod MN, Latkovskis G, Lee APW, Linssen GCM, Llamas-Esperón G, Mareev V, Martinez FA, Melenovský V, Merkely B, Nodari S, Petrie MC, Saldarriaga CI, Saraiva JFK, Sato N, Schou M, Sharma K, Troughton R, Udell JA, Ukkonen H, Vardeny O, Verma S, von Lewinski D, Voronkov LG, Yilmaz MB, Zieroth S, Lay-Flurrie J, van Gameren I, Amarante F, Viswanathan P, McMurray JJV. Baseline characteristics of patients with heart failure with mildly reduced or preserved ejection fraction: The FINEARTS-HF trial. Eur J Heart Fail 2024; 26:1334-1346. [PMID: 38733212 DOI: 10.1002/ejhf.3266] [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: 04/11/2024] [Revised: 04/18/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
AIMS To describe the baseline characteristics of participants in the FINEARTS-HF trial, contextualized with prior trials including patients with heart failure (HF) with mildly reduced and preserved ejection fraction (HFmrEF/HFpEF). The FINEARTS-HF trial is comparing the effects of the non-steroidal mineralocorticoid receptor antagonist finerenone with placebo in reducing cardiovascular death and total worsening HF events in patients with HFmrEF/HFpEF. METHODS AND RESULTS Patients with symptomatic HF, left ventricular ejection fraction (LVEF) ≥40%, estimated glomerular filtration rate ≥ 25 ml/min/1.73 m2, elevated natriuretic peptide levels and evidence of structural heart disease were enrolled and randomized to finerenone titrated to a maximum of 40 mg once daily or matching placebo. We validly randomized 6001 patients to finerenone or placebo (mean age 72 ± 10 years, 46% women). The majority were New York Heart Association functional class II (69%). The baseline mean LVEF was 53 ± 8% (range 34-84%); 36% of participants had a LVEF <50% and 64% had a LVEF ≥50%. The median N-terminal pro-B-type natriuretic peptide (NT-proBNP) was 1041 (interquartile range 449-1946) pg/ml. A total of 1219 (20%) patients were enrolled during or within 7 days of a worsening HF event, and 3247 (54%) patients were enrolled within 3 months of a worsening HF event. Compared with prior large-scale HFmrEF/HFpEF trials, FINEARTS-HF participants were more likely to have recent (within 6 months) HF hospitalization and greater symptoms and functional limitations. Further, concomitant medications included a larger percentage of sodium-glucose cotransporter 2 inhibitors and angiotensin receptor-neprilysin inhibitors than previous trials. CONCLUSIONS FINEARTS-HF has enrolled a broad range of high-risk patients with HFmrEF and HFpEF. The trial will determine the safety and efficacy of finerenone in this population.
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Affiliation(s)
- Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John W Ostrominski
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore, Singapore, Singapore
| | - Bertram Pitt
- University of Michigan, School of Medicine, Ann Arbor, MI, USA
| | - Michele Senni
- University Bicocca Milan, Italy, and, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Adriaan A Voors
- University Medical Center Groningen, Groningen, The Netherlands
| | - Faiez Zannad
- Université de Lorraine, Inserm Clinical Investigation Centre, CHU, Nancy, France
| | | | | | - John J Atherton
- Cardiology Research Department, Royal Brisbane and Women's Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Chang-Sheng Ma
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | | | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C.C. Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Vijay Chopra
- Clinical Cardiology, Heart Failure and Research, Max Super Specialty Hospital, New Delhi, India
| | - Josep Comin-Colet
- Department of Cardiology, Bellvitge University Hospital and Bellvitge Biomedical Research Institute, CIBER-CV, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Gerasimos Filippatos
- Department of Cardiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Cândida Fonseca
- Department of Internal Medicine, Hospital São Francisco Xavier, NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Grzegorz Gajos
- Department of Coronary Disease and Heart Failure, Jagiellonian University Medical College, Kraków, Poland
| | - Sorel Goland
- Heart Failure Unit, Kaplan Medical Center, Rehovot, Israel
| | | | - Seok-Min Kang
- Division of Cardiology, Severance Hospital, Yonsei University Health System, Seoul, South Korea
| | - Tzvetana Katova
- Department of Noninvasive Cardiology, National Cardiology Hospital, Sofia, Bulgaria
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Gustavs Latkovskis
- Latvian Center of Cardiology, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Alex Pui-Wai Lee
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Gerard C M Linssen
- Department of Cardiology, Hospital Group Twente, Almelo, The Netherlands
| | | | - Vyacheslav Mareev
- University Clinic of Lomonosov Moscow State University, Moscow, Russia
| | | | - Vojtěch Melenovský
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Savina Nodari
- Department of Cardiology, University of Brescia and ASST 'Spedali Civili' Hospital, Brescia, Italy
| | - Mark C Petrie
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | | | | | - Naoki Sato
- Kawaguchi Cardiovascular and Respiratory Hospital, Saitama, Japan
| | - Morten Schou
- Department of Cardiology, Herlev-Gentofte University Hospital, Hellerup, Denmark
| | - Kavita Sharma
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard Troughton
- Christchurch Heart Institute, Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Jacob A Udell
- Women's College Hospital and Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Orly Vardeny
- Department of Medicine, University of Minnesota, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Dirk von Lewinski
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Leonid G Voronkov
- National Scientific Center, Strazhesko Institute of Cardiology, National Academy of Medical Sciences, Kyiv, Ukraine
| | | | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Ilse van Gameren
- Bayer, Research & Development, Pharmaceuticals, Hoofddorp, The Netherlands
| | | | | | - John J V McMurray
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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