Effects of intensive blood pressure control on mortality and cardiorenal function in chronic kidney disease patients

Emerging role of PANoptosis in kidney diseases: molecular mechanisms and therapeutic opportunities

Kidney diseases represent a significant global public health challenge, characterized by complex pathogenesis, high incidence, low awareness, insufficient early screening, and substantial treatment disparities. Effective therapeutic options remain lacking. Programmed cell death (PCD), including apoptosis, pyroptosis, and necroptosis, play pivotal roles in the pathogenesis of various kidney diseases. In 2019, PANoptosis, a novel form of inflammatory cell death, was introduced, providing new insights into innate immunity and PCD research. Although research on PANoptosis in kidney diseases is still limited, identifying key molecules within PANoptosomes and understanding their regulatory roles is critical for disease prevention and management. This review summarizes the various forms of PCD implicated in kidney diseases, along with PANoptosomes activated by Z-DNA binding protein 1 (ZBP1), absent in melanoma 2 (AIM2), receptor-interacting protein kinase 1 (RIPK1), NOD-like receptor family CARD domain containing 12 (NLRP12), and NOD-like receptor family member C5 (NLRC5). It also reviews the advancements in PANoptosis research in the field of kidney diseases, particularly in renal tumors and acute kidney injuries (AKI). The goal is to establish a foundation for future research into the role of PANoptosis in kidney diseases.

Antihypertensive Treatment Patterns in CKD Stages 3 and 4: The CKD-REIN Cohort Study

Rationale & Objective

Blood pressure (BP) control is essential for preventing cardiorenal complications in chronic kidney disease (CKD), but most patients fail to reach BP target. We assessed longitudinal patterns of antihypertensive drug prescription and systolic BP.

Study Design

Prospective observational cohort study.

Setting & Population

In total, 2,755 hypertensive patients with CKD stages 3-4, receiving care from a nephrologist, from the French CKD-Renal Epidemiology and Information Network (CKD-REIN cohort study).

Exposure

Patient factors, including sociodemographic characteristics, medical history, and laboratory data, and provider factors, including number of primary care physician and specialist encounters.

Outcomes

Changes in antihypertensive drug-class prescription during follow-up: add-on or withdrawal.

Analytical Approach

Hierarchical shared-frailty models to estimate hazard ratios (HR) to deal with clustering at the nephrologist level and linear mixed models to describe systolic BP trajectory.

Results

At baseline, median age was 69 years, and mean estimated glomerular filtration rate was 33 mL/min/1.73 m². In total, 66% of patients were men, 81% had BP ≥ 130/80 mm Hg, and 75% were prescribed ≥2 antihypertensive drugs. During a median 5-year follow-up, the rate of changes of antihypertensive prescription was 50 per 100 person-years, 23 per 100 for add-ons, and 25 per 100 for withdrawals. After adjusting for risk factors, systolic BP, and the number of antihypertensive drugs, poor medication adherence was associated with increased HR for add-on (1.35, 95% confidence interval [CI], 1.01-1.80), whereas a lower education level was associated with increased HR for withdrawal (1.23, 95% CI, 1.02-1.49) for 9-11 years versus ≥12 years. More frequent nephrologist visits (≥4 vs none) were associated with higher HRs of add-on and withdrawal (1.52, 95% CI, 1.06-2.18; 1.57, 95% CI, 1.12-2.19, respectively), whereas associations with visit frequency to other physicians varied with their specialty. Mean systolic BP decreased by 4 mm Hg following drug add-on but tended to increase thereafter.

Limitations

Lack of information on prescriber and drug dosing.

Conclusions

In patients with CKD and poor BP control, changes in antihypertensive drug prescriptions are common and relate to clinician preferences and patients' tolerability. Sustainable reduction in systolic BP after add-on of a drug class is infrequently achieved.

Characteristics and Influencing Factors of Intra-Dialysis Blood Pressure Variability in Hemodialysis Patients: A Retrospective Study

Objective

To investigate the correlation between background factors and blood pressure variability (BPV), and the prognostic value of intra-dialytic BPV metrics for cardiovascular death and all-cause mortality in hemodialysis (HD) patients.

Methods

A retrospective study of 264 hD patients was followed up for 36 months. The intra-dialytic BP during the 3-month period for each patient was used to calculate BPV metrics, including standard deviation (SD), coefficient of variation (CV), average real variability (ARV), blood pressure change (ΔBP), and percent change in blood pressure (ΔBP/pre-BP). The primary outcomes were CVD death and all-cause mortality.

Results

Age, body mass index (BMI), predialysis blood pressure, inter-dialytic weight gain rate (IDWG%), α- blockers, and cholesterol levels were positively correlated with intra-dialytic BPV. Hemoglobin and albumin are negatively associated with intra-dialytic BPV. In Cox regression analysis, SBP-ARV, ΔSBP, and ΔSBP/pre-SBP were independent risk factors for CVD death (HR: 1.087, 95% CI: 1.001-1.181, p = 0.047; HR: 1.072, 95% CI: 1.016-1.131, p = 0.011; HR: 1.107, 95% CI: 1.011-1.211, p = 0.028). SBP-ARV showed the largest AUC of 0.593 (p = 0.022) in predicting all-cause death. SBP-ARV, ΔSBP, and ΔSBP/pre-SBP showed relatively large area (AUC = 0.631, 0.639, and 0.620; p = 0.007, 0.004, and 0.013 respectively) in predicting CVD death.

Conclusion

Age, BMI, IDWG%, predialysis blood pressure, albumin, hemoglobin, α- blockers, and total cholesterol were significantly correlated with intra-dialytic BPV. SBP-ARV, ΔSBP, and ΔSBP/pre-SBP were independent risk factors for CVD mortality, and there were no differences in prognostic value among various BPV metrics.

Therapeutic Drug Monitoring in Arterial Hypertension

(1) Background: This study was planned to assess the concentration of antihypertensive drugs (AHD) in the blood serum in patients with controlled and uncontrolled arterial hypertension (AH). (2) Methods: We assessed 46 patients with AH. Based on the results of 24 h blood pressure monitoring (ABPM), the patients were randomized into two groups. The first group consisted of the patients with controlled AH; the second group consisted of the patients with uncontrolled AH. Venous blood was taken in both groups of patients in the morning before and 2 h after taking drugs to assess the concentration of lisinopril, amlodipine, valsartan, and indapamide. (3) Results. The first group included 27 patients, and the second group 19 patients. In patients with uncontrolled AH, the median concentrations of lisinopril, indapamide, amlodipine, and valsartan before and after taking the drugs did not differ from patients who reached the target BP values. (p > 0.05). In some patients with uncontrolled and controlled (shown for the first time) AH the concentration of AHD was below the limit of quantitative determination. (4) Conclusions. The obtained results indicate that the pharmacokinetics of AHD, apparently, does not play a significant role in the development of ineffectiveness of the ongoing therapy for AH. Therapeutic drug monitoring can be used to test adherence to the treatment.

[Nephrological management and drug dosing in patients with rheumatic diseases and renal insufficiency]

BACKGROUND

In patients with inflammatory rheumatic diseases and renal insufficiency there are two challenges for physicians: to adapt the antirheumatic medication to the renal function and to carry out a nephroprotective treatment that prevents long-term deterioration of renal function and reduces the elevated cardiovascular risk.

METHODS

A literature search (in PubMed) was carried out and the current state of knowledge on nephroprotective treatment strategies and the treatment of rheumatic diseases in the presence of renal insufficiency was collated, evaluated and summarized.

RESULTS

Lifestyle interventions, especially the cessation of smoking and drug treatment strategies form the basis of nephroprotection including the control of diabetes mellitus with metformin, sodium glucose transporter 2 (SGLT2) inhibitors, glucagon-like peptide 1 (GLP1) analogues and control of hypertension with blockade of the renin-angiotensin-aldosterone system (RAAS), hyperlipidemia, hyperphosphatemia and metabolic acidosis. The SGLT2 inhibitors are also effective for nondiabetic nephropathy. The elevated cardiovascular risk is further reduced by effective control of inflammatory rheumatic activity. Numerous conventional disease modifying antirheumatic drugs, especially methotrexate and the Janus kinase (JAK) inhibitors baricitinib and filgotinib, must mostly be adapted to the renal function. In contrast, biologics can be given in standard doses with the exception of anakinra. The increased cardiovascular risk currently limits the use of tofacitinib in patients with renal insufficiency.

CONCLUSION

The antirheumatic medication should be modified and a complex nephroprotective treatment concept is mandatory in the management of patients with rheumatic disease and renal insufficiency, that in the best-case scenario can be guaranteed by a close interdisciplinary cooperation of rheumatologists and nephrologists.

Tight Blood Pressure Control in Chronic Kidney Disease

Hypertension affects over a billion people worldwide and is the leading cause of cardiovascular disease and premature death worldwide, as well as one of the key determinants of chronic kidney disease worldwide. People with chronic kidney disease and hypertension are at very high risk of renal outcomes, including progression to end-stage renal disease, and, even more importantly, cardiovascular outcomes. Hence, blood pressure control is crucial in reducing the human and socio-economic burden of renal and cardiovascular outcomes in those patients. However, current guidelines from hypertension and renal societies have issued different and sometimes conflicting recommendations, which risk confusing clinicians and potentially contributing to a less effective prevention of renal and cardiovascular outcomes. In this review, we critically appraise existing evidence and key international guidelines, and we finally formulate our own opinion that clinicians should aim for a blood pressure target lower than 130/80 in all patients with chronic kidney disease and hypertension, unless they are frail or with multiple comorbidities. We also advocate for an even more ambitious systolic blood pressure target lower than 120 mmHg in younger patients with a lower burden of comorbidities, to minimise their risk of renal and cardiovascular events during their lifetime.

The assessment of hypertension in kidney transplant patients: time to change our approach?

Kidney transplantation (KT) is an increasingly utilized treatment for end-stage kidney disease. Hypertension either as a cause of kidney disease or as a complication of chronic kidney disease is the most frequently encountered comorbidity of KT patients. Hence, the management of hypertension in KT patients is crucial to prolong patient and graft survival. Ambulatory blood pressure monitoring (ABPM) appeared as a promising technique that has superiority over office and home blood pressure (BP) monitoring to correctly diagnose and manage hypertension. A recent meta-analysis by Pisano et al. including 42 studies with 4115 participants provided strong data for the comparison of ABPM with office BP monitoring in KT patients. In addition to the current literature knowledge, the findings of Pisano et al. filled the long-awaited evidence gap to suggest ABPM as a first-line BP monitoring technique for KT patients. Despite its disadvantages, such as patient discomfort, cost–effectiveness and limited availability, ABPM has crucial advantages in the management of hypertension including the detection of abnormal circadian BP patterns, the assessment of effects of physical activity and short-term variability of BP, and the exclusion of masked and white-coat hypertension.