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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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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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Meifang W, Ying W, Wen C, Kaizu X, Meiyan S, Liming L. Advance in the pharmacological and comorbidities management of heart failure with preserved ejection fraction: evidence from clinical trials. Heart Fail Rev 2024; 29:305-320. [PMID: 37561223 DOI: 10.1007/s10741-023-10338-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] [Accepted: 08/01/2023] [Indexed: 08/11/2023]
Abstract
The prevalence of heart failure with preserved ejection fraction (HFpEF) accounts for approximately 50% of the total heart failure population, and with the aging of the population and the increasing prevalence of hypertension, obesity, and type 2 diabetes (T2DM), the incidence of HFpEF continues to rise and has become the most common subtype of heart failure. Compared with heart failure with reduced ejection fraction, HFpEF has a more complex pathophysiology and is more often associated with hypertension, T2DM, obesity, atrial fibrillation, renal insufficiency, pulmonary hypertension, obstructive sleep apnea, and other comorbidities. HFpEF has generally been considered a syndrome with high phenotypic heterogeneity, and no effective treatments have been shown to reduce mortality to date. Diuretics and comorbidity management are traditional treatments for HFpEF; however, they are mostly empirical due to a lack of clinical evidence in the setting of HFpEF. With the EMPEROR-Preserved and DELIVER results, sodium-glucose cotransporter 2 inhibitors become the first evidence-based therapies to reduce rehospitalization for heart failure. Subgroup analyses of the PARAGON-HF, TOPCAT, and CHARM-Preserved trials suggest that angiotensin receptor-neprilysin inhibitors, spironolactone, and angiotensin II receptor blockers may be beneficial in patients at the lower end of the ejection fraction spectrum. Other potential pharmacotherapies represented by non-steroidal mineralocorticoid receptor antagonists finerenone and antifibrotic agent pirfenidone also hold promise for the treatment of HFpEF. This article intends to review the clinical evidence on current pharmacotherapies of HFpEF, as well as the comorbidities management of atrial fibrillation, hypertension, T2DM, obesity, pulmonary hypertension, renal insufficiency, obstructive sleep apnea, and iron deficiency, to optimize the clinical management of HFpEF.
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Affiliation(s)
- Wu Meifang
- Department of Cardiology, School of Clinical Medicine, Fujian Medical University, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
| | - Wu Ying
- Department of Cardiology, School of Clinical Medicine, Fujian Medical University, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
| | - Chen Wen
- Department of Cardiology, School of Clinical Medicine, Fujian Medical University, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
| | - Xu Kaizu
- Department of Cardiology, School of Clinical Medicine, Fujian Medical University, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
| | - Song Meiyan
- Department of Cardiology, School of Clinical Medicine, Fujian Medical University, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
| | - Lin Liming
- Department of Cardiology, School of Clinical Medicine, Fujian Medical University, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China.
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Mottl AK, Nicholas SB. KDOQI Commentary on the KDIGO 2022 Update to the Clinical Practice Guideline for Diabetes Management in CKD. Am J Kidney Dis 2024; 83:277-287. [PMID: 38142396 DOI: 10.1053/j.ajkd.2023.09.003] [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: 08/09/2023] [Accepted: 09/20/2023] [Indexed: 12/25/2023]
Abstract
The Kidney Disease: Improving Global Outcomes (KDIGO) guideline for diabetes management in chronic kidney disease (CKD) was updated in 2022, just 2 years after the previous update. The need for this rapid update is reflective of the recent and unprecedented positive results of numerous clinical trials aimed at reducing kidney and cardiovascular morbidity and mortality in people with diabetes. The Kidney Disease Outcomes Quality Initiative (KDOQI) work group for diabetes in CKD, convened by the National Kidney Foundation, provides herein a commentary on these changes, particularly the implications for health care in the United States. Changes to the KDIGO guideline mirror the evolution of sodium/glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 receptor agonists from purely antihyperglycemic agents to cardiorenal-metabolic therapeutics, and the lower estimated glomerular filtration rate of≥20mL/min/1.73m2 for SGLT2 inhibitor initiation. New data have also brought the addition of the first-in-class, Federal Drug Administration-approved nonsteroidal mineralocorticoid receptor antagonist finerenone as an agent to reduce cardiorenal end points. While there has been significant progress in innovation, there remain serious challenges to implementation, particularly in the United States where inequities in insurance coverage and high costs limit their use, particularly in vulnerable populations, ultimately widening health care disparities.
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Affiliation(s)
- Amy K Mottl
- Division of Nephrology, Department of Medicine, University of North Carolina Kidney Center, University of North Carolina, Chapel Hill, North Carolina.
| | - Susanne B Nicholas
- Divisions of Nephrology and Endocrinology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
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Scurt FG, Ganz MJ, Herzog C, Bose K, Mertens PR, Chatzikyrkou C. Association of metabolic syndrome and chronic kidney disease. Obes Rev 2024; 25:e13649. [PMID: 37783465 DOI: 10.1111/obr.13649] [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: 06/21/2023] [Accepted: 09/15/2023] [Indexed: 10/04/2023]
Abstract
The prevalence of kidney disease is increasing rapidly worldwide, reflecting rising rates of obesity, diabetes, and associated metabolic syndrome (MetS). Chronic kidney disease and related comorbidities such as obesity, diabetes, and hypertension place a significant financial burden on healthcare systems. Despite the widespread use of RAAS inhibitors, intensive blood pressure and glycemic control, and newer therapeutic options consisting of sodium/glucose cotransporter-2 (SGLT-2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists, a significant risk of progression to end-stage renal disease remains in the high-risk obese and diabetic population. The MetS is a cluster of cardiovascular risk factors that adversely affect the development and progression of chronic kidney failure. According to the criteria of the World Health Organization, it is defined by visceral adiposity, impaired glucose tolerance or insulin resistance, atherogenic dyslipidemia, raised blood pressure, and microalbuminuria with a albumin-to-creatinine ratio ≥30 mg/g. At molecular level MetS is marked by a proinflammatory state and increased oxidative stress leading to various pathophysiological changes causing endothelial dysfunction and a hypercoagulable state. Because the kidney is a highly vascularized organ, it is especially susceptible for those microvascular changes. Therefore, the MetS and its individual components are associated with the premature development, acceleration, and progression of chronic kidney disease. Therefore, it is becoming increasingly important to elucidate the underlying mechanisms of MetS-associated chronic kidney disease in order to develop new strategies for preventing and slowing the progression of renal disease. In this review, we will elucidate (i) the renal structural, hemodynamic, and metabolic changes that occur in obesity and obesity-related kidney injury; (ii) the clinicopathological characteristics of obesity-related kidney injury, primarily focusing on obesity-associated glomerulopathy; (iii) the potential additional factors or predisposing factors that may turn patients more susceptible to renal structural or functional compensatory failure and subsequent injury.
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Affiliation(s)
- Florian G Scurt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, Medical Faculty, Otto-von Guericke University Magdeburg, Magdeburg, Germany
| | - Maximilian J Ganz
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, Medical Faculty, Otto-von Guericke University Magdeburg, Magdeburg, Germany
| | - Carolin Herzog
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, Medical Faculty, Otto-von Guericke University Magdeburg, Magdeburg, Germany
| | - Katrin Bose
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
| | - Peter R Mertens
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, Medical Faculty, Otto-von Guericke University Magdeburg, Magdeburg, Germany
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Natalia B, Tomasz M, Ewa C, Anna GP. Sex-dependent effects of finerenone on hemostasis in normoglycemic and streptozotocin-induced diabetic mice. Biomed Pharmacother 2023; 169:115910. [PMID: 38006618 DOI: 10.1016/j.biopha.2023.115910] [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: 09/20/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 11/27/2023] Open
Abstract
Diabetes is associated with aldosterone excess and the overactivation of its mineralocorticoid receptor (MR) which leads to the development of many cardiovascular dysfunctions. Therefore, MR antagonists have been found to exert favorable effects on the cardiovascular system. Finerenone is a new nonsteroidal MR antagonist approved for the treatment of chronic kidney disease associated with type 2 diabetes. Clinical studies have demonstrated that finerenone improves cardiovascular outcomes. However, its influence on hemostasis in the cardioprotective effect is unknown. Therefore, the main aim of our study was to evaluate the effects of finerenone (10 mg/kg, p.o.) on selected hemostasis parameters in streptozotocin (180 mg/kg, i.p.)-induced diabetes. Since regulation of the MR activity is sex-dependent, the study was conducted in both female and male mice. The most beneficial effects of finerenone were observed in diabetic female mice which included a decrease in thrombus formation, attenuation of platelet activity, inhibition of the coagulation system, and activation of fibrinolysis. In contrast, in male diabetic mice only an attenuation of the coagulation system was observed. Furthermore, finerenone also exerted unfavorable effects, but only in normoglycemic mice, manifested as a slight increase in platelet activity in males and an enhancement of the coagulation system activity in females. Our study is the first to show the sex-dependent and glycemia-dependent effects of finerenone on hemostasis in diabetes. The occurrence of beneficial effects only in female diabetic mice requires in-depth study.
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Affiliation(s)
- Bielicka Natalia
- Department of Biopharmacy and Radiopharmacy, Medical University of Bialystok, ul. Mickiewicza 2C, 15-222 Bialystok, Poland.
| | - Misztal Tomasz
- Department of Physical Chemistry, Medical University of Bialystok, ul. Mickiewicza 2A, 15-089 Bialystok, Poland
| | - Chabielska Ewa
- Department of Biopharmacy and Radiopharmacy, Medical University of Bialystok, ul. Mickiewicza 2C, 15-222 Bialystok, Poland
| | - Gromotowicz-Popławska Anna
- Department of Biopharmacy and Radiopharmacy, Medical University of Bialystok, ul. Mickiewicza 2C, 15-222 Bialystok, Poland
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Heinig R, Eissing T. The Pharmacokinetics of the Nonsteroidal Mineralocorticoid Receptor Antagonist Finerenone. Clin Pharmacokinet 2023; 62:1673-1693. [PMID: 37875671 PMCID: PMC10684710 DOI: 10.1007/s40262-023-01312-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 10/26/2023]
Abstract
Finerenone, a selective and nonsteroidal antagonist of the mineralocorticoid receptor, has received regulatory approval with the indication of cardiorenal protection in patients with chronic kidney disease associated with type 2 diabetes. It is rapidly and completely absorbed and undergoes first-pass metabolism in the gut wall and liver resulting in a bioavailability of 43.5%. Finerenone can be taken with or without food. The pharmacokinetics of finerenone are linear and its half-life is 2 to 3 h in the dose range of up to 20 mg. Cytochrome P450 (CYP) 3A4 (90%) and CYP2C8 (10%) are involved in the extensive biotransformation of finerenone to pharmacologically inactive metabolites, which are excreted via both renal (80%) and biliary (20%) routes. Moderate or severe renal impairment, or moderate hepatic impairment result in area-under-the-curve increases of finerenone (< 40%), which do not require a dose adjustment per se, as the starting dose is based on estimated glomerular filtration rate (eGFR) and titrated according to serum potassium levels and eGFR decline. No relevant effects of age, sex, body size or ethnicity on systemic finerenone exposure were identified. Modulators of CYP3A4 activity were found to affect finerenone exposure, consistent with its classification as a sensitive CYP3A4 substrate. Serum potassium should be monitored during drug initiation or dosage adjustment of either a moderate or weak CYP3A4 inhibitor or finerenone, and the dose of finerenone should be adjusted as appropriate. Its use with strong inhibitors is contraindicated and strong or moderate inducers of CYP3A4 should be avoided. Finerenone has no potential to affect relevant CYP enzymes and drug transporters.
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Affiliation(s)
- Roland Heinig
- Bayer AG, Research & Development, Pharmaceuticals, Translational Medicine, 42096, Wuppertal, Germany.
| | - Thomas Eissing
- Bayer AG, Research & Development, Pharmaceuticals, Pharmacometrics, Leverkusen, Germany
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Pradhan N, Dobre M. Emerging Preventive Strategies in Chronic Kidney Disease: Recent Evidence and Gaps in Knowledge. Curr Atheroscler Rep 2023; 25:1047-1058. [PMID: 38038822 DOI: 10.1007/s11883-023-01172-5] [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] [Accepted: 11/10/2023] [Indexed: 12/02/2023]
Abstract
PURPOSE OF REVIEW Chronic kidney disease (CKD) is increasingly prevalent worldwide and is associated with increased cardiovascular risk. New therapeutic options to slow CKD progression and reduce cardiovascular morbidity and mortality have recently emerged. This review highlights recent evidence and gaps in knowledge in emerging CKD preventive strategies. RECENT FINDINGS EMPA-Kidney trial found that empagliflozin, a sodium-glucose co-transporter 2 inhibitor (SGLT2i) led to 28% lower risk of progression of kidney disease or death from cardiovascular causes, compared to placebo. This reinforced the previous findings from DAPA-CKD and CREDENCE trials and led to inclusion of SGLT2i as the cornerstone of CKD preventive therapy in both diabetic and non-diabetic CKD. Finerenone, a selective nonsteroidal mineralocorticoid receptor antagonist, slowed diabetic kidney disease progression by 23% compared to placebo in a pool analysis of FIDELIO-DKD and FIGARO-DKD trials. Non-pharmacological interventions, including low protein diet, and early CKD detection and risk stratification strategies based on novel biomarkers have also gained momentum. Ongoing efforts to explore the wealth of molecular mechanisms in CKD, added to integrative omics modeling are well posed to lead to novel therapeutic targets in kidney care. While breakthrough pharmacological interventions continue to improve outcomes in CKD, the heterogeneity of kidney diseases warrants additional investigation. Further research into specific kidney disease mechanisms will facilitate the identification of patient populations most likely to benefit from targeted interventions.
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Affiliation(s)
- Nishigandha Pradhan
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Mirela Dobre
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA.
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA.
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Junho CVC, Frisch J, Soppert J, Wollenhaupt J, Noels H. Cardiomyopathy in chronic kidney disease: clinical features, biomarkers and the contribution of murine models in understanding pathophysiology. Clin Kidney J 2023; 16:1786-1803. [PMID: 37915935 PMCID: PMC10616472 DOI: 10.1093/ckj/sfad085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Indexed: 11/03/2023] Open
Abstract
The cardiorenal syndrome (CRS) is described as a multi-organ disease encompassing bidirectionally heart and kidney. In CRS type 4, chronic kidney disease (CKD) leads to cardiac injury. Different pathological mechanisms have been identified to contribute to the establishment of CKD-induced cardiomyopathy, including a neurohormonal dysregulation, disturbances in the mineral metabolism and an accumulation of uremic toxins, playing an important role in the development of inflammation and oxidative stress. Combined, this leads to cardiac dysfunction and cardiac pathophysiological and morphological changes, like left ventricular hypertrophy, myocardial fibrosis and cardiac electrical changes. Given that around 80% of dialysis patients suffer from uremic cardiomyopathy, the study of cardiac outcomes in CKD is clinically highly relevant. The present review summarizes clinical features and biomarkers of CKD-induced cardiomyopathy and discusses underlying pathophysiological mechanisms recently uncovered in the literature. It discloses how animal models have contributed to the understanding of pathological kidney-heart crosstalk, but also provides insights into the variability in observed effects of CKD on the heart in different CKD mouse models, covering both "single hit" as well as "multifactorial hit" models. Overall, this review aims to support research progress in the field of CKD-induced cardiomyopathy.
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Affiliation(s)
| | - Janina Frisch
- Department of Biophysics, Center for Integrative Physiology and Molecular Medicine, Medical Faculty, Saarland University, Center for Human and Molecular Biology, Homburg/Saar, Germany
| | - Josefin Soppert
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen, Aachen, Germany
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Julia Wollenhaupt
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen, Aachen, Germany
| | - Heidi Noels
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen, Aachen, Germany
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
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Vachek J, Tesař V. Finerenone. VNITRNI LEKARSTVI 2023; 69:20-23. [PMID: 37468332 DOI: 10.36290/vnl.2023.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
In developed countries, diabetes mellitus (DM) is one of the main causes of end stage renal disease (ESRD). In addition, the development of chronic kidney disease (CKD) further increases the already significantly increased cardiovascular (CV) risk in patients with diabetes. Both albuminuria and impaired renal function predict CV disease-related morbidity. The multifactorial pathogenesis of DM-related CKD involves structural, physiological, hemodynamic, and inflammatory processes. Instead of a so-called glucocentric approach, current evidence suggests that a multimodal, interdisciplinary treatment approach is needed to also prevent further progression of CKD and reduce the risk of cardiovascular events. Combined antihypertensive, antihyperglycemic and hypolipidemic therapy is the basis of a comprehensive approach to prevent the progression of diabetic kidney disease. According to recent evidence, adjunctive therapy with the non-steroidal mineralocorticoid receptor antagonist (MRA) finerenone - in addition to the use of an ACE (angiotensin converting enzyme) or AT1 (angiotensin II receptor subtype 1) blocker and an SGLT2 (sodium-glucose cotransporter-2) inhibitor - represents an effective therapeutic tool to improve nephroprotection in CKD. The aim of this review is to provide brief information on this promising pharmacotherapeutic approach to the treatment of diabetic kidney disease.
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