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Zardoost P, Tyabuddin S, Cantu A, Abu‐Jubara M, Mittlesteadt J, Wehrum H. Primary focal segmental glomerulosclerosis in a patient with ankylosing spondylitis: A rare presentation requiring a broad differential in nephrotic syndrome. Clin Case Rep 2024; 12:e8901. [PMID: 38751961 PMCID: PMC11093901 DOI: 10.1002/ccr3.8901] [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: 03/18/2024] [Revised: 04/15/2024] [Accepted: 04/22/2024] [Indexed: 05/18/2024] Open
Abstract
Ankylosing spondylitis (AS) presents with renal failure and proteinuria in a minority of cases, usually due to secondary amyloidosis or IgA nephropathy. While focal segmental glomerulosclerosis (FSGS) is less common, it should still be in the differential regardless of the patient's clinical profile.
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Ko SF, Yang CC, Sung PH, Cheng BC, Shao PL, Chen YL, Yip HK. Dapagliflozin-entresto protected kidney from renal hypertension via downregulating cell-stress signaling and upregulating SIRT1/PGC-1α/Mfn2-medicated mitochondrial homeostasis. Exp Biol Med (Maywood) 2023; 248:2421-2439. [PMID: 38059322 PMCID: PMC10903247 DOI: 10.1177/15353702231198087] [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: 03/11/2023] [Accepted: 07/10/2023] [Indexed: 12/08/2023] Open
Abstract
This study tested whether combined dapagliflozin and entresto would be superior to mere one therapy on protecting the residual renal function and integrity of kidney parenchyma in hypertensive kidney disease (HKD) rat. In vitro results showed that the protein expressions of oxidative-stress/mitochondrial-damaged (NOX-1/NOX-2/oxidized-protein/cytosolic-cytochrome-C)/apoptotic (mitochondrial-Bax/cleaved caspeases 3, 9)/cell-stress (p-ERK/p-JNK/p-p38) biomarkers were significantly increased in H2O2-treated NRK-52E cells than those of controls that were reversed by dapagliflozin or entresto treatment. Adult-male SD rats (n = 50) were equally categorized into group 1 (sham-operated-control), group 2 (HKD by 5/6 nephrectomy + DOCA-salt/25 mg/kg/subcutaneous injection/twice weekly), group 3 (HKD + dapagliflozin/orally, 20 mg/kg/day for 4 weeks since day 7 after HKD induction), group 4 (HKD + entresto/orally, 100 mg/kg/day for 4 weeks since day 7 after HKD induction), and group 5 (HKD + dapagliflozin + entresto/the procedure and treatment strategy were identical to groups 2/3/4). By day 35, circulatory levels of blood-urine-nitrogen (BUN)/creatinine and urine protein/creatinine ratio were lowest in group 1, highest in group 2, and significantly lower in group 5 than in groups 3/4, but no difference between groups 3/4. Histopathological findings showed the kidney injury score/fibrotic area/cellular expressions of oxidative-stress/kidney-injury-molecule (8-OHdG+/KIM-1+) exhibited an identical trend, whereas the cellular expressions of podocyte components (synaptopodin/ZO-1/E-cadherin) exhibited an opposite pattern of BUN level among the groups. The protein expressions of oxidative stress/mitochondrial-damaged (NOX-1/NOX-2/oxidized protein/cytosolic-cytochrome-C/cyclophilin-D)/apoptotic (mitochondrial-Bax/cleaved-caspase 3)/mitochondrial-fission (PINK1/Parkin/p-DRP1)/autophagic (LC3BII/LC3BI ratio, Atg5/beclin-1)/MAPK-family (p-ERK/p-JNK/p-p38) biomarkers displayed a similar pattern, whereas the protein expression of mitochondria-biogenesis signaling (SIRT1/PGC-1α-Mfn2/complex I-V) displayed an opposite pattern of BUN among the groups. In conclusion, combined dapagliflozin-entresto therapy offered additional benefits on protecting the residual kidney function and architectural integrity in HKD rat.
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Affiliation(s)
- Sheung-Fat Ko
- Department of Radiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 88301
| | - Chih-Chao Yang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 88301
| | - Pei-Hsun Sung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 88301
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 88301
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 88301
| | - Ben-Chung Cheng
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 88301
| | - Pei-Lin Shao
- Department of Nursing, Asia University, Taichung 41354
| | - Yi-Ling Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 88301
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 88301
| | - Hon-Kan Yip
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 88301
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 88301
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 88301
- Department of Nursing, Asia University, Taichung 41354
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung 40402
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302
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Potasso L, Monnerat S, Refardt J, Lindner G, Burst V, Winzeler B, Christ-Crain M. Chloride and Potassium Assessment Is a Helpful Tool for Differential Diagnosis of Thiazide-Associated Hyponatremia. J Clin Endocrinol Metab 2023; 108:2248-2254. [PMID: 36899489 PMCID: PMC10438879 DOI: 10.1210/clinem/dgad133] [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: 11/04/2022] [Revised: 02/10/2023] [Accepted: 03/06/2023] [Indexed: 03/12/2023]
Abstract
CONTEXT Differential diagnosis of thiazide-associated hyponatremia (TAH) is challenging. Patients can either have volume depletion or a syndrome of inappropriate antidiuresis (SIAD)-like presentation. OBJECTIVE To evaluate the impact of the simplified apparent strong ion difference in serum (aSID; sodium + potassium - chloride) as well as the urine chloride and potassium score (ChU; chloride - potassium in urine) in the differential diagnosis of TAH, in addition to assessment of fractional uric acid excretion (FUA). METHODS Post hoc analysis of prospectively collected data from June 2011 to August 2013 from 98 hospitalized patients with TAH < 125 mmol/L enrolled at University Hospital Basel and University Medical Clinic Aarau, Switzerland. Patients were categorized according to treatment response in volume-depleted TAH requiring volume substitution or SIAD-like TAH requiring fluid restriction. We computed sensitivity analyses with ROC curves for positive predictive value (PPV) and negative predictive value (NPV) of aSID, ChU, and FUA in differential diagnosis of TAH. RESULTS An aSID > 42 mmol/L had a PPV of 79.1% in identifying patients with volume-depleted TAH, whereas a value < 39 mmol/L excluded it with a NPV of 76.5%. In patients for whom aSID was inconclusive, a ChU < 15 mmol/L had a PPV of 100% and a NPV of 83.3%, whereas FUA < 12% had a PPV of 85.7% and a NPV of 64.3% in identifying patients with volume-depleted TAH. CONCLUSION In patients with TAH, assessment of aSID, potassium, and chloride in urine can help identifying patients with volume-depleted TAH requiring fluid substitution vs patients with SIAD-like TAH requiring fluid restriction.
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Affiliation(s)
- Laura Potasso
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
| | - Sophie Monnerat
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
| | - Julie Refardt
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
| | - Gregor Lindner
- Department of Internal and Emergency Medicine, Buergerspital Solothurn, 4500 Solothurn, Switzerland
- Department of Emergency Medicine, Inselspital, University Hospital Bern, 3008 Bern, Switzerland
| | - Volker Burst
- Department II of Internal Medicine (Nephrology, Rheumatology, Diabetes, and General Internal Medicine) and Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
- Emergency Department, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Bettina Winzeler
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
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Aralica M, Šupak-Smolčić V, Honović L, Franin L, Šonjić P, Šimac M, Horvat M, Poropat N. Laboratory medicine in arterial hypertension. Biochem Med (Zagreb) 2023; 33:010501. [PMID: 36817852 PMCID: PMC9927727 DOI: 10.11613/bm.2023.010501] [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: 09/01/2022] [Accepted: 12/08/2022] [Indexed: 02/05/2023] Open
Abstract
In the initial diagnostics of arterial hypertension (AH) laboratory medicine is a cornerstone, along with a blood pressure (BP) measurement and an electrocardiogram. It mainly refers to routine blood and urine tests for diagnosis and monitoring primary hypertension and its associated conditions such as asymptomatic hypertension-mediated organ damage, chronic kidney disease and hypertensive disorders of pregnancy. In addition, long term non-fatal and fatal risks for cardiovascular (CV) events in hypertension are assessed based on clinical and laboratory data. Furthermore, laboratory medicine is involved in the management of hypertension, especially in monitoring the disease progression. However, antihypertensive drugs may interfere with laboratory test results. Diuretics, especially thiazides, can affect blood and urine sodium concentrations, or angiotensin-converting enzyme inhibitors and angiotensin receptor blockers can affect the blood biomarkers of the renin-angiotensin-aldosterone system (RAAS). It's dysfunction plays a critical role in primary aldosteronism (PA), the most common endocrine disorder in secondary hypertension, which accounts for only small proportion of AH in relative terms but substantial proportion of hypertensives in absolute terms, affecting younger population and carrying a higher risk of CV mortality and morbidity. When screening for PA, aldosterone-to-renin ratio still contributes massively to the increased incidence of the disease, despite certain limits. In conclusion, laboratory medicine is involved in the screening, diagnosis, monitoring and prognosis of hypertension. It is of great importance to understand the preanalytical and analytical factors influencing final laboratory result.
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Affiliation(s)
- Merica Aralica
- Clinical Department for Laboratory Diagnostics, Clinical Hospital Centre Rijeka, Rijeka, Croatia,Corresponding author:
| | - Vesna Šupak-Smolčić
- Clinical Department for Laboratory Diagnostics, Clinical Hospital Centre Rijeka, Rijeka, Croatia,Department of Medical Informatics, Rijeka University School of Medicine, Rijeka, Croatia
| | - Lorena Honović
- Department of Medical Biochemistry and Laboratory Medicine, General Hospital Pula, Pula, Croatia
| | - Lucija Franin
- Clinical Department for Laboratory Diagnostics, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Pavica Šonjić
- Clinical Department for Laboratory Diagnostics, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Maja Šimac
- Clinical Department for Laboratory Diagnostics, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Mihovil Horvat
- Clinical Department for Laboratory Diagnostics, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Nina Poropat
- Department of Endocrinology, Diabetes and Metabolic Disorders, Clinical Hospital Centre, Rijeka, Croatia
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Schytz PA, Nissen AB, Torp-Pedersen C, Gislason GH, Nelveg-Kristensen KE, Hommel K, Gerds TA, Carlson N. Creatinine increase following initiation of antihypertensives is associated with cardiovascular risk: a nationwide cohort study. J Hypertens 2020; 38:2519-2526. [PMID: 32694338 DOI: 10.1097/hjh.0000000000002573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Abrupt decline in renal function following initiation of renin-angiotensin system inhibitor is associated with increased risk of cardiovascular disease, but studies of other antihypertensive drugs are sparse. We investigated the risk of cardiovascular event associated with increased plasma creatinine after initiating first-line antihypertensive treatment. METHODS In a nationwide cohort study, we identified adult Danish primary care patients initiating either renin-angiotensin system inhibitor, calcium channel blocker or thiazide, between 2008 and mid-2018. Patients with prior end-stage renal disease, renal transplantation, or cardiovascular disease were excluded. Percentual plasma creatinine increase was calculated between the nearest creatinine measurement up to 1 year before redeeming the prescription (baseline), and the nearest measurement 90 days or less after (index). Multiple logistic regression and restricted cubic splines were applied to estimate the 6-month absolute risk of cardiovascular event (ischemic heart disease, heart failure or stroke) associated with this creatinine increase. RESULTS We included 20 789 patients. Within the first 6 months of follow-up, 283 (1.4%) cardiovascular events and 93 (0.4%) all-cause deaths were registered. With a creatinine increase of 0 and 30%, 6-month absolute risk [CI] of cardiovascular event was 1.4% [1.1-1.9] and 3.5% [2.4-5.2], respectively (in men aged 50-79 years with estimated glomerular filtration rate at least 60 ml/min per 1.73 m and no diabetes). Higher age and reduced renal function, but not the type of antihypertensive treatment, were associated with higher cardiovascular risk. CONCLUSION In primary care, patients initiating first-line antihypertensive treatment, an increase in plasma creatinine above 30% was associated with increased absolute 6-month risk of cardiovascular event.
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Affiliation(s)
| | | | | | - Gunnar H Gislason
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen.,The Danish Heart Foundation, Copenhagen
| | | | | | - Thomas A Gerds
- Department of Biostatistics, Copenhagen University, Copenhagen, Denmark
| | - Nicholas Carlson
- The Danish Heart Foundation, Copenhagen.,Department of Nephrology, Rigshospitalet Copenhagen
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Potassium binding for conservative and preservative management of chronic kidney disease. Curr Opin Nephrol Hypertens 2020; 29:29-38. [DOI: 10.1097/mnh.0000000000000564] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Bianchi S, Regolisti G. Pivotal clinical trials, meta-analyses and current guidelines in the treatment of hyperkalemia. Nephrol Dial Transplant 2019; 34:iii51-iii61. [DOI: 10.1093/ndt/gfz213] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Indexed: 01/14/2023] Open
Abstract
Abstract
Hyperkalemia (HK) is the most common electrolyte disturbance observed in patients with advanced stages of chronic kidney disease (CKD), is a potentially life-threatening clinical condition due to an increased risk of fatal arrhythmias, and strongly impacts the quality of life and prognosis of CKD patients. Moreover, while renin–angiotensin–aldosterone system inhibitors (RAASIs) represent the most cardio-nephro-protective drugs used in clinical practice, the treatment with these drugs per se increases serum potassium (sK) values, particularly when heart failure and diabetes mellitus coexist. In fact, the onset or recurrence of HK is frequently associated with not starting, down-titrating or withdrawing RAASIs, and is an indication to begin renal replacement treatment in end-stage renal disease. Current strategies aimed at preventing and treating chronic HK are still unsatisfactory, as evidenced by the relatively high prevalence of HK also in patients under stable nephrology care, and even in the ideal setting of randomized clinical trials. Indeed, dietary potassium restriction, the use of sodium bicarbonate or diuretics, the withdrawal or down-titration of RAASIs, or the administration of old potassium binders, namely sodium polystyrene sulphonate and calcium polystyrene sulphonate, have limited efficacy and are poorly tolerated; therefore, these strategies are not suitable for long-term control of sK. As such, there is an important unmet need for novel therapeutic options for the chronic management of patients at risk for HK. The development of new potassium binders may change the treatment landscape in the near future. This review summarizes the current evidence on the treatment of chronic HK in cardio-renal patients.
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Affiliation(s)
- Stefano Bianchi
- Nephrology and Dialysis Unit, Department of Internal Medicine, ASL Toscana Nordovest, Regione Toscana, Livorno, Italy
| | - Giuseppe Regolisti
- Unit of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
- Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Mutig K, Bachmann S. Hyperkalemia and blood pressure regulation. Nephrol Dial Transplant 2019; 34:iii26-iii35. [PMID: 31800077 DOI: 10.1093/ndt/gfz218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Indexed: 11/12/2022] Open
Abstract
Hypertension is common in the general population. Management of hypertensive patients at risk of hyperkalemia is challenging due to potential life-threatening complications such as cardiac arrest. Chronic hyperkalemia is often associated with impaired renal ability to excrete excessive potassium ions (K+). This may refer to chronic kidney disease or certain pharmacological interventions, including broadly used renin-angiotensin-aldosterone system and calcineurin inhibitors. Understanding the intrinsic mechanisms permitting kidney adaptations to hyperkalemia is critical for choosing therapeutic strategies. Valuable insights were obtained from the analysis of familial hyperkalemic hypertension (FHHt) syndrome, which became a classic model for coincidence of high blood pressure and hyperkalemia. FHHt can be caused by mutations in several genes, all of them resulting in excessive activity of with-no-lysine kinases (WNKs) in the distal nephron of the kidney. WNKs have been increasingly recognized as key signalling enzymes in the regulation of renal sodium ions (Na+) and K+ handling, enabling adaptive responses to systemic shifts of potassium homoeostasis consequent to variations in dietary potassium intake or disease. The WNK signalling pathway recruits a complex protein network mediating catalytic and non-catalytic effects of distinct WNK isoforms on relevant Na+- or K+-transporting proteins. In this review article, we summarize recent progress in understanding WNK signalling. An update of available models for renal adaptation to hyperkalemic conditions is presented. Consequences for blood pressure regulation are discussed. Pharmacological targeting of WNKs or their substrates offers promising options to manage hypertension while preventing hyperkalemia.
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Affiliation(s)
- Kerim Mutig
- Institute of Vegetative Anatomy, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Pharmacology, I.M. Sechenov First Moscow State Medical University of the Ministry of Healthcare of the Russian Federation (Sechenovskiy University), Moscow, Russia
| | - Sebastian Bachmann
- Institute of Vegetative Anatomy, Charité-Universitätsmedizin Berlin, Berlin, Germany
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