1
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Pun PH. Spironolactone and Cardiac Arrhythmias in Hemodialysis Patients: Helpful or Harmful? KIDNEY360 2023; 4:e429-e430. [PMID: 37103956 PMCID: PMC10278809 DOI: 10.34067/kid.0000000000000096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Affiliation(s)
- Patrick H. Pun
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham North Carolina
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2
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Lin DSH, Lin FJ, Lin YS, Lee JK, Lin YH. The effects of mineralocorticoid receptor antagonists on cardiovascular outcomes in patients with end-stage renal disease and heart failure. Eur J Heart Fail 2023; 25:98-107. [PMID: 36404402 DOI: 10.1002/ejhf.2740] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 10/20/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022] Open
Abstract
AIMS Mineralocorticoid receptor antagonists (MRAs) have been shown to provide survival benefits in patients with heart failure; however, MRA use in patients with chronic kidney disease has been limited by safety concerns. The effects of MRAs on outcomes in patients with end-stage renal disease (ESRD) and heart failure remain unknown. The aim of this study was to evaluate the effects of MRAs on cardiovascular outcomes in patients with heart failure under maintenance dialysis in a real-world setting. METHODS AND RESULTS A retrospective cohort study was conducted by collecting data from the Taiwan National Health Insurance Research Database (NHIRD). Patients diagnosed with heart failure and ESRD and who started maintenance dialysis between 1 January 2001 and 31 December 2013 were identified. Patients were grouped according to MRA prescription. The outcomes of interest included cardiovascular (CV) death, hospitalization for heart failure (HHF), all-cause mortality, acute myocardial infarction (AMI), ischaemic stroke, any coronary revascularization procedures, and new-onset hyperkalaemia. Propensity score matching was performed at a 1:3 ratio between MRA users and non-users to minimize selection bias. A total of 50 872 patients who satisfied our inclusion and exclusion criteria were identified. After 1:3 matching, 2176 patients were included in the MRA group, and 6528 patients were included in the non-MRA group. The risk of CV death was significantly lower among patients who received MRAs than those who did not (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.80-0.95), as was the risk of all-cause mortality (HR 0.88, 95% CI 0.83-0.94). Reductions in the risks of CV death and all-cause mortality were more prominent among patients undergoing haemodialysis and those with coronary artery disease. CONCLUSIONS In patients undergoing regular dialysis who are diagnosed with heart failure, the use of MRAs is associated with lower risks of all-cause mortality and CV death. The benefits of MRA treatment in heart failure may persist in patients with ESRD. Further investigations through randomized controlled trials are needed to assess the efficacy and safety of MRAs in this high-risk population.
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Affiliation(s)
- Donna Shu-Han Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, Taiwan
| | - Fang-Ju Lin
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan.,College of Medicine, Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan City, Taiwan
| | - Jen-Kuang Lee
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Laboratory Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.,Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan.,Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Laboratory Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.,Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
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3
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Association between adrenal function and dialysis vintage in hemodialysis patients. Clin Exp Nephrol 2022; 26:933-941. [PMID: 35596828 DOI: 10.1007/s10157-022-02230-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 04/17/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Adrenal insufficiency in hemodialysis patients is commonly encountered in clinical practice. However, its association with end-stage renal disease is unclear. We investigated the relationship between adrenal function and relevant clinical parameters, focusing on dialysis vintage. METHODS Altogether, 100 maintenance hemodialysis patients were enrolled (age: 69.8 ± 11.8 years, dialysis vintage: 9.4 ± 9.2 years). Basal serum cortisol levels were measured and their associations with relevant clinical parameters were investigated. Subsequently, hormone stimulation tests were performed to assess adrenal function. RESULTS Basal serum cortisol significantly decreased with an increase in dialysis vintage (< 10 years, 11.9 ± 3.7 μg/dL; 10-19 years, 10.9 ± 2.9 μg/dL; ≥ 20 years, 9.7 ± 3.8 μg/dL). Basal cortisol was negatively correlated with dry weight, β2-microglobulin, creatinine, and lymphocyte count and positively correlated with brachial-ankle pulse wave velocity. Significant negative correlations were observed between basal cortisol and dialysis vintage after adjusting for confounding variables in the multivariate analysis. Standard adrenocorticotropic hormone (ACTH) and corticotropin-releasing hormone (CRH) stimulation tests were performed in 17 patients. Seven patients were diagnosed with adrenal insufficiency and all of them had a long dialysis vintage (≥ 10 years). According to the rapid ACTH test, cortisol responses were significantly decreased in patients with long dialysis vintage compared to those with short dialysis vintage (< 10 years). Similar findings were observed in ten patients without adrenal insufficiency. The CRH loading test showed similar tendencies, although the differences were not statistically significant. CONCLUSIONS Adrenal function decreased with an increase in dialysis vintage. Long-term dialysis patients might be susceptible to adrenal insufficiency.
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Kim J, Yun KS, Cho A, Kim DH, Lee YK, Choi MJ, Kim SH, Kim H, Yoon JW, Park HC. High cortisol levels are associated with oxidative stress and mortality in maintenance hemodialysis patients. BMC Nephrol 2022; 23:98. [PMID: 35260104 PMCID: PMC8903641 DOI: 10.1186/s12882-022-02722-w] [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: 08/15/2021] [Accepted: 03/01/2022] [Indexed: 11/18/2022] Open
Abstract
Background Chronic stimulation of the mineralocorticoid receptor has been suggested as one of the potential causes of cardiovascular events and death in patients with end-stage renal disease. This observational cohort study was performed to demonstrate that serum cortisol might be a predictive marker for patient mortality and to evaluate its association with oxidized low-density lipoprotein (oxLDL) in hemodialysis (HD) patients. Methods Patients receiving HD three times a week were screened for enrollment at two institutions. Baseline cortisol levels were measured before each HD session, and the patients were divided into two groups according to the median value of serum cortisol before analysis. The baseline characteristics and laboratory values of the high and low cortisol groups were compared. Serum cortisol, adrenocorticotropic hormone, renin, aldosterone, and oxLDL were measured in 52 patients to evaluate the effect of oxidative stress on serum cortisol levels. Results A total of 133 HD patients were enrolled in this cohort study. Compared to the patients with low serum cortisol levels, the patients with high serum cortisol levels (baseline cortisol ≥ 10 μg/dL) showed higher rates of cardiovascular disease (59.7% vs. 39.4%, P=0.019) and left ventricular systolic dysfunction (LVSD) (25.9% vs. 8.0%, P=0.016). The patients in the high cortisol group demonstrated higher all-cause mortality than those in the low cortisol group. The serum cortisol level was an independent risk factor for patient mortality (hazard ratio 1.234, 95% confidence interval 1.022-1.49, P=0.029). Among the 52 patients with oxLDL measurements, oxLDL was an independent risk factor for elevated serum cortisol levels (Exp(B) 1.114, P=0.013) and LVSD (Exp(B) 12.308, P=0.045). However, plasma aldosterone levels did not affect serum cortisol levels. Conclusions Serum cortisol is a useful predictive marker for all-cause death among patients receiving HD. OxLDL is an independent marker for elevated serum cortisol among HD patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02722-w.
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Affiliation(s)
- Juhee Kim
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul, 07441, Republic of Korea
| | - Kyu-Sang Yun
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul, 07441, Republic of Korea
| | - Ajin Cho
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul, 07441, Republic of Korea.,Hallym University Kidney Research Institute, Seoul, Korea
| | - Do Hyoung Kim
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul, 07441, Republic of Korea.,Hallym University Kidney Research Institute, Seoul, Korea
| | - Young-Ki Lee
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul, 07441, Republic of Korea.,Hallym University Kidney Research Institute, Seoul, Korea
| | - Myung-Jin Choi
- Department of Internal Medicine, Korean Armed Forces Capital Hospital, Seongnam, Korea
| | - Seok-Hyung Kim
- Hallym University Kidney Research Institute, Seoul, Korea.,Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Hyunsuk Kim
- Hallym University Kidney Research Institute, Seoul, Korea.,Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Jong-Woo Yoon
- Hallym University Kidney Research Institute, Seoul, Korea.,Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Hayne C Park
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul, 07441, Republic of Korea. .,Hallym University Kidney Research Institute, Seoul, Korea.
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5
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Sagmeister MS, Harper L, Hardy RS. Cortisol excess in chronic kidney disease - A review of changes and impact on mortality. Front Endocrinol (Lausanne) 2022; 13:1075809. [PMID: 36733794 PMCID: PMC9886668 DOI: 10.3389/fendo.2022.1075809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/27/2022] [Indexed: 01/18/2023] Open
Abstract
Chronic kidney disease (CKD) describes the long-term condition of impaired kidney function from any cause. CKD is common and associated with a wide array of complications including higher mortality, cardiovascular disease, hypertension, insulin resistance, dyslipidemia, sarcopenia, osteoporosis, aberrant immune function, cognitive impairment, mood disturbances and poor sleep quality. Glucocorticoids are endogenous pleiotropic steroid hormones and their excess produces a pattern of morbidity that possesses considerable overlap with CKD. Circulating levels of cortisol, the major active glucocorticoid in humans, are determined by a complex interplay between several processes. The hypothalamic-pituitary-adrenal axis (HPA) regulates cortisol synthesis and release, 11β-hydroxysteroid dehydrogenase enzymes mediate metabolic interconversion between active and inactive forms, and clearance from the circulation depends on irreversible metabolic inactivation in the liver followed by urinary excretion. Chronic stress, inflammatory states and other aspects of CKD can disturb these processes, enhancing cortisol secretion via the HPA axis and inducing tissue-resident amplification of glucocorticoid signals. Progressive renal impairment can further impact on cortisol metabolism and urinary clearance of cortisol metabolites. Consequently, significant interest exists to precisely understand the dysregulation of cortisol in CKD and its significance for adverse clinical outcomes. In this review, we summarize the latest literature on alterations in endogenous glucocorticoid regulation in adults with CKD and evaluate the available evidence on cortisol as a mechanistic driver of excess mortality and morbidity. The emerging picture is one of subclinical hypercortisolism with blunted diurnal decline of cortisol levels, impaired negative feedback regulation and reduced cortisol clearance. An association between cortisol and adjusted all-cause mortality has been reported in observational studies for patients with end-stage renal failure, but further research is required to assess links between cortisol and clinical outcomes in CKD. We propose recommendations for future research, including therapeutic strategies that aim to reduce complications of CKD by correcting or reversing dysregulation of cortisol.
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Affiliation(s)
- Michael S. Sagmeister
- Institute for Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- *Correspondence: Michael S. Sagmeister,
| | - Lorraine Harper
- Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Rowan S. Hardy
- Institute for Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Research into Inflammatory Arthritis Centre Versus Arthritis, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- Institute of Clinical Science, University of Birmingham, Birmingham, United Kingdom
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6
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Choi SR, Lee YK, Park HC, Kim DH, Cho AJ, Kim J, Yun KS, Noh JW, Kang MK. The paradoxical effect of aldosterone on cardiovascular outcome in maintenance hemodialysis patients. Kidney Res Clin Pract 2021; 41:77-88. [PMID: 34974657 PMCID: PMC8816408 DOI: 10.23876/j.krcp.21.096] [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: 04/25/2021] [Accepted: 07/19/2021] [Indexed: 11/04/2022] Open
Abstract
Background Patients with end-stage kidney disease face increased risk of cardiovascular events, and left ventricular diastolic dysfunction (LVDD) contributes to the high occurrence of cardiovascular mortality (CM). Although a high serum aldosterone (sALD) level is involved in the development of cardiovascular complications in the general population, this association is unclear in patients undergoing hemodialysis. We aimed to determine the impact of sALD on LVDD and CM among hemodialysis patients (HDPs). Methods We performed a prospective cohort study of maintenance HDPs without cardiovascular disease. The patients were divided into two groups according to the median level of sALD. All patients underwent baseline echocardiography to evaluate diastolic dysfunction (E/e´ ratio > 15). The LVDD and CM rates were compared between the high and low aldosterone groups. Results We enrolled a total of 60 adult patients (mean age, 57.9 ± 12.1 years; males, 30.0%). The low aldosterone group had an increased left ventricular diastolic dimension compared with the high aldosterone group (52.2 ± 8.4 mm vs. 50.3 ± 5.2 mm, respectively; p = 0.03). Low log-aldosterone (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.19-0.86) and large left atrial dimension (OR, 1.31; 95% CI, 1.11-1.54) were independent risk factors for LVDD at baseline. In addition, Cox regression analysis demonstrated that low sALD was an independent predictor of CM in HDPs (hazard ratio, 0.46; 95% CI, 0.25-0.85; p = 0.01) during follow-up. Conclusion Low sALD was not only associated with LVDD but was also an independent predictor of CM among HDPs regardless of their interdialytic weight gain.
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Affiliation(s)
- Sun Ryoung Choi
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Dongtan, Republic of Korea.,Kidney Research Institute, Hallym University, Seoul, Republic of Korea
| | - Young-Ki Lee
- Kidney Research Institute, Hallym University, Seoul, Republic of Korea.,Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Hayne Cho Park
- Kidney Research Institute, Hallym University, Seoul, Republic of Korea.,Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Do Hyoung Kim
- Kidney Research Institute, Hallym University, Seoul, Republic of Korea.,Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - AJin Cho
- Kidney Research Institute, Hallym University, Seoul, Republic of Korea.,Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Juhee Kim
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Kyu Sang Yun
- Kidney Research Institute, Hallym University, Seoul, Republic of Korea.,Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Jung-Woo Noh
- Kidney Research Institute, Hallym University, Seoul, Republic of Korea.,Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Min-Kyung Kang
- Department of Cardiology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
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7
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Erraez S, López-Mesa M, Gómez-Fernández P. Mineralcorticoid receptor blockers in chronic kidney disease. Nefrologia 2021; 41:258-275. [PMID: 36166243 DOI: 10.1016/j.nefroe.2021.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 10/17/2020] [Indexed: 06/16/2023] Open
Abstract
There are many experimental data supporting the involvement of aldosterone and mineralcorticoid receptor (MR) activation in the genesis and progression of chronic kidney disease (CKD) and cardiovascular damage. Many studies have shown that in diabetic and non-diabetic CKD, blocking the renin-angiotensin-aldosterone (RAAS) system with conversion enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) decreases proteinuria, progression of CKD and mortality, but there is still a significant residual risk of developing these events. In subjects treated with ACEi or ARBs there may be an aldosterone breakthrough whose prevalence in subjects with CKD can reach 50%. Several studies have shown that in CKD, the aldosterone antagonists (spironolactone, eplerenone) added to ACEi or ARBs, reduce proteinuria, but increase the risk of hyperkalemia. Other studies in subjects treated with dialysis suggest a possible beneficial effect of antialdosteronic drugs on CV events and mortality. Newer potassium binders drugs can prevent/decrease hyperkalemia induced by RAAS blockade, and may reduce the high discontinuation rates or dose reduction of RAAS-blockers. The nonsteroidal MR blockers, with more potency and selectivity than the classic ones, reduce proteinuria and have a lower risk of hyperkalemia. Several clinical trials, currently underway, will determine the effect of classic MR blockers on CV events and mortality in subjects with stage 3b CKD and in dialysis patients, and whether in patients with type 2 diabetes mellitus and CKD, optimally treated and with high risk of CV and kidney events, the addition of finerenone to their treatment produces cardiorenal benefits. Large randomized trials have shown that sodium glucose type 2 cotransporter inhibitors (SGLT2i) reduce mortality and the development and progression of diabetic and nondiabetic CKD. There are pathophysiological arguments, which raise the possibility that the triple combination ACEi or ARBs, SGLT2i and aldosterone antagonist provide additional renal and cardiovascular protection.
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Affiliation(s)
- Sara Erraez
- Unidad de Factores de Riesgo Vascular, Nefrología, Hospital Universitario de Jerez, Jerez de la Frontera, Cádiz, Spain
| | | | - Pablo Gómez-Fernández
- Unidad de Factores de Riesgo Vascular, Nefrología, Hospital Universitario de Jerez, Jerez de la Frontera, Cádiz, Spain.
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8
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Pilz S, Theiler-Schwetz V, Trummer C, Keppel MH, Grübler MR, Verheyen N, Odler B, Meinitzer A, Voelkl J, März W. Associations of Serum Cortisol with Cardiovascular Risk and Mortality in Patients Referred to Coronary Angiography. J Endocr Soc 2021; 5:bvab017. [PMID: 33869979 PMCID: PMC8041336 DOI: 10.1210/jendso/bvab017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Indexed: 12/26/2022] Open
Abstract
CONTEXT Serum cortisol may be associated with cardiovascular risk factors and mortality in patients undergoing coronary angiography, but previous data on this topic are limited and controversial. OBJECTIVE We evaluated whether morning serum cortisol is associated with cardiovascular risk factors, lymphocyte subtypes, and mortality. METHODS This is a prospective cohort study performed at a tertiary care centre in south-west Germany between 1997 and 2000. We included 3052 study participants who underwent coronary angiography. The primary outcome measures were cardiovascular risk factors, lymphocyte subtypes, and all-cause and cardiovascular mortality. RESULTS Serum cortisol was associated with an adverse cardiovascular risk profile, but there was no significant association with coronary artery disease or acute coronary syndrome. In a subsample of 2107 participants, serum cortisol was positively associated with certain lymphocyte subsets, including CD16+CD56+ (natural killer) cells (P < 0.001). Comparing the fourth versus the first serum cortisol quartile, the crude Cox proportional hazard ratios (with 95% CIs) were 1.22 (1.00-1.47) for all-cause and 1.32 (1.04-1.67) for cardiovascular mortality, respectively. After adjustments for various cardiovascular risk factors, these associations were attenuated to 0.93 (0.76-1.14) for all-cause, and 0.97 (0.76-1.25) for cardiovascular mortality, respectively. CONCLUSIONS Despite significant associations with classic cardiovascular risk factors and natural killer cells, serum cortisol was not a significant and independent predictor of mortality in patients referred to coronary angiography. These findings might reflect that adverse cardiovascular effects of cortisol could be counterbalanced by some cardiovascular protective actions.
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Affiliation(s)
- Stefan Pilz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, 8036 Graz, Austria
| | - Verena Theiler-Schwetz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, 8036 Graz, Austria
| | - Christian Trummer
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, 8036 Graz, Austria
| | - Martin H Keppel
- University Institute for Medical and Chemical Laboratory Diagnostics, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Martin R Grübler
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, 8036 Graz, Austria
- Department of Geriatrics and Aging Research, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland
| | - Nicolas Verheyen
- Department of Cardiology, Medical University of Graz, 8036 Graz, Austria
| | - Balazs Odler
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, 8036 Graz, Austria
| | - Andreas Meinitzer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics Medical, University of Graz, 8036 Graz, Austria
| | - Jakob Voelkl
- Institute for Physiology, Johannes Kepler University Linz, 4040 Linz, Austria
- Departments of Nephrology and Medical Intensive Care and Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, 10117 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, 10785 Berlin, Germany
| | - Winfried März
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, 8036 Graz, Austria
- Synlab Academy, 68159 Mannheim, Germany
- Medical Clinic V (Nephrology, Hypertensiology, Rheumatology, Endocrinology, Diabetology), Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany
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9
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[Mineralcorticoid receptor blockers in chronic kidney disease]. Nefrologia 2020; 41:258-275. [PMID: 33358451 DOI: 10.1016/j.nefro.2020.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 08/17/2020] [Accepted: 10/17/2020] [Indexed: 12/12/2022] Open
Abstract
There are many experimental data supporting the involvement of aldosterone and mineralcorticoid receptor (MR) activation in the genesis and progression of chronic kidney disease (CKD) and cardiovascular damage. Many studies have shown that in diabetic and non-diabetic CKD, blocking the renin- angiotensin-aldosterone (RAAS) system with conversion enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) decreases proteinuria, progression of CKD and mortality, but there is still a significant residual risk of developing these events. In subjects treated with ACEi or ARBs there may be an aldosterone breakthrough whose prevalence in subjects with CKD can reach 50%. Several studies have shown that in CKD, the aldosterone antagonists (spironolactone, eplerenone) added to ACEi or ARBs, reduce proteinuria, but increase the risk of hyperkalemia. Other studies in subjects treated with dialysis suggest a possible beneficial effect of antialdosteronic drugs on CV events and mortality. Newer potassium binders drugs can prevent / decrease hyperkalemia induced by RAAS blockade, and may reduce the high discontinuation rates or dose reduction of RAAS-blockers. The nonsteroidal MR blockers, with more potency and selectivity than the classic ones, reduce proteinuria and have a lower risk of hyperkalemia. Several clinical trials, currently underway, will determine the effect of classic MR blockers on CV events and mortality in subjects with stage 3b CKD and in dialysis patients, and whether in patients with type 2 diabetes mellitus and CKD, optimally treated and with high risk of CV and kidney events, the addition of finerenone to their treatment produces cardiorenal benefits. Large randomized trials have shown that sodium glucose type 2 cotransporter inhibitors (SGLT2i) reduce mortality and the development and progression of diabetic and nondiabetic CKD. There are pathophysiological arguments, which raise the possibility that the triple combination ACEi or ARBs, SGLT2i and aldosterone antagonist provide additional renal and cardiovascular protection.
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10
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Affiliation(s)
- Adhish Agarwal
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah Health Center, Salt Lake City, Utah
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah Health Center, Salt Lake City, Utah
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11
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Gosmanova EO, Kovesdy CP. Patient-Centered Approach for Hypertension Management in End-Stage Kidney Disease: Art or Science? Semin Nephrol 2018; 38:355-368. [PMID: 30082056 DOI: 10.1016/j.semnephrol.2018.05.006] [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: 10/28/2022]
Abstract
Hypertension is present in most patients with end-stage kidney disease initiating dialysis and management of hypertension is a routine but challenging task in everyday dialysis care. End-stage kidney disease patients are uniquely heterogeneous individuals with significant variations in demographic characteristics, functional capacity, and presence of concomitant comorbid conditions and their severity. Therefore, these patients require personalized approaches in addressing not only hypertension but related illnesses, while also accounting for overall prognosis and projected longevity. There are only limited clinical trial data to guide individualized blood pressure management and current guidelines are based predominantly on observational evidence and expert opinions. Inthis review, we reflect on the shortcomings of peridialytic blood pressure recordings and discuss an important paradigm shift toward using out-of-dialysis blood pressure for evaluating hypertension control and for making treatment decisions. In addition, we provide our personal view on blood pressure goals and summarize nonpharmacologic and pharmacologic treatment options for individualized management of hypertension in end-stage kidney disease.
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Affiliation(s)
- Elvira O Gosmanova
- Nephrology Section, Stratton VA Medical Center, Albany, NY.; Division of Nephrology, Department of Medicine, Albany Medical College, Albany, NY
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of TennesseeHealth Science Center, Memphis, TN.; Nephrology Section, Memphis VA Medical Center, Memphis, TN..
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12
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Wakino S, Minakuchi H, Miya K, Takamatsu N, Tada H, Tani E, Inamoto H, Minakuchi J, Kawashima S, Itoh H. Aldosterone and Insulin Resistance: Vicious Combination in Patients on Maintenance Hemodialysis. Ther Apher Dial 2017; 22:142-151. [PMID: 29271574 DOI: 10.1111/1744-9987.12632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/20/2017] [Accepted: 08/28/2017] [Indexed: 12/14/2022]
Abstract
Recently, we demonstrated that plasma aldosterone contributed to insulin resistance in chronic kidney disease. The aim of this study is the clinical impact of this relationship in hemodialysis patients. In a cross section study using a total of 128 hemodialysis patients, multiple regression analysis revealed that plasma aldosterone levels were independently associated with HOMA-IR, insulin resistance index. This association was found to be more stringent in diabetic patients than in non-diabetic patients. Aldosterone levels were associated with cardiac hypertrophy and carotid artery stenosis. HOMA-IR was associated with cardiac hypertrophy. The patients whose aldosterone and HOMA-IR were above the top tertile of each parameter in this cohort showed more severe cardiac hypertrophy and lower contractile function as compared with the patients whose aldosterone levels and HOMA-IR are below the lowest tertile of each parameter. In conclusion, in hemodialysis patients, aldosterone levels and insulin resistance are closely interrelated and the constellation of the two is related to severe cardiovascular tissue damages.
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Affiliation(s)
- Shu Wakino
- Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Hitoshi Minakuchi
- Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Keiko Miya
- Department of Internal Medicine, Kawashima Hospital, Tokushima, Japan
| | | | - Hiroaki Tada
- Department of Laboratory Medicine, Kawashima Hospital, Tokushima, Japan
| | - Erina Tani
- Department of Laboratory Medicine, Kawashima Hospital, Tokushima, Japan
| | | | - Jun Minakuchi
- Department of Internal Medicine, Kawashima Hospital, Tokushima, Japan
| | - Shu Kawashima
- Department of Internal Medicine, Kawashima Hospital, Tokushima, Japan
| | - Hiroshi Itoh
- Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
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Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH). J Hypertens 2017; 35:657-676. [PMID: 28157814 DOI: 10.1097/hjh.0000000000001283] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In patients with end-stage renal disease treated with hemodialysis or peritoneal dialysis, hypertension is very common and often poorly controlled. Blood pressure (BP) recordings obtained before or after hemodialysis display a J-shaped or U-shaped association with cardiovascular events and survival, but this most likely reflects the low accuracy of these measurements and the peculiar hemodynamic setting related with dialysis treatment. Elevated BP by home or ambulatory BP monitoring is clearly associated with shorter survival. Sodium and volume excess is the prominent mechanism of hypertension in dialysis patients, but other pathways, such as arterial stiffness, activation of the renin-angiotensin-aldosterone and sympathetic nervous systems, endothelial dysfunction, sleep apnea and the use of erythropoietin-stimulating agents may also be involved. Nonpharmacologic interventions targeting sodium and volume excess are fundamental for hypertension control in this population. If BP remains elevated after appropriate treatment of sodium-volume excess, the use of antihypertensive agents is necessary. Drug treatment in the dialysis population should take into consideration the patient's comorbidities and specific characteristics of each agent, such as dialysability. This document is an overview of the diagnosis, epidemiology, pathogenesis and treatment of hypertension in patients on dialysis, aiming to offer the renal physician practical recommendations based on current knowledge and expert opinion and to highlight areas for future research.
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Abstract
PURPOSE OF REVIEW The purpose of this study was to summarize recent findings about cardiovascular benefits and safety of aldosterone blockade in patients with end-stage renal disease (ESRD). RECENT FINDINGS It is now well recognized that aldosterone's deleterious cardiovascular impact is not limited to its pressor effect arising from an increase in sodium reabsorption in the kidneys. Aldosterone has also been shown to increase blood pressure by a direct activation of the sympathetic nervous system, to cause endothelial and vascular smooth muscle cell dysfunction, myocardial remodeling and fibrosis, and to have pro-arrhythmogenic actions in the heart. These unconventional extra-renal effects of aldosterone make its blockade feasible and potentially beneficial for patients with ESRD. Accumulating data support the idea that aldosterone antagonism leads to a better blood pressure control, reduction in left ventricular (LV) mass, improved LV function, and reduced all-cause and cardiovascular mortality in ESRD patients. Reassuringly, rates of major adverse events, especially, significant hyperkalemia-the most feared adverse consequence-were low with careful patient selection and monitoring.
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Affiliation(s)
- Radmila Lyubarova
- Division of Cardiology, Department of Medicine, Albany Medical College, Albany, NY, USA
| | - Elvira O Gosmanova
- Nephrology Section, Stratton VA Medical Center, 113 Holland Ave, Albany, NY, 12208, USA.
- Division of Nephrology and Hypertension, Department of Medicine, Albany Medical College, Albany, NY, USA.
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Fernández-Reyes M, Velasco S, Gutierrez C, Gonzalez Villalba M, Heras M, Molina A, Callejas R, Rodríguez A, Calle L, Lopes V. Niveles elevados de aldosterona sérica en pacientes en diálisis: ¿estamos infrautilizando los bloqueantes del sistema renina angiotensina aldosterona en diálisis? HIPERTENSION Y RIESGO VASCULAR 2017; 34:108-114. [DOI: 10.1016/j.hipert.2016.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/10/2016] [Accepted: 11/21/2016] [Indexed: 11/26/2022]
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Gungor O, Kocyigit I, Carrero JJ, Yılmaz MI. Hormonal changes in hemodialysis patients: Novel risk factors for mortality? Semin Dial 2017; 30:446-452. [PMID: 28608932 DOI: 10.1111/sdi.12611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients with end-stage renal disease undergoing dialysis commonly experience derangements in the hypothalamic-pituitary-gonadal axis together with alterations at the level of synthesis and clearance of many hormones. This hormonal imbalance, even if asymptomatic, has recently been associated with increased mortality in these patients. In this review, we summarize observational and mechanistic evidence linking hormonal alterations at the level of the thyroid and sex-hormone systems with this mortality risks.
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Affiliation(s)
- Ozkan Gungor
- Nephrology Department, Faculty of Medicine, Kahramanmaraş Sütçü İmam University, Kahramanmaras, Turkey
| | - Ismail Kocyigit
- Nephrology Department, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Juan Jesus Carrero
- Division of Renal Medicine, Centre for Gender Medicine and Centre for Molecular Medicine, Karolinska Institute, Stockholm, Sweden
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Sarafidis PA, Persu A, Agarwal R, Burnier M, de Leeuw P, Ferro CJ, Halimi JM, Heine GH, Jadoul M, Jarraya F, Kanbay M, Mallamaci F, Mark PB, Ortiz A, Parati G, Pontremoli R, Rossignol P, Ruilope L, Van der Niepen P, Vanholder R, Verhaar MC, Wiecek A, Wuerzner G, London GM, Zoccali C. Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH). Nephrol Dial Transplant 2017; 32:620-640. [PMID: 28340239 DOI: 10.1093/ndt/gfw433] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 11/14/2016] [Indexed: 01/07/2023] Open
Abstract
In patients with end-stage renal disease (ESRD) treated with haemodialysis or peritoneal dialysis, hypertension is common and often poorly controlled. Blood pressure (BP) recordings obtained before or after haemodialysis display a J- or U-shaped association with cardiovascular events and survival, but this most likely reflects the low accuracy of these measurements and the peculiar haemodynamic setting related to dialysis treatment. Elevated BP detected by home or ambulatory BP monitoring is clearly associated with shorter survival. Sodium and volume excess is the prominent mechanism of hypertension in dialysis patients, but other pathways, such as arterial stiffness, activation of the renin-angiotensin-aldosterone and sympathetic nervous systems, endothelial dysfunction, sleep apnoea and the use of erythropoietin-stimulating agents may also be involved. Non-pharmacologic interventions targeting sodium and volume excess are fundamental for hypertension control in this population. If BP remains elevated after appropriate treatment of sodium and volume excess, the use of antihypertensive agents is necessary. Drug treatment in the dialysis population should take into consideration the patient's comorbidities and specific characteristics of each agent, such as dialysability. This document is an overview of the diagnosis, epidemiology, pathogenesis and treatment of hypertension in patients on dialysis, aiming to offer the renal physician practical recommendations based on current knowledge and expert opinion and to highlight areas for future research.
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Affiliation(s)
- Pantelis A Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
| | - Michel Burnier
- Service of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland
| | - Peter de Leeuw
- Department of Medicine, Maastricht University Medical Center, Maastricht and Zuyderland Medical Center, Geleen/Heerlen, The Netherlands
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jean-Michel Halimi
- Service de Néphrologie-Immunologie Clinique, Hôpital Bretonneau, François-Rabelais University, Tours, France
| | - Gunnar H Heine
- Saarland University Medical Center, Internal Medicine IV-Nephrology and Hypertension, Homburg, Germany
| | - Michel Jadoul
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Faical Jarraya
- Department of Nephrology, Sfax University Hospital and Research Unit, Faculty of Medicine, Sfax University, Sfax, Tunisia
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz, School of Medicine, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain
| | - Gianfranco Parati
- Department of Cardiovascular, Neural, and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano and Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Roberto Pontremoli
- Università degli Studi and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genova, Italy
| | - Patrick Rossignol
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, UMR 1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, and Association Lorraine de Traitement de l'Insuffisance Rénale, Nancy, France
| | - Luis Ruilope
- Hypertension Unit & Institute of Research i?+?12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Patricia Van der Niepen
- Department of Nephrology and Hypertension, Universitair Ziekenhuis Brussel - VUB, Brussels, Belgium
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, The Netherlands
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Katowice, Poland
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Carmine Zoccali
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
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Jaisser F, Farman N. Emerging Roles of the Mineralocorticoid Receptor in Pathology: Toward New Paradigms in Clinical Pharmacology. Pharmacol Rev 2016; 68:49-75. [PMID: 26668301 DOI: 10.1124/pr.115.011106] [Citation(s) in RCA: 197] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The mineralocorticoid receptor (MR) and its ligand aldosterone are the principal modulators of hormone-regulated renal sodium reabsorption. In addition to the kidney, there are several other cells and organs expressing MR, in which its activation mediates pathologic changes, indicating potential therapeutic applications of pharmacological MR antagonism. Steroidal MR antagonists have been used for decades to fight hypertension and more recently heart failure. New therapeutic indications are now arising, and nonsteroidal MR antagonists are currently under development. This review is focused on nonclassic MR targets in cardiac, vascular, renal, metabolic, ocular, and cutaneous diseases. The MR, associated with other risk factors, is involved in organ fibrosis, inflammation, oxidative stress, and aging; for example, in the kidney and heart MR mediates hormonal tissue-specific ion channel regulation. Genetic and epigenetic modifications of MR expression/activity that have been documented in hypertension may also present significant risk factors in other diseases and be susceptible to MR antagonism. Excess mineralocorticoid signaling, mediated by aldosterone or glucocorticoids binding, now appears deleterious in the progression of pathologies that may lead to end-stage organ failure and could therefore benefit from the repositioning of pharmacological MR antagonists.
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Affiliation(s)
- F Jaisser
- INSERM UMR 1138 Team 1, Cordeliers Research Center, Pierre et Marie Curie University, Paris, France (F.J., N.F); and University Paris-Est Creteil, Creteil, France (F.J.)
| | - N Farman
- INSERM UMR 1138 Team 1, Cordeliers Research Center, Pierre et Marie Curie University, Paris, France (F.J., N.F); and University Paris-Est Creteil, Creteil, France (F.J.)
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Ramesh S, Zalucky A, Hemmelgarn BR, Roberts DJ, Ahmed SB, Wilton SB, Jun M. Incidence of sudden cardiac death in adults with end-stage renal disease: a systematic review and meta-analysis. BMC Nephrol 2016; 17:78. [PMID: 27401469 PMCID: PMC4940956 DOI: 10.1186/s12882-016-0293-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 06/14/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Although sudden cardiac death (SCD) is recognized as a distinct cause of death in patients with end stage renal disease (ESRD), its incidence has not been well summarized. METHODS We performed a systematic review and meta-analysis of the literature based on a protocol developed a priori. We searched MEDLINE and EMBASE (inception to March 2015) for randomized controlled trials and cohort studies reporting the incidence of SCD in adult patients with ESRD on hemodialysis or peritoneal dialysis. We collected data on number of SCD as well as the definition of SCD for each individual study. A random-effects model was used to summarize the incidence of SCD. We conducted subgroup analyses to explore sources of heterogeneity. RESULTS Forty two studies (n = 80,382 patients) were included in the meta-analysis. The incidence of SCD among adults with ESRD ranged from 0.4 to 10.04 deaths per 100 person-years. The definitions and assessment of SCD varied across the included studies. There was evidence of significant heterogeneity (I(2) = 98; p < 0.001), which was not explained by subgroup analyses stratified by mean age, proportion of hypertensive or diabetic patients, follow-up time, study size, or type of cohort studied. CONCLUSION Current estimates of the incidence of SCD among adults with ESRD vary widely. There is a need for further studies to more accurately estimate the incidence of SCD in patients with ESRD.
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Affiliation(s)
- Sharanya Ramesh
- />Cumming School of Medicine, University of Calgary, Calgary, AB Canada
| | - Ann Zalucky
- />Cumming School of Medicine, University of Calgary, Calgary, AB Canada
| | - Brenda R. Hemmelgarn
- />Department of Medicine, Division of Nephrology, University of Calgary, Health Sciences Building, Room G233, 3330 Hospital Drive NW, Calgary, AB T2N 4N1 Canada
- />Department of Community Health Sciences, University of Calgary, Calgary, AB Canada
| | - Derek J. Roberts
- />Department of Community Health Sciences, University of Calgary, Calgary, AB Canada
- />Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, AB Canada
| | - Sofia B. Ahmed
- />Cumming School of Medicine, University of Calgary, Calgary, AB Canada
- />Libin Cardiovascular Institute of Alberta, Calgary, AB Canada
| | - Stephen B. Wilton
- />Cumming School of Medicine, University of Calgary, Calgary, AB Canada
- />Libin Cardiovascular Institute of Alberta, Calgary, AB Canada
| | - Min Jun
- />Department of Medicine, Division of Nephrology, University of Calgary, Health Sciences Building, Room G233, 3330 Hospital Drive NW, Calgary, AB T2N 4N1 Canada
- />Department of Community Health Sciences, University of Calgary, Calgary, AB Canada
- />The George Institute for Global Health, The University of Sydney, Sydney, Australia
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Fülöp T, Zsom L, Rodríguez B, Afshan S, Davidson JV, Szarvas T, Dixit MP, Tapolyai MB, Rosivall L. Clinical Utility of Potassium-Sparing Diuretics to Maintain Normal Serum Potassium in Peritoneal Dialysis Patients. Perit Dial Int 2016; 37:63-69. [PMID: 27282853 DOI: 10.3747/pdi.2016.00022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 04/01/2016] [Indexed: 11/15/2022] Open
Abstract
♦ BACKGROUND: Hypokalemia is a vexing problem in end-stage renal disease patients on peritoneal dialysis (PD), and oral potassium supplements (OPS) have limited palatability. Potassium-sparing diuretics (KSD) (spironolactone, amiloride) may be effective in these patients. ♦ METHODS: We performed a cross-sectional review of 75 current or past (vintage > 6 months) PD patients with regard to serum potassium (K+), OPS, and KSD utilization. We reviewed charts for multiple clinical and laboratory variables, including dialysis adequacy, residual renal function, nutritional status and co-existing medical therapy. ♦ RESULTS: The cohort was middle-aged with a mean age of 49.2 years (standard deviation [SD] = 14.7) and overweight with a body mass index of 29.5 (6.7) kg/m2. Of all the participants, 57.3% were female, 73.3% African-American, and 48% diabetic with an overall PD vintage of 28.2 (24.3) months at the time of enrollment. Weekly Kt/V was 2.12 (0.43), creatinine clearance was 73.5 (33.6) L/week/1.73 m2 with total daily exchange volume of 10.8 (2.7) L. Residual urine output (RUO) measured at 440 (494) mL (anuric 30.6%). Three-month averaged serum K+ measured at 4 (0.5) mmol/L with 36% of the participants receiving K+ supplements (median: 20 [0;20] mmol/day) and 41.3% KSD (spironolactone dose: 25 - 200 mg/day; amiloride dose: 5 - 10 mg/day). Serum K+ correlated positively with weekly Kt/V (r = 0.239; p = 0.039), PD vintage (r = 0.272; p = 0.018) but not with PD modality, daily exchange volume, RUO, or KSD use. However, KSD use was associated with decreased use of OPS (r = -0.646; p < 0.0001). ♦ CONCLUSIONS: Potassium-sparing diuretics were effective in this cohort of PD patients and decreased the need for OPS utilization.
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Affiliation(s)
- Tibor Fülöp
- Department of Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Lajos Zsom
- Department of Surgery, Division of Transplantation, University of Debrecen, Debrecen, Hungary
| | - Betzaida Rodríguez
- Department of Medicine, Division of Hospital Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Sabahat Afshan
- Department of Pediatrics, Division of Pediatric Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jamie V Davidson
- Department of Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Tibor Szarvas
- Department of Mathematics, Louisiana State University Shreveport, LA, USA
| | - Mehul P Dixit
- Department of Pediatrics, Division of Pediatric Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
| | | | - László Rosivall
- Institute of Pathophysiology, Semmelweis University, Budapest, Hungary
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Electrocardiographic Abnormalities and QTc Interval in Patients Undergoing Hemodialysis. PLoS One 2016; 11:e0155445. [PMID: 27171393 PMCID: PMC4865146 DOI: 10.1371/journal.pone.0155445] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 04/28/2016] [Indexed: 01/23/2023] Open
Abstract
Background Sudden cardiac death is one of the primary causes of mortality in chronic hemodialysis (HD) patients. Prolonged QTc interval is associated with increased rate of sudden cardiac death. The aim of this article is to assess the abnormalities found in electrocardiograms (ECGs), and to explore factors that can influence the QTc interval. Methods A total of 141 conventional HD patients were enrolled in this study. ECG tests were conducted on each patient before a single dialysis session and 15 minutes before the end of dialysis session (at peak stress). Echocardiography tests were conducted before dialysis session began. Blood samples were drawn by phlebotomy immediately before and after the dialysis session. Results Before dialysis, 93.62% of the patients were in sinus rhythm, and approximately 65% of the patients showed a prolonged QTc interval (i.e., a QTc interval above 440 ms in males and above 460ms in females). A comparison of ECG parameters before dialysis and at peak stress showed increases in heart rate (77.45±11.92 vs. 80.38±14.65 bpm, p = 0.001) and QTc interval (460.05±24.53 ms vs. 470.93±24.92 ms, p<0.001). After dividing patients into two groups according to the QTc interval, lower pre-dialysis serum concentrations of potassium (K+), calcium (Ca2+), phosphorus, calcium* phosphorus (Ca*P), and higher concentrations of plasma brain natriuretic peptide (BNP) were found in the group with prolonged QTc intervals. Patients in this group also had a larger left atrial diameter (LAD) and a thicker interventricular septum, and they tended to be older than patients in the other group. Then patients were divided into two groups according to ΔQTc (ΔQTc = QTc peak-stress- QTc pre-HD). When analyzing the patients whose QTc intervals were longer at peak stress than before HD, we found that they had higher concentrations of Ca2+ and P5+ and lower concentrations of K+, ferritin, UA, and BNP. They were also more likely to be female. In addition, more cardiac construction abnormalities were found in this group. In multiple regression analyses, serum Ca2+ concentration before HD and LAD were independent variables of QTc interval prolongation. UA, ferritin, and interventricular septum were independent variables of ΔQTc. Conclusion Prolonged QT interval is very common in HD patients and is associated with several risk factors. An appropriate concentration of dialysate electrolytes should be chosen depending on patients’ clinical conditions.
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Haller H, Bertram A, Stahl K, Menne J. Finerenone: a New Mineralocorticoid Receptor Antagonist Without Hyperkalemia: an Opportunity in Patients with CKD? Curr Hypertens Rep 2016; 18:41. [DOI: 10.1007/s11906-016-0649-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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23
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Epstein M. Reduction of cardiovascular risk in chronic kidney disease by mineralocorticoid receptor antagonism. Lancet Diabetes Endocrinol 2015; 3:993-1003. [PMID: 26429402 DOI: 10.1016/s2213-8587(15)00289-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/24/2015] [Accepted: 07/30/2015] [Indexed: 12/24/2022]
Abstract
Cardiovascular disease is the leading cause of death and morbidity in people with chronic kidney disease, but there are few evidence-based treatments for reducing cardiovascular events in these patients. The failure of novel drug candidates to delay progression to end-stage renal disease and limit or abrogate cardiovascular morbidity and mortality has led to increased interest in a mineralocorticoid receptor (MR) antagonist-based treatment model to reduce cardiovascular risk in patients with chronic kidney disease and end-stage renal disease. Aldosterone concentrations and MR signalling are associated with an enhanced risk of cardiovascular injury and the incidence of sudden death, and MR blockade decreases the risk of cardiovascular events and sudden death in patients with reduced glomerular filtration rate. Since evidence from clinical trials shows that treatment with MR antagonists confers a morbidity and mortality advantage for patients with cardiovascular disorders, similar benefits might also accrue in patients with chronic kidney disease. Large prospective trials are urgently needed to answer this question. In this Review, I argue that despite differences in the pathophysiology and clinical features of cardiovascular disease in patients with and without chronic kidney disease, MR antagonists could provide cardiovascular benefit in patients with chronic kidney disease.
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Affiliation(s)
- Murray Epstein
- Division of Nephrology and Hypertension, University of Miami, Leonard M Miller School of Medicine, Miami, FL, USA.
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Abd ElHafeez S, Tripepi G, Mallamaci F, Zoccali C. Aldosterone, mortality, cardiovascular events and reverse epidemiology in end stage renal disease. Eur J Clin Invest 2015; 45:1077-86. [PMID: 26343265 DOI: 10.1111/eci.12509] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 07/22/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Plasma aldosterone is markedly increased in end stage renal disease (ESRD). The relationship between aldosterone, all-cause and cardiovascular (CV) mortality in observational studies performed so far is controversial. DESIGN We investigated the relationship between aldosterone, mortality and CV events in multivariate analyses including nutrition status, inflammation, LV function and fluids volume biomarkers in 278 ESRD patients without heart failure at baseline. RESULTS In univariate analyses aldosterone was an inverse predictor of death (3rd tertile vs. 1st tertile Hazard ratios (HR): 0·58; 95% confidence interval (CI) 0·38-0·90. P = 0·01) and CV events (HR: 0·63; 95% CI 0·41-0·96; P = 0·03). Data adjustment for inflammation and malnutrition biomarkers substantially reduced the inverse relationship between aldosterone, mortality and CV events to be largely not significant (P = 0·31 and P = 0·36, respectively). The same was true by adjusting for volume expansion and LV dysfunction (left atrial volume and atrial natriuretic peptide) biomarkers (P = 0·30 for both outcomes). In a model adjusting for the full set of biomarkers of protein energy wasting/inflammation and volume expansion/LV dysfunction the inverse relationship between aldosterone and death and CV events was nullified (HR for death 0·98, P = 0·93; HR for CV events 0·96, P = 0·87). CONCLUSIONS Aldosterone is an inverse predictor of mortality and CV events in ESRD patients. This seemingly paradoxical relationship is abolished by statistical adjustment for inflammation, protein energy malnutrition, and volume expansion biomarkers indicating that it is the mere expression of the confounding effect of these factors. A clinical trial is needed to establish if aldosterone antagonism may improve clinical outcomes in ESRD.
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Affiliation(s)
- Samar Abd ElHafeez
- Department of Epidemiology, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Giovanni Tripepi
- CNR - IFC/IBIM Clinical Epidemiology and Physiopathology of Renal Disease and Hypertension, Reggio Calabria, Italy
| | - Francesca Mallamaci
- CNR - IFC/IBIM Clinical Epidemiology and Physiopathology of Renal Disease and Hypertension, Reggio Calabria, Italy
| | - Carmine Zoccali
- CNR - IFC/IBIM Clinical Epidemiology and Physiopathology of Renal Disease and Hypertension, Reggio Calabria, Italy
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Suthar SD, Middleton JP. Clinical Outcomes in Dialysis Patients: Prospects for Improvement with Aldosterone Receptor Antagonists. Semin Dial 2015; 29:52-61. [DOI: 10.1111/sdi.12421] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Samantha Dias Suthar
- Division of Nephrology; Department of Medicine; Duke University School of Medicine; Durham North Carolina
| | - John P. Middleton
- Division of Nephrology; Department of Medicine; Duke University School of Medicine; Durham North Carolina
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Güder G, Hammer F, Deutschbein T, Brenner S, Berliner D, Deubner N, Bidlingmaier M, Ertl G, Allolio B, Angermann CE, Fassnacht M, Störk S. Prognostic Value of Aldosterone and Cortisol in Patients Hospitalized for Acutely Decompensated Chronic Heart Failure With and Without Mineralocorticoid Receptor Antagonism. J Card Fail 2015; 21:208-16. [DOI: 10.1016/j.cardfail.2014.12.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 12/10/2014] [Accepted: 12/19/2014] [Indexed: 01/10/2023]
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The relationship of serum cortisol levels with depression, cognitive function and sleep disorders in chronic kidney disease and hemodialysis patients. Psychiatr Q 2014; 85:479-86. [PMID: 25069791 DOI: 10.1007/s11126-014-9307-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In the present study, the relationships between cortisol, cognitive function, depressive behavior, and sleep quality in chronic kidney disease (CKD) and hemodialysis (HD) patients was investigated. Patients underwent history taking, physical examination, biochemical analysis, 24-h urine collection (for CKD patients only), measurement of dialysis adequacy (for HD patients only), evaluation of cognitive function, depressive behavior and sleep quality. Among study participants 58 had creatinine clearance ≥60 mL/min/1.73 m(2) (Group 1), 41 had creatinine clearance between 30 and 59 mL/min/1.73 m(2) (Group 2), 25 had creatinine clearance between 15 and 29 mL/min/1.73 m(2) (Group 3) and 12 had creatinine clearance <15 mL/min/1.73 m(2) (Group 4). 38 patients were regular HD patients (Group 5). The cortisol levels in Group 1, 2, 3, 4 and 5 patients were 472.3 ± 138.4, 490.2 ± 214.3, 541.6 ± 172.8, 569.9 ± 101.0 and 637.8 ± 153.7 nmol/L, respectively (P < 0.0001 for trend). In both non-dialysis patient group and dialysis patients linear regression analysis showed that cortisol was independently related with Beck depression inventory (BDI) score (P: 0.013 and 0.001, respectively) but not with cognitive function and sleep quality. In conclusion serum cortisol levels were independently associated with depressive behavior both in CKD and HD patients but not with cognitive function and sleep quality.
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Gravez B, Tarjus A, Jaisser F. Mineralocorticoid receptor and cardiac arrhythmia. Clin Exp Pharmacol Physiol 2014; 40:910-5. [PMID: 23888997 DOI: 10.1111/1440-1681.12156] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 07/15/2013] [Accepted: 07/21/2013] [Indexed: 01/21/2023]
Abstract
Mineralocorticoid receptor (MR) activation has been shown to play a deleterious role in the development of heart disease in studies using specific MR antagonists (spironolactone, eplerenone) in both experimental models and patients. Pharmacological MR blockade attenuates the transition to heart failure (HF) in models of systolic left ventricular dysfunction and myocardial infarction, as well as diastolic dysfunction, in rats and mice. In humans, MR antagonism is highly beneficial in patients with mild or advanced HF and postinfarct HF. The consequences of aldosterone and MR activation for cardiac arrhythmia and its prevention and/or correction by MR antagonists are often underestimated. Activation of MR modulates cardiac electrical activity, causing atrial and ventricular arrhythmias. A pro-arrhythmogenic effect of aldosterone (possibly partly dependent on fibrosis) has been suggested by several studies. Cardiac MR activation has important consequences for the control of cellular calcium homeostasis, action potential lengthening, modulation of calcium transients and sarcoplasmic reticulum diastolic leaks, resulting in the promotion of rhythm disorders. Aldosterone and/or MR activation (in both cardiomyocytes and coronary vessels) result in vascular dysfunction and also contribute to pro-arrhythmogenic conditions. Together, the pro-arrhythmic effects of aldosterone and/or MR may explain the highly beneficial effect of MR antagonism, namely a decrease in the incidence of sudden death, observed in the Randomized Aldactone Evaluation Study (RALES) and Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) studies.
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Affiliation(s)
- Basile Gravez
- INSERM UMR 872 Team 1, Centre de Recherche des Cordeliers, University Pierre and Marie Curie, Paris, France
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Deo R, Yang W, Khan AM, Bansal N, Zhang X, Leonard MB, Keane MG, Soliman EZ, Steigerwalt S, Townsend RR, Shlipak MG, Feldman HI. Serum aldosterone and death, end-stage renal disease, and cardiovascular events in blacks and whites: findings from the Chronic Renal Insufficiency Cohort (CRIC) Study. Hypertension 2014; 64:103-10. [PMID: 24752431 DOI: 10.1161/hypertensionaha.114.03311] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Prior studies have demonstrated that elevated aldosterone concentrations are an independent risk factor for death in patients with cardiovascular disease. Limited studies, however, have evaluated systematically the association between serum aldosterone and adverse events in the setting of chronic kidney disease. We investigated the association between serum aldosterone and death and end-stage renal disease in 3866 participants from the Chronic Renal Insufficiency Cohort. We also evaluated the association between aldosterone and incident congestive heart failure and atherosclerotic events in participants without baseline cardiovascular disease. Cox proportional hazards models were used to evaluate independent associations between elevated aldosterone concentrations and each outcome. Interactions were hypothesized and explored between aldosterone and sex, race, and the use of loop diuretics and renin-angiotensin-aldosterone system inhibitors. During a median follow-up period of 5.4 years, 587 participants died, 743 developed end-stage renal disease, 187 developed congestive heart failure, and 177 experienced an atherosclerotic event. Aldosterone concentrations (per SD of the log-transformed aldosterone) were not an independent risk factor for death (adjusted hazard ratio, 1.00; 95% confidence interval, 0.93-1.12), end-stage renal disease (adjusted hazard ratio, 1.07; 95% confidence interval, 0.99-1.17), or atherosclerotic events (adjusted hazard ratio, 1.04; 95% confidence interval, 0.85-1.18). Aldosterone was associated with congestive heart failure (adjusted hazard ratio, 1.21; 95% confidence interval, 1.02-1.35). Among participants with chronic kidney disease, higher aldosterone concentrations were independently associated with the development of congestive heart failure but not for death, end-stage renal disease, or atherosclerotic events. Further studies should evaluate whether mineralocorticoid receptor antagonists may reduce adverse events in individuals with chronic kidney disease because elevated cortisol levels may activate the mineralocorticoid receptor.
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Affiliation(s)
- Rajat Deo
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.).
| | - Wei Yang
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Abigail M Khan
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Nisha Bansal
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Xiaoming Zhang
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Mary B Leonard
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Martin G Keane
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Elsayed Z Soliman
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Susan Steigerwalt
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Raymond R Townsend
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Michael G Shlipak
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Harold I Feldman
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
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30
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Vázquez E, Sánchez-Perales C, García-García F, García-Cortés MJ, Torres J, Borrego F, Salas D, Liébana A, Fernandez-Guerrero JC. Sudden death in incident dialysis patients. Am J Nephrol 2014; 39:331-6. [PMID: 24751807 DOI: 10.1159/000360547] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 02/10/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Sudden death (SD) constitutes one of the principal causes of death and is an important problem in healthcare provision. Cardiovascular diseases have a high prevalence in dialysis patients and constitute the principal cause of death. We sought to analyze retrospectively the incidence of SD in patients commencing dialysis and the factors related to its presence. METHODS We evaluated all the patients who began dialysis in our center between 1/11/2003 and 15/9/2007, and who were followed up until death, transplant, or study completion on 31/12/2012. We determined the presence of SD according to the following criteria: SD at 24 h (SD 24H): unexpected death occurring in the 24 h following the start of symptoms, or when the patient was found dead and had been seen alive 24 h earlier; SD at 1 h (SD 1H): death witnessed as occurring in the first hour following the start of symptoms. RESULTS We evaluated 285 patients, mean age 65.67 ± 15.7 years. In a follow-up of 39.9 ± 34.2 months (947.6 patient-years of follow-up) 168 died (59%), 28 (10%) patients presented SD 24H (2.9/100 patient-years), and 16 (6%) patients presented SD 1H (1.7/100 patient-years). In the multivariate analysis, having had a myocardial infarction or having had electrocardiographic abnormalities (Q wave, negative T wave, subendocardial lesion or QRS >120 ms) were the principal independent predictors of SD 24H (OR 7.83; 95% CI 2.20-27.86; p = 0.001) and of SD 1H (OR 13.43; 95% CI 1.56-115.42; p = 0.018). CONCLUSIONS SD on dialysis is very frequent. Two groups can be identified easily, with risk profiles clearly differentiated.
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Affiliation(s)
- Eduardo Vázquez
- Department of Cardiology, Complejo Hospitalario de Jaén, Jaén, Spain
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31
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Mark PB, Taylor AHM, McQuarrie EP, Jardine AG. How is the heart best protected in chronic dialysis patients?: Is there life in the old drugs yet? Mineralocorticoid receptor antagonism for cardiovascular prevention in chronic dialysis patients. Semin Dial 2014; 27:328-32. [PMID: 24499322 DOI: 10.1111/sdi.12178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
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32
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Tomaschitz A, Ritz E, Pieske B, Rus-Machan J, Kienreich K, Verheyen N, Gaksch M, Grübler M, Fahrleitner-Pammer A, Mrak P, Toplak H, Kraigher-Krainer E, März W, Pilz S. Aldosterone and parathyroid hormone interactions as mediators of metabolic and cardiovascular disease. Metabolism 2014; 63:20-31. [PMID: 24095631 DOI: 10.1016/j.metabol.2013.08.016] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Revised: 08/26/2013] [Accepted: 08/28/2013] [Indexed: 01/09/2023]
Abstract
Inappropriate aldosterone and parathyroid hormone (PTH) secretion is strongly linked with development and progression of cardiovascular (CV) disease. Accumulating evidence suggests a bidirectional interplay between parathyroid hormone and aldosterone. This interaction may lead to a disproportionally increased risk of CV damage, metabolic and bone diseases. This review focuses on mechanisms underlying the mutual interplay between aldosterone and PTH as well as their potential impact on CV, metabolic and bone health. PTH stimulates aldosterone secretion by increasing the calcium concentration in the cells of the adrenal zona glomerulosa as a result of binding to the PTH/PTH-rP receptor and indirectly by potentiating angiotensin 2 induced effects. This may explain why after parathyroidectomy lower aldosterone levels are seen in parallel with improved cardiovascular outcomes. Aldosterone mediated effects are inappropriately pronounced in conditions such as chronic heart failure, excess dietary salt intake (relative aldosterone excess) and primary aldosteronism. PTH is increased as a result of (1) the MR (mineralocorticoid receptor) mediated calciuretic and magnesiuretic effects with a trend of hypocalcemia and hypomagnesemia; the resulting secondary hyperparathyroidism causes myocardial fibrosis and disturbed bone metabolism; and (2) direct effects of aldosterone on parathyroid cells via binding to the MR. This adverse sequence is interrupted by mineralocorticoid receptor blockade and adrenalectomy. Hyperaldosteronism due to klotho deficiency results in vascular calcification, which can be mitigated by spironolactone treatment. In view of the documented reciprocal interaction between aldosterone and PTH as well as the potentially ensuing target organ damage, studies are needed to evaluate diagnostic and therapeutic strategies to address this increasingly recognized pathophysiological phenomenon.
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Affiliation(s)
- Andreas Tomaschitz
- Department of Cardiology, Medical University of Graz, Graz, Austria; Specialist Clinic for Rehabilitation PV Bad Aussee, Bad Aussee, Austria.
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33
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Poulikakos D, Banerjee D, Malik M. Risk of sudden cardiac death in chronic kidney disease. J Cardiovasc Electrophysiol 2013; 25:222-31. [PMID: 24256575 DOI: 10.1111/jce.12328] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 11/12/2013] [Indexed: 12/14/2022]
Abstract
The review discusses the epidemiology and the possible underlying mechanisms of sudden cardiac death (SCD) in chronic kidney disease (CKD), and highlights the unmet clinical need for noninvasive risk stratification strategies in these patients. Although renal dysfunction shares common risk factors and often coexists with atherosclerotic cardiovascular disease, the presence of renal impairment increases the risk of arrhythmic complications to an extent that cannot be explained by the severity of the atherosclerotic process. Renal impairment is an independent risk factor for SCD from the early stages of CKD; the risk increases as renal function declines and reaches very high levels in patients with end-stage renal disease on dialysis. Autonomic imbalance, uremic cardiomyopathy, and electrolyte disturbances likely play a role in increasing the arrhythmic risk and can be potential targets for treatment. Cardioverter defibrillator treatment could be offered as lifesaving treatment in selected patients, although selection strategies for this treatment mode are presently problematic in dialyzed patients. The review also examines the current experience with risk stratification tools in renal patients and suggests that noninvasive electrophysiological testing during dialysis may be of clinical value as it provides the necessary standardized environment for reproducible measurements for risk stratification purposes.
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Affiliation(s)
- Dimitrios Poulikakos
- Cardiovascular Sciences Research Centre, St. George's University of London, London, UK; Renal and Transplantation Unit, St. George's Hospital NHS Trust, London, UK
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34
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Ritz E, Tomaschitz A. Aldosterone and the kidney: a rapidly moving frontier (an update). Nephrol Dial Transplant 2013; 29:2012-9. [PMID: 24194611 DOI: 10.1093/ndt/gft035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Beyond the classical effect of aldosterone on sodium reabsorption in the distal nephron, the spectrum of aldosterone-induced effects on the kidney (and the cardiovascular system) continues to expand at a rapid pace. Blockade of this system has become an attractive target for intervention. Major contributions have been reported in the past 2-3 years. By necessity this brief summary addresses only some of the emerging issues of nephrological relevance. In this fast moving field, we try to give a concise discussion of papers with potential nephrological relevance in the past 2-3 years.
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Affiliation(s)
- Eberhard Ritz
- Nierenzentrum, Im Neuenheimer Feld 162, Heidelberg, Germany
| | - Andreas Tomaschitz
- Department of Cardiology, Medical University Graz, Graz, Austria Specialist Clinic for Rehabilitation PV Bad Aussee, Bad Aussee, Austria
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35
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Meuwese CL, Carrero JJ. Chronic Kidney Disease and Hypothalamic–Pituitary Axis Dysfunction: The Chicken or the Egg? Arch Med Res 2013; 44:591-600. [DOI: 10.1016/j.arcmed.2013.10.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 10/15/2013] [Indexed: 10/26/2022]
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