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David-Neto E, Filho MPM, de Sá ÍJAS, Agena F, de Andrade JL, de Paula FJ. The impact of mTOR inhibitors in the regression of left ventricular hypertrophy in elderly kidney transplant recipients. Clin Transplant 2022; 36:e14742. [PMID: 35678134 DOI: 10.1111/ctr.14742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/24/2022] [Accepted: 06/02/2022] [Indexed: 11/27/2022]
Abstract
End-stage kidney disease is frequently associated with left ventricular hypertrophy (LVH), a condition more prevalent in the elderly, that may increase mortality after renal transplantation (RTx). Previous studies suggested that mTOR inhibitors (mTORi) can improve LVH, but this has never been tested in elderly kidney transplant recipients. In this prospective randomized clinical trial, we analyzed the impact of Everolimus (EVL) on the reversal of LVH after RTx in elderly recipients (≥60 years) submitted to different immunosuppressive regimens: EVL/lowTacrolimus (EVL group, n = 53) or mycophenolate sodium/regularTacrolimus (MPS group, n = 47). Patients performed echocardiograms (Echo) up to 3 months after RTx and then annually. At baseline, mean age was 65±3 years in both groups and LVH was observed in 63.6% of patients in EVL group and in 61.8% of MPS group. Last Echo was performed at mean time of 47 and 49 months after RTx in EVL and MPS groups, respectively (P = .34). LVH regression was observed in 23.8% (EVL group) and 19% (MPS group) of patients (P = 1.00). Mean eGFR, blood pressure, and use of RAS blockers were similar between groups throughout follow-up. EVL did not improve LVH in this cohort, and this lack of benefit may be attributed to concomitant use of TAC, senescence, or both.
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Affiliation(s)
- Elias David-Neto
- Kidney Transplant Service, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Marcelo Paes Menezes Filho
- Kidney Transplant Service, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Fabiana Agena
- Kidney Transplant Service, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - José Lázaro de Andrade
- Echochardiographic Service of the Image and Radiology Institute, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Flávio Jota de Paula
- Kidney Transplant Service, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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2
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Braunisch MC, Gundel P, Werfel S, Mayer CC, Bauer A, Haller B, Günthner R, Lorenz G, Angermann S, Matschkal J, Schaller C, Holzmann-Littig C, Kemmner S, Mann J, Krieter A, Renders L, Wassertheurer S, Schmidt G, Heemann U, Malik M, Schmaderer C. Electrocardiographic parameters of left ventricular hypertrophy and prediction of mortality in hemodialysis patients. J Nephrol 2022; 35:233-244. [PMID: 34014512 PMCID: PMC8803820 DOI: 10.1007/s40620-021-01068-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/09/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND In hemodialysis patients, left ventricular hypertrophy (LVH) contributes to high cardiovascular mortality. We examined cardiovascular mortality prediction by the recently proposed Peguero-Lo Presti voltage since it identifies more patients with electrocardiographic (ECG) LVH than Cornell or Sokolow-Lyon voltages. METHODS A total of 308 patients on hemodialysis underwent 24 h ECG recordings. LVH parameters were measured before and after dialysis. The primary endpoint of cardiovascular mortality was recorded during a median 3-year follow up. Risk prediction was assessed by Cox regression, both unadjusted and adjusted for the Charlson Comorbidity Index and the Cardiovascular Mortality Risk Score. RESULTS The Peguero-Lo Presti voltage identified with 21% the most patients with positive LVH criteria. All voltages significantly increased during dialysis. Factors such as ultrafiltration rate, Kt/V, body mass index, sex, and phosphate were the most relevant for these changes. During follow-up, 26 cardiovascular deaths occurred. Post-dialysis Peguero-Lo Presti cut-off as well as the Peguero-Lo Presti and Cornell voltages were independently associated with cardiovascular mortality in unadjusted and adjusted analysis. The Sokolow-Lyon voltage was not significantly associated with mortality. An optimal cut-off for the prediction of cardiovascular mortality was estimated at 1.38 mV for the Peguero-Lo Presti. CONCLUSIONS The post-dialysis Peguero-Lo Presti cut-off as well as the Peguero-Lo Presti and Cornell voltages allowed independent risk prediction of cardiovascular mortality in hemodialysis patients. Measuring the ECG LVH parameters after dialysis might allow a standardized interpretation as dialysis-specific factors influence the voltages.
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Affiliation(s)
- Matthias C Braunisch
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Peter Gundel
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Klinik für Innere Medizin 4, Schwerpunkt Nephrologie und Hypertensiologie, Klinikum Nürnberg, Nuremberg, Germany
| | - Stanislas Werfel
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christopher C Mayer
- Center for Health and Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Axel Bauer
- University Hospital for Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
- Department of Cardiology, Munich University Clinic, DZHK (German Centre for Cardiovascular Research), Ludwig-Maximilians University, Munich, Germany
| | - Bernhard Haller
- Institute of Medical Informatics, Statistics and Epidemiology (IMedIS), School of Medicine, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Roman Günthner
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Georg Lorenz
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Susanne Angermann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Julia Matschkal
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Carolin Schaller
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christopher Holzmann-Littig
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- TUM Medical Education Center, School of Medicine, Technical University of Munich, Munich, Germany
| | - Stephan Kemmner
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Transplant Center, University Hospital Munich, Ludwig-Maximillians University (LMU), Munich, Germany
| | - Johannes Mann
- Department of Nephrology, University of Erlangen-Nürnberg, Erlangen, Germany
- KfH Kidney Center Munich, Isoldenstraße 15, Munich, Germany
| | - Axel Krieter
- Nephrocare München-Ost, Rosenkavalierplatz 5, Munich, Germany
| | - Lutz Renders
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Siegfried Wassertheurer
- Center for Health and Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Georg Schmidt
- School of Medicine, Klinik für Innere Medizin I, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Uwe Heemann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Marek Malik
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Christoph Schmaderer
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.
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Leache L, Gutiérrez-Valencia M, Finizola RM, Infante E, Finizola B, Pardo Pardo J, Flores Y, Granero R, Arai KJ. Pharmacotherapy for hypertension-induced left ventricular hypertrophy. Cochrane Database Syst Rev 2021; 10:CD012039. [PMID: 34628642 PMCID: PMC8502530 DOI: 10.1002/14651858.cd012039.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hypertension is the leading preventable risk factor for cardiovascular disease and premature death worldwide. One of the clinical effects of hypertension is left ventricular hypertrophy (LVH), a process of cardiac remodelling. It is estimated that over 30% of people with hypertension also suffer from LVH, although the prevalence rates vary according to the LVH diagnostic criteria. Severity of LVH is associated with a higher prevalence of cardiovascular disease and an increased risk of death. The role of antihypertensives in the regression of left ventricular mass has been extensively studied. However, uncertainty exists regarding the role of antihypertensive therapy compared to placebo in the morbidity and mortality of individuals with hypertension-induced LVH. OBJECTIVES To assess the effect of antihypertensive pharmacotherapy compared to placebo or no treatment on morbidity and mortality of adults with hypertension-induced LVH. SEARCH METHODS Cochrane Hypertension's Information Specialist searched the following databases for studies: Cochrane Hypertension Specialised Register (to 26 September 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2020, Issue 9), Ovid MEDLINE (1946 to 22 September 2020), and Ovid Embase (1974 to 22 September 2020). We searched the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov for ongoing trials. We also searched Epistemonikos (to 19 February 2021), LILACS BIREME (to 19 February 2021), and Clarivate Web of Science (to 26 February 2021), and contacted authors and funders of the identified trials to obtain additional information and individual participant data. There were no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) with at least 12 months' follow-up comparing antihypertensive pharmacological therapy (monotherapy or in combination) with placebo or no treatment in adults (18 years of age or older) with hypertension-induced LVH were eligible for inclusion. The trials must have analysed at least one primary outcome (all-cause mortality, cardiovascular events, or total serious adverse events) to be considered for inclusion. DATA COLLECTION AND ANALYSIS Two review authors screened the search results, with any disagreements resolved by consensus amongst all review authors. Two review authors carried out the data extraction and analyses. We assessed risk of bias of the included studies following Cochrane methodology. We used the GRADE approach to assess the certainty of the body of evidence. MAIN RESULTS We included three multicentre RCTs. We selected 930 participants from the included studies for the analyses, with a mean follow-up of 3.8 years (range 3.5 to 4.3 years). All of the included trials performed an intention-to-treat analysis. We obtained evidence for the review by identifying the population of interest from the trials' total samples. None of the trials provided information on the cause of LVH. The intervention varied amongst the included trials: hydrochlorothiazide plus triamterene with the possibility of adding alpha methyldopa, spironolactone, or olmesartan. Placebo was administered to participants in the control arm in two trials, whereas participants in the control arm of the remaining trial did not receive any add-on treatment. The evidence is very uncertain regarding the effect of additional antihypertensive pharmacological therapy compared to placebo or no treatment on mortality (14.3% intervention versus 13.6% control; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.74 to 1.40; 3 studies; 930 participants; very low-certainty evidence); cardiovascular events (12.6% intervention versus 11.5% control; RR 1.09, 95% CI 0.77 to 1.55; 3 studies; 930 participants; very low-certainty evidence); and hospitalisation for heart failure (10.7% intervention versus 12.5% control; RR 0.82, 95% CI 0.57 to 1.17; 2 studies; 915 participants; very low-certainty evidence). Although both arms yielded similar results for total serious adverse events (48.9% intervention versus 48.1% control; RR 1.02, 95% CI 0.89 to 1.16; 3 studies; 930 participants; very low-certainty evidence) and total adverse events (68.3% intervention versus 67.2% control; RR 1.07, 95% CI 0.86 to 1.34; 2 studies; 915 participants), the incidence of withdrawal due to adverse events may be significantly higher with antihypertensive drug therapy (15.2% intervention versus 4.9% control; RR 3.09, 95% CI 1.69 to 5.66; 1 study; 522 participants; very low-certainty evidence). Sensitivity analyses limited to blinded trials, trials with low risk of bias in core domains, and trials with no funding from the pharmaceutical industry did not change the results of the main analyses. Limited evidence on the change in left ventricular mass index prevented us from drawing any firm conclusions. AUTHORS' CONCLUSIONS We are uncertain about the effects of adding additional antihypertensive drug therapy on the morbidity and mortality of participants with LVH and hypertension compared to placebo. Although the incidence of serious adverse events was similar between study arms, additional antihypertensive therapy may be associated with more withdrawals due to adverse events. Limited and low-certainty evidence requires that caution be used when interpreting the findings. High-quality clinical trials addressing the effect of antihypertensives on clinically relevant variables and carried out specifically in individuals with hypertension-induced LVH are warranted.
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Affiliation(s)
- Leire Leache
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain
| | | | - Rosa M Finizola
- Unit of Special Projects, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | - Elizabeth Infante
- Unit of Systems, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | - Bartolome Finizola
- General Coordination, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | - Jordi Pardo Pardo
- Centre for Practice-Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, Ottawa, Canada
| | - Yris Flores
- Echocardiography Department and Cardiac Tomography Department, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | | | - Kaduo J Arai
- Coronary Care Unit, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
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De Luca MR, Sorriento D, Massa D, Valente V, De Luise F, Barbato E, Morisco C. Effects of inhibition of the renin-angiotensin system on hypertension-induced target organ damage: clinical and experimental evidence. Monaldi Arch Chest Dis 2021; 91. [PMID: 33567818 DOI: 10.4081/monaldi.2021.1570] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/03/2020] [Indexed: 11/23/2022] Open
Abstract
The dysregulation of renin-angiotensin-system (RAS) plays a pivotal role in hypertension and in the development of the related target organ damage (TOD). The main goal of treating hypertension is represented by the long-term reduction of cardiovascular (CV) risk. RAS inhibition either by angiotensin converting enzyme (ACE)-inhibitors or by type 1 Angiotensin II receptors blockers (ARBs), reduce the incidence of CV events in hypertensive patients. Actually, ACE-inhibitors and ARBs have been demonstrated to be effective to prevent, or delay TOD like left ventricular hypertrophy, chronic kidney disease, and atherosclerosis. The beneficial effects of RAS blockers on clinical outcome of hypertensive patients are due to the key role of angiotensin II in the pathogenesis of TOD. In particular, Angiotensin II through an inflammatory-mediated mechanism plays a role in the initiation, progression and vulnerability of atherosclerotic plaque. In addition, Angiotensin II can be considered the hormonal transductor of the pressure overload in cardiac myocytes, and through an autocrine-paracrine mechanism plays a role in the development of left ventricular hypertrophy. Angiotensin II by modulating the redox status and the immune system participates to the development of chronic kidney disease. The RAS blocker should be considered the first therapeutic option in patients with hypertension, even if ACE-inhibitors and ARBs have different impact on CV prevention. ARBs seem to have greater neuro-protective effects, while ACE-inhibitors have greater cardio-protective action.
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Affiliation(s)
| | - Daniela Sorriento
- Department of Advanced Biomedical Sciences, Federico II University of Naples.
| | - Domenico Massa
- Department of Advanced Biomedical Sciences, Federico II University of Naples.
| | - Valeria Valente
- Department of Translational Medical Sciences, Federico II University of Naples.
| | - Federica De Luise
- Department of Advanced Biomedical Sciences, Federico II University of Naples.
| | - Emanuele Barbato
- Department of Advanced Biomedical Sciences, Federico II University of Naples.
| | - Carmine Morisco
- Department of Advanced Biomedical Sciences, Federico II University of Naples.
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High-sensitivity Troponin T in hemodialysis patients: a randomized placebo-controlled sub-study investigating angiotensin-II-blockade, variation over time and associations with clinical outcome. BMC Nephrol 2020; 21:452. [PMID: 33115436 PMCID: PMC7594269 DOI: 10.1186/s12882-020-02103-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 10/14/2020] [Indexed: 11/15/2022] Open
Abstract
Background Troponin T (TnT) is a well-known risk factor for negative outcome in hemodialysis (HD) patients, but little is known about variation over time, and the impact of clinical and dialysis specific factors. This study investigated the effect of angiotensin II receptor blockade (ARB), short and long-term variation in TnT and associations with clinical parameters. Methods In this analysis based on the SAFIR-cohort (Clinical Trials ID: NCT00791830) 81 HD patients were randomized double-blind for placebo (n = 40) or angiotensin II receptor blocker (ARB) treatment (n = 41) with irbesartan (150–300 mg) and followed for 12 months with six serial measurements of TnT using a high-sensitivity assay. Results Fifty-four patients (67%) completed follow-up. Baseline TnT-medians (min-max) were (placebo/ARB): 45(14–295)/46(10–343) ng/L. ARB-treatment did not significantly affect mean TnT-levels over the 12-month study period. Median week-to-week and one-year TnT-variation (5th–95th-percentile range) using all samples regardless of intervention were: 0(− 14–10) ng/L (week-to-week) and 3(− 40–71) ng/L (12 months). Median TnT-amplitude, capturing the change from the lowest to the highest TnT-value observed during the one-year study period was 38% or 20.5 ng/L. Median ratios with 95% limits of agreement were: 1.00(0.73–1.37); P = 0.92 (1 week/baseline; n = 77) and 1.07(0.52–2.25); P = 0.19 (12 months/baseline; n = 54). Baseline TnT was positively correlated with diabetes, ultrafiltration volume, arterial stiffness, change in intradialytic total peripheral resistance and N-terminal pro b-type natriuretic peptide (NT-proBNP) and negatively correlated with hematocrit, residual renal function and change in intradialytic cardiac output. High baseline TnT was associated with a higher risk of admission and cardiovascular (CV) events during follow-up. Increase in TnT over time (ΔTnT = 12-months-baseline) was significantly associated with increase in left ventricular (LV) mass and NT-proBNP and decrease in LV ejection fraction and late intradialytic stroke volume. ΔTnT was not significantly associated with admissions, CV or intradialytic hypotensive events during follow-up. Admissions were significantly more likely with a high (TnT-amplitude> 20.5 ng/L) than a low TnT-amplitude. Peaks in TnT were less frequent in aspirin-treated patients. Conclusion ARB-treatment had no significant effect on TnT-levels. Week-to-week variation was generally low, yet over 12 months individual patients had considerable TnT fluctuations. Rise in TnT over time was significantly correlated with markers of cardiac deterioration. Trial registration ClinicalTrials.gov Identifier: NCT00791830. Date of registration: November 17, 2008. EudraCT no: 2008–001267-11. Supplementary information Supplementary information accompanies this paper at 10.1186/s12882-020-02103-1.
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Xu Y, Li X, Zuo X, Jia H, Han E, Liang F, Xie L, Gao J. Effects of coenzyme Q10 on endothelial and cardiac function in patients undergoing haemodialysis: study protocol for a pilot randomised controlled trial. BMJ Open 2020; 10:e036732. [PMID: 32873669 PMCID: PMC7467521 DOI: 10.1136/bmjopen-2019-036732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Endothelial and cardiac dysfunction are highly prevalent and are associated with cardiovascular morbidity and mortality among patients undergoing dialysis. For patients undergoing dialysis, no study has explored the effect of supplementation of coenzyme Q10 (CoQ10) on endothelial function. To our best of knowledge, only two small sample studies focused on the efficacy of supplementation of CoQ10 on cardiac function. However, the effect of CoQ10 supplementation on cardiac function remains uncertain in patients who undergo haemodialysis. The aim of this study is to explore whether CoQ10 supplementation can improve endothelial and cardiac function in patients undergoing haemodialysis. METHODS AND ANALYSIS This is a pilot randomised controlled study. Eligible patients undergoing haemodialysis in our haemodialysis centre will be randomly allocated to the CoQ10 and control groups. The follow-up time is 12 months. The primary outcome is to assess the change of brachial artery endothelial-dependent flow-mediated dilation, left ventricular systolic function, diastolic function and Myocardial Performance Index at 12 months from baseline. Secondary outcomes are death or hospitalisation due to cardiovascular events, all-cause mortality, change of CoQ10 concentration, the ratio of ubiquinol to ubiquinone, the change of oxidative stress markers (including malondialdehyde and 8-hydroxy-deoxyguanosine) and Left Ventricular Mass Index. ETHICS AND DISSEMINATION Risks associated with CoQ10 are minor, even at doses as high as 1800 mg according to previous studies. The trial has received ethics approval from the Medical Ethics Committee for Clinical Trials of Drugs, the 306th Hospital of Chinese PLA. The results of the study are expected to be published in a peer-reviewed journal and presented at academic conferences. TRIAL REGISTRATION NUMBER ChiCTR1900022258.
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Affiliation(s)
- Yongxing Xu
- Department of Nephrology, Chinese PLA Strategic Support Force Characteristic Medical Center (The 306th Hospital of Chinese PLA), Beijing, China
| | - Xinlou Li
- Department of Medical Research, Chinese PLA Strategic Support Force Characteristic Medical Center (The 306th Hospital of Chinese PLA), Beijing, China
| | - Xiaowen Zuo
- Department of Ultrasound in Medicine, Chinese PLA Strategic Support Force Characteristic Medical Center (The 306th Hospital of Chinese PLA), Beijing, China
| | - Huaping Jia
- Department of Ultrasound in Medicine, Chinese PLA Strategic Support Force Characteristic Medical Center (The 306th Hospital of Chinese PLA), Beijing, China
| | - Enhong Han
- Department of Nephrology, Chinese PLA Strategic Support Force Characteristic Medical Center (The 306th Hospital of Chinese PLA), Beijing, China
| | - Fugui Liang
- Department of Nephrology, Chinese PLA Strategic Support Force Characteristic Medical Center (The 306th Hospital of Chinese PLA), Beijing, China
| | - Lei Xie
- Department of Nephrology, Chinese PLA Strategic Support Force Characteristic Medical Center (The 306th Hospital of Chinese PLA), Beijing, China
| | - Jianjun Gao
- Department of Nephrology, Chinese PLA Strategic Support Force Characteristic Medical Center (The 306th Hospital of Chinese PLA), Beijing, China
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Aftab RA, Sellappans R, Ming CK, Shaik I. Taking a Step Further in Identifying Ideal Blood Pressure Range Among Hemodialysis Patients: A Systematic Review and a Meta-Analysis. Front Pharmacol 2020; 11:729. [PMID: 32528285 PMCID: PMC7265661 DOI: 10.3389/fphar.2020.00729] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 05/01/2020] [Indexed: 02/02/2023] Open
Abstract
Background Hypertension is one of the primary predictor of mortality among end-stage renal disease (ESRD) patients on dialysis. However, there is no consensus on an ideal blood pressure range for this population. Aims and Objective To identify an ideal systolic blood pressure range based on optimal survival among ESRD patients on dialysis. Method A systematic search for clinical trials assessing the impact of different systolic blood pressure range on mortality among ESRD patients on hemodialysis was conducted through PubMed, EBSCOhost, Science Direct, Google Scholar, and Scopus. All randomized control trials (RCTs) involving ESRD patients on hemodialysis with primary or secondary outcome of assessing the impact different systolic blood pressure range (< 140 and >140 mm Hg) on all-cause mortality were included. The quality of reporting of the included studies was evaluated using the Jadad scale. Two researchers independently conducted eligibility assessment. Discrepancies were resolved by discussion and consultation with a third researcher when needed. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated. Results A total of 1,787 research articles were identified during the initial search, after which six RCTs met our inclusion criteria. According to the Jadad scale, all six RCTs scored 3 points each for quality of reporting. Four RCTs employed pharmacological intervention while two RCTs assessed non-pharmacological intervention. Of the six RCTs, two studies were able to achieve a systolic blood pressure of <140 mm Hg at the end of trial with a RR for reduction in mortality of 0.56 (95% CI, 0.3–1.07; P = 0.08). Four RCTs were able to achieve a systolic blood pressure of >140 mm Hg at the end of trial, with the RR for reduction of mortality of 0.72 (95% CI, 0.54–0.96; P = 0.003). Overall, pooled estimates of the six RCTs suggested the reduction in systolic blood pressure statistically reduce all cause of mortality (RR, 0.69%; 95% CI, 0.53–0.90; P = 0.006) among ESRD patients on hemodialysis. Conclusion Though not statically significant, the current study identifies <140 mm Hg as a promising blood pressure range for optimum survival among ESRD patients on hemodialysis. However, further studies are required to establish an ideal blood pressure range among hemodialysis patients. Systematic Review Registration The study protocol was registered under PROSPERO (CRD42019121102).
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Affiliation(s)
- Raja Ahsan Aftab
- Faculty of Health and Medical Sciences, School of Pharmacy, Taylor's University, Subang Jaya, Malaysia
| | - Renukha Sellappans
- Faculty of Health and Medical Sciences, School of Pharmacy, Taylor's University, Subang Jaya, Malaysia
| | - Cheong Kah Ming
- Faculty of Health and Medical Sciences, School of Pharmacy, Taylor's University, Subang Jaya, Malaysia
| | - Imam Shaik
- Faculty of Health and Medical Science, School of Medicine, Taylor's University, Subang Jaya, Malaysia
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Lee HF, See LC, Chan YH, Yeh YH, Wu LS, Liu JR, Tu HT, Wang CL, Kuo CT, Chang SH. End-stage renal disease patients using angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may reduce the risk of mortality: a Taiwanese Nationwide cohort study. Intern Med J 2018; 48:1123-1132. [DOI: 10.1111/imj.13971] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 05/06/2018] [Accepted: 05/17/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Hsin-Fu Lee
- Department of Cardiology, Chang Gung Memorial Hospital; Chang Gung University; Linkou Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine; Chang Gung University; Taoyuan Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine; Chang Gung University; Taoyuan Taiwan
- Biostatistics Core Laboratory, Molecular Medicine Research Center; Chang Gung University; Taoyuan Taiwan
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine; Chang Gung Memorial Hospital; Linkou Taiwan
| | - Yi-Hsin Chan
- Department of Cardiology, Chang Gung Memorial Hospital; Chang Gung University; Linkou Taiwan
| | - Yung-Hsin Yeh
- Department of Cardiology, Chang Gung Memorial Hospital; Chang Gung University; Linkou Taiwan
| | - Lung-Sheng Wu
- Department of Cardiology, Chang Gung Memorial Hospital; Chang Gung University; Linkou Taiwan
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine; Chang Gung University; Taoyuan Taiwan
| | - Hui-Tzu Tu
- Department of Public Health, College of Medicine; Chang Gung University; Taoyuan Taiwan
| | - Chun-Li Wang
- Department of Cardiology, Chang Gung Memorial Hospital; Chang Gung University; Linkou Taiwan
| | - Chi-Tai Kuo
- Department of Cardiology, Chang Gung Memorial Hospital; Chang Gung University; Linkou Taiwan
| | - Shang-Hung Chang
- Department of Cardiology, Chang Gung Memorial Hospital; Chang Gung University; Linkou Taiwan
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Karaboyas A, Xu H, Morgenstern H, Locatelli F, Jadoul M, Nitta K, Dasgupta I, Tentori F, Port FK, Robinson BM. DOPPS data suggest a possible survival benefit of renin angiotensin-aldosterone system inhibitors and other antihypertensive medications for hemodialysis patients. Kidney Int 2018; 94:589-598. [PMID: 29908836 DOI: 10.1016/j.kint.2018.03.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 02/28/2018] [Accepted: 03/15/2018] [Indexed: 11/25/2022]
Abstract
The benefits of renin angiotensin-aldosterone system inhibitors (RAASi) are well-established in the general population, particularly among those with diabetes, congestive heart failure (CHF), or coronary artery disease (CAD). However, conflicting evidence from trials and concerns about hyperkalemia limit RAASi use in hemodialysis patients, relative to other antihypertensive agents, including beta blockers and calcium channel blockers. Therefore, we investigated prescription patterns and associations with mortality for RAASi and other antihypertensive agents using data from the international Dialysis Outcomes and Practice Patterns Study (DOPPS). Cox regression was used to estimate the effect of the prescription of RAASi and other antihypertensive agents at study entry on mortality in 11,421 incident (120 days or less) hemodialysis and 37,124 prevalent (over 120 days) hemodialysis patients from DOPPS phases 2-5 (2002-2015). Over 95% of RAASi were angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. RAASi prevalence was 39% and varied minimally by CHF and CAD. The adjusted hazard ratio for RAASi (vs. no RAASi) was 0.89 (95% confidence interval 0.80-0.99) among incident and 0.94 (0.90-0.99) among prevalent hemodialysis patients, with no convincing evidence of interaction with diabetes, CAD or CHF. Inverse associations with mortality were also observed for beta blockers and calcium channel blockers, and were stronger for angiotensin receptor blockers than angiotensin-converting enzyme inhibitors, but this latter finding requires further study. Thus, our observations suggest a relatively small survival benefit of RAASi and other antihypertensive agents in hemodialysis patients, though randomized prospective studies are needed to potentially change prescribing criteria.
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Affiliation(s)
- Angelo Karaboyas
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA.
| | - Hairong Xu
- Global Medical Affairs, AstraZeneca, Gaithersburg, Maryland, USA
| | - Hal Morgenstern
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA; University of Michigan, Departments of Epidemiology and Environmental Health Sciences, School of Public Health, and Department of Urology, Medical School, Ann Arbor, Michigan, USA
| | | | - Michel Jadoul
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Kosaku Nitta
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | | | | | - Friedrich K Port
- University of Michigan, Department of Internal Medicine, Ann Arbor, Michigan, USA
| | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA; University of Michigan, Department of Internal Medicine, Ann Arbor, Michigan, 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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Huang J, Huang H, Pan W, Ou D, Dai W, Lin Y, Wu J, Xie W, Chen X. Renal denervation attenuates cardiac hypertrophy in spontaneously hypertensive rats via regulation of autophagy. Mol Med Rep 2017. [PMID: 28627693 PMCID: PMC5562017 DOI: 10.3892/mmr.2017.6790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
It has been suggested that renal denervation (RD) may attenuate left ventricular (LV) hypertrophy. However, the role that autophagy serves in this process is currently unclear. In the present study, utilizing a model of hypertension-induced cardiac hypertrophy in spontaneous hypertensive rats, it was demonstrated that RD was significantly associated with a reduction in LV hypertrophy. Furthermore, a decrease in the myocardial mRNA of hypertrophy-associated genes was demonstrated in RD rats compared with sham controls. In addition, RD in hypertension-induced LV hypertrophy rats was associated with the attenuation of cellular autophagic response over activation at a physiological level. This was indicated by a reduction in the expression of Beclin-1, autophagy related 9A and microtubule-associated protein 1A/1B-light chain 3 II/I in RD rats to physiological levels that are observed in control rats. Furthermore, the number of autophagosomes was restored to physiological levels in the cardiomyocytes of RD rats. The results of the current study suggest that RD may attenuate LV hypertrophy via the regulation of autophagic responses.
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Affiliation(s)
- Jionghua Huang
- Department of Cardiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, P.R. China
| | - He Huang
- Department of Cardiology, The First Affiliated Hospital of Gannan Medical College, Ganzhou, Jiangxi 341000, P.R. China
| | - Wei Pan
- Department of Cardiology, Nanhai Hospital Affiliated to Southern Medical University, Foshan, Guangdong 528200, P.R. China
| | - Dejin Ou
- Department of Laboratory Medicine, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, P.R. China
| | - Wenjun Dai
- Department of Cardiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, P.R. China
| | - Yuhui Lin
- Department of Cardiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, P.R. China
| | - Jinlei Wu
- Department of Cardiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, P.R. China
| | - Wenjie Xie
- Department of Cardiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, P.R. China
| | - Ximing Chen
- Department of Cardiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, P.R. China
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12
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Shen JI, Saxena AB, Montez-Rath ME, Chang TI, Winkelmayer WC. Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use and cardiovascular outcomes in patients initiating peritoneal dialysis. Nephrol Dial Transplant 2017; 32:862-869. [PMID: 27190342 DOI: 10.1093/ndt/gfw053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 02/22/2016] [Indexed: 11/14/2022] Open
Abstract
Background Data on the effectiveness of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) in reducing cardiovascular (CV) risk in patients undergoing peritoneal dialysis (PD) are limited. We investigated the association between ACEI/ARB use and CV outcomes in patients initiating PD. Methods In this observational cohort study, we identified from the United States Renal Data System all adult patients who initiated PD from 2007 to 2011 and participated in Medicare Part D, a federal prescription drug benefits program, for the first 90 days of dialysis. Patients who filled a prescription for an ACEI or ARB in those 90 days were considered users. We applied Cox regression to an inverse probability of treatment weighted cohort to estimate the hazard ratios (HRs) for the combined outcome of death, ischemic stroke or myocardial infarction (MI) and each outcome individually. Results Among 4879 patients, 2063 (42%) used an ACEI/ARB. Patients were followed up for a median of 1.2 years. We recorded 1771 events, for a composite rate of 25 events per 100 person-years. ACEI/ARB use (versus nonuse) was associated with a reduced risk of the composite outcome {HR 0.84 [95% confidence interval (CI) 0.76-0.93]}, all-cause mortality [HR 0.83 (95% CI 0.75-0.92)] and CV death [HR 0.74 (95% CI 0.63-0.87)], but not MI [HR 0.88 (95% CI 0.69-1.12)] or ischemic stroke [HR 1.06 (95% CI 0.79-1.43)]. Results were similar in as-treated analyses. In a subgroup analysis, we did not find any effect modification by residual renal function. Conclusions ACEI/ARB use is common in patients initiating PD and is associated with a lower risk of fatal CV outcomes.
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Affiliation(s)
- Jenny I Shen
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1000 W. Carson St., C-1 Annex, Torrance, CA, USA.,Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Anjali B Saxena
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tara I Chang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Wolfgang C Winkelmayer
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.,Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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13
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Iyngkaran P, Liew D, McDonald P, Thomas MC, Reid C, Chew D, Hare DL. Phase 4 Studies in Heart Failure - What is Done and What is Needed? Curr Cardiol Rev 2016; 12:216-30. [PMID: 27280303 PMCID: PMC5011189 DOI: 10.2174/1573403x12666160606121458] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 12/18/2015] [Accepted: 01/11/2016] [Indexed: 02/07/2023] Open
Abstract
Congestive heart failure (CHF) therapeutics is generated through a well-described evidence generating process. Phases 1 - 3 of this process are required prior to approval and widespread clinical use. Phase 3 in almost all cases is a methodologically sound randomized controlled trial (RCT). After this phase it is generally accepted that the treatment has a significant, independent and prognostically beneficial effect on the pathophysiological process. A major criticism of RCTs is the population to whom the result is applicable. When this population is significantly different from the trial cohort the external validity comes into question. Should the continuation of the evidence generating process continue these problems might be identified. Post marketing surveillance through phase 4 and comparative effectiveness studies through phase 5 trials are often underperformed in comparison to the RCT. These processes can help identify remote adverse events and define new hypotheses for community level benefits. This review is aimed at exploring the post-marketing scene for CHF therapeutics from an Australian health system perspective. We explore the phases of clinical trials, the level of evidence currently available and options for ensuring greater accountability for community level CHF clinical outcomes.
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Affiliation(s)
- Pupalan Iyngkaran
- Cardiologist & Senior Lecturer NT Medical School, Flinders University, Australia.
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Omae K, Ogawa T, Yoshikawa M, Sakura H, Nitta K. Impact of serum potassium on therapeutic prognosis of maintenance hemodialysis patients on angiotensin receptor antagonists. RENAL REPLACEMENT THERAPY 2016. [DOI: 10.1186/s41100-016-0026-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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15
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Shireman TI, Mahnken JD, Phadnis MA, Ellerbeck EF, Wetmore JB. Comparative Effectiveness of Renin-Angiotensin System Antagonists in Maintenance Dialysis Patients. Kidney Blood Press Res 2016; 41:873-885. [PMID: 27871075 DOI: 10.1159/000452590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND/AIMS Whether angiotensin converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) are differentially associated with reductions in cardiovascular events and mortality in patients receiving maintenance dialysis is uncertain. We compared outcomes between ACE and ARB users among hypertensive, maintenance dialysis patients. METHODS National retrospective cohort study of hypertensive, Medicare-Medicaid eligible patients initiating chronic dialysis between 1/1/2000 to 12/31/2005. The exposure of interest was new use of either an ACEI or ARB. Outcomes were all-cause mortality (ACM) and combined cardiovascular hospitalization or death (CV-endpoint). Cox proportion hazards models were used to compare the effect of ACEI vs ARB use on ACM and, separately, CV-endpoint. RESULTS ACM models were based on 3,555 ACEI and 1,442 ARB new users, while CV-endpoint models included 3,289 ACEI and 1,346 ARB new users. After statistical adjustments, ACEI users had higher hazard ratios for ACM (AHR = 1.22, 99% CI 1.05-1.42) and CV-endpoint (AHR = 1.12, 99% CI 0.99-1.27). CONCLUSIONS Patients initiating maintenance dialysis who received an ACEI faced an increased risk for mortality and a trend towards an increased risk for CV-endpoints when compared to patients who received an ARB. Validation of these results in a rigorous clinical trial is warranted.
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Affiliation(s)
- Theresa I Shireman
- Center for Gerontology & Health Care Research, Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
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Abstract
Among patients on dialysis, hypertension is highly prevalent and contributes to the high burden of cardiovascular morbidity and mortality. Strict volume control via sodium restriction and probing of dry weight are first-line approaches for the treatment of hypertension in this population; however, antihypertensive drug therapy is often needed to control BP. Few trials compare head-to-head the superiority of one antihypertensive drug class over another with respect to improving BP control or altering cardiovascular outcomes; accordingly, selection of the appropriate antihypertensive regimen should be individualized. To individualize therapy, consideration should be given to intra- and interdialytic pharmacokinetics, effect on cardiovascular reflexes, ability to treat comorbid illnesses, and adverse effect profile. β-Blockers followed by dihydropyridine calcium-channel blockers are our first- and second-line choices for antihypertensive drug use. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers seem to be reasonable third-line choices, because the evidence base to support their use in patients on dialysis is sparse. Add-on therapy with mineralocorticoid receptor antagonists in specific subgroups of patients on dialysis (i.e., those with severe congestive heart failure) seems to be another promising option in anticipation of the ongoing trials evaluating their efficacy and safety. Adequately powered, multicenter, randomized trials evaluating hard cardiovascular end points are urgently warranted to elucidate the comparative effectiveness of antihypertensive drug classes in patients on dialysis. In this review, we provide an overview of the randomized evidence on pharmacotherapy of hypertension in patients on dialysis, and we conclude with suggestions for future research to address critical gaps in this important area.
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Affiliation(s)
- Panagiotis I. Georgianos
- Division of Nephrology and Hypertension, First Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indianapolis; and
- Division of Nephrology, Department of Medicine, Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indianapolis
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Georgianos PI, Agarwal R. Epidemiology, diagnosis and management of hypertension among patients on chronic dialysis. Nat Rev Nephrol 2016; 12:636-47. [PMID: 27573731 DOI: 10.1038/nrneph.2016.129] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The diagnosis and management of hypertension among patients on chronic dialysis is challenging. Routine peridialytic blood pressure recordings are unable to accurately diagnose hypertension and stratify cardiovascular risk. By contrast, blood pressure recordings taken outside the dialysis setting exhibit clear prognostic associations with survival and might facilitate the diagnosis and long-term management of hypertension. Once accurately diagnosed, management of hypertension in individuals on chronic dialysis should initially involve non-pharmacological strategies to control volume overload. Accordingly, first-line strategies should focus on achieving dry weight, individualizing dialysate sodium concentrations and ensuring dialysis sessions are at least 4 h in duration. If blood pressure remains unresponsive to volume management strategies, pharmacological treatment is required. The choice of appropriate antihypertensive regimen should be individualized taking into account the efficacy, safety, and pharmacokinetic properties of the antihypertensive medications as well as any comorbid conditions and the overall risk profile of the patient. In contrast to their effects in the general hypertensive population, emerging evidence suggests that β-blockers might offer the greatest cardioprotection in hypertensive patients on dialysis. In this Review, we discuss estimates of the epidemiology of hypertension in the dialysis population as well as the challenges in diagnosing and managing hypertension among these patients.
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Affiliation(s)
- Panagiotis I Georgianos
- Division of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, St. Kyriakidi 1, Thessaloniki GR54006, Greece
| | - Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Mail Code: 111N, 1481 West 10th Street, Indianapolis 46202-2884 USA
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Wang AYM, Brimble KS, Brunier G, Holt SG, Jha V, Johnson DW, Kang SW, Kooman JP, Lambie M, McIntyre C, Mehrotra R, Pecoits-Filho R. ISPD Cardiovascular and Metabolic Guidelines in Adult Peritoneal Dialysis Patients Part II - Management of Various Cardiovascular Complications. Perit Dial Int 2016; 35:388-96. [PMID: 26228783 DOI: 10.3747/pdi.2014.00278] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Cardiovascular mortality has remained high in patients on peritoneal dialysis (PD) due to the high prevalence of various cardiovascular complications including coronary artery disease, left ventricular hypertrophy and dysfunction, heart failure, arrhythmia (especially atrial fibrillation), cerebrovascular disease, and peripheral arterial disease. In addition, nearly a quarter of PD patients develop sudden cardiac death as the terminal life event. Thus, it is essential to identify effective treatment that may lower cardiovascular mortality and improve survival of PD patients. The International Society for Peritoneal Dialysis (ISPD) commissioned a global workgroup in 2012 to formulate a series of recommendation statements regarding lifestyle modification, assessment and management of various cardiovascular risk factors, and management of the various cardiovascular complications to be published in 2 guideline documents. This publication forms the second part of the guideline documents and includes recommendation statements on the management of various cardiovascular complications in adult chronic PD patients. The documents are intended to serve as a global clinical practice guideline for clinicians who look after PD patients. We also define areas where evidence is clearly deficient and make suggestions for future research in each specific area.
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Affiliation(s)
| | - K Scott Brimble
- St. Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada
| | - Gillian Brunier
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Stephen G Holt
- Division of Nephrology, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Vivekanand Jha
- George Institute for Global Health India, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - David W Johnson
- University of Queensland at Princess Alexandra Hospital, Brisbane, Australia Centre for Kidney Disease Research, Translational Research Institute, Brisbane, Australia
| | - Shin-Wook Kang
- Department of Internal Medicine, College of Medicine, Severance Biomedical Science Institute, Yonsei University, Korea
| | - Jeroen P Kooman
- Division of Nephrology, University Hospital Maastricht, Maastricht, The Netherlands
| | - Mark Lambie
- Health Services Research Unit, Institute for Science and Technology in Medicine, Keele University, Keele, Staffordshire, United Kingdom
| | - Chris McIntyre
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, United Kingdom
| | - Rajnish Mehrotra
- Harborview Medical Center, Division of Nephrology/Department of Medicine, University of Washington, Washington, DC, United States
| | - Roberto Pecoits-Filho
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
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Slomka T, Lennon ES, Akbar H, Gosmanova EO, Bhattacharya SK, Oliphant CS, Khouzam RN. Effects of Renin-Angiotensin-Aldosterone System Blockade in Patients with End-Stage Renal Disease. Am J Med Sci 2016; 351:309-16. [DOI: 10.1016/j.amjms.2015.12.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 12/04/2015] [Indexed: 01/27/2023]
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Tanaka M, Yamashita T, Koyama M, Moniwa N, Ohno K, Mitsumata K, Itoh T, Furuhashi M, Ohnishi H, Yoshida H, Tsuchihashi K, Miura T. Impact of use of angiotensin II receptor blocker on all-cause mortality in hemodialysis patients: prospective cohort study using a propensity-score analysis. Clin Exp Nephrol 2015; 20:469-78. [PMID: 26500097 DOI: 10.1007/s10157-015-1182-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 10/07/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND It is controversial whether treatment with an angiotensin II receptor blocker (ARB) or a calcium channel blocker (CCB) improves prognosis of hemodialysis (HD) patients. METHODS This study was designed as a multicenter prospective cohort study. HD patients (n = 1071) were enrolled from 22 institutes in January 2009 and followed up for 3 years. Patients with missing data, kidney transplantation or retraction of consent during the follow-up period (n = 204) were excluded, and 867 patients contributed to analysis of mortality. Propensity score (PS) for use of ARB and that for CCB was calculated using a multiple logistic regression model. RESULTS ARB and CCB were prescribed in 45.6 and 54.7 % of patients at enrollment. During the 3-year follow-up period, all-cause mortality and cardiovascular mortality rates were 18.8 and 5.1 %, respectively. Kaplan-Meier curves showed that all-cause and cardiovascular mortality rates were lower in the ARB group than in the non-ARB group, though the mortality rates were similar in the CCB group and non-CCB group. In PS-stratified Cox regression analysis, ARB treatment was associated with 34 and 45 % reduction of all-cause death and cardiovascular death, respectively. In PS matching analysis, ARB treatment was associated with a significant reduction (46 % reduction) in the risk of all-cause death. A significant impact of CCB treatment on all-cause or cardiovascular mortality was not detected in PS analysis. CONCLUSIONS The use of an ARB, but not a CCB, is associated with reduced all-cause and cardiovascular mortalities in patients on HD.
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Affiliation(s)
- Marenao Tanaka
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, S-1, W-16, Chuo-ku, Sapporo, 060-8543, Japan.
| | - Tomohisa Yamashita
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, S-1, W-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Masayuki Koyama
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, S-1, W-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Norihito Moniwa
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, S-1, W-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Kohei Ohno
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, S-1, W-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Kaneto Mitsumata
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, S-1, W-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Takahito Itoh
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, S-1, W-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Masato Furuhashi
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, S-1, W-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Hirofumi Ohnishi
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, S-1, W-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Hideaki Yoshida
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, S-1, W-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Kazufumi Tsuchihashi
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, S-1, W-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Tetsuji Miura
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, S-1, W-16, Chuo-ku, Sapporo, 060-8543, Japan
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Peters CD, Kjaergaard KD, Jensen JD, Christensen KL, Strandhave C, Tietze IN, Novosel MK, Bibby BM, Jespersen B. Short and Long-Term Effects of the Angiotensin II Receptor Blocker Irbesartan on Intradialytic Central Hemodynamics: A Randomized Double-Blind Placebo-Controlled One-Year Intervention Trial (the SAFIR Study). PLoS One 2015; 10:e0126882. [PMID: 26030651 PMCID: PMC4452642 DOI: 10.1371/journal.pone.0126882] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 03/08/2015] [Indexed: 01/29/2023] Open
Abstract
Background and Aim Little is known about the tolerability of antihypertensive drugs during hemodialysis treatment. The present study evaluated the use of the angiotensin II receptor blocker (ARB) irbesartan. Design Randomized, double-blind, placebo-controlled, one-year intervention trial. Setting and Participants Eighty-two hemodialysis patients with urine output >300 mL/day and dialysis vintage <1 year. Intervention Irbesartan/placebo 300 mg/day for 12 months administered as add-on to antihypertensive treatment using a predialytic systolic blood pressure target of 140 mmHg in all patients. Outcomes and Measurements Cardiac output, stroke volume, central blood volume, total peripheral resistance, mean arterial blood pressure, and frequency of intradialytic hypotension. Results At baseline, the groups were similar regarding age, comorbidity, blood pressure, antihypertensive medication, ultrafiltration volume, and dialysis parameters. Over the one-year period, predialytic systolic blood pressure decreased significantly, but similarly in both groups. Mean start and mean end cardiac output, stroke volume, total peripheral resistance, heart rate, and mean arterial pressure were stable and similar in the two groups, whereas central blood volume increased slightly but similarly over time. The mean hemodynamic response observed during a dialysis session was a drop in cardiac output, in stroke volume, in mean arterial pressure, and in central blood volume, whereas heart rate increased. Total peripheral resistance did not change significantly. Overall, this pattern remained stable over time in both groups and was uninfluenced by ARB treatment. The total number of intradialytic hypotensive episodes was (placebo/ARB) 50/63 (P = 0.4). Ultrafiltration volume, left ventricular mass index, plasma albumin, and change in intradialytic total peripheral resistance were significantly associated with intradialytic hypotension in a multivariate logistic regression analysis based on baseline parameters. Conclusion Use of the ARB irbesartan as an add-on to other antihypertensive therapy did not significantly affect intradialytic hemodynamics, neither in short nor long-term, and no significant increase in hypotensive episodes was seen. Trial registration Clinicaltrials.gov NCT00791830
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Affiliation(s)
- Christian Daugaard Peters
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Krista Dybtved Kjaergaard
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Dam Jensen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | | | | | - Bo Martin Bibby
- Department of Biostatistics, Aarhus University, Aarhus, Denmark
| | - Bente Jespersen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Suzuki H, Kikuta T, Inoue T, Hamada U. Time to re-evaluate effects of renin-angiotensin system inhibitors on renal and cardiovascular outcomes in diabetic nephropathy. World J Nephrol 2015; 4:118-26. [PMID: 25664254 PMCID: PMC4317622 DOI: 10.5527/wjn.v4.i1.118] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 11/13/2014] [Accepted: 12/03/2014] [Indexed: 02/06/2023] Open
Abstract
The use of renin-angiotensin system (RAS) inhibitors, such angiotensin converting enzyme inhibitors/angiotensin-II receptor blockers, to slow progression of chronic kidney disease (CKD) in a large group dominated by elderly people in the real world is not supported by available evidence. Large-scale clinical trials had many faults, among them a lack of focus on the elderly. However, it would be difficult to conduct clinical trials of a similar scale in elderly CKD patients. Besides, progression of kidney disease is often slow in elderly persons, and the vast majority of older adults with CKD will die before reaching end stage renal disease. Moreover, since it is not clear that progression of kidney disease, and even of proteinuric diabetic nephropathy, is not inhibited through the use of RAS inhibitors, the most patient-centric goal of therapy for many elderly individuals should be individualized.
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23
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No significant effect of angiotensin II receptor blockade on intermediate cardiovascular end points in hemodialysis patients. Kidney Int 2014; 86:625-37. [DOI: 10.1038/ki.2014.69] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 01/29/2014] [Accepted: 01/30/2014] [Indexed: 01/21/2023]
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The efficacy and tolerability of azilsartan in obese insulin-resistant mice with left ventricular pressure overload. J Cardiovasc Pharmacol 2014; 62:381-7. [PMID: 23921308 DOI: 10.1097/fjc.0b013e31829f0c1b] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Angiotensin II receptor blockers (ARBs) are used widely for the treatment of heart failure. However, their use in obese and insulin-resistant patients remains controversial. To clarify their potential efficacy in these conditions, we administered azilsartan medoxomil (azilsartan), a prodrug of an angiotensin II receptor blocker to mice fed a high-fat diet (HFD) with left ventricular (LV) pressure overload (aortic banding). LV fibrosis (hydroxyproline), cardiac plasminogen activator inhibitor-1 (PAI-1; a marker of profibrosis), and creatine kinase (a marker of myocardial viability and energetics) were assessed. LV wall thickness and cardiac function were assessed echocardiographically. Mice given a HFD were obese and insulin resistant. Their LV hypertrophy was accompanied by greater LV PAI-1 and reduced LV creatine kinase compared with normal diet controls. Drug treatment reduced LV wall thickness, hypertrophy, and PAI-1 and increased cardiac output after aortic banding compared with results in HFD vehicle controls. Thus, azilsartan exerted favorable biological effects on the hearts of obese insulin-resistant mice subjected to LV pressure overload consistent with its potential utility in patients with analogous conditions.
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Abstract
The advent of dialytic therapy has enabled nephrologists to provide life-saving therapy, but potassium balance continues to be an ever present challenge in the ESRD population. Although a small percent of patients are chronically hypokalemic, hyperkalemia is by far the most common abnormality in dialysis patients. It is associated with increased all-cause mortality, cardiovascular mortality, and arrhythmogenic death. Although alterations of the dialysis bath may decrease predialysis potassium, potassium baths <2 mEq/l are associated with a higher risk of sudden cardiac death. Studies show that patients are aware of the risks of hyperkalemia, but adherence to a low potassium diet is suboptimal. ACEI, ARBs, and spironolactone may cause slight increases in potassium even in anuric patients, requiring increased surveillance. Fludrocortisone and potassium binders have not been proven to be beneficial in lowering interdialytic potassium levels. Frequent hemodialysis may be a viable option, and studies of prophylactic placement of implantable cardioverter/defibrillators are underway.
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Affiliation(s)
- Sarah Sanghavi
- Division of Nephrology, Department of Medicine, Mount Sinai School of Medicine, New York City, New York
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Vogelzang JL, Heestermans LWAA, van Stralen KJ, Jager KJ, Groothoff JW. Simultaneous reversal of risk factors for cardiac death and intensified therapy in long-term survivors of paediatric end-stage renal disease over the last 10 years. Nephrol Dial Transplant 2013; 28:2545-52. [DOI: 10.1093/ndt/gft257] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Autophagy attenuates diabetic glomerular damage through protection of hyperglycemia-induced podocyte injury. PLoS One 2013; 8:e60546. [PMID: 23593240 PMCID: PMC3623813 DOI: 10.1371/journal.pone.0060546] [Citation(s) in RCA: 159] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 02/27/2013] [Indexed: 12/11/2022] Open
Abstract
Despite the recent attention focused on the important role of autophagy in maintaining podocyte homeostasis, little is known about the changes and mechanisms of autophagy in podocyte dysfunction under diabetic condition. In this study, we investigated the role of autophagy in podocyte biology and its involvement in the pathogenesis of diabetic nephropathy. Podocytes had a high basal level of autophagy. And basal autophagy inhibition either by 3-methyladenenine (3-MA) or by Beclin-1 siRNA was detrimental to its architectural structure. However, under diabetic condition in vivo and under high glucose conditions in vitro, high basal level of autophagy in podocytes became defective and defective autophagy facilitated the podocyte injury. Since the dynamics of endoplasmic reticulum(ER) seemed to play a vital role in regulating the autophagic flux, the results that Salubrinal/Tauroursodeoxycholic acid (TUDCA) could restore defective autophagy further indicated that the evolution of autophagy may be mediated by the changes of cytoprotective output in the ER stress. Finally, we demonstrated in vivo that the autophagy of podocyte was inhibited under diabetic status and TUDCA could improve defective autophagy. Taken together, these data suggested that autophagy might be interrupted due to the failure of ER cytoprotective capacity upon high glucose induced unmitigated stress, and the defective autophagy might accelerate the irreparable progression of diabetic nephropathy.
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