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Pereira PG, Alves LL, Ciambarella BT, Rabelo K, Nascimento ALR, Moraes ACN, Bernardi A, Guimarães FV, Carvalho GM, da Silva JFR, de Carvalho JJ. Capybara Oil Improves Renal Pathophysiology and Inflammation in Obese Mice. Nutrients 2023; 15:2925. [PMID: 37447251 DOI: 10.3390/nu15132925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/06/2023] [Accepted: 01/10/2023] [Indexed: 07/15/2023] Open
Abstract
Obesity is an inflammatory disease associated with secondary diseases such as kidney disease, which can cause lipotoxicity, inflammation and loss of organ function. Polyunsaturated fatty acids act in the production of lipid mediators and have anti-inflammatory characteristics. In this work, the objective was to evaluate renal histopathology in obese mice and the effects of treatment with capybara oil (CO) (5000 mg/kg/day for 4 weeks). Parameters such as body mass, lipid profile, systolic blood pressure, urinary creatinine and protein excretion, structure and ultrastructure of the renal cortex, fibrosis, tissue inflammation and oxidative stress were analyzed. CO treatment in obese mice showed improvement in the lipid profile and reduction in systolic blood pressure levels, in addition to beneficial remodeling of the renal cortex. Our data demonstrated that CO decreased inflammation, oxidative stress and renal fibrosis, as evidenced by quantifying the expression of TNF-α, IL-10, CAT, SOD, α-SMA and TGF-β. Although treatment with CO did not show improvement in renal function, ultrastructural analysis showed that the treatment was effective in restoring podocytes and pedicels, with restructuring of the glomerular filtration barrier. These results demonstrate, for the first time, that treatment with CO is effective in reducing kidney damage, being considered a promising treatment for obesity.
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Affiliation(s)
- Priscila G Pereira
- Ultrastructure and Tissue Biology Laboratory, Institute of Biology, Rio de Janeiro State University, Boulevard Vinte e Oito de Setembro, 87 Fundos, 3° Andar Vila Isabel, Rio de Janeiro 20551-030, RJ, Brazil
| | - Luciana L Alves
- Ultrastructure and Tissue Biology Laboratory, Institute of Biology, Rio de Janeiro State University, Boulevard Vinte e Oito de Setembro, 87 Fundos, 3° Andar Vila Isabel, Rio de Janeiro 20551-030, RJ, Brazil
| | - Bianca T Ciambarella
- Ultrastructure and Tissue Biology Laboratory, Institute of Biology, Rio de Janeiro State University, Boulevard Vinte e Oito de Setembro, 87 Fundos, 3° Andar Vila Isabel, Rio de Janeiro 20551-030, RJ, Brazil
| | - Kíssila Rabelo
- Ultrastructure and Tissue Biology Laboratory, Institute of Biology, Rio de Janeiro State University, Boulevard Vinte e Oito de Setembro, 87 Fundos, 3° Andar Vila Isabel, Rio de Janeiro 20551-030, RJ, Brazil
| | - Ana Lúcia R Nascimento
- Ultrastructure and Tissue Biology Laboratory, Institute of Biology, Rio de Janeiro State University, Boulevard Vinte e Oito de Setembro, 87 Fundos, 3° Andar Vila Isabel, Rio de Janeiro 20551-030, RJ, Brazil
| | - Alan Cesar N Moraes
- Electron Microscopy Laboratory of Biology Institute, University of Federal Fluminense, Rio de Janeiro 21040-900, RJ, Brazil
| | - Andressa Bernardi
- Inflammation Laboratory, Fiocruz, Rio de Janeiro 21040-900, RJ, Brazil
| | | | - Gabriela M Carvalho
- Ultrastructure and Tissue Biology Laboratory, Institute of Biology, Rio de Janeiro State University, Boulevard Vinte e Oito de Setembro, 87 Fundos, 3° Andar Vila Isabel, Rio de Janeiro 20551-030, RJ, Brazil
| | - Jemima F R da Silva
- Ultrastructure and Tissue Biology Laboratory, Institute of Biology, Rio de Janeiro State University, Boulevard Vinte e Oito de Setembro, 87 Fundos, 3° Andar Vila Isabel, Rio de Janeiro 20551-030, RJ, Brazil
| | - Jorge J de Carvalho
- Ultrastructure and Tissue Biology Laboratory, Institute of Biology, Rio de Janeiro State University, Boulevard Vinte e Oito de Setembro, 87 Fundos, 3° Andar Vila Isabel, Rio de Janeiro 20551-030, RJ, Brazil
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Kutumova E, Kiselev I, Sharipov R, Lifshits G, Kolpakov F. Mathematical modeling of antihypertensive therapy. Front Physiol 2022; 13:1070115. [PMID: 36589434 PMCID: PMC9795234 DOI: 10.3389/fphys.2022.1070115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
Hypertension is a multifactorial disease arising from complex pathophysiological pathways. Individual characteristics of patients result in different responses to various classes of antihypertensive medications. Therefore, evaluating the efficacy of therapy based on in silico predictions is an important task. This study is a continuation of research on the modular agent-based model of the cardiovascular and renal systems (presented in the previously published article). In the current work, we included in the model equations simulating the response to antihypertensive therapies with different mechanisms of action. For this, we used the pharmacodynamic effects of the angiotensin II receptor blocker losartan, the calcium channel blocker amlodipine, the angiotensin-converting enzyme inhibitor enalapril, the direct renin inhibitor aliskiren, the thiazide diuretic hydrochlorothiazide, and the β-blocker bisoprolol. We fitted therapy parameters based on known clinical trials for all considered medications, and then tested the model's ability to show reasonable dynamics (expected by clinical observations) after treatment with individual drugs and their dual combinations in a group of virtual patients with hypertension. The extended model paves the way for the next step in personalized medicine that is adapting the model parameters to a real patient and predicting his response to antihypertensive therapy. The model is implemented in the BioUML software and is available at https://gitlab.sirius-web.org/virtual-patient/antihypertensive-treatment-modeling.
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Affiliation(s)
- Elena Kutumova
- Department of Computational Biology, Sirius University of Science and Technology, Sochi, Russia,Laboratory of Bioinformatics, Federal Research Center for Information and Computational Technologies, Novosibirsk, Russia,Biosoft.Ru, Ltd., Novosibirsk, Russia,*Correspondence: Elena Kutumova,
| | - Ilya Kiselev
- Department of Computational Biology, Sirius University of Science and Technology, Sochi, Russia,Laboratory of Bioinformatics, Federal Research Center for Information and Computational Technologies, Novosibirsk, Russia,Biosoft.Ru, Ltd., Novosibirsk, Russia
| | - Ruslan Sharipov
- Department of Computational Biology, Sirius University of Science and Technology, Sochi, Russia,Laboratory of Bioinformatics, Federal Research Center for Information and Computational Technologies, Novosibirsk, Russia,Biosoft.Ru, Ltd., Novosibirsk, Russia,Specialized Educational Scientific Center, Novosibirsk State University, Novosibirsk, Russia
| | - Galina Lifshits
- Laboratory for Personalized Medicine, Center of New Medical Technologies, Institute of Chemical Biology and Fundamental Medicine SB RAS, Novosibirsk, Russia
| | - Fedor Kolpakov
- Department of Computational Biology, Sirius University of Science and Technology, Sochi, Russia,Laboratory of Bioinformatics, Federal Research Center for Information and Computational Technologies, Novosibirsk, Russia,Biosoft.Ru, Ltd., Novosibirsk, Russia
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Steglich A, Hickmann L, Linkermann A, Bornstein S, Hugo C, Todorov VT. Beyond the Paradigm: Novel Functions of Renin-Producing Cells. Rev Physiol Biochem Pharmacol 2020; 177:53-81. [PMID: 32691160 DOI: 10.1007/112_2020_27] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The juxtaglomerular renin-producing cells (RPC) of the kidney are referred to as the major source of circulating renin. Renin is the limiting factor in renin-angiotensin system (RAS), which represents a proteolytic cascade in blood plasma that plays a central role in the regulation of blood pressure. Further cells disseminated in the entire organism express renin at a low level as part of tissue RASs, which are thought to locally modulate the effects of systemic RAS. In recent years, it became increasingly clear that the renal RPC are involved in developmental, physiological, and pathophysiological processes outside RAS. Based on recent experimental evidence, a novel concept emerges postulating that next to their traditional role, the RPC have non-canonical RAS-independent progenitor and renoprotective functions. Moreover, the RPC are part of a widespread renin lineage population, which may act as a global stem cell pool coordinating homeostatic, stress, and regenerative responses throughout the organism. This review focuses on the RAS-unrelated functions of RPC - a dynamic research area that increasingly attracts attention.
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Affiliation(s)
- Anne Steglich
- Experimental Nephrology, Division of Nephrology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Linda Hickmann
- Experimental Nephrology, Division of Nephrology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Andreas Linkermann
- Experimental Nephrology, Division of Nephrology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Stefan Bornstein
- Experimental Nephrology, Division of Nephrology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Christian Hugo
- Experimental Nephrology, Division of Nephrology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Vladimir T Todorov
- Experimental Nephrology, Division of Nephrology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany.
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Pereira PG, Rabelo K, da Silva JFR, Ciambarella BT, Argento JGC, Nascimento ALR, Vieira AB, de Carvalho JJ. Aliskiren improves renal morphophysiology and inflammation in Wistar rats with 2K1C renovascular hypertension. Histol Histopathol 2019; 35:609-621. [PMID: 31625581 DOI: 10.14670/hh-18-173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Hypertension is characterized by persistent elevated blood pressure levels, one of the leading causes of death in the world. Renovascular hypertension represents the most common cause of secondary hypertension, and its progress is associated with overactivation of the renin angiotensin aldosterone system (RAAS), causing systemic and local changes. Aliskiren is a renin-inhibiting drug that optimizes RAAS suppression. In this sense, the objective of the present study was to analyze the morphophysiology of the left kidney in Wistar rats with renovascular hypertension after treatment with Aliskiren. Parameters such as systolic blood pressure, urinary creatinine and protein excretion, renal cortex structure and ultrastructure, fibrosis and tissue inflammation were analyzed. Our results showed that the hypertensive animals treated with Aliskiren presented a reestablishment of blood pressure, expression of renin, and renal function, as well as a remodeling of morphological alterations through the reduction of fibrosis. The treatment regulated the laminin expression and decreased pro-inflammatory cytokines, restoring the integrity of the glomerular filtration barrier. Therefore, our findings suggest that Aliskiren has a renoprotective effect acting on the improvement of the morphology, physiology and pathology of the renal cortex of animals with renovascular hypertension.
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Affiliation(s)
- Priscila G Pereira
- Laboratory of Ultrastructure and Tecidual Biology, Institute of Biology, State University of Rio de Janeiro, RJ, Brazil
| | - Kíssila Rabelo
- Laboratory of Ultrastructure and Tecidual Biology, Institute of Biology, State University of Rio de Janeiro, RJ, Brazil
| | - Jemima F R da Silva
- Laboratory of Ultrastructure and Tecidual Biology, Institute of Biology, State University of Rio de Janeiro, RJ, Brazil
| | - Bianca T Ciambarella
- Laboratory of Ultrastructure and Tecidual Biology, Institute of Biology, State University of Rio de Janeiro, RJ, Brazil
| | - Juliana G C Argento
- Laboratory of Ultrastructure and Tecidual Biology, Institute of Biology, State University of Rio de Janeiro, RJ, Brazil
| | - Ana L R Nascimento
- Laboratory of Ultrastructure and Tecidual Biology, Institute of Biology, State University of Rio de Janeiro, RJ, Brazil
| | - Aline B Vieira
- Ross University School of Veterinary Medicine, Biomedical Department, Basseterre, Saint Kitts
| | - Jorge J de Carvalho
- Laboratory of Ultrastructure and Tecidual Biology, Institute of Biology, State University of Rio de Janeiro, RJ, Brazil.
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Leete J, Layton AT. Sex-specific long-term blood pressure regulation: Modeling and analysis. Comput Biol Med 2018; 104:139-148. [PMID: 30472496 DOI: 10.1016/j.compbiomed.2018.11.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 11/01/2018] [Accepted: 11/03/2018] [Indexed: 01/17/2023]
Abstract
Hypertension is a global health challenge: it affects one billion people worldwide and is estimated to account for >60% of all cases or types of cardiovascular disease. In part because sex differences in blood pressure regulation mechanisms are not sufficiently well understood, fewer hypertensive women achieve blood pressure control compared to men, even though compliance and treatment rates are generally higher in women. Thus, the objective of this study is to identify which factors contribute to the sexual dimorphism in response to anti-hypertensive therapies targeting the renin angiotensin system (RAS). To accomplish that goal, we develop sex-specific blood pressure regulation models. Sex differences in the RAS, baseline adosterone level, and the reactivity of renal sympathetic nervous activity (RSNA) are represented. A novel aspect of the model is the representation of sex-specific vasodilatory effect of the bound angiotensin II type two receptor (AT2R-bound Ang II) on renal vascular resistance. Model simulations suggest that sex differences in RSNA are the largest cause of female resistance to developing hypertension due to the direct influence of RSNA on afferent arteriole resistance. Furthermore, the model predicts that the sex-specific vasodilatory effects of AT2R-bound Ang II on renal vascular resistance may explain the higher effectiveness of angiotensin receptor blockers in treating hypertensive women (but not men), compared to angiotensin converting enzyme inhibitors.
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Affiliation(s)
- Jessica Leete
- Computational Biology & Bioinformatics Program, Duke University, Durham, NC, USA.
| | - Anita T Layton
- Departments of Mathematics, Biomedical Engineering, and Medicine, Duke University, Durham, NC, USA; Department of Applied Mathematics and School of Pharmacy, University of Waterloo, Waterloo, Ontario, N2L 3G1, Canada
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Schrover IM, Dorresteijn JAN, Smits JE, Danser AHJ, Visseren FLJ, Spiering W. Identifying treatment response to antihypertensives in patients with obesity-related hypertension. Clin Hypertens 2017; 23:20. [PMID: 29085669 PMCID: PMC5654008 DOI: 10.1186/s40885-017-0077-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 09/18/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND In patients with obesity-related hypertension (ORH), reaction to antihypertensive medication is likely influenced by patientcharacteristics. METHODS Effects of aliskiren, moxonidine and hydrochlorothiazide on 24-h blood pressure (BP) were compared to placebo. Linear mixed effect models were used to analyze the effect of patient characteristics on BP levels and treatment response. RESULTS Systolic BP response to aliskiren was higher in patients with a BMI > 30.7 kg/m2 compared to patients with a BMI ≤ 30.7 kg/m2 (-21 mmHg versus -4 mmHg). In patients with a hsCRP > 1.8 mg/L the systolic BP response to aliskiren was higher than in patients with a low hsCRP (-15 mmHg versus -7 mmHg). Hydrochlorothiazide (HCTZ) treatment effect on systolic BP was -13 mmHg when heart rate > 71 beats/min compared to -3 mmHg when heart rate was ≤ 71 beats/min. CONCLUSION In patients with ORH, BP response to aliskiren is positively related to BMI and hsCRP. Systolic BP response to HCTZ is positively related to heart rate and negatively to renin levels. TRIAL REGISTRATION NCT01138423. Registered June 4th, 2010.
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Affiliation(s)
- Ilse M Schrover
- Department of Vascular Medicine, University Medical Center Utrecht, P.O. Box 85500, 3584 GA Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, P.O. Box 85500, 3584 GA Utrecht, The Netherlands
| | - Jodine E Smits
- Department of Vascular Medicine, University Medical Center Utrecht, P.O. Box 85500, 3584 GA Utrecht, The Netherlands
| | - A H Jan Danser
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, P.O. Box 85500, 3584 GA Utrecht, The Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, P.O. Box 85500, 3584 GA Utrecht, The Netherlands
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Musini VM, Lawrence KAK, Fortin PM, Bassett K, Wright JM. Blood pressure lowering efficacy of renin inhibitors for primary hypertension. Cochrane Database Syst Rev 2017; 4:CD007066. [PMID: 28379619 PMCID: PMC6478238 DOI: 10.1002/14651858.cd007066.pub3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hypertension is a chronic condition associated with an increased risk of mortality and morbidity. Renin is the enzyme responsible for converting angiotensinogen to angiotensin I, which is then converted to angiotensin II. Renin inhibitors are a new class of drugs that decrease blood pressure (BP) by preventing the formation of both angiotensin I and angiotensin II. OBJECTIVES To quantify the dose-related BP lowering efficacy of renin inhibitors compared to placebo in the treatment of primary hypertension.To determine the change in BP variability, pulse pressure, and heart rate and to evaluate adverse events (mortality, non-fatal serious adverse events, total adverse events, withdrawal due to adverse effects and specific adverse events such as dry cough, diarrhoea and angioedema). SEARCH METHODS The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials (RCTs) up to February 2017: the Cochrane Hypertension Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (2017, Issue 2), MEDLINE (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. There was no restriction by language or publication status. We also searched the European Medicines Agency (EMA) for clinical study reports, the Novartis Clinical Study Results Database, bibliographic citations from retrieved references, and contacted authors of relevant papers regarding further published and unpublished work. SELECTION CRITERIA We included randomized, double-blinded, placebo-controlled studies evaluating BP lowering efficacy of fixed-dose monotherapy with renin inhibitor compared with placebo for a minimum duration of three to 12 weeks in adult patients with primary hypertension. DATA COLLECTION AND ANALYSIS This systematic review is a comprehensive update which includes four additional studies and extensive detail from nine clinical study reports (CSRs) of previously included studies obtained from EMA. The remaining three CSRs are not available.Two review authors independently assessed study eligibility and extracted data. In all cases where there was a difference between the CSR and the published report, data from the CSR was used. Dichotomous outcomes were reported as risk ratio (RR) with 95% confidence intervals (CIs) and continuous outcomes as mean difference (MD) with 95% CIs. MAIN RESULTS 12 studies (mean duration of eight weeks) in 7439 mostly Caucasian patients (mean age 54 years) with mild-to-moderate uncomplicated hypertension were eligible for inclusion in the review. Aliskiren was the only renin inhibitor evaluated. All included studies were assessed to have high likelihood of attrition, reporting and funding bias.Aliskiren has a dose-related systolic/diastolic blood pressure (SBP/DBP) lowering effect as compared with placebo MD with 95% CI: aliskiren 75 mg (MD -2.97, 95% CI -4.76 to -1.18)/(MD -2.05, 95% CI -3.13 to -0.96) mm Hg (moderate-quality evidence), aliskiren 150 mg (MD -5.95, 95% CI -6.85 to -5.06)/ (MD -3.16, 95% CI -3.74 to -2.58) mm Hg (moderate-quality evidence), aliskiren 300 mg (MD -7.88, 95% CI -8.94 to -6.82)/ (MD -4.49, 95% CI -5.17 to -3.82) mm Hg (moderate-quality evidence), aliskiren 600 mg (MD -11.35, 95% CI -14.43 to -8.27)/ (MD -5.86, 95% CI -7.73 to -3.99) mm Hg (low-quality evidence). There was a dose-dependent decrease in blood pressure for aliskiren 75 mg, 150 mg and 300 mg. The blood pressure lowering effect of aliskiren 600 mg was not different from 300 mg (MD -0.61, 95% CI -2.78 to 1.56)/(MD -0.68, 95% CI -2.03 to 0.67). Aliskiren had no effect on blood pressure variability. Due to very limited information available regarding change in heart rate and pulse pressure, it was not possible to meta-analyze these outcomes.Mortality and non-fatal serious adverse events were not increased. This review found that in studies of eight week duration aliskiren may not increase withdrawal due to adverse events (low-quality evidence). Diarrhoea was increased in a dose-dependent manner (RR 7.00, 95% CI 2.48 to 19.72) with aliskiren 600 mg (low-quality evidence). The most frequent adverse events reported were headache, nasopharyngitis, diarrhoea, dizziness and fatigue. AUTHORS' CONCLUSIONS Compared to placebo, aliskiren lowered BP and this effect is dose-dependent. This magnitude of BP lowering effect is similar to that for angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). There is no difference in mortality, nonfatal serious adverse events or withdrawal due to adverse effects with short term aliskiren monotherapy. Diarrhoea was considerably increased with aliskiren 600 mg.
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Affiliation(s)
- Vijaya M Musini
- University of British ColumbiaDepartment of Anesthesiology, Pharmacology and Therapeutics2176 Health Science MallVancouverBCCanadaV6T 1Z3
| | | | - Patricia M Fortin
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Ken Bassett
- University of British ColumbiaDepartment of Anesthesiology, Pharmacology and Therapeutics2176 Health Science MallVancouverBCCanadaV6T 1Z3
| | - James M Wright
- University of British ColumbiaDepartment of Anesthesiology, Pharmacology and Therapeutics2176 Health Science MallVancouverBCCanadaV6T 1Z3
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Kistner I, Zeymer U, Dechend R, Hagedorn I, Riemer T, Bramlage P, Pittrow D, Senges J, Schmieder RE. Benefits and Risks of Aliskiren Treatment in Patients With Type 2 Diabetes: Analyses of the 3A Registry. J Clin Hypertens (Greenwich) 2016; 18:1045-1053. [PMID: 27094460 DOI: 10.1111/jch.12828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 02/16/2016] [Accepted: 02/22/2016] [Indexed: 11/28/2022]
Abstract
The authors sought to retrospectively analyze the real-world evidence on aliskiren in diabetic patients with or without concomitant renin-angiotensin system (RAS) blocker use based on the Registry for Ambulant Therapy With RAS Inhibitors in Hypertension Patients in Germany (3A). Of 14,986 patients included, 3772 patients had diabetes and 28.5% received aliskiren, 14.3% received angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), 35.4% received aliskiren plus an ACE inhibitor/ARB, and 10.5% received other drugs. Ambulatory blood pressure (BP) monitoring (baseline BP 148±15.8/84.0±10.9 mm Hg) revealed stronger diastolic BP reduction for aliskiren plus ACE inhibitor/ARB than aliskiren alone in the low (2.8±0.5 vs 0.6±0.6; P=.004) and intermediate (5.9±0.5 vs 4.5±0.5; P=.04) baseline BP groups. There was a lesser ambulatory BP reduction observed for patients receiving non-RAS in the high baseline category for both systolic (12.5±1.8 vs 17.1±1.0; P=.02) and diastolic (6.9±1.0 vs 9.8±0.6; P=.01) BP. In patients with hypertension and type 2 diabetes, aliskiren was beneficial in lowering BP, with no observed increases in major adverse effects compared with RAS-blocking therapy alone.
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Affiliation(s)
- Iris Kistner
- Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Uwe Zeymer
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany.,Medizinische Klinik B, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany
| | - Ralf Dechend
- Medizinische Klinik mit Schwerpunkt Molekulare and Klinische Kardiologie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ina Hagedorn
- Clinical and Regulatory Affairs, Novartis Pharma GmbH, Nürnberg, Germany
| | - Thomas Riemer
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - Peter Bramlage
- Institut für Pharmakologie and präventive Medizin, Mahlow, Germany
| | - David Pittrow
- Institute for Clinical Pharmacology, Medical Faculty, Technical University Dresden, Dresden, Germany
| | - Jochen Senges
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - Roland E Schmieder
- Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, Erlangen, Germany.
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Burckhardt BB, Tins J, Ramusovic S, Läer S. Tailored Assays for Pharmacokinetic and Pharmacodynamic Investigations of Aliskiren and Enalapril in Children: An Application in Serum, Urine, and Saliva. J Pediatr Pharmacol Ther 2015; 20:431-52. [PMID: 26766933 PMCID: PMC4708953 DOI: 10.5863/1551-6776-20.6.431] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Drugs that are effectively used to treat hypertension in adults (e.g., enalapril) have not been sufficiently investigated in children. Studies required for pediatric approval require special consideration regarding ethics, study design, and conduct and are also associated with special demands for the bioanalytic method. Pediatric-appropriate assays can overcome these burdens and enable systematic investigations of pharmacokinetics and pharmacodynamic in all pediatric age groups. METHODS Tailored assays were developed for pharmacokinetic investigation of a drug in 100 μL of serum, saliva, and urine. All assays were applied in a proof-of-concept study to 22 healthy volunteers who had been given 300 mg aliskiren hemifumarate or 20 mg enalapril maleate and allowed for dense sampling. Changes in humoral parameters of the renin-angiotensin-aldosterone system were also evaluated with 6 parameters in 2.1 mL blood per time point. RESULTS The pharmacokinetic results of aliskiren and enalapril obtained by low-volume assays in serum and urine were comparable to that noted in the literature. The dense sampling enabled very detailed concentration-time profiles that showed high intersubject variability and biphasic absorption behavior of aliskiren. The replacement of invasive sampling by saliva collection appears inappropriate for both drugs because the correlations of drug concentrations in both fluids were low. A low-volume assay was also used to determine values for in the renin-angiotensin-aldosterone system and to compare those results with the published literature. CONCLUSION These results support both the use of low-volume assays in pediatric research and the systematic investigation of their use in neonates and infants. Use of this assay methodology will increase information about drug pharmacokinetics and pharmacodynamics in this vulnerable population and might contribute to safe and effective use of pharmacotherapy.
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Affiliation(s)
- Bjoern B. Burckhardt
- Department of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-University, Düsseldorf, Germany
| | - Jutta Tins
- Department of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-University, Düsseldorf, Germany
| | - Sergej Ramusovic
- Department of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-University, Düsseldorf, Germany
| | - Stephanie Läer
- Department of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-University, Düsseldorf, Germany
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Te Riet L, van Esch JHM, Roks AJM, van den Meiracker AH, Danser AHJ. Hypertension: renin-angiotensin-aldosterone system alterations. Circ Res 2015; 116:960-75. [PMID: 25767283 DOI: 10.1161/circresaha.116.303587] [Citation(s) in RCA: 456] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Blockers of the renin-angiotensin-aldosterone system (RAAS), that is, renin inhibitors, angiotensin (Ang)-converting enzyme (ACE) inhibitors, Ang II type 1 receptor antagonists, and mineralocorticoid receptor antagonists, are a cornerstone in the treatment of hypertension. How exactly they exert their effect, in particular in patients with low circulating RAAS activity, also taking into consideration the so-called Ang II/aldosterone escape that often occurs after initial blockade, is still incompletely understood. Multiple studies have tried to find parameters that predict the response to RAAS blockade, allowing a personalized treatment approach. Consequently, the question should now be answered on what basis (eg, sex, ethnicity, age, salt intake, baseline renin, ACE or aldosterone, and genetic variance) a RAAS blocker can be chosen to treat an individual patient. Are all blockers equal? Does optimal blockade imply maximum RAAS blockade, for example, by combining ≥2 RAAS blockers or by simply increasing the dose of 1 blocker? Exciting recent investigations reveal a range of unanticipated extrarenal effects of aldosterone, as well as a detailed insight in the genetic causes of primary aldosteronism, and mineralocorticoid receptor blockers have now become an important treatment option for resistant hypertension. Finally, apart from the deleterious ACE-Ang II-Ang II type 1 receptor arm, animal studies support the existence of protective aminopeptidase A-Ang III-Ang II type 2 receptor and ACE2-Ang-(1 to 7)-Mas receptor arms, paving the way for multiple new treatment options. This review provides an update about all these aspects, critically discussing the many controversies and allowing the reader to obtain a full understanding of what we currently know about RAAS alterations in hypertension.
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Affiliation(s)
- Luuk Te Riet
- From the Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Joep H M van Esch
- From the Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Anton J M Roks
- From the Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Anton H van den Meiracker
- From the Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - A H Jan Danser
- From the Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands.
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Renin-angiotensin system phenotyping as a guidance toward personalized medicine for ACE inhibitors: can the response to ACE inhibition be predicted on the basis of plasma renin or ACE? Cardiovasc Drugs Ther 2015; 28:335-45. [PMID: 24958603 DOI: 10.1007/s10557-014-6537-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE & METHODS Not all hypertensive patients respond well to ACE inhibition. Here we determined whether renin-angiotensin system (RAS) phenotyping, i.e., the measurement of renin or ACE, can predict the individual response to RAS blockade, either chronically (enalapril vs. enalapril + candesartan) or acutely (enalapril ± hydrochlorothiazide, HCT). RESULTS Chronic enalapril + candesartan induced larger renin rises, but did not lower blood pressure (BP) more than enalapril. Similar observations were made for enalapril + HCT vs. enalapril when given acutely. Baseline renin predicted the peak changes in BP chronically, but not acutely. Baseline ACE levels had no predictive value. Yet, after acute drug intake, the degree of ACE inhibition, like Δrenin, did correlate with ΔBP. Only the relationship with Δrenin remained significant after chronic RAS blockade. Thus, a high degree of ACE inhibition and a steep renin rise associate with larger acute responses to enalapril. However, variation was large, ranging >50 mm Hg for a given degree of ACE inhibition or Δrenin. The same was true for the relationships between Δrenin and ΔBP, and between baseline renin and the maximum reduction in BP in the chronic study. CONCLUSIONS Our data do not support that RAS phenotyping will help to predict the individual BP response to RAS blockade. Notably, these conclusions were reached in a carefully characterized, homogenous population, and when taking into account the known fluctuations in renin that relate to gender, age, ethnicity, salt intake and diuretic treatment, it seems unlikely that a cut-off renin level can be defined that has predictive value.
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Maeda Y, Araki Y, Uno T, Nishigaki K, Inaba N. Successful treatment of hypertension in anuric hemodialysis patients with a direct Renin inhibitor, aliskiren. ACTA ACUST UNITED AC 2015; 6:26-31. [PMID: 25648150 PMCID: PMC4309347 DOI: 10.2185/jrm.6.26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE A direct renin-inhibitor (DRI), aliskiren, was administered to anuric patients to investigate whether it can be a new optional therapy against hypertension in hemodialysis (HD) patients. PATIENTS The patients that received aliskiren comprised 8 males and 2 females with a mean ± SD age of 63 ± 8 years (43-72 years). They were exposed to dialysis therapy for 118 ± 73 months (8-251 months), with diabetes mellitus in 4 cases, chronic glomerulonephritis in 4 cases, and other diagnoses in 2 cases. METHODS After the plasma renin activity (PRA) and plasma aldosterone concentration (PAC) were measured before an HD session, aliskiren, 150 mg as an initial dose, was administered to the patients. PRA and PAC were also examined a week after initiating aliskiren. The blood pressure (BP) levels at the start of each HD session for a period of 2 weeks (6 HD sessions) were compared between before and after administration of aliskiren. The change of doses in other antihypertensive agents was also counted. RESULTS The averaged reduction of mean blood pressure was 4 ± 5 mmHg, and doses of antihypertensives other than aliskiren were reduced in 4 patients. Of the examined parameters, only the reduction rate of PRA x PAC seemed correlated with the BP lowering effect of aliskiren, which was calculated as the sum of the mean BP reduction in mmHg and drug reduction with 1 tablet (capsule)/day considered to be 10 mmHg. CONCLUSION A DRI, aliskiren, was effective even in anuric dialysis patients, and monitoring of PRA and PAC was valuable for selecting cases responsive to aliskiren.
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Affiliation(s)
- Yoshitaka Maeda
- Nephrology Division, Department of Internal Medicine, JA Toride Medical Center, Japan
| | - Yuya Araki
- Nephrology Division, Department of Internal Medicine, JA Toride Medical Center, Japan
| | - Tomomi Uno
- Nephrology Division, Department of Internal Medicine, JA Toride Medical Center, Japan
| | - Keisuke Nishigaki
- Nephrology Division, Department of Internal Medicine, JA Toride Medical Center, Japan
| | - Naoto Inaba
- Nephrology Division, Department of Internal Medicine, JA Toride Medical Center, Japan
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Friedrich S, Zeymer U, Dechend R, Hagedorn I, Riemer T, Zemmrich C, Bramlage P, Pittrow D, Senges J, Schmieder RE. The impact of age on the benefits and risks of aliskiren treatment: analyses of the 3A registry. J Hum Hypertens 2014; 29:316-23. [PMID: 25273857 DOI: 10.1038/jhh.2014.86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 08/04/2014] [Accepted: 08/11/2014] [Indexed: 11/09/2022]
Abstract
We aimed to analyze benefits and risks of aliskiren treatment in older adults (⩾ 65 years) in clinical practice. Patients (n = 14,986) were assigned to either aliskiren (ALIS), an angiotensin-converting-enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB), or an agent not blocking the renin-angiotensin system (non-RAS). Older adults (n = 7396) had a longer history of hypertension (8.7 vs 4.7 years; P < 0.0001), lower mean diastolic blood pressure (DBP; 87.7 ± 11.0 vs 92.1 ± 11.0 mm Hg) and more renal (12.0 vs 5.6%; P < 0.0001) or cardiovascular disease (44.0 vs 18.9%; P < 0.0001); 4548 received aliskiren (68.8%), 1215 ACEi/ARBs (18.4%) and 850 non-RAS treatments (12.9%). Office BP at 1 year was reduced by 18.4 ± 21.5/7.2 ± 12.0 mm Hg. BP reductions were greater (19.5 ± 21.7/7.6 ± 12.1 mm Hg) in the aliskiren group than in the ACEi/ARB (15.6 ± 20.9/6.4 ± 11.9) and non-RAS groups (16.1 ± 20.7/6.5 ± 11.7 mm Hg), respectively (P<0.0001 for systolic BP (SBP) and <0.01 for DBP). After multivariable adjustment, differences in SBP reductions were clinically irrelevant and no differences were noted for DBP. Adverse effects were higher in older adults with no differences between treatment groups. In conclusion, the present analysis of a large, unselected cohort of patients in clinical practice from the 3A study, offers real-life evidence of the effectiveness and safety of aliskiren for the treatment of hypertension in older adults.
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Affiliation(s)
- S Friedrich
- Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, Erlangen, Germany
| | - U Zeymer
- 1] Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany [2] Medizinische Klinik B, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany
| | - R Dechend
- Experimental and Clinical Research Center, Charité Campus Buch, HELIOS-Klinikum Berlin, Berlin, Germany
| | - I Hagedorn
- Clinical and Regulatory Affairs, Novartis Pharma GmbH, Nürnberg, Germany
| | - T Riemer
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - C Zemmrich
- Institut für Pharmakologie und präventive Medizin, Mahlow, Germany
| | - P Bramlage
- Institut für Pharmakologie und präventive Medizin, Mahlow, Germany
| | - D Pittrow
- Institute for Clinical Pharmacology, Medical Faculty, Technical University Dresden, Germany
| | - J Senges
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - R E Schmieder
- Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, Erlangen, Germany
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Abstract
Aliskiren is a novel drug with the ability to lower plasma renin activity, reducing proteinuria in hypertension and in diabetic nephropathy. In primary and secondary glomerular diseases, important causes of endstage kidney disease, proteinuria is a hallmark. Moreover, urinary protein is a marker of renal disease progression. The renin angiotensin-aldosterone system is generally activated in these patients. A complete blockade with the use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers with or without aldosterone receptor blockers is not easy to achieve, and side effects are not uncommon. Plasma renin activity is even increased in patients with this approach. Aliskiren should be considered as a new therapeutic option to be assessed in glomerular diseases, as plasma renin activity can be reduced and a better control of the renin-angiotensin system could be achieved with the consequent reduction in the amount of urinary protein excretion.
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Affiliation(s)
- Hernán Trimarchi
- Nephrology Section, Department of Internal Medicine, Hospital Británico de Buenos Aires, Argentina
| | - Marcelo Orías
- Nephrology Section, Sanatorio Allende, Ciudad de Cordoba, Argentina
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Hallow KM, Lo A, Beh J, Rodrigo M, Ermakov S, Friedman S, de Leon H, Sarkar A, Xiong Y, Sarangapani R, Schmidt H, Webb R, Kondic AG. A model-based approach to investigating the pathophysiological mechanisms of hypertension and response to antihypertensive therapies: extending the Guyton model. Am J Physiol Regul Integr Comp Physiol 2014; 306:R647-62. [PMID: 24500431 DOI: 10.1152/ajpregu.00039.2013] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Reproducibly differential responses to different classes of antihypertensive agents are observed among hypertensive patients and may be due to interindividual differences in hypertension pathology. Computational models provide a tool for investigating the impact of underlying disease mechanisms on the response to antihypertensive therapies with different mechanisms of action. We present the development, calibration, validation, and application of an extension of the Guyton/Karaaslan model of blood pressure regulation. The model incorporates a detailed submodel of the renin-angiotensin-aldosterone system (RAAS), allowing therapies that target different parts of this pathway to be distinguished. Literature data on RAAS biomarker and blood pressure responses to different classes of therapies were used to refine the physiological actions of ANG II and aldosterone on renin secretion, renal vascular resistance, and sodium reabsorption. The calibrated model was able to accurately reproduce the RAAS biomarker and blood pressure responses to combinations of dual-RAAS agents, as well as RAAS therapies in combination with diuretics or calcium channel blockers. The final model was used to explore the impact of underlying mechanisms of hypertension on the blood pressure response to different classes of antihypertensive agents. Simulations indicate that the underlying etiology of hypertension can impact the magnitude of response to a given class of therapy, making a patient more sensitive to one class and less sensitive others. Given that hypertension is usually the result of multiple mechanisms, rather than a single factor, these findings yield insight into why combination therapy is often required to adequately control blood pressure.
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Affiliation(s)
- K Melissa Hallow
- Department of Modeling and Simulation, Primary Care Franchise, Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
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Epstein BJ, Smith SM, Choksi R. Recent changes in the landscape of combination RAS blockade. Expert Rev Cardiovasc Ther 2014; 7:1373-84. [DOI: 10.1586/erc.09.127] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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17
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Renin and the IGFII/M6P receptor system in cardiac biology. ScientificWorldJournal 2013; 2013:260298. [PMID: 24288471 PMCID: PMC3826467 DOI: 10.1155/2013/260298] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 08/20/2013] [Indexed: 11/17/2022] Open
Abstract
Nonenzymatic cardiac activities of renin are well described during the last years and contribute either to cardiac-specific effects of the renin-angiotensin-aldosterone-system (RAAS) or to the pharmacological effects of RAAS inhibition. The interaction of renin with insulin-like growth factor II/mannose-6-phosphate (IGFII/M6P) receptors participates in nonclassical renin effects and contributes to cardiac remodelling caused by RAAS activation. The current findings suggest an important role for renin IGFII/M6P receptor interaction in cardiac adaptation to stress and support the idea that excessive accumulation of renin during inhibition of RAAS directly contributes to blood pressure-independent effects of these pharmacological interventions. It becomes a challenge for future studies focussing on chronic hypertension or myocardial infarction to comprise regulatory adaptations of the kidney, the main source of plasma renin and prorenin, because they directly contribute to key steps in regulation of cardiac (mal)adaptation via IGFII/M6P receptors. This receptor system is part of peptide/receptor interactions that modifies and possibly limits adverse remodelling effects caused by angiotensin II. Evaluation of interactions of renin with other pro-hypertrophic agonists is required to decide whether this receptor may become a target of pharmacological intervention.
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De Rosa ML, Musella F, Ilardi F, D'Amore C, Luciano R, Maresca F. Effects of antihypertensive therapy on glucose, insulin metabolism, left ventricular diastolic dysfunction and renin system in overweight and obese hypertensives. J Renin Angiotensin Aldosterone Syst 2013; 15:196-204. [PMID: 23396551 DOI: 10.1177/1470320312474053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND We attempted to test the hypothesis that the direct renin inhibitor aliskiren can improve diastolic dysfunction, glucose, and insulin metabolism (GIM) in overweight and obese hypertensive patients. METHODS AND RESULTS Seventy-eight hypertensive patients were divided into two groups: 38 treated with aliskiren for six months, and 40 treated without aliskiren but with only traditional anti-hypertensive therapy, as controls. Doppler mitral flow velocity patterns were assessed before and after aliskiren during a six-month period. GIM (three-hour intravenous glucose tolerance test) was measured after four to six weeks of washout and six months of treatment. The mitral E/A ratio increased from 0.65 ± 0.11 to 0.75 ± 0.19. None of the indexes changed in the control group. In the control group, GIM parameters, fasting glucose levels (5.3 ± 0.9 to 6.0 ± 1.5 mmol/l; p = 0.003), fasting insulin levels (121 ± 121 to 189 ± 228 pmol/l; p = 0.03), and most other relevant metabolic measures (p < 0.05 for all) significantly worsened. Aliskiren did not affect GIM. In the control group LVM/height was not affected (119 ± 12 to 120 ± 17 g/m; p = 0.8), whereas aliskiren significantly reduced LVM/height (120 ± 13 to 111 ± 19 g/m; p = 0.04). CONCLUSIONS Optimal target BP was achieved in the group as a whole and in both obese patient groups, while benefits to cardiac structure were of a smaller magnitude. In high-risk, overweight/obese patients with hypertension, traditional therapy provides significantly greater BP- versus aliskiren-lowering throughout the 24-hour dosing interval. Therefore in obese, hypertensive individuals, adequate and similar blood pressure control was achieved with aliskiren; however, the aliskiren group and not the control group was associated with a more favorable GIM profile and led to a significant regression of LVM; overall aliskiren-based treatment offers sustained control of PRA.
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Abstract
PURPOSE OF REVIEW This review examines the evidence that plasma renin and/or prorenin level may be used to guide therapy in hypertension and as an independent risk factor for future cardiovascular events. RECENT FINDINGS A large number of retrospective analyses of patient populations in clinical trials, in whom 'baseline' renin measurements were available, supports that high renin, but not high prorenin levels, are indicative of future cardiovascular disease and death, particularly in patients with kidney dysfunction and/or hypertension. The relationship is not affected by the use of renin-angiotensin system (RAS) blockers. High renin levels also tend to support the use of RAS inhibitors as first-choice antihypertensive agents. However, the added value of a renin measurement on top of traditional risk factors is modest, and the pressure response to RAS blockade, even in high-renin patients, varies widely. SUMMARY Measuring 'baseline' renin as a marker of future cardiovascular events or to determine the choice of drug is of limited value in an individual patient.
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Braun-Dullaeus RC, Shustov SB, Alvarez C, Rogelio GG, Zhang J, Hristoskova S, Häring DA. Treatment with aliskiren/amlodipine combination in patients with moderate-to-severe hypertension: a randomised, double-blind, active comparator trial. Int J Clin Pract 2012; 66:834-42. [PMID: 22897460 DOI: 10.1111/j.1742-1241.2012.02967.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIMS To assess the extent of reduction in blood pressure (BP) of aliskiren/amlodipine combination therapy compared with amlodipine monotherapy in moderate-to-severe hypertensive patients. METHODS This was an 8-week multicentre, randomised, double-blind study. After a 1-to 4-week washout period, eligible patients [mean sitting systolic blood pressure (msSBP) ≥ 160 to < 200 mmHg] were randomised to receive a once-daily dose of aliskiren/amlodipine 150/5mg (n = 244) or amlodipine 5 mg (n = 241) for 1 week, followed by up-titration to aliskiren/amlodipine 300/10 mg or amlodipine 10 mg for 7 weeks. Efficacy outcome measures included change from baseline to week 8 endpoint in msSBP (primary endpoint), mean sitting diastolic blood pressure (msDBP), and BP control rate (< 140/90 mmHg). Safety was assessed by monitoring and recording all adverse events (AEs) and laboratory abnormalities. RESULTS Patients' demographic characteristics were balanced between the two groups, mean baseline BP being 171.0/94.3 mmHg for aliskiren/amlodipine and 171.8/95.6 mmHg for amlodipine. Of 485 randomised patients, 433 (89.3%) completed the study. At week 8 endpoint, combination therapy resulted in significantly greater msSBP/msDBP reductions and BP control rate, compared with monotherapy (all: p ≤ 0.0001). The overall incidence of AEs was similar between the two groups. The most commonly reported AE was peripheral oedema with the incidence lower for combination therapy (14.4%) than for monotherapy (18.3%). CONCLUSION In this population with considerably elevated BP, use of aliskiren/amlodipine combination showed significantly greater BP reductions and allowed more patients to achieve BP control compared with amlodipine monotherapy, with no additional safety concerns.
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Affiliation(s)
- R C Braun-Dullaeus
- Otto-von-Guericke-University, Magdeburg, Germany State Educational Institution of High Professional Education, St. Petersburg, Russia.
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Lu H, Balakrishnan A, Howatt DA, Wu C, Charnigo R, Liau G, Cassis LA, Daugherty A. Comparative effects of different modes of renin angiotensin system inhibition on hypercholesterolaemia-induced atherosclerosis. Br J Pharmacol 2012; 165:2000-2008. [PMID: 22014125 DOI: 10.1111/j.1476-5381.2011.01712.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND PURPOSE Inhibition of the renin angiotensin system (RAS) has been consistently demonstrated to reduce atherosclerosis. However, there has been no direct comparison among the three available pharmacological modes of inhibiting the RAS, which are inhibitors of renin, ACE and angiotensin II type 1 receptor. The purpose of this study was to determine the relative effects of these three modes of pharmacological RAS inhibition in reducing atherosclerosis by determining the dose-response relationships. EXPERIMENTAL APPROACH Male LDL receptor -/- mice were administered either vehicle or any of three doses of aliskiren, enalapril or losartan through s.c. infusion for 12 weeks. All mice were fed a saturated fat-enriched diet during drug infusions. Systolic and diastolic BPs were measured during the study using a non-invasive tail-cuff system. Plasma cholesterol and renin concentrations, atherosclerotic lesions, and renal angiotensin II concentrations were determined at the termination of the study. KEY RESULTS Plasma renin concentrations were increased by all three drugs. None of the drugs changed plasma cholesterol concentrations. All drugs produced a dose-related decrease in BP. All three drugs also profoundly reduced atherosclerosis in a dose-dependent manner. The highest dose of each drug markedly attenuated lesion size, with no significant differences between the different drugs. The highest dose of each drug also similarly reduced renal angiotensin II concentrations. CONCLUSION AND IMPLICATIONS Drugs that inhibit the RAS, irrespective of their mode of inhibition, profoundly affect atherosclerotic lesion development in a dose-dependent manner.
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Affiliation(s)
- Hong Lu
- Saha Cardiovascular Research CenterGraduate Center for Nutritional SciencesDepartment of Statistics, University of Kentucky, Lexington, KY, USANovartis Institutes for Biomedical Research, Cambridge, MA, USA
| | - Anju Balakrishnan
- Saha Cardiovascular Research CenterGraduate Center for Nutritional SciencesDepartment of Statistics, University of Kentucky, Lexington, KY, USANovartis Institutes for Biomedical Research, Cambridge, MA, USA
| | - Deborah A Howatt
- Saha Cardiovascular Research CenterGraduate Center for Nutritional SciencesDepartment of Statistics, University of Kentucky, Lexington, KY, USANovartis Institutes for Biomedical Research, Cambridge, MA, USA
| | - Congqing Wu
- Saha Cardiovascular Research CenterGraduate Center for Nutritional SciencesDepartment of Statistics, University of Kentucky, Lexington, KY, USANovartis Institutes for Biomedical Research, Cambridge, MA, USA
| | - Richard Charnigo
- Saha Cardiovascular Research CenterGraduate Center for Nutritional SciencesDepartment of Statistics, University of Kentucky, Lexington, KY, USANovartis Institutes for Biomedical Research, Cambridge, MA, USA
| | - Gene Liau
- Saha Cardiovascular Research CenterGraduate Center for Nutritional SciencesDepartment of Statistics, University of Kentucky, Lexington, KY, USANovartis Institutes for Biomedical Research, Cambridge, MA, USA
| | - Lisa A Cassis
- Saha Cardiovascular Research CenterGraduate Center for Nutritional SciencesDepartment of Statistics, University of Kentucky, Lexington, KY, USANovartis Institutes for Biomedical Research, Cambridge, MA, USA
| | - Alan Daugherty
- Saha Cardiovascular Research CenterGraduate Center for Nutritional SciencesDepartment of Statistics, University of Kentucky, Lexington, KY, USANovartis Institutes for Biomedical Research, Cambridge, MA, USA
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Aliskiren and perindopril reduce the levels of transforming growth factor-β in patients with non-diabetic kidney disease. Am J Hypertens 2012; 25:636-9. [PMID: 22357413 DOI: 10.1038/ajh.2012.14] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND It is highly likely that the rise in plasma prorenin and plasma renin during renin inhibitor treatment is induced at least as much by the fall in blood pressure (BP) as it is by the negative feedback of angiotensin II. This could potentially be harmful because high levels of renin and prorenin may stimulate the (pro)renin receptor, thus inducing profibrotic effects. To further understand this relationship, the influence of aliskiren on the urinary excretion of transforming growth factor-β1 (TGF-β1) and procollagen III N-terminal propeptide (PIIINP) was evaluated in patients with nondiabetic kidney diseases. METHODS Aliskiren 300 mg and perindopril 10 mg, were each individually administered for 12 weeks separated by a placebo period in a cross-over, randomized, double-blinded pilot study. RESULTS A 1,131% (P < 0.001) and 628% (P < 0.001) increase in plasma renin concentration was observed after the aliskiren and perindopril therapies, respectively, as compared to the placebo. Aliskiren and perindopril increased prorenin concentrations as compared to the placebo by 100% (P < 0.01) and 52.4% (P = 0.53), respectively. The TGF-β1 excretion was lower after tested therapies compared to the placebo (55.0 ± 7.56 vs. 56.21 ± 8.56 vs. 85.79 ± 14.11 pg/mg creatinine; P = 0.016); without differences between aliskiren and perindopril. PIIINP excretion did not differ between treatments. CONCLUSIONS The study shows that both aliskiren and perindopril suppress TGF-β1 in patients with chronic kidney diseases. This effect was observed despite significant increases in the renin and prorenin concentrations. Further studies involving histological assessments are required to elucidate the exact impact of these agents on renal fibrosis.
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Judd E, Jaimes EA. Aliskiren, amlodipine and hydrochlorothiazide triple combination for hypertension. Expert Rev Cardiovasc Ther 2012; 10:293-303. [PMID: 22390800 DOI: 10.1586/erc.12.7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Cardiovascular-related morbidity and mortality is linked to hypertension with proportional gains in cardiovascular risk factor reduction with the lowering of blood pressure. Clinical trial data has shown that attaining goal blood pressure requires, for most patients, at least two antihypertensive medications, with a significant proportion requiring regimens of three or more medications. Single-pill triple combinations have returned to the market following results of increased efficacy and adherence over dual- and mono-therapy. The combination of aliskiren, amlodipine and hydrochlorothiazide is a rational choice for combination therapy and recent studies suggest that it is safe and effective in lowering blood pressure in patients who fail dual combination therapy.
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Affiliation(s)
- Eric Judd
- University of Alabama at Birmingham, Vascular Biology and Hypertension Program, 115 Community Health Services Building, 933 19th Street South, Birmingham, AL, USA
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Weintraub HS, Duprez DA, Cushman WC, Zappe DH, Purkayastha D, Samuel R, Izzo JL. Antihypertensive Response to Thiazide Diuretic or Angiotensin Receptor Blocker in Elderly Hypertensives Is Not Influenced by Pretreatment Plasma Renin Activity. Cardiovasc Drugs Ther 2012; 26:145-55. [DOI: 10.1007/s10557-011-6365-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Moniwa N, Varagic J, Ahmad S, VonCannon JL, Ferrario CM. Restoration of the blood pressure circadian rhythm by direct renin inhibition and blockade of angiotensin II receptors in mRen2.Lewis hypertensive rats. Ther Adv Cardiovasc Dis 2012; 6:15-29. [PMID: 22222314 DOI: 10.1177/1753944711434039] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Alterations in the circadian arterial pressure rhythm predict cardiovascular mortality. We examined the circadian arterial pressure rhythm and the effect of renin-angiotensin system blockade in congenic mRen2.Lewis hypertensive rats, a renin-dependent model of hypertension derived from the backcross of transgenic hypertensive [mRen-2]27 rats with Lewis normotensive ones. METHODS Twenty-nine mRen2.Lewis hypertensive rats were randomly assigned to drink tap water (vehicle; n = 9), valsartan (30 mg/kg/day; n = 10), or valsartan (30 mg/kg/day) combined with aliskiren given subcutaneously (50 mg/kg/day; n = 10) for 2 weeks. Arterial pressure, heart rate, and locomotive activity were recorded with chronically implanted radiotelemetry probes. The awake/asleep ratio was calculated as [awake mean arterial pressure (MAP) mean - asleep MAP mean)] / (awake MAP mean) x 100. Plasma renin activity (PRA) and concentration (PRC), and plasma and kidney angiotensin II (Ang II) were measured by radioimmunoassay (RIAs). RESULTS Untreated hypertensive rats showed an inverse arterial pressure rhythm, higher at day and lower at night, accompanied by normal rhythms of heart rate and locomotive activity. Treatment with valsartan or aliskiren and valsartan normalized the elevated arterial pressure and the arterial pressure rhythm, with the combination therapy being more effective in reducing MAP and in restoring the awake/asleep ratio. While PRA and PRC increased with the treatments, the addition of aliskiren to valsartan partially reversed the increases in plasma Ang II levels. Valsartan and the aliskiren and valsartan combination markedly reduced the renal cortical content of Ang II. CONCLUSION The altered circadian arterial pressure rhythm in this renin-dependent hypertension model uncovers a significant role of Ang II in the desynchronization of the circadian rhythm of arterial pressure, heart rate, and locomotive activity.
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Affiliation(s)
- Norihito Moniwa
- Division of Surgical Sciences, Wake Forest University School of Medicine, Winston Salem, NC 27157, USA.
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Rashikh A, Ahmad SJ, Pillai KK, Najmi AK. Aliskiren as a novel therapeutic agent for hypertension and cardio-renal diseases. J Pharm Pharmacol 2011; 64:470-81. [DOI: 10.1111/j.2042-7158.2011.01414.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Abstract
Objectives
High blood pressure (BP) is a major risk factor for cardiovascular and renal complications. A majority of treated hypertensive patients still complain of high BP. The renin-angiotensin aldosterone system (RAAS) has been a centre-stage target for all the cardiovascular and cardio-renal complications. Aliskiren, is the first direct renin inhibitor (DRI) to be approved by the US FDA. Renin controls the rate-limiting step in the RAAS cascade and hence is the most favorable target for RAAS suppression.
Key findings
This review article strives to summarize the pharmacokinetic, preclinical and clinical studies done so far pertaining to the efficacy of aliskiren. Further, the pharmacology of aliskiren has been comprehensively dealt with to enhance understanding so as to further research in this unfathomed area in the multitude of cardiovascular disorders and renal diseases.
Summary
Aliskiren has been shown to have comparable BP-lowering effects to other RAAS inhibitors. Recent clinical trials have indicated that it might contribute significantly in combination with other agents for the protection of end-organ diseases.
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Affiliation(s)
- Azhar Rashikh
- Department of Pharmacology, Faculty of Pharmacy, Jamia Hamdard (Hamdard University), New Delhi, India
| | - Shibli Jameel Ahmad
- Department of Pharmacology, Faculty of Pharmacy, Jamia Hamdard (Hamdard University), New Delhi, India
| | - Krishna Kolappa Pillai
- Department of Pharmacology, Faculty of Pharmacy, Jamia Hamdard (Hamdard University), New Delhi, India
| | - Abul Kalam Najmi
- Department of Pharmacology, Faculty of Pharmacy, Jamia Hamdard (Hamdard University), New Delhi, India
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Laragh JH, Sealey JE. The plasma renin test reveals the contribution of body sodium-volume content (V) and renin-angiotensin (R) vasoconstriction to long-term blood pressure. Am J Hypertens 2011; 24:1164-80. [PMID: 21938070 DOI: 10.1038/ajh.2011.171] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Body sodium works together with the plasma renin-angiotensin system to ensure adequate blood flow to the tissues. Body sodium content determines the extracellular fluid (ECF) volume ensuring that, with each heart beat, a sufficient volume of fluid is delivered into the arterial space. At the same time the kidneys monitor ECF volume and blood pressure (BP), so that the juxtaglomerular cells can adjust their net secretion rate of renin to maintain an appropriate plasma renin activity (PRA) level. Plasma renin produces angiotensin II (Ang II) to constrict the arterioles and thereby ensure sufficient BP to deliver an appropriate rate of flow for cardiovascular homeostasis. The low renin, sodium-volume dependent (V) form of essential hypertension occurs whenever body sodium content increases beyond the point where plasma renin-angiotensin vasoconstrictor activity is turned off. In contrast, medium to high renin (R) hypertension occurs when too much renin is secreted relative to the body sodium content. Thus, BP = V × R. This volume-vasoconstriction dual support of long-term hypertension is validated by the fact that all effective long-term antihypertensive drug types are either (i) natriuretic to reduce body salt and volume content (anti-V), or (ii) antirenin to reduce or block the activity of the circulating renin-angiotensin system (anti-R). The PRA test defines the relative participation of the concurrent volume and vasoconstrictor factors. In the hypertensive patient PRA testing can guide initiation, addition or subtraction of anti-V or anti-R antihypertensive drug types to thereby improve BP control and prognosis while reducing drug type usage and cost.
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Gruson D, Maisin D, Lison P, Maiter D, Persu A. Two-site automated chemiluminescent assay for measurement of immunoreactive renin. Biomarkers 2011; 16:605-9. [DOI: 10.3109/1354750x.2011.614015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Direct renin inhibition with aliskiren normalizes blood pressure in Cyp1a1-Ren2 transgenic rats with inducible angiotensin ii-dependent malignant hypertension. Am J Med Sci 2011; 341:383-7. [PMID: 21358304 DOI: 10.1097/maj.0b013e31820fa8da] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Cyp1a1-Ren2 transgenic rats [strain name: TGR(Cyp1a1Ren2)], administered indole-3-carbinol (I3C) develop angiotensin (ANG) II-dependent hypertension due to hepatic expression of the Ren2 renin gene. Although AT1 receptor blockade prevents the development of hypertension and normalizes the elevated arterial blood pressure of Cyp1-Ren2 rats, little information is available regarding the blood pressure and renal functional responses to direct inhibition of renin in this high circulating renin model of ANG II-dependent hypertension. This study was performed to determine the effects of acute direct renin inhibition with aliskiren on blood pressure and renal hemodynamics in Cyp1a1-Ren2 rats with ANG II-dependent malignant hypertension. METHODS Mean arterial pressure (MAP) and renal hemodynamics were measured in pentobarbital-anesthetized male Cyp1a1-Ren2 rats during control conditions and after administration of the renin inhibitor, aliskiren (10 mg/kg, intravenous). RESULTS Rats induced with I3C had higher MAP (194 ± 7 versus 141 ± 2 mm Hg, P < 0.001), lower renal plasma flow (RPF; 2.47 ± 0.23 versus 4.17 ± 0.35 mL/min/g, P < 0.001) and lower glomerular filtration rate (GFR; 1.01 ± 0.07 versus 1.34 ± 0.06 mL/min/g, P = 0.01) than noninduced Cyp1a1-Ren2 rats (n = 5). Aliskiren administration decreased MAP (194 ± 7 to 136 ± 2 mm Hg, P < 0.001) and increased RPF (2.47 ± 0.23 versus 4.31 ± 0.20 mL/min/g, P < 0.001) in hypertensive but not in normotensive rats, without altering GFR. CONCLUSIONS Acute renin inhibition with aliskiren normalizes MAP and RPF in Cyp1a1-Ren2 rats with malignant hypertension. The normalization of MAP and RPF after acute renin inhibition indicates that renin generated by expression of the Ren2 gene is responsible for the maintenance of malignant hypertension and the associated reduction in renal hemodynamic function in Cyp1a1-Ren2 rats.
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A pharmacogenetic analysis of determinants of hypertension and blood pressure response to angiotensin-converting enzyme inhibitor therapy in patients with vascular disease and healthy individuals. J Hypertens 2011; 29:509-19. [PMID: 21157371 DOI: 10.1097/hjh.0b013e328341d117] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIMS To investigate whether genetic variation in the renin-angiotensin-aldosterone system (RAAS) and kallikrein-bradykinin pathways is related to hypertension and blood pressure (BP) response to angiotensin-converting enzyme (ACE) inhibitor therapy in stable coronary artery disease (CAD) patients. METHODS AND RESULTS In 8907 stable CAD patients from the EUROPA trial, 52 haplotype-tagging single-nucleotide polymorphisms (SNPs) in 12 candidate genes within the RAAS and kallikrein-bradykinin pathways were investigated for association with hypertension (defined as BP ≥160/95 mmHg or use of antihypertensives) and BP response to ACE inhibitors, during a 4-week run-in period. All analyses were adjusted for age, sex, body mass index and creatinine clearance and corrected for multiple testing. RESULTS Hypertension was present in 28.3% of the patients (n = 2526); median BP reduction after perindopril was 10/4 mmHg. Four polymorphisms, located in the ACE (rs4291), angiotensinogen (rs5049) and (pro)renin receptor (rs2968915; rs5981008) genes were significantly associated with hypertension in two vascular disease populations of CAD (EUROPA) and cerebrovascular disease (PROGRESS; n = 3571). A cumulative profile demonstrated a stepwise increase in the prevalence of hypertension, mounting to a 2-3-fold increase (P for trend <0.001). Similar associations on hypertension were observed for angiotensinogen in a healthy population (n = 2197). In addition, genetic polymorphisms were identified that significantly modified the BP reduction by ACE inhibitor therapy; however, the observed BP differences were small and did not remain significant after permutation analysis. CONCLUSION This large genetic association study identified genetic determinants of hypertension in three cohorts of patients with vascular disease and healthy individuals.
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Abstract
There is now clear evidence that reducing blood pressure (BP) with a broad range of agents, including angiotensin converting enzyme inhibitors and angiotensin receptor blockers, improves cardiovascular and renal outcomes. There is also evidence suggesting that these drugs have beneficial effects that are independent of BP lowering. Aliskiren is a direct renin inhibitor that interrupts the renin-angiotensin-aldosterone system (RAAS) at its rate-limiting step. Unlike angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, aliskiren produces a sustained reduction in plasma renin activity and reduces plasma levels of angiotensin II and aldosterone. Preclinical data and clinical trials in high-risk patients using surrogate markers increasingly suggest that aliskiren can reduce the progression of end-organ damage beyond that afforded by BP control. With its unique mechanism of action, combining aliskiren with another RAAS-blocking agent that has a different mechanism of action may provide more comprehensive blockade of the RAAS, potentially conferring additional clinical benefits. Evaluation of these end-organ effects in humans is underway in clinical trials designed to assess the effects of aliskiren alone and in combination with other antihypertensive agents on cardiovascular and renal outcomes.
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Alreja G, Joseph J. Renin and cardiovascular disease: Worn-out path, or new direction. World J Cardiol 2011; 3:72-83. [PMID: 21499495 PMCID: PMC3077814 DOI: 10.4330/wjc.v3.i3.72] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Revised: 03/02/2011] [Accepted: 03/09/2011] [Indexed: 02/06/2023] Open
Abstract
Inhibition of the renin angiotensin system has beneficial effects in cardiovascular prevention and treatment. The advent of orally active direct renin inhibitors adds a novel approach to antagonism of the renin-angiotensin system. Inhibition of the first and rate-limiting step of the renin angiotensin cascade offers theoretical advantages over downstream blockade. However, the recent discovery of the (pro)renin receptor which binds both renin and prorenin, and which can not only augment catalytic activity of both renin and prorenin in converting angiotensinogen to angiotensin I, but also signal intracellularly via various pathways to modulate gene expression, adds a significant level of complexity to the field. In this review, we will examine the basic and clinical data on renin and its inhibition in the context of cardiovascular pathophysiology.
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Affiliation(s)
- Gaurav Alreja
- Gaurav Alreja, Jacob Joseph, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, United States
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Using a Systems Biology Approach to Explore Hypotheses Underlying Clinical Diversity of the Renin Angiotensin System and the Response to Antihypertensive Therapies. ACTA ACUST UNITED AC 2010. [DOI: 10.1007/978-1-4419-7415-0_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Schmieder R. Usefulness of direct renin inhibition with aliskiren as antihypertensive treatment. HIPERTENSION Y RIESGO VASCULAR 2010. [DOI: 10.1016/j.hipert.2010.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rashid HU. Renoprotection, renin inhibition, and blood pressure control: the impact of aliskiren on integrated blood pressure control. Integr Blood Press Control 2010; 3:133-44. [PMID: 21949629 PMCID: PMC3172064 DOI: 10.2147/ibpc.s12407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Indexed: 12/17/2022] Open
Abstract
Hypertension (HTN) is an important factor in progressive loss of renal function. The kidney can be both a contributor to and a target of HTN. The functional integrity of the kidney is vital for the maintenance of cardiovascular homeostasis. Chronic activation of the renin system causes HTN and, ultimately, end-organ damage. Direct renin inhibitors (DRIs) inhibit plasma renin activity (PRA), thereby preventing the conversion of angiotensinogen to angiotensin I; consequently, the levels of both Ang I and Ang II are reduced. There is no compensatory increase in PRA activity with DRIs as seen with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs). There are reasons to speculate that renin inhibition might prove to be a superior strategy for blocking the renin-angiotensin-aldosterone system compared with ACEIs or ARBs. Evidence for the efficacy of aliskiren (a DRI) is considered to be relatively strong, based on published, short-term, double-blind, randomized, controlled trials showing that aliskiren is as effective as other antihypertensive agents in reducing blood pressure (BP), with no rebound effects on BP after treatment withdrawal. When combined with diuretics, fully additive BP reduction is seen. When given with an ACEI or ARB, aliskiren produces significant additional BP reduction indicative of complimentary pharmacology and more complete renin-angiotensin system blockade.
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Affiliation(s)
- Haroon-Ur Rashid
- Department of Cardiology, Baylor College of Medicine, Texas Heart Institute, Houston, TX, USA
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Affiliation(s)
- Sean T Duggan
- Adis, a Wolters Kluwer Business, Mairangi Bay, North Shore, Auckland, New Zealand.
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Jones-Burton C, Rubino J, Roy S, Mai Y, Meehan A, Bellet M, Feig P. Effects of the renin inhibitor MK-8141 (ACT-077825) in patients with hypertension. ACTA ACUST UNITED AC 2010; 4:219-26. [DOI: 10.1016/j.jash.2010.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 06/15/2010] [Accepted: 06/24/2010] [Indexed: 11/17/2022]
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Webb RL, Schiering N, Sedrani R, Maibaum J. Direct Renin Inhibitors as a New Therapy for Hypertension. J Med Chem 2010; 53:7490-520. [DOI: 10.1021/jm901885s] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Randy L. Webb
- Novartis Pharmaceuticals Corp., Institutes for BioMedical Research, East Hanover, New Jersey
| | - Nikolaus Schiering
- Novartis Pharma AG, Institutes for BioMedical Research, Novartis Campus, CH-4056 Basel, Switzerland
| | - Richard Sedrani
- Novartis Pharma AG, Institutes for BioMedical Research, Novartis Campus, CH-4056 Basel, Switzerland
| | - Jürgen Maibaum
- Novartis Pharma AG, Institutes for BioMedical Research, Novartis Campus, CH-4056 Basel, Switzerland
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Abstract
Hypertension, a serious disease affecting almost a billion people (25% of adults) worldwide, is a major modifiable risk factor for cardiovascular (CV) and renal disease. Despite numerous advances in the pharmacologic treatment of high blood pressure (BP) and availability of several antihypertensive drugs to treat hypertension, a significant proportion of treated hypertensive patients still have uncontrolled high BP, and thus, face serious morbidity and mortality. Furthermore, it is not sufficient to aim for optimum BP control, but to treat all CV risk factors, protect end-organ damage, prevent progression of disease, and prevent long-range adverse effects of the drugs. Therefore, new therapeutic modalities have to be developed to achieve the above objectives. Some years ago, investigators identified renin inhibition as the preferred pharmacologic approach to blockade of the renin-angiotensin system. Renin is a monospecific enzyme that catalyzes the rate-limiting step in the synthesis of angiotensin II. Amplified enzymatic activity and additional physiologic effects occur when renin and prorenin bind to the (pro)renin receptor. Until very recently, development of clinically effective renin inhibitors remained elusive but molecular modeling was used to develop aliskiren and other renin inhibitors that produce sustained suppression of plasma renin activity after oral administration with a dose-dependent BP. Additional studies will ultimately determine the place of renin inhibition in the treatment of hypertension and related CV disorders.
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Ichihara A, Sakoda M, Kurauchi-Mito A, Narita T, Kinouchi K, Bokuda K, Itoh H. New approaches to blockade of the renin-angiotensin-aldosterone system: characteristics and usefulness of the direct renin inhibitor aliskiren. J Pharmacol Sci 2010; 113:296-300. [PMID: 20675959 DOI: 10.1254/jphs.10r04fm] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Since renin inhibition interferes with the first and rate-limiting steps in the renin-angiotensin system, the renin step is a very attractive target for lowering blood pressure and minimizing target-organ damage. The newly developed direct renin inhibitor aliskiren has several attractive characteristics: it definitively reduces plasma renin activity among inhibitors of the renin-angiotensin system, is remarkably specific for human renin, exhibits a long half-life in plasma comparable to that of amlodipine, and has a high affinity for renal glomeruli and vasculature. Although these characteristics suggest the clinical usefulness and safety of aliskiren, several problems remain unsolved. Why does aliskiren have beneficial effects on the heart and kidneys of patients treated with angiotensin-converting enzyme (ACE) inhibitors and/or angiotensin II type 1-receptor blockers (ARBs)? Is the blood-pressure-lowering effect of aliskiren dependent on the plasma renin activity? Does aliskiren exert a possible adverse effect via (pro)renin receptor-dependent intracellular signals? Here, we review the characteristics and usefulness of aliskiren and discuss the current issues associated with this direct renin inhibitor.
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Affiliation(s)
- Atsuhiro Ichihara
- Department of Anti-Aging Medicine, Keio University School of Medicine, Tokyo, Japan.
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Chaudhary K, Nistala R, Whaley-Connell A. Is there a future for direct renin inhibitors? Expert Opin Investig Drugs 2010; 19:653-61. [DOI: 10.1517/13543781003781906] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Krone W, Hanefeld M, Meyer HF, Jung T, Bartlett M, Yeh CM, Rajman I, Prescott MF, Dole WP. Comparative efficacy and safety of aliskiren and irbesartan in patients with hypertension and metabolic syndrome. J Hum Hypertens 2010; 25:186-95. [PMID: 20376075 DOI: 10.1038/jhh.2010.38] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Metabolic syndrome, a cluster of risk factors that increase the risk of cardiovascular morbidity and mortality, is common in patients with hypertension. Chronic renin-angiotensin-aldosterone system (RAAS) activation, shown by elevated plasma renin activity (PRA), is implicated in many of the features of metabolic syndrome. The direct renin inhibitor aliskiren may be of benefit in this patient group as aliskiren targets the RAAS at the rate-limiting step. In this double-blind study, 141 patients with hypertension (mean baseline BP 155/93 mm Hg) and metabolic syndrome (modified National Cholesterol Education Program ATP III criteria) were randomized to aliskiren 300 mg or irbesartan 300 mg once daily. Patients treated with aliskiren 300 mg had their mean sitting blood pressure (BP) lowered by 13.8/7.1 mm Hg after 12 weeks, significantly greater (P≤0.001) than the 5.8/2.8 mm Hg reduction observed in patients treated with irbesartan 300 mg. A significantly greater proportion of patients treated with aliskiren achieved BP control to <135/85 mm Hg (29.2 vs 16.7% with irbesartan; P=0.019). Aliskiren treatment led to a 60% decrease in PRA from baseline, whereas irbesartan increased PRA by 99% (both P<0.001). Aliskiren and irbesartan had similar effects on glucose and lipid profiles and on a panel of biomarkers of inflammation and cardiovascular risk. Both aliskiren and irbesartan were well tolerated. Collectively, these results suggest that aliskiren 300 mg may offer treatment benefits compared with irbesartan 300 mg for BP reduction in patients with hypertension and metabolic syndrome.
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Affiliation(s)
- W Krone
- Klinik II und Poliklinik für Innere Medizin, Zentrum für Molekulare Medizin der Universität zu Köln, Cologne, Germany.
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Puig JG, Schunkert H, Taylor AA, Boye S, Jin J, Keefe DL. Evaluation of the dose--response relationship of aliskiren, a direct renin inhibitor, in an 8-week, multicenter, randomized, double-blind, parallel-group, placebo-controlled study in adult patients with stage 1 or 2 essential hypertension. Clin Ther 2010; 31:2839-50. [PMID: 20110023 DOI: 10.1016/j.clinthera.2009.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2009] [Indexed: 12/20/2022]
Abstract
BACKGROUND Aliskiren is approved for the treatment of hypertension at once-daily doses of 150 or 300 mg by the US Food and Drug Administration and the European Commission. It is generally well tolerated and provides 24-hour, dose-dependent blood pressure (BP) reduction; however, the effect of the 75-mg dose has been inconsistent in previous trials. OBJECTIVES This study was designed to assess the efficacy and tolerability of once-daily administration of aliskiren 75 mg and to evaluate the dose-response relationship across all 3 doses of aliskiren (75, 150, and 300 mg). METHODS In this 8-week, multicenter, randomized, double-blind, parallel-group, placebo-controlled study, patients aged > or =18 years with stage 1 or 2 essential hypertension entered a 3- to 4-week, single-blind, placebo run-in period. Eligible patients were randomized (1:1:1:1) to receive oral, once-daily doses of aliskiren 75, 150, or 300 mg or placebo. The primary efficacy variable was the change from baseline in mean sitting diastolic BP (msDBP) at the week-8 end point. Tolerability was assessed by monitoring and recording all adverse events (AEs). RESULTS A total of 642 patients (mean [SD] age, 52.0 [10.73] years; 60.0% male; 80.8% white; mean body weight, 89.2 [18.4] kg [range, 50-160 kg]) were included in the study. Overall, 576 patients (89.7%) completed the double-blind treatment period. The most frequent reasons for discontinuation were unsatisfactory therapeutic effect (27/642 randomized patients [4.2%]) and AEs (17/642 [2.6%]). At end point, aliskiren 150 and 300 mg significantly reduced msDBP (both, P < 0.001) and mean sitting systolic CONCLUSIONS This study found a positive linear dose-response relationship in BP reduction with aliskiren 75, 150, and 300 mg dosed once daily, but only aliskiren 150 and 300 mg provided statistically significant reductions from baseline compared with placebo. All 3 doses of aliskiren were generally well tolerated.
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Affiliation(s)
- Juan G Puig
- Vascular Risk Unit, Department of Internal Medicine, La Paz Hospital, Madrid, Spain
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Romet M. [The renin-angiotensin system in hypertension and in cardiovascular and renal diseases: highlights of the World Congress of Nephrology 2009]]. Nephrol Ther 2010; 6 Spec No 1:H10-3. [PMID: 20129455 DOI: 10.1016/s1769-7255(10)70002-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- M Romet
- Santé active édition, 9 Villa Chanoine, 92270 Bois-Colombes, France
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Renal and cardio-protective effects of direct renin inhibition: a systematic literature review. J Hypertens 2010; 27:2321-31. [PMID: 19727007 DOI: 10.1097/hjh.0b013e3283310f92] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Blockade of the renin-angiotensin-aldosterone system (RAAS) at its rate-limiting step by means of renin inhibition has led to the development of direct renin inhibitors (DRIs). Given the renal and cardioprotective effects of RAAS blockade by angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers, DRIs may increase the armamentarium for further organ protection. Over the last two decades the effects of DRIs on biomarkers for renal and cardiovascular disease have been investigated. This systematic review aims to delineate the effects of DRIs on surrogate markers of renal and cardiovascular function. METHODS MEDLINE and previous systematic reviews were searched for articles reported between 1980 and 2008. A standardized dataset was extracted from articles describing the effects of DRIs on markers of renal and cardiac damage and hard outcomes. RESULTS Fifty-two articles were included. Blood pressure reductions were generally insufficient using early generation DRIs. However, recent DRIs have greater blood pressure-lowering effects. Preclinical and clinical studies showed profound effects of DRIs on markers of renal function, including clear increases in renal plasma flow and reductions in albuminuria. These effects were observed either alone or in combination with other RAAS inhibitors and suggest potential large renal protective benefit. DRIs improved hemodynamic cardiovascular parameters, such as total peripheral resistance, arterial pressure and left ventricular mass index, to a similar extent as those observed with other RAAS inhibitors. Furthermore, addition of DRIs to optimal heart failure treatment resulted in further reductions in B-type natriuretic peptide. CONCLUSIONS Evidence from preclinical and clinical studies suggests that DRIs may have renal and cardiovascular effects beyond their ability to lower blood pressure. Results of ongoing hard outcome trials are awaited to definitively assess the renal and cardio-protective effects of these agents.
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Ferrario CM. Addressing the theoretical and clinical advantages of combination therapy with inhibitors of the renin-angiotensin-aldosterone system: antihypertensive effects and benefits beyond BP control. Life Sci 2009; 86:289-99. [PMID: 19958778 DOI: 10.1016/j.lfs.2009.11.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 11/12/2009] [Accepted: 11/25/2009] [Indexed: 01/08/2023]
Abstract
AIMS This article reviews the importance of the renin-angiotensin-aldosterone system (RAAS) in the cardiometabolic continuum; presents the pros and cons of dual RAAS blockade with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs); and examines the theoretical and practical benefits supporting the use of direct renin inhibitors (DRIs) in combination with ACEIs or ARBs. MAIN METHODS The author reviewed the literature for key publications related to the biochemical physiology of the RAAS and the pharmacodynamic effects of ACEIs, ARBs, and DRIs, with a particular focus on dual RAAS blockade with these drug classes. KEY FINDINGS Although ACEI/ARB combination therapy produces modest improvement in BP, it has not resulted in the major improvements predicted given the importance of the RAAS across the cardiorenal disease continuum. This may reflect the fact that RAAS blockade with ACEIs and/or ARBs leads to exacerbated renin release through loss of negative-feedback inhibition, as well as ACE/aldosterone escape through RAAS and non-RAAS-mediated mechanisms. Plasma renin activity (PRA) is an independent predictor of morbidity and mortality, even for patients receiving ACEIs and ARBs. When used alone or in combination with ACEIs and ARBs, the DRI aliskiren effectively reduces PRA. Reductions in BP are greater with these combinations, relative to the individual components alone. SIGNIFICANCE It is possible that aliskiren plus either an ACEI or ARB may provide greater RAAS blockade than monotherapy with ACEIs or ARBs, and lead to additive improvement in BP and clinically important outcomes.
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Affiliation(s)
- Carlos M Ferrario
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1032, United States.
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Stanton AV, Gradman AH, Schmieder RE, Nussberger J, Sarangapani R, Prescott MF. Aliskiren monotherapy does not cause paradoxical blood pressure rises: meta-analysis of data from 8 clinical trials. Hypertension 2009; 55:54-60. [PMID: 19917876 DOI: 10.1161/hypertensionaha.109.135772] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and diuretics all cause reactive rises in plasma renin concentration, but particularly high levels have been reported with aliskiren. This prompted speculation that blockade of plasma renin activity with aliskiren could be overwhelmed, leading to paradoxical increases in blood pressure. This meta-analysis of data from 4877 patients from 8 randomized, double-blind, placebo- and/or active-controlled trials examined this hypothesis. The analysis focused on the incidence of paradoxical blood pressure increases above predefined thresholds, after > or =4 weeks of treatment with 300 mg of aliskiren, angiotensin receptor blockers (300 mg of irbesartan, 100 mg of losartan, or 320 mg of valsartan), 10 mg of ramipril, 25 mg of hydrochlorothiazide, or placebo. There were no significant differences in the frequency of increases in systolic (>10 mm Hg; P=0.30) or diastolic (>5 mm Hg; P=0.65) pressure among those treated with aliskiren (3.9% and 3.1%, respectively), angiotensin receptor blockers (4.0% and 3.7%), ramipril (5.7% and 2.6%), or hydrochlorothiazide (4.4% and 2.7%). Increases in blood pressure were considerably more frequent in the placebo group (12.6% and 11.4%; P<0.001). None of the 536 patients with plasma renin activity data who received 300 mg of aliskiren exhibited an increase in systolic pressure >10 mm Hg that was associated with an increase in plasma renin activity >0.1 ng/mL per hour. In conclusion, the incidence of blood pressure increases with aliskiren was similar to that during treatment with other antihypertensive drugs. Blood pressure rises on aliskiren treatment were not associated with increases in plasma renin activity. This meta-analysis found no evidence that aliskiren uniquely causes paradoxical rises in blood pressure.
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Affiliation(s)
- Alice V Stanton
- Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin 2, Ireland.
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Danser AHJ. The increase in renin during renin inhibition: does it result in harmful effects by the (pro)renin receptor? Hypertens Res 2009; 33:4-10. [PMID: 19893565 DOI: 10.1038/hr.2009.186] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Renin inhibitors, similar to all renin-angiotensin system (RAS) blockers, increase the plasma concentration of renin because they attenuate the negative feedback effect of angiotensin (Ang) II on renin release. The increase in renin has been suggested to be higher than that during other types of RAS blockade. This could potentially limit the effectiveness of renin inhibition, either because Ang II generation might occur again ('Ang II escape'), possibly even at the levels above baseline, as has been described before for angiotensin-converting enzyme inhibitors, or because high levels of renin will stimulate the recently discovered (pro)renin receptor, and thus induce effects in an Ang-independent manner. This review shows first that the cause(s) of the renin increase during treatment with the renin inhibitor aliskiren is the consequence of a combination of factors, including an assay artifact, allowing the detection of prorenin as renin, and a change in renin half-life. When correcting for these phenomena the increase is unlikely to be as excessive as originally thought. The review then critically describes the consequence(s) of such a increase, concluding (i) that an Ang II escape is highly unlikely, given the [aliskiren]/[renin] stoichiometry, and (ii) that renin and prorenin downregulate their receptor (similar to many agonists). On the basis of the latter, one could even speculate that this will be more substantial when the renin and prorenin levels are higher. Thus, from this point of view the larger increase in renin during renin inhibition will cause a stronger reduction in (pro)renin receptor expression, and a greater suppression of (pro)renin receptor-mediated effects than other renin-Ang blockers.
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Affiliation(s)
- A H Jan Danser
- Division of Pharmacology, Vascular and Metabolic Diseases, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands.
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