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Khattar G, Asmar S, Sanayeh EB, Keesari P, Rahi W, Sakr F, Khoury M, Cinelli M, Lee S, Weinberg M, Kowalski M, Parikh V. Unveiling the Hidden Stroke Threat in Patients With Atrial Fibrillation and Primary Hyperparathyroidism. Am J Cardiol 2024; 218:94-101. [PMID: 38452840 DOI: 10.1016/j.amjcard.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/17/2024] [Accepted: 03/01/2024] [Indexed: 03/09/2024]
Abstract
Recent American College of Cardiology (ACC), American Heart Association (AHA), American College of Clinical Pharmacy (ACCP), and Heart Rhythm Society (HRS) guidelines suggest that patients with atrial fibrillation (AF) at intermediate to low annual risk of ischemic stroke can benefit from consideration of factors that might modify their risk of stroke. The role of nontraditional risk factors, such as primary hyperparathyroidism (PHPT), remains unexplored. In our study, we investigated the potential association between PHPT and the risk of ischemic stroke in patients with AF. Using data from the Nationwide Inpatient Sample Database, a retrospective cohort study focused on the adult population with AF, we stratified the participants based on PHPT presence. Demographic information, co-morbidities, and hospitalization details were extracted using International Classification of Diseases, Tenth revision codes. Propensity score matching was applied, encompassing over 20 confounding variables, including the risk factors outlined in the CHA2DS2-VASc (Congestive heart failure (C), Hypertension (H), Age ≥75 years (A₂), Diabetes Mellitus (D), Stroke/Transient Ischemic Attack (TIA)/Thromboembolism (S₂), Vascular disease (V), Age 65-74 years (A), Sex category [female] (Sc)) score. Multivariate logistic regression analysis was performed after matching to assess the independent impact of PHPT as an ischemic stroke risk factor. A total of 2,051 of the identified 395,249 patients with AF had PHPT. The PHPT group had an average age of 74 years and consisted of more women (66.1% vs 53.0%). After matching, it was observed that the PHPT group had longer hospital stays (5 vs 4 days) and higher hospitalization charges ($45,126 vs $36,644). This group exhibited higher rates of ischemic stroke (6.0% vs 4.4%) and mortality (6.3% vs 4.9%). The adjusted outcomes showed a 1.4-fold increased risk for ischemic stroke and a 1.32-fold increased risk for mortality in the PHPT cohort. The subgroup analysis showed a higher incidence of mortality in men with a high CHA2DS2-VASc score. In conclusion, this study highlights a marked association between PHPT and ischemic stroke in patients with AF, independent of the conventional CHA2DS2-VASc score. The potential mechanisms implicated include vascular changes, cardiac dysfunction, and coagulation cascade alterations. The presence of PHPT should be taken into consideration when deciding the assessment of thromboembolic risk.
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Affiliation(s)
- Georges Khattar
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, New York.
| | - Samer Asmar
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, New York
| | - Elie Bou Sanayeh
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, New York
| | - Praneeth Keesari
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, New York
| | - Wissam Rahi
- Department of Internal Medicine, Lankeneau Medical Center, Wynnewood, Pennsylvania; Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Fouad Sakr
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, New York
| | - Michel Khoury
- Department of Cardiology, Staten Island University Hospital/Northwell Health, Staten Island, New York
| | - Michael Cinelli
- Department of Cardiology, Staten Island University Hospital/Northwell Health, Staten Island, New York
| | - Samantha Lee
- Department of Cardiology, Staten Island University Hospital/Northwell Health, Staten Island, New York
| | - Mitchell Weinberg
- Department of Interventional Cardiology and Vascular Medicine, Staten Island University Hospital/Northwell Health, Staten Island, New York; Chair of Cardiology, Staten Island University Hospital/Northwell Health, Staten Island, New York
| | - Marcin Kowalski
- Department of Cardiology, Staten Island University Hospital/Northwell Health, Staten Island, New York; Department of Cardiac Electrophysiology, Staten Island University Hospital/Northwell Health, Staten Island, New York; Zucker School of Medicine at Hofstra/Northwell, New York
| | - Valay Parikh
- Department of Cardiology, Staten Island University Hospital/Northwell Health, Staten Island, New York; Department of Cardiac Electrophysiology, Staten Island University Hospital/Northwell Health, Staten Island, New York; Zucker School of Medicine at Hofstra/Northwell, New York
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Fishbane SN, Nigwekar S. Phosphate Absorption and Hyperphosphatemia Management in Kidney Disease: A Physiology-Based Review. Kidney Med 2021; 3:1057-1064. [PMID: 34939015 PMCID: PMC8664730 DOI: 10.1016/j.xkme.2021.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Phosphate absorption occurs in the gastrointestinal tract through paracellular absorption and transcellular transport. The paracellular pathway does not saturate and has a significantly higher absorption capacity than does the transcellular pathway. Evidence indicates that this pathway is the primary mechanism of intestinal phosphate absorption, particularly with Western diets containing high amounts of phosphorus. Elevated serum phosphorus concentrations are associated with cardiovascular morbidity and mortality but serum phosphorus concentrations > 5.5 mg/dL are highly prevalent despite best efforts with dietary phosphate restriction, dialysis, and the use of phosphate binders. The efficacy of phosphate binders may be inherently limited because the mechanism of action does not target any phosphate absorption pathway. Thus, therapeutic innovations are needed to address the limitations of phosphate binders. Novel therapies leveraging new mechanistic understandings of phosphate absorption and the primacy of the paracellular pathway may improve phosphate control. Phosphate absorption inhibitors that target the pathway are a novel therapeutic class. Tenapanor is an investigational first-in-class nonbinder phosphate absorption inhibitor that inhibits the sodium-hydrogen exchanger isoform 3 to reduce paracellular permeability specific to phosphate. Phosphate absorption inhibitors may represent a new mechanistic approach to phosphate management with the potential to improve clinical outcomes.
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Affiliation(s)
- Steven N. Fishbane
- Department of Medicine, Zucker School of Medicine at Hofstra, Hempstead, Great Neck, NY
- Northwell, Great Neck, NY
| | - Sagar Nigwekar
- Department of Medicine, Harvard Medical School, Boston, MA
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Martínez-Arias L, Panizo-García S, Martín-Vírgala J, Martín-Carro B, Fernández-Villabrille S, Avello-Llano N, Miguel-Fernández D, Ruíz Torres MP, Cannata-Andía JB, Carrillo-López N, Naves-Díaz M. Contribution of phosphorus and PTH to the development of cardiac hypertrophy and fibrosis in an experimental model of chronic renal failure. Nefrologia 2021; 41:640-651. [PMID: 36165154 DOI: 10.1016/j.nefroe.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 02/01/2021] [Accepted: 02/07/2021] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Adequate serum phosphorus levels in patients with chronic kidney disease is essential for their clinical management. However, the control of hyperphosphatemia is difficult because is normally associated with increases in serum PTH. In the present study, the effects of hyperphosphatemia, in the presence of elevated and normal PTH, on cardiac inflammation, hypertrophy and fibrosis in an experimental renal failure model were analyzed. MATERIALS AND METHODS 4 groups of rats were formed. Two groups underwent total parathyroidectomy (PTx). Rats with Ca <7.5 mg/dL and PTH < 50 pg/mL underwent 7/8 nephrectomy (CRF) and a subcutaneous pellet was placed that releases PTH 1-34 (5 µg/kg/day). One group received a diet with normal P (NP) (CRF + PTx + rPTH + NP group) and another with a high P diet (0.9% - HP) (CRF + PTx + rPTH + HP group). Other 2 groups that only had CRF received NP (CRF + NP) and HP (CRF + HP) diet. A SHAM group for nephrectomy and parathyroidectomy was also added. After 14 weeks the rats were sacrificed. RESULTS The groups with a diet high in phosphorus (CRF + H A and CRF + PTx + rPTH + HP) had a significant reduction in creatinine clearance and also in body weight with an increase in serum phosphorus regardless of parathyroidectomy, but not serum levels of calcium, FGF23 and calcitriol that were 2-3 times higher in the group with secondary hyperparathyroidism (CRF + HP). The diameter of the cardiomyocytes was greater in the CRF + HP group, while parathyroidectomy (CRF + PTx + rPTH + HP) significantly reduced them, despite the high and similar serum phosphorus values. TNF-α, Adam17 and cardiac fibrosis at the histological and molecular level showed a similar pattern with increases in the group with severe secondary hyperparathyroidism (CRF + HP). CONCLUSIONS Hyperphosphatemia confirmed its importance in the genesis of secondary hyperparathyroidism, but also of kidney damage that was independent of PTH levels. However, inflammation, fibrosis, and cardiomyocyte growth were more closely related to PTH levels, since in the presence of similar severe hyperphosphatemia, parathyroidectomy reduced the values of inflammatory parameters, cardiac hypertrophy, and fibrosis.
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Affiliation(s)
- Laura Martínez-Arias
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, Spain
| | - Sara Panizo-García
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, Spain
| | - Julia Martín-Vírgala
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, Spain
| | - Beatriz Martín-Carro
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, Spain
| | - Sara Fernández-Villabrille
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, Spain
| | - Noelia Avello-Llano
- Laboratorio de Medicina, Hospital Universitario Central de Asturias, Universidad de Oviedo, Oviedo, Spain
| | - Diego Miguel-Fernández
- Laboratorio de Medicina, Hospital Universitario Central de Asturias, Universidad de Oviedo, Oviedo, Spain
| | - María Piedad Ruíz Torres
- Departamento de Biología de Sistemas, Unidad de Fisiología, Facultad de Medicina, Universidad de Alcalá de Henares, Retic REDinREN-ISCIII, Madrid, Spain
| | - Jorge B Cannata-Andía
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, Spain.
| | - Natalia Carrillo-López
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, Spain
| | - Manuel Naves-Díaz
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, Spain
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Hsu HC, Norton GR, Peters F, Robinson C, Dlongolo N, Solomon A, Teckie G, Woodiwiss AJ, Dessein PH. Association of Post Transplantation Anaemia and Persistent Secondary Hyperparathyroidism with Diastolic Function in Stable Kidney Transplant Recipients. Int J Nephrol Renovasc Dis 2021; 14:211-223. [PMID: 34239319 PMCID: PMC8259932 DOI: 10.2147/ijnrd.s314313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/05/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction We hypothesized that post transplantation anaemia and persistent secondary hyperparathyroidism are potential determinants of diastolic function in stable kidney transplant recipients. Methods We assessed traditional and non-traditional cardiovascular risk factors and determined carotid artery intima-media thickness and plaque by ultrasound, arterial function by applanation tonometry using SphygmoCor software and diastolic function by echocardiography in 43 kidney transplant recipients with a transplant duration of ≥6 months, no acute rejection and a glomerular filtration rate of ≥15 mL/min/1.73m2. Results Mean (SD; range) transplant duration was 12.3 (8.0; 0.5–33.8) years. Post transplantation anaemia and persistent secondary hyperparathyroidism were identified in 27.9% and 30.8% of the patients, respectively; 67.5% of the participants were overweight or obese. In established confounder adjusted analysis, haemoglobin (partial R=−0.394, p=0.01) and parathyroid hormone concentrations (partial R=0.382, p=0.02) were associated with E/e’. In multivariable analysis, haemoglobin (partial R=−0.278, p=0.01) and parathyroid levels (partial R=0.324, p=0.04) were independently associated with E/e’. Waist–height ratio (partial R=−0.526, p=0.001 and partial R=−0.355, p=0.03), waist circumference (partial R=−0.433, p=0.008 and partial R=−0.393, p=0.02) and body mass index (partial R=−0.332, p=0.04 and partial R=−0.489, p=0.002) were associated with both e’ and E/A, respectively, in established confounder adjusted analysis. The haemoglobin-E/e’ (partial R=−0.422, p=0.02), parathyroid hormone-E/e’ (partial R=0.434, p=0.03), waist–height ratio-e’ (partial R=−0.497, p=0.007) and body mass index-E/A (partial R=−0.386, p=0.04) relationships remained consistent after additional adjustment for left ventricular mass index and cardiac preload and afterload measures. Conclusion Haemoglobin and parathyroid hormone concentrations as well as adiposity measures are independently associated with diastolic function in kidney transplant recipients. Whether adequate management of post transplantation anaemia, persistent secondary hyperparathyroidism and excess adiposity can prevent the development of heart failure with preserved ejection fraction in kidney transplant recipients merits further investigation.
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Affiliation(s)
- Hon-Chun Hsu
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Nephrology Unit, Milpark Hospital, Johannesburg, South Africa
| | - Gavin R Norton
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ferande Peters
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Chanel Robinson
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Noluntu Dlongolo
- Rheumatology Unit, Rosebank Hospital, Johannesburg, South Africa
| | - Ahmed Solomon
- Division of Rheumatology, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Gloria Teckie
- Division of Nephrology, Department of Medicine, Chris Hani Baragwanath Hospital and Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Angela J Woodiwiss
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Patrick H Dessein
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Internal Medicine Department, University of the Witwatersrand, Johannesburg, South Africa.,Internal Medicine Department, Free University and University Hospital, Brussels, Belgium
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5
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Martínez-Arias L, Panizo-García S, Martín-Vírgala J, Martín-Carro B, Fernández-Villabrille S, Avello-Llano N, Miguel-Fernández D, Ruiz Torres MP, Cannata-Andía JB, Carrillo-López N, Naves-Díaz M. Contribution of phosphorus and PTH to the development of cardiac hypertrophy and fibrosis in an experimental model of chronic renal failure. Nefrologia 2021; 41:S0211-6995(21)00033-3. [PMID: 33715866 DOI: 10.1016/j.nefro.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 02/01/2021] [Accepted: 02/07/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Adequate serum phosphorus levels in patients with chronic kidney disease is essential for their clinical management. However, the control of hyperphosphatemia is difficult because is normally associated with increases in serum PTH. In the present study, the effects of hyperphosphatemia, in the presence of elevated and normal PTH, on cardiac inflammation, hypertrophy and fibrosis in an experimental renal failure model were analyzed. MATERIALS AND METHODS Four groups of rats were formed. Two groups underwent total parathyroidectomy (PTx). Rats with Ca < 7.5 mg/dL and PTH < 50 pg/mL underwent 7/8 nephrectomy (CRF) and a subcutaneous pellet was placed that releases PTH 1-34 (5 μg/kg/day). One group received a diet with normal P (NP) (CRF + PTx + rPTH + NP group) and another with a high P diet (0.9% HP) (CRF + PTx + rPTH + HP group). Other two groups that only had CRF received NP (CRF + NP) and HP (CRF + HP) diet. A SHAM group for nephrectomy and parathyroidectomy was also added. After 14 weeks the rats were sacrificed. RESULTS The groups with a diet high in phosphorus (CRF + H A and CRF + PTx + rPTH + HP) had a significant reduction in creatinine clearance and also in body weight with an increase in serum phosphorus regardless of parathyroidectomy, but not serum levels of calcium, FGF23 and calcitriol that were 2-3 times higher in the group with secondary hyperparathyroidism (CRF + HP). The diameter of the cardiomyocytes was greater in the CRF + HP group, while parathyroidectomy (CRF + PTx + rPTH + HP) significantly reduced them, despite the high and similar serum phosphorus values. TNF-α, Adam17 and cardiac fibrosis at the histological and molecular level showed a similar pattern with increases in the group with severe secondary hyperparathyroidism (CRF + HP). CONCLUSIONS Hyperphosphatemia confirmed its importance in the genesis of secondary hyperparathyroidism, but also of kidney damage that was independent of PTH levels. However, inflammation, fibrosis, and cardiomyocyte growth were more closely related to PTH levels, since in the presence of similar severe hyperphosphatemia, parathyroidectomy reduced the values of inflammatory parameters, cardiac hypertrophy, and fibrosis.
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Affiliation(s)
- Laura Martínez-Arias
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, España
| | - Sara Panizo-García
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, España
| | - Julia Martín-Vírgala
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, España
| | - Beatriz Martín-Carro
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, España
| | - Sara Fernández-Villabrille
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, España
| | - Noelia Avello-Llano
- Laboratorio de Medicina, Hospital Universitario Central de Asturias, Universidad de Oviedo, Oviedo, España
| | - Diego Miguel-Fernández
- Laboratorio de Medicina, Hospital Universitario Central de Asturias, Universidad de Oviedo, Oviedo, España
| | - María Piedad Ruiz Torres
- Departamento de Biología de Sistemas, Unidad de Fisiología, Facultad de Medicina, Universidad de Alcalá de Henares, Retic REDinREN-ISCIII, Madrid, España
| | - Jorge B Cannata-Andía
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, España.
| | - Natalia Carrillo-López
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, España
| | - Manuel Naves-Díaz
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, España
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AlQudah M, Hale TM, Czubryt MP. Targeting the renin-angiotensin-aldosterone system in fibrosis. Matrix Biol 2020; 91-92:92-108. [PMID: 32422329 DOI: 10.1016/j.matbio.2020.04.005] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 02/06/2023]
Abstract
Fibrosis is characterized by excessive deposition of extracellular matrix components such as collagen in tissues or organs. Fibrosis can develop in the heart, kidneys, liver, skin or any other body organ in response to injury or maladaptive reparative processes, reducing overall function and leading eventually to organ failure. A variety of cellular and molecular signaling mechanisms are involved in the pathogenesis of fibrosis. The renin-angiotensin-aldosterone system (RAAS) interacts with the potent Transforming Growth Factor β (TGFβ) pro-fibrotic pathway to mediate fibrosis in many cell and tissue types. RAAS consists of both classical and alternative pathways, which act to potentiate or antagonize fibrotic signaling mechanisms, respectively. This review provides an overview of recent literature describing the roles of RAAS in the pathogenesis of fibrosis, particularly in the liver, heart, kidney and skin, and with a focus on RAAS interactions with TGFβ signaling. Targeting RAAS to combat fibrosis represents a promising therapeutic approach, particularly given the lack of strategies for treating fibrosis as its own entity, thus animal and clinical studies to examine the impact of natural and synthetic substances to alter RAAS signaling as a means to treat fibrosis are reviewed as well.
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Affiliation(s)
- Mohammad AlQudah
- Department of Physiology and Pathophysiology, Rady Faculty of Health Sciences, University of Manitoba, Canada; Department of Physiology and Biochemistry, College of Medicine, Jordan University of Science and Technology, Jordan
| | - Taben M Hale
- Department of Basic Medical Sciences, University of Arizona College of Medicine Phoenix, United States
| | - Michael P Czubryt
- Department of Physiology and Pathophysiology, Rady Faculty of Health Sciences, University of Manitoba, Canada.
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Chu TP, Yang PS, Lee JJ, Wu CJ, Cheng SP. Increasing Age Hinders the Decline in B-Type Natriuretic Peptide Following Parathyroidectomy in Dialysis Patients. In Vivo 2019; 33:1691-1696. [PMID: 31471425 DOI: 10.21873/invivo.11657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 07/09/2019] [Accepted: 07/15/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND/AIM Parathyroidectomy has beneficial effects on all-cause and cardiovascular mortality in patients with uncontrolled hyperparathyroidism. B-Type natriuretic peptide (BNP) correlates with the severity of heart failure. We aimed to investigate whether parathyroidectomy modulates the BNP levels in dialysis patients. PATIENTS AND METHODS Patients who underwent surgical intervention for hyperparathyroidism were included. The serum BNP levels were determined before parathyroidectomy and during follow-up. RESULTS The preoperative and postoperative BNP levels were 499±561 and 453±442 pg/ml, respectively (p=0.82). The baseline BNP level was positively correlated with weakness and headache, but not biochemical parameters. In multivariate analysis, age (odds ratio=0.837) and preoperative symptom score (odds ratio=0.935) were independent predictors for the postoperative decline in BNP levels Conclusion: The serum BNP levels may increase or decrease after parathyroidectomy. Younger age and lower symptom burden are associated with decline in BNP levels.
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Affiliation(s)
- Tun-Pang Chu
- Department of Surgery, MacKay Memorial Hospital and Mackay Medical College, Taipei, Taiwan, R.O.C
| | - Po-Sheng Yang
- Department of Surgery, MacKay Memorial Hospital and Mackay Medical College, Taipei, Taiwan, R.O.C
| | - Jie-Jen Lee
- Department of Surgery, MacKay Memorial Hospital and Mackay Medical College, Taipei, Taiwan, R.O.C
| | - Chih-Jen Wu
- Division of Nephrology, Department of Internal Medicine, MacKay Memorial Hospital and Mackay Medical College, Taipei, Taiwan, R.O.C.,Department of Pharmacology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, R.O.C
| | - Shih-Ping Cheng
- Department of Surgery, MacKay Memorial Hospital and Mackay Medical College, Taipei, Taiwan, R.O.C. .,Department of Pharmacology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, R.O.C
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Edmonston D, Morris JD, Middleton JP. Working Toward an Improved Understanding of Chronic Cardiorenal Syndrome Type 4. Adv Chronic Kidney Dis 2018; 25:454-467. [PMID: 30309463 DOI: 10.1053/j.ackd.2018.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/09/2018] [Accepted: 08/15/2018] [Indexed: 12/17/2022]
Abstract
Chronic diseases of the heart and of the kidneys commonly coexist in individuals. Certainly combined and persistent heart and kidney failure can arise from a common pathologic insult, for example, as a consequence of poorly controlled hypertension or of severe diffuse arterial disease. However, strong evidence is emerging to suggest that cross talk exists between the heart and the kidney. Independent processes are set in motion when kidney function is chronically diminished, and these processes can have distinct adverse effects on the heart. The complex chronic heart condition that results from chronic kidney disease (CKD) has been termed cardiorenal syndrome type 4. This review will include an updated description of the cardiac morphology in patients who have CKD, an overview of the most likely CKD-sourced culprits for these cardiac changes, and the potential therapeutic strategies to limit cardiac complications in patients who have CKD.
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Charytan DM, Fishbane S, Malyszko J, McCullough PA, Goldsmith D. Cardiorenal Syndrome and the Role of the Bone-Mineral Axis and Anemia. Am J Kidney Dis 2015; 66:196-205. [PMID: 25727384 PMCID: PMC4516683 DOI: 10.1053/j.ajkd.2014.12.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 12/09/2014] [Indexed: 12/12/2022]
Abstract
The association between chronic kidney disease (CKD) and cardiovascular disease (CVD) is well established, and there is mounting evidence of interorgan cross talk that may accelerate pathologic processes and the progression of organ dysfunction in both systems. This process, termed cardiorenal syndrome (CRS) by the Acute Dialysis Quality Initiative, is considered a major health problem: patients with CKD and CVD are at much higher risk of mortality than patients with either condition alone. To date, the majority of CRS research has focused on neurohormonal mechanisms and hemodynamic alterations. However, mounting evidence suggests that abnormalities in the normal pathophysiology of the bone-mineral axis, iron, and erythropoietin play a role in accelerating CKD and CVD. The goal of this article is to review the role and interrelated effects of the bone-mineral axis and anemia in the pathogenesis of chronic CRS.
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Affiliation(s)
| | - Steven Fishbane
- Division of Kidney Diseases and Hypertension, North Shore University Hospital and Long Island Jewish Medical Center, Great Neck, NY
| | - Jolanta Malyszko
- 2nd Department of Nephrology, Medical University, Bialystok, Poland
| | - Peter A McCullough
- Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas; The Heart Hospital, Plano, TX
| | - David Goldsmith
- Department of Nephrology, King's Health Partners Academic Health Sciences Centre, London, United Kingdom
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Prado-Uribe MDC, Soto-Abraham MV, Mora-Villalpando CJ, Gallardo JM, Bonilla E, Avila M, Tena E, Paniagua R. Role of thyroid hormones and mir-208 in myocardial remodeling in 5/6 nephrectomized rats. Arch Med Res 2013; 44:616-22. [PMID: 24246300 DOI: 10.1016/j.arcmed.2013.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 10/30/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND AIMS Thyroid hormones exert important effects on heart remodeling through mir-208. The process may have a role in myocardial changes in chronic kidney disease where thyroid abnormalities are common. In this study the effect of T4 supplementation on left ventricle (LV) remodeling in 5/6 nephrectomized rats (5/6Nx) was analyzed. METHODS 5/6Nx rats and 5/6Nx under T4 supplementation (5/6Nx + T4) were compared with control (C) and thyroidectomized (Tx) rats. After 8 weeks of follow-up, LV was analyzed for α-MHC, β-MHC, TGF-β, and mir-208 expression, hydroxyproline content, and myocardial fibrosis. Serum collagenase activity was also analyzed. RESULTS Heart weight increased in 5/6Nx rats compared to C, which was prevented with T4 supplementation (C, 1.5 ± 0.04; 5/6Nx, 1.8 ± 0.09; 5/6Nx + T4, 1.6 ± 0.07 g, p <0.05). The same pattern was seen for LV wall thickness, hydroxyproline content, LV fibrosis, and mRNA TGF-β expression (C, 0.47 ± 0.17; 5/6Nx, 10.55 ± 3.4; 5/6Nx + T4, 3.01 ± 0.52, p <0.01). Tx rats had reduction in heart weight, increased LV wall thickness, and fibrosis. Collagenase activity did not change in any group. mRNA expression of α-, β-MHC, and TGF-β increased in 5/6Nx in comparison to C and 5/6Nx + T4. Expression of mir-208 decreased in 5/6Nx groups, and levels were restored with T4 supplementation (4.21 ± 0.28, 3.39 ± 0.29, and 4.26 ± 0.37 RU, respectively, p <0.01). CONCLUSIONS Decreased plasma level of thyroid hormones or sensitivity at tissue level observed in chronic kidney disease induced by 5/6Nx has an important effect in heart remodeling processes, some of it related or mediated by mir-208 and TGF-β expression in the heart.
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Affiliation(s)
- María-Del-Carmen Prado-Uribe
- Medical Research Unit in Nephrology Diseases, Specialty Hospital, Centro Médico Nacional Siglo XXI, Mexican Social Security Institute, Mexico City, Mexico.
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11
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Fisher A, Srikusalanukul W, Davis M, Smith P. Cardiovascular diseases in older patients with osteoporotic hip fracture: prevalence, disturbances in mineral and bone metabolism, and bidirectional links. Clin Interv Aging 2013; 8:239-56. [PMID: 23460043 PMCID: PMC3585505 DOI: 10.2147/cia.s38856] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Considerable controversy exists regarding the contribution of mineral/bone metabolism abnormalities to the association between cardiovascular diseases (CVDs) and osteoporotic fractures. AIMS AND METHODS To determine the relationships between mineral/bone metabolism biomarkers and CVD in 746 older patients with hip fracture, clinical data were recorded and serum concentrations of parathyroid hormone (PTH), 25-hydroxyvitamin D, calcium, phosphate, magnesium, troponin I, parameters of bone turnover, and renal, liver, and thyroid functions were measured. RESULTS CVDs were diagnosed in 472 (63.3%) patients. Vitamin D deficiency was similarly prevalent in patients with (78.0%) and without (82.1%) CVD. The CVD group had significantly higher mean PTH concentrations (7.6 vs 6.0 pmol/L, P < 0.001), a higher prevalence of secondary hyperparathyroidism (SPTH) (PTH > 6.8 pmol/L, 43.0% vs 23.3%, P < 0.001), and excess bone resorption (urinary deoxypyridinoline corrected by creatinine [DPD/Cr] > 7.5 nmol/μmol, 87.9% vs 74.8%, P < 0.001). In multivariate regression analysis, SHPT (odds ratio [OR] 2.6, P = 0.007) and high DPD/Cr (OR 2.8, P = 0.016) were independent indictors of CVD. Compared to those with both PTH and DPD/Cr in the normal range, multivariate-adjusted ORs for the presence of CVD were 17.3 (P = 0.004) in subjects with SHPT and 9.7 (P < 0.001) in patients with high DPD/Cr. CVD was an independent predicator of SHPT (OR 2.8, P = 0.007) and excess DPD/Cr (OR 2.5, P = 0.031). CVD was predictive of postoperative myocardial injury, while SHPT was also an independent predictor of prolonged hospital stay and in-hospital death. CONCLUSION SHPT and excess bone resorption are independent pathophysiological mediators underlying the bidirectional associations between CVD and hip fracture, and therefore are important diagnostic and therapeutic targets.
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Affiliation(s)
- A Fisher
- Department of Geriatric Medicine, The Canberra Hospital, Canberra, ACT, Australia.
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12
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Shih CJ, Tarng DC, Yang WC, Yang CY. Parathyroidectomy Reduces Intradialytic Hypotension in Hemodialysis Patients with Secondary Hyperparathyroidism. ACTA ACUST UNITED AC 2013; 37:323-31. [DOI: 10.1159/000350160] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2013] [Indexed: 11/19/2022]
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13
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Tomaschitz A, Fahrleitner-Pammer A, Pieske B, Verheyen N, Amrein K, Ritz E, Kienreich K, Horina JH, Schmidt A, Kraigher-Krainer E, Colantonio C, Meinitzer A, Pilz S. Effect of eplerenone on parathyroid hormone levels in patients with primary hyperparathyroidism: a randomized, double-blind, placebo-controlled trial. BMC Endocr Disord 2012; 12:19. [PMID: 22974443 PMCID: PMC3515510 DOI: 10.1186/1472-6823-12-19] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 08/31/2012] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Increasing evidence suggests the bidirectional interplay between parathyroid hormone and aldosterone as an important mechanism behind the increased risk of cardiovascular damage and bone disease observed in primary hyperparathyroidism. Our primary object is to assess the efficacy of the mineralocorticoid receptor-blocker eplerenone to reduce parathyroid hormone secretion in patients with parathyroid hormone excess. METHODS/DESIGN Overall, 110 adult male and female patients with primary hyperparathyroidism will be randomly assigned to eplerenone (25 mg once daily for 4 weeks and 4 weeks with 50 mg once daily after dose titration] or placebo, over eight weeks. Each participant will undergo detailed clinical assessment, including anthropometric evaluation, 24-h ambulatory arterial blood pressure monitoring, echocardiography, kidney function and detailed laboratory determination of biomarkers of bone metabolism and cardiovascular disease.The study comprises the following exploratory endpoints: mean change from baseline to week eight in (1) parathyroid hormone(1-84) as the primary endpoint and (2) 24-h systolic and diastolic ambulatory blood pressure levels, NT-pro-BNP, biomarkers of bone metabolism, 24-h urinary protein/albumin excretion and echocardiographic parameters reflecting systolic and diastolic function as well as cardiac dimensions, as secondary endpoints. DISCUSSION In view of the reciprocal interaction between aldosterone and parathyroid hormone and the potentially ensuing target organ damage, the EPATH trial is designed to determine whether eplerenone, compared to placebo, will effectively impact on parathyroid hormone secretion and improve cardiovascular, renal and bone health in patients with primary hyperparathyroidism. TRIAL REGISTRATION ISRCTN33941607.
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Affiliation(s)
- Andreas Tomaschitz
- Department of Cardiology, Medical University of Graz, Auenbruggerplatz 15, Graz, 8036, Austria
| | - Astrid Fahrleitner-Pammer
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Medical University of Graz, Auenbruggerplatz 15, Graz, 8036, Austria
| | - Burkert Pieske
- Department of Cardiology, Medical University of Graz, Auenbruggerplatz 15, Graz, 8036, Austria
| | - Nicolas Verheyen
- Department of Cardiology, Medical University of Graz, Auenbruggerplatz 15, Graz, 8036, Austria
| | - Karin Amrein
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Medical University of Graz, Auenbruggerplatz 15, Graz, 8036, Austria
| | - Eberhard Ritz
- Department of Medicine, Division of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Katharina Kienreich
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Medical University of Graz, Auenbruggerplatz 15, Graz, 8036, Austria
| | - Jörg H Horina
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Albrecht Schmidt
- Department of Cardiology, Medical University of Graz, Auenbruggerplatz 15, Graz, 8036, Austria
| | | | - Caterina Colantonio
- Department of Cardiology, Medical University of Graz, Auenbruggerplatz 15, Graz, 8036, Austria
| | - Andreas Meinitzer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Stefan Pilz
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Medical University of Graz, Auenbruggerplatz 15, Graz, 8036, Austria
- Department of Epidemiology and Biostatistics and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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Pun PH, Lehrich RW, Honeycutt EF, Herzog CA, Middleton JP. Modifiable risk factors associated with sudden cardiac arrest within hemodialysis clinics. Kidney Int 2011; 79:218-27. [DOI: 10.1038/ki.2010.315] [Citation(s) in RCA: 189] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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15
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Brunaud L, Germain A, Zarnegar R, Rancier M, Alrasheedi S, Caillard C, Ayav A, Weryha G, Mirallie E, Bresler L. Serum aldosterone is correlated positively to parathyroid hormone (PTH) levels in patients with primary hyperparathyroidism. Surgery 2009; 146:1035-41. [DOI: 10.1016/j.surg.2009.09.041] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2009] [Accepted: 09/17/2009] [Indexed: 10/20/2022]
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Grossmann C, Krug AW, Freudinger R, Mildenberger S, Voelker K, Gekle M. Aldosterone-induced EGFR expression: interaction between the human mineralocorticoid receptor and the human EGFR promoter. Am J Physiol Endocrinol Metab 2007; 292:E1790-800. [PMID: 17311890 DOI: 10.1152/ajpendo.00708.2006] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Aldosterone plays a key role in cardiovascular and renal injury. The underlying mechanisms are not completely understood. Because the epidermal growth factor receptor (EGFR) is involved in the development of fibrosis and vascular dysfunction, upregulation of EGFR expression by aldosterone-bound mineralocorticoid receptor (MR) is an attractive hypothesis. We investigated the effect of aldosterone on EGFR expression in the aorta of adrenalectomized rats and in human aorta smooth muscle cells (HAoSMC) in primary culture. Aldosterone, but not dexamethasone, stimulated EGFR expression in vivo in the aorta as well as in HAoSMC. EGFR degradation was not affected. Aldosterone-induced EGFR expression in HAoSMC was dose dependent and prevented by spironolactone. Furthermore, incubation of HAoSMC with aldosterone led to enhanced EGF-induced ERK1/2 phosphorylation and an EGFR-dependent increase in media fibronectin. EGFR promoter reporter gene assay as well as chromatin immunoprecipitation data indicate that MR interacts with the EGFR promoter. With deletion constructs we gained evidence that this interaction takes place between the hMR and the EGFR promoter regions 316-163 (stronger activation site, EC50 approximately 1.0 nM) and 163-1 (weaker activation site, EC50 approximately 0.7 nM), which do not comprise canonical glucocorticoid response elements and are not activated by the human glucocorticoid receptor. The interactions require in part the NH2-terminal domains of MR. ELISA-based transcription factor DNA binding assay with in vitro synthesized hMR suggest direct binding to region 163-1. Our results indicate that aldosterone leads to enhanced EGFR expression via an interaction with the EGFR promoter, which is MR specific and could contribute to the aldosterone-induced increase in fibronectin abundance.
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Affiliation(s)
- Claudia Grossmann
- Physiologisches Institut, Universitaet Wuerzburg, Roentgenring 9, 97070 Wuerzburg, Germany
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