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Ashruf OS, Ashruf Z, Orozco Z, Zinter M, Abu-Arja R, Yerigeri K, Haq IU, Kaelber DC, Bissler J, Raina R. Epidemiology, Risk Factors, and Clinical Outcomes of AKI in Pediatric Hematopoietic Stem Cell Transplant Patients. KIDNEY360 2024; 5:802-811. [PMID: 38935491 PMCID: PMC11219119 DOI: 10.34067/kid.0000000000000410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 02/26/2024] [Indexed: 06/29/2024]
Abstract
Key Points The cumulative incidence of AKI diagnosis post–hematopoietic stem cell transplantation was 12.9%. Calcineurin inhibitor use was associated with the highest cumulative incidence, 21.6%, after hematopoietic stem cell transplantation. Patients with AKI with hypertension/hypertensive disease had a 30-day survival probability of 63.9% (hazard ratio, 4.86, 95% confidence interval, 3.58 to 6.60). Patients with AKI were 2.5 times more likely to experience composite hospitalization and/or mortality at 30 days. Of patients who developed AKI, dialysis dependence has nearly tripled since 2014. Background AKI is a common complication in pediatric patients undergoing hematopoietic stem cell transplantation (HSCT), with a reported prevalence ranging from 68% to 84%. Few multicenter pediatric studies comprehensively assess the epidemiologic associations and clinical outcomes associated with AKI development. Methods An observational, retrospective analysis was conducted using an aggregated electronic health record data platform. The study population consisted of pediatric patients (age <18 years) who underwent HSCT over a 20-year period. The study groups consisted of patients with an encounter diagnosis of AKI (n =713) and those without AKI (n =4455). Both groups were propensity matched for age, sex, race, prior cancer diagnosis, and other comorbidities. End points were incidence, mortality risk, clinical outcomes, and prevalence of dialysis dependence. Competing risks analysis, Cox proportional hazard analyses, Kaplan–Meier survival curves, and incidence/prevalence rates were calculated. Results After matching, 688 patients were identified. Cumulative incidence of AKI diagnosis post-HSCT was 13.7%. Hypertensive disease, calcineurin inhibitors, and vancomycin were the most prevalent risk factors for AKI, with calcineurin inhibitors showing the highest cumulative incidence (21.6%). Patients with AKI with hypertensive disease had a survival probability of 63.9% at 30 days, followed by calcineurin inhibitors (64.4%) and vancomycin (65.9%). Patients with AKI were 1.7 times more likely to experience composite hospitalization and/or mortality at 30 days. At 365 days post-HSCT, patients with AKI had higher rates of all-cause emergency department visits, intensive care unit admissions, and mechanical ventilation compared with non-AKI. Of patients who developed AKI, the prevalence of dialysis dependence has nearly tripled since 2014. Conclusions The findings highlight a strong association between specific risk factors, such as hypertension, calcineurin inhibitor use, and vancomycin use, with increased mortality and adverse clinical outcomes in patients with AKI after HSCT. These results emphasize the need for preventative actions such as 24-hour BP monitoring and discontinuation of potential nephrotoxic medications.
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Affiliation(s)
- Omer S. Ashruf
- Department of Internal Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Zaid Ashruf
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
| | - Zara Orozco
- Department of Internal Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Matt Zinter
- Division of Critical Care Medicine, Department of Pediatrics, School of Medicine, University of California, San Francisco, California
| | - Rolla Abu-Arja
- Division of Hematology, Oncology, Blood and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Keval Yerigeri
- Department of Internal Medicine-Pediatrics, The MetroHealth System, Cleveland, Ohio
| | - Imad U. Haq
- Department of Internal Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - David C. Kaelber
- Center for Clinical Informatics Research and Education, The MetroHealth System and the Departments of Internal Medicine, Pediatrics, and Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - John Bissler
- Department of Pediatrics, University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Rupesh Raina
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
- Department of Nephrology, Akron Children's Hospital, Akron, Ohio
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Cadour F, Thuny F, Sourdon J. New Insights in Early Detection of Anticancer Drug-Related Cardiotoxicity Using Perfusion and Metabolic Imaging. Front Cardiovasc Med 2022; 9:813883. [PMID: 35198613 PMCID: PMC8858802 DOI: 10.3389/fcvm.2022.813883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/06/2022] [Indexed: 12/16/2022] Open
Abstract
Cardio-oncology requires a good knowledge of the cardiotoxicity of anticancer drugs, their mechanisms, and their diagnosis for better management. Anthracyclines, anti-vascular endothelial growth factor (VEGF), alkylating agents, antimetabolites, anti-human epidermal growth factor receptor (HER), and receptor tyrosine kinase inhibitors (RTKi) are therapeutics whose cardiotoxicity involves several mechanisms at the cellular and subcellular levels. Current guidelines for anticancer drugs cardiotoxicity are essentially based on monitoring left ventricle ejection fraction (LVEF). However, knowledge of microvascular and metabolic dysfunction allows for better imaging assessment before overt LVEF impairment. Early detection of anticancer drug-related cardiotoxicity would therefore advance the prevention and patient care. In this review, we provide a comprehensive overview of the cardiotoxic effects of anticancer drugs and describe myocardial perfusion, metabolic, and mitochondrial function imaging approaches to detect them before over LVEF impairment.
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Affiliation(s)
- Farah Cadour
- Aix-Marseille Université, CNRS, CRMBM, Marseille, France
- APHM, Hôpital Universitaire Timone, CEMEREM, Marseille, France
| | - Franck Thuny
- Aix-Marseille University, University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Department of Cardiology, North Hospital, Assistance Publique - Hôpitaux de Marseille, Centre for CardioVascular and Nutrition Research (C2VN), Inserm 1263, Inrae 1260, Marseille, France
| | - Joevin Sourdon
- Aix-Marseille Université, CNRS, CRMBM, Marseille, France
- APHM, Hôpital Universitaire Timone, CEMEREM, Marseille, France
- *Correspondence: Joevin Sourdon
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3
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Liu HC, Zhou XT, Zheng YS, He H, Liu XQ. PK/PD modeling based on NO-ET homeostasis for improving management of sunitinib-induced hypertension in rats. Acta Pharmacol Sin 2020; 41:719-728. [PMID: 31932646 PMCID: PMC7471499 DOI: 10.1038/s41401-019-0331-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 11/04/2019] [Indexed: 11/09/2022] Open
Abstract
Sunitinib is an oral small molecule multitargeted tyrosine kinase inhibitor, which is currently used to treat severe cancers. Clinical research has shown that patients treated with sunitinib develop hypertension. As soon as sunitinib-induced hypertension appears, it is usual to administer anti-hypertension agent. But this treatment may cause acute blood pressure fluctuation which may lead to additional cardiovascular risk. The aim of this study is to establish a mathematical model for managing sunitinib-induced hypertension and blood pressure fluctuation. A mechanism-based PK/PD model was developed based on animal experiments. Then this model was used to perform simulations, thus to propose an anti-hypertension indication, according to which the anti-hypertension treatment might yield relative low-level AUC and fluctuation of blood pressure. The simulation results suggest that the anti-hypertension agent may yield low-level AUC and fluctuation of blood pressure when relative ET-1 level ranges from −15% to 5% and relative NO level is more than 10% compared to control group. Finally, animal experiments were conducted to verify the simulation results. Macitentan (30 mg/kg) was administered based on the above anti-hypertension indication. Compared with the untreated group, the optimized treatment significantly reduced the AUC of blood pressure; meanwhile the fluctuation of blood pressure in optimized treatment group was 70% less than that in immediate treatment group. This work provides a novel model with potential translational value for managing sunitinib-induced hypertension.
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Abstract
PURPOSE OF REVIEW Here, we review current concepts on hypertensive crisis (HTN-C) with a focus on epidemiology, causes, pathophysiology and prognosis. We also offer a practical approach to the management of HTN-C. RECENT FINDINGS HTN-C is characterized by a severe and abrupt increase in blood pressure (BP) with impending or progressive acute end-organ damage (EOD). HTN-C can be divided into hypertensive emergency (HTN-E) and hypertensive urgency (HTN-U) based on the presence or absence of acute EOD, respectively. Recent retrospective studies have demonstrated that emergency department (ED) referrals from an outpatient clinic or rapid BP-lowering strategies in the ED do not lead to improved outcomes in patients with HTN-U. SUMMARY HTN-C can be a de-novo manifestation or a complication of essential or secondary HTN. The presence of acute EOD is a major poor prognostic indicator in HTN-C. The main objectives of the management of HTN-C are distinction of HTN-E from HTN-U and appropriate risk stratification, prevention or regression of acute EOD due to severely elevated BP, prevention of recurrence of HTN-C with an effective long-term management plan and avoidance of rapid lowering of BP except in some special circumstances. The majority of patients with asymptomatic HTN-U can be safely managed in the outpatient setting without exposing them to the risks of aggressive BP lowering. However, patients with HTN-E require hospitalization, prompt treatment and close monitoring.
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5
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Sourdon J, Lager F, Viel T, Balvay D, Moorhouse R, Bennana E, Renault G, Tharaux PL, Dhaun N, Tavitian B. Cardiac Metabolic Deregulation Induced by the Tyrosine Kinase Receptor Inhibitor Sunitinib is rescued by Endothelin Receptor Antagonism. Theranostics 2017; 7:2757-2774. [PMID: 28824714 PMCID: PMC5562214 DOI: 10.7150/thno.19551] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/31/2017] [Indexed: 02/06/2023] Open
Abstract
The growing field of cardio-oncology addresses the side effects of cancer treatment on the cardiovascular system. Here, we explored the cardiotoxicity of the antiangiogenic therapy, sunitinib, in the mouse heart from a diagnostic and therapeutic perspective. We showed that sunitinib induces an anaerobic switch of cellular metabolism within the myocardium which is associated with the development of myocardial fibrosis and reduced left ventricular ejection fraction as demonstrated by echocardiography. The capacity of positron emission tomography with [18F]fluorodeoxyglucose to detect the changes in cardiac metabolism caused by sunitinib was dependent on fasting status and duration of treatment. Pan proteomic analysis in the myocardium showed that sunitinib induced (i) an early metabolic switch with enhanced glycolysis and reduced oxidative phosphorylation, and (ii) a metabolic failure to use glucose as energy substrate, similar to the insulin resistance found in type 2 diabetes. Co-administration of the endothelin receptor antagonist, macitentan, to sunitinib-treated animals prevented both metabolic defects, restored glucose uptake and cardiac function, and prevented myocardial fibrosis. These results support the endothelin system in mediating the cardiotoxic effects of sunitinib and endothelin receptor antagonism as a potential therapeutic approach to prevent cardiotoxicity. Furthermore, metabolic and functional imaging can monitor the cardiotoxic effects and the benefits of endothelin antagonism in a theranostic approach.
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Affiliation(s)
- Joevin Sourdon
- Paris Cardiovascular Research Center (PARCC); INSERM UMR970; Université Paris Descartes; Paris, France
| | - Franck Lager
- Institut Cochin, Université Paris Descartes, INSERM U1016, Paris 75014, France
| | - Thomas Viel
- Paris Cardiovascular Research Center (PARCC); INSERM UMR970; Université Paris Descartes; Paris, France
| | - Daniel Balvay
- Paris Cardiovascular Research Center (PARCC); INSERM UMR970; Université Paris Descartes; Paris, France
| | - Rebecca Moorhouse
- University/British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Evangeline Bennana
- Institut Cochin, Université Paris Descartes, INSERM U1016, Paris 75014, France
- 3P5 proteomics facility, Université Paris Descartes, Université Sorbonne Paris Cité, Paris, France
| | - Gilles Renault
- Institut Cochin, Université Paris Descartes, INSERM U1016, Paris 75014, France
| | - Pierre-Louis Tharaux
- Paris Cardiovascular Research Center (PARCC); INSERM UMR970; Université Paris Descartes; Paris, France
| | - Neeraj Dhaun
- University/British Heart Foundation Centre of Research Excellence, The Queen's Medical Research Institute, University of Edinburgh, United Kingdom
| | - Bertrand Tavitian
- Paris Cardiovascular Research Center (PARCC); INSERM UMR970; Université Paris Descartes; Paris, France
- Service de Radiologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
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Raina R, Herrera N, Krishnappa V, Sethi SK, Deep A, Kao WM, Bunchman T, Abu-Arja R. Hematopoietic stem cell transplantation and acute kidney injury in children: A comprehensive review. Pediatr Transplant 2017; 21. [PMID: 28485097 DOI: 10.1111/petr.12935] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2017] [Indexed: 12/27/2022]
Abstract
AKI in the setting of HSCT is commonly investigated among adult patients. In the same way, malignancies requiring treatment with HSCT are not limited to the adult patient population, AKI following HSCT is frequently encountered within pediatric patient populations. However, inadequate information regarding epidemiology and pathophysiology specific to pediatric patients prevents development of appropriate and successful therapeutic strategies for those afflicted. Addressing AKI in the context of sinusoidal obstruction syndrome, chemotherapy, thrombotic microangiopathy and hypertension post chemotherapy, glomerulonephritis, and graft versus host disease provides greater insight into renal impairment associated with these HSCT-related ailments. To obtain a better understanding of AKI among pediatric patients receiving HSCT, we investigated the current literature specifically addressing these areas of concern.
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Affiliation(s)
- Rupesh Raina
- Department of Pediatric Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Nicholas Herrera
- Department of Pediatrics-Nephrology, UH Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Vinod Krishnappa
- Cleveland Clinic Akron General/Akron Nephrology Associates, Akron, OH, USA
| | - Sidharth Kumar Sethi
- Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Akash Deep
- Department of Paediatric Intensive Care, King's College Hospital, London, UK
| | - Wei-Ming Kao
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Timothy Bunchman
- Children's Hospital of Richmond, VCU School of Medicine, Richmond, VA, USA
| | - Rolla Abu-Arja
- Department of Pediatric Hematology & Oncology Pediatrics, Nationwide Children's Hospital/Ohio State University, Columbus, OH, USA
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Lankhorst S, Saleh L, Danser AJ, van den Meiracker AH. Etiology of angiogenesis inhibition-related hypertension. Curr Opin Pharmacol 2014; 21:7-13. [PMID: 25500206 DOI: 10.1016/j.coph.2014.11.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 11/18/2014] [Accepted: 11/26/2014] [Indexed: 11/24/2022]
Abstract
Angiogenesis inhibition, targeting vascular endothelial growth factor (VEGF) or its receptors, is an established treatment for solid tumors. A common side effect of this treatment is the development of sometimes severe hypertension. This hypertension is associated with a decrease in nitric oxide production, activation of the endothelin-signaling pathway and renin suppression. The mechanism underlying activation of the endothelin-signaling pathway is not fully understood. Both activation of endothelial cells and disinhibition of the VEGF-induced suppression of endothelin production by endothelial cells may be involved. The development of hypertension can be a reason to discontinue the angiogenesis inhibitor, thereby compromising anticancer treatment, but possibly is also a biomarker for a favorable antitumor response.
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Affiliation(s)
- Stephanie Lankhorst
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Langeza Saleh
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Ah Jan Danser
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Anton H van den Meiracker
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands.
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8
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Rizzoni D, Paini A, Salvetti M, Rossini C, De Ciuceis C, Agabiti Rosei C, Muiesan ML. Inhibitors of Angiogenesis and Blood Pressure. CURRENT CARDIOVASCULAR RISK REPORTS 2013. [DOI: 10.1007/s12170-013-0309-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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9
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Kruzliak P, Kovacova G, Pechanova O. Therapeutic potential of nitric oxide donors in the prevention and treatment of angiogenesis-inhibitor-induced hypertension. Angiogenesis 2012. [PMID: 23203441 PMCID: PMC3595470 DOI: 10.1007/s10456-012-9327-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Angiogenesis is critical to tumor growth as well as to metastases. This process is tightly regulated by pro- and anti-angiogenic growth factors and their receptors. Some of these factors are highly specific for the endothelium-e.g., vascular endothelial growth factor (VEGF). A variety of drugs that target VEGF or its receptors have been developed for the treatment of different tumor types and a number of new agents is expected to be introduced within the coming years. However, clinical experience has revealed that inhibition of VEGF induces several side effects including hypertension and renal and cardiac toxicity. Angiogenesis-inhibitor-induced hypertension represents "crux medicorum" as it is often pharmacoresistant to antihypertensive therapy. We consider two most important pathomechanisms in the development of hypertension induced by angiogenesis inhibitors. The first represents direct inhibition of NO production leading to reduced vasodilatation and the second consists in increased proliferation of vascular medial cells mediated by NO deficiency and is resulting in fixation of hypertension. Based on the results of experimental and clinical studies as well as on our clinical experience, we assume that NO donors could be successfully used not only for the treatment of developed angiogenesis-inhibitor-induced hypertension but also for preventive effects. We thoroughly documented three clinical cases of cancer patients with resistant hypertension who on receiving NO donor treatment achieved target blood pressure level and a good clinical status.
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Affiliation(s)
- Peter Kruzliak
- Institute of Normal and Pathological Physiology, Centre of Excellence for Regulatory Role of Nitric Oxide in Civilization Diseases, Slovak Academy of Sciences, 813 71, Bratislava, Slovak Republic.
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Van der Veldt AAM, Lubberink M, Bahce I, Walraven M, de Boer MP, Greuter HNJM, Hendrikse NH, Eriksson J, Windhorst AD, Postmus PE, Verheul HM, Serné EH, Lammertsma AA, Smit EF. Rapid decrease in delivery of chemotherapy to tumors after anti-VEGF therapy: implications for scheduling of anti-angiogenic drugs. Cancer Cell 2012; 21:82-91. [PMID: 22264790 DOI: 10.1016/j.ccr.2011.11.023] [Citation(s) in RCA: 255] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Revised: 11/02/2011] [Accepted: 11/29/2011] [Indexed: 12/12/2022]
Abstract
Current strategies combining anti-angiogenic drugs with chemotherapy provide clinical benefit in cancer patients. It is assumed that anti-angiogenic drugs, such as bevacizumab, transiently normalize abnormal tumor vasculature and contribute to improved delivery of subsequent chemotherapy. To investigate this concept, a study was performed in non-small cell lung cancer (NSCLC) patients using positron emission tomography (PET) and radiolabeled docetaxel ([(11)C]docetaxel). In NSCLC, bevacizumab reduced both perfusion and net influx rate of [(11)C]docetaxel within 5 hr. These effects persisted after 4 days. The clinical relevance of these findings is notable, as there was no evidence for a substantial improvement in drug delivery to tumors. These findings highlight the importance of drug scheduling and advocate further studies to optimize scheduling of anti-angiogenic drugs.
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Affiliation(s)
- Astrid A M Van der Veldt
- Department of Nuclear Medicine and PET Research, VU University Medical Center, Amsterdam, The Netherlands.
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Kappers MH, de Beer VJ, Zhou Z, Danser AJ, Sleijfer S, Duncker DJ, van den Meiracker AH, Merkus D. Sunitinib-Induced Systemic Vasoconstriction in Swine Is Endothelin Mediated and Does Not Involve Nitric Oxide or Oxidative Stress. Hypertension 2012; 59:151-7. [DOI: 10.1161/hypertensionaha.111.182220] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Angiogenesis inhibition with agents targeting tyrosine kinases of vascular endothelial growth factor receptors is an established anticancer treatment, but is, unfortunately, frequently accompanied by systemic hypertension and cardiac toxicity. Whether vascular endothelial growth factor receptor antagonism also has adverse effects on the pulmonary and coronary circulations is presently unknown. In chronically instrumented awake swine, the effects of the vascular endothelial growth factor receptor antagonist sunitinib on the systemic, pulmonary, and coronary circulation were studied. One week after sunitinib (50 mg PO daily), mean aortic blood pressure (MABP) had increased from 83±5 mm Hg at baseline to 97±6 mm Hg (
P
<0.05) because of a 57±20% increase in systemic vascular resistance as cardiac output decreased. In contrast, sunitinib had no discernible effects on pulmonary and coronary hemodynamics or cardiac function. We subsequently investigated the mechanisms underlying the sunitinib-induced systemic hypertension. Intravenous administration of NO synthase inhibitor
N
G
-nitro-
l
-arginine increased MABP by 24±1 mm Hg under baseline conditions, whereas it increased MABP even further after sunitinib administration (32±3 mm Hg;
P
<0.05). Reactive oxygen species scavenging with a mixture of antioxidants lowered MABP by 13±2 mm Hg before but only by 5±2 mm Hg (
P
<0.05) after sunitinib administration. However, intravenous administration of the dual endothelin A/endothelin B receptor blocker tezosentan, which did not lower MABP at baseline, completely reversed MABP to presunitinib values. These findings indicate that sunitinib produces vasoconstriction selectively in the systemic vascular bed, without affecting pulmonary or coronary circulations. The sunitinib-mediated systemic hypertension is principally attributed to an increased vasoconstrictor influence of endothelin, with no apparent contributions of a loss of NO bioavailability or increased oxidative stress.
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Affiliation(s)
- Mariëtte H.W. Kappers
- From the Division of Pharmacology and Vascular Medicine, Department of Internal Medicine (M.H.W.K., A.H.J.D., A.H.v.d.M.), Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter (V.J.d.B., Z.Z., D.J.D., D.M.), and Department of Medical Oncology (S.S.), Erasmus Medical Center, Rotterdam, The Netherlands
| | - Vincent J. de Beer
- From the Division of Pharmacology and Vascular Medicine, Department of Internal Medicine (M.H.W.K., A.H.J.D., A.H.v.d.M.), Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter (V.J.d.B., Z.Z., D.J.D., D.M.), and Department of Medical Oncology (S.S.), Erasmus Medical Center, Rotterdam, The Netherlands
| | - Zhichao Zhou
- From the Division of Pharmacology and Vascular Medicine, Department of Internal Medicine (M.H.W.K., A.H.J.D., A.H.v.d.M.), Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter (V.J.d.B., Z.Z., D.J.D., D.M.), and Department of Medical Oncology (S.S.), Erasmus Medical Center, Rotterdam, The Netherlands
| | - A.H. Jan Danser
- From the Division of Pharmacology and Vascular Medicine, Department of Internal Medicine (M.H.W.K., A.H.J.D., A.H.v.d.M.), Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter (V.J.d.B., Z.Z., D.J.D., D.M.), and Department of Medical Oncology (S.S.), Erasmus Medical Center, Rotterdam, The Netherlands
| | - Stefan Sleijfer
- From the Division of Pharmacology and Vascular Medicine, Department of Internal Medicine (M.H.W.K., A.H.J.D., A.H.v.d.M.), Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter (V.J.d.B., Z.Z., D.J.D., D.M.), and Department of Medical Oncology (S.S.), Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dirk J. Duncker
- From the Division of Pharmacology and Vascular Medicine, Department of Internal Medicine (M.H.W.K., A.H.J.D., A.H.v.d.M.), Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter (V.J.d.B., Z.Z., D.J.D., D.M.), and Department of Medical Oncology (S.S.), Erasmus Medical Center, Rotterdam, The Netherlands
| | - Anton H. van den Meiracker
- From the Division of Pharmacology and Vascular Medicine, Department of Internal Medicine (M.H.W.K., A.H.J.D., A.H.v.d.M.), Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter (V.J.d.B., Z.Z., D.J.D., D.M.), and Department of Medical Oncology (S.S.), Erasmus Medical Center, Rotterdam, The Netherlands
| | - Daphne Merkus
- From the Division of Pharmacology and Vascular Medicine, Department of Internal Medicine (M.H.W.K., A.H.J.D., A.H.v.d.M.), Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter (V.J.d.B., Z.Z., D.J.D., D.M.), and Department of Medical Oncology (S.S.), Erasmus Medical Center, Rotterdam, The Netherlands
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12
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Kappers MHW, Smedts FMM, Horn T, van Esch JHM, Sleijfer S, Leijten F, Wesseling S, Strevens H, Jan Danser AH, van den Meiracker AH. The vascular endothelial growth factor receptor inhibitor sunitinib causes a preeclampsia-like syndrome with activation of the endothelin system. Hypertension 2011; 58:295-302. [PMID: 21670421 DOI: 10.1161/hypertensionaha.111.173559] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Angiogenesis inhibition is an established treatment for several tumor types. Unfortunately, this therapy is associated with adverse effects, including hypertension and renal toxicity, referred to as "preeclampsia." Recently, we demonstrated in patients and in rats that the multitarget tyrosine kinase inhibitor sunitinib induces a rise in blood pressure (BP), renal dysfunction, and proteinuria associated with activation of the endothelin system. In the current study we investigated the effects of sunitinib on rat renal histology, including the resemblance with preeclampsia, as well as the roles of endothelin 1, decreased nitric oxide (NO) bioavailability, and increased oxidative stress in the development of sunitinib-induced hypertension and renal toxicity. In rats on sunitinib, light and electron microscopic examination revealed marked glomerular endotheliosis, a characteristic histological feature of preeclampsia, which was partly reversible after sunitinib discontinuation. The histological abnormalities were accompanied by an increase in urinary excretion of endothelin 1 and diminished NO metabolite excretion. In rats on sunitinib alone, BP increased (ΔBP: 31.6±0.9 mm Hg). This rise could largely be prevented with the endothelin receptor antagonist macitentan (ΔBP: 12.3±1.5 mm Hg) and only mildly with Tempol, a superoxide dismutase mimetic (ΔBP: 25.9±2.3 mm Hg). Both compounds could not prevent the sunitinib-induced rise in serum creatinine or renal histological abnormalities and had no effect on urine nitrates but decreased proteinuria and urinary endothelin 1 excretion. Our findings indicate that both the endothelin system and oxidative stress play important roles in the development of sunitinib-induced proteinuria and that the endothelin system rather than oxidative stress is important for the development of sunitinib-induced hypertension.
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Affiliation(s)
- Mariëtte H W Kappers
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, 's Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands.
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