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Ferrario CM, Mullick AE. Renin angiotensin aldosterone inhibition in the treatment of cardiovascular disease. Pharmacol Res 2017; 125:57-71. [PMID: 28571891 PMCID: PMC5648016 DOI: 10.1016/j.phrs.2017.05.020] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/11/2017] [Accepted: 05/15/2017] [Indexed: 02/07/2023]
Abstract
A collective century of discoveries establishes the importance of the renin angiotensin aldosterone system in maintaining blood pressure, fluid volume and electrolyte homeostasis via autocrine, paracrine and endocrine signaling. While research continues to yield new functions of angiotensin II and angiotensin-(1-7), the gap between basic research and clinical application of these new findings is widening. As data accumulates on the efficacy of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers as drugs of fundamental importance in the treatment of cardiovascular and renal disorders, it is becoming apparent that the achieved clinical benefits is suboptimal and surprisingly no different than what can be achieved with other therapeutic interventions. We discuss this issue and summarize new pathways and mechanisms effecting the synthesis and actions of angiotensin II. The presence of renin-independent non-canonical pathways for angiotensin II production are largely unaffected by agents inhibiting renin angiotensin system activity. Hence, new efforts should be directed to develop drugs that can effectively block the synthesis and/or action of intracellular angiotensin II. Improved drug penetration into cardiac or renal sites of disease, inhibiting chymase the primary angiotensin II forming enzyme in the human heart, and/or inhibiting angiotensinogen synthesis would all be more effective strategies to inhibit the system. Additionally, given the role of angiotensin II in the maintenance of renal homeostatic mechanisms, any new inhibitor should possess greater selectivity of targeting pathogenic angiotensin II signaling processes and thereby limit inappropriate inhibition.
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Affiliation(s)
- Carlos M Ferrario
- Department of Surgery, Wake Forest University Health Science, Medical Center Blvd., Winston Salem, NC 27157, United States.
| | - Adam E Mullick
- Cardiovascular Antisense Drug Discovery, Ionis Pharmaceuticals, Inc., Carlsbad, CA 92010, United States
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Antlanger M, Bernhofer S, Kovarik JJ, Kopecky C, Kaltenecker CC, Domenig O, Poglitsch M, Säemann MD. Effects of direct renin inhibition versus angiotensin II receptor blockade on angiotensin profiles in non-diabetic chronic kidney disease. Ann Med 2017; 49:525-533. [PMID: 28358246 DOI: 10.1080/07853890.2017.1313447] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Direct renin inhibition (DRI) is clinically inferior to other blockers of the renin-angiotensin system (RAS). Thus far, the underlying molecular causes of this finding remain unknown. METHODS Twenty four patients with non-diabetic chronic kidney disease (CKD) stages III-IV and albuminuria were randomized to DRI or angiotensin receptor blocker (ARB). Employing a novel mass-spectrometry method, the concentrations of renin, aldosterone and plasma angiotensin peptides [Ang I, Ang II, Ang-(1-7), Ang-(1-5), Ang-(2-8), Ang-(3-8)] were quantified before and after an 8-week treatment. RESULTS While blood pressure, renal function and albuminuria decreased comparably in both groups, profound RAS component differences were observed: DRI led to a massive renin increase, while suppressing both vasoconstrictive (Ang I and Ang II) and vasodilatory RAS metabolites (Ang-(1-7) and Ang-(1-5)). In contrast, ARB led to a four-fold increase of Ang I and Ang II, while Ang-(1-7) and Ang-(1-5) increased moderately but significantly. With ARB treatment, a decreased aldosterone-to-Ang II ratio suggested efficacy in blocking AT1 receptor. CONCLUSIONS DRI therapy abolishes all RAS effector peptides. ARB increases both vasoconstrictive and vasodilative angiotensins, while this is accompanied by efficient blockade of vasoconstrictive effects. These differential molecular regulations should be considered when selecting optimal antihypertensive and disease-modifying therapy in CKD patients. Key messages Direct renin inhibition leads to a complete and lasting abolition of both classical and alternative RAS components. Angiotensin receptor blockade leads to effective receptor blockade and up-regulation of alternative RAS components. Differential molecular regulations of the RAS should be considered when selecting optimal antihypertensive and disease-modifying therapy in CKD patients.
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Affiliation(s)
- Marlies Antlanger
- a Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis , Medical University of Vienna , Vienna , Austria
| | - Sebastian Bernhofer
- a Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis , Medical University of Vienna , Vienna , Austria
| | - Johannes J Kovarik
- a Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis , Medical University of Vienna , Vienna , Austria
| | - Chantal Kopecky
- a Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis , Medical University of Vienna , Vienna , Austria
| | - Christopher C Kaltenecker
- a Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis , Medical University of Vienna , Vienna , Austria
| | - Oliver Domenig
- a Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis , Medical University of Vienna , Vienna , Austria
| | | | - Marcus D Säemann
- a Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis , Medical University of Vienna , Vienna , Austria.,c Department of Internal Medicine VI, Division of Nephrology , Wilhelminenspital , Vienna , Austria
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Vascular Aging: Lessons From Pediatric Hypertension. Can J Cardiol 2016; 32:642-9. [PMID: 27040097 DOI: 10.1016/j.cjca.2016.02.064] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 02/05/2016] [Accepted: 02/23/2016] [Indexed: 12/31/2022] Open
Abstract
Hypertension (HTN) in children is associated with early vascular aging (EVA) and underlying immunologic-metabolic abnormalities and accelerated biological maturation. Morphologic and functional vascular changes underlying EVA and HTN in children resemble those seen in the elderly including but not limited to an increase in intima-media thickness (IMT) and arterial stiffness and endothelial dysfunction. Although progeria syndrome leading to EVA and the development of clinically manifested cardiovascular (CV) disease in the second decade of life is a rare hereditary disorder, primary HTN, which is also associated with EVA, is much more common (reported in up to 10% in adolescents). EVA associated with HTN in children leads to the premature development of target organ injury in childhood and CV events in early adulthood. Limited evidence from prospective observational studies in children and adolescents indicates that early lifestyle measures (low salt/low sugar intake and exercise) or pharmacologic treatment of HTN, or both, partially reverses morphologic and functional changes underlying EVA such as an increase in carotid IMT and pulse wave velocity, a decrease in flow-mediated dilation of the brachial artery, and an increase in oxidative stress and visceral fat. Future mechanistic and therapeutic clinical trials are desirable to assess the mechanisms and treatment strategies of EVA in the context of HTN in children and their effect on CV events in early adulthood.
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Paulis L, Rajkovicova R, Simko F. New developments in the pharmacological treatment of hypertension: dead-end or a glimmer at the horizon? Curr Hypertens Rep 2015; 17:557. [PMID: 25893478 PMCID: PMC4412646 DOI: 10.1007/s11906-015-0557-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Arterial hypertension is the most prevalent controllable disease world-wide. Yet, we still need to further improve blood pressure control, deal with resistant hypertension, and we hope to reduce risk "beyond blood pressure." The number of candidate molecules aspiring for these aims is constantly declining. The new possible approaches to combat high blood pressure include neprilysin/neutral endopeptidase (NEP) inhibition, particularly when combined with an angiotensin receptor blockade (such as the ARNI, LCZ696), phosphodiesterase 5 (PDE5) inhibition (KD027/Slx-2101), natriuretic agents (PL3994), or a long-lasting vasointestinal peptide (VIP) analogue (PB1046). Other options exploit the protective arm of the renin-angiotensin-aldosterone system by stimulating the angiotensin AT2 receptor (compound 21), the Mas receptor (AVE-0991), or the angiotensin converting enzyme 2. Finally, we review the possibilities how to optimize the use of the available treatment options by using drug combinations or by tailoring therapy to each patient's angiotensin peptide profile.
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Affiliation(s)
- Ludovit Paulis
- />Institute of Pathophysiology, Faculty of Medicine, Comenius University, Sasinkova 4, 81108 Bratislava, Slovak Republic
- />Institute of Normal and Pathological Physiology, Slovak Academy of Sciences, Sienkiewiczova 1, 81371 Bratislava, Slovak Republic
| | - Romana Rajkovicova
- />Institute of Pathophysiology, Faculty of Medicine, Comenius University, Sasinkova 4, 81108 Bratislava, Slovak Republic
| | - Fedor Simko
- />Institute of Pathophysiology, Faculty of Medicine, Comenius University, Sasinkova 4, 81108 Bratislava, Slovak Republic
- />Institute of Experimental Endocrinology, Slovak Academy of Sciences, Vlárska 3, 83306 Bratislava, Slovak Republic
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Le Jemtel TH, Rajapreyar I, Selby MG, Payne B, Barnidge DR, Milic N, Garovic VD. Direct evidence of podocyte damage in cardiorenal syndrome type 2: preliminary evidence. Cardiorenal Med 2015; 5:125-34. [PMID: 25999961 DOI: 10.1159/000375130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 01/06/2015] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Renal structural alterations have been partially uncovered in cardiorenal syndrome (CRS). Patients with CRS may have evidence of tubular damage, but markers of glomerular damage other than proteinuria have not been thoroughly investigated. The nature of renal damage in CRS may have therapeutic implications, as glomerular damage requires tight blood pressure control and renin-angiotensin-aldosterone system (RAAS) inhibition. The present investigation evaluates patients with CRS type 2 (CRS-2) for direct evidence of glomerular damage as evidenced by the presence of urinary podocin. METHODS The presence of glomerular damage was assessed in acutely decompensated patients with CRS-2 and healthy controls. Urinary podocin was determined by quantification of a tryptic peptide of podocin with high-performance liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS). Morning urine samples were collected for podocin, creatinine (Cr), and protein. Urinary podocin was expressed in femtomoles of podocin/milligram of Cr. RESULTS The urinary podocin/Cr ratio was greater in patients than in controls (0.37 ± 0.77 vs. 0.06 ± 0.05 fmol podocin/mg Cr, p = 0.04). A total of 40% of the patients had a urinary podocin/Cr ratio greater than the upper limit of normal (>0.2 fmol podocin/mg Cr). Patients with an elevated podocin/Cr ratio were more likely to have received ≤50% of the maximum dose of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (p = 0.04) than patients with a podocin/Cr ratio in the normal range. CONCLUSIONS CRS-2 may be associated with glomerular damage as evidenced by an elevated urinary podocin/Cr ratio. Modulators of RAAS may have a protective effect on urinary podocin loss.
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Affiliation(s)
| | | | - Michael G Selby
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minn., USA
| | - Brian Payne
- Division of Cardiology, Tulane University, New Orleans, La., USA
| | - David R Barnidge
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, Minn., USA
| | - Natasa Milic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minn., USA ; Department of Medical Statistics and Informatics, University of Belgrade School of Medicine, Belgrade, Serbia
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minn., USA
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Trnka P, Orellana L, Walsh M, Pool L, Borzi P. Reninoma: an uncommon cause of Renin-mediated hypertension. Front Pediatr 2014; 2:89. [PMID: 25177679 PMCID: PMC4133731 DOI: 10.3389/fped.2014.00089] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 08/04/2014] [Indexed: 11/13/2022] Open
Abstract
Reninoma (juxtaglomerular cell tumor) is a rare cause of renin-mediated hypertension. Reninomas are usually diagnosed in adolescents and young adults with occasional reports in younger children. Patients typically present with a long history of headaches leading to a diagnosis of severe hypertension that responds well to antihypertensive treatment targeting the renin-angiotensin-aldosterone system. The clue to clinical diagnosis is the presence of hypokalemia and metabolic alkalosis on the first blood sample drawn before any treatment is instituted. Elevated blood levels of renin and aldosterone confirm the clinical suspicion of renin-mediated hypertension. Diagnostic imaging is employed to identify the source of excessive renin production. While renal ultrasound can miss reninoma, contrast CT or magnetic resonance imaging of the kidneys are diagnostic modalities of choice leading to the correct diagnosis. Renal vein renin sampling with lateralization might help to identify the site of excessive renin production. Nephron-sparing surgery is curative with maintenance of normal blood pressure after discontinuation of antihypertensive medications in the majority of patients. In this paper, we present the case of reninoma in an adolescent girl emphasizing clinical presentation, diagnostic evaluation, and medical and surgical treatment of this rare tumor. We also discuss important points in the management of children presenting with renin-mediated hypertension.
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Affiliation(s)
- Peter Trnka
- Department of Paediatrics and Child Health, The University of Queensland , Brisbane, QLD , Australia ; Department of Paediatrics, Mater Children's Hospital , Brisbane, QLD , Australia
| | - Luisa Orellana
- Department of Paediatrics, Mater Children's Hospital , Brisbane, QLD , Australia
| | - Mark Walsh
- Department of Medical Imaging, Mater Children's Hospital , Brisbane, QLD , Australia
| | - Louis Pool
- Department of Pathology, Mater Adult Hospital , Brisbane, QLD , Australia
| | - Peter Borzi
- Department of Paediatrics and Child Health, The University of Queensland , Brisbane, QLD , Australia ; Department of Paediatric Surgery, Royal Children's Hospital , Brisbane, QLD , Australia
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