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Motiejunaite J, Flamant M, Arnoult F, Lahens A, Tabibzadeh N, Boutten A, Rouzet F, Vrtovsnik F, Vidal-Petiot E, de Pinho NA. Predictors of daytime blood pressure, nighttime blood pressure, and nocturnal dipping in patients with chronic kidney disease. Hypertens Res 2024:10.1038/s41440-024-01778-5. [PMID: 38969804 DOI: 10.1038/s41440-024-01778-5] [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: 11/21/2023] [Revised: 04/02/2024] [Accepted: 06/04/2024] [Indexed: 07/07/2024]
Abstract
Increasing attention has recently been paid to discrepancies between office and ambulatory blood pressure (BP) control in patients with chronic kidney disease (CKD), but information on mechanisms underlying circadian BP variations in CKD remains scarce. We described circadian BP patterns and their predictors in patients with CKD stages 1 to 5 referred for kidney function testing in a French tertiary hospital: 1122 ambulatory BP measurements from 635 participants. Factors associated with daytime and nighttime systolic BP (SBP) as well as with nocturnal SBP dipping (ratio of average nighttime to daytime SBP) were analyzed with linear mixed regression models. Participants (mean age 55 ± 16 years; 36% female, mean GFR 51 ± 22 mL/min/1.73m2) had a mean daytime and nighttime SBP of 130 ± 17 and 118 ± 18 mm Hg, respectively. The prevalence of impaired dipping (nighttime over daytime SBP ratio ≥ 0.9) increased from 32% in CKD stage 1 to 68% in CKD stages 4-5. After multivariable adjustment, measured GFR, diabetes, and sub-Saharan African origin were more strongly associated with nighttime than with daytime SBP, which led to significant associations with altered nocturnal BP dipping. For a 1 SD decrease in measured GFR, nighttime BP was 2.87 mmHg (95%CI, 1.44-4.30) higher and nocturnal SBP dipping ratio was 1.55% higher (95%CI, 0.85-2.26%). In conclusion, the prevalence of impaired nocturnal BP dipping increases substantially across the spectrum of CKD. Along with sub-Saharan African origin and diabetes, lower measured GFR was a robust and specific predictor of higher nighttime BP and blunted nocturnal BP decline.
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Affiliation(s)
- Justina Motiejunaite
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
- Université Paris Cité, Paris, France
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France
| | - Martin Flamant
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
- Université Paris Cité, Paris, France
- Center for Research on Inflammation, Université de Paris, Institut National de la Santé et de la Recherche Médicale (INSERM) U1149, F-75018, Paris, France
| | - Florence Arnoult
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
| | - Alexandre Lahens
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
- Université Paris Cité, Paris, France
| | - Nahid Tabibzadeh
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
- Université Paris Cité, Paris, France
- Université de Paris, Unité Mixte de Recherche (UMR) S1138, Cordeliers Research Center, 75006, Paris, France
| | - Anne Boutten
- Departement de Biochimie, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
| | - François Rouzet
- Université Paris Cité, Paris, France
- Service de Médecine nucléaire, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, LVTS, F-75018, Paris, France
| | - François Vrtovsnik
- Université Paris Cité, Paris, France
- Center for Research on Inflammation, Université de Paris, Institut National de la Santé et de la Recherche Médicale (INSERM) U1149, F-75018, Paris, France
- Service de Néphrologie, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
| | - Emmanuelle Vidal-Petiot
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018, Paris, France
- Université Paris Cité, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, LVTS, F-75018, Paris, France
| | - Natalia Alencar de Pinho
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France.
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Faucon AL, Lambert O, Massy Z, Drüeke TB, Combe C, Fouque D, Frimat L, Jacquelinet C, Laville M, Liabeuf S, Pecoits-Filho R, Hauguel-Moreau M, Mansencal N, de Pinho NA, Stengel B. Sex and the Risk of Atheromatous and Non-Atheromatous Cardiovascular Disease in CKD: Findings From the CKD-REIN Cohort Study. Am J Kidney Dis 2024:S0272-6386(24)00811-4. [PMID: 38925506 DOI: 10.1053/j.ajkd.2024.04.013] [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: 11/24/2023] [Revised: 03/26/2024] [Accepted: 04/14/2024] [Indexed: 06/28/2024]
Abstract
RATIONALE & OBJECTIVE Sex differences in cardiovascular disease (CVD) are well-established, but whether chronic kidney disease (CKD) modifies these risk differences, and whether they differ between atheromatous (ACVD) and non-atheromatous (N-ACVD) CVD is unknown. Assessing this interaction was the principal goal of this study. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS Adults enrolled in the CKD-Renal Epidemiology and Information Network (CKD-REIN) cohort from from 2013 to 2020, a nationally representative sample of 40 nephrology clinics in France. EXPOSURE Sex. OUTCOMES Fatal and non-fatal composite ACVD events (ischaemic coronary, cerebral, and peripheral artery disease) and composite N-ACVD events (heart failure, haemorrhagic stroke, and arrhythmias). ANALYTICAL APPROACH Multivariable cause-specific Cox proportional hazards models. RESULTS 1,044 women and 1,976 men with moderate to severe CKD (median age, 67 vs. 69; mean estimated glomerular filtration rate [eGFR], 32±12 vs. 33±12 mL/min/1.73m2) were studied. Over a median follow-up of 5.0 (interquartile range, 4.8;5.2) years, the ACVD rate (per 100 patient-years) was significantly lower in women than men: 2.1 (95% confidence interval: 1.6-2.5) vs 3.6 (3.2-4.0) (P<0.01), while the N-ACVD rate was not: 5.7 (5.0-6.5) vs 6.4 (5.8-7.0) (P=0.55). N-ACVD had a steeper relationship with eGFR than did ACVD. There was an interaction (P<0.01) between sex and baseline eGFR and the ACVD hazard: the adjusted hazard ratio for women compared to men was 0.42 (0.25;0.71) at 45 mL/min/1.73m2 and gradually attenuated at lower levels of eGFR, reaching 1.00 (0.62;1.63) at 16 mL/min/1.73m2. In contrast, the N-ACVD hazard did not differ between the sexes across the eGFR range studied. LIMITATIONS Cardiovascular biomarkers and sex hormones were not assessed. CONCLUSION This study shows how the lower risk of ACVD among women compared to men attenuates fully with kidney disease progression. The equal risk of N-ACVD between sexes across CKD stages and its steeper association with eGFR suggest an important contribution of CKD to the development of this CVD type.
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Affiliation(s)
- Anne-Laure Faucon
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France
| | - Oriane Lambert
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France
| | - Ziad Massy
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France; Department of Nephrology, AP-HP, CHU Ambroise Paré, Boulogne-Billancourt, France
| | - Tilman B Drüeke
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France
| | - Christian Combe
- Department of Nephrology, transplantation, dialysis, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France; Inserm U1026, Biotis, Bordeaux University, France
| | - Denis Fouque
- Department of Nephrology, CHU Lyon-Sud, Université de Lyon, Lyon, France; Inserm U1060, CARMEN, Lyon, France
| | - Luc Frimat
- Department of Nephrology, CHRU de Nancy, Vandoeuvre-lès-Nancy, France; Inserm CIC 1433, Clinical Epidemiology Unit, Vandoeuvre-lès-Nancy, France
| | | | - Maurice Laville
- Department of Nephrology, CHU Lyon-Sud, Université de Lyon, Lyon, France
| | - Sophie Liabeuf
- Department of Pharmacology, CHU Amiens-Picardie, MP3CV Unit, Université Picardie Jules Verne, Amiens, France
| | | | - Marie Hauguel-Moreau
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France; Department of Cardiology, AP-HP, CHU Ambroise Paré, Boulogne-Billancourt, France
| | - Nicolas Mansencal
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France; Department of Cardiology, AP-HP, CHU Ambroise Paré, Boulogne-Billancourt, France
| | - Natalia Alencar de Pinho
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France.
| | - Bénédicte Stengel
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France
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Legrand F, Motiejunaite J, Arnoult F, Lahens A, Tabibzadeh N, Robert-Mercier T, Rouzet F, De Pinho NA, Vrtovsnik F, Flamant M, Vidal-Petiot E. Prevalence and factors associated with masked hypertension in chronic kidney disease. J Hypertens 2024; 42:1000-1008. [PMID: 38647162 DOI: 10.1097/hjh.0000000000003680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVES Optimal blood pressure (BP) control is key to prevent cardiovascular complications in patients with chronic kidney disease (CKD). We described the prevalence and factors associated with masked hypertension in CKD. METHODS We analyzed 1113 ambulatory 24-h BP monitoring (ABPM) records of 632 patients referred for kidney function evaluation. Masked hypertension was defined as office BP less than 140/90 mmHg but daytime BP at least 135/85 mmHg or nighttime BP at least 120/70 mmHg. Factors associated with masked hypertension were assessed with mixed logistic regression models. RESULTS At inclusion, 424 patients (67%) had controlled office BP, of whom 56% had masked hypertension. In multivariable analysis conducted in all visits with controlled office BP ( n = 782), masked hypertension was positively associated with male sex [adjusted OR (95% confidence interval) 1.91 (1.16-3.27)], sub-Saharan African origin [2.51 (1.32-4.63)], BMI [1.11 (1.01-1.17) per 1 kg/m 2 ], and albuminuria [1.29 [1.12 - 1.47] per 1 log unit), and was negatively associated with plasma potassium (0.42 [0.29 - 0.71] per 1 mmol/L) and 24-h urinary potassium excretion (0.91 [0.82 - 0.99] per 10 mmol/24 h) as well as the use of renin-angiotensin-aldosterone (RAAS) blockers (0.56 [0.31 - 0.97]) and diuretics (0.41 [0.27 - 0.72]). CONCLUSION Our findings support the routine use of ABPM in CKD, as more than half of the patients with controlled office BP had masked hypertension. Weight control, higher potassium intake (with caution in advanced CKD), correction of hypokalemia, and larger use of diuretics and RAAS blockers could be potential levers for better out-of-office BP control.
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Affiliation(s)
| | - Justina Motiejunaite
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard
- Université Paris Cité, Paris
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif
| | - Florence Arnoult
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard
| | - Alexandre Lahens
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard
- Université Paris Cité, Paris
| | - Nahid Tabibzadeh
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard
- Université Paris Cité, Paris
- Université Paris Cité, Unité Mixte de Recherche (UMR) S1138, Cordeliers Research Center
| | - Tiphaine Robert-Mercier
- Departement de Biochimie, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 75018 Paris, France
| | - François Rouzet
- Université Paris Cité, Paris
- Service de médecine nucléaire, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, LVTS
| | - Natalia Alencar De Pinho
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif
| | - François Vrtovsnik
- Université Paris Cité, Paris
- Center for Research on Inflammation, Université Paris Cité, Institut National de la Santé et de la Recherche Médicale (INSERM) U1149
- Service de Néphrologie, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France
| | - Martin Flamant
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard
- Université Paris Cité, Paris
- Center for Research on Inflammation, Université Paris Cité, Institut National de la Santé et de la Recherche Médicale (INSERM) U1149
| | - Emmanuelle Vidal-Petiot
- Service de Physiologie et Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard
- Université Paris Cité, Paris
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, LVTS
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Faucon AL, Fu EL, Stengel B, Mazhar F, Evans M, Carrero JJ. A nationwide cohort study comparing the effectiveness of diuretics and calcium channel blockers on top of renin-angiotensin system inhibitors on chronic kidney disease progression and mortality. Kidney Int 2023; 104:542-551. [PMID: 37330214 DOI: 10.1016/j.kint.2023.05.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 05/07/2023] [Accepted: 05/18/2023] [Indexed: 06/19/2023]
Abstract
It is unknown whether initiating diuretics on top of renin-angiotensin system inhibitors (RASi) is superior to alternative antihypertensive agents such as calcium channel blockers (CCBs) in patients with chronic kidney disease (CKD). For this purpose, we emulated a target trial in the Swedish Renal Registry 2007-2022 that included nephrologist-referred patients with moderate-advanced CKD and treated with RASi, who initiated diuretics or CCB. Using propensity score-weighted cause-specific Cox regression, we compared risks of major adverse kidney events (MAKE; composite of kidney replacement therapy [KRT], experiencing over a 40% eGFR decline from baseline, or an eGFR under 15 ml/min per 1.73m2), major cardiovascular events (MACE; composite of cardiovascular death, myocardial infarction or stroke), and all-cause mortality. We identified 5875 patients (median age 71 years, 64% men, median eGFR 26 ml/min per 1.73m2), of whom 3165 started a diuretic and 2710 a CCB. After a median follow-up of 6.3 years, 2558 MAKE, 1178 MACE and 2299 deaths occurred. Compared to CCB, diuretic use was associated with a lower risk of MAKE (weighted hazard ratio 0.87 [95% confidence interval: 0.77-0.97]), consistent across single components (KRT: 0.77 [0.66-0.88], over 40% eGFR decline: 0.80 [0.71-0.91] and eGFR under 15ml/min/1.73m2: 0.84 [0.74-0.96]). The risks of MACE (1.14 [0.96-1.36]) and all-cause mortality (1.07 [0.94-1.23]) did not differ between therapies. Results were consistent when modeling the total time drug exposure, across sub-groups and a broad range of sensitivity analyses. Thus, our observational study suggests that in patients with advanced CKD, using a diuretic rather than a CCB on top of RASi may improve kidney outcomes without compromising cardioprotection.
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Affiliation(s)
- Anne-Laure Faucon
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; INSERM UMR 1018, Department of Clinical Epidemiology, Centre for Epidemiology and Population Health, Paris-Saclay University, Villejuif, France.
| | - Edouard L Fu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bénédicte Stengel
- INSERM UMR 1018, Department of Clinical Epidemiology, Centre for Epidemiology and Population Health, Paris-Saclay University, Villejuif, France
| | - Faizan Mazhar
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Marie Evans
- Division of Nephrology, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Juan-Jesús Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Division of Nephrology, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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Tang H, Xu C, Zhang P, Luo T, Huang Y, Yang X. A profile of SGLT-2 inhibitors in hyponatremia: The evidence to date. Eur J Pharm Sci 2023; 184:106415. [PMID: 36870579 DOI: 10.1016/j.ejps.2023.106415] [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: 11/27/2022] [Revised: 02/14/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023]
Abstract
Hyponatremia is the most common electrolyte disorder in clinical practice, which may lead to life-threatening complications. Several lines of evidence suggest that hyponatremia is associated not only with significant increases in length of stay, cost, and financial burden, but also with increased morbidity and mortality. Hyponatremia is also considered to be a negative prognostic factor in patients with heart failure and cancer. Although multiple therapeutic methods are available for treating hyponatremia, most have some limitations, such as poor compliance, rapid correction of serum Na+, other negative side effects and high cost. Given these limitations, identifying novel therapies for hyponatremia is essential. Recent clinical studies have shown that SGLT-2 inhibitors (SGLT 2i) significantly increased serum Na+ levels and were well tolerated by patients who underwent this treatment. Therefore, oral administration of SGLT 2i appears to be an effective treatment for hyponatremia. This article will briefly review the etiology of hyponatremia and integrated control of sodium within the kidney, current therapies for hyponatremia, potential mechanisms and efficacy of SGLT 2i for hyponatremia, and the benefits in cardiovascular, cancer, and kidney disease by regulating sodium and water balance.
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Affiliation(s)
- Hui Tang
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; School of Pharmacy, Southwest Medical University, Luzhou 646000, China
| | - Changjing Xu
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Piao Zhang
- Department of Pharmacy, Ya 'an People's Hospital, Ya 'an, Sichuan 646000, China
| | - Taimin Luo
- Department of pharmacy, Chengdu Seventh People's Hospital, Chengdu, Sichuan 610000, China
| | - Yilan Huang
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; School of Pharmacy, Southwest Medical University, Luzhou 646000, China.
| | - Xuping Yang
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; School of Pharmacy, Southwest Medical University, Luzhou 646000, China.
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Ume AC, Wenegieme TY, Adams DN, Adesina SE, Williams CR. Zinc Deficiency: A Potential Hidden Driver of the Detrimental Cycle of Chronic Kidney Disease and Hypertension. KIDNEY360 2023; 4:398-404. [PMID: 36996303 PMCID: PMC10103339 DOI: 10.34067/kid.0007812021] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 12/18/2022] [Indexed: 12/23/2022]
Abstract
Globally, over 103 million individuals are afflicted by CKD, a silent killer claiming the lives of 1.2 million people annually. CKD is characterized by five progressive stages, in which dialysis and kidney transplant are life-saving routes for patients with end stage kidney failure. While kidney damage impairs kidney function and derails BP regulation, uncontrolled hypertension accelerates the development and progression of CKD. Zinc (Zn) deficiency has emerged as a potential hidden driver within this detrimental cycle of CKD and hypertension. This review article will (1) highlight mechanisms of Zn procurement and trafficking, (2) provide evidence that urinary Zn wasting can fuel Zn deficiency in CKD, (3) discuss how Zn deficiency can accelerate the progression of hypertension and kidney damage in CKD, and (4) consider Zn supplementation as an exit strategy with the potential to rectify the course of hypertension and CKD progression.
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Affiliation(s)
- Adaku C. Ume
- Department of Neuroscience, Cell Biology and Physiology, Boonshoft School of Medicine, College of Science and Mathematics, Wright State University, Dayton, Ohio
| | - Tara-Yesomi Wenegieme
- Department of Neuroscience, Cell Biology and Physiology, Boonshoft School of Medicine, College of Science and Mathematics, Wright State University, Dayton, Ohio
| | - Danielle N. Adams
- Department of Neuroscience, Cell Biology and Physiology, Boonshoft School of Medicine, College of Science and Mathematics, Wright State University, Dayton, Ohio
| | - Sherry E. Adesina
- Division of Pulmonary Medicine, Department of Medicine, Emory University, Atlanta, Georgia
| | - Clintoria R. Williams
- Department of Neuroscience, Cell Biology and Physiology, Boonshoft School of Medicine, College of Science and Mathematics, Wright State University, Dayton, Ohio
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7
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Abstract
PURPOSE OF REVIEW Cardiovascular disease is the leading cause of death in individuals with chronic kidney disease (CKD). The mechanisms connecting CKD and cardiovascular disease are complex, and serum biomarkers can help improve our understanding. Nt-proBNP and troponin have documented success as biomarkers to diagnose and provide mechanistic insights in non-CKD populations. The purpose of this review is to summarize evidence suggesting efficacy and potential for clinical application of Nt-proBNP and troponin in individuals with CKD. RECENT FINDINGS Our understanding of how Nt-proBNP and Troponin should be interpreted in those with CKD is evolving. Although both biomarkers are in part cleared by the kidney, elevated levels predominantly reflect cardiovascular disease. Both Nt-proBNP and troponin are associated with risk for future cardiovascular events in CKD. Determining CKD-specific cutoffs and using biomarkers to guide therapy remains under active investigation. SUMMARY Of the many serum biomarkers under investigation, Nt-proBNP and troponin best meet the criteria for effective biomarkers in CKD. Assays are widely available and proven to be accurate in CKD populations. Nt-proBNP and troponin deserve special focus in ongoing research of cardiovascular risk reduction in CKD, especially to identify patients at the highest risk, suggest targetable mechanisms and assess treatment efficacy.
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Affiliation(s)
- Alexander Kula
- Division of Pediatric Nephrology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Nisha Bansal
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
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8
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Odion-Omonhimin LO, Marwizi FM, Chive M, Obasi NB, Akinrinmade AO, Obitulata-Ugwu VO, Victor F, Obijiofor NB. Etiology and Management of Treatment-Resistant Hypertension in African American Adults ≥18 Years: A Literature Review. Cureus 2022; 14:e29566. [PMID: 36312638 PMCID: PMC9595575 DOI: 10.7759/cureus.29566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2022] [Indexed: 11/25/2022] Open
Abstract
Treatment-resistant hypertension (TRH) is defined as blood pressure levels that remain above the therapeutic goal despite concurrent use of three or more antihypertensive medications taken at maximally tolerated doses, one of which should be a diuretic. Additionally, individuals on four or more antihypertensive agents regardless of blood pressure are also considered to have TRH. Amongst people diagnosed with TRH, African American adults face a huge management gap, resulting in increased cardiovascular disease risk. The primary objective of this review was to identify the commonly encountered etiologies and extensively discuss the current management strategies of TRH with a particular focus on African Americans. Relevant studies were identified by analyzing scientific databases and journals such as PubMed, Cochrane, MEDLINE, Cureus, and American Heart Association (AHA). The studies identified and examined common causes of TRH, describing their pathophysiology and highlighting different treatment options for the respective etiologies. The most prevalent etiologies of TRH amongst African Americans were chronic kidney disease (CKD), renal artery stenosis (RAS), fibromuscular dysplasia, obstructive sleep apnea (OSA), endocrine causes (Conn syndrome, Cushing syndrome, etc.), sympathetic nervous system overactivity, lifestyle factors, inaccurate blood pressure measurement, and inappropriate treatment. Of the etiologies reviewed, OSA, lifestyle factors, and CKD exhibited a striking prevalence among the subpopulation studied. Unfortunately, there was a paucity of articles addressing this topic amongst African Americans, and therefore there was not a substantial appreciation of the prevalence of some of the identified etiologies in the population of interest. Thorough diagnostic testing for associated or underlying conditions provides a basis for successful management. This review brought to the fore the need for doctors and patients to collaborate in order to improve TRH management and help patients lead healthier lives.
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Ali S, Navaneethan SD, Virani SS, Gregg LP. Revisiting diuretic choice in chronic kidney disease. Curr Opin Nephrol Hypertens 2022; 31:406-413. [PMID: 35894274 PMCID: PMC9455225 DOI: 10.1097/mnh.0000000000000814] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Existing guidelines offer little direction about the use of thiazide and loop diuretics in patients with chronic kidney disease (CKD). This review summarizes recent studies impacting indications and safety considerations for these agents in patients with CKD. RECENT FINDINGS Chlorthalidone reduces blood pressure compared to placebo in patients with advanced CKD, challenging the belief that thiazide diuretics lose efficacy at lower glomerular filtration rates (GFR). Existing studies show no clear impact of thiazide or loop diuretic use on kidney or cardiovascular outcomes in patients with CKD. Sodium-glucose co-transporter type 2 (SGLT2) inhibitors have diuretic effects, but concomitant use of a diuretic does not diminish the preventive benefits of these agents against acute kidney injury (AKI). Despite theoretical concerns, thiazide diuretics likely do not worsen circulating vasopressin levels or cyst progression in polycystic kidney disease and may be useful for alleviating polyuria from tolvaptan. Diuretics cause multiple adverse effects, including electrolyte abnormalities, hemodynamic-mediated decrease in estimated GFR, and AKI. SUMMARY Recent evidence supports expanded indications for diuretics in patients with kidney disease, including chlorthalidone for hypertension in advanced CKD. Monitoring electrolytes and estimated GFR is critical to ensure patient safety when prescribing these agents for patients with CKD.
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Affiliation(s)
- Sehrish Ali
- Selzman Institute for Kidney Health, Section of Nephrology,
Department of Medicine, Baylor College of Medicine, Houston, TX
- Section of Nephrology, Michael E. DeBakey Veterans Affairs
Medical Center, Houston, TX
| | - Sankar D. Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology,
Department of Medicine, Baylor College of Medicine, Houston, TX
- Section of Nephrology, Michael E. DeBakey Veterans Affairs
Medical Center, Houston, TX
- Veterans Affairs Health Services Research and Development
Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
- Institute of Clinical and Translational Research, Baylor
College of Medicine, Houston, TX
| | - Salim S. Virani
- Veterans Affairs Health Services Research and Development
Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
- Division of Cardiology, Baylor College of Medicine,
Houston, TX
- Division of Cardiology, Department of Medicine, Michael E.
DeBakey VA Medical Center, Houston, TX
| | - L. Parker Gregg
- Selzman Institute for Kidney Health, Section of Nephrology,
Department of Medicine, Baylor College of Medicine, Houston, TX
- Section of Nephrology, Michael E. DeBakey Veterans Affairs
Medical Center, Houston, TX
- Veterans Affairs Health Services Research and Development
Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
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10
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Tabibzadeh N, Faucon AL, Vidal-Petiot E, Serrano F, Males L, Fernandez P, Khalil A, Rouzet F, Tardivon C, Mazer N, Dubertret C, Delavest M, Marlinge E, Etain B, Bellivier F, Vrtovsnik F, Flamant M. Determinants of Kidney Function and Accuracy of Kidney Microcysts Detection in Patients Treated With Lithium Salts for Bipolar Disorder. Front Pharmacol 2022; 12:784298. [PMID: 35069203 PMCID: PMC8776633 DOI: 10.3389/fphar.2021.784298] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/02/2021] [Indexed: 12/12/2022] Open
Abstract
Objectives: Early kidney damage during lithium treatment in bipolar disorder is still hypothetical. We aimed at identifying the determinants of a decreased measured glomerular filtration rate (mGFR) and the accuracy of kidney MRI imaging in its detection. Methods: In this cross-sectional cohort study, 217 consecutive lithium-treated patients underwent mGFR and kidney MRI with half-Fourier turbo spin-echo and Single-shot with long echo time sequences. Results: Median age was 51 [27–62] years, and median lithium treatment duration was 5 [2–14] years. 52% of patients had a stage 2 CKD. In multivariable analysis, the determinants of a lower mGFR were a longer lithium treatment duration (β −0.8 [−1; −0.6] ml/min/1.73 m2 GFR decrease for each year of treatment), a higher age (β −0.4 [−0.6; −0.3] ml/min/1.73 m2 for each year of age, p < 0.001), albuminuria (β −3.97 [−6.6; −1.3], p = 0.003), hypertension (β −6.85 [−12.6; −1.1], p = 0.02) and hypothyroidism (β −7.1 [−11.7; −2.5], p = 0.003). Serum lithium concentration was not associated with mGFR. Renal MRI displayed renal microcyst(s) in 51% of patients, detected as early as 1 year after lithium treatment initiation. mGFR and lithium treatment duration were strongly correlated in patients with microcyst(s) (r = −0.64, p < 0.001), but not in patients with no microcysts (r = −0.24, p = 0.09). The presence of microcysts was associated with the detection of an mGFR <45 ml/min/1.73 m2 (AUC 0.893, p < 0.001, sensitivity 80%, specificity 81% for a cut-off value of five microcysts). Conclusion: Lithium treatment duration and hypothyroidism strongly impacted mGFR independently of age, especially in patients with microcysts. MRI might help detect early lithium-induced kidney damage and inform preventive strategies.
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Affiliation(s)
- Nahid Tabibzadeh
- Physiologie Rénale-Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France.,Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Laboratoire de Physiologie Rénale et Tubulopathies, F-75006, Paris, France.,CNRS ERL 8228-Unité Métabolisme et Physiologie Rénale, F-75006, Paris, France
| | - Anne-Laure Faucon
- Centre de recherche en Epidémiologie et Santé des Populations, INSERM UMR 1018, Renal and Cardiovascular Epidemiology, Université Paris-Saclay, Paris, France
| | - Emmanuelle Vidal-Petiot
- Physiologie Rénale-Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France.,Université de Paris, Paris, France.,Inserm U1149, Paris, France
| | - Fidéline Serrano
- Université de Paris, Paris, France.,UF d'Hormonologie, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France.,Institut Cochin-Inserm, U1016-CNRS, UMR8104, Paris, France
| | - Lisa Males
- Radiologie, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France
| | - Pedro Fernandez
- Radiologie, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France
| | - Antoine Khalil
- Université de Paris, Paris, France.,Radiologie, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France
| | - François Rouzet
- Université de Paris, Paris, France.,Médecine Nucléaire, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France
| | - Coralie Tardivon
- Université de Paris, Paris, France.,AP-HP, Hôpital Bichat, Département Epidémiologie Biostatistiques et Recherche Clinique, F-75018, Paris, France.,INSERM, Centre d'Investigations cliniques-Epidémiologie Clinique 1425, Hôpital Bichat, F-75018, Paris, France
| | - Nicolas Mazer
- Psychiatrie, Assistance Publique Hôpitaux de Paris, Hôpital Louis Mourier, Paris, France
| | - Caroline Dubertret
- Université de Paris, Paris, France.,Psychiatrie, Assistance Publique Hôpitaux de Paris, Hôpital Louis Mourier, Paris, France
| | - Marine Delavest
- Psychiatrie et Medicine Addictologique, DMU Neurosciences, Assistance Publique Hôpitaux de Paris, GH Saint-Louis-Lariboisiere-Fernand-Widal, Paris, France
| | - Emeline Marlinge
- Psychiatrie et Medicine Addictologique, DMU Neurosciences, Assistance Publique Hôpitaux de Paris, GH Saint-Louis-Lariboisiere-Fernand-Widal, Paris, France
| | - Bruno Etain
- Université de Paris, Paris, France.,Psychiatrie et Medicine Addictologique, DMU Neurosciences, Assistance Publique Hôpitaux de Paris, GH Saint-Louis-Lariboisiere-Fernand-Widal, Paris, France
| | - Frank Bellivier
- Université de Paris, Paris, France.,Psychiatrie et Medicine Addictologique, DMU Neurosciences, Assistance Publique Hôpitaux de Paris, GH Saint-Louis-Lariboisiere-Fernand-Widal, Paris, France
| | - François Vrtovsnik
- Université de Paris, Paris, France.,Inserm U1149, Paris, France.,Néphrologie, Assistance Publique Hô pitaux de Paris, Hô pital Bichat-Claude Bernard, Paris, France
| | - Martin Flamant
- Physiologie Rénale-Explorations Fonctionnelles, FHU APOLLO, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France.,Université de Paris, Paris, France.,Inserm U1149, Paris, France
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11
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Affiliation(s)
- David H Ellison
- From the Oregon Clinical and Translational Research Institute, Oregon Health and Science University (D.H.E) and the VA Portland Health Care System (D.H.E.) - both in Portland; and LeDucq Transatlantic Network of Excellence (D.H.E., P.W.) and the Departments of Medicine and Physiology, Johns Hopkins University (P.W.) - both in Baltimore
| | - Paul Welling
- From the Oregon Clinical and Translational Research Institute, Oregon Health and Science University (D.H.E) and the VA Portland Health Care System (D.H.E.) - both in Portland; and LeDucq Transatlantic Network of Excellence (D.H.E., P.W.) and the Departments of Medicine and Physiology, Johns Hopkins University (P.W.) - both in Baltimore
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12
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Wang C, Fu W, Cao S, Xu H, Tian Q, Gan Y, Guo Y, Yan S, Yan F, Yue W, Lv C, Lu Z. Association of adiposity indicators with hypertension among Chinese adults. Nutr Metab Cardiovasc Dis 2021; 31:1391-1400. [PMID: 33812733 DOI: 10.1016/j.numecd.2021.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 01/01/2021] [Accepted: 01/05/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS Obesity has been linked to the development of hypertension, but the comparison of relationships between different obesity parameters with hypertension are scarcely studied with nationally representative Chinese adults samples. We sought to compare the predictive strengths of different obesity indicators to hypertension. METHODS AND RESULTS Data in this study were obtained from the Chinese National Stroke Prevention Project with a nationally representative sample of Chinese aged 40 years and older. A total of 162,880 individuals were included. Multi-level analyses and Receiver Operating Characteristic (ROC) curves were used to examine the risk of hypertension in relation to different obesity parameters, including body mass index (BMI), waist circumference (WC), lipid accumulation product index (LAP), visceral adiposity index (VAI), and body adiposity index (BAI). As results, the BMI, WC, LAP, VAI, and BAI were positively associated with the risk of hypertension (P < 0.001). In total, BMI had the strongest association with hypertension when compared with other obesity indicators, and one SD up of BMI would increase the risk of hypertension by 53.9% (95% CI: 1.514-1.566). For men, WC was most associated with hypertension, and one SD up of WC would increase the risk of hypertension by 73.3% (95% CI: 1.685-1.782). For women, BMI showed the strongest predictive power, one SD up of BMI would increase the risk of hypertension by 51.0% (95% CI: 1.479-1.543). CONCLUSIONS BMI, WC, LAP, VAI, and BAI are all positively corrected to hypertension, but gender disparities should be considered in predicting hypertension by obesity indicators.
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Affiliation(s)
- Chao Wang
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenning Fu
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiyi Cao
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongbin Xu
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qingfeng Tian
- College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Yong Gan
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yingying Guo
- Children's Healthcare Department, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shijiao Yan
- School of International Education, Hainan Medical University, Haikou, China
| | - Feng Yan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wei Yue
- Neurology Department, Tianjin Huanhu Hospital, Tianjin, China
| | - Chuanzhu Lv
- Emergency and Trauma College, Hainan Medical University, Haikou, China; Department of Emergency, The Second Affiliated Hospital of Hainan Medical University, Haikou, China.
| | - Zuxun Lu
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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13
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Bovée DM, Uijl E, Severs D, Rubio-Beltrán E, van Veghel R, Maassen van den Brink A, Joles JA, Zietse R, Cuevas CA, Danser AHJ, Hoorn EJ. Dietary salt modifies the blood pressure response to renin-angiotensin inhibition in experimental chronic kidney disease. Am J Physiol Renal Physiol 2021; 320:F654-F668. [PMID: 33586496 DOI: 10.1152/ajprenal.00603.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Chronic kidney disease contributes to hypertension, but the mechanisms are incompletely understood. To address this, we applied the 5/6th nephrectomy rat model to characterize hypertension and the response to dietary salt and renin-angiotensin inhibition. 5/6th nephrectomy caused low-renin, salt-sensitive hypertension with hyperkalemia and unsuppressed aldosterone. Compared with sham rats, 5/6th nephrectomized rats had lower Na+/H+ exchanger isoform 3, Na+-K+-2Cl- cotransporter, Na+-Cl- cotransporter, α-epithelial Na+ channel (ENaC), and Kir4.1 levels but higher serum and glucocorticoid-regulated kinase 1, prostasin, γ-ENaC, and Kir5.1 levels. These differences correlated with plasma renin, aldosterone, and/or K+. On a normal-salt diet, adrenalectomy (0 ± 9 mmHg) and spironolactone (-11 ± 10 mmHg) prevented a progressive rise in blood pressure (10 ± 8 mmHg), and this was enhanced in combination with losartan (-41 ± 12 and -43 ± 9 mmHg). A high-salt diet caused skin Na+ and water accumulation and aggravated hypertension that could only be attenuated by spironolactone (-16 ± 7 mmHg) and in which the additive effect of losartan was lost. Spironolactone also increased natriuresis, reduced skin water accumulation, and restored vasorelaxation. In summary, in the 5/6th nephrectomy rat chronic kidney disease model, salt-sensitive hypertension develops with a selective increase in γ-ENaC and despite appropriate transporter adaptations to low renin and hyperkalemia. With a normal-salt diet, hypertension in 5/6th nephrectomy depends on angiotensin II and aldosterone, whereas a high-salt diet causes more severe hypertension mediated through the mineralocorticoid receptor.NEW & NOTEWORTHY Chronic kidney disease (CKD) causes salt-sensitive hypertension, but the interactions between dietary salt and the renin-angiotensin system are incompletely understood. In rats with CKD on a normal-salt diet targeting aldosterone, the mineralocorticoid receptor (MR) and especially angiotensin II reduced blood pressure. On a high-salt diet, however, only MR blockade attenuated hypertension. These results reiterate the importance of dietary salt restriction to maintain renin-angiotensin system inhibitor efficacy and specify the MR as a target in CKD.
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Affiliation(s)
- Dominique M Bovée
- Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Estrellita Uijl
- Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - David Severs
- Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Eloisa Rubio-Beltrán
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Richard van Veghel
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Antoinette Maassen van den Brink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robert Zietse
- Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Catherina A Cuevas
- Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - A H Jan Danser
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ewout J Hoorn
- Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
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14
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Bovée DM, Cuevas CA, Zietse R, Danser AHJ, Mirabito Colafella KM, Hoorn EJ. Salt-sensitive hypertension in chronic kidney disease: distal tubular mechanisms. Am J Physiol Renal Physiol 2020; 319:F729-F745. [DOI: 10.1152/ajprenal.00407.2020] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Chronic kidney disease (CKD) causes salt-sensitive hypertension that is often resistant to treatment and contributes to the progression of kidney injury and cardiovascular disease. A better understanding of the mechanisms contributing to salt-sensitive hypertension in CKD is essential to improve these outcomes. This review critically explores these mechanisms by focusing on how CKD affects distal nephron Na+ reabsorption. CKD causes glomerulotubular imbalance with reduced proximal Na+ reabsorption and increased distal Na+ delivery and reabsorption. Aldosterone secretion further contributes to distal Na+ reabsorption in CKD and is not only mediated by renin and K+ but also by metabolic acidosis, endothelin-1, and vasopressin. CKD also activates the intrarenal renin-angiotensin system, generating intratubular angiotensin II to promote distal Na+ reabsorption. High dietary Na+ intake in CKD contributes to Na+ retention by aldosterone-independent activation of the mineralocorticoid receptor mediated through Rac1. High dietary Na+ also produces an inflammatory response mediated by T helper 17 cells and cytokines increasing distal Na+ transport. CKD is often accompanied by proteinuria, which contains plasmin capable of activating the epithelial Na+ channel. Thus, CKD causes both local and systemic changes that together promote distal nephron Na+ reabsorption and salt-sensitive hypertension. Future studies should address remaining knowledge gaps, including the relative contribution of each mechanism, the influence of sex, differences between stages and etiologies of CKD, and the clinical relevance of experimentally identified mechanisms. Several pathways offer opportunities for intervention, including with dietary Na+ reduction, distal diuretics, renin-angiotensin system inhibitors, mineralocorticoid receptor antagonists, and K+ or H+ binders.
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Affiliation(s)
- Dominique M. Bovée
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
- Division of Vascular Medicine, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Catharina A. Cuevas
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Robert Zietse
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A. H. Jan Danser
- Division of Vascular Medicine, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Katrina M. Mirabito Colafella
- Cardiovascular Disease Program, Monash Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
- Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - Ewout J. Hoorn
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
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15
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Han BG, Lee JY, Kim MR, Shin H, Kim JS, Yang JW, Kim JY. Fluid overload is a determinant for cardiac structural and functional impairments in type 2 diabetes mellitus and chronic kidney disease stage 5 not undergoing dialysis. PLoS One 2020; 15:e0235640. [PMID: 32730268 PMCID: PMC7392282 DOI: 10.1371/journal.pone.0235640] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/19/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Fluid overload is common in patients with diabetes and chronic kidney disease (DM and CKD; DMCKD) and can lead to structural and functional cardiac abnormalities including left ventricular hypertrophy (LVH) and left ventricular diastolic dysfunction (LVDD). Fluid overload represents a crucial step in the pathophysiological pathways to chronic heart failure in patients with end-stage renal disease. We evaluated the impact of fluid overload on cardiac alterations in patients with diabetes and non-dialysis-dependent CKD stage 5 (DMCKD5-ND) without intrinsic heart disease. METHODS Bioimpedance spectroscopy, echocardiography, and N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) measurement were performed in 135 consecutive patients on the same day. Patients were divided into groups by tertiles of overhydration/extracellular water (OH/ECW) per bioimpedance spectroscopy. RESULTS Fluid balance markers including OH/ECW and NT-proBNP were significantly higher in the LVDD+LVH group. OH/ECW and its exacerbation were positively associated with the ratio between early mitral inflow and annular early diastolic velocities (E/e' ratio) and left ventricular mass index (LVMI). The prevalence of LVH progressively increased across increasing tertiles of OH/ECW. In multiple regression analyses, OH/ECW as a continuous and categorical variable was independently associated with the E/e' ratio and LVMI after adjustment for multiple confounding factors. CONCLUSIONS Fluid overload was independently associated with LVDD and LVH in patients with DMCKD5-ND. Our study suggests that structural and functional cardiac abnormalities and volume status should be evaluated simultaneously in patients with early-stage DMCKD rather than only DMCKD5-ND, in addition to intensive blood pressure and glycemic control, regardless of evident cardiovascular disease.
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Affiliation(s)
- Byoung-Geun Han
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Kang-won, Korea
| | - Jun Young Lee
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Kang-won, Korea
| | - Mi Ryung Kim
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Kang-won, Korea
| | - Hanwul Shin
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Kang-won, Korea
| | - Jae-Seok Kim
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Kang-won, Korea
| | - Jae-Won Yang
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Kang-won, Korea
| | - Jong Yeon Kim
- Department of Neurosurgery, Yonsei University Wonju College of Medicine, Wonju, Kang-won, Korea
- * E-mail:
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16
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Bovée DM, Visser WJ, Middel I, De Mik-van Egmond A, Greupink R, Masereeuw R, Russel FGM, Danser AHJ, Zietse R, Hoorn EJ. A Randomized Trial of Distal Diuretics versus Dietary Sodium Restriction for Hypertension in Chronic Kidney Disease. J Am Soc Nephrol 2020; 31:650-662. [PMID: 31996411 DOI: 10.1681/asn.2019090905] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 12/11/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Distal diuretics are considered less effective than loop diuretics in CKD. However, data to support this perception are limited. METHODS To investigate whether distal diuretics are noninferior to dietary sodium restriction in reducing BP in patients with CKD stage G3 or G4 and hypertension, we conducted a 6-week, randomized, open-label crossover trial comparing amiloride/hydrochlorothiazide (5 mg/50 mg daily) with dietary sodium restriction (60 mmol per day). Antihypertension medication was discontinued for a 2-week period before randomization. We analyzed effects on BP, kidney function, and fluid balance and related this to renal clearance of diuretics. RESULTS A total of 26 patients (with a mean eGFR of 39 ml/min per 1.73 m2) completed both treatments. Dietary sodium restriction reduced sodium excretion from 160 to 64 mmol per day. Diuretics produced a greater reduction in 24-hour systolic BP (SBP; from 138 to 124 mm Hg) compared with sodium restriction (from 134 to 129 mm Hg), as well as a significantly greater effect on extracellular water, eGFR, plasma renin, and aldosterone. Both interventions resulted in a similar decrease in body weight and NT-proBNP. Neither approaches decreased albuminuria significantly, whereas diuretics did significantly reduce urinary angiotensinogen and β2-microglobulin excretion. Although lower eGFR and higher plasma indoxyl sulfate correlated with lower diuretic clearance, the diuretic effects on body weight and BP at lower eGFR were maintained. During diuretic treatment, higher PGE2 excretion correlated with lower free water clearance, and four patients developed mild hyponatremia. CONCLUSIONS Distal diuretics are noninferior to dietary sodium restriction in reducing BP and extracellular volume in CKD. Diuretic sensitivity in CKD is maintained despite lower diuretic clearance. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER DD-study: Diet or Diuretics for Salt-sensitivity in Chronic Kidney Disease (DD), NCT02875886.
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Affiliation(s)
| | | | - Igor Middel
- Division of Pharmacology, Department of Pharmaceutical Sciences, University Utrecht, Utrecht, The Netherlands; and
| | | | - Rick Greupink
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rosalinde Masereeuw
- Division of Pharmacology, Department of Pharmaceutical Sciences, University Utrecht, Utrecht, The Netherlands; and
| | - Frans G M Russel
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A H Jan Danser
- Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
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17
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Vidal-Petiot E, Metzger M, Faucon AL, Boffa JJ, Haymann JP, Thervet E, Houillier P, Geri G, Stengel B, Vrtovsnik F, Flamant M. Extracellular Fluid Volume Is an Independent Determinant of Uncontrolled and Resistant Hypertension in Chronic Kidney Disease: A NephroTest Cohort Study. J Am Heart Assoc 2019; 7:e010278. [PMID: 30371309 PMCID: PMC6404875 DOI: 10.1161/jaha.118.010278] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Hypertension is highly prevalent during chronic kidney disease (CKD) and, in turn, worsens CKD prognosis. We aimed to describe the determinants of uncontrolled and resistant hypertension during CKD. Methods and Results We analyzed baseline data from patients with CKD stage 1 to 5 (NephroTest cohort) who underwent thorough renal explorations, including measurements of glomerular filtration rate (clearance of 51Cr‐EDTA) and of extracellular water (volume of distribution of the tracer). Hypertension was defined as blood pressure (BP; average of 3 office measurements) ≥140/90 mm Hg or the use of antihypertensive drugs. In 2015 patients (mean age, 58.7±15.3 years; 67% men; mean glomerular filtration rate, 42±15 mL/min per 1.73 m2), prevalence of hypertension was 88%. Among hypertensive patients, 44% and 32% had uncontrolled (≥140/90 mm Hg) and resistant (uncontrolled BP despite 3 drugs, including a diuretic, or ≥4 drugs, including a diuretic, regardless of BP level) hypertension, respectively. In multivariable analysis, extracellular water, older age, higher albuminuria, diabetic nephropathy, and the absence of aldosterone blockers were independently associated with uncontrolled BP. Extracellular water, older age, lower glomerular filtration rate, higher albuminuria and body mass index, male sex, African origin, diabetes mellitus, and diabetic and glomerular nephropathies were associated with resistant hypertension. Conclusions In this large population of patients with CKD, a lower glomerular filtration rate, a higher body mass index, diabetic status, and African origin were associated with hypertension severity but not with BP control. Higher extracellular water, older age, and higher albuminuria were independent determinants of both resistant and uncontrolled hypertension during CKD. Our results advocate for the large use of diuretics in this population.
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Affiliation(s)
- Emmanuelle Vidal-Petiot
- 1 Physiology Department Assistance Publique-Hôpitaux de Paris Hôpital Bichat and Inserm U1149 Paris France.,2 Paris Diderot University Sorbonne Paris Cité Paris France
| | - Marie Metzger
- 3 Inserm Centre de recherche en Epidéemiologie et Santée des Populations U1018 Hôpital Paul Brousse Villejuif France
| | - Anne-Laure Faucon
- 3 Inserm Centre de recherche en Epidéemiologie et Santée des Populations U1018 Hôpital Paul Brousse Villejuif France
| | - Jean-Jacques Boffa
- 4 Nephrology Department APHP, Hôpital Tenon Paris France.,5 Pierre et Marie Curie University Paris France
| | - Jean-Philippe Haymann
- 5 Pierre et Marie Curie University Paris France.,6 Physiology Department APHP, Hôpital Tenon Paris France
| | - Eric Thervet
- 7 Nephrology Department APHP HEGP Paris France.,8 Paris Descartes University Sorbonne Paris Cité Paris France
| | - Pascal Houillier
- 1 Physiology Department Assistance Publique-Hôpitaux de Paris Hôpital Bichat and Inserm U1149 Paris France.,8 Paris Descartes University Sorbonne Paris Cité Paris France.,9 Physiology Department APHP Hôpital Tenon, Georges Pompidou Paris France.,10 INSERM UMR_S1138 Paris France
| | - Guillaume Geri
- 3 Inserm Centre de recherche en Epidéemiologie et Santée des Populations U1018 Hôpital Paul Brousse Villejuif France.,11 Intensive Care Unit APHP, Hopital Ambroise Paré Boulogne France.,12 Versailles Saint Quentin University Versailles France
| | - Bénédicte Stengel
- 3 Inserm Centre de recherche en Epidéemiologie et Santée des Populations U1018 Hôpital Paul Brousse Villejuif France
| | - François Vrtovsnik
- 2 Paris Diderot University Sorbonne Paris Cité Paris France.,13 Nephrology Department APHP, Hôpital Bichat Paris France
| | - Martin Flamant
- 1 Physiology Department Assistance Publique-Hôpitaux de Paris Hôpital Bichat and Inserm U1149 Paris France.,2 Paris Diderot University Sorbonne Paris Cité Paris France
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