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Bargagli M, Anderegg MA, Fuster DG. Effects of thiazides and new findings on kidney stones and dysglycemic side effects. Acta Physiol (Oxf) 2024; 240:e14155. [PMID: 38698738 DOI: 10.1111/apha.14155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/08/2024] [Accepted: 04/22/2024] [Indexed: 05/05/2024]
Abstract
Thiazide and thiazide-like diuretics (thiazides) belong to the most frequently prescribed drugs worldwide. By virtue of their natriuretic and vasodilating properties, thiazides effectively lower blood pressure and prevent adverse cardiovascular outcomes. In addition, through their unique characteristic of reducing urine calcium, thiazides are also widely employed for the prevention of kidney stone recurrence and reduction of bone fracture risk. Since their introduction into clinical medicine in the early 1960s, thiazides have been recognized for their association with metabolic side effects, particularly impaired glucose tolerance, and new-onset diabetes mellitus. Numerous hypotheses have been advanced to explain thiazide-induced glucose intolerance, yet underlying mechanisms remain poorly defined. Regrettably, the lack of understanding and unpredictability of these side effects has prompted numerous physicians to refrain from prescribing these effective, inexpensive, and widely accessible drugs. In this review, we outline the pharmacology and mechanism of action of thiazides, highlight recent advances in the understanding of thiazide-induced glucose intolerance, and provide an up-to-date discussion on the role of thiazides in kidney stone prevention.
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Affiliation(s)
- Matteo Bargagli
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Swiss National Centre of Competence in Research (NCCR) Kidney.CH, University of Zürich, Zürich, Switzerland
- Department for Biomedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Manuel A Anderegg
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Swiss National Centre of Competence in Research (NCCR) Kidney.CH, University of Zürich, Zürich, Switzerland
- Department for Biomedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Daniel G Fuster
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Swiss National Centre of Competence in Research (NCCR) Kidney.CH, University of Zürich, Zürich, Switzerland
- Department for Biomedical Research (DBMR), University of Bern, Bern, Switzerland
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2
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Siew K, Nestler KA, Nelson C, D'Ambrosio V, Zhong C, Li Z, Grillo A, Wan ER, Patel V, Overbey E, Kim J, Yun S, Vaughan MB, Cheshire C, Cubitt L, Broni-Tabi J, Al-Jaber MY, Boyko V, Meydan C, Barker P, Arif S, Afsari F, Allen N, Al-Maadheed M, Altinok S, Bah N, Border S, Brown AL, Burling K, Cheng-Campbell M, Colón LM, Degoricija L, Figg N, Finch R, Foox J, Faridi P, French A, Gebre S, Gordon P, Houerbi N, Valipour Kahrood H, Kiffer FC, Klosinska AS, Kubik A, Lee HC, Li Y, Lucarelli N, Marullo AL, Matei I, McCann CM, Mimar S, Naglah A, Nicod J, O'Shaughnessy KM, Oliveira LCD, Oswalt L, Patras LI, Lai Polo SH, Rodríguez-Lopez M, Roufosse C, Sadeghi-Alavijeh O, Sanchez-Hodge R, Paul AS, Schittenhelm RB, Schweickart A, Scott RT, Choy Lim Kam Sian TC, da Silveira WA, Slawinski H, Snell D, Sosa J, Saravia-Butler AM, Tabetah M, Tanuwidjaya E, Walker-Samuel S, Yang X, Yasmin, Zhang H, Godovac-Zimmermann J, Sarder P, Sanders LM, Costes SV, Campbell RAA, Karouia F, Mohamed-Alis V, Rodriques S, Lynham S, Steele JR, Baranzini S, Fazelinia H, Dai Z, Uruno A, Shiba D, Yamamoto M, A C Almeida E, Blaber E, Schisler JC, Eisch AJ, Muratani M, Zwart SR, Smith SM, Galazka JM, Mason CE, Beheshti A, Walsh SB. Cosmic kidney disease: an integrated pan-omic, physiological and morphological study into spaceflight-induced renal dysfunction. Nat Commun 2024; 15:4923. [PMID: 38862484 PMCID: PMC11167060 DOI: 10.1038/s41467-024-49212-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 05/28/2024] [Indexed: 06/13/2024] Open
Abstract
Missions into Deep Space are planned this decade. Yet the health consequences of exposure to microgravity and galactic cosmic radiation (GCR) over years-long missions on indispensable visceral organs such as the kidney are largely unexplored. We performed biomolecular (epigenomic, transcriptomic, proteomic, epiproteomic, metabolomic, metagenomic), clinical chemistry (electrolytes, endocrinology, biochemistry) and morphometry (histology, 3D imaging, miRNA-ISH, tissue weights) analyses using samples and datasets available from 11 spaceflight-exposed mouse and 5 human, 1 simulated microgravity rat and 4 simulated GCR-exposed mouse missions. We found that spaceflight induces: 1) renal transporter dephosphorylation which may indicate astronauts' increased risk of nephrolithiasis is in part a primary renal phenomenon rather than solely a secondary consequence of bone loss; 2) remodelling of the nephron that results in expansion of distal convoluted tubule size but loss of overall tubule density; 3) renal damage and dysfunction when exposed to a Mars roundtrip dose-equivalent of simulated GCR.
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Affiliation(s)
- Keith Siew
- London Tubular Centre, Department of Renal Medicine, University College London, London, UK.
| | - Kevin A Nestler
- The Institute for Biomedical Sciences (IBS), The George Washington University, Washington, DC, USA
| | - Charlotte Nelson
- Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Viola D'Ambrosio
- London Tubular Centre, Department of Renal Medicine, University College London, London, UK
- Department of Experimental and Translational Medicine, Università Cattolica del Sacro Cuore di Roma, Rome, Italy
| | - Chutong Zhong
- London Tubular Centre, Department of Renal Medicine, University College London, London, UK
| | - Zhongwang Li
- London Tubular Centre, Department of Renal Medicine, University College London, London, UK
- Centre for Advanced Biomedical Imaging, University College London, London, UK
- Centre for Computational Medicine, University College London, London, UK
| | - Alessandra Grillo
- London Tubular Centre, Department of Renal Medicine, University College London, London, UK
| | - Elizabeth R Wan
- London Tubular Centre, Department of Renal Medicine, University College London, London, UK
| | - Vaksha Patel
- Department of Renal Medicine, University College London, London, UK
| | - Eliah Overbey
- Institute for Computational Biomedicine, Weill Cornell Medical College, New York, NY, USA
| | - JangKeun Kim
- Institute for Computational Biomedicine, Weill Cornell Medical College, New York, NY, USA
| | - Sanghee Yun
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael B Vaughan
- School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland
- Tissue Engineering and Biomaterials Group, Ghent University, Ghent, Belgium
- Center for Medical Genetics, Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Chris Cheshire
- Bioinformatics and Computational Biology Laboratory, The Francis Crick Institute, London, UK
| | - Laura Cubitt
- Applied Biotechnology Laboratory, The Francis Crick Institute, London, UK
| | - Jessica Broni-Tabi
- Sainsbury Wellcome Centre for Neural Circuits and Behaviour, University College London, London, UK
| | | | - Valery Boyko
- Space Biosciences Division, NASA Ames Research Center, Moffett Field, CA, USA
| | - Cem Meydan
- Institute for Computational Biomedicine, Weill Cornell Medical College, New York, NY, USA
| | - Peter Barker
- MRC MDU Mouse Biochemistry Laboratory, University of Cambridge, Cambridge, UK
| | - Shehbeel Arif
- Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fatemeh Afsari
- Department of Medicine-Nephrology & Intelligent Critical Care Center, University of Florida, Gainesville, FL, USA
| | - Noah Allen
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY, USA
| | - Mohammed Al-Maadheed
- Anti-Doping Laboratory Qatar, Doha, Qatar
- Centre of Metabolism and Inflammation, University College London, London, UK
| | - Selin Altinok
- School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nourdine Bah
- Applied Biotechnology Laboratory, The Francis Crick Institute, London, UK
| | - Samuel Border
- Department of Medicine-Nephrology & Intelligent Critical Care Center, University of Florida, Gainesville, FL, USA
| | - Amanda L Brown
- Pharmacology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Keith Burling
- MRC MDU Mouse Biochemistry Laboratory, University of Cambridge, Cambridge, UK
| | - Margareth Cheng-Campbell
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY, USA
- Blue Marble Space Institute of Science, Seattle, WA, USA
| | - Lorianna M Colón
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, USA
| | - Lovorka Degoricija
- KBR, Space Biosciences Division, NASA Ames Research Center, Moffett Field, CA, USA
| | - Nichola Figg
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Rebecca Finch
- School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
| | - Jonathan Foox
- Department of Physiology and Biophysics, Weill Cornell Medical College, New York, NY, USA
- The HRH Prince Alwaleed Bin Talal Bin Abdulaziz Alsaud Institute for Computational Biomedicine, Weill Cornell Medical College, New York, NY, USA
| | - Pouya Faridi
- Monash Proteomics and Metabolomics Platform, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Alison French
- Space Biosciences Division, NASA Ames Research Center, Moffett Field, CA, USA
| | - Samrawit Gebre
- Space Biosciences Division, NASA Ames Research Center, Moffett Field, CA, USA
| | - Peter Gordon
- Sainsbury Wellcome Centre for Neural Circuits and Behaviour, University College London, London, UK
| | - Nadia Houerbi
- Physiology, Biophysics & Systems Biology, Weill Cornell Medical College, New York, NY, USA
| | - Hossein Valipour Kahrood
- Monash Proteomics and Metabolomics Platform, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
- Monash Bioinformatics Platform, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Frederico C Kiffer
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Aleksandra S Klosinska
- Division of Experimental Medicine & Immunotherapeutics (EMIT), Department of Medicine, University of Cambridge, Cambridge, UK
| | - Angela Kubik
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY, USA
| | - Han-Chung Lee
- Monash Proteomics and Metabolomics Platform, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Yinghui Li
- State Key Laboratory of Space Medicine Fundamentals and Application, China Astronaut Research and Training Center, Beijing, China
| | - Nicholas Lucarelli
- Department of Medicine-Nephrology & Intelligent Critical Care Center, University of Florida, Gainesville, FL, USA
| | - Anthony L Marullo
- School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Irina Matei
- Cornell Center for Immunology, Cornell University, Ithaca, NY, USA
- Children's Cancer and Blood Foundation Laboratories, Departments of Pediatrics and Cell and Developmental Biology, Drukier Institute for Children's Health, Meyer Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | - Colleen M McCann
- Pharmacology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sayat Mimar
- Department of Medicine-Nephrology & Intelligent Critical Care Center, University of Florida, Gainesville, FL, USA
| | - Ahmed Naglah
- Department of Medicine-Nephrology & Intelligent Critical Care Center, University of Florida, Gainesville, FL, USA
| | - Jérôme Nicod
- Advanced Sequencing Facility, The Francis Crick Institute, London, UK
| | - Kevin M O'Shaughnessy
- Division of Experimental Medicine & Immunotherapeutics (EMIT), Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - Leah Oswalt
- Pharmacology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - San-Huei Lai Polo
- KBR, Space Biosciences Division, NASA Ames Research Center, Moffett Field, CA, USA
| | | | - Candice Roufosse
- Department of Immunology and Inflammation, Imperial College London, London, UK
| | | | | | - Anindya S Paul
- Department of Medicine-Nephrology & Intelligent Critical Care Center, University of Florida, Gainesville, FL, USA
| | - Ralf Bernd Schittenhelm
- Monash Proteomics and Metabolomics Platform, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Annalise Schweickart
- Institute for Computational Biomedicine, Weill Cornell Medical College, New York, NY, USA
- Englander Institute for Precision Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Ryan T Scott
- KBR, Space Biosciences Division, NASA Ames Research Center, Moffett Field, CA, USA
| | - Terry Chin Choy Lim Kam Sian
- Monash Proteomics and Metabolomics Platform, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Willian A da Silveira
- School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
- International Space University, 67400, Illkirch-Graffenstaden, France
| | - Hubert Slawinski
- Advanced Sequencing Facility, The Francis Crick Institute, London, UK
| | - Daniel Snell
- Advanced Sequencing Facility, The Francis Crick Institute, London, UK
| | - Julio Sosa
- University Health Network, Toronto, ON, Canada
| | | | - Marshall Tabetah
- Department of Agricultural and Biological Engineering, Purdue University, West Lafayette, IN, USA
| | - Erwin Tanuwidjaya
- Monash Proteomics and Metabolomics Platform, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Simon Walker-Samuel
- Centre for Advanced Biomedical Imaging, University College London, London, UK
- Centre for Computational Medicine, University College London, London, UK
| | | | - Yasmin
- Division of Experimental Medicine & Immunotherapeutics (EMIT), Department of Medicine, University of Cambridge, Cambridge, UK
| | - Haijian Zhang
- Monash Proteomics and Metabolomics Platform, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | | | - Pinaki Sarder
- Department of Medicine-Quantitative Health Section, University of Florida, Gainesville, FL, USA
- Departments of Biomedical Engineering and Electrical and Computer Engineering, University of Florida, Gainesville, FL, USA
| | - Lauren M Sanders
- Space Biosciences Division, NASA Ames Research Center, Moffett Field, CA, USA
- Blue Marble Space Institute of Science, Seattle, WA, USA
| | - Sylvain V Costes
- Space Biosciences Division, NASA Ames Research Center, Moffett Field, CA, USA
| | - Robert A A Campbell
- Sainsbury Wellcome Centre for Neural Circuits and Behaviour, University College London, London, UK
| | - Fathi Karouia
- Blue Marble Space Institute of Science, Seattle, WA, USA
- Space Research Within Reach, San Francisco, CA, USA
- Center for Space Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Vidya Mohamed-Alis
- Anti-Doping Laboratory Qatar, Doha, Qatar
- Centre of Metabolism and Inflammation, University College London, London, UK
| | - Samuel Rodriques
- Applied Biotechnology Laboratory, The Francis Crick Institute, London, UK
| | | | - Joel Ricky Steele
- Monash Proteomics and Metabolomics Platform, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Sergio Baranzini
- Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Hossein Fazelinia
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, USA
| | - Zhongquan Dai
- State Key Laboratory of Space Medicine Fundamentals and Application, China Astronaut Research and Training Center, Beijing, China
| | - Akira Uruno
- Department of Integrative Genomics, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan
| | - Dai Shiba
- Mouse Epigenetics Project, ISS/Kibo experiment, Japan Aerospace Exploration Agency (JAXA), Tsukuba, Ibaraki, Japan
- JEM Utilization Center, Human Spaceflight Technology Directorate, Japan Aerospace Exploration Agency (JAXA), Tsukuba, Ibaraki, Japan
| | - Masayuki Yamamoto
- Department of Integrative Genomics, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan
- Department of Medical Biochemistry, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Eduardo A C Almeida
- Space Biosciences Division, NASA Ames Research Center, Moffett Field, CA, USA
| | - Elizabeth Blaber
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY, USA
- Center for Biotechnology & Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, NY, USA
- Stanley Center for Psychiatric Research, Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA
| | - Jonathan C Schisler
- Pharmacology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Amelia J Eisch
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Neuroscience, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Masafumi Muratani
- Institute of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Sara R Zwart
- Department of Preventative Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, USA
| | | | - Jonathan M Galazka
- Space Biosciences Division, NASA Ames Research Center, Moffett Field, CA, USA
| | - Christopher E Mason
- Department of Physiology and Biophysics, Weill Cornell Medical College, New York, NY, USA
- The HRH Prince Alwaleed Bin Talal Bin Abdulaziz Alsaud Institute for Computational Biomedicine, Weill Cornell Medical College, New York, NY, USA
- The WorldQuant Initiative for Quantitative Prediction, Weill Cornell Medical College, New York, NY, USA
- The Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
| | - Afshin Beheshti
- KBR, Space Biosciences Division, NASA Ames Research Center, Moffett Field, CA, USA
- Broad Institute, Cambridge, MA, USA
- Space Biosciences Division, Universities Space Research Association (USRA), Washington, DC, USA
| | - Stephen B Walsh
- London Tubular Centre, Department of Renal Medicine, University College London, London, UK.
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Geurts F, Rudolphi CF, Pelouto A, van der Burgh AC, Salih M, Imenez Silva PH, Fenton RA, Chaker L, Hoorn EJ. The Effect of Thiazide Diuretics on Urinary Prostaglandin E2 Excretion and Serum Sodium in the General Population. J Clin Endocrinol Metab 2024:dgae352. [PMID: 38776231 DOI: 10.1210/clinem/dgae352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/16/2024] [Accepted: 05/20/2024] [Indexed: 05/24/2024]
Abstract
CONTEXT Thiazide-induced hyponatremia is one of the most common forms of hyponatremia, but its pathogenesis is incompletely understood. Recent clinical data suggest links with prostaglandin E2 (PGE2) and a single nucleotide polymorphism (SNP) in the prostaglandin transporter gene (SLCO2A1), but it is unknown if these findings also apply to the general population. OBJECTIVE To study the associations between serum sodium, thiazide diuretics, urinary excretions of PGE2 and its metabolite (PGEM), and the rs34550074 SNP in SLCO2A1 in the general population. DESIGN Prospective population-based cohort study (Rotterdam Study). SETTING General population. PARTICIPANTS 2,178 participants (65% female, age 64 ± 8 years). INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Serum sodium levels. RESULTS Higher urinary PGE2 excretion was associated with lower serum sodium: difference in serum sodium for each two-fold higher PGE2 -0.19 mmol/l (95%CI -0.31 to -0.06), PGEM -0.29 mmol/l (95%CI -0.41 to -0.17). This association was stronger in thiazide users (per two-fold higher PGE2 -0.73 vs. -0.12 mmol/l and PGEM -0.6 vs. -0.25 mmol/l, p for interaction < 0.05 for both). A propensity score matching analysis of thiazide vs. non-thiazide users yielded similar results. The SNP rs34550074 was not associated with lower serum sodium or higher urinary PGE2 or PGEM excretion in thiazide or non-thiazide users. CONCLUSIONS Serum sodium is lower in people with higher urinary PGE2 and PGEM excretion and this association is stronger in thiazide users. This suggests that PGE2-mediated water reabsorption regulates serum sodium, which is relevant for the pathogenesis of hyponatremia in general and thiazide-induced hyponatremia in specific.
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Affiliation(s)
- Frank Geurts
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Crissy F Rudolphi
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Anissa Pelouto
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Anna C van der Burgh
- Department of Epidemiology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mahdi Salih
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Pedro Henrique Imenez Silva
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Robert A Fenton
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Layal Chaker
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ewout J Hoorn
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Mocking TAM, van Oostveen WM, van Veldhoven JPD, Minnee H, Fehres CM, Whitehurst CE, IJzerman AP, Heitman LH. Label-free detection of prostaglandin transporter (SLCO2A1) function and inhibition: insights by wound healing and TRACT assays. Front Pharmacol 2024; 15:1372109. [PMID: 38783936 PMCID: PMC11111933 DOI: 10.3389/fphar.2024.1372109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 04/19/2024] [Indexed: 05/25/2024] Open
Abstract
The prostaglandin transporter (PGT, SLCO2A1) mediates transport of prostanoids (a.o. prostaglandin E2 (PGE2)) into cells and thereby promotes their degradation. Overexpression of PGT leads to low extracellular PGE2 levels and has been linked to impaired wound healing of diabetic foot ulcers. Inhibition of PGT could thus be beneficial, however, no PGT inhibitors are currently on the market and drug discovery efforts are hampered by lack of high-through screening assays for this transporter. Here we report on a label-free impedance-based assay for PGT that measures transport activity through receptor activation (TRACT) utilizing prostaglandin E2 receptor subtype EP3 and EP4 that are activated by PGE2. We found that induction of PGT expression on HEK293-JumpIn-SLCO2A1 cells that also express EP3 and EP4 leads to an over 10-fold reduction in agonistic potency of PGE2. PGE2 potency could be recovered upon inhibition of PGT-mediated PGE2 uptake with PGT inhibitors olmesartan and T26A, the potency of which could be established as well. Moreover, the TRACT assay enabled the assessment of transport function of PGT natural variants. Lastly, HUVEC cells endogenously expressing prostanoid receptors and PGT were exploited to study wound healing properties of PGE2 and T26A in real-time using a novel impedance-based scratch-induced wound healing assay. These novel impedance-based assays will advance PGT drug discovery efforts and pave the way for the development of PGT-based therapies.
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Affiliation(s)
- Tamara A. M. Mocking
- Division of Drug Discovery and Safety, Leiden Academic Centre for Drug Research, Leiden University, Leiden, Netherlands
| | | | | | - Hugo Minnee
- Division of Drug Discovery and Safety, Leiden Academic Centre for Drug Research, Leiden University, Leiden, Netherlands
| | - Cynthia M. Fehres
- Department of Rheumatology, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Charles E. Whitehurst
- Immunology and Respiratory Diseases, Boehringer-Ingelheim, Ridgefield, CT, United States
| | - Adriaan P. IJzerman
- Division of Drug Discovery and Safety, Leiden Academic Centre for Drug Research, Leiden University, Leiden, Netherlands
| | - Laura H. Heitman
- Division of Drug Discovery and Safety, Leiden Academic Centre for Drug Research, Leiden University, Leiden, Netherlands
- Oncode Institute, Leiden, Netherlands
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5
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Bassi V, Apuzzi V, Sodano M, Fattoruso O. Euvolemic hypotonic hyponatremia in SIAD and thiazide-treated patients: similarities and differences. J Nephrol 2024; 37:527-529. [PMID: 37882963 DOI: 10.1007/s40620-023-01784-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 09/03/2023] [Indexed: 10/27/2023]
Affiliation(s)
- Vincenzo Bassi
- U.O.C. di Medicina Generale e Lungodegenza, San Giovanni Bosco Hospital, ASL Na1 Centro, Naples, Italy
| | - Valentina Apuzzi
- U.O.C. di Medicina Generale e Lungodegenza, San Giovanni Bosco Hospital, ASL Na1 Centro, Naples, Italy.
| | - Marta Sodano
- U.O.C. di Medicina Generale e Lungodegenza, San Giovanni Bosco Hospital, ASL Na1 Centro, Naples, Italy
| | - Olimpia Fattoruso
- U.O.C. di Patologia Clinica, San Giovanni Bosco Hospital, ASL Na1 Centro, Naples, Italy
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6
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Geurts F, Chaker L, van der Burgh AC, Cronin‐Fenton D, Fenton RA, Hoorn EJ. Urinary Prostaglandin E2 Excretion and the Risk of Cardiovascular and Kidney Disease. J Am Heart Assoc 2024; 13:e032835. [PMID: 38362883 PMCID: PMC11010119 DOI: 10.1161/jaha.123.032835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 01/23/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Inhibition of prostaglandin synthesis by nonsteroidal anti-inflammatory drugs is associated with cardiovascular mortality and kidney disease. This study hypothesizes that urinary prostaglandin E2 (PGE2) and PGE2 metabolite (PGEM) excretions are markers of cardiovascular and kidney health, because they reflect both systemic and kidney-derived PGE2 production. METHODS AND RESULTS PGE2 and PGEM were measured in spot urine samples from 2291 participants (≥55 years old) of the population-based Rotterdam Study. Urinary PGE2 and PGEM excretions were analyzed using linear regression analyses to identify cross-sectional associations with cardiovascular risk factors and baseline estimated glomerular filtration rate (eGFR). Longitudinal associations with cardiovascular mortality and kidney outcomes (eGFR <60 or <45 mL/min per 1.73 m2 and the composite outcome 40% eGFR loss or kidney failure) were assessed with Cox regression. Urinary PGE2 and PGEM excretions were higher with increasing age, lower eGFR, smoking, diabetes, and albuminuria. A 2-fold higher urinary PGE2 and PGEM excretion was associated with a higher risk of cardiovascular mortality (28 825 patient-years; 160 events; PGE2 hazard ratio [HR], 1.27, [95% CI, 1.06-1.54]; PGEM HR, 1.36 [95% CI, 1.10-1.67]). Higher PGE2 excretions were also associated with a higher risk of incident eGFR <60 mL/min per 1.73 m2 (31 530 person-years; 691 events; HR, 1.13 [95% CI, 1.02-1.25]) with similar HRs for the other kidney outcomes. CONCLUSIONS Urinary PGE2 and PGEM excretions are novel markers for the presence and progression of cardiovascular and kidney disease. Future studies should address whether these associations are causal and can be targeted to improve cardiovascular and kidney outcomes.
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Affiliation(s)
- Frank Geurts
- Department of Internal Medicine, Erasmus Medical CenterUniversity Medical Center RotterdamRotterdamThe Netherlands
- Department of Epidemiology, Erasmus Medical CenterUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Layal Chaker
- Department of Internal Medicine, Erasmus Medical CenterUniversity Medical Center RotterdamRotterdamThe Netherlands
- Department of Epidemiology, Erasmus Medical CenterUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Anna C. van der Burgh
- Department of Epidemiology, Erasmus Medical CenterUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Deirdre Cronin‐Fenton
- Department of Clinical Epidemiology, Department of Clinical MedicineAarhus University Hospital and Aarhus UniversityAarhusDenmark
| | | | - Ewout J. Hoorn
- Department of Internal Medicine, Erasmus Medical CenterUniversity Medical Center RotterdamRotterdamThe Netherlands
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7
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Geurts F, Xue L, Kramers BJ, Zietse R, Gansevoort RT, Fenton RA, Meijer E, Salih M, Hoorn EJ. Prostaglandin E2, Osmoregulation, and Disease Progression in Autosomal Dominant Polycystic Kidney Disease. Clin J Am Soc Nephrol 2023; 18:1426-1434. [PMID: 37574650 PMCID: PMC10637469 DOI: 10.2215/cjn.0000000000000269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/06/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Prostaglandin E2 (PGE2) plays a physiological role in osmoregulation, a process that is affected early in autosomal dominant polycystic kidney disease (ADPKD). PGE2 has also been implicated in the pathogenesis of ADPKD in preclinical models, but human data are limited. Here, we hypothesized that urinary PGE2 excretion is associated with impaired osmoregulation, disease severity, and disease progression in human ADPKD. METHODS Urinary excretions of PGE2 and its metabolite (PGEM) were measured in a prospective cohort of patients with ADPKD. The associations between urinary PGE2 and PGEM excretions, markers of osmoregulation, eGFR and height-adjusted total kidney volume were assessed using linear regression models. Cox regression and linear mixed models were used for the longitudinal analysis of the associations between urinary PGE2 and PGEM excretions and disease progression defined as 40% eGFR loss or kidney failure, and change in eGFR over time. In two intervention studies, we quantified the effect of starting tolvaptan and adding hydrochlorothiazide to tolvaptan on urinary PGE2 and PGEM excretions. RESULTS In 562 patients with ADPKD (61% female, eGFR 63±28 ml/min per 1.73 m 2 ), higher urinary PGE2 or PGEM excretions were independently associated with higher plasma copeptin, lower urine osmolality, lower eGFR, and greater total kidney volume. Participants with higher baseline urinary PGE2 and PGEM excretions had a higher risk of 40% eGFR loss or kidney failure (hazard ratio, 1.28; 95% confidence interval [CI], 1.13 to 1.46 and hazard ratio, 1.50; 95% CI, 1.26 to 1.80 per two-fold higher urinary PGE2 or PGEM excretions) and a faster change in eGFR over time (-0.39 [95% CI, -0.59 to -0.20] and -0.53 [95% CI, -0.75 to -0.31] ml/min per 1.73 m 2 per year). In the intervention studies, urinary PGEM excretion was higher after starting tolvaptan, while urinary PGE2 excretion was higher after adding hydrochlorothiazide to tolvaptan. CONCLUSIONS Higher urinary PGE2 and PGEM excretions in patients with ADPKD are associated with impaired osmoregulation, disease severity, and progression.
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Affiliation(s)
- Frank Geurts
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Laixi Xue
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bart J. Kramers
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert Zietse
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ron T. Gansevoort
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Esther Meijer
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Mahdi Salih
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ewout J. Hoorn
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Warren AM, Grossmann M, Christ-Crain M, Russell N. Syndrome of Inappropriate Antidiuresis: From Pathophysiology to Management. Endocr Rev 2023; 44:819-861. [PMID: 36974717 PMCID: PMC10502587 DOI: 10.1210/endrev/bnad010] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 02/19/2023] [Accepted: 03/27/2023] [Indexed: 03/29/2023]
Abstract
Hyponatremia is the most common electrolyte disorder, affecting more than 15% of patients in the hospital. Syndrome of inappropriate antidiuresis (SIAD) is the most frequent cause of hypotonic hyponatremia, mediated by nonosmotic release of arginine vasopressin (AVP, previously known as antidiuretic hormone), which acts on the renal V2 receptors to promote water retention. There are a variety of underlying causes of SIAD, including malignancy, pulmonary pathology, and central nervous system pathology. In clinical practice, the etiology of hyponatremia is frequently multifactorial and the management approach may need to evolve during treatment of a single episode. It is therefore important to regularly reassess clinical status and biochemistry, while remaining alert to potential underlying etiological factors that may become more apparent during the course of treatment. In the absence of severe symptoms requiring urgent intervention, fluid restriction (FR) is widely endorsed as the first-line treatment for SIAD in current guidelines, but there is considerable controversy regarding second-line therapy in instances where FR is unsuccessful, which occurs in around half of cases. We review the epidemiology, pathophysiology, and differential diagnosis of SIAD, and summarize recent evidence for therapeutic options beyond FR, with a focus on tolvaptan, urea, and sodium-glucose cotransporter 2 inhibitors.
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Affiliation(s)
- Annabelle M Warren
- Department of Medicine, University of Melbourne, Victoria 3010, Australia
- Department of Endocrinology, The Austin Hospital, Victoria 3084, Australia
| | - Mathis Grossmann
- Department of Medicine, University of Melbourne, Victoria 3010, Australia
- Department of Endocrinology, The Austin Hospital, Victoria 3084, Australia
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel 4031, Switzerland
- Department of Clinical Research, University of Basel and University Hospital Basel, Basel 4031, Switzerland
| | - Nicholas Russell
- Department of Medicine, University of Melbourne, Victoria 3010, Australia
- Department of Endocrinology, The Austin Hospital, Victoria 3084, Australia
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Workeneh BT, Meena P, Christ-Crain M, Rondon-Berrios H. Hyponatremia Demystified: Integrating Physiology to Shape Clinical Practice. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:85-101. [PMID: 36868737 PMCID: PMC9993811 DOI: 10.1053/j.akdh.2022.11.004] [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: 05/28/2022] [Revised: 10/05/2022] [Accepted: 11/07/2022] [Indexed: 12/24/2022]
Abstract
Hyponatremia is one of the most common problems encountered in clinical practice and one of the least-understood because accurate diagnosis and management require some familiarity with water homeostasis physiology, making the topic seemingly complex. The prevalence of hyponatremia depends on the nature of the population studied and the criteria used to define it. Hyponatremia is associated with poor outcomes including increased mortality and morbidity. The pathogenesis of hypotonic hyponatremia involves the accumulation of electrolyte-free water caused by either increased intake and/or decrease in kidney excretion. Plasma osmolality, urine osmolality, and urine sodium can help to differentiate among the different etiologies. Brain adaptation to plasma hypotonicity consisting of solute extrusion to mitigate further water influx into brain cells best explains the clinical manifestations of hyponatremia. Acute hyponatremia has an onset within 48 hours, commonly resulting in severe symptoms, while chronic hyponatremia develops over 48 hours and usually is pauci-symptomatic. However, the latter increases the risk of osmotic demyelination syndrome if hyponatremia is corrected rapidly; therefore, extreme caution must be exercised when correcting plasma sodium. Management strategies depend on the presence of symptoms and the cause of hyponatremia and are discussed in this review.
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Affiliation(s)
- Biruh T Workeneh
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Priti Meena
- All India Institute of Medical Sciences, Bhubaneswar, India
| | - Mirjam Christ-Crain
- Departments of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
| | - Helbert Rondon-Berrios
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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10
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Exercise-Associated Hyponatremia in Marathon Runners. J Clin Med 2022; 11:jcm11226775. [PMID: 36431252 PMCID: PMC9699060 DOI: 10.3390/jcm11226775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 11/01/2022] [Accepted: 11/05/2022] [Indexed: 11/19/2022] Open
Abstract
Exercise-associated hyponatremia (EAH) was first described as water intoxication by Noakes et al. in 1985 and has become an important topic linked to several pathological conditions. However, despite progressive research, neurological disorders and even deaths due to hyponatremic encephalopathy continue to occur. Therefore, and due to the growing popularity of exercise-associated hyponatremia, this topic is of great importance for marathon runners and all professionals involved in runners' training (e.g., coaches, medical staff, nutritionists, and trainers). The present narrative review sought to evaluate the prevalence of EAH among marathon runners and to identify associated etiological and risk factors. Furthermore, the aim was to derive preventive and therapeutic action plans for marathon runners based on current evidence. The search was conducted on PubMed, Scopus and Google Scholar using a predefined search algorithm by aggregating multiple terms (marathon run; exercise; sport; EAH; electrolyte disorder; fluid balance; dehydration; sodium concentration; hyponatremia). By this criterion, 135 articles were considered for the present study. Our results revealed that a complex interaction of different factors could cause EAH, which can be differentiated into event-related (high temperatures) and person-related (female sex) risk factors. There is variation in the reported prevalence of EAH, and two major studies indicated an incidence ranging from 7 to 15% for symptomatic and asymptomatic EAH. Athletes and coaches must be aware of EAH and its related problems and take appropriate measures for both training and competition. Coaches need to educate their athletes about the early symptoms of EAH to intervene at the earliest possible stage. In addition, individual hydration strategies need to be developed for the daily training routine, ideally in regard to sweat rate and salt losses via sweat. Future studies need to investigate the correlation between the risk factors of EAH and specific subgroups of marathon runners.
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11
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Kim GH. Pathophysiology of Drug-Induced Hyponatremia. J Clin Med 2022; 11:jcm11195810. [PMID: 36233678 PMCID: PMC9572915 DOI: 10.3390/jcm11195810] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Drug-induced hyponatremia caused by renal water retention is mainly due to syndrome of inappropriate antidiuresis (SIAD). SIAD can be grouped into syndrome of inappropriate antidiuretic hormone secretion (SIADH) and nephrogenic syndrome of inappropriate antidiuresis (NSIAD). The former is characterized by uncontrolled hypersecretion of arginine vasopressin (AVP), and the latter is produced by intrarenal activation for water reabsorption and characterized by suppressed plasma AVP levels. Desmopressin is useful for the treatment of diabetes insipidus because of its selective binding to vasopressin V2 receptor (V2R), but it can induce hyponatremia when prescribed for nocturnal polyuria in older patients. Oxytocin also acts as a V2R agonist and can produce hyponatremia when used to induce labor or abortion. In current clinical practice, psychotropic agents, anticancer chemotherapeutic agents, and thiazide diuretics are the major causes of drug-induced hyponatremia. Among these, vincristine and ifosfamide were associated with sustained plasma AVP levels and are thought to cause SIADH. However, others including antipsychotics, antidepressants, anticonvulsants, cyclophosphamide, and thiazide diuretics may induce hyponatremia by intrarenal mechanisms for aquaporin-2 (AQP2) upregulation, compatible with NSIAD. In these cases, plasma AVP levels are suppressed by negative feedback. In rat inner medullary collecting duct cells, haloperidol, sertraline, carbamazepine, and cyclophosphamide upregulated V2R mRNA and increased cAMP production in the absence of vasopressin. The resultant AQP2 upregulation was blocked by a V2R antagonist tolvaptan or protein kinase A (PKA) inhibitors, suggestive of the activation of V2R-cAMP-PKA signaling. Hydrochlorothiazide can also upregulate AQP2 in the collecting duct without vasopressin, either directly or via the prostaglandin E2 pathway. In brief, nephrogenic antidiuresis, or NSIAD, is the major mechanism for drug-induced hyponatremia. The associations between pharmacogenetic variants and drug-induced hyponatremia is an area of ongoing research.
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Affiliation(s)
- Gheun-Ho Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, Korea
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12
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Abstract
IMPORTANCE Hyponatremia is the most common electrolyte disorder and it affects approximately 5% of adults and 35% of hospitalized patients. Hyponatremia is defined by a serum sodium level of less than 135 mEq/L and most commonly results from water retention. Even mild hyponatremia is associated with increased hospital stay and mortality. OBSERVATIONS Symptoms and signs of hyponatremia range from mild and nonspecific (such as weakness or nausea) to severe and life-threatening (such as seizures or coma). Symptom severity depends on the rapidity of development, duration, and severity of hyponatremia. Mild chronic hyponatremia is associated with cognitive impairment, gait disturbances, and increased rates of falls and fractures. In a prospective study, patients with hyponatremia more frequently reported a history of falling compared with people with normal serum sodium levels (23.8% vs 16.4%, respectively; P < .01) and had a higher rate of new fractures over a mean follow-up of 7.4 years (23.3% vs 17.3%; P < .004). Hyponatremia is a secondary cause of osteoporosis. When evaluating patients, clinicians should categorize them according to their fluid volume status (hypovolemic hyponatremia, euvolemic hyponatremia, or hypervolemic hyponatremia). For most patients, the approach to managing hyponatremia should consist of treating the underlying cause. Urea and vaptans can be effective treatments for the syndrome of inappropriate antidiuresis and hyponatremia in patients with heart failure, but have adverse effects (eg, poor palatability and gastric intolerance with urea; and overly rapid correction of hyponatremia and increased thirst with vaptans). Severely symptomatic hyponatremia (with signs of somnolence, obtundation, coma, seizures, or cardiorespiratory distress) is a medical emergency. US and European guidelines recommend treating severely symptomatic hyponatremia with bolus hypertonic saline to reverse hyponatremic encephalopathy by increasing the serum sodium level by 4 mEq/L to 6 mEq/L within 1 to 2 hours but by no more than 10 mEq/L (correction limit) within the first 24 hours. This treatment approach exceeds the correction limit in about 4.5% to 28% of people. Overly rapid correction of chronic hyponatremia may cause osmotic demyelination, a rare but severe neurological condition, which can result in parkinsonism, quadriparesis, or even death. CONCLUSIONS AND RELEVANCE Hyponatremia affects approximately 5% of adults and 35% of patients who are hospitalized. Most patients should be managed by treating their underlying disease and according to whether they have hypovolemic, euvolemic, or hypervolemic hyponatremia. Urea and vaptans can be effective in managing the syndrome of inappropriate antidiuresis and hyponatremia in patients with heart failure; hypertonic saline is reserved for patients with severely symptomatic hyponatremia.
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Affiliation(s)
- Horacio J Adrogué
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Division of Nephrology, Department of Medicine, Houston Methodist Hospital, Houston, Texas
| | - Bryan M Tucker
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Division of Nephrology, Department of Medicine, Houston Methodist Hospital, Houston, Texas
| | - Nicolaos E Madias
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
- Division of Nephrology, Department of Medicine, St Elizabeth's Medical Center, Boston, Massachusetts
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Mannheimer B, Sterea-Grossu A, Falhammar H, Calissendorff J, Skov J, Lindh JD. Current and Future Burdens of Heat-Related Hyponatremia: A Nationwide Register-Based Study. J Clin Endocrinol Metab 2022; 107:e2388-e2393. [PMID: 35192707 PMCID: PMC9113787 DOI: 10.1210/clinem/dgac103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT A seasonal variation in hyponatremia, with higher incidence rates during hot summer days, has been demonstrated. Whether this applies to cool temperate regions is currently unknown. OBJECTIVE The aim of this study was to investigate the influence of ambient temperature on hyponatremia in the Swedish population under current and future climate scenarios. METHODS This nationwide cohort study identified all patients hospitalized with a first-ever principal diagnosis of hyponatremia between October 2005 and December 2014. Incidence rates for hyponatremia were calculated as number of hospitalizations divided by person-days at risk in the adult Swedish population at a given temperature, in increments of 1 °C. RESULTS The incidence of hyponatremia was stable at 0.3 per million person-days from -10 to 10 °C, but increased rapidly at 24-hour mean temperatures above 15 °C, with 2.26 hospitalizations per million days at the highest recorded temperature of 25 °C. Women and elderly carried the greatest risk, with an incidence of 35 hospitalizations per million days in individuals ≥ 80 years of age on the hottest days, corresponding to a 15-fold increase in incidence compared with cool days. A future 1 or 2 °C increase in mean temperature is expected to increase the incidence of hyponatremia by 6.3% and 13.9%, respectively. CONCLUSION The risk of hospitalization due to hyponatremia increases rapidly at temperatures above 15 °C, indicating a threshold effect. Over the next decades, rising global temperatures are expected to increase the inpatient burden of hyponatremia by approximately 10%. Strategies for protecting vulnerable groups are necessary to reduce this risk.
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Affiliation(s)
- Buster Mannheimer
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Alin Sterea-Grossu
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Calissendorff
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Jakob Skov
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Karlstad Central Hospital, Karlstad, Sweden
- Correspondence: Dr. Jakob Skov, ME Endokrinologi, QB85, Karolinska Universitetssjukhuset – Solna, SE-17176 Stockholm, Sweden. ;
| | - Jonatan D Lindh
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska University Hospital Huddinge, Karolinska Institutet, Huddinge, Sweden
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Wang TD, Chiang CE, Chao TH, Cheng HM, Wu YW, Wu YJ, Lin YH, Chen MYC, Ueng KC, Chang WT, Lee YH, Wang YC, Chu PH, Chao TF, Kao HL, Hou CJY, Lin TH. 2022 Guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the Management of Hypertension. ACTA CARDIOLOGICA SINICA 2022; 38:225-325. [PMID: 35673334 PMCID: PMC9121756 DOI: 10.6515/acs.202205_38(3).20220321a] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/22/2022] [Indexed: 11/23/2022]
Abstract
Hypertension is the most important modifiable cause of cardiovascular (CV) disease and all-cause mortality worldwide. Despite the positive correlations between blood pressure (BP) levels and later CV events since BP levels as low as 100/60 mmHg have been reported in numerous epidemiological studies, the diagnostic criteria of hypertension and BP thresholds and targets of antihypertensive therapy have largely remained at the level of 140/90 mmHg in the past 30 years. The publication of both the SPRINT and STEP trials (comprising > 8,500 Caucasian/African and Chinese participants, respectively) provided evidence to shake this 140/90 mmHg dogma. Another dogma regarding hypertension management is the dependence on office (or clinic) BP measurements. Although standardized office BP measurements have been widely recommended and adopted in large-scale CV outcome trials, the practice of office BP measurements has never been ideal in real-world practice. Home BP monitoring (HBPM) is easy to perform, more likely to be free of environmental and/or emotional stress, feasible to document long-term BP variations, of good reproducibility and reliability, and more correlated with hypertension-mediated organ damage (HMOD) and CV events, compared to routine office BP measurements. In the 2022 Taiwan Hypertension Guidelines of the Taiwan Society of Cardiology (TSOC) and the Taiwan Hypertension Society (THS), we break these two dogmas by recommending the definition of hypertension as ≥ 130/80 mmHg and a universal BP target of < 130/80 mmHg, based on standardized HBPM obtained according to the 722 protocol. The 722 protocol refers to duplicate BP readings taken per occasion ("2"), twice daily ("2"), over seven consecutive days ("7"). To facilitate implementation of the guidelines, a series of flowcharts encompassing assessment, adjustment, and HBPM-guided hypertension management are provided. Other key messages include that: 1) lifestyle modification, summarized as the mnemonic S-ABCDE, should be applied to people with elevated BP and hypertensive patients to reduce life-time BP burden; 2) all 5 major antihypertensive drugs (angiotensin-converting enzyme inhibitors [A], angiotensin receptor blockers [A], β-blockers [B], calcium-channel blockers [C], and thiazide diuretics [D]) are recommended as first-line antihypertensive drugs; 3) initial combination therapy, preferably in a single-pill combination, is recommended for patients with BP ≥ 20/10 mmHg above targets; 4) a target hierarchy (HBPM-HMOD- ambulatory BP monitoring [ABPM]) should be considered to optimize hypertension management, which indicates reaching the HBPM target first and then keeping HMOD stable or regressed, otherwise ABPM can be arranged to guide treatment adjustment; and 5) renal denervation can be considered as an alternative BP-lowering strategy after careful clinical and imaging evaluation.
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Affiliation(s)
- Tzung-Dau Wang
- Cardiovascular Center and Divisions of Cardiology and Hospital Medicine, Department of Internal Medicine, National Taiwan University Hospital
- Department of Internal Medicine, School of Medicine, National Taiwan University College of Medicine
| | - Chern-En Chiang
- General Clinical Research Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Ting-Hsing Chao
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan
| | - Hao-Min Cheng
- School of Medicine, Institute of Public Health and Community Medicine Research Center, and Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University
- Center for Evidence-based Medicine, Department of Medical Education, Taipei Veterans General Hospital, Taipei
| | - Yen-Wen Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei
- Division of Cardiology, Cardiovascular Medical Center, and Department of Nuclear Medicine, Far Eastern Memorial Hospital
| | - Yih-Jer Wu
- Department of Medicine, Mackay Medical College, New Taipei City
- Cardiovascular Center, Department of Internal Medicine, MacKay Memorial Hospital
| | - Yen-Hung Lin
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Michael Yu-Chih Chen
- Division of Cardiology, Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Hualien
| | - Kwo-Chang Ueng
- Department of Internal Medicine, Chung-Shan Medical University Hospital, Taichung
| | - Wei-Ting Chang
- Division of Cardiology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan
| | - Ying-Hsiang Lee
- Department of Medicine, Mackay Medical College, New Taipei City
- Cardiovascular Center, Department of Internal Medicine, MacKay Memorial Hospital
| | - Yu-Chen Wang
- Division of Cardiology, Department of Medicine, Asia University Hospital
- Department of Medical Laboratory Science and Biotechnology, Asia University
- Division of Cardiology, Department of Internal Medicine, China Medical University College of Medicine and Hospital, Taichung
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital
- School of Medicine, Chang Gung University, Taoyuan
| | - Tzu-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei
| | - Hsien-Li Kao
- Department of Internal Medicine, School of Medicine, National Taiwan University College of Medicine
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Charles Jia-Yin Hou
- Department of Medicine, Mackay Medical College, New Taipei City
- Cardiovascular Center, Department of Internal Medicine, MacKay Memorial Hospital
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine Kaohsiung Medical University Hospital
- Faculty of Medicine and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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15
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Klhůfek J, Šálek T. Thiazide-associated hyponatremia in internal medicine patients: analysis of epidemiological and biochemical profiles. Postgrad Med 2022; 134:487-493. [PMID: 35382687 DOI: 10.1080/00325481.2022.2063634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Thiazide-associated hyponatremia (TAH) is a clinically important side effect of the therapy with thiazide and thiazide-like diuretics. This study aims to analyze epidemiological, biochemical, and symptomatological profiles (including volume status) of patients admitted with TAH. A retrospective hospital record study was performed. Epidemiological and biochemical parameters and symptoms were compared between the thiazide (n = 143) and non-thiazide (n = 282) groups. Patients in the thiazide group were classified as hypo-, normo-, or hypervolemic. Furthermore, the comparison of epidemiological, biochemical, partially pharmacotherapeutical, and symptomatological parameters between the hypovolemic and normovolemic groups was performed. The thiazide group showed lower s-Na (p = 0.008), s-K (p <0.001), s-Cl (p <0.001), measured s-osmolality (p = 0.021), and eGFR (p <0.001); higher s-urea (p <0.001), s-creatinine (p = 0.023), s-glucose (p <0.001), u-osmolality (p = 0.012), u-Na (p <0.001), u-K (p = 0.023), and u-Cl (p <0.001). Patients using thiazide were older (p <0.001), more likely to be female (p = 0.011), and with symptoms corresponding more to chronic hyponatremia. Compared to the normovolemic group (n = 93; 65%), the hypovolemic patients (n = 47; 32.9%) showed higher s-urea (p = 0.005), s-creatinine (p = 0.045), and s-UA (p = 0.010); lower eGFR (p = 0.032), u-Na (p = 0.015), u-Cl (p = 0.016), anorexia (p <0.001), and a higher frequency of furosemide use (p <0.001). Thiazide use is a crucial etiological cause of hypotonic hyponatremia among internal medicine inpatients, associated with more severe hyponatremia, but with no difference in the in-hospital mortality. Even in hypo-osmolar conditions of TAH, 32.9% of patients exhibited signs of volume depletion. FE-UA did not differ between the hypovolemic and the normovolemic patients in TAH conditions. Anorexia and the combination of thiazide together with furosemide, rather than thiazide use alone, were risk factors for hypovolemic hyponatremia without affecting FE-UA.
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Affiliation(s)
| | - Tomáš Šálek
- Department of Clinical biochemistry and pharmacology, Tomas Bata Hospital in Zlín, a. s., Havlíčkovo nábřeží 600, 76275 Zlín, The Czech Republic, and Institute of Laboratory Medicine, Medical Faculty, University of Ostrava, The Czech Republic
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Kramers BJ, Koorevaar IW, van Gastel MD, van Goor H, Hallows KR, Heerspink HL, Li H, Leonhard WN, Peters DJ, Qiu J, Touw DJ, Gansevoort RT, Meijer E. Effects of Hydrochlorothiazide and Metformin on Aquaresis and Nephroprotection by a Vasopressin V2 Receptor Antagonist in ADPKD: A Randomized Crossover Trial. Clin J Am Soc Nephrol 2022; 17:507-517. [PMID: 35314480 PMCID: PMC8993480 DOI: 10.2215/cjn.11260821] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 02/17/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES The vasopressin V2 receptor antagonist tolvaptan is the only drug that has been proven to be nephroprotective in autosomal dominant polycystic kidney disease (ADPKD). Tolvaptan also causes polyuria, limiting tolerability. We hypothesized that cotreatment with hydrochlorothiazide or metformin may ameliorate this side effect. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a clinical study and an animal study. In a randomized, controlled, double-blind, crossover trial, we included 13 tolvaptan-treated patients with ADPKD. Patients were treated for three 2-week periods with hydrochlorothiazide, metformin, or placebo in random order. Primary outcome was change in 24-hour urine volume. We also measured GFR and a range of metabolic and kidney injury markers. RESULTS Patients (age 45±8 years, 54% women, measured GFR of 55±11 ml/min per 1.73 m2) had a baseline urine volume on tolvaptan of 6.9±1.4 L/24 h. Urine volume decreased to 5.1 L/24 h (P<0.001) with hydrochlorothiazide and to 5.4 L/24 h (P<0.001) on metformin. During hydrochlorothiazide treatment, plasma copeptin (surrogate for vasopressin) decreased, quality of life improved, and several markers of kidney damage and glucose metabolism improved. Metformin did not induce changes in these markers or in quality of life. Given these results, the effect of adding hydrochlorothiazide to tolvaptan was investigated on long-term kidney outcome in an animal experiment. Water intake in tolvaptan-hydrochlorothiazide cotreated mice was 35% lower than in mice treated with tolvaptan only. Combination treatment was superior to "no treatment" on markers of disease progression (kidney weight, P=0.003 and cystic index, P=0.04) and superior or equal to tolvaptan alone. CONCLUSIONS Both metformin and hydrochlorothiazide reduced tolvaptan-caused polyuria in a short-term study. Hydrochlorothiazide also reduced polyuria in a long-term animal model without negatively affecting nephroprotection. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_03_21_CJN11260821.mp3.
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Affiliation(s)
- Bart J. Kramers
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Iris W. Koorevaar
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maatje D.A. van Gastel
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Harry van Goor
- Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Kenneth R. Hallows
- Division of Nephrology and Hypertension, Department of Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
- University of Southern California/University Kidney Research Organization Kidney Research Center, Department of Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Hiddo L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University, Hospital Groningen, Groningen, The Netherlands
| | - Hui Li
- Division of Nephrology and Hypertension, Department of Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
- University of Southern California/University Kidney Research Organization Kidney Research Center, Department of Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Wouter N. Leonhard
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dorien J.M. Peters
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jiedong Qiu
- Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Daan J. Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University, Hospital Groningen, Groningen, The Netherlands
- Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Ron T. Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Esther Meijer
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Pareek A, Chandurkar N, Dharmadhikari S. Risk vs Benefits of Thiazides in Clinical Use: Need for a Holistic Approach. Am J Med 2022; 135:e82-e83. [PMID: 35249636 DOI: 10.1016/j.amjmed.2021.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 10/11/2021] [Indexed: 11/01/2022]
Affiliation(s)
| | - Nitin Chandurkar
- Clinical Research and Development Ipca Laboratories Limited Mumbai, India
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Deen PMT, Boone M, Schweer H, Olesen ETB, Carmone C, Wetzels JFM, Fenton RA, Kortenoeven MLA. A Vasopressin-Induced Change in Prostaglandin Receptor Subtype Expression Explains the Differential Effect of PGE2 on AQP2 Expression. Front Physiol 2022; 12:787598. [PMID: 35126177 PMCID: PMC8814457 DOI: 10.3389/fphys.2021.787598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/07/2021] [Indexed: 11/20/2022] Open
Abstract
Arginine vasopressin (AVP) stimulates the concentration of renal urine by increasing the principal cell expression of aquaporin-2 (AQP2) water channels. Prostaglandin E2 (PGE2) and prostaglandin2α (PGF2α) increase the water absorption of the principal cell without AVP, but PGE2 decreases it in the presence of AVP. The underlying mechanism of this paradoxical response was investigated here. Mouse cortical collecting duct (mkpCCDc14) cells mimic principal cells as they endogenously express AQP2 in response to AVP. PGE2 increased AQP2 abundance without desmopressin (dDAVP), while in the presence of dDAVP, PGE2, and PGF2α reduced AQP2 abundance. dDAVP increased the cellular PGD2 and PGE2 release and decreased the PGF2α release. MpkCCD cells expressed mRNAs for the receptors of PGE2 (EP1/EP4), PGF2 (FP), and TxB2 (TP). Incubation with dDAVP increased the expression of EP1 and FP but decreased the expression of EP4. In the absence of dDAVP, incubation of mpkCCD cells with an EP4, but not EP1/3, agonist increased AQP2 abundance, and the PGE2-induced increase in AQP2 was blocked with an EP4 antagonist. Moreover, in the presence of dDAVP, an EP1/3, but not EP4, agonist decreased the AQP2 abundance, and the addition of EP1 antagonists prevented the PGE2-mediated downregulation of AQP2. Our study shows that in mpkCCDc14 cells, reduced EP4 receptor and increased EP1/FP receptor expression by dDAVP explains the differential effects of PGE2 and PGF2α on AQP2 abundance with or without dDAVP. As the V2R and EP4 receptor, but not the EP1 and FP receptor, can couple to Gs and stimulate the cyclic adenosine monophosphate (cAMP) pathway, our data support a view that cells can desensitize themselves for receptors activating the same pathway and sensitize themselves for receptors of alternative pathways.
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Affiliation(s)
- Peter M. T. Deen
- Department of Physiology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
| | - Michelle Boone
- Department of Physiology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
| | - Horst Schweer
- Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Emma T. B. Olesen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Endocrinology and Nephrology, North Zealand Hospital, Hillerød, Denmark
| | - Claudia Carmone
- Department of Physiology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
| | - Jack F. M. Wetzels
- Department of Nephrology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
| | | | - Marleen L. A. Kortenoeven
- Department of Physiology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- Department of Cardiovascular and Renal Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
- *Correspondence: Marleen L. A. Kortenoeven
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Kim S, Jo CH, Kim GH. The Role of Vasopressin V2 Receptor in Drug-Induced Hyponatremia. Front Physiol 2021; 12:797039. [PMID: 34955900 PMCID: PMC8703040 DOI: 10.3389/fphys.2021.797039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/19/2021] [Indexed: 12/15/2022] Open
Abstract
Hyponatremia is frequently encountered in clinical practice and usually induced by renal water retention. Many medications are considered to be among the various causes of hyponatremia, because they either stimulate the release of arginine vasopressin (AVP) or potentiate its action in the kidney. Antidepressants, anticonvulsants, antipsychotics, diuretics, and cytotoxic agents are the major causes of drug-induced hyponatremia. However, studies addressing the potential of these drugs to increase AVP release from the posterior pituitary gland or enhance urine concentration through intrarenal mechanisms are lacking. We previously showed that in the absence of AVP, sertraline, carbamazepine, haloperidol, and cyclophosphamide each increased vasopressin V2 receptor (V2R) mRNA and aquaporin-2 (AQP2) protein and mRNA expression in primary cultured inner medullary collecting duct cells. The upregulation of AQP2 was blocked by the V2R antagonist tolvaptan or protein kinase A (PKA) inhibitors. These findings led us to conclude that the nephrogenic syndrome of inappropriate antidiuresis (NSIAD) is the main mechanism of drug-induced hyponatremia. Previous studies have also shown that the V2R has a role in chlorpropamide-induced hyponatremia. Several other agents, including metformin and statins, have been found to induce antidiuresis and AQP2 upregulation through various V2R-independent pathways in animal experiments but are not associated with hyponatremia despite being frequently used clinically. In brief, drug-induced hyponatremia can be largely explained by AQP2 upregulation from V2R-cAMP-PKA signaling in the absence of AVP stimulation. This paper reviews the central and nephrogenic mechanisms of drug-induced hyponatremia and discusses the importance of the canonical pathway of AQP2 upregulation in drug-induced NSIAD.
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Affiliation(s)
- Sua Kim
- Institute of Biomedical Science, Hanyang University College of Medicine, Seoul, South Korea
| | - Chor Ho Jo
- Institute of Biomedical Science, Hanyang University College of Medicine, Seoul, South Korea
| | - Gheun-Ho Kim
- Institute of Biomedical Science, Hanyang University College of Medicine, Seoul, South Korea.,Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea
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20
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Kramers BJ, Koorevaar IW, De Boer R, Hoorn EJ, Pena MJ, Gansevoort RT, Meijer E. Thiazide diuretics and the rate of disease progression in autosomal dominant polycystic kidney disease: an observational study. Nephrol Dial Transplant 2021; 36:1828-1836. [PMID: 33150452 PMCID: PMC8476080 DOI: 10.1093/ndt/gfaa150] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In autosomal dominant polycystic kidney disease (ADPKD), hypertension is prevalent and cardiovascular events are the main cause of death. Thiazide diuretics are often prescribed as second-line antihypertensives, on top of renin-angiotensin-aldosterone system (RAAS) blockade. There is a concern, however, that diuretics may increase vasopressin concentration and RAAS activity, thereby worsening disease progression in ADPKD. We aimed to investigate the validity of these suggestions. METHODS We analysed an observational cohort of 533 ADPKD patients. Plasma copeptin (surrogate for vasopressin), aldosterone and renin were measured by enzyme-linked immunosorbent assay and radioimmunoassay, respectively. Linear mixed models were used to assess the association of thiazide use with estimated glomerular filtration rate (eGFR) decline and Cox proportional hazards models for the association with the composite kidney endpoint of incident end-stage kidney disease, 40% eGFR decline or death. RESULTS A total of 23% of participants (n = 125) used thiazide diuretics at baseline. Compared with non-users, thiazide users were older, a larger proportion was male, they had lower eGFRs and similar blood pressure under more antihypertensives. Plasma copeptin was higher, but this difference disappeared after adjustment for age and sex. Both renin and aldosterone were higher in thiazide users. There was no difference between thiazide users and non-users in the rate of eGFR decline {difference -0.35 mL/min/1.73 m2 per year [95% confidence interval (CI) -0.83 to -0.14], P = 0.2} during 3.9 years of follow-up (interquartile range 2.5-4.9). This did not change after adjustment for potential confounders [difference final model: 0.08 mL/min/1.73 m2 per year [95% CI -0.46 to -0.62], P = 0.8). In the crude model, thiazide use was associated with a higher incidence of the composite kidney endpoint [hazard ratio (HR) 1.53 (95% CI 1.05-2.23), P = 0.03]. However, this association lost significance after adjustment for age and sex and remained unassociated after adjustment for additional confounders [final model: HR 0.80 (95% CI 0.50-1.29), P = 0.4]. CONCLUSIONS These data do not show that thiazide diuretics have a detrimental effect on the rate of disease progression in ADPKD and suggest that these drugs can be prescribed as second-line antihypertensives.
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Affiliation(s)
- Bart J Kramers
- Departments of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Iris W Koorevaar
- Departments of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rudolf De Boer
- Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ewout J Hoorn
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michelle J Pena
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University Hospital Groningen, Groningen, The Netherlands
| | - Ron T Gansevoort
- Departments of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Esther Meijer
- Departments of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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21
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Risk of Electrolyte Disorders, Syncope, and Falls in Patients Taking Thiazide Diuretics: Results of a Cross-Sectional Study. Am J Med 2021; 134:1148-1154. [PMID: 33974908 DOI: 10.1016/j.amjmed.2021.04.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/02/2021] [Accepted: 04/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Thiazide diuretics are a mainstay in the management of hypertension and often associated with dyselectrolytemias. We investigated the prevalence of and risk factors for hyponatremia and hypokalemia in thiazide users, substance-specific differences, and the association of thiazides with syncope and falls. METHODS In this cross-sectional analysis all patients admitted to an interdisciplinary emergency department in Switzerland between January 1, 2017, and December 31, 2018, with measurements of serum sodium and potassium were included. Data regarding serum electrolytes and creatinine were analyzed to classify for dysnatremias, dyskalemias, and acute kidney injury. Chart reviews were performed to screen for syncope or falls. RESULTS A total of 1604 patients (7.9%) took thiazides. Acute kidney injury was significantly more common in thiazide users (22.1 vs 7%, P < .0001). Hyponatremia (22.1 vs 9.8%, P < .0001) and hypokalemia (19 vs 11%, P < .0001) were more frequent with thiazides. Thiazide use together with higher age and female sex were independent predictors of hyponatremia and hypokalemia. A dose-dependent effect was found for electrolyte disorders, and there was a variance in risk between the investigated substances with chlorthalidone bearing the highest and hydrochlorothiazide the lowest risk. Patients taking thiazide diuretics had significantly more episodes of syncope and falls. CONCLUSIONS Thiazide use is a clear risk factor for hyponatremia and hypokalemia. The effect appears to be dose-dependent and highly variable depending on the substance. Syncope and falls seem to be causally related to thiazide use. Especially in patients who are elderly, female, and prone to falls, the use of thiazide diuretics should be thoroughly questioned.
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Potential Use of Pharmacogenetics to Reduce Drug-Induced Syndrome of Inappropriate Antidiuretic Hormone (SIADH). J Pers Med 2021; 11:jpm11090853. [PMID: 34575630 PMCID: PMC8466173 DOI: 10.3390/jpm11090853] [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: 07/29/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 11/21/2022] Open
Abstract
Syndrome of inappropriate antidiuretic hormone (SIADH) is a common cause of hyponatremia, and many cases represent adverse reactions to drugs that alter ion channel conductance within the peptidergic nerve terminals of the posterior pituitary. The frequency of drug-induced SIADH increases with age; as many as 20% of patients residing in nursing homes have serum sodium levels below 135 mEq/L. Mild hyponatremia is associated with cognitive changes, gait instability, and falls. Severe hyponatremia is associated with cerebral edema, seizures, permanent disability, and/or death. Although pharmacogenetic tests are now being deployed for some drugs capable of causing SIADH (e.g., antidepressants, antipsychotics, and opioid analgesics), the implementation of these tests has been based upon the prior known association of these drugs with other serious adverse drug reactions (e.g., electrocardiographic abnormalities). Work is needed in large observational cohorts to quantify the strength of association between pharmacogene variants and drug-induced SIADH so that decision support can be developed to identify patients at high risk.
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Bassi V, Fattoruso O. The Combined Use of Fractional Urate and Potassium Excretion in the Diagnosis of Diuretic-Induced Hyponatremia. Cureus 2021; 13:e15308. [PMID: 34221761 PMCID: PMC8238019 DOI: 10.7759/cureus.15308] [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] [Indexed: 11/05/2022] Open
Abstract
Introduction Thiazide and loop-diuretics are among the most widely used drugs in the therapy of hypertension and chronic heart failure. Furthermore, hyponatremia is the most prevalent electrolyte imbalance affecting up to 25-30% of hospitalized patients while syndrome of inappropriate antidiuresis (SIAD) is involving approximately 35% of hyponatraemic inpatients. Clinical and laboratoristic algorithms support the differential diagnosis of hypotonic hyponatremia in actual guidelines of SIAD, but a potential bias is represented by the misleading clinical assessment of the extracellular volume status in diuretic-treated patients where the necessity of withdrawal of the therapy is mandatory. We investigated the role of fractional uric acid and potassium excretion (FEUA and FEK) in the differential diagnosis of hypotonic hyponatremia in SIAD and diuretic-treated patients. Methods Thirty-six SIAD, 30 thiazide-induced hyponatremia (TIH), and 32 diuretic-induced hyponatremia (DIH) patients were investigated calculating FEUA and FEK values in receiver operating characteristic (ROC) curve analysis to improve the diagnostic approach of hypotonic hyponatremia. Results The combination of the two investigated markers showed different significative results generating patterns useful to discriminate among the three different hyponatremic groups. Conclusion The fractional uric acid and potassium excretion could be considered as new markers in the diagnostic approach of hyponatremic diuretic-treated patients where classical algorithms could fail.
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Affiliation(s)
- Vincenzo Bassi
- Unità Operativa Complessa (UOC) di Medicina Generale e Lungodegenza, San Giovanni Bosco Hospital, Azienda Sanitaria Locale (ASL) Napoli 1 Centro, Naples, ITA
| | - Olimpia Fattoruso
- Unità Operativa Complessa (UOC) di Patologia Generale, San Giovanni Bosco Hospital, Azienda Sanitaria Locale (ASL) Napoli 1 Centro, Naples, ITA
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Kamel KS, Halperin ML. Use of Urine Electrolytes and Urine Osmolality in the Clinical Diagnosis of Fluid, Electrolytes, and Acid-Base Disorders. Kidney Int Rep 2021; 6:1211-1224. [PMID: 34013099 PMCID: PMC8116912 DOI: 10.1016/j.ekir.2021.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 02/01/2021] [Indexed: 01/16/2023] Open
Abstract
We discuss the use of urine electrolytes and urine osmolality in the clinical diagnosis of patients with fluid, electrolytes, and acid-base disorders, emphasizing their physiological basis, their utility, and the caveats and limitations in their use. While our focus is on information obtained from measurements in the urine, clinical diagnosis in these patients must integrate information obtained from the history, the physical examination, and other laboratory data.
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Affiliation(s)
- Kamel S. Kamel
- Renal Division, St. Michael’s Hospital and The University of Toronto, Toronto, Ontario, Canada
- Keenan Research Center in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Mitchell L. Halperin
- Renal Division, St. Michael’s Hospital and The University of Toronto, Toronto, Ontario, Canada
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Kim S, Jo CH, Kim GH. Psychotropic drugs upregulate aquaporin-2 via vasopressin-2 receptor/cAMP/protein kinase A signaling in inner medullary collecting duct cells. Am J Physiol Renal Physiol 2021; 320:F963-F971. [PMID: 33843270 DOI: 10.1152/ajprenal.00576.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 04/07/2021] [Indexed: 12/17/2022] Open
Abstract
Psychotropic drugs may be associated with hyponatremia, but an understanding of how they induce water retention in the kidney remains elusive. Previous studies have postulated that they may increase vasopressin production in the hypothalamus without supporting evidence. In this study, we investigated the possibility of drug-induced nephrogenic syndrome of inappropriate antidiuresis using haloperidol, sertraline, and carbamazepine. Haloperidol, sertraline, or carbamazepine were treated in inner medullary collecting duct (IMCD) suspensions and primary cultured IMCD cells prepared from male Sprague-Dawley rats. The responses of intracellular cAMP production, aquaporin-2 (AQP2) protein expression and localization, vasopressin-2 receptor (V2R) and AQP2 mRNA, and cAMP-responsive element-binding protein (CREB) were tested with and without tolvaptan and the protein kinase A (PKA) inhibitors H89 and Rp-cAMPS. In IMCD suspensions, cAMP production was increased by haloperidol, sertraline, or carbamazepine and was relieved by tolvaptan cotreatment. In primary cultured IMCD cells, haloperidol, sertraline, or carbamazepine treatment increased total AQP2 and decreased phosphorylated Ser261-AQP2 protein expression. Notably, these responses were reversed by cotreatment with tolvaptan or a PKA inhibitor. AQP2 membrane trafficking was induced by haloperidol, sertraline, or carbamazepine and was also blocked by cotreatment with tolvaptan or a PKA inhibitor. Furthermore, upregulation of V2R and AQP2 mRNA and phosphorylated CREB was induced by haloperidol, sertraline, or carbamazepine and was blocked by tolvaptan cotreatment. We conclude that, in the rat IMCD, psychotropic drugs upregulate AQP2 via V2R-cAMP-PKA signaling in the absence of vasopressin stimulation. The vasopressin-like action on the kidney appears to accelerate AQP2 transcription and dephosphorylate AQP2 at Ser261.NEW & NOTEWORTHY It is unclear whether antipsychotic drugs can retain water in the kidney in the absence of vasopressin. This study demonstrates that haloperidol, sertraline, and carbamazepine can produce nephrogenic syndrome of inappropriate antidiuresis because they directly upregulate vasopressin-2 receptor and aquaporin-2 (AQP2) via cAMP/PKA signaling. We showed that, in addition to AQP2 trafficking, AQP2 protein abundance was rapidly increased by treatment with antipsychotic drugs in association with dephosphorylation of AQP2 at Ser261 and accelerated AQP2 transcription.
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Affiliation(s)
- Sua Kim
- Institute of Biomedical Science, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Chor Ho Jo
- Institute of Biomedical Science, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Gheun-Ho Kim
- Institute of Biomedical Science, Hanyang University College of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
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[Hyponatremia - causes, diagnostic evaluation and treatment]. Dtsch Med Wochenschr 2021; 146:176-180. [PMID: 33513652 DOI: 10.1055/a-1198-3814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Intact osmoregulation prevents osmotic gradients thereby limiting cell swelling and shrinking. Hyponatremia is a state of an osmole-free water excess compared to the amounts of solutes and clinical management of hyponatremic patients requires pathophysiology-oriented approaches to select appropriate treatments. Clinicians need to assess the patient's volume status to differentiate hyponatremia with volume depletion, expansion or normovolemia, respectively. In addition, work-up includes differentiation between acute and chronic and asymptomatic and symptomatic hyponatremia. Estimation of free water-clearance helps predicting Serum-Na+ changes and is important to prevent overcorrection of hyponatremia. Water restriction, hypertonic salt, urea, V2-receptor-blockers and recently sodium glucose cotransporter 2 (SGLT2) inhibitors were employed to treat patients with hyponatremia.
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Nakanishi T, Nakamura Y, Umeno J. Recent advances in studies of SLCO2A1 as a key regulator of the delivery of prostaglandins to their sites of action. Pharmacol Ther 2021; 223:107803. [PMID: 33465398 DOI: 10.1016/j.pharmthera.2021.107803] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/18/2020] [Indexed: 02/08/2023]
Abstract
Solute carrier organic anion transporter family member 2A1 (SLCO2A1, also known as PGT, OATP2A1, PHOAR2, or SLC21A2) is a plasma membrane transporter consisting of 12 transmembrane domains. It is ubiquitously expressed in tissues, and mediates the membrane transport of prostaglandins (PGs, mainly PGE2, PGF2α, PGD2) and thromboxanes (e.g., TxB2). SLCO2A1-mediated transport is electrogenic and is facilitated by an outwardly directed gradient of lactate. PGs imported by SLCO2A1 are rapidly oxidized by cytoplasmic 15-hydroxyprostaglandin dehydrogenase (15-PGDH, encoded by HPGD). Accumulated evidence suggests that SLCO2A1 plays critical roles in many physiological processes in mammals, and it is considered a potential pharmacological target for diabetic foot ulcer treatment, antipyresis, and non-hormonal contraception. Furthermore, whole-exome analyses suggest that recessive inheritance of SLCO2A1 mutations is associated with two refractory diseases, primary hypertrophic osteoarthropathy (PHO) and chronic enteropathy associated with SLCO2A1 (CEAS). Intriguingly, SLCO2A1 is also a key component of the Maxi-Cl channel, which regulates fluxes of inorganic and organic anions, including ATP. Further study of the bimodal function of SLCO2A1 as a transporter and ion channel is expected to throw new light on the complex pathology of human diseases. Here, we review and summarize recent information on the molecular functions of SLCO2A1, and we discuss its pathophysiological significance.
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Affiliation(s)
- Takeo Nakanishi
- Faculty of Pharmacy, Takasaki University of Health and Welfare, Takasaki, Gunma 370-0033, Japan.
| | - Yoshinobu Nakamura
- Faculty of Pharmacy, Takasaki University of Health and Welfare, Takasaki, Gunma 370-0033, Japan
| | - Junji Umeno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka 812-8582, Japan
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Association between newly initiated thiazide diuretics and hospitalization due to hyponatremia. Eur J Clin Pharmacol 2021; 77:1049-1055. [PMID: 33452584 PMCID: PMC8184529 DOI: 10.1007/s00228-020-03086-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/29/2020] [Indexed: 01/31/2023]
Abstract
Purpose Thiazide diuretics are the most common origin of drug-induced hyponatremia. However, population-based studies on clinical outcomes are lacking. We therefore explored the time course and absolute risk of thiazide-associated hospitalization due to hyponatremia in Sweden. Methods Population-based case-control study including patients hospitalized with a principal diagnosis of hyponatremia (n = 11,213) compared with controls (n = 44,801). Linkage of registers was used to acquire data. Multivariable regression was applied to explore time-dependent associations between thiazide diuretics and hospitalization due to hyponatremia. Attributable risks were calculated assessing the disease burden attributable to thiazides. Results Individuals initiating thiazide treatment were exposed to an immediate increase in risk for hospitalization with adjusted odds ratio (aOR) (95% CI) of 48 (28–89). The associations gradually declined reaching an aOR of 2.9 (2.7–3.1) for individuals treated for longer than 13 weeks. The attributable risk of hyponatremia-associated hospitalization due to thiazides of any treatment length was 27% (3095/11,213). Among 806 patients initiating treatment < 90 days before hospitalization, hyponatremia could be attributed to thiazides in 754. Based on nationwide data, 616,678 individuals were initiated on thiazides during the 8-year study period suggesting an absolute risk of 0.12% (754/661,678) for subsequent hospitalization with a main diagnosis of hyponatremia. Conclusions Thiazide diuretics attributed to more than one in four individuals hospitalized due to hyponatremia. The risk increase was very pronounced during the first month of treatment and then gradually declined, without returning to normal. However, the absolute risk for the development of hyponatremia demanding hospitalization may for most individuals be modest. Supplementary Information The online version contains supplementary material available at 10.1007/s00228-020-03086-6.
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The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2019). Hypertens Res 2020; 42:1235-1481. [PMID: 31375757 DOI: 10.1038/s41440-019-0284-9] [Citation(s) in RCA: 1037] [Impact Index Per Article: 259.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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MicroRNA-132 regulates salt-dependent steady-state renin levels in mice. Commun Biol 2020; 3:238. [PMID: 32409785 PMCID: PMC7224281 DOI: 10.1038/s42003-020-0967-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 04/21/2020] [Indexed: 12/21/2022] Open
Abstract
The body's salt and fluid balance is regulated by the renin-angiotensin-aldosterone system. Generation of prostaglandin-E2 (PGE2) in a cyclo-oxygenase-2 (COX-2)-dependent manner in the macula densa, the salt-sensing cells of the kidney, plays a dominant role in renin regulation. Here we show that miR-132 directly targets Cox-2 and affects subsequent PGE2 and renin levels. MiR-132 is induced and reduced by low- and high salt treatment, respectively, in a p38- and ERK1/2-independent and CREB- and salt inducible kinase-dependent manner. Silencing of miR-132 in mice increases macula densa COX-2 expression and elevates PGE2 and renin levels, which are abrogated by the selective COX-2-inhibitor Celecoxib. Furthermore, a low or high salt diet induces and reduces macula densa miR-132 expression, while low salt diet combined with silencing miR-132 further increases renin levels. Taken together, we demonstrate a posttranscriptional regulatory role for salt-dependent miR-132 in fine-tuning the steady-state levels of renin.
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Decaux G, Gankam Kengne F. Hypertonic saline, isotonic saline, water restriction, long loops diuretics, urea or vaptans to treat hyponatremia. Expert Rev Endocrinol Metab 2020; 15:195-214. [PMID: 32401559 DOI: 10.1080/17446651.2020.1755259] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/09/2020] [Indexed: 01/08/2023]
Abstract
Introduction: Hyponatremia is the most common fluid and electrolyte abnormality. It is associated with much higher morbidity and mortality rates than found in non hyponatremic patients.Areas covered: When the physician is faced to a hyponatremic patient he first has to confirm that hyponatremia is associated with hypoosmolality. Then he must answer to a series of questions: What is its origin? Is it acute or chronic? Which treatment is the most appropriate? We will discuss the various options for the treatment of hypotonic hyponatremia. For a better comprehensive approach of the treatment we will also discuss some pathophysiological data. The use of urea in euvolemic and hypervolemic hyponatremia will be particularly discussed. Literature was reviewed from Jan 1970 to Dec 2019.Expert opinion: Prospective studies showing the benefit in decreasing morbidity by increasing SNa in patients with chronic hyponatremia should be done. These studies should also compare the efficacy and side effects of urea therapy compare to vaptans.
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Affiliation(s)
- Guy Decaux
- Department of Internal Medicine, Erasmus University Hospital, ULB, Brussels, Belgium
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Bassi V, Fattoruso O. The Role of Fractional Excretion of Uric Acid in the Differential Diagnosis of Hypotonic Hyponatraemia in Patients with Diuretic Therapy. Cureus 2020; 12:e7762. [PMID: 32455079 PMCID: PMC7243088 DOI: 10.7759/cureus.7762] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Hyponatraemia is the most common electrolyte imbalance found in hospital population and worldwide thiazide and loop-diuretics are among the most widely used drugs. Syndrome of inappropriate antidiuresis diagnosis (SIAD) is complicated in the presence of diuretic therapy due to the misleading clinical assessment of the extracellular volume status, and in order to make SIAD diagnosis it is often necessary to withdraw diuretic therapy. Our study aimed to investigate the diagnostic role of these alternative markers of volume status, serum uric acid (sUA) and fractional excretion of uric acid (FEUA), in hyponatraemic patients treated with different diuretic drugs. Eighty-nine patients were enrolled with the diagnosis of SIAD, diuretic-induced hyponatremia (DIH, treated with furosemide and potassium canrenoate) or thiazide-induced hyponatremia (TIH, treated with hydrochlorothiazide, metolazone or indapamide) and investigated with receiver operating characteristic analysis and a sensitivity test. Our results show that FEUA discriminated better than sUA between SIAD and DIH patients (area under curve 0.96, <0.001 vs. 0.88, <0.001) while it was a poor marker to discriminate between SIAD and TIH (0.65, NS vs. 0.67, NS). In conclusions, FEUA is an excellent marker to discriminate SIAD vs. sodium depleted patients treated with furosemide and/or potassium canrenoate while the diuretic withdrawal, beyond obtaining a serum Na normalization, is still mandatory for differential diagnosis of sodium depleted patients affected by thiazide-induced hyponatraemia.
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Affiliation(s)
- Vincenzo Bassi
- Internal Medicine, San Giovanni Bosco Hospital, ASL Napoli 1 Centro, Naples, ITA
| | - Olimpia Fattoruso
- Pathology, San Giovanni Bosco Hospital, ASL Napoli 1 Centro, Naples, ITA
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Filippone EJ, Ruzieh M, Foy A. Thiazide-Associated Hyponatremia: Clinical Manifestations and Pathophysiology. Am J Kidney Dis 2020; 75:256-264. [DOI: 10.1053/j.ajkd.2019.07.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 07/05/2019] [Indexed: 11/11/2022]
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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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Ramírez E, Rodríguez A, Queiruga J, García I, Díaz L, Martínez L, Muñoz R, Muñoz M, Tong HY, Martínez JC, Borobia AM, Carcas AJ, Frías J. Severe Hyponatremia Is Often Drug Induced: 10‐Year Results of a Prospective Pharmacovigilance Program. Clin Pharmacol Ther 2019; 106:1362-1379. [DOI: 10.1002/cpt.1562] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 06/08/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Elena Ramírez
- Department of Clinical Pharmacology La Paz University Hospital‐Carlos III IdiPAZ School of Medicine Autonomous University of Madrid Madrid Spain
| | - Amelia Rodríguez
- Department of Clinical Pharmacology La Paz University Hospital‐Carlos III IdiPAZ School of Medicine Autonomous University of Madrid Madrid Spain
| | - Javier Queiruga
- Department of Clinical Pharmacology La Paz University Hospital‐Carlos III IdiPAZ School of Medicine Autonomous University of Madrid Madrid Spain
| | - Irene García
- Department of Clinical Pharmacology La Paz University Hospital‐Carlos III IdiPAZ School of Medicine Autonomous University of Madrid Madrid Spain
| | - Lucía Díaz
- Department of Clinical Pharmacology La Paz University Hospital‐Carlos III IdiPAZ School of Medicine Autonomous University of Madrid Madrid Spain
| | - Lucía Martínez
- Department of Clinical Pharmacology La Paz University Hospital‐Carlos III IdiPAZ School of Medicine Autonomous University of Madrid Madrid Spain
| | - Raúl Muñoz
- Department of Clinical Pharmacology La Paz University Hospital‐Carlos III IdiPAZ School of Medicine Autonomous University of Madrid Madrid Spain
| | - Mario Muñoz
- Department of Clinical Pharmacology La Paz University Hospital‐Carlos III IdiPAZ School of Medicine Autonomous University of Madrid Madrid Spain
| | - Hoi Y. Tong
- Department of Clinical Pharmacology La Paz University Hospital‐Carlos III IdiPAZ School of Medicine Autonomous University of Madrid Madrid Spain
| | - José Carlos Martínez
- Department of Clinical Pharmacology La Paz University Hospital‐Carlos III IdiPAZ School of Medicine Autonomous University of Madrid Madrid Spain
| | - Alberto M. Borobia
- Department of Clinical Pharmacology La Paz University Hospital‐Carlos III IdiPAZ School of Medicine Autonomous University of Madrid Madrid Spain
| | - Antonio J. Carcas
- Department of Clinical Pharmacology La Paz University Hospital‐Carlos III IdiPAZ School of Medicine Autonomous University of Madrid Madrid Spain
| | - Jesús Frías
- Department of Clinical Pharmacology La Paz University Hospital‐Carlos III IdiPAZ School of Medicine Autonomous University of Madrid Madrid Spain
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Recent developments in the management of acute and chronic hyponatremia. Curr Opin Nephrol Hypertens 2019; 28:424-432. [DOI: 10.1097/mnh.0000000000000528] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Rapoport RM, Soleimani M. Mechanism of Thiazide Diuretic Arterial Pressure Reduction: The Search Continues. Front Pharmacol 2019; 10:815. [PMID: 31543812 PMCID: PMC6730501 DOI: 10.3389/fphar.2019.00815] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/24/2019] [Indexed: 12/21/2022] Open
Abstract
Thiazide diuretic (TZD)-mediated chronic reduction of arterial pressure is thought to occur through decreased total peripheral vascular resistance. Further, the decreased peripheral vascular resistance is accomplished through TZD activation of an extrarenal target, resulting in inhibition of vascular constriction. However, despite greater than five decades of investigation, little progress has been made into the identification of the TZD extrarenal target. Proposed mechanisms range from direct inhibition of constrictor and activation of relaxant signaling pathways in the vascular smooth muscle to indirect inhibition through decreased neurogenic and hormonal regulatory pathways. Surprisingly, particularly in view of this lack of progress, comprehensive reviews of the subject are absent. Moreover, even though it is well recognized that 1) several types of hypertension are insensitive to TZD reduction of arterial pressure and, further, TZD fail to reduce arterial pressure in normotensive subjects and animals, and 2) different mechanisms underlie acute and chronic TZD, findings derived from these models and parameters remain largely undifferentiated. This review 1) comprehensively describes findings associated with TZD reduction of arterial pressure; 2) differentiates between observations in TZD-sensitive and TZD-insensitive hypertension, normotensive subjects/animals, and acute and chronic effects of TZD; 3) critically evaluates proposed TZD extrarenal targets; 4) proposes guiding parameters for relevant investigations into extrarenal TZD target identification; and 5) proposes a working model for TZD chronic reduction of arterial pressure through vascular dilation.
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Affiliation(s)
- Robert M Rapoport
- Department of Pharmacology and Systems Physiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Manoocher Soleimani
- Research Service, Veterans Affairs Medical Center, Cincinnati, OH, United States.,Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Bomfim GF, Cau SBA, Bruno AS, Fedoce AG, Carneiro FS. Hypertension: a new treatment for an old disease? Targeting the immune system. Br J Pharmacol 2019; 176:2028-2048. [PMID: 29969833 PMCID: PMC6534786 DOI: 10.1111/bph.14436] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/14/2018] [Accepted: 06/24/2018] [Indexed: 12/22/2022] Open
Abstract
Arterial hypertension represents a serious public health problem, being a major cause of morbidity and mortality worldwide. The availability of many antihypertensive therapeutic strategies still fails to adequately treat around 20% of hypertensive patients, who are considered resistant to conventional treatment. In the pathogenesis of hypertension, immune system mechanisms are activated and both the innate and adaptive immune responses play a crucial role. However, what, when and how the immune system is triggered during hypertension development is still largely undefined. In this context, this review highlights scientific advances in the manipulation of the immune system in order to attenuate hypertension and end-organ damage. Here, we discuss the potential use of immunosuppressants and immunomodulators as pharmacological tools to control the activation of the immune system, by non-specific and specific mechanisms, to treat hypertension and improve end-organ damage. Nevertheless, more clinical trials should be performed with these drugs to establish their therapeutic efficacy, safety and risk-benefit ratio in hypertensive conditions. LINKED ARTICLES: This article is part of a themed section on Immune Targets in Hypertension. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.12/issuetoc.
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Affiliation(s)
| | - Stefany Bruno Assis Cau
- Department of Pharmacology, Institute of Biological ScienceFederal University of Minas GeraisBelo HorizonteMGBrazil
| | - Alexandre Santos Bruno
- Department of Pharmacology, Institute of Biological ScienceFederal University of Minas GeraisBelo HorizonteMGBrazil
| | - Aline Garcia Fedoce
- Department of Pharmacology, Ribeirão Preto Medical SchoolUniversity of São PauloSão PauloBrazil
| | - Fernando S Carneiro
- Department of Pharmacology, Ribeirão Preto Medical SchoolUniversity of São PauloSão PauloBrazil
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Matsuno Y, Umeno J, Esaki M, Hirakawa Y, Fuyuno Y, Okamoto Y, Hirano A, Yasukawa S, Hirai F, Matsui T, Hosomi S, Watanabe K, Hosoe N, Ogata H, Hisamatsu T, Yanai S, Kochi S, Kurahara K, Yao T, Torisu T, Kitazono T, Matsumoto T. Measurement of prostaglandin metabolites is useful in diagnosis of small bowel ulcerations. World J Gastroenterol 2019; 25:1753-1763. [PMID: 31011259 PMCID: PMC6465938 DOI: 10.3748/wjg.v25.i14.1753] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/27/2019] [Accepted: 03/12/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We recently reported on a hereditary enteropathy associated with a gene encoding a prostaglandin transporter and referred to as chronic enteropathy associated with SLCO2A1 gene (CEAS). Crohn’s disease (CD) is a major differential diagnosis of CEAS, because these diseases share some clinical features. Therefore, there is a need to develop a convenient screening test to distinguish CEAS from CD.
AIM To examine whether prostaglandin E major urinary metabolites (PGE-MUM) can serve as a biomarker to distinguish CEAS from CD.
METHODS This was a transactional study of 20 patients with CEAS and 98 patients with CD. CEAS was diagnosed by the confirmation of homozygous or compound heterozygous mutation of SLCO2A1. We measured the concentration of PGE-MUM in spot urine by radioimmunoassay, and the concentration was compared between the two groups of patients. We also determined the optimal cut-off value of PGE-MUM to distinguish CEAS from CD by receiver operating characteristic (ROC) curve analysis.
RESULTS Twenty Japanese patients with CEAS and 98 patients with CD were enrolled. PGE-MUM concentration in patients with CEAS was significantly higher than that in patients with CD (median 102.7 vs 27.9 μg/g × Cre, P < 0.0001). One log unit increase in PGE-MUM contributed to 7.3 increase in the likelihood for the diagnosis of CEAS [95% confidence interval (CI) 3.2-16.7]. A logistic regression analysis revealed that the association was significant even after adjusting confounding factors (adjusted odds ratio 29.6, 95%CI 4.7-185.7). ROC curve analysis revealed the optimal PGE-MUM cut-off value for the distinction of CEAS from CD to be 48.9 μg/g × Cre with 95.0% sensitivity and 79.6% specificity.
CONCLUSION PGE-MUM measurement is a convenient, non-invasive and useful test for the distinction of CEAS from CD.
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Affiliation(s)
- Yuichi Matsuno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Junji Umeno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Motohiro Esaki
- Department of Endoscopic Diagnostics and Therapeutic, Saga University Hospital, Saga 849-8501, Japan
| | - Yoichiro Hirakawa
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Yuta Fuyuno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Yasuharu Okamoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Atsushi Hirano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Shigeyoshi Yasukawa
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino 818-8502, Japan
| | - Fumihito Hirai
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino 818-8502, Japan
| | - Toshiyuki Matsui
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino 818-8502, Japan
| | - Shuhei Hosomi
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka 545-8586, Japan
| | - Kenji Watanabe
- Department of Intestinal Inflammation Research, Hyogo College of Medicine, Nishinomiya 663-8501, Japan
| | - Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, School of Medicine, Keio University, Tokyo 160-0016, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, School of Medicine, Keio University, Tokyo 160-0016, Japan
| | - Tadakazu Hisamatsu
- the Third Department of Internal Medicine, Kyorin University School of Medicine, Mitaka 181-8611, Japan
| | - Shunichi Yanai
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Morioka 020-8505, Japan
| | - Shuji Kochi
- Division of Gastroenterology, Matsuyama Red Cross Hospital, Matsuyama 790-8524, Japan
| | - Koichi Kurahara
- Division of Gastroenterology, Matsuyama Red Cross Hospital, Matsuyama 790-8524, Japan
| | - Tsuneyoshi Yao
- Department of Gastroenterology, Sada Hospital, Fukuoka 810-0004, Japan
| | - Takehiro Torisu
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Morioka 020-8505, Japan
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Berghuis B, Stapleton C, Sonsma ACM, Hulst J, de Haan G, Lindhout D, Demurtas R, Krause R, Depondt C, Kunz WS, Zara F, Striano P, Craig J, Auce P, Marson AG, Stefansson H, O'Brien TJ, Johnson MR, Sills GJ, Wolking S, Lerche H, Sisodiya SM, Sander JW, Cavalleri GL, Koeleman BPC, McCormack M. A genome-wide association study of sodium levels and drug metabolism in an epilepsy cohort treated with carbamazepine and oxcarbazepine. Epilepsia Open 2019; 4:102-109. [PMID: 30868120 PMCID: PMC6398103 DOI: 10.1002/epi4.12297] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/02/2018] [Accepted: 12/06/2018] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To ascertain the clinical and genetic factors contributing to carbamazepine- and oxcarbazepine-induced hyponatremia (COIH), and to carbamazepine (CBZ) metabolism, in a retrospectively collected, cross-sectional cohort of people with epilepsy. METHODS We collected data on serum sodium levels and antiepileptic drug levels in people with epilepsy attending a tertiary epilepsy center while on treatment with CBZ or OXC. We defined hyponatremia as Na+ ≤134 mEq/L. We estimated the CBZ metabolic ratio defined as the log transformation of the ratio of metabolite CBZ-diol to unchanged drug precursor substrate as measured in serum. RESULTS Clinical and genetic data relating to carbamazepine and oxcarbazepine trials were collected in 1141 patients. We did not observe any genome-wide significant associations with sodium level in a linear trend or hyponatremia as a dichotomous trait. Age, sex, number of comedications, phenytoin use, phenobarbital use, and sodium valproate use were significant predictors of CBZ metabolic ratio. No genome-wide significant associations with CBZ metabolic ratio were found. SIGNIFICANCE Although we did not detect a genetic predictor of hyponatremia or CBZ metabolism in our cohort, our findings suggest that the determinants of CBZ metabolism are multifactorial.
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Affiliation(s)
- Bianca Berghuis
- Stichting Epilepsie Instellingen Nederland (SEIN)ZwolleThe Netherlands
| | - Caragh Stapleton
- Molecular and Cellular TherapeuticsRoyal College of Surgeons in IrelandDublinIreland
| | - Anja C. M. Sonsma
- Department of GeneticsUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Janic Hulst
- Stichting Epilepsie Instellingen Nederland (SEIN)ZwolleThe Netherlands
| | | | - Dick Lindhout
- Stichting Epilepsie Instellingen Nederland (SEIN)ZwolleThe Netherlands
- Department of GeneticsUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Rita Demurtas
- Department of Clinical and Experimental EpilepsyInstitute of NeurologyUniversity College LondonLondonUK
| | - Roland Krause
- Luxembourg Centre for Systems BiomedicineUniversity of LuxembourgEsch‐sur‐AlzetteLuxembourg
| | - Chantal Depondt
- Laboratory of Experimental NeurologyHôpital ErasmeUniversité Libre de BruxellesBrusselsBelgium
| | - Wolfram S. Kunz
- Institute of Experimental Epileptology and Cognition Research and Department of EpileptologyUniversity of BonnBonnGermany
| | - Federico Zara
- Laboratory of Neurogenetics and NeuroscienceInstitute G. GasliniGenovaItaly
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases UnitDINOGMI‐Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child HealthUniversity of GenovaInstitute “G. Gaslini”GenovaItaly
| | - John Craig
- Department of NeurosciencesBelfast Health and Social Care TrustBelfastUK
| | - Pauls Auce
- Department of Molecular and Clinical PharmacologyInstitute of Translational MedicineUniversity of LiverpoolLiverpoolUK
| | - Anthony G. Marson
- Department of Molecular and Clinical PharmacologyInstitute of Translational MedicineUniversity of LiverpoolLiverpoolUK
| | | | - Terence J. O'Brien
- The Departments of Medicine and NeurologyThe Melbourne Brain CentreThe University of MelbourneThe Royal Melbourne HospitalMelbourneAustralia
| | | | - Graeme J. Sills
- Department of Molecular and Clinical PharmacologyInstitute of Translational MedicineUniversity of LiverpoolLiverpoolUK
| | - Stefan Wolking
- Department of Neurology and EpileptologyUniversity of TübingenHertie Institute for Clinical Brain ResearchTübingenGermany
| | - Holger Lerche
- Department of Neurology and EpileptologyUniversity of TübingenHertie Institute for Clinical Brain ResearchTübingenGermany
| | - Sanjay M. Sisodiya
- Department of Clinical and Experimental EpilepsyInstitute of NeurologyUniversity College LondonLondonUK
- Chalfont Centre for EpilepsyChalfont St. PeterUK
| | - Josemir W. Sander
- Stichting Epilepsie Instellingen Nederland (SEIN)ZwolleThe Netherlands
- Department of Clinical and Experimental EpilepsyInstitute of NeurologyUniversity College LondonLondonUK
- Chalfont Centre for EpilepsyChalfont St. PeterUK
| | - Gianpiero L. Cavalleri
- Molecular and Cellular TherapeuticsRoyal College of Surgeons in IrelandDublinIreland
- The FutureNeuro Research CentreRoyal College of Surgeons in IrelandDublinIreland
| | | | - Mark McCormack
- Molecular and Cellular TherapeuticsRoyal College of Surgeons in IrelandDublinIreland
- Department of GeneticsUniversity Medical Center UtrechtUtrechtThe Netherlands
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41
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Decaux G. Approach to and management of abnormalities in plasma sodium. Acta Clin Belg 2019; 74:7-20. [PMID: 30311550 DOI: 10.1080/17843286.2018.1531616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The differential diagnosis between hypertonic, isotonic and hypotonic hyponatremia are presented. The help of some usual serum (urea, uric acid and TCO2) and urine parameters (mainly osmolality and sodium concentration) are discussed and help to determine the best treatment. Morbidity associated with untreated hyponatremia and with the different treatment available is also discussed. Who to prevent and treat ODS (osmotic demyelating syndrome) is recalled. The pathophysiology and treatment of hypernatremia are also discussed.
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Affiliation(s)
- G. Decaux
- Service de Médecine Interne, Hôpital Universitaire Erasme, Bruxelles, Belgium
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42
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Channavajjhala SK, Bramley R, Peltz T, Oosthuyzen W, Jia W, Kinnear S, Sampson B, Martin N, Hall IP, Bailey MA, Dear JW, Glover M. Urinary Extracellular Vesicle Protein Profiling and Endogenous Lithium Clearance Support Excessive Renal Sodium Wasting and Water Reabsorption in Thiazide-Induced Hyponatremia. Kidney Int Rep 2018; 4:139-147. [PMID: 30596177 PMCID: PMC6308385 DOI: 10.1016/j.ekir.2018.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/22/2018] [Accepted: 09/17/2018] [Indexed: 12/11/2022] Open
Abstract
Introduction Thiazide diuretics are among the most widely used antihypertensive medications worldwide. Thiazide-induced hyponatremia (TIH) is 1 of their most clinically significant adverse effects. A priori TIH must result from excessive saliuresis and/or water reabsorption. We hypothesized that pathways regulating the thiazide-sensitive sodium-chloride cotransporter NCC and the water channel aquaporin-2 (AQP2) may be involved. Our aim was to assess whether patients with TIH would show evidence of altered NCC and AQP2 expression in urinary extracellular vesicles (UEVs), and also whether abnormalities of renal sodium reabsorption would be evident using endogenous lithium clearance (ELC). Methods Blood and urine samples were donated by patients admitted to hospital with acute symptomatic TIH, after recovery to normonatremia, and also from normonatremic controls on and off thiazides. Urinary extracellular vesicles were isolated and target proteins evaluated by western blotting and by nanoparticle tracking analysis. Endogenous lithium clearance was assessed by inductively coupled plasma mass spectrometry. Results Analysis of UEVs by western blotting showed that patients with acute TIH displayed reduced total NCC and increased phospho-NCC and AQP2 relative to appropriate control groups; smaller differences in NCC and AQP2 expression persisted after recovery from TIH. These findings were confirmed by nanoparticle tracking analysis. Renal ELC was lower in acute TIH compared to that in controls and convalescent case patients. Conclusion Reduced NCC expression and increased AQP2 expression would be expected to result in saliuresis and water reabsorption in TIH patients. This study raises the possibility that UEV analysis may be of diagnostic utility in less clear-cut cases of thiazide-associated hyponatremia, and may help to identify patients at risk for TIH before thiazide initiation.
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Affiliation(s)
- Sarath K Channavajjhala
- Division of Therapeutics and Molecular Medicine, University of Nottingham, Nottingham, UK.,NIHR-Nottingham Biomedical Research Centre, Nottinghamshire, UK
| | - Roger Bramley
- Trace Element Laboratory, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Theresa Peltz
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Wilna Oosthuyzen
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Wenjing Jia
- Division of Therapeutics and Molecular Medicine, University of Nottingham, Nottingham, UK.,NIHR-Nottingham Biomedical Research Centre, Nottinghamshire, UK
| | - Sue Kinnear
- Division of Therapeutics and Molecular Medicine, University of Nottingham, Nottingham, UK.,NIHR-Nottingham Biomedical Research Centre, Nottinghamshire, UK
| | - Barry Sampson
- Trace Element Laboratory, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Nick Martin
- Trace Element Laboratory, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Ian P Hall
- Division of Therapeutics and Molecular Medicine, University of Nottingham, Nottingham, UK.,NIHR-Nottingham Biomedical Research Centre, Nottinghamshire, UK
| | - Matthew A Bailey
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - James W Dear
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Mark Glover
- Division of Therapeutics and Molecular Medicine, University of Nottingham, Nottingham, UK.,NIHR-Nottingham Biomedical Research Centre, Nottinghamshire, UK
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Stewart D, Iancu D, Ashton E, Courtney AE, Connor A, Walsh SB. Transplantation of a Gitelman Syndrome Kidney Ameliorates Hypertension: A Case Report. Am J Kidney Dis 2018; 73:421-424. [PMID: 30201548 DOI: 10.1053/j.ajkd.2018.06.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 06/27/2018] [Indexed: 01/16/2023]
Abstract
Gitelman syndrome is caused by inactivating mutations of the gene that encodes the renal sodium/chloride cotransporter (NCC; encoded by SLC12A3), resulting in hypokalemia, hypomagnesemia, hypocalciuria, and metabolic alkalosis. Renal salt wasting commonly provokes mild hypotension. The paucity of previous kidney transplants from donors with known tubulopathies suggests that such conditions may be considered contraindications to donation. A 76-year-old man received a live unrelated kidney transplant from a donor with known Gitelman syndrome secondary to a pathogenic mutation of SLC12A3. Immediate graft function preceded the emergence of the Gitelman syndrome biochemical phenotype and blood pressure subsequently improved. The recipient developed unexpected hyponatremia. Potential causes are discussed, including the possibility that it paralleled the physiologic changes seen in the high-volume state of thiazide-induced hyponatremia. Transplanted kidneys are subject to nephrotoxicity from the use of calcineurin inhibitors. Acquired Gitelman syndrome may confer a potential long-term advantage to the recipient through both improved blood pressure control and protection against the calcineurin inhibitor-induced side-effect profile caused by NCC overactivation. Both the donor and recipient remain well. In conclusion, Gitelman syndrome need not preclude kidney donation and transference of the phenotype may have benefits for the recipient.
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Affiliation(s)
- Daniel Stewart
- South West Transplant Centre, Derriford Hospital, Plymouth, Devon
| | | | - Emma Ashton
- North East Thames Regional Genetics Service Laboratories, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | - Aisling E Courtney
- Regional Nephrology & Transplant Unit, Belfast City Hospital, Belfast, United Kingdom
| | - Andrew Connor
- South West Transplant Centre, Derriford Hospital, Plymouth, Devon.
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44
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Ng FL, Warren HR, Caulfield MJ. Hypertension genomics and cardiovascular prevention. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:291. [PMID: 30211179 DOI: 10.21037/atm.2018.06.34] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Hypertension continues to be a major risk factor for global mortality, and recent genome-wide association studies (GWAS) have expanded in size, leading to the identification of further genetic loci influencing blood pressure. In light of the new knowledge from the largest cardiovascular GWAS to date, we review the potential impact of genomics on discovering potential drug targets, risk stratification with genetic risk scores, drug selection with pharmacogenetics, and exploring insights provided by gene-environment interactions.
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Affiliation(s)
- Fu Liang Ng
- William Harvey Research Institute, The NIHR Biomedical Research Centre at Barts, Queen Mary University London, London, UK.,Barts BP Centre of Excellence, Barts Heart Centre, The NIHR Biomedical Research Centre at Barts, St Bartholomew's Hospital, W Smithfield, London, UK
| | - Helen R Warren
- William Harvey Research Institute, The NIHR Biomedical Research Centre at Barts, Queen Mary University London, London, UK
| | - Mark J Caulfield
- William Harvey Research Institute, The NIHR Biomedical Research Centre at Barts, Queen Mary University London, London, UK.,Barts BP Centre of Excellence, Barts Heart Centre, The NIHR Biomedical Research Centre at Barts, St Bartholomew's Hospital, W Smithfield, London, UK
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45
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Palmer BF, Clegg DJ. Altered Prostaglandin Signaling as a Cause of Thiazide-Induced Hyponatremia. Am J Kidney Dis 2018; 71:769-771. [PMID: 29501264 DOI: 10.1053/j.ajkd.2017.11.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 11/19/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Biff F Palmer
- University of Texas Southwestern Medical Center, Dallas, TX.
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Abstract
Purpose of Review Hypertension affects more than 30% of the world’s adult population and thiazide (and thiazide-like) diuretics are amongst the most widely used, effective, and least costly treatments available, with all-cause mortality benefits equivalent to angiotensin-converting enzyme inhibitors or calcium channel antagonists. A minority of patients develop thiazide-induced hyponatremia (TIH) and this is largely unpredictable at the point of thiazide prescription. In some cases, TIH can cause debilitating symptoms and require hospital admission. Although TIH affects only a minority of patients exposed to thiazides, the high prevalence of hypertension leads to TIH being the most common cause of drug-induced hyponatremia requiring hospital admission in the UK. This review examines current clinical and scientific understanding of TIH. Consideration is given to demographic associations, limitations of current electrolyte monitoring regimens, clinical presentation, the phenotype evident on routine clinical blood and urine tests as well as more extensive analyses of blood and urine in research settings, recent genetic associations with TIH, and thoughts on management of the condition. Recent Findings Recent genetic and phenotyping analysis has suggested that prostaglandin E2 pathways in the collecting duct may have a role in the development of TIH in a subgroup of patients. Greater understanding of the molecular pathophysiology of TIH raises the prospect of pre-prescription TIH risk profiling and may offer novel insights into how TIH may be avoided, prevented and treated. Summary The rising prevalence of hypertension and the widespread use of thiazides mean that further understanding of TIH will continue to be a pressing issue for patients, physicians, and scientists alike for the foreseeable future.
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47
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Palmer BF, Clegg DJ. Renal Considerations in the Treatment of Hypertension. Am J Hypertens 2018; 31:394-401. [PMID: 29373638 DOI: 10.1093/ajh/hpy013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
There are renal implications when employing intensive blood pressure control strategies. While this approach provides cardiovascular benefit in patients with and without chronic kidney disease, the impact on renal disease progression differs according to the pattern of underlying renal injury. In the setting of proteinuria, stringent blood pressure control has generally conferred a protective effect on renal disease progression, but in the absence of proteinuria, this benefit tends to be much less impressive. Thiazide diuretics are frequently part of the regimen to achieve intensive blood pressure control. These drugs can cause hyponatremia and present with biochemical evidence mimicking the syndrome of inappropriate antidiuretic hormone secretion. Altered prostaglandin transport may explain the unique susceptibility to this complication observed in some patients. Hyperkalemia is also a complication of intensive blood pressure lowering particularly in the setting of renin-angiotensin-aldosterone blockade. There are strategies and new drugs now available that can allow use of these blockers and at the same time ensure a normal plasma potassium concentration.
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Affiliation(s)
- Biff F Palmer
- Department of Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Deborah J Clegg
- Biomedical Research Department, Diabetes and Obesity Research Division, Cedars-Sinai Medical Center, Los Angeles, California
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48
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Abstract
Adverse drug reactions can be caused by a wide range of therapeutics. Adverse drug reactions affect many bodily organ systems and vary widely in severity. Milder adverse drug reactions often resolve quickly following withdrawal of the casual drug or sometimes after dose reduction. Some adverse drug reactions are severe and lead to significant organ/tissue injury which can be fatal. Adverse drug reactions also represent a financial burden to both healthcare providers and the pharmaceutical industry. Thus, a number of stakeholders would benefit from development of new, robust biomarkers for the prediction, diagnosis, and prognostication of adverse drug reactions. There has been significant recent progress in identifying predictive genomic biomarkers with the potential to be used in clinical settings to reduce the burden of adverse drug reactions. These have included biomarkers that can be used to alter drug dose (for example, Thiopurine methyltransferase (TPMT) and azathioprine dose) and drug choice. The latter have in particular included human leukocyte antigen (HLA) biomarkers which identify susceptibility to immune-mediated injuries to major organs such as skin, liver, and bone marrow from a variety of drugs. This review covers both the current state of the art with regard to genomic adverse drug reaction biomarkers. We also review circulating biomarkers that have the potential to be used for both diagnosis and prognosis, and have the added advantage of providing mechanistic information. In the future, we will not be relying on single biomarkers (genomic/non-genomic), but on multiple biomarker panels, integrated through the application of different omics technologies, which will provide information on predisposition, early diagnosis, prognosis, and mechanisms. Impact statement • Genetic and circulating biomarkers present significant opportunities to personalize patient therapy to minimize the risk of adverse drug reactions. ADRs are a significant heath issue and represent a significant burden to patients, healthcare providers, and the pharmaceutical industry. • This review details the current state of the art in biomarkers of ADRs (both genetic and circulating). There is still significant variability in patient response which cannot be explained by current knowledge of genetic risk factors for ADRs; however, we discussed how specific advances in genomics have the potential to yield better and more predictive models. • Many current clinically utilized circulating biomarkers of tissue injury are valid biomarkers for a number of ADRs. However, they often give little insight into the specific cell or tissue subtype which may be affected. Emerging circulating biomarkers with potential to provide greater information on the etiology/pathophysiology of ADRs are described.
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Affiliation(s)
- Daniel F Carr
- Department of Molecular and Clinical Pharmacology, Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GL, UK
- Department of Molecular and Clinical Pharmacology, MRC Centre for Drug Safety Science, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GL, UK
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GL, UK
- Department of Molecular and Clinical Pharmacology, MRC Centre for Drug Safety Science, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GL, UK
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49
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Filippatos TD, Makri A, Elisaf MS, Liamis G. Hyponatremia in the elderly: challenges and solutions. Clin Interv Aging 2017; 12:1957-1965. [PMID: 29180859 PMCID: PMC5694198 DOI: 10.2147/cia.s138535] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Decreased serum sodium concentration is a rather frequent electrolyte disorder in the elderly population because of the presence of factors contributing to increased antidiuretic hormone, the frequent prescription of drugs associated with hyponatremia and also because of other mechanisms such as the “tea and toast” syndrome. The aim of this review is to present certain challenges in the evaluation and treatment of hyponatremia in the elderly population and provide practical solutions. Hyponatremia in elderly subjects is mainly caused by drugs (more frequently thiazides and antidepressants), the syndrome of inappropriate antidiuretic hormone secretion (SIAD) or endocrinopathies; however, hyponatremia is multifactorial in a significant proportion of patients. Special attention is needed in the elderly population to exclude endocrinopathies as a cause of hyponatremia before establishing the diagnosis of SIAD, which then requires a stepped diagnostic approach to reveal its underlying cause. The treatment of hyponatremia depends on the type of hyponatremia. Special attention is also needed to correct serum sodium levels at the appropriate rate, especially in chronic hyponatremia, in order to avoid the osmotic demyelination syndrome. In conclusion, both the evaluation and the treatment of hyponatremia pose many challenges in the elderly population.
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Affiliation(s)
- Theodosios D Filippatos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Andromachi Makri
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Moses S Elisaf
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - George Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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50
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Hoorn EJ, Wetzels JFM. Renal physiology: Prostaglandins in thiazide-induced hyponatraemia: do they hold water? Nat Rev Nephrol 2017; 13:665-666. [PMID: 28944774 DOI: 10.1038/nrneph.2017.133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Ewout J Hoorn
- Department of Internal Medicine, Division of Nephrology &Transplantation, Erasmus Medical Center, Room H-438, PO Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Jack F M Wetzels
- Department of Nephrology 464, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, Netherlands
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