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Fujimoto K, Hisanaga S, Kuroda S, Kodama K, Sugiyama F, Kikuchi M, Kita T, Yamashita A, Nagai T, Kamimura T, Kaikita K, Imamura T, Fujimoto S. A case of primary aldosteronism with excessive secretion of renin that was unmasked by kidney transplantation. CEN Case Rep 2024; 13:1-8. [PMID: 37010722 PMCID: PMC10834915 DOI: 10.1007/s13730-023-00784-9] [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: 06/16/2022] [Accepted: 03/10/2023] [Indexed: 04/04/2023] Open
Abstract
A 42-year-old man showed marked hypokalemia after kidney transplantation. He was diagnosed with hypertension and suffered from acute myocardial infarction at 33 and 38 years of age. At 40 years of age, hemodialysis was introduced. A left adrenal tumor was noted and suspected as a non-functional adrenal adenoma at that time. Therefore, he received a living-donor kidney transplant at 42 years of age. After kidney transplantation, the serum creatinine level dropped. His blood pressure remained high, and the serum potassium level decreased. The PRA and PAC were elevated, and ARR was not elevated. Based on the results of various confirmatory tests and vein sampling, he was diagnosed with excessive secretion of renin from the native kidneys that was complicated by primary aldosteronism (PA), and left nephrectomy and adrenalectomy were performed. The overproduction of aldosterone in the resected adrenal adenoma and over secretion of renin in the kidney with arteriolosclerosis were immunohistologically confirmed. After surgery, the PAC decreased, but the PRA did not decrease. The postoperative serum potassium level improved, and the blood pressure was well controlled with a small dose of medication. This is the first reported case of PA with hyperreninemia after kidney transplantation. It should be noted that PA in dialysis patients and kidney transplant recipients may not fulfill the usual diagnostic criteria of an elevated ARR. In such patients, PA should be suspected based on the absolute value of the PAC and responsiveness to ACTH stimulation, and adrenal and renal vein sampling is required for a definitive diagnosis.
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Affiliation(s)
- Kenta Fujimoto
- Department of Internal Medicine, Koga General Hospital, Miyazaki, Japan, 1749-1 Sudaki, Ikeuchi, 880-0041.
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan.
| | - Shuichi Hisanaga
- Department of Internal Medicine, Koga General Hospital, Miyazaki, Japan, 1749-1 Sudaki, Ikeuchi, 880-0041
| | - Sayaka Kuroda
- Department of Internal Medicine, Koga General Hospital, Miyazaki, Japan, 1749-1 Sudaki, Ikeuchi, 880-0041
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Kotoko Kodama
- Department of Internal Medicine, Koga General Hospital, Miyazaki, Japan, 1749-1 Sudaki, Ikeuchi, 880-0041
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Fumiko Sugiyama
- Department of Internal Medicine, Koga General Hospital, Miyazaki, Japan, 1749-1 Sudaki, Ikeuchi, 880-0041
| | - Masao Kikuchi
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Toshihiro Kita
- Department of Projects Research, Frontier Science Research Center, University of Miyazaki, Miyazaki, Japan
| | - Atsushi Yamashita
- Pathophysiology Section, Department of Pathology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Takahiro Nagai
- Department of Urology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Toshio Kamimura
- Department of Urology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Takuroh Imamura
- Department of Internal Medicine, Koga General Hospital, Miyazaki, Japan, 1749-1 Sudaki, Ikeuchi, 880-0041
| | - Shouichi Fujimoto
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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Crompton M, Skinner LJ, Satchell SC, Butler MJ. Aldosterone: Essential for Life but Damaging to the Vascular Endothelium. Biomolecules 2023; 13:1004. [PMID: 37371584 PMCID: PMC10296074 DOI: 10.3390/biom13061004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
The renin angiotensin aldosterone system is a key regulator of blood pressure. Aldosterone is the final effector of this pathway, acting predominantly via mineralocorticoid receptors. Aldosterone facilitates the conservation of sodium and, with it, water and acts as a powerful stimulus for potassium excretion. However, evidence for the pathological impact of excess mineralocorticoid receptor stimulation is increasing. Here, we discussed how in the heart, hyperaldosteronism is associated with fibrosis, cardiac dysfunction, and maladaptive hypertrophy. In the kidney, aldosterone was shown to cause proteinuria and fibrosis and may contribute to the progression of kidney disease. More recently, studies suggested that aldosterone excess damaged endothelial cells. Here, we reviewed how damage to the endothelial glycocalyx may contribute to this process. The endothelial glycocalyx is a heterogenous, negatively charged layer on the luminal surface of cells. Aldosterone exposure alters this layer. The resulting structural changes reduced endothelial reactivity in response to protective shear stress, altered permeability, and increased immune cell trafficking. Finally, we reviewed current therapeutic strategies for limiting endothelial damage and suggested that preventing glycocalyx remodelling in response to aldosterone exposure may provide a novel strategy, free from the serious adverse effect of hyperkalaemia seen in response to mineralocorticoid blockade.
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Affiliation(s)
| | | | | | - Matthew J. Butler
- Bristol Renal, Dorothy Hodgkin Building, University of Bristol, Whitson Street, Bristol BS1 3NY, UK
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Mirfakhraee S, Rodriguez M, Ganji N, Auchus RJ, Hamidi O. A Real Saline Challenge: Diagnosing Primary Aldosteronism in the Setting of Chronic Kidney Disease. J Investig Med High Impact Case Rep 2021; 9:23247096211034337. [PMID: 34293951 PMCID: PMC8312167 DOI: 10.1177/23247096211034337] [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: 11/25/2022] Open
Abstract
Primary aldosteronism (PA) is the most common cause of secondary hypertension but remains largely undiagnosed. Chronic kidney disease (CKD) complicates the diagnosis of PA by affecting the biochemical screening evaluation and confirmatory testing, and by increasing the complication rate of adrenal venous sampling (AVS). To raise clinician awareness of the challenges of PA diagnosis in CKD, we present an illustrative case with subsequent review of the literature and discuss some recent developments in PA diagnostic strategies particularly applicable to the CKD population. A 67-year-old man with stage IIIb CKD was suspected of having PA due to treatment with 6 antihypertensive agents and the presence of intermittent hypokalemia. He had a positive biochemical screen for PA, and AVS demonstrated unilateral aldosterone excess. Subsequently, unilateral adrenalectomy resolved his PA, eliminating the patient’s hypokalemia and improving his blood pressure. A MEDLINE literature search revealed 10 studies totaling 11 cases (including our own) of PA diagnosed in the setting of CKD. For each case, the clinical presentation, biochemical data, results of cross-sectional imaging, AVS details, and clinical response to surgery or medical therapy were characterized. The optimal strategy for the diagnosis and management of PA patients with CKD is not known. Although CKD patients often receive screening and subtype testing for PA similar to non-CKD patients, there are challenges in the interpretation of these tests. Novel strategies may include less invasive subtype testing or empiric treatment with mineralocorticoid receptor antagonists but additional studies are necessary.
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Affiliation(s)
| | - Maria Rodriguez
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Oksana Hamidi
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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Mineralocorticoid Receptor Antagonist Use in Heart Failure With Reduced Ejection Fraction and End-Stage Renal Disease Patients on Dialysis: A Literature Review. Cardiol Rev 2021; 28:107-115. [PMID: 31985521 DOI: 10.1097/crd.0000000000000286] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Mineralocorticoid receptor antagonists (MRAs) are known to have a proven mortality benefit in heart failure with reduced ejection fraction (HFrEF) without kidney disease. As patients with end-stage renal disease (ESRD) requiring either peritoneal dialysis or hemodialysis were excluded in clinical trials of HFrEF, the data are scant on the appropriate use of MRAs in this population. The unknown efficacy, along with concerns of adverse effects such as hyperkalemia, has limited the willingness of clinicians to consider using MRAs in these patients. However, it is unclear whether the risk of hyperkalemia is present if a patient is oliguric or anuric. Current guidelines recommend against the use of MRAs in patients with chronic kidney disease, but do not address the use of MRAs in patients requiring dialysis. This article will review the epidemiology of heart failure in ESRD, the pathophysiological derangements of the renin-angiotensin-aldosterone system in patients with kidney disease, and the results from case series and trials of the use of MRAs in ESRD with HFrEF. Although limited to several small trials using MRAs in peritoneal and hemodialysis patients with or without HFrEF, the current literature appears to show the potential for clinical benefits with little risk.
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Bovée DM, Cuevas CA, Zietse R, Danser AHJ, Mirabito Colafella KM, Hoorn EJ. Salt-sensitive hypertension in chronic kidney disease: distal tubular mechanisms. Am J Physiol Renal Physiol 2020; 319:F729-F745. [DOI: 10.1152/ajprenal.00407.2020] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Chronic kidney disease (CKD) causes salt-sensitive hypertension that is often resistant to treatment and contributes to the progression of kidney injury and cardiovascular disease. A better understanding of the mechanisms contributing to salt-sensitive hypertension in CKD is essential to improve these outcomes. This review critically explores these mechanisms by focusing on how CKD affects distal nephron Na+ reabsorption. CKD causes glomerulotubular imbalance with reduced proximal Na+ reabsorption and increased distal Na+ delivery and reabsorption. Aldosterone secretion further contributes to distal Na+ reabsorption in CKD and is not only mediated by renin and K+ but also by metabolic acidosis, endothelin-1, and vasopressin. CKD also activates the intrarenal renin-angiotensin system, generating intratubular angiotensin II to promote distal Na+ reabsorption. High dietary Na+ intake in CKD contributes to Na+ retention by aldosterone-independent activation of the mineralocorticoid receptor mediated through Rac1. High dietary Na+ also produces an inflammatory response mediated by T helper 17 cells and cytokines increasing distal Na+ transport. CKD is often accompanied by proteinuria, which contains plasmin capable of activating the epithelial Na+ channel. Thus, CKD causes both local and systemic changes that together promote distal nephron Na+ reabsorption and salt-sensitive hypertension. Future studies should address remaining knowledge gaps, including the relative contribution of each mechanism, the influence of sex, differences between stages and etiologies of CKD, and the clinical relevance of experimentally identified mechanisms. Several pathways offer opportunities for intervention, including with dietary Na+ reduction, distal diuretics, renin-angiotensin system inhibitors, mineralocorticoid receptor antagonists, and K+ or H+ binders.
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Affiliation(s)
- Dominique M. Bovée
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
- Division of Vascular Medicine, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Catharina A. Cuevas
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Robert Zietse
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A. H. Jan Danser
- Division of Vascular Medicine, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Katrina M. Mirabito Colafella
- Cardiovascular Disease Program, Monash Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
- Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - Ewout J. Hoorn
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
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Oliveira e Silva V, Stringuetta Belik F, Hueb J, de Souza Gonçalves R, Costa Teixeira Caramori J, Perez Vogt B, Barretti P, Zanati Bazan S, De Stefano G, Martin L, da Silva Franco R. Aerobic Exercise Training and Nontraditional Cardiovascular Risk Factors in Hemodialysis Patients: Results from a Prospective Randomized Trial. Cardiorenal Med 2019; 9:391-399. [DOI: 10.1159/000501589] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 06/14/2019] [Indexed: 11/19/2022] Open
Abstract
Introduction: Chronic kidney disease (CKD) patients have a high incidence of cardiovascular diseases (CVD) which increases their morbidity and mortality. A sedentary lifestyle in CKD is directly linked to the onset of CVD. Physical activity can bring beneficial effects to CKD patients. Aims: The aim of this study was assess the impact of aerobic training on nontraditional cardiovascular risk factors in CKD patients on hemodialysis. Materials and Methods: This is a prospective, controlled, and randomized clinical trial with analysis of intention to treat. Thirty patients underwent an exercise treadmill test, an arterial stiffness evaluation, echocardiography and analysis of endothelial reactivity, and carotid ultrasound and laboratorial tests, including analysis of serum aldosterone. The intervention group (IG) (n =15) underwent aerobic exercise during hemodialysis 3 times a week for 4 months. The control group (CG) (n =15) had no intervention. All of the patients were reassessed after 4 months. Results: In the IG, there was a statistically significant improvement in flow-mediated vasodilation (FMV; p = 0.002) and a reduction in left ventricular hypertrophy (p = 0.006) and serum aldosterone (p = 0.016). There was an increase in C-reactive protein in the CG (p = 0.002). Conclusion: This aerobic training protocol was able to improve endothelial function with enhanced FMV and reduce left ventricular hypertrophy and serum aldosterone, which could have a positive impact on the reduction of nontraditional cardiovascular risk factors in CKD patients on hemodialysis.
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Butler MJ, Ramnath R, Kadoya H, Desposito D, Riquier-Brison A, Ferguson JK, Onions KL, Ogier AS, ElHegni H, Coward RJ, Welsh GI, Foster RR, Peti-Peterdi J, Satchell SC. Aldosterone induces albuminuria via matrix metalloproteinase-dependent damage of the endothelial glycocalyx. Kidney Int 2018; 95:94-107. [PMID: 30389198 DOI: 10.1016/j.kint.2018.08.024] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 07/16/2018] [Accepted: 08/16/2018] [Indexed: 12/12/2022]
Abstract
Aldosterone contributes to end-organ damage in heart failure and chronic kidney disease. Mineralocorticoid-receptor inhibitors limit activation of the receptor by aldosterone and slow disease progression, but side effects, including hyperkalemia, limit their clinical use. Damage to the endothelial glycocalyx (a luminal biopolymer layer) has been implicated in the pathogenesis of endothelial dysfunction and albuminuria, but to date no one has investigated whether the glomerular endothelial glycocalyx is affected by aldosterone. In vitro, human glomerular endothelial cells exposed to 0.1 nM aldosterone and 145 mMol NaCl exhibited reduced cell surface glycocalyx components (heparan sulfate and syndecan-4) and disrupted shear sensing consistent with damage of the glycocalyx. In vivo, administration of 0.6 μg/g/d of aldosterone (subcutaneous minipump) and 1% NaCl drinking water increased glomerular matrix metalloproteinase 2 activity, reduced syndecan 4 expression, and caused albuminuria. Intravital multiphoton imaging confirmed that aldosterone caused damage of the glomerular endothelial glycocalyx and increased the glomerular sieving coefficient for albumin. Targeting matrix metalloproteinases 2 and 9 with a specific gelatinase inhibitor preserved the glycocalyx, blocked the rise in glomerular sieving coefficient, and prevented albuminuria. Together these data suggest that preservation of the glomerular endothelial glycocalyx may represent a novel strategy for limiting the pathological effects of aldosterone.
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Affiliation(s)
- Matthew J Butler
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Raina Ramnath
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hiroyuki Kadoya
- Department of Physiology and Neuroscience, Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Dorinne Desposito
- Department of Physiology and Neuroscience, Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Anne Riquier-Brison
- Department of Physiology and Neuroscience, Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Joanne K Ferguson
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK
| | - Karen L Onions
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK
| | - Anna S Ogier
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hesham ElHegni
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK
| | - Richard J Coward
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK
| | - Gavin I Welsh
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rebecca R Foster
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK
| | - Janos Peti-Peterdi
- Department of Physiology and Neuroscience, Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Simon C Satchell
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK
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Antlanger M, Domenig O, Kovarik JJ, Kaltenecker CC, Kopecky C, Poglitsch M, Säemann MD. Molecular remodeling of the renin-angiotensin system after kidney transplantation. J Renin Angiotensin Aldosterone Syst 2018; 18:1470320317705232. [PMID: 28490223 PMCID: PMC5843863 DOI: 10.1177/1470320317705232] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective: We aimed at assessing the molecular adaptation of the renin-angiotensin system (RAS) after successful kidney transplantation (KTX). Materials and methods: In this prospective, exploratory study we analyzed 12 hemodialysis (HD) patients, who received a KTX and had excellent graft function six to 12 months thereafter. The concentrations of plasma Angiotensin (Ang) peptides (Ang I, Ang II, Ang-(1–7), Ang-(1–5), Ang-(2–8), Ang-(3–8)) were simultaneously quantified with a novel mass spectrometry-based method. Further, renin and aldosterone concentrations were determined by standard immunoassays. Results: Ang values showed a strong inter-individual variability among HD patients. Yet, despite a continued broad dispersion of Ang values after KTX, a substantial improvement of the renin/Ang II correlation was observed in patients without RAS blockade or on angiotensin receptor blocker (HD: renin/Ang II R2 = 0.660, KTX: renin/Ang II R2 = 0.918). Ang-(1–7) representing the alternative RAS axis was only marginally detectable both on HD and after KTX. Conclusions: Following KTX, renin-dependent Ang II formation adapts in non-ACE inhibitor-treated patients. Thus, a largely normal RAS regulation is reconstituted after successful KTX. However, individual Ang concentration variations and a lack of potentially beneficial alternative peptides after KTX call for individualized treatment. The long-term post-transplant RAS regulation remains to be determined.
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Affiliation(s)
- Marlies Antlanger
- 1 Medical University of Vienna, Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Austria
| | - Oliver Domenig
- 1 Medical University of Vienna, Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Austria
| | - Johannes J Kovarik
- 1 Medical University of Vienna, Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Austria
| | - Christopher C Kaltenecker
- 1 Medical University of Vienna, Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Austria
| | - Chantal Kopecky
- 1 Medical University of Vienna, Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Austria
| | | | - Marcus D Säemann
- 1 Medical University of Vienna, Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Austria
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Non-uniform relationship between salt status and aldosterone activity in patients with chronic kidney disease. Clin Sci (Lond) 2018; 132:285-294. [PMID: 29321218 DOI: 10.1042/cs20171603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 12/28/2017] [Accepted: 01/07/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Hypertension is prevalent in chronic kidney disease (CKD). Studies suggest that reduction in dietary salt intake reduces blood pressure (BP). We studied relationships between salt intake, BP and renin-angiotensin system regulation in order to establish if it is disordered in CKD. METHODS Mechanistic crossover study of CKD patients versus non-CKD controls. Participants underwent modified saline suppression test prior to randomization to either low or high salt diet for 5 days and then crossed over to the alternate diet. Angiotensin-II stimulation testing was performed in both salt states. BP, urea and electrolytes, and plasma aldosterone concentration (PAC) were measured. RESULTS Twenty-seven subjects were recruited (12 CKD, 15 control). There was no difference in age and baseline BP between the groups. Following administration of intravenous saline, systolic BP increased in CKD but not controls (131 ± 16 to 139 ± 14 mmHg, P=0.016 vs 125 ± 20 to 128 ± 22 mmHg, P=0.38). Median PAC reduced from 184 (124,340) to 95 (80,167) pmol in controls (P=0.003), but failed to suppress in CKD (230 (137,334) to 222 (147,326) pmol (P=0.17)). Following dietary salt modification, there was no change in BP in either group. Median PAC was lower following high salt compared with low salt diet in CKD and controls. There was a comparable increase in systolic BP in response to angiotensin-II in both groups. DISCUSSION We demonstrate dysregulation of aldosterone in CKD in response to salt loading with intravenous saline, but not to dietary salt modification.
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Feniman De Stefano GMM, Zanati-Basan SG, De Stefano LM, Silva VROE, Xavier PS, Barretti P, da Silva Franco RJ, Caramori JCT, Martin LC. Aldosterone is associated with left ventricular hypertrophy in hemodialysis patients. Ther Adv Cardiovasc Dis 2016; 10:304-13. [PMID: 27122492 PMCID: PMC5933569 DOI: 10.1177/1753944716644583] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Patients with chronic kidney disease present a higher degree of left ventricular hypertrophy than expected for hypertension levels. In chronic kidney disease the plot between the quotient extracellular water/total body water and aldosterone is shifted up and to the right. There are few studies that verified the role of aldosterone in cardiac remodeling in this set of patients. The aim of this study was to evaluate the relationship between serum aldosterone and left ventricular mass index in patients with chronic kidney disease on hemodialysis. METHODS The patients were submitted to clinical and laboratory evaluation, bioelectrical impedance, echocardiography and ambulatory blood pressure monitoring. The 27 patients included were divided into two groups according to aldosterone level and compared with each other. RESULTS The group of patients with higher aldosterone levels had higher left ventricular mass index. These groups were heterogeneous with regard to ambulatory systolic blood pressure, body mass index, and aldosterone levels and homogeneous with regard to the quotient extracellular water/total body water, renin-angiotensin-aldosterone system blockers, beta blocker use and other clinical characteristics. The association between aldosterone levels and left ventricular mass index was adjusted to confounding variables by a multiple linear regression analysis in which aldosterone was independently associated with left ventricular mass index. CONCLUSION The data presented are consistent with a pathogenic role of aldosterone in left ventricular hypertrophy in patients with chronic kidney dialysis in dialysis patients. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01128101.
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Affiliation(s)
- Greicy Mara Mengue Feniman De Stefano
- Departamento de Clínica Médica da Faculdade de Medicina de Botucatu - UNESP, Curso de Farmácia da Faculdade Sudoeste Paulista - FSP, Rua João Miguel Rafael. 440, CEP 18602-220 - Botucatu - SP, Brazil
| | | | | | | | - Patrícia Santi Xavier
- Departamento de Clínica Médica da Faculdade de Medicina de Botucatu - UNESP, Botucatu - SP, Brazil
| | - Pasqual Barretti
- Departamento de Clínica Médica da Faculdade de Medicina de Botucatu - UNESP, Botucatu - SP, Brazil
| | | | | | - Luis Cuadrado Martin
- Departamento de Clínica Médica da Faculdade de Medicina de Botucatu - UNESP, Botucatu - SP, Brazil
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11
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Schwenk MH, Hirsch JS, Bomback AS. Aldosterone blockade in CKD: emphasis on pharmacology. Adv Chronic Kidney Dis 2015; 22:123-32. [PMID: 25704349 DOI: 10.1053/j.ackd.2014.08.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 08/11/2014] [Indexed: 12/16/2022]
Abstract
Besides its epithelial effect on sodium retention and potassium excretion in the distal tubule, aldosterone promotes inflammation and fibrosis in the heart, kidneys, and blood vessels. As glomerular filtration rate falls, aldosterone is inappropriately elevated relative to extracellular fluid expansion. In addition, studies in CKD patients on angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and/or direct renin inhibitors have shown that aldosterone levels paradoxically rise in approximately 30% to 40% of patients on these renin-angiotensin system-blocking drugs. Hence, there is interest in using mineralocorticoid receptor blockers that directly target the inflammatory and fibrotic effects of aldosterone in CKD patients. This interest, however, is tempered by a number of unresolved issues, including the safety of using such drugs in advanced CKD and ESRD populations, and the potential for differences in drug efficacy according to race and ethnicity of patient populations. A better understanding of mineralocorticoid receptor blocker pharmacology should help inform future research directions and clinical practice decisions as to how best to use these agents in CKD.
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12
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Hypervolemia for hypertension pathophysiology: a population-based study. BIOMED RESEARCH INTERNATIONAL 2014; 2014:895401. [PMID: 25177700 PMCID: PMC4142663 DOI: 10.1155/2014/895401] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 06/26/2014] [Accepted: 06/30/2014] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Hypertension and hypervolemia relationship was proven among renal disease, although it is not known in normal population. Present study determines the fluid distribution defects in relation to blood pressure. MATERIAL AND METHODS In a population-based survey in Turkey demographics, height, weight, blood pressure, urine analysis, and serum creatinine measurements were recorded. Bioimpedance measured with the Body Composition Monitor. RESULTS Total 2034 population of 71.6% male, mean age 47 ± 12.6 (18-89) years, systolic blood pressure (SBP) 134.7 ± 20, diastolic blood pressure 77.9 ± 11.6 mmHg. Body mass index (BMI) was 28.5 ± 4.5 (15.8-50.6) kg/m(2); overhydration was 0.05 ± 1.05 L. There was a correlation between extracellular water (ECW)/height and SBP (r = 0.21, P < 0.001). Receiver operating characteristic (ROC) curve with the performance of 0.60 (P < 0.001) that showed cut-off value of ECW/height was 10.06 L/m, with the 69% sensitivity and 45% specificity for SBP: 140 mmHg values. Risk factors for high SBP were increase of ECW/Height, age, BMI and presence of diabetes. ECW/height, SBP, and fat tissue index (FTI) increased in BMI categories (low, normal, and obese) and in diabetics. SBP and FTI were lower in smokers. CONCLUSIONS High blood pressure may be accompanied by increased extracellular volume indices. In the future volume status assessment could be of use in evaluating the effectiveness of pharmacological intervention in the treatment of hypertension.
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Abstract
Although blockade of the renin-angiotensin-aldosterone system with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers has become standard therapy for chronic kidney disease (CKD), renewed interest in the role of aldosterone in mediating the injuries and progressive insults of CKD has highlighted the potential role of treatments targeting the mineralocorticoid receptor (MR). Although salt restriction is an important component of mitigating the profibrotic effects of MR activation, a growing body of literature has shown that MR antagonists, spironolactone and eplerenone, can reduce proteinuria and blood pressure in patients at all stages of CKD. These agents carry a risk of hyperkalemia, but this risk likely can be predicted based on baseline renal function and mitigated using dietary modifications and adjustments of concomitant medications. Data on hard outcomes, such as progression to end-stage renal disease and overall mortality, still are lacking in patients with CKD.
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Affiliation(s)
- Jamie S Hirsch
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Yelena Drexler
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Andrew S Bomback
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, NY.
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14
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Mark PB, Taylor AHM, McQuarrie EP, Jardine AG. How is the heart best protected in chronic dialysis patients?: Is there life in the old drugs yet? Mineralocorticoid receptor antagonism for cardiovascular prevention in chronic dialysis patients. Semin Dial 2014; 27:328-32. [PMID: 24499322 DOI: 10.1111/sdi.12178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
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Arkouche W, Giaime P, Mercadal L. [Fluid overload and arterial hypertension in hemodialysis patients]. Nephrol Ther 2013; 9:408-15. [PMID: 23953783 DOI: 10.1016/j.nephro.2013.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 04/24/2013] [Indexed: 10/26/2022]
Abstract
The water sodium overload is a factor of morbi-mortality and its treatment is one of the markers of adequacy of the hemodialysis treatment. Its first clinical assessment was improved by tools such as echocardiography and ultrasonography of the inferior vena cava, the per-dialytic curve of plasma volume, measuring BNP or proBNP and by impedancemetry. The combination of the evaluation of these parameters and of the clinical situation allows one to assess the extracellular overload, the state of the blood volume and the potential of plasma refilling. The latter is a key factor of the per-dialytic hemodynamic tolerance. It is itself a determining factor in weight can be achieved at the end of the session. Getting the "dry" weight can require modifications of the prescriptions of the hemodialysis sessions, a filling by albumin even a drugs support. Finally, the overload treatment is the central part of the treatment of arterial hypertension, which has to benefit however often from antihypertensive treatment the profit of which is demonstrated.
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Affiliation(s)
- Walid Arkouche
- Association pour l'utilisation du rein artificiel dans la région lyonnaise (AURAL), 69008 Lyon, France
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Hung SC, Lin YP, Huang HL, Pu HF, Tarng DC. Aldosterone and mortality in hemodialysis patients: role of volume overload. PLoS One 2013; 8:e57511. [PMID: 23469009 PMCID: PMC3585342 DOI: 10.1371/journal.pone.0057511] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 01/22/2013] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Elevated aldosterone is associated with increased mortality in the general population. In patients on dialysis, however, the association is reversed. This paradox may be explained by volume overload, which is associated with lower aldosterone and higher mortality. METHODS We evaluated the relationship between aldosterone and outcomes in a prospective cohort of 328 hemodialysis patients stratified by the presence or absence of volume overload (defined as extracellular water/total body water >48%, as measured with bioimpedance). Baseline plasma aldosterone was measured before dialysis and categorized as low (<140 pg/mL), middle (140 to 280 pg/mL) and high (>280 pg/mL). RESULTS Overall, 36% (n = 119) of the hemodialysis patients had evidence of volume overload. Baseline aldosterone was significantly lower in the presence of volume overload than in its absence. During a median follow-up of 54 months, 83 deaths and 70 cardiovascular events occurred. Cox multivariate analysis showed that by using the low aldosterone as the reference, high aldosterone was inversely associated with decreased hazard ratios for mortality (0.49; 95% confidence interval, 0.25-0.76) and first cardiovascular event (0.70; 95% confidence interval, 0.33-0.78) in the presence of volume overload. In contrast, high aldosterone was associated with an increased risk for mortality (1.97; 95% confidence interval, 1.69-3.75) and first cardiovascular event (2.01; 95% confidence interval, 1.28-4.15) in the absence of volume overload. CONCLUSIONS The inverse association of aldosterone with adverse outcomes in hemodialysis patients is due to the confounding effect of volume overload. These findings support treatment of hyperaldosteronemia in hemodialysis patients who have achieved strict volume control.
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Affiliation(s)
- Szu-Chun Hung
- Division of Nephrology, Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei, Taiwan
| | - Yao-Ping Lin
- Division of Nephrology, Department of Medicine, and Immunology Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsin-Lei Huang
- Department and Institute of Physiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiao-Fung Pu
- Department and Institute of Physiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Der-Cherng Tarng
- Division of Nephrology, Department of Medicine, and Immunology Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department and Institute of Physiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- * E-mail:
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McQuarrie EP, Freel EM, Mark PB, Fraser R, Connell JM, Jardine AG. Urinary sodium excretion is the main determinant of mineralocorticoid excretion rates in patients with chronic kidney disease. Nephrol Dial Transplant 2013; 28:1526-32. [DOI: 10.1093/ndt/gft007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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18
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Baker WL, White WB. Safety of mineralocorticoid receptor antagonists in patients receiving hemodialysis. Ann Pharmacother 2012; 46:889-94. [PMID: 22669801 DOI: 10.1345/aph.1r011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the literature supporting the safe use of mineralocorticoid antagonists (MRAs) in patients with end-stage renal disease who are receiving hemodialysis. DATA SOURCES A review of the literature was performed using MEDLINE (1950 through week 2 of February 2012) using the key words and MeSH terms mineralocorticoid antagonists, aldosterone antagonists, spironolactone, or eplerenone combined with dialysis, renal disease, or kidney disease. STUDY SELECTION AND DATA EXTRACTION Studies eligible for inclusion evaluated the impact of MRAs on serum potassium levels in patients with end-stage renal disease receiving hemodialysis. Data related to the patient populations and outcomes of interest were extracted from each publication. DATA SYNTHESIS Ten studies were included in this review (spironolactone, 9; eplerenone, 1) and reported on the impact of MRAs on potassium levels in this population. In aggregate, the studies, with spironolactone doses ranging from 25 mg 3 times/week after dialysis to 300 mg/day and eplerenone doses of 25 mg twice daily, have shown little increases in serum potassium, particularly with the lower doses. The overall incidence of severe hyperkalemia was low. The literature base is limited by significant methodologic weaknesses of the studies, including low patient numbers, short follow-up periods, and lack of a blinded control group. CONCLUSIONS The current literature suggests that MRAs may be used safely in patients with end-stage renal disease receiving hemodialysis, although additional large controlled trials are needed before definitive treatment recommendations can be made.
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Affiliation(s)
- William L Baker
- Schools of Pharmacy and Medicine, University of Connecticut, Farmington, CT,
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Bomback AS, Klemmer PJ. Mineralocorticoid Receptor Blockade in Chronic Kidney Disease. Blood Purif 2012; 33:119-24. [DOI: 10.1159/000334161] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Volk MJ, Bomback AS, Klemmer PJ. Mineralocorticoid Receptor Blockade in Chronic Kidney Disease. Curr Hypertens Rep 2011; 13:282-8. [DOI: 10.1007/s11906-011-0202-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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