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Gupta S, Pepper RJ, Ashman N, Walsh SB. Nephrotic Syndrome: Oedema Formation and Its Treatment With Diuretics. Front Physiol 2019; 9:1868. [PMID: 30697163 PMCID: PMC6341062 DOI: 10.3389/fphys.2018.01868] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/11/2018] [Indexed: 01/01/2023] Open
Abstract
Oedema is a defining element of the nephrotic syndrome. Its' management varies considerably between clinicians, with no national or international clinical guidelines, and hence variable outcomes. Oedema may have serious sequelae such as immobility, skin breakdown and local or systemic infection. Treatment of nephrotic oedema is often of limited efficacy, with frequent side-effects and interactions with other pharmacotherapy. Here, we describe the current paradigms of oedema in nephrosis, including insights into emerging mechanisms such as the role of the abnormal activation of the epithelial sodium channel in the collecting duct. We then discuss the physiological basis for traditional and novel therapies for the treatment of nephrotic oedema. Despite being the cardinal symptom of nephrosis, few clinical studies guide clinicians to the rational use of therapy. This is reflected in the scarcity of publications in this field; it is time to undertake new clinical trials to direct clinical practice.
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Affiliation(s)
- Sanjana Gupta
- UCL Centre for Nephrology, University College London, London, United Kingdom.,Renal Unit, The Royal London Hospital, Bart's Health NHS Trust, London, United Kingdom
| | - Ruth J Pepper
- UCL Centre for Nephrology, University College London, London, United Kingdom
| | - Neil Ashman
- Renal Unit, The Royal London Hospital, Bart's Health NHS Trust, London, United Kingdom
| | - Stephen B Walsh
- UCL Centre for Nephrology, University College London, London, United Kingdom
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Isobe-Sasaki Y, Fukuda M, Ogiyama Y, Sato R, Miura T, Fuwa D, Mizuno M, Matsuoka T, Shibata H, Ito H, Ono M, Abe-Dohmae S, Kiyono K, Yamamoto Y, Kobori H, Michikawa M, Hayano J, Ohte N. Sodium balance, circadian BP rhythm, heart rate variability, and intrarenal renin-angiotensin-aldosterone and dopaminergic systems in acute phase of ARB therapy. Physiol Rep 2018; 5:5/11/e13309. [PMID: 28576855 PMCID: PMC5471446 DOI: 10.14814/phy2.13309] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 04/29/2017] [Accepted: 05/10/2017] [Indexed: 01/11/2023] Open
Abstract
We have revealed that even in humans, activated intrarenal renin–angiotensin–aldosterone system (RAAS) enhances tubular sodium reabsorption to facilitate salt sensitivity and nondipper rhythm of blood pressure (BP), and that angiotensin receptor blocker (ARB) could increase daytime urinary sodium excretion rate (UNaV) to produce lower sodium balance and restore nondipper rhythm. However, the sympathetic nervous system and intrarenal dopaminergic system can also contribute to renal sodium handling. A total of 20 patients with chronic kidney disease (61 ± 15 years) underwent 24‐h ambulatory BP monitoring before and during two‐day treatment with ARB, azilsartan. Urinary angiotensinogen excretion rate (UAGTV, μg/gCre) was measured as intrarenal RAAS; urinary dopamine excretion rate (UDAV, pg/gCre) as intrarenal dopaminergic system; heart rate variabilities (HRV, calculated from 24‐h Holter‐ECG) of non‐Gaussianity index λ25s as sympathetic nerve activity; and power of high‐frequency (HF) component or deceleration capacity (DC) as parasympathetic nerve activity. At baseline, glomerular filtration rate correlated inversely with UAGTV (r = −0.47, P = 0.04) and positively with UDAV (r = 0.58, P = 0.009). HF was a determinant of night/day BP ratio (β = −0.50, F = 5.8), rather than DC or λ25s. During the acute phase of ARB treatment, a lower steady sodium balance was not achieved. Increase in daytime UNaV preceded restoration of BP rhythm, accompanied by decreased UAGTV (r = −0.88, P = 0.05) and increased UDAV (r = 0.87, P = 0.05), but with no changes in HRVs. Diminished sodium excretion can cause nondipper BP rhythm. This was attributable to intrarenal RAAS and dopaminergic system and impaired parasympathetic nerve activity. During the acute phase of ARB treatment, cooperative effects of ARB and intrarenal dopaminergic system exert natriuresis to restore circadian BP rhythm.
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Affiliation(s)
- Yukako Isobe-Sasaki
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Michio Fukuda
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yoshiaki Ogiyama
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Ryo Sato
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Toshiyuki Miura
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Daisuke Fuwa
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masashi Mizuno
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tetsuhei Matsuoka
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiroko Shibata
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiroyuki Ito
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Minamo Ono
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Sumiko Abe-Dohmae
- Department of Biochemistry, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Ken Kiyono
- Department of Mechanical Science and Bioengineering, Osaka University, Osaka, Japan
| | - Yoshiharu Yamamoto
- Department of Physical and Health Education, University of Tokyo Graduate School of Education, Tokyo, Japan
| | - Hiroyuki Kobori
- International University of Health and Welfare, Tokyo, Japan
| | - Makoto Michikawa
- Department of Biochemistry, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Junichiro Hayano
- Department of Medical Education, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Nobuyuki Ohte
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Fuwa D, Fukuda M, Ogiyama Y, Sato R, Mizuno M, Miura T, Abe-Dohmae S, Michikawa M, Kobori H, Ohte N. Addition of hydrochlorothiazide to angiotensin receptor blocker therapy can achieve a lower sodium balance with no acceleration of intrarenal renin angiotensin system in patients with chronic kidney disease. J Renin Angiotensin Aldosterone Syst 2016; 17:1470320316652032. [PMID: 27283968 PMCID: PMC4940185 DOI: 10.1177/1470320316652032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 04/14/2016] [Indexed: 01/09/2023] Open
Abstract
Objective: Angiotensin receptor blockers (ARBs) produce a lower sodium (Na) balance, and the natriuretic effect is enhanced under Na deprivation, despite falls in blood pressure (BP) and glomerular filtration rate (GFR). Methods: The effect of additional hydrochlorothiazide (HCTZ; 12.5 mg/day) to ARB treatment (valsartan; 80 mg/day) on glomerulotubular Na balance was evaluated in 23 patients with chronic kidney disease. Results: Add-on HCTZ decreased GFR, tubular Na load, and tubular Na reabsorption (tNa), although 24-hour urinary Na excretion (UNaV) remained constant. Daily urinary angiotensinogen excretion (UAGTV, 152±10→82±17 μg/g Cre) reduced (p=0.02). Changes in tubular Na load (r2=0.26) and tNa (r2=0.25) correlated with baseline 24-hour UAGTV. Changes in filtered Na load correlated with changes in nighttime systolic BP (r2=0.17), but not with changes in daytime systolic BP. The change in the tNa to filtered Na load ratio was influenced by the change in daytime UNaV (β=−0.67, F=16.8), rather than the change in nighttime UNaV. Conclusions: Lower Na balance was produced by add-on HCTZ to ARB treatment without an increase of intra-renal renin-angiotensin system activity, leading to restoration of nocturnal hypertension. A further study is needed to demonstrate that the reduction of UAGTV by additional diuretics to ARBs prevents the progression of nephropathy or cardiovascular events.
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Affiliation(s)
- Daisuke Fuwa
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Michio Fukuda
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Yoshiaki Ogiyama
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Ryo Sato
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Masashi Mizuno
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Toshiyuki Miura
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Sumiko Abe-Dohmae
- Department of Biochemistry, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Makoto Michikawa
- Department of Biochemistry, Nagoya City University Graduate School of Medical Sciences, Japan
| | | | - Nobuyuki Ohte
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Japan
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