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Natale P, Palmer SC, Navaneethan SD, Craig JC, Strippoli GF. Angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers for preventing the progression of diabetic kidney disease. Cochrane Database Syst Rev 2024; 4:CD006257. [PMID: 38682786 PMCID: PMC11057222 DOI: 10.1002/14651858.cd006257.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
BACKGROUND Guidelines suggest that adults with diabetes and kidney disease receive treatment with angiotensin-converting-enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB). This is an update of a Cochrane review published in 2006. OBJECTIVES We compared the efficacy and safety of ACEi and ARB therapy (either as monotherapy or in combination) on cardiovascular and kidney outcomes in adults with diabetes and kidney disease. SEARCH METHODS We searched the Cochrane Kidney and Transplants Register of Studies to 17 March 2024 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included studies evaluating ACEi or ARB alone or in combination, compared to each other, placebo or no treatment in people with diabetes and kidney disease. DATA COLLECTION AND ANALYSIS Two authors independently assessed the risk of bias and extracted data. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS One hundred and nine studies (28,341 randomised participants) were eligible for inclusion. Overall, the risk of bias was high. Compared to placebo or no treatment, ACEi may make little or no difference to all-cause death (24 studies, 7413 participants: RR 0.91, 95% CI 0.73 to 1.15; I2 = 23%; low certainty) and with similar withdrawals from treatment (7 studies, 5306 participants: RR 1.03, 95% CI 0.90 to 1.19; I2 = 0%; low certainty). ACEi may prevent kidney failure (8 studies, 6643 participants: RR 0.61, 95% CI 0.39 to 0.94; I2 = 0%; low certainty). Compared to placebo or no treatment, ARB may make little or no difference to all-cause death (11 studies, 4260 participants: RR 0.99, 95% CI 0.85 to 1.16; I2 = 0%; low certainty). ARB have uncertain effects on withdrawal from treatment (3 studies, 721 participants: RR 0.85, 95% CI 0.58 to 1.26; I2 = 2%; low certainty) and cardiovascular death (6 studies, 878 participants: RR 3.36, 95% CI 0.93 to 12.07; low certainty). ARB may prevent kidney failure (3 studies, 3227 participants: RR 0.82, 95% CI 0.72 to 0.94; I2 = 0%; low certainty), doubling of serum creatinine (SCr) (4 studies, 3280 participants: RR 0.84, 95% CI 0.72 to 0.97; I2 = 32%; low certainty), and the progression from microalbuminuria to macroalbuminuria (5 studies, 815 participants: RR 0.44, 95% CI 0.23 to 0.85; I2 = 74%; low certainty). Compared to ACEi, ARB had uncertain effects on all-cause death (15 studies, 1739 participants: RR 1.13, 95% CI 0.68 to 1.88; I2 = 0%; low certainty), withdrawal from treatment (6 studies, 612 participants: RR 0.91, 95% CI 0.65 to 1.28; I2 = 0%; low certainty), cardiovascular death (13 studies, 1606 participants: RR 1.15, 95% CI 0.45 to 2.98; I2 = 0%; low certainty), kidney failure (3 studies, 837 participants: RR 0.56, 95% CI 0.29 to 1.07; I2 = 0%; low certainty), and doubling of SCr (2 studies, 767 participants: RR 0.88, 95% CI 0.52 to 1.48; I2 = 0%; low certainty). Compared to ACEi plus ARB, ACEi alone has uncertain effects on all-cause death (6 studies, 1166 participants: RR 1.08, 95% CI 0.49 to 2.40; I2 = 20%; low certainty), withdrawal from treatment (2 studies, 172 participants: RR 0.78, 95% CI 0.33 to 1.86; I2 = 0%; low certainty), cardiovascular death (4 studies, 994 participants: RR 3.02, 95% CI 0.61 to 14.85; low certainty), kidney failure (3 studies, 880 participants: RR 1.36, 95% CI 0.79 to 2.32; I2 = 0%; low certainty), and doubling of SCr (2 studies, 813 participants: RR 1.14, 95% CI 0.70 to 1.85; I2 = 0%; low certainty). Compared to ACEi plus ARB, ARB alone has uncertain effects on all-cause death (7 studies, 2607 participants: RR 1.02, 95% CI 0.76 to 1.37; I2 = 0%; low certainty), withdrawn from treatment (3 studies, 1615 participants: RR 0.81, 95% CI 0.53 to 1.24; I2 = 0%; low certainty), cardiovascular death (4 studies, 992 participants: RR 3.03, 95% CI 0.62 to 14.93; low certainty), kidney failure (4 studies, 2321 participants: RR 1.15, 95% CI 0.67 to 1.95; I2 = 29%; low certainty), and doubling of SCr (3 studies, 2252 participants: RR 1.18, 95% CI 0.85 to 1.64; I2 = 0%; low certainty). Comparative effects of different ACEi or ARB and low-dose versus high-dose ARB were rarely evaluated. No study compared different doses of ACEi. Adverse events of ACEi and ARB were rarely reported. AUTHORS' CONCLUSIONS ACEi or ARB may make little or no difference to all-cause and cardiovascular death compared to placebo or no treatment in people with diabetes and kidney disease but may prevent kidney failure. ARB may prevent the doubling of SCr and the progression from microalbuminuria to macroalbuminuria compared with a placebo or no treatment. Despite the international guidelines suggesting not combining ACEi and ARB treatment, the effects of ACEi or ARB monotherapy compared to dual therapy have not been adequately assessed. The limited data availability and the low quality of the included studies prevented the assessment of the benefits and harms of ACEi or ARB in people with diabetes and kidney disease. Low and very low certainty evidence indicates that it is possible that further studies might provide different results.
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Affiliation(s)
- Patrizia Natale
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | | | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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2
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Cooper TE, Teng C, Tunnicliffe DJ, Cashmore BA, Strippoli GF. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for adults with early (stage 1 to 3) non-diabetic chronic kidney disease. Cochrane Database Syst Rev 2023; 7:CD007751. [PMID: 37466151 PMCID: PMC10355090 DOI: 10.1002/14651858.cd007751.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a long-term condition that occurs as a result of damage to the kidneys. Early recognition of CKD is becoming increasingly common due to widespread laboratory estimated glomerular filtration rate (eGFR) reporting, raised clinical awareness, and international adoption of the Kidney Disease Improving Global Outcomes (KDIGO) classifications. Early recognition and management of CKD affords the opportunity to prepare for progressive kidney impairment and impending kidney replacement therapy and for intervention to reduce the risk of progression and cardiovascular disease. Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) are two classes of antihypertensive drugs that act on the renin-angiotensin-aldosterone system. Beneficial effects of ACEi and ARB on kidney outcomes and survival in people with a wide range of severity of kidney impairment have been reported; however, their effectiveness in the subgroup of people with early CKD (stage 1 to 3) is less certain. This is an update of a review that was last published in 2011. OBJECTIVES To evaluate the benefits and harms of ACEi and ARB or both in the management of people with early (stage 1 to 3) CKD who do not have diabetes mellitus (DM). SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 6 July 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and Embase, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) reporting the effect of ACEi or ARB in people with early (stage 1 to 3) CKD who did not have DM were selected for inclusion. Only studies of at least four weeks duration were selected. Authors independently assessed the retrieved titles and abstracts and, where necessary, the full text to determine which satisfied the inclusion criteria. DATA COLLECTION AND ANALYSIS Data extraction was carried out by two authors independently, using a standard data extraction form. The methodological quality of included studies was assessed using the Cochrane risk of bias tool. Data entry was carried out by one author and cross-checked by another. When more than one study reported similar outcomes, data were pooled using the random-effects model. Heterogeneity was analysed using a Chi² test and the I² test. Results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach MAIN RESULTS: Six studies randomising 9379 participants with CKD stages 1 to 3 (without DM) met our inclusion criteria. Participants were adults with hypertension; 79% were male from China, Europe, Japan, and the USA. Treatment periods ranged from 12 weeks to three years. Overall, studies were judged to be at unclear or high risk of bias across all domains, and the quality of the evidence was poor, with GRADE rated as low or very low certainty. In low certainty evidence, ACEi (benazepril 10 mg or trandolapril 2 mg) compared to placebo may make little or no difference to death (any cause) (2 studies, 8873 participants): RR 2.00, 95% CI 0.26 to 15.37; I² = 76%), total cardiovascular events (2 studies, 8873 participants): RR 0.97, 95% CI 0.90 to 1.05; I² = 0%), cardiovascular-related death (2 studies, 8873 participants): RR 1.73, 95% CI 0.26 to 11.66; I² = 54%), stroke (2 studies, 8873 participants): RR 0.76, 95% CI 0.56 to 1.03; I² = 0%), myocardial infarction (2 studies, 8873 participants): RR 1.00, 95% CI 0.84 to 1.20; I² = 0%), and adverse events (2 studies, 8873 participants): RR 1.33, 95% CI 1.26 to 1.41; I² = 0%). It is uncertain whether ACEi (benazepril 10 mg or trandolapril 2 mg) compared to placebo reduces congestive heart failure (1 study, 8290 participants): RR 0.75, 95% CI 0.59 to 0.95) or transient ischaemic attack (1 study, 583 participants): RR 0.94, 95% CI 0.06 to 15.01; I² = 0%) because the certainty of the evidence is very low. It is uncertain whether ARB (losartan 50 mg) compared to placebo (1 study, 226 participants) reduces: death (any-cause) (no events), adverse events (RR 19.34, 95% CI 1.14 to 328.30), eGFR rate of decline (MD 5.00 mL/min/1.73 m2, 95% CI 3.03 to 6.97), presence of proteinuria (MD -0.65 g/24 hours, 95% CI -0.78 to -0.52), systolic blood pressure (MD -0.80 mm Hg, 95% CI -3.89 to 2.29), or diastolic blood pressure (MD -1.10 mm Hg, 95% CI -3.29 to 1.09) because the certainty of the evidence is very low. It is uncertain whether ACEi (enalapril 20 mg, perindopril 2 mg or trandolapril 1 mg) compared to ARB (olmesartan 20 mg, losartan 25 mg or candesartan 4 mg) (1 study, 26 participants) reduces: proteinuria (MD -0.40, 95% CI -0.60 to -0.20), systolic blood pressure (MD -3.00 mm Hg, 95% CI -6.08 to 0.08) or diastolic blood pressure (MD -1.00 mm Hg, 95% CI -3.31 to 1.31) because the certainty of the evidence is very low. AUTHORS' CONCLUSIONS There is currently insufficient evidence to determine the effectiveness of ACEi or ARB in patients with stage 1 to 3 CKD who do not have DM. The available evidence is overall of very low certainty and high risk of bias. We have identified an area of large uncertainty for a group of patients who account for most of those diagnosed as having CKD.
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Affiliation(s)
- Tess E Cooper
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Claris Teng
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | | | - Brydee A Cashmore
- Centre for Kidney Research, The University of Sydney and The Children's Hospital at Westmead, Sydney, Australia
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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3
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Zucker IH, Xia Z, Wang HJ. Potential Neuromodulation of the Cardio-Renal Syndrome. J Clin Med 2023; 12:803. [PMID: 36769450 PMCID: PMC9917464 DOI: 10.3390/jcm12030803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
The cardio-renal syndrome (CRS) type 2 is defined as a progressive loss of renal function following a primary insult to the myocardium that may be either acute or chronic but is accompanied by a decline in myocardial pump performance. The treatment of patients with CRS is difficult, and the disease often progresses to end-stage renal disease that is refractory to conventional therapy. While a good deal of information is known concerning renal injury in the CRS, less is understood about how reflex control of renal sympathetic nerve activity affects this syndrome. In this review, we provide insight into the role of the renal nerves, both from the afferent or sensory side and from the efferent side, in mediating renal dysfunction in CRS. We discuss how interventions such as renal denervation and abrogation of systemic reflexes may be used to alleviate renal dysfunction in the setting of chronic heart failure. We specifically focus on a novel cardiac sensory reflex that is sensitized in heart failure and activates the sympathetic nervous system, especially outflow to the kidney. This so-called Cardiac Sympathetic Afferent Reflex (CSAR) can be ablated using the potent neurotoxin resinferitoxin due to the high expression of Transient Receptor Potential Vanilloid 1 (TRPV1) receptors. Following ablation of the CSAR, several markers of renal dysfunction are reversed in the post-myocardial infarction heart failure state. This review puts forth the novel idea of neuromodulation at the cardiac level in the treatment of CRS Type 2.
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Affiliation(s)
- Irving H. Zucker
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Zhiqiu Xia
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Han-Jun Wang
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
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Ohkuma T, Harris K, Cooper M, Grobbee DE, Hamet P, Harrap S, Mancia G, Marre M, Patel A, Rodgers A, Williams B, Woodward M, Chalmers J. Short-Term Changes in Serum Potassium and the Risk of Subsequent Vascular Events and Mortality: Results from a Randomized Controlled Trial of ACE Inhibitors. Clin J Am Soc Nephrol 2022; 17:1139-1149. [PMID: 35896277 PMCID: PMC9435974 DOI: 10.2215/cjn.00180122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 06/17/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Hyperkalemia after starting renin-angiotensin system inhibitors has been shown to be subsequently associated with a higher risk of cardiovascular and kidney outcomes. However, whether to continue or discontinue the drug after hyperkalemia remains unclear. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data came from the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial, which included a run-in period where all participants initiated angiotensin-converting enzyme inhibitor-based therapy (a fixed combination of perindopril and indapamide). The study population was taken as patients with type 2 diabetes with normokalemia (serum potassium of 3.5 to <5.0 mEq/L) at the start of run-in. Potassium was remeasured 3 weeks later when a total of 9694 participants were classified into hyperkalemia (≥5.0 mEq/L), normokalemia, and hypokalemia (<3.5 mEq/L) groups. After run-in, patients were randomized to continuation of the angiotensin-converting enzyme inhibitor-based therapy or placebo; major macrovascular, microvascular, and mortality outcomes were analyzed using Cox regression during the following 4.4 years (median). RESULTS During active run-in, 556 (6%) participants experienced hyperkalemia. During follow-up, 1505 participants experienced the primary composite outcome of major macrovascular and microvascular events. Randomized treatment of angiotensin-converting enzyme inhibitor-based therapy significantly decreased the risk of the primary outcome (38.1 versus 42.0 per 1000 person-years; hazard ratio, 0.91; 95% confidence interval, 0.83 to 1.00; P=0.04) compared with placebo. The magnitude of effects did not differ across subgroups defined by short-term changes in serum potassium during run-in (P for heterogeneity =0.66). Similar consistent treatment effects were also observed for all-cause death, cardiovascular death, major coronary events, major cerebrovascular events, and new or worsening nephropathy (P for heterogeneity ≥0.27). CONCLUSIONS Continuation of angiotensin-converting enzyme inhibitor-based therapy consistently decreased the subsequent risk of clinical outcomes, including cardiovascular and kidney outcomes and death, regardless of short-term changes in serum potassium. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE), NCT00145925.
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Affiliation(s)
- Toshiaki Ohkuma
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Katie Harris
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Mark Cooper
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Diederick E. Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pavel Hamet
- Centre de Recherche, Center Hospitalier de l’Universite de Montreal, Montreal, Quebec, Canada
| | - Stephen Harrap
- Department of Physiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Giuseppe Mancia
- Istituto Auxologico Italiano, University of Milan-Bicocca, Milan, Italy
| | - Michel Marre
- Hopital Bichat-Claude Bernard, Universite Paris, Paris, France
| | - Anushka Patel
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Bryan Williams
- NIHR University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia,The George Institute for Global Health, School of Public Health, Imperial College London, London, United Kingdom
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
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5
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Trevisan M, Clase CM, Evans M, Popov T, Ludvigsson JF, Sjölander A, Carrero JJ. Patterns of chronic and transient hyperkalaemia and clinically important outcomes in patients with chronic kidney disease. Clin Kidney J 2021; 15:153-161. [PMID: 35035946 PMCID: PMC8757415 DOI: 10.1093/ckj/sfab159] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Indexed: 12/27/2022] Open
Abstract
Background Whether hyperkalaemia in CKD is chronic or transient, and whether this has different outcome implications, is not known. Methods This was an observational study of adults with CKD G3–5 from Stockholm, Sweden 2006–11. We examined individual trajectories of potassium from all measurements obtained through routine outpatient care. For each month of follow-up, we created a rolling assessment of the proportion of time in which potassium was abnormal during the previous 12 months. We defined patterns of hyperkalaemia as transient (≤50% of time during the previous year with potassium >5.0 mmol/L) and chronic (>50% of time with potassium >5.0 mmol/L), and examined whether previous hyperkalaemia pattern offers additional predictive value beyond that provided by the most recent (current) potassium value. Results We included 36 511 participants (56% women) with CKD G3–5 and median estimated glomerular filtration rate 46 mL/min/1.73 m2. Transient and chronic hyperkalaemia, respectively, were observed in 15% and 4% of patients with CKD G3a, and in 50% and 17% of patients with CKD G5. In fully adjusted models, transient (hazard ratio 1.36, 95% confidence interval 1.29–1.46) or chronic (1.16, 1.04–1.32) hyperkalaemia patterns, but not current hyperkalaemia, were associated with major adverse cardiovascular events (MACE), compared with normokalaemia. Transient hyperkalaemia (1.43, 1.35–1.52) and current potassium values, but not chronic hyperkalaemia, were associated with the risk of death. Conclusions Between 4% and 17% of patients with CKD G3–5 develop chronic hyperkalaemia. In general, hyperkalaemia predicted MACE and death; however, the lack of effect of current potassium on MACE when adjusted for the previous pattern, and the stronger effects on death than on MACE, lead us to question whether hyperkalaemia is causal in these relationships.
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Affiliation(s)
- Marco Trevisan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Catherine M Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, ON, Hamilton, Canada
| | - Marie Evans
- Department of Clinical Science Intervention and Technology, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Tamara Popov
- Medical Affairs, Vifor Pharma Group, Glattbrugg, Switzerland
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
| | - Arvid Sjölander
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Sorraya N, Farrokhzad A, Hassani B, Talebi S. Association between serum potassium and risk of all-cause mortality among chronic kidney diseases patients: A systematic review and dose-response meta-analysis of more than one million participants. Food Sci Nutr 2021; 9:5312-5323. [PMID: 34532036 PMCID: PMC8441339 DOI: 10.1002/fsn3.2478] [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: 12/26/2020] [Revised: 07/02/2021] [Accepted: 07/06/2021] [Indexed: 11/10/2022] Open
Abstract
We aimed to perform a meta-analysis, using prospective cohort studies, to test the association between serum potassium and all-cause mortality among chronic kidney diseases (CKD) patients. A systematic search was performed using PubMed-MEDLINE and Scopus, up to July 2020. Prospective cohort studies which reported risk estimates of all-cause mortality in CKD patients with different serum potassium levels were included in the present meta-analysis. Thirteen studies were included in the analysis. A nonlinear dose-response meta-analysis suggested that there is a J-shaped association between serum potassium levels and the risk of all-cause mortality, with a nadir at serum potassium of 4.5 mmol/L. Subgroup analyses indicated that the strength and shape of the association between serum potassium and all-cause mortality may be influenced by age. Our meta-analysis provides supportive evidence that there is a J-shape association between serum potassium and all-cause mortality among CKD patients.
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Affiliation(s)
- Nasim Sorraya
- Department of Community NutritionSchool of Nutrition and Food ScienceFood Security Research CenterIsfahan University of Medical SciencesIsfahanIran
| | | | - Bahar Hassani
- Department of NutritionAhvaz Jundishapur University of Medical SciencesAhvazIran
- Department of Health Safety and Environment (HSE)Razi Petrochemical CompanyMahshahrIran
| | - Shokoofeh Talebi
- Department of Clinical NutritionSchool of Nutrition and Food ScienceFood Security Research CenterIsfahan University of Medical SciencesIsfahanIran
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7
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Gimpel C, Bergmann C, Bockenhauer D, Breysem L, Cadnapaphornchai MA, Cetiner M, Dudley J, Emma F, Konrad M, Harris T, Harris PC, König J, Liebau MC, Marlais M, Mekahli D, Metcalfe AM, Oh J, Perrone RD, Sinha MD, Titieni A, Torra R, Weber S, Winyard PJD, Schaefer F. International consensus statement on the diagnosis and management of autosomal dominant polycystic kidney disease in children and young people. Nat Rev Nephrol 2019; 15:713-726. [PMID: 31118499 PMCID: PMC7136168 DOI: 10.1038/s41581-019-0155-2] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
These recommendations were systematically developed on behalf of the Network for Early Onset Cystic Kidney Disease (NEOCYST) by an international group of experts in autosomal dominant polycystic kidney disease (ADPKD) from paediatric and adult nephrology, human genetics, paediatric radiology and ethics specialties together with patient representatives. They have been endorsed by the International Pediatric Nephrology Association (IPNA) and the European Society of Paediatric Nephrology (ESPN). For asymptomatic minors at risk of ADPKD, ongoing surveillance (repeated screening for treatable disease manifestations without diagnostic testing) or immediate diagnostic screening are equally valid clinical approaches. Ultrasonography is the current radiological method of choice for screening. Sonographic detection of one or more cysts in an at-risk child is highly suggestive of ADPKD, but a negative scan cannot rule out ADPKD in childhood. Genetic testing is recommended for infants with very-early-onset symptomatic disease and for children with a negative family history and progressive disease. Children with a positive family history and either confirmed or unknown disease status should be monitored for hypertension (preferably by ambulatory blood pressure monitoring) and albuminuria. Currently, vasopressin antagonists should not be offered routinely but off-label use can be considered in selected children. No consensus was reached on the use of statins, but mTOR inhibitors and somatostatin analogues are not recommended. Children with ADPKD should be strongly encouraged to achieve the low dietary salt intake that is recommended for all children.
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Affiliation(s)
- Charlotte Gimpel
- Division of Pediatric Nephrology, Department of General Pediatrics, Adolescent Medicine and Neonatology, Center for Pediatrics, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg, Germany.
| | - Carsten Bergmann
- Department of Medicine IV, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Human Genetics, Bioscientia, Ingelheim, Germany
| | - Detlef Bockenhauer
- University College London, Great Ormond Street Hospital, Institute of Child Health, London, UK
| | - Luc Breysem
- Department of Pediatric Radiology, University Hospital of Leuven, Leuven, Belgium
| | - Melissa A Cadnapaphornchai
- Rocky Mountain Pediatric Kidney Center, Rocky Mountain Hospital for Children at Presbyterian St Luke's Medical Center, Denver, CO, USA
| | - Metin Cetiner
- Department of Pediatrics II, University Hospital Essen, Essen, Germany
| | - Jan Dudley
- Renal Department, Bristol Royal Hospital for Children, Bristol, UK
| | - Francesco Emma
- Division of Nephrology and Dialysis, Ospedale Pediatrico Bambino Gesù-IRCCS, Rome, Italy
| | - Martin Konrad
- Department of General Pediatrics, University Children's Hospital, Münster, Germany
| | - Tess Harris
- PKD International, Geneva, Switzerland
- PKD Charity, London, UK
| | - Peter C Harris
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Jens König
- Department of General Pediatrics, University Children's Hospital, Münster, Germany
| | - Max C Liebau
- Department of Pediatrics and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Matko Marlais
- University College London, Great Ormond Street Hospital, Institute of Child Health, London, UK
| | - Djalila Mekahli
- Department of Pediatric Nephrology, University Hospital of Leuven, Leuven, Belgium
- PKD Research Group, Laboratory of Pediatrics, Department of Development and Regeneration, GPURE, KU Leuven, Leuven, Belgium
| | - Alison M Metcalfe
- Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
| | - Jun Oh
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ronald D Perrone
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Manish D Sinha
- Kings College London, Department of Paediatric Nephrology, Evelina London Children's Hospital, London, UK
| | - Andrea Titieni
- Department of General Pediatrics, University Children's Hospital, Münster, Germany
| | - Roser Torra
- Department of Nephrology, University of Barcelona, Barcelona, Spain
| | - Stefanie Weber
- Department of Pediatrics, University of Marburg, Marburg, Germany
| | - Paul J D Winyard
- University College London, Great Ormond Street Hospital, Institute of Child Health, London, UK
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University Hospital, Heidelberg, Germany
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8
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Should ACE inhibitors and ARBs be used in combination in children? Pediatr Nephrol 2019; 34:1521-1532. [PMID: 30112656 PMCID: PMC7058114 DOI: 10.1007/s00467-018-4046-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/30/2018] [Accepted: 08/03/2018] [Indexed: 10/28/2022]
Abstract
The renin-angiotensin-aldosterone system (RAAS) plays a pivotal role in a host of renal and cardiovascular functions. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), drugs that disrupt RAAS function, are effective in treating hypertension and offer other renoprotective effects independent of blood pressure (BP) reduction. As our understanding of RAAS physiology and the feedback mechanisms of ACE inhibition and angiotensin receptor blockade have improved, questions have been raised as to whether combination ACEI/ARB therapy is warranted in certain patients with incomplete angiotensin blockade on one agent. In this review, we discuss the rationale for combination ACEI/ARB therapy and summarize the results of key adult studies and the limited pediatric literature that have investigated this therapeutic approach. We additionally review novel therapies that have been developed over the past decade as alternative approaches to combination ACEI/ARB therapy, or that may be potentially used in combination with ACEIs or ARBs, in which further adult and pediatric studies are needed.
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9
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Dyskalemia, its patterns, and prognosis among patients with incident heart failure: A nationwide study of US veterans. PLoS One 2019; 14:e0219899. [PMID: 31393910 PMCID: PMC6687136 DOI: 10.1371/journal.pone.0219899] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 07/04/2019] [Indexed: 12/01/2022] Open
Abstract
Background Although hypokalemia has been viewed as a significant concern among patients with heart failure (HF), recent advances in HF management tend to increase the risk of hyperkalemia. Objective To characterize contemporary data regarding correlates and prognostic values of dyskalemia in patients with HF. Design, setting, and participants In cross-sectional and longitudinal analyses, we studied 142,087 patients with newly diagnosed HF in US nationwide Veterans Administration database from 2005 through 2013. Exposures Demographic characteristics, laboratory variables, comorbidities, and medication use for the analysis of correlates of dyskalemia as well as potassium level in the analysis of mortality. Main Outcomes and Measures Dyskalemia and mortality. Results Hypokalemia (<3.5 mmol/L) at baseline was observed in 3.0% of the population, whereas hyperkalemia (≥5.5 mmol/L) was seen in 0.9%. An additional 20.4% and 5.7% had mild hypokalemia (3.5–3.9 mmol/L) and mild hyperkalemia (5.0–5.4 mmol/L). Key correlates were black race, higher blood pressure, and use of potassium-wasting diuretics for hypokalemia, and lower kidney function for hyperkalemia. Baseline potassium levels showed a U-shaped association with mortality, with the lowest risk between 4.0–4.5 mmol/L. With respect to potassium levels over a year after HF diagnosis, persistent (>50% of measurements), intermittent (>1 occurrence but ≤50%), and transient (1 occurrence) hypo- and hyperkalemia were also related to increased mortality in a graded fashion regardless of the aforementioned thresholds for dyskalemia. These dyskalemic patterns were also related to other clinical actions and demands such as emergency room visit. Conclusions Potassium levels below 4 mmol/L and above 5 mmol/L at and after HF diagnosis were associated with poor prognosis and the clinical actions. HF patients (particularly with risk factors for dyskalemia like black race and kidney dysfunction) may require special attention for both hypo- and hyperkalemia.
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10
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Lindhardt M, Persson F, Oxlund C, Jacobsen IA, Zürbig P, Mischak H, Rossing P, Heerspink HJL. Predicting albuminuria response to spironolactone treatment with urinary proteomics in patients with type 2 diabetes and hypertension. Nephrol Dial Transplant 2019; 33:296-303. [PMID: 28064163 DOI: 10.1093/ndt/gfw406] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 10/24/2016] [Indexed: 01/07/2023] Open
Abstract
Background The mineralocorticoid receptor antagonist spironolactone significantly reduces albuminuria in patients with diabetes. Prior studies have shown large between-patient variability in albuminuria treatment response. We previously developed and validated a urinary proteomic classifier that predicts onset and progression of chronic kidney disease. Here, we tested whether the proteomic classifier based on 273 urinary peptides (CKD273) predicts albuminuria response to spironolactone treatment. Methods We performed a post hoc analysis in a double-blind randomized clinical trial with allocation to either spironolactone 12.5-50 mg/day (n = 57) or placebo (n = 54) for 16 weeks. Patients were diagnosed with type 2 diabetes and resistant hypertension. Treatment was an adjunct to renin-angiotensin system inhibition. Primary endpoint was the percentage change in urine albumin to creatinine ratio (UACR). Capillary electrophoresis mass spectrometry was used to quantify urinary peptides at baseline. The previously validated combination of 273 known urinary peptides was used as proteomic classifier. Results Spironolactone reduced UACR relative to placebo by 50%, although with a large between-patient variability in UACR response (5th to 95th percentile, 7 to 312%). An interaction was detected between CKD273 and treatment assignment (β = -1.09, P = 0.026). Higher values of CKD273 at baseline were associated with a larger reduction in UACR in the spironolactone group (β = -0.70, P = 0.049), but not in the placebo group (β = 0.39, P = 0.25). Stratified in tertiles of baseline CKD273, reduction in UACR was greater in the highest tertile, 63% (95% confidence interval: 35-79%), as compared with the two other tertiles combined, 16% (-17 to 40%) (P = 0.011). Conclusions A urinary proteomics classifier can be used to identify individuals with type 2 diabetes who are more likely to show an albuminuria-lowering response to spironolactone treatment. These results suggest that urinary proteomics may be a valuable tool to tailor therapy, but confirmation in a larger clinical trial is required.
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Affiliation(s)
| | | | - Christina Oxlund
- University of Southern Denmark, Research Unit for Cardiovascular and renal protection, Odense, Denmark
| | - Ib A Jacobsen
- University of Southern Denmark, Research Unit for Cardiovascular and renal protection, Odense, Denmark
| | | | | | - Peter Rossing
- Faculty of Heath, University of Aarhus, Aarhus, Denmark.,The Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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11
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Zhu Q, Li X, Tan F, Deng Y, Gong C, Hu J, Huang P, Zhou S. Prevalence and risk factors for hypokalemia in patients scheduled for laparoscopic colorectal resection and its association with post-operative recovery. BMC Gastroenterol 2018; 18:152. [PMID: 30340534 PMCID: PMC6194555 DOI: 10.1186/s12876-018-0876-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 09/27/2018] [Indexed: 02/05/2023] Open
Abstract
Background Perioperative serum potassium levels are closely associated with postoperative clinical outcomes after gastrointestinal surgery. The aim of our retrospective study was to identify the prevalence and risk factors for preoperative hypokalemia (before pneumoperitoneum) and to evaluate the influence of preoperative hypokalemia on the recovery of postoperative gastrointestinal function. Methods In this retrospective study, patients scheduled for laparoscopic colorectal resection from November 11 2014 to October 20 2016, were considered for inclusion. A blood potassium level between 3.5 and 5.5 mmol/L was defined as normal, with levels between 3.0 to 3.5 mmol/L, 2.5 to 3.0 mmol/L and < 2.5 mmol/L considered as slight, moderate, and severe level of hypokalemia. The factors including age, gender, ASA grade, BMI, hypertension, diabetes, anti-hypertension drugs, lactose oral soluble, oral cathartics, oral cathartics, cathartic enemas, and blood potassium level before gastrointestinal preparation which might be associated with blood potassium level before pneumoperitoneum were analysed. The time to postoperative first flatus (FFL) and first feces (FFE) was compared between patients with and without hypokalemia. Results The final analysis was based on the data of 108 patients. Hypokalemia was identified in 70.37% patients, with the following distribution of blood potassium levels before pneumoperitoneum: slight, 49 (45.37%) patients; moderate, 23 (21.30%); and severe, 4 (3.70%) patients. Hypokalemia was significantly associated with hypertension and the use of ≥2 types of oral cathartics for preoperative gastrointestinal preparation. With treatment, potassium levels recovered to normal levels in all patients within 48 h postoperatively. Hypokalemia was associated with a longer postoperative time to first feces, compared to patients with a normal potassium level before pneumoperitoneum. Conclusions Our findings underlie the importance of early monitoring and management of serum potassium levels in these patients.
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Affiliation(s)
- Qianqian Zhu
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-Sen University, 600th Tianhe Road, Tianhe District, 510360, Guangzhou City, People's Republic of China.,Department of Anesthesiology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen City, People's Republic of China
| | - Xianlong Li
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-Sen University, 600th Tianhe Road, Tianhe District, 510360, Guangzhou City, People's Republic of China
| | - Fang Tan
- Department of Anesthesiology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen City, People's Republic of China
| | - Yingqing Deng
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-Sen University, 600th Tianhe Road, Tianhe District, 510360, Guangzhou City, People's Republic of China
| | - Chulian Gong
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-Sen University, 600th Tianhe Road, Tianhe District, 510360, Guangzhou City, People's Republic of China
| | - Jingping Hu
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-Sen University, 600th Tianhe Road, Tianhe District, 510360, Guangzhou City, People's Republic of China
| | - Pinjie Huang
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-Sen University, 600th Tianhe Road, Tianhe District, 510360, Guangzhou City, People's Republic of China.
| | - Shaoli Zhou
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-Sen University, 600th Tianhe Road, Tianhe District, 510360, Guangzhou City, People's Republic of China.
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12
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Heerspink HJL, Andress DL, Bakris G, Brennan JJ, Correa‐Rotter R, Dey J, Hou FF, Kitzman DW, Kohan D, Makino H, McMurray J, Perkovic V, Tobe S, Wigderson M, Parving H, de Zeeuw D. Rationale and protocol of the Study Of diabetic Nephropathy with AtRasentan (SONAR) trial: A clinical trial design novel to diabetic nephropathy. Diabetes Obes Metab 2018; 20:1369-1376. [PMID: 29405626 PMCID: PMC5969254 DOI: 10.1111/dom.13245] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/30/2018] [Accepted: 02/01/2018] [Indexed: 02/06/2023]
Abstract
AIMS Individuals with diabetes and chronic kidney disease (CKD) are at high risk for renal events. Recent trials of novel treatments have been negative, possibly because of variability in response to treatment of the target risk factor. Atrasentan is a selective endothelin A receptor antagonist that reduces urinary albumin-to-creatinine ratio (UACR), with a large variability between patients. We are assessing its effect on renal outcomes in the Study Of diabetic Nephropathy with AtRasentan (SONAR; NCT01858532) with an enrichment design (>30% lowering of albuminuria) to select patients most likely to benefit. MATERIALS AND METHODS SONAR is a randomized, double-blind, placebo-controlled trial with approximately 3500 participants who have stage 2-4 CKD and macroalbuminuria and are receiving a maximum tolerated dose of a renin-angiotensin system inhibitor. RESULTS After 6 weeks of exposure to atrasentan 0.75 mg once daily (enrichment period), participants with ≥30% UACR decrease and no tolerability issues (responders) were randomly assigned to placebo or atrasentan 0.75 mg/day. The responder group will be used for primary efficacy and safety analyses. Approximately 1000 participants with <30% UACR reduction (non-responders) were also randomized to placebo or atrasentan. The primary endpoint is a composite of a sustained doubling of serum creatinine or end-stage renal disease. The original power calculation indicated that a total of 425 primary renal events in the responder group provides 90% power to detect a 27% reduction in relative risk (alpha level of .05). CONCLUSION SONAR aims to determine whether atrasentan added to guideline-recommended therapies safely reduces the risk of CKD progression and delays the onset of end-stage renal disease in patients with type 2 diabetes and nephropathy. SONAR also aims to establish whether the enrichment of patients based on their initial "surrogate" response to atrasentan will deliver a trial design in accord with personalized treatment of diabetic kidney disease.
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Affiliation(s)
- Hiddo J. L. Heerspink
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
| | | | - George Bakris
- Department of Medicine, Section of Endocrinology, ASH Comprehensive Hypertension CenterUniversity of Chicago Medicine and Biological SciencesChicagoIllinois
| | | | - Ricardo Correa‐Rotter
- Department of Nephrology and Mineral Metabolism, National Medical Science and Nutrition Institute Salvador ZubiránMexico CityMexico
| | | | - Fan Fan Hou
- Division of NephrologyNanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney DiseaseGuangzhouChina
| | - Dalane W. Kitzman
- Department of Internal MedicineWake Forest School of MedicineWinston‐SalemNorth Carolina
| | - Donald Kohan
- Division of NephrologyUniversity of Utah Health Sciences CenterSalt Lake CityUtah
| | - Hirofumi Makino
- Department of Nephrology, Rheumatology, Endocrinology and MetabolismOkayama UniversityOkayama‐ShiJapan
| | - John McMurray
- BHF Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
| | - Vlado Perkovic
- Faculty of MedicineGeorge Institute for Global Health, UNSW SydneyNewtownAustralia
| | - Sheldon Tobe
- Department of Medicine, Division of NephrologySunnybrook Health Sciences Centre, University of Toronto and the Northern Ontario School of MedicineTorontoCanada
| | | | - Hans‐Henrik Parving
- Department of Medical Endocrinology, RigshospitaletUniversity of CopenhagenCopenhagenDenmark
- Faculty of Health ScienceAarhus UniversityAarhusDenmark
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
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13
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Kovesdy CP, Matsushita K, Sang Y, Brunskill NJ, Carrero JJ, Chodick G, Hasegawa T, Heerspink HL, Hirayama A, Landman GWD, Levin A, Nitsch D, Wheeler DC, Coresh J, Hallan SI, Shalev V, Grams ME. Serum potassium and adverse outcomes across the range of kidney function: a CKD Prognosis Consortium meta-analysis. Eur Heart J 2018; 39:1535-1542. [PMID: 29554312 PMCID: PMC5930249 DOI: 10.1093/eurheartj/ehy100] [Citation(s) in RCA: 193] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 11/22/2017] [Accepted: 02/14/2018] [Indexed: 12/20/2022] Open
Abstract
Aims Both hypo- and hyperkalaemia can have immediate deleterious physiological effects, and less is known about long-term risks. The objective was to determine the risks of all-cause mortality, cardiovascular mortality, and end-stage renal disease associated with potassium levels across the range of kidney function and evaluate for consistency across cohorts in a global consortium. Methods and results We performed an individual-level data meta-analysis of 27 international cohorts [10 general population, 7 high cardiovascular risk, and 10 chronic kidney disease (CKD)] in the CKD Prognosis Consortium. We used Cox regression followed by random-effects meta-analysis to assess the relationship between baseline potassium and adverse outcomes, adjusted for demographic and clinical characteristics, overall and across strata of estimated glomerular filtration rate (eGFR) and albuminuria. We included 1 217 986 participants followed up for a mean of 6.9 years. The average age was 55 ± 16 years, average eGFR was 83 ± 23 mL/min/1.73 m2, and 17% had moderate- to-severe increased albuminuria levels. The mean baseline potassium was 4.2 ± 0.4 mmol/L. The risk of serum potassium of >5.5 mmol/L was related to lower eGFR and higher albuminuria. The risk relationship between potassium levels and adverse outcomes was U-shaped, with the lowest risk at serum potassium of 4-4.5 mmol/L. Compared with a reference of 4.2 mmol/L, the adjusted hazard ratio for all-cause mortality was 1.22 [95% confidence interval (CI) 1.15-1.29] at 5.5 mmol/L and 1.49 (95% CI 1.26-1.76) at 3.0 mmol/L. Risks were similar by eGFR, albuminuria, renin-angiotensin-aldosterone system inhibitor use, and across cohorts. Conclusions Outpatient potassium levels both above and below the normal range are consistently associated with adverse outcomes, with similar risk relationships across eGFR and albuminuria.
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Affiliation(s)
- Csaba P Kovesdy
- University of Tennessee Health Science Center, Memphis, TN, USA
- Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Nigel J Brunskill
- Department of Infection Immunity and Inflammation, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester, Leicester, UK
| | - Juan J Carrero
- Department of Medical Epidemiology and Biosatistics (MEB), Karolinska Institutet, Stockholm, Sweden
| | - Gabriel Chodick
- Medical Division, Maccabi Healthcare Services, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Takeshi Hasegawa
- Showa University, Office for Promoting Medical Research, Tokyo, Japan
- Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
- Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Public Health, Kyoto, Japan
| | - Hiddo L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Atsushi Hirayama
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | | | - Adeera Levin
- BC Provincial Renal Agency, Vancouver, BC, Canada
- University of British Columbia, Vancouver, BC, Canada
| | - Dorothea Nitsch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - David C Wheeler
- Centre for Nephrology, University College London, London, UK
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Stein I Hallan
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science Technology, Trondheim, Norway
- Division of Nephrology, Department of Medicine, St Olav University Hospital, Trondheim, Norway
| | - Varda Shalev
- Medical Division, Maccabi Healthcare Services, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
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14
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Impact of Different Serum Potassium Levels on Postresuscitation Heart Function and Hemodynamics in Patients with Nontraumatic Out-of-Hospital Cardiac Arrest. Bioinorg Chem Appl 2018; 2018:5825929. [PMID: 29849540 PMCID: PMC5907484 DOI: 10.1155/2018/5825929] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/25/2018] [Accepted: 03/19/2018] [Indexed: 12/20/2022] Open
Abstract
Background Sustained return of spontaneous circulation (ROSC) can be initially established in patients with out-of-hospital cardiac arrest (OHCA); however, the early postresuscitation hemodynamics can still be impaired by high levels of serum potassium (hyperkalemia). The impact of different potassium levels on early postresuscitation heart function has remained unclear. We aim to analyze the relationship between different levels of serum potassium and postresuscitation heart function during the early postresuscitation period (the first hour after achieving sustained ROSC). Methods Information on 479 nontraumatic OHCA patients with sustained ROSC was retrospectively obtained. Measures of early postresuscitation heart function (rate, blood pressure, and rhythm), hemodynamics (urine output and blood pH), and the duration of survival were analyzed in the case of different serum potassium levels (low: <3.5; normal: 3.5–5; high: >5 mmol/L). Results Most patients (59.9%, n = 287) had previously presented with high levels of potassium. Bradycardia, nonsinus rhythm, urine output <1 ml/kg/hr, and acidosis (pH < 7.35) were more common in patients with high levels of potassium (all p < 0.05). Compared with hyperkalemia, a normal potassium level was more likely to be associated with a normal heart rate (OR: 2.97, 95% CI: 1.74–5.08) and sinus rhythm (OR: 2.28, 95% CI: 1.45–3.58). A low level of potassium was more likely to be associated with tachycardia (OR: 3.54, 95% CI: 1.32–9.51), urine output >1 ml/kg/hr (OR: 5.35, 95% CI: 2.58–11.10), and nonacidosis (blood pH >7.35, OR: 7.74, 95% CI: 3.78–15.58). The duration of survival was shorter in patients with hyperkalemia than that in patients whose potassium levels were low or normal (p < 0.05). Conclusion Early postresuscitation heart function and hemodynamics were associated with the serum potassium level. A high potassium level was more likely to be associated with bradycardia, nonsinus rhythm, urine output <1 ml/kg/hr, and acidosis. More importantly, a high potassium level decreased the duration of survival.
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15
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Affiliation(s)
- Federico Guerra
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Italy
| | - Alessandro Capucci
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Italy
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16
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Cao L, Zhang S, Jia CM, He W, Wu LT, Li YQ, Wang W, Li Z, Ma J. Antihypertensive drugs use and the risk of prostate cancer: a meta-analysis of 21 observational studies. BMC Urol 2018. [PMID: 29514670 PMCID: PMC5842557 DOI: 10.1186/s12894-018-0318-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background Due to the lack of strong evidence to identify the relationship between antihypertensive drugs use and the risk of prostate cancer, it was needed to do a systematic review to go into the subject. Methods We systematically searched PubMed, Web of Science and Embase to identify studies published, through May 2015. Two evaluators independently reviewed and selected articles involving the subject. We used the Newcastle-Ottawa Scale (NOS) to assess the quality of the studies. All extracted results to evaluate the relationship between antihypertensive drugs usage and prostate cancer risk were pool-analysed using Stata 12.0 software. Results A total of 12 cohort and 9 case-control studies were ultimately included in our review. Most of the studies were evaluated to be of high quality. There was no significant relationship between angiotensin converting enzyme inhibitors (ACEI) usage and the risk of prostate cancer (RR 1.07, 95% CI 0.96–1.20), according to the total pool-analysed. Use of angiotensin receptor blocker (ARB) was not associated with the risk of prostate cancer (RR 1.09, 95% CI 0.97–1.21), while use of CCB may well increase prostate cancer risk based on the total pool-analysed (RR 1.08, 95% CI 1–1.16). Moreover, subgroup analysis suggested that use of CCB clearly increased prostate cancer risk (RR 1.10, 95% CI 1.04–1.16) in terms of case-control studies. There was also no significant relationship between use of diuretic (RR 1.09, 95% CI 0.95–1.25) or antiadrenergic agents (RR 1.22, 95% CI 0.76–1.96) and prostate cancer risk. Conclusions There is no significant relationship between the use of antihypertensive drugs (ACEI, ARB, beta-blockers and diuretics) and prostate cancer risk, but CCB may well increase prostate cancer risk, according to existing observational studies. Electronic supplementary material The online version of this article (10.1186/s12894-018-0318-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Liang Cao
- Department of Traditional Chinese Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, People's Republic of China
| | - Sha Zhang
- Shanxi University of Chinese Medicine, Xian yang, 712046, People's Republic of China
| | - Cheng-Ming Jia
- Department of Traditional Chinese Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, People's Republic of China
| | - Wei He
- Shanxi University of Chinese Medicine, Xian yang, 712046, People's Republic of China
| | - Lei-Tao Wu
- Department of Traditional Chinese Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, People's Republic of China
| | - Ying-Qi Li
- Department of Traditional Chinese Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, People's Republic of China
| | - Wen Wang
- Department of Traditional Chinese Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, People's Republic of China
| | - Zhe Li
- Shanxi University of Chinese Medicine, Xian yang, 712046, People's Republic of China.
| | - Jing Ma
- Department of Traditional Chinese Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, People's Republic of China.
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17
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Colombo MG, Kirchberger I, Amann U, Dinser L, Meisinger C. Association of serum potassium concentration with mortality and ventricular arrhythmias in patients with acute myocardial infarction: A systematic review and meta-analysis. Eur J Prev Cardiol 2018; 25:576-595. [DOI: 10.1177/2047487318759694] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Challenging clinical practice guidelines that recommend serum potassium concentration between 4.0–5.0 mEq/L or ≥4.5 mEq/L in patients with acute myocardial infarction, recent studies found increased mortality risks in patients with a serum potassium concentration of ≥4.5 mEq/L. Studies investigating consequences of hypokalemia after acute myocardial infarction revealed conflicting results. Therefore, the aim of this systematic review and meta-analysis was to combine evidence from previous studies on the association of serum potassium concentration with both short and long-term mortality as well as the occurrence of ventricular arrhythmias. Design Systematic review and meta-analysis. Methods A structured search of MEDLINE and EMBASE databases yielded 23 articles published between 1990 and January 2017 that met the inclusion criteria. Study selection, data extraction and quality assessment were carried out by three reviewers. Random effects models were used to pool estimates across the included studies and sensitivity analyses were performed when possible. Results Twelve studies were included in the meta-analysis. Both pooled results from six studies investigating short-term mortality and from five studies examining long-term mortality revealed significantly increased risks in patients with serum potassium concentrations of <3.5 mEq/L, 4.5–<5.0 mEq/L and ≥5.0 mEq/L after acute myocardial infarction. In addition, a serum potassium concentration of <3.5 mEq/L was significantly associated with the occurrence of ventricular arrhythmias. Conclusions Mortality, both short and long term, and the occurrence of ventricular arrhythmias in patients with acute myocardial infarction seem to be negatively associated with hypokalemic serum potassium concentration. There is evidence for adverse consequences of serum potassium concentrations of ≥4.5 mEq/L. Due to the heterogeneity among existing studies, further research is necessary to confirm the need to change clinical practice guidelines.
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Affiliation(s)
- Miriam Giovanna Colombo
- MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Germany
| | - Inge Kirchberger
- MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Germany
- Chair of Epidemiology, UNIKA-T, Ludwig-Maximilians-Universität München, Germany
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERcv), Spain
| | - Ute Amann
- MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Germany
- Chair of Epidemiology, UNIKA-T, Ludwig-Maximilians-Universität München, Germany
| | - Lisa Dinser
- MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Germany
| | - Christa Meisinger
- MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Germany
- Chair of Epidemiology, UNIKA-T, Ludwig-Maximilians-Universität München, Germany
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Al‐Naher A, Wright D, Devonald MAJ, Pirmohamed M. Renal function monitoring in heart failure - what is the optimal frequency? A narrative review. Br J Clin Pharmacol 2018; 84:5-17. [PMID: 28901643 PMCID: PMC5736847 DOI: 10.1111/bcp.13434] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 08/31/2017] [Accepted: 09/05/2017] [Indexed: 12/29/2022] Open
Abstract
The second most common cause of hospitalization due to adverse drug reactions in the UK is renal dysfunction due to diuretics, particularly in patients with heart failure, where diuretic therapy is a mainstay of treatment regimens. Therefore, the optimal frequency for monitoring renal function in these patients is an important consideration for preventing renal failure and hospitalization. This review looks at the current evidence for optimal monitoring practices of renal function in patients with heart failure according to national and international guidelines on the management of heart failure (AHA/NICE/ESC/SIGN). Current guidance of renal function monitoring is in large part based on expert opinion, with a lack of clinical studies that have specifically evaluated the optimal frequency of renal function monitoring in patients with heart failure. Furthermore, there is variability between guidelines, and recommendations are typically nonspecific. Safer prescribing of diuretics in combination with other antiheart failure treatments requires better evidence for frequency of renal function monitoring. We suggest developing more personalized monitoring rather than from the current medication-based guidance. Such flexible clinical guidelines could be implemented using intelligent clinical decision support systems. Personalized renal function monitoring would be more effective in preventing renal decline, rather than reacting to it.
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Affiliation(s)
- Ahmed Al‐Naher
- The Wolfson Centre for Personalised MedicineThe University of LiverpoolLiverpoolUK
| | - David Wright
- Institute of Cardiovascular Medicine and ScienceLiverpool Heart and Chest HospitalLiverpoolUK
| | | | - Munir Pirmohamed
- The Wolfson Centre for Personalised MedicineThe University of LiverpoolLiverpoolUK
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19
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Campbell KL, Rangan GK, Lopez-Vargas P, Tong A. KHA-CARI Autosomal Dominant Polycystic Kidney Disease Guideline: Diet and Lifestyle Management. Semin Nephrol 2016; 35:572-581.e17. [PMID: 26718161 DOI: 10.1016/j.semnephrol.2015.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Katrina L Campbell
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, QLD, Australia; Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia.
| | - Gopala K Rangan
- Department of Renal Medicine, Westmead Hospital, Western Sydney Local Health District, Sydney, Australia; Centre for Transplant and Renal Research, Westmead Institute for Medical Research, University of Sydney, Westmead, Sydney, Australia
| | - Pamela Lopez-Vargas
- KHA-CARI Guidelines, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Sydney, Australia; Sydney School of Public Health, University of Sydney, NSW, Australia
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
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20
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Chang M. Challenges and Considerations in the Management of Hyperkalaemia in Patients With Chronic Kidney Disease. EUROPEAN MEDICAL JOURNAL 2016. [DOI: 10.33590/emj/10310466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
rof David Goldsmith opened the symposium by highlighting the objectives of the meeting. The education objectives of the symposium were to summarise the mechanisms that regulate potassium balance, specifically highlighting how these mechanisms are affected by inhibition of the renin-angiotensinaldosterone system (RAAS); to examine the pathophysiology of hyperkalaemia and illustrate the impact on clinical outcomes; to evaluate current clinical evidence and outline key considerations that help determine the urgency; and to describe recent clinical trial data on investigational oral ion exchangers and the potential future role of these emerging therapies in clinical practice.
In the first presentation, Prof Johannes F. E. Mann discussed the predisposing factors of hyperkalaemia by presenting a case of a heart failure (HF) patient with Stage 3 chronic kidney disease (CKD), and also discussed the epidemiology and pathophysiology of hyperkalaemia. Dr Martin H. de Borst then discussed the current therapeutic options available for the outpatient treatment of hyperkalaemia, along with recent clinical data on novel treatments, in particular patiromer and zirconium cyclosilicate (known as ZS-9).
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Ziff OJ, Covic A, Goldsmith D. Calibrating the impact of dual RAAS blockade on the heart and the kidney - balancing risks and benefits. Int J Clin Pract 2016; 70:537-53. [PMID: 27278080 DOI: 10.1111/ijcp.12803] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Overactivity of the renin-angiotensin-aldosterone system (RAAS) plays a key role in the pathophysiology of heart failure (HF) and chronic kidney disease (CKD). RAAS antagonists can significantly improve clinical outcomes, but monotherapy blocks but one step of the RAAS and can be bypassed through compensatory mechanisms. Providing more complete RAAS blockade by deploying drugs with complementary actions seemed logical - hence the practice of using dual (or triple) RAAS inhibitors. However, RAAS antagonists also exhibit dose-limiting side effects, including acute kidney injury, hyperkalaemia and hypotension, which blunt their overall effectiveness. Despite achieving better RAAS blockade, several trials failed to show clinical outcome improvements. Patients with concomitant CKD and HF (cardiorenal syndrome) are at the greatest risk of these adverse events and therefore the least able to benefit, yet they also have the worst prognosis. This paradox, where those most in need have fewest therapeutic options, poses three questions which are the focus of this review: whether (i) novel therapies that prevent adverse effects can restore therapeutic benefits to patients who would otherwise be RAAS-therapy intolerant, (ii) there are any validated alternatives to their use and (iii) newer approaches to the detection of fluid congestion are ready for implementation.
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Affiliation(s)
- O J Ziff
- Institute of Cardiovascular Science, University College London, London, UK
| | - A Covic
- 'Gr. T. Popa' University of Medicine and 'C. I. Parhon' University Hospital Iasi, Lasi, Romania
| | - D Goldsmith
- Department of Nephrology, King's Health Partners Academic Health Sciences Centre, London, UK
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Abstract
Hyperkalemia is a common electrolyte disturbance with multiple potential etiologies. It is usually observed in the setting of reduced renal function. Mild to moderate hyperkalemia is usually asymptomatic, but is associated with poor prognosis. When severe, hyperkalemia may cause serious acute cardiac arrhythmias and conduction abnormalities, and may result in sudden death. The rising prevalence of conditions associated with hyperkalemia (heart failure, chronic kidney disease, and diabetes) and broad use of renin-angiotensin-aldosterone system (RAAS) inhibitors and mineralocorticoid receptor antagonists (MRAs), which improve patient outcomes but increase the risk of hyperkalemia, have led to a significant rise in hyperkalemia-related hospitalizations and deaths. Current non-invasive therapies for hyperkalemia either do not remove excess potassium or have poor efficacy and tolerability. There is a clear need for safer, more effective potassium-lowering therapies suitable for both acute and chronic settings. Patiromer sorbitex calcium and sodium zirconium cyclosilicate (ZS-9) are two new potassium-lowering compounds currently in development. Although they have not yet been approved by the US FDA, both have demonstrated efficacy and safety in recent trials. Patiromer sorbitex calcium is a polymer resin and sorbitol complex that binds potassium in exchange for calcium; ZS-9, a non-absorbed, highly selective inorganic cation exchanger, traps potassium in exchange for sodium and hydrogen. This review discusses the merits of both novel drugs and how they may help optimize the future management of patients with hyperkalemia.
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Affiliation(s)
- David K Packham
- The Melbourne Renal Research Group, Department of Medicine, University of Melbourne, 73 Pine St., Reservoir, Melbourne, VIC, 3073, Australia.
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, VIC, Australia.
| | - Mikhail Kosiborod
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- Department of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
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Abstract
Significant improvements in the morbidity and mortality associated with chronic heart failure have been gained with the use ACE inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists, and diuretics. However, the use of these agents is often limited by their propensity to precipitate worsening renal function and hyperkalemia, particularly in patients with chronic kidney disease. Several pharmacologic agents have been developed in recent years that utilize the gastrointestinal tract as an alternate route for drug absorption, electrolyte exchange, and drug and electrolyte elimination. The existing data establishing the safety and efficacy of these novel agents will be the focus of this review.
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Affiliation(s)
- Alanna A Morris
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA,
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24
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Surrogate endpoints in clinical trials of chronic kidney disease progression. Curr Opin Nephrol Hypertens 2015; 24:492-7. [DOI: 10.1097/mnh.0000000000000159] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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25
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Keyzer CA, de Jong MA, Fenna van Breda G, Vervloet MG, Laverman GD, Hemmelder M, Janssen WM, Lambers Heerspink HJ, Navis G, de Borst MH. Vitamin D receptor activator and dietary sodium restriction to reduce residual urinary albumin excretion in chronic kidney disease (ViRTUE study): rationale and study protocol. Nephrol Dial Transplant 2015; 31:1081-7. [PMID: 25744274 DOI: 10.1093/ndt/gfv033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 01/18/2015] [Indexed: 12/30/2022] Open
Abstract
UNLABELLED Optimal albuminuria reduction is considered essential to halting chronic kidney disease (CKD) progression. Both vitamin D receptor activator (VDRA) treatment and dietary sodium restriction potentiate the efficacy of renin-angiotensin-aldosterone-system (RAAS) blockade to reduce albuminuria. The ViRTUE study addresses whether a VDRA in combination with dietary sodium restriction provides further albuminuria reduction in non-diabetic CKD patients on top of RAAS blockade. The ViRTUE study is an investigator-initiated, prospective, multi-centre, randomized, double-blind (paricalcitol versus placebo), placebo-controlled trial targeting stage 1-3 CKD patients with residual albuminuria of >300 mg/day due to non-diabetic glomerular disease, despite angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use. During run-in, all subjects switched to standardized RAAS blockade (ramipril 10 mg/day) and blood pressure titrated to <140/90 mmHg according to a standardized protocol. Eligible patients are subsequently enrolled and undergo four consecutive study periods in random order of 8 weeks each: (i) paricalcitol (2 µg/day) combined with a liberal sodium diet (∼200 mmol Na(+)/day, i.e. mean sodium intake in the general population), (ii) paricalcitol (2 µg/day) combined with dietary sodium restriction (target: 50 mmol Na(+)/day), (iii) placebo combined with a liberal sodium diet and (iv) placebo combined with dietary sodium restriction. Data are collected at the end of each study period. The primary outcome is 24-h urinary albumin excretion. Secondary study outcomes are blood pressure, renal function (estimated glomerular filtration rate), plasma renin activity and, in a sub-population (N = 9), renal haemodynamics (measured glomerular filtration rate and effective renal plasma flow). A sample size of 50 patients provides 90% power to detect a 23% reduction in albuminuria, assuming a 25% dropout rate. Further reduction of residual albuminuria by combination of VDRA treatment and sodium restriction during single-agent RAAS-blockade will justify long-term studies on cardiorenal outcomes and safety. CLINICAL TRIAL REGISTRATION NTR2898 (Dutch trial register).
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Affiliation(s)
- Charlotte A Keyzer
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten A de Jong
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - G Fenna van Breda
- Department of Nephrology and Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Marc G Vervloet
- Department of Nephrology and Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Gozewijn D Laverman
- Department of Internal Medicine, Division of Nephrology, ZGT Hospital, Almelo, The Netherlands
| | - Marc Hemmelder
- Department of Internal Medicine, Division of Nephrology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Wilbert M Janssen
- Department of Internal Medicine, Division of Nephrology, Martini Hospital Groningen, Groningen, The Netherlands
| | - Hiddo J Lambers Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gerjan Navis
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin H de Borst
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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26
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Clinical trials: New nonabsorbable potassium-exchange resins in hyperkalaemia. Nat Rev Nephrol 2015; 11:205-6. [PMID: 25599617 DOI: 10.1038/nrneph.2014.252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Michel A, Martín-Pérez M, Ruigómez A, García Rodríguez LA. Risk factors for hyperkalaemia in a cohort of patients with newly diagnosed heart failure: a nested case-control study in UK general practice. Eur J Heart Fail 2015; 17:205-13. [PMID: 25581138 DOI: 10.1002/ejhf.226] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/09/2014] [Accepted: 12/12/2014] [Indexed: 12/22/2022] Open
Abstract
AIMS The aim of this study was to identify risk factors for hyperkalaemia in a cohort of patients with newly diagnosed heart failure in the UK. METHODS AND RESULTS A nested case-control study was conducted using data from The Health Improvement Network primary care database. A cohort of 19 194 patients aged 1-89 years between January 2000 and December 2005 with newly diagnosed heart failure was followed up and cases of hyperkalaemia identified. Cases were frequency matched to controls by age, sex, and calendar year, and information on demographics, co-morbidities, co-medications, and lifestyle factors was extracted from the database. Using unconditional logistic regression models, odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to identify potential risk factors. In total, 2176 hyperkalaemia cases were identified over a mean follow-up of 3.9 years. Significant risk factors for hyperkalaemia were: renal failure (OR 3.81; 95% CI 3.29-4.42), type II diabetes (OR 1.52; 95% CI 1.31-1.75), valvular heart disease (OR 1.28; 95% CI 1.06-1.54), and current use of potassium-sparing diuretics (OR 3.01; 95% CI 2.61-3.48), ACE inhibitors (OR 1.70; 95% CI 1.41-2.04), trimethoprim (OR 2.82; 95% CI 1.88-4.23), non-steroidal anti-inflammatory drugs (OR 1.41; 95% CI 1.11-1.79), and several drug combinations. The risk was highest within the first month of medication use and decreased thereafter. CONCLUSION Our findings may help to better identify patients with heart failure most likely to benefit from careful monitoring of serum potassium levels. Particular vigilance is needed during the start of treatment with certain medications.
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28
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Wu CK, Yang YH, Juang JMJ, Wang YC, Tsai CT, Lai LP, Hwang JJ, Chiang FT, Chen PC, Lin JL, Lin LY. Effects of angiotensin converting enzyme inhibition or angiotensin receptor blockade in dialysis patients: a nationwide data survey and propensity analysis. Medicine (Baltimore) 2015; 94:e424. [PMID: 25621694 PMCID: PMC4602640 DOI: 10.1097/md.0000000000000424] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Long-term benefit of using a renin-angiotensin-aldosterone system blocker such as an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin II receptor blocker (ARB) for patients already receiving dialysis remains undetermined. The aim of this study is to assess the efficacy and safety of ACEI or ARB use in dialysis patients. We performed a population-based cohort study with time-to-event analyses to estimate the relation between the use of ACEI/ARB and their outcomes. We used a nationwide database (Registry for Catastrophic Illnesses) for Taiwan, which has data from 1995 to 2008 nearly of all patients who received dialysis therapy. The records of all dialysis patients aged ≥18 with no evidence of cardiovascular (CV) events in 1997 and 1998 (133,564 patients) were examined. Users (n = 50,961) and nonusers (n = 59,913) of an ACEI/ARB were derived. We then used propensity score matching and Cox proportional hazards regression models to estimate adjusted hazard ratios (HRs) for all-cause mortality and CV events in users and nonusers of an ACRI/ARB. The 15,182 patients, who used an ACEI/ARB, and the 15,182 nonusers had comparable baseline characteristics during the 14 years of follow-up. The mortality was significantly greater in patients who did not use an ACEI/ARB (HR = 0.90, 95% confidence interval = 0.86-0.93). Subgroup analysis of 3 tertiles of patients who used different total amounts of ACEI/ARB during the study period indicated that CV events were more common in patients who used an ACEI/ARB for a short duration (tertile 1: HR = 1.63), but less common in those who used an ACEI/ARB for long durations (tertile 2: HR = 1.05; tertile 3: HR = 0.94; trend for declining HR from tertile 1 to 3: P < 0.001). The mortality benefit provided by use of an ACEI/ARB was consistent across most patient subgroups, as was the benefit of ARB monotherapy rather than ACEI monotherapy. Independent of traditional risk factors, overall mortality was significantly lower in dialysis patients who used an ACEI/ARB. In addition, subjects who used an ACEI/ARB for longer durations were significantly less likely to experience CV events.
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Affiliation(s)
- Cho-Kai Wu
- From the Division of Cardiology (C-KW, J-MJJ, Y-CW, C-TT, L-PL, J-JH, F-TC, J-LL, L-YL), Department of Internal Medicine, National Taiwan University College of Medicine and Hospital; Graduate Institute of Clinical Medicine (C-KW), College of Medicine, National Taiwan University, Taipei; Department for Traditional Chinese Medicine (Y-HY), Chang Gung Memorial Hospital, Chia-Yi; Institute of Occupational Medicine and Industrial Hygiene (Y-HY, P-CC), National Taiwan University College of Public Health; and Department of Laboratory Medicine (F-TC), National Taiwan University Hospital, Taipei, Taiwan
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29
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Kaur P, Muthuraman A, Kaur J. Ameliorative potential of angiotensin-converting enzyme inhibitor (ramipril) on chronic constriction injury of sciatic nerve induced neuropathic pain in mice. J Renin Angiotensin Aldosterone Syst 2014; 16:103-12. [DOI: 10.1177/1470320314556171] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 08/09/2014] [Indexed: 01/12/2023] Open
Affiliation(s)
- Parneet Kaur
- Department of Pharmacology, Akal College of Pharmacy & Technical Education, Punjab, India
| | - Arunachalam Muthuraman
- Department of Pharmacology, Akal College of Pharmacy & Technical Education, Punjab, India
| | - Jaspreet Kaur
- Department of Pharmacology, Akal College of Pharmacy & Technical Education, Punjab, India
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Heerspink HJL, Grobbee DE, de Zeeuw D. A novel approach for establishing cardiovascular drug efficacy. Nat Rev Drug Discov 2014; 13:942. [PMID: 25398246 DOI: 10.1038/nrd4090-c2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Hiddo J Lambers Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, the Netherlands
| | - Diederick E Grobbee
- Julius Center for Health Science and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, the Netherlands
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