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Hegazy SK, Amaar WA, Hegab WSM. Tadalafil versus pentoxifylline in the management of diabetic kidney disease: a randomized clinical trial. Diabetol Metab Syndr 2024; 16:138. [PMID: 38915115 PMCID: PMC11194930 DOI: 10.1186/s13098-024-01363-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 05/29/2024] [Indexed: 06/26/2024] Open
Abstract
AIMS To investigate the efficacy and safety of tadalafil (TAD) versus pentoxifylline (PTX) in the management of diabetic kidney disease (DKD). Some animal studies and clinical trials reported that tadalafil and pentoxifylline have a reducing effect on different blood glucose parameters and lipid profiles which contribute to progress the patients with diabetes mellitus (DM) to DKD. METHODS From February 2022 to March 2023, 90 patients with type 2 DM and DKD (micro-albuminuria) were enrolled in this randomized-controlled study. The patients were randomized into three equal groups: control group, TAD group, and PTX group. The three groups received traditional blood glucose lowering therapy + ramipril 10 mg PO. The TAD group also received tadalafil 20 mg PO every other day. The PTX group also received pentoxifylline 400 mg PO twice daily. RESULTS Both TAD and PTX groups produced statistically significant improvement in the primary outcomes by a significant reduction in Urinary albumin/creatinine ratio (UACR) which was pronounced by a reduction percentage of-47.47%, -53.73% respectively. In addition to a significant decrease in Hemoglobin A1C (HbA1c) (mmol/mol), Fasting blood glucose (FBG), 2-h postprandial blood glucose (2-h PPG) (p < 0.001). Only the PTX group showed a significant increase in Cr Cl and a significant decrease in S. Cr (p < 0.001). Only the TAD group showed a significant increase in high-density lipoprotein-cholesterol (HDL-C) (p < 0.001), while the PTX group showed a significant decrease in low-density lipoprotein-cholesterol (LDL-C) (p-value 0.011), and triglyceride (p-value 0.002). Both TAD and PTX groups showed a decrease in tumor necrosis factor-α (TNF-α) which was significant only in the PTX group (p < 0.001). There was a significant increase in malondialdehyde (MDA) (p < 0.001), and an increase in urinary neutrophil gelatinase-associated Lipocalin (uNGAL) (p-value 0.850, 0.014 respectively) which was significant only in the PTX group. CONCLUSIONS The use of tadalafil or pentoxifylline may serve as an effective adjuvant therapy for patients with diabetic kidney disease. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT05487755, July 25, 2022.
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Affiliation(s)
- Sahar Kamal Hegazy
- Clinical Pharmacy Department, Faculty of Pharmacy, Tanta University, Tanta, 31527, Al-Gharbia, Egypt
| | - Walaa Ahmed Amaar
- Clinical Pharmacy Department, Faculty of Pharmacy, Tanta University, Tanta, 31527, Al-Gharbia, Egypt.
| | - Wafaa Salah Mohamed Hegab
- National Institute of Diabetes and Endocrinology of General Organization for Teaching Hospitals and Institutes, Cairo, Egypt
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Ghose S, Satariano M, Korada S, Cahill T, Shah R, Raina R. Advancements in diabetic kidney disease management: integrating innovative therapies and targeted drug development. Am J Physiol Endocrinol Metab 2024; 326:E791-E806. [PMID: 38630049 DOI: 10.1152/ajpendo.00026.2024] [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] [Received: 01/16/2024] [Revised: 03/27/2024] [Accepted: 04/01/2024] [Indexed: 05/21/2024]
Abstract
Diabetic kidney disease (DKD) is a leading cause of chronic kidney disease and affects approximately 40% of individuals with diabetes . Cases of DKD continue to rise globally as the prevalence of diabetes mellitus increases, with an estimated 415 million people living with diabetes in 2015 and a projected 642 million by 2040. DKD is associated with significant morbidity and mortality, representing 34% and 36% of all chronic kidney disease deaths in men and women, respectively. Common comorbidities including hypertension and ageing-related nephron loss further complicate disease diagnosis and progression. The progression of DKD involves several mechanisms including glomerular endothelial cell dysfunction, inflammation, and fibrosis. Targeting these mechanisms has formed the basis of several therapeutic agents. Renin-angiotensin-aldosterone system (RAAS) blockers, specifically angiotensin receptor blockers (ARBs), demonstrate significant reductions in macroalbuminuria. Sodium-glucose transporter type 2 (SGLT-2) inhibitors demonstrate kidney protection independent of diabetes control while also decreasing the incidence of cardiovascular events. Emerging agents including glucagon-like peptide 1 (GLP-1) agonists, anti-inflammatory agents like bardoxolone, and mineralocorticoid receptor antagonists show promise in mitigating DKD progression. Many novel therapies including monoclonal antibodies CSL346, lixudebart, and tozorakimab; mesenchymal stem/stromal cell infusion; and cannabinoid-1 receptor inverse agonism via INV-202 are currently in clinical trials and present opportunities for further drug development.
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Affiliation(s)
- Shaarav Ghose
- Department of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, United States
| | - Matthew Satariano
- Department of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, United States
| | - Saichidroopi Korada
- Department of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, United States
| | - Thomas Cahill
- Department of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, United States
| | - Raghav Shah
- Department of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, United States
| | - Rupesh Raina
- Department of Medicine, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, United States
- Department of Nephrology, Akron Children's Hospital, Akron, Ohio, United States
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Colombijn JM, Hooft L, Jun M, Webster AC, Bots ML, Verhaar MC, Vernooij RW. Antioxidants for adults with chronic kidney disease. Cochrane Database Syst Rev 2023; 11:CD008176. [PMID: 37916745 PMCID: PMC10621004 DOI: 10.1002/14651858.cd008176.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: 11/03/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a significant risk factor for cardiovascular disease (CVD) and death. Increased oxidative stress in people with CKD has been implicated as a potential causative factor. Antioxidant therapy decreases oxidative stress and may consequently reduce cardiovascular morbidity and death in people with CKD. This is an update of a Cochrane review first published in 2012. OBJECTIVES To examine the benefits and harms of antioxidant therapy on death and cardiovascular and kidney endpoints in adults with CKD stages 3 to 5, patients undergoing dialysis, and kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies until 15 November 2022 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 all randomised controlled trials investigating the use of antioxidants, compared with placebo, usual or standard care, no treatment, or other antioxidants, for adults with CKD on cardiovascular and kidney endpoints. DATA COLLECTION AND ANALYSIS Titles and abstracts were screened independently by two authors who also performed data extraction using standardised forms. Results were pooled using random effects models and expressed as risk ratios (RR) or mean difference (MD) with 95% confidence intervals (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We included 95 studies (10,468 randomised patients) that evaluated antioxidant therapy in adults with non-dialysis-dependent CKD (31 studies, 5342 patients), dialysis-dependent CKD (41 studies, 3444 patients) and kidney transplant recipients (21 studies, 1529 patients). Two studies enrolled dialysis and non-dialysis patients (153 patients). Twenty-one studies assessed the effects of vitamin antioxidants, and 74 assessed the effects of non-vitamin antioxidants. Overall, the quality of included studies was moderate to low or very low due to unclear or high risk of bias for randomisation, allocation concealment, blinding, and loss to follow-up. Compared with placebo, usual care, or no treatment, antioxidant therapy may have little or no effect on cardiovascular death (8 studies, 3813 patients: RR 0.94, 95% CI 0.64 to 1.40; I² = 33%; low certainty of evidence) and probably has little to no effect on death (any cause) (45 studies, 7530 patients: RR 0.95, 95% CI 0.82 to 1.11; I² = 0%; moderate certainty of evidence), CVD (16 studies, 4768 patients: RR 0.79, 95% CI 0.63 to 0.99; I² = 23%; moderate certainty of evidence), or loss of kidney transplant (graft loss) (11 studies, 1053 patients: RR 0.88, 95% CI 0.67 to 1.17; I² = 0%; moderate certainty of evidence). Compared with placebo, usual care, or no treatment, antioxidants had little to no effect on the slope of urinary albumin/creatinine ratio (change in UACR) (7 studies, 1286 patients: MD -0.04 mg/mmol, 95% CI -0.55 to 0.47; I² = 37%; very low certainty of evidence) but the evidence is very uncertain. Antioxidants probably reduced the progression to kidney failure (10 studies, 3201 patients: RR 0.65, 95% CI 0.41 to 1.02; I² = 41%; moderate certainty of evidence), may improve the slope of estimated glomerular filtration rate (change in eGFR) (28 studies, 4128 patients: MD 3.65 mL/min/1.73 m², 95% CI 2.81 to 4.50; I² = 99%; low certainty of evidence), but had uncertain effects on the slope of serum creatinine (change in SCr) (16 studies, 3180 patients: MD -13.35 µmol/L, 95% CI -23.49 to -3.23; I² = 98%; very low certainty of evidence). Possible safety concerns are an observed increase in the risk of infection (14 studies, 3697 patients: RR 1.30, 95% CI 1.14 to 1.50; I² = 3%; moderate certainty of evidence) and heart failure (6 studies, 3733 patients: RR 1.40, 95% CI 1.11 to 1.75; I² = 0; moderate certainty of evidence) among antioxidant users. Results of studies with a low risk of bias or longer follow-ups generally were comparable to the main analyses. AUTHORS' CONCLUSIONS We found no evidence that antioxidants reduced death or improved kidney transplant outcomes or proteinuria in patients with CKD. Antioxidants likely reduce cardiovascular events and progression to kidney failure and may improve kidney function. Possible concerns are an increased risk of infections and heart failure among antioxidant users. However, most studies were of suboptimal quality and had limited follow-up, and few included people undergoing dialysis or kidney transplant recipients. Furthermore, the large heterogeneity in interventions hampers drawing conclusions on the efficacy and safety of individual agents.
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Affiliation(s)
- Julia Mt Colombijn
- Department of Nephrology and Hypertension, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Lotty Hooft
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Min Jun
- The George Institute for Global Health, UNSW, Sydney, Australia
| | - Angela C Webster
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Westmead Applied Research Centre, The University of Sydney at Westmead, Westmead, Australia
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Transplant and Renal Medicine, Westmead Hospital, Westmead, Australia
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University of Utrecht, Utrecht, Netherlands
| | - Robin Wm Vernooij
- Department of Nephrology and Hypertension, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
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ONAN E, PAYDAS S, BALAL M, TAKTAKOĞLU O, KARA E. Diabetik Nefropati Progresyonuna Pentoksifilin Tedavisinin Etkisi. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2022. [DOI: 10.17517/ksutfd.1110544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Amaç: Diabetik nefropati (DN) son dönem böbrek yetersizliğinin önemli bir nedenidir. Vasküler hastalıklarda kullanılan ve anti-inflamatuar özellikleri olan pentoksifilinin diyabetik nefropatide olumlu etkileri olabileceği öne sürülmüştür. Bu çalışmada DN nedeni ile takipte olan ve pentoksifilin kullanan hastaların tedavi öncesi ve sonrası dönemdeki böbrek fonksiyonları ve proteinürileri değerlendirilmiştir.
Gereç ve Yöntemler: Kliniğimizde takipte olup pentoksifilin (1200 mg/gün) tedavisi alan 36 diabetik nefropati hastası retrospektif olarak tarandı. Tedavi başlanmadan önceki 3. ve 6. ay; pentoksifilin tedavisinin 3., 6., 9. ve 12. aylardaki günlük proteinüri miktarı ve eGFR (estimated glomerular filtration rate, tahmini glomerüler filtrasyon hızı) değerleri kayıt edildi.
Bulgular: Çalışmaya alınan 36 hastanın ortalama yaşı 51,9±12,3 yıl, 12’si erkek ve 16’sı Anjiotensin dönüştürücü enzim (Angiotensin converting enzyme inhibitor, ACEİ) ya da Anjiotensin reseptör blokeri (Angiotensin receptor blocker, ARB) kullanıyordu. Pentoksifilini 23 hasta ≤6 ay (A grubu) 13 hasta >6 ay (B grubu) süre kullanmıştı. Proteinüri miktarı ve eGFR kaybı yönünden her iki grupta anlamlı farklılık saptanmadı.
Sonuç: Çalışmamızda diabetik nefropatili hastalarda 1 yıllık takip sırasında pentoksifilin tedavisinin proteinüri miktarı ve eGFR kaybına etkisi saptanamamıştır.
Anahtar kelimeler: Diabetik nefropati, pentoksifilin, proteinüri
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Affiliation(s)
- Engin ONAN
- Adana Şehir Eğitim ve Araştırma Hastanesi
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Moosaie F, Rabizadeh S, Fallahzadeh A, Sheikhy A, Meysamie A, Dehghani Firouzabadi F, Nakhjavani M, Esteghamati A. Effects of Pentoxifylline on Serum Markers of Diabetic Nephropathy in Type 2 Diabetes. Diabetes Ther 2022; 13:1023-1036. [PMID: 35380410 PMCID: PMC9076784 DOI: 10.1007/s13300-022-01250-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/08/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To investigate the effects of pentoxifylline (PTX) in combination with losartan compared to the high dose of losartan alone on serum markers of diabetic nephropathy such as HSP70, copeptin, CRP, and TNFα in patients with type 2 diabetes and nephropathy. METHODS A single-center, randomized, double-blind, open-label clinical trial was conducted. Sixty-two patients were eligible and allocated to "PTX + losartan" and "high-dose losartan" arms of the trial using software for random number generation. The first arm received 400 mg PTX two times a day (BD) plus 50 mg losartan daily, while the second arm received 50 mg losartan two times a day (BD) for 12 weeks. Comparison of the biomarkers' levels before and after treatment was done using paired sample t test variance. ANCOVA was applied to evaluate the comparative efficacy of the two interventions. The effect size was calculated and reported for each biomarker. RESULTS Urine albumin excretion (UAE), hs-CRP, and HbA1c significantly decreased in both trial arms compared to the baseline measures. Copeptin and TNFα showed significant differences (after vs before) only in the losartan group (p = 0.017 and p = 0.043, respectively). The losartan arm was more successful in reducing TNFα, copeptin, HSP70, systolic blood pressure (SBP), and diastolic blood pressure (DBP) values (p = 0.045, effect size = 7.3%; p = 0.018, effect size 10.1%; p = 0.046, effect size 4.7%, p = 0.001, effect size 23%; p = 0.012, effect size 10.2%, respectively) and the PTX arm was associated with a superior reduction of UAE and hs-CRP levels (p = 0.018, effect size 9.1%; p = 0.028, effect size 9.2%, respectively). CONCLUSION Add-on PTX to losartan may have more effective anti-inflammatory and anti-albuminuric roles and therefore may be more applicable in the management of diabetic nephropathy compared with high-dose losartan alone. TRAIL REGISTRATION Trial number IRCT 20121104011356N10.
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Affiliation(s)
- Fatemeh Moosaie
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, P.O. Box 13145-784, Tehran, Iran
| | - Soghra Rabizadeh
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, P.O. Box 13145-784, Tehran, Iran
| | - Aida Fallahzadeh
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, P.O. Box 13145-784, Tehran, Iran
| | - Ali Sheikhy
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, P.O. Box 13145-784, Tehran, Iran
| | - Alipasha Meysamie
- Department of Community Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Dehghani Firouzabadi
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, P.O. Box 13145-784, Tehran, Iran
| | - Manouchehr Nakhjavani
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, P.O. Box 13145-784, Tehran, Iran
| | - Alireza Esteghamati
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, P.O. Box 13145-784, Tehran, Iran.
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Garcia Sanchez JJ, Thompson J, Scott DA, Evans R, Rao N, Sörstadius E, James G, Nolan S, Wittbrodt ET, Abdul Sultan A, Stefansson BV, Jackson D, Abrams KR. Treatments for Chronic Kidney Disease: A Systematic Literature Review of Randomized Controlled Trials. Adv Ther 2022; 39:193-220. [PMID: 34881414 PMCID: PMC8799552 DOI: 10.1007/s12325-021-02006-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/26/2021] [Indexed: 01/06/2023]
Abstract
Delaying disease progression and reducing the risk of mortality are key goals in the treatment of chronic kidney disease (CKD). New drug classes to augment renin-angiotensin-aldosterone system (RAAS) inhibitors as the standard of care have scarcely met their primary endpoints until recently. This systematic literature review explored treatments evaluated in patients with CKD since 1990 to understand what contemporary data add to the treatment landscape. Eighty-nine clinical trials were identified that had enrolled patients with estimated glomerular filtration rate 13.9-102.8 mL/min/1.73 m2 and urinary albumin-to-creatinine ratio (UACR) 29.9-2911.0 mg/g, with (75.5%) and without (20.6%) type 2 diabetes (T2D). Clinically objective outcomes of kidney failure and all-cause mortality (ACM) were reported in 32 and 64 trials, respectively. Significant reductions (P < 0.05) in the risk of kidney failure were observed in seven trials: five small trials published before 2008 had evaluated the RAAS inhibitors losartan, benazepril, or ramipril in patients with (n = 751) or without (n = 84-436) T2D; two larger trials (n = 2152-2202) published onwards of 2019 had evaluated the sodium-glucose co-transporter 2 (SGLT2) inhibitors canagliflozin (in patients with T2D and UACR > 300-5000 mg/g) and dapagliflozin (in patients with or without T2D and UACR 200-5000 mg/g) added to a background of RAAS inhibition. Significant reductions in ACM were observed with dapagliflozin in the DAPA-CKD trial. Contemporary data therefore suggest that augmenting RAAS inhibitors with new drug classes has the potential to improve clinical outcomes in a broad range of patients with CKD.
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Affiliation(s)
| | | | | | | | - Naveen Rao
- BioPharmaceuticals Medical, AstraZeneca, Academy House, 136 Hills Road, Cambridge, CB2 8PA, UK
| | | | - Glen James
- BioPharmaceuticals Medical, AstraZeneca, Academy House, 136 Hills Road, Cambridge, CB2 8PA, UK
| | - Stephen Nolan
- BioPharmaceuticals Medical, AstraZeneca, Academy House, 136 Hills Road, Cambridge, CB2 8PA, UK
| | | | - Alyshah Abdul Sultan
- BioPharmaceuticals Medical, AstraZeneca, Academy House, 136 Hills Road, Cambridge, CB2 8PA, UK
| | | | - Dan Jackson
- BioPharmaceuticals Medical, AstraZeneca, Academy House, 136 Hills Road, Cambridge, CB2 8PA, UK
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Bell DSH. Are the Protean Effects of Pentoxifylline in the Therapy of Diabetes and Its Complications Still Relevant? Diabetes Ther 2021; 12:3025-3035. [PMID: 34647189 PMCID: PMC8586317 DOI: 10.1007/s13300-021-01168-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/29/2021] [Indexed: 12/17/2022] Open
Abstract
Pentoxifylline (Px) has protean effects that can be utilized in the therapy of diabetes and its complications. There have been well-documented but often inconclusive improvements in peripheral arterial disease, foot ulcers, peripheral neuropathy, nephropathy, retinopathy, ischemic heart disease and cerebrovascular disease. In addition, non-alcoholic steatosis and steatohepatitis, which are closely associated with insulin resistance and type 2 diabetes, have been shown to improve with pentoxifylline. Surprisingly, pentoxifylline modestly improves insulin resistance through improvements in capillary blood flow as well as beta cell function and decreased hepatic glucose production. The therapeutic effects of pentoxifylline are complementary to the effects of drugs such as blockers of the renin-angiotensin-aldosterone system when utilized in the therapy of diabetic nephropathy.
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Affiliation(s)
- David S H Bell
- Southside Endocrinology, 1900 Crestwood Blvd, Suite 201, Irondale, AL, 35210, USA.
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Leehey DJ, Carlson K, Reda DJ, Craig I, Clise C, Conner TA, Agarwal R, Kaufman JS, Anderson RJ, Lammie D, Huminik J, Polzin L, McBurney C, Huang GD, Emanuele NV. Pentoxifylline in diabetic kidney disease (VA PTXRx): protocol for a pragmatic randomised controlled trial. BMJ Open 2021; 11:e053019. [PMID: 34400461 PMCID: PMC8370537 DOI: 10.1136/bmjopen-2021-053019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/16/2021] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Diabetic kidney disease (DKD) is the most frequent cause of end-stage renal disease (ESRD) in the USA and worldwide. Recent experimental and clinical data suggest that the non-specific phosphodiesterase inhibitor pentoxifylline (PTX) may decrease progression of chronic kidney disease. However, a large-scale randomised clinical trial is needed to determine whether PTX can reduce ESRD and death in DKD. METHODS AND ANALYSIS Veterans Affairs (VA) PTXRx is a pragmatic, randomised, placebo-controlled multicentre VA Cooperative Study to test the hypothesis that PTX, when added to usual care, leads to a reduction in the time to ESRD or death in patients with type 2 diabetes with DKD when compared with usual care plus placebo. The study aims to enrol 2510 patients over a 4-year period with an additional up to 5-year follow-up to generate a total of 646 primary events. The primary objective of this study is to compare the time until ESRD or death (all-cause mortality) between participants randomised to PTX or placebo. Secondary endpoints will be: (1) health-related quality of life, (2) time to doubling of serum creatinine, (3) incidence of hospitalisations for congestive heart failure, (4) incidence of a three-point major adverse cardiovascular events composite (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke), (5) incidence of peripheral vascular disease, (6) change in urinary albumin-to-creatinine ratio from baseline to 6 months and (7) rate of annual change in estimated glomerular filtration rate (eGFR) during the study period. ETHICS AND DISSEMINATION This study was approved by the VA Central Institutional Review Board (cIRB/18-36) and will be conducted in compliance with the Declaration of Helsinki and the Guidelines for Good Clinical Practice. The Hines Cooperative Studies Programme will finalise the study results, which will be published in accordance with the Consolidated Standards of Reporting Trials statement in a peer-reviewed scientific journal. TRIAL REGISTRATION NUMBER NCT03625648.
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Affiliation(s)
- David J Leehey
- Edward Hines Junior VA Hospital, Hines, Illinois, USA
- Loyola University Medical Center, Maywood, Illinois, USA
| | - Kimberly Carlson
- Cooperative Studies Program, Edward Hines Junior VA Hospital, Hines, Illinois, USA
| | - Domenic J Reda
- Cooperative Studies Program, Edward Hines Junior VA Hospital, Hines, Illinois, USA
| | - Ian Craig
- Division of Strategic Innovation, Evaluation, and Communication, Center for Clinical Standards and Quality, Baltimore, Maryland, USA
| | - Christina Clise
- VA Cooperative Studies Program, Clinical Research Pharmacy Coordinating Center, Albuquerque, New Mexico, USA
| | - Todd A Conner
- VA Cooperative Studies Program, Clinical Research Pharmacy Coordinating Center, Albuquerque, New Mexico, USA
| | - Rajiv Agarwal
- Veterans' Affairs Medical Center, Indianapolis, Indiana, USA
| | - James S Kaufman
- Research Service, New York Harbor Health Care System, New York, New York, USA
| | | | - Douglas Lammie
- Cooperative Studies Program, Edward Hines Junior VA Hospital, Hines, Illinois, USA
| | - Jeffrey Huminik
- VA Cooperative Studies Program, Clinical Research Pharmacy Coordinating Center, Albuquerque, New Mexico, USA
| | - Linda Polzin
- Edward Hines Junior VA Hospital, Hines, Illinois, USA
| | | | - Grant D Huang
- Veterans Affairs Office of Research and Development, Washington, District of Columbia, USA
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Changes in the transcriptional activity of the entero-insular axis genes in streptozotocin-induced diabetes and after the administration of TNF-α non-selective blockers. Endocr Regul 2021; 54:160-171. [PMID: 32857721 DOI: 10.2478/enr-2020-0019] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE The aim of the present study was to investigate the transcriptional activity of the GLP-1R, DPP-4, SGLT-1, INSR, and IGF-1R genes in GALT cells of rats with streptozotocin-induced diabetes in both untreated and treated with pentoxifylline, as a non-specific blocker of TNF-α. METHODS The expression of GLP-1R, DPP-4, SGLT-1, INSR, and IGF-1R genes in GALT cells of rats was studied by real time quantitative polymerase chain reaction. RESULTS It was shown that the development of diabetes was accompanied by the decrease of GLP-1R and an increase of DPP-4 genes expression in rat ileum. The administration of pentoxifyl-line to diabetic animals led to an increase in the transcriptional activity of GLP-1R on the 4th week and decrease in transcriptional activity of DPP-4 on the 2nd and 4th weeks of the experiment. An increase in the normalized expression of SGLT-1 on the 4th week of the experimental diabetes was also noted, while the administration of pentoxifylline to diabetic animals did not lead to significant changes in this index. The transcriptional activity of the INSR and IGF-1R genes was reduced in diabetic rats and the administration of the non-specific TNF-α blocker - pentoxifylline led to a significant increase only for INSR gene in animals on the 4th week of the experimental diabetes. CONCLUSIONS The expression of incretins, glucose transporters, and pro-inflammatory cytokines (e.g. TNF-α) in immune cells may be used as markers of several autoimmune pathologies progression such as type 1 diabetes due to their effect on the balance of pro- and anti-inflammatory factors.
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Ali M, Bakr MH, Abdelzaher LA, Sayed SA, Mali V, Desai AA, Radwan E. Lisofylline mitigates cardiac inflammation in a mouse model of obesity through improving insulin secretion and activating cardiac AMPK signaling pathway. Cytokine 2020; 138:155398. [PMID: 33341003 DOI: 10.1016/j.cyto.2020.155398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 12/01/2020] [Accepted: 12/03/2020] [Indexed: 12/20/2022]
Abstract
Obesity has emerged as a leading cause of death in the last few decades, mainly due to associated cardiovascular diseases. Obesity, inflammation, and insulin resistance are strongly interlinked. Lisofylline (LSF), an anti-inflammatory agent, demonstrated protection against type 1 diabetes, as well as reduced obesity-induced insulin resistance and adipose tissue inflammation. However, its role in mitigating cardiac inflammation associated with obesity is not well studied. Mice were divided into 4 groups; the first group was fed regular chow diet, the second was fed regular chow diet and treated with LSF, the third was fed high fat diet (HFD), and the fourth was fed HFD and treated with LSF. Cardiac inflammation was interrogated via expression levels of TNF α, interleukins 6 and 10, phosphorylated STAT4 and lipoxygenases 12 and 12/15. Apoptosis and expression of the survival gene, AMPK, were also evaluated. We observed that LSF alleviated obesity-induced cardiac injury indirectly by improving both pancreatic β-cell function and insulin sensitivity, as well as, directly via upregulation of cardiac AMPK expression and downregulation of cardiac inflammation and apoptosis. LSF may represent an effective therapy targeting obesity-induced metabolic and cardiovascular complications.
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Affiliation(s)
- Maha Ali
- Department of Medical Biochemistry, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Marwa H Bakr
- Department of Histology and Cell Biology, Faculty of Medicine, Assiut University, Assiut, Egypt.
| | - Lobna A Abdelzaher
- Department of Pharmacology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Sally A Sayed
- Department of Physiology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Vishal Mali
- Krannert Institute of Cardiology, Department of Medicine, Indiana University, Indianapolis, IN, United States
| | - Ankit A Desai
- Krannert Institute of Cardiology, Department of Medicine, Indiana University, Indianapolis, IN, United States
| | - Eman Radwan
- Department of Medical Biochemistry, Faculty of Medicine, Assiut University, Assiut, Egypt
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11
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Barrera-Chimal J, Jaisser F. Pathophysiologic mechanisms in diabetic kidney disease: A focus on current and future therapeutic targets. Diabetes Obes Metab 2020; 22 Suppl 1:16-31. [PMID: 32267077 DOI: 10.1111/dom.13969] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/07/2020] [Accepted: 01/13/2020] [Indexed: 12/22/2022]
Abstract
Diabetic kidney disease (DKD) is the primary cause of chronic kidney disease around the globe and is one of the main complications in patients with type 1 and 2 diabetes. The standard treatment for DKD is drugs controlling hyperglycemia and high blood pressure. Renin angiotensin aldosterone system blockade and sodium glucose cotransporter 2 (SGLT2) inhibition have yielded promising results in DKD, but many diabetic patients on such treatments nevertheless continue to develop DKD, leading to kidney failure and cardiovascular comorbidities. New therapeutic options are urgently required. We review here the promising therapeutic avenues based on insights into the mechanisms of DKD that have recently emerged, including mineralocorticoid receptor antagonists, SGLT2 inhibitors, glucagon-like peptide-1 receptor agonist, endothelin receptor A inhibition, anti-inflammatory agents, autophagy activators and epigenetic remodelling. The involvement of several molecular mechanisms in DKD pathogenesis, together with the genetic and epigenetic variability of this condition, makes it difficult to target this heterogeneous patient population with a single drug. Personalized medicine, taking into account the genetic and mechanistic variability, may therefore improve renal and cardiovascular protection in diabetic patients with DKD.
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Affiliation(s)
- Jonatan Barrera-Chimal
- Laboratorio de Fisiología Cardiovascular y Trasplante Renal, Unidad de Investigación en Medicina Traslacional, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México and Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Frédéric Jaisser
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Sorbonne University, Paris Descartes University, Paris, France
- INSERM U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France
- INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
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12
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Leehey DJ. Targeting Inflammation in Diabetic Kidney Disease: Is There a Role for Pentoxifylline? ACTA ACUST UNITED AC 2020; 1:292-299. [DOI: 10.34067/kid.0001252019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Diabetic kidney disease (DKD) is the most common cause of ESKD in the United States and worldwide. Current treatment for DKD includes strict glycemic control and normalization of BP with renin-angiotensin-aldosterone system (RAAS) blockade. Although RAAS blockers slow progression of disease, they do not generally prevent ESKD and none of the studies with these agents in DKD included patients who were nonproteinuric, which make up an increasingly large percentage of patients with diabetes now seen in clinical practice. Recent studies with glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 (SGLT2) inhibitors have shown beneficial renal effects, and the benefits of SGLT2 inhibitors likely extend to patients who are nonproteinuric. However, there remains a need to develop new therapies for DKD, particularly in those patients with advanced disease. A role of chronic low-grade inflammation in microvascular complications in patients with diabetes has now been widely accepted. Large clinical trials are being carried out with experimental agents such as bardoxolone and selonsertib that target inflammation and oxidative stress. The Food and Drug Administration–approved, nonspecific phosphodiesterase inhibitor pentoxifylline (PTX) has been shown to have anti-inflammatory effects in both animal and human studies by inhibiting the production of proinflammatory cytokines. Small randomized clinical trials and meta-analyses indicate that PTX may have therapeutic benefits in DKD, raising the possibility that a clinically available drug may be able to be repurposed to treat this disease. A large, multicenter, randomized clinical trial to determine whether this agent can decrease time to ESKD or death is currently being conducted, but results will not be available for several years. At this time, the combination of RAAS blockade plus SGLT2 inhibition is considered standard of care for DKD, but it may be reasonable for clinicians to consider addition of PTX in patients whose disease continues to progress despite optimization of current standard-of-care therapies.
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13
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Kalmykova ZA, Kononenko IV, Mayorov AY. [Diabetes mellitus and chronic liver diseases. Literature review (part 2): treatment features]. TERAPEVT ARKH 2019; 91:115-121. [PMID: 32598598 DOI: 10.26442/00403660.2019.12.000166] [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: 04/16/2020] [Indexed: 11/22/2022]
Abstract
Diabetes mellitus (DM) and chronic liver disease (CLD) are pathological conditions associated with each other and reaching epidemic proportions. There is a strong pathogenetic relationship of carbohydrate metabolism disorders and a number of CLD. Common mechanisms that provoke metabolic and autoimmune disorders in the development of various CLD, leading to steatosis, insulin resistance (IR), impaired glucose tolerance and the development of DM are described. Effective glycemic control can have a beneficial effect on the treatment of these patients, and, conversely, there is evidence of a positive effect of CLD therapy on carbohydrate metabolism. This review discusses the correction of carbohydrate metabolism in patients with CLD, the main groups of modern hypoglycemic drugs, mechanisms of their action, the impact on the physiology of the liver, the possibility of using each of these pharmacological groups in patients with impaired liver function. The modern approaches and possibilities of drug effects on the process of fibrogenesis in CLD, the effect of these drugs on carbohydrate metabolism are listed.
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14
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Murkamilov IT, Aitbaev KA, Fomin VV, Murkamilova ZA, Bayzhigitova AA. Pentoxifylline and nephroprotection: effects on renal dysfunction and cardiovascular risks. TERAPEVT ARKH 2019; 91:95-100. [PMID: 31090379 DOI: 10.26442/00403660.2019.01.000037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Generalized data on nephroprotective efficacy of pentoxifylline in chronic kidney disease (CKD) are presented. The potential of this drug in treating people suffering from CKD and cardiovascular diseases (CVD) with a high risk of developing the terminal stage of renal dysfunction is considered. Antiproteinuric, antifibrotic and anti-inflammatory effects of pentoxifylline significantly reduce the risk of progression of CKD and joining of CVD in the future. Efficacy in preventing the onset of the uremic stage of CKD, safety andapplicability at all stages of renal dysfunction development make pentoxifylline a very appealing drug not only for nephrologists but also for physicians. Keywords: chronic kidney disease, progression, pentoxifylline, nephroprotection, cardiovascular diseases.
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Affiliation(s)
- I T Murkamilov
- Kyrgyz State Medical Academy named after I.K. Akhunbaev, Bishkek, Kyrgyzstan.,Kyrgyz Russian Slavic University named after the First President of Russia B.N. Yeltsin, Bishkek, Kyrgyzstan
| | - K A Aitbaev
- Scientific Research Institute of Molecular Biology and Medicine, Bishkek, Kyrgyzstan
| | - V V Fomin
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian
| | | | - A A Bayzhigitova
- National Hospital under the Ministry of Health of the Kyrgyz Republic, Bishkek, Kyrgyzstan
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15
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Allinovi M, De Chiara L, Angelotti ML, Becherucci F, Romagnani P. Anti-fibrotic treatments: A review of clinical evidence. Matrix Biol 2018; 68-69:333-354. [DOI: 10.1016/j.matbio.2018.02.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 02/19/2018] [Accepted: 02/20/2018] [Indexed: 02/06/2023]
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16
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Arcaro CA, Assis RP, Zanon NM, Paula-Gomes S, Navegantes LCC, Kettelhut IC, Brunetti IL, Baviera AM. Involvement of cAMP/EPAC/Akt signaling in the antiproteolytic effects of pentoxifylline on skeletal muscles of diabetic rats. J Appl Physiol (1985) 2017; 124:704-716. [PMID: 29357512 DOI: 10.1152/japplphysiol.00499.2017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Advances in the knowledge of the mechanisms controlling protein breakdown in skeletal muscles have allowed the exploration of new options for treating muscle-wasting conditions. Pentoxifylline (PTX), a nonselective phosphodiesterase (PDE) inhibitor, attenuates the loss of muscle mass during catabolic conditions, mainly via inhibiting protein breakdown. The aim of this study was to explore the mechanisms by which PTX inhibits proteolysis in the soleus and extensor digitorum longus (EDL) muscles of streptozotocin-induced diabetic rats. The levels of atrogin-1 and muscle RING finger-1 were decreased, as were the activities of caspase-3 (EDL) and calpains (soleus and EDL), in diabetic rats treated with PTX, which at least partly explains the drop in the ubiquitin conjugate (EDL) levels and in proteasome activity (soleus and EDL). Treatment with PTX decreased PDE activity and increased cAMP content in muscles of diabetic rats; moreover, it also increased both the protein levels of exchange protein directly activated by cAMP (EPAC, a cAMP effector) and the phosphorylation of Akt. The loss of muscle mass was practically prevented in diabetic rats treated with PTX. These findings advance our understanding of the mechanisms underlying the antiproteolytic effects of PTX and suggest the use of PDE inhibitors as a strategy to activate cAMP signaling, which is emerging as a promising target for treating muscle mass loss during atrophic conditions. NEW & NOTEWORTHY cAMP signaling has been explored as a strategy to attenuate skeletal muscle atrophies. Therefore, in addition to β2AR agonists, phosphodiesterase inhibitors such as pentoxifylline (PTX) can be an interesting option. This study advances the understanding of the mechanisms related to the antiproteolytic effects of PTX on skeletal muscles of diabetic rats, which involve the activation of both exchange protein directly activated by cAMP and Akt effectors, inhibiting the expression of atrogenes and calpain/caspase-3-proteolytic machinery.
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Affiliation(s)
- Carlos Alberto Arcaro
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University, Araraquara, University of São Paulo , São Paulo , Brazil
| | - Renata Pires Assis
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University, Araraquara, University of São Paulo , São Paulo , Brazil
| | - Neusa Maria Zanon
- Department of Physiology, University of São Paulo, Ribeirão Preto Medical School , Ribeirão Preto, São Paulo , Brazil
| | - Silvia Paula-Gomes
- Department of Biochemistry/Immunology, University of São Paulo, Ribeirão Preto Medical School , Ribeirão Preto, São Paulo , Brazil
| | | | - Isis Carmo Kettelhut
- Department of Physiology, University of São Paulo, Ribeirão Preto Medical School , Ribeirão Preto, São Paulo , Brazil.,Department of Biochemistry/Immunology, University of São Paulo, Ribeirão Preto Medical School , Ribeirão Preto, São Paulo , Brazil
| | - Iguatemy Lourenço Brunetti
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University, Araraquara, University of São Paulo , São Paulo , Brazil
| | - Amanda Martins Baviera
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University, Araraquara, University of São Paulo , São Paulo , Brazil
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17
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Chen YM, Chiang WC, Lin SL, Tsai TJ. Therapeutic efficacy of pentoxifylline on proteinuria and renal progression: an update. J Biomed Sci 2017; 24:84. [PMID: 29132351 PMCID: PMC5683556 DOI: 10.1186/s12929-017-0390-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 10/30/2017] [Indexed: 01/17/2023] Open
Abstract
Blood pressure control with renin-angiotensin system (RAS) blockade has remained the gold standard for treating patients with proteinuric chronic kidney disease (CKD) up to date. Nevertheless, RAS blockade slows but does not halt the progression of kidney disease, thus highlighting the need to search for additional therapeutic approaches. The nonselective phosphodiesterase (PDE) inhibitor pentoxifylline (PTX) is an old drug that exhibits prominent anti-inflammatory, anti-proliferative and anti-fibrotic activities both in vitro and in vivo. Studies in human subjects have shown that PTX monotherapy decreases urinary protein excretion, and add-on therapy of PTX to background RAS blockade additively reduces proteinuria in patients with CKD of various etiology. More recent studies find that PTX combined with RAS blockade delays the decline of glomerular filtration rate in diabetic patients with mild to moderate CKD, and reduces the risk of end-stage renal disease in diabetic and non-diabetic patients in late stage of CKD with high proteinuria levels. In this review, we update the clinical trial results of PTX as monotherapy, or in conjunction or in comparison with RAS blockade on patients with proteinuria and CKD, and propose a mechanistic scheme explaining the renoprotective activities of this drug.
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Affiliation(s)
- Yung-Ming Chen
- Renal Division, Department of Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Wen-Chih Chiang
- Renal Division, Department of Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Shuei-Liong Lin
- Renal Division, Department of Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Chung-Shan South Road, Taipei, Taiwan
- Graduate Institute of Physiology, College of Medicine, National Taiwan University, No. 1, Jen-Ai Road, Section 1, Taipei, Taiwan
| | - Tun-Jun Tsai
- Renal Division, Department of Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Chung-Shan South Road, Taipei, Taiwan
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18
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Sharma D, Bhattacharya P, Kalia K, Tiwari V. Diabetic nephropathy: New insights into established therapeutic paradigms and novel molecular targets. Diabetes Res Clin Pract 2017; 128:91-108. [PMID: 28453961 DOI: 10.1016/j.diabres.2017.04.010] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 04/07/2017] [Indexed: 02/06/2023]
Abstract
Diabetic nephropathy is one of the most prevalent microvascular complication in patients suffering from diabetes and is reported to be the major cause of renal failure when compared to any other kidney disease. Currently, available therapies provide only symptomatic relief and unable to treat the underlying pathophysiology of diabetic nephropathy. This review will explore new insights into the established therapeutic paradigms targeting oxidative stress, inflammation and endoplasmic reticulum stress with the focus on recent clinical developments. Apart from this, the involvement of novel cellular and molecular mechanisms including the role of endothelin-receptor antagonists, Wnt signaling pathway, epigenetics and micro RNA is also discussed so that key molecular switches involved in the pathogenesis of diabetic nephropathy can be identified. Elucidating new molecular pathways will help in the development of novel therapeutics for the prevention and treatment of diabetic nephropathy.
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Affiliation(s)
- Dilip Sharma
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)-Ahmedabad, Gandhinagar 382355, Gujarat, India
| | - Pallab Bhattacharya
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)-Ahmedabad, Gandhinagar 382355, Gujarat, India
| | - Kiran Kalia
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)-Ahmedabad, Gandhinagar 382355, Gujarat, India.
| | - Vinod Tiwari
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)-Ahmedabad, Gandhinagar 382355, Gujarat, India.
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19
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Pichler R, Afkarian M, Dieter BP, Tuttle KR. Immunity and inflammation in diabetic kidney disease: translating mechanisms to biomarkers and treatment targets. Am J Physiol Renal Physiol 2017; 312:F716-F731. [PMID: 27558558 PMCID: PMC6109808 DOI: 10.1152/ajprenal.00314.2016] [Citation(s) in RCA: 162] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 08/16/2016] [Indexed: 01/10/2023] Open
Abstract
Increasing incidences of obesity and diabetes have made diabetic kidney disease (DKD) the leading cause of chronic kidney disease and end-stage renal disease worldwide. Despite current pharmacological treatments, including strategies for optimizing glycemic control and inhibitors of the renin-angiotensin system, DKD still makes up almost one-half of all cases of end-stage renal disease in the United States. Compelling and mounting evidence has clearly demonstrated that immunity and inflammation play a paramount role in the pathogenesis of DKD. This article reviews the involvement of the immune system in DKD and identifies important roles of key immune and inflammatory mediators. One of the most recently identified biomarkers is serum amyloid A, which appears to be relatively specific for DKD. Novel and evolving treatment approaches target protein kinases, transcription factors, chemokines, adhesion molecules, growth factors, advanced glycation end-products, and other inflammatory molecules. This is the beginning of a new era in the understanding and treatment of DKD, and we may have finally reached a tipping point in our fight against the growing burden of DKD.
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Affiliation(s)
- Raimund Pichler
- Division of Nephrology, University of Washington, Seattle, Washington;
| | - Maryam Afkarian
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington; and
| | - Brad P Dieter
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington; and
- Providence Health Care, Spokane, Washington
| | - Katherine R Tuttle
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington; and
- Providence Health Care, Spokane, Washington
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20
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Preventive Effects of Pentoxifylline on the Development of Colonic Premalignant Lesions in Obese and Diabetic Mice. Int J Mol Sci 2017; 18:ijms18020413. [PMID: 28212276 PMCID: PMC5343947 DOI: 10.3390/ijms18020413] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 01/19/2017] [Accepted: 02/10/2017] [Indexed: 12/31/2022] Open
Abstract
Obesity and its related metabolic abnormalities, including enhanced oxidative stress and chronic inflammation, are closely related to colorectal tumorigenesis. Pentoxifylline (PTX), a methylxanthine derivative, has been reported to suppress the production of tumor necrosis factor (TNF)-α and possess anti-inflammatory properties. The present study investigated the effects of PTX on the development of carcinogen-induced colorectal premalignant lesions in obese and diabetic mice. Male C57BL/KsJ-db/db mice, which are severely obese and diabetic, were administered weekly subcutaneous injections of the colonic carcinogen azoxymethane (15 mg/kg body weight) for four weeks and then received drinking water containing 125 or 500 ppm PTX for eight weeks. At the time of sacrifice, PTX administration markedly suppressed the development of premalignant lesions in the colorectum. The levels of oxidative stress markers were significantly decreased in the PTX-treated group compared with those in the untreated control group. In PTX-administered mice, the mRNA expression levels of cyclooxygenase (COX)-2, interleukin (IL)-6, and TNF-α, and the number of proliferating cell nuclear antigen (PCNA)-positive cells in the colonic mucosa, were significantly reduced. These observations suggest that PTX attenuated chronic inflammation and oxidative stress, and prevented the development of colonic tumorigenesis in an obesity-related colon cancer model.
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21
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Lai TS, Chiang WC, Chen YM. Pentoxifylline: Evidence strong enough for renoprotection? J Formos Med Assoc 2016; 115:591-2. [DOI: 10.1016/j.jfma.2015.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 12/23/2015] [Indexed: 12/19/2022] Open
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McCarty MF, O'Keefe JH, DiNicolantonio JJ. Pentoxifylline for vascular health: a brief review of the literature. Open Heart 2016; 3:e000365. [PMID: 26870389 PMCID: PMC4746528 DOI: 10.1136/openhrt-2015-000365] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 01/07/2016] [Accepted: 01/11/2016] [Indexed: 01/08/2023] Open
Abstract
Pentoxifylline is a methylxanthine derivative that has been used for several decades in the symptomatic management of intermittent claudication. For reasons that remain fairly obscure, this drug benefits blood rheology in a number of complementary ways: decreasing blood and plasma viscosity, lowering plasma fibrinogen while promoting fibrinolysis, and improving blood filterability by enhancing erythrocyte distensibility and lessening neutrophil activation. Anti-inflammatory effects on neutrophils and macrophage/monocytes—some of them attributable to pentoxifylline metabolites—appear to play a mediating role in this regard. Although clinical trials with pentoxifylline have often been too small in size to reach statistically significant findings regarding impacts on hard end points, a review of the existing literature suggests that pentoxifylline may have potential for slowing the progression of atherosclerosis, stabilising plaque, reducing risk for vascular events, improving the outcome of vascular events, dampening the systemic inflammatory response following cardiopulmonary bypass, providing symptomatic benefit in angina and intermittent claudication, enhancing cerebral blood flow in patients with cerebrovascular disease while slowing progression of vascular dementia, improving prognosis in congestive heart failure, and aiding diabetes control. This safe and usually well-tolerated drug works in ways quite distinct from other drugs more commonly used for cardiovascular protection, and hence may confer complementary benefit when used in conjunction with them. Major clinical trials of adequate statistical power are now needed to confirm the scope of benefits that pentoxifylline can confer; studies evaluating hard end points in acute coronary syndrome, stroke/transient ischaemic attack and systolic heart failure might be particularly valuable.
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Affiliation(s)
| | - James H O'Keefe
- Saint Luke's Mid-America Heart Institute , Kansas City, Missouri , USA
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23
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Bhanot S, Leehey DJ. Pentoxifylline for Diabetic Nephropathy: an Important Opportunity to Re-purpose an Old Drug? Curr Hypertens Rep 2016; 18:8. [DOI: 10.1007/s11906-015-0612-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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