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Crompton M, Skinner LJ, Satchell SC, Butler MJ. Aldosterone: Essential for Life but Damaging to the Vascular Endothelium. Biomolecules 2023; 13:1004. [PMID: 37371584 PMCID: PMC10296074 DOI: 10.3390/biom13061004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
The renin angiotensin aldosterone system is a key regulator of blood pressure. Aldosterone is the final effector of this pathway, acting predominantly via mineralocorticoid receptors. Aldosterone facilitates the conservation of sodium and, with it, water and acts as a powerful stimulus for potassium excretion. However, evidence for the pathological impact of excess mineralocorticoid receptor stimulation is increasing. Here, we discussed how in the heart, hyperaldosteronism is associated with fibrosis, cardiac dysfunction, and maladaptive hypertrophy. In the kidney, aldosterone was shown to cause proteinuria and fibrosis and may contribute to the progression of kidney disease. More recently, studies suggested that aldosterone excess damaged endothelial cells. Here, we reviewed how damage to the endothelial glycocalyx may contribute to this process. The endothelial glycocalyx is a heterogenous, negatively charged layer on the luminal surface of cells. Aldosterone exposure alters this layer. The resulting structural changes reduced endothelial reactivity in response to protective shear stress, altered permeability, and increased immune cell trafficking. Finally, we reviewed current therapeutic strategies for limiting endothelial damage and suggested that preventing glycocalyx remodelling in response to aldosterone exposure may provide a novel strategy, free from the serious adverse effect of hyperkalaemia seen in response to mineralocorticoid blockade.
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Affiliation(s)
| | | | | | - Matthew J. Butler
- Bristol Renal, Dorothy Hodgkin Building, University of Bristol, Whitson Street, Bristol BS1 3NY, UK
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Janse RJ, Fu EL, Clase CM, Tomlinson L, Lindholm B, van Diepen M, Dekker FW, Carrero JJ. Stopping Versus Continuing Renin-Angiotensin System Inhibitors After Acute Kidney Injury and Adverse Clinical Outcomes; An Observational Study From Routine Care Data. Clin Kidney J 2022; 15:1109-1119. [PMID: 35664269 PMCID: PMC9155253 DOI: 10.1093/ckj/sfac003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Indexed: 11/18/2022] Open
Abstract
Background The risk–benefit ratio of continuing with renin–angiotensin system inhibitors (RASi)
after an episode of acute kidney injury (AKI) is unclear. While stopping RASi may
prevent recurrent AKI or hyperkalaemia, it may deprive patients of the cardiovascular
benefits of using RASi. Methods We analysed outcomes of long-term RASi users experiencing AKI (stage 2 or 3, or
clinically coded) during hospitalization in Stockholm and Sweden during 2007–18. We
compared stopping RASi within 3 months after discharge with continuing RASi. The primary
study outcome was the composite of all-cause mortality, myocardial infarction (MI) and
stroke. Recurrent AKI was our secondary outcome and we considered hyperkalaemia as a
positive control outcome. Propensity score overlap weighted Cox models were used to
estimate hazard ratios (HRs), balancing 75 confounders. Weighted absolute risk
differences (ARDs) were also determined. Results We included 10 165 individuals, of whom 4429 stopped and 5736 continued RASi, with a
median follow-up of 2.3 years. The median age was 78 years; 45% were women and median
kidney function before the index episode of AKI was 55 mL/min/1.73 m2. After
weighting, those who stopped had an increased risk [HR, 95% confidence interval (CI)] of
the composite of death, MI and stroke [1.13, 1.07–1.19; ARD 3.7, 95% CI 2.6–4.8]
compared with those who continued, a similar risk of recurrent AKI (0.94, 0.84–1.05) and
a decreased risk of hyperkalaemia (0.79, 0.71–0.88). Discussion Stopping RASi use among survivors of moderate-to-severe AKI was associated with a
similar risk of recurrent AKI, but higher risk of the composite of death, MI and
stroke.
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Affiliation(s)
- Roemer J Janse
- Department of Clinical Epidemiology, Leiden University Medical Center, The Netherlands
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden
| | - Edouard L Fu
- Department of Clinical Epidemiology, Leiden University Medical Center, The Netherlands
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden
| | - Catherine M Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Ontario, Canada
| | - Laurie Tomlinson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Bengt Lindholm
- Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, The Netherlands
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden
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Scheen AJ, Delanaye P. Acute renal injury events in diabetic patients treated with SGLT2 inhibitors: A comprehensive review with a special reference to RAAS blockers. DIABETES & METABOLISM 2021; 48:101315. [PMID: 34910981 DOI: 10.1016/j.diabet.2021.101315] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/03/2021] [Indexed: 01/13/2023]
Abstract
Renin-angiotensin-aldosterone system (RAAS) blockers and sodium-glucose cotransporter type 2 inhibitors (SGLT2is) are two pharmacological classes that proved a remarkable nephroprotective effect, yet a risk of acute kidney injury (AKI) was also pointed out. In 2016, the US Food and Drug Administration recommended caution with the concomitant use of these medications. While the literature devoted to RAAS blockers remained surprisingly limited, numerous articles were published in recent years with SGLT2is. Safety analyses of large prospective cardiorenal trials showed a reduced rather than an increased number of AKI events in patients with type 2 diabetes treated with SGLT2is compared with those treated with placebo, despite the fact that a majority of patients received RAAS blockers at baseline. Interestingly, retrospective observational studies confirmed these reassuring findings in real-life conditions in more heterogeneous and possibly more frailty populations also commonly treated with RAAS blockers by showing a reduced risk of AKI with SGLT2is compared with other glucose-lowering drugs. Currently, there are no evidence of an increased risk of AKI with RAAS blocker-SGLT2i combinations in absence of haemodynamic instability. Several underlying mechanisms could explain a decreased rather than an increased risk of AKI with SGLT2is, including in patients treated with RAAS blockers.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium; Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège (ULiege), Liège, Belgium.
| | - Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liège (ULiege), CHU Sart Tilman, Liège, Belgium; Department of Nephrology-Dialysis-Apheresis, Hôpital Universitaire Carémeau, Nîmes, France
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Sud M, Ko DT, Chong A, Koh M, Azizi PM, Austin PC, Stukel TA, Jackevicius CA. Renin-angiotensin-aldosterone system inhibitors and major cardiovascular events and acute kidney injury in patients with coronary artery disease. Pharmacotherapy 2021; 41:988-997. [PMID: 34496067 DOI: 10.1002/phar.2624] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/11/2021] [Accepted: 07/14/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Renin-angiotensin-aldosterone system inhibitors (RAASIs) are recommended for most patients with coronary artery disease (CAD). However, there is debate across guidelines as to which patients with CAD benefit the most from these agents. This study investigated the association between RAASIs and cardiovascular outcomes and acute kidney injury in a contemporary cohort of patients with CAD. METHODS Patients ≥65 years of age with CAD alive on April 1, 2012 in Ontario, Canada were included. Outcomes included major adverse cardiovascular events (MACE: cardiovascular death, myocardial infarction (MI), unstable angina, stroke, or coronary revascularization), and acute kidney injury (AKI) hospitalizations at 4 years. Inverse probability of treatment-weighted Cox proportional hazards regression models was used to compare the rates of each outcome in patients treated with and without RAASIs (angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers). RESULTS There were 165,058 patients with CAD identified (mean age 75 years, 65.5% male, 64.7% prescribed RAASIs). After inverse-probability weighting, treatment with RAASIs was associated with a lower rate of MACE compared with treatment without RAASIs (17.6% vs 18.2%, hazard ratio [HR]: 0.96, 95% CI: 0.93-0.99, respectively). However, treatment with RAASIs was associated with a higher rate of AKI compared with treatment without RAASIs (1.7% vs 1.5%, HR: 1.14, 95% CI: 1.02-1.29, respectively). The reduction in MACE was greater in patients with prior MI (HR: 0.87, 95% CI: 0.82-0.92) compared with patients without prior MI (HR: 1.00, 95% CI: 0.97-1.04, interaction p < 0.01). The increase in AKI was lower in patients with prior MI (HR: 0.82, 95% CI: 0.66-1.00) compared with patients without prior MI (HR: 1.37, 95% CI: 1.19-1.57, interaction p < 0.01). CONCLUSIONS This study supports the continued use of RAASIs in patients with CAD, although the benefit appears smaller in magnitude than observed in prior trials. High-risk patients, particularly those with prior MI, appear to benefit the most from RAASIs.
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Affiliation(s)
- Maneesh Sud
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dennis T Ko
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | - Paymon M Azizi
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter C Austin
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| | - Thérèse A Stukel
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| | - Cynthia A Jackevicius
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Western University of Health Services, Pomona, California, USA.,VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
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Mansfield KE, Nitsch D, Smeeth L, Bhaskaran K, Tomlinson LA. Prescription of renin-angiotensin system blockers and risk of acute kidney injury: a population-based cohort study. BMJ Open 2016; 6:e012690. [PMID: 28003286 PMCID: PMC5223684 DOI: 10.1136/bmjopen-2016-012690] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To investigate whether there is an association between use of ACE inhibitors (ACEI) and angiotensin receptor blockers (ARB) and risk of acute kidney injury (AKI). STUDY DESIGN We conducted a new-user cohort study of the rate of AKI among users of common antihypertensives. SETTING UK primary care practices contributing to the Clinical Practice Research Datalink (CPRD) eligible for linkage to hospital records data from the Hospital Episode Statistics (HES) database between April 1997 and March 2014. PARTICIPANTS New users of antihypertensives: ACEI/ARB, β-blockers, calcium channel blockers and thiazide diuretics. OUTCOMES The outcome was first episode of AKI. We estimated incidence rate ratio (RR) for AKI during time exposed to ACEI/ARB compared to time unexposed, adjusting for age, sex, comorbidities, use of other antihypertensive drugs and calendar period using Poisson regression. Covariates were time updated. RESULTS Among 570 445 participants, 303 761 were prescribed ACEI/ARB with a mean follow-up of 4.1 years. The adjusted RR of AKI during time exposed to ACEI/ARB compared to time unexposed was 1.12 (95% CI 1.07 to 1.17). This relative risk varied depending on absolute risk of AKI, with lower or no increased relative risk from the drugs among those at greatest absolute risk. For example, among people with stage 4 chronic kidney disease (who had 6.69 (95% CI 5.57 to 8.03) times higher rate of AKI compared to those without chronic kidney disease), the adjusted RR of AKI during time exposed to ACEI/ARB compared to time unexposed was 0.66 (95% CI 0.44 to 0.97) in contrast to 1.17 (95% CI 1.09 to 1.25) among people without chronic kidney disease. CONCLUSIONS Treatment with ACEI/ARB is associated with only a small increase in AKI risk while individual patient characteristics are much more strongly associated with the rate of AKI. The degree of increased risk varies between patient groups.
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Affiliation(s)
- Kathryn E Mansfield
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Krishnan Bhaskaran
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Laurie A Tomlinson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Zhang J, Rudemiller NP, Patel MB, Wei Q, Karlovich NS, Jeffs AD, Wu M, Sparks MA, Privratsky JR, Herrera M, Gurley SB, Nedospasov SA, Crowley SD. Competing Actions of Type 1 Angiotensin II Receptors Expressed on T Lymphocytes and Kidney Epithelium during Cisplatin-Induced AKI. J Am Soc Nephrol 2016; 27:2257-64. [PMID: 26744488 DOI: 10.1681/asn.2015060683] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 11/25/2015] [Indexed: 12/18/2022] Open
Abstract
Inappropriate activation of the renin-angiotensin system (RAS) contributes to many CKDs. However, the role of the RAS in modulating AKI requires elucidation, particularly because stimulating type 1 angiotensin II (AT1) receptors in the kidney or circulating inflammatory cells can have opposing effects on the generation of inflammatory mediators that underpin the pathogenesis of AKI. For example, TNF-α is a fundamental driver of cisplatin nephrotoxicity, and generation of TNF-α is suppressed or enhanced by AT1 receptor signaling in T lymphocytes or the distal nephron, respectively. In this study, cell tracking experiments with CD4-Cre mT/mG reporter mice revealed robust infiltration of T lymphocytes into the kidney after cisplatin injection. Notably, knockout of AT1 receptors on T lymphocytes exacerbated the severity of cisplatin-induced AKI and enhanced the cisplatin-induced increase in TNF-α levels locally within the kidney and in the systemic circulation. In contrast, knockout of AT1 receptors on kidney epithelial cells ameliorated the severity of AKI and suppressed local and systemic TNF-α production induced by cisplatin. Finally, disrupting TNF-α production specifically within the renal tubular epithelium attenuated the AKI and the increase in circulating TNF-α levels induced by cisplatin. These results illustrate discrepant tissue-specific effects of RAS stimulation on cisplatin nephrotoxicity and raise the concern that inflammatory mediators produced by renal parenchymal cells may influence the function of remote organs by altering systemic cytokine levels. Our findings suggest selective inhibition of AT1 receptors within the nephron as a promising intervention for protecting patients from cisplatin-induced nephrotoxicity.
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Affiliation(s)
| | | | | | - QingQing Wei
- Department of Cellular Biology and Anatomy, Georgia Regents University, Augusta, Georgia; and
| | | | | | - Min Wu
- Division of Nephrology, Department of Medicine and
| | | | - Jamie R Privratsky
- Department of Anesthesiology, Duke University and Durham Veterans Affairs Medical Centers, Durham, North Carolina
| | | | | | - Sergei A Nedospasov
- Laboratory of Molecular Immunology, Engelhardt Institute of Molecular Biology and Lomonosov Moscow State University, Moscow, Russia
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