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Ferreira JP, Butler J, Anker SD, Januzzi JL, Panova-Noeva M, Reese-Petersen AL, Sattar N, Schueler E, Pocock SJ, Filippatos G, Packer M, Sumin M, Zannad F. Effects of empagliflozin on collagen biomarkers in patients with heart failure: Findings from the EMPEROR trials. Eur J Heart Fail 2024; 26:274-284. [PMID: 38037709 DOI: 10.1002/ejhf.3101] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/09/2023] [Accepted: 11/27/2023] [Indexed: 12/02/2023] Open
Abstract
AIMS Extracellular matrix remodelling is one of the key pathways involved in heart failure (HF) progression. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) may have a role in attenuating myocardial fibrosis. The impact of SGLT2i on blood markers of collagen turnover in humans is not fully elucidated. This study aimed to investigate the effect of empagliflozin on serum markers of collagen turnover in patients enrolled in the EMPEROR-Preserved and EMPEROR-Reduced trials. METHODS AND RESULTS Overall, 1084 patients (545 in empagliflozin and 539 in placebo) were included in the analysis. Procollagen type I carboxy-terminal propeptide (PICP), a fragment of N-terminal type III collagen (PRO-C3), procollagen type I amino-terminal peptide (PINP), a fragment of C-terminal type VIa3 collagen (PRO-C6), a fragment of type I collagen (C1M), and a fragment of type III collagen (C3M) were measured in serum at baseline, 12 and 52 weeks. A mixed model repeated measurements model was used to evaluate the effect of empagliflozin versus placebo on the analysed biomarkers. Higher baseline PICP, PRO-C6 and PINP levels were associated with older age, a more severe HF presentation, higher levels of natriuretic peptides and high-sensitivity troponin T, and the presence of comorbid conditions such as chronic kidney disease and atrial fibrillation. Higher PICP levels were associated with the occurrence of the study primary endpoint (a composite of HF hospitalization or cardiovascular death), and PRO-C6 and PINP were associated with the occurrence of sustained worsening of kidney function. On the other hand, PRO-C3, C1M, and C3M were not associated with worse HF severity or study outcomes. Compared to placebo, empagliflozin reduced PICP at week 12 by 5% and at week 52 by 8% (week 12: geometric mean ratio = 0.95, 95% confidence interval [CI] 0.91-0.99, p = 0.012; week 52: geometric mean ratio = 0.92, 95% CI 0.88-0.97, p = 0.003). Additionally, empagliflozin reduced PRO-C3 at week 52 by 7% (week 12: geometric mean ratio = 0.98, 95% CI 0.95-1.02, p = 0.42; week 52: geometric mean ratio = 0.93, 95% CI 0.89-0.98, p = 0.003), without impact on other collagen markers. CONCLUSION Our observations are consistent with experimental observations that empagliflozin down-regulates profibrotic signalling. The importance of such an effect for the clinical benefits of SGLT2i in HF remains to be elucidated.
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Affiliation(s)
- João Pedro Ferreira
- Department of Surgery and Physiology, Cardiovascular Research and Development Center (UnIC@RISE), Faculty of Medicine of the University of Porto, Porto, Portugal
- Centre d'Investigations Cliniques Plurithématique 14-33, Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
- Cardiovascular Research and Development Center, Nancy, France
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - James L Januzzi
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Milton Packer
- Baylor University Medical Center, Dallas, TX, USA
- Imperial College, London, UK
| | - Mikhail Sumin
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 14-33, Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
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Ding K, Li Z, Lu Y, Sun L. Efficacy and safety assessment of mineralocorticoid receptor antagonists in patients with chronic kidney disease. Eur J Intern Med 2023; 115:114-127. [PMID: 37328398 DOI: 10.1016/j.ejim.2023.05.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/09/2023] [Accepted: 05/29/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND The objective of our study is to evaluate the efficacy and safety of mineralocorticoid receptor antagonists (MRAs) and determine the optimal MRA treatment regimen in patients with chronic kidney disease (CKD). METHODS We searched PubMed, Embase, Web of Science, and the Cochrane Library from their inception to June 20, 2022. The composite kidney outcome, cardiovascular events, urinary albumin to creatinine ratio (UACR), estimated glomerular filtration rate (EGFR), serum potassium, systolic blood pressure (SBP), diastolic blood pressure (DBP), creatine and creatine clearance were included for analysis. We conducted pairwise meta-analyses and Bayesian network meta-analyses (NMA) and calculated the surface under the cumulative ranking curve (SUCRA). RESULTS We included 26 studies with 15,531 participants. By pairwise meta-analyses, we found that MRA treatment could significantly reduce UACR in CKD patients with or without diabetes. Notably, compared to placebo, Finerenone was associated with a lower risk of composite kidney outcome and cardiovascular events. Data from NMA demonstrated an overt UACR reduction without increasing serum potassium by Apararenone, Esaxerenone, and Finerenone in CKD patients. Spironolactone decreased SBP and DBP but elevated CKD patients' serum potassium. CONCLUSIONS Compared to placebo, Apararenone, Esaxerenone, and Finerenone might ameliorate albuminuria in CKD patients without causing elevated serum potassium levels. Remarkably, Finerenone conferred a cardiovascular benefit, and Spironolactone lowered blood pressure in CKD patients.
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Affiliation(s)
- Kaiyue Ding
- Department of Nephrology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China; Hunan Key Laboratory of Kidney Disease and Blood Purification, Changsha, Hunan, China
| | - Zhuoyu Li
- Department of Nephrology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China; Hunan Key Laboratory of Kidney Disease and Blood Purification, Changsha, Hunan, China
| | - Yingying Lu
- Department of Nephrology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China; Hunan Key Laboratory of Kidney Disease and Blood Purification, Changsha, Hunan, China
| | - Lin Sun
- Department of Nephrology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China; Hunan Key Laboratory of Kidney Disease and Blood Purification, Changsha, Hunan, China.
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Hu H, Cao M, Sun Y, Jin X, Zhao X, Cong X. Efficacy and Safety of Eplerenone for Treating Chronic Kidney Disease: A Meta-Analysis. Int J Hypertens 2023; 2023:6683987. [PMID: 36938116 PMCID: PMC10019978 DOI: 10.1155/2023/6683987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/08/2023] [Accepted: 03/01/2023] [Indexed: 03/17/2023] Open
Abstract
Background In recent years, a large amount of clinical evidence and animal experiments have demonstrated the unique advantages of mineralocorticoid receptor antagonists (MRA) for treating chronic kidney disease (CKD). Aims Accordingly, the present study aimed to systematically assess the second-generation selective MRAs eplerenone's safety and effectiveness for treating CKD. Methods Four databases (PubMed, The Cochrane Library, Embase, and Web of Science) were searched for randomized controlled trials (RCT) correlated with eplerenone for treating CKD up to September 21, 2022. By complying with the inclusion and exclusion criteria, literature screening, and data extraction were conducted. Results A total of 19 randomized controlled articles involving 4501 cases were covered. As suggested from the meta-analysis, significant differences were reported with the 24-h urine protein (MD = -42.23, 95% confidence interval [CI] = -76.72 to -7.73, P = 0.02), urinary albumin-creatinine ratio (UACR) (MD = -23.57, 95% CI = -29.28 to -17.86, P < 0.00001), the systolic blood pressure (SBP) (MD = -2.73, 95% CI = -4.86 to -0.59, P = 0.01), and eGFR (MD = -1.56, 95% CI = -2.78 to -0.34, P = 0.01) in the subgroup of eplerenone vs placebo. The subgroups of eplerenone vs placebo (MD = 0.13, 95% CI = 0.07 to 0.18, P < 0.00001) and eplerenone vs thiazide diuretic (MD = 0.18, 95% CI = 0.13 to 0.23, P < 0.00001) showed the significantly increased potassium levels. However, no statistical significance was reported between the eplerenone treatment groups and the control in the effect exerted by serum creatinine (MD=0.03, 95% CI = -0.01 to 0.07, P = 0.12) and diastolic blood pressure (DBP) (MD = 0.11, 95% CI = -0.41 to 0.63, P = 0.68). Furthermore, significant risks of hyperkalemia were reported in the eplerenone group (K+ ≥ 5.5 mmol/l, RR = 1.70, 95%CI = 1.35 to 2.13, P=<0.00001; K+≥6.0 mmol/l, RR = 1.61, 95% CIs = 1.06 to 2.44, P = 0.02), respectively. Conclusions Eplerenone has beneficial effects on CKD by reducing urinary protein and the systolic blood pressure, but it also elevates the risk of hyperkalemia.
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Affiliation(s)
- Honglei Hu
- 1Department of Endocrinology, Shandong Zibo Central Hospital, Zibo 255000, China
| | - Mengdie Cao
- 2Department of Endocrinology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou 215000, China
| | - Yao Sun
- 1Department of Endocrinology, Shandong Zibo Central Hospital, Zibo 255000, China
| | - Xingqian Jin
- 1Department of Endocrinology, Shandong Zibo Central Hospital, Zibo 255000, China
| | - Xiaodong Zhao
- 1Department of Endocrinology, Shandong Zibo Central Hospital, Zibo 255000, China
| | - Xiangguo Cong
- 2Department of Endocrinology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou 215000, China
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Iversen E, Boesby L, Hansen D, Houlind MB. Comparison of 24-hour urinary creatinine clearance and estimated glomerular filtration rate based on a panel of filtration markers in patients with chronic kidney disease. Pharmacol Res Perspect 2022; 10:e01002. [PMID: 36069238 PMCID: PMC9449817 DOI: 10.1002/prp2.1002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 07/27/2022] [Indexed: 11/22/2022] Open
Abstract
Diagnosis and management of chronic kidney disease (CKD) requires accurate assessment of glomerular filtration rate (GFR). In practice, GFR is typically estimated by equations based on creatinine concentration in blood, but creatinine is affected by non-GFR factors such as age and sex. Alternative filtration markers such as cystatin C, beta-trace protein (BTP), and beta-2 microglobulin (B2M) may be less dependent on age and sex, but equations combining these markers have not been investigated in patients with chronic kidney disease (CKD). In this cross-sectional study of 50 patients with CKD stage 3-4, we compared kidney function estimates based on creatinine, cystatin C, BTP, B2M, or a combination of markers. Compared to the creatinine/cystatin C combination equation, the panel equation yielded a mean difference of only 2.8 ml/min/1.73 m2 , indicating that switching to the panel equation would be unlikely to affect management.
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Affiliation(s)
- Esben Iversen
- Department of Clinical ResearchCopenhagen University Hospital Amager and HvidovreHvidovreDenmark
- Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Lene Boesby
- Department of NephrologyCopenhagen University Hospital Herlev and GentofteCopenhagenDenmark
- Department of Internal MedicineZealand University Hospital RoskildeRoskildeDenmark
| | - Ditte Hansen
- Department of NephrologyCopenhagen University Hospital Herlev and GentofteCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Morten Baltzer Houlind
- Department of Clinical ResearchCopenhagen University Hospital Amager and HvidovreHvidovreDenmark
- Capital Region PharmacyHerlevDenmark
- Department of Drug Design and PharmacologyUniversity of CopenhagenCopenhagenDenmark
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Eklund M, Hellberg O, Furuland H, Cao Y, Wall K, Nilsson E. Effect of spironolactone on vascular stiffness in hemodialysis patients: a randomized crossover trial. Ups J Med Sci 2022; 127:8594. [PMID: 35722182 PMCID: PMC9169545 DOI: 10.48101/ujms.v127.8594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 12/02/2022] Open
Abstract
Background The role of spironolactone treatment in hemodialysis patients is debated, but a survival benefit is suggested. Mineralocorticoids and chronic kidney disease have been linked to cardiovascular fibrosis. Therefore, we hypothesized that spironolactone would affect vascular stiffness, cardiac systolic, and diastolic function in hemodialysis patients. Methods This was a randomized crossover study in hemodialysis patients supplemented with an echocardiographic case series. All outcomes reported here were secondary in the trial and were assessed without blinding. Block randomization and allocation determined treatment order. Participants received 50 mg spironolactone daily for 12 weeks and untreated observation for another 12 weeks. Pulse wave velocity (PWV) was measured before and after treatment and observation. Doppler-echocardiography was conducted before and after treatment. Systemic arterial compliance indexed to body surface area (SACi), left ventricular ejection fraction (LVEF), the peak early diastolic mitral inflow velocity (E), the peak late diastolic mitral inflow velocity (A), and the peak early diastolic myocardial lengthening velocity (E') were measured. E/A and E/E' were then calculated. Statistical analyses were conducted per protocol. A generalized linear mixed model with random participant effects was used for PWV. The Wilcoxon signed-rank test was used for echocardiographic variables. Results Thirty participants were recruited, 18 completed follow-up, and 17 were included in PWV-analyses. Spironolactone treatment showed a tendency toward an increase in PWV of 1.34 (95% confidence interval: -0.11 to 2.78) m/s, which was not statistically significant (P = 0.07). There were no significant changes in any of the other variables (LVEF, E/A, E/E', or SACi). Conclusions We found no evidence supporting an effect of 12-week administration of spironolactone 50 mg daily on vascular stiffness, cardiac systolic, or diastolic function in hemodialysis patients.
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Affiliation(s)
- Michael Eklund
- Department of Internal Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Olof Hellberg
- Department of Internal Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Hans Furuland
- Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Kent Wall
- Department of Clinical Physiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Erik Nilsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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González-Blázquez R, Alcalá M, Cárdenas-Rebollo JM, Viana M, Steckelings UM, Boisvert WA, Unger T, Fernández-Alfonso MS, Somoza B, Gil-Ortega M. AT2R stimulation with C21 prevents arterial stiffening and endothelial dysfunction in the abdominal aorta from mice fed a high-fat diet. Clin Sci (Lond) 2021; 135:2763-2780. [PMID: 34854902 DOI: 10.1042/cs20210971] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/25/2021] [Accepted: 12/02/2021] [Indexed: 12/16/2022]
Abstract
The aim of the present study was to evaluate the effect of Compound 21 (C21), a selective AT2R agonist, on the prevention of endothelial dysfunction, extracellular matrix (ECM) remodeling and arterial stiffness associated with diet-induced obesity (DIO). Five-week-old male C57BL/6J mice were fed a standard (Chow) or high-fat diet (HF) for 6 weeks. Half of the animals of each group were simultaneously treated with C21 (1 mg/kg/day, in the drinking water), generating four groups: Chow C, Chow C21, HF C, and HF C21. Vascular function and mechanical properties were determined in the abdominal aorta. To evaluate ECM remodeling, collagen deposition and TGF-β1 concentrations were determined in the abdominal aorta and the activity of metalloproteinases (MMP) 2 and 9 was analyzed in the plasma. Abdominal aortas from HF C mice showed endothelial dysfunction as well as enhanced contractile but reduced relaxant responses to Ang II. This effect was abrogated with C21 treatment by preserving NO availability. A left-shift in the tension-stretch relationship, paralleled by an augmented β-index (marker of intrinsic arterial stiffness), and enhanced collagen deposition and MMP-2/-9 activities were also detected in HF mice. However, when treated with C21, HF mice exhibited lower TGF-β1 levels in abdominal aortas together with reduced MMP activities and collagen deposition compared with HF C mice. In conclusion, these data demonstrate that AT2R stimulation by C21 in obesity preserves NO availability and prevents unhealthy vascular remodeling, thus protecting the abdominal aorta in HF mice against the development of endothelial dysfunction, ECM remodeling and arterial stiffness.
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Affiliation(s)
- Raquel González-Blázquez
- Departamento de Ciencias Farmacéuticas y de la Salud, Facultad de Farmacia, Universidad San Pablo-CEU, CEU Universities, 28925, Madrid, Spain
| | - Martín Alcalá
- Departamento de Química y Bioquímica, Facultad de Farmacia, Universidad CEU-San Pablo, CEU Universities, 28925, Madrid, Spain
| | - José Miguel Cárdenas-Rebollo
- Departamento de Matemática Aplicada y Estadística. Facultad de Ciencias Económicas y Empresariales. Universidad San Pablo-CEU, CEU Universities, 28925, Madrid, Spain
| | - Marta Viana
- Departamento de Química y Bioquímica, Facultad de Farmacia, Universidad CEU-San Pablo, CEU Universities, 28925, Madrid, Spain
| | - Ulrike Muscha Steckelings
- Department of Cardiovascular and Renal Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - William A Boisvert
- Center for Cardiovascular Research, John A. Burns School of Medicine, University of Hawaii, 651 Ilalo Street, BSB311, Honolulu, HI 96813, USA
- Institute of Fundamental Medicine and Biology, Kazan Federal University, 18 Kremlevskaya Str., Kazan 420008, Russia
| | - Thomas Unger
- CARIM - School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - María S Fernández-Alfonso
- Instituto Pluridisciplinar, Unidad de Cartografía Cerebral, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Departamento de Farmacología, Facultad de Farmacia, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Beatriz Somoza
- Departamento de Ciencias Farmacéuticas y de la Salud, Facultad de Farmacia, Universidad San Pablo-CEU, CEU Universities, 28925, Madrid, Spain
| | - Marta Gil-Ortega
- Departamento de Ciencias Farmacéuticas y de la Salud, Facultad de Farmacia, Universidad San Pablo-CEU, CEU Universities, 28925, Madrid, Spain
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Sakima A, Arima H, Matayoshi T, Ishida A, Ohya Y. Effect of Mineralocorticoid Receptor Blockade on Arterial Stiffness and Endothelial Function: A Meta-Analysis of Randomized Trials. Hypertension 2021; 77:929-937. [PMID: 33461316 DOI: 10.1161/hypertensionaha.120.16397] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although numerous studies have confirmed the beneficial effects of pharmacological therapy for arterial stiffness and endothelial dysfunction, which are predictors/therapeutic targets for cardiovascular diseases, only a few overall quantitative evaluations of MRAs (mineralocorticoid receptor antagonists) exist. We searched PubMed and Cochrane CENTRAL (Cochrane Central Register of Controlled Trials) for randomized trials evaluating MRA effects on arterial stiffness measured by pulse wave velocity (PWV) or augmentation index and endothelial function measured by flow-mediated dilation. Data from the included trials were pooled by using random-effects meta-analysis of the weighted mean difference (MD) between the comparator groups. The primary outcome was the MD of PWV. In 11 trials including 515 patients, the MRA treatment reduced the PWV when compared with control (MD, -0.75 m/s [95% CI, -1.12 to -0.39], P<0.00001), without heterogeneity. There were comparable effects of MRA on carotid-femoral PWV and those on other forms of PWV (P=0.705 for heterogeneity). The effects of MRA on PWV were independent of blood pressure reduction related to the treatment according to meta-regression analysis. The MRA treatment reduced the augmentation index compared with control in 5 trials including 283 patients (MD, -6.74% [95% CI, -10.26 to -3.21], P=0.0002) and increased the flow-mediated dilation in 11 trials including 570 patients (MD, 1.18% [95% CI, 0.14 to 2.23], P=0.03). In conclusion, the current meta-analysis demonstrates the beneficial effects of MRA on PWV, augmentation index, and flow-mediated dilation.
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Affiliation(s)
- Atsushi Sakima
- From the Health Administration Center (A.S.), University of the Ryukyus, Okinawa, Japan
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan (H.A.)
| | - Tetsutaro Matayoshi
- Department of Cardiovascular Medicine, Nephrology, and Neurology, Graduate School of Medicine (A.S., T.M., A.I., Y.O.), University of the Ryukyus, Okinawa, Japan.,Doctors Career Support Center, University Hospital of the Ryukyus, Okinawa, Japan (T.M.)
| | - Akio Ishida
- Department of Cardiovascular Medicine, Nephrology, and Neurology, Graduate School of Medicine (A.S., T.M., A.I., Y.O.), University of the Ryukyus, Okinawa, Japan
| | - Yusuke Ohya
- Department of Cardiovascular Medicine, Nephrology, and Neurology, Graduate School of Medicine (A.S., T.M., A.I., Y.O.), University of the Ryukyus, Okinawa, Japan
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Chung EY, Ruospo M, Natale P, Bolignano D, Navaneethan SD, Palmer SC, Strippoli GF. Aldosterone antagonists in addition to renin angiotensin system antagonists for preventing the progression of chronic kidney disease. Cochrane Database Syst Rev 2020; 10:CD007004. [PMID: 33107592 PMCID: PMC8094274 DOI: 10.1002/14651858.cd007004.pub4] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Treatment with angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) is used to reduce proteinuria and retard the progression of chronic kidney disease (CKD). However, resolution of proteinuria may be incomplete with these therapies and the addition of an aldosterone antagonist may be added to further prevent progression of CKD. This is an update of a Cochrane review first published in 2009 and updated in 2014. OBJECTIVES To evaluate the effects of aldosterone antagonists (selective (eplerenone), non-selective (spironolactone or canrenone), or non-steroidal mineralocorticoid antagonists (finerenone)) in adults who have CKD with proteinuria (nephrotic and non-nephrotic range) on: patient-centred endpoints including kidney failure (previously know as end-stage kidney disease (ESKD)), major cardiovascular events, and death (any cause); kidney function (proteinuria, estimated glomerular filtration rate (eGFR), and doubling of serum creatinine); blood pressure; and adverse events (including hyperkalaemia, acute kidney injury, and gynaecomastia). SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 13 January 2020 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 Register (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs that compared aldosterone antagonists in combination with ACEi or ARB (or both) to other anti-hypertensive strategies or placebo in participants with proteinuric CKD. DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality and extracted data. Data were summarised using random effects meta-analysis. We expressed summary treatment estimates as a risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, or standardised mean difference (SMD) when different scales were used together with their 95% confidence interval (CI). Risk of bias were assessed using the Cochrane tool. Evidence certainty was evaluated using GRADE. MAIN RESULTS Forty-four studies (5745 participants) were included. Risk of bias in the evaluated methodological domains were unclear or high risk in most studies. Adequate random sequence generation was present in 12 studies, allocation concealment in five studies, blinding of participant and investigators in 18 studies, blinding of outcome assessment in 15 studies, and complete outcome reporting in 24 studies. All studies comparing aldosterone antagonists to placebo or standard care were used in addition to an ACEi or ARB (or both). None of the studies were powered to detect differences in patient-level outcomes including kidney failure, major cardiovascular events or death. Aldosterone antagonists had uncertain effects on kidney failure (2 studies, 84 participants: RR 3.00, 95% CI 0.33 to 27.65, I² = 0%; very low certainty evidence), death (3 studies, 421 participants: RR 0.58, 95% CI 0.10 to 3.50, I² = 0%; low certainty evidence), and cardiovascular events (3 studies, 1067 participants: RR 0.95, 95% CI 0.26 to 3.56; I² = 42%; low certainty evidence) compared to placebo or standard care. Aldosterone antagonists may reduce protein excretion (14 studies, 1193 participants: SMD -0.51, 95% CI -0.82 to -0.20, I² = 82%; very low certainty evidence), eGFR (13 studies, 1165 participants, MD -3.00 mL/min/1.73 m², 95% CI -5.51 to -0.49, I² = 0%, low certainty evidence) and systolic blood pressure (14 studies, 911 participants: MD -4.98 mmHg, 95% CI -8.22 to -1.75, I² = 87%; very low certainty evidence) compared to placebo or standard care. Aldosterone antagonists probably increase the risk of hyperkalaemia (17 studies, 3001 participants: RR 2.17, 95% CI 1.47 to 3.22, I² = 0%; moderate certainty evidence), acute kidney injury (5 studies, 1446 participants: RR 2.04, 95% CI 1.05 to 3.97, I² = 0%; moderate certainty evidence), and gynaecomastia (4 studies, 281 participants: RR 5.14, 95% CI 1.14 to 23.23, I² = 0%; moderate certainty evidence) compared to placebo or standard care. Non-selective aldosterone antagonists plus ACEi or ARB had uncertain effects on protein excretion (2 studies, 139 participants: SMD -1.59, 95% CI -3.80 to 0.62, I² = 93%; very low certainty evidence) but may increase serum potassium (2 studies, 121 participants: MD 0.31 mEq/L, 95% CI 0.17 to 0.45, I² = 0%; low certainty evidence) compared to diuretics plus ACEi or ARB. Selective aldosterone antagonists may increase the risk of hyperkalaemia (2 studies, 500 participants: RR 1.62, 95% CI 0.66 to 3.95, I² = 0%; low certainty evidence) compared ACEi or ARB (or both). There were insufficient studies to perform meta-analyses for the comparison between non-selective aldosterone antagonists and calcium channel blockers, selective aldosterone antagonists plus ACEi or ARB (or both) and nitrate plus ACEi or ARB (or both), and non-steroidal mineralocorticoid antagonists and selective aldosterone antagonists. AUTHORS' CONCLUSIONS The effects of aldosterone antagonists when added to ACEi or ARB (or both) on the risks of death, major cardiovascular events, and kidney failure in people with proteinuric CKD are uncertain. Aldosterone antagonists may reduce proteinuria, eGFR, and systolic blood pressure in adults who have mild to moderate CKD but may increase the risk of hyperkalaemia, acute kidney injury and gynaecomastia when added to ACEi and/or ARB.
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Affiliation(s)
- Edmund Ym Chung
- Department of Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Marinella Ruospo
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Patrizia Natale
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Davide Bolignano
- Institute of Clinical Physiology, CNR - Italian National Council of Research, Reggio Calabria, Italy
| | | | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - 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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9
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Kousios A, Kouis P, Hadjivasilis A, Panayiotou A. Cardiovascular Risk Assessment Using Ultrasonographic Surrogate Markers of Atherosclerosis and Arterial Stiffness in Patients With Chronic Renal Impairment: A Narrative Review of the Evidence and a Critical View of Their Utility in Clinical Practice. Can J Kidney Health Dis 2020; 7:2054358120954939. [PMID: 32963791 PMCID: PMC7488604 DOI: 10.1177/2054358120954939] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 07/23/2020] [Indexed: 01/20/2023] Open
Abstract
PURPOSE OF THE REVIEW Validated tools to improve cardiovascular disease (CVD) risk assessment and mortality in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) are lacking. Noninvasive measures of arteriosclerosis and subclinical atherosclerosis such as pulse wave velocity (PWV) and carotid intima-media thickness (cIMT), respectively, have emerged as promising risk stratification tools and potential modifiable biomarkers. Their wide use as surrogate markers in clinical research studies is based on the strong pathophysiological links with CVD. However, whether their effect as risk stratification or intervention targets is superior to established clinical approaches is uncertain. In this review, we examine the evidence on the utility of PWV, cIMT, and plaque assessment in routine practice and highlight unanswered questions from the clinician's perspective. SOURCES OF INFORMATION Electronic databases PubMed and Google Scholar were searched until February 2020. METHODS This narrative review is based on peer-reviewed meta-analyses, national and international societies' guidelines, and on focused critical review of recent original studies and landmark studies in the field. KEY FINDINGS Although patients with CKD are considered in the high-risk CVD groups, there is still need for tools to improve risk stratification and individualized management strategies within this group of patients. Carotid intima-media thickness is associated with all-cause mortality, CVD mortality, and events in CKD and hemodialysis cohorts. However, the evidence that measurement of cIMT has a clinically meaningful role over and above existing risk scores and management strategies is limited. Plaque assessment is a better predictor than cIMT in non-CKD populations and it has been incorporated in recent nonrenal-specific guidelines. In the CKD population, one large observational study provided evidence for a potential role of plaque assessment in CKD similar to the non-CKD studies; however, whether it improves prediction and outcomes in CKD is largely understudied. Pulse wave velocity as a marker of arterial stiffness has a strong pathophysiological link with CVD in CKD and numerous observational studies demonstrated associations with increased cardiovascular risk. However, PWV did not improve CVD reclassification of dialysis patients when added to common risk factors in a reanalysis of ESRD cohorts with available PWV data. Therapeutic strategies to regress PWV, independently from blood pressure reduction, have not been studied in well-conducted randomized trials. LIMITATIONS This study provides a comprehensive review based on extensive literature search and critical appraisal of included studies. Nevertheless, formal systematic literature review and quality assessment were not performed and the possibility of selection bias cannot be excluded. IMPLICATIONS Larger, prospective, randomized studies with homogeneous approach, designed to answer specific clinical questions and taking into consideration special characteristics of CKD and dialysis, are needed to study the potentially beneficial role of cIMT/plaque assessment and PWV in routine practice.
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Affiliation(s)
- Andreas Kousios
- West London Renal and Transplant Centre,
Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
- Cardiovascular Epidemiology and Genetics
Research Lab, Cyprus International Institute for Environmental and Public Health,
Cyprus University of Technology, Limassol, Cyprus
| | - Panayiotis Kouis
- Cardiovascular Epidemiology and Genetics
Research Lab, Cyprus International Institute for Environmental and Public Health,
Cyprus University of Technology, Limassol, Cyprus
- Respiratory Physiology Laboratory,
Medical School, University of Cyprus, Nicosia, Cyprus
| | - Alexandros Hadjivasilis
- Cardiovascular Epidemiology and Genetics
Research Lab, Cyprus International Institute for Environmental and Public Health,
Cyprus University of Technology, Limassol, Cyprus
| | - Andrie Panayiotou
- Cardiovascular Epidemiology and Genetics
Research Lab, Cyprus International Institute for Environmental and Public Health,
Cyprus University of Technology, Limassol, Cyprus
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10
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Gołębiowski T, Kusztal M, Konieczny A, Letachowicz K, Gawryś A, Skolimowska B, Ostrowska B, Zmonarski S, Janczak D, Krajewska M. Disability of Dialysis Patients and the Condition of Blood Vessels. J Clin Med 2020; 9:E1806. [PMID: 32531965 PMCID: PMC7356767 DOI: 10.3390/jcm9061806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 01/31/2023] Open
Abstract
The number of elderly hemodialysis patients is constantly increasing worldwide. This population has a high burden of comorbid conditions, which impair daily activities. The aim of the study was to analyze problems of disability in hemodialysis patients in the context of cardiovascular (CV) complications and vascular condition. In this cross-sectional study, 129 patients (mean age 64.5) were enrolled. The degree of disability in Barthel index (Bi) and 10-year cardiovascular risk (QRISK®3) were assessed. A Mobil-O-Graph monitor was used for measuring hemodynamic parameters. Only 6.2% of patients were professionally active, 19% used a wheelchair for transport, and 16% used crutches. More than half (51%) were independent in everyday activities reaching 80-100 points on Bi. The rest, with Bi < 80, were considered as dependent. The most common causes of disability were CV complications. The independent group (80-100 points) was characterized by significantly lower pulse wave velocity (PWV) and lower QRISK®3 compared to dependent patients. The degree of disability negatively correlated with age, PWV, and QRISK®3. Multivariate logistic regression revealed that disability (Bi < 80) was independently associated with CV events in the past adjusted odds ratio (adj.OR) 4.83 (95% confidence interval (95% CI): 1.74-13.41) and higher PWV adj.OR 1.45 (95% CI: 1.15-1.82). Our results indicate that CV diseases are the most important cause of functional impairment.
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Affiliation(s)
- Tomasz Gołębiowski
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (K.L.); (A.G.); (S.Z.); (M.K.)
| | - Mariusz Kusztal
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (K.L.); (A.G.); (S.Z.); (M.K.)
| | - Andrzej Konieczny
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (K.L.); (A.G.); (S.Z.); (M.K.)
| | - Krzysztof Letachowicz
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (K.L.); (A.G.); (S.Z.); (M.K.)
| | - Ada Gawryś
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (K.L.); (A.G.); (S.Z.); (M.K.)
| | - Beata Skolimowska
- Department of Occupational Therapy, University School of Physical Education in Wroclaw, 51-612 Wroclaw, Poland; (B.S.); (B.O.)
| | - Bożena Ostrowska
- Department of Occupational Therapy, University School of Physical Education in Wroclaw, 51-612 Wroclaw, Poland; (B.S.); (B.O.)
| | - Sławomir Zmonarski
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (K.L.); (A.G.); (S.Z.); (M.K.)
| | - Dariusz Janczak
- Department of Vascular, General and Transplantation Surgery, Wroclaw Medical University, 50-556 Wroclaw, Poland;
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (K.L.); (A.G.); (S.Z.); (M.K.)
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11
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Spencer S, Wheeler‐Jones C, Elliott J. Aldosterone and the mineralocorticoid receptor in renal injury: A potential therapeutic target in feline chronic kidney disease. J Vet Pharmacol Ther 2020; 43:243-267. [PMID: 32128854 PMCID: PMC8614124 DOI: 10.1111/jvp.12848] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/20/2020] [Accepted: 02/09/2020] [Indexed: 12/24/2022]
Abstract
There is a growing body of experimental and clinical evidence supporting mineralocorticoid receptor (MR) activation as a powerful mediator of renal damage in laboratory animals and humans. Multiple pathophysiological mechanisms are proposed, with the strongest evidence supporting aldosterone-induced vasculopathy, exacerbation of oxidative stress and inflammation, and increased growth factor signalling promoting fibroblast proliferation and deranged extracellular matrix homeostasis. Further involvement of the MR is supported by extensive animal model experiments where MR antagonists (such as spironolactone and eplerenone) abrogate renal injury, including ischaemia-induced damage. Additionally, clinical trials have shown MR antagonists to be beneficial in human chronic kidney disease (CKD) in terms of reducing proteinuria and cardiovascular events, though current studies have not evaluated primary end points which allow conclusions to made about whether MR antagonists reduce mortality or slow CKD progression. Although differences between human and feline CKD exist, feline CKD shares many characteristics with human disease including tubulointerstitial fibrosis. This review evaluates the evidence for the role of the MR in renal injury and summarizes the literature concerning aldosterone in feline CKD. MR antagonists may represent a promising therapeutic strategy in feline CKD.
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Affiliation(s)
- Sarah Spencer
- Comparative Biomedical SciencesThe Royal Veterinary CollegeLondonUK
| | | | - Jonathan Elliott
- Comparative Biomedical SciencesThe Royal Veterinary CollegeLondonUK
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12
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Effects of Angiotensin-Converting Enzyme Inhibitors on Arterial Stiffness: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Cardiovasc Ther 2020; 2020:7056184. [PMID: 32190121 PMCID: PMC7068147 DOI: 10.1155/2020/7056184] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/31/2019] [Accepted: 01/08/2020] [Indexed: 12/11/2022] Open
Abstract
To determine the effects of ACEIs on arterial stiffness, a meta-analysis of randomized controlled trials was conducted. Relevant articles that investigated the effects of ACEIs on arterial stiffness from PubMed, Embase, and the Cochrane library from inception to September 2018 were systematically retrieved. The investigated outcomes included brachial-ankle pulse wave velocity (ba-PWV) and carotid-femoral PWV (cf-PWV) by using weighted mean differences (WMDs) and 95% confidence intervals (CIs) with the random-effects model. A total of 17 RCTs including 1,458 individuals were included. The summary results indicated no significant differences between ACEIs and control for ba-PWV and cf-PWV. Also, no significant differences between ACEI and control for ba-PWV and cf-PWV were observed in hypertensive patients, while the therapeutic effects of ACEI versus placebo showed statistically significant difference. Moreover, subgroup analysis indicated that the levels of ba-PWV were significantly associated if the study was conducted in Western countries, mean age <60.0 years, percentage male ≥60.0%, compared with ARBs, baseline PWV <10.0, and high-quality study. Furthermore, the significant levels of cf-PWV in patients who received ACEIs were observed when percentage male was ≥60.0% and the studies were of high-quality. Finally, no significant differences were observed between ACEIs and other antihypertensive drugs regarding the changes of systolic blood pressure (SBP) and diastolic blood pressure (DBP). The overall analysis suggested no significant differences between ACEIs and other antihypertensive drugs for ba-PWV and cf-PWV levels, whereas ACEIs versus placebo showed lower levels of ba-PWV and cf-PWV.
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13
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Barrera-Chimal J, Girerd S, Jaisser F. Mineralocorticoid receptor antagonists and kidney diseases: pathophysiological basis. Kidney Int 2019; 96:302-319. [PMID: 31133455 DOI: 10.1016/j.kint.2019.02.030] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 02/04/2019] [Accepted: 02/20/2019] [Indexed: 12/13/2022]
Abstract
Chronic kidney disease (CKD) represents a global health concern, and its prevalence is increasing. The ultimate therapeutic option for CKD is kidney transplantation. However, the use of drugs that target specific pathways to delay or halt CKD progression, such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and sodium-glucose co-transporter-2 (SGLT-2) inhibitors is limited in clinical practice. Mineralocorticoid receptor activation in nonclassical tissues, such as the endothelium, smooth muscle cells, inflammatory cells, podocytes, and fibroblasts may have deleterious effects on kidney structure and function. Several preclinical studies have shown that mineralocorticoid receptor antagonists (MRAs) ameliorate or cure kidney injury and dysfunction in different models of kidney disease. In this review, we present the preclinical evidence showing a benefit of MRAs in acute kidney injury, the transition from acute kidney injury to CKD, hypertensive and diabetic nephropathy, glomerulonephritis, and kidney toxicity induced by calcineurin inhibitors. We also discuss the molecular mechanisms responsible for renoprotection related to MRAs that lead to reduced oxidative stress, inflammation, fibrosis, and hemodynamic alterations. The available clinical data support a benefit of MRA in reducing proteinuria in diabetic kidney disease and improving cardiovascular outcomes in CKD patients. Moreover, a benefit of MRAs in kidney transplantation has also been observed. The past and present clinical trials describing the effect of MRAs on kidney injury are presented, and the risk of hyperkalemia and use of other options, such as potassium binding agents or nonsteroidal MRAs, are also addressed. Altogether, the available preclinical and clinical data support a benefit of using MRAs in CKD, an approach that should be further explored in future clinical trials.
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Affiliation(s)
- Jonatan Barrera-Chimal
- Laboratorio de Fisiología Cardiovascular y Trasplante Renal, Unidad de Medicina Traslacional, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México and Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Sophie Girerd
- Transplant Unit, Nephrology Department, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France; Institut national de la santé et de la recherche médicale U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France; Investigation Network Initiative - Cardiovascular and Renal Clinical Trialists, French-Clinical Research Infrastructure Network, Nancy, France
| | - Frederic Jaisser
- Institut national de la santé et de la recherche médicale U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France; Investigation Network Initiative - Cardiovascular and Renal Clinical Trialists, French-Clinical Research Infrastructure Network, Nancy, France; Institut national de la santé et de la recherche médicale, UMRS 1138, Team 1, Centre de Recherche des Cordeliers, Sorbonne University, Paris Descartes University, Paris, France.
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14
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Nowak KL, Gitomer B, Farmer-Bailey H, Wang W, Malaczewski M, Klawitter J, You Z, George D, Patel N, Jovanovich A, Chonchol M. Mineralocorticoid Antagonism and Vascular Function in Early Autosomal Dominant Polycystic Kidney Disease: A Randomized Controlled Trial. Am J Kidney Dis 2019; 74:213-223. [PMID: 30803706 DOI: 10.1053/j.ajkd.2018.12.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 12/17/2018] [Indexed: 02/07/2023]
Abstract
RATIONALE & OBJECTIVE Vascular dysfunction, characterized by impaired vascular endothelial function and increased large-elastic artery stiffness, is evident early in autosomal dominant polycystic kidney disease (ADPKD) and is an important predictor of cardiovascular events and mortality. Aldosterone excess has been implicated in the development of endothelial dysfunction and arterial stiffness, in part by causing increased oxidative stress and inflammation. We hypothesized that aldosterone antagonism would reduce vascular dysfunction in patients with early-stage ADPKD. STUDY DESIGN Prospective, randomized, controlled, double-blind, clinical trial. SETTING & PARTICIPANTS 61 adults aged 20 to 55 years with ADPKD, estimated glomerular filtration rate ≥ 60mL/min/1.73m2, and receiving a renin-angiotensin-aldosterone system inhibitor. INTERVENTION Spironolactone (maximum dose, 50mg/d) or placebo for 24 weeks. OUTCOMES Change in brachial artery flow-mediated dilation (FMDBA) was the primary end point and change in carotid-femoral pulse-wave velocity (CFPWV) was the secondary end point. RESULTS 60 participants completed the trial. Participants had a mean age of 34±10 (SD) years, 54% were women, and 84% were non-Hispanic white. Spironolactone did not change FMDBA (8.0% ± 5.5% and 7.8% ± 4.3% at baseline and 24 weeks, respectively, vs corresponding values in the placebo group of 8.4% ± 6.2% and 8.0% ± 4.6%; P=0.9for comparison of change between groups) or CFPWV (640±127 and 603±101cm/s at baseline and 24 weeks, respectively, vs corresponding values in the placebo group of 659±138 and 658±131cm/s; P=0.1). Brachial systolic blood pressure was reduced with spironolactone (median change, -6 [IQR, -15, 1] vs -2 [IQR, -7, 10] mm Hg in the placebo group; P=0.04). Spironolactone did not change the majority of circulating and/or endothelial cell markers of oxidative stress/inflammation and did not change vascular oxidative stress. LIMITATIONS Low level of baseline vascular dysfunction; lack of aldosterone measurements. CONCLUSIONS 24 weeks of aldosterone antagonism reduced systolic blood pressure without changing vascular function in patients with early-stage ADPKD. FUNDING NIDDK, NIH National Center for Advancing Translational Sciences, and the Zell Family Foundation. TRIAL REGISTRATION Registered at ClinicalTrials.gov with study number NCT01853553.
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Affiliation(s)
- Kristen L Nowak
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.
| | - Berenice Gitomer
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Heather Farmer-Bailey
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Wei Wang
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Mikaela Malaczewski
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jelena Klawitter
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Zhiying You
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Diana George
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Nayana Patel
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Anna Jovanovich
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Renal Section, Medical Service, Veteran Affairs Eastern Colorado Health Care System, Denver, CO
| | - Michel Chonchol
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
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15
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Lioufas N, Hawley CM, Cameron JD, Toussaint ND. Chronic Kidney Disease and Pulse Wave Velocity: A Narrative Review. Int J Hypertens 2019; 2019:9189362. [PMID: 30906591 PMCID: PMC6397961 DOI: 10.1155/2019/9189362] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 01/13/2019] [Indexed: 12/28/2022] Open
Abstract
Chronic kidney disease (CKD) is associated with excess cardiovascular mortality, resulting from both traditional and nontraditional, CKD-specific, cardiovascular risk factors. Nontraditional risk factors include the entity Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) which is characterised by disorders of bone and mineral metabolism, including biochemical abnormalities of hyperphosphatemia and hyperparathyroidism, renal osteodystrophy, and vascular calcification. Increased arterial stiffness in the CKD population can be attributed amongst other influences to progression of vascular calcification, with significant resultant contribution to the cardiovascular disease burden. Pulse wave velocity (PWV) measured over the carotid-femoral arterial segments is the noninvasive gold-standard technique for measurement of aortic stiffness and has been suggested as a surrogate cardiovascular end-point. A PWV value of 10 m/s or greater has been recommended as a suitable cut-off for an increased risk of cardiovascular mortality. CKD is a risk factor for an excessive rate of increase in aortic stiffness, reflected by increases in PWV, and increased aortic PWV in CKD shows faster progression than for individuals with normal kidney function. Patients with varying stages of CKD, as well as those on dialysis or with a kidney transplant, have different biological milieu which influence aortic stiffness and associated changes in PWV. This review discusses the pathophysiology of arterial stiffness with CKD and outlines the literature on PWV across the spectrum of CKD, highlighting that determination of arterial stiffness using aortic PWV can be a useful diagnostic and prognostic tool for assessing cardiovascular disease in the CKD population.
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Affiliation(s)
- Nicole Lioufas
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, Australia
- Department of Medicine, Western Health, St Albans, Australia
| | - Carmel M. Hawley
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Faculty of Medicine, University of Queensland, Woolloongabba, Australia
| | - James D. Cameron
- Monash Cardiovascular Research Centre, Monash Health, Clayton, Australia
- Monash University, Clayton, Australia
| | - Nigel D. Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, Australia
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16
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Girerd S, Jaisser F. Mineralocorticoid receptor antagonists in kidney transplantation: time to consider? Nephrol Dial Transplant 2018; 33:2080-2091. [DOI: 10.1093/ndt/gfy065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 02/27/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Sophie Girerd
- Transplant Unit, Nephrology Department, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
- INSERM U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France
- INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
| | - Frédéric Jaisser
- INSERM U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France
- INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
- INSERM, UMRS 1138, Team 1, Centre de Recherche des Cordeliers, Pierre et Marie Curie University, Paris Descartes University, Paris, France
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17
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Lacolley P, Regnault V, Segers P, Laurent S. Vascular Smooth Muscle Cells and Arterial Stiffening: Relevance in Development, Aging, and Disease. Physiol Rev 2017; 97:1555-1617. [DOI: 10.1152/physrev.00003.2017] [Citation(s) in RCA: 332] [Impact Index Per Article: 47.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/15/2017] [Accepted: 05/26/2017] [Indexed: 12/18/2022] Open
Abstract
The cushioning function of large arteries encompasses distension during systole and recoil during diastole which transforms pulsatile flow into a steady flow in the microcirculation. Arterial stiffness, the inverse of distensibility, has been implicated in various etiologies of chronic common and monogenic cardiovascular diseases and is a major cause of morbidity and mortality globally. The first components that contribute to arterial stiffening are extracellular matrix (ECM) proteins that support the mechanical load, while the second important components are vascular smooth muscle cells (VSMCs), which not only regulate actomyosin interactions for contraction but mediate also mechanotransduction in cell-ECM homeostasis. Eventually, VSMC plasticity and signaling in both conductance and resistance arteries are highly relevant to the physiology of normal and early vascular aging. This review summarizes current concepts of central pressure and tensile pulsatile circumferential stress as key mechanical determinants of arterial wall remodeling, cell-ECM interactions depending mainly on the architecture of cytoskeletal proteins and focal adhesion, the large/small arteries cross-talk that gives rise to target organ damage, and inflammatory pathways leading to calcification or atherosclerosis. We further speculate on the contribution of cellular stiffness along the arterial tree to vascular wall stiffness. In addition, this review provides the latest advances in the identification of gene variants affecting arterial stiffening. Now that important hemodynamic and molecular mechanisms of arterial stiffness have been elucidated, and the complex interplay between ECM, cells, and sensors identified, further research should study their potential to halt or to reverse the development of arterial stiffness.
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Affiliation(s)
- Patrick Lacolley
- INSERM, U1116, Vandœuvre-lès-Nancy, France; Université de Lorraine, Nancy, France; IBiTech-bioMMeda, Department of Electronics and Information Systems, Ghent University, Gent, Belgium; Department of Pharmacology, European Georges Pompidou Hospital, Assistance Publique Hôpitaux de Paris, France; PARCC INSERM, UMR 970, Paris, France; and University Paris Descartes, Paris, France
| | - Véronique Regnault
- INSERM, U1116, Vandœuvre-lès-Nancy, France; Université de Lorraine, Nancy, France; IBiTech-bioMMeda, Department of Electronics and Information Systems, Ghent University, Gent, Belgium; Department of Pharmacology, European Georges Pompidou Hospital, Assistance Publique Hôpitaux de Paris, France; PARCC INSERM, UMR 970, Paris, France; and University Paris Descartes, Paris, France
| | - Patrick Segers
- INSERM, U1116, Vandœuvre-lès-Nancy, France; Université de Lorraine, Nancy, France; IBiTech-bioMMeda, Department of Electronics and Information Systems, Ghent University, Gent, Belgium; Department of Pharmacology, European Georges Pompidou Hospital, Assistance Publique Hôpitaux de Paris, France; PARCC INSERM, UMR 970, Paris, France; and University Paris Descartes, Paris, France
| | - Stéphane Laurent
- INSERM, U1116, Vandœuvre-lès-Nancy, France; Université de Lorraine, Nancy, France; IBiTech-bioMMeda, Department of Electronics and Information Systems, Ghent University, Gent, Belgium; Department of Pharmacology, European Georges Pompidou Hospital, Assistance Publique Hôpitaux de Paris, France; PARCC INSERM, UMR 970, Paris, France; and University Paris Descartes, Paris, France
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18
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Low dose-eplerenone treatment decreases aortic stiffness in patients with resistant hypertension. J Clin Hypertens (Greenwich) 2017; 19:669-676. [DOI: 10.1111/jch.12986] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 12/13/2016] [Accepted: 12/25/2016] [Indexed: 11/26/2022]
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19
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Effect of aldosterone antagonists on common carotid artery’s intima-media thickness, stiffness indices and flow mediated vasodilatation of brachial artery in CAD patients. Artery Res 2017. [DOI: 10.1016/j.artres.2017.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Zhang J, Wang Y, Hu H, Yang X, Tian Z, Liu D, Gu G, Zheng H, Xie R, Cui W. Early intervention of long-acting nifedipine GITS reduces brachial-ankle pulse wave velocity and improves arterial stiffness in Chinese patients with mild hypertension: a 24-week, single-arm, open-label, prospective study. DRUG DESIGN DEVELOPMENT AND THERAPY 2016; 10:3399-3406. [PMID: 27799740 PMCID: PMC5076851 DOI: 10.2147/dddt.s117221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Nifedipine gastrointestinal therapeutic system (GITS) is used to treat angina and hypertension. The authors aimed to study the early intervention impact on arterial stiffness and pulse wave velocity (PWV) independent of its blood-pressure-(BP) lowering effect in mild hypertensive patients. Methods This single-center, single-arm, open-label, prospective, Phase IV study recruited patients with mild hypertension and increased PWV from December 2013 to December 2014 (N=138; age, 18–75 years; systolic blood pressure, 140–160 mmHg; diastolic BP, 90–100 mmHg; increased brachial–ankle pulse wave velocity [baPWV, ≥12 m/s]). Nifedipine GITS (30 mg/d) was administered for 24 weeks to achieve target BP of <140/90 mmHg. The dose was uptitrated at 60 mg/d in case of unsatisfactory BP reduction after 4 weeks. Primary study end point was the change in baPWV after nifedipine GITS treatment. Hemodynamic parameters (office BP, 24-hour ambulatory BP monitoring, and heart rate and adverse events) were evaluated at baseline and followed-up at 2, 4, 8, 12, 18, and 24 weeks. Results Majority of patients (n=117; 84.8%) completed the study. baPWV decreased significantly at 4 weeks compared with baseline (1,598.87±239.82 vs 1,500.89±241.15 cm/s, P<0.001), was stable at 12 weeks (1,482.24±215.14 cm/s, P<0.001), and remained steady through 24 weeks (1,472.58±205.01 cm/s, P<0.001). Office BP reduced from baseline to week 4 (154/95 vs 136/85 mmHg) and remained steady until 24 weeks. Nifedipine GITS significantly decreased 24-hour ambulatory BP monitoring (P<0.001) after 24 weeks from baseline. Mean arterial pressure and pulse pressure were lowered significantly after 4, 12, and 24 weeks of treatment (P<0.001). These changes in baPWV were significantly correlated with changes in systolic blood pressure, diastolic BP, and mean arterial pressure (P<0.05), but not with changes in pulse pressure (P>0.05). There were no other drug-related serious adverse events. Conclusion Nifedipine GITS was considerably effective in reducing baPWV and BP, indicating improvement in arterial stiffness as early as 4 weeks.
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Affiliation(s)
- Jidong Zhang
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Yan Wang
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Haijuan Hu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Xiaohong Yang
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Zejun Tian
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Demin Liu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Guoqiang Gu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Hongmei Zheng
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Ruiqin Xie
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Wei Cui
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
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Currie G, Taylor AHM, Fujita T, Ohtsu H, Lindhardt M, Rossing P, Boesby L, Edwards NC, Ferro CJ, Townend JN, van den Meiracker AH, Saklayen MG, Oveisi S, Jardine AG, Delles C, Preiss DJ, Mark PB. Effect of mineralocorticoid receptor antagonists on proteinuria and progression of chronic kidney disease: a systematic review and meta-analysis. BMC Nephrol 2016; 17:127. [PMID: 27609359 PMCID: PMC5015203 DOI: 10.1186/s12882-016-0337-0] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 08/25/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Hypertension and proteinuria are critically involved in the progression of chronic kidney disease. Despite treatment with renin angiotensin system inhibition, kidney function declines in many patients. Aldosterone excess is a risk factor for progression of kidney disease. Hyperkalaemia is a concern with the use of mineralocorticoid receptor antagonists. We aimed to determine whether the renal protective benefits of mineralocorticoid antagonists outweigh the risk of hyperkalaemia associated with this treatment in patients with chronic kidney disease. METHODS We conducted a meta-analysis investigating renoprotective effects and risk of hyperkalaemia in trials of mineralocorticoid receptor antagonists in chronic kidney disease. Trials were identified from MEDLINE (1966-2014), EMBASE (1947-2014) and the Cochrane Clinical Trials Database. Unpublished summary data were obtained from investigators. We included randomised controlled trials, and the first period of randomised cross over trials lasting ≥4 weeks in adults. RESULTS Nineteen trials (21 study groups, 1 646 patients) were included. In random effects meta-analysis, addition of mineralocorticoid receptor antagonists to renin angiotensin system inhibition resulted in a reduction from baseline in systolic blood pressure (-5.7 [-9.0, -2.3] mmHg), diastolic blood pressure (-1.7 [-3.4, -0.1] mmHg) and glomerular filtration rate (-3.2 [-5.4, -1.0] mL/min/1.73 m(2)). Mineralocorticoid receptor antagonism reduced weighted mean protein/albumin excretion by 38.7 % but with a threefold higher relative risk of withdrawing from the trial due to hyperkalaemia (3.21, [1.19, 8.71]). Death, cardiovascular events and hard renal end points were not reported in sufficient numbers to analyse. CONCLUSIONS Mineralocorticoid receptor antagonism reduces blood pressure and urinary protein/albumin excretion with a quantifiable risk of hyperkalaemia above predefined study upper limit.
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Affiliation(s)
- Gemma Currie
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Center, 126 University Place, Glasgow, UK.
| | - Alison H M Taylor
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Center, 126 University Place, Glasgow, UK
| | - Toshiro Fujita
- Division of Clinical Epigenetics, Research Center for Advanced Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Ohtsu
- Department of Clinical Study and Informatics, Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | | | - Peter Rossing
- Steno Diabetes Center, Niels Steensens Vej, Gentofte, Denmark
- Health, Aarhus University, Aarhus, Denmark
- NNF Centre for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Lene Boesby
- Department of Nephrology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Nicola C Edwards
- Departments of Cardiology and Nephrology, University Hospital Birmingham and School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - Charles J Ferro
- Departments of Cardiology and Nephrology, University Hospital Birmingham and School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - Jonathan N Townend
- Departments of Cardiology and Nephrology, University Hospital Birmingham and School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | | | | | - Sonia Oveisi
- Metabolic Diseases Research Center, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Alan G Jardine
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Center, 126 University Place, Glasgow, UK
| | - Christian Delles
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Center, 126 University Place, Glasgow, UK
| | - David J Preiss
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Center, 126 University Place, Glasgow, UK
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Lu R, Zhang Y, Zhu X, Fan Z, Zhu S, Cui M, Zhang Y, Tang F. Effects of mineralocorticoid receptor antagonists on left ventricular mass in chronic kidney disease patients: a systematic review and meta-analysis. Int Urol Nephrol 2016; 48:1499-509. [PMID: 27193436 DOI: 10.1007/s11255-016-1319-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 05/09/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND Mineralocorticoid receptor antagonists (MRAs) are used widely in treatment of heart failure, but their effects on cardiovascular complications and mortality of chronic kidney disease (CKD) are not well known. Thus, we aim to assess such therapeutic effects of MRAs on CKD. METHODS Electronic literature published in any language until Dec 31, 2015, was systematically searched on PubMed, Embase, and Cochrane Central Register of Controlled Trials. Primary outcome was left ventricular mass (LVM) or LVM index (LVMI), and secondary outcome was all-cause mortality and major adverse cardiovascular events (MACEs). Results of continuous outcomes were pooled using mean difference (MD) and standard mean difference (SMD). Risk ratios (RRs) with 95 % confidence intervals (CIs) were pooled using a random- or fixed-effects model. RESULTS Totally 12 studies (6 randomized controlled trials with 1003 participants) involving 4935 patients were included. MRA treatment versus non-MRA treatment resulted in a significant change of 0.93 SMD (standard mean difference) in LVM (LVMI), a significant reduction of 22 % in all-cause mortality, a significant reduction of incidence of MACEs (RR 0.65, P = 0.001), significantly higher prevalence rates of hyperkalemia (>5.5 mmol/L), but no significant change in prevalence rates of severe hyperkalemia (>6.0 mmol/L). CONCLUSION MRA benefits CKD patients in terms of LVMI, all-cause mortality, and MACEs with no incidence of severe hyperkalemia. Nevertheless, the real effects of MRAs on cardiovascular events and mortality as well as their safety in CKD patients should be identified by further studies with prospective and large-sample clinical trials.
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Affiliation(s)
- RenJie Lu
- Department of Pharmacy, The Third People's Hospital of Changzhou, Changzhou, Jiangsu, People's Republic of China
| | - Yan Zhang
- Department of Internal Medicine, The Third People's Hospital of Changzhou, Changzhou, Jiangsu, People's Republic of China
| | - Xishan Zhu
- Department of Urinary Surgery, The Third People's Hospital of Changzhou, Changzhou, Jiangsu, People's Republic of China
| | - Zhengda Fan
- Department of Pharmacy, The Third People's Hospital of Changzhou, Changzhou, Jiangsu, People's Republic of China
| | - Shanmei Zhu
- Department of Pharmacy, The Third People's Hospital of Changzhou, Changzhou, Jiangsu, People's Republic of China
| | - Manman Cui
- Department of Infectious Diseases, The Third People's Hospital of Changzhou, Changzhou, Jiangsu, People's Republic of China
| | - Yanping Zhang
- Department of Infectious Diseases, The Third People's Hospital of Changzhou, Changzhou, Jiangsu, People's Republic of China
| | - Fenglei Tang
- Department of Pharmacy, The Third People's Hospital of Changzhou, Changzhou, Jiangsu, People's Republic of China.
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László A, Reusz G, Nemcsik J. Ambulatory arterial stiffness in chronic kidney disease: a methodological review. Hypertens Res 2015; 39:192-8. [DOI: 10.1038/hr.2015.137] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 09/27/2015] [Accepted: 10/06/2015] [Indexed: 11/09/2022]
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Townsend RR, Wilkinson IB, Schiffrin EL, Avolio AP, Chirinos JA, Cockcroft JR, Heffernan KS, Lakatta EG, McEniery CM, Mitchell GF, Najjar SS, Nichols WW, Urbina EM, Weber T. Recommendations for Improving and Standardizing Vascular Research on Arterial Stiffness: A Scientific Statement From the American Heart Association. Hypertension 2015; 66:698-722. [PMID: 26160955 DOI: 10.1161/hyp.0000000000000033] [Citation(s) in RCA: 947] [Impact Index Per Article: 105.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Kollias A, Rarra V, Karpettas N, Roussias L, O'Brien E, Stergiou GS. Treatment-induced changes in ambulatory arterial stiffness index: one-year prospective study and meta-analysis of evidence. Hypertens Res 2015; 38:627-31. [PMID: 25809579 DOI: 10.1038/hr.2015.44] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 12/28/2014] [Accepted: 02/25/2015] [Indexed: 11/09/2022]
Abstract
The ambulatory arterial stiffness index (AASI) has been introduced as an index of arterial function, predicting cardiovascular events. However, treatment-induced changes in AASI are rather equivocal. This study aims to: (i) present the results of treatment-induced changes in AASI in untreated subjects with elevated blood pressure (BP), subjected to antihypertensive treatment for 1 year and (ii) perform a meta-analysis of studies reporting on treatment-induced change in AASI. A total of 104 subjects (mean age 51.4±10.3 years, 62% males, mean follow-up: 13.6±2.4 months) were analyzed. Despite significant reductions in 24-h ambulatory systolic/diastolic BP, pulse pressure and pulse wave velocity (mean change: -15.9±12/-10.4±7.6 mm Hg, -5.4±6.8 mm Hg, -0.7±1.9 m s(-1), respectively, all P<0.05), there was no significant change (Follow up-Baseline) in AASI values (mean change: 0.01±0.17, P=not significant). The treatment-induced change in AASI was correlated with baseline AASI (r=-0.61), baseline 24-h pulse pressure (-0.26), treatment-induced change in 24-h pulse pressure (0.26) and in systolic/diastolic nocturnal dipping (-0.25/-0.40, respectively). Meta-analysis of eight trials (n=990) revealed a marginal decrease in AASI with antihypertensive treatment (pooled change: -0.018 (95% confidence interval (CI): -0.033,-0.003)). When the analysis was restricted to data with renin-angiotensin system blockers (n=755, 76% of total), the results did not significantly change (pooled change -0.028 (95% CI -0.048, -0.007)). In conclusion, although AASI is an independent predictor of cardiovascular events, its response to antihypertensive treatment is only marginal and clinically uncertain, which may render its use as a therapeutic target in clinical practice questionable.
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Affiliation(s)
- Anastasios Kollias
- Hypertension Center, STRIDE -7, Third University Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Vayia Rarra
- Hypertension Center, STRIDE -7, Third University Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Nikos Karpettas
- Hypertension Center, STRIDE -7, Third University Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Leonidas Roussias
- Hypertension Center, STRIDE -7, Third University Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Eoin O'Brien
- Conway Institute, University College, Dublin, Ireland
| | - George S Stergiou
- Hypertension Center, STRIDE -7, Third University Department of Medicine, Sotiria Hospital, Athens, Greece
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Ng KP, Arnold J, Sharif A, Gill P, Townend JN, Ferro CJ. Cardiovascular actions of mineralocorticoid receptor antagonists in patients with chronic kidney disease: A systematic review and meta-analysis of randomized trials. J Renin Angiotensin Aldosterone Syst 2015; 16:599-613. [PMID: 25784710 DOI: 10.1177/1470320315575849] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 02/07/2015] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION The safety and actions of mineralocorticoid receptor antagonists on surrogate markers of cardiovascular disease as well as major patient level cardiovascular end-points in patients with chronic kidney disease are unclear. METHODS MEDLINE, EMBASE, Trip Database, Cochrane Central Register of Controlled Trials, Cochrane Renal Group specialized register, Current Controlled Trials and clinicaltrials.gov were searched for relevant trials. RESULTS Twenty-nine trials (1581 patients) were included. Overall, mineralocorticoid receptor antagonists lowered both systolic and diastolic blood pressure (-5.24, 95% confidence interval (CI) -8.65, -1.82 mmHg; p=0.003 and -1.96, 95% CI -3.22, -0.69 mmHg; p=0.002 respectively). There were insufficient data to perform a meta-analysis of other cardiovascular effects. However, a systematic review of the studies included suggested a consistent improvement in surrogate markers of cardiovascular disease. Overall, the use of mineralocorticoid receptor antagonists was associated with an increased serum potassium (0.23, 95% CI 0.13, 0.33 mmol/l; p<0.0001) and higher risk ratio (1.76, 95% CI 1.20, 2.57; p=0.001) of hyperkalemia. Data on long-term cardiovascular outcomes and mortality were not available in any of the trials. CONCLUSIONS The long-term effects of mineralocorticoid receptor antagonists on cardiovascular events, mortality and safety need to be established.
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Affiliation(s)
- Khai P Ng
- Department of Nephrology, Queen Elizabeth Hospital and University of Birmingham, UK
| | - Julia Arnold
- Department of Nephrology, Queen Elizabeth Hospital and University of Birmingham, UK
| | - Adnan Sharif
- Department of Nephrology, Queen Elizabeth Hospital and University of Birmingham, UK
| | - Paramjit Gill
- Primary Care Clinical Sciences, University of Birmingham, UK
| | - Jonathan N Townend
- Department of Cardiology, Queen Elizabeth Hospital and University of Birmingham, UK
| | - Charles J Ferro
- Department of Nephrology, Queen Elizabeth Hospital and University of Birmingham, UK
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Shibata T, Tsutsumi J, Hasegawa J, Sato N, Murashima E, Mori C, Hongo K, Yoshimura M. Effects of Add-on Therapy Consisting of a Selective Mineralocorticoid Receptor Blocker on Arterial Stiffness in Patients with Uncontrolled Hypertension. Intern Med 2015; 54:1583-9. [PMID: 26134187 DOI: 10.2169/internalmedicine.54.3427] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Aldosterone plays an important role in the pathogenesis of atherosclerosis; however, the significance of mineralocorticoid receptor blockade for atherosclerosis has not been fully elucidated. In this study, the effect of add-on eplerenone on the degree of arterial stiffness was examined in patients with uncontrolled hypertension. METHODS Forty-seven uncontrolled hypertensive patients who had previously been treated with anti-hypertensive drugs were examined retrospectively. Thirty-two patients received add-on therapy consisting of eplerenone (Group E) and 15 patients received add-on therapy with a Calcium channel blocker (CCB) or an increased dose of CCB (Group C) in addition to their baseline medications. Both the systolic blood pressure (SBP) and diastolic blood pressure (DBP) values were significantly decreased at two and 12 months in Group C. In contrast, neither the SBP nor DBP values were significantly changed at two months and eventually decreased at 12 months in Group E. The degree of arterial stiffness, as evaluated according to the cardio-ankle vascular index (CAVI), did not improve at either two or 12 months in Group C, whereas the CAVI values improved as early as at two months and the improvement was sustained at 12 months in Group E. The extent of change in the CAVI was not associated with the level of changes in the SBP or DBP values in Group E. CONCLUSION Treatment with eplerenone added to the patient's baseline medications improves the degree of arterial stiffness as early as at two months after the beginning of treatment, independent of the blood pressure-lowering actions of these drugs in patients with uncontrolled hypertension.
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Affiliation(s)
- Takahiro Shibata
- Division of Cardiology, Department of Internal Medicine, The Jikei Daisan Hospital, Japan
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Tan W, Madhavan K, Hunter KS, Park D, Stenmark KR. Vascular stiffening in pulmonary hypertension: cause or consequence? (2013 Grover Conference series). Pulm Circ 2014; 4:560-80. [PMID: 25610594 PMCID: PMC4278618 DOI: 10.1086/677370] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 05/27/2014] [Indexed: 12/24/2022] Open
Abstract
Recent studies have indicated that systemic arterial stiffening is a precursor to hypertension and that hypertension, in turn, can perpetuate arterial stiffening. Pulmonary artery (PA) stiffening is also well documented to occur in pulmonary hypertension (PH), and there is evidence that pulmonary vascular stiffness (PVS) may be a better predictor of outcome than pulmonary vascular resistance (PVR). We have hypothesized that the decreased flow-damping function of elastic PAs in PH likely initiates and/or perpetuates dysfunction of pulmonary microvasculature. Recent studies have shown that large-vessel stiffening increases flow pulsatility in the distal pulmonary vasculature, leading to endothelial dysfunction within a proinflammatory, vasoconstricting, and profibrogenic environment. The intricate role of stiffening-stimulated high pulsatile flow in endothelial cell dysfunction includes stepwise molecular events underlying PA hypertrophy, inflammation, endothelial-mesenchymal transition, and fibrosis. In addition to contributing to microenvironmental alterations of the distal vasculature, disordered proximal-distal PA coupling likely also plays a role in increasing ventricular afterload, ultimately causing right ventricle (RV) dysfunction and death. Current therapeutic treatments do not provide a realistic approach to destiffening arteries and, thus, to potentially abrogating the effects of high pulsatile flow on the distal pulmonary vasculature or the increased work imposed by stiffening on the RV. Scrutinizing the effect of PA stiffening on high pulsatile flow-induced cellular and molecular changes, and vice versa, might lead to important new therapeutic options that abrogate PA remodeling and PH development. With a clear understanding that PA stiffening may contribute to the progression of PH to an irreversible state by contributing to chronic microvascular damage in lungs, future studies should be aimed first at defining the underlying mechanisms leading to PA stiffening and then at improved treatment approaches based on these findings.
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Affiliation(s)
- Wei Tan
- Department of Pediatrics, University of Colorado Denver, Aurora, Colorado, USA
- Cardiovascular Pulmonary Research Laboratories, University of Colorado Denver, Aurora, Colorado, USA
- Department of Mechanical Engineering, University of Colorado Boulder, Boulder, Colorado, USA
| | - Krishna Madhavan
- Department of Pediatrics, University of Colorado Denver, Aurora, Colorado, USA
- Department of Bioengineering, University of Colorado Denver, Aurora, Colorado, USA
| | - Kendall S. Hunter
- Department of Pediatrics, University of Colorado Denver, Aurora, Colorado, USA
- Department of Bioengineering, University of Colorado Denver, Aurora, Colorado, USA
| | - Daewon Park
- Department of Bioengineering, University of Colorado Denver, Aurora, Colorado, USA
| | - Kurt R. Stenmark
- Department of Pediatrics, University of Colorado Denver, Aurora, Colorado, USA
- Cardiovascular Pulmonary Research Laboratories, University of Colorado Denver, Aurora, Colorado, USA
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Abstract
PURPOSE OF REVIEW Epidemiological studies have established arterial stiffness as an important risk factor for cardiovascular events and mortality in people with chronic kidney disease (CKD) at all stages. Although much has been learned about the mechanisms that lead to arterial stiffening in CKD, many questions remain unanswered and the optimal interventions for attenuating arterial stiffness remain to be determined. RECENT FINDINGS Recent data have confirmed the value of arterial stiffness as a predictor of both cardiovascular and renal risk. Advanced glycation end-product accumulation and chronic cytomegalovirus infection have been identified as novel potential contributors to arterial stiffening, but fibroblast growth factor 23 has not. Genetic studies suggest that the association between chronic kidney and cardiovascular disease is a result of clinical and environmental rather than genetic factors. Treatment with angiotensin-converting enzyme inhibitor or aldosterone inhibitor improves arterial stiffness in association with lowering blood pressure, but several potential novel interventions for reducing arterial stiffness await further investigation. SUMMARY Arterial stiffness is increasingly recognized as an important potentially modifiable measure of subclinical vascular disease in people with CKD. The introduction of arterial stiffness into routine practice awaits research focussed on including pulse wave velocity in renal and cardiovascular risk prediction tools, as well as interventions for ameliorating arterial stiffness.
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Arterial stiffness and cardiovascular therapy. BIOMED RESEARCH INTERNATIONAL 2014; 2014:621437. [PMID: 25170513 PMCID: PMC4142148 DOI: 10.1155/2014/621437] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 07/14/2014] [Accepted: 07/14/2014] [Indexed: 12/12/2022]
Abstract
The world population is aging and the number of old people is continuously increasing. Arterial structure and function change with age, progressively leading to arterial stiffening. Arterial stiffness is best characterized by measurement of pulse wave velocity (PWV), which is its surrogate marker. It has been shown that PWV could improve cardiovascular event prediction in models that included standard risk factors. Consequently, it might therefore enable better identification of populations at high-risk of cardiovascular morbidity and mortality. The present review is focused on a survey of different pharmacological therapeutic options for decreasing arterial stiffness. The influence of several groups of drugs is described: antihypertensive drugs (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, beta-blockers, diuretics, and nitrates), statins, peroral antidiabetics, advanced glycation end-products (AGE) cross-link breakers, anti-inflammatory drugs, endothelin-A receptor antagonists, and vasopeptidase inhibitors. All of these have shown some effect in decreasing arterial stiffness. Nevertheless, further studies are needed which should address the influence of arterial stiffness diminishment on major adverse cardiovascular and cerebrovascular events (MACCE).
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Liu W, Ye H, Tang B, Sun Z, Wen P, Wu W, Bian X, Shen X, Yang J. Comparison of 44-hour and fixed 24-hour ambulatory blood pressure monitoring in dialysis patients. J Clin Hypertens (Greenwich) 2013; 16:63-9. [PMID: 24172171 DOI: 10.1111/jch.12217] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Revised: 09/16/2013] [Accepted: 09/16/2013] [Indexed: 11/29/2022]
Abstract
The two most commonly used strategies to evaluate dialysis patients' blood pressure (BP) level are 44-hour and 24-hour ambulatory blood pressure monitoring (ABPM). The objective of this study was to find an appropriate 24-hour period that correlated well with the 44-hour BP level and determine the differences between these strategies. In a group of 51 dialysis patients, the authors performed 44-hour ABPM and extracted data for a fixed 24-hour ABPM. The fixed 24-hour ABPM started at 6 am on the nondialysis day. A strong correlation was found between all parameters of 44-hour and the fixed 24-hour ABPM, with paired sample t test showing only small magnitude changes in a few parameters. Both 24-hour ABPM and 44-hour ABPM were superior to clinic BP in predicting left ventricular mass index (LVMI) by multiple regression analysis. It was found that 44-hour ambulatory arterial stiffness index (AASI), but not 24-hour AASI, had a positive association with LVMI (r=0.328, P=.021). However, after adjustment for 44-hour systolic blood pressure, this association disappeared. Fixed 24-hour ABPM is a good surrogate of 44-hour ABPM to some extent, while 44-hour ABPM can provide more accurate and detailed information.
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Affiliation(s)
- Wenjin Liu
- Center for Kidney Disease, Second Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
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