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Umeh CA, Mohta T, Kaur G, Truong R, Darji P, Vue C, Cherukuri VB, Eghreriniovo B, Gupta R. Acetazolamide and Hydrochlorothiazide in Patients With Acute Decompensated Heart Failure: Insights From Recent Trials. Cardiol Res 2024; 15:69-74. [PMID: 38645830 PMCID: PMC11027779 DOI: 10.14740/cr1627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 03/05/2024] [Indexed: 04/23/2024] Open
Abstract
Acetazolamide and thiazide diuretics have been combined with loop diuretics to overcome diuretic resistance in heart failure patients. However, recent studies have assessed the upfront combination of acetazolamide and hydrochlorothiazide with loop diuretics in hospitalized patients with acute decompensated heart failure without loop diuretic resistance. We reviewed two recent randomized controlled trials on the upfront use of acetazolamide and thiazide diuretics in acute decompensated heart failure, respectively. When the two trials on acetazolamide are considered together, adding oral or intravenous acetazolamide to loop diuretics in decompensated heart failure patients resulted in increased diuresis and natriuresis. However, the effects were significantly higher in patients with serum bicarbonate ≥ 27 mmol/L and those with higher baseline glomerular filtration rate (GFR). Similarly, when the two trials on thiazide diuretics are considered together, adding hydrochlorothiazide to loop diuretics in decompensated heart failure patients resulted in increased diuresis and weight loss. However, it increases the risk of impaired renal function. When all the trials are considered together, the upfront use of acetazolamide may be helpful in carefully selected patients, including patients with underlying elevated bicarbonate levels (≥ 27 mmol/L) and those with good renal function (GFR > 50). Conversely, though the upfront use of thiazide diuretic added to intravenous furosemide improved diuretic response in acute decompensated heart failure, it causes an increased risk of worsening renal function and lack of clear evidence of reducing hospital length of stay.
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Affiliation(s)
- Chukwuemeka A. Umeh
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
- School of Medicine, St. George’s University, Grenada, West Indies, Grenada
- American University of Antigua, Osbourn, Antigua and Barbuda
| | - Tamanna Mohta
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
| | - Gagan Kaur
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
| | - Roland Truong
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
| | - Puja Darji
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
| | - Chong Vue
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
- American University of Antigua, Osbourn, Antigua and Barbuda
| | - Vijaya Bhargavi Cherukuri
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
- American University of Antigua, Osbourn, Antigua and Barbuda
| | - Benson Eghreriniovo
- Department of Internal Medicine, Hemet Global Medical Center, Hemet, CA, USA
| | - Rahul Gupta
- Department of Internal Medicine, University of California, San Diego, CA 92122, USA
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Novel insights in classic versus relative glomerular hyperfiltration and implications on pharmacotherapy. Curr Opin Nephrol Hypertens 2023; 32:58-66. [PMID: 36444663 DOI: 10.1097/mnh.0000000000000847] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Glomerular filtration rate (GFR) assessment and its estimation (eGFR) is a long-lasting challenge in medicine and public health. Current eGFR formulae are indexed for standardized body surface area (BSA) of 1.73 m2, ignoring persons and populations wherein the ratio of BSA or metabolic rate to nephron number might be different, due to increased BSA, increased metabolic rate or reduced nephron number. These equations are based on creatinine, cystatin C or a combination of the two, which adds another confounder to eGFR assessment. Unusually high GFR values, also known as renal hyperfiltration, have not been well defined under these equations. RECENT FINDINGS Special conditions such as solitary kidney in kidney donors, high dietary protein intake, obesity and diabetes are often associated with renal hyperfiltration and amenable to errors in GFR estimation. In all hyperfiltration types, there is an increased intraglomerular pressure that can be physiologic, but its persistence over time is detrimental to glomerulus leading to progressive glomerular damage and renal fibrosis. Hyperfiltration might be underdiagnosed due to BSA standardization embedded in the formula. Hence, timely intervention is delayed. Reducing intraglomerular pressure in diabetes can be achieved by SGLT2 inhibitors or low protein diet to reverse the glomerulopathy process. SUMMARY Accurate identification of glomerular hyperfiltration as a pre-CKD condition needs accurate estimation of GFR in the above normal range should establish a threshold for timely intervention.
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Valtuille R. Cardiovascular Risk Related to Glomerular Hyperfiltration in Nondiabetic Individuals: Increasing Visibility is Crucial. Curr Hypertens Rev 2023; 19:139-148. [PMID: 38018215 DOI: 10.2174/0115734021268893231116045914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/30/2023]
Abstract
Glomerular hyperfiltration (GHF), defined by different estimation formulas, has been widely studied as a predictor of proteinuria and progression to chronic kidney disease (CKD) in diabetic patients. GHF is also an important cardiovascular (CV) risk factor and is related to allcause mortality in non-diabetic populations; however, the upper limit of glomerular filtration rate (GFR) above which it indicates the presence of GHF is weakly defined. This higher risk is as high as in the intermediate stages of CKD and is greater than the presence of diabetes or smoking and is still present in non-albuminuria patients. The original Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) estimation GFR formula showed lower error at higher glomerular filtration (GF) values, was the most used in population studies, and behaved as a better risk predictor. In our review (including approximately 3.6 million individuals), higher GFR values related to increased mortality risk varied from 106.6 to 113.7 ml/min, which are usually not considered risk values for standard guidelines in non-albuminuric patients. However, the lack of consensus on a GF cutoff value, as well as its variability due to sex and progressive reduction with age, affect the knowledge of this serious phenomenon in clinical practice. Although the elderly population is not exempted from the effects of GHF, the search for this phenomenon should be intensified in middle-aged populations because of their lower disease burden, where this situation may be more evident, and the possibility of reversing the consequences is greater. A population group often considered healthy includes obese people, essential hypertensives, smokers, and carriers of fatty liver, where the GHF phenomenon is frequent and is associated with CV disease, kidney disease, and higher mortality. Increasing its visibility by the medical community is essential to reduce the effects of GHF, emphasizing more frequent controls and implementing general measures that include strict control of hypertension, Na restriction, rich in vegetables diets and increased physical activity. Initiatives to confirm the beneficial effects of sodium-glucose cotransporter-2 inhibitors to treat isolated GHF would be an important breakthrough in reducing the severe consequences of this phenomenon.
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Affiliation(s)
- Rodolfo Valtuille
- Diplomatura Terapias Reemplazo Renal, Universidad de Ciencias Empresariales y Sociales, Caracas 4599 C1419 EJU, Argentina
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Cirillo L, Ravaglia F, Errichiello C, Anders HJ, Romagnani P, Becherucci F. Expectations in children with glomerular diseases from SGLT2 inhibitors. Pediatr Nephrol 2022; 37:2997-3008. [PMID: 35286452 DOI: 10.1007/s00467-022-05504-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 01/10/2023]
Abstract
Chronic kidney disease (CKD) is a global public healthcare concern in the pediatric population, where glomerulopathies represent the second most common cause. Although classification and diagnosis of glomerulopathies still rely mostly on histopathological patterns, patient stratification should complement information supplied by kidney biopsy with clinical data and etiological criteria. Genetic determinants of glomerular injury are particularly relevant in children, with important implications for prognosis and treatment. Targeted therapies addressing the primary cause of the disease are available for a limited number of glomerular diseases. Consequently, in the majority of cases, the treatment of glomerulopathies is actually the treatment of CKD. The efficacy of the currently available strategies is limited, but new prospects evolve. Although the exact mechanisms of action are still under investigation, accumulating data in adults demonstrate the efficacy of sodium-glucose transporter 2 inhibitors (SGLT2i) in slowing the progression of CKD due to diabetic and non-diabetic kidney disease. SGLT2i has proved effective on other comorbidities, such as obesity, glycemic control, and cardiovascular risk that frequently accompany CKD. The use of SGLT2i is not yet approved in children. However, no pathophysiological clues theoretically exclude their application. The hallmark of pediatric CKD is the inevitable imbalance between the metabolic needs of a growing child and the functional capacity of a failing kidney to handle those needs. In this view, developing better strategies to address any modifiable progressor in kidney disease is mandatory, especially considering the long lifespan typical of the pediatric population. By improving the hemodynamic adaptation of the kidney and providing additional beneficial effects on the overall complications of CKD, SGLT2i is a candidate as a potentially innovative drug for the treatment of CKD and glomerular diseases in children.
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Affiliation(s)
- Luigi Cirillo
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | | | | | - Hans-Joachim Anders
- Division of Nephrology, Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Paola Romagnani
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
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Abstract
Circulating blood is filtered across the glomerular barrier to form an ultrafiltrate of plasma in the Bowman's space. The volume of glomerular filtration adjusted by time is defined as the glomerular filtration rate (GFR), and the total GFR is the sum of all single-nephron GFRs. Thus, when the single-nephron GFR is increased in the context of a normal number of functioning nephrons, single glomerular hyperfiltration results in 'absolute' hyperfiltration in the kidney. 'Absolute' hyperfiltration can occur in healthy people after high protein intake, during pregnancy and in patients with diabetes, obesity or autosomal-dominant polycystic kidney disease. When the number of functioning nephrons is reduced, single-nephron glomerular hyperfiltration can result in a GFR that is within or below the normal range. This 'relative' hyperfiltration can occur in patients with a congenitally reduced nephron number or with an acquired reduction in nephron mass consequent to surgery or kidney disease. Improved understanding of the mechanisms that underlie 'absolute' and 'relative' glomerular hyperfiltration in different clinical settings, and of whether and how the single-nephron haemodynamic and related biomechanical forces that underlie glomerular hyperfiltration promote glomerular injury, will pave the way toward the development of novel therapeutic interventions that attenuate glomerular hyperfiltration and potentially prevent or limit consequent progressive kidney injury and loss of function.
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Sharma M, Singh V, Sharma R, Koul A, McCarthy ET, Savin VJ, Joshi T, Srivastava T. Glomerular Biomechanical Stress and Lipid Mediators during Cellular Changes Leading to Chronic Kidney Disease. Biomedicines 2022; 10:biomedicines10020407. [PMID: 35203616 PMCID: PMC8962328 DOI: 10.3390/biomedicines10020407] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 01/31/2022] [Accepted: 02/04/2022] [Indexed: 02/04/2023] Open
Abstract
Hyperfiltration is an important underlying cause of glomerular dysfunction associated with several systemic and intrinsic glomerular conditions leading to chronic kidney disease (CKD). These include obesity, diabetes, hypertension, focal segmental glomerulosclerosis (FSGS), congenital abnormalities and reduced renal mass (low nephron number). Hyperfiltration-associated biomechanical forces directly impact the cell membrane, generating tensile and fluid flow shear stresses in multiple segments of the nephron. Ongoing research suggests these biomechanical forces as the initial mediators of hyperfiltration-induced deterioration of podocyte structure and function leading to their detachment and irreplaceable loss from the glomerular filtration barrier. Membrane lipid-derived polyunsaturated fatty acids (PUFA) and their metabolites are potent transducers of biomechanical stress from the cell surface to intracellular compartments. Omega-6 and ω-3 long-chain PUFA from membrane phospholipids generate many versatile and autacoid oxylipins that modulate pro-inflammatory as well as anti-inflammatory autocrine and paracrine signaling. We advance the idea that lipid signaling molecules, related enzymes, metabolites and receptors are not just mediators of cellular stress but also potential targets for developing novel interventions. With the growing emphasis on lifestyle changes for wellness, dietary fatty acids are potential adjunct-therapeutics to minimize/treat hyperfiltration-induced progressive glomerular damage and CKD.
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Affiliation(s)
- Mukut Sharma
- Research and Development Service, Kansas City VA Medical Center, Kansas City, MO 64128, USA;
- Midwest Veterans’ Biomedical Research Foundation, Kansas City, MO 64128, USA; (A.K.); (V.J.S.); (T.S.)
- Department of Internal Medicine, The Jared Grantham Kidney Institute, University of Kansas Medical Center, Kansas City, MO 66160, USA;
- Correspondence: ; Tel.: +1-816-861-4700 (ext. 58222)
| | - Vikas Singh
- Neurology, Kansas City VA Medical Center, Kansas City, MO 64128, USA;
| | - Ram Sharma
- Research and Development Service, Kansas City VA Medical Center, Kansas City, MO 64128, USA;
| | - Arnav Koul
- Midwest Veterans’ Biomedical Research Foundation, Kansas City, MO 64128, USA; (A.K.); (V.J.S.); (T.S.)
| | - Ellen T. McCarthy
- Department of Internal Medicine, The Jared Grantham Kidney Institute, University of Kansas Medical Center, Kansas City, MO 66160, USA;
| | - Virginia J. Savin
- Midwest Veterans’ Biomedical Research Foundation, Kansas City, MO 64128, USA; (A.K.); (V.J.S.); (T.S.)
| | - Trupti Joshi
- Department of Health Management and Informatics, University of Missouri, Columbia, MO 65201, USA;
| | - Tarak Srivastava
- Midwest Veterans’ Biomedical Research Foundation, Kansas City, MO 64128, USA; (A.K.); (V.J.S.); (T.S.)
- Section of Nephrology, Children’s Mercy Hospital and University of Missouri, Kansas City, MO 64108, USA
- Department of Oral and Craniofacial Sciences, School of Dentistry, University of Missouri, Kansas City, MO 64108, USA
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7
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Kidney Damage Caused by Obesity and Its Feasible Treatment Drugs. Int J Mol Sci 2022; 23:ijms23020747. [PMID: 35054932 PMCID: PMC8775419 DOI: 10.3390/ijms23020747] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/05/2022] [Accepted: 01/08/2022] [Indexed: 02/07/2023] Open
Abstract
The rapid growth of obesity worldwide has made it a major health problem, while the dramatic increase in the prevalence of obesity has had a significant impact on the magnitude of chronic kidney disease (CKD), especially in developing countries. A vast amount of researchers have reported a strong relationship between obesity and chronic kidney disease, and obesity can serve as an independent risk factor for kidney disease. The histological changes of kidneys in obesity-induced renal injury include glomerular or tubular hypertrophy, focal segmental glomerulosclerosis or bulbous sclerosis. Furthermore, inflammation, renal hemodynamic changes, insulin resistance and lipid metabolism disorders are all involved in the development and progression of obesity-induced nephropathy. However, there is no targeted treatment for obesity-related kidney disease. In this review, RAS inhibitors, SGLT2 inhibitors and melatonin would be presented to treat obesity-induced kidney injury. Furthermore, we concluded that melatonin can protect the kidney damage caused by obesity by inhibiting inflammation and oxidative stress, revealing its therapeutic potential.
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8
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Abstract
The kidney is one of the target organs that may show health disorders as a result of obesity. Obesity-related glomerulopathy (ORG) is a kidney disease category based on a biopsy diagnosis that may occur secondary to obesity. Detailed clinicopathologic observations of ORG have provided significant knowledge regarding obesity-associated renal complications. Glomerulomegaly with focal segmental glomerulosclerosis of perihilar locations is a typical renal histopathologic finding in ORG, which has long been considered to represent a state of single-nephron glomerular hyperfiltration. This hypothesis was recently confirmed in ORG patients by estimating single-nephron glomerular filtration rate using a combined image analysis and biopsy-based stereology. Overshooting in glomerulotubular and tubuloglomerular interactions may lead to glomerular hyperfiltration/hypertension, podocyte failure, tubular protein-traffic overload, and tubulointerstitial scarring, constituting a vicious cycle of a common pathway to the further loss of functioning nephrons and the progression of kidney functional impairment.
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Affiliation(s)
- Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
| | - Yusuke Okabayashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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Trujillo H, Caravaca-Fontán F, Caro J, Morales E, Praga M. The Forgotten Antiproteinuric Properties of Diuretics. Am J Nephrol 2021; 52:435-449. [PMID: 34233330 DOI: 10.1159/000517020] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/30/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although diuretics are one of the most widely used drugs by nephrologists, their antiproteinuric properties are not generally taken into consideration. SUMMARY Thiazide diuretics have been shown to reduce proteinuria by >35% in several prospective controlled studies, and these values are markedly increased when combined with a low-salt diet. Thiazide-like diuretics (indapamide and chlorthalidone) have shown similar effectiveness. The antiproteinuric effect of mineralocorticoid receptor antagonists (spironolactone, eplerenone, and finerenone) has been clearly established through prospective and controlled studies, and treatment with finerenone reduces the risk of chronic kidney disease progression in type-2 diabetic patients. The efficacy of other diuretics such as amiloride, triamterene, acetazolamide, or loop diuretics has been less explored, but different investigations suggest that they might share the same antiproteinuric properties of other diuretics that should be evaluated through controlled studies. Although the inclusion of sodium-glucose cotransporter-2 inhibitors (SGLT2i) among diuretics is a controversial issue, their renoprotective and cardioprotective properties, confirmed in various landmark trials, constitute a true revolution in the treatment of patients with kidney disease. Recent subanalyses of these trials have shown that the early antiproteinuric effect induced by SGLT2i predicts long-term preservation of kidney function. Key Message: Whether the early reduction in proteinuria induced by diuretics other than finerenone and SGLT2i, as summarized in this review, also translates into long-term renoprotection requires further prospective and observational studies. In any case, it is important for the clinician to be aware of the antiproteinuric properties of drugs so often used in daily clinical practice.
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Affiliation(s)
- Hernando Trujillo
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain,
| | | | - Jara Caro
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
| | - Enrique Morales
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
- Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Manuel Praga
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
- Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Friedman AN, Considine RV, Quinney SK. Inquiry into the short- and long-term effects of Roux-en-Y gastric bypass on the glomerular filtration rate. Ren Fail 2021; 42:624-628. [PMID: 32654577 PMCID: PMC7470048 DOI: 10.1080/0886022x.2020.1790389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Bariatric surgery is known to attenuate glomerular hyperfiltration over the long term and thereby protect the kidney from mechanical damage. Whether this effect is directly related to weight loss or is independent of weight as are some of its other beneficial metabolic effects is not known. We explored this question in a preliminary study that directly measured glomerular filtration rate (GFR) before, immediately after, and again many months after Roux-en-Y gastric bypass after large weight loss had occurred. We simultaneously measured stimulated circulating glucagon-like peptide-1, which is upregulated after Roux-en-Y gastric bypass and is a putative mediator of GFR after bariatric surgery. We found no weight-independent effect of Roux-en-Y gastric bypass on GFR nor an association between circulating GLP-1 levels and GFR. These findings, if confirmed in larger studies, will help steer future enquiries in this area.
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Affiliation(s)
- Allon N Friedman
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert V Considine
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sara K Quinney
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN, USA
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Conley MM, McFarlane CM, Johnson DW, Kelly JT, Campbell KL, MacLaughlin HL. Interventions for weight loss in people with chronic kidney disease who are overweight or obese. Cochrane Database Syst Rev 2021; 3:CD013119. [PMID: 33782940 PMCID: PMC8094234 DOI: 10.1002/14651858.cd013119.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Obesity and chronic kidney disease (CKD) are highly prevalent worldwide and result in substantial health care costs. Obesity is a predictor of incident CKD and progression to kidney failure. Whether weight loss interventions are safe and effective to impact on disease progression and clinical outcomes, such as death remains unclear. OBJECTIVES This review aimed to evaluate the safety and efficacy of intentional weight loss interventions in overweight and obese adults with CKD; including those with end-stage kidney disease (ESKD) being treated with dialysis, kidney transplantation, or supportive care. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 14 December 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, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs of more than four weeks duration, reporting on intentional weight loss interventions, in individuals with any stage of CKD, designed to promote weight loss as one of their primary stated goals, in any health care setting. DATA COLLECTION AND ANALYSIS Two authors independently assessed study eligibility and extracted data. We applied the Cochrane 'Risk of Bias' tool and used the GRADE process to assess the certainty of evidence. We estimated treatment effects using random-effects meta-analysis. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardised mean difference (SMD) for continuous outcomes or in descriptive format when meta-analysis was not possible. MAIN RESULTS We included 17 RCTs enrolling 988 overweight or obese adults with CKD. The weight loss interventions and comparators across studies varied. We categorised comparisons into three groups: any weight loss intervention versus usual care or control; any weight loss intervention versus dietary intervention; and surgical intervention versus non-surgical intervention. Methodological quality was varied, with many studies providing insufficient information to accurately judge the risk of bias. Death (any cause), cardiovascular events, successful kidney transplantation, nutritional status, cost effectiveness and economic analysis were not measured in any of the included studies. Across all 17 studies many clinical parameters, patient-centred outcomes, and adverse events were not measured limiting comparisons for these outcomes. In studies comparing any weight loss intervention to usual care or control, weight loss interventions may lead to weight loss or reduction in body weight post intervention (6 studies, 180 participants: MD -3.69 kg, 95% CI -5.82 to -1.57; follow-up: 5 weeks to 12 months, very low-certainty evidence). In very low certainty evidence any weight loss intervention had uncertain effects on body mass index (BMI) (4 studies, 100 participants: MD -2.18 kg/m², 95% CI -4.90 to 0.54), waist circumference (2 studies, 53 participants: MD 0.68 cm, 95% CI -7.6 to 6.24), proteinuria (4 studies, 84 participants: 0.29 g/day, 95% CI -0.76 to 0.18), systolic (4 studies, 139 participants: -3.45 mmHg, 95% CI -9.99 to 3.09) and diastolic blood pressure (4 studies, 139 participants: -2.02 mmHg, 95% CI -3.79 to 0.24). Any weight loss intervention made little or no difference to total cholesterol, high density lipoprotein cholesterol, and inflammation, but may lower low density lipoprotein cholesterol. There was little or no difference between any weight loss interventions (lifestyle or pharmacological) compared to dietary-only weight loss interventions for weight loss, BMI, waist circumference, proteinuria, and systolic blood pressure, however diastolic blood pressure was probably reduced. Furthermore, studies comparing the efficacy of different types of dietary interventions failed to find a specific dietary intervention to be superior for weight loss or a reduction in BMI. Surgical interventions probably reduced body weight (1 study, 11 participants: MD -29.50 kg, 95% CI -36.4 to -23.35), BMI (2 studies, 17 participants: MD -10.43 kg/m², 95% CI -13.58 to -7.29), and waist circumference (MD -30.00 cm, 95% CI -39.93 to -20.07) when compared to non-surgical weight loss interventions after 12 months of follow-up. Proteinuria and blood pressure were not reported. All results across all comparators should be interpreted with caution due to the small number of studies, very low quality of evidence and heterogeneity across interventions and comparators. AUTHORS' CONCLUSIONS All types of weight loss interventions had uncertain effects on death and cardiovascular events among overweight and obese adults with CKD as no studies reported these outcome measures. Non-surgical weight loss interventions (predominately lifestyle) appear to be an effective treatment to reduce body weight, and LDL cholesterol. Surgical interventions probably reduce body weight, waist circumference, and fat mass. The current evidence is limited by the small number of included studies, as well as the significant heterogeneity and a high risk of bias in most studies.
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Affiliation(s)
- Marguerite M Conley
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Woolloongabba, Australia
- School of Exercise and Nutrition Sciences, Queensland University of Technology, Brisbane, Australia
| | | | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Jaimon T Kelly
- Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, Nathan, Australia
| | - Katrina L Campbell
- Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, Nathan, Australia
| | - Helen L MacLaughlin
- School of Exercise and Nutrition Sciences, Queensland University of Technology, Brisbane, Australia
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12
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Ischemic Renal Injury: Can Renal Anatomy and Associated Vascular Congestion Explain Why the Medulla and Not the Cortex Is Where the Trouble Starts? Semin Nephrol 2020; 39:520-529. [PMID: 31836035 DOI: 10.1016/j.semnephrol.2019.10.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The kidneys receive approximately 20% of cardiac output and have a low fractional oxygen extraction. Quite paradoxically, however, the kidneys are highly susceptible to ischemic injury (injury associated with inadequate blood supply), which is most evident in the renal medulla. The predominant proposal to explain this susceptibility has been a mismatch between oxygen supply and metabolic demand. It has been proposed that unlike the well-perfused renal cortex, the renal medulla normally operates just above the threshold for hypoxia and that further reductions in renal perfusion cause hypoxic injury in this metabolically active region. An alternative proposal is that the true cause of ischemic injury is not a simple mismatch between medullary metabolic demand and oxygen supply, but rather the susceptibility of the outer medulla to vascular congestion. The capillary plexus of the renal outer medullary region is especially prone to vascular congestion during periods of ischemia. It is the failure to restore the circulation to the outer medulla that mediates complete and prolonged ischemia to much of this region, leading to injury and tubular cell death. We suggest that greater emphasis on developing clinically useful methods to help prevent or reverse the congestion of the renal medullary vasculature may provide a means to reduce the incidence and cost of acute kidney injury.
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Luseogliflozin, a sodium-glucose cotransporter 2 inhibitor, preserves renal function irrespective of acute changes in the estimated glomerular filtration rate in Japanese patients with type 2 diabetes. Hypertens Res 2020; 43:876-883. [DOI: 10.1038/s41440-020-0426-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/03/2020] [Accepted: 02/20/2020] [Indexed: 01/05/2023]
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Than WH, Chan GCK, Ng JKC, Szeto CC. The role of obesity on chronic kidney disease development, progression, and cardiovascular complications. ADVANCES IN BIOMARKER SCIENCES AND TECHNOLOGY 2020. [DOI: 10.1016/j.abst.2020.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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15
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Mazaheri M, Assadi F, Sadeghi-Bojd S. Adjunctive acetazolamide therapy for the treatment of Bartter syndrome. Int Urol Nephrol 2019; 52:121-128. [PMID: 31820361 DOI: 10.1007/s11255-019-02351-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/24/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE Bartter syndrome is a rare hereditary salt-losing tubulopathy caused by mutations of several genes in the thick ascending limb of Henle's loop, characterized by polyuria, hypokalemic metabolic alkalosis, growth retardation and normal blood pressure. Cyclooxygenase inhibitors, potassium-sparing diuretics and angiotensin-converting enzyme inhibitors are currently used to treat electrolyte derangements, but with poor response. Whether treatment with acetazolamide, a carbonic-anhydrase inhibitor, would result in better clinical outcomes is unknown. METHODS We randomly assigned children with Bartter syndrome in a 1:1 ratio to either receive indomethacin, enalapril, and spironolactone or indomethacin, enalapril, and spironolactone plus acetazolamide once daily in the morning for 4 weeks. After 2 days of washout, participants crossed over to receive the alternative intervention for 4 weeks. The present study examines the serum bicarbonate lowering effect of acetazolamide as an adjunctive therapy in children with Batter syndrome. RESULTS Of the 43 patients screened for eligibility, 22 (51%), between the ages 6 and 42 months, were randomized to intervention. Baseline characteristics were similar between the two groups. Addition of acetazolamide for a period of 4 weeks significantly reduced serum bicarbonate and increased serum potassium levels, parallel with a reduction in serum aldosterone and plasma renin concentration. The 24-h urine volume, sodium, potassium, and chloride decreased significantly. CONCLUSION Our data define a new physiologic and therapeutic role of acetazolamide for the management of children with Bartter syndrome.
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Affiliation(s)
- Mojgan Mazaheri
- Department of Pediatrics, Section of Nephrology, Semnan University of Medical Science, Semnan, Iran
| | - Farahnak Assadi
- Department of Pediatrics, Division of Nephrology, Rush University Medical Center, 445 East North Water Street, Chicago, IL, USA.
| | - Simin Sadeghi-Bojd
- Department of Pediatrics, Division of Nephrology, Zahedan University of Medical Sciences, Zahedan, Iran
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16
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Diuretic treatment of the patient with diabetes and heart failure. Role of SGLT2 inhibitors and similarities with carbonic anhydrase inhibitors. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2019.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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17
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Kohagura K, Furuichi K, Kochi M, Shimizu M, Yuzawa Y, Hara A, Toyama T, Kitamura H, Suzuki Y, Sato H, Uesugi N, Ubara Y, Hoshino J, Hisano S, Ueda Y, Nishi S, Yokoyama H, Nishino T, Ogawa D, Mise K, Shibagaki Y, Kimura K, Haneda M, Makino H, Matsuo S, Wada T. Amplified Association Between Blood Pressure and Albuminuria in Overweight Patients With Biopsy-Proven Hypertensive Nephrosclerosis. Am J Hypertens 2019; 32:486-491. [PMID: 30689693 DOI: 10.1093/ajh/hpz010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 12/25/2018] [Accepted: 01/16/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND An overweight person is at high risk for hypertensive renal damage. The effect of weight on the association between systolic blood pressure (SBP) and albuminuria remains unknown in patients with histologically diagnosed hypertensive nephrosclerosis. METHODS A total of 97 patients with biopsy-confirmed hypertensive nephrosclerosis were recruited from 13 centers throughout Japan. We examined the relationship between SBP and proteinuria among those who were overweight, which is defined as a body mass index ≥25 kg/m2, and those who were not. We examined the interaction of weight and SBP with albuminuria at baseline and with the changes in estimated glomerular filtration rate (eGFR) during the observational period. RESULTS Our results included mean age (54 years old), blood pressure (138/80), eGFR (53 ml/min/1.73 m2), and urine albumin levels (0.2 g/day). SBP was significantly correlated with log-transformed urine albumin levels (r = 0.4, P = 0.01) in patients who were overweight (n = 38) compared with patients who were not overweight (n = 59). Multiple regression analysis revealed that the interaction between being overweight and SBP with respect to albuminuria was significantly correlated with the log-transformed urine albumin level (β = 0.39, P = 0.047) and was independent of age, sex, and potential confounding factors. The interaction between weight and SBP ≥140 mm Hg was significantly associated with a greater decrease in eGFR in the following 3 years. CONCLUSIONS Being overweight may enhance susceptibility to hypertensive glomerular damage and may eventually lead to renal progression in patients with hypertensive nephrosclerosis.
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Affiliation(s)
- Kentaro Kohagura
- Dialysis Unit, University Hospital of the Ryukyus, Okinawa, Japan
| | - Kengo Furuichi
- Division of Nephrology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Masako Kochi
- Department of Cardiovascular Medicine, Nephrology and Neurology, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Miho Shimizu
- Division of Nephrology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Yukio Yuzawa
- Department of Nephrology, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Akinori Hara
- Division of Nephrology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Tadashi Toyama
- Division of Nephrology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Hiroshi Kitamura
- Department of Pathology, Clinical Research Center, National Hospital Organization Chiba-East National Hospital, Chiba, Chiba, Japan
| | - Yoshiki Suzuki
- Health Administration Center, Niigata University, Niigata, Niigata, Japan
| | - Hiroshi Sato
- Clinical Pharmacology and Therapeutics, Tohoku University Graduate School of Pharmaceutical Sciences, Aoba-ku, Sendai, Japan
| | - Noriko Uesugi
- Department of Pathology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | | | | | - Satoshi Hisano
- Department of Pathology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yoshihiko Ueda
- Department of Pathology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Shinichi Nishi
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Hitoshi Yokoyama
- Department of Nephrology, Kanazawa Medical University School of Medicine, Uchinada, Ishikawa, Japan
| | - Tomoya Nishino
- Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan
| | - Daisuke Ogawa
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Koki Mise
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Yokohama, Kanagawa, Japan
| | | | - Masakazu Haneda
- Division of Metabolism and Biosystemic Science, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Hirofumi Makino
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Seiichi Matsuo
- Division of Nephrology, Department of Internal Medicine, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
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Solini A, Seghieri M, Santini E, Giannini L, Biancalana E, Taddei S, Volterrani D, Bruno RM. Renal Resistive Index Predicts Post-Bariatric Surgery Renal Outcome in Nondiabetic Individuals with Severe Obesity. Obesity (Silver Spring) 2019; 27:68-74. [PMID: 30516353 DOI: 10.1002/oby.22355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 09/24/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Bariatric surgery may ameliorate renal function through vascular mechanisms. This study tested surgery's ability to improve measured glomerular filtration rate (mGFR) and identified clinical, renal, and systemic vascular predictors of such improvement. METHODS Twenty-five nondiabetic subjects with severe obesity were studied before and 1 year after Roux-en-Y gastric bypass, evaluating mGFR and renal plasma flow, basal renal resistive index (RI) and dynamic renal RI, renal visceral fat, and systemic vascular parameters, including flow-mediated dilation, aortic pulse wave velocity, and carotid intima media thickness and stiffness. RESULTS After Roux-en-Y gastric bypass, BMI decreased by 31%. At follow-up, body surface area (BSA)-adjusted mGFR increased (from 86.9 ± 15.2 to 109.0 ± 18.2 mL/min/1.73 m2 , P < 0.001), whereas the absolute mGFR did not change. Renal plasma flow did not vary. RI decreased; flow-mediated dilation, pulse wave velocity, carotid intima media thickness, and carotid stiffness improved. mGFR changes after surgery (ΔmGFR/BSA) were associated with younger age and lower fasting glucose. Among vascular variables, an improved ΔmGFR/BSA was associated with smaller brachial artery diameter, lower intima media thickness, and lower RI; this latter association remained after adjusting for covariates. No measure of adiposity was associated with ΔmGFR. CONCLUSIONS In subjects with obesity and normal renal function, bariatric surgery improves mGFR/BSA (although absolute mGFR is unchanged) and renal and systemic vascular function. Lower renal intravascular resistance can predict these improvements, maximizing them in relatively young individuals.
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Affiliation(s)
- Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Italy
| | - Marta Seghieri
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Eleonora Santini
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Livia Giannini
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Edoardo Biancalana
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Duccio Volterrani
- Department of Translational Research and Novel Technologies, University of Pisa, Italy
| | - Rosa Maria Bruno
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
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León Jiménez D, Gómez Huelgas R, Fernández Romero AJ, López Chozas JM, Pérez de Isla L, Miramontes González JP. Diuretic treatment of the patient with diabetes and heart failure. Role of SGLT2 inhibitors and similarities with carbonic anhydrase inhibitors. Rev Clin Esp 2018; 219:208-217. [PMID: 30553441 DOI: 10.1016/j.rce.2018.09.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/25/2018] [Accepted: 09/28/2018] [Indexed: 12/28/2022]
Abstract
Sodium-glucose cotransporter-2 inhibitors have changed the concept of the effects that hypoglycemic drugs have on hearth failure (HF). For the first time, a therapeutic group has modified the evolution of HF. Its effect goes beyond glycemic control, and different theories have been postulated to justify this benefit. In the article we sent, we analyze the influence of the different pharmacological groups used in type 2 diabetes mellitus on HF, and we present the theory of the mechanism of action associated with the benefit of these drugs. In our opinion, this benefit in HF is secondary to its diuretic effect, specifically an effect very similar to carbon dioxide inhibitors. We think that our theory is novel, explains the mechanism of action and we have not found in the literature any article that explains the mechanism of action in such a precise way.
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Affiliation(s)
- D León Jiménez
- Unidad de Riesgo Vascular, Medicina Interna, Hospital Universitario Virgen Macarena, Sevilla, España.
| | - R Gómez Huelgas
- Unidad de Gestión Clínica de Medicina Interna, Hospital Regional Universitario, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, España
| | | | - J M López Chozas
- Unidad de Gestión Clínica de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - L Pérez de Isla
- Departamento de Cardiología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IDISSC), Universidad Complutense, Madrid, España
| | - J P Miramontes González
- Medicina Interna, Instituto de Investigación Biomédica de Salamanca (IBSAL), Hospital Universitario de Salamanca, Salamanca, España
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20
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Mullens W, Verbrugge FH, Nijst P, Martens P, Tartaglia K, Theunissen E, Bruckers L, Droogne W, Troisfontaines P, Damman K, Lassus J, Mebazaa A, Filippatos G, Ruschitzka F, Dupont M. Rationale and design of the ADVOR (Acetazolamide in Decompensated Heart Failure with Volume Overload) trial. Eur J Heart Fail 2018; 20:1591-1600. [DOI: 10.1002/ejhf.1307] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 07/11/2018] [Accepted: 08/02/2018] [Indexed: 12/20/2022] Open
Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost-Limburg; Genk Belgium
- Hasselt University, Diepenbeek/Hasselt; Belgium
| | | | | | | | | | | | | | | | | | - Kevin Damman
- University Medical Center Groningen; Groningen The Netherlands
| | - Johan Lassus
- Helsinki University Central Hospital; Helsinki Finland
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21
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León Jiménez D, Cherney DZI, Bjornstad P, Castilla-Guerra L, Miramontes González JP. Antihyperglycemic agents as novel natriuretic therapies in diabetic kidney disease. Am J Physiol Renal Physiol 2018; 315:F1406-F1415. [PMID: 30066584 DOI: 10.1152/ajprenal.00384.2017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
While sodium-glucose cotransporter-2 (SGLT2) inhibitors have been used for the routine management of type 2 diabetes for several years, it is perhaps their natriuretic effects that are most important clinically. This natriuresis activates tubuloglomerular feedback, resulting in reduced glomerular hypertension and proteinuria, leading to renal protective effects in the EMPA-REG OUTCOME and CANVAS Program trials. In the cardiovascular system, it is likely that plasma volume contraction due to natriuresis in response to SGLT2 inhibition is at least in part responsible for the reduction in the risk of heart failure observed in these trials. We compare this mechanism of action with other antidiabetics. Importantly, other diuretic classes, including thiazide and loop diuretics, have not resulted in such robust clinical benefits in patients with type 2 diabetes, possibly because these older agents do not influence intraglomerular pressure directly. In contrast, SGLT2 inhibitors do have important physiological similarities with carbonic anhydrase inhibitors, which also act proximally, and have been shown to activate tubuloglomerular feedback.
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Affiliation(s)
- David León Jiménez
- Vascular Risk Unit, Internal Medicine Clinical Management Unit, Hospital Universitario Virgen Macarena , Seville , Spain
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology. Toronto General Hospital, University of Toronto , Toronto , Ontario, Canada
| | - Petter Bjornstad
- Department of Pediatrics, Division of Endocrinology and Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado , Aurora, Colorado
| | - Luis Castilla-Guerra
- Vascular Risk Unit, Internal Medicine Clinical Management Unit, Hospital Universitario Virgen Macarena , Seville , Spain
| | - José Pablo Miramontes González
- Service of Internal Medicine, Institute of Biomedical Research of Salamanca (IBSAL), Hospital Universitario de Salamanca , Salamanca , Spain
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22
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Do effects of sodium-glucose cotransporter-2 inhibitors in patients with diabetes give insight into potential use in non-diabetic kidney disease? Curr Opin Nephrol Hypertens 2018; 26:358-367. [PMID: 28582367 DOI: 10.1097/mnh.0000000000000343] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW Our aim was to review the rationale for the role of sodium-glucose cotransporter-2 inhibitors (SGLT-2i) as renoprotective therapy in patients with and without diabetes. RECENT FINDINGS SGLT-2i are antihyperglycemic agents, approved for treating type 2 diabetes to reduce glycosylated hemoglobin, type A1c. Primary glucoregulatory effects occur through selective inhibition of SGLT-2 at the renal proximal tubule promoting glucosuria leading to blood glucose lowering. From a hemodynamic perspective, SGLT-2 inhibition is also associated with decreased glomerular hyperfiltration, an effect that is mediated through natriuresis and tubuloglomerular feedback. With renal injury and progressive nephron loss, diabetic kidney disease, and nondiabetic chronic kidney diseases share overlapping phenotypes exhibiting single nephron hyperfiltration, along with increased proteinuria. Importantly, the impact of SGLT-2 inhibition on renal and systemic hemodynamic function, including effects on lowering blood pressure, hyperfiltration, and plasma volume, are independent of blood glucose lowering and instead are because of natriuresis. Accordingly, large clinical trials with SGLT-2i investigating the potential use of SGLT-2i in patients without diabetes are now underway. SUMMARY Based on prominent nonglycemic effects, the clinical use of SGLT-2i as renoprotective therapy may extend to nondiabetic chronic kidney diseases subtypes, which could help to address a large, unmet clinical need.
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Affiliation(s)
- James E Novak
- Henry Ford Hospital, Wayne State University, Detroit, MI
| | - Jerry Yee
- Henry Ford Hospital, Wayne State University, Detroit, MI
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24
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León Jiménez D, Gómez Huelgas R, Miramontes González JP. The mechanism of action of sodium-glucose co-transporter 2 inhibitors is similar to carbonic anhydrase inhibitors. Eur J Heart Fail 2017; 20:409. [PMID: 29171186 DOI: 10.1002/ejhf.1068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/03/2017] [Accepted: 10/03/2017] [Indexed: 11/07/2022] Open
Affiliation(s)
- David León Jiménez
- Medicina Interna, Hospital Universitario Virgen Macarena de Sevilla, Sevilla, Spain
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25
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Rajasekeran H, Reich HN, Hladunewich MA, Cattran D, Lovshin JA, Lytvyn Y, Bjornstad P, Lai V, Tse J, Cham L, Majumder S, Bowskill BB, Kabir MG, Advani SL, Gibson IW, Sood MM, Advani A, Cherney DZI. Dapagliflozin in focal segmental glomerulosclerosis: a combined human-rodent pilot study. Am J Physiol Renal Physiol 2017; 314:F412-F422. [PMID: 29141939 DOI: 10.1152/ajprenal.00445.2017] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Focal segmental glomerulosclerosis (FSGS) is an important cause of nondiabetic chronic kidney disease (CKD). Sodium-glucose cotransporter 2 inhibition (SGLT2i) therapy attenuates the progression of diabetic nephropathy, but it remains unclear whether SGLT2i provides renoprotection in nondiabetic CKD such as FSGS. The primary aim of this pilot study was to determine the effect of 8 wk of dapagliflozin on glomerular filtration rate (GFR) in humans and in experimental FSGS. Secondary end points were related to changes in renal hemodynamic function, proteinuria, and blood pressure (BP). GFR (inulin) and renal plasma flow (para-aminohippurate), proteinuria, and BP were measured in patients with FSGS ( n = 10), and similar parameters were measured in subtotally nephrectomized (SNx) rats. In response to dapagliflozin, changes in GFR, renal plasma flow, and 24-h urine protein excretion were not statistically significant in humans or rats. Systolic BP (SBP) decreased in SNx rats (196 ± 26 vs. 165 ± 33 mmHg; P < 0.001), whereas changes were not statistically significant in humans (SBP 112.7 ± 8.5 to 112.8 ± 11.2 mmHg, diastolic BP 71.8 ± 6.5 to 69.6 ± 8.4 mmHg; P = not significant), although hematocrit increased (0.40 ± 0.05 to 0.42 ± 0.05%; P = 0.03). In archival kidney tissue from a separate patient cohort, renal parenchymal SGLT2 mRNA expression was decreased in individuals with FSGS compared with controls. Short-term treatment with the SGLT2i dapagliflozin did not modify renal hemodynamic function or attenuate proteinuria in humans or in experimental FSGS. This may be related to downregulation of renal SGLT2 expression. Studies examining the impact of SGLT2i on markers of kidney disease in patients with other causes of nondiabetic CKD are needed.
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Affiliation(s)
- Harindra Rajasekeran
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto , Toronto, Ontario , Canada.,Department of Physiology, University of Toronto , Toronto, Ontario , Canada
| | - Heather N Reich
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto , Toronto, Ontario , Canada
| | - Michelle A Hladunewich
- Department of Medicine, Division of Nephrology, Sunnybrook Health Sciences Centre, University of Toronto , Toronto, Ontario , Canada
| | - Daniel Cattran
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto , Toronto, Ontario , Canada
| | - Julie A Lovshin
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto , Toronto, Ontario , Canada
| | - Yuliya Lytvyn
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto , Toronto, Ontario , Canada
| | - Petter Bjornstad
- Department of Pediatric Endocrinology, University of Colorado School of Medicine , Aurora, Colorado.,Barbara Davis Center for Diabetes, University of Colorado Denver , Aurora, Colorado
| | - Vesta Lai
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto , Toronto, Ontario , Canada
| | - Josephine Tse
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto , Toronto, Ontario , Canada
| | - Leslie Cham
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto , Toronto, Ontario , Canada
| | - Syamantak Majumder
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto, Ontario , Canada
| | - Bridgit B Bowskill
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto, Ontario , Canada
| | - M Golam Kabir
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto, Ontario , Canada
| | - Suzanne L Advani
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto, Ontario , Canada
| | - Ian W Gibson
- Department of Pathology, University of Manitoba , Winnipeg, Manitoba , Canada
| | - Manish M Sood
- Ottawa Hospital Research Institute, University of Ottawa , Ottawa, Ontario , Canada
| | - Andrew Advani
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto, Ontario , Canada
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto , Toronto, Ontario , Canada.,Department of Physiology, University of Toronto , Toronto, Ontario , Canada
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26
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de Groot T, Doornebal J, Christensen BM, Cockx S, Sinke AP, Baumgarten R, Bedford JJ, Walker RJ, Wetzels JFM, Deen PMT. Lithium-induced NDI: acetazolamide reduces polyuria but does not improve urine concentrating ability. Am J Physiol Renal Physiol 2017; 313:F669-F676. [DOI: 10.1152/ajprenal.00147.2017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/07/2017] [Accepted: 06/09/2017] [Indexed: 01/07/2023] Open
Abstract
Lithium is the mainstay treatment for patients with bipolar disorder, but it generally causes nephrogenic diabetes insipidus (NDI), a disorder in which the renal urine concentrating ability has become vasopressin insensitive. Li-NDI is caused by lithium uptake by collecting duct principal cells and downregulation of aquaporin-2 (AQP2) water channels, which are essential for water uptake from tubular urine. Recently, we found that the prophylactic administration of acetazolamide to mice effectively attenuated Li-NDI. To evaluate whether acetazolamide might benefit lithium-treated patients, we administered acetazolamide to mice with established Li-NDI and six patients with a lithium-induced urinary concentrating defect. In mice, acetazolamide partially reversed lithium-induced polyuria and increased urine osmolality, which, however, did not coincide with increased AQP2 abundances. In patients, acetazolamide led to the withdrawal of two patients from the study due to side effects. In the four remaining patients acetazolamide did not lead to clinically relevant changes in maximal urine osmolality. Urine output was also not affected, although none of these patients demonstrated overt lithium-induced polyuria. In three out of four patients, acetazolamide treatment increased serum creatinine levels, indicating a decreased glomerular filtration rate (GFR). Strikingly, these three patients also showed a decrease in systemic blood pressure. All together, our data reveal that acetazolamide does not improve the urinary concentrating defect caused by lithium, but it lowers the GFR, likely explaining the reduced urine output in our mice and in a recently reported patient with lithium-induced polyuria. The reduced GFR in patients prone to chronic kidney disease development, however, warrants against application of acetazolamide in Li-NDI patients without long-term (pre)clinical studies.
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Affiliation(s)
- Theun de Groot
- Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joan Doornebal
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Nephrology, Isala Clinics, Zwolle, The Netherlands
| | | | - Simone Cockx
- Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Anne P. Sinke
- Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | - Robert J. Walker
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Jack F. M. Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter M. T. Deen
- Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
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Xu T, Sheng Z, Yao L. Obesity-related glomerulopathy: pathogenesis, pathologic, clinical characteristics and treatment. Front Med 2017; 11:340-348. [DOI: 10.1007/s11684-017-0570-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 07/19/2017] [Indexed: 12/12/2022]
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Martens P, Mathieu C, Verbrugge FH. Promise of SGLT2 Inhibitors in Heart Failure: Diabetes and Beyond. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:23. [DOI: 10.1007/s11936-017-0522-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Tonneijck L, Muskiet MHA, Smits MM, van Bommel EJ, Heerspink HJL, van Raalte DH, Joles JA. Glomerular Hyperfiltration in Diabetes: Mechanisms, Clinical Significance, and Treatment. J Am Soc Nephrol 2017; 28:1023-1039. [PMID: 28143897 DOI: 10.1681/asn.2016060666] [Citation(s) in RCA: 452] [Impact Index Per Article: 64.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
An absolute, supraphysiologic elevation in GFR is observed early in the natural history in 10%-67% and 6%-73% of patients with type 1 and type 2 diabetes, respectively. Moreover, at the single-nephron level, diabetes-related renal hemodynamic alterations-as an adaptation to reduction in functional nephron mass and/or in response to prevailing metabolic and (neuro)hormonal stimuli-increase glomerular hydraulic pressure and transcapillary convective flux of ultrafiltrate and macromolecules. This phenomenon, known as glomerular hyperfiltration, classically has been hypothesized to predispose to irreversible nephron damage, thereby contributing to initiation and progression of kidney disease in diabetes. However, dedicated studies with appropriate diagnostic measures and clinically relevant end points are warranted to confirm this assumption. In this review, we summarize the hitherto proposed mechanisms involved in diabetic hyperfiltration, focusing on ultrastructural, vascular, and tubular factors. Furthermore, we review available evidence on the clinical significance of hyperfiltration in diabetes and discuss currently available and emerging interventions that may attenuate this renal hemodynamic abnormality. The revived interest in glomerular hyperfiltration as a prognostic and pathophysiologic factor in diabetes may lead to improved and timely detection of (progressive) kidney disease, and could provide new therapeutic opportunities in alleviating the renal burden in this population.
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Affiliation(s)
- Lennart Tonneijck
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands;
| | - Marcel H A Muskiet
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Mark M Smits
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Erik J van Bommel
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacology, University Medical Center Groningen, Groningen, The Netherlands; and
| | - Daniël H van Raalte
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center, Utrecht, The Netherlands
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Tsuboi N, Okabayashi Y, Shimizu A, Yokoo T. The Renal Pathology of Obesity. Kidney Int Rep 2017; 2:251-260. [PMID: 29142961 PMCID: PMC5678647 DOI: 10.1016/j.ekir.2017.01.007] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 01/16/2017] [Indexed: 01/25/2023] Open
Abstract
Obesity causes various structural, hemodynamic, and metabolic alterations in the kidney. Most of these are likely to be compensatory responses to the systemic increase in metabolic demand that is seen with obesity. In some cases, however, renal injury becomes clinically apparent as a result of compensatory failure. Obesity-related glomerulopathy is the best known of such disease states. Factors that may sensitize obese individuals to renal compensatory failure and associated injury include the severity and number of obesity-associated conditions or complications, including components of metabolic syndrome, and the mismatch of body size to nephron mass, due to nephron reductions of congenital or acquired origin.
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Affiliation(s)
- Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Yusuke Okabayashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.,Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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Stefansson VTN, Schei J, Jenssen TG, Melsom T, Eriksen BO. Central obesity associates with renal hyperfiltration in the non-diabetic general population: a cross-sectional study. BMC Nephrol 2016; 17:172. [PMID: 27832768 PMCID: PMC5103601 DOI: 10.1186/s12882-016-0386-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 11/01/2016] [Indexed: 01/22/2023] Open
Abstract
Background Obesity is a risk factor for end-stage renal disease. Renal hyperfiltration, defined as an abnormally high glomerular filtration rate (GFR), is a link in the causal chain between diabetes and chronic kidney disease. Whether obesity is associated with hyperfiltration in the non-diabetic general population, remains unresolved due to a lack of consensus regarding the definition of hyperfiltration and the limited precision of high-range GFR estimations with creatinine and/or cystatin C. Methods 1555 middle-aged participants without diabetes, renal or cardiovascular disease were enrolled from the general population in the Renal Iohexol Clearance Survey from the 6th Tromsø Study (RENIS-T6) between 2007 and 2009. Obesity was assessed using the body mass index (BMI), waist circumference (WC) and the waist-hip ratio (WHR). GFR was measured by iohexol clearance. Dichotomous variables for hyperfiltration were based on two alternative definitions using unadjusted GFR (mL/min) above the 90th percentile. The 90th percentile was age-, sex- and height-specific in one definition and age-, sex-, height- and weight-specific in the other. Results In multivariable adjusted logistic regression models, only WHR was consistently associated with hyperfiltration based on both definitions. For the definition based on the age-, sex-, height- and weight-specific 90th percentile, the association with the WHR (odds ratios (95 % confidence intervals)) for hyperfiltration was 1.48 (1.08–2.02) per 0.10 WHR increase. Conclusions Central obesity is associated with hyperfiltration in the general population. The WHR may serve as a better indicator of the renal effects of obesity than BMI or WC. Electronic supplementary material The online version of this article (doi:10.1186/s12882-016-0386-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vidar Tor Nyborg Stefansson
- Metabolic and Renal Research Group, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway.
| | - Jørgen Schei
- Metabolic and Renal Research Group, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Trond Geir Jenssen
- Metabolic and Renal Research Group, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Organ Transplantation, Oslo University Hospital, Oslo, Norway
| | - Toralf Melsom
- Metabolic and Renal Research Group, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway.,Section of Nephrology, University Hospital of North Norway, Tromsø, Norway
| | - Bjørn Odvar Eriksen
- Metabolic and Renal Research Group, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway.,Section of Nephrology, University Hospital of North Norway, Tromsø, Norway
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Musso G, Cassader M, Cohney S, De Michieli F, Pinach S, Saba F, Gambino R. Fatty Liver and Chronic Kidney Disease: Novel Mechanistic Insights and Therapeutic Opportunities. Diabetes Care 2016; 39:1830-45. [PMID: 27660122 DOI: 10.2337/dc15-1182] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 07/10/2016] [Indexed: 02/03/2023]
Abstract
Chronic kidney disease (CKD) is a risk factor for end-stage renal disease (ESRD) and cardiovascular disease (CVD). ESRD or CVD develop in a substantial proportion of patients with CKD receiving standard-of-care therapy, and mortality in CKD remains unchanged. These data suggest that key pathogenetic mechanisms underlying CKD progression go unaffected by current treatments. Growing evidence suggests that nonalcoholic fatty liver disease (NAFLD) and CKD share common pathogenetic mechanisms and potential therapeutic targets. Common nutritional conditions predisposing to both NAFLD and CKD include excessive fructose intake and vitamin D deficiency. Modulation of nuclear transcription factors regulating key pathways of lipid metabolism, inflammation, and fibrosis, including peroxisome proliferator-activated receptors and farnesoid X receptor, is advancing to stage III clinical development. The relevance of epigenetic regulation in the pathogenesis of NAFLD and CKD is also emerging, and modulation of microRNA21 is a promising therapeutic target. Although single antioxidant supplementation has yielded variable results, modulation of key effectors of redox regulation and molecular sensors of intracellular energy, nutrient, or oxygen status show promising preclinical results. Other emerging therapeutic approaches target key mediators of inflammation, such as chemokines; fibrogenesis, such as galectin-3; or gut dysfunction through gut microbiota manipulation and incretin-based therapies. Furthermore, NAFLD per se affects CKD through lipoprotein metabolism and hepatokine secretion, and conversely, targeting the renal tubule by sodium-glucose cotransporter 2 inhibitors can improve both CKD and NAFLD. Implications for the treatment of NAFLD and CKD are discussed in light of this new therapeutic armamentarium.
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Affiliation(s)
- Giovanni Musso
- Humanitas Gradenigo Hospital, University of Turin, Turin, Italy
| | - Maurizio Cassader
- Department of Medical Sciences, San Giovanni Battista Hospital, University of Turin, Turin, Italy
| | - Solomon Cohney
- Department of Nephrology, Western & Royal Melbourne Hospitals, Melbourne, VIC, Australia
| | - Franco De Michieli
- Department of Medical Sciences, San Giovanni Battista Hospital, University of Turin, Turin, Italy
| | - Silvia Pinach
- Department of Medical Sciences, San Giovanni Battista Hospital, University of Turin, Turin, Italy
| | - Francesca Saba
- Department of Medical Sciences, San Giovanni Battista Hospital, University of Turin, Turin, Italy
| | - Roberto Gambino
- Department of Medical Sciences, San Giovanni Battista Hospital, University of Turin, Turin, Italy
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Heerspink HJL, Perkins BA, Fitchett DH, Husain M, Cherney DZI. Sodium Glucose Cotransporter 2 Inhibitors in the Treatment of Diabetes Mellitus: Cardiovascular and Kidney Effects, Potential Mechanisms, and Clinical Applications. Circulation 2016; 134:752-72. [PMID: 27470878 DOI: 10.1161/circulationaha.116.021887] [Citation(s) in RCA: 839] [Impact Index Per Article: 104.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Sodium-glucose cotransporter-2 (SGLT2) inhibitors, including empagliflozin, dapagliflozin, and canagliflozin, are now widely approved antihyperglycemic therapies. Because of their unique glycosuric mechanism, SGLT2 inhibitors also reduce weight. Perhaps more important are the osmotic diuretic and natriuretic effects contributing to plasma volume contraction, and decreases in systolic and diastolic blood pressures by 4 to 6 and 1 to 2 mm Hg, respectively, which may underlie cardiovascular and kidney benefits. SGLT2 inhibition also is associated with an acute, dose-dependent reduction in estimated glomerular filtration rate by ≈5 mL·min(-1)·1.73 m(-2) and ≈30% to 40% reduction in albuminuria. These effects mirror preclinical observations suggesting that proximal tubular natriuresis activates renal tubuloglomerular feedback through increased macula densa sodium and chloride delivery, leading to afferent vasoconstriction. On the basis of reduced glomerular filtration, glycosuric and weight loss effects are attenuated in patients with chronic kidney disease (estimated glomerular filtration rate <60 mL·min(-1)·1.73 m(-2)). In contrast, blood pressure lowering, estimated glomerular filtration rate, and albuminuric effects are preserved, and perhaps exaggerated in chronic kidney disease. With regard to long-term clinical outcomes, the EMPA-REG OUTCOME trial (Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes) in patients with type 2 diabetes mellitus and established cardiovascular disease randomly assigned to empagliflozin versus placebo reported a 14% reduction in the primary composite outcome of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, and >30% reductions in cardiovascular mortality, overall mortality, and heart failure hospitalizations associated with empagliflozin, even though, by design, the hemoglobin A1c difference between the randomized groups was marginal. Aside from an increased risk of mycotic genital infections, empagliflozin-treated patients had fewer serious adverse events, including a lower risk of acute kidney injury. In light of the EMPA-REG OUTCOME results, some diabetes clinical practice guidelines now recommend that SGLT2 inhibitors with proven cardiovascular benefit be prioritized in patients with type 2 diabetes mellitus who have not achieved glycemic targets and who have prevalent atherosclerotic cardiovascular disease. With additional cardiorenal protection trials underway, sodium-related physiological effects of SGLT2 inhibitors and clinical correlates of natriuresis, such as the impact on blood pressure, heart failure, kidney protection, and mortality, will be a major management focus.
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Affiliation(s)
- Hiddo J L Heerspink
- From Department of Clinical Pharmacy & Pharmacology, University of Groningen, University Medical Center Groningen, Netherlands (H.J.L.H.); Department of Medicine, Division of Endocrinology, Mount Sinai Hospital, University of Toronto, ON, Canada (B.A.P.); Department of Medicine, Division of Cardiology, St. Michael's Hospital, University of Toronto, ON, Canada (D.H.F.); Ted Rogers Centre for Heart Research and Department of Medicine, Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, ON, Canada (M.H.); Department of Medicine, Division of Nephrology, Toronto General Hospital, Department of Physiology, Banting and Best Diabetes Centre, University of Toronto, ON, Canada (D.Z.I.C.); Department of Physiology, University of Toronto, ON, Canada (D.Z.I.C.); and Banting and Best Diabetes Centre, University of Toronto, ON, Canada (D.Z.I.C.)
| | - Bruce A Perkins
- From Department of Clinical Pharmacy & Pharmacology, University of Groningen, University Medical Center Groningen, Netherlands (H.J.L.H.); Department of Medicine, Division of Endocrinology, Mount Sinai Hospital, University of Toronto, ON, Canada (B.A.P.); Department of Medicine, Division of Cardiology, St. Michael's Hospital, University of Toronto, ON, Canada (D.H.F.); Ted Rogers Centre for Heart Research and Department of Medicine, Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, ON, Canada (M.H.); Department of Medicine, Division of Nephrology, Toronto General Hospital, Department of Physiology, Banting and Best Diabetes Centre, University of Toronto, ON, Canada (D.Z.I.C.); Department of Physiology, University of Toronto, ON, Canada (D.Z.I.C.); and Banting and Best Diabetes Centre, University of Toronto, ON, Canada (D.Z.I.C.)
| | - David H Fitchett
- From Department of Clinical Pharmacy & Pharmacology, University of Groningen, University Medical Center Groningen, Netherlands (H.J.L.H.); Department of Medicine, Division of Endocrinology, Mount Sinai Hospital, University of Toronto, ON, Canada (B.A.P.); Department of Medicine, Division of Cardiology, St. Michael's Hospital, University of Toronto, ON, Canada (D.H.F.); Ted Rogers Centre for Heart Research and Department of Medicine, Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, ON, Canada (M.H.); Department of Medicine, Division of Nephrology, Toronto General Hospital, Department of Physiology, Banting and Best Diabetes Centre, University of Toronto, ON, Canada (D.Z.I.C.); Department of Physiology, University of Toronto, ON, Canada (D.Z.I.C.); and Banting and Best Diabetes Centre, University of Toronto, ON, Canada (D.Z.I.C.)
| | - Mansoor Husain
- From Department of Clinical Pharmacy & Pharmacology, University of Groningen, University Medical Center Groningen, Netherlands (H.J.L.H.); Department of Medicine, Division of Endocrinology, Mount Sinai Hospital, University of Toronto, ON, Canada (B.A.P.); Department of Medicine, Division of Cardiology, St. Michael's Hospital, University of Toronto, ON, Canada (D.H.F.); Ted Rogers Centre for Heart Research and Department of Medicine, Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, ON, Canada (M.H.); Department of Medicine, Division of Nephrology, Toronto General Hospital, Department of Physiology, Banting and Best Diabetes Centre, University of Toronto, ON, Canada (D.Z.I.C.); Department of Physiology, University of Toronto, ON, Canada (D.Z.I.C.); and Banting and Best Diabetes Centre, University of Toronto, ON, Canada (D.Z.I.C.)
| | - David Z I Cherney
- From Department of Clinical Pharmacy & Pharmacology, University of Groningen, University Medical Center Groningen, Netherlands (H.J.L.H.); Department of Medicine, Division of Endocrinology, Mount Sinai Hospital, University of Toronto, ON, Canada (B.A.P.); Department of Medicine, Division of Cardiology, St. Michael's Hospital, University of Toronto, ON, Canada (D.H.F.); Ted Rogers Centre for Heart Research and Department of Medicine, Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, ON, Canada (M.H.); Department of Medicine, Division of Nephrology, Toronto General Hospital, Department of Physiology, Banting and Best Diabetes Centre, University of Toronto, ON, Canada (D.Z.I.C.); Department of Physiology, University of Toronto, ON, Canada (D.Z.I.C.); and Banting and Best Diabetes Centre, University of Toronto, ON, Canada (D.Z.I.C.).
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Obesity-related glomerulopathy: clinical and pathologic characteristics and pathogenesis. Nat Rev Nephrol 2016; 12:453-71. [PMID: 27263398 DOI: 10.1038/nrneph.2016.75] [Citation(s) in RCA: 408] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The prevalence of obesity-related glomerulopathy is increasing in parallel with the worldwide obesity epidemic. Glomerular hypertrophy and adaptive focal segmental glomerulosclerosis define the condition pathologically. The glomerulus enlarges in response to obesity-induced increases in glomerular filtration rate, renal plasma flow, filtration fraction and tubular sodium reabsorption. Normal insulin/phosphatidylinositol 3-kinase/Akt and mTOR signalling are critical for podocyte hypertrophy and adaptation. Adipokines and ectopic lipid accumulation in the kidney promote insulin resistance of podocytes and maladaptive responses to cope with the mechanical forces of renal hyperfiltration. Although most patients have stable or slowly progressive proteinuria, up to one-third develop progressive renal failure and end-stage renal disease. Renin-angiotensin-aldosterone blockade is effective in the short-term but weight loss by hypocaloric diet or bariatric surgery has induced more consistent and dramatic antiproteinuric effects and reversal of hyperfiltration. Altered fatty acid and cholesterol metabolism are increasingly recognized as key mediators of renal lipid accumulation, inflammation, oxidative stress and fibrosis. Newer therapies directed to lipid metabolism, including SREBP antagonists, PPARα agonists, FXR and TGR5 agonists, and LXR agonists, hold therapeutic promise.
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