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Kohan DE, Bedard P, Jenkinson C, Hendry B, Komers R. Mechanism of protective actions of sparsentan in the kidney: lessons from studies in models of chronic kidney disease. Clin Sci (Lond) 2024; 138:645-662. [PMID: 38808486 PMCID: PMC11139641 DOI: 10.1042/cs20240249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 05/30/2024]
Abstract
Simultaneous inhibition of angiotensin II AT1 and endothelin ETA receptors has emerged as a promising approach for treatment of chronic progressive kidney disease. This therapeutic approach has been advanced by the introduction of sparsentan, the first dual AT1 and ETA receptor antagonist. Sparsentan is a single molecule with high affinity for both receptors. It is US Food and Drug Administration approved for immunoglobulin A nephropathy (IgAN) and is currently being developed as a treatment for rare kidney diseases, such as focal segmental glomerulosclerosis. Clinical studies have demonstrated the efficacy and safety of sparsentan in these conditions. In parallel with clinical development, studies have been conducted to elucidate the mechanisms of action of sparsentan and its position in the context of published evidence characterizing the nephroprotective effects of dual ETA and AT1 receptor inhibition. This review summarizes this evidence, documenting beneficial anti-inflammatory, antifibrotic, and hemodynamic actions of sparsentan in the kidney and protective actions in glomerular endothelial cells, mesangial cells, the tubulointerstitium, and podocytes, thus providing the rationale for the use of sparsentan as therapy for focal segmental glomerulosclerosis and IgAN and suggesting potential benefits in other renal diseases, such as Alport syndrome.
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Affiliation(s)
- Donald E. Kohan
- Division of Nephrology, University of Utah Health, Salt Lake City, UT, U.S.A
| | | | | | - Bruce Hendry
- Travere Therapeutics, Inc., San Diego, CA, U.S.A
| | - Radko Komers
- Travere Therapeutics, Inc., San Diego, CA, U.S.A
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Saleh L, Verdonk K, Visser W, van den Meiracker AH, Danser AHJ. The emerging role of endothelin-1 in the pathogenesis of pre-eclampsia. Ther Adv Cardiovasc Dis 2016; 10:282-93. [PMID: 26755746 DOI: 10.1177/1753944715624853] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Pre-eclampsia (PE) is the most frequently encountered medical complication during pregnancy. It is characterized by a rise in systemic vascular resistance with a relatively low cardiac output and hypovolemia, combined with severe proteinuria. Despite the hypovolemia, renin-angiotensin system (RAS) activity is suppressed and aldosterone levels are decreased to the same degree as renin. This suggests that the RAS is not the cause of the hypertension in PE, but rather that its suppression is the consequence of the rise in blood pressure. Abnormal placentation early in pregnancy is widely assumed to be an important initial event in the onset of PE. Eventually, this results in the release of anti-angiogenic factors [in particular, soluble Fms-like tyrosine kinase-1 (sFlt-1)] and cytokines, leading to generalized vascular dysfunction. Elevated sFlt-1 levels bind and inactivate vascular endothelial growth factor (VEGF). Of interest, VEGF inhibition with drugs like sunitinib, applied in cancer patients, results in a PE-like syndrome, characterized by hypertension, proteinuria and renal toxicity. Both in cancer patients treated with sunitinib and in pregnant women with PE, significant rises in endothelin-1 occur. Multiple regression analysis revealed that endothelin-1 is an independent determinant of the hypertension and proteinuria in PE, and additionally a renin suppressor. Moreover, studies in animal models representative of PE, have shown that endothelin receptor blockers prevent the development of this disease. Similarly, endothelin receptor blockers are protective during sunitinib treatment. Taken together, activation of the endothelin system emerges as an important pathway causing the clinical manifestations of PE. This paper critically addresses this concept, taking into consideration both clinical and preclinical data, and simultaneously discusses the therapeutic consequences of this observation.
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Affiliation(s)
- Langeza Saleh
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, Rotterdam, The NetherlandsDivision Obstetrics & Prenatal Medicine, Department of Obstetrics & Gynaecology, Erasmus MC, Rotterdam, The Netherlands
| | - Koen Verdonk
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Willy Visser
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, Rotterdam, The NetherlandsDivision Obstetrics & Prenatal Medicine, Department of Obstetrics & Gynaecology, Erasmus MC, Rotterdam, The Netherlands
| | - Anton H van den Meiracker
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - A H Jan Danser
- Department of Internal Medicine, Division of Vascular Medicine & Pharmacology, Room EE1418, Erasmus MC, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
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Verdonk K, Saleh L, Lankhorst S, Smilde JEI, van Ingen MM, Garrelds IM, Friesema ECH, Russcher H, van den Meiracker AH, Visser W, Danser AHJ. Association studies suggest a key role for endothelin-1 in the pathogenesis of preeclampsia and the accompanying renin-angiotensin-aldosterone system suppression. Hypertension 2015; 65:1316-23. [PMID: 25870197 DOI: 10.1161/hypertensionaha.115.05267] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 03/22/2015] [Indexed: 01/09/2023]
Abstract
Women with preeclampsia display low renin-angiotensin-aldosterone system activity and a high antiangiogenic state, the latter characterized by high levels of soluble Fms-like tyrosine kinase (sFlt)-1 and reduced placental growth factor levels. To investigate whether renin-angiotensin-aldosterone system suppression in preeclampsia is because of this disturbed angiogenic balance, we measured mean arterial pressure, creatinine, endothelin-1 (ET-1), and renin-angiotensin-aldosterone system components in pregnant women with a high (≥85; n=38) or low (<85; n=65) soluble Fms-like tyrosine kinase-1/placental growth factor ratio. Plasma ET-1 levels were increased in women with a high ratio, whereas their plasma renin activity and plasma concentrations of renin, angiotensinogen, and aldosterone were decreased. Plasma renin activity-aldosterone relationships were identical in both the groups. Multiple regression analysis revealed that plasma renin concentration correlated independently with mean arterial pressure and plasma ET-1. Plasma ET-1 correlated positively with soluble Fms-like tyrosine kinase-1 and negatively with plasma renin concentration, and urinary protein correlated with plasma ET-1 and mean arterial pressure. Despite the lower plasma levels of renin and angiotensinogen in the high-ratio group, their urinary levels of these components were elevated. Correction for albumin revealed that this was because of increased glomerular filtration. Subcutaneous arteries obtained from patients with preeclampsia displayed an enhanced, AT2 receptor-mediated response to angiotensin II. In conclusion, a high antiangiogenic state associates with ET-1 activation, which together with the increased mean arterial pressure may underlie the parallel reductions in renin and aldosterone in preeclampsia. Because ET-1 also was a major determinant of urinary protein, our data reveal a key role for ET-1 in the pathogenesis of preeclampsia. Finally, the enhanced angiotensin responsiveness in preeclampsia involves constrictor AT2 receptors.
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Affiliation(s)
- Koen Verdonk
- From the Division of Vascular Medicine and Pharmacology, Department of Internal Medicine (K.V., L.S., S.L., J.E.I.S., M.M.v.I., I.M.G., E.C.H.F., A.H.v.d.M., A.H.J.D.), Division Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology (W.V.), and Department of Clinical Chemistry (H.R.), Erasmus MC, Rotterdam, The Netherlands
| | - Langeza Saleh
- From the Division of Vascular Medicine and Pharmacology, Department of Internal Medicine (K.V., L.S., S.L., J.E.I.S., M.M.v.I., I.M.G., E.C.H.F., A.H.v.d.M., A.H.J.D.), Division Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology (W.V.), and Department of Clinical Chemistry (H.R.), Erasmus MC, Rotterdam, The Netherlands
| | - Stephanie Lankhorst
- From the Division of Vascular Medicine and Pharmacology, Department of Internal Medicine (K.V., L.S., S.L., J.E.I.S., M.M.v.I., I.M.G., E.C.H.F., A.H.v.d.M., A.H.J.D.), Division Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology (W.V.), and Department of Clinical Chemistry (H.R.), Erasmus MC, Rotterdam, The Netherlands
| | - J E Ilse Smilde
- From the Division of Vascular Medicine and Pharmacology, Department of Internal Medicine (K.V., L.S., S.L., J.E.I.S., M.M.v.I., I.M.G., E.C.H.F., A.H.v.d.M., A.H.J.D.), Division Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology (W.V.), and Department of Clinical Chemistry (H.R.), Erasmus MC, Rotterdam, The Netherlands
| | - Manon M van Ingen
- From the Division of Vascular Medicine and Pharmacology, Department of Internal Medicine (K.V., L.S., S.L., J.E.I.S., M.M.v.I., I.M.G., E.C.H.F., A.H.v.d.M., A.H.J.D.), Division Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology (W.V.), and Department of Clinical Chemistry (H.R.), Erasmus MC, Rotterdam, The Netherlands
| | - Ingrid M Garrelds
- From the Division of Vascular Medicine and Pharmacology, Department of Internal Medicine (K.V., L.S., S.L., J.E.I.S., M.M.v.I., I.M.G., E.C.H.F., A.H.v.d.M., A.H.J.D.), Division Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology (W.V.), and Department of Clinical Chemistry (H.R.), Erasmus MC, Rotterdam, The Netherlands
| | - Edith C H Friesema
- From the Division of Vascular Medicine and Pharmacology, Department of Internal Medicine (K.V., L.S., S.L., J.E.I.S., M.M.v.I., I.M.G., E.C.H.F., A.H.v.d.M., A.H.J.D.), Division Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology (W.V.), and Department of Clinical Chemistry (H.R.), Erasmus MC, Rotterdam, The Netherlands
| | - Henk Russcher
- From the Division of Vascular Medicine and Pharmacology, Department of Internal Medicine (K.V., L.S., S.L., J.E.I.S., M.M.v.I., I.M.G., E.C.H.F., A.H.v.d.M., A.H.J.D.), Division Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology (W.V.), and Department of Clinical Chemistry (H.R.), Erasmus MC, Rotterdam, The Netherlands
| | - Anton H van den Meiracker
- From the Division of Vascular Medicine and Pharmacology, Department of Internal Medicine (K.V., L.S., S.L., J.E.I.S., M.M.v.I., I.M.G., E.C.H.F., A.H.v.d.M., A.H.J.D.), Division Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology (W.V.), and Department of Clinical Chemistry (H.R.), Erasmus MC, Rotterdam, The Netherlands
| | - Willy Visser
- From the Division of Vascular Medicine and Pharmacology, Department of Internal Medicine (K.V., L.S., S.L., J.E.I.S., M.M.v.I., I.M.G., E.C.H.F., A.H.v.d.M., A.H.J.D.), Division Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology (W.V.), and Department of Clinical Chemistry (H.R.), Erasmus MC, Rotterdam, The Netherlands
| | - A H Jan Danser
- From the Division of Vascular Medicine and Pharmacology, Department of Internal Medicine (K.V., L.S., S.L., J.E.I.S., M.M.v.I., I.M.G., E.C.H.F., A.H.v.d.M., A.H.J.D.), Division Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology (W.V.), and Department of Clinical Chemistry (H.R.), Erasmus MC, Rotterdam, The Netherlands.
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