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McGrath MS, Wentworth BJ. The Renin-Angiotensin System in Liver Disease. Int J Mol Sci 2024; 25:5807. [PMID: 38891995 PMCID: PMC11172481 DOI: 10.3390/ijms25115807] [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: 05/04/2024] [Revised: 05/23/2024] [Accepted: 05/25/2024] [Indexed: 06/21/2024] Open
Abstract
The renin-angiotensin system (RAS) is a complex homeostatic entity with multiorgan systemic and local effects. Traditionally, RAS works in conjunction with the kidney to control effective arterial circulation, systemic vascular resistance, and electrolyte balance. However, chronic hepatic injury and resulting splanchnic dilation may disrupt this delicate balance. The role of RAS in liver disease, however, is even more extensive, modulating hepatic fibrosis and portal hypertension. Recognition of an alternative RAS pathway in the past few decades has changed our understanding of RAS in liver disease, and the concept of opposing vs. "rebalanced" forces is an ongoing focus of research. Whether RAS inhibition is beneficial in patients with chronic liver disease appears to be context-dependent, but further study is needed to optimize clinical management and reduce organ-specific morbidity and mortality. This review presents the current understanding of RAS in liver disease, acknowledges areas of uncertainty, and describes potential areas of future investigation.
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Affiliation(s)
- Mary S. McGrath
- Department of Medicine, School of Medicine, University of Virginia, Charlottesville, VA 22903, USA;
| | - Brian J. Wentworth
- Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia, Charlottesville, VA 22903, USA
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2
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Kang SH, Lee M, Kim MY, Lee JH, Jun BG, Kim TS, Choi DH, Suk KT, Kim YD, Cheon GJ, Kim DJ, Baik SK. The longitudinal outcomes of applying non-selective beta-blockers in portal hypertension: real-world multicenter study. Hepatol Int 2021; 15:424-436. [PMID: 33860898 DOI: 10.1007/s12072-021-10160-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 02/14/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND/AIM We investigated the effect of non-selective β-blockers (NSBB) in real-world situations and whether low-dose NSBB is beneficial compared to maximally tolerated doses. METHODS We performed a retrospective study of 740 patients with cirrhosis requiring prophylactic treatment of esophageal varices: 473 primary prophylaxis (PP: NSBB = 349, non-NSBB = 124) and 267 secondary prophylaxis (SP: NSBB = 200, non-NSBB = 67). The NSBB group was divided into low-dose (≤ 80 mg/day) and high-dose (> 80 mg/day). RESULTS In the PP group, NSBB treatment reduced mortality and showed the most pronounced effect in patients with moderate/severe ascites (hazard ratio [HR], 0.46; p < 0.01), HVPG ≥ 16 mmHg (HR, 0.53; p = 0.04), or CTP class B/C (HR, 0.46; p < 0.01) but not in those with no/mild ascites, HVPG < 16 mmHg, or CTP class A. Low-dose NSBB group showed a significant reduction in mortality compared with non-NSBB (moderate/severe ascites: HR, 0.61; p = 0.02 and CTP class B/C: HR, 0.41; p < 0.01) and the effect size was stronger than the high-dose NSBB. NSBB was associated with a reduced risk of infection (HR, 0.36; p = 0.01). In the SP group, NSBB prolonged survival in patients with moderate/severe ascites (HR, 0.56; p = 0.02), HVPG ≥ 16 mmHg (HR, 0.42; p < 0.01), or CTP class B/C (HR, 0.52; p < 0.01). Low-dose NSBB was more beneficial with 56% risk reduction (p < 0.01) of mortality compared with 33% risk reduction in the high-dose NSBB (p = 0.05). CONCLUSION NSBB therapy was associated with longer survival in PP and SP groups who had an advanced stage of cirrhosis. Moreover, low-dose NSBB exhibited a better benefit than a standard-titrated high-dose NSBB with better tolerability.
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Affiliation(s)
- Seong Hee Kang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, 20, Ilsan-ro, Wonju, 26426, Korea.,Regenerative Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea.,Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Minjong Lee
- School of Medicine, Ewha Womans University, Seoul, Korea.,Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Moon Young Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, 20, Ilsan-ro, Wonju, 26426, Korea. .,Regenerative Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea. .,Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea.
| | - Jun Hyeok Lee
- Department of Biostatistics, Yonsei University Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Baek Gyu Jun
- Department of Internal Medicine, University of Ulsan College of Medicine, Gangneung, Korea.,Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Tae Suk Kim
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Dae Hee Choi
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Ki Tae Suk
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Young Don Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Gangneung, Korea
| | - Gab Jin Cheon
- Department of Internal Medicine, University of Ulsan College of Medicine, Gangneung, Korea
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Soon Koo Baik
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, 20, Ilsan-ro, Wonju, 26426, Korea.,Regenerative Medicine Research Center, Yonsei University Wonju College of Medicine, Wonju, Korea.,Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
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3
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Sansoè G, Aragno M, Wong F. Pathways of hepatic and renal damage through non-classical activation of the renin-angiotensin system in chronic liver disease. Liver Int 2020; 40:18-31. [PMID: 31580514 DOI: 10.1111/liv.14272] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/24/2019] [Accepted: 09/30/2019] [Indexed: 12/17/2022]
Abstract
In liver cirrhosis, renin-angiotensin system (RAS) activation sustains renal sodium retention and hepatic fibrogenesis. New information has recently enlivened the traditional concept of RAS. For instance, renin and prorenin bind their ubiquitous receptors, resulting in the local production of angiotensin (Ang) II; increased serum calcium and calcimimetic agents, through stimulation of extracellular calcium-sensing receptors (CaSR), blunt renin production and lead to natriuretic effects in human and experimental cirrhosis. Alongside systemic production, there is Ang II tissue production within various organs through RAS enzymes different from angiotensin-converting enzyme (ACE), that is chymase, tissue plasminogen activator and several cathepsins. In experimental cirrhosis, inhibition of chymase leads to natriuretic and hepatic antifibrotic effects, without changes in systemic haemodynamics. In the kidney, local RAS coordinates proximal and distal tubular sodium reabsorption. However, renalase, whose plasma and tissue levels are severely altered in experimental cirrhosis, degrades systemic and renal tubule catecholamines, antagonizing the effects of renal RAS. Angiotensinogen-derived natriuretic and vasodilating peptides (Ang1-9, Ang1-7, Ang3-8) and their receptors have been described. Receptor agonists or antagonists are available to affect portal hypertension and sodium retention in cirrhosis. ACE2-dependent generation of Ang1-7 may inhibit experimental liver fibrosis. inhibition of Ang1-7 clearance by means of neprilysin blockade has portal hypotensive and natriuretic effects. Ang1-12, whose production renin does not regulate, is converted to several different angiotensin peptides via chymase. Finally, Ang II behaves as either an antinatriuretic or a natriuretic agent, based on the tissue content of AT1 R and AT2 R receptors, their ratio being prone to pharmacological modulation.
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Affiliation(s)
- Giovanni Sansoè
- Division of Gastroenterology, Humanitas Gradenigo Hospital, Torino, Italy
| | - Manuela Aragno
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Florence Wong
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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Abstract
Terlipressin, somatostatin, or octreotide are recommended as pharmacologic treatment of acute variceal hemorrhage. Nonselective β-blockers decrease the risk of variceal hemorrhage and hepatic decompensation, particularly in those 30% to 40% of patients with good hemodynamic response. Carvedilol, statins, and anticoagulants are promising agents in the management of portal hypertension. Recent advances in the pharmacologic treatment of portal hypertension have mainly focused on modifying an increased intrahepatic resistance through nitric oxide and/or modulation of vasoactive substances. Several novel pharmacologic agents for portal hypertension are being evaluated in humans.
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Affiliation(s)
- Chalermrat Bunchorntavakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Rajavithi Road, Ratchathewi, Bangkok 10400, Thailand; Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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5
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Manka P, Zeller A, Syn WK. Fibrosis in Chronic Liver Disease: An Update on Diagnostic and Treatment Modalities. Drugs 2019; 79:903-927. [DOI: 10.1007/s40265-019-01126-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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6
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Simonetto DA, Liu M, Kamath PS. Portal Hypertension and Related Complications: Diagnosis and Management. Mayo Clin Proc 2019; 94:714-726. [PMID: 30947834 DOI: 10.1016/j.mayocp.2018.12.020] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 12/11/2018] [Accepted: 12/21/2018] [Indexed: 02/06/2023]
Abstract
Portal hypertension is a major complication of cirrhosis, and its consequences, including ascites, esophageal varices, hepatic encephalopathy, and hepatorenal syndrome, lead to substantial morbidity and mortality. The past several decades have seen major improvements in the clinical management of complications of portal hypertension, resulting in substantial gains in patient outcomes. However, important challenges remain. This review focuses on the pathophysiology and diagnosis of portal hypertension and discusses general approaches in the management of patients with ascites as a result of portal hypertension.
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Affiliation(s)
| | - Mengfei Liu
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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Abstract
Propranolol is a beta-adrenergic receptor antagonist that was developed by the British scientist Sir James Black primarily for the treatment of angina pectoris, more than 50 years ago. It was not long before several other cardiovascular as well as noncardiovascular therapeutic uses of propranolol were discovered. Propranolol soon became a powerful tool for physicians in the treatment of numerous conditions such as hypertension, cardiac arrhythmias, myocardial infarction, migraine, portal hypertension, anxiety, essential tremors, hyperthyroidism, and pheochromocytoma. Owing to its action at multiple receptor sites, propranolol exerts several central and peripheral effects and is therefore useful in various conditions. Right from reduction in postmyocardial mortality to control of anxiety in performers, propranolol plays an important role in a plethora of medical conditions. Interestingly, even today, newer indications of this age-old drug are being discovered. Moreover, propranolol treatment has been found to be cost-effective when compared to other corresponding treatment options for individual indications. In this article, we attempt to recount the journey of propranolol right from its inception to the present day.
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Affiliation(s)
- A. V. Srinivasan
- Former Professor of Neurology and Head - Institute of Neurology, Madras Medical College, Chennai, Emeritus Professor - The Tamil Nadu Dr. M.G.R. Medical University, Adjunct Professor - Indian Institute of Technology (IIT - Chennai), Tamil Nadu, India
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8
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Yao H, Zhang C. Angiotensin II receptor blockers for the treatment of portal hypertension in patients with liver cirrhosis: a systematic review and meta-analysis of randomized controlled trials. Ir J Med Sci 2018; 187:925-934. [PMID: 29470765 DOI: 10.1007/s11845-018-1765-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/02/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Randomized controlled trials (RCTs) showed inconsistent results regarding the efficacy of angiotensin II receptor blockers (ARBs) on portal pressure as indicated by hepatic venous pressure gradient (HVPG). METHODS A meta-analysis of RCTs was performed to evaluate the influence of ARBs treatment on HVPG. PubMed, Embase, and Cochrane's Library were searched for relevant RCTs. A fixed or a randomized effect model was used to pool the results according the heterogeneity. Subgroup analyses were performed to explore the source of heterogeneity. RESULTS Eleven RCTs with 394 patients were included. ARBs treatment did not significantly change HVPG as compared with controls (weighted mean difference [WMD] = -0.63, 95% confidence interval [CI] -1.73 to 0.47 mmHg, p = 0.26; I2 = 60%). These results were consistent in studies comparing ARBs with propranolol (WMD = -0.40, 95% CI -2.22 to 1.41 mmHg, p = 0.67; I2 = 68%), and those comparing ARBs with non-active controls including placebo or no treatment (WMD = -1.05, 95% CI -2.33 to 0.24 mmHg, p = 0.13; I2 = 44%). These results were also not affected by the individual ARBs used. Moreover, treatment of ARBs significantly reduced mean arterial blood pressure (WMD = -6.12, 95% CI -9.69 to -2.55 mmHg, p = 0.008; I2 = 53%), and the risk of symptomatic hypotension was increased (RR = 4.13, 95% CI 0.94 to 18.18, p = 0.06; I2 = 0%). CONCLUSIONS ARBs did not reduce portal pressure in patients with cirrhosis; moreover, the risk of symptomatic hypotension may increase.
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Affiliation(s)
- Huijing Yao
- Department of Digestive Diseases, Shandong Provincial Hospital affiliated to Shandong University, No. 9677 Jingshi Road, Lixia District, Jinan, 250014, China
- Department of Digestive Diseases, Tai'an Central Hospital, Tai'an, 271000, China
| | - Chunqing Zhang
- Department of Digestive Diseases, Shandong Provincial Hospital affiliated to Shandong University, No. 9677 Jingshi Road, Lixia District, Jinan, 250014, China.
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9
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Kang SH, Jeong WK, Baik SK, Cha SH, Kim MY. Impact of sarcopenia on prognostic value of cirrhosis: going beyond the hepatic venous pressure gradient and MELD score. J Cachexia Sarcopenia Muscle 2018; 9:860-870. [PMID: 30371017 PMCID: PMC6204582 DOI: 10.1002/jcsm.12333] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 06/03/2018] [Accepted: 06/21/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Sarcopenia has been reported as a prognostic factor. We evaluated the impact of sarcopenia to the conventional prognostic factors [Model for End-Stage Liver Disease (MELD) score, Child-Turcotte-Pugh (CTP) score, hepatic venous pressure gradient (HVPG)] in cirrhosis. METHODS Overall, 452 patients with cirrhosis were stratified by MELD score (low < 15, high ≥ 15), CTP class, and HVPG [non-clinically significant portal hypertension (CSPH), 6-9 mmHg; CSPH, 10-19 mmHg; extremely severe PH, ≥20 mmHg]. L3 skeletal muscle index as marker of sarcopenia was subdivided into quartiles (47.01-52.25-58.22 cm2 /m2 ). RESULTS Among the patients, 42% (190/452) presented with sarcopenia. During a median follow-up period of 21.2 months, sarcopenia was associated with mortality (adjusted hazard ratio = 2.253, P < 0.001) and specifically with compensated and early decompensated stages of cirrhosis, but not with advanced decompensated stages; low (P < 0.001) and high (P = 0.095) MELD scores; CTP classes A (P = 0.034), B (P < 0.001), and C (P = 0.205); and non-CSPH (P = 0.018), CSPH (P < 0.001), and extremely severe PH (P = 0.846). In quartiles of sarcopenia, MELD score, CTP class, and HVPG were independent predictors of mortality in non-sarcopenia, but not in severe sarcopenia (MELD, P = 0.182; CTP, P = 0.187; HVPG, P = 0.077). CONCLUSIONS Sarcopenia is associated with mortality in compensated and early decompensated cirrhosis, and existing conventional prognostic factors had limited value in severe sarcopenia. Therefore, incorporating sarcopenia in the conventional prognostic factors had added value, particularly in compensated and early decompensated cirrhosis. Subclassification of prognostic factors according to sarcopenia may help to better assess the prognosis of cirrhosis.
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Affiliation(s)
- Seong Hee Kang
- Department of Internal MedicineYonsei University Wonju College of MedicineWonjuKorea
| | - Woo Kyoung Jeong
- Department of Radiology and Center for Imaging ScienceSungkyunkwan University School of MedicineSeoulKorea
| | - Soon Koo Baik
- Department of Internal MedicineYonsei University Wonju College of MedicineWonjuKorea
- Cell Therapy and Tissue Engineering CenterYonsei University Wonju College of MedicineWonjuKorea
- Institute of Evidence Based MedicineYonsei University Wonju College of MedicineWonjuKorea
| | - Seung Hwan Cha
- Department of RadiologyYonsei University Wonju College of MedicineWonjuKorea
| | - Moon Young Kim
- Department of Internal MedicineYonsei University Wonju College of MedicineWonjuKorea
- Cell Therapy and Tissue Engineering CenterYonsei University Wonju College of MedicineWonjuKorea
- Institute of Evidence Based MedicineYonsei University Wonju College of MedicineWonjuKorea
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10
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Lim YL, Kim MY, Jang YO, Baik SK, Kwon SO. Rifaximin and Propranolol Combination Therapy Is More Effective than Propranolol Monotherapy for the Reduction of Portal Pressure: An Open Randomized Controlled Pilot Study. Gut Liver 2018. [PMID: 28651304 PMCID: PMC5593333 DOI: 10.5009/gnl16478] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Non-selective beta blockers (NSBBs) are currently the only accepted regimen for preventing portal hypertension (PHT)-related complications. However, the effect of NSBBs is insufficient in many cases. Bacterial translocation (BT) is one of the aggravating factors of PHT in cirrhosis; therefore, selective intestinal decontamination by rifaximin is a possible therapeutic option for improving PHT. We investigated whether the addition of rifaximin to propranolol therapy can improve hepatic venous pressure gradient (HVPG) response. Methods Sixty-four cirrhosis patients were randomly assigned to propranolol monotherapy (n=48) versus rifaximin and propranolol combination therapy (n=16). Baseline and post-treatment HVPG values, BT-related markers (lipopolysaccharide [LPS], LPS-binding protein [LBP], interleukin-6 [IL-6], and tumor necrosis factor α [TNF-α]), serological data, and adverse event data were collected. HVPG response rate was the primary endpoint. Results Combination therapy was associated with better HVPG response rates than monotherapy (56.2% vs 87.5%, p=0.034). In combination therapy, posttreatment BT-related markers were significantly decreased (LPS, p=0.005; LBP, p=0.005; IL-6, p=0.005; TNF-α, p=0.047). Conclusions Rifaximin combination therapy showed an additive effect in improving PHT compared to propranolol monotherapy. These pilot data suggest that the addition of rifaximin to NSBBs could be a good therapeutic option for overcoming the limited effectiveness of NSBBs.
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Affiliation(s)
- Yoo Li Lim
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yoon Ok Jang
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea.,Department of Cell Therapy and Tissue Engineering, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea.,Department of Cell Therapy and Tissue Engineering, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sang Ok Kwon
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
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11
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Shim KY, Eom YW, Kim MY, Kang SH, Baik SK. Role of the renin-angiotensin system in hepatic fibrosis and portal hypertension. Korean J Intern Med 2018; 33:453-461. [PMID: 29462546 PMCID: PMC5943664 DOI: 10.3904/kjim.2017.317] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 09/05/2017] [Indexed: 02/08/2023] Open
Abstract
The renin-angiotensin system (RAS) is an important regulator of cirrhosis and portal hypertension. As hepatic fibrosis progresses, levels of the RAS components angiotensin (Ang) II, Ang-(1-7), angiotensin-converting enzyme (ACE), and Ang II type 1 receptor (AT1R) are increased. The primary effector Ang II regulates vasoconstriction, sodium homoeostasis, fibrosis, cell proliferation, and inflammation in various diseases, including liver cirrhosis, through the ACE/Ang II/AT1R axis in the classical RAS. The ACE2/Ang-(1-7)/Mas receptor and ACE2/Ang-(1-9)/AT2R axes make up the alternative RAS and promote vasodilation, antigrowth, proapoptotic, and anti-inflammatory effects; thus, countering the effects of the classical RAS axis to reduce hepatic fibrogenesis and portal hypertension. Patients with portal hypertension have been treated with RAS antagonists such as ACE inhibitors, Ang receptor blockers, and aldosterone antagonists, with very promising hemodynamic results. In this review, we examine the RAS, its roles in hepatic fibrosis and portal hypertension, and current therapeutic approaches based on the use of RAS antagonists in patients with portal hypertension.
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Affiliation(s)
- Kwang Yong Shim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Woo Eom
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seong Hee Kang
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Institute of Evidence Based Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Correspondence to Soon Koo Baik, M.D. Department of Internal Medicine, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju 26426, Korea Tel: +82-33-741-1223 Fax: +82-33-745-6782 E-mail:
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12
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Kim G, Shim KY, Baik SK. Diagnostic Accuracy of Hepatic Vein Arrival Time Performed with Contrast-Enhanced Ultrasonography for Cirrhosis: A Systematic Review and Meta-Analysis. Gut Liver 2017; 11:93-101. [PMID: 27538445 PMCID: PMC5221866 DOI: 10.5009/gnl16031] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/07/2016] [Accepted: 03/14/2016] [Indexed: 12/15/2022] Open
Abstract
Background/Aims We identified reports in the literature regarding the diagnostic accuracy of hepatic vein arrival time (HVAT) measured by contrast-enhanced ultrasonography (CEUS) to assess hepatic fibrosis in cirrhosis. Methods The Ovid MEDLINE, Embase, and Cochrane databases were searched for all studies published up to 23 July 2015 that evaluated liver status using CEUS and liver biopsy (LB). The QUADAS-II (quality assessment of diagnostic accuracy studies-II) was applied to assess the internal validity of the diagnostic studies. Selected studies were subjected to a meta-analysis with MetaDisc 1.4 and RevMan 5.3. Results A total of 12 studies including 844 patients with chronic liver disease met our inclusion criteria. The overall summary sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of the HVAT measured by CEUS for the detection of cirrhosis compared to LB were 0.83 (95% confidence interval [CI], 0.77 to 0.89), 0.75 (95% CI, 0.69 to 0.79), 3.45 (95% CI, 1.60 to 7.43), and 0.28 (95% CI, 0.10 to 0.74), respectively. The summary diagnostic odds ratio (random effects model) was 15.23 (95% CI, 3.07 to 75.47), the summary receiver operator characteristics area under the curve was 0.74 (standard error [SE]=0.14), and the index Q was 0.69 (SE=0.11). Conclusions Based on a systematic review, the measurement of HVAT by CEUS exhibited an increased accuracy and correlation for the detection of cirrhosis.
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Affiliation(s)
- Gaeun Kim
- Department of Nursing, Keimyung University College of Nursing, Daegu, Korea
| | - Kwang Yong Shim
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
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13
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Kang SH, Kim MY, Baik SK. Novelties in the pathophysiology and management of portal hypertension: new treatments on the horizon. Hepatol Int 2017; 12:112-121. [DOI: 10.1007/s12072-017-9806-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 06/08/2017] [Indexed: 02/06/2023]
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14
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Schwabl P, Laleman W. Novel treatment options for portal hypertension. Gastroenterol Rep (Oxf) 2017; 5:90-103. [PMID: 28533907 PMCID: PMC5421460 DOI: 10.1093/gastro/gox011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 03/12/2017] [Indexed: 12/13/2022] Open
Abstract
Portal hypertension is most frequently associated with cirrhosis and is a major driver for associated complications, such as variceal bleeding, ascites or hepatic encephalopathy. As such, clinically significant portal hypertension forms the prelude to decompensation and impacts significantly on the prognosis of patients with liver cirrhosis. At present, non-selective β-blockers, vasopressin analogues and somatostatin analogues are the mainstay of treatment but these strategies are far from satisfactory and only target splanchnic hyperemia. In contrast, safe and reliable strategies to reduce the increased intrahepatic resistance in cirrhotic patients still represent a pending issue. In recent years, several preclinical and clinical trials have focused on this latter component and other therapeutic avenues. In this review, we highlight novel data in this context and address potentially interesting therapeutic options for the future.
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Affiliation(s)
- Philipp Schwabl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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Kim COK, Jeon S, Han S, Hong T, Park MS, Yoon YR, Yim DS. Decreased potency of fimasartan in liver cirrhosis was quantified using mixed-effects analysis. Transl Clin Pharmacol 2017; 25:43-51. [PMID: 32095458 PMCID: PMC7033533 DOI: 10.12793/tcp.2017.25.1.43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 03/07/2017] [Accepted: 03/07/2017] [Indexed: 11/30/2022] Open
Abstract
Fimasartan is a nonpeptide angiotensin II receptor blocker. In a previous study that compared the pharmacokinetics (PK) of fimasartan between patients with hepatic impairment (cirrhosis) and healthy subjects, the exposure to fimasartan was found to be higher in patients, but the decrease of blood pressure (BP) was not clinically significant in those with moderate hepatic impairment. The aims of this study were to develop a population PK-pharmacodynamic (PD) model of fimasartan and to evaluate the effect of hepatic function on BP reduction by fimasartan using previously published data. A 2-compartment linear model with mixed zero-order absorption followed by first-order absorption with a lag time adequately described fimasartan PK, and the effect of fimasartan on BP changes was well explained by the inhibitory sigmoid function in the turnover PK-PD model overlaid with a model of circadian rhythm (NONMEM version 7.2). According to our PD model, the lower BP responses in hepatic impairment were the result of the increased fimasartan EC50 in patients, rather than from a saturation of effect. This is congruent with the reported pathophysiological change of increased plasma ACE and renin activity in hepatic cirrhosis.
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Affiliation(s)
- Choon OK Kim
- Department of Clinical Pharmacology, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
| | | | - Seunghoon Han
- Department of Clinical Pharmacology and Therapeutics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
| | - Taegon Hong
- Department of Clinical Pharmacology, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Min Soo Park
- Department of Clinical Pharmacology, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Young-Ran Yoon
- Clinical Trial Center, Kyungpook National University Hospital, Daegu 41944, Korea
| | - Dong-Seok Yim
- Department of Clinical Pharmacology and Therapeutics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
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Kim G, Kim J, Lim YL, Kim MY, Baik SK. Renin-angiotensin system inhibitors and fibrosis in chronic liver disease: a systematic review. Hepatol Int 2016; 10:819-28. [PMID: 26903052 DOI: 10.1007/s12072-016-9705-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 01/11/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The renin-angiotensin system (RAS) has an important role in hepatic fibrosis and portal hypertension. RAS inhibitors are already accepted in clinical fields for antihypertensive management, but their effects on hepatic fibrosis are controversial. The aim of this study was to systematically review the effects of RAS inhibitors on hepatic fibrosis based on histological assessment. METHODS We performed a systematic review and meta-analysis (MA) of the literature using the Ovid-MEDLINE, EMBASE, and Cochrane Library databases (up to January 2015) to identify clinical studies evaluating the effects of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers on hepatic fibrosis or cirrhosis patients based on histological assessment. Of the 455 studies identified, we analyzed 7, including a total of 1066 patients, which met our selection criteria. RESULTS According to the MA, patients treated with RAS inhibitors had significantly lower fibrosis scores (SMD -0.68, 95 % CI -1.03, -0.34, I (2) = 0 %, p < 0.0001) and smaller fibrosis areas (SMD -0.80, 95 % CI -1.18, -0.41, I (2) = 0 %, p < 0.0001) than controls. Serum fibrosis markers such as TGF-β1, collagen I, IV, TIMP-1, and MMP2 were significantly reduced in the intervention group. In two studies, mean arterial pressures were significantly decreased in RAS inhibitor users, but there were no reports about symptoms related to decreased blood pressure. No significant difference was found in serum creatinine levels between the intervention and control groups, and significant renal dysfunction was not observed after administration of RAS inhibitors. CONCLUSIONS RAS inhibitors are potential therapeutic agents for hepatic fibrosis, which can be safely used in patients with chronic liver disease.
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Affiliation(s)
- Gaeun Kim
- Research Institute for Nursing Science, College of Nursing, Keimyung University, Dalgubeoldae-ro 1095, Dalseo-Gu, Daegu, 704-701, Republic of Korea
| | - Juyoung Kim
- Research Institute for Nursing Science, College of Nursing, Keimyung University, Dalgubeoldae-ro 1095, Dalseo-Gu, Daegu, 704-701, Republic of Korea
| | - Yoo Li Lim
- Cell Therapy and Tissue Engineering Center, Wonju College of Medicine, Yonsei University, Ilsan-ro 20, Wonju, Gangwon-do, 220-701, Republic of Korea
- Department of Internal Medicine, Wonju College of Medicine, Yonsei University, Ilsan-ro 20, Wonju, Gangwon-do, 220-701, Republic of Korea
| | - Moon Young Kim
- Cell Therapy and Tissue Engineering Center, Wonju College of Medicine, Yonsei University, Ilsan-ro 20, Wonju, Gangwon-do, 220-701, Republic of Korea
- Department of Internal Medicine, Wonju College of Medicine, Yonsei University, Ilsan-ro 20, Wonju, Gangwon-do, 220-701, Republic of Korea
| | - Soon Koo Baik
- Cell Therapy and Tissue Engineering Center, Wonju College of Medicine, Yonsei University, Ilsan-ro 20, Wonju, Gangwon-do, 220-701, Republic of Korea.
- Department of Internal Medicine, Wonju College of Medicine, Yonsei University, Ilsan-ro 20, Wonju, Gangwon-do, 220-701, Republic of Korea.
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Nair H, Berzigotti A, Bosch J. Emerging therapies for portal hypertension in cirrhosis. Expert Opin Emerg Drugs 2016; 21:167-81. [PMID: 27148904 DOI: 10.1080/14728214.2016.1184647] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Counteracting splanchnic vasodilatation and increased portal-collateral blood flow has been the mainstay for the treatment of portal hypertension (PH) over the past three decades. However, there is still large room for improvement in the treatment of PH. AREAS COVERED The basic mechanism leading to portal hypertension is the increased hepatic vascular resistance to portal blood flow caused by liver structural abnormalities inherent to cirrhosis and increased hepatic vascular tone. Molecules modulating microvascular dysfunction which have undergone preclinical and clinical trials are summarized, potential drug development issues are addressed, and situations relevant to design of clinical trials are considered. EXPERT OPINION Experimental and clinical evidence indicates that molecules modulating liver microvascular dysfunction may allow for 30-40% reduction in portal pressure. Several agents could be utilized in the earlier stages of cirrhosis (antifibrotics, antiangiogenics, etiological therapies) may allow reduction of fibrosis and halt progression of PH. This 'nip at the bud' policy, by combining therapies with existing agents used in advanced phase of cirrhosis and novel agents which could be used in early phase of cirrhotic spectrum, which are likely to hit the market soon would be the future strategy for PH therapy.
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Affiliation(s)
- Harikumar Nair
- a Inselspital Universitatsspital Bern , Bern , Switzerland
| | | | - Jaime Bosch
- a Inselspital Universitatsspital Bern , Bern , Switzerland.,b Hospital Clinic de Barcelona , University of Barcelona , Barcelona , Spain
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Hajighasemi F, Mirshafiey A. In Vitro Effects of Propranolol on T Helper Type 1 Cytokine Profile in Human Leukemic T Cells. Int J Hematol Oncol Stem Cell Res 2016; 10:99-105. [PMID: 27252810 PMCID: PMC4888155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Cytokines are a large group of proteins play a key role in inflammation. Down-regulation of pro-inflammatory cytokines has beneficial effect on heart function. Propranolol, as a non selective beta-adrenergic blocker, has been extensively used for treatment of many cardiovascular problems such as arrhythmias and heart malfunction. In addition anti-inflammatory effects of propranolol have been revealed. In this study the propranolol effect on T helper type 1 cytokine profile in human leukemic T cells has been assessed in vitro. MATERIALS AND METHODS Human leukemic T cells (Molt-4 and Jurkat) were cultured in complete RPMI medium. The cells were then incubated with different concentrations of propranolol (0.03- 30 µM) in the presence or absence of PHA (10 µg/ml) for 48 hours. The supernatants of cell culture media were collected and used for cytokines assay. RESULTS Propranolol significantly decreased the T helper type 1 cytokine profile [Interleukin-2 (IL-2) and Interferon- γ (IFN-γ)] production in PHA stimulated Molt-4 and Jurkat cells, after 48 hour of incubation time, dose-dependently compared to untreated control cells. CONCLUSION Our data showed a dose dependent inhibitory effect of propranolol on the IL-2 and IFN-γ production in human leukemic Molt-4 and Jurkat cells. The anti- inflammatory effect of propranolol reported by other investigators may be in part due to its suppressive effect on production of inflammatory cytokines such as IL-2 and IFN-γ. So, propranolol along with its chronic long-term usage in cardiovascular problems may have potential implication in treatment of inflammatory-based disorders.
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Affiliation(s)
- Fatemeh Hajighasemi
- Department of Immunology, Faculty of Medicine, Shahed University, Tehran, Iran
| | - Abbas Mirshafiey
- Department of Pathobiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Lee HW. Angiotensin receptor blocker add-on therapy in portal hypertension: to use angiotensin receptor blocker or not to use, that is the question. Clin Mol Hepatol 2014; 20:345-6. [PMID: 25548739 PMCID: PMC4278064 DOI: 10.3350/cmh.2014.20.4.345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 12/03/2014] [Indexed: 12/16/2022] Open
Affiliation(s)
- Hyun Woong Lee
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
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