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Nishihara M, Shinohara K, Ikeda S, Akahoshi T, Tsutsui H. Impact of sympathetic hyperactivity induced by brain microglial activation on organ damage in sepsis with chronic kidney disease. J Intensive Care 2024; 12:31. [PMID: 39223624 PMCID: PMC11367766 DOI: 10.1186/s40560-024-00742-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 07/12/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Sympathetic nerve activity (SNA) plays a central role in the pathogenesis of several diseases such as sepsis and chronic kidney disease (CKD). Activation of microglia in the paraventricular nucleus of the hypothalamus (PVN) has been implicated in SNA. The mechanisms responsible for the adverse prognosis observed in sepsis associated with CKD remain to be determined. Therefore, we aimed to clarify the impact of increased SNA resulting from microglial activation on hemodynamics and organ damage in sepsis associated with CKD. METHODS AND RESULTS In protocol 1, male Sprague-Dawley rats underwent either nephrectomy (Nx) or sham surgery followed by cecal ligation and puncture (CLP) or sham surgery. After CLP, Nx-CLP rats exhibited decreased blood pressure, increased heart rate, elevated serum creatinine and bilirubin levels, and decreased platelet count compared to Nx-Sham rats. Heart rate variability analysis revealed an increased low to high frequency (LF/HF) ratio in Nx-CLP rats, indicating increased SNA. Nx-CLP rats also had higher creatinine and bilirubin levels and lower platelet counts than sham-CLP rats after CLP. In protocol 2, Nx-CLP rats were divided into two subgroups: one received minocycline, an inhibitor of microglial activation, while the other received artificial cerebrospinal fluid (CSF) intracerebroventricularly via an osmotic minipump. The minocycline-treated group (Nx-mino-CLP) showed attenuated hypotensive and increased heart rate responses compared to the CSF-treated group (Nx-CSF-CLP), and the LF/HF ratio was also decreased. Echocardiography showed larger left ventricular dimensions and inferior vena cava in the Nx-mino-CLP group. In addition, creatinine and bilirubin levels were lower and platelet counts were higher in the Nx-mino-CLP group compared to the Nx-CSF-CLP group. CONCLUSIONS In septic rats with concomitant CKD, SNA was significantly enhanced and organ dysfunction was increased. It has been suggested that the mechanism of exacerbated organ dysfunction in these models may involve abnormal systemic hemodynamics, possibly triggered by activation of the central sympathetic nervous system through activation of microglia in the PVN.
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Affiliation(s)
- Masaaki Nishihara
- Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan.
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Keisuke Shinohara
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shota Ikeda
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomohiko Akahoshi
- Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
- Department of Advanced Emergency and Disaster medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
- School of Medicine and Graduate School, International University of Health and Welfare, Fukuoka, Japan
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2
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Akinterinwa OE, Singh M, Vemuri S, Tyagi SC. A Need to Preserve Ejection Fraction during Heart Failure. Int J Mol Sci 2024; 25:8780. [PMID: 39201469 PMCID: PMC11354382 DOI: 10.3390/ijms25168780] [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: 06/10/2024] [Revised: 07/20/2024] [Accepted: 08/07/2024] [Indexed: 09/02/2024] Open
Abstract
Heart failure (HF) is a significant global healthcare burden with increasing prevalence and high morbidity and mortality rates. The diagnosis and management of HF are closely tied to ejection fraction (EF), a crucial parameter for evaluating disease severity and determining treatment plans. This paper emphasizes the urgent need to maintain EF during heart failure, highlighting the distinct phenotypes of HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF). It discusses the complexities of HFrEF pathophysiology and its negative impact on patient outcomes, stressing the importance of ongoing research and the development of effective therapeutic interventions to slow down the progression from preserved to reduced ejection fraction. Additionally, it explores the potential role of renal denervation in preserving ejection fraction and its implications for HFrEF management. This comprehensive review aims to offer valuable insights into the critical role of EF preservation in enhancing outcomes for patients with heart failure.
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Affiliation(s)
- Oluwaseun E. Akinterinwa
- Department of Physiology, University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Mahavir Singh
- Department of Physiology, University of Louisville School of Medicine, Louisville, KY 40202, USA
- Center for Predictive Medicine (CPM) for Biodefense and Emerging Infectious Diseases, University of Louisville, Louisville, KY 40202, USA
| | - Sreevatsa Vemuri
- Department of Physiology, University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Suresh C. Tyagi
- Department of Physiology, University of Louisville School of Medicine, Louisville, KY 40202, USA
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3
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Serban-Feier LF, Cuiban E, Gogosoiu EB, Stepan E, Radulescu D. Renalase Potential as a Marker and Therapeutic Target in Chronic Kidney Disease. Biomedicines 2024; 12:1715. [PMID: 39200179 PMCID: PMC11351300 DOI: 10.3390/biomedicines12081715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Revised: 07/24/2024] [Accepted: 07/26/2024] [Indexed: 09/02/2024] Open
Abstract
Hypertension and cardiovascular disease are prominent features of chronic kidney disease, and they are associated with premature mortality and progression toward end-stage kidney disease. Renalase, an enzyme secreted predominantly by the kidney and identified in 2005, seems to be one of the missing pieces in the puzzle of heart and kidney interaction in chronic kidney disease by lowering blood pressure and reducing the overactivity of sympathetic tone. This review aims to summarize evidence from clinical studies performed on subjects with CKD in order to explore the value of renalase as a marker and/or a therapeutic target in this disease.
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Affiliation(s)
- Larisa Florina Serban-Feier
- Department of Nephrology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.F.S.-F.); (E.S.); (D.R.)
- Department of Nephrology, Sfantul Ioan Clinical Emergency Hospital, 042122 Bucharest, Romania;
| | - Elena Cuiban
- Department of Nephrology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.F.S.-F.); (E.S.); (D.R.)
- Department of Nephrology, Sfantul Ioan Clinical Emergency Hospital, 042122 Bucharest, Romania;
| | - Elena Bianca Gogosoiu
- Department of Nephrology, Sfantul Ioan Clinical Emergency Hospital, 042122 Bucharest, Romania;
| | - Elena Stepan
- Department of Nephrology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.F.S.-F.); (E.S.); (D.R.)
| | - Daniela Radulescu
- Department of Nephrology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.F.S.-F.); (E.S.); (D.R.)
- Department of Nephrology, Sfantul Ioan Clinical Emergency Hospital, 042122 Bucharest, Romania;
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4
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Mather M. The emotion paradox in the aging body and brain. Ann N Y Acad Sci 2024; 1536:13-41. [PMID: 38676452 DOI: 10.1111/nyas.15138] [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] [Indexed: 04/29/2024]
Abstract
With age, parasympathetic activity decreases, while sympathetic activity increases. Thus, the typical older adult has low heart rate variability (HRV) and high noradrenaline levels. Younger adults with this physiological profile tend to be unhappy and stressed. Yet, with age, emotional experience tends to improve. Why does older adults' emotional well-being not suffer as their HRV decreases? To address this apparent paradox, I present the autonomic compensation model. In this model, failing organs, the initial phases of Alzheimer's pathology, and other age-related diseases trigger noradrenergic hyperactivity. To compensate, older brains increase autonomic regulatory activity in the pregenual prefrontal cortex (PFC). Age-related declines in nerve conduction reduce the ability of the pregenual PFC to reduce hyperactive noradrenergic activity and increase peripheral HRV. But these pregenual PFC autonomic compensation efforts have a significant impact in the brain, where they bias processing in favor of stimuli that tend to increase parasympathetic activity (e.g., stimuli that increase feelings of safety) and against stimuli that tend to increase sympathetic activity (e.g., threatening stimuli). In summary, the autonomic compensation model posits that age-related chronic sympathetic/noradrenergic hyperactivity stimulates regulatory attempts that have the side effect of enhancing emotional well-being.
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Affiliation(s)
- Mara Mather
- Leonard Davis School of Gerontology, Department of Psychology, and Department of Biomedical Engineering, University of Southern California, Los Angeles, California, USA
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5
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Upadhyay A. SGLT2 Inhibitors and Kidney Protection: Mechanisms Beyond Tubuloglomerular Feedback. KIDNEY360 2024; 5:771-782. [PMID: 38523127 PMCID: PMC11146657 DOI: 10.34067/kid.0000000000000425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 03/19/2024] [Indexed: 03/26/2024]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk for kidney failure and are a key component of guideline-directed therapy for CKD. While SGLT2 inhibitors' ability to activate tubuloglomerular feedback and reduce hyperfiltration-mediated kidney injury is considered to be the central mechanism for kidney protection, recent data from experimental studies raise questions on the primacy of this mechanism. This review examines SGLT2 inhibitors' role in tubuloglomerular feedback and summarizes emerging evidence on following of SGLT2 inhibitors' other putative mechanisms for kidney protection: optimization of kidney's energy substrate utilization and delivery, regulation of autophagy and maintenance of cellular homeostasis, attenuation of sympathetic hyperactivity, and improvement in vascular health and microvascular function. It is imperative to examine the effect of SGLT2 inhibition on these different physiologic processes to help our understanding of mechanisms underpinning kidney protection with this important class of drugs.
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Affiliation(s)
- Ashish Upadhyay
- Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
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6
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Le Page AK, Johnson EC, Greenberg JH. Is mild dehydration a risk for progression of childhood chronic kidney disease? Pediatr Nephrol 2024:10.1007/s00467-024-06332-6. [PMID: 38632124 DOI: 10.1007/s00467-024-06332-6] [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: 10/31/2023] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 04/19/2024]
Abstract
Children with chronic kidney disease (CKD) can have an inherent vulnerability to dehydration. Younger children are unable to freely access water, and CKD aetiology and stage can associate with reduced kidney concentrating capacity, which can also impact risk. This article aims to review the risk factors and consequences of mild dehydration and underhydration in CKD, with a particular focus on evidence for risk of CKD progression. We discuss that assessment of dehydration in the CKD population is more challenging than in the healthy population, thus complicating the definition of adequate hydration and clinical research in this field. We review pathophysiologic studies that suggest mild dehydration and underhydration may cause hyperfiltration injury and impact renal function, with arginine vasopressin as a key mediator. Randomised controlled trials in adults have not shown an impact of improved hydration in CKD outcomes, but more vulnerable populations with baseline low fluid intake or poor kidney concentrating capacity need to be studied. There is little published data on the frequency of dehydration, and risk of complications, acute or chronic, in children with CKD. Despite conflicting evidence and the need for more research, we propose that paediatric CKD management should routinely include an assessment of individual dehydration risk along with a treatment plan, and we provide a framework that could be used in outpatient settings.
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Affiliation(s)
- Amelia K Le Page
- Department of Nephrology, Monash Children's Hospital, Clayton, VIC, Australia.
- Department of Pediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.
| | - Evan C Johnson
- Division of Kinesiology & Health, College of Health Sciences, University of Wyoming, Laramie, WY, USA
| | - Jason H Greenberg
- Section of Nephrology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, CT, USA
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7
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Zanuzzi MG, Jeong J, DaCosta DR, Park J. Sex differences in sympathetic activity and pulse wave velocity in adults with chronic kidney disease. Am J Physiol Renal Physiol 2024; 326:F661-F668. [PMID: 38385174 PMCID: PMC11208017 DOI: 10.1152/ajprenal.00308.2023] [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: 10/02/2023] [Revised: 02/14/2024] [Accepted: 02/14/2024] [Indexed: 02/23/2024] Open
Abstract
Chronic kidney disease (CKD) is characterized by sympathetic nervous system (SNS) overactivity that contributes to increased vascular stiffness and cardiovascular risk. Although it is well established that SNS activity and vascular stiffness are substantially elevated in CKD, whether sex differences in autonomic and vascular function exist in CKD remains unknown. We tested the hypothesis that compared with females, males with CKD have higher baseline sympathetic activity that is related to increased arterial stiffness. One hundred twenty-nine participants (96 males and 33 females) with CKD stages III and IV were recruited and enrolled. During two separate study visits, vascular stiffness was assessed by measuring carotid-to-femoral pulse wave velocity (cfPWV), and resting muscle sympathetic nerve activity (MSNA) was measured by microneurography. Males with CKD had higher resting MSNA compared with females with CKD (68 ± 16 vs. 55 ± 14 bursts/100 heart beats, P = 0.005), whereas there was no difference in cfPWV between the groups (P = 0.248). Resting MSNA was not associated with cfPWV in both males and females. In conclusion, males with CKD have higher resting sympathetic activity compared with females with CKD. However, there was no difference in vascular stiffness between the sexes. There was no correlation between resting MSNA and cfPWV, suggesting that non-neural mechanisms may play a greater role in the progression of vascular stiffness in CKD, particularly in females.NEW & NOTEWORTHY Males with chronic kidney disease (CKD) have higher resting muscle sympathetic nerve activity (MSNA) compared with females. There was no correlation between MSNA and carotid-to-femoral pulse wave velocity (cfPWV), suggesting that non-neural mechanisms may play a greater role in the progression of vascular stiffness in CKD. Sex differences in SNS activity may play a mechanistic role in observations from epidemiological studies suggesting greater cardiovascular risk in males compared with females with CKD.
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Affiliation(s)
- Matias G Zanuzzi
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States
- Department of Veterans Affairs Health Care System, Research Service Line, Decatur, Georgia, United States
| | - Jinhee Jeong
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States
- Department of Veterans Affairs Health Care System, Research Service Line, Decatur, Georgia, United States
| | - Dana R DaCosta
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States
- Department of Veterans Affairs Health Care System, Research Service Line, Decatur, Georgia, United States
| | - Jeanie Park
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States
- Department of Veterans Affairs Health Care System, Research Service Line, Decatur, Georgia, United States
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8
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Lv Z, Fu Y, Liu C, Ma Y, Yuan M, Ren J, Gao D. The role of cardiac remodeling associated with renal function in mediating cardiovascular event outcomes. iScience 2024; 27:109143. [PMID: 38384844 PMCID: PMC10879695 DOI: 10.1016/j.isci.2024.109143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 01/09/2024] [Accepted: 02/01/2024] [Indexed: 02/23/2024] Open
Abstract
The potential impact of renal function-related cardiovascular remodeling on associated cardiovascular risk has not been previously investigated. Hence, we conducted multiple mediation analyses in the UK Biobank study to evaluate this association. Using multiple Cox models, we found lower renal function (estimated glomerular filtration rate based on cystatin C, eGFR-cysC) was independently related to increased risks of various cardiovascular events and mortalities. Multivariable linear regression revealed a progressive relationship between declining eGFR-cysC and adverse left ventricular (LV) remodeling and impaired systolic function. In Cox models, larger LV volume, mass, as well as decreased systolic function, were significantly correlated with adverse events, particularly in heart failure. Mediation analyses showed that undesirable LV remodeling and cardiometabolic diseases were independent mediators. Our study explores the connections between reduced renal function and poor cardiovascular phenotypes, as well as their significant independent role in mediating renal function-cardiovascular outcome relationships.
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Affiliation(s)
- Zhi Lv
- Department of Cardiology, The Second Affiliated Hospital, Xi’an Jiaotong University, No. 157, West 5th Road, Xi’an 710004, Shaanxi, China
| | - Yangzhi Fu
- West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu 610041, Sichuan, China
| | - Chang Liu
- Department of Cardiology, The Second Affiliated Hospital, Xi’an Jiaotong University, No. 157, West 5th Road, Xi’an 710004, Shaanxi, China
| | - Yao Ma
- Department of Cardiology, The Second Affiliated Hospital, Xi’an Jiaotong University, No. 157, West 5th Road, Xi’an 710004, Shaanxi, China
| | - Miao Yuan
- Department of Cardiology, The Second Affiliated Hospital, Xi’an Jiaotong University, No. 157, West 5th Road, Xi’an 710004, Shaanxi, China
| | - Junru Ren
- The Second Affiliated Hospital, Xi’an Jiaotong University, No. 157, West 5th Road, Xi’an 710004, Shaanxi, China
| | - Dengfeng Gao
- Department of Cardiology, The Second Affiliated Hospital, Xi’an Jiaotong University, No. 157, West 5th Road, Xi’an 710004, Shaanxi, China
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9
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Alrosan AZ, Heilat GB, Alrosan K, Aleikish AA, Rabbaa AN, Shakhatreh AM, Alshalout EM, Al Momany EM. Autonomic brain functioning and age-related health concerns. Curr Res Physiol 2024; 7:100123. [PMID: 38510918 PMCID: PMC10950753 DOI: 10.1016/j.crphys.2024.100123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/02/2024] [Accepted: 03/04/2024] [Indexed: 03/22/2024] Open
Abstract
The autonomic nervous system (ANS) regulates involuntary bodily functions such as blood pressure, heart rate, breathing, and digestion, in addition to controlling motivation and behavior. In older adults, the ANS is dysregulated, which changes the ability of the ANS to respond to physiological signals, regulate cardiovascular autonomic functionality, diminish gastric motility, and exacerbate sleep problems. For example, a decrease in heart rate variability, or the variation in the interval between heartbeats, is one of the most well-known alterations in the ANS associated with health issues, including cardiovascular diseases and cognitive decline. The inability to perform fundamental activities of daily living and compromising the physiological reactivity or motivational responses of older adults to moving toward or away from specific environmental stimuli are significant negative consequences of chronic and geriatric conditions that pose grave threats to autonomy, health, and well-being. The most updated research has investigated the associations between the action responsiveness of older adults and the maintenance of their physiological and physical health or the development of mental and physical health problems. Once autonomic dysfunction may significantly influence the development of different age-related diseases, including ischemic stroke, cardiovascular disease, and autoimmune diseases, this review aimed to assess the relationship between aging and autonomic functions. The review explored how motivational responses, physiological reactivity, cognitive processes, and lifelong developmental changes associated with aging impact the ANS and contribute to the emergence of health problems.
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Affiliation(s)
- Amjad Z. Alrosan
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, The Hashemite University, Zarqa, 13133, Jordan
| | - Ghaith B. Heilat
- Department of General Surgery and Urology, Faculty of Medicine, The Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Khaled Alrosan
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, The Hashemite University, Zarqa, 13133, Jordan
| | - Abrar A. Aleikish
- Master of Pharmacology, Department of Pharmacology, Faculty of Medicine, The Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Aya N. Rabbaa
- Faculty of Pharmaceutical Sciences, The Hashemite University, Zarqa, 13133, Jordan
| | - Aseel M. Shakhatreh
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, The Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Ehab M. Alshalout
- Faculty of Pharmaceutical Sciences, The Hashemite University, Zarqa, 13133, Jordan
| | - Enaam M.A. Al Momany
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, The Hashemite University, Zarqa, 13133, Jordan
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10
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Vondenhoff S, Schunk SJ, Noels H. Increased cardiovascular risk in patients with chronic kidney disease. Herz 2024; 49:95-104. [PMID: 38416185 PMCID: PMC10917854 DOI: 10.1007/s00059-024-05235-4] [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] [Accepted: 01/17/2024] [Indexed: 02/29/2024]
Abstract
Cardiovascular disease (CVD) is highly prevalent in patients suffering from chronic kidney disease (CKD). The risk of patients with CKD developing CVD is manifested already in the early stages of CKD development. The impact of declined kidney function on increased cardiovascular risk and the underlying mechanisms are complex and multifactorial. This review discusses the impact of (a) traditional cardiovascular risk factors such as smoking, dyslipidemia, diabetes, and hypertension as well as (b) CKD-specific pathophysiological and molecular mechanisms associated with an increased cardiovascular risk. The latter include uremic toxins, post-translational modifications and uremic lipids, innate immune cell activation and inflammation, oxidative stress, endothelial cell dysfunction, increased coagulation and altered platelet responses, vascular calcification, renin-angiotensin-aldosterone-system (RAAS) and sympathetic activation, as well as anemia. Unraveling the complex interplay of different risk factors, especially in the context of patient subcohorts, will help to find new therapeutic approaches in order to reduce the increased cardiovascular risk in this vulnerable patient cohort.
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Affiliation(s)
- Sonja Vondenhoff
- Institute for Molecular Cardiovascular Research (IMCAR), RWTH Aachen University, 52074, Aachen, Germany
- Biochemistry Department, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen University, 52074, Aachen, Germany
| | - Stefan J Schunk
- Klinik für Innere Medizin IV, Nieren- und Hochdruckkrankheiten, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Heidi Noels
- Institute for Molecular Cardiovascular Research (IMCAR), RWTH Aachen University, 52074, Aachen, Germany.
- Biochemistry Department, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.
- Aachen-Maastricht Institute for Cardiorenal Research (AMICARE), University Hospital Aachen, Aachen, Germany.
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen University, 52074, Aachen, Germany.
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11
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Doiron JE, Li Z, Yu X, LaPenna KB, Quiriarte H, Allerton TD, Koul K, Malek A, Shah SJ, Sharp TE, Goodchild TT, Kapusta DR, Lefer DJ. Early Renal Denervation Attenuates Cardiac Dysfunction in Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2024; 13:e032646. [PMID: 38353216 PMCID: PMC11010115 DOI: 10.1161/jaha.123.032646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/08/2023] [Indexed: 02/21/2024]
Abstract
BACKGROUND The renal sympathetic nervous system modulates systemic blood pressure, cardiac performance, and renal function. Pathological increases in renal sympathetic nerve activity contribute to the pathogenesis of heart failure with preserved ejection fraction (HFpEF). We investigated the effects of renal sympathetic denervation performed at early or late stages of HFpEF progression. METHODS AND RESULTS Male ZSF1 obese rats were subjected to radiofrequency renal denervation (RF-RDN) or sham procedure at either 8 weeks or 20 weeks of age and assessed for cardiovascular function, exercise capacity, and cardiorenal fibrosis. Renal norepinephrine and renal nerve tyrosine hydroxylase staining were performed to quantify denervation following RF-RDN. In addition, renal injury, oxidative stress, inflammation, and profibrotic biomarkers were evaluated to determine pathways associated with RDN. RF-RDN significantly reduced renal norepinephrine and tyrosine hydroxylase content in both study cohorts. RF-RDN therapy performed at 8 weeks of age attenuated cardiac dysfunction, reduced cardiorenal fibrosis, and improved endothelial-dependent vascular reactivity. These improvements were associated with reductions in renal injury markers, expression of renal NLR family pyrin domain containing 3/interleukin 1β, and expression of profibrotic mediators. RF-RDN failed to exert beneficial effects when administered in the 20-week-old HFpEF cohort. CONCLUSIONS Our data demonstrate that early RF-RDN therapy protects against HFpEF disease progression in part due to the attenuation of renal fibrosis and inflammation. In contrast, the renoprotective and left ventricular functional improvements were lost when RF-RDN was performed in later HFpEF progression. These results suggest that RDN may be a viable treatment option for HFpEF during the early stages of this systemic inflammatory disease.
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Affiliation(s)
- Jake E. Doiron
- Department of Pharmacology and Experimental TherapeuticsLouisiana State University Health Sciences CenterNew OrleansLAUSA
| | - Zhen Li
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Xiaoman Yu
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Kyle B. LaPenna
- Department of Pharmacology and Experimental TherapeuticsLouisiana State University Health Sciences CenterNew OrleansLAUSA
| | - Heather Quiriarte
- Department of Vascular MetabolismPennington Biomedical Research CenterBaton RougeLAUSA
| | - Timothy D. Allerton
- Department of Vascular MetabolismPennington Biomedical Research CenterBaton RougeLAUSA
| | - Kashyap Koul
- School of MedicineLouisiana State University Health Sciences Center New OrleansNew OrleansLAUSA
| | - Andrew Malek
- School of MedicineLouisiana State University Health Sciences Center New OrleansNew OrleansLAUSA
| | - Sanjiv J. Shah
- Division of Cardiology, Department of Medicine and Bluhm Cardiovascular InstituteNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Thomas E. Sharp
- Department of Molecular Pharmacology and Physiology, Morsani College of MedicineUniversity of South FloridaTampaFLUSA
- USF Health Heart InstituteTampaFLUSA
| | - Traci T. Goodchild
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Daniel R. Kapusta
- Department of Pharmacology and Experimental TherapeuticsLouisiana State University Health Sciences CenterNew OrleansLAUSA
| | - David J. Lefer
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
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12
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Chisty TTE, Sarif S, Jahan I, Ismail IN, Chowdhury FI, Siddiqua S, Yasmin T, Islam MN, Khan F, Subhan N, Alam MA. Protective effects of l-carnitine on isoprenaline -induced heart and kidney dysfunctions: Modulation of inflammation and oxidative stress-related gene expression in rats. Heliyon 2024; 10:e25057. [PMID: 38322874 PMCID: PMC10845729 DOI: 10.1016/j.heliyon.2024.e25057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 12/11/2023] [Accepted: 01/19/2024] [Indexed: 02/08/2024] Open
Abstract
The aim of this study was to evaluate the effect of l-carnitine (L-CAR) treatment on isoprenaline (ISO) administered kidney and heart impairment in male Long Evans rats. Four groups of rats were engaged in this study such as control, ISO, control + L-CAR, and ISO + L-CAR, where n = 6 in each group. The rats were also provided with chow food and water ad libitum. At the end of the study, all rats were sacrificed, and blood and tissue samples were collected for bio-chemical analysis. Oxidative stress parameters and antioxidant enzyme activities were determined in plasma and tissues. Antioxidant and inflammatory genes expression were analyzed in the kidney cortex, and histopathological studies of kidney tissues were performed. This study showed that creatinine and uric acid in plasma were significantly increased in ISO-administered rats. l-carnitine treatment lowered the uric acid and creatinine level. ISO-administered rats showed increased lipid peroxidation and declined levels of antioxidant enzymes activities in kidneys and heart. l-carnitine treatment restored antioxidant enzymes activities and protect against oxidative stress in kidney and heart. This effect is correlated with the restoration of Nrf-2-HO-1 genes expression followed by increased SOD and catalase genes expression in the kidney. l-carnitine treatment also prevented the TNF-α, IL-6, and NF-кB expression in kidneys of ISO administered rats. Histopathology staining showed that l-carnitine treatment prevented kidney damage and collagen deposition in ISO administered rats. The result of this study exhibited that l-carnitine treatment reduced oxidative stress and increased antioxidant enzyme activities by enhancing antioxidant genes expression in ISO administered rats.
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Affiliation(s)
| | - Sumaia Sarif
- Department of Pharmaceutical Sciences, North South University, Bangladesh
| | - Ishrat Jahan
- Department of Pharmaceutical Sciences, North South University, Bangladesh
| | | | | | | | - Tahmina Yasmin
- Department of Pharmaceutical Sciences, North South University, Bangladesh
| | - Md Nurul Islam
- Department of Pharmaceutical Sciences, North South University, Bangladesh
| | - Ferdous Khan
- Department of Pharmaceutical Sciences, North South University, Bangladesh
| | - Nusrat Subhan
- Department of Pharmaceutical Sciences, North South University, Bangladesh
| | - Md Ashraful Alam
- Department of Pharmaceutical Sciences, North South University, Bangladesh
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13
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Coovadia Y, Schwende BK, Taylor CE, Usselman CW. Limb-specific muscle sympathetic nerve activity responses to the cold pressor test. Auton Neurosci 2024; 251:103146. [PMID: 38181550 DOI: 10.1016/j.autneu.2023.103146] [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: 09/29/2023] [Revised: 12/22/2023] [Accepted: 12/26/2023] [Indexed: 01/07/2024]
Abstract
Recent studies have demonstrated that muscle sympathetic nerve activity (MSNA) responses to isometric exercise differs between active and inactive limbs. Whether limb-dependent responses are characteristic of responses to the cold pressor test (CPT) remains to be established. Therefore, we tested the hypothesis that CPT-induced MSNA responses differ between affected and unaffected limbs such that MSNA in the affected lower limb is greater than MSNA responses in the contralateral lower limb and the upper limb. Integrated peroneal MSNA (microneurography) was measured in young healthy individuals (n = 10) at rest and during three separate 3-min CPTs: the microneurography foot, opposite foot, and opposite hand. Peak MSNA responses were extracted for further analysis, as well as corresponding hemodynamic outcomes including mean arterial pressure (MAP; Finometer). MSNA responses were greater when the microneurography foot was immersed in ice water than when the opposite foot was immersed (38 ± 18 vs 28 ± 16 bursts/100hb: P < 0.01). MSNA responses when the opposite hand was immersed were greater than both the microneurography foot (46 ± 22 vs 38 ± 18 bursts/100hb: P < 0.01) and opposite foot (46 ± 22 vs 28 ± 16 bursts/100hb: P ≤0.01). Likewise, MAP responses were greater during the hand CPT than the microneurography foot (99 ± 9 vs 96 ± 8 mmHg: P < 0.01) and opposite foot CPT (99 ± 9 vs 96 ± 9 mmHg: P < 0.01). These data indicate that (a) upper limbs and (b) immersed limbs elicit greater MSNA responses to the CPT than lower and/or non-immersed limbs.
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Affiliation(s)
- Yasmine Coovadia
- Cardiovascular Health and Autonomic Regulation Laboratory, McGill University, Montreal, Quebec, Canada
| | - Brittany K Schwende
- Cardiovascular Health and Autonomic Regulation Laboratory, McGill University, Montreal, Quebec, Canada
| | - Chloe E Taylor
- School of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia
| | - Charlotte W Usselman
- Cardiovascular Health and Autonomic Regulation Laboratory, McGill University, Montreal, Quebec, Canada.
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14
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Mallamaci F, Tripepi G. Risk Factors of Chronic Kidney Disease Progression: Between Old and New Concepts. J Clin Med 2024; 13:678. [PMID: 38337372 PMCID: PMC10856768 DOI: 10.3390/jcm13030678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/17/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
Chronic kidney disease (CKD) is a condition characterized by the gradual loss of kidney function over time and it is a worldwide health issue. The estimated frequency of CKD is 10% of the world's population, but it varies greatly on a global scale. In absolute terms, the staggering number of subjects affected by various degrees of CKD is 850,000,000, and 85% of them are in low- to middle-income countries. The most important risk factors for chronic kidney disease are age, arterial hypertension, diabetes, obesity, proteinuria, dyslipidemia, and environmental risk factors such as dietary salt intake and a more recently investigated agent: pollution. In this narrative review, we will focus by choice just on some risk factors such as age, which is the most important non-modifiable risk factor, and among modifiable risk factors, we will focus on hypertension, salt intake, obesity, and sympathetic overactivity.
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Affiliation(s)
- Francesca Mallamaci
- Nephrology, Dialysis and Transplantation Unit, Grande Ospedale Metropolitano, Bianchi-Melacrino-Morelli (BMM), 89124 Reggio Calabria, Italy
- Research Unit of Clinical Epidemiology of Reggio Calabria, Institute of Clinical Physiology (IFC), National Research Council (CNR), 89124 Reggio Calabria, Italy
| | - Giovanni Tripepi
- Research Unit of Clinical Epidemiology of Reggio Calabria, Institute of Clinical Physiology (IFC), National Research Council (CNR), 89124 Reggio Calabria, Italy
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15
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Yao J, Sprick JD, Jeong J, Park J, Reiter DA. Differences in peripheral microcirculatory blood flow regulation in chronic kidney disease based on wavelet analysis of resting near-infrared spectroscopy. Microvasc Res 2024; 151:104624. [PMID: 37926135 PMCID: PMC11018197 DOI: 10.1016/j.mvr.2023.104624] [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: 08/11/2023] [Revised: 10/13/2023] [Accepted: 11/01/2023] [Indexed: 11/07/2023]
Abstract
Vascular impairment is closely related to increased mortality in chronic kidney disease (CKD). The objective of this study was to assess impairments in the regulation of peripheral microvascular perfusion in patients with CKD based on time-frequency spectral analysis of resting near-infrared spectroscopy (NIRS) signals. Total hemoglobin (tHb) concentration and tissue saturation index (TSI) signals were collected using NIRS for a continuous 5 mins at 10 Hz from the forearm of 55 participants (34 CKD including 5 with end-stage renal disease, and 21 age-matched control). Continuous wavelet transform-based spectral analysis was used to quantify the spectral amplitude within five pre-defined frequency intervals (I, 0.0095-0.021 Hz; II, 0.021-0.052 Hz; III, 0.052-0.145 Hz; IV, 0.145-0.6 Hz and V, 0.6-2.0 Hz), representing endothelial, neurogenic, myogenic, respiratory and heartbeat activity, respectively. CKD patients showed lower tHb average spectral amplitude within the neurogenic frequency interval compared with controls (p = 0.014), consistent with an increased sympathetic outflow observed in CKD. CKD patients also showed lower TSI average spectral amplitude within the endothelial frequency interval compared with controls (p = 0.046), consistent with a reduced endothelial function in CKD. These findings demonstrate the potential of wavelet analysis of NIRS to provide complementary information on peripheral microvascular regulation in CKD.
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Affiliation(s)
- Jingting Yao
- Department of Radiology and Imaging Science, Emory University, Atlanta, GA, United States; Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Justin D Sprick
- Department of Kinesiology, Health Promotion, and Recreation, University of North Texas, Denton, TX, United States
| | - Jinhee Jeong
- Division of Renal Medicine, Emory University, Atlanta, GA, United States; Atlanta Veterans Affairs Medical Center, Decatur, GA, United States
| | - Jeanie Park
- Division of Renal Medicine, Emory University, Atlanta, GA, United States; Atlanta Veterans Affairs Medical Center, Decatur, GA, United States
| | - David A Reiter
- Department of Radiology and Imaging Science, Emory University, Atlanta, GA, United States; Department of Orthopedics, Emory University, Atlanta, GA, United States; Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, United States.
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16
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Burke J, Pugh D, Farrah T, Hamid C, Godden E, MacGillivray TJ, Dhaun N, Baillie JK, King S, MacCormick IJC. Evaluation of an Automated Choroid Segmentation Algorithm in a Longitudinal Kidney Donor and Recipient Cohort. Transl Vis Sci Technol 2023; 12:19. [PMID: 37975844 PMCID: PMC10668611 DOI: 10.1167/tvst.12.11.19] [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: 03/01/2023] [Accepted: 10/16/2023] [Indexed: 11/19/2023] Open
Abstract
Purpose To evaluate the performance of an automated choroid segmentation algorithm in optical coherence tomography (OCT) data using a longitudinal kidney donor and recipient cohort. Methods We assessed 22 donors and 23 patients requiring renal transplantation over up to 1 year posttransplant. We measured choroidal thickness (CT) and area and compared our automated CT measurements to manual ones at the same locations. We estimated associations between choroidal measurements and markers of renal function (estimated glomerular filtration rate [eGFR], serum creatinine, and urea) using correlation and linear mixed-effects (LME) modeling. Results There was good agreement between manual and automated CT. Automated measures were more precise because of smaller measurement error over time. External adjudication of major discrepancies was in favor of automated measures. Significant differences were observed in the choroid pre- and posttransplant in both cohorts, and LME modeling revealed significant linear associations observed between choroidal measures and renal function in recipients. Significant associations were mostly stronger with automated CT (eGFR, P < 0.001; creatinine, P = 0.004; urea, P = 0.04) compared to manual CT (eGFR, P = 0.002; creatinine, P = 0.01; urea, P = 0.03). Conclusions Our automated approach has greater precision than human-performed manual measurements, which may explain stronger associations with renal function compared to manual measurements. To improve detection of meaningful associations with clinical endpoints in longitudinal studies of OCT, reducing measurement error should be a priority, and automated measurements help achieve this. Translational Relevance We introduce a novel choroid segmentation algorithm that can replace manual grading for studying the choroid in renal disease and other clinical conditions.
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Affiliation(s)
- Jamie Burke
- School of Mathematics, University of Edinburgh, College of Science and Engineering, Edinburgh, UK
| | - Dan Pugh
- University/BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Tariq Farrah
- University/BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Charlene Hamid
- Imaging Facility, University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, UK
| | - Emily Godden
- Emergency Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Neeraj Dhaun
- University/BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - J. Kenneth Baillie
- Deanery of Clinical Sciences, University of Edinburgh, College of Medicine and Veterinary Medicine, Edinburgh, UK
| | - Stuart King
- School of Mathematics, University of Edinburgh, College of Science and Engineering, Edinburgh, UK
| | - Ian J. C. MacCormick
- Centre for Inflammation Research, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
- Institute for Adaptive and Neural Computation, School of Informatics, University of Edinburgh, Edinburgh, UK
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17
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Kharazmi F, Hosseini-Dastgerdi H, Pourshanazari AA, Nematbakhsh M. The denervation or activation of renal sympathetic nerve and renal blood flow. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2023; 28:76. [PMID: 38152073 PMCID: PMC10751519 DOI: 10.4103/jrms.jrms_216_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/09/2023] [Accepted: 07/17/2023] [Indexed: 12/29/2023]
Abstract
The denervation or activation of the sympathetic nerve in the kidney can affect renal hemodynamics. The sympathetic nervous system regulates the physiological functions of the kidneys. Stimulation of sympathetic efferent nerves affects various parameters related to renal hemodynamics, including sodium excretion, renin secretion, and renal blood flow (RBF). Hence, renal sympathetic fibers may also play an essential role in regulating systemic vascular resistance and controlling blood pressure. In the absence of renal nerves, the hemodynamics response to stimuli is negligible or absent. The effect of renal sympathetic denervation on RBF is dependent on several factors such as interspecies differences, the basic level of nerve activity in the vessels or local density of adrenergic receptor in the vascular bed. The role of renal denervation has been investigated therapeutically in hypertension and related disorders. Hence, the dynamic impact of renal nerves on RBF enables using RBF dynamic criteria as a marker for renal denervation therapy.
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Affiliation(s)
- Fatemeh Kharazmi
- Water and Electrolytes Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Physiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hajaralsadat Hosseini-Dastgerdi
- Water and Electrolytes Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Physiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Mehdi Nematbakhsh
- Water and Electrolytes Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Physiology, Isfahan University of Medical Sciences, Isfahan, Iran
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18
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Su H, Wu H, Wu S, Zhou M. Effects of electroacupuncture at KI3 and ST36 on the hypothalamic paraventricular nucleus in a rat model of chronic glomerulonephritis. Acupunct Med 2023; 41:307-316. [PMID: 37166069 DOI: 10.1177/09645284231166718] [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] [Indexed: 05/12/2023]
Abstract
OBJECTIVE The hypothalamic paraventricular nucleus (PVN) acts as a critical integrating center of endocrine/autonomic responses and regulates visceral functional activities. However, its involvement in electroacupuncture (EA) treatment of chronic glomerulonephritis (CGN) remains unclear. METHODS Over four experiments, we randomized 111 rats into: control, untreated model (CGN) or EA-treated model (CGN + EA) groups, a model group receiving EA after PVN damage (CGN + EA + Lesion) or untreated model groups injected with adeno-associated viral vectors encoding human M4 muscarinic receptor (CGN + hM4D) or enhanced green fluorescent protein (CGN + EGFP). CGN was modeled by intraperitoneal injection of bovine serum albumin for 2 weeks. Rats in the CGN + EA and CGN + EA + Lesion groups received EA at bilateral ST36 and KI3 for 14 days. Urine/serum samples were collected to evaluate inflammatory factors and changes in renal function. RESULTS EA inhibited the release of interleukin (IL)-6, tumor necrosis factor (TNF)-α and IL-1β, and decreased urine protein (PRO), creatinine (Cre) and blood urea nitrogen (BUN) levels. PVN damage influenced the effect of EA on the levels of these parameters. EA appeared to inhibit the firing frequency and spectral energy of PVN neurons. In the viral vector experiment, levels of PRO, Cre, IL-6, IL-1β and TNF-α in the CGN group were increased in CGN versus control groups (p < 0.0001), decreased in CGN + hM4D versus CGN groups (p < 0.05) and did not differ between CGN + EGFP and control groups (p > 0.05). CONCLUSION Our findings indicate that EA at ST36 and KI3 improves CGN in this rat model by weakening the activity of PVN neurons, alleviating impairment of renal function impairment and restricting the release of inflammatory factors.
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Affiliation(s)
- Hang Su
- Graduate School of Anhui University of Traditional Chinese Medicine, Hefei, China
| | - Haosheng Wu
- Graduate School of Anhui University of Traditional Chinese Medicine, Hefei, China
| | - Shengbing Wu
- Key Laboratory of Xin'an Medicine, Ministry of Education, Anhui University of Chinese Medicine, Hefei, China
| | - Meiqi Zhou
- Anhui Academy of Traditional Medicine, Bozhou Institute of Chinese Medicine, Bozhou, China
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19
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Echefu G, Stowe I, Burka S, Basu-Ray I, Kumbala D. Pathophysiological concepts and screening of cardiovascular disease in dialysis patients. FRONTIERS IN NEPHROLOGY 2023; 3:1198560. [PMID: 37840653 PMCID: PMC10570458 DOI: 10.3389/fneph.2023.1198560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/10/2023] [Indexed: 10/17/2023]
Abstract
Dialysis patients experience 10-20 times higher cardiovascular mortality than the general population. The high burden of both conventional and nontraditional risk factors attributable to loss of renal function can explain higher rates of cardiovascular disease (CVD) morbidity and death among dialysis patients. As renal function declines, uremic toxins accumulate in the blood and disrupt cell function, causing cardiovascular damage. Hemodialysis patients have many cardiovascular complications, including sudden cardiac death. Peritoneal dialysis puts dialysis patients with end-stage renal disease at increased risk of CVD complications and emergency hospitalization. The current standard of care in this population is based on observational data, which has a high potential for bias due to the paucity of dedicated randomized clinical trials. Furthermore, guidelines lack specific guidelines for these patients, often inferring them from non-dialysis patient trials. A crucial step in the prevention and treatment of CVD would be to gain better knowledge of the influence of these predisposing risk factors. This review highlights the current evidence regarding the influence of advanced chronic disease on the cardiovascular system in patients undergoing renal dialysis.
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Affiliation(s)
- Gift Echefu
- Division of Cardiovascular Medicine, The University of Tennessee Health Science Center, Memphis, TN, United States
| | - Ifeoluwa Stowe
- Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge, LA, United States
| | - Semenawit Burka
- Department of Internal Medicine, University of Texas Rio Grande Valley, McAllen, TX, United States
| | - Indranill Basu-Ray
- Department of Cardiology, Memphis Veterans Affairs (VA) Medical Center, Memphis, TN, United States
| | - Damodar Kumbala
- Nephrology Division, Renal Associates of Baton Rouge, Baton Rouge, LA, United States
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20
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Dai D, Zhu Z, Han H, Xu T, Feng S, Zhang W, Ding F, Zhang R, Zhu J. Enhanced tyrosine sulfation is associated with chronic kidney disease-related atherosclerosis. BMC Biol 2023; 21:151. [PMID: 37424015 DOI: 10.1186/s12915-023-01641-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 06/02/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) accelerates atherosclerosis, but the mechanisms remain unclear. Tyrosine sulfation has been recognized as a key post-translational modification (PTM) in regulation of various cellular processes, and the sulfated adhesion molecules and chemokine receptors have been shown to participate in the pathogenesis of atherosclerosis via enhancement of monocyte/macrophage function. The levels of inorganic sulfate, the essential substrate for the sulfation reaction, are dramatically increased in patients with CKD, which indicates a change of sulfation status in CKD patients. Thus, in the present study, we detected the sulfation status in CKD patients and probed into the impact of sulfation on CKD-related atherosclerosis by targeting tyrosine sulfation function. RESULTS PBMCs from individuals with CKD showed higher amounts of total sulfotyrosine and tyrosylprotein sulfotransferase (TPST) type 1 and 2 protein levels. The plasma level of O-sulfotyrosine, the metabolic end product of tyrosine sulfation, increased significantly in CKD patients. Statistically, O-sulfotyrosine and the coronary atherosclerosis severity SYNTAX score positively correlated. Mechanically, more sulfate-positive nucleated cells in peripheral blood and more abundant infiltration of sulfated macrophages in deteriorated vascular plaques in CKD ApoE null mice were noted. Knockout of TPST1 and TPST2 decreased atherosclerosis and peritoneal macrophage adherence and migration in CKD condition. The sulfation of the chemokine receptors, CCR2 and CCR5, was increased in PBMCs from CKD patients. CONCLUSIONS CKD is associated with increased sulfation status. Increased sulfation contributes to monocyte/macrophage activation and might be involved in CKD-related atherosclerosis. Inhibition of sulfation may suppress CKD-related atherosclerosis and is worthy of further study.
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Affiliation(s)
- Daopeng Dai
- Department of Vascular & Cardiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Road II, Shanghai, 200025, China
- Institute of Cardiovascular Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhengbin Zhu
- Department of Vascular & Cardiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Road II, Shanghai, 200025, China
| | - Hui Han
- Department of Vascular & Cardiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Road II, Shanghai, 200025, China
| | - Tian Xu
- Department of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shuo Feng
- Institute of Cardiovascular Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenli Zhang
- Department of Vascular & Cardiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Road II, Shanghai, 200025, China
| | - Fenghua Ding
- Department of Vascular & Cardiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Road II, Shanghai, 200025, China
| | - Ruiyan Zhang
- Department of Vascular & Cardiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Road II, Shanghai, 200025, China.
- Institute of Cardiovascular Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Jinzhou Zhu
- Department of Vascular & Cardiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Road II, Shanghai, 200025, China.
- Institute of Cardiovascular Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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21
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Sprick JD, Jeong J, Sabino-Carvalho JL, Li S, Park J. Neurocirculatory regulation and adaptations to exercise in chronic kidney disease. Am J Physiol Heart Circ Physiol 2023; 324:H843-H855. [PMID: 37000610 PMCID: PMC10191135 DOI: 10.1152/ajpheart.00115.2023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/23/2023] [Accepted: 03/29/2023] [Indexed: 04/01/2023]
Abstract
Chronic kidney disease (CKD) is characterized by pronounced exercise intolerance and exaggerated blood pressure reactivity during exercise. Classic mechanisms of exercise intolerance in CKD have been extensively described previously and include uremic myopathy, chronic inflammation, malnutrition, and anemia. We contend that these classic mechanisms only partially explain the exercise intolerance experienced in CKD and that alterations in cardiovascular and autonomic regulation also play a key contributing role. The purpose of this review is to examine the physiological factors that contribute to neurocirculatory dysregulation during exercise and discuss the adaptations that result from regular exercise training in CKD. Key neurocirculatory mechanisms contributing to exercise intolerance in CKD include augmentation of the exercise pressor reflex, aberrations in neurocirculatory control, and increased neurovascular transduction. In addition, we highlight how some contributing factors may be improved through exercise training, with a specific focus on the sympathetic nervous system. Important areas for future work include understanding how the exercise prescription may best be optimized in CKD and how the beneficial effects of exercise training may extend to the brain.
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Affiliation(s)
- Justin D Sprick
- Department of Kinesiology, Health Promotion and Recreation, University of North Texas, Denton, Texas, United States
| | - Jinhee Jeong
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States
- Department of Veterans Affairs Health Care System, Research Service Line, Decatur, Georgia, United States
| | - Jeann L Sabino-Carvalho
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States
- Department of Veterans Affairs Health Care System, Research Service Line, Decatur, Georgia, United States
| | - Sabrina Li
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States
- Department of Veterans Affairs Health Care System, Research Service Line, Decatur, Georgia, United States
| | - Jeanie Park
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States
- Department of Veterans Affairs Health Care System, Research Service Line, Decatur, Georgia, United States
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22
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Baaten CCFMJ, Vondenhoff S, Noels H. Endothelial Cell Dysfunction and Increased Cardiovascular Risk in Patients With Chronic Kidney Disease. Circ Res 2023; 132:970-992. [PMID: 37053275 PMCID: PMC10097498 DOI: 10.1161/circresaha.123.321752] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
The endothelium is considered to be the gatekeeper of the vessel wall, maintaining and regulating vascular integrity. In patients with chronic kidney disease, protective endothelial cell functions are impaired due to the proinflammatory, prothrombotic and uremic environment caused by the decline in kidney function, adding to the increase in cardiovascular complications in this vulnerable patient population. In this review, we discuss endothelial cell functioning in healthy conditions and the contribution of endothelial cell dysfunction to cardiovascular disease. Further, we summarize the phenotypic changes of the endothelium in chronic kidney disease patients and the relation of endothelial cell dysfunction to cardiovascular risk in chronic kidney disease. We also review the mechanisms that underlie endothelial changes in chronic kidney disease and consider potential pharmacological interventions that can ameliorate endothelial health.
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Affiliation(s)
- Constance C F M J Baaten
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen, Aachen, Germany (C.C.F.M.J.B., S.V., H.N.)
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands (C.C.F.M.J.B., H.N.)
| | - Sonja Vondenhoff
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen, Aachen, Germany (C.C.F.M.J.B., S.V., H.N.)
| | - Heidi Noels
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen, Aachen, Germany (C.C.F.M.J.B., S.V., H.N.)
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands (C.C.F.M.J.B., H.N.)
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23
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Li N, Wang Y, Wei P, Min Y, Yu M, Zhou G, Yuan G, Sun J, Dai H, Zhou E, He W, Sheng M, Gao K, Zheng M, Sun W, Zhou D, Zhang L. Causal Effects of Specific Gut Microbiota on Chronic Kidney Diseases and Renal Function-A Two-Sample Mendelian Randomization Study. Nutrients 2023; 15:nu15020360. [PMID: 36678231 PMCID: PMC9863044 DOI: 10.3390/nu15020360] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/02/2023] [Accepted: 01/05/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Targeting the gut microbiota may become a new therapeutic to prevent and delay the progression of chronic kidney disease (CKD). Nonetheless, the causal relationship between specific intestinal flora and CKD is still unclear. MATERIALS AND METHOD To identify genetically predicted microbiota, we used summary data from genome-wide association studies on gut microbiota in 18340 participants from 24 cohorts. Furthermore, we genetically predicted the causal relationship between 211 gut microbiotas and six phenotypes (outcomes) (CKD, estimated glomerular filtration rate (eGFR), urine albumin to creatinine ratio (UACR), dialysis, rapid progress to CKD, and rapid decline of eGFR). Four Mendelian randomization (MR) methods, including inverse variance weighted (IVW), MR-Egger, weighted median, and weighted mode were used to investigate the casual relationship between gut microbiotas and various outcomes. The result of IVW was deemed as the primary result. Then, Cochrane's Q test, MR-Egger, and MR-PRESSO Global test were used to detect heterogeneity and pleiotropy. The leave-one method was used for testing the stability of MR results and Bonferroni-corrected was used to test the strength of the causal relationship between exposure and outcome. RESULTS Through the MR analysis of 211 microbiotas and six clinical phenotypes, a total of 36 intestinal microflora were found to be associated with various outcomes. Among them, Class Bacteroidia (=-0.005, 95% CI: -0.001 to -0.008, p = 0.002) has a strong causality with lower eGFR after the Bonferroni-corrected test, whereas phylum Actinobacteria (OR = 1.0009, 95%CI: 1.0003-1.0015, p = 0.0024) has a strong causal relationship with dialysis. The Cochrane's Q test reveals that there is no significant heterogeneity between various single nucleotide polymorphisms. In addition, no significant level of pleiotropy was found according to MR-Egger and MR-PRESSO Global tests. CONCLUSIONS Through the two-sample MR analysis, we identified the specific intestinal flora that has a causal relationship with the incidence and progression of CKD at the level of gene prediction, which may provide helpful biomarkers for early disease diagnosis and potential therapeutic targets for CKD.
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Affiliation(s)
- Ning Li
- Division of Nephrology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Yi Wang
- Division of Nephrology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Ping Wei
- Division of Nephrology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Yu Min
- Department of Biotherapy and National Clinical Research Center, Sichuan University, Chengdu 610041, China
| | - Manshu Yu
- Division of Nephrology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Guowei Zhou
- Division of Nephrology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Gui Yuan
- Division of Nephrology, Department of Medicine, University of Connecticut, School of Medicine, Farmington, CT 06030, USA
| | - Jinyi Sun
- Division of Nephrology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Huibo Dai
- Division of Nephrology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Enchao Zhou
- Division of Nephrology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Weiming He
- Division of Nephrology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Meixiao Sheng
- Division of Nephrology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Kun Gao
- Division of Nephrology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Min Zheng
- Division of Nephrology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Wei Sun
- Division of Nephrology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
| | - Dong Zhou
- Division of Nephrology, Department of Medicine, University of Connecticut, School of Medicine, Farmington, CT 06030, USA
- Correspondence: (D.Z.); (L.Z.)
| | - Lu Zhang
- Division of Nephrology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China
- Correspondence: (D.Z.); (L.Z.)
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Liu S, Bian R, Qian Y, Liao H, Gao X, Zhang Y, Dong W. Catheter-based renal denervation in Chinese patients with chronic kidney disease and uncontrolled hypertension. J Clin Hypertens (Greenwich) 2022; 25:71-77. [PMID: 36478498 PMCID: PMC9832231 DOI: 10.1111/jch.14605] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/06/2022] [Accepted: 11/15/2022] [Indexed: 12/12/2022]
Abstract
Sympathetic activation contributes to the progression of hypertension and chronic kidney disease (CKD). Ablation of renal sympathetic nerves lowers blood pressure (BP) and preserves renal function in patients with CKD and uncontrolled hypertension by reducing sympathetic nerve activity. But whether this approach is safe and effective in Chinese patients with CKD is unknown. We performed an observational study of eight patients with CKD stages from 1 to 5, office BP ≥150/90 mmHg, while on at least three antihypertensive drug classes including a diuretic, and diagnosis confirmed by 24 h ambulatory systolic BP measurement ≥135 mmHg. All patients underwent catheter-based renal denervation (RDN) using a newly designed RDN System (Golden Leaf Medtech, Shanghai, China). For up to 6 months after RDN, BP was monitored and renal function was assessed. Mean baseline office BP was 165.0 ± 13.9/97.8 ± 5.5 mmHg, despite treatment with three antihypertensive drugs. Six months after RDN, office BP was reduced by 22.1 ± 12.0 (P = .002)/11.0 ± 8.8 mmHg (P = .012) and average 24 h ambulatory BP by 18 ± 13.7 (P = .01)/9.3 ± 7.7 mmHg (P = .016). After RDN, heart rate and estimated glomerular filtration rate (GFR) had no significant change compared with before RDN. In Chinese patients with CKD, our observational pilot study found that treating hypertension with RDN lowers BP while not affecting renal function. Brief Abstract: We performed RDN in eight Chinese patients with hypertension and CKD. The results showed that RDN lowered blood pressure of these patients significantly and eGFR was stable. No obvious adverse event was observed.
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Affiliation(s)
- Senyan Liu
- Department of NephrologyChangzheng HospitalNaval Medical UniversityShanghaiChina
| | - Rongrong Bian
- Department of NephrologyChangzheng HospitalNaval Medical UniversityShanghaiChina
| | - Yixin Qian
- Department of NephrologyChangzheng HospitalNaval Medical UniversityShanghaiChina
| | - Huaqiang Liao
- Department of Interventional MedicineChangzheng HospitalNaval Medical UniversityShanghaiChina
| | - Xiang Gao
- Department of NephrologyChangzheng HospitalNaval Medical UniversityShanghaiChina
| | - Yuqiang Zhang
- Department of NephrologyChangzheng HospitalNaval Medical UniversityShanghaiChina
| | - Weihua Dong
- Department of Interventional MedicineChangzheng HospitalNaval Medical UniversityShanghaiChina
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25
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Clemmer JS, Shafi T, Obi Y. Physiological Mechanisms of Hypertension and Cardiovascular Disease in End-Stage Kidney Disease. Curr Hypertens Rep 2022; 24:413-424. [PMID: 35708820 PMCID: PMC10041674 DOI: 10.1007/s11906-022-01203-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW In this article, we summarize recent advances in understanding hypertension and cardiovascular disease in patients with end-stage kidney disease. RECENT FINDINGS Factors such as anemia, valvular and vascular calcification, vasoconstrictors, uremic toxins, hypoglycemia, carbamylated proteins, oxidative stress, and inflammation have all been associated with the progression of cardiovascular disease in end-stage kidney disease but the causality of these mechanisms has not been proven. The high risk of cardiovascular mortality has not improved as in the general population despite many advancements in cardiovascular care over the last two decades. Mechanisms that increase hypertension risk in these patients are centered on the control of extracellular fluid volume; however, over-correction of volume with dialysis can increase risks of intradialytic hypotension and death in these patients. This review presents both recent and classic work that increases our understanding of hypertension and cardiovascular disease in end-stage kidney disease.
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Affiliation(s)
- John S Clemmer
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS, USA
| | - Tariq Shafi
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS, USA.,Division of Nephrology, University of Mississippi Medical Center, 2500 North State Street, Suite L-504, Jackson, MS, 39216, USA
| | - Yoshitsugu Obi
- Division of Nephrology, University of Mississippi Medical Center, 2500 North State Street, Suite L-504, Jackson, MS, 39216, USA.
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26
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Epidemiology and risk of cardiovascular disease in populations with chronic kidney disease. Nat Rev Nephrol 2022; 18:696-707. [DOI: 10.1038/s41581-022-00616-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2022] [Indexed: 11/08/2022]
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27
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Alexandrou ME, Ferro CJ, Boletis I, Papagianni A, Sarafidis P. Hypertension in kidney transplant recipients. World J Transplant 2022; 12:211-222. [PMID: 36159073 PMCID: PMC9453294 DOI: 10.5500/wjt.v12.i8.211] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/07/2022] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
Kidney transplantation is considered the treatment of choice for end-stage kidney disease patients. However, the residual cardiovascular risk remains significantly higher in kidney transplant recipients (KTRs) than in the general population. Hypertension is highly prevalent in KTRs and represents a major modifiable risk factor associated with adverse cardiovascular outcomes and reduced patient and graft survival. Proper definition of hypertension and recognition of special phenotypes and abnormal diurnal blood pressure (BP) patterns is crucial for adequate BP control. Misclassification by office BP is commonly encountered in these patients, and a high proportion of masked and uncontrolled hypertension, as well as of white-coat hypertension, has been revealed in these patients with the use of ambulatory BP monitoring. The pathophysiology of hypertension in KTRs is multifactorial, involving traditional risk factors, factors related to chronic kidney disease and factors related to the transplantation procedure. In the absence of evidence from large-scale randomized controlled trials in this population, BP targets for hypertension management in KTR have been extrapolated from chronic kidney disease populations. The most recent Kidney Disease Improving Global Outcomes 2021 guidelines recommend lowering BP to less than 130/80 mmHg using standardized BP office measurements. Dihydropyridine calcium channel blockers and angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers have been established as the preferred first-line agents, on the basis of emphasis placed on their favorable outcomes on graft survival. The aim of this review is to provide previous and recent evidence on prevalence, accurate diagnosis, pathophysiology and treatment of hypertension in KTRs.
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Affiliation(s)
- Maria-Eleni Alexandrou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WB, United Kingdom
| | - Ioannis Boletis
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens 11527, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
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28
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Renalase: a novel regulator of cardiometabolic and renal diseases. Hypertens Res 2022; 45:1582-1598. [PMID: 35941358 PMCID: PMC9358379 DOI: 10.1038/s41440-022-00986-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/26/2022] [Accepted: 06/05/2022] [Indexed: 11/13/2022]
Abstract
Renalase is a ~38 kDa flavin-adenine dinucleotide (FAD) domain-containing protein that can function as a cytokine and an anomerase. It is emerging as a novel regulator of cardiometabolic diseases. Expressed mainly in the kidneys, renalase has been reported to have a hypotensive effect and may control blood pressure through regulation of sympathetic tone. Furthermore, genetic variations in the renalase gene, such as a functional missense polymorphism (Glu37Asp), have implications in the cardiovascular and renal systems and can potentially increase the risk of cardiometabolic disorders. Research on the physiological functions and biochemical actions of renalase over the years has indicated a role for renalase as one of the key proteins involved in various disease states, such as diabetes, impaired lipid metabolism, and cancer. Recent studies have identified three transcription factors (viz., Sp1, STAT3, and ZBP89) as key positive regulators in modulating the expression of the human renalase gene. Moreover, renalase is under the post-transcriptional regulation of two microRNAs (viz., miR-29b, and miR-146a), which downregulate renalase expression. While renalase supplementation may be useful for treating hypertension, inhibition of renalase signaling may be beneficial to patients with cancerous tumors. However, more incisive investigations are required to unravel the potential therapeutic applications of renalase. Based on the literature pertaining to the function and physiology of renalase, this review attempts to consolidate and comprehend the role of renalase in regulating cardiometabolic and renal disorders. ![]()
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29
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D’Elia JA, Bayliss GP, Weinrauch LA. The Diabetic Cardiorenal Nexus. Int J Mol Sci 2022; 23:ijms23137351. [PMID: 35806355 PMCID: PMC9266839 DOI: 10.3390/ijms23137351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/24/2022] [Accepted: 06/25/2022] [Indexed: 12/10/2022] Open
Abstract
The end-stage of the clinical combination of heart failure and kidney disease has become known as cardiorenal syndrome. Adverse consequences related to diabetes, hyperlipidemia, obesity, hypertension and renal impairment on cardiovascular function, morbidity and mortality are well known. Guidelines for the treatment of these risk factors have led to the improved prognosis of patients with coronary artery disease and reduced ejection fraction. Heart failure hospital admissions and readmission often occur, however, in the presence of metabolic, renal dysfunction and relatively preserved systolic function. In this domain, few advances have been described. Diabetes, kidney and cardiac dysfunction act synergistically to magnify healthcare costs. Current therapy relies on improving hemodynamic factors destructive to both the heart and kidney. We consider that additional hemodynamic solutions may be limited without the use of animal models focusing on the cardiomyocyte, nephron and extracellular matrices. We review herein potential common pathophysiologic targets for treatment to prevent and ameliorate this syndrome.
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Affiliation(s)
- John A. D’Elia
- Kidney and Hypertension Section, E P Joslin Research Laboratory, Joslin Diabetes Center, Boston, MA 02215, USA
| | - George P. Bayliss
- Division of Organ Transplantation, Rhode Island Hospital, Providence, RI 02903, USA;
| | - Larry A. Weinrauch
- Kidney and Hypertension Section, E P Joslin Research Laboratory, Joslin Diabetes Center, Boston, MA 02215, USA
- Correspondence: ; Tel.: +617-923-0800; Fax: +617-926-5665
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30
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Wu LL, Zhang Y, Li XZ, Du XL, Gao Y, Wang JX, Wang XL, Chen Q, Li YH, Zhu GQ, Tan X. Impact of Selective Renal Afferent Denervation on Oxidative Stress and Vascular Remodeling in Spontaneously Hypertensive Rats. Antioxidants (Basel) 2022; 11:1003. [PMID: 35624870 PMCID: PMC9137540 DOI: 10.3390/antiox11051003] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/15/2022] [Accepted: 05/18/2022] [Indexed: 02/01/2023] Open
Abstract
Oxidative stress and sustained sympathetic over-activity contribute to the pathogenesis of hypertension. Catheter-based renal denervation has been used as a strategy for treatment of resistant hypertension, which interrupts both afferent and efferent renal fibers. However, it is unknown whether selective renal afferent denervation (RAD) may play beneficial roles in attenuating oxidative stress and sympathetic activity in hypertension. This study investigated the impact of selective RAD on hypertension and vascular remodeling. Nine-week-old normotensive Wistar-Kyoto rats (WKY) and spontaneously hypertensive rats (SHR) were subjected to selective renal afferent denervation (RAD) with 33 mM of capsaicin for 15 min. Treatment with the vehicle of capsaicin was used as a control. The selective denervation was confirmed by the reduced calcitonin gene-related peptide expression and the undamaged renal sympathetic nerve activity response to the stimulation of adipose white tissue. Selective RAD reduced plasma norepinephrine levels, improved heart rate variability (HRV) and attenuated hypertension in SHR.It reduced NADPH oxidase (NOX) expression and activity, and superoxide production in the hypothalamic paraventricular nucleus (PVN), aorta and mesenteric artery of SHR. Moreover, the selective RAD attenuated the vascular remodeling of the aorta and mesenteric artery of SHR. These results indicate that selective removal of renal afferents attenuates sympathetic activity, oxidative stress, vascular remodeling and hypertension in SHR. The attenuated superoxide signaling in the PVN is involved in the attenuation of sympathetic activity in SHR, and the reduced sympathetic activity at least partially contributes to the attenuation of vascular oxidative stress and remodeling in the arteries of hypertensive rats.
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Affiliation(s)
- Lu-Lu Wu
- Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center of Translational Medicine for Cardiovascular Disease, and Department of Physiology, Nanjing Medical University, Nanjing 211166, China; (L.-L.W.); (J.-X.W.); (X.-L.W.)
| | - Yue Zhang
- Emergency Department, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 211166, China; (Y.Z.); (X.-Z.L.); (X.-L.D.); (Y.G.)
| | - Xiu-Zhen Li
- Emergency Department, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 211166, China; (Y.Z.); (X.-Z.L.); (X.-L.D.); (Y.G.)
| | - Xin-Li Du
- Emergency Department, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 211166, China; (Y.Z.); (X.-Z.L.); (X.-L.D.); (Y.G.)
| | - Ying Gao
- Emergency Department, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 211166, China; (Y.Z.); (X.-Z.L.); (X.-L.D.); (Y.G.)
| | - Jing-Xiao Wang
- Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center of Translational Medicine for Cardiovascular Disease, and Department of Physiology, Nanjing Medical University, Nanjing 211166, China; (L.-L.W.); (J.-X.W.); (X.-L.W.)
| | - Xiao-Li Wang
- Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center of Translational Medicine for Cardiovascular Disease, and Department of Physiology, Nanjing Medical University, Nanjing 211166, China; (L.-L.W.); (J.-X.W.); (X.-L.W.)
| | - Qi Chen
- Department of Pathophysiology, Nanjing Medical University, Nanjing 211166, China; (Q.C.); (Y.-H.L.)
| | - Yue-Hua Li
- Department of Pathophysiology, Nanjing Medical University, Nanjing 211166, China; (Q.C.); (Y.-H.L.)
| | - Guo-Qing Zhu
- Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center of Translational Medicine for Cardiovascular Disease, and Department of Physiology, Nanjing Medical University, Nanjing 211166, China; (L.-L.W.); (J.-X.W.); (X.-L.W.)
| | - Xiao Tan
- Emergency Department, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 211166, China; (Y.Z.); (X.-Z.L.); (X.-L.D.); (Y.G.)
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31
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Zhang Y, Wang J, Xing Y, Cui C, Cheng H, Chen Z, Chen H, Liu C, Wang N, Chen M. Dynamics of Cardiac Autonomic Responses During Hemodialysis Measured by Heart Rate Variability and Skin Sympathetic Nerve Activity: The Impact of Interdialytic Weight Gain. Front Physiol 2022; 13:890536. [PMID: 35651871 PMCID: PMC9149205 DOI: 10.3389/fphys.2022.890536] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/20/2022] [Indexed: 01/08/2023] Open
Abstract
Background: Autonomic nervous regulation plays a critical role in end-stage kidney disease (ESKD) patients with cardiovascular complications. However, studies on autonomic regulation in ESKD patients are limited to heart rate variability (HRV) analysis. Skin sympathetic nerve activity (SKNA), which noninvasively reflects the sympathetic nerve activity, has not been used in ESKD patients.Methods: Seventy-six patients on maintenance hemodialysis (MHD) treatment (a 4-h HD session, three times a week) were enrolled. Utilizing a noninvasive, single-lead, high-frequency recording system, we analyzed the dynamic change in HRV parameters and SKNA during HD. The different characteristics between the subgroups divided based on interdialytic weight gain (IDWG, <3 kg or ≥3 kg) were also demonstrated.Results: After the HD, values for heart rate (75.1 ± 11.3 to 80.3 ± 12.3 bpm, p < 0.001) and LF/HF (1.92 ± 1.67 to 2.18 ± 2.17, p = 0.013) were significantly higher than baseline. In subgroup analysis, average voltage of skin sympathetic nerve activity (aSKNA) in IDWG ≥3 kg group was lower than the IDWG <3 kg group at the end of MHD (1.06 ± 0.30 vs 1.32 ± 0.61 μV, p = 0.046). Moreover, there was a linear correlation between mean heart rate (HR) and aSKNA in low IDWG patients (p < 0.001), which was not found in high IDWG patients. At the 1-year follow-up, high IDWG patients had a higher incidence of cardiovascular hospitalization (p = 0.046).Conclusions: In MHD patients, a gradual activation of sympathetic nerve activity could be measured by HRV and aSKNA. A lower aSKNA at the end of HD and a loss of HR-aSKNA correlation in overhydrated patients were observed. Extensive volume control is promising to improve the autonomic nervous function and clinical outcomes in this population.
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Affiliation(s)
- Yike Zhang
- Division of Cardiology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Wang
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yantao Xing
- School of Instrument Science and Engineering, Southeast University, Nanjing, China
| | - Chang Cui
- Division of Cardiology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongyi Cheng
- Division of Cardiology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhenye Chen
- Division of Cardiology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongwu Chen
- Division of Cardiology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chengyu Liu
- School of Instrument Science and Engineering, Southeast University, Nanjing, China
| | - Ningning Wang
- Department of Nephrology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Ningning Wang, ; Minglong Chen,
| | - Minglong Chen
- Division of Cardiology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Ningning Wang, ; Minglong Chen,
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32
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Evaluation of cardiovascular risk in children with solitary functioning kidney. Clin Exp Nephrol 2022; 26:415-423. [PMID: 35037126 DOI: 10.1007/s10157-021-02169-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 12/05/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The present study investigates cardiovascular risk and kidney damage in patients with solitary kidneys. METHODS Included in the study were 40 children with a unilateral functioning kidney and 60 healthy controls, all of whom were evaluated for carotid intima-media thickness, ischemia-modified albumin and oxidative stress parameters, and 24-h ambulatory blood pressure monitoring. RESULTS Serum creatinine and urine microalbumin levels were higher and creatinine clearance was lower in the patient group than in the control group, and serum ischemia-modified albumin, carotid intima-media thickness, aldosterone, plasma renin activity and blood pressure were all higher in the patient group than in the control group. In addition, the patient group was showed a non-dipper pattern. CONCLUSION Children with a normal functioning solitary kidney are likely at higher risk of developing cardiovascular disease and such patients should be followed closely before marked kidney impairment occurs.
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33
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Nolde JM, Lugo-Gavidia LM, Carnagarin R, Azzam O, Kiuchi MG, Mian A, Schlaich MP. K-means panning - Developing a new standard in automated MSNA signal recognition with a weakly supervised learning approach. Comput Biol Med 2022; 140:105087. [PMID: 34864300 DOI: 10.1016/j.compbiomed.2021.105087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/15/2021] [Accepted: 11/25/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Accessibility of labelled datasets is often a key limitation for the application of Machine Learning in clinical research. A novel semi-automated weak-labelling approach based on unsupervised clustering was developed to classify a large dataset of microneurography signals and subsequently used to train a Neural Network to reproduce the labelling process. METHODS Clusters of microneurography signals were created with k-means and then labelled in terms of the validity of the signals contained in each cluster. Only purely positive or negative clusters were labelled, whereas clusters with mixed content were passed on to the next iteration of the algorithm to undergo another cycle of unsupervised clustering and labelling of the clusters. After several iterations of this process, only pure labelled clusters remained which were used to train a Deep Neural Network. RESULTS Overall, 334,548 individual signal peaks form the integrated data were extracted and more than 99.99% of the data was labelled in six iterations of this novel application of weak labelling with the help of a domain expert. A Deep Neural Network trained based on this dataset achieved consistent accuracies above 95%. DISCUSSION Data extraction and the novel iterative approach of labelling unsupervised clusters enabled creation of a large, labelled dataset combining unsupervised learning and expert ratings of signal-peaks on cluster basis in a time effective manner. Further research is needed to validate the methodology and employ it on other types of physiologic data for which it may enable efficient generation of large labelled datasets.
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Affiliation(s)
- Janis M Nolde
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit / Royal Perth Hospital Medical Research Foundation, University of Western Australia, Perth, Australia
| | - Leslie Marisol Lugo-Gavidia
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit / Royal Perth Hospital Medical Research Foundation, University of Western Australia, Perth, Australia
| | - Revathy Carnagarin
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit / Royal Perth Hospital Medical Research Foundation, University of Western Australia, Perth, Australia
| | - Omar Azzam
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit / Royal Perth Hospital Medical Research Foundation, University of Western Australia, Perth, Australia
| | - Márcio Galindo Kiuchi
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit / Royal Perth Hospital Medical Research Foundation, University of Western Australia, Perth, Australia
| | - Ajmal Mian
- School of Computer Science and Software Engineering, The University of Western Australia, Perth, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit / Royal Perth Hospital Medical Research Foundation, University of Western Australia, Perth, Australia; Department of Cardiology and Nephrology, Royal Perth Hospital, Perth, Australia; Department of Nephrology, Royal Perth Hospital, Perth, Australia; Neurovascular Hypertension & Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia.
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Cooley AJ, Savage A, Snowdon CT. Vascular, cardiac, and renal lesions attributed to primary systemic hypertension in western pygmy marmosets ( Cebuella pygmaea). Vet Pathol 2021; 59:358-370. [PMID: 34872391 DOI: 10.1177/03009858211052664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In a retrospective study of a western pygmy marmoset (Cebuella pygmaea) colony, postmortem examination of 1/8 juvenile and 29/47 adult animals identified vascular, cardiac, and renal lesions consistent with systemic hypertension. This included frequent renal arteriolar hypertrophy, hyaline and proliferative arteriolosclerosis, fibrinoid necrosis of arterioles, glomerulosclerosis, and nephrosclerosis. Affected animals ranged from 0.6 to 12 years of age (mean 6 years) and had an observed male predominance. Genealogical relatedness was evident in several breeding pairs and spanned multiple generations. Concurrent cardiac and renal disease was commonly identified, although frequently subclinical, and both were important causes of morbidity and mortality in affected animals. Cardiomegaly and hypertrophy were typical features and were accompanied by left atrial thrombosis in 10 animals. Signs of heart failure included chronic pulmonary edema in 20 cases and body cavity effusions in 17. In the kidneys, 19 cases had glomerular disease and hypertensive vasculopathy, and 26 cases had nephrosclerosis or glomerulosclerosis. Common extrarenal secondary causes of hypertension were excluded by necropsy examination. The pathogenesis is suggested to involve primary hypertension leading to renal and cardiac disease. Elevated sympathetic activity might be an underlying factor in the frequent development of primary systemic hypertension in the pygmy marmoset, as for the owl monkey.
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Vergaro G, Aimo A, Campora A, Castiglione V, Prontera C, Masotti S, Musetti V, Chianca M, Valleggi A, Spini V, Emdin M, Passino C. Patients with cardiac amyloidosis have a greater neurohormonal activation than those with non-amyloidotic heart failure. Amyloid 2021; 28:252-258. [PMID: 34396857 DOI: 10.1080/13506129.2021.1966624] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Neurohormonal activation has never been investigated in patients with cardiac amyloidosis (CA). METHODS Forty-seven patients with amyloid light-chain (AL)-CA and 61 with transthyretin (ATTR)-CA were matched to non-amyloidotic heart failure (HF) patients based on age, sex, left ventricular ejection fraction ranges, renal function and HF therapies. N-terminal pro-B-type natriuretic peptide (NT-proBNP), norepinephrine and renin were dosed. The primary and secondary endpoints were 1-year cardiovascular death or HF hospitalisation, and 5-year cardiovascular death, respectively. RESULTS Patients with AL-CA had a 10-fold higher NT-proBNP than HF patients (6548 ng/L [2059-15,097] vs. 692 [243-2241], p < 0.001), and slightly higher norepinephrine (595 ng/L [383-869] vs. 416 [250-693], p = 0.047). Patients with ATTR-CA had higher NT-proBNP (3984 ng/L [2275-9505] vs. 1751 [470-4768], p = 0.006), norepinephrine (552 ng/L [344-855] vs. 441 [323-601], p = 0.020), and renin (14 mU/L [8-80] vs. 10 [4-34], p = 0.017). Patients with AL- or ATTR-CA had more often 2 or 3 neurohormones above the corresponding upper reference limits than matched HF patients. NT-proBNP and aldosterone were univariate predictors of the primary endpoint in patients with ATTR-CA, but not in matched controls. NT-proBNP and renin predicted the secondary endpoint in patients with AL-CA, but not in matched controls. CONCLUSIONS Patients with CA display a neurohormonal activation, with some prognostic significance.
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Affiliation(s)
- Giuseppe Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | | | - Concetta Prontera
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Silvia Masotti
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Veronica Musetti
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michela Chianca
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - Valentina Spini
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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36
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Loutradis C, Sarafidis P, Marinaki S, Berry M, Borrows R, Sharif A, Ferro CJ. Role of hypertension in kidney transplant recipients. J Hum Hypertens 2021; 35:958-969. [PMID: 33947943 DOI: 10.1038/s41371-021-00540-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/24/2021] [Accepted: 04/09/2021] [Indexed: 02/03/2023]
Abstract
Cardiovascular events are one of the leading causes of mortality in kidney transplant recipients. Hypertension is the most common comorbidity accompanying chronic kidney disease, with prevalence remaining as high as 90% even after kidney transplantation. It is often poorly controlled. Abnormal blood pressure profiles, such as masked or white-coat hypertension, are also extremely common in these patients. The pathophysiology of blood pressure elevation in kidney transplant recipients is complex and includes transplantation-specific risk factors, which are added to the traditional or chronic kidney disease-related factors. Despite these observations, hypertension management has been an under-researched area in kidney transplantation. Thus, relevant evidence derives either from studies in the general population or from small trials in kidney transplant recipients. Based on the relevant guidelines in the general population, lifestyle modifications should probably be applied as the first step of hypertension management in kidney transplant recipients. The optimal pharmacological management of hypertension in kidney transplant recipients is also not clear. Dihydropyridine calcium channel blockers are commonly used as first line agents because of their lack of adverse effects on the kidney, while other antihypertensive drug classes are under-utilised due to fear of the possible haemodynamic consequences on renal function. This review summarizes the existing data on the pathophysiology, diagnosis, prognostic significance and management of hypertension in kidney transplantation.
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Affiliation(s)
- Charalampos Loutradis
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK.,Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Smaragdi Marinaki
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens, Greece
| | - Miriam Berry
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
| | - Richard Borrows
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
| | - Adnan Sharif
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK. .,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.
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Zoccali C, Ortiz A, Blumbyte IA, Rudolf S, Beck-Sickinger AG, Malyszko J, Spasovski G, Carriazo S, Viggiano D, Kurganaite J, Sarkeviciene V, Rastenyte D, Figurek A, Rroji M, Mayer C, Arici M, Martino G, Tedeschi G, Bruchfeld A, Spoto B, Rychlik I, Wiecek A, Okusa M, Remuzzi G, Mallamaci F. Neuropeptide Y as a risk factor for cardiorenal disease and cognitive dysfunction in CKD: translational opportunities and challenges. Nephrol Dial Transplant 2021; 37:ii14-ii23. [PMID: 34724060 PMCID: PMC8713155 DOI: 10.1093/ndt/gfab284] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
Neuropeptide Y (NPY) is a 36-amino-acid peptide member of a family also including peptide YY and pancreatic polypeptide, which are all ligands to Gi/Go coupled receptors. NPY regulates several fundamental biologic functions including appetite/satiety, sex and reproduction, learning and memory, cardiovascular and renal function and immune functions. The mesenteric circulation is a major source of NPY in the blood in man and this peptide is considered a key regulator of gut–brain cross talk. A progressive increase in circulating NPY accompanies the progression of chronic kidney disease (CKD) toward kidney failure and NPY robustly predicts cardiovascular events in this population. Furthermore, NPY is suspected as a possible player in accelerated cognitive function decline and dementia in patients with CKD and in dialysis patients. In theory, interfering with the NPY system has relevant potential for the treatment of diverse diseases from cardiovascular and renal diseases to diseases of the central nervous system. Pharmaceutical formulations for effective drug delivery and cost, as well as the complexity of diseases potentially addressable by NPY/NPY antagonists, have been a problem until now. This in part explains the slow progress of knowledge about the NPY system in the clinical arena. There is now renewed research interest in the NPY system in psychopharmacology and in pharmacology in general and new studies and a new breed of clinical trials may eventually bring the expected benefits in human health with drugs interfering with this system.
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Affiliation(s)
- Carmine Zoccali
- Renal Research Institute, New York,USA and Associazione Ipertensione Nefrologia Trapianto Renale (IPNET) Reggio Cal., Italy c/o CNR-IFC, Ospedali Riuniti, Reggio Calabria, Italy
| | - Alberto Ortiz
- Institute of Biochemistry, Leipzig University, Faculty of Life Sciences, Leipzig, Germany
| | - Inga Arune Blumbyte
- Lithuanian University of Health Sciences, Nephrology Department, Kaunas, Lithuania
| | - Sarina Rudolf
- Institute of Biochemistry, Leipzig University, Faculty of Life Sciences, Leipzig, Germany
| | | | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Warsaw, Poland
| | - Goce Spasovski
- Department of Nephrology, University "Sts. Cyril and Methodius", Skopje, MK, Republic of Macedonia
| | - Sol Carriazo
- Institute of Biochemistry, Leipzig University, Faculty of Life Sciences, Leipzig, Germany
| | - Davide Viggiano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy. and Biogem Scarl, Ariano Irpino, Italy
| | - Justina Kurganaite
- Lithuanian University of Health Sciences, Nephrology Department, Kaunas, Lithuania
| | - Vaiva Sarkeviciene
- Lithuanian University of Health Sciences, Nephrology Department, Kaunas, Lithuania
| | - Daiva Rastenyte
- Lithuanian University of Health Sciences, Neurology Department, Kaunas, Lithuania
| | - Andreja Figurek
- Department of Nephrology, University "Sts. Cyril and Methodius", Skopje, MK, Republic of Macedonia
| | - Merita Rroji
- Department of Nephrology, University "Sts. Cyril and Methodius", Skopje, MK, Republic of Macedonia
| | - Christopher Mayer
- Health and Bioresources, Biomedical Systems, Austrian Institute of Technology, Vienna, Austria
| | - Mustapha Arici
- Department of Nephrology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Gianvito Martino
- Neurology Department, San Raffaele Scientific Institute and Vita-Salute University San Raffaele, Milan, Italy
| | - Gioacchino Tedeschi
- Department of Advanced Medical and Surgical Sciences, and 3T-MRI Research Center, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Annette Bruchfeld
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden and Department of Renal Medicine, CLINTEC Karolinska Institutet, Stockholm, Sweden
| | | | - Ivan Rychlik
- Department of Medicine, Third Faculty of Medicine, Charles University and Faculty Hospital Kralovske Vinohrady,Prague, Czech Republic
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Katowice, Poland
| | - Mark Okusa
- Division of Nephrology and Center for Immunity, Inflammation, and Regenerative Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Aldo & Cele Daccò Clinical Research Center for Rare Diseases, Bergamo, Italy
| | - Francesca Mallamaci
- Nephrology and Transplantation Unit, Grande Ospedale Metropolitano and CNR-IFC, Reggio Cal, Italy
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Chavda V, Chaurasia B, Deora H, Umana GE. Chronic Kidney disease and stroke: A Bi-directional risk cascade and therapeutic update. BRAIN DISORDERS 2021. [DOI: 10.1016/j.dscb.2021.100017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
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Salusin-β in Intermediate Dorsal Motor Nucleus of the Vagus Regulates Sympathetic-Parasympathetic Balance and Blood Pressure. Biomedicines 2021; 9:biomedicines9091118. [PMID: 34572305 PMCID: PMC8467440 DOI: 10.3390/biomedicines9091118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/22/2021] [Accepted: 08/24/2021] [Indexed: 12/20/2022] Open
Abstract
The dorsal motor nucleus of the vagus (DMV) is known to control vagal activity. It is unknown whether the DMV regulates sympathetic activity and whether salusin-β in the DMV contributes to autonomic nervous activity. We investigated the roles of salusin-β in DMV in regulating sympathetic-parasympathetic balance and its underline mechanisms. Microinjections were carried out in the DMV and hypothalamic paraventricular nucleus (PVN) in male adult anesthetized rats. Renal sympathetic nerve activity (RSNA), blood pressure and heart rate were recorded. Immunohistochemistry for salusin-β and reactive oxidative species (ROS) production in the DMV were examined. Salusin-β was expressed in the intermediate DMV (iDMV). Salusin-β in the iDMV not only inhibited RSNA but also enhanced vagal activity and thereby reduced blood pressure and heart rate. The roles of salusin-β in causing vagal activation were mediated by NAD(P)H oxidase-dependent superoxide anion production in the iDMV. The roles of salusin-β in inhibiting RSNA were mediated by not only the NAD(P)H oxidase-originated superoxide anion production in the iDMV but also the γ-aminobutyric acid (GABA)A receptor activation in PVN. Moreover, endogenous salusin-β and ROS production in the iDMV play a tonic role in inhibiting RSNA. These results indicate that salusin-β in the iDMV inhibits sympathetic activity and enhances vagal activity, and thereby reduces blood pressure and heart rate, which are mediated by NAD(P)H oxidase-dependent ROS production in the iDMV. Moreover, GABAA receptor in the PVN mediates the effect of salusin-β on sympathetic inhibition. Endogenous salusin-β and ROS production in the iDMV play a tonic role in inhibiting sympathetic activity.
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40
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Nolde JM, Marisol Lugo‐Gavidia L, Carnagarin R, Azzam O, Galindo Kiuchi M, Mian A, Schlaich MP. Machine learning powered tools for automated analysis of muscle sympathetic nerve activity recordings. Physiol Rep 2021; 9:e14996. [PMID: 34427381 PMCID: PMC8383713 DOI: 10.14814/phy2.14996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/07/2021] [Accepted: 07/10/2021] [Indexed: 01/04/2023] Open
Abstract
Automated analysis and quantification of physiological signals in clinical practice and medical research can reduce manual labor, increase efficiency, and provide more objective, reproducible results. To build a novel platform for the analysis of muscle sympathetic nerve activity (MSNA), we employed state-of-the-art data processing and machine learning applications. Data processing methods for integrated MSNA recordings were developed to evaluate signals regarding the overall quality of the signal, the validity of individual signal peaks regarding the potential to be MSNA bursts and the timing of their occurrence. An overall probability score was derived from this flexible platform to evaluate each individual signal peak automatically. Overall, three deep neural networks were designed and trained to validate individual signal peaks randomly sampled from recordings representing only electrical noise and valid microneurography recordings. A novel data processing method for the whole signal was developed to differentiate between periods of valid MSNA signal recordings and periods in which the signal was not available or lost due to involuntary movement of the recording electrode. A probabilistic model for timing of the signal bursts was implemented as part of the system. Machine Learning algorithms and data processing tools were implemented to replicate the complex decision-making process of manual MSNA analysis. Validation of manual MSNA analysis including intra- and inter-rater validity and a comparison with automated MSNA tools is required. The developed toolbox for automated MSNA analysis can be extended in a flexible way to include algorithms based on other datasets.
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Affiliation(s)
- Janis M. Nolde
- Dobney Hypertension CentreSchool of Medicine ‐ Royal Perth Hospital Research FoundationFaculty of MedicineDentistry & Health SciencesThe University of Western AustraliaPerthAustralia
| | - Leslie Marisol Lugo‐Gavidia
- Dobney Hypertension CentreSchool of Medicine ‐ Royal Perth Hospital Research FoundationFaculty of MedicineDentistry & Health SciencesThe University of Western AustraliaPerthAustralia
| | - Revathy Carnagarin
- Dobney Hypertension CentreSchool of Medicine ‐ Royal Perth Hospital Research FoundationFaculty of MedicineDentistry & Health SciencesThe University of Western AustraliaPerthAustralia
| | - Omar Azzam
- Dobney Hypertension CentreSchool of Medicine ‐ Royal Perth Hospital Research FoundationFaculty of MedicineDentistry & Health SciencesThe University of Western AustraliaPerthAustralia
| | - Márcio Galindo Kiuchi
- Dobney Hypertension CentreSchool of Medicine ‐ Royal Perth Hospital Research FoundationFaculty of MedicineDentistry & Health SciencesThe University of Western AustraliaPerthAustralia
| | - Ajmal Mian
- School of Computer Science and Software EngineeringThe University of Western AustraliaPerthAustralia
| | - Markus P. Schlaich
- Dobney Hypertension CentreSchool of Medicine ‐ Royal Perth Hospital Research FoundationFaculty of MedicineDentistry & Health SciencesThe University of Western AustraliaPerthAustralia
- Departments of Cardiology and NephrologyRoyal Perth HospitalPerthAustralia
- Neurovascular Hypertension & Kidney Disease LaboratoryBaker Heart and Diabetes InstituteMelbourneAustralia
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Albakr RB, Bargman JM. A Comparison of Hemodialysis and Peritoneal Dialysis in Patients with Cardiovascular Disease. Cardiol Clin 2021; 39:447-453. [PMID: 34247757 DOI: 10.1016/j.ccl.2021.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The high prevalence of cardiovascular disease is caused by the traditional cardiovascular risk factors common among end-stage renal disease patients, and nontraditional risk factors attributed to underlying kidney disease, including chronic inflammation, anemia, bone mineral disease, and the dialysis procedure itself. Individualization of the treatment of cardiovascular disease in end-stage renal disease that could impact the underlying mechanisms of the cardiovascular diseases is important to improve outcomes. This article reviews and compares hemodialysis and peritoneal dialysis in association with different cardiovascular diseases affecting dialysis patients, including hypertension, coronary artery disease, myocardial stunning, cardiac arrhythmias, heart failure, and the cardiorenal syndrome.
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Affiliation(s)
- Rehab B Albakr
- Division of Nephrology, University of Toronto, University Health Network, 200 Elizabeth Street 8N-840, Toronto, ON M5G 2C4, Canada; Division of Nephrology, College of Medicine, King Saud University, King Khalid Street, Riyadh-Al-Diriyah 12372, Saudi Arabia
| | - Joanne M Bargman
- Division of Nephrology, University of Toronto, University Health Network/Toronto General Hospital, 200 Elizabeth Street, 8N-840, Toronto, Ontario M5G 2C4, Canada.
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42
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Possible Preventative/Rehabilitative Role of Gliflozins in OSA and T2DM. A Systematic Literature Review-Based Hypothesis. Adv Ther 2021; 38:4195-4214. [PMID: 34273093 PMCID: PMC8342338 DOI: 10.1007/s12325-021-01791-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/13/2021] [Indexed: 02/07/2023]
Abstract
Obstructive sleep apnoea (OSA) is characterized by frequent apnoea episodes during sleep due to upper airway obstruction. The present review summarizes current knowledge on inter-relationships between OSA and type 2 diabetes mellitus (T2DM) and suggests the former as a possible target for sodium-glucose co-transporter-2 inhibitors (SGLT-2i). Based on pathophysiological mechanisms underlying OSA onset and renal SGLT-2 effects, we suggest that SGLT-2i indications might expand beyond current ones, including glucose, lipids, uric acid, blood pressure, and body weight control as well as chronic heart failure and kidney disease prevention.
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43
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Archer M, Dogra N, Dovey Z, Ganta T, Jang HS, Khusid JA, Lantz A, Mihalopoulos M, Stockert JA, Zahalka A, Björnebo L, Gaglani S, Noh MR, Kaplan SA, Mehrazin R, Badani KK, Wiklund P, Tsao K, Lundon DJ, Mohamed N, Lucien F, Padanilam B, Gupta M, Tewari AK, Kyprianou N. Role of α- and β-adrenergic signaling in phenotypic targeting: significance in benign and malignant urologic disease. Cell Commun Signal 2021; 19:78. [PMID: 34284799 PMCID: PMC8290582 DOI: 10.1186/s12964-021-00755-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/28/2021] [Indexed: 01/17/2023] Open
Abstract
The urinary tract is highly innervated by autonomic nerves which are essential in urinary tract development, the production of growth factors, and the control of homeostasis. These neural signals may become dysregulated in several genitourinary (GU) disease states, both benign and malignant. Accordingly, the autonomic nervous system is a therapeutic target for several genitourinary pathologies including cancer, voiding dysfunction, and obstructing nephrolithiasis. Adrenergic receptors (adrenoceptors) are G-Protein coupled-receptors that are distributed throughout the body. The major function of α1-adrenoceptors is signaling smooth muscle contractions through GPCR and intracellular calcium influx. Pharmacologic intervention of α-and β-adrenoceptors is routinely and successfully implemented in the treatment of benign urologic illnesses, through the use of α-adrenoceptor antagonists. Furthermore, cell-based evidence recently established the antitumor effect of α1-adrenoceptor antagonists in prostate, bladder and renal tumors by reducing neovascularity and impairing growth within the tumor microenvironment via regulation of the phenotypic epithelial-mesenchymal transition (EMT). There has been a significant focus on repurposing the routinely used, Food and Drug Administration-approved α1-adrenoceptor antagonists to inhibit GU tumor growth and angiogenesis in patients with advanced prostate, bladder, and renal cancer. In this review we discuss the current evidence on (a) the signaling events of the autonomic nervous system mediated by its cognate α- and β-adrenoceptors in regulating the phenotypic landscape (EMT) of genitourinary organs; and (b) the therapeutic significance of targeting this signaling pathway in benign and malignant urologic disease. Video abstract.
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Affiliation(s)
- M. Archer
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
| | - N. Dogra
- Department of Pathology and Molecular and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Z. Dovey
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
| | - T. Ganta
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Division of Hematology and Medical Oncology, Mount Sinai Hospital, New York, NY USA
| | - H.-S. Jang
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
| | - J. A. Khusid
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
| | - A. Lantz
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - M. Mihalopoulos
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - J. A. Stockert
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
| | - A. Zahalka
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
| | - L. Björnebo
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - S. Gaglani
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
| | - M. R. Noh
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
| | - S. A. Kaplan
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
| | - R. Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - K. K. Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - P. Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - K. Tsao
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Division of Hematology and Medical Oncology, Mount Sinai Hospital, New York, NY USA
| | - D. J. Lundon
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - N. Mohamed
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - F. Lucien
- Department of Urology, Mayo Clinic, Rochester, MN USA
| | - B. Padanilam
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
| | - M. Gupta
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
| | - A. K. Tewari
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - N. Kyprianou
- Department of Urology, Icahn School of Medicine at Mount Sinai, 6th Floor, 1425 Madison Avenue, New York, NY 10029 USA
- Department of Pathology and Molecular and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY USA
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44
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Ye C, Zheng F, Wang JX, Wang XL, Chen Q, Li YH, Kang YM, Zhu GQ. Dysregulation of the Excitatory Renal Reflex in the Sympathetic Activation of Spontaneously Hypertensive Rat. Front Physiol 2021; 12:673950. [PMID: 34149454 PMCID: PMC8209386 DOI: 10.3389/fphys.2021.673950] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/08/2021] [Indexed: 11/20/2022] Open
Abstract
Excessive sympathetic activation plays crucial roles in the pathogenesis of hypertension. Chemical stimulation of renal afferents increases the sympathetic activity and blood pressure in normal rats. This study investigated the excitatory renal reflex (ERR) in the development of hypertension in the spontaneously hypertensive rat (SHR). Experiments were performed in the Wistar-Kyoto rat (WKY) and SHR aged at 4, 12, and 24 weeks under anesthesia. Renal infusion of capsaicin was used to stimulate renal afferents, and thus, to induce ERR. The ERR was evaluated by the changes in the contralateral renal sympathetic nerve activity and mean arterial pressure. At the age of 4 weeks, the early stage with a slight or moderate hypertension, the ERR was more enhanced in SHR compared with WKY. The pressor response was greater than the sympathetic activation response in the SHR. At the age of 12 weeks, the development stage with severe hypertension, there was no significant difference in the ERR between the WKY and SHR. At the age of 24 weeks, the later stage of hypertension with long-term several hypertensions, the ERR was more attenuated in the SHR compared with the WKY. On the other hand, the pressor response to sympathetic activation due to the ERR was smaller at the age of 12 and 24 weeks than those at the age of 4 weeks. These results indicate that ERR is enhanced in the early stage of hypertension, and attenuated in the later stage of hypertension in the SHR. Abnormal ERR is involved in the sympathetic activation and the development of hypertension.
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Affiliation(s)
- Chao Ye
- Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center of Translational Medicine for Cardiovascular Disease, Department of Physiology, Nanjing Medical University, Nanjing, China
| | - Fen Zheng
- Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center of Translational Medicine for Cardiovascular Disease, Department of Physiology, Nanjing Medical University, Nanjing, China
| | - Jing-Xiao Wang
- Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center of Translational Medicine for Cardiovascular Disease, Department of Physiology, Nanjing Medical University, Nanjing, China
| | - Xiao-Li Wang
- Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center of Translational Medicine for Cardiovascular Disease, Department of Physiology, Nanjing Medical University, Nanjing, China
| | - Qi Chen
- Department of Pathophysiology, Nanjing Medical University, Nanjing, China
| | - Yue-Hua Li
- Department of Pathophysiology, Nanjing Medical University, Nanjing, China
| | - Yu-Ming Kang
- Department of Physiology and Pathophysiology, Cardiovascular Research Center, Xi'an Jiaotong University School of Medicine, Xi'an, China
| | - Guo-Qing Zhu
- Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center of Translational Medicine for Cardiovascular Disease, Department of Physiology, Nanjing Medical University, Nanjing, China.,Department of Pathophysiology, Nanjing Medical University, Nanjing, China
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45
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Hou YC, Huang CL, Lu CL, Zheng CM, Lin YF, Lu KC, Chung YL, Chen RM. The Role of Plasma Neurofilament Light Protein for Assessing Cognitive Impairment in Patients With End-Stage Renal Disease. Front Aging Neurosci 2021; 13:657794. [PMID: 34122041 PMCID: PMC8192845 DOI: 10.3389/fnagi.2021.657794] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 05/03/2021] [Indexed: 12/26/2022] Open
Abstract
Introduction: End-stage renal disease (ESRD) is defined as the irreversible loss of renal function, necessitating renal replacement therapy. Patients with ESRD tend to have more risk factors for cognitive impairment than the general population, including hypertension, accumulative uremic toxin, anemia, and old age. The association between these risk factors and the pathologic protein was lacking. Blood-based assays for detecting pathologic protein, such as amyloid beta (Aβ), total tau protein, and neurofilament light chain (NfL), have the advantages of being less invasive and more cost-effective for diagnosing patients with cognitive impairment. The aim of the study is to validate if the common neurologic biomarkers were different in ESRD patients and to differentiate if the specific biomarkers could correlate with specific correctable risk factors. Methods: In total, 67 participants aged >45 years were enrolled. The definition of ESRD was receiving maintenance hemodialysis for >3 months. Cognitive impairment was defined as a Mini-Mental State Examination score of <24. The participants were divided into groups for ESRD with and without cognitive impairment. The blood-based biomarkers (tau protein, Aβ1/40, Aβ1/42, and NfL) were analyzed through immunomagnetic reduction assay. Other biochemical and hematologic data were obtained simultaneously. Summary of results: The study enrolled 43 patients with ESRD who did not have cognitive impairment and 24 patients with ESRD who had cognitive impairment [Mini-Mental State Examination (MMSE): 27.60 ± 1.80 vs. 16.84 ± 6.40, p < 0.05]. Among the blood-based biomarkers, NfL was marginally higher in the ESRD with cognitive impairment group than in the ESRD without cognitive impairment group (10.41 ± 3.26 vs. 8.74 ± 2.81 pg/mL, p = 0.037). The concentrations of tau protein, amyloid β 1/42, and amyloid β 1/40 (p = 0.504, 0.393, and 0.952, respectively) were similar between the two groups. The area under the curve of NfL to distinguish cognitively impaired and unimpaired ESRD patients was 0.687 (95% confidence interval: 0.548-0.825, p = 0.034). There was no correlation between the concentration of NfL and MMSE among total population (r = -0.153, p = 0.277), patients with (r = 0.137, p = 0.583) or without cognitive impairment (r = 0.155, p = 0.333). Conclusion: Patients with ESRD who had cognitive impairment had marginally higher plasma NfL concentrations. NfL concentration was not correlated with the biochemical parameters, total MMSE among total population or individual groups with or without cognitive impairment. The concentrations of Aβ1/40, Aβ1/42, and tau were similar between the groups.
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Affiliation(s)
- Yi-Chou Hou
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Internal Medicine, Cardinal Tien Hospital, New Taipei City, Taiwan.,School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chuen-Lin Huang
- Department of Medical Research, Cardinal Tien Hospital, New Taipei City, Taiwan.,Department of Physiology and Biophysics, National Defense Medical Center, Graduate Institute of Physiology, Taipei, Taiwan
| | - Chien-Lin Lu
- School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan.,Department of Nephrology, Fu Jen Catholic University Hospital, New Taipei City, Taiwan
| | - Cai-Mei Zheng
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan.,Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Taipei Medical University-Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan
| | - Yuh-Feng Lin
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan.,Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Taipei Medical University-Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan.,National Defense Medical Center, Graduate Institute of Medical Sciences, Taipei, Taiwan
| | - Kuo-Cheng Lu
- Department of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Ya-Lin Chung
- Department of Medical Laboratory, Cardinal-Tien Hospital, New Taipei City, Taiwan
| | - Ruei-Ming Chen
- TMU Research Center of Cancer Translational Medicine, Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Cell Physiology and Molecular Image Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
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46
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Honetschlagerová Z, Škaroupková P, Kikerlová S, Husková Z, Maxová H, Melenovský V, Kompanowska-Jezierska E, Sadowski J, Gawrys O, Kujal P, Červenka L, Čertíková Chábová V. Effects of renal sympathetic denervation on the course of congestive heart failure combined with chronic kidney disease: Insight from studies with fawn-hooded hypertensive rats with volume overload induced using aorto-caval fistula. Clin Exp Hypertens 2021; 43:522-535. [PMID: 33783285 DOI: 10.1080/10641963.2021.1907398] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background: The coincidence of congestive heart failure (CHF) and chronic kidney disease (CKD) results in poor survival rate. The aim of the study was to examine if renal denervation (RDN) would improve the survival rate in CHF induced by creation of aorto-caval fistula (ACF).Methods: Fawn-hooded hypertensive rats (FHH), a genetic model of spontaneous hypertension associated with CKD development, were used. Fawn-hooded low-pressure rats (FHL), without CKD, served as controls. RDN was performed 4 weeks after creation of ACF and the follow-up period was 10 weeks.Results: We found that intact (non-denervated) ACF FHH exhibited survival rate of 58.8% (20 out of 34 rats), significantly lower than in intact ACF FHL (81.3%, 26/32 rats). In intact ACF FHL albuminuria remained stable throughout the study, whereas in ACF FHH it increased significantly, up to a level 40-fold higher than the basal values. ACF FHL did not show increases in renal glomerular and tubulointerstitial injury as compared with FHL, while ACF FHH exhibited marked increases in kidney injury as compared with FHH. RDN did not improve the survival rate in either ACF FHL or ACF FHH and did not alter the course of albuminuria in ACF FHL. RDN attenuated the albuminuria, but did not reduce the kidney injury in ACF FHH.Conclusions: Our present results support the notion that even modest CKD increases CHF-related mortality. RDN did not attenuate CHF-dependent mortality in ACF FHH, it delayed the progressive rise in albuminuria, but it did not reduce the degree of kidney injury.
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Affiliation(s)
- Zuzana Honetschlagerová
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Petra Škaroupková
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Soňa Kikerlová
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Zuzana Husková
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Hana Maxová
- Department of Pathophysiology, Medicine, Charles University, Prague, Czech Republic
| | - Vojtěch Melenovský
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Elzbieta Kompanowska-Jezierska
- Department of Renal and Body Fluid Physiology, Mossakowski Medical Research Institute, Polish Academy of Science, Warsaw, Poland
| | - Janusz Sadowski
- Department of Renal and Body Fluid Physiology, Mossakowski Medical Research Institute, Polish Academy of Science, Warsaw, Poland
| | - Olga Gawrys
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Department of Renal and Body Fluid Physiology, Mossakowski Medical Research Institute, Polish Academy of Science, Warsaw, Poland
| | - Petr Kujal
- Center for Experimental Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Department of Pathology, Medicine, Charles University, Prague, Czech Republic
| | - Luděk Červenka
- Department of Pathophysiology, Medicine, Charles University, Prague, Czech Republic
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Soomro QH, Charytan DM. Cardiovascular autonomic nervous system dysfunction in chronic kidney disease and end-stage kidney disease: disruption of the complementary forces. Curr Opin Nephrol Hypertens 2021; 30:198-207. [PMID: 33395034 DOI: 10.1097/mnh.0000000000000686] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Several nontraditional risk factors have been the focus of research in an attempt to understand the disproportionately high cardiovascular morbidity and mortality in chronic kidney disease (CKD) and end-stage kidney disease (ESKD) populations. One such category of risk factors is cardiovascular autonomic dysfunction. Its true prevalence in the CKD/ESKD population is unknown but existing evidence suggests it is common. Due to lack of standardized diagnostic and treatment options, this condition remains undiagnosed and untreated in many patients. In this review, we discuss current evidence pointing toward the role of autonomic nervous system (ANS) dysfunction in CKD, building off of crucial historical evidence and thereby highlighting the areas in need for future research interest. RECENT FINDINGS There are several key mediators and pathways leading to cardiovascular autonomic dysfunction in CKD and ESKD. We review studies exploring the mechanisms involved and discuss the current measurement tools and indices to evaluate the ANS and their pitfalls. There is a strong line of evidence establishing the temporal sequence of worsening autonomic function and kidney function and vice versa. Evidence linking ANS dysfunction and arrhythmia, sudden cardiac death, intradialytic hypotension, heart failure and hypertension are discussed. SUMMARY There is a need for early recognition and referral of CKD and ESKD patients suspected of cardiovascular ANS dysfunction to prevent the downstream effects described in this review.There are many unknowns in this area and a clear need for further research.
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Affiliation(s)
- Qandeel H Soomro
- Nephrology Division, Department of Medicine, NYU Langone Medical Center, New York, New York, USA
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de Deus LA, Neves RVP, Corrêa HDL, Reis AL, Honorato FS, Silva VL, de Araújo TB, Souza MK, Sousa CV, Simões HG, Prestes J, Silva Neto LS, Rodrigues Santos CA, Melo GF, Stone WJ, Rosa TS. Improving the prognosis of renal patients: The effects of blood flow-restricted resistance training on redox balance and cardiac autonomic function. Exp Physiol 2021; 106:1099-1109. [PMID: 33586254 DOI: 10.1113/ep089341] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 01/28/2021] [Indexed: 12/28/2022]
Abstract
NEW FINDINGS What is the central question of this study? Can resistance training with and without blood flow restriction improve redox balance and positively impact the autonomic cardiac modulation in chronic kidney disease patients? What is the main finding and its importance? Resistance training with and without blood flow restriction improved antioxidant defence (paraoxonase 1), decreased the pro-oxidative myeloperoxidase, improved cardiac autonomic function and slowed the decrease in renal function. We draw attention to the important clinical implications for the management of redox balance and autonomic cardiac function in chronic kidney disease patients. ABSTRACT Patients with chronic kidney disease (CKD) are prone to cardiovascular diseases secondary to abnormalities in both autonomic cardiac function and redox balance [myeloperoxidase (MPO) to paraoxonase 1 (PON1) ratio]. Although aerobic training improves both autonomic balance and redox balance in patients with CKD, the cardioprotective effects of resistance training (RT), with and without blood flow restriction (BFR), remain unknown. We aimed to compare the effects of RT and RT+BFR on antioxidant defence (PON1), pro-oxidative status (MPO), cardiac autonomic function (quantified by heart rate variability analysis) and renal function. Conservative CKD (stages 1 to 5 who do not need hemodialysis) patients (n = 105, 33 female) of both sexes were randomized into three groups: control (CTL; 57.6 ± 5.2 years; body mass index, 33.23 ± 1.62 kg/m2 ), RT (58.09 ± 6.26 years; body mass index 33.63 ± 2.05 kg/m2 ) and RT+BFR (58.06 ± 6.47 years; body mass index, 33.32 ± 1.87 kg/m2 ). Patients completed 6 months of RT or RT+BFR on three non-consecutive days per week under the supervision of strength and conditioning professionals. Training loads were adjusted every 2 months. Heart rate variability was recorded with a Polar-RS800 and data were analysed for time and frequency domains using Kubios software. The redox balance markers were PON1 and MPO, which were analysed in plasma samples. Renal function was estimated as estimated glomerular filtration rate. The RT and RT+BFR decreased pro-oxidative MPO (RT, ∼34 ng/ml and RT+BFR, ∼27 ng/ml), improved both antioxidant defence (PON1: RT, ∼23 U/L and RT+BFR, ∼31 U/L) and cardiac autonomic function (R-R interval: RT, ∼120.4 ms and RT+BFR, ∼117.7 ms), and slowed the deterioration of renal function (P < 0.0001). Redox balance markers were inversely correlated with heart rate variability time-domain indices. Our data indicated that both training models were effective as non-pharmacological tools to increase the antioxidant defences, decrease oxidative stress and improve the cardiac autonomic function of CKD patients.
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Affiliation(s)
| | | | - Hugo de Luca Corrêa
- Graduate Program in Physical Education, Catholic University of Brasília, DF, Brazil
| | - Andrea Lucena Reis
- Graduate Program in Physical Education, Catholic University of Brasília, DF, Brazil
| | | | - Victor Lopes Silva
- Graduate Program in Physical Education, Catholic University of Brasília, DF, Brazil
| | | | - Michel Kendy Souza
- Graduate Program in Physical Education, Catholic University of Brasília, DF, Brazil
| | - Caio Victor Sousa
- Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts, USA
| | | | - Jonato Prestes
- Graduate Program in Physical Education, Catholic University of Brasília, DF, Brazil
| | | | | | | | - Whitley Jo Stone
- School of Kinesiology, Recreation, and Sport, Western Kentucky University, Bowling Green, Kentucky, USA
| | - Thiago Santos Rosa
- Graduate Program in Physical Education, Catholic University of Brasília, DF, Brazil
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49
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Zoccali C, Roumeliotis S, Mallamaci F. Sleep Apnea as a Cardiorenal Risk Factor in CKD and Renal Transplant Patients. Blood Purif 2021; 50:642-648. [PMID: 33588408 DOI: 10.1159/000513424] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/27/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a public health priority of increasing concern worldwide. Sleep apnea (SA) of moderate-to-severe degree has a 3-9% prevalence in women and 10-17% in men in the general population. SUMMARY In CKD patients, the prevalence of SA parallels the decline of the GFR being 27% in CKD patients with a GFR of >60 mL/min/1.73 m2 and 57% in patients with end-stage kidney disease (ESKD). In the early CKD stages, fluid overload is probably the sole risk factor for SA in this population. At more severe CKD stages, disturbed central and peripheral chemosensitivity and the accumulation of uremic toxins might contribute to SA. Still, there is no direct evidence supporting this hypothesis in human studies. Observational studies coherently show that SA is a risk factor for CKD incidence and CKD progression as well as for cardiovascular disease and death in this population. However, there is no randomized clinical trial testing continuous positive airway pressure or other interventions documenting that attenuation of SA may have a favorable effect on renal and cardiovascular outcomes in CKD and ESKD patients. However, most likely, the causal nature of the association between SA and cardiorenal outcomes remains unproven. Renal transplantation is the most effective treatment of SA in patients with ESKD, but this disturbance re-emerges on long-term observation in this population. However, after renal transplantation, SA does not seem to be a predictor of adverse health outcomes.
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Affiliation(s)
- Carmine Zoccali
- CNR-IFC, Clinical Epidemiology of Renal Disease and Hypertension, Reggio Cal, Italy,
| | - Stefanos Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, School of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology of Renal Disease and Hypertension, Reggio Cal, Italy.,Nephrology, Dialysis and Renal Transplantation Unit, Grande Ospedale Metropolitano di Reggio Cal, Reggio Cal, Italy
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50
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Abstract
SGLT2 inhibitors increase renal glucose excretion and thus decrease both fasting and postprandial plasma glucose levels. The effects of SGLT2 inhibition outweigh those on glycemic control and are also associated with the induction of hemodynamic changes that improve cardiovascular and renal function in people with type 2 diabetes. The exact mechanisms have not yet been completely clarified. This review is focused on the potential relationship between SGLT2 inhibition and sympathetic nerve activity. There is accumulating evidence for a suppressive effect of SGLT2 inhibitors on the sympathetic nerve tone, which might be a putative mechanism for cardiovascular protection in subjects with type 2 diabetes.
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Affiliation(s)
- Rumyana Dimova
- Department of Endocrinology, Medical University of Sofia, Sofia, Bulgaria
| | - Tsvetalina Tankova
- Department of Endocrinology, Medical University of Sofia, Sofia, Bulgaria
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