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Marathias KP, Lambadiari VA, Markakis KP, Vlahakos VD, Bacharaki D, Raptis AE, Dimitriadis GD, Vlahakos DV. Competing Effects of Renin Angiotensin System Blockade and Sodium-Glucose Cotransporter-2 Inhibitors on Erythropoietin Secretion in Diabetes. Am J Nephrol 2020; 51:349-356. [PMID: 32241009 DOI: 10.1159/000507272] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/14/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Anaemia is a common finding in diabetes, particularly in those patients with albuminuria or renal dysfunction and is associated with impaired erythropoietin (EPO) secretion. This review focuses on mechanisms involved in the regulation of erythropoiesis in diabetic patients in an effort to elucidate the competing effects of the renin angiotensin system (RAS) blockade and sodium-glucose cotransporter-2 (SGLT2) inhibitors on haemoglobin concentration and hematocrit values. SUMMARY The RAS shows significant activation in diabetic subjects. Angiotensin II, its active octapeptide, causes renal tubulointerstitial hypoxia, which stimulates hypoxia-inducible factors (HIF) and increases EPO secretion and erythropoiesis. As expected, drugs that inactivate RAS, such as angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEi/ARB) are associated with a significant hematocrit-lowering effect and/or anaemia in various clinical conditions, including diabetes. Dual blockade by a combination of ACEi and ARB in diabetic patients achieves a better RAS inhibition, but at the same time a worse drop of haemoglobin concentration. Increased glucose reabsorption by SGLTs in diabetic subjects generates a high-glucose environment in renal tubulointerstitium, which may impair HIF-1, damage renal erythropoietin-producing cells (REPs) and decrease EPO secretion and erythropoiesis. SGLT2 inhibitors, which inhibit glucose reabsorption, may attenuate glucotoxicity in renal tubulointerstitium, allowing REPs to resume their function and increase EPO secretion. Indeed, EPO levels increase within a few weeks after initiation of therapy with all known SGLT2 inhibitors, followed by increased reticulocyte count and a gradual elevation of haemoglobin concentration and hematocrit level, which reach zenith values after 2-3 months. Key Messages: The competing effects of RAS blockade and SGLT2 inhibitors on erythropoiesis may have important clinical implications. The rise of hematocrit values by SGLT2 inhibitors given on top of RAS blockade in recent outcome trials may significantly contribute to the cardiorenal protection attained. The relative contribution of each system to erythropoiesis and outcome remains to be revealed in future studies.
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Affiliation(s)
| | - Vaia A Lambadiari
- 2nd Department of Internal Medicine-Propaedeutic, Research Institute and Diabetes Centre, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Konstantinos P Markakis
- 2nd Department of Internal Medicine-Propaedeutic, Research Institute and Diabetes Centre, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Vassilios D Vlahakos
- Department of Pulmonary and Critical Care Services, Evangelismos Hospital, Athens, Greece
| | - Dimitra Bacharaki
- 2nd Department of Internal Medicine-Propaedeutic, Research Institute and Diabetes Centre, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Athanasios E Raptis
- 2nd Department of Internal Medicine-Propaedeutic, Research Institute and Diabetes Centre, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - George D Dimitriadis
- 2nd Department of Internal Medicine-Propaedeutic, Research Institute and Diabetes Centre, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Demetrios V Vlahakos
- 2nd Department of Internal Medicine-Propaedeutic, Research Institute and Diabetes Centre, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece,
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Raptis AE, Markakis KP, Mazioti MC, Ikonomidis I, Maratou EP, Vlahakos DV, Kotsifaki EE, Voumvourakis AN, Tsirogianni AG, Lambadiari VA, Lekakis JP, Raptis SA, Dimitriadis GD. Effect of aliskiren on circulating endothelial progenitor cells and vascular function in patients with type 2 diabetes and essential hypertension. Am J Hypertens 2015; 28:22-9. [PMID: 24994608 DOI: 10.1093/ajh/hpu119] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the effects of aliskiren on vascular function and endothelial progenitor cells (EPCs) in patients with type 2 diabetes and essential hypertension. METHODS The study enrolled type 2 diabetic patients aged >50 years under stable glycemic control and first diagnosed mild essential hypertension. In phase A (n = 20), patients received aliskiren 150-300 mg daily for 3 months. In phase B (n = 12), hydrochlorothiazide (HCTZ) 12.5-25mg daily substituted for aliskiren for 3 more months. At baseline and at the end of each phase, we assessed (i) brachial blood pressure (BBP); (ii) central aortic systolic pressure (CSP), aortic augmentation index (Aix), and pulse wave velocity (PWV) as markers of arterial stiffness; (iii) brachial artery flow-mediated dilatation (FMD) as a marker of endothelial function; (iv) left ventricular (LV) twisting and untwisting as markers of LV function and (v) EPC numbers in culture of peripheral blood mononuclear cells. RESULTS Aliskiren similarly reduced BBP and CSP, increased FMD (P < 0.001) and EPC numbers (P < 0.001), decreased PWV and Aix (P < 0.05), and improved LV twisting and untwisting (P < 0.05). Although substitution of HCTZ sustained BBP at similar levels, CSP and echocardiographic indices nearly returned at baseline levels, and the improvement of FMD, PWV, Aix, and EPC numbers was abolished. CONCLUSIONS Aliskiren had a favorable effect on endothelial function and EPCs, reduced arterial stiffness, and improved LV twisting and untwisting. These effects were independent of BBP lowering, as they were not observed after the achievement of similar values of BBP with HCTZ.
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Affiliation(s)
- Athanasios E Raptis
- 2nd Department of Medicine-Propaedeutic Clinic, Research Institute, and Diabetes Centre, Athens University Medical School, Attikon University General Hospital, Haidari, Athens, Greece
| | - Konstantinos P Markakis
- 2nd Department of Medicine-Propaedeutic Clinic, Research Institute, and Diabetes Centre, Athens University Medical School, Attikon University General Hospital, Haidari, Athens, Greece
| | - Maria C Mazioti
- 2nd Department of Medicine-Propaedeutic Clinic, Research Institute, and Diabetes Centre, Athens University Medical School, Attikon University General Hospital, Haidari, Athens, Greece
| | - Ignantios Ikonomidis
- 2nd Department of Cardiology, Athens University Medical School, Attikon University General Hospital, Haidari, Athens, Greece
| | - Eirini P Maratou
- Hellenic National Center for Research, Prevention and Treatment of Diabetes Mellitus and its Complications, Athens, Greece
| | - Dimitrios V Vlahakos
- 2nd Department of Medicine-Propaedeutic Clinic, Research Institute, and Diabetes Centre, Athens University Medical School, Attikon University General Hospital, Haidari, Athens, Greece
| | - Eleni E Kotsifaki
- Department of Experimental Physiology, Athens University Medical School, Athens, Greece
| | - Asterios N Voumvourakis
- 2nd Department of Cardiology, Athens University Medical School, Attikon University General Hospital, Haidari, Athens, Greece
| | | | - Vaia A Lambadiari
- 2nd Department of Medicine-Propaedeutic Clinic, Research Institute, and Diabetes Centre, Athens University Medical School, Attikon University General Hospital, Haidari, Athens, Greece
| | - John P Lekakis
- 2nd Department of Cardiology, Athens University Medical School, Attikon University General Hospital, Haidari, Athens, Greece
| | - Sotirios A Raptis
- 2nd Department of Medicine-Propaedeutic Clinic, Research Institute, and Diabetes Centre, Athens University Medical School, Attikon University General Hospital, Haidari, Athens, Greece Hellenic National Center for Research, Prevention and Treatment of Diabetes Mellitus and its Complications, Athens, Greece
| | - George D Dimitriadis
- 2nd Department of Medicine-Propaedeutic Clinic, Research Institute, and Diabetes Centre, Athens University Medical School, Attikon University General Hospital, Haidari, Athens, Greece
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