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Afsar B, Afsar RE, Caliskan Y, Lentine KL. Mineralocorticoid receptor blockage in kidney transplantation: too much of a good thing or not? Int Urol Nephrol 2025; 57:839-854. [PMID: 39470940 DOI: 10.1007/s11255-024-04256-6] [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: 07/03/2024] [Accepted: 10/21/2024] [Indexed: 11/01/2024]
Abstract
Although, kidney transplantation (KT) is the best treatment option for patients with end-stage kidney disease, long-term complications including chronic kidney allograft disease (CKAD) and major adverse cardiovascular events (MACE) are common. To decrease these complications new therapeutic options are necessary. Mineralocorticoid receptor antagonists (MRAs) are one of the promising drugs in this context. In the general population, MRAs had favorable effects on blood pressure regulation, MACE, proteinuria and progression of chronic kidney disease. In the context of KT, there are limited studies showing beneficial effects such as reducing proteinuria and oxidative stress. In this review, we performed a narrative review to assess the use and impact of MRAs in kidney transplant recipients. We found that in KTRs, MRAs are safe and they have favorable or neutral impact on blood pressure, glomerular filtration rate, urinary protein/albumin excretion, and oxidative stress. No data was found regarding major cardiovascular adverse events.
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Affiliation(s)
- Baris Afsar
- School of Medicine, Division of Nephrology, Saint Louis University, SSM Health Saint Louis University Hospital, St. Louis, MO, USA.
| | - Rengin Elsurer Afsar
- School of Medicine, Division of Nephrology, Saint Louis University, SSM Health Saint Louis University Hospital, St. Louis, MO, USA
| | - Yasar Caliskan
- School of Medicine, Division of Nephrology, Saint Louis University, SSM Health Saint Louis University Hospital, St. Louis, MO, USA
| | - Krista L Lentine
- School of Medicine, Division of Nephrology, Saint Louis University, SSM Health Saint Louis University Hospital, St. Louis, MO, USA
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Miyasako K, Maeoka Y, Masaki T. Recent Advances and Perspectives on the Use of Mineralocorticoid Receptor Antagonists for the Treatment of Hypertension and Chronic Kidney Disease: A Review. Biomedicines 2024; 13:53. [PMID: 39857638 PMCID: PMC11760469 DOI: 10.3390/biomedicines13010053] [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: 12/13/2024] [Revised: 12/26/2024] [Accepted: 12/27/2024] [Indexed: 01/27/2025] Open
Abstract
Chronic kidney disease (CKD) is a major public health concern around the world. It is a significant risk factor for cardiovascular disease (CVD), and, as it progresses, the risk of cardiovascular events increases. Furthermore, end-stage kidney disease severely affects life expectancy and quality of life. Type 2 diabetes and hypertension are not only primary causes of CKD but also independent risk factors for CVD, which underscores the importance of effective treatment strategies for these conditions. The current therapies, including angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and sodium-glucose co-transporter 2 inhibitors, are administered to control hypertension, slow the progression of CKD, and reduce cardiovascular risk. However, their efficacy remains suboptimal in certain instances. Mineralocorticoid receptor (MR), a nuclear receptor found in various tissues, such as the kidney and heart, plays a pivotal role in the progression of CKD. Overactivation of MR triggers inflammation and fibrosis, which exacerbates kidney damage and accelerates disease progression. MR antagonists (MRAs) have substantial beneficial effects in patients with cardiac and renal conditions; however, their use has been constrained because of adverse effects, such as hyperkalemia and kidney dysfunction. Recently, novel non-steroidal MRAs are more efficacious and have superior safety profiles to steroidal MRAs, making them promising potential components of future treatment strategies. Here, we discuss recent findings and the roles of MRAs in the management of hypertension and CKD, with a focus on the evidence obtained from fundamental research and major clinical trials.
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Affiliation(s)
| | - Yujiro Maeoka
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan;
| | - Takao Masaki
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan;
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Kanbay M, Copur S, Mizrak B, Mallamaci F, Zoccali C. Mineralocorticoid receptor antagonists in kidney transplantation. Eur J Clin Invest 2024; 54:e14206. [PMID: 38578116 DOI: 10.1111/eci.14206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/16/2024] [Accepted: 03/19/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND The fundamental role of the renin-angiotensin-aldosterone system in the pathophysiology of chronic kidney disease, congestive heart failure, hypertension and proteinuria is well established in pre-clinical and clinical studies. Mineralocorticoid receptor antagonists are among the primary options for renin-angiotensin-aldosterone system blockage, along with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. METHODS In this narrative review, we aim to evaluate the efficiency and safety of mineralocorticoid receptor antagonists in kidney transplant recipients, including the potential underlying pathophysiology. RESULTS The efficiency and safety of mineralocorticoid receptor antagonists in managing chronic kidney disease and proteinuria, either non-nephrotic or nephrotic range, have been demonstrated among nontransplanted patients, though studies investigating the role of mineralocorticoid receptor antagonists among kidney transplant recipients are scarce. Nevertheless, promising results have been reported in pre-clinical and clinical studies among kidney transplant recipients regarding the role of mineralocorticoid receptor antagonists in terms of ischaemia-reperfusion injury, proteinuria, or calcineurin inhibitor-mediated nephrotoxicity without considerable adverse events such as hypotension, hyperkalaemia or worsening renal functions. CONCLUSION Even though initial results regarding the role of mineralocorticoid receptor antagonist therapy for kidney transplant recipients are promising, there is clear need for large-scale randomized clinical trials with long-term follow-up data.
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Affiliation(s)
- Mehmet Kanbay
- Division of Nephrology, Department of Internal Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Sidar Copur
- Department of Internal Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Berk Mizrak
- Department of Internal Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Francesca Mallamaci
- Nephrology, Dialysis and Transplantation Unit Azienda Ospedaliera "Bianchi-Melacrino-Morelli" & CNR-IFC, Institute of Clinical Physiology, Research Unit of Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension of Reggio Calabria, Reggio Calabria, Italy
| | - Carmine Zoccali
- Renal Research Institute, New York, New York, USA
- Associazione Ipertensione Nefrologia Trapianto Renal (IPNET), Reggio Calabria, Italy
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Maideen NMP, Balasubramanian R, Muthusamy S, Nallasamy V. An Overview of Clinically Imperative and Pharmacodynamically Significant Drug Interactions of Renin-Angiotensin-Aldosterone System (RAAS) Blockers. Curr Cardiol Rev 2022; 18:e110522204611. [PMID: 35546745 PMCID: PMC9893153 DOI: 10.2174/1573403x18666220511152330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 02/26/2022] [Accepted: 03/28/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Hypertension is a leading cause of cardiovascular disease and chronic kidney disease, resulting in premature death and disability. The Renin-Angiotensin-Aldosterone System (RAAS) blockers, including Angiotensin-Converting Enzyme (ACE) inhibitors or Angiotensin Receptor Blockers (ARBs), are used as first-line antihypertensive therapy to treat hypertensive patients with comorbidities, including diabetes, ischemic heart disease, heart failure, and chronic kidney disease. The use of RAS blockers is associated with the risks, such as hyperkalemia, angioedema, etc. The drugs potentiating them interact pharmacodynamically, resulting in adverse consequences. This review article focuses on the clinically important drug interactions of RAAS blockers. MATERIALS AND METHODS The electronic databases, such as Medline/PubMed Central/PubMed, Google Scholar, ScienceDirect, Cochrane Library, Directory of Open Access Journals (DOAJ), Embase, and reference lists were searched to identify relevant articles. RESULTS The risk of hyperkalemia may be enhanced potentially in patients receiving a RAS blocker and potassium-sparing diuretics, potassium supplements, trimethoprim, adrenergic betablockers, antifungal agents, calcineurin inhibitors, pentamidine, heparins or an NSAID, concomitantly. The patients taking ACE inhibitors and mTOR inhibitors, DPP4 inhibitors, alteplase, or sacubitril/valsartan concurrently may be at increased risk of developing angioedema. CONCLUSION Clinicians, pharmacists, and other healthcare practitioners should be accountable for medication safety. To avoid adverse implications, prescribers and pharmacists must be aware of the drugs that interact with RAAS blockers.
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Affiliation(s)
| | | | - Sudha Muthusamy
- Department of Pharmacology, J.K.K. Nattraja College of Pharmacy, Komarapalayam- 638 183, India
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Single, Double and Triple Blockade of RAAS in Alport Syndrome: Different Tools to Freeze the Evolution of the Disease. J Clin Med 2021; 10:jcm10214946. [PMID: 34768466 PMCID: PMC8584724 DOI: 10.3390/jcm10214946] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/17/2021] [Accepted: 10/20/2021] [Indexed: 12/29/2022] Open
Abstract
Background: The goal of the treatment of Alport syndrome (AS) is to delay the progression of kidney damage. The current standard of care is the use of Renin Angiotensin Aldosterone System (RAAS) blockers: angiotensin-converting enzyme inhibition (ACEi), angiotensin receptor blockade, and, recently, spironolactone (SP). Aim of the study: the purpose of this retrospective study is to evaluate the efficacy (reduction of proteinuria and changes of glomerular function) and safety of a sequential introduction of RAAS blockers up to a triple RAAS blockade in pediatric proteinuric patients with AS. Methods: in this retrospective study (1995 to 2019), we evaluated proteinuria values in AS patients, during the 12 months following the beginning of a new RAAS blocker, up to a triple blockade. ACEi was always the first line of treatment; then ARB and SP were sequentially added if uPCR increased by 50% from the basal level in 2 consecutive samples during a 3-months observation period, or when uPCR ratio was >2 mg/mg. Results: 26 patients (mean age at treatment onset was 10.55 ± 5.02 years) were enrolled. All patients were on ACEi, 14/26 were started on a second drug (6/14 ARB, 8/14 SP) after a mean time of 2.2 ± 1.7 years, 7/26 were on triple RAAS blockade after a further period of 5.5 ± 2.3 years from the introduction of a second drug. Repeated Measure Anova analysis of log-transformed data shows that the reduction of uPCR values after Time 0 from the introduction of the first, second and third drug is highly significant in all three cases (p values = 0.0016, 0.003, and 0.014, respectively). No significant changes in eGFR were recorded in any group, apart from a 15-year-old boy with X-linked AS, who developed kidney failure. One patient developed mild hyperkaliemia, and one gynecomastia and symptomatic hypotension. No life-threatening events were recorded. Conclusions: double and triple RAAS blockade is an effective and safe strategy to reduce proteinuria in children with AS. Nevertheless, we suggest monitoring eGFR and Kaliemia during follow-up.
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Rakugi H, Yamakawa S, Sugimoto K. Management of hyperkalemia during treatment with mineralocorticoid receptor blockers: findings from esaxerenone. Hypertens Res 2021; 44:371-385. [PMID: 33214722 PMCID: PMC8019656 DOI: 10.1038/s41440-020-00569-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/29/2020] [Accepted: 09/29/2020] [Indexed: 01/06/2023]
Abstract
The nonsteroidal mineralocorticoid receptor (MR) blocker esaxerenone has demonstrated good antihypertensive activity in a variety of patients, including those with uncomplicated grade I-III hypertension, hypertension with moderate renal dysfunction, hypertension with type 2 diabetes mellitus with albuminuria, and hypertension associated with primary aldosteronism. Hyperkalemia has long been recognized as a potential side effect occurring during treatment with MR blockers, but there is a lack of understanding and guidance about the appropriate management of hyperkalemia during antihypertensive therapy with MR blockers, especially in regard to the newer agent esaxerenone. In this article, we first highlight risk factors for hyperkalemia, including advanced chronic kidney disease, diabetes mellitus, cardiovascular disease, age, and use of renin-angiotensin-aldosterone system inhibitors. Next, we examine approaches to prevention and management, including potassium monitoring, diet, and the use of appropriate therapeutic techniques. Finally, we summarize the currently available data for esaxerenone and hyperkalemia. Proper management of serum potassium is required to ensure safe clinical use of MR blockers, including awareness of at-risk patient groups, choosing appropriate dosages for therapy initiation and dosage titration, and monitoring of serum potassium during therapy. It is critical that physicians take such factors into consideration to optimize MR blocker therapy in patients with hypertension.
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Affiliation(s)
- Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Satoru Yamakawa
- Clinical Development Department III, R&D Division, Daiichi Sankyo Co., Ltd., 1-2-58, Hiromachi, Shinagawa-ku, Tokyo, 140-8710, Japan
| | - Kotaro Sugimoto
- Medical Science Department, Daiichi Sankyo Co., Ltd., 3-5-1, Nihonbashi Honcho, Chuo-ku, Tokyo, 103-8426, Japan
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Abstract
Interstitial fibrosis with tubule atrophy (IF/TA) is the response to virtually any sustained kidney injury and correlates inversely with kidney function and allograft survival. IF/TA is driven by various pathways that include hypoxia, renin-angiotensin-aldosterone system, transforming growth factor (TGF)-β signaling, cellular rejection, inflammation and others. In this review we will focus on key pathways in the progress of renal fibrosis, diagnosis and therapy of allograft fibrosis. This review discusses the role and origin of myofibroblasts as matrix producing cells and therapeutic targets in renal fibrosis with a particular focus on renal allografts. We summarize current trends to use multi-omic approaches to identify new biomarkers for IF/TA detection and to predict allograft survival. Furthermore, we review current imaging strategies that might help to identify and follow-up IF/TA complementary or as alternative to invasive biopsies. We further discuss current clinical trials and therapeutic strategies to treat kidney fibrosis.Supplemental Visual Abstract; http://links.lww.com/TP/C141.
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Hamrahian SM, Fülöp T. Hyperkalemia and Hypertension Post Organ Transplantation - A Management Challenge. Am J Med Sci 2020; 361:106-110. [PMID: 32709394 DOI: 10.1016/j.amjms.2020.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/22/2020] [Accepted: 06/22/2020] [Indexed: 10/24/2022]
Abstract
Potassium is the most important intracellular cation and the kidneys play a pivotal role in potassium homeostasis. Potassium disorder is a common electrolyte abnormality and it increases the risk of death from any cause, particularly cardiovascular events. Hyperkalemia is a common electrolyte abnormality encountered post organ transplantation. The etiology is multifactorial, and includes drugs such as calcineurin inhibitors. In certain regards, the clinical picture of post-transplantation hyperkalemia and hypertension resembles that of Gordon syndrome or familial hyperkalemic hypertension, a disorder characterized by over activity of thiazide-sensitive sodium chloride cotransporter. Effective and safe management of chronic hyperkalemia can be challenging in this special patient population. Despite the significant short-term and long-term side effects, fludrocortisone (a potent synthetic oral mineralocorticoid receptor agonist) has emerged as the default drug of choice for treatment of refractory hyperkalemia in many organ transplant recipients. However, the long-term efficacy and safety of fludrocortisone for management of hyperkalemia in organ transplant recipients remains unknown. This review discusses potassium homeostasis, including the role of the kidneys, and focuses on calcineurin inhibitor-induced hyperkalemia and on the under-appreciated role of thiazide-type diuretic use in management of hyperkalemia and hypertension. We present an illustrative case of post-transplantation hyperkalemia and hypertension with relevant literature.
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Affiliation(s)
- Seyed Mehrdad Hamrahian
- Division of Nephrology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA.
| | - Tibor Fülöp
- Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina; Medicine Service, Ralph H. Johnson VA Medical Center, Charleston, South Carolina
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9
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Tantisattamo E, Molnar MZ, Ho BT, Reddy UG, Dafoe DC, Ichii H, Ferrey AJ, Hanna RM, Kalantar-Zadeh K, Amin A. Approach and Management of Hypertension After Kidney Transplantation. Front Med (Lausanne) 2020; 7:229. [PMID: 32613001 PMCID: PMC7310511 DOI: 10.3389/fmed.2020.00229] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/04/2020] [Indexed: 12/14/2022] Open
Abstract
Hypertension is one of the most common cardiovascular co-morbidities after successful kidney transplantation. It commonly occurs in patients with other metabolic diseases, such as diabetes mellitus, hyperlipidemia, and obesity. The pathogenesis of post-transplant hypertension is complex and is a result of the interplay between immunological and non-immunological factors. Post-transplant hypertension can be divided into immediate, early, and late post-transplant periods. This classification can help clinicians determine the etiology and provide the appropriate management for these complex patients. Volume overload from intravenous fluid administration is common during the immediate post-transplant period and commonly contributes to hypertension seen early after transplantation. Immunosuppressive medications and donor kidneys are associated with post-transplant hypertension occurring at any time point after transplantation. Transplant renal artery stenosis (TRAS) and obstructive sleep apnea (OSA) are recognized but common and treatable causes of resistant hypertension post-transplantation. During late post-transplant period, chronic renal allograft dysfunction becomes an additional cause of hypertension. As these patients develop more substantial chronic kidney disease affecting their allografts, fibroblast growth factor 23 (FGF23) increases and is associated with increased cardiovascular and all-cause mortality in kidney transplant recipients. The exact relationship between increased FGF23 and post-transplant hypertension remains poorly understood. Blood pressure (BP) targets and management involve both non-pharmacologic and pharmacologic treatment and should be individualized. Until strong evidence in the kidney transplant population exists, a BP of <130/80 mmHg is a reasonable target. Similar to complete renal denervation in non-transplant patients, bilateral native nephrectomy is another treatment option for resistant post-transplant hypertension. Native renal denervation offers promising outcomes for controlling resistant hypertension with no significant procedure-related complications. This review addresses the epidemiology, pathogenesis, and specific etiologies of post-transplant hypertension including TRAS, calcineurin inhibitor effects, OSA, and failed native kidney. The cardiovascular and survival outcomes related to post-transplant hypertension and the utility of 24-h blood pressure monitoring will be briefly discussed. Antihypertensive medications and their mechanism of actions relevant to kidney transplantation will be highlighted. A summary of guidelines from different professional societies for BP targets and antihypertensive medications as well as non-pharmacological interventions, including bilateral native nephrectomy and native renal denervation, will be reviewed.
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Affiliation(s)
- Ekamol Tantisattamo
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States.,Section of Nephrology, Department of Internal Medicine, Multi-Organ Transplant Center, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI, United States
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, United States.,Methodist University Hospital Transplant Institute, Memphis, TN, United States.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Bing T Ho
- Division of Nephrology and Hypertension, Department of Medicine, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Uttam G Reddy
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States
| | - Donald C Dafoe
- Division of Transplantation, Department of Surgery, University of California Irvine School of Medicine, Orange, CA, United States
| | - Hirohito Ichii
- Division of Transplantation, Department of Surgery, University of California Irvine School of Medicine, Orange, CA, United States
| | - Antoney J Ferrey
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States
| | - Ramy M Hanna
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States
| | - Alpesh Amin
- Department of Medicine, University of California Irvine School of Medicine, Orange, CA, United States
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Abdelhakim AM, Abd-ElGawad M. Impact of mineralocorticoid receptor antagonist in renal transplant patients: a systematic review and meta-analysis of randomized controlled trials. J Nephrol 2020; 33:529-538. [PMID: 31828668 DOI: 10.1007/s40620-019-00681-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 11/26/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mineralocorticoid receptor (MR) antagonism can stop the occurrence of acute kidney injury induced by ischemia/reperfusion (IR) in pig and rodent and pig models. However, there are controversies regarding MR antagonist use in renal transplant patients to attenuate IR injury. We aim to perform this study to build evidence regarding benefits of MR antagonist use in renal transplant patients. METHODS We searched four authentic databases during August 2019. We included randomized controlled trials (RCTs) which compared MR antagonists versus control in renal transplant patients. Data were extracted from eligible studies and pooled in a meta-analysis model using RevMan software. Our primary outcome was serum creatinine. Our secondary outcomes were serum potassium, serum aldosterone, urinary heat shock protein 72 (Hsp72), and 8-hydroxy-2-deoxyguanosine (8-OHdG). RESULTS Four RCTs with 167 patients were included in our analysis. We found that MR antagonists were significantly superior to control group in decreasing serum creatinine after removal of heterogeneity (MD = - 0.23, 95% CI [- 0.44, - 0.02], p = 0.04). Control group was superior to MR antagonists in serum potassium and aldosterone respectively, (MD = 0.28, 95% CI [0.17, 0.38], p < 0.00001), (MD = 33.08, 95% CI [28.61, 37.54], p < 00001). MR antagonists were significantly associated with reduction in Urinary Hsp72, and Urinary 8-OHdG respectively (MD = - 3.08, 95% CI [- 5.45, - 0.71], p = 0.01), (MD = - 0.24, 95% CI [- 0.40, -0.09], p = 0.002). CONCLUSION Although an improvement in serum creatinine and urinary Hsp72 and 8-OHdG, as an expression of renoprotection induced by MR antagonists, was observed in kidney transplanted recipients, the different designs of the 4 studies limit the meaningful of this conclusion. Thus, more powered RCTs are warranted.
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Affiliation(s)
- Ahmed Mohamed Abdelhakim
- Kasr Alainy, Faculty of Medicine, Cairo University, 395 Portsaid Street, Bab el-kalq, Cairo, Egypt.
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11
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Morales-Buenrostro LE, Ortega-Trejo JA, Pérez-Villalva R, Marino LA, González-Bobadilla Y, Juárez H, Zamora-Mejía FM, González N, Espinoza R, Barrera-Chimal J, Bobadilla NA. Spironolactone reduces oxidative stress in living donor kidney transplantation: a randomized controlled trial. Am J Physiol Renal Physiol 2019; 317:F519-F528. [DOI: 10.1152/ajprenal.00606.2018] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Mineralocorticoid receptor antagonism prevents acute kidney injury induced by ischemia-reperfusion in rodent and pig preclinical models. In a pilot study, we showed that spironolactone (25 mg) reduced oxidative stress after 5 days of kidney transplant (KT). In the present study, we investigated the effects of higher doses (50 and 100 mg) of spironolactone on kidney function, tubular injury markers, and oxidative stress in living donor KT recipients. We included KT recipients aged 18 yr or older who received immunosuppression therapy with IL-2 receptor antagonist, mycophenolate mofetil, corticosteroids, and tacrolimus with negative cross-match, and compatible blood group. Patients were randomized to receive placebo ( n = 27), spironolactone (50 mg, n = 25), or spironolactone (100 mg, n = 25). Treatment was given from 3 days before and up to 5 days after KT. Serum creatinine, K+, urine neutrophil gelatinase-associated lipocalin-2, heat shock protein 72, and 8-hydroxy-2-deoxyguanosine levels were assessed. As expected, kidney function was improved after KT. Serum K+ remained in the normal range along the study. There was no significant effect of spironolactone on urinary neutrophil gelatinase-associated lipocalin-2 levels, whereas the increase in urinary heat shock protein 72 levels tended to be less intense in the 100 mg spironolactone-treated group ( P = 0.054). In the placebo-treated group, urinary 8-hydroxylated-guanosine levels increased on days 3 and 5 after transplantation. This effect was prevented in patients that received spironolactone. In conclusion, spironolactone reduces the acute increase in urinary oxidative stress in living donor KT recipients.
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Affiliation(s)
| | - Juan Antonio Ortega-Trejo
- Department of Nephrology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Molecular Physiology Unit, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Rosalba Pérez-Villalva
- Department of Nephrology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Molecular Physiology Unit, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Lluvia A. Marino
- Department of Nephrology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Yvett González-Bobadilla
- Department of Nephrology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Molecular Physiology Unit, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Hilda Juárez
- Department of Nephrology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Flor M. Zamora-Mejía
- Department of Nephrology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Norma González
- Department of Nephrology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Molecular Physiology Unit, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Ramón Espinoza
- Transplantation Unit, Centro Médico Nacional Siglo XXI, Mexico City, Mexico
| | - Jonatan Barrera-Chimal
- Molecular Physiology Unit, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
- Unidad de Medicina Traslacional, UNAM-Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Norma A. Bobadilla
- Department of Nephrology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Molecular Physiology Unit, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
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12
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Barrera-Chimal J, Girerd S, Jaisser F. Mineralocorticoid receptor antagonists and kidney diseases: pathophysiological basis. Kidney Int 2019; 96:302-319. [PMID: 31133455 DOI: 10.1016/j.kint.2019.02.030] [Citation(s) in RCA: 132] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 02/04/2019] [Accepted: 02/20/2019] [Indexed: 12/13/2022]
Abstract
Chronic kidney disease (CKD) represents a global health concern, and its prevalence is increasing. The ultimate therapeutic option for CKD is kidney transplantation. However, the use of drugs that target specific pathways to delay or halt CKD progression, such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and sodium-glucose co-transporter-2 (SGLT-2) inhibitors is limited in clinical practice. Mineralocorticoid receptor activation in nonclassical tissues, such as the endothelium, smooth muscle cells, inflammatory cells, podocytes, and fibroblasts may have deleterious effects on kidney structure and function. Several preclinical studies have shown that mineralocorticoid receptor antagonists (MRAs) ameliorate or cure kidney injury and dysfunction in different models of kidney disease. In this review, we present the preclinical evidence showing a benefit of MRAs in acute kidney injury, the transition from acute kidney injury to CKD, hypertensive and diabetic nephropathy, glomerulonephritis, and kidney toxicity induced by calcineurin inhibitors. We also discuss the molecular mechanisms responsible for renoprotection related to MRAs that lead to reduced oxidative stress, inflammation, fibrosis, and hemodynamic alterations. The available clinical data support a benefit of MRA in reducing proteinuria in diabetic kidney disease and improving cardiovascular outcomes in CKD patients. Moreover, a benefit of MRAs in kidney transplantation has also been observed. The past and present clinical trials describing the effect of MRAs on kidney injury are presented, and the risk of hyperkalemia and use of other options, such as potassium binding agents or nonsteroidal MRAs, are also addressed. Altogether, the available preclinical and clinical data support a benefit of using MRAs in CKD, an approach that should be further explored in future clinical trials.
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Affiliation(s)
- Jonatan Barrera-Chimal
- Laboratorio de Fisiología Cardiovascular y Trasplante Renal, Unidad de Medicina Traslacional, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México and Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Sophie Girerd
- Transplant Unit, Nephrology Department, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France; Institut national de la santé et de la recherche médicale U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France; Investigation Network Initiative - Cardiovascular and Renal Clinical Trialists, French-Clinical Research Infrastructure Network, Nancy, France
| | - Frederic Jaisser
- Institut national de la santé et de la recherche médicale U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France; Investigation Network Initiative - Cardiovascular and Renal Clinical Trialists, French-Clinical Research Infrastructure Network, Nancy, France; Institut national de la santé et de la recherche médicale, UMRS 1138, Team 1, Centre de Recherche des Cordeliers, Sorbonne University, Paris Descartes University, Paris, France.
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Mortensen LA, Thiesson HC, Tougaard B, Egfjord M, Fischer ASL, Bistrup C. The effect of spironolactone on calcineurin inhibitor induced nephrotoxicity: a multicenter randomized, double-blind, clinical trial (the SPIREN trial). BMC Nephrol 2018; 19:105. [PMID: 29724188 PMCID: PMC5934785 DOI: 10.1186/s12882-018-0885-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 03/26/2018] [Indexed: 11/12/2022] Open
Abstract
Background Calcineurin inhibitor induced nephrotoxicity contributes to late allograft failure in kidney transplant patients. Evidence points towards aldosterone to play a role in the development of fibrosis in multiple organs. Animal studies have indicated a beneficial effect of mineralocorticoid receptor antagonists preventing calcineurin inhibitor induced nephrotoxicity. Only few studies have explored this effect in humans. The objective of this study is to evaluate the effect of spironolactone on glomerular filtration rate and fibrosis in kidney transplant patients. Method Prospective, double-blind, randomized, clinical trial including 170 prevalent kidney transplant patients. Patients are randomized to spironolactone 25–50 mg/day or placebo for three years. Primary outcome is glomerular filtration rate evaluated by chrome-EDTA clearance. Secondary outcomes are 24-h protein excretion, amount of interstitial fibrosis in renal allograft biopsies, and cardiovascular events. As an exploratory outcome, we aim to identify markers of fibrosis in blood and urine. Discussion Long term allograft survival remains a key issue in renal transplantation, partly due to calcineurin inhibitor induced nephrotoxicity. Evidence from animal- and small human studies indicate a beneficial effect of mineralocorticoid receptor antagonism on renal function and fibrosis. This study aims to test this hypothesis in a sufficiently powered randomized clinical trial. Results might influence the future management of long term allograft survival in renal transplantation. Trial registration ClinicalTrials.gov identifier (05/17/2012): NCT01602861. EudraCT number (05/31/2011): 2011–002243-98.
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Affiliation(s)
- Line Aas Mortensen
- Department of Nephrology, Odense University Hospital, Sdr. Boulevard 29, DK-5000, Odense C, Denmark. .,Department of Clinical Research, University of Southern Denmark, Winsløwparken 19, 3. Sal, 5000, Odense C, Denmark.
| | - Helle C Thiesson
- Department of Nephrology, Odense University Hospital, Sdr. Boulevard 29, DK-5000, Odense C, Denmark.,Department of Clinical Research, University of Southern Denmark, Winsløwparken 19, 3. Sal, 5000, Odense C, Denmark
| | - Birgitte Tougaard
- Department of Nephrology, Kolding Hospital, Sygehusvej 24, 6000, Kolding, Denmark
| | - Martin Egfjord
- Department of Nephrology, Rigshospitalet, Blegdamsvej 9, 2100, København Ø, Denmark
| | - Anne Sophie Lind Fischer
- Department of Nephrology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Claus Bistrup
- Department of Nephrology, Odense University Hospital, Sdr. Boulevard 29, DK-5000, Odense C, Denmark.,Department of Clinical Research, University of Southern Denmark, Winsløwparken 19, 3. Sal, 5000, Odense C, Denmark
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Girerd S, Jaisser F. Mineralocorticoid receptor antagonists in kidney transplantation: time to consider? Nephrol Dial Transplant 2018; 33:2080-2091. [DOI: 10.1093/ndt/gfy065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 02/27/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Sophie Girerd
- Transplant Unit, Nephrology Department, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
- INSERM U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France
- INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
| | - Frédéric Jaisser
- INSERM U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France
- INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
- INSERM, UMRS 1138, Team 1, Centre de Recherche des Cordeliers, Pierre et Marie Curie University, Paris Descartes University, Paris, France
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Abstract
BACKGROUND Aldosterone is involved in the process of renal allograft fibrosis, clinically manifest by proteinuria and allograft dysfunction, with increased risk for cardiovascular death. The treatment with aldosterone antagonists appears to be effective in controlling proteinuria, with a protective effect on progression of renal fibrosis. METHODS This retrospective, cohort study included kidney transplant recipients from January 1993 to June 2015. Inclusion criteria were persistent proteinuria >0.5 g/d, longer than 6 months, and spironolactone therapy. RESULTS One hundred forty transplant recipients fulfilled the inclusion criteria and were divided into 3 groups, according to proteinuria levels at the beginning of spironolactone therapy: low (<1 g/24 h), intermediate (1-3 g/24 h), and nephrotic (>3 g/24 h). Groups were comparable in demographic data, with a higher incidence of living related donors in the nephrotic group. In patients with proteinuria ≥1 g/d, we observed a significant reduction in proteinuria after 6 months of therapy that persisted over time. Blood pressure and glomerular filtration rate persisted stable over time. Adverse events were not severe to withdrawal therapy. CONCLUSIONS Spironolactone can be a safe alternative to control post-transplant proteinuria, especially in patients with mild to moderate allograft dysfunction with proteinuria ≥1 g/day.
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Mortensen LA, Bistrup C, Thiesson HC. Does Mineralocorticoid Receptor Antagonism Prevent Calcineurin Inhibitor-Induced Nephrotoxicity? Front Med (Lausanne) 2017; 4:210. [PMID: 29226122 PMCID: PMC5705552 DOI: 10.3389/fmed.2017.00210] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/08/2017] [Indexed: 01/15/2023] Open
Abstract
Calcineurin inhibitors have markedly reduced acute rejection rates in renal transplantation, thus significantly improved short-term outcome. The beneficial effects are, however, tampered by acute and chronic nephrotoxicity leading to interstitial fibrosis and tubular atrophy, which impairs long-term allograft survival. The mineralocorticoid hormone aldosterone induces fibrosis in numerous organs, including the kidney. Evidence from animal models suggests a beneficial effect of aldosterone antagonism in reducing calcineurin inhibitor-induced nephrotoxicity. This review summarizes current evidence of mineralocorticoid receptor antagonism in animal models of calcineurin inhibitor-induced nephrotoxicity and the results from studies of mineralocorticoid antagonism in renal transplant patients.
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Affiliation(s)
- Line Aas Mortensen
- Department of Nephrology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Claus Bistrup
- Department of Nephrology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Helle Charlotte Thiesson
- Department of Nephrology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Bertocchio JP, Barbe C, Lavaud S, Toupance O, Nazeyrollas P, Jaisser F, Rieu P. Safety of Eplerenone for Kidney-Transplant Recipients with Impaired Renal Function and Receiving Cyclosporine A. PLoS One 2016; 11:e0153635. [PMID: 27088859 PMCID: PMC4835088 DOI: 10.1371/journal.pone.0153635] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 04/01/2016] [Indexed: 12/22/2022] Open
Abstract
Background Animal studies have highlighted the role of vascular mineralocorticoid receptor during Cyclosporine A-induced nephrotoxicity. Mineralocorticoid receptor antagonists could improve kidney survival but are not commonly used during renal impairment and in association with several immunosuppressive drugs due to a supposed higher risk of adverse events. We tested the tolerance of eplerenone according to its expected adverse events: hyperkalemia, metabolic acidosis, hypotension, acute kidney failure, or any other adverse event. Methods We conducted a single-center, prospective, open-label study in 31 kidney-transplant recipients with impaired renal function (30 and 50 mL/min/1.73m2) and receiving cyclosporine A. All patients received eplerenone 25 mg/d for 8 weeks. Serum potassium, renal function and expected adverse events were closely monitored. Results Eight patients experienced mild hyperkalemia (>5 mmol/L), one moderate hyperkalemia (>5.5 mmol/L) and had to receive potassium-exchange resin. No severe hyperkalemia (>6 mmol/L) occurred. One acute kidney failure was observed, secondary to diarrhea. Basal serum potassium and bicarbonate were independently associated with a higher risk of developing mild hyperkalemia (>5 mmol/L) under treatment (OR 6.5, p = 0.003 and 0.7, p = 0.007, respectively). A cut-off value of 4.35 mmol/L for basal serum potassium was the best factor to predict the risk of developing mild hyperkalemia (>5 mmol/L). Conclusions Until eGFR falls to 30 mL/min/1.73m2, eplerenone could be safely given to kidney-transplant recipients receiving cyclosporine A, if kalemia is closely monitored. When renal function is impaired and if basal kalemia is >4.35 mmol/L, then clinicians should properly balance risk and benefit of eplerenone use and offer dietary advice. An adequately powered prospective randomized study is now needed to test its efficiency (and safety) in this population. Trial Registration ClinicalTrials.gov NCT01834768
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Affiliation(s)
- Jean-Philippe Bertocchio
- Nephrology, Dialysis and Transplantation Unit, Reims University Hospital, Avenue Cognacq Jay, 51092 Reims CEDEX, France.,INSERM UMRS 1138 -Team 1, Research Centre of Cordeliers, 15 rue de l'école de médecine, 75006 Paris CEDEX, France
| | - Coralie Barbe
- Biostatistics and methodology unit, Reims University Hospital, Avenue Cognacq Jay, 51092 Reims CEDEX, France
| | - Sylvie Lavaud
- Nephrology, Dialysis and Transplantation Unit, Reims University Hospital, Avenue Cognacq Jay, 51092 Reims CEDEX, France
| | - Olivier Toupance
- Nephrology, Dialysis and Transplantation Unit, Reims University Hospital, Avenue Cognacq Jay, 51092 Reims CEDEX, France
| | - Pierre Nazeyrollas
- Biostatistics and methodology unit, Reims University Hospital, Avenue Cognacq Jay, 51092 Reims CEDEX, France
| | - Frederic Jaisser
- INSERM UMRS 1138 -Team 1, Research Centre of Cordeliers, 15 rue de l'école de médecine, 75006 Paris CEDEX, France
| | - Philippe Rieu
- Nephrology, Dialysis and Transplantation Unit, Reims University Hospital, Avenue Cognacq Jay, 51092 Reims CEDEX, France
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Jaisser F, Farman N. Emerging Roles of the Mineralocorticoid Receptor in Pathology: Toward New Paradigms in Clinical Pharmacology. Pharmacol Rev 2016; 68:49-75. [PMID: 26668301 DOI: 10.1124/pr.115.011106] [Citation(s) in RCA: 209] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The mineralocorticoid receptor (MR) and its ligand aldosterone are the principal modulators of hormone-regulated renal sodium reabsorption. In addition to the kidney, there are several other cells and organs expressing MR, in which its activation mediates pathologic changes, indicating potential therapeutic applications of pharmacological MR antagonism. Steroidal MR antagonists have been used for decades to fight hypertension and more recently heart failure. New therapeutic indications are now arising, and nonsteroidal MR antagonists are currently under development. This review is focused on nonclassic MR targets in cardiac, vascular, renal, metabolic, ocular, and cutaneous diseases. The MR, associated with other risk factors, is involved in organ fibrosis, inflammation, oxidative stress, and aging; for example, in the kidney and heart MR mediates hormonal tissue-specific ion channel regulation. Genetic and epigenetic modifications of MR expression/activity that have been documented in hypertension may also present significant risk factors in other diseases and be susceptible to MR antagonism. Excess mineralocorticoid signaling, mediated by aldosterone or glucocorticoids binding, now appears deleterious in the progression of pathologies that may lead to end-stage organ failure and could therefore benefit from the repositioning of pharmacological MR antagonists.
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Affiliation(s)
- F Jaisser
- INSERM UMR 1138 Team 1, Cordeliers Research Center, Pierre et Marie Curie University, Paris, France (F.J., N.F); and University Paris-Est Creteil, Creteil, France (F.J.)
| | - N Farman
- INSERM UMR 1138 Team 1, Cordeliers Research Center, Pierre et Marie Curie University, Paris, France (F.J., N.F); and University Paris-Est Creteil, Creteil, France (F.J.)
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Giani M, Mastrangelo A, Villa R, Turolo S, Marra G, Tirelli AS, Hopfer H, Edefonti A. Alport syndrome: the effects of spironolactone on proteinuria and urinary TGF-β1. Pediatr Nephrol 2013; 28:1837-42. [PMID: 23748277 DOI: 10.1007/s00467-013-2490-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/16/2013] [Accepted: 04/09/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Alport syndrome (AS) is a progressive hereditary glomerular disease. Recent data indicate that aldosterone promotes fibrosis mediated by the transforming growth factor-β1 (TGF-β1) pathway, which may worsen proteinuria. Spironolactone (SP) antagonizes aldosterone and this study aimed to evaluate the efficacy of SP in reducing proteinuria and urinary TGF-β1 excretion in proteinuric AS patients. METHODS The study involved ten children with AS, normal renal function, and persistent proteinuria (>6 months; uPr/uCr ratio >1). SP 25 mg once a day for 6 months was added to existing ACE inhibitor treatment with or without angiotensin-II receptor blockade. Urine and blood samples were examined monthly. Urinary TGF-β1 levels were measured twice before and three times during SP treatment. Plasma renin activity (PRA) and serum aldosterone levels were also measured. In eight patients, uProt/uCreat was also assessed after 9 months and 12 months of SP treatment. RESULTS After beginning SP therapy, all patients showed significant decrease in mean uProt/uCreat ratio (1.77 ± 0.8 to 0.86 ± 0.6; p < 0.001) and mean urinary TGF-β1 levels (104 ± 54 to 41 ± 20 pg/mgCreatinine; p < 0.01), beginning after 30 days of treatment and remaining stable throughout SP administration. PRA remain unchanged, and mean serum aldosterone increased from 105 ± 72 pg/ml to 303 ± 156 pg/ml (p < 0.001). The only side effect was gynecomastia in an obese boy. After 1 year of therapy, mean uProt/uCreat remains low (0.82 ± 0.48). CONCLUSIONS Addition of SP to ACE-I treatment with or without angiotensin II receptor blokers (ARB) significantly reduced proteinuria. This was mediated by decreased urinary TGF-β1 levels and not associated with major side effects.
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Affiliation(s)
- Marisa Giani
- Pediatric Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy
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Management of hyperkalaemia consequent to mineralocorticoid-receptor antagonist therapy. Nat Rev Nephrol 2012; 8:691-9. [DOI: 10.1038/nrneph.2012.217] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Fourtounas C. Management of hypertension after kidney transplantation: a possible role for spironolactone? J Hypertens 2012; 30:830-832. [PMID: 22418913 DOI: 10.1097/hjh.0b013e328350e5c7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ruiz JC, Sánchez-Fructuoso A, Zárraga S. Management of proteinuria in clinical practice after kidney transplantation. Transplant Rev (Orlando) 2012; 26:36-43. [DOI: 10.1016/j.trre.2011.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 07/28/2011] [Indexed: 01/06/2023]
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