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Tsikouras P, Nikolettos K, Kotanidou S, Kritsotaki N, Oikonomou E, Bothou A, Andreou S, Nalmpanti T, Chalkia K, Spanakis V, Tsikouras N, Pagkaki C, Iatrakis G, Damaskos C, Garmpis N, Machairiotis N, Nikolettos N. Renal Function and the Role of the Renin-Angiotensin-Aldosterone System (RAAS) in Normal Pregnancy and Pre-Eclampsia. J Clin Med 2025; 14:892. [PMID: 39941563 PMCID: PMC11818630 DOI: 10.3390/jcm14030892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2024] [Revised: 01/02/2025] [Accepted: 01/12/2025] [Indexed: 02/16/2025] Open
Abstract
Objective: Pre-eclampsia (PE) is a complex, advancing condition marked either by the recent emergence of hypertension and proteinuria or by the recent onset of hypertension accompanied by notable end-organ impairment, which may occur with or without proteinuria. PE usually appears in the postpartum phase or after the 20th week of gestation, though it might appear sooner in cases of molar pregnancy. Pathophysiology: This disorder is a serious multisystem condition during pregnancy that can lead to serious, life-threatening complications for both the mother and the fetus if it is not diagnosed and managed promptly. These changes result from widespread and intense vasoconstriction caused by renin, angiotensin II (Ang II), aldosterone, and catecholamines. The renin-angiotensin-aldosterone system (RAAS) and its sequence of signaling reactions demonstrate its crucial role in regulating blood pressure and electrolyte balance that diverges in PE from that observed in healthy pregnancies. However, it is widely recognized that the above description is incomplete for pre-eclampsia and further relationships should be analyzed. The purpose of this article is to review and synthesize alterations in renal function and the RAAS during normal pregnancy and pre-eclampsia. We aim to provide clinical gynecologists with a comprehensive understanding of how pregnancy-specific adaptations can impact renal function and the RAAS, as well as the deviations observed in pre-eclampsia. Conclusion: This information is essential to enhance clinical awareness, improve the accuracy of diagnosis, and support evidence-based decision-making in the management of pregnant patients, especially those complicated by pre-eclampsia.
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Affiliation(s)
- Panagiotis Tsikouras
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (K.N.); (S.K.); (N.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (C.P.); (N.N.)
| | - Konstantinos Nikolettos
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (K.N.); (S.K.); (N.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (C.P.); (N.N.)
| | - Sonia Kotanidou
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (K.N.); (S.K.); (N.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (C.P.); (N.N.)
| | - Nektaria Kritsotaki
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (K.N.); (S.K.); (N.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (C.P.); (N.N.)
| | - Efthymios Oikonomou
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (K.N.); (S.K.); (N.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (C.P.); (N.N.)
| | - Anastasia Bothou
- Department of Midwifery, School of Health Sciences, University of West Attica (UNIWA), Egaleo Park Campus-28, Ag. Spyridonos Street, 12243 Egaleo, Greece; (A.B.); (G.I.)
| | - Sotiris Andreou
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (K.N.); (S.K.); (N.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (C.P.); (N.N.)
| | - Theopi Nalmpanti
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (K.N.); (S.K.); (N.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (C.P.); (N.N.)
| | - Kyriaki Chalkia
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (K.N.); (S.K.); (N.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (C.P.); (N.N.)
| | - Vlasios Spanakis
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (K.N.); (S.K.); (N.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (C.P.); (N.N.)
| | - Nikolaos Tsikouras
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (K.N.); (S.K.); (N.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (C.P.); (N.N.)
| | - Christina Pagkaki
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (K.N.); (S.K.); (N.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (C.P.); (N.N.)
| | - George Iatrakis
- Department of Midwifery, School of Health Sciences, University of West Attica (UNIWA), Egaleo Park Campus-28, Ag. Spyridonos Street, 12243 Egaleo, Greece; (A.B.); (G.I.)
| | - Christos Damaskos
- Department of Emergency Surgery, Laiko General Hospital, 11527 Athens, Greece;
- N.S. Christeas Laboratory of Experimental Surgery and Surgical Research, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Nikolaos Garmpis
- N.S. Christeas Laboratory of Experimental Surgery and Surgical Research, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece;
- Department of Surgery, Sotiria General Hospital, 11527 Athens, Greece
| | | | - Nikolaos Nikolettos
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (K.N.); (S.K.); (N.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (C.P.); (N.N.)
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Clark CR, Khalil RA. Regulation of vascular angiotensin II type 1 and type 2 receptor and angiotensin-(1-7)/MasR signaling in normal and hypertensive pregnancy. Biochem Pharmacol 2024; 220:115963. [PMID: 38061417 PMCID: PMC10860599 DOI: 10.1016/j.bcp.2023.115963] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 01/01/2024]
Abstract
Normal pregnancy (Norm-Preg) is associated with a slight reduction in blood pressure (BP) and decreased BP response to vasoconstrictor stimuli such as angiotensin II (Ang II), although the renin-angiotensin-aldosterone system (RAAS) is upregulated. Preeclampsia (PE) is a complication of pregnancy manifested as hypertension-in-pregnancy (HTN-Preg), and dysregulation of angiotensin biosynthesis and signaling have been implicated. Ang II activates vascular Ang II type-1 receptor (AT1R) and Ang II type-2 receptor (AT2R), while angiotensin-(1-7) promotes Ang-(1-7)/MasR signaling. The role of AT1R in vasoconstriction and the activated cellular mechanisms are well-characterized. The sensitivity of vascular AT1R to Ang II and consequent activation of vasoconstrictor mechanisms decrease during Norm-Preg, but dramatically increase in HTN-Preg. Placental ischemia in late pregnancy could also initiate the release of AT1R agonistic autoantibodies (AT1AA) with significant impact on endothelial dysfunction and activation of contraction pathways in vascular smooth muscle including [Ca2+]c and protein kinase C. On the other hand, the role of AT2R and Ang-(1-7)/MasR in vascular relaxation, particularly during Norm-Preg and PE, is less clear. During Norm-Preg, increases in the expression/activity of vascular AT2R and Ang-(1-7)/MasR promote the production of endothelium-derived relaxing factors such as nitric oxide (NO), prostacyclin and endothelium-derived hyperpolarizing factor leading to generalized vasodilation. Aortic segments of Preg rats show prominent endothelial AT2R staining and increased relaxation and NO production in response to AT2R agonist CGP42112A, and treatment with AT2R antagonist PD123319 enhances phenylephrine-induced contraction. Decreased vascular AT2R and Ang-(1-7)/MasR expression and receptor-mediated mechanisms of vascular relaxation have been suggested in HTN-Preg animal models, but their role in human PE needs further testing. Changes in angiotensin-converting enzyme-2 (ACE2) have been observed in COVID-19 patients, and whether ACE2 influences the course of COVID-19 viral infection/immunity in Norm-Preg and PE is an intriguing area for research.
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Affiliation(s)
- Caroline R Clark
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA 02115, USA
| | - Raouf A Khalil
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA 02115, USA.
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Wang X, Kong Y, Chen X, Weng Z, Li B. Pertinence between risk of preeclampsia and the renin-angiotensin-aldosterone system (RAAS) gene polymorphisms: an updated meta-analysis based on 73 studies. J OBSTET GYNAECOL 2023; 43:2171782. [PMID: 36718570 DOI: 10.1080/01443615.2023.2171782] [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: 02/01/2023]
Abstract
The aetiological mechanism of preeclampsia (PE) is unclear exactly, so we attempted to investigate the association between susceptibility to preeclampsia and renin-angiotensin-aldosterone system (RAAS) gene polymorphisms to explore the aetiology in terms of genetics. A systematic search was performed in electronic databases to identify relevant studies. Eventually 73 studies were enrolled, odds ratios were generated by 5 genetic models. In overall analysis, significant associations were detected for AGT M235T, AT1R A1166C and CYP11B2 C344T whereas negative correlation was shown for AGT T174M. As stratified by race and geography, AGT 235T allele and AT1R 1166C allele increased preeclampsia risk and AGT T174M was justified uncorrelated with preeclampsia. Our meta-analysis illustrated that AGT 235T allele and AT1R 1166C allele increased and CYP11B2 344T allele decreased preeclampsia risk while AGT T174M polymorphism did not change preeclampsia risk. Hence, pregnant women carrying high-risk genotypes need strengthened management to prevent and early identification of preeclampsia.
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Affiliation(s)
- Xin Wang
- Department of Obstetrics, Qingdao Municipal Hospital, Affiliated to Qingdao University, Medical College, Qingdao, China
| | - Yujie Kong
- Department of Obstetrics, Qingdao Municipal Hospital, Affiliated to Qingdao University, Medical College, Qingdao, China
| | - Xi Chen
- School of Health, Brooks College (Sunnyvale), Sunnyvale, CA, USA.,Department of Epidemiology and Statistics, School of Public Health, Medical College, Zhejiang University, Hangzhou, China
| | - Zhanping Weng
- Department of Obstetrics, Qingdao Municipal Hospital, Affiliated to Qingdao University, Medical College, Qingdao, China
| | - Baolai Li
- Department of Obstetrics, Qingdao Municipal Hospital, Affiliated to Qingdao University, Medical College, Qingdao, China
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