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Hu J, Xu Y, Bachmann S, Mutig K. Angiotensin II receptor blockade alleviates calcineurin inhibitor nephrotoxicity by restoring cyclooxygenase 2 expression in kidney cortex. Acta Physiol (Oxf) 2021; 232:e13612. [PMID: 33377278 DOI: 10.1111/apha.13612] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 12/27/2022]
Abstract
AIM The use of calcineurin inhibitors such as cyclosporine A (CsA) for immunosuppression after solid organ transplantation is commonly limited by renal side effects. CsA-induced deterioration of glomerular filtration rate and sodium retention may be related to juxtaglomerular dysregulation as a result of suppressed cyclooxygenase 2 (COX-2) and stimulated renin biosynthesis. We tested whether CsA-induced COX-2 suppression is caused by hyperactive renin-angiotensin system (RAS) and whether RAS inhibition may alleviate the related side effects. METHODS Rats received CsA, the RAS inhibitor candesartan, or the COX-2 inhibitor celecoxib acutely (3 days) or chronically (3 weeks). Molecular pathways mediating effects of CsA and RAS on COX-2 were studied in cultured macula densa cells. RESULTS Pharmacological or siRNA-mediated calcineurin inhibition in cultured cells enhanced COX-2 expression via p38 mitogen-activated protein kinase and NF-kB signalling, whereas angiotensin II abolished these effects. Acute and chronic CsA administration to rats led to RAS activation along with reduced cortical COX-2 expression, creatinine clearance and fractional sodium excretion. Evaluation of major distal salt transporters, NKCC2 and NCC, showed increased levels of their activating phosphorylation upon CsA. Concomitant candesartan treatment blunted these effects acutely and completely normalized the COX-2 expression and renal functional parameters at long term. Celecoxib prevented the candesartan-induced improvements of creatinine clearance and sodium excretion. CONCLUSION Suppression of juxtaglomerular COX-2 upon CsA results from RAS activation, which overrides the cell-autonomous, COX-2-stimulatory effects of calcineurin inhibition. Angiotensin II antagonism alleviates CsA nephrotoxicity via the COX-2-dependent normalization of creatinine clearance and sodium excretion.
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Affiliation(s)
- Junda Hu
- Department of Anatomy Charité‐Universitätsmedizin Berlin Berlin Germany
| | - Yan Xu
- Department of Anatomy Charité‐Universitätsmedizin Berlin Berlin Germany
| | | | - Kerim Mutig
- Department of Anatomy Charité‐Universitätsmedizin Berlin Berlin Germany
- Department of Pharmacology I.M. Sechenov First Moscow State Medical University (Sechenov University) Moscow Russian Federation
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Schiffl H, Bergner A. Angiotensin-II, Renal Anemia and Hyporesponsiveness to Recombinant Human Erythropoietin. Int J Artif Organs 2018. [DOI: 10.1177/039139889902201003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- H. Schiffl
- Nephrology Section, Department of Internal Medicine, Klinikum Innenstadt, University of Munich - Germany
| | - A. Bergner
- Nephrology Section, Department of Internal Medicine, Klinikum Innenstadt, University of Munich - Germany
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Okumi M, Kawada N, Ichimaru N, Kitamura H, Abe T, Imamura R, Kojima Y, Kokado Y, Isaka Y, Rakugi H, Nonomura N, Moriyama T, Takahara S. Safety and efficacy of administering the maximal dose of candesartan in renal transplant recipients. Clin Exp Nephrol 2011; 15:907-15. [DOI: 10.1007/s10157-011-0503-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Accepted: 07/08/2011] [Indexed: 10/17/2022]
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Tian DF, Tian XL, Tian T, Wang ZY, Mo FK. Simultaneous Determination of Valsartan and Hydrochlorothiazide in Tablets by RP-HPLC. Indian J Pharm Sci 2011; 70:372-4. [PMID: 20046750 PMCID: PMC2792532 DOI: 10.4103/0250-474x.43006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Revised: 12/03/2007] [Accepted: 06/14/2008] [Indexed: 11/04/2022] Open
Abstract
A simple, reproducible and efficient reverse phase high performance liquid chromatographic method was developed for simultaneous determination of valsartan and hydrochlorothiazide in tablets. A column having 200 x 4.6 mm i.d. in isocratic mode with mobile phase containing methanol:acetonitrile:water:isopropylalcohol (22:18:68:2; adjusted to pH 8.0 using triethylamine; v/v) was used. The flow rate was 1.0 ml/min and effluent was monitored at 270 nm. The retention time (min) and linearity range (mug/ml) for valsartan and hydrochlorothiazide were (3.42, 8.43) and (5-150, 78-234), respectively. The developed method was found to be accurate, precise and selective for simultaneous determination of valsartan and hydrochlorothiazide in tablets.
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Affiliation(s)
- D F Tian
- Department of Pharmacy, School of Pharmacy, Shenyang Pharmaceutical University, 110016 Shenyang, China
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Philipp T, Martinez F, Geiger H, Moulin B, Mourad G, Schmieder R, Lievre M, Heemann U, Legendre C. Candesartan improves blood pressure control and reduces proteinuria in renal transplant recipients: results from SECRET. Nephrol Dial Transplant 2009; 25:967-76. [DOI: 10.1093/ndt/gfp581] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Gill JS. Cardiovascular disease in transplant recipients: current and future treatment strategies. Clin J Am Soc Nephrol 2008; 3 Suppl 2:S29-37. [PMID: 18309001 PMCID: PMC3152272 DOI: 10.2215/cjn.02690707] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A cardiovascular disease event in a transplant recipient may be the result of a pretransplantation disease process, a direct effect of immunosuppressant medications, or the result of exposure to a variety of traditional and nontraditional risk factors after transplantation. Although the understanding of posttransplantation cardiovascular disease remains incomplete, there is evidence that the impact of posttransplantation cardiovascular disease has been decreased, through increased attention to this problem. In the absence of controlled studies to guide therapy, this review summarizes treatment of cardiovascular disease risk factors for which there is strong evidence of benefit in the nontransplantation setting, observational evidence of a similar risk in transplant recipients, and evidence that treatment can be safely administered to transplant recipients. Putative risk factors for posttransplantation cardiovascular disease for which the current level of evidence is insufficient to support specific treatment recommendations are also discussed. Potential new strategies to decrease the risk for cardiovascular disease events after transplantation in the future, including aggressive pretransplantation risk reduction, individualized treatments to prevent different types of cardiovascular disease, dedicated efforts to reduce cardiovascular disease events during transitions between dialysis and transplantation, and manipulation of immunosuppressant protocols, are also introduced.
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Affiliation(s)
- John S Gill
- Division of Nephrology, University of British Columbia, St. Paul's Hospital, Providence Building, Ward 6a, 1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6.
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Salzberg DJ. Is RAS blockade routinely indicated in hypertensive kidney transplant patients? Curr Hypertens Rep 2007; 9:422-9. [DOI: 10.1007/s11906-007-0077-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Oxidative Stress in Cyclosporine-Induced Hypertension: Evidence of Beneficial Effects or Tolerance Development With Nitrate Therapy. Transplant Proc 2007; 39:2494-500. [DOI: 10.1016/j.transproceed.2007.07.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
Liver allograft recipients are at increased risk of death from cerebrovascular and cardiovascular disease. We propose the following strategy of risk-reduction, based on currently available literature. Lifestyle: standard advice should be given (avoidance of smoking, excess alcohol and obesity, adequate exercise, reduction of excess sodium intake). Hypertension: target blood pressure should be 140/90 mmHg or lower, but for those with diabetes or renal disease, 130/80 mmHg or lower. For patients without proteinuria, antihypertensive therapy should be initiated with a calcium channel blocker and for those with proteinuria, an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker. If monotherapy fails to achieve adequate response, calcium channel blockers and ACE-inhibitors or angiotensin II receptor blockers should be combined. If hypertension remains uncontrolled, an alpha-blocker may be added. Consideration should be given to changing immunosuppression and avoiding use of calcineurin inhibitors. Diabetes: recipients should be regularly screened for diabetes. For patients with new-onset diabetes after transplant, stepwise therapy should be guided by HbA1c concentrations, as with type II diabetes mellitus. Hyperlipidemia: annual screening of lipid profile should be undertaken, with treatment thresholds and targets based on those advocated for the high risk general population. Dietary intervention is appropriate for all patients. A statin should be considered as the first line treatment to achieve specified targets. In patients receiving a calcineurin inhibitor, Pravastatin should be commenced at a dose of 10 mg/day. In patients receiving other forms of immunosuppression, pravastatin may be commenced at a dose of 20 mg/day. Liver tests should be monitored and patients warned to report myalgia. If monotherapy is inadequate, ezetimibe or a fibrate may be added. Consideration may be given to change in immunosuppression if combination lipid-lowering therapy proves inadequate.
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Affiliation(s)
- George Mells
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
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Abstract
By the time of renal transplantation, end-stage renal disease patients have a huge burden of cardiovascular disease (CVD) and are heavily saturated with atherosclerotic risk factors. Worsening of preexisting risk factors or new CVD risk factors may develop in the posttransplant period consequent in part to the diabetogenic and atherogenic potential of immunosuppressive drugs. The annual risk of a fatal or non-fatal CVD event of 3.5 to 5% in kidney transplant recipients is 50-fold higher than the general population. Renal allograft dysfunction, proteinuria, anemia, moderate hyperhomocysteinemia and elevated serum C-reactive protein concentrations, each dependently confer greater risk of CVD morbidity and mortality in the posttransplant period. Long-term care of renal transplant recipients should programmatically incorporate the recommendations of the National Kidney Foundation Working Groups and European Best Practice Guidelines Expert Group on Renal Transplantations into the management of hypertension, dyslipidemia, smoking, and posttransplant diabetes mellitus. Timely utilization of coronary revascularization procedures should be undertaken as these treatments are equally effective in the kidney transplant population.
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Andrés A, Morales E, Morales JM, Bosch I, Campo C, Ruilope LM. Efficacy and Safety of Valsartan, an Angiotensin II Receptor Antagonist, in Hypertension After Renal Transplantation: A Randomized Multicenter Study. Transplant Proc 2006; 38:2419-23. [PMID: 17097955 DOI: 10.1016/j.transproceed.2006.08.066] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The prevalence of posttransplant hypertension is high, and it appears to be a major risk factor for graft and patient survival. The aim of this study was to assess the efficacy and safety of valsartan, an angiotensin-receptor blocker (ARB), in the treatment of posttransplant hypertension. METHODS A multinational, multicenter, prospective, randomized, double-blind, placebo-controlled study was performed on the treatment of hypertension (systolic blood pressure [BP] >/= 140 and/or diastolic BP >/= 90 mm Hg) in adult cyclosporin-treated renal transplant recipients randomized to receive either valsartan (80 mg once daily) or a matching placebo for 8 weeks. After the first 4 weeks, furosemide 20 mg twice daily was added on a open basis if systolic BP remained >/= 130 mm Hg and/or diastolic BP remained >/= 85 mm Hg. RESULTS One hundred fifteen (valsartan = 57, placebo = 58) uncontrolled hypertensive patients despite monotherapy for hypertension, other than angiotensin-converting enzyme inhibitor or ARB, were randomized. In the valsartan group, significant decreases were seen in systolic BP (from 153 +/- 11 to 140.9 +/- 18.35 mm Hg at 4 weeks, and 136.5 +/- 15 mm Hg at 8 weeks) and diastolic BP (from 93 +/- 9 to 85.2 +/- 11.28 mm Hg at 4 weeks, and 83.8 +/- 9.2 mm Hg at 8 weeks). There was no significant change in the placebo group. In the valsartan group, a statistically but not clinically significant reduction was observed in the mean hemoglobin concentration (12.9 +/- 1.6 g/dL versus 13.8 +/- 1.6 g/dL at 4 weeks, P < .01; and 12.3 +/- 1.6 versus 13.8 +/- 1.7 at 8 weeks; P < .001) as well as a significant increase in serum potassium (4.4 +/- 0.5 mmol/L versus 4.1 +/- 0.4 mmol/L at 4 weeks, P < .01) vs placebo. CONCLUSIONS Valsartan is effective in the treatment of posttransplant hypertension and is well tolerated.
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Affiliation(s)
- A Andrés
- Hospital 12 de Octubre, Nephrology Department, Barcelona, Spain.
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Ersoy A. Current and future antihypertensive drugs in post-transplant hypertension and related patents. Expert Opin Ther Pat 2006. [DOI: 10.1517/13543776.16.8.1093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Stamp L, Searle M, O'Donnell J, Chapman P. Gout in solid organ transplantation: a challenging clinical problem. Drugs 2006; 65:2593-611. [PMID: 16392875 DOI: 10.2165/00003495-200565180-00004] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Hyperuricaemia occurs in 5-84% and gout in 1.7-28% of recipients of solid organ transplants. Gout may be severe and crippling, and may hinder the improved quality of life gained through organ transplantation. Risk factors for gout in the general population include hyperuricaemia, obesity, weight gain, hypertension and diuretic use. In transplant recipients, therapy with ciclosporin (cyclosporin) is an additional risk factor. Hyperuricaemia is recognised as an independent risk factor for cardiovascular disease; however, whether anti-hyperuricaemic therapy reduces cardiovascular events remains to be determined. Dietary advice is important in the management of gout and patients should be educated to partake in a low-calorie diet with moderate carbohydrate restriction and increased proportional intake of protein and unsaturated fat. While gout is curable, its pharmacological management in transplant recipients is complicated by the risk of adverse effects and potentially severe interactions between immunosuppressive and hypouricaemic drugs. NSAIDs, colchicine and corticosteroids may be used to treat acute gouty attacks. NSAIDs have effects on renal haemodynamics, and must be used with caution and with close monitoring of renal function. Colchicine myotoxicty is of particular concern in transplant recipients with renal impairment or when used in combination with ciclosporin. Long-term urate-lowering therapy is required to promote dissolution of uric acid crystals, thereby preventing recurrent attacks of gout. Allopurinol should be used with caution because of its interaction with azathioprine, which results in bone marrow suppression. Substitution of mycophenylate mofetil for azathioprine avoids this interaction. Uricosuric agents, such as probenecid, are ineffective in patients with renal impairment. The exception is benzbromarone, which is effective in those with a creatinine clearance >25 mL/min. Benzbromarone is indicated in allopurinol-intolerant patients with renal failure, solid organ transplant or tophaceous/polyarticular gout. Monitoring for hepatotoxicty is essential for patients taking benzbromarone. Physicians should carefully consider therapeutic options for the management of hypertension and hyperlipidaemia, which are common in transplant recipients. While loop and thiazide diuretics increase serum urate, amlodipine and losartan have the same antihypertensive effect with the additional benefit of lowering serum urate. Atorvastatin, but not simvastatin, may lower uric acid, and while fenofibrate may reduce serum urate it has been associated with a decline in renal function. Gout in solid organ transplantation is an increasing and challenging clinical problem; it impacts adversely on patients' quality of life. Recognition and, if possible, alleviation of risk factors, prompt treatment of acute attacks and early introduction of hypouricaemic therapy with careful monitoring are the keys to successful management.
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Affiliation(s)
- Lisa Stamp
- Department of Medicine, Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch, New Zealand.
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Ribeiro AB. Angiotensin II antagonists--therapeutic benefits spanning the cardiovascular disease continuum from hypertension to heart failure and diabetic nephropathy. Curr Med Res Opin 2006; 22:1-16. [PMID: 16393425 DOI: 10.1185/030079905x75041] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The cardiovascular benefits of angiotensin II antagonists (AIIAs) have been evaluated not only in terms of their ability to lower blood pressure but also on their ability to prevent strokes, cardiac events, and target organ damage. This review summarizes the body of evidence-based data demonstrating the efficacy of AIIAs across the spectrum of cardiovascular disease. METHODS A PubMed/MEDLINE search of English-language articles (1990 to September 2005) was used to identify articles describing clinical studies, particularly outcome trials, or mechanisms of therapeutic action pertinent to the therapy of cardiovascular disease or nephropathy. FINDINGS The antihypertensive efficacy of AIIAs is apparent across a wide spectrum of hypertensive patients, including black and Asian patients and patients with isolated systolic hypertension. More importantly, large outcome-based studies have demonstrated the efficacy of AIIAs across the continuum of cardiovascular disease, including hypertension, heart failure, post-myocardial infarction, and diabetic nephropathy. The Losartan Intervention For Endpoint reduction in hypertension study (LIFE), Reduction of Endpoints in Non-insulin-dependent Diabetes Mellitus with the AII Antagonist Losartan (RENAAL), and the Irbesartan Type 2 Diabetic Nephropathy Trial (IDNT) indicate that AIIAs confer cardiovascular and renal protective effects beyond their ability to lower blood pressure. These bloodpressure independent protective benefits of AIIAs may arise not only by blocking the deleterious effects of AII mediated via the AT1-receptor but may also be due to beneficial molecule-specific effects. As a class, AIIAs are well tolerated with an overall adverse event profile generally comparable to placebo and superior to that typically seen with calcium channel blockers, ACE inhibitors, diuretics, and beta-blockers. CONCLUSIONS By utilizing the body of clinical trial evidence as a guide to rational prescribing of AIIAs, practitioners can expect to deliver clinical benefits to their patients in terms of survival, prognosis, and quality of life.
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Affiliation(s)
- Artur Beltrame Ribeiro
- Nephrology Division - UNIFESP - EPM, Hospital do Rim e Hipertensão, Fundação Oswaldo Ramos, Rua Borges Lagoa, 960, 04038-002 - Sao Paulo, SP, Brazil.
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Ersoy A, Kahvecioglu S, Ersoy C, Cift A, Dilek K. Anemia Due to Losartan in Hypertensive Renal Transplant Recipients Without Posttransplant Erythrocytosis. Transplant Proc 2005; 37:2148-50. [PMID: 15964363 DOI: 10.1016/j.transproceed.2005.03.085] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2004] [Indexed: 11/30/2022]
Abstract
Losartan is a safe, effective long-term treatment for hypertension or posttransplant erythrocytosis (PTE) in renal transplant recipients. There were only a few studies in patients without PTE and their results were different. Starting from week 6 and continuing to the week 12 we observed a decrease in hemoglobin (Hb) and hematocrit (Hct) levels in patients without PTE. Anemia developed in 42.8% of the patients, and Hb levels increased after the withdrawal of losartan treatment. There was a significant decrease in Hct levels beginning from week 3 when compared with the control group. Our study suggests that losartan therapy can decrease Hb beyond its antihypertensive efficacy. Based on the capacity of losartan to decrease Hb and Hct, this drug should be carefully used in patients with preexistent anemia or low Hb levels.
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Affiliation(s)
- A Ersoy
- Department of Nephrology, Uludağ University Medical School, 16059 Gorukle/Bursa, Turkey.
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de Champlain J. Do angiotensin II antagonists provide benefits beyond blood pressure reduction? Adv Ther 2005; 22:117-36. [PMID: 16020402 DOI: 10.1007/bf02849883] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Hypertension is a powerful risk factor for cardiovascular (CV) morbidity and mortality; therefore, blood pressure (BP) lowering plays a central role in reducing the cardiovascular complications of hypertension, including stroke. Recent outcomes studies--Losartan Intervention For Endpoint reduction in hypertension, Reduction of Endpoints in Non-insulin-dependent Diabetes Mellitus with the Angiotensin II Antagonist Losartan, and the Irbesartan Type 2 Diabetic Nephropathy Trial--suggest that some angiotensin II antagonists are associated with CV and renal effects beyond their ability to lower BP in patients with hypertension or diabetic nephropathy and may play a role in the prevention of new-onset type 2 diabetes. Angiotensin II antagonists are associated with a wide variety of vascular, cardiac, and renal effects, as well as molecule-specific effects independent of those induced by the angiotensin-I receptor. These actions may offer a mechanistic explanation for the outcome benefits observed in patients with hypertension or diabetic nephropathy. Angiotensin-converting enzyme inhibitors and calcium-channel blockers may also have effects that are not completely explained by differences in the antihypertensive response to these agents, but the evidence is less robust. Collectively, these findings suggest that management of patients with hypertension, with or without diabetes or renal disease, should no longer be viewed as simply a matter of correcting elevated BP. Antihypertensive agents that possess CV benefits beyond their BP-reducing effects should be used to prevent the development of end-organ damage.
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Affiliation(s)
- Jacques de Champlain
- Department of Physiology and Medicine, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada
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References. Am J Kidney Dis 2004. [DOI: 10.1053/j.ajkd.2004.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Montanaro D, Gropuzzo M, Tulissi P, Boscutti G, Mioni R, Risaliti A, Baccarani U, Adani GL, Sainz M, Bresadola F, Mioni G. Renal allograft protection with early angiotensin-converting enzyme inhibitors administration. Transplant Proc 2004; 36:692-4. [PMID: 15110633 DOI: 10.1016/j.transproceed.2004.03.071] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Twenty renal transplant recipients (RTx) with a normal ultrasound pattern of renal artery who began angiotensin-converting enzyme inhibitor (ACEI) therapy within 14 months after surgery (ACEI(+)) were studied retrospectively to evaluate endogenous creatinine clearance/1.73 m(2) body surface area (CrCl), proteinuria (UP), UP/CrCl (FUP), mean arterial pressure (MBP), total cholesterol, LDL, HDL, and triglycerides. Before (T(0)) and every month for 2 years after initiation of ACEI. Twenty-four RTx who never received ACEI (ACEI(-)) were studied in the same fashion. No differences in the parameters were noted at T(0); all RTx had CrCl >60 mL/min, Up less than 0.5 g/d, and stable renal function for 3 months before the study. In the ACEI cohort CrCl was reduced after 2 years compared with T(0) (65.6 +/- 2.8 vs 76 +/- 3.2 mL/min, P <.004), UP and FUP were both increased (660 +/- 60 vs 130 +/- 20 mg/d, 8.9 +/- 1.3 vs 2.8 +/- 0.6 mg/mL x 10(3); P <.001 and.002, respectively). UP >0.5 g/d was present in three cases. After 2 years the ACEI(+) group showed a decrease in CrCl (68.2 +/- 3.1 vs 73 +/- 2.2 mL/min) and the increase in UP (181 +/- 21 vs 139 +/- 18 mg/d) and in FUP (3.1 +/- 0.7 vs 2.6 +/- 0.9 mg/mL x 10(3)), which were not significantly different from the values at T(0). No cases showed UP >0.5 g/d. Moreover UP (P <.04), FUP (P <.03) and the percent reduction of CrCl (11.2 +/- 2.5% vs 4.6 +/- 1.8%, P <.05) were greater among ACEI(-) than ACEI(+) patients at 2 years. ACEI(-) patients showed correlation between the percent reduction of CrCl and UP (r =.51, P <.04). The values of MBP and lipids did not reveal any significant difference between the two groups. In conclusion, this study suggests that ACEI have a renoprotective effect, when used early, and may also prevent chronic allograft nephropathy.
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Affiliation(s)
- D Montanaro
- Division of Nephrology, "S.Maria della Misericordia" Hospital, Udine, Italy.
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Ruilope LM, Segura J. Losartan and other angiotensin II antagonists for nephropathy in type 2 diabetes mellitus: A review of the clinical trial evidence. Clin Ther 2003; 25:3044-64. [PMID: 14749145 DOI: 10.1016/s0149-2918(03)90091-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND End-stage renal disease (ESRD) in patients with type 2 diabetes mellitus (DM) is associated with a bleak prognosis. The life span of patients with DM who have undergone renal transplantation or who are undergoing dialysis is up to 30% shorter than that of individuals in the general population. Preventing or delaying the progression of renal disease from microalbuminuria to nephropathy, and ultimately, to ESRD is thus a crucial goal of DM management. OBJECTIVE This article reviews the growing worldwide problem of type 2 DM and ESRD, the renoprotective benefits of angiotensin II (AII) antagonists (AIIAs) such as losartan in patients with or without type 1 or 2 DM, potential mechanisms of renoprotection of AIIAs beyond blood pressure (BP) control, and the clinical-practice implications of available megatrials. METHODS Articles included in this review were identified using a MEDLINE search for English-language studies published between 1990 and 2003 and included the search terms diabetic nephropathy, type 2 diabetes mellitus, microalbuminuria, proteinuria, angiotensin II antagonists, angiotensin-converting enzyme inhibitors, and cardiovascular disease. Articles describing major clinical trials, new data, or new mechanisms pertinent to the management of type 2 DM were selected for review. RESULTS Currently, AIIAs such as losartan represent the only evidence-based treatment strategy for patients with type 2 DM and proteinuria. The Irbesartan in Patients with Type 2 Diabetes and Microalbuminuria (IRMA-2) study, the Reduction of End Points in Non-Insulin Dependent Diabetes Mellitus with the Angiotensin II Antagonist Losartan (RENAAL) study, and the Irbesartan Type 2 Diabetic Nephropathy Trial (IDNT) indicate that AIIAs postpone the progression of type 2 diabetic renal disease at all stages, ranging from microproteinuria to overt nephropathy and ESRD, RENAAL showed that losartan improves renal outcomes in patients with type 2 DM and nephropathy over and above that attributable to BP control alone. The renoprotective effect of losartan corresponded to an average delay of 2 years in the need for dialysis or kidney transplantation. CONCLUSIONS AIIAs such as losartan should perhaps be considered mandatory therapy in patients with diabetic nephropathy and should complement existing management strategies, such as reduced dietary protein intake, strict blood glucose control, and standard antihypertensive therapy. Collectively, these measures should improve survival and quality of life and reduce the health care burden of managing patients with diabetic nephropathy.
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Affiliation(s)
- Luis M Ruilope
- Hypertension Unit, Hospital 12 de Octubre, Madrid, Spain.
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Omoto K, Tanabe K, Tokumoto T, Shimmura H, Ishida H, Toma H. Use of candesartan cilexetil decreases proteinuria in renal transplant patients with chronic allograft dysfunction. Transplantation 2003; 76:1170-4. [PMID: 14578748 DOI: 10.1097/01.tp.0000073615.57523.ac] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Posttransplant proteinuria and hypertension are difficult to treat after renal transplantation. Therefore, we examined whether candesartan cilexetil is effective in reducing urinary protein excretion or in controlling hypertension in patients with renal allograft dysfunction. METHODS Sixty-two renal transplant recipients with proteinuria were enrolled in this study. They underwent kidney transplantation under cyclosporine or tacrolimus immunosuppression between February 1983 and December 1998. Causes of proteinuria were chronic rejection in 28, glomerulonephritis in 16, cyclosporine or tacrolimus nephrotoxicity in 9, and unknown in 9 recipients. The dose of candesartan cilexetil ranged from 4 to 12 mg/day. Eleven patients with proteinuria who had not been treated with candesartan cilexetil constituted a matched control population. RESULTS Hypertension was well controlled by administration of candesartan cilexetil. Both systolic blood pressure and diastolic blood pressure significantly decreased from 141.7+/-14.8 mm Hg to 118.7+/-11.9 mm Hg and 121.2+/-11.6 mm Hg, and from 89.0+/-13.0 mm Hg to 72.0+/-10.4 mm Hg and 74.9+/-9.4 mm Hg, at 2 months and 1 year after administration, respectively. Urinary protein excretion was reduced from 0.93+/-1.2 g/day to 0.34+/-0.7 g/day and 0.43+/-1.2 g/day at 2 months and 1 year after administration, respectively. The levels of creatinine clearance were 55.7+/-28.9 mL/min before treatment, 50.9+/-24.8 mL/min at 2 months, and 52.6+/-24.8 mL/min at 1 year after treatment, respectively. There was no clinically significant difference between them. Regarding the calcineurin inhibitor levels, there was no significant difference between the levels before and 1 year after treatment. There was a significant difference in all examinations (systolic blood pressure, diastolic blood pressure, proteinuria, and renal function) between the patients with and without candesartan at 1 year after treatment. No significant adverse effects occurred. CONCLUSIONS Candesartan cilexetil can effectively control hypertension and proteinuria without deterioration in renal allograft function. These data suggest that treatment with candesartan cilexetil may be useful for maintaining long-term renal allograft function.
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Affiliation(s)
- Kazuya Omoto
- Department of Urology, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
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23
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Al-Uzri A, Yorgin PD, Kling PJ. Anemia in children after transplantation: etiology and the effect of immunosuppressive therapy on erythropoiesis. Pediatr Transplant 2003; 7:253-64. [PMID: 12890002 DOI: 10.1034/j.1399-3046.2003.00042.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Anemia in children after renal transplantation is more common than previously appreciated. Multiple factors appear to play roles in the development of post-transplant anemia, the most common of which is absolute and/or functional iron deficiency anemia. Most experts recommend that iron limited anemias in transplant patients should be diagnosed using the same criteria as for chronic renal failure patients. Serum erythropoietin (EPO) levels are expected to normalize after a successful renal transplantation with a normal kidney function, yet both EPO deficiency and resistance have been reported. While no large controlled trials comparing the effect of different immunosuppressive agents on erythropoiesis after transplantation have been performed, generalized bone marrow suppression attributable to azathioprine (AZA), mycophenolate mofetil (MMF), tacrolimus, antithymocyte preparations has been reported. Pure red cell aplasia (PRCA) occurs rarely after transplantation and is characterized by the selective suppression of erythroid cells in the bone marrow. PRCA has been reported with the use of AZA, MMF, tacrolimus, angiotensin converting enzyme inhibitors (ACEI), but not with cyclosporine (CSA) use. Post-transplant hemolytic uremic syndrome has been reported with orthoclone anti T-cell antibody (OKT3), CSA and tacrolimus therapy. Viral infections including cytomegalovirus, Epstein-Barr virus and human parvovirus B19 have been reported to cause generalized marrow suppression. Management of severe anemia associated with immunosuppressive drugs generally requires lowering the dose, drug substitution or, when possible, discontinuation of the drug. Because this topic has been incompletely studied, our recommendation as to the best immunosuppressive protocol after renal transplantation remains largely dependent on the clinical response of the individual patient.
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Affiliation(s)
- Amira Al-Uzri
- Department of Pediatrics, Section of Pediatric Nephrology, Oregon Health Sciences University, 707 SW Gaines Road, Portland, OR, USA.
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Baroletti SA, Gabardi S, Magee CC, Milford EL. Calcium channel blockers as the treatment of choice for hypertension in renal transplant recipients: fact or fiction. Pharmacotherapy 2003; 23:788-801. [PMID: 12820820 DOI: 10.1592/phco.23.6.788.32180] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Posttransplantation hypertension has been identified as an independent risk factor for chronic allograft dysfunction and loss. Based on available morbidity and mortality data, posttransplantation hypertension must be identified and managed appropriately. During the past decade, calcium channel blockers have been recommended by some as the antihypertensive agents of choice in this population, because it was theorized that their vasodilatory effects would counteract the vasoconstrictive effects of the calcineurin inhibitors. With increasing data becoming available, reexamining the use of traditional antihypertensive agents, including diuretics and beta-blockers, or the newer agents, angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers, may be beneficial. Transplant clinicians must choose antihypertensive agents that will provide their patients with maximum benefit, from both a renal and a cardiovascular perspective. Beta-blockers, diuretics, and ACE inhibitors have all demonstrated significant benefit on morbidity and mortality in patients with cardiovascular disease. Calcium channel blockers have been shown to possess the ability to counteract cyclosporine-induced nephrotoxicity. When compared with beta-blockers, diuretics, and ACE inhibitors, however, the relative risk of cardiovascular events is increased with calcium channel blockers. With the long-term benefits of calcium channel blockers on the kidney unknown and a negative cardiovascular profile, these agents are best reserved as adjunctive therapy to beta-blockers, diuretics, and ACE inhibitors.
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Affiliation(s)
- Steven A Baroletti
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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25
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Abstract
PURPOSE OF REVIEW Hypertension is very common in renal transplant recipients and is a significant risk factor for mortality from cardiovascular diseases and for development of graft dysfunction. RECENT FINDINGS Recent guidelines for the treatment of hypertension (Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure VI Report and World Health Organization Guidelines) do not directly address post-transplant hypertension. Specific recommendations for the drug treatment of hypertension in renal allograft recipients have not been given in the Clinical Practice Guidelines of the American Society of Transplantation or those of the European Renal Association. SUMMARY The present paper summarizes some important aspects of post-transplant hypertension and discusses potential treatment strategies aimed at reducing blood pressure and thus improving patient and allograft survival.
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Affiliation(s)
- Leszek Tylicki
- Department of Internal Medicine, Nephrology and Transplantology, Medical University of Gdansk, Gdansk, Poland.
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26
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Vetuschi C, Giannandrea A. Anti-beer Evaluation of Hydrochlorothiazide and Losartan by UV Derivative Spectrophotometry. ANAL LETT 2003. [DOI: 10.1081/al-120019262] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Kim W, Lee S, Kang SK, Yu HC, Cho BH, Park SK. Effects of angiotensin converting enzyme inhibitor and angiotensin II receptor antagonist therapy in hypertensive renal transplant recipients. Transplant Proc 2002; 34:3223-4. [PMID: 12493427 DOI: 10.1016/s0041-1345(02)03688-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- W Kim
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, South Korea
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28
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Christians U, Jacobsen W, Benet LZ, Lampen A. Mechanisms of clinically relevant drug interactions associated with tacrolimus. Clin Pharmacokinet 2002; 41:813-51. [PMID: 12190331 DOI: 10.2165/00003088-200241110-00003] [Citation(s) in RCA: 223] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The clinical management of tacrolimus, a macrolide used as immunosuppressant after transplantation, is complicated by its narrow therapeutic index in combination with inter- and intraindividually variable pharmacokinetics. As a substrate of cytochrome P450 (CYP) 3A enzymes and P-glycoprotein, tacrolimus interacts with several other drugs used in transplantation medicine, which also are known CYP3A and/or P-glycoprotein inhibitors and/or inducers. In clinical studies, CYP3A/P-glycoprotein inhibitors and inducers primarily affect oral bioavailability of tacrolimus rather than its clearance, indicating a key role of intestinal P-glycoprotein and CYP3A. There is an almost complete overlap between the reported clinical drug interactions of tacrolimus and those of cyclosporin. However, in comparison with cyclosporin, only few controlled drug interaction studies have been carried out, but tacrolimus drug interactions have been extensively studied in vitro. These results are inconsistent and are of poor predictive value for clinical drug interactions because of false negative results. P-glycoprotein regulates distribution of tacrolimus through the blood-brain barrier into the brain as well as distribution into lymphocytes. Interaction of other drugs with P-glycoprotein may change tacrolimus tissue distribution and modify its toxicity and immunosuppressive activity. There is evidence that ethnic and gender differences exist for tacrolimus drug interactions. Therapeutic drug monitoring to guide dosage adjustments of tacrolimus is an efficient tool to manage drug interactions. In the near future, progress can be expected from studies evaluating potential pharmacokinetic interactions caused by herbal preparations and food components, the exact biochemical mechanism underlying tacrolimus toxicity, and the potential of inhibition of CYP3A and P-glycoprotein to improve oral bioavailability and to decrease intraindividual variability of tacrolimus pharmacokinetics.
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Affiliation(s)
- Uwe Christians
- Department of Anesthesiology, University of Colorado Health Sciences Center, Denver, Colorado, USA.
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29
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Quaglia MG, Donati E, Carlucci G, Mazzeo P, Fanali S. Determination of losartan and hydrochlorothiazide in tablets by CE and CEC. J Pharm Biomed Anal 2002; 29:981-7. [PMID: 12110382 DOI: 10.1016/s0731-7085(02)00138-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Capillary Electrophoresis (CE) and Capillary Electrochromatography (CEC) have been used to determine losartan and hydrochlorothiazide. The CE separation was carried out in an uncoated capillary filled with a 100 mM sodium borate pH 9 solution containing trimethyl-beta-cyclodextrins. CEC was performed using a capillary packed with a RP-18 stationary phase. The mobile phase was a mixture of 50 mM ammonium acetate pH 7, water, acetonitrile (1/1.5/7.5). By CE and CEC suitable methods to determine simultaneously losartan and hydrochlorothiazide in working standard mixture or pharmaceutical form were obtained. The proposed methods are very simple and both gave accurate and precise results.
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Affiliation(s)
- M G Quaglia
- Dipartimento Studi Farmaceutici, Università degli Studi di Roma, La Sapienza, Piazzale Aldo Moro 5, Rome, Italy.
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30
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Ersoy A, Dilek K, Usta M, Yavuz M, Güllülü M, Oktay B, Yurtkuran M. Angiotensin-II receptor antagonist losartan reduces microalbuminuria in hypertensive renal transplant recipients. Clin Transplant 2002; 16:202-5. [PMID: 12010144 DOI: 10.1034/j.1399-0012.2002.01127.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In recent years, it has been demonstrated that losartan lowers macroproteinuria in diabetic or non-diabetic renal transplant recipients (RTx) similar to angiotensin converting enzyme (ACE) inhibitors. Microalbuminuria (MAU) may reflect subclinical hyperfiltration damage of the glomerulus. It could be a marker of kidney dysfunction in renal transplantation. The aim of the study was to assess the efficacy of losartan in hypertensive RTx with MAU. This study was conducted in 17 (M/F: 4/13) stable RTx. No change was made in the medical treatment of the patients. All cases received 50 mg/day losartan therapy for 12 wk. Renal functions and MAU were determined 12 and 6 wk and just before the treatment as well as sixth and twelfth week of the treatment in all patients. Losartan satisfactorily lowered systemic blood pressure. A significant reduction in MAU was observed from 103 +/- 53 microg/min at the beginning to 59 +/- 25 microg/min in the sixth week and 47 +/- 24 microg/min in the twelfth week (p=0.0007 and 0.0005, respectively). From the sixth week of the treatment, the therapy significantly decreased hemoglobin, hematocrit and erythrocyte levels but did not change mean leukocyte and platelet counts, urea, creatinine levels and creatinine clearances. No serious side-effect was observed during the study. In conclusion, we found that losartan decreased MAU in hypertensive RTx. For that reason, it might be considered as the first choise antihypertensive agent for the renoprotection in selected patients.
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Affiliation(s)
- Alparslan Ersoy
- Division of Nephrology, Department of Internal Medicine, Uludag School of Medicine, Bursa, Turkey.
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31
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Domínguez-Gil B, Ortiz M, Sierra MP, Muñoz MA, Morales E, Andres A, Rodicio JL, Morales JM. Losartan reduces massive proteinuria in kidney transplant patients: a pilot study. Transplant Proc 2002; 34:368-9. [PMID: 11959331 DOI: 10.1016/s0041-1345(01)02806-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
There is ample evidence to support the recommendation of renin-angiotensin system blockade therapy as the standard of care for strategies aimed at preserving renal function in chronic renal disease. Nevertheless, despite the well established antihypertensive effects of these drugs, the use of renin-angiotensin system blockers in renal transplantation has been quite limited so far, nephrologists being afraid of the possibility of inducing renal insufficiency in patients with a single kidney transplant. However, current knowledge of the ability of these agents to control blood pressure and urinary protein excretion, as well as post-transplant erythrocytosis, effectively in kidney transplant recipients suggests that it is now time to apply renin-angiotensin system blockers to the field of renal transplantation.
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Affiliation(s)
- Giuseppe Remuzzi
- Department of Immunology and Clinic of Organ Transplantation, Ospedali Riuniti di Bergamo and Mario Negri Institute for Pharmacological Research, Bergamo, Italy.
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33
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Domínguez-Gil B, Espejo B, Muñoz M, Rodicio J, Morales J. Hipertensión arterial después del trasplante renal. HIPERTENSION Y RIESGO VASCULAR 2002. [DOI: 10.1016/s1889-1837(02)71231-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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34
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Altiparmak MR, Trablus S, Apaydin S, Başar O, Sariyar M, Serdengeçti K, Erek E. Is losartan as effective as enalapril on posttransplant persistent proteinuria? Transplant Proc 2001; 33:3368-9. [PMID: 11750440 DOI: 10.1016/s0041-1345(01)02450-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- M R Altiparmak
- Cerrahpasa Medical Faculty, Department of Nephrology, Istanbul, Turkey
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35
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Nakache R, Weinbroum A, Merhav H, Katz P, Kaplan E. Management of massive proteinuria following renal transplantation with mycophenolate mofetil and blood pressure normalization. Transplant Proc 2001; 33:2294-5. [PMID: 11377533 DOI: 10.1016/s0041-1345(01)01995-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- R Nakache
- Transplantation Unit, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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36
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Schmidt A, Gruber U, Böhmig G, Köller E, Mayer G. The effect of ACE inhibitor and angiotensin II receptor antagonist therapy on serum uric acid levels and potassium homeostasis in hypertensive renal transplant recipients treated with CsA. Nephrol Dial Transplant 2001; 16:1034-7. [PMID: 11328912 DOI: 10.1093/ndt/16.5.1034] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The angiotensin II (AT II) type I receptor antagonist losartan has been reported to increase urinary uric acid and potassium excretion. These effects might be beneficial in cyclosporin (CsA)-treated renal transplant recipients, who frequently suffer from hyperuricaemia and hyperkalaemia. METHODS In this prospective, open, randomized, two-way cross-over study we included 13 hypertensive CsA-treated patients after renal transplantation and administered either the angiotensin-converting enzyme (ACE) inhibitors enalapril or losartan. Laboratory parameters, 24-h urinary protein excretion, and mean 24-h arterial blood pressure (MAP) were checked after 3 weeks treatment with enalapril, after a wash-out period of 2 weeks, and before and after a 3-week treatment course with losartan. RESULTS Both drugs slightly reduced MAP (losartan from 97+/-6 to 94+/-9 and enalapril to 93+/-8 mmHg). Serum potassium levels significantly increased during enalapril therapy (from 4.3+/-0.5 to 4.8+/-0.4 mmol/l, P<0.05), as did, although not significantly, uric acid concentrations (from 7.8+/-1.9 to 8.2+/-1.8 mg/dl, P=0.5). Losartan, on the contrary, only mildly affected serum potassium (4.3+/-0.5 vs 4.5+/-0.5 mmol/l, P=0.25) and serum uric acid decreased (from 7.8+/-2.4 to 7.3+/-1.8 mg/dl, P=0.6). Serum aldosterone and urinary aldosterone excretion were significantly reduced only during ACE inhibitor treatment, which might explain the variable effects on potassium homeostasis. CONCLUSION Losartan may be a useful agent to reduce blood pressure and serum uric acid levels in renal transplant recipients treated with CSA: Furthermore, in this high-risk population, the effects on serum potassium levels are less marked with losartan than with enalapril.
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Affiliation(s)
- A Schmidt
- Division of Nephrology and Dialysis, Department of Medicine III, University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
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37
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Colak T, Emiroglu R, Karakayali H, Haberal M. The effect of losartan on posttransplant erythrocytosis. Transplant Proc 2001; 33:2014-5. [PMID: 11267606 DOI: 10.1016/s0041-1345(00)02771-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- T Colak
- Başkent University Faculty of Medicine, Department of General Surgery and Nephrology, Ankara, Turkey
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38
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Brenner BM, Cooper ME, de Zeeuw D, Grunfeld JP, Keane WF, Kurokawa K, McGill JB, Mitch WE, Parving HH, Remuzzi G, Ribeiro AB, Schluchter MD, Snavely D, Zhang Z, Simpson R, Ramjit D, Shahinfar S. The losartan renal protection study--rationale, study design and baseline characteristics of RENAAL (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan). J Renin Angiotensin Aldosterone Syst 2000; 1:328-35. [PMID: 11967819 DOI: 10.3317/jraas.2000.062] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The RENAAL Study is a double-blind, placebo-controlled trial to evaluate the renal protective effects of losartan in Type 2 diabetic patients with nephropathy. The study has enrolled 1513 patients and is expected to continue for 3.5 years after the last patient has been entered. Eligible patients must have a urinary albumin:creatinine ratio of at least 300 mg/g and serum creatinine between 1.3 to 3.0 mg/dL. Eligible hypertensive or normotensive patients are randomised to receive either losartan or placebo, in addition to their existing antihypertensive therapy. Medications that block angiotensin production or action, are excluded. The primary endpoint is a composite of the time to first event of doubling of serum creatinine, end-stage renal disease, or death; secondary endpoints include cardiovascular events, progression of renal disease, and changes in proteinuria; tertiary endpoints include quality of life, healthcare resource utilisation, and amputations. Patients include Caucasians (48.6%), Blacks (15.2%), Asians (16.7%), and Hispanics (18.2%). Baseline urinary albumin:creatinine ratio and serum creatinine levels average 1867 mg/g and 1.9 mg/dL, respectively. Mean systolic and diastolic blood pressures are 153 and 82 mmHg, respectively. RENAAL will document whether blockade of the AII receptor with losartan produces clinical benefits in patients with Type 2 diabetes and nephropathy.
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Affiliation(s)
- B M Brenner
- Renal Division, Brigham and Women's Hospital, Boston, MA, USA
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Klingbeil AU, Müller HJ, Delles C, Fleischmann E, Schmieder RE. Regression of left ventricular hypertrophy by AT1 receptor blockade in renal transplant recipients. Am J Hypertens 2000; 13:1295-300. [PMID: 11130774 DOI: 10.1016/s0895-7061(00)01213-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AT1 receptor antagonists control blood pressure (BP) effectively and reduce left ventricular hypertrophy in patients with essential hypertension. Because left ventricular hypertrophy is very common in renal transplant recipients, we examined the cardiovascular effects and the safety profile of the AT1 receptor antagonist losartan in hypertensive renal transplant recipients. In 20 renal transplant recipients with stable renal graft function 50 mg of losartan was added to the preexisting antihypertensive treatment (no angiotensin-converting enzyme inhibitors) at least 6 months after renal transplantation. Twenty-four-hour ambulatory BP, two-dimensional-guided M-mode echocardiography, and duplex sonography, as well as renal function, red blood cell count, cyclosporine A and FK 506 levels, erythropoetin, and angiotensin II concentration were determined at baseline and after 6 months of therapy. With 24-h ambulatory BP measurement, systolic blood pressure (SBP) was reduced by 7.5 +/- 2.4 mm Hg and diastolic blood pressure (DBP) by 4.5 +/- 1.8 mm Hg (P < .01 and P < .05, respectively). Posterior, septal, and relative wall thickness decreased by 0.95 +/- 0.2 mm, 0.91 +/- 0.2 mm and 0.04 +/- 0.01 mm, respectively (all P < .001). Left ventricular mass index decreased by 18.1 +/- 4.7 g/m2 (P < .01). Ejection fraction and midwall fractional fiber shortening as systolic parameters and the relation of passive-to-active diastolic filling of the left ventricle were unaltered. Serum creatinine and cyclosporine A concentration remained stable in all patients. Hemoglobin and hematocrit decreased by 1.0 +/- 0.3 g/dL and 3.6% +/- 0.9%, respectively (P < .002 and P < .001) without a change in serum erythropoetin level. In renal transplant recipients the AT1 receptor antagonist losartan reduces left ventricular hypertrophy without altering systolic or diastolic function. It is safe with regard to renal function and immunosuppression, but slightly decreases hemoglobin level.
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Affiliation(s)
- A U Klingbeil
- Department of Medicine IV and Nephrology, University of Erlangen-Nürnberg, Germany
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40
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Affiliation(s)
- K S Wong
- Department of Renal Medicine, Singapore General Hospital, Singapore
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41
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Klassen DK. How aggressively should blood pressure be treated in renal transplant recipients? Curr Hypertens Rep 2000; 2:473-7. [PMID: 10995523 DOI: 10.1007/s11906-000-0030-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Renal transplantation is the treatment of choice for many patients with endstage renal disease. Patient survival is improved compared with dialysis for all patient ages and racial groups. Renal allograft survival is closely connected with recipient blood pressure. Blood pressure treatment goals that improve patient outcome have been defined for patients with nontransplant renal disease but not for patients with renal transplants. Extrapolating from data from nonrenal transplant patients suggests that aggressive treatment of hypertension in renal transplant patients may improve allograft and patient survival.
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Affiliation(s)
- D K Klassen
- Division of Nephrology, University of Maryland Medical Systems, 22 S. Greene Street - N3W143, Baltimore, MD 21201, USA.
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42
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Carlucci G, Palumbo G, Mazzeo P, Quaglia MG. Simultaneous determination of losartan and hydrochlorothiazide in tablets by high-performance liquid chromatography. J Pharm Biomed Anal 2000; 23:185-9. [PMID: 10898169 DOI: 10.1016/s0731-7085(00)00268-5] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A method for the simultaneous determination of losartan potassium and hydrochlorothiazide in tablets is described. The procedure, based on the use of reversed-phase high-performance liquid chromatography, is linear in the concentration range 3.0-7.0 microg ml(-1) for losartan and 0.5-2.0 microg ml(-1) for hydrochlorothiazide, is simple and rapid and allows accurate and precise results. The limit of detection was 0.08 microg ml(-1) for losartan and 0.05 microg ml(-1) for hydrochlorothiazide.
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Affiliation(s)
- G Carlucci
- Dipartimeto di Chimica, Ingegneria Chimica e Materiali, Università dell'Aquila, Coppito (L'Aquila), Italy.
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43
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Abstract
In landmark clinical trials, pharmacological inhibition of the renin-angiotensin system (RAS) with angiotensin-converting enzyme inhibitors (ACEIs) attenuated the decline in renal function associated with chronic renal disease (CRD). Hemodynamic and nonhemodynamic effects of angiotensin II (Ang II) attest to its central role in the pathogenesis of CRD. Angiotensin II subtype 1 receptor antagonists (AT1RA) differ from ACEI in their effects on the RAS and on bradykinin metabolism. Elevations in bradykinin levels associated with ACEI and stimulation of angiotensin subtype 2 receptors resulting from AT1RA may produce therapeutic effects unique to each class of drug. Nevertheless, in animal models of CRD, ACEI and AT1RA exert equivalent renoprotection, implying that their renoprotective effects result primarily from inhibition of Ang II-mediated stimulation of angiotensin subtype 1 receptors. Clinical data comparing ACEI and AT1RA therapy in renal disease are limited to short-term studies, which indicate that AT1RAs have equivalent effects to ACEI on the major determinants of CRD progression, namely blood pressure and proteinuria. AT1RAs were well tolerated, with side-effect profiles similar to placebo. Taken together, available evidence suggests that AT1RAs will share the renoprotective properties of ACEI in human CRD. Nevertheless, the results of long-term clinical trials are required before AT1RA can be recommended as an alternative to ACEI in renoprotective therapy.
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Affiliation(s)
- M W Taal
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Strawn WB, Dean RH, Ferrario CM. Novel mechanisms linking angiotensin II and early atherogenesis. J Renin Angiotensin Aldosterone Syst 2000; 1:11-7. [PMID: 11967786 DOI: 10.3317/jraas.2000.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
We propose that Ang II exerts an as yet uncharacterized immunomodulatory effect on monocyte maturation, differentiation, or extravasation, which may depend on the myelomonocytic phenotype. Since the myelopoietic process originating at stem cells and culminating in release to the blood is at least 6 days, it is conceivable that the observation of reduced monocyte CD11b expression two weeks after completion of losartan treatment indicates a suppression of the CD11b phenotype in newly released CD14(+)/CD45(+) monocytes. Other studies employing suppression of AT(1)-receptors with deoxy-oligonucleotides have reported effects on blood pressure that surpass those predicted by the duration of the treatment.(87) These data would suggest that it is possible to interrupt a stimulatory signal by Ang II through a gene-related mechanism that in our experiments may reside in the mechanisms that regulate myelopoiesis. While our knowledge of the role of Ang II in the regulation of monocyte formation and function is incomplete, we have taken a first step in attempting to synthesize the data described above into a comprehensive hypothesis for further evaluation of the factors that initiate atherogenesis. Such effects may crucially contribute to the clinical benefit of AT(1)-receptor antagonists, independent of depressor effects, and may represent a paradigm for novel, anti-inflammatory actions by this class of drugs.
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Campistol JM, Iñigo P, Jimenez W, Lario S, Clesca PH, Oppenheimer F, Rivera F. Losartan decreases plasma levels of TGF-beta1 in transplant patients with chronic allograft nephropathy. Kidney Int 1999; 56:714-9. [PMID: 10432413 DOI: 10.1046/j.1523-1755.1999.00597.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Chronic allograft nephropathy represents the principal cause of graft loss after the first year of transplantation. Transforming growth factor-beta1 (TGF-beta1) is a key factor in fibrogenesis and has been involved in the pathogenesis of chronic allograft nephropathy and other chronic nephropathies. Experimental studies have demonstrated that the angiotensin II receptor antagonist (losartan) could decrease the synthesis of TGF-beta1. The aim of this study was to determine the plasma levels of TGF-beta1 in transplant patients with chronic allograft nephropathy, and to evaluate the effect of losartan on TGF-beta1 plasma levels and other vasoactive peptides (angiotensin II, plasma renin activity, aldosterone, endothelin-1, and nitrites and nitrates). Angiotensin-converting enzyme genotypes were also determined in all patients. METHODS Fourteen transplant patients with chronic allograft nephropathy were included. Treatment with losartan (50 mg) was introduced. Consecutive determinations of TGF-beta1 and other vasoactive peptides were performed during follow-up. RESULTS Patients with chronic allograft nephropathy presented higher plasma levels of TGF-beta1 than the control groups. The treatment with losartan significantly decreased the plasma levels of TGF-beta1 (P < 0.05) and endothelin (P < 0.05) in all patients. The decrease of TGF-beta1 was statistically correlated with the blockade of the angiotensin II receptor (P < 0.05). No significant correlation could be demonstrated between angiotensin-converting enzyme genotypes and TGF-beta, endothelin-1, and nitrite-nitrate serum levels. CONCLUSIONS This study demonstrates that losartan significantly decreases the plasma levels of TGF-beta1, the most important fibrogenetic factor. These results could play a decisive role in the treatment and prevention of chronic nephropathies, not only graft nephropathy, because the intrinsic pathogenetic mechanism is very similar in all forms, with a crucial roles for the renal renin-angiotensin system and TGF-beta1.
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Affiliation(s)
- J M Campistol
- Renal Transplant Unit and Hormonal Laboratory, Hospital Clinic, Institut d'Investigació Biomediques August Pi i Sunyer, University of Barcelona, Spain.
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