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Elgendy AM, Nafie MS, Nabil ZI, El-Shenawy NS, Gad El-Hak HN. Unveiling the antiurolithiatic potentiality of two benzene sulfonamide derivatives against ethylene glycol-induced renal calculi. Nefrologia 2025; 45:167-181. [PMID: 39986714 DOI: 10.1016/j.nefroe.2025.02.003] [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: 08/07/2024] [Accepted: 09/24/2024] [Indexed: 02/24/2025] Open
Abstract
OBJECTIVE Oxidative stress and inflammation play crucial roles in the onset of kidney injury and crystal formation caused by hyperoxaluria. Indapamide is a potent medication for treating renal calculi, but it has severe side effects such as hypokalemia, hypercalcemia, and hyperuricemia. Therefore, it is advisable to explore alternative treatments that do not have these side effects. The study aimed to reveal the antiurolithiatic potential of two benzene sulfonamide derivatives (SBCl and SBF; A and B, respectively) against ethylene glycol-induced kidney stones. METHODS The rats were divided into two main groups: the first group consisted of 20 rats with induced kidney stones, and the second group included 15 control rats. This division enabled a comparative analysis between rats with kidney stones and those without, offering insights into the effects of kidney stone induction on various physiological parameters and biochemical markers. The effectiveness of benzene sulfonamide derivatives (compounds A and B) was assessed in rats with induced kidney stones. The treatment was given orally by gavage for 21 days, administered every 48h after inducing kidney stones with 0.12ml of 5% ethylene glycol (EG). RESULTS The influence of compounds A and B on electrolytes, biochemical, antioxidant, and inflammatory reactions in induced kidneys underscores their potential therapeutic advantages in alleviating the advancement of kidney stone disease and related complications. CONCLUSION Both compounds were found to possess equal effectiveness in inhibiting the complications of stone formation. However, SBCl-EG showed superior antioxidant and inflammatory parameters effects compared to SBF-EG. Our study's findings underscore the potential benefits of derivatives in treating nephrolithiasis and related oxidative disorders, highlighting their superior effects on antioxidant and inflammatory responses compared to standard treatments.
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Affiliation(s)
- Ahmed M Elgendy
- Zoology Department, Faculty of Science, Suez Canal University, Ismailia 41522, Egypt
| | - Mohamed S Nafie
- Department of Chemistry, College of Sciences, University of Sharjah, Sharjah 27272, United Arab Emirates (UAE); Chemistry Department, Faculty of Science, Suez Canal University, Ismailia 41522, Egypt
| | - Zohour I Nabil
- Zoology Department, Faculty of Science, Suez Canal University, Ismailia 41522, Egypt
| | - Nahla S El-Shenawy
- Zoology Department, Faculty of Science, Suez Canal University, Ismailia 41522, Egypt.
| | - Heba N Gad El-Hak
- Zoology Department, Faculty of Science, Suez Canal University, Ismailia 41522, Egypt
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Schork A, Vogel E, Bohnert BN, Essigke D, Wörn M, Fischer I, Heyne N, Birkenfeld AL, Artunc F. Amiloride versus furosemide for the treatment of edema in patients with nephrotic syndrome: A pilot study (AMILOR). Acta Physiol (Oxf) 2024; 240:e14183. [PMID: 38822593 DOI: 10.1111/apha.14183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 05/14/2024] [Accepted: 05/18/2024] [Indexed: 06/03/2024]
Abstract
AIM In rodent models of nephrotic syndrome (NS), edema formation was prevented by blockade of the epithelial sodium channel ENaC with amiloride. However, apart from case reports, there is no evidence favoring ENaC blockade in patients with NS. METHODS The monocentric randomized controlled AMILOR study investigated the antiedematous effect of amiloride (starting dose 5 mg/day, max. 15 mg/day) in comparison to standard therapy with the loop diuretic furosemide (40 mg/day, max. 120 mg/day) over 16 days. Overhydration (OH) was measured by bioimpedance spectroscopy (BCM, Fresenius). Depending on the OH response, diuretic dose was adjusted on days 2, 5, 8 and 12, and if necessary, hydrochlorothiazide (HCT) was added from d8 (12.5 mg/day, max. 25 mg/day). The primary endpoint was the decrease in OH on d8. The study was terminated prematurely due to insufficient recruitment and a low statistical power due to a low actual effect size. RESULTS Median baseline OH was +26.4 (interquartile range 15.5-35.1)% extracellular water (ECW) in the amiloride arm and + 27.9 (24.1-29.4)% ECW in the furosemide arm and decreased by 1.95 (0.80-6.40) and 5.15 (0.90-8.30)% ECW after 8 days, respectively, and by 10.10 (1.30-14.40) and 7.40 (2.80-10.10)% ECW after 16 days, respectively. OH decrease on d8 and d16 was not significantly different between both arms. CONCLUSION The AMILOR study is the first randomized controlled pilot study suggesting a similar antiedematous effect as furosemide. Further studies are required to better define the role of amiloride in NS (EudraCT 2019-002607-18).
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Affiliation(s)
- Anja Schork
- Division of Diabetology, Endocrinology and Nephrology, Department of Internal Medicine IV, University Hospital Tübingen, Tübingen, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Tübingen, Germany
| | - Elisabeth Vogel
- Division of Diabetology, Endocrinology and Nephrology, Department of Internal Medicine IV, University Hospital Tübingen, Tübingen, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Tübingen, Germany
| | - Bernhard N Bohnert
- Division of Diabetology, Endocrinology and Nephrology, Department of Internal Medicine IV, University Hospital Tübingen, Tübingen, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Tübingen, Germany
| | - Daniel Essigke
- Division of Diabetology, Endocrinology and Nephrology, Department of Internal Medicine IV, University Hospital Tübingen, Tübingen, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Tübingen, Germany
| | - Matthias Wörn
- Division of Diabetology, Endocrinology and Nephrology, Department of Internal Medicine IV, University Hospital Tübingen, Tübingen, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Tübingen, Germany
| | - Imma Fischer
- Institute for Clinical Epidemiology and Applied Biometry, University Hospital Tübingen, Tübingen, Germany
| | - Nils Heyne
- Division of Diabetology, Endocrinology and Nephrology, Department of Internal Medicine IV, University Hospital Tübingen, Tübingen, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Tübingen, Germany
| | - Andreas L Birkenfeld
- Division of Diabetology, Endocrinology and Nephrology, Department of Internal Medicine IV, University Hospital Tübingen, Tübingen, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Tübingen, Germany
| | - Ferruh Artunc
- Division of Diabetology, Endocrinology and Nephrology, Department of Internal Medicine IV, University Hospital Tübingen, Tübingen, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Tübingen, Germany
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Yue Z, Xue X, Qian J. The association between polypharmacy and health-related quality of life among older adults with prostate cancer. J Geriatr Oncol 2024; 15:101772. [PMID: 38676976 DOI: 10.1016/j.jgo.2024.101772] [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: 11/10/2023] [Revised: 03/25/2024] [Accepted: 04/11/2024] [Indexed: 04/29/2024]
Abstract
INTRODUCTION Older adults with prostate cancer (PC) are at risk of polypharmacy, which further complicates disease management and health-related quality of life (HRQoL). This study evaluated the association between polypharmacy and HRQoL among Medicare beneficiaries with PC. MATERIALS AND METHODS This observational, retrospective study analyzed data from the Surveillance, Epidemiology, and End Results (SEER) Medicare Health Outcomes Survey (MHOS) data resource. Beneficiaries aged ≥65 and enrolled in Medicare Advantage Organizations were included if they had a PC diagnosis and continuously enrolled in Part D for 12 months prior to the completion of MHOS. Polypharmacy was determined based on the unique number of concurrent Part D prescriptions during 12 months before survey: no polypharmacy (NP, n = 0-4), polypharmacy (PP, n = 5-9), and excessive polypharmacy (EPP, n ≥ 10). HRQoL was assessed using the Physical and Mental Component Summary T-scores (PCS and MCS, respectively) in MHOS. ANOVA and Pearson's Chi-Square tests were performed to assess variances between polypharmacy and continuous/categorical variables. Multivariate linear regression models with generalized estimating equations were used to assess the association between polypharmacy and HRQoL. The severely impaired HRQoL cohort was identified based on normalized z-scores of PCS and MCS. Odds ratios were calculated to prioritize drug-drug and class-class pairs associated with patients with severely impaired HRQoL. RESULTS Data from 16,573 beneficiaries (24,126 records) showed that 44.4% had PP and 10.1% had EPP. Beneficiaries with PP and EPP had significantly lower mean PCS and MCS scores compared to those without polypharmacy (p < 0.001). After adjusting for covariates, beneficiaries with EPP had clinically significantly lower PCS (adjusted marginal difference: -8.47 [-9.00, -7.94]) and MCS (adjusted marginal difference: -4.32 [-4.89, -3.75]) compared to the NP group. Top-ranked drug-drug pairs like tiotropium bromide and oxycodone/acetaminophen exhibited significant associations with HRQoL decline. Analysis of class-class pairs highlighted (1) corticosteroid hormone receptor agonists and opioid agonists and (2) benzodiazepines and adrenergic beta2-agonists as having significant associations with HRQoL decline. DISCUSSION Polypharmacy exhibits a significant association with HRQoL declines among older adults with PC.
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Affiliation(s)
- Zongliang Yue
- Auburn University Harrison College of Pharmacy, Auburn, AL, USA
| | - Xiangzhong Xue
- Auburn University Harrison College of Pharmacy, Auburn, AL, USA
| | - Jingjing Qian
- Auburn University Harrison College of Pharmacy, Auburn, AL, USA.
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Frățilă G, Sorohan BM, Achim C, Andronesi A, Obrișcă B, Lupușoru G, Zilișteanu D, Jurubiță R, Bobeică R, Bălănică S, Micu G, Mocanu V, Ismail G. Oral Furosemide and Hydrochlorothiazide/Amiloride versus Intravenous Furosemide for the Treatment of Resistant Nephrotic Syndrome. J Clin Med 2023; 12:6895. [PMID: 37959360 PMCID: PMC10648037 DOI: 10.3390/jcm12216895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Data on diuretic treatment in nephrotic syndrome (NS) are scarce. Our goal was to assess the non-inferiority of the combined oral diuretics (furosemide/hydrochlorothiazide/amiloride) compared to intravenous (i.v.) furosemide in patients with NS and resistant edema. METHODS We conducted a prospective randomized trial on 22 patients with resistant nephrotic edema (RNE), defined as hypervolemia and a FENa < 0.2%. Based on a computer-generated 1:1 randomization, we assigned patients to receive either intravenous furosemide (40 mg bolus and then continuous administration of 5 mg/h) or oral furosemide (40 mg/day) and hydrochlorothiazide/amiloride (50/5 mg/day) for a period of 5 days. Clinical and laboratory measurements were performed daily. Hydration status was assessed by bioimpedance on day 1 and at the end of day 5 after treatment initiation. The primary endpoint was weight change from baseline to day 5. Secondary endpoints were hydration status change measured by bioimpedance and safety outcomes (low blood pressure, severe electrolyte disturbances, acute kidney injury and worsening hypervolemia). RESULTS Primary endpoint analysis showed that after 5 days of treatment, there was a significant difference in weight change from baseline between groups [adjusted mean difference: -3.33 kg (95% CI: -6.34 to -0.31), p = 0.03], with a higher mean weight change in the oral diuretic treatment group [-7.10 kg (95% CI: -18.30 to -4.30) vs. -4.55 kg (95%CI: -6.73 to -2.36)]. Secondary endpoint analysis showed that there was no significant difference between groups regarding hydration status change [adjusted mean difference: -0.05 L (95% CI: -2.6 to 2.6), p = 0.96], with a mean hydration status change in the oral diuretic treatment group of -4.71 L (95% CI: -6.87 to -2.54) and -3.91 L (95% CI: -5.69 to -2.13) in the i.v. diuretic treatment group. We observed a significant decrease in adjusted mean serum sodium of -2.15 mmol/L [(95% CI: -4.25 to -0.05), p = 0.04]), favored by the combined oral diuretic treatment [-2.70 mmol/L (95% CI: -4.89 to -0.50) vs. -0.10 mmol/L (95%CI: -1.30 to 1.10)]. No statistically significant difference was observed between the two groups in terms of adverse events. CONCLUSIONS A combination of oral diuretics based on furosemide, amiloride and hydrochlorothiazide is non-inferior to i.v. furosemide in weight control of patients with RNE and a similar safety profile.
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Affiliation(s)
- Georgiana Frățilă
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (G.I.)
| | - Bogdan Marian Sorohan
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (G.I.)
- Department of Kidney Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Camelia Achim
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (G.I.)
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (R.B.); (S.B.); (G.M.); (V.M.)
| | - Andreea Andronesi
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (G.I.)
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (R.B.); (S.B.); (G.M.); (V.M.)
| | - Bogdan Obrișcă
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (G.I.)
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (R.B.); (S.B.); (G.M.); (V.M.)
| | - Gabriela Lupușoru
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (G.I.)
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (R.B.); (S.B.); (G.M.); (V.M.)
| | - Diana Zilișteanu
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (G.I.)
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (R.B.); (S.B.); (G.M.); (V.M.)
| | - Roxana Jurubiță
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (R.B.); (S.B.); (G.M.); (V.M.)
| | - Raluca Bobeică
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (R.B.); (S.B.); (G.M.); (V.M.)
| | - Sonia Bălănică
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (R.B.); (S.B.); (G.M.); (V.M.)
| | - Georgia Micu
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (R.B.); (S.B.); (G.M.); (V.M.)
| | - Valentin Mocanu
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (R.B.); (S.B.); (G.M.); (V.M.)
| | - Gener Ismail
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (G.I.)
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (R.B.); (S.B.); (G.M.); (V.M.)
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Ying Y, Li N, Wang S, Zhang H, Zuo Y, Tang Y, Qiao P, Quan Y, Li M, Yang B. Urea Transporter Inhibitor 25a Reduces Ascites in Cirrhotic Rats. Biomedicines 2023; 11:biomedicines11020607. [PMID: 36831143 PMCID: PMC9953117 DOI: 10.3390/biomedicines11020607] [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: 12/22/2022] [Revised: 02/03/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
Ascites is a typical symptom of liver cirrhosis that is caused by a variety of liver diseases. Ascites severely affects the life quality of patients and needs long-term treatment. 25a is a specific urea transporter inhibitor with a diuretic effect that does not disturb the electrolyte balance. In this study, we aimed to determine the therapeutic effect of 25a on ascites with a dimethylnitrosamine (DMN)-induced cirrhotic rat model. It was found that 100 mg/kg of 25a significantly increased the daily urine output by 60% to 97% and reduced the daily abdominal circumference change by 220% to 260% in cirrhotic rats with a water intake limitation. The 25a treatment kept the serum electrolyte levels within normal ranges in cirrhotic rats. The H&E and Masson staining of liver tissue showed that 25a did not change the cirrhotic degree. A serum biochemical examination showed that 25a did not improve the liver function in cirrhotic rats. A Western blot analysis showed that 25a did not change the expression of fibrosis-related marker protein α-SMA, but significantly decreased the expressions of type I collagen in the liver of cirrhotic rats, indicating that 25a did not reverse cirrhosis, but could slow the cirrhotic progression. These data indicated that 25a significantly reduced ascites via diuresis without an electrolyte imbalance in cirrhotic rats. Our study provides a proof of concept that urea transporter inhibitors might be developed as novel diuretics to treat cirrhotic ascites.
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Affiliation(s)
- Yi Ying
- Department of Pharmacology, School of Basic Medical Sciences, Peking University, Beijing 100191, China
| | - Nannan Li
- Department of Pharmacology, School of Basic Medical Sciences, Peking University, Beijing 100191, China
| | - Shuyuan Wang
- Department of Pharmacology, School of Basic Medical Sciences, Peking University, Beijing 100191, China
| | - Hang Zhang
- Department of Pharmacology, School of Basic Medical Sciences, Peking University, Beijing 100191, China
| | - Yinglin Zuo
- The State Key Laboratory of Anti-Infective Drug Development, Sunshine Lake Pharma Co., Ltd., Dongguan 523871, China
| | - Yiwen Tang
- Department of Pharmacology, School of Basic Medical Sciences, Peking University, Beijing 100191, China
| | - Panshuang Qiao
- Department of Pharmacology, School of Basic Medical Sciences, Peking University, Beijing 100191, China
| | - Yazhu Quan
- Department of Pharmacology, School of Basic Medical Sciences, Peking University, Beijing 100191, China
| | - Min Li
- Department of Pharmacology, School of Basic Medical Sciences, Peking University, Beijing 100191, China
| | - Baoxue Yang
- Department of Pharmacology, School of Basic Medical Sciences, Peking University, Beijing 100191, China
- Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing 100191, China
- Correspondence:
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Guo L, Fu B, Liu Y, Hao N, Ji Y, Yang H. Diuretic resistance in patients with kidney disease: Challenges and opportunities. Biomed Pharmacother 2023; 157:114058. [PMID: 36473405 DOI: 10.1016/j.biopha.2022.114058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 11/15/2022] [Accepted: 11/27/2022] [Indexed: 12/10/2022] Open
Abstract
Edema caused by kidney disease is called renal edema. Edema is a common symptom of many human kidney diseases. Patients with renal edema often need to take diuretics.However, After taking diuretics, patients with kidney diseases are prone to kidney congestion, decreased renal perfusion, decreased diuretics secreted by renal tubules, neuroendocrine system abnormalities, abnormal ion transporter transport, drug interaction, electrolyte disorder, and hypoproteinemia, which lead to ineffective or weakened diuretic use and increase readmission rate and mortality. The main causes and coping strategies of diuretic resistance in patients with kidney diseases were described in detail in this report. The common causes of DR included poor diet (electrolyte disturbance and hypoproteinemia due to patients' failure to limit diet according to correct sodium, chlorine, potassium, and protein level) and poor drug compliance (the patient did not take adequate doses of diuretics. true resistance occurs only if the patient takes adequate doses of diuretics, but they are not effective), changes in pharmacokinetics and pharmacodynamics, electrolyte disorders, changes in renal adaptation, functional nephron reduction, and decreased renal blood flow. Common treatment measures include increasing in the diuretic dose and/or frequency, sequential nephron blockade,using new diuretics, ultrafiltration treatment, etc. In clinical work, measures should be taken to prevent or delay the occurrence and development of DR in patients with kidney diseases according to the actual situation of patients and the mechanism of various causes. Currently, there are many studies on DR in patients with heart diseases. Although the phenomenon of DR in patients with kidney diseases is common, there is a relatively little overview of the mechanism and treatment strategy of DR in patients with kidney diseases. Therefore, this paper hopes to show the information on DR in patients with kidney diseases to clinicians and researchers and broaden the research direction and ideas to a certain extent.
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Affiliation(s)
- Luxuan Guo
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Baohui Fu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Yang Liu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Na Hao
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Yue Ji
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Hongtao Yang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China.
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Inoue T, Hisamichi M, Ichikawa D, Shibagaki Y, Yazawa M. The Effect of Add-on Acetazolamide to Conventional Diuretics for Diuretic-resistant Edema Complicated with Hypercapnia: A Report of Two Cases. Intern Med 2022; 61:373-378. [PMID: 34373379 PMCID: PMC8866788 DOI: 10.2169/internalmedicine.7896-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
We herein report two cases in which add-on acetazolamide to furosemide was effective for diuretic-resistant volume overload and hypercapnia. Case 1 was a woman in her 40s presenting with volume overload due to the nephrotic syndrome with diabetes mellitus. Case 2 was a man in his 60s with fluid overload and non-nephrotic proteinuria and sepsis. In both cases, although fluid overload was resistant to high-dose loop diuretics and complicated with hypercapnia due to pulmonary effusion, add-on acetazolamide administration resulted in symptom resolution. The additional effect of acetazolamide occurred regardless of the degree of proteinuria and kidney function.
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Affiliation(s)
- Tomohiko Inoue
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Mikako Hisamichi
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
- Division of Nephrology, Department of Internal Medicine, Tokyo Takanawa Hospital, Japan
| | - Daisuke Ichikawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Masahiko Yazawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
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Wilcox CS, Testani JM, Pitt B. Pathophysiology of Diuretic Resistance and Its Implications for the Management of Chronic Heart Failure. Hypertension 2020; 76:1045-1054. [PMID: 32829662 PMCID: PMC10683075 DOI: 10.1161/hypertensionaha.120.15205] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diuretic resistance implies a failure to increase fluid and sodium (Na+) output sufficiently to relieve volume overload, edema, or congestion, despite escalating doses of a loop diuretic to a ceiling level (80 mg of furosemide once or twice daily or greater in those with reduced glomerular filtration rate or heart failure). It is a major cause of recurrent hospitalizations in patients with chronic heart failure and predicts death but is difficult to diagnose unequivocally. Pharmacokinetic mechanisms include the low and variable bioavailability of furosemide and the short duration of all loop diuretics that provides time for the kidneys to restore diuretic-induced Na+ losses between doses. Pathophysiological mechanisms of diuretic resistance include an inappropriately high daily salt intake that exceeds the acute diuretic-induced salt loss, hyponatremia or hypokalemic, hypochloremic metabolic alkalosis, and reflex activation of the renal nerves. Nephron mechanisms include tubular tolerance that can develop even during the time that the renal tubules are exposed to a single dose of diuretic, or enhanced reabsorption in the proximal tubule that limits delivery to the loop, or an adaptive increase in reabsorption in the downstream distal tubule and collecting ducts that offsets ongoing blockade of Na+ reabsorption in the loop of Henle. These provide rationales for novel strategies including the concurrent use of diuretics that block these nephron segments and even sequential nephron blockade with multiple diuretics and aquaretics combined in severely diuretic-resistant patients with heart failure.
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Affiliation(s)
- Christopher Stuart Wilcox
- From the Division of Nephrology and Hypertension and Hypertension Center, Georgetown University, Washington DC (C.S.W.)
| | | | - Bertram Pitt
- Division of Cardiology, University of Michigan, Ann Arbor, MI (B.P.)
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Abstract
Podocytopathies are kidney diseases in which direct or indirect podocyte injury drives proteinuria or nephrotic syndrome. In children and young adults, genetic variants in >50 podocyte-expressed genes, syndromal non-podocyte-specific genes and phenocopies with other underlying genetic abnormalities cause podocytopathies associated with steroid-resistant nephrotic syndrome or severe proteinuria. A variety of genetic variants likely contribute to disease development. Among genes with non-Mendelian inheritance, variants in APOL1 have the largest effect size. In addition to genetic variants, environmental triggers such as immune-related, infection-related, toxic and haemodynamic factors and obesity are also important causes of podocyte injury and frequently combine to cause various degrees of proteinuria in children and adults. Typical manifestations on kidney biopsy are minimal change lesions and focal segmental glomerulosclerosis lesions. Standard treatment for primary podocytopathies manifesting with focal segmental glomerulosclerosis lesions includes glucocorticoids and other immunosuppressive drugs; individuals not responding with a resolution of proteinuria have a poor renal prognosis. Renin-angiotensin system antagonists help to control proteinuria and slow the progression of fibrosis. Symptomatic management may include the use of diuretics, statins, infection prophylaxis and anticoagulation. This Primer discusses a shift in paradigm from patient stratification based on kidney biopsy findings towards personalized management based on clinical, morphological and genetic data as well as pathophysiological understanding.
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Trautmann A, Vivarelli M, Samuel S, Gipson D, Sinha A, Schaefer F, Hui NK, Boyer O, Saleem MA, Feltran L, Müller-Deile J, Becker JU, Cano F, Xu H, Lim YN, Smoyer W, Anochie I, Nakanishi K, Hodson E, Haffner D. IPNA clinical practice recommendations for the diagnosis and management of children with steroid-resistant nephrotic syndrome. Pediatr Nephrol 2020; 35:1529-1561. [PMID: 32382828 PMCID: PMC7316686 DOI: 10.1007/s00467-020-04519-1] [Citation(s) in RCA: 206] [Impact Index Per Article: 41.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 02/07/2020] [Accepted: 02/21/2020] [Indexed: 02/06/2023]
Abstract
Idiopathic nephrotic syndrome newly affects 1-3 per 100,000 children per year. Approximately 85% of cases show complete remission of proteinuria following glucocorticoid treatment. Patients who do not achieve complete remission within 4-6 weeks of glucocorticoid treatment have steroid-resistant nephrotic syndrome (SRNS). In 10-30% of steroid-resistant patients, mutations in podocyte-associated genes can be detected, whereas an undefined circulating factor of immune origin is assumed in the remaining ones. Diagnosis and management of SRNS is a great challenge due to its heterogeneous etiology, frequent lack of remission by further immunosuppressive treatment, and severe complications including the development of end-stage kidney disease and recurrence after renal transplantation. A team of experts including pediatric nephrologists and renal geneticists from the International Pediatric Nephrology Association (IPNA), a renal pathologist, and an adult nephrologist have now developed comprehensive clinical practice recommendations on the diagnosis and management of SRNS in children. The team performed a systematic literature review on 9 clinically relevant PICO (Patient or Population covered, Intervention, Comparator, Outcome) questions, formulated recommendations and formally graded them at a consensus meeting, with input from patient representatives and a dietician acting as external advisors and a voting panel of pediatric nephrologists. Research recommendations are also given.
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Affiliation(s)
- Agnes Trautmann
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Marina Vivarelli
- Department of Pediatric Subspecialties, Division of Nephrology and Dialysis, Bambino Gesù Pediatric Hospital and Research Center, Rome, Italy
| | - Susan Samuel
- Department of Pediatrics, Section of Pediatric Nephrology, Alberta Children's Hospital, University of Calgary, Calgary, Canada
| | - Debbie Gipson
- Division of Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - Aditi Sinha
- Department of Pediatrics, Division of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Ng Kar Hui
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Olivia Boyer
- Laboratory of Hereditary Kidney Diseases, Imagine Institute, INSERM U1163, Paris Descartes University, Paris, France
- Department of Pediatric Nephrology, Reference Center for Idiopathic Nephrotic Syndrome in Children and Adults, Necker Hospital, APHP, 75015, Paris, France
| | - Moin A Saleem
- Department of Pediatric Nephrology, Bristol Royal Hospital for Children, University of Bristol, Bristol, UK
| | - Luciana Feltran
- Hospital Samaritano and HRim/UNIFESP, Federal University of São Paulo, São Paulo, Brazil
| | | | - Jan Ulrich Becker
- Institute of Pathology, University Hospital of Cologne, Cologne, Germany
| | - Francisco Cano
- Department of Nephrology, Luis Calvo Mackenna Children's Hospital, University of Chile, Santiago, Chile
| | - Hong Xu
- Department of Nephrology, Children's Hospital of Fudan University, Shanghai, China
| | - Yam Ngo Lim
- Department of Pediatrics, Prince Court Medical Centre, Kuala Lumpur, Malaysia
| | - William Smoyer
- The Research Institute at Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Ifeoma Anochie
- Department of Paediatrics, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
| | - Koichi Nakanishi
- Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Elisabeth Hodson
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead and the Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Dieter Haffner
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover, Germany.
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Paediatric Research Center, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
- Center for Rare Diseases, Hannover Medical School Children's Hospital, Hannover, Germany.
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Wongboonsin J, Thongprayoon C, Bathini T, Ungprasert P, Aeddula NR, Mao MA, Cheungpasitporn W. Acetazolamide Therapy in Patients with Heart Failure: A Meta-Analysis. J Clin Med 2019; 8:jcm8030349. [PMID: 30871038 PMCID: PMC6463174 DOI: 10.3390/jcm8030349] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/04/2019] [Accepted: 03/08/2019] [Indexed: 02/07/2023] Open
Abstract
Background and objectives: Fluid overload and central sleep apnea are highly prevalent in patients with heart failure (HF). We performed this meta-analysis to assess the effects of acetazolamide therapy on acid/base balance and apnea indexes. Methods: A literature search was conducted using EMBASE, MEDLINE, and Cochrane Database from inception through 18 November 2017 to identify studies evaluating the use of acetazolamide in HF. Study results were analyzed using a random effects model. The protocol for this systematic review is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42017065401). Results: Nine studies (three randomized controlled trials and six cohort studies) with a total of 229 HF patients were enrolled. After acetazolamide treatment, there were significant decreases in serum pH (mean difference (MD) of −0.04 (95% CI, −0.06 to −0.02)), pCO2 (MD of −2.06 mmHg (95% CI, −3.60 to −0.53 mmHg)), and serum bicarbonate levels (MD of −6.42 mmol/L (95% CI, −10.05 to −2.79 mmol/L)). When compared to a placebo, acetazolamide significantly increased natriuresis (standardized mean difference (SMD) of 0.67 (95% CI, 0.08 to 1.27)), and decreased the apnea-hypopnea index (AHI) (SMD of −1.06 (95% CI, −1.75 to −0.36)) and central apnea index (CAI) (SMD of −1.10 (95% CI, −1.80 to −0.40)). Egger’s regression asymmetry tests revealed no publication bias with p = 0.20, 0.75 and 0.59 for analysis of the changes in pH, pCO2, and serum bicarbonate levels with use of acetazolamide in HF patients. Conclusion: Our study demonstrates significant reduction in serum pH, increase in natriuresis, and improvements in apnea indexes with use of acetazolamide among HF patients.
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Affiliation(s)
- Janewit Wongboonsin
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA.
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA.
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85721, USA.
| | - Patompong Ungprasert
- Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
| | - Narothama Reddy Aeddula
- Division of Nephrology, Department of Medicine, Deaconess Health System, Evansville, IN 47747, USA.
| | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA.
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA.
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Gupta S, Pepper RJ, Ashman N, Walsh SB. Nephrotic Syndrome: Oedema Formation and Its Treatment With Diuretics. Front Physiol 2019; 9:1868. [PMID: 30697163 PMCID: PMC6341062 DOI: 10.3389/fphys.2018.01868] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/11/2018] [Indexed: 01/01/2023] Open
Abstract
Oedema is a defining element of the nephrotic syndrome. Its' management varies considerably between clinicians, with no national or international clinical guidelines, and hence variable outcomes. Oedema may have serious sequelae such as immobility, skin breakdown and local or systemic infection. Treatment of nephrotic oedema is often of limited efficacy, with frequent side-effects and interactions with other pharmacotherapy. Here, we describe the current paradigms of oedema in nephrosis, including insights into emerging mechanisms such as the role of the abnormal activation of the epithelial sodium channel in the collecting duct. We then discuss the physiological basis for traditional and novel therapies for the treatment of nephrotic oedema. Despite being the cardinal symptom of nephrosis, few clinical studies guide clinicians to the rational use of therapy. This is reflected in the scarcity of publications in this field; it is time to undertake new clinical trials to direct clinical practice.
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Affiliation(s)
- Sanjana Gupta
- UCL Centre for Nephrology, University College London, London, United Kingdom.,Renal Unit, The Royal London Hospital, Bart's Health NHS Trust, London, United Kingdom
| | - Ruth J Pepper
- UCL Centre for Nephrology, University College London, London, United Kingdom
| | - Neil Ashman
- Renal Unit, The Royal London Hospital, Bart's Health NHS Trust, London, United Kingdom
| | - Stephen B Walsh
- UCL Centre for Nephrology, University College London, London, United Kingdom
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Acid-base disturbances in nephrotic syndrome: analysis using the CO 2/HCO 3 method (traditional Boston model) and the physicochemical method (Stewart model). Clin Exp Nephrol 2017; 21:866-876. [PMID: 28289910 PMCID: PMC5648741 DOI: 10.1007/s10157-017-1387-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 02/04/2017] [Indexed: 11/19/2022]
Abstract
Background The Stewart model for analyzing acid–base disturbances emphasizes serum albumin levels, which are ignored in the traditional Boston model. We compared data derived using the Stewart model to those using the Boston model in patients with nephrotic syndrome. Methods Twenty-nine patients with nephrotic syndrome and six patients without urinary protein or acid–base disturbances provided blood and urine samples for analysis that included routine biochemical and arterial blood gas tests, plasma renin activity, and aldosterone. The total concentration of non-volatile weak acids (ATOT), apparent strong ion difference (SIDa), effective strong ion difference (SIDe), and strong ion gap (SIG) were calculated according to the formulas of Agrafiotis in the Stewart model. Results According to the Boston model, 25 of 29 patients (90%) had alkalemia. Eighteen patients had respiratory alkalosis, 11 had metabolic alkalosis, and 4 had both conditions. Only three patients had hyperreninemic hyperaldosteronism. The Stewart model demonstrated respiratory alkalosis based on decreased PaCO2, metabolic alkalosis based on decreased ATOT, and metabolic acidosis based on decreased SIDa. We could diagnose metabolic alkalosis or acidosis with a normal anion gap after comparing delta ATOT [(14.09 − measured ATOT) or (11.77 − 2.64 × Alb (g/dL))] and delta SIDa [(42.7 − measured SIDa) or (42.7 − (Na + K − Cl)]). We could also identify metabolic acidosis with an increased anion gap using SIG > 7.0 (SIG = 0.9463 × corrected anion gap—8.1956). Conclusions Patients with nephrotic syndrome had primary respiratory alkalosis, decreased ATOT due to hypoalbuminemia (power to metabolic alkalosis), and decreased levels of SIDa (power to metabolic acidosis). We could detect metabolic acidosis with an increased anion gap by calculating SIG. The Stewart model in combination with the Boston model facilitates the analysis of complex acid–base disturbances in nephrotic syndrome.
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