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Ridgway H, Moore GJ, Gadanec LK, Zulli A, Apostolopoulos V, Hoffmann W, Węgrzyn K, Vassilaki N, Mpekoulis G, Zouridakis M, Giastas P, Vidali VP, Kelaidonis K, Matsoukas MT, Dimitriou M, Mavromoustakos T, Tsiodras S, Gorgoulis VG, Karakasiliotis I, Chasapis CT, Matsoukas JM. Novel benzimidazole angiotensin receptor blockers with anti-SARS-CoV-2 activity equipotent to that of nirmatrelvir: computational and enzymatic studies. Expert Opin Ther Targets 2024. [PMID: 38828744 DOI: 10.1080/14728222.2024.2362675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/29/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Pre-existing hypertensive pathologies are linked to worsened outcomes in patients infected with severe-acute respiratory syndrome (SARS-CoV-2). Sartans, a family of anti-hypertensive angiotensin receptor blockers (ARBs), reduce morbidity and mortality in coronavirus 2019 patients by aeffecting angiotensin-converting enzyme-2 (ACE2). The purpose of this study was to determine the anti-SARS-CoV-2viral and antihypertensive abilities of nirmatrelvir, and commercially available (e.g. candesartan, losartan, and losartan carboxylic (Exp3174))) and newly synthesized sartans (e.g. benzimidazole-N-biphenyl carboxyl (ACC519C), and benzimidazole-N-biphenyl tetrazole (ACC519T)), compared to nirmatrelvir, the antiviral component of paxlovid. RESEARCH DESIGN AND METHODS Surface plasmon resonance-binding (SPR) and enzymatic studies were used to determine drug effect on ACE2, antiviral abilities were evaluated using Vero E6 cells infected with SARS-CoV-2 and antihypertensive effects were investigated using rabbit iliac arteries contracted to angiotensin II-dose response. RESULTS The antiviral activity of benzimidazole-based candesartan and ACC519C were equipotent with nirmatrelvir (95% inhibition), while the imidazole-based losartan and E×p3174and ACC519T were less potent (75-80 and 50%, respectively%) and E×p3174was the least effective (50%). Furthermore, SPR analysis revealed a high binding affinity of sartans for ACE2 protein. Moreover, candesartan and nirmatrelvir exhibited the greatest inhibitory and cytopathic effect (3.96%) when given in combination rather than individually (6.10% and 5.08%, respectively). In addition,The ACE2 enzymatic activity assays demonstrated enhancement or inhibition properties of novel sartans toward ACE2 enzyme. Lastly, ACC519T potently reduced angiotensin II-mediated contraction while nirmatrelvir and ACC519T(2) had no effect. CONCLUSION This study describes the discovery of a new class of benzimidazole-based sartans that drastically inhibit SARS-CoV-2, which could be attributed, at least in part, to their interaction with ACE2.
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Affiliation(s)
- Harry Ridgway
- AquaMem Consultants, Rodeo, NM, USA
- Institute for Sustainable Industries and Liveable Cities, Victoria University, Melbourne, Australia
| | - Graham J Moore
- Pepmetics Inc, 772 Murphy Place, Victoria, BC, Canada
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Laura Kate Gadanec
- Institute for Health and Sport, Immunology and Translational Research, Victoria University, Melbourne, Australia
| | - Anthony Zulli
- Institute for Health and Sport, Immunology and Translational Research, Victoria University, Melbourne, Australia
| | - Vasso Apostolopoulos
- Institute for Health and Sport, Immunology and Translational Research, Victoria University, Melbourne, Australia
- Immunology Program, Australian Institute for Musculoskeletal Science (AIMSS), Melbourne, Australia
| | - Weronika Hoffmann
- Intercollegiate Faculty of Biotechnology of University of Gdańsk and Medical University of Gdańsk, Gdańsk, Poland
| | - Katarzyna Węgrzyn
- Intercollegiate Faculty of Biotechnology of University of Gdańsk and Medical University of Gdańsk, Gdańsk, Poland
| | - Niki Vassilaki
- Laboratory of Molecular Virology, Hellenic Pasteur Institute, Athens, Greece
| | - George Mpekoulis
- Laboratory of Molecular Virology, Hellenic Pasteur Institute, Athens, Greece
| | - Marios Zouridakis
- Structural Neurobiology Research Group, Laboratory of Molecular Neurobiology and Immunology, Hellenic Pasteur Institute, Athens, Greece
| | - Petros Giastas
- Structural Neurobiology Research Group, Laboratory of Molecular Neurobiology and Immunology, Hellenic Pasteur Institute, Athens, Greece
- Department of Biotechnology, Agricultural University of Athens, Athens, Greece
| | - Veroniki P Vidali
- Natural Products and Bioorganic Chemistry Laboratory, Institute of Nanoscience & Nanotechnology, NCSR "Demokritos", Athens, Greece
| | | | | | - Marios Dimitriou
- Laboratory of Biology, Department of Medicine, Democritus University of Thrace, Xanthi, Greece
| | - Thomas Mavromoustakos
- Department of Chemistry, Laboratory of Organic Chemistry, National Kapodistrian University of Athens, Athens, Greece
| | - Sotirios Tsiodras
- Faculty of Medicine, 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilis G Gorgoulis
- Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
- Department of Histology and Embryology, Faculty of Medicine, National Kapodistrian University of Athens, Athens, Greece
- Faculty Institute for Cancer Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Biomedical Research Foundation, Academy of Athens, Athens, Greece
- Faculty of Health and Medical Sciences, University of Surrey, UK
| | - Ioannis Karakasiliotis
- Laboratory of Biology, Department of Medicine, Democritus University of Thrace, Xanthi, Greece
| | - Christos T Chasapis
- Institute of Chemical Biology, National Hellenic Research Foundation, Athens, Greece
| | - John M Matsoukas
- Institute for Health and Sport, Immunology and Translational Research, Victoria University, Melbourne, Australia
- NewDrug PC, Patras Science Park, Patras, Greece
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Chemistry, University of Patras, Patras, Greece
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Gracia-Ramos AE, Ángeles-Durán GY, Flores-Gómez IR, Flores-Martínez E, Valdin-Orozco TI, Reyes-Peralta JR, Pedraza-Hervert C, Garcia-Arroyo FA, Cortés Ortíz A, Pecero-Hidalgo MJ. Standard of care plus telmisartan on respiratory failure due to COVID-19 (STAR-COVID trial). Minerva Cardiol Angiol 2024; 72:102-110. [PMID: 38231079 DOI: 10.23736/s2724-5683.23.06463-3] [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: 01/18/2024]
Abstract
BACKGROUND The potential influence of renin-angiotensin inhibitors on the severity of SARS-CoV-2 infection has been considered in preclinical and observational studies with contradictory results. Therefore, we investigated the effect of telmisartan in reducing lung injury among hospitalized COVID-19 patients. METHODS The STAR-COVID trial was conducted as a prospective, parallel-group, randomized, open-label study involving hospitalized adult patients with severe COVID-19 (NCT04510662). Sixty-six patients were enrolled: 33 were assigned to the telmisartan group and 33 to the control group. The mean age of participants was 48.8 years, with 62.5% being male. Participants were randomly assigned in a 1:1 ratio to receive either telmisartan (40 mg daily for 14 days or until discharge) plus standard of care or standard of care alone. The primary outcome assessed was the initiation of mechanical ventilation within 14 days. Secondary outcomes included 30-day mortality, the need for vasopressors, hemodialysis requirements, and length of hospital stay. RESULTS Comparison between the telmisartan group and the control group revealed no significant difference in the occurrence of mechanical ventilation at 14 days (25% with telmisartan vs. 18.7% with control, P=0.579). Additionally, there were no significant differences observed in terms of mortality (25% vs. 21.9%, P=0.768), the need for vasopressors (18.8% in both groups, P=1.000), hemodialysis requirements (6.3% vs. 3.1%, P=0.500), and length of hospital stay (median of 7 days in both groups, P=0.962). CONCLUSIONS Compared with the standard of care, telmisartan therapy demonstrated no significant impact on respiratory failure in hospitalized patients with severe COVID-19.
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Affiliation(s)
- Abraham E Gracia-Ramos
- Department of Internal Medicine, La Raza Medical Complex, Mexican Social Security Institute, UMAE Hospital General "Dr. Gaudencio González Garza, " Mexico City, Mexico -
- School of Medicine, Section of Graduate Studies and Research, National Polytechnic Institute of Mexico, Mexico City, Mexico -
| | - Gissel Y Ángeles-Durán
- Department of Internal Medicine, Hospital Regional de Alta Especialidad de Zumpango (HRAEZ), Zumpango, Mexico
| | - Iván R Flores-Gómez
- Department of Internal Medicine, Hospital Regional de Alta Especialidad de Zumpango (HRAEZ), Zumpango, Mexico
| | - Emmanuel Flores-Martínez
- Department of Internal Medicine, Hospital Regional de Alta Especialidad de Zumpango (HRAEZ), Zumpango, Mexico
| | - Tania I Valdin-Orozco
- Department of Internal Medicine, Hospital Regional de Alta Especialidad de Zumpango (HRAEZ), Zumpango, Mexico
| | - Jesús R Reyes-Peralta
- Department of Internal Medicine, Hospital Regional de Alta Especialidad de Zumpango (HRAEZ), Zumpango, Mexico
| | - César Pedraza-Hervert
- Department of Internal Medicine, Hospital Regional de Alta Especialidad de Zumpango (HRAEZ), Zumpango, Mexico
| | - Flor A Garcia-Arroyo
- Department of Internal Medicine, Hospital Regional de Alta Especialidad de Zumpango (HRAEZ), Zumpango, Mexico
| | - Antonio Cortés Ortíz
- Department of Cardiology, Hospital Regional de Alta Especialidad de Zumpango (HRAEZ), Zumpango, Mexico
| | - María J Pecero-Hidalgo
- Director Office, Hospital Regional de Alta Especialidad de Zumpango (HRAEZ), Zumpango, Mexico
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Fernainy P, Cohen AA, Murray E, Losina E, Lamontagne F, Sourial N. Rethinking the pros and cons of randomized controlled trials and observational studies in the era of big data and advanced methods: a panel discussion. BMC Proc 2024; 18:1. [PMID: 38233894 PMCID: PMC10795211 DOI: 10.1186/s12919-023-00285-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
Randomized controlled trials (RCTs) have traditionally been considered the gold standard for medical evidence. However, in light of emerging methodologies in data science, many experts question the role of RCTs. Within this context, experts in the USA and Canada came together to debate whether the primacy of RCTs as the gold standard for medical evidence, still holds in light of recent methodological advances in data science and in the era of big data. The purpose of this manuscript, aims to raise awareness of the pros and cons of RCTs and observational studies in order to help guide clinicians, researchers, students, and decision-makers in making informed decisions on the quality of medical evidence to support their work. In particular, new and underappreciated advantages and disadvantages of both designs are contrasted. Innovations taking place in both of these research methodologies, which can blur the lines between the two, are also discussed. Finally, practical guidance for clinicians and future directions in assessing the quality of evidence is offered.
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Affiliation(s)
- Pamela Fernainy
- Department of Health Management, Evaluation and Policy, School of Public Health, University of Montreal, Montreal, QC, Canada.
- Research Centre of the Centre Hospitalier de L'Université de Montréal (CHUM), Montreal, QC, Canada.
| | - Alan A Cohen
- Department of Family and Emergency Medicine, Faculty of Medicine and Health Sciences, University of Sherbrooke, Montreal, QC, Canada
- CHUS Research Centre, Montreal, QC, Canada
- Centre de Recherche Sur Le Vieillissement, Montreal, QC, Canada
- Butler Columbia Aging Center, New York, NY, USA
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University New York, New York, USA
| | - Eleanor Murray
- School of Public Health, Boston University, Boston, MA, USA
| | - Elena Losina
- Harvard Medical School Department of Orthopedic Surgery, Cambridge, MA, USA
| | - Francois Lamontagne
- CHUS Research Centre, Montreal, QC, Canada
- Departement de Medicine, University of Sherbrooke, Montreal, QC, Canada
| | - Nadia Sourial
- Department of Health Management, Evaluation and Policy, School of Public Health, University of Montreal, Montreal, QC, Canada
- Research Centre of the Centre Hospitalier de L'Université de Montréal (CHUM), Montreal, QC, Canada
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Lee MMY, Kondo T, Campbell RT, Petrie MC, Sattar N, Solomon SD, Vaduganathan M, Jhund PS, McMurray JJV. Effects of renin-angiotensin system blockers on outcomes from COVID-19: a systematic review and meta-analysis of randomized controlled trials. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:68-80. [PMID: 37740450 PMCID: PMC10766905 DOI: 10.1093/ehjcvp/pvad067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/18/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND AND AIMS Randomized controlled trials (RCTs) have assessed the effects of renin-angiotensin system (RAS) blockers in adults with coronavirus disease 2019 (COVID-19). This meta-analysis provides estimates of the safety and efficacy of treatment with (vs. without) RAS blockers from these trials. METHODS PubMed, Web of Science, and ClinicalTrials.gov were searched (1 March-12 April 2023). Event/patient numbers were extracted, comparing angiotensin-converting enzyme (ACE) inhibitor/angiotensin-receptor blocker (ARB) treatment with no treatment, for the outcomes: intensive care unit (ICU) admission, mechanical ventilation, vasopressor use, acute kidney injury (AKI), renal replacement therapy (RRT), acute myocardial infarction, stroke/transient ischaemic attack, heart failure, thromboembolic events, and all-cause death. Fixed-effects meta-analysis estimates were pooled. RESULTS Sixteen RCTs including 3492 patients were analysed. Compared with discontinuation of RAS blockers, continuation was not associated with increased risk of ICU [risk ratio (RR) 0.96, 0.66-1.41], ventilation (RR 0.77, 0.55-1.09), vasopressors (RR 0.92, 0.58-1.44), AKI (RR 1.01, 0.40-2.56), RRT (RR 1.01, 0.46-2.21), or thromboembolic events (RR 1.07, 0.36-3.19). RAS blocker initiation was not associated with increased risk of ICU (RR 0.71, 0.47-1.08), ventilation (RR 1.12, 0.91-1.38), AKI (RR 1.28, 0.89-1.86), RRT (RR 1.66, 0.89-3.12), or thromboembolic events (RR 1.20, 0.06-23.70), although vasopressor use increased (RR 1.27, 1.02-1.57). The RR for all-cause death in the continuation/discontinuation trials was 1.24 (0.80-1.92), and 1.22 (0.96-1.55) in the initiation trials. In patients with severe/critical COVID-19, RAS blocker initiation increased the risk of all-cause death (RR 1.31, 1.01-1.72). CONCLUSION ACE inhibitors and ARBs may be continued in non-severe COVID-19 infection, where indicated. Conversely, initiation of RAS blockers may be harmful in critically ill patients.PROSPERO registration number: CRD42023408926.
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Affiliation(s)
- Matthew M Y Lee
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ross T Campbell
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - Mark C Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - Naveed Sattar
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
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5
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Fumeaux T, Berger C, Bausch A, Wright M, Vilimanovich U, Soldatovic I, Vehreschild MJ. The KINETIC phase 2 randomized controlled trial of oral pamapimod-pioglitazone in non-critically ill COVID-19 inpatients. iScience 2023; 26:108038. [PMID: 37876609 PMCID: PMC10590811 DOI: 10.1016/j.isci.2023.108038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/18/2023] [Accepted: 09/21/2023] [Indexed: 10/26/2023] Open
Abstract
The combination of pamapimod and pioglitazone (KIN001) has a synergetic antiviral, anti-inflammatory, and antifibrotic activity, which may prevent evolution toward COVID-19-associated severe respiratory failure. In a randomized, placebo-controlled, double-blind, phase 2, multicenter trial, 128 non-critically ill hospitalized patients with confirmed COVID-19 were treated with KIN001 or a placebo for 28 days. The proportion of patients alive and free of oxygen or respiratory support at the end of the therapy was lower than anticipated but not different in the two groups (KIN001 n = 19, 29%, placebo n = 21, 33%). 85 participants had at least one adverse event, with no difference in the number and distribution of events between the two groups. The clinical trial was stopped for futility, mainly due to a lower-than-expected incidence of the primary endpoint. KIN001 was safe and well-tolerated but had no significant effect on clinical outcome.
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Affiliation(s)
- Thierry Fumeaux
- Kinarus Therapeutics AG, Technologiepark Basel, Hochbergerstrasse 60C, 4057 Basel, Switzerland
| | - Claudia Berger
- Kinarus Therapeutics AG, Technologiepark Basel, Hochbergerstrasse 60C, 4057 Basel, Switzerland
| | - Alexander Bausch
- Kinarus Therapeutics AG, Technologiepark Basel, Hochbergerstrasse 60C, 4057 Basel, Switzerland
| | - Matthew Wright
- Kinarus Therapeutics AG, Technologiepark Basel, Hochbergerstrasse 60C, 4057 Basel, Switzerland
| | | | | | - Maria J.G.T. Vehreschild
- Department of Internal Medicine II, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, 60596 Frankfurt Am Main, Germany
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Gonçalves J, Santos CD, Fresco P, Fernandez-Llimos F. Reply to: RAAS inhibitors in COVID-19: Not all are created equal! Rev Port Cardiol 2023; 42:817-818. [PMID: 37356667 PMCID: PMC10288312 DOI: 10.1016/j.repc.2023.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023] Open
Affiliation(s)
- Jorge Gonçalves
- Laboratório de Farmacologia, Faculdade de Farmácia, Universidade do Porto, Portugal; Mechanistic Pharmacology and Pharmacotherapy Unit, UCIBIO-i4HB, Faculty of Pharmacy, University of Porto, Porto, Portugal.
| | - Catarina D Santos
- Laboratório de Farmacologia, Faculdade de Farmácia, Universidade do Porto, Portugal
| | - Paula Fresco
- Laboratório de Farmacologia, Faculdade de Farmácia, Universidade do Porto, Portugal; Mechanistic Pharmacology and Pharmacotherapy Unit, UCIBIO-i4HB, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Fernando Fernandez-Llimos
- Laboratório de Farmacologia, Faculdade de Farmácia, Universidade do Porto, Portugal; Mechanistic Pharmacology and Pharmacotherapy Unit, UCIBIO-i4HB, Faculty of Pharmacy, University of Porto, Porto, Portugal
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Hamada S, Suzuki T, Tokuda Y, Taniguchi K, Shibuya K. Comparing clinical outcomes of ARB and ACEi in patients hospitalized for acute COVID-19. Sci Rep 2023; 13:11810. [PMID: 37479767 PMCID: PMC10361955 DOI: 10.1038/s41598-023-38838-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/16/2023] [Indexed: 07/23/2023] Open
Abstract
Continued receipt of Renin-Angiotensin-Aldosterone inhibitors in patients with COVID-19 has shown potential in producing better clinical outcomes. However, superiority between ACEi (angiotensin-converting enzyme inhibitors) and ARB (angiotensin II receptor blockers) regarding clinical outcomes in this setting remains unknown. We retrospectively collected data on patients hospitalized for acute COVID-19 using the nationwide administrative database (Diagnosis and Procedure Combinations, DPC). The DPC data covered around 25% of all acute care hospitals in Japan. Patient outcomes, with focus on inpatient mortality, were compared between patients previously prescribed ACEi and those prescribed ARB. Comparisons based on crude, multivariate and propensity-score adjusted analysis were conducted. We examined a total of 7613 patients (ARB group, 6903; ACEi group 710). The ARB group showed lower crude in-hospital mortality, compared to the ACEi group (5% vs 8%; odds ratio, 0.65; 95% CI 0.48-0.87), however not in the multivariate-adjusted model (odds ratio, 0.95; 95% CI 0.69-1.3) or propensity-score adjusted models (odds ratio, 0.86; 95% CI 0.63-1.2). ARB shows potential in reducing hospital stay duration over ACEi in patients admitted for COVID-19, but does not significantly reduce in-hospital mortality. Further prospective studies are needed to draw a definitive conclusion, but continuation of either of these medications is warranted to improve clinical outcomes.
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Affiliation(s)
| | | | - Yasuharu Tokuda
- The Tokyo Foundation for Policy Research, Minato-ku, Tokyo, Japan.
- Muribushi Okinawa Center for Teaching Hospitals, 3-42-8 Iso, Urasoe, Okinawa, 901-2132, Japan.
- University of Tsukuba School of Medicine, Tsukuba, Japan.
| | - Kiyosu Taniguchi
- National Hospital Organization Mie National Hospital, Tsu, Mie, Japan
| | - Kenji Shibuya
- The Tokyo Foundation for Policy Research, Minato-ku, Tokyo, Japan
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Dutsch A, Schunkert H. RAAS inhibition and beyond-cardiovascular medications in patients at risk of or affected by COVID-19. Herz 2023:10.1007/s00059-023-05168-4. [PMID: 37097476 PMCID: PMC10127983 DOI: 10.1007/s00059-023-05168-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2023] [Indexed: 04/26/2023]
Abstract
The COVID-19 pandemic led to an enormous burden on healthcare systems worldwide. Causal therapy is still in its infancy. Contrary to initial views that the use of angiotensin-converting enzyme inhibitors (ACEi)/angiotensin II receptor blockers (ARBs) may increase the risk for a deleterious disease course, it has been shown that these agents may actually be beneficial for patients affected by COVID-19. In this article, we provide an overview of the three most commonly used classes of drugs in cardiovascular disease (ACEi/ARB, statins, beta-blockers) and their potential role in COVID-19 therapy. More results from randomized clinical trials are necessary to identify patients that can benefit most from the use of the respective drugs.
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Affiliation(s)
- Alexander Dutsch
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Lazarettstraße 36, 80636, Munich, Germany
- DZHK e. V. (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Munich, Germany
| | - Heribert Schunkert
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Lazarettstraße 36, 80636, Munich, Germany.
- DZHK e. V. (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Munich, Germany.
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Lawler PR, Derde LPG, van de Veerdonk FL, McVerry BJ, Huang DT, Berry LR, Lorenzi E, van Kimmenade R, Gommans F, Vaduganathan M, Leaf DE, Baron RM, Kim EY, Frankfurter C, Epelman S, Kwan Y, Grieve R, O'Neill S, Sadique Z, Puskarich M, Marshall JC, Higgins AM, Mouncey PR, Rowan KM, Al-Beidh F, Annane D, Arabi YM, Au C, Beane A, van Bentum-Puijk W, Bonten MJM, Bradbury CA, Brunkhorst FM, Burrell A, Buzgau A, Buxton M, Cecconi M, Cheng AC, Cove M, Detry MA, Estcourt LJ, Ezekowitz J, Fitzgerald M, Gattas D, Godoy LC, Goossens H, Haniffa R, Harrison DA, Hills T, Horvat CM, Ichihara N, Lamontagne F, Linstrum KM, McAuley DF, McGlothlin A, McGuinness SP, McQuilten Z, Murthy S, Nichol AD, Owen DRJ, Parke RL, Parker JC, Pollock KM, Reyes LF, Saito H, Santos MS, Saunders CT, Seymour CW, Shankar-Hari M, Singh V, Turgeon AF, Turner AM, Zarychanski R, Green C, Lewis RJ, Angus DC, Berry S, Gordon AC, McArthur CJ, Webb SA. Effect of Angiotensin-Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Initiation on Organ Support-Free Days in Patients Hospitalized With COVID-19: A Randomized Clinical Trial. JAMA 2023; 329:1183-1196. [PMID: 37039790 PMCID: PMC10326520 DOI: 10.1001/jama.2023.4480] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/07/2023] [Indexed: 04/12/2023]
Abstract
IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non-critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support-free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support-free days among critically ill patients was 10 (-1 to 16) in the ACE inhibitor group (n = 231), 8 (-1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support-free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Patrick R Lawler
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
- McGill University Health Centre, Montreal, QC, Canada
| | | | | | | | | | | | | | | | - Frank Gommans
- Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - David E Leaf
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rebecca M Baron
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edy Y Kim
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Slava Epelman
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Yvonne Kwan
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Richard Grieve
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Stephen O'Neill
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Zia Sadique
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | - Paul R Mouncey
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Kathryn M Rowan
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Djillali Annane
- Hospital Raymond Poincaré (Assistance Publique Hôpitaux de Paris), Garches, France
- Université Versailles SQY - Université Paris Saclay, Montigny-le-Bretonneux, France
| | - Yaseen M Arabi
- King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Carly Au
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Abi Beane
- University of Oxford, Oxford, England
| | | | | | | | | | | | | | - Meredith Buxton
- Global Coalition for Adaptive Research, Larkspur, California
| | | | | | - Matthew Cove
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | | | | | | | | | - David Gattas
- The George Institute for Global Health, Sydney, Australia
| | - Lucas C Godoy
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | | | - Rashan Haniffa
- University of Oxford, Bangkok, Thailand
- National Intensive Care Surveillance (NICST), Colombo, Sri Lanka
| | - David A Harrison
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Thomas Hills
- Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand
| | | | | | | | | | - Daniel F McAuley
- Queen's University Belfast, Belfast, Northern Ireland
- Royal Victoria Hospital, Belfast, Northern Ireland
| | | | - Shay P McGuinness
- Monash University, Melbourne, Australia
- Auckland City Hospital, Auckland, New Zealand
| | | | | | - Alistair D Nichol
- Monash University, Melbourne, Australia
- University College Dublin, Dublin, Ireland
| | - David R J Owen
- Department of Brain Sciences, Imperial College London, London, United Kingdom
- UK Dementia Research Institute of Imperial College London, London, United Kingdom
| | - Rachael L Parke
- Auckland City Hospital, Auckland, New Zealand
- University of Auckland, Auckland, New Zealand
| | | | | | - Luis Felipe Reyes
- Universidad de La Sabana, Chia, Colombia
- Clinica Universidad de La Sabana, Chia, Colombia
| | - Hiroki Saito
- St Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | | | | | | | | | | | - Alexis F Turgeon
- Université Laval, Québec City, Canada
- CHU de Québec-Université Laval Research Center, Québec City, Canada
| | - Anne M Turner
- Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand
| | | | | | - Roger J Lewis
- Berry Consultants, Austin, Texas
- Harbor-UCLA Medical Center, Torrance, California
- Statistical Editor, JAMA
| | - Derek C Angus
- University of Pittsburgh, Pittsburgh, Pennsylvania
- Senior Editor, JAMA
| | | | - Anthony C Gordon
- Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, United Kingdom
| | | | - Steve A Webb
- Monash University, Melbourne, Australia
- St John of God Hospital, Subiaco, Australia
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10
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Rothlin RP, Pelorosso FG, Duarte M, Nicolosi L, Ignacio FC, Salgado MV, Vetulli H. Telmisartan and losartan: The marked differences between their chemical and pharmacological properties may explain the difference in therapeutic efficacy in hospitalized patients with COVID-19. Pharmacol Res Perspect 2023; 11:e01083. [PMID: 37038324 PMCID: PMC10086312 DOI: 10.1002/prp2.1083] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 03/17/2023] [Accepted: 03/25/2023] [Indexed: 04/12/2023] Open
Affiliation(s)
- Rodolfo Pedro Rothlin
- Sociedad Argentina de Farmacología Clínica, Asociación Médica Argentina, Buenos Aires, Argentina
| | - Facundo Germán Pelorosso
- Servicio de Anatomía Patológica, Hospital de Alta Complejidad El Calafate SAMIC, Santa Cruz, Argentina
| | - Mariano Duarte
- Laboratorio de Hipertensión, División de Cardiología, Hospital de Clínicas "José de San Martín", Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
- Segunda Cátedra de Fisiología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Liliana Nicolosi
- División de Cardiología, Hospital Español de Buenos Aires, Buenos Aires, Argentina
| | - Fernandez Criado Ignacio
- Sección de Tecnología Educativa e Informática Médica, Hospital de Clínicas "José de San Martín", Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - María Victoria Salgado
- Centro de Estudios de Estado y Sociedad, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
- Servicio de Medicina Familiar, Hospital de Alta Complejidad El Calafate SAMIC, Santa Cruz, Argentina
| | - Héctor Vetulli
- Servicio de Electrofisiología Cardíaca, Arritmias y Marcapasos, Sanatorio Otamendi y Miroli, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
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11
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Mackey K, Kansagara D, Vela K. Update Alert 10: Risks and Impact of Angiotensin-Converting Enzyme Inhibitors or Angiotensin-Receptor Blockers on SARS-CoV-2 Infection in Adults. Ann Intern Med 2023; 176:eL230049. [PMID: 36940439 PMCID: PMC10064412 DOI: 10.7326/l23-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2023] Open
Affiliation(s)
| | | | - Kathryn Vela
- VA Portland Health Care System, Portland, Oregon
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12
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Paguio JA, Casipit BA, John TA, Balu A, Lo KB. Angiotensin converting enzyme inhibitors and angiotensin II receptor blockers and outcomes in hospitalized patients with COVID-19: an updated systematic review and meta-analysis of randomized clinical trials. Expert Rev Cardiovasc Ther 2023; 21:219-226. [PMID: 36821251 DOI: 10.1080/14779072.2023.2184351] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND Our prior analysis demonstrated no significant difference in risk of mortality or disease progression among patients with COVID-19. With the availability of findings from randomized controlled trials (RCTs), we provide an updated review of RCTs which explored the outcomes among hospitalized patients with COVID-19 treated with Angiotensin Converting Enzyme inhibitor (ACEis)/Angiotensin Receptor Blockers (ARBs) versus control. RESEARCH DESIGN AND METHODS This systematic review and meta-analysis covers RCTs exploring mortality, intensive care unit admission, and mechanical ventilation outcomes among hospitalized COVID-19 patients treated with ACEi/ARBs. RESULTS Ten studies were included in this meta-analysis. For mortality with ACEi/ARB utilization among hospitalized COVID-19 patients, the pooled risk ratio (RR) was 0.97 (95% CI 0.64-1.47, p = 0.89) with heterogeneity of 26%. Further, the pooled RR for ACEi/ARB use on ICU admission and mechanical ventilation were 0.55 (0.55-1.08, p = 0.13) with a heterogeneity of 0% and 1.02 (0.78-1.32, p = 0.91) with a heterogeneity of 0%, respectively. CONCLUSION Among hospitalized patients with COVID-19, the use of ACEi/ARB was not associated with increased risk of mortality, ICU admission, or mechanical ventilation compared to control. These findings support continuation of ACEi/ARB for whom baseline clinical indications for these agents exist.
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Affiliation(s)
- Joseph Alexander Paguio
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA.,Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Bruce Adrian Casipit
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA.,Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Tara A John
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA.,Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Aniruddh Balu
- Longfellow Middle School, Fairfax, Pennsylvania, USA
| | - Kevin Bryan Lo
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA.,Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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13
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Human Coronavirus Cell Receptors Provide Challenging Therapeutic Targets. Vaccines (Basel) 2023; 11:vaccines11010174. [PMID: 36680018 PMCID: PMC9862439 DOI: 10.3390/vaccines11010174] [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: 12/02/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 01/15/2023] Open
Abstract
Coronaviruses interact with protein or carbohydrate receptors through their spike proteins to infect cells. Even if the known protein receptors for these viruses have no evolutionary relationships, they do share ontological commonalities that the virus might leverage to exacerbate the pathophysiology. ANPEP/CD13, DPP IV/CD26, and ACE2 are the three protein receptors that are known to be exploited by several human coronaviruses. These receptors are moonlighting enzymes involved in several physiological processes such as digestion, metabolism, and blood pressure regulation; moreover, the three proteins are expressed in kidney, intestine, endothelium, and other tissues/cell types. Here, we spot the commonalities between the three enzymes, the physiological functions of the enzymes are outlined, and how blocking either enzyme results in systemic deregulations and multi-organ failures via viral infection or therapeutic interventions is addressed. It can be difficult to pinpoint any coronavirus as the target when creating a medication to fight them, due to the multiple processes that receptors are linked to and their extensive expression.
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14
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Prasad N, Yadav AK, Kundu M, Jaryal A, Sircar D, Modi G, Sahay M, Gopalakrishnan N, Vikrant S, Varughese S, Baid-Agrawal S, Singh S, Gang S, Parameswaran S, Ghosh A, Kumar V, Jha V. Renin-angiotensin blocker use is associated with improved cardiovascular mortality in Indian patients with mild-moderate chronic kidney disease-findings from the ICKD study. Front Med (Lausanne) 2022; 9:1060148. [PMID: 36606058 PMCID: PMC9807808 DOI: 10.3389/fmed.2022.1060148] [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: 10/02/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) are the antihypertensive drug class of choice in patients with chronic kidney disease (CKD). Head-to-head comparisons of the renal or non-renal outcomes between ACEI/ARB users and nonusers have not been conducted in all population groups. We examined the renal and cardiovascular outcomes in users and nonusers enrolled in the Indian Chronic Kidney Disease (ICKD) Study. Methods A total of 4,056 patients with mild-moderate CKD were studied. Patients were categorized as ACEI/ARB users or nonusers. Major adverse kidney events [ESKD (end stage kidney disease), ≥50% decline in eGFR and kidney death], all-cause mortality, and cardiovascular mortality were analyzed over a median follow-up period of 2.64 (1.40, 3.89) years between the two groups. Results Out of a total of 4,056 patients, 3,487 (87%) were hypertensive. The adjusted sub-hazard ratio (SHR) and 95 % CI for ACEI /ARB users was 0.85 (0.71, 1.02) for MAKE, 0.80 (0.64, 0.99) for a 50% decline in eGFR, and 0.72 (0.58, 0.90) for ESKD. For cardiovascular mortality, ACEI/ARB users were at lower risk (SHR = 0.55, 95% CI: 0.34, 0.88). Diuretic users were at increased risk of all-cause mortality (HR = 1.95, 95% CI: 1.50, 2.53) and cardiovascular mortality (adjusted SHR = 1.73, 95% CI: 1.09, 2.73). There was non-significant association between the use of other antihypertensives and any of the end points. Discussion ACEI/ARB use is associated with slower rate of decline in eGFR in those with CKD stage 1-3. ACEI/ARB users had a significantly lower risk of renal outcomes, and cardiovascular mortality.
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Affiliation(s)
- Narayan Prasad
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Science, Lucknow, India
| | - Ashok Kumar Yadav
- Department of Experimental Medicine and Biotechnology, Postgraduate Institute of Medical, Chandigarh, India
| | - Monica Kundu
- George Institute for Global Health India, Delhi, India
| | - Ajay Jaryal
- Department of Nephrology, Indira Gandhi Medical College, Shimla, India
| | - Dipankar Sircar
- Department of Nephrology, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Gopesh Modi
- Department of Nephrology, Samarpan Kidney Institute and Research Center, Bhopal, India
| | - Manisha Sahay
- Osmania Medical College, Osmania General Hospital, Hyderabad, India
| | | | - Sanjay Vikrant
- Department of Nephrology, Indira Gandhi Medical College, Shimla, India
| | | | - Seema Baid-Agrawal
- Department of Nephrology and Transplant Center, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Shivendra Singh
- Department of Nephrology Institute of Medical Science, Banaras Hindu University, Varanasi, India
| | - Sishir Gang
- Department of Nephrology, Muljibhai Patel Urological Hospital, Nadiad, India
| | - Sreejith Parameswaran
- Department of Nephrology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Arpita Ghosh
- George Institute for Global Health India, Delhi, India
| | - Vivek Kumar
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivekanand Jha
- George Institute for Global Health India, Delhi, India,School of Public Health, Imperial College, London, United Kingdom,Prasanna school of Public Health, Manipal Academy of Higher Education, Manipal, India,*Correspondence: Vivekanand Jha ✉
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