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Moiz A, Zolotarova T, Eisenberg MJ. Outpatient management of essential hypertension: a review based on the latest clinical guidelines. Ann Med 2024; 56:2338242. [PMID: 38604225 PMCID: PMC11011233 DOI: 10.1080/07853890.2024.2338242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 03/15/2024] [Indexed: 04/13/2024] Open
Abstract
Background: Essential hypertension, a prevalent cardiovascular condition, poses a significant health burden worldwide. Based on the latest American clinical guidelines, half of adults in the United States have hypertension. Of these, only about a half are treated and about a quarter are adequately controlled for hypertension. Given its impact on morbidity and mortality, ensuring effective management of high blood pressure is crucial to reduce associated risks and improve patient outcomes.Objective: This review aims to provide a comprehensive and up-to-date summary of the latest cardiology guidelines and evidence-based research on essential hypertension, with a focus on guiding outpatient clinical practice.Methods: The review evaluates both non-pharmacological approaches and pharmacological interventions to offer clinicians practical insights. Notably, it emphasizes the importance of individualized treatment plans tailored to patients' specific risk profiles and comorbidities.Results: By consolidating the latest advancements in hypertension management, this review provides clinicians with an up-to-date reference, offering a nuanced understanding of treatment goals and strategies.Conclusion: Through the incorporation of evidence-based recommendations, healthcare practitioners can optimize patient care, mitigate potential complications, and improve overall outcomes in essential hypertension.
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Affiliation(s)
- Areesha Moiz
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Canada
| | - Tetiana Zolotarova
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Canada
| | - Mark J. Eisenberg
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Canada
- Department of Medicine and Health Sciences, McGill University, Montreal, Canada
- Departments of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada
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2
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Redon J, Carmena R. Present and future of drug therapy in hypertension: an overview. Blood Press 2024; 33:2320401. [PMID: 38444381 DOI: 10.1080/08037051.2024.2320401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 02/12/2024] [Indexed: 03/07/2024]
Abstract
Purpose: High blood pressure (HBP) is the leading cause of mortality and years of disability, and its prevalence is increasing. Therefore, diagnosis and effective treatment of HBP is one of the main goals to prevent and reduce its complications, and pharmacological treatment is the cornerstone of hypertension management.Materials and Methods: The gradual introduction of different drug families has led to the development of new molecules that have improved efficacy and reduced adverse effects. Results: Current drugs include a large number that target key mechanisms of blood pressure regulation as well as those that contribute to hypertension-induced organ damage. Recently, new antihypertensive drugs have been introduced that not only aim to lower blood pressure but also provide additional protection against organ damage and metabolic disorders. Some of them were introduced for specific indications other than hypertension and other are based in a pharmacogenomic approach. Other routes of administration, such subcutaneous injection, are also being explored to improve protection and compliance.Conclusions: The main characteristics of each class of antihypertensive drug are summarised.
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Affiliation(s)
- Josep Redon
- INCLIVA Research Institute, University of Valencia, Valencia, Spain
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3
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Mostaza JM, Pintó X, Armario P, Masana L, Real JT, Valdivielso P, Arrobas-Velilla T, Baeza-Trinidad R, Calmarza P, Cebollada J, Civera-Andrés M, Cuende Melero JI, Díaz-Díaz JL, Espíldora-Hernández J, Fernández Pardo J, Guijarro C, Jericó C, Laclaustra M, Lahoz C, López-Miranda J, Martínez-Hervás S, Muñiz-Grijalvo O, Páramo JA, Pascual V, Pedro-Botet J, Pérez-Martínez P, Puzo J. SEA 2024 Standards for Global Control of Vascular Risk. Clin Investig Arterioscler 2024; 36:133-194. [PMID: 38490888 DOI: 10.1016/j.arteri.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/03/2024] [Indexed: 03/17/2024]
Abstract
One of the objectives of the Spanish Society of Arteriosclerosis is to contribute to the knowledge, prevention and treatment of vascular diseases, which are the leading cause of death in Spain and entail a high degree of disability and health expenditure. Atherosclerosis is a multifactorial disease and its prevention requires a global approach that takes into account the associated risk factors. This document summarises the current evidence and includes recommendations for patients with established vascular disease or at high vascular risk: it reviews the symptoms and signs to evaluate, the laboratory and imaging procedures to request routinely or in special situations, and includes the estimation of vascular risk, diagnostic criteria for entities that are vascular risk factors, and general and specific recommendations for their treatment. Finally, it presents aspects that are not usually referenced in the literature, such as the organisation of a vascular risk consultation.
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Affiliation(s)
- José María Mostaza
- Servicio de Medicina Interna, Unidad de Lípidos y Arteriosclerosis, Hospital La Paz-Carlos III, Madrid, España.
| | - Xavier Pintó
- Unidad de Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario Bellvitge, Centro de Investigación Biomédica en Red, Fisiopatología de la Obesidad y Nutrición (CIBERobn), Fundación para la Investigación y Prevención de las Enfermedades Cardiovasculares (FIPEC), Universidad de Barcelona, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, España
| | - Pedro Armario
- Servicio de Medicina Interna, Área de Atención Integrada de Riesgo Vascular, Complex Hospitalari Universitari Moisès Broggi, Consorci Sanitari Integral (CSI), Sant Joan Despí, Universidad de Barcelona, Barcelona, España
| | - Luis Masana
- Unidad de Medicina Vascular y Metabolismo (UVASMET), Institut d'Investigació Sanitària Pere Virgili (IISPV), Hospital Universitari Sant Joan de Reus, Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Universitat Rovira i Virgili, Tarragona, España
| | - José T Real
- Servicio de Endocrinología y Nutrición, Hospital Clínico, Universidad de València, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España; CIBER de Diabetes y Enfermedades Metabólicas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - Pedro Valdivielso
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA-Bionand), Universidad de Málaga, Málaga, España
| | - Teresa Arrobas-Velilla
- Laboratorio de Nutrición y RCV, UGC de Bioquímica clínica, Hospital Virgen Macarena, Sevilla, España
| | | | - Pilar Calmarza
- Servicio de Bioquímica Clínica, Hospital Universitario Miguel Servet, Zaragoza, España; Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Investigación Sanitaria (ISS) de Aragón, Universidad de Zaragoza, Zaragoza, España
| | - Jesús Cebollada
- Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - Miguel Civera-Andrés
- Servicio de Endocrinología y Nutrición, Hospital Clínico, Universidad de València, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España
| | - José I Cuende Melero
- Consulta de Riesgo Cardiovascular, Servicio de Medicina Interna, Complejo Asistencial Universitario de Palencia, Palencia, España
| | - José L Díaz-Díaz
- Sección de Medicina Interna, Unidad de Lípidos y Riesgo Cardiovascular, Hospital Abente y Lago Complejo Hospitalario Universitario A Coruña, La Coruña, España
| | - Javier Espíldora-Hernández
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA-Bionand), Universidad de Málaga, Málaga, España; Unidad de Lípidos y Unidad Asistencial de Hipertensión Arterial- Riesgo Vascular (HTA-RV), UGC Medicina Interna, Hospital Universitario Virgen de la Victoria, Málaga, España
| | - Jacinto Fernández Pardo
- Servicio de Medicina Interna, Hospital General Universitario Reina Sofía de Murcia, Universidad de Murcia, Murcia, España
| | - Carlos Guijarro
- Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Universidad Rey Juan Carlos, Alcorón, España
| | - Carles Jericó
- Servicio de Medicina Interna, Área de Atención Integrada de Riesgo Vascular, Complex Hospitalari Universitari Moisès Broggi, Consorci Sanitari Integral (CSI), Sant Joan Despí, Universidad de Barcelona, Barcelona, España
| | - Martín Laclaustra
- Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Investigación Sanitaria (ISS) de Aragón, Universidad de Zaragoza, Zaragoza, España
| | - Carlos Lahoz
- Servicio de Medicina Interna, Unidad de Lípidos y Arteriosclerosis, Hospital La Paz-Carlos III, Madrid, España
| | - José López-Miranda
- Unidad de Lípidos y Arteriosclerosis, UGC de Medicina Interna, Hospital Universitario Reina Sofía, Córdoba, España; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, España; CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - Sergio Martínez-Hervás
- Servicio de Endocrinología y Nutrición, Hospital Clínico, Universidad de València, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España; CIBER de Diabetes y Enfermedades Metabólicas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - Ovidio Muñiz-Grijalvo
- Servicio de Medicina Interna, UCERV, UCAMI, Hospital Virgen del Rocío de Sevilla, Sevilla, España
| | - José A Páramo
- Servicio de Hematología, Clínica Universidad de Navarra, Navarra, España; Laboratorio Aterotrombosis, CIMA, Universidad de Navarra, Pamplona, España
| | - Vicente Pascual
- Centro de Salud Palleter, Universidad CEU-Cardenal Herrera, Castellón, España
| | - Juan Pedro-Botet
- Unidad de Lípidos y Riesgo Vascular, Servicio de Endocrinología y Nutrición, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, España
| | - Pablo Pérez-Martínez
- Unidad de Lípidos y Arteriosclerosis, UGC de Medicina Interna, Hospital Universitario Reina Sofía, Córdoba, España; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, España; CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - José Puzo
- Servicio de Bioquímica Clínica, Unidad de Lípidos, Hospital General Universitario San Jorge de Huesca, Huesca, España; Departamento de Medicina, Universidad de Zaragoza, Zaragoza, España
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Bansal S, Boucher R, Shen J, Wei G, Chertow GM, Whelton PK, Cushman WC, Cheung AK, Beddhu S. Role of Diuretics in Cardiovascular Events and Mortality in Systolic Blood Pressure Intervention Trial: A Post Hoc Analysis. Clin J Am Soc Nephrol 2024; 19:620-627. [PMID: 38262377 DOI: 10.2215/cjn.0000000000000406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 01/03/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND In a post hoc analysis, we examined whether postrandomization diuretics use can explain and/or mediate the beneficial effects of intensive systolic BP lowering on cardiovascular disease and all-cause mortality in the Systolic Blood Pressure Intervention Trial (SPRINT). METHODS SPRINT was a randomized, controlled trial of 9361 participants comparing the effects of intensive (systolic BP target <120 mm Hg) versus standard (systolic BP target <140 mm Hg) BP control on a primary composite cardiovascular end point in participants aged 50 years or older with systolic BP of 130-180 mm Hg. In time-varying multivariable Cox analyses, we assessed hazard ratios (HRs) of cardiovascular end points and all-cause mortality in participants on thiazide type, loop and/or potassium (K) sparing, or no diuretics. We also conducted mediation analysis to formally assess the role of diuretics in the effects of intensive systolic BP lowering. RESULTS At baseline, diuretics were prescribed in 46% and 48% of participants in standard and intensive systolic BP-lowering groups, respectively, and in 46% and 74% in the corresponding groups during the trial. The lower risk of cardiovascular end points in the intensive group (HR, 0.75; 95% confidence interval [CI], 0.64 to 0.89) persisted after adjustment for postrandomization time-varying diuretics use (HR, 0.74; 95% CI, 0.62 to 0.89). Across the entire study population, time-varying diuretics use was not associated with cardiovascular end points (compared with no diuretics, HR for thiazide type, 0.89; 95% CI, 0.73 to 1.10, and loop/K sparing, 1.29; 95% CI, 0.97 to 1.73). However, thiazide-type diuretics were associated with lower risk of cardiovascular end points in the intensive (HR, 0.62; 95% CI, 0.46 to 0.85) but not in the standard (HR, 1.07; 95% CI, 0.82 to 1.39) group. In mediation analysis, HRs for total effect, direct effect (not mediated through diuretics use), and indirect effect (mediated through diuretics) of the intervention on cardiovascular end points were 0.66 (95% CI, 0.54 to 0.79), 0.67 (95% CI, 0.54 to 0.81), and 0.98 (95% CI, 0.88 to 1.10), respectively. The results were largely similar for all-cause mortality. CONCLUSIONS The favorable effects of intensive systolic BP lowering on cardiovascular end points and all-cause mortality in SPRINT were independent of and not mediated by time-varying diuretics use. However, thiazide-type diuretics use associated with benefit if intensive systolic BP lowering was targeted.
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Affiliation(s)
- Shweta Bansal
- Division of Nephrology, University of Texas Health San Antonio, San Antonio, Texas
| | - Robert Boucher
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
- Renal Section, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Jincheng Shen
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Guo Wei
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
- Renal Section, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - William C Cushman
- Department of Preventive Medicine, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
- Renal Section, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Srinivasan Beddhu
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
- Renal Section, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
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5
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Van Laecke S. Thiazides in kidney transplant recipients: skin in the game. Nat Rev Nephrol 2024:10.1038/s41581-024-00839-9. [PMID: 38632382 DOI: 10.1038/s41581-024-00839-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Affiliation(s)
- Steven Van Laecke
- Renal Division, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium.
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6
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Raikou VD. Renoprotective strategies. World J Nephrol 2024; 13:89637. [PMID: 38596266 PMCID: PMC11000037 DOI: 10.5527/wjn.v13.i1.89637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/01/2023] [Accepted: 12/26/2023] [Indexed: 03/22/2024] Open
Abstract
Kidney disease remains a condition with an increasing incidence, high morbidity and mortality associated with cardiovascular events. The incidence of end-stage renal disease is expected to increase. Despite of the technical improvement, dialysis never achieved a full clearance of the blood dialysis. Therefore, the demand for new renoprotective measures has never been greater. Here, we report new strategies for preventing renal damage.
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Affiliation(s)
- Vaia D Raikou
- Department of Nephrology, Doctors’General Clinic, Athens 11257, Greece
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7
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Georgianos PI, Vaios V, Kontogiorgos I, Divani M, Liakopoulos V. The thiazide-like diuretic chlorthalidone as an alternative evidence-based therapy for resistant hypertension in patients with stage 4 chronic kidney disease. Expert Rev Clin Pharmacol 2024:1-4. [PMID: 38511397 DOI: 10.1080/17512433.2024.2333776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 03/19/2024] [Indexed: 03/22/2024]
Affiliation(s)
- Panagiotis I Georgianos
- 2nd Department of Nephrology, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasilios Vaios
- 2nd Department of Nephrology, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Kontogiorgos
- 2nd Department of Nephrology, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Divani
- Hemodialysis Unit, General Hospital of Larissa, Larissa, Greece
| | - Vassilios Liakopoulos
- 2nd Department of Nephrology, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Hall RK, Kazancıoğlu R, Thanachayanont T, Wong G, Sabanayagam D, Battistella M, Ahmed SB, Inker LA, Barreto EF, Fu EL, Clase CM, Carrero JJ. Drug stewardship in chronic kidney disease to achieve effective and safe medication use. Nat Rev Nephrol 2024:10.1038/s41581-024-00823-3. [PMID: 38491222 DOI: 10.1038/s41581-024-00823-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 03/18/2024]
Abstract
People living with chronic kidney disease (CKD) often experience multimorbidity and require polypharmacy. Kidney dysfunction can also alter the pharmacokinetics and pharmacodynamics of medications, which can modify their risks and benefits; the extent of these changes is not well understood for all situations or medications. The principle of drug stewardship is aimed at maximizing medication safety and effectiveness in a population of patients through a variety of processes including medication reconciliation, medication selection, dose adjustment, monitoring for effectiveness and safety, and discontinuation (deprescribing) when no longer necessary. This Review is aimed at serving as a resource for achieving optimal drug stewardship for patients with CKD. We describe special considerations for medication use during pregnancy and lactation, during acute illness and in patients with cancer, as well as guidance for the responsible use of over-the-counter drugs, herbal remedies, supplements and sick-day rules. We also highlight inequities in medication access worldwide and suggest policies to improve access to quality and essential medications for all persons with CKD. Further strategies to promote drug stewardship include patient education and engagement, the use of digital health tools, shared decision-making and collaboration within interdisciplinary teams. Throughout, we position the person with CKD at the centre of all drug stewardship efforts.
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Affiliation(s)
- Rasheeda K Hall
- Division of Nephrology, Department of Medicine, and Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | | | | | - Sofia B Ahmed
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lesley A Inker
- Division of Nephrology, Department of Internal Medicine, Tufts Medical Center, Boston, MA, USA
| | | | - Edouard L Fu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, USA
| | - Catherine M Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Ontario, Canada
| | - Juan J Carrero
- Medical Epidemiology and Biostatistics, Karolinska Institutet, and Division of Nephrology, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden.
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9
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Pitt B, Vaidya A. Moving Forward by Looking Backwards: The Role of Combination Therapy With a Mineralocorticoid Receptor Antagonist and a Thiazide Diuretic in Patients With Hypertension. Am J Hypertens 2024; 37:261-263. [PMID: 38198751 DOI: 10.1093/ajh/hpae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/06/2024] [Indexed: 01/12/2024] Open
Affiliation(s)
- Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Anand Vaidya
- Division of Endocrinology, Diabetes, and Hypertension, Center for Adrenal Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
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Lin HJ, Shih PY, Tsai SCS, Chuang WL, Hsieh TL, Lin HJ, Yu TS, Tsai FJ, Chen CY, Chang KH. Risk of CKD among patients with DM taking diuretics or SGLT2i: a retrospective cohort study in Taiwan. BMC Pharmacol Toxicol 2024; 25:24. [PMID: 38443996 PMCID: PMC10913410 DOI: 10.1186/s40360-024-00745-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/20/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND This study aimed to evaluate the long-term risk of CKD and renal function declines using a combination of diuretics and SGLT2i. METHODS We selected the data of subjects who had at least two outpatient records or at least one inpatient record for DM treatment as the DM group from the National Health Insurance Research Database (NHIRD). Patients receiving versus not receiving SGLT2i were defined as the SGLT2i and non-SGLT2i cohorts, respectively. The patients in the two groups were matched 1:1 through propensity score matching based on age, sex, year of index date, and comorbidities. RESULTS The diuretics-only group had a higher risk of CKD (aHR, 2.46; 95% CI, 1.68-3.61) compared to the neither SGLT2i nor diuretics group, while the both SGLT2i and diuretics group and the SGLT2i only group had lower risks (aHR, 0.45, 95% CI, 0.32-0.63; aHR, 0.26, 95% CI, 0.17-0.40) than the diuretics-only group. The SGLT2i-only group had a lower risk (aHR, 0.58, 95% CI, 0.36-0.94) than the both SGLT2i and diuretics group. CONCLUSION This study indicates that diuretics could raise the risk of CKD in diabetic patients, but when used in combination with SGLT2i, they continue to offer protection against CKD.
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Affiliation(s)
- Han-Jie Lin
- Department of Otolaryngology, Tungs' Taichung MetroHarbor Hospital, 435, Taichung, Taiwan
| | - Pin-Yang Shih
- Department of Public Health, China Medical University, 406040, Taichung City, Taiwan
| | - Stella Chin-Shaw Tsai
- Department of Otolaryngology, Tungs' Taichung MetroHarbor Hospital, 435, Taichung, Taiwan
- Rong Hsing Research Center for Translational Medicine, College of Life Sciences, National Chung Hsing University, 402, Taichung, Taiwan
| | - Wu-Lung Chuang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital, 500, Changhua City, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Lukang Christian Hospital, 505, Changhua County, Taiwan
| | - Tsai-Ling Hsieh
- Department of Otolaryngology, Tungs' Taichung MetroHarbor Hospital, 435, Taichung, Taiwan
- Department of Medical Research, Tungs' Taichung MetroHarbor Hospital, 435, Taichung, Taiwan
| | - Heng-Jun Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Teng-Shun Yu
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Fuu-Jen Tsai
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, 404, Taichung, Taiwan
- Department of Medical Research, China Medical University Hospital, China Medical University, 404, Taichung, Taiwan
- Division of Medical Genetics, China Medical University Children's Hospital, 404, Taichung, Taiwan
- Department of Biotechnology and Bioinformatics, Asia University, 413, Taichung, Taiwan
| | - Chiu-Ying Chen
- Department of Public Health, China Medical University, 406040, Taichung City, Taiwan.
| | - Kuang-Hsi Chang
- Department of Medical Research, Tungs' Taichung MetroHarbor Hospital, 435, Taichung, Taiwan.
- Center for General Education, China Medical University, 404, Taichung, Taiwan.
- General Education Center, Jen-Teh Junior College of Medicine, Nursing and Management, 356, Miaoli, Taiwan.
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Rafique F, Mushtaq MN, Ahmed H, Younis W. Evaluation and estimation of diuretic activity of the linalyl acetate in the rats. BRAZ J BIOL 2024; 83:e277354. [PMID: 38452187 DOI: 10.1590/1519-6984.277354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 12/07/2023] [Indexed: 03/09/2024] Open
Abstract
This study aimed to explore the diuretic activity of linalyl acetate (LA). LA is an essential oil, it is an integral phyto-constituent of various plants. In this study, acute and chronic diuretic activities were explored by measuring the levels of different electrolytes and pH in the urine of experimental rats. Rats were divided into five groups. The control group was given 10 mg/kg normal saline, the treated group was given 10 mg/kg furosemide, and the remaining 3 groups received different doses of LA including 25, 50, and 75 mg/kg through intraperitoneal route, to determine its diuretic potential. Urine volume for acute diuretic activity was measured for 6 hours however for chronic diuretic activity was measured for 6 days. For a comparative study of LA with a control group and treated group with reference drug, diuretic index was used. Moreover, the underlying mechanism of the diuretic activity was also explored by comparing atropine, L-NAME, and indomethacin. The results of each group with 6 rats in each group were obtained by ± standard error of the mean of every group. Analysis of Variance (ANOVA) was used for statistical analysis. Results revealed that the LA 75 mg/kg dose showed comparable results as of furosemide. Moreover, this study revealed the involvement of muscarinic receptors to produce diuresis in comparison with atropine with very little involvement of prostanoids and no effect on NO pathway induced by indomethacin and L-NAME respectively. It is concluded that LA possess anti-diuretic potential. Muscarinic receptors might be involved in producing diuretic effects.
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Affiliation(s)
- F Rafique
- The University of Lahore, Faculty of Pharmacy, Lahore, Pakistan
| | - M N Mushtaq
- The University of Lahore, Faculty of Pharmacy, Lahore, Pakistan
| | - H Ahmed
- Sialkot Institute of Science and Technology, Sialkot, Pakistan
| | - W Younis
- The University of Lahore, Faculty of Pharmacy, Lahore, Pakistan
- New Jersey Medical School-Rutgers, Department of Pharmacology, Physiology and Neuroscience, Newark, NJ, United States
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12
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Thieme D, Weigel K, Anielski P, Krumbholz A, Sporkert F, Keiler AM. Elimination profile of low-dose chlortalidone and its detection in hair for doping analysis-Implication for unintentional non-therapeutic exposure. Drug Test Anal 2024. [PMID: 38374541 DOI: 10.1002/dta.3661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 02/21/2024]
Abstract
Chlortalidone (CLT) is a thiazide-type diuretic with high affinity for the erythrocyte carbonic anhydrase. Therapeutically, it is mostly used to treat edema and hypertension due to liver cirrhosis, heart insufficiency, or renal dysfunction. Although diuretics and masking agents are prohibited by the World Anti-Doping Agency (WADA) at all times in sports, substances belonging to this category are constantly detected in athlete samples, according to WADA's annual testing figures. Within this group of structurally diverse compounds, a threshold of 20 ng/mL has been introduced for six substances solely due to their presence as contaminants in other permitted drugs because of pharmaceutical production processes. In a recent presumptive doping case with a low urinary CLT concentration, the question of unintentional doping, for example, by contaminated non-steroidal anti-inflammatory drug intake, arose. To examine this potential scenario, a co-elimination of low-dose CLT and hydrochlorothiazide (HCTA; 20 × 50 μg, 0.2 mg/day each) was conducted on five consecutive days in two volunteers. Urine samples were subjected to liquid chromatography-tandem mass spectrometry (LC-MS/MS). Moreover, we examined the incorporation of CLT in scalp hair. HCTA is rapidly excreted renally in comparatively high concentrations. In contrast, the elimination of CLT is considerably slower (terminal elimination half-life extended by a factor of 12) and, consequently, much less concentrated in corresponding urine samples (45 and 53 ng/mL, respectively). Conversely, a higher hair incorporation of chlorthalidone was observed with simultaneous dosing of both. The results suggest that an unintentional intake of sub-therapeutic CLT doses due to contamination might result in an adverse analytical finding.
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Affiliation(s)
- Detlef Thieme
- Institute of Doping Analysis and Sports Biochemistry Dresden, Kreischa, Germany
| | - Kai Weigel
- Institute of Doping Analysis and Sports Biochemistry Dresden, Kreischa, Germany
| | - Patricia Anielski
- Institute of Doping Analysis and Sports Biochemistry Dresden, Kreischa, Germany
| | - Aniko Krumbholz
- Institute of Doping Analysis and Sports Biochemistry Dresden, Kreischa, Germany
| | - Frank Sporkert
- Centre of Legal Medicine, Forensic Toxicology and Chemistry Unit, Lausanne and Geneva Universities, Lausanne, Switzerland
| | - Annekathrin M Keiler
- Institute of Doping Analysis and Sports Biochemistry Dresden, Kreischa, Germany
- Environmental Monitoring and Endocrinology, TU Dresden, Dresden, Germany
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13
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Hausberg M. [Are thiazide diuretics ineffective with a glomerular filtration rate lower than 50 ml/min?]. Inn Med (Heidelb) 2024; 65:180-184. [PMID: 38112725 DOI: 10.1007/s00108-023-01617-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 12/21/2023]
Abstract
Many treatment guidelines do not recommend the use of thiazide diuretics or thiazide-like diuretics in patients with impaired kidney function. The rationale is a presumed lack of efficacy of these diuretics in cases of a reduced glomerular filtration rate (GFR); however, this paradigm could not be verified in recent studies. Thiazide diuretics and thiazide-like diuretics are also effective in patients with substantially reduced GFR, which pertains to natriuresis, correction of volume overload and lowering of blood pressure; however, in patients with chronic kidney disease loop diuretics can control volume overload more rapidly. Particularly effective is the combination of loop diuretics with thiazide diuretics or thiazide-like diuretics in patients with markedly limited GFR. Therefore, thiazide diuretics and thiazide-like diuretics should also be prescribed even for patients with higher grade impairments of kidney function (chronic kidney disease in stages 3-5), except for anuric patients where they are ineffective.
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Affiliation(s)
- Martin Hausberg
- Medizinische Klinik I, Städtisches Klinikum Karlsruhe, Moltkestraße 90, 76133, Karlsruhe, Deutschland.
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14
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Lauder L, Mahfoud F, Böhm M. Management of Resistant Hypertension. Annu Rev Med 2024; 75:443-457. [PMID: 37738507 DOI: 10.1146/annurev-med-050922-052605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
Resistant hypertension (RH) is a severe form of hypertension associated with increased cardiovascular risk. Although true RH affects less than 10% of the patients receiving antihypertensive therapy, the absolute number is high and continues to increase. The workup of these patients requires screening for secondary hypertension and pseudoresistance, including poor adherence to prescribed medicines and the white-coat phenomenon. The treatment of RH consists of lifestyle modifications and pharmacological therapies. Lifestyle modifications include dietary adjustments, weight loss, physical activity, and limiting alcohol consumption; pharmacological therapies include diuretics, mineralocorticoid receptor antagonists, beta blockers, angiotensin receptor-neprilysin inhibitors, and others. Over the last 15 years, interventional approaches have emerged as adjunct treatment options; we highlight catheter-based renal denervation. This review summarizes the rationales and latest clinical evidence and, based thereon, proposes an updated algorithm for the management of RH.
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Affiliation(s)
- Lucas Lauder
- Department of Internal Medicine III, Cardiology, Angiology, and Intensive Care Medicine, Universitätsklinikum des Saarlandes and Saarland University, Homburg, Germany; , ,
| | - Felix Mahfoud
- Department of Internal Medicine III, Cardiology, Angiology, and Intensive Care Medicine, Universitätsklinikum des Saarlandes and Saarland University, Homburg, Germany; , ,
| | - Michael Böhm
- Department of Internal Medicine III, Cardiology, Angiology, and Intensive Care Medicine, Universitätsklinikum des Saarlandes and Saarland University, Homburg, Germany; , ,
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15
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Agarwal R. Blocking aldosterone or its receptor-what is the difference? Lancet 2024; 403:330-332. [PMID: 38109915 DOI: 10.1016/s0140-6736(23)02542-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 11/10/2023] [Indexed: 12/20/2023]
Affiliation(s)
- Rajiv Agarwal
- Richard L Roudebush VA Medical Center, Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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Wilson BJ, Bates D. Diuretic Strategies in Acute Decompensated Heart Failure: A Narrative Review. Can J Hosp Pharm 2024; 77:e3323. [PMID: 38204501 PMCID: PMC10754413 DOI: 10.4212/cjhp.3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/15/2023] [Indexed: 01/12/2024]
Abstract
Background Heart failure is a common condition with considerable associated costs, morbidity, and mortality. Patients often present to hospital with dyspnea and edema. Inadequate inpatient decongestion is an important contributor to high readmission rates. There is little evidence concerning diuresis to guide clinicians in caring for patients with acute decompensated heart failure. Contemporary diuretic strategies have been defined by expert opinion and older landmark clinical trials. Objective To present a narrative review of contemporary recommendations, along with their underlying evidence and pharmacologic rationale, for diuretic strategies in inpatients with acute decompensated heart failure. Data Sources PubMed, OVID, and Embase databases were searched from inception to December 22, 2022, with the following search terms: heart failure, acute heart failure, decompensated heart failure, furosemide, bumetanide, ethacrynic acid, hydrochlorothiazide, indapamide, metolazone, chlorthalidone, spironolactone, eplerenone, and acetazolamide. Study Selection Randomized controlled trials and systematic reviews involving at least 100 adult patients (> 18 years) were included. Trials involving torsemide, chlorothiazide, and tolvaptan were excluded. Data Synthesis Early, aggressive administration of a loop diuretic has been associated with expedited symptom resolution, shorter length of stay, and possibly reduced mortality. Guidelines make recommendations about dose and frequency but do not recommend any particular loop diuretic over another; however, furosemide is most commonly used. Guidelines recommend that the initial furosemide dose (on admission) be 2-2.5 times the patient's home dose. A satisfactory diuretic response can be defined as spot urine sodium content greater than 50-70 mmol/L at 2 hours; urine output greater than 100-150 mL/h in the first 6 hours or 3-5 L in 24 hours; or a change in weight of 0.5-1.5 kg in 24 hours. If congestion persists after the maximization of loop diuretic therapy over the first 24-48 hours, an adjunctive diuretic such as thiazide or acetazolamide should be added. If decongestion targets are not met, continuous infusion of furosemide may be considered. Conclusions Heart failure with congestion can be managed with careful administration of high-dose loop diuretics, supported by thiazides and acetazolamide when necessary. Clinical trials are underway to further evaluate this strategy.
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Affiliation(s)
- Ben J Wilson
- , MD, FRCPC, is a Clinical Assistant Professor with the Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Duane Bates
- , BScPharm, ACPR, is a Clinical Pharmacist with the Calgary Zone, Alberta Health Services, Calgary, Alberta
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17
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Valdivielso JM, Carriazo S, Martin M, Fernandez-Fernandez B, Bermudez-López M, Ortiz A. Gender-specific risk factors and outcomes of hyperkalemia in CKD patients: smoking as a driver of hyperkalemia in men. Clin Kidney J 2024; 17:sfad212. [PMID: 38186899 PMCID: PMC10768768 DOI: 10.1093/ckj/sfad212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Indexed: 01/09/2024] Open
Abstract
Background Hyperkalemia is common among patients with chronic kidney disease (CKD) but there is scarce information on differential risk factors and outcomes for men and women. For instance, smoking has been suggested to be a risk factor for hyperkalemia, but specific analysis of the sex-specific impact of smoking on hyperkalemia in CKD is lacking. Methods We studied serum potassium levels in 2891 participants from the NEFRONA cohort: 483 controls (47% women) and 2408 CKD patients (38% women) without prior cardiovascular disease (CVD), assessing whether smoking is a risk factor for hyperkalemia, and if hyperkalemia is associated with outcomes separately for men and women. Results Median potassium levels and prevalence of hypo and hyperkalemia were higher in CKD participants than in controls. Serum potassium levels were higher and hyperkalemia and severe hyperkalemia more prevalent in men than in women with non-dialysis CKD (G3-G5). The highest prevalence of hyperkalemia for each gender was found in CKD G4-G5 and hemodialysis patients for men (46%) and in hemodialysis (54%) for women. Gender-specific etiological multivariate analysis identified current smoking as a risk factor for hyperkalemia only in men. Hyperkalemia was independently associated with stopping RAASi, an outcome which was more common in women. Hyperkalemia was also associated to higher risk of cardiovascular events within 4 years in men. In conclusion, hyperkalemia is common among men and women with CKD, but the prevalence, risk factors and outcomes may differ by gender. Specifically, current smoking is a driver of hyperkalemia in men.
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Affiliation(s)
- Jose M Valdivielso
- Vascular and Renal Translational Research Group, UDETMA, REDinREN del ISCIII, IRBLleida, University of Lleida, Lleida, Spain
| | - Sol Carriazo
- IIS-Fundacion Jimenez Diaz, School of Medicine, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain
- ISCIII RICORS2040 Kidney Disease Research Network, Madrid, Spain
| | - Marisa Martin
- Vascular and Renal Translational Research Group, UDETMA, REDinREN del ISCIII, IRBLleida, University of Lleida, Lleida, Spain
| | - Beatriz Fernandez-Fernandez
- IIS-Fundacion Jimenez Diaz, School of Medicine, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain
- ISCIII RICORS2040 Kidney Disease Research Network, Madrid, Spain
| | - Marcelino Bermudez-López
- Vascular and Renal Translational Research Group, UDETMA, REDinREN del ISCIII, IRBLleida, University of Lleida, Lleida, Spain
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz, School of Medicine, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain
- ISCIII RICORS2040 Kidney Disease Research Network, Madrid, Spain
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18
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Camafort M, Kreutz R, Cho MC. Diagnosis and management of resistant hypertension. Heart 2023:heartjnl-2022-321730. [PMID: 38135468 DOI: 10.1136/heartjnl-2022-321730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2023] Open
Abstract
Resistant hypertension is a condition where blood pressure levels remain elevated above target despite changes in lifestyle and concurrent use of at least three antihypertensive agents, including a long-acting calcium channel blocker (CCB), a blocker of the renin-angiotensin system (ACE inhibitor or angiotensin receptor blocker) and a diuretic. To be diagnosed as resistant hypertension, maintaining adherence to therapy is required along with confirmation of blood pressure levels above target by out-of-office blood pressure measurements and exclusion of secondary causes of hypertension. The key management points of this condition include lifestyle changes such as reduced sodium and alcohol intake, regular physical activity, weight loss and discontinuation of substances that can interfere with blood pressure control. It is also recommended that current treatment be rationalised, including single pill combination treatment where antihypertensive drugs should be provided at the maximum tolerated dose. It is further recommended that current drugs be replaced with a more appropriate and less difficult treatment regimen based on the patient's age, ethnicity, comorbidities and risk of drug-drug interactions. The fourth line of treatment for patients with resistant hypertension should include mineralocorticoid receptor antagonists such as spironolactone, as demonstrated in the PATHWAY-2 trial and meta-analyses. Alternatives to spironolactone include amiloride, doxazosin, eplerenone, clonidine and beta-blockers, as well as any other antihypertensive drugs not already in use. New approaches under research are selective non-steroidal mineralocorticoid receptor antagonists such as finerenone, esaxerenone and ocedurenone, selective aldosterone synthase inhibitors such as baxdrostat, and dual endothelin antagonist aprocitentan.
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Affiliation(s)
- Miguel Camafort
- Hypertensión Unit. Internal Medicine Department, Hospital Clinic de Barcelona, Barcelona, Spain
- CIBEROBN, Instituto de Salud Carlos III, Madrid, Spain
| | - Reinhold Kreutz
- Charite Medical Faculty Berlin, Berlin, Germany
- Institut für Klinische Pharmakologie und Toxikologie, Berlin Institute of Health at Charite, Berlin, Germany
| | - Myeong-Chan Cho
- Cardiology, Chungbuk National University Hospital, Cheongju, Korea
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19
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Chen TK, Hoenig MP, Nitsch D, Grams ME. Advances in the management of chronic kidney disease. BMJ 2023; 383:e074216. [PMID: 38052474 DOI: 10.1136/bmj-2022-074216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
Chronic kidney disease (CKD) represents a global public health crisis, but awareness by patients and providers is poor. Defined as persistent abnormalities in kidney structure or function for more than three months, manifested as either low glomerular filtration rate or presence of a marker of kidney damage such as albuminuria, CKD can be identified through readily available blood and urine tests. Early recognition of CKD is crucial for harnessing major advances in staging, prognosis, and treatment. This review discusses the evidence behind the general principles of CKD management, such as blood pressure and glucose control, renin-angiotensin-aldosterone system blockade, statin therapy, and dietary management. It additionally describes individualized approaches to treatment based on risk of kidney failure and cause of CKD. Finally, it reviews novel classes of kidney protective agents including sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists, non-steroidal selective mineralocorticoid receptor antagonists, and endothelin receptor antagonists. Appropriate, widespread implementation of these highly effective therapies should improve the lives of people with CKD and decrease the worldwide incidence of kidney failure.
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Affiliation(s)
- Teresa K Chen
- Kidney Health Research Collaborative and Division of Nephrology, Department of Medicine, University of California San Francisco; and San Francisco VA Health Care System, San Francisco, CA, USA
| | - Melanie P Hoenig
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Morgan E Grams
- Department of Medicine, New York University Langone School of Medicine, New York, NY, USA
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20
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Teles F, Peçanha de Miranda Coelho JA, Albino RM, Verçosa Pacheco FC, Rodrigues de Oliveira E, Silveira MAD, Diógenes M. Feitosa A, Bezerra R. Effectiveness of thiazide and thiazide-like diuretics in advanced chronic kidney disease: a systematic review and meta-analysis. Ren Fail 2023; 45:2163903. [PMID: 36637019 PMCID: PMC9848247 DOI: 10.1080/0886022x.2022.2163903] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Thiazide diuretics are first-line drugs for the treatment of hypertension, but hypertension treatment guidelines have systematically discouraged their use in patients with advanced chronic kidney disease (CKD). For the first time, a systematic review and random-effects meta-analysis were performed to assess the effectiveness of thiazides and thiazide-like diuretics to treat hypertension in patients with stages 3b, 4, and 5 CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A systematic review and random-effects meta-analysis that included a literature search using the following databases were performed: MEDLINE through PubMed, Cochrane Database of Systematic Reviews (CDSR) and Cochrane Central Register of Controlled Trials (CENTRAL) through the Cochrane Library, Embase, and ISI - Web of Science (all databases). Prospective studies that evaluated the effectiveness of thiazide and thiazide-like diuretics in individuals with a GFR < 45 mL/min/1.73 m2 were included. RESULTS Five clinical trials, totaling 214 participants, were included, and the mean GFR ranged from 13.0 ± 5.9 mL/min/1.73 m2 to 26.8 ± 8.8 mL/min/1.73 m2. There was evidence of a reduction in mean blood pressure and in GFR, as well as in fractional sodium excretion and fractional chloride excretion. CONCLUSION Thiazide and thiazide-like diuretics seem to maintain their effectiveness in lowering blood pressure in patients with advanced chronic kidney disease. These findings should spur new prospective randomized trials and spark discussions, particularly about upcoming hypertension guidelines.
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Affiliation(s)
- Flávio Teles
- School of Medicine, Federal University of Alagoas (UFAL), Maceió, Brazil,School of Medicine, State University of Health Sciences of Alagoas (UNCISAL), Maceió, Brazil
| | | | - Rosivânia Maria Albino
- School of Medicine, State University of Health Sciences of Alagoas (UNCISAL), Maceió, Brazil
| | | | | | | | | | - Rodrigo Bezerra
- Pernambuco Hypertension Service (SHIP), PROCAPE - University of Pernambuco (UPE), Recife, Brazil,Keizo Asami Laboratory of Immunopathology, Federal University of Pernambuco, Recife, Brazil,CONTACT Rodrigo Bezerra PROCAPE-University of Pernambuco, Brazil. Rua dos Palmares, S/N – Santo Amaro, Recife – PE - CEP: 74970-240, Brazil
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21
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Park J, Yang CW, Huan Y, Aggarwal S. Polypill and Combination Therapy: Blood Pressure and Cardiovascular Risk Reduction. Curr Cardiol Rep 2023; 25:1851-1858. [PMID: 37991626 DOI: 10.1007/s11886-023-02000-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE OF REVIEW The number of medications prescribed to patients has been progressively increasing, primarily driven by cardioprotective medications. The advent of pharmaceutical 3D printing technology holds the promise of reducing the burden of multiple pills by combining various medications with different release mechanisms into a single tablet. This development encourages a comprehensive review of the evidence supporting the use of combination pills. RECENT FINDINGS Recent randomized studies have shown higher BP control rates in quadpill groups than in monotherapy groups and improved 6-month BP control rates with a low-dose triple fixed-dose combination (FDC) medication compared to usual care. Recent randomized controlled trials also support FDC use for primary and secondary prevention of cardiovascular disease. Three-dimensional printing technologies such as powder-based (PB) 3D printing, fused deposition modeling (FDM) 3D printing, and semisolid extrusion (EXT) 3D printing are examples of promising technologies that could be utilized to combine multiple medications with different release mechanisms into a single tablet. FDC therapy can provide patients with combination regimens with a reduced pill burden, which promotes improved adherence and efficacy. Recent randomized trials have shown that FDC can be used for primary and secondary prevention of cardiovascular disease with no significant difference in adverse events. Multidisciplinary approaches should be implemented to enhance long-term adherence, and further research on establishing affordable and effective initial dual antihypertensive therapy options is necessary. Pharmaceutical 3D printing technology may play an important role in enhancing the flexibility, affordability, and feasibility of clinical FDC utilization.
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Affiliation(s)
- Jinwook Park
- Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA.
| | - Chien-Wen Yang
- Department of Nephrology, Ochsner Medical Center, New Orleans, LA, USA
| | - Yonghong Huan
- Division of Renal Electrolyte and Hypertension, Perelman School of Medicineat the , University of Pennsylvania, Philadelphia, PA, USA
| | - Sandeep Aggarwal
- Division of Renal Electrolyte and Hypertension, Perelman School of Medicineat the , University of Pennsylvania, Philadelphia, PA, USA
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22
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Myke-Mbata BK, Basil B, Oloche JJ, Igbom A. Pharmacological Considerations in the Interpretation of Biochemical Results in Diabetic Patients with Cardiovascular Complications. EJIFCC 2023; 34:305-316. [PMID: 38303751 PMCID: PMC10828539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Diabetes mellitus with cardiovascular diseases is often a multi-systemic disease that requires a multi-therapeutic approach which mostly poses a challenge to laboratory result interpretation. The non-availability of information on many patients due to poor referral, documentation and record keeping has resulted in isolated interpretation of laboratory result of diabetic patients with multisystemic complications. This has led to both analytical and post-analytical errors which has a negative impact on total quality of results. Therefore, this review showed the possible therapeutic treatment of a diabetic patient with cardiovascular disease and how their pharmacological role could affect laboratory result.
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Affiliation(s)
| | - Bruno Basil
- Department of Chemical Pathology, Benue State University, Makurdi, Nigeria
| | - Jeremiah John Oloche
- Department of Pharmacology and Therapeutics, Benue State University, Makurdi, Nigeria
| | - Amarachukwu Igbom
- Department of Family Medicine, Lake District Hospital& Health Centre, Burns Lake, BC., Canada
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23
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Martinez JD, Thomas IC, Montez-Rath ME, Pao AC, Fung E, Charu V, Sim JJ, An J, Odden MC, Tamura MK. Treatment and Control of Hypertension Among Adults With Chronic Kidney Disease, 2011 to 2019. Hypertension 2023; 80:2533-2543. [PMID: 37706307 PMCID: PMC10873114 DOI: 10.1161/hypertensionaha.123.21523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/01/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Hypertension frequently accompanies chronic kidney disease (CKD) as etiology and sequela. We examined contemporary trends in hypertension treatment and control in a national sample of adults with CKD. METHODS We evaluated 5% cross-sectional samples of adults with CKD between 2011 and 2019 in the Veterans Health Administration. We defined CKD as a sustained estimated glomerular filtration rate value <60 mL/min per 1.73 m2 or a urine albumin-to-creatinine ratio ≥30 mg/g. The main outcomes were blood pressure (BP) control, defined as a systolic BP <140 mm Hg and a diastolic BP <90 mm Hg based on the mean of monthly BP measurements, and prescriptions for antihypertensive medications. RESULTS The annual samples ranged between n=22 110 and n=33 039 individuals, with a mean age of 72 years, 96% of whom were men. Between 2011 and 2014, the age-adjusted proportion of adults with controlled BP declined from 78.0% to 72.2% (P value for linear trend, <0.001), reached a nadir of 71.0% in 2015, and then increased to 72.9% by 2019 (P value for linear trend, <0.001). Among adults with BP above goal, the age-adjusted proportion who did not receive antihypertensive treatment increased throughout the decade from 18.8% to 21.6%, and the age-adjusted proportion who received ≥3 antihypertensive medications decreased from 41.8% to 36.3%. Prescriptions for first-line antihypertensive agents also decreased. CONCLUSIONS Among adults with CKD treated in the Veterans Health Administration, the proportion with controlled BP declined between 2011 and 2015 followed by a modest increase, coinciding with fewer prescriptions for antihypertensive medications.
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Affiliation(s)
- Joshua D. Martinez
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine and VA Palo Alto Health Care System, Palo Alto, CA
| | - I-Chun Thomas
- Geriatric Research and Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
| | - Maria E. Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine and VA Palo Alto Health Care System, Palo Alto, CA
| | - Alan C. Pao
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine and VA Palo Alto Health Care System, Palo Alto, CA
| | - Enrica Fung
- Division of Nephrology, Department of Medicine, Loma Linda University School of Medicine and Loma Linda VA Health Care System, Loma Linda, CA
| | - Vivek Charu
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - John J. Sim
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Jaejin An
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Michelle C. Odden
- Geriatric Research and Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, CA
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine and VA Palo Alto Health Care System, Palo Alto, CA
- Geriatric Research and Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
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Georgianos PI, Agarwal R. Hypertension in chronic kidney disease-treatment standard 2023. Nephrol Dial Transplant 2023; 38:2694-2703. [PMID: 37355779 PMCID: PMC10689140 DOI: 10.1093/ndt/gfad118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Indexed: 06/26/2023] Open
Abstract
Hypertension is very common and remains often poorly controlled in patients with chronic kidney disease (CKD). Accurate blood pressure (BP) measurement is the essential first step in the diagnosis and management of hypertension. Dietary sodium restriction is often overlooked, but can improve BP control, especially among patients treated with an agent to block the renin-angiotensin system. In the presence of very high albuminuria, international guidelines consistently and strongly recommend the use of an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker as the antihypertensive agent of first choice. Long-acting dihydropyridine calcium channel blockers and diuretics are reasonable second- and third-line therapeutic options. For patients with treatment-resistant hypertension, guidelines recommend the addition of spironolactone to the baseline antihypertensive regimen. However, the associated risk of hyperkalemia restricts the broad utilization of spironolactone in patients with moderate-to-advanced CKD. Evidence from the CLICK (Chlorthalidone in Chronic Kidney Disease) trial indicates that the thiazide-like diuretic chlorthalidone is effective and serves as an alternative therapeutic opportunity for patients with stage 4 CKD and uncontrolled hypertension, including those with treatment-resistant hypertension. Chlorthalidone can also mitigate the risk of hyperkalemia to enable the concomitant use of spironolactone, but this combination requires careful monitoring of BP and kidney function for the prevention of adverse events. Emerging agents, such as the non-steroidal mineralocorticoid receptor antagonist ocedurenone, dual endothelin receptor antagonist aprocitentan and the aldosterone synthase inhibitor baxdrostat offer novel targets and strategies to control BP better. Larger and longer term clinical trials are needed to demonstrate the safety and efficacy of these novel therapies in the future. In this article, we review the current standards of treatment and discuss novel developments in pathophysiology, diagnosis, outcome prediction and management of hypertension in patients with CKD.
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Affiliation(s)
- Panagiotis I Georgianos
- 2nd Department of Nephrology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
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Janakiraman A, Cohen DL. New Potential Treatments for Resistant Hypertension. Curr Cardiol Rep 2023; 25:1443-1449. [PMID: 37755638 DOI: 10.1007/s11886-023-01966-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2023] [Indexed: 09/28/2023]
Abstract
PURPOSE OF REVIEW To provide an update and review approaches to the treatment of resistant hypertension (RH) with a focus on emerging potential therapies. RECENT FINDINGS Resistant hypertension is defined as a blood pressure that remains elevated above a patient's individualized target despite the concurrent use of 3 antihypertensive agents of different classes including a diuretic or use of 4 or more antihypertensive agents. Patients with RH have an increased risk of adverse cardiovascular and renal outcomes. Most RH is attributed to apparent RH and is not true RH. True RH is a diagnosis of exclusion after apparent RH has been excluded. Treatment of RH is challenging, and blood pressure goal is often difficult to achieve. Currently several new therapies have emerged with forthcoming data that provide promise for improved blood pressure control in those with resistant hypertension. Once RH has been diagnosed, patients should be on standardized therapy that includes agents from three different classes including a diuretic with addition in most cases of a mineralocorticoid as a fourth line agent. There are newer agents in development currently being studied in clinical trials including dual endothelin receptor antagonists and aldosterone synthase inhibitors that appear to be efficacious. Other approved medications including SGLT2 inhibitors and non-steroidal mineralocorticoids such as finerenone also need to be incorporated into treatment paradigms. Renal denervation with catheter based devices is another potential promising treatment option in this population.
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Affiliation(s)
- Arun Janakiraman
- Department of Medicine, Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, 1 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA, 19147, USA
| | - Debbie L Cohen
- Department of Medicine, Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, 1 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA, 19147, USA.
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Wang AYM, Mallamaci F, Zoccali C. What is central to renal nutrition: protein or sodium intake? Clin Kidney J 2023; 16:1824-1833. [PMID: 37915942 PMCID: PMC10616450 DOI: 10.1093/ckj/sfad151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Indexed: 11/03/2023] Open
Abstract
Historically, nutrition intervention has been primarily focused on limiting kidney injury, reducing generation of uraemic metabolites, as well as maintaining nutrition status and preventing protein-energy wasting in patients with chronic kidney disease (CKD). This forms an important rationale for prescribing restricted protein diet and restricted salt diet in patients with CKD. However, evidence supporting a specific protein intake threshold or salt intake threshold remains far from compelling. Some international or national guidelines organizations have provided strong or 'level 1' recommendations for restricted protein diet and restricted salt diet in CKD. However, it is uncertain whether salt or protein restriction plays a more central role in renal nutrition management. A key challenge in successful implementation or wide acceptance of a restricted protein diet and a restricted salt diet is patients' long-term dietary adherence. These challenges also explain the practical difficulties in conducting randomized trials that evaluate the impact of dietary therapy on patients' outcomes. It is increasingly recognized that successful implementation of a restricted dietary prescription or nutrition intervention requires a highly personalized, holistic care approach with support and input from a dedicated multidisciplinary team that provides regular support, counselling and close monitoring of patients. With the advent of novel drug therapies for CKD management such as sodium-glucose cotransporter-2 inhibitors or non-steroidal mineralocorticoid receptor antagonist, it is uncertain whether restricted protein diet and restricted salt diet may still be necessary and have incremental benefits. Powered randomized controlled trials with novel design are clearly indicated to inform clinical practice on recommended dietary protein and salt intake threshold for CKD in this new era.
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Affiliation(s)
- Angela Yee-Moon Wang
- University Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, SAR, China
| | - Francesca Mallamaci
- Nefrologia and CNR Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
| | - Carmine Zoccali
- Renal Research Institute, New York, USA
- Institute of Molecular Biology and Genetics (Biogem), Ariano Irpino, Italy
- Associazione Ipertensione Nefrologia Trapianto Renal (IPNET), Nefrologia, Grande Ospedale Metropolitano, Reggio Calabria, Italy
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Park S, Shin J, Ihm SH, Kim KI, Kim HL, Kim HC, Lee EM, Lee JH, Ahn SY, Cho EJ, Kim JH, Kang HT, Lee HY, Lee S, Kim W, Park JM. Resistant hypertension: consensus document from the Korean society of hypertension. Clin Hypertens 2023; 29:30. [PMID: 37908019 PMCID: PMC10619268 DOI: 10.1186/s40885-023-00255-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/09/2023] [Indexed: 11/02/2023] Open
Abstract
Although reports vary, the prevalence of true resistant hypertension and apparent treatment-resistant hypertension (aTRH) has been reported to be 10.3% and 14.7%, respectively. As there is a rapid increase in the prevalence of obesity, chronic kidney disease, and diabetes mellitus, factors that are associated with resistant hypertension, the prevalence of resistant hypertension is expected to rise as well. Frequently, patients with aTRH have pseudoresistant hypertension [aTRH due to white-coat uncontrolled hypertension (WUCH), drug underdosing, poor adherence, and inaccurate office blood pressure (BP) measurements]. As the prevalence of WUCH is high among patients with aTRH, the use of out-of-office BP measurements, both ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM), is essential to exclude WUCH. Non-adherence is especially problematic, and methods to assess adherence remain limited and often not clinically feasible. Therefore, the use of HBPM and higher utilization of single-pill fixed-dose combination treatments should be emphasized to improve drug adherence. In addition, primary aldosteronism and symptomatic obstructive sleep apnea are quite common in patients with hypertension and more so in patients with resistant hypertension. Screening for these diseases is essential, as the treatment of these secondary causes may help control BP in patients who are otherwise difficult to treat. Finally, a proper drug regimen combined with lifestyle modifications is essential to control BP in these patients.
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Affiliation(s)
- Sungha Park
- Division of Cardiology, Severance Cardiovascular Hospital, Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jinho Shin
- Division of Cardiology, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, South Korea
| | - Sang Hyun Ihm
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea.
- Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Bucheon St. Mary's Hospital327 Sosa-Ro, Wonmi-guGyunggi-do, Bucheon-si, 14647, Republic of Korea.
| | - Kwang-Il Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Hack-Lyoung Kim
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeon Chang Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Mi Lee
- Division of Cardiology, Department of Internal Medicine, Wonkwang University Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Republic of Korea
| | - Jang Hoon Lee
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, South Korea
- School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Shin Young Ahn
- Division of Nephrology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Eun Joo Cho
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ju Han Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Hee-Taik Kang
- Department of Family Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hae-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sunki Lee
- Hallym University, Dongtan Hospital, Gyeonggi-do, Korea
| | - Woohyeun Kim
- Division of Cardiology, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, South Korea
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Lo R, Narasaki Y, Lei S, Rhee CM. Management of traditional risk factors for the development and progression of chronic kidney disease. Clin Kidney J 2023; 16:1737-1750. [PMID: 37915906 PMCID: PMC10616454 DOI: 10.1093/ckj/sfad101] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Indexed: 11/03/2023] Open
Abstract
Chronic kidney disease (CKD) and its downstream complications (i.e. cardiovascular) are a major source of morbidity worldwide. Additionally, deaths due to CKD or CKD-attributable cardiovascular disease account for a sizeable proportion of global mortality. However, the advent of new pharmacotherapies, diagnostic tools, and global initiatives are directing greater attention to kidney health in the public health agenda, including the implementation of effective strategies that (i) prevent kidney disease, (ii) provide early CKD detection, and (iii) ameliorate CKD progression and its related complications. In this Review, we discuss major risk factors for incident CKD and CKD progression categorized across cardiovascular (i.e. hypertension, dyslipidemia, cardiorenal syndrome), endocrine (i.e. diabetes mellitus, hypothyroidism, testosterone), lifestyle (i.e. obesity, dietary factors, smoking), and genetic/environmental (i.e. CKDu/Mesoamerican nephropathy, APOL1, herbal nephropathy) domains, as well as scope, mechanistic underpinnings, and management.
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Affiliation(s)
- Robin Lo
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Yoko Narasaki
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Sean Lei
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
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Ortiz A, Galán CDA, Carlos Fernández-García J, Cerezo JG, Ochoa RI, Núñez J, Gutiérrez FP, Navarro-González JF. Consensus document on the management of hyperkalemia. Nefrologia 2023; 43:765-782. [PMID: 38169239 DOI: 10.1016/j.nefroe.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/08/2023] [Indexed: 01/05/2024] Open
Abstract
Hyperkalaemia is a common electrolyte imbalance with potentially serious short-, medium- and long-term consequences on morbidity and mortality rates and the use of national health service resources. The fact that different medical specialities can manage hyperkalaemia makes it important to have a unified approach, and the recent availability of new specific drug treatments means that the approach needs to be updated. This consensus document from the scientific societies most directly involved in the management of hyperkalaemia (Sociedad Española de Cardiología [Spanish Society of Cardiology], Sociedad Española de Endocrinología y Nutrición [Spanish Society of Endocrinology and Nutrition], Sociedad Española de Medicina Interna [Spanish Society of Internal Medicine], Sociedad Española de Medicina de Urgencias y Emergencias [Spanish Society of Accident and Emergency Medicine] and Sociedad Española de Nefrología [Spanish Society of Nephrology]) first of all reviews basic aspects of potassium balance and blood potassium. Then it goes on to focus on the concept, epidemiology, pathophysiology and diagnostic and therapeutic approaches to hyperkalaemia. The available evidence and the main published studies have been reviewed with the aim of providing a useful tool in the multidisciplinary approach to patients with hyperkalaemia.
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Affiliation(s)
| | | | | | | | - Rosa Ibán Ochoa
- Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), Spain
| | - Julio Núñez
- Sociedad Española de Cardiología (SEC), Spain
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30
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Trullàs JC, Morales-Rull JL, Casado J, Carrera-Izquierdo M, Sánchez-Marteles M, Conde-Martel A, Dávila-Ramos MF, Llácer P, Salamanca-Bautista P, Chivite D, Jordana-Comajuncosa R, Villalonga M, Páez-Rubio MI, Manzano L, Formiga F. Combining loop and thiazide diuretics for acute heart failure across the estimated glomerular filtration rate spectrum: A post-hoc analysis of the CLOROTIC trial. Eur J Heart Fail 2023; 25:1784-1793. [PMID: 37540036 DOI: 10.1002/ejhf.2988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/24/2023] [Accepted: 07/27/2023] [Indexed: 08/05/2023] Open
Abstract
AIMS In patients with acute heart failure (AHF), the addition of hydrochlorothiazide (HCTZ) to furosemide improved diuretic response in the CLOROTIC trial. This work aimed to evaluate if these effects differ across the estimated glomerular filtration rate (eGFR) spectrum. METHODS AND RESULTS This post-hoc analysis of the CLOROTIC trial analysed 230 patients with AHF and explored the influence of eGFR on primary and secondary endpoints. The median eGFR was 43 ml/min/1.73 m2 (range 14-109) and 23% had eGFR ≥60 ml/min/1.73 m2 (group 1), 24% from 45 to 59 ml/min/1.73 m2 (group 2), and 53% <45 ml/min/1.73 m2 (group 3). Patients treated with HCTZ had greatest weight loss at 72 h in all three groups, but patients in group 1 had a significantly greater response (-2.1 kg [-3.0 to 0.5]), compared to patients in groups 2 (-1.3 kg [-2.3 to 0.2]) and 3 (-0.1 kg [-1.3 to 0.4]) (p-value for interaction = 0.246). At 96 h, the differences in weight were -1.8 kg (-3.0 to -0.3), -1.4 kg (-2.6 to 0.3), and -0.5 kg (-1.3 to -0.1) in groups 1, 2, and 3, respectively (p-value for interaction = 0.256). There were no significant differences observed with the addition of HCTZ in terms of diuretic response, mortality or rehospitalizations, or safety endpoints (impaired renal function, hyponatraemia, and hypokalaemia) among the three eGFR groups (all p-values for interaction were no significant). CONCLUSION The addition of eGFR-adjusted doses of oral HCTZ to loop diuretics in patients with AHF improved diuretic response across the eGFR spectrum. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov: NCT01647932; EudraCT number: 2013-001852-36.
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Affiliation(s)
- Joan Carles Trullàs
- Internal Medicine Department, Hospital d'Olot i Comarcal de la Garrotxa, Girona, Spain
- Tissue Repair and Regeneration Laboratory (TR2Lab), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut a la Catalunya Central (IrisCC), Barcelona, Spain
| | - José Luís Morales-Rull
- Heart Failure Unit, Internal Medicine Department, Hospital Universitari Arnau de Villanova, Institut de Recerca Biomédica (IRBLleida), Lleida, Spain
| | - Jesús Casado
- Internal Medicine Department, Hospital Universitario de Getafe, Madrid, Spain
| | | | - Marta Sánchez-Marteles
- Internal Medicine Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | - Alicia Conde-Martel
- Internal Medicine Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | | | - Pau Llácer
- Internal Medicine Department, Hospital de Manises, Manises, Spain
| | - Prado Salamanca-Bautista
- Internal Medicine Department, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Sevilla, Spain
| | - David Chivite
- Internal Medicine Department, Hospital Universitari de Bellvitge, IDIBELL, Barcelona, Spain
| | | | - Maria Villalonga
- Internal Medicine Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | | | - Luís Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - Francesc Formiga
- Internal Medicine Department, Hospital Universitari de Bellvitge, IDIBELL, Barcelona, Spain
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Martens P, Mullens W. Using combinational diuretics across the spectrum of renal function. Eur J Heart Fail 2023; 25:1794-1796. [PMID: 37671569 DOI: 10.1002/ejhf.3030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 09/04/2023] [Indexed: 09/07/2023] Open
Affiliation(s)
- Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V., Genk, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V., Genk, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
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Chan RJ, Helmeczi W, Hiremath SS. Revisiting resistant hypertension: a comprehensive review. Intern Med J 2023; 53:1739-1751. [PMID: 37493367 DOI: 10.1111/imj.16189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 07/06/2023] [Indexed: 07/27/2023]
Abstract
Resistant hypertension (RHT) is typically defined as blood pressure that remains above guideline-directed targets despite the use of three anti-hypertensives, usually including a diuretic, at optimal or maximally tolerated doses. It is generally estimated to affect 10-30% of those diagnosed with hypertension, though the true incidence might be lower after one factor in the prevalence of non-adherence. Risk factors for its development include diabetes, obesity and other adverse lifestyle factors, and a diagnosis of RHT confers a greater risk of adverse cardiovascular outcomes, such as stroke, heart failure and mortality. It is essential to exclude pseudoresistance and secondary hypertension and to ensure non-pharmacologic management is optimised prior to consideration of fourth-line anti-hypertensive agents or advanced interventions, such as device therapies. In this review, we will cover the different definitions of RHT, along with the importance of careful diagnosis and management strategies, and discuss newer agents and research needs.
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Affiliation(s)
- Ryan J Chan
- Division of Nephrology, Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, Ontario, Canada
| | - Wryan Helmeczi
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Swapnil S Hiremath
- Division of Nephrology, Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Afify H, Gonzalez-Morales U, Asmar A, Alvarez CA, Mansi IA. Association of Thiazide Diuretics With Diabetes Progression, Kidney Disease Progression, Cardiovascular Outcomes, and Death Among Patients With Diabetes Who Initiate Statins. Am J Cardiol 2023; 203:274-284. [PMID: 37516035 DOI: 10.1016/j.amjcard.2023.07.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/10/2023] [Indexed: 07/31/2023]
Abstract
Statins have been associated with diabetes mellitus (DM) progression but their cardiovascular benefit in patients with DM outweigh the harm. However, the effects of concurrent use of other medications that similarly increase blood glucose level, such as thiazide diuretics, are not well studied. This study aimed to evaluate the association of concurrent use of thiazide diuretics and statins on DM progression, cardiovascular and renal outcomes, and death in patients with DM. This is a retrospective cohort study of Veterans with DM who initiated statins between 2003 and 2015. The cohort comprised thiazide users (concomitantly used thiazides and statins for ≥6 months) and active comparators (concomitantly used calciun channel blockers [CCB] but not thiazides and statins for ≥6 months). We excluded patients who were <18 years old, with chronic kidney disease stage 4 or worse, or used loop diuretics. We propensity-score-matched comparison groups on 99 baseline characteristics including demographics, healthcare utilization, co-morbidities, cardiovascular and co-morbidity scores, vital signs, laboratory data, and medication class usage. Outcomes were: (1) DM progression (new insulin initiation, increase in the number of glucose-lowering medication classes, and hyperglycemic episodes); (2) kidney disease progression (doubling of serum creatinine, incidence of chronic kidney disease stage 5, initiation of renal replacement therapy, and incidence of diabetic nephropathy); (3) cardiovascular outcomes (acute myocardial infarction, stroke, cardiac arrest); and (4) total mortality. From 297,967 statin users (228,509 Thiazide-statin users and 69,458 active comparators), we successfully matched 67,614 pairs. In comparison to active comparators, thiazide-statin users had increased risk of DM progression (65.6% in CCB group vs 68.1% in thiazide group; odds ratio [OR]: 1.12, 95% confidence interval [CI]: 1.09 to 1.15), decreased risk of kidney progression (16.9% in CCB group vs 16.5 in thiazide group; OR: 0.97, 95% CI: 0.94 to 0.99), decreased risk of cardiovascular outcomes (15.7% in CCB group vs 14.6% in thiazide group; OR: 0.92, 95% CI: 0.89 to 0.95), and similar risk of total mortality (19.7% in each group; OR: 1.00, 95% CI: 0.98 to 1.03). This study attempted to answer an important clinical question whether thiazide diuretics should be discontinued or substituted upon statin initiation. Our results showed that concurrent use of statin and thiazides in patients with DM was associated with DM progression but with less kidney progression and cardiovascular outcomes and no difference in mortality. Clinicians should closely monitor DM control when thiazides and statins are used concurrently.
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Affiliation(s)
- Hesham Afify
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Louisville Medical Center, Louisville, Kentucky
| | | | - Abdo Asmar
- Department of Education, Orlando VA Healthcare System, Orlando, Florida; University of Central Florida/HCA Healthcare GME, Greater Orlando, Florida; Department of Internal Medicine, University of Central Florida, College of Medicine, Orlando, Florida
| | - Carlos A Alvarez
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, Center for Excellence in Real-world Evidence and North Texas Health Care System, Dallas, Texas
| | - Ishak A Mansi
- Department of Education, Orlando VA Healthcare System, Orlando, Florida; Department of Internal Medicine, University of Central Florida, College of Medicine, Orlando, Florida.
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Zoccali C, Mallamaci F, Adamczak M, de Oliveira RB, Massy ZA, Sarafidis P, Agarwal R, Mark PB, Kotanko P, Ferro CJ, Wanner C, Burnier M, Vanholder R, Wiecek A. Cardiovascular complications in chronic kidney disease: a review from the European Renal and Cardiovascular Medicine Working Group of the European Renal Association. Cardiovasc Res 2023; 119:2017-2032. [PMID: 37249051 PMCID: PMC10478756 DOI: 10.1093/cvr/cvad083] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/29/2022] [Accepted: 01/09/2023] [Indexed: 05/31/2023] Open
Abstract
Chronic kidney disease (CKD) is classified into five stages with kidney failure being the most severe stage (stage G5). CKD conveys a high risk for coronary artery disease, heart failure, arrhythmias, and sudden cardiac death. Cardiovascular complications are the most common causes of death in patients with kidney failure (stage G5) who are maintained on regular dialysis treatment. Because of the high death rate attributable to cardiovascular (CV) disease, most patients with progressive CKD die before reaching kidney failure. Classical risk factors implicated in CV disease are involved in the early stages of CKD. In intermediate and late stages, non-traditional risk factors, including iso-osmotic and non-osmotic sodium retention, volume expansion, anaemia, inflammation, malnutrition, sympathetic overactivity, mineral bone disorders, accumulation of a class of endogenous compounds called 'uremic toxins', and a variety of hormonal disorders are the main factors that accelerate the progression of CV disease in these patients. Arterial disease in CKD patients is characterized by an almost unique propensity to calcification and vascular stiffness. Left ventricular hypertrophy, a major risk factor for heart failure, occurs early in CKD and reaches a prevalence of 70-80% in patients with kidney failure. Recent clinical trials have shown the potential benefits of hypoxia-inducible factor prolyl hydroxylase inhibitors, especially as an oral agent in CKD patients. Likewise, the value of proactively administered intravenous iron for safely treating anaemia in dialysis patients has been shown. Sodium/glucose cotransporter-2 inhibitors are now fully emerged as a class of drugs that substantially reduces the risk for CV complications in patients who are already being treated with adequate doses of inhibitors of the renin-angiotensin system. Concerted efforts are being made by major scientific societies to advance basic and clinical research on CV disease in patients with CKD, a research area that remains insufficiently explored.
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Affiliation(s)
- Carmine Zoccali
- Renal Research Institute, 315 E, 62nd St., New York, NY 10065, USA
- Associazione Ipertensione Nefrologia e Trapianto Renale (IPNET) c/o Nefrologia e CNR, Grande Ospedale Metropolitano, Contrada Camporeale, 83031 Ariano Irpino Avellino, Italy
| | - Francesca Mallamaci
- Nephrology and Transplantation Unit, Grande Ospedale Metropolitano Reggio Cal and CNR-IFC, Via Giuseppe Melacrino 21, 89124 Reggio Calabria, Italy
| | - Marcin Adamczak
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Francuska 20-24 St. 40-027 Katowice, Poland
| | - Rodrigo Bueno de Oliveira
- Department of Internal Medicine (Nephrology), School of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | - Ziad A Massy
- Ambroise Paré University Hospital, APHP, Boulogne Billancourt/Paris, and INSERM U-1018, Centre de recherche en épidémiologie et santé des populations (CESP), Equipe 5, Paris-Saclay University (PSU) and University of Paris Ouest-Versailles-Saint-Quentin-en-Yvelines (UVSQ), FCRIN INI-CRCT, Villejuif, France
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Indiana University School of Medicine and Richard L. Roudebush VA Medical Center, 1481 W 10th St, Indianapolis, IN 46202, USA
| | - Patrick B Mark
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Peter Kotanko
- Renal Research Institute, LLC Icahn School of Medicine at Mount Sinai, 315 East 62nd Street, 3rd Floor, New York, NY 10065, USA
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Michel Burnier
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine and Pediatrics, University Hospital, Ghent, Belgium
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Francuska 20-24 St. 40-027 Katowice, Poland
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Kollias A, Kyriakoulis KG, Stergiou GS. Chlorthalidone versus hydrochlorothiazide for preventing cardiovascular disease in hypertension: Is the case closed? Hellenic J Cardiol 2023; 73:84-85. [PMID: 37429505 DOI: 10.1016/j.hjc.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/05/2023] [Indexed: 07/12/2023] Open
Abstract
The optimal diuretic choice [hydrochlorothiazide (HCTZ) or chlorthalidone (CTD)] for the management of hypertension has been an ongoing debate for several years. HCTZ is widely used in the form of single-pill combinations, whereas CTD is a more potent drug vs. HCTZ, especially in reducing nighttime blood pressure (BP), with some indirect evidence suggesting a superiority in terms of cardiovascular (CV) risk reduction. In addition, recent data showed that CTD was safe and effective in terms of BP lowering in predialysis patients with stage 4 chronic kidney disease. The Diuretic Comparison Project was the first head-to-head pragmatic, open-label trial that randomly assigned elderly patients with hypertension under HCTZ therapy to continue with HCTZ or to switch to CTD (equivalent doses). Office BP was similar for both groups throughout the study. The trial showed no difference in major CV events or non-cancer-related deaths during a median follow-up of 2.4 years; yet, CTD was associated with a benefit in participants with a previous myocardial infarction or stroke, which might be a chance finding but could also indicate that a high-risk population is more suitable for revealing the impact of slight differences in the 24-hour BP profile in a relatively short-term follow-up. Interestingly CTD vs. HCTZ was associated with higher hypokalemia rates apart from the latter group of patients where there was no difference. Overall, the available data do not confirm the superiority of CTD over HCTZ in general, but this could be questionable in selected patients.
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Affiliation(s)
- Anastasios Kollias
- Hypertension Center STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Konstantinos G Kyriakoulis
- Hypertension Center STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George S Stergiou
- Hypertension Center STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Bezerra R, de Farias FT, Feitosa A, Nadruz W, Brandão AA, Barroso WKS. Suspension of Thiazide Diuretics in Advanced Chronic Kidney Disease. Time to Review an Old Concept. Arq Bras Cardiol 2023; 120:e20230115. [PMID: 37878894 PMCID: PMC10547429 DOI: 10.36660/abc.20230115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/05/2023] [Accepted: 04/05/2023] [Indexed: 10/27/2023] Open
Affiliation(s)
- Rodrigo Bezerra
- Universidade Federal de PernambucoLaboratório de Imunopatologia Keizo AsamiRecifePEBrasilUniversidade Federal de Pernambuco - Laboratório de Imunopatologia Keizo Asami, Recife, PE – Brasil
- Universidade de PernambucoPronto Socorro Cardiológico de PernambucoRecifePEBrasilUniversidade de Pernambuco - Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE – Brasil
| | - Flávio Teles de Farias
- Universidade Federal de AlagoasMaceióALBrasilUniversidade Federal de Alagoas, Maceió, AL – Brasil
| | - Audes Feitosa
- Universidade de PernambucoPronto Socorro Cardiológico de PernambucoRecifePEBrasilUniversidade de Pernambuco - Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE – Brasil
| | - Wilson Nadruz
- Universidade Estadual de CampinasCampinasSPBrasilUniversidade Estadual de Campinas (UNICAMP), Campinas, SP – Brasil
| | - Andrea Araújo Brandão
- Universidade do Estado do Rio de JaneiroDepartamento de Doenças do TóraxRio de JaneiroRJBrasilUniversidade do Estado do Rio de Janeiro - Departamento de Doenças do Tórax, Rio de Janeiro, RJ – Brasil
| | - Weimar Kunz Sebba Barroso
- Universidade Federal de GoiásServiço de CardiologiaLiga de Hipertensão ArterialGoiâniaGOBrasilUniversidade Federal de Goiás - Serviço de Cardiologia, Liga de Hipertensão Arterial, Goiânia, GO – Brasil
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Kannuthurai V, Gaffo A. Management of Patients with Gout and Kidney Disease: A Review of Available Therapies and Common Missteps. Kidney360 2023; 4:e1332-e1340. [PMID: 37526648 PMCID: PMC10550007 DOI: 10.34067/kid.0000000000000221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/13/2023] [Indexed: 08/02/2023]
Abstract
Gout, a common form of inflammatory arthritis, is characterized by deposition of monosodium urate crystals in articular and periarticular tissues. Repeated flares of gout cause joint damage as well as significant health care utilization and decreased quality of life. Patients with CKD have a higher prevalence of gout. Treating Patients with CKD and gout is challenging because of the lack of quality data to guide management in this specific population. This often leads to suboptimal treatment of patients with gout and impaired renal function because concerns regarding the efficacy and safety of available gout therapies in this population often result in significant interphysician variability in treatment regimens and dosages. Acute gout flares are treated with various agents, including nonsteroidal anti-inflammatory drugs, colchicine, glucocorticoids, and-more recently-IL-1 inhibitors. These medications can also be used as prophylaxis if urate-lowering therapy (ULT) is initiated. While these drugs can be used in patients with gout and CKD, there are often factors that complicate treatment, such as the numerous medication interactions involving colchicine and the effect of glucocorticoids on common comorbidities, such as diabetes and hypertension. ULT is recommended to treat recurrent flares, tophaceous deposits, and patients with moderate-to-severe CKD with a serum urate goal of <6 mg/dl recommended to prevent flares. While many misconceptions exist around the risks of using urate-lowering agents in patients with CKD, there is some evidence that these medications can be used safely in Patients with renal impairment. Additional questions exist as to whether gout treatment is indicated for Patients on RRT. Furthermore, there are conflicting data on whether ULT can affect renal function and cardiovascular disease in patients. All of these factors contribute to the unique challenges physicians face when treating patients with gout and CKD.
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Affiliation(s)
- Vijay Kannuthurai
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Angelo Gaffo
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Birmingham VA Medical Center, Birmingham, Alabama
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Dybiec J, Krzemińska J, Radzioch E, Szlagor M, Wronka M, Młynarska E, Rysz J, Franczyk B. Advances in the Pathogenesis and Treatment of Resistant Hypertension. Int J Mol Sci 2023; 24:12911. [PMID: 37629095 PMCID: PMC10454510 DOI: 10.3390/ijms241612911] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/25/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Hypertension is a prevalent chronic disease associated with an increased risk of cardiovascular (CV) premature death, and its severe form manifests as resistant hypertension (RH). The accurate prevalence of resistant hypertension is difficult to determine due to the discrepancy in data from various populations, but according to recent publications, it ranges from 6% to 18% in hypertensive patients. However, a comprehensive understanding of the pathogenesis and treatment of RH is essential. This review emphasizes the importance of identifying the causes of treatment resistance in antihypertensive therapy and highlights the utilization of appropriate diagnostic methods. We discussed innovative therapies such as autonomic neuromodulation techniques like renal denervation (RDN) and carotid baroreceptor stimulation, along with invasive interventions such as arteriovenous anastomosis as potential approaches to support patients with inadequate medical treatment and enhance outcomes in RH.
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Affiliation(s)
- Jill Dybiec
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Łódź, Poland; (J.D.); (J.K.); (E.R.); (M.S.); (M.W.); (B.F.)
| | - Julia Krzemińska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Łódź, Poland; (J.D.); (J.K.); (E.R.); (M.S.); (M.W.); (B.F.)
| | - Ewa Radzioch
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Łódź, Poland; (J.D.); (J.K.); (E.R.); (M.S.); (M.W.); (B.F.)
| | - Magdalena Szlagor
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Łódź, Poland; (J.D.); (J.K.); (E.R.); (M.S.); (M.W.); (B.F.)
| | - Magdalena Wronka
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Łódź, Poland; (J.D.); (J.K.); (E.R.); (M.S.); (M.W.); (B.F.)
| | - Ewelina Młynarska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Łódź, Poland; (J.D.); (J.K.); (E.R.); (M.S.); (M.W.); (B.F.)
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Żeromskiego 113, 90-549 Łódź, Poland;
| | - Beata Franczyk
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Łódź, Poland; (J.D.); (J.K.); (E.R.); (M.S.); (M.W.); (B.F.)
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Stompór T, Adamczak M, Kurnatowska I, Naumnik B, Nowicki M, Tylicki L, Winiarska A, Krajewska M. Pharmacological Nephroprotection in Non-Diabetic Chronic Kidney Disease-Clinical Practice Position Statement of the Polish Society of Nephrology. J Clin Med 2023; 12:5184. [PMID: 37629226 PMCID: PMC10455736 DOI: 10.3390/jcm12165184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/03/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Chronic kidney disease (CKD) is a modern epidemic worldwide. Introducing renin-angiotensin system (RAS) inhibitors (i.e., ACEi or ARB) not only as blood-pressure-lowering agents, but also as nephroprotective drugs with antiproteinuric potential was a milestone in the therapy of CKD. For decades, this treatment remained the only proven strategy to slow down CKD progression. This situation changed some years ago primarily due to the introduction of drugs designed to treat diabetes that turned into nephroprotective strategies not only in diabetic kidney disease, but also in CKD unrelated to diabetes. In addition, several drugs emerged that precisely target the pathogenetic mechanisms of particular kidney diseases. Finally, the role of metabolic acidosis in CKD progression (and not only the sequelae of CKD) came to light. In this review, we aim to comprehensively discuss all relevant therapies that slow down the progression of non-diabetic kidney disease, including the lowering of blood pressure, through the nephroprotective effects of ACEi/ARB and spironolactone independent from BP lowering, as well as the role of sodium-glucose co-transporter type 2 inhibitors, acidosis correction and disease-specific treatment strategies. We also briefly address the therapies that attempt to slow down the progression of CKD, which did not confirm this effect. We are convinced that our in-depth review with practical statements on multiple aspects of treatment offered to non-diabetic CKD fills the existing gap in the available literature. We believe that it may help clinicians who take care of CKD patients in their practice. Finally, we propose the strategy that should be implemented in most non-diabetic CKD patients to prevent disease progression.
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Affiliation(s)
- Tomasz Stompór
- Department of Nephrology, Hypertension and Internal Medicine, University of Warmia and Mazury in Olsztyn, 10-516 Olsztyn, Poland
| | - Marcin Adamczak
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, 40-027 Katowice, Poland
| | - Ilona Kurnatowska
- Department of Internal Diseases and Transplant Nephrology, Medical University of Lodz, 90-419 Lodz, Poland
| | - Beata Naumnik
- Ist Department of Nephrology and Transplantation with Dialysis Unit, Medical University of Bialystok, Zurawia 14 St., 15-540 Bialystok, Poland
| | - Michał Nowicki
- Department of Nephrology, Hypertension and Kidney Transplantation, Central University Hospital, Medical University of Lodz, 92-213 Lodz, Poland
| | - Leszek Tylicki
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdansk, 80-952 Gdansk, Poland
| | - Agata Winiarska
- Department of Nephrology, Hypertension and Internal Medicine, University of Warmia and Mazury in Olsztyn, 10-516 Olsztyn, Poland
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland;
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Theofilis P, Vordoni A, Kalaitzidis RG. Novel therapeutic approaches in the management of chronic kidney disease: a narrative review. Postgrad Med 2023; 135:543-550. [PMID: 37401536 DOI: 10.1080/00325481.2023.2233492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/27/2023] [Indexed: 07/05/2023]
Abstract
Chronic kidney disease (CKD) remains a pathologic entity with constantly rising incidence and high rates of morbidity and mortality, which are associated with serious cardiovascular complications. Moreover, the incidence of end-stage renal disease tends to increase. The epidemiological trends of CKD warrant the development of novel therapeutic approaches aiming to prevent its development or retard its progression through the control of major risk factors: type 2 diabetes mellitus, arterial hypertension, and dyslipidemia. Contemporary therapeutics such as sodium-glucose cotransporter-2 inhibitors and second-generation mineralocorticoid receptor antagonists are utilized in this direction. Additionally, experimental and clinical studies present novel drug categories that could be employed in managing CKD, such as aldosterone synthesis inhibitors or activators guanylate cyclase, while the role of melatonin should be further tested in the clinical setting. Finally, in this patient population, the use of hypolipidemic agents may provide incremental benefits.
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Affiliation(s)
- Panagiotis Theofilis
- Center for Nephrology, "G. Papadakis" General Hospital of Nikaia-Piraeus "Ag. Panteleimon", Athens, Greece
| | - Aikaterini Vordoni
- Center for Nephrology, "G. Papadakis" General Hospital of Nikaia-Piraeus "Ag. Panteleimon", Athens, Greece
| | - Rigas G Kalaitzidis
- Center for Nephrology, "G. Papadakis" General Hospital of Nikaia-Piraeus "Ag. Panteleimon", Athens, Greece
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Massicotte-Azarniouch D, Canney M, Sood MM, Hundemer GL. Managing Hyperkalemia in the Modern Era: A Case-Based Approach. Kidney Int Rep 2023; 8:1290-1300. [PMID: 37441466 PMCID: PMC10334407 DOI: 10.1016/j.ekir.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 04/15/2023] [Accepted: 04/17/2023] [Indexed: 07/15/2023] Open
Abstract
The last decade has seen tremendous advances in the prevention and treatment of recurrent hyperkalemia. In this narrative review, we aim to highlight contemporary data on key areas in the epidemiology and management of hyperkalemia. Focusing on drug-induced hyperkalemia (the implications of renin-angiotensin-aldosterone system inhibitors [RAASi] discontinuation and the role of mineralocorticoid receptor antagonists), newer concurrent therapies that modify potassium handling (sodium-glucose transporter 2 inhibitors [SGLT2i]), the introduction of new treatment agents (oral potassium binding agents), and the controversial role of dietary potassium restriction, we apply recent research findings and review the evidence in a case-based format.
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Affiliation(s)
- David Massicotte-Azarniouch
- Department of Medicine, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mark Canney
- Department of Medicine, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Manish M. Sood
- Department of Medicine, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Gregory L. Hundemer
- Department of Medicine, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Ortiz A, Alcázar Arroyo R, Casado Escribano PP, Fernández-Fernández B, Martínez Debén F, Mediavilla JD, Michan-Doña A, Soler MJ, Gorriz JL. Optimization of potassium management in patients with chronic kidney disease and type 2 diabetes on finerenone. Expert Rev Clin Pharmacol 2023:1-14. [PMID: 37190957 DOI: 10.1080/17512433.2023.2213888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Patients with type 2 diabetes (T2DM) and chronic kidney disease (CKD) are at high risk of CKD progression and cardiovascular events. Despite treatment with renin-angiotensin system inhibitors and SGLT-2 inhibitors, the residual risk is substantial. There is preclinical and clinical evidence supporting a key role of mineralocorticoid receptor in cardiorenal injury in T2DM. AREAS COVERED Finerenone is a selective and nonsteroidal mineralocorticoid receptor antagonist that reduces -on preclinical studies- heart and kidney inflammation and fibrosis. Clinical trials have demonstrated that among patients with T2DM and CKD, finerenone reduces CKD progression and the risk of cardiovascular events. The incidence of adverse events is similar than for placebo. Permanent discontinuation of study drug due to hyperkalemia was low (1.7% of finerenone and 0.6% of placebo participants) as was the risk of hyperkalemia-related severe-adverse events (1.1%). We provide an overview of risk factors for hyperkalemia and management of serum potassium in people with CKD and T2DM on finerenone. EXPERT OPINION As finerenone increases potassium levels in a predictable way, patients at risk of hyperkalemia can be identified early in clinical practice and monitored for an easy management. This will allow people with T2DM and CKD to safely benefit from improved cardiorenal outcomes.
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Affiliation(s)
- Alberto Ortiz
- Nephrology and Hypertension Department, IIS-FJD and Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | | | | | - Beatriz Fernández-Fernández
- Nephrology and Hypertension Department, IIS-FJD and Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Francisco Martínez Debén
- Internal Medicine Department, Hospital Naval, Complexo Hospitalario Universitario de Ferrol. Departamento de Ciencias de la Salud. Universidad de La Coruña, Spain
| | - Juan Diego Mediavilla
- Internal Medicine Department, Instituto de Investigación Biosanitaria ibs, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Alfredo Michan-Doña
- Department of Medicine, Hospital Universitario de Jerez, Biomedical Research and Innovation Institute of Cadiz (INiBICA), Cádiz, Spain
| | - Maria Jose Soler
- Nephrology Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Jose Luis Gorriz
- Nephrology Department, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, Spain
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Jo W, Koh ES, Chung S. Therapeutic roles of thiazides and loop diuretics in blood pressure control and renal protection against chronic kidney disease. Clin Hypertens 2023; 29:14. [PMID: 37183259 PMCID: PMC10184374 DOI: 10.1186/s40885-023-00238-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 03/17/2023] [Indexed: 05/16/2023] Open
Abstract
Fluid overload secondary to loss of functional nephron mass can elevate blood pressure, which is characteristic of hypertension shown in chronic kidney disease (CKD). Therefore, it is logical to use diuretics at appropriate dose to lower blood pressure in patients with CKD and hypertension. Despite the theoretical background on the use of diuretics in CKD, there have been no definitive data on the effectiveness or safety of diuretics as first-line therapy for the management of hypertension in patients with CKD. Results from some clinical trials have demonstrated that diuretics would not lower blood pressure. They could even worsen electrolyte imbalance and kidney function when they are administered in patients with CKD. Major clinical practice guidelines on management of blood pressure or CKD have stated that evidence for benefits of thiazide diuretics is not conclusive yet in patients with advanced CKD, although loop diuretics are often effective for volume control at lower glomerular filtration rate. Recently, evidence for diuretics as effective blood pressure lowering agents in patients with advanced CKD is increasing. Renoprotective effect of thiazide or loop diuretics might represent a consequence of their influence on blood pressure or their ability to potentiate the effect of renin-angiotensin system blockade by making intraglomerular pressure more renin-angiotensin system-dependent, although their direct benefit on renal function remains controversial. This review summarizes recent data on the possible role of diuretics in lowering blood pressure, slowing the progression of kidney disease, and reducing cardiovascular risk in CKD patients.
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Affiliation(s)
- Wonji Jo
- Division of Nephrology, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Sil Koh
- Division of Nephrology, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sungjin Chung
- Division of Nephrology, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Tuot DS, Powe NR. Care of the Patient With Abnormal Kidney Test Results. Ann Intern Med 2023; 176:ITC65-ITC80. [PMID: 37155988 DOI: 10.7326/aitc202305160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Blood and urine tests are commonly performed by clinicians in both ambulatory and hospital settings that detect chronic and acute kidney disease. Thresholds for these tests have been established that signal the presence and severity of kidney injury or dysfunction. In the appropriate clinical context of a patient's history and physical examination, an abnormal test result should trigger specific actions for clinicians, including reviewing patient medication use, follow-up testing, prescribing lifestyle modifications, and specialist referral. Tests for kidney disease can also be used to determine the future risk for kidney failure as well as cardiovascular death.
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Affiliation(s)
- Delphine S Tuot
- Division of Nephrology and Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, and Department of Medicine, University of California San Francisco, San Francisco, California (D.S.T.)
| | - Neil R Powe
- Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, and Department of Medicine, University of California San Francisco, San Francisco, California (N.R.P.)
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Luft FC. Sixty Years of Confronting Diabetes and Kidney Disease. Semin Nephrol 2023; 43:151426. [PMID: 37862743 DOI: 10.1016/j.semnephrol.2023.151426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
The good old days were not good, at least in terms of treating patients with type 2 diabetes. In the 1960s, the development of a radioimmunoassay for insulin permitted determination of the distinguishing features of type 1 and type 2 diabetes. The latter was treated with sulfonylureas and then phenformin, although the mechanisms of action at the time were unknown. The University Group Diabetes Program was a randomized controlled trial experienced by my medical generation, and the results were dramatic, both medically and legally. Next came the thiazolidinediones. All compounds were associated with weight gain and any end point benefits were uncertain. Nevertheless, basic science explained how glucose is sensed and even found a home for sulfonylureas in some patients. Next came the boom in renin-angiotensin-aldosterone system blockade, sacred ground for many, albeit the benefits were less than astounding. Other wonder drugs came and went. Over the decades, great strides were made in defining the pathology of diabetic renal disease, which is appropriate because the condition has become a primary cause of end-stage renal failure. Nonetheless, recent advances have turned around a depressing situation and are reasons for optimism. We now have compounds that actually could help patients with type 2 diabetes. One hundred years after insulin's introduction, it is high time.
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Affiliation(s)
- Friedrich C Luft
- Experimental and Clinical Research Center, Max-Delbrück Center for Molecular Medicine, Charité Medical Faculty, Berlin, Germany.
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Agarwal R. Should we CLICK on chlorthalidone for treatment-resistant hypertension in chronic kidney disease? Clin Kidney J 2023; 16:793-796. [PMID: 37151421 PMCID: PMC10157782 DOI: 10.1093/ckj/sfac272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Indexed: 12/24/2022] Open
Abstract
Treatment-resistant hypertension is common among patients with advanced chronic kidney disease (CKD). In people with preserved kidney function, spironolactone is an evidence-based treatment. However, the risk for hyperkalemia limits its use in people with more advanced CKD. In the Chlorthalidone in Chronic Kidney Disease (CLICK) trial, 160 patients with stage 4 CKD and poorly controlled hypertension as confirmed by 24-hour ambulatory blood pressure (ABP) monitoring were randomly assigned to either placebo or chlorthalidone 12.5 mg daily in a 1:1 ratio stratified by prior loop diuretic use. The primary endpoint was the change in 24-hour systolic ABP from baseline to 12 weeks. The trial showed a treatment-induced reduction of 24-hour systolic ABP by 10.5 mmHg. Of the 160 patients randomized, 113 (71%) had resistant hypertension, of which 90 (80%) were on loop diuretics and the mean number of antihypertensive medications prescribed was 4.1 (standard deviation 1.1). In this subgroup of patients with treatment-resistant hypertension, the adjusted change from baseline to 12 weeks in the between-group difference in 24-hour systolic ABP was -13.9 mmHg (95% CI -19.4 to -8.4; P < .0001). Furthermore, compared with placebo, the urine albumin:creatinine ratio in the chlorthalidone group at 12 weeks was 54% lower (95% CI -65 to -40). Following randomization, hypokalemia, reversible increases in serum creatinine, hyperglycemia, dizziness, orthostatic hypotension and hyperuricemia occurred more frequently in the chlorthalidone group. Chlorthalidone has the potential to improve BP control among patients with advanced CKD and treatment-resistant hypertension. However, caution is advised when treating patients, especially when they are on loop diuretics.
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Affiliation(s)
- Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
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Samal L, Wu E, Aaron S, Kilgallon JL, Gannon M, McCoy A, Blecker S, Dykes PC, Bates DW, Lipsitz S, Wright A. Refining Clinical Phenotypes to Improve Clinical Decision Support and Reduce Alert Fatigue: A Feasibility Study. Appl Clin Inform 2023; 14:528-537. [PMID: 37437601 PMCID: PMC10338104 DOI: 10.1055/s-0043-1768994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 04/18/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is common and associated with adverse clinical outcomes. Most care for early CKD is provided in primary care, including hypertension (HTN) management. Computerized clinical decision support (CDS) can improve the quality of care for CKD but can also cause alert fatigue for primary care physicians (PCPs). Computable phenotypes (CPs) are algorithms to identify disease populations using, for example, specific laboratory data criteria. OBJECTIVES Our objective was to determine the feasibility of implementation of CDS alerts by developing CPs and estimating potential alert burden. METHODS We utilized clinical guidelines to develop a set of five CPs for patients with stage 3 to 4 CKD, uncontrolled HTN, and indications for initiation or titration of guideline-recommended antihypertensive agents. We then conducted an iterative data analytic process consisting of database queries, data validation, and subject matter expert discussion, to make iterative changes to the CPs. We estimated the potential alert burden to make final decisions about the scope of the CDS alerts. Specifically, the number of times that each alert could fire was limited to once per patient. RESULTS In our primary care network, there were 239,339 encounters for 105,992 primary care patients between April 1, 2018 and April 1, 2019. Of these patients, 9,081 (8.6%) had stage 3 and 4 CKD. Almost half of the CKD patients, 4,191 patients, also had uncontrolled HTN. The majority of CKD patients were female, elderly, white, and English-speaking. We estimated that 5,369 alerts would fire if alerts were triggered multiple times per patient, with a mean number of alerts shown to each PCP ranging from 0.07-to 0.17 alerts per week. CONCLUSION Development of CPs and estimation of alert burden allows researchers to iteratively fine-tune CDS prior to implementation. This method of assessment can help organizations balance the tradeoff between standardization of care and alert fatigue.
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Affiliation(s)
- Lipika Samal
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Edward Wu
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Alabama College of Osteopathic Medicine, Dothan, Alabama, United States
| | - Skye Aaron
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - John L. Kilgallon
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Michael Gannon
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Eastern Virginia Medical School, Norfolk, Virginia, United States
| | - Allison McCoy
- Vanderbilt University, Nashville, Tennessee, United States
| | - Saul Blecker
- NYU School of Medicine, New York, New York, United States
| | - Patricia C. Dykes
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - David W. Bates
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Stuart Lipsitz
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States
| | - Adam Wright
- Vanderbilt University, Nashville, Tennessee, United States
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Khan MS, Rashid AM, Shafi T, Ferreira JP, Butler J. Management of Heart Failure With Reduced Ejection Fraction in Patients With Diabetes Mellitus and Chronic Kidney Disease. Semin Nephrol 2023; 43:151429. [PMID: 37871362 DOI: 10.1016/j.semnephrol.2023.151429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Heart failure (HF), diabetes, and chronic kidney disease (CKD) frequently coexist, with one comorbidity worsening the prognosis of another. β-blockers, angiotensin-receptor-neprilysin inhibitors, renin-angiotensin-aldosterone system inhibitors, mineralocorticoid-receptor antagonists, and sodium-glucose cotransporter-2 inhibitors all have been shown to reduce mortality in patients with HF with reduced ejection fraction. However, their uptake in real-world clinical practice remains low, especially among patients who have multiple other comorbidities such as CKD and diabetes. The management of HF in patients with diabetes and CKD can be especially challenging because these patients typically are older, frail, and have multiple other comorbidities, and guideline-directed medical therapy used in HF potentially can affect renal function acutely and chronically. In this article, we discuss the available evidence for each of the foundational HF therapies in patients with diabetes and CKD, emphasizing the current challenges and outlining future directions to optimize the management of HF among these high-risk patients.
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Affiliation(s)
| | | | - Tariq Shafi
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS
| | - Joao Pedro Ferreira
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, Centre Hospitalier Régional Universitaire (CHRU) Nancy, French Clinical Research Infrastructure Network Investigation Network Initiative Cardiovascular and Renal Clinical Trialist (FCRIN INI-CRCT), Nancy, France
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS; Baylor Scott and White Research Institute, Dallas, TX.
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Abstract
Hypertension is the leading modifiable cause of premature death and hence one of the global targets of World Health Organization for prevention. Hypertension also affects the great majority of patients with chronic kidney disease (CKD). Both hypertension and CKD are intrinsically related, as hypertension is a strong determinant of worse renal and cardiovascular outcomes and renal function decline aggravates hypertension. This bidirectional relationship is well documented by the high prevalence of hypertension across CKD stages and the dual benefits of effective antihypertensive treatments on renal and cardiovascular risk reduction. Achieving an optimal blood pressure (BP) target is mandatory and requires several pharmacological and lifestyle measures. However, it also requires a correct diagnosis based on reliable BP measurements (eg, 24-hour ambulatory BP monitoring, home BP), especially for populations like patients with CKD where reduced or reverse dipping patterns or masked and resistant hypertension are frequent and associated with a poor cardiovascular and renal prognosis. Even after achieving BP targets, which remain debated in CKD, the residual cardiovascular risk remains high. Current antihypertensive options have been enriched with novel agents that enable to lower the existing renal and cardiovascular risks, such as SGLT2 (sodium-glucose cotransporter-2) inhibitors and novel nonsteroidal mineralocorticoid receptor antagonists. Although their beneficial effects may be driven mostly from actions beyond BP control, recent evidence underline potential improvements on abnormal 24-hour BP phenotypes such as nondipping. Other promising novelties are still to come for the management of hypertension in CKD. In the present review, we shall discuss the existing evidence of hypertension as a cardiovascular risk factor in CKD, the importance of identifying hypertension phenotypes among patients with CKD, and the traditional and novel aspects of the management of hypertensives with CKD.
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Affiliation(s)
- Michel Burnier
- Hypertension Research Foundation (M.B.), University of Lausanne, Switzerland
- Faculty of Biology and Medicine (M.B.), University of Lausanne, Switzerland
- Service of Nephrology and Hypertension, Centre Hospitalier Universitaire Vaudois, Lausanne Switzerland (M.B., A.D.)
| | - Aikaterini Damianaki
- Service of Nephrology and Hypertension, Centre Hospitalier Universitaire Vaudois, Lausanne Switzerland (M.B., A.D.)
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Tanriover C, Ucku D, Akyol M, Cevik E, Kanbay A, Sridhar VS, Cherney DZI, Kanbay M. Potential Use of SGLT-2 Inhibitors in Obstructive Sleep Apnea: A new treatment on the horizon. Sleep Breath 2023; 27:77-89. [PMID: 35378662 DOI: 10.1007/s11325-022-02606-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/20/2022] [Accepted: 03/22/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is characterized by hypoxic episodes due to collapse of the airway during sleep and is frequently associated with obesity, type 2 diabetes mellitus (T2DM) and cardiovascular diseases (CVD). There is currently no pharmacological agent approved for the treatment of OSA. Sodium-glucose cotransporter-2 (SGLT2) inhibitors have the potential to both increase life expectancy and quality of life of these patients making them promising agents for this role. There are relatively few studies investigating this possible beneficial relationship between these drugs and OSA. METHOD We aimed to increase awareness on the potential benefits of SGLT2 inhibitors in OSA patients by describing the current evidence on the effectiveness of these inhibitors in both overall and cardiovascular morbidity and mortality. We performed a literature search for articles reporting on the use of SGLT2 inhibitors in patients with OSA and T2DM. RESULTS We identified 4 manuscripts studying the use of SGLT2 inhibitors in 475 OSA patients with T2DM. Among them, 332 patients were administered SGLT2 inhibitors, and 143 patients were in a control group. SGLT2 inhibitors have many potential positive impacts on OSA patients by targeting various mechanisms involved in OSA pathogenesis. CONCLUSION SGLT2 inhibitors are prime pharmacological candidates for the treatment of OSA, and additional studies are needed to better explore mechanisms and outcomes unique to this population. Additionally, patients with OSA often have multiple comorbidities that are clinical indications for SGLT2 inhibitor therapy. Physicians should recognize and encourage the use of these agents in such patients.
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