1
|
Rivetti G, Gizzone P, Di Sessa A, Guarino S, Miraglia Del Giudice E, Marzuillo P. Response to letter to the editor: therapeutic importance of proteinuria classification in children with congenital anomalies of the kidney and urinary tract. Expert Rev Clin Pharmacol 2024; 17:113-114. [PMID: 38087987 DOI: 10.1080/17512433.2023.2295005] [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: 11/28/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Affiliation(s)
- Giulio Rivetti
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Pietro Gizzone
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Anna Di Sessa
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Stefano Guarino
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Emanuele Miraglia Del Giudice
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Pierluigi Marzuillo
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Napoli, Italy
| |
Collapse
|
2
|
Maxson R, Starr J, Sewell J, Lyas C. SGLT2 Inhibitors to Slow Chronic Kidney Disease Progression: A Review. Clin Ther 2024; 46:e23-e28. [PMID: 37951783 DOI: 10.1016/j.clinthera.2023.10.014] [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: 06/13/2023] [Revised: 10/06/2023] [Accepted: 10/11/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE One in seven Americans is at risk for chronic kidney disease (CKD). For decades, the only treatment proven to slow progression of CKD was the use of renin-angiotensin-aldosterone system inhibitors. Based on promising secondary kidney outcomes in the cardiovascular outcome trials with sodium-glucose co-transporter-2 inhibitors, kidney outcome trials in patients with CKD were published for canagliflozin, dapagliflozin, and empagliflozin. METHODS A literature search was conducted of PubMed using the MeSH terms "Sodium-Glucose Transporter 2 Inhibitors" and "Renal Insufficiency, Chronic" and looking for clinical trials, meta-analyses, or randomized controlled trials in humans between 2015 and 2023. FINDINGS Primary and secondary outcomes from CREDENCE (Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation), DAPA-CKD (Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease), and EMPA-KIDNEY (Empagliflozin in Patients with Chronic Kidney Disease) are described along with complete descriptions of the patient populations studied. IMPLICATIONS This review describes the role of sodium-glucose co-transporter-2 inhibitors in slowing the progression of CKD, describes guideline changes that have occurred because of these data, and provides information on how these agents may be used clinically.
Collapse
Affiliation(s)
- Rebecca Maxson
- Harrison College of Pharmacy, Auburn University, Birmingham, Alabama, USA.
| | - Jessica Starr
- Harrison College of Pharmacy, Auburn University, Birmingham, Alabama, USA
| | - Jeanna Sewell
- Harrison College of Pharmacy, Auburn University, Auburn, Alabama, USA
| | - Claretha Lyas
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| |
Collapse
|
3
|
Giannese D, D'Alessandro C, Pellegrino N, Panichi V, Cupisti A. RAASi Therapy Attenuates the Association between 24-h Urinary Potassium Excretion and Dietary Potassium Intake in CKD Patients. Nutrients 2023; 15:nu15112454. [PMID: 37299418 DOI: 10.3390/nu15112454] [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: 03/02/2023] [Revised: 05/10/2023] [Accepted: 05/19/2023] [Indexed: 06/12/2023] Open
Abstract
The aim of this study was to evaluate urinary potassium (K) excretion as a reliable marker of dietary K intake, in a cohort of CKD patients with or without Renin-Angiotensin-Aldosterone System (RAAS) inhibitor therapy. One hundred and thirty-eight consecutive out-patients (51 f and 87 m) aged 60 ± 13 years and affected by CKD stage 3-4, who were metabolically and nutritionally stable, entered the study between November 2021 and October 2022. No difference was observed between patients with (n = 85) or without (n = 53) RAAS inhibitor therapy, regarding dietary intakes, blood biochemistry, and 24-h urine excretion parameters. Considering all patients, urinary K showed a weak relationship with eGFR (r = 0.243, p < 0.01), and with dietary K intake (r = 0.184, p < 0.05). Serum K was not associated with dietary K intake, but an inverse relationship was observed with eGFR (r = -0.269, p < 0.01). When patients were examined depending on whether they were receiving RAAS inhibitor therapy, the weak inverse relationship between serum K and eGFR was maintained in both groups. Conversely, urinary K excretion remained positively associated with dietary K intake only in the no RAAS inhibitor group. In conclusion, 24-h urine K excretion may be used as a surrogate of K intake, but RAAS inhibitor therapy reduces the association between 24-h urine K excretion and dietary K intake in CKD patients.
Collapse
Affiliation(s)
- Domenico Giannese
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Claudia D'Alessandro
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Nicola Pellegrino
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Vincenzo Panichi
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| |
Collapse
|
4
|
Özdemir G, Gülhan B, Kurt-Şükür ED, Atayar E, Atan R, Dursun İ, Özçakar ZB, Saygılı S, Soylu A, Söylemezoğlu O, Yılmaz A, Bayazıt AK, Kara Eroğlu F, Kasap Demir B, Yüksel S, Tabel Y, Ağbaş A, Düzova A, Hayran M, Özaltın F, Topaloğlu R. The outcomes of renin-angiotensin-aldosterone system inhibition and immunosuppressive therapy in children with X-linked Alport syndrome. Turk J Pediatr 2023; 65:456-468. [PMID: 37395965 DOI: 10.24953/turkjped.2022.735] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
BACKGROUND Alport syndrome (AS) is characterized by progressive kidney disease. There is increasing evidence that renin-angiotensin-aldosterone system (RAAS) inhibition delays chronic kidney disease (CKD) while the effectiveness of immunosuppressive (IS) therapy in AS is still uncertain. In this study, we aimed to analyze the outcomes of pediatric patients with X-linked AS (XLAS) who received RAAS inhibitors and IS therapy. METHODS Seventy-four children with XLAS were included in this multicenter study. Demographic features, clinical and laboratory data, treatments, histopathological examinations, and genetic analyses were analyzed retrospectively. RESULTS Among 74 children, 52 (70.2%) received RAAS inhibitors, 11 (14.9%) received RAAS inhibitors and IS, and 11 (14.9%) were followed up without treatment. During follow-up, glomerular filtration rate (GFR) decreased < 60 ml/min/1.73 m2 in 7 (9.5%) of 74 patients (M/F=6/1). In male patients with XLAS, kidney survival was not different between RAAS and RAAS+IS groups (p=0.42). The rate of progression to CKD was significantly higher in patients with nephrotic range proteinuria and nephrotic syndrome (NS), respectively (p=0.006, p=0.05). The median age at the onset of RAAS inhibitors was significantly higher in male patients who progressed to CKD (13.9 vs 8.1 years, p=0.003). CONCLUSIONS RAAS inhibitors have beneficial effects on proteinuria and early initiation of therapy may delay the progression to CKD in children with XLAS. There was no significant difference between the RAAS and RAAS+IS groups in kidney survival. AS patients presenting with NS or nephrotic range proteinuria should be followed up more carefully considering the risk of early progression to CKD.
Collapse
Affiliation(s)
- Gülşah Özdemir
- Division of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Ankara
| | - Bora Gülhan
- Division of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Ankara
| | - Eda Didem Kurt-Şükür
- Division of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Ankara
| | - Emine Atayar
- Division of Pediatric Nephrology, Nephrogenetics Laboratory, Hacettepe University Faculty of Medicine, Ankara
| | - Raziye Atan
- Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara
| | - İsmail Dursun
- Division of Pediatric Nephrology, Erciyes University Faculty of Medicine, Kayseri
| | | | - Seha Saygılı
- Division of Pediatric Nephrology, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul
| | - Alper Soylu
- Division of Pediatric Nephrology, Dokuz Eylül University Faculty of Medicine, İzmir
| | - Oğuz Söylemezoğlu
- Division of Pediatric Nephrology, Gazi University Faculty of Medicine, Ankara
| | - Alev Yılmaz
- Division of Pediatric Nephrology, İstanbul University Çapa Faculty of Medicine, Istanbul
| | | | - Fehime Kara Eroğlu
- Division of Pediatric Nephrology, Dr. Sami Ulus Maternity and Children's Health Hospital, Ankara
| | - Belde Kasap Demir
- Division of Pediatric Nephrology, İzmir Katip Çelebi University, Tepecik Research and Training Hospital, İzmir
| | - Selçuk Yüksel
- Division of Pediatric Nephrology, Pamukkale University Faculty of Medicine, Denizli
| | - Yılmaz Tabel
- Division of Pediatric Nephrology, İnönü University Faculty of Medicine, Malatya
| | - Ayşe Ağbaş
- Division of Pediatric Nephrology, Haseki Training and Research Hospital, İstanbul
| | - Ali Düzova
- Division of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Ankara
| | - Mutlu Hayran
- Department of Preventive Oncology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
| | - Fatih Özaltın
- Division of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Ankara
| | - Rezan Topaloğlu
- Division of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Ankara
| |
Collapse
|
5
|
Khalangot M, Sheichenko N, Gurianov V, Zakharchenko T, Kravchenko V, Tronko M. RAAS inhibitors are associated with a better chance of surviving of inpatients with Covid-19 without a diagnosis of diabetes mellitus, compared with similar patients who did not require antihypertensive therapy or were treated with other antihypertensives. Front Endocrinol (Lausanne) 2023; 14:1077959. [PMID: 36755914 PMCID: PMC9900734 DOI: 10.3389/fendo.2023.1077959] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 01/06/2023] [Indexed: 01/20/2023] Open
Abstract
PURPOSE The effect of renin-angiotensin-aldosterone system (RAAS) inhibitors in combination with COVID-19 and diabetes mellitus (DM) remains unknown. We assessed the risk of death in COVID-19 inpatients based on the presence or absence of DM, arterial hypertension (AH) and the use of RAAS inhibitors or other antihypertensives. METHODS The results of treatment of all adult PCR-confirmed COVID-19 inpatients (n = 1097, women 63.9%) from 02/12/2020 to 07/01/2022 are presented. The presence of DM at the time of admission and the category of antihypertensive drugs during hospital stay were noted. Leaving the hospital due to recovery or death was considered as a treatment outcome. Multivariable logistic regression analysis was used to assess the risk of death. Patients with COVID-19 without AH were considered the reference group. RESULTS DM was known in 150 of 1,097 patients with COVID-19 (13.7%). Mortality among DM inpatients was higher: 20.0% vs. 12.4% respectively (p=0.014). Male gender, age, fasting plasma glucose (FPG) and antihypertensives were independently associated with the risk of dying in patients without DM. In DM group such independent association was confirmed for FPG and treatment of AH. We found a reduction in the risk of death for COVID-19 inpatients without DM, who received RAAS inhibitors compared with the corresponding risk of normotensive inpatients, who did not receive antihypertensives: OR 0.22 (95% CI 0.07-0.72) adjusted for age, gender and FPG. CONCLUSION This result raises a question about the study of RAAS inhibitors effect in patients with Covid-19 without AH.
Collapse
Affiliation(s)
- Mykola Khalangot
- Endocrinology, Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine
- Epidemiology of Endocrine Diseases, V. P. Komisarenko Institute of Endocrinology and Metabolism, Kyiv, Ukraine
- *Correspondence: Mykola Khalangot,
| | | | - Vitaly Gurianov
- Healthcare Management, Bohomolets National Medical University, Kyiv, Ukraine
| | - Tamara Zakharchenko
- Epidemiology of Endocrine Diseases, V. P. Komisarenko Institute of Endocrinology and Metabolism, Kyiv, Ukraine
| | - Victor Kravchenko
- Epidemiology of Endocrine Diseases, V. P. Komisarenko Institute of Endocrinology and Metabolism, Kyiv, Ukraine
| | - Mykola Tronko
- Endocrinology, Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine
- Epidemiology of Endocrine Diseases, V. P. Komisarenko Institute of Endocrinology and Metabolism, Kyiv, Ukraine
| |
Collapse
|
6
|
Tardif JC, Rouleau J, Chertow GM, Al-Shurbaji A, Lisovskaja V, Gustavson S, Zhao Y, Bouabdallaoui N, Desai AS, Chernyavskiy A, Evsina M, Merkely B, McMurray JJV, Pfeffer MA. Potassium reduction with sodium zirconium cyclosilicate in patients with heart failure. ESC Heart Fail 2022; 10:1066-1076. [PMID: 36564955 PMCID: PMC10053160 DOI: 10.1002/ehf2.14268] [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: 02/11/2022] [Revised: 11/07/2022] [Accepted: 11/30/2022] [Indexed: 12/25/2022] Open
Abstract
AIMS Several patients with heart failure and reduced ejection fraction (HFrEF) do not receive renin-angiotensin-aldosterone system (RAAS) inhibitors at the recommended dose or at all, frequently due to actual or feared hyperkalaemia. Sodium zirconium cyclosilicate (SZC) is an orally administered non-absorbed intestinal potassium binder proven to lower serum potassium concentrations. METHODS AND RESULTS PRIORITIZE-HF was an international, multicentre, parallel-group, randomized, double-blind, placebo-controlled study to evaluate the benefits and risks of using SZC to intensify RAAS inhibitor therapy. Patients with symptomatic HFrEF were eligible and randomly assigned to receive SZC 5 g or placebo once daily for 12 weeks. Doses of study medication and RAAS inhibitors were titrated during the treatment period. The primary endpoint was the proportion of patients at 12 weeks in the following categories: (i) any RAAS inhibitor at less than target dose, and no MRA; (ii) any RAAS inhibitor at target dose and no MRA; (ii) MRA at less than target dose; and (iv) MRA at target dose. Due to challenges in participant management related to the COVID-19 pandemic, the study was prematurely terminated with 182 randomized patients. There was no statistically significant difference in the distribution of patients by RAAS inhibitor treatment categories at 3 months (P = 0.43). The proportion of patients at target MRA dose was numerically higher in the SZC group (56.4%) compared with the placebo group (47.0%). Overall, SZC was well tolerated. CONCLUSIONS PRIORITIZE-HF was terminated prematurely due to COVID-19 and did not demonstrate a statistically significant increase in the intensity of RAAS inhibitor therapies with the potassium-reducing agent SZC compared with placebo.
Collapse
Affiliation(s)
- Jean-Claude Tardif
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street East, Montreal, H1T1C8, Quebec, Canada
| | - Jean Rouleau
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street East, Montreal, H1T1C8, Quebec, Canada
| | | | | | | | | | | | - Nadia Bouabdallaoui
- Montreal Heart Institute, Université de Montréal, 5000 Belanger Street East, Montreal, H1T1C8, Quebec, Canada
| | - Akshay S Desai
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander Chernyavskiy
- E. Meshalkin National Medical Research Center, Ministry of Health of the Russia Federation, Moscow, Russia
| | | | - Béla Merkely
- Semmelweis Universtiy Heart and Vascular Center, Budapest, Hungary
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Centre of Research, University of Glasgow, Glasgow, UK
| | - Marc A Pfeffer
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
7
|
Ranjbar T, Oza PP, Kashfi K. The Renin-Angiotensin-Aldosterone System, Nitric Oxide, and Hydrogen Sulfide at the Crossroads of Hypertension and COVID-19: Racial Disparities and Outcomes. Int J Mol Sci 2022; 23:ijms232213895. [PMID: 36430371 PMCID: PMC9699619 DOI: 10.3390/ijms232213895] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
Coronavirus disease 2019 is caused by SARS-CoV-2 and is more severe in the elderly, racial minorities, and those with comorbidities such as hypertension and diabetes. These pathologies are often controlled with medications involving the renin-angiotensin-aldosterone system (RAAS). RAAS is an endocrine system involved in maintaining blood pressure and blood volume through components of the system. SARS-CoV-2 enters the cells through ACE2, a membrane-bound protein related to RAAS. Therefore, the use of RAAS inhibitors could worsen the severity of COVID-19's symptoms, especially amongst those with pre-existing comorbidities. Although a vaccine is currently available to prevent and reduce the symptom severity of COVID-19, other options, such as nitric oxide and hydrogen sulfide, may also have utility to prevent and treat this virus.
Collapse
Affiliation(s)
- Tara Ranjbar
- Department of Molecular, Cellular and Biomedical Sciences, Sophie Davis School of Biomedical Education, City University of New York School of Medicine, New York, NY 10031, USA
| | - Palak P. Oza
- Department of Molecular, Cellular and Biomedical Sciences, Sophie Davis School of Biomedical Education, City University of New York School of Medicine, New York, NY 10031, USA
| | - Khosrow Kashfi
- Department of Molecular, Cellular and Biomedical Sciences, Sophie Davis School of Biomedical Education, City University of New York School of Medicine, New York, NY 10031, USA
- Graduate Program in Biology, City University of New York Graduate Center, New York, NY 10016, USA
- Correspondence:
| |
Collapse
|
8
|
Gonçalves de Oliveira M, Nadruz W Jr, Zakia Mónica F. Endothelial and Vascular Smooth Muscle Dysfunction in Hypertension. Biochem Pharmacol 2022;:115263. [PMID: 36174768 DOI: 10.1016/j.bcp.2022.115263] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 12/11/2022]
Abstract
The development of essential hypertension involves several factors. Vascular dysfunction, characterized by endothelial dysfunction, low-grade inflammation and structural remodeling, plays an important role in the initiation and maintenance of essential hypertension. Although the mechanistic pathways by which essential hypertension develops are poorly understood, several pharmacological classes available on the clinical settings improve blood pressure by interfering in the cardiac output and/or vascular function. This review is divided in two major sections. The first section depicts the major molecular pathways as renin angiotensin aldosterone system (RAAS), endothelin, nitric oxide signalling pathway and oxidative stress in the development of vascular dysfunction. The second section describes the role of some pharmacological classes such as i) RAAS inhibitors, ii) dual angiotensin receptor-neprilysin inhibitors, iii) endothelin-1 receptor antagonists, iv) soluble guanylate cyclase modulators, v) phosphodiesterase type 5 inhibitors and vi) sodium-glucose cotransporter 2 inhibitors in the context of hypertension. Some classes are already approved in the treatment of hypertension, but others are not yet approved. However, due to their potential benefits these classes were included.
Collapse
|
9
|
Barbieri L, Trabattoni D, Stefanini GG, Vizzardi E, Tumminello G, Assanelli E, Adamo M, Pivato CA, Provenzale G, Gentile D, Metra M, Carugo S. Impact of RAAS Inhibitors on Clinical Outcome and Mortality in Patients With STEMI During the COVID-19 Era: A Multicenter Observational Study. Front Cardiovasc Med 2021; 8:792804. [PMID: 35004902 PMCID: PMC8739948 DOI: 10.3389/fcvm.2021.792804] [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] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/30/2021] [Indexed: 12/02/2022] Open
Abstract
Conflicting results are available regarding the influence of ACEi/ARBs on the risk of COVID-19 infection, while less is known about their impact on the clinical outcome of patients with STEMI diagnosed with COVID-19. Our aim was to evaluate the impact of ACEi/ARBs therapy on in-hospital mortality and clinical outcomes of patients with STEMI during the COVID-19 pandemic. We retrospectively analyzed consecutive patients with STEMI hospitalized from February 20 to May 10, 2020 in four Hospitals in Lombardy. SARS-COV-2 diagnosis was performed by nasopharyngeal swab test. Procedural outcome, respiratory complications, and in-hospital mortality were reported. Univariate and multivariate analyses were performed by logistic regressions. Our population was represented by 182 patients with STEMI, 76.9% of which were males, and mean age was 67 ± 12.5. Hypertension was reported in 53.3%, and 29.1% was treated with ACEi/ARBs. COVID-19 diagnosis was confirmed in 17.1% of the patients. In-hospital mortality (13.2%) was significantly higher in patients with COVID-19 (31 vs. 10%, p = 0.003), even if ejection fraction [OR 0.93 (95% CI) 0.87-0.99; p = 0.03] and respiratory complications [OR 9.39 (95% CI) 1.91-45.9; p = 0.006] were the only two independent predictors. The incidence of COVID-19 infection was not influenced by ACEi/ARBs (16.5 in naïve vs. 18.8%) whose presence on admission did not correlate with respiratory complications or mortality both in the case of discontinuation and maintenance. In conclusion, in a high-risk population, such as that of patients with STEMI, the potential benefit of ACEi/ARB discontinuation in patients with COVID-19 is overcome by its detrimental effect. Intensive care, additional preventive respiratory investigations, regardless of swab test result, should be suggested for all patients admitted for STEMI during the pandemic.
Collapse
Affiliation(s)
- Lucia Barbieri
- Cardiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Giulio G. Stefanini
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Enrico Vizzardi
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Gabriele Tumminello
- Cardiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Marianna Adamo
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Carlo A. Pivato
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Giovanni Provenzale
- Cardiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Domitilla Gentile
- Cardiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Stefano Carugo
- Cardiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
10
|
Babajani F, Kakavand A, Mohammadi H, Sharifi A, Zakeri S, Asadi S, Afshar ZM, Rahimi Z, Sayad B. COVID-19 and renin angiotensin aldosterone system: Pathogenesis and therapy. Health Sci Rep 2021; 4:e440. [PMID: 34869917 PMCID: PMC8596942 DOI: 10.1002/hsr2.440] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 09/14/2021] [Accepted: 10/06/2021] [Indexed: 12/23/2022] Open
Abstract
AIMS The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) binds to the ACE2 component of the renin-angiotensin aldosterone system (RAAS) and infects the human cells. The aims of the present review were to look at the role and alteration of the RAAS components in SARS-CoV-2 infection, therapeutic approaches, and clinical trials in this field. METHODS We surveyed the literature (PubMed, Web of Science, and Scopus) till August 18, 2021, and 59 published papers regarding the components of the RAAS and their role and alterations in SARS-CoV-2 infection along with various COVID-19 therapies based on the RASS components were included in the study. RESULTS ACE inhibitors, angiotensin receptor blockers, and mineralocorticoid receptor inhibitors are agents that significantly enhance the ACE2 and Ang-(1-7) levels, which can be suggestive for their role as therapeutics against SARS-CoV-2 infection. Beta-adrenergic blockers, which negatively regulate renin release from juxtaglomerular cells, and vitamin D, as a regulator of the RAAS and renin expression, are proposed therapeutics in the treatment of COVID-19. Some antihyperglycemic agents could be potentially protective against COVID-19-induced lung injury. Also, the inhibition of the Janus kinase/signal transducer and activator of the transcription pathway as a potential treatment for COVID-19 has been suggested. Finally, resveratrol, an antioxidant that can suppress Ang II, has been suggested as an adjunct to other therapies. CONCLUSION Regarding the suggested potential therapies for COVID-19, there are many clinical trials whose results might change the treatment strategies of SARS-CoV-2 infection. So, the results of well-organized clinical trials on the efficacy and safety of the mentioned agents in the treatment of COVID-19 will be useful in the management and therapy of the disease.
Collapse
Affiliation(s)
- Fatemeh Babajani
- Students Research CommitteeKermanshah University of Medical SciencesKermanshahIran
| | - Atefeh Kakavand
- Students Research CommitteeKermanshah University of Medical SciencesKermanshahIran
| | - Hossien Mohammadi
- Students Research CommitteeKermanshah University of Medical SciencesKermanshahIran
| | - Armin Sharifi
- Students Research CommitteeKermanshah University of Medical SciencesKermanshahIran
| | - Saba Zakeri
- Students Research CommitteeKermanshah University of Medical SciencesKermanshahIran
| | - Soheila Asadi
- Department of Clinical BiochemistryKermanshah University of Medical SciencesKermanshahIran
| | - Zeinab Mohseni Afshar
- Infectious Diseases Research CenterKermanshah University of Medical SciencesKermanshahIran
| | - Zohreh Rahimi
- Department of Clinical BiochemistryKermanshah University of Medical SciencesKermanshahIran
- Behavioral Research CenterKermanshah University of Medical SciencesKermanshahIran
| | - Babak Sayad
- Infectious Diseases Research CenterKermanshah University of Medical SciencesKermanshahIran
| |
Collapse
|
11
|
Fagyas M, Bánhegyi V, Úri K, Enyedi A, Lizanecz E, Mányiné IS, Mártha L, Fülöp GÁ, Radovits T, Pólos M, Merkely B, Kovács Á, Szilvássy Z, Ungvári Z, Édes I, Csanádi Z, Boczán J, Takács I, Szabó G, Balla J, Balla G, Seferovic P, Papp Z, Tóth A. Changes in the SARS-CoV-2 cellular receptor ACE2 levels in cardiovascular patients: a potential biomarker for the stratification of COVID-19 patients. GeroScience 2021; 43:2289-2304. [PMID: 34674152 PMCID: PMC8529378 DOI: 10.1007/s11357-021-00467-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 09/22/2021] [Indexed: 01/25/2023] Open
Abstract
Angiotensin-converting enzyme 2 (ACE2) is essential for SARS-CoV-2 cellular entry. Here we studied the effects of common comorbidities in severe COVID-19 on ACE2 expression. ACE2 levels (by enzyme activity and ELISA measurements) were determined in human serum, heart and lung samples from patients with hypertension (n = 540), heart transplantation (289) and thoracic surgery (n = 49). Healthy individuals (n = 46) represented the controls. Serum ACE2 activity was increased in hypertensive subjects (132%) and substantially elevated in end-stage heart failure patients (689%) and showed a strong negative correlation with the left ventricular ejection fraction. Serum ACE2 activity was higher in male (147%), overweight (122%), obese (126%) and elderly (115%) hypertensive patients. Primary lung cancer resulted in higher circulating ACE2 activity, without affecting ACE2 levels in the surrounding lung tissue. Male sex resulted in elevated serum ACE2 activities in patients with heart transplantation or thoracic surgery (146% and 150%, respectively). Left ventricular (tissular) ACE2 activity was unaffected by sex and was lower in overweight (67%), obese (62%) and older (73%) patients with end-stage heart failure. There was no correlation between serum and tissular (left ventricular or lung) ACE2 activities. Neither serum nor tissue (left ventricle or lung) ACE2 levels were affected by RAS inhibitory medications. Abandoning of ACEi treatment (non-compliance) resulted in elevated blood pressure without effects on circulating ACE2 activities. ACE2 levels associate with the severity of cardiovascular diseases, suggestive for a role of ACE2 in the pathomechanisms of cardiovascular diseases and providing a potential explanation for the higher mortality of COVID-19 among cardiovascular patients. Abandoning RAS inhibitory medication worsens the cardiovascular status without affecting circulating or tissue ACE2 levels.
Collapse
Affiliation(s)
- Miklós Fagyas
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, 22 Móricz Zsigmond street, Debrecen, 4032, Hungary
- Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Viktor Bánhegyi
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, 22 Móricz Zsigmond street, Debrecen, 4032, Hungary
- Doctoral School of Kálmán Laki, University of Debrecen, Debrecen, Hungary
- Department of Cardiac Surgery, University of Halle, Halle (Saale), Germany
| | - Katalin Úri
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, 22 Móricz Zsigmond street, Debrecen, 4032, Hungary
| | - Attila Enyedi
- Department of Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Erzsébet Lizanecz
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, 22 Móricz Zsigmond street, Debrecen, 4032, Hungary
- Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Ivetta Siket Mányiné
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, 22 Móricz Zsigmond street, Debrecen, 4032, Hungary
| | - Lilla Mártha
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, 22 Móricz Zsigmond street, Debrecen, 4032, Hungary
| | - Gábor Áron Fülöp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, 22 Móricz Zsigmond street, Debrecen, 4032, Hungary
- Doctoral School of Kálmán Laki, University of Debrecen, Debrecen, Hungary
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Tamás Radovits
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Miklós Pólos
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Árpád Kovács
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, 22 Móricz Zsigmond street, Debrecen, 4032, Hungary
- Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Szilvássy
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Ungvári
- Vascular Cognitive Impairment and Neurodegeneration Program, Oklahoma Center for Geroscience, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - István Édes
- Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Csanádi
- Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Judit Boczán
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - István Takács
- Department of Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Gábor Szabó
- Department of Cardiac Surgery, University of Halle, Halle (Saale), Germany
| | - József Balla
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, Budapest, Hungary
| | - György Balla
- HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, Budapest, Hungary
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Petar Seferovic
- Heart Failure Center, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Zoltán Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, 22 Móricz Zsigmond street, Debrecen, 4032, Hungary
- HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, Budapest, Hungary
| | - Attila Tóth
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, 22 Móricz Zsigmond street, Debrecen, 4032, Hungary.
- HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, Budapest, Hungary.
| |
Collapse
|
12
|
Bussalino E, Panaro L, Marsano L, Bellino D, Ravera M, Paoletti E. Prevalence and clinical correlates of hyperkalemia in stable kidney transplant recipients. Intern Emerg Med 2021; 16:1787-1792. [PMID: 33544373 DOI: 10.1007/s11739-021-02649-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 07/08/2020] [Accepted: 01/19/2021] [Indexed: 12/28/2022]
Abstract
Although hyperkalemia (HK) is often associated with adverse clinical outcomes in renal patients, few studies are available in the setting of kidney transplantation. Therefore, we evaluated prevalence and clinical correlates of HK in stable kidney transplant recipients (KTRs) on standard of care immunosuppressive therapy. We studied 160 stable KTRs (post-transplant vintage 46.6 ± 16.6 months), most of whom (96.2%) on calcineurin inhibitor (CNI)-based immunosuppressive therapy. HK was defined as plasma potassium levels above 5 mEq/L, confirmed in two consecutive samples. Office blood pressure was measured, and renal graft function was expressed by estimated glomerular filtration rate (eGFR), calculated according to the CKD-EPI formula. HK prevalence was 8.8%, and plasma K above 5.5 mEq/L was found in 2.5% of all KTRs. In the univariate logistic regression analysis HK was significantly associated with serum urea concentration (OR 1.03, 95% CI 1.01-1.05 for each 1 mg/dL increase), tCO2 (OR 0.77, 95% CI 0.66-0.90 for each 1 mmol/L increase), the presence of arterial hypertension (OR 4.01, 95% CI 1.3-12.64), the use of RAAS inhibitors (OR 5.26, 95% CI 1.6-17.7), and eGFR less than 30 ml/min/1.73 m2 (OR 7.51, 95% CI 2.37-23.77). By multivariable backward stepwise regression analysis, the presence of metabolic acidosis (OR 0.83, 95% CI 0.69-0.99, P = 0.04), arterial hypertension (OR 4.65 95% CI 1.01-17.46 P = 0.03), and to be administered RAAS inhibitors (OR 6.11, 95% CI 1.03-25.96 P = 0.03) remained significantly associated with HK. We conclude that in stable KTRs the prevalence of HK is about 9%, slightly lower than previously reported. Moreover, it is not associated with eGFR, but with metabolic acidosis, arterial hypertension, and the use of RAAS inhibitors.
Collapse
Affiliation(s)
- Elisabetta Bussalino
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Laura Panaro
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Luigina Marsano
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Diego Bellino
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Maura Ravera
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Ernesto Paoletti
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy.
| |
Collapse
|
13
|
Hundemer GL, Sood MM. Hyperkalemia with RAAS inhibition: Mechanism, clinical significance, and management. Pharmacol Res 2021; 172:105835. [PMID: 34438065 DOI: 10.1016/j.phrs.2021.105835] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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] [Received: 07/06/2021] [Revised: 08/09/2021] [Accepted: 08/16/2021] [Indexed: 12/30/2022]
Abstract
Renin-angiotensin-aldosterone system (RAAS) inhibitors are evidence-based treatments for a number of conditions including hypertension, diabetes mellitus, chronic kidney disease, and congestive heart failure. Among the most common adverse effects of RAAS inhibitors is hyperkalemia which results from either reduced secretion of aldosterone or increased resistance to aldosterone. Many of the conditions for which RAAS inhibitors are recommended further amplify the risk for hyperkalemia in and of themselves. RAAS inhibitor-related hyperkalemia is associated with an increased risk for cardiovascular events, hospitalizations, and death. Yet discontinuation of RAAS inhibitors for patients with chronic kidney disease and congestive heart failure is also associated with an increased risk for cardiovascular events, hospitalizations, and death. Therefore, clinicians are often left to struggle with the dilemma of the best management approach to RAAS inhibitor-related hyperkalemia. The ideal solution involves pharmacotherapies that are safe and effective in mitigating hyperkalemia and allow patients to continue to receive the beneficial effects from RAAS inhibitors. In this regard, modern pharmacologic agents such as patiromer and zirconium cyclosilicate are providing a mechanism whereby physicians are better equipped to maintain their patients on RAAS inhibitors.
Collapse
Affiliation(s)
- Gregory L Hundemer
- Department of Medicine (Division of Nephrology) and The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
| | - Manish M Sood
- Department of Medicine (Division of Nephrology) and The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Institute for Clinical Evaluative Sciences, Ottawa, Canada
| |
Collapse
|
14
|
Sajdel-Sulkowska EM. A Dual-Route Perspective of SARS-CoV-2 Infection: Lung- vs. Gut-specific Effects of ACE-2 Deficiency. Front Pharmacol 2021; 12:684610. [PMID: 34177593 PMCID: PMC8226136 DOI: 10.3389/fphar.2021.684610] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 03/24/2021] [Accepted: 05/21/2021] [Indexed: 12/11/2022] Open
Abstract
SARS-CoV-2, primarily considered a respiratory virus, is increasingly recognized as having gastrointestinal aspects based on its presence in the gastrointestinal (GI) tract and feces. SARS-CoV-2 uses as a receptor angiotensin-converting enzyme 2 (ACE-2), a critical member of the renin-angiotensin-aldosterone system (RAAS) involved in the regulation of blood pressure and fluid system. In addition to the systemic endocrine functions, RAAS components are also involved in intracrine and organ-specific local functions. The angiotensin-converting enzyme 2 (ACE-2) is a key component of RAAS and a receptor for SARS-CoV-2. It is expressed in many tissues with gastrointestinal (GI) tract ACE-2 levels far exceeding those in the respiratory tract. SARS-CoV-2 binding to its receptor results in a deficiency of ACE-2 activity in endocrine, intracrine, and local lung and GI tract ACE-2. The local ACE-2 has different organ-specific functions, including hypertension-independent activities; dysregulations of these functions may contribute to multiorgan COVID-19 pathology, its severity, long-term effects, and mortality. We review supporting evidence from this standpoint. Notably, COVID-19 comorbidities involving hypertension, obesity, heart disease, kidney disease, and diabetes are associated with gastrointestinal problems and display ACE-2 deficits. While RAAS inhibitors target both endocrine and intracrine ACE-2 activity, the deficit of the local ACE-2 activity in the lungs and more so in the gut have not been targeted. Consequently, the therapeutic approach to COVID-19 should be carefully reconsidered. Ongoing clinical trials testing oral probiotic bound ACE-2 delivery are promising.
Collapse
|
15
|
Bezabih YM, Bezabih A, Alamneh E, Peterson GM, Bezabhe W. Comparison of renin-angiotensin-aldosterone system inhibitors with other antihypertensives in association with coronavirus disease-19 clinical outcomes. BMC Infect Dis 2021; 21:527. [PMID: 34090358 PMCID: PMC8178664 DOI: 10.1186/s12879-021-06088-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 04/20/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Reports on the effects of renin-angiotensin-aldosterone system (RAAS) inhibitors on the clinical outcomes of coronavirus disease-19 (COVID-19) have been conflicting. We performed this meta-analysis to find conclusive evidence. METHODS We searched published articles through PubMed, EMBASE and medRxiv from 5 January 2020 to 3 August 2020. Studies that reported clinical outcomes of patients with COVID-19, stratified by the class of antihypertensives, were included. Random and fixed-effects models were used to estimate pooled odds ratio (OR). RESULTS A total 36 studies involving 30,795 patients with COVID-19 were included. The overall risk of poor patient outcomes (severe COVID-19 or death) was lower in patients taking RAAS inhibitors (OR = 0.79, 95% CI: [0.67, 0.95]) compared with those receiving non-RAAS inhibitor antihypertensives. However, further sub-meta-analysis showed that specific RAAS inhibitors did not show a reduction of poor COVID-19 outcomes when compared with any class of antihypertensive except beta-blockers (BBs). For example, compared to calcium channel blockers (CCBs), neither angiotensin-I-converting enzyme inhibitors (ACEIs) (OR = 0.91, 95% CI: [0.67, 1.23]) nor angiotensin-II receptor blockers (ARBs) (OR = 0.90, 95% CI: [0.62, 1.33]) showed a reduction of poor COVID-19 outcomes. When compared with BBs, however, both ACEIs (OR = 0.85, 95% CI: [0.73, 0.99) and ARBs (OR = 0.72, 95% CI: [0.55, 0.94]) showed an apparent decrease in poor COVID-19 outcomes. CONCLUSIONS RAAS inhibitors did not increase the risk of mortality or severity of COVID-19. Differences in COVID-19 clinical outcomes between different class of antihypertensive drugs were likely due to the underlying comorbidities for which the antihypertensive drugs were prescribed, although adverse effects of drugs such as BBs could not be excluded.
Collapse
Affiliation(s)
- Yihienew M. Bezabih
- Arsi University College of Health Sciences, Arsi University, P. O. Box, 04, Assela, Ethiopia
| | - Alemayehu Bezabih
- École Nationale Vétérinaire, Agroalimentaire et de L’alimentation, Nantes-Atlantique, BIOEPAR (UMR1300 INRA/ONIRIS), Atlanpole-Chantrerie CS-40706 44307, Nantes Cedex 3, France
| | - Endalkachew Alamneh
- School of Pharmacy and Pharmacology, University of Tasmania, Private Bag 26, Hobart, TAS 7001 Australia
| | - Gregory M. Peterson
- School of Pharmacy and Pharmacology, University of Tasmania, Private Bag 26, Hobart, TAS 7001 Australia
| | - Woldesellassie Bezabhe
- School of Pharmacy and Pharmacology, University of Tasmania, Private Bag 26, Hobart, TAS 7001 Australia
| |
Collapse
|
16
|
Panagides V, Vincent F, Weizman O, Jonveaux M, Trimaille A, Pommier T, Cellier J, Geneste L, Marsou W, Deney A, Attou S, Delmotte T, Fauvel C, Ezzouhairi N, Perin B, Zakine C, Levasseur T, Ma I, Chavignier D, Noirclerc N, Darmon A, Mevelec M, Karsenty C, Duceau B, Sutter W, Mika D, Pezel T, Waldmann V, Ternacle J, Cohen A, Bonnet G. History of heart failure in patients with coronavirus disease 2019: Insights from a French registry. Arch Cardiovasc Dis 2021; 114:415-425. [PMID: 34099379 PMCID: PMC8141712 DOI: 10.1016/j.acvd.2021.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/20/2021] [Accepted: 04/27/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although cardiovascular comorbidities seem to be strongly associated with worse outcomes in patients with coronavirus disease 2019 (COVID-19), data regarding patients with preexisting heart failure are limited. AIMS To investigate the incidence, characteristics and clinical outcomes of patients with COVID-19 with a history of heart failure with preserved or reduced ejection fraction. METHODS We performed an observational multicentre study including all patients hospitalized for COVID-19 across 24 centres in France from 26 February to 20 April 2020. The primary endpoint was a composite of in-hospital death or need for orotracheal intubation. RESULTS Overall, 2809 patients (mean age 66.4±16.9years) were included. Three hundred and seventeen patients (11.2%) had a history of heart failure; among them, 49.2% had heart failure with reduced ejection fraction and 50.8% had heart failure with preserved ejection fraction. COVID-19 severity at admission, defined by a quick sequential organ failure assessment score>1, was similar in patients with versus without a history of heart failure. Before and after adjustment for age, male sex, cardiovascular comorbidities and quick sequential organ failure assessment score, history of heart failure was associated with the primary endpoint (hazard ratio [HR]: 1.41, 95% confidence interval [CI]: 1.06-1.90; P=0.02). This result seemed to be mainly driven by a history of heart failure with preserved ejection fraction (HR: 1.61, 95% CI: 1.13-2.27; P=0.01) rather than heart failure with reduced ejection fraction (HR: 1.19, 95% CI: 0.79-1.81; P=0.41). CONCLUSIONS History of heart failure in patients with COVID-19 was associated with a higher risk of in-hospital death or orotracheal intubation. These findings suggest that patients with a history of heart failure, particularly heart failure with preserved ejection fraction, should be considered at high risk of clinical deterioration.
Collapse
Affiliation(s)
- Vassili Panagides
- Aix-Marseille Université, Intensive Care Unit, Hôpital Nord, AP-HM, 13015 Marseille, France
| | - Flavien Vincent
- Centre Hospitalier Universitaire de Lille, Institut Cœur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, INSERM U1011, Institut Pasteur de Lille, EGID, Université de Lille, 59800 Lille, France
| | - Orianne Weizman
- Institut Lorrain du Cœur et des Vaisseaux, CHU de Nancy, 54500 Vandœuvre-les-Nancy, France; Université de Paris, Paris Cardiovascular Research Centre (PARCC), INSERM, UMR-S970, 75015 Paris, France
| | - Melchior Jonveaux
- Département de Cardiologie, Expert Valve Center, Assistance Publique-Hôpitaux de Paris, Hôpital Henri Mondor, 94010 Créteil, France
| | - Antonin Trimaille
- Nouvel Hôpital Civil, Centre Hospitalier Régional Universitaire de Strasbourg, 67000 Strasbourg, France
| | - Thibaut Pommier
- Centre Hospitalier Universitaire de Dijon, 21000 Dijon, France
| | - Joffrey Cellier
- Hôpital Européen Georges-Pompidou, Université de Paris, 75015 Paris, France
| | - Laura Geneste
- Centre Hospitalier Universitaire d'Amiens-Picardie, 80000 Amiens, France
| | - Wassima Marsou
- GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, 59800 Lille, France
| | - Antoine Deney
- Centre Hospitalier Universitaire de Toulouse, 31400 Toulouse, France
| | - Sabir Attou
- Centre Hospitalier Universitaire de Caen-Normandie, 14000 Caen, France
| | - Thomas Delmotte
- Centre Hospitalier Universitaire de Reims, 51100 Reims, France
| | - Charles Fauvel
- Rouen University Hospital, FHU REMOD-VHF, 76000 Rouen, France
| | - Nacim Ezzouhairi
- University of Bordeaux, Hôpital Cardiologique Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France
| | - Benjamin Perin
- Institut Lorrain du Cœur et des Vaisseaux, CHU de Nancy, 54500 Vandœuvre-les-Nancy, France
| | - Cyril Zakine
- Clinique Saint-Gatien, 37540 Saint-Cyr-sur-Loire, France
| | - Thomas Levasseur
- Centre Hospitalier Intercommunal Fréjus-Saint-Raphaël, 83600 Fréjus, France
| | - Iris Ma
- Hôpital Européen Georges-Pompidou, Université de Paris, 75015 Paris, France
| | | | | | - Arthur Darmon
- Hôpital Bichat-Claude-Bernard, AP-HP, Université de Paris, 75018 Paris, France
| | - Marine Mevelec
- Centre Hospitalier Annecy Genevois, 74370 Épagny-Metz-Tessy, France
| | - Clément Karsenty
- Centre Hospitalier Universitaire de Toulouse, 31400 Toulouse, France
| | - Baptiste Duceau
- Département de Cardiologie, Expert Valve Center, Assistance Publique-Hôpitaux de Paris, Hôpital Henri Mondor, 94010 Créteil, France
| | - Willy Sutter
- Département de Cardiologie, Expert Valve Center, Assistance Publique-Hôpitaux de Paris, Hôpital Henri Mondor, 94010 Créteil, France
| | - Delphine Mika
- Université Paris-Saclay, INSERM, UMR-S 1180, 92296 Châtenay-Malabry, France
| | - Théo Pezel
- Hôpital Lariboisière, AP-HP, University of Paris, 75010 Paris, France
| | - Victor Waldmann
- Département de Cardiologie, Expert Valve Center, Assistance Publique-Hôpitaux de Paris, Hôpital Henri Mondor, 94010 Créteil, France
| | - Julien Ternacle
- University of Bordeaux, Hôpital Cardiologique Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval/Québec Heart and Lung Institute, Laval University, Québec G1V 4G5, Canada
| | | | - Guillaume Bonnet
- Université de Paris, Paris Cardiovascular Research Centre (PARCC), INSERM, UMR-S970, 75015 Paris, France; University of Bordeaux, Hôpital Cardiologique Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France
| | | |
Collapse
|
17
|
Yang XC, Shao LL, Mi YJ, Zhang WH, Liu NY, Liu RB, Zhou XX, Zhang WH, Tian QB. Effect of renin-angiotensin-aldosterone system inhibitors on all-cause mortality and major cardiovascular events in patients with diabetes: A meta-analysis focusing on the number needed to treat and minimal clinical effect. J Diabetes Complications 2021; 35:107830. [PMID: 33446411 DOI: 10.1016/j.jdiacomp.2020.107830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 09/02/2020] [Revised: 11/22/2020] [Accepted: 12/01/2020] [Indexed: 11/29/2022]
Abstract
AIMS To assess the effectiveness of renin-angiotensin-aldosterone system (RAAS) inhibitors, angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) separately to prevent all-cause mortality, myocardial infarction (MI), stroke and heart failure (HF) in patients with diabetes considering the number needed to treat (NNT) and minimal clinical effect (MCE). METHODS Data from 17 morbidity-mortality trials in patients with diabetes were used to calculate NNTs and evaluate MCE to prevent all-cause mortality, myocardial infarction, stroke, and heart failure. RESULTS A total of 17 trials involving 42,037 patients were included in this meta-analysis. Mean follow-up was 3.7 years. ACEIs significantly reduced the risk of all-cause mortality, MI and HF; the corresponding mean NNTBs were 48, 62 and 78, respectively, but ARBs were only associated with a reduction in heart failure. The clinical significance assessment of the included trials indicated that most of the statistically significant trial results had no definitive clinical significance, and only some of them had possible clinical significance. CONCLUSIONS Among patients with diabetes, ACEIs reduced all-cause mortality, MI and HF, whereas ARBs could only prevent HF. However, none of the results of these trials had clear clinical significance, and most had only possible clinical significance.
Collapse
Affiliation(s)
- Xiao-Chun Yang
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, 361 East Zhongshan Road, Shijiazhuang 050017, China; Hebei Province Key Laboratory of Environment and Human Health, 361 East Zhongshan Road, Shijiazhuang 050017, China
| | - Li-Li Shao
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, 361 East Zhongshan Road, Shijiazhuang 050017, China; Hebei Province Key Laboratory of Environment and Human Health, 361 East Zhongshan Road, Shijiazhuang 050017, China
| | - Ying-Jun Mi
- Hebei Province Key Laboratory of Environment and Human Health, 361 East Zhongshan Road, Shijiazhuang 050017, China; Department of Social Medicine and Health Care Management, School of Public Health, Hebei Medical University, 361 East Zhongshan Road, Shijiazhuang 050017, China
| | - Wen-Hao Zhang
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, 361 East Zhongshan Road, Shijiazhuang 050017, China; Hebei Province Key Laboratory of Environment and Human Health, 361 East Zhongshan Road, Shijiazhuang 050017, China
| | - Nuo-Ya Liu
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, 361 East Zhongshan Road, Shijiazhuang 050017, China; Hebei Province Key Laboratory of Environment and Human Health, 361 East Zhongshan Road, Shijiazhuang 050017, China
| | - Ruo-Bin Liu
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, 361 East Zhongshan Road, Shijiazhuang 050017, China; Hebei Province Key Laboratory of Environment and Human Health, 361 East Zhongshan Road, Shijiazhuang 050017, China
| | - Xiao-Xi Zhou
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, 361 East Zhongshan Road, Shijiazhuang 050017, China; Hebei Province Key Laboratory of Environment and Human Health, 361 East Zhongshan Road, Shijiazhuang 050017, China
| | - Wei-Hong Zhang
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, University of Ghent. Belgium C. Heymanslaan 10, Entrance 75/ICRH, 9000 Gent, Belgium
| | - Qing-Bao Tian
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, 361 East Zhongshan Road, Shijiazhuang 050017, China; Hebei Province Key Laboratory of Environment and Human Health, 361 East Zhongshan Road, Shijiazhuang 050017, China.
| |
Collapse
|
18
|
Caspani F, Tralongo AC, Campiotti L, Asteggiano R, Guasti L, Squizzato A. Prevention of anthracycline-induced cardiotoxicity: a systematic review and meta-analysis. Intern Emerg Med 2021; 16:477-486. [PMID: 33011930 DOI: 10.1007/s11739-020-02508-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 06/11/2020] [Accepted: 09/12/2020] [Indexed: 12/23/2022]
Abstract
Anthracyclines are extensively used in oncologic patients, in particular for breast cancer and hematological malignancies. Cardiac injury is a potentially dangerous side effect of these drugs. In this systematic review, we analyzed published randomized controlled trials (RCTs) to assess if potential cardioprotective drugs (i.e., renin-angiotensin-aldosterone system [RAAS] blockers and β-blockers) may prevent heart damage by anthracyclines. Studies were identified by electronic search of MEDLINE and EMBASE database until August 2020. The impact of cardioprotective drugs to prevent anthracyclines-induced cardiac injury was expressed as mean difference (MD) or odds ratio (OR) and 95% confidence intervals (95% CI). Statistical heterogeneity was assessed with the I2 statistic. Twelve RCTs for a total of 1.035 cancer patients treated with anthracyclines were included. RAAS blockers, β-blockers, and aldosterone antagonists showed a statistically significant benefit in preventing left ventricular ejection fraction (LVEF) reduction (MD 3.57, 95% CI 1.04, 6.09) in 11 studies. A non-statistically significant difference was observed in preventing E/A velocity decrease (MD 0.09, 95% CI 0.00, 0.17; 9 studies), left ventricular end-systolic diameter (LVESD) increase (MD - 0.88, 95% CI, - 2.75,0.99; 6 studies), left ventricular end-diastolic diameter (LVEDD) increase (MD -0.95, 95% CI - 2.67,0.76; 6 studies), and mitral A velocity decrease (MD - 1.42, 95% CI - 3.01,0.17; 4 studies). Heart failure was non-significantly reduced in the cardioprotective arm (OR 0.31, 95% CI 0.06, 1.59; 5 studies). Hypotension was non-significantly increased in the cardioprotective arm (OR 3.91, 95% CI 0.42, 36.46, 3 studies). Cardioprotective drugs reduce anthracycline-induced cardiac damage as assessed by echocardiographic parameters. The clinical relevance of this positive effect is still to be defined.
Collapse
Affiliation(s)
| | | | - Leonardo Campiotti
- Department of Medicine and Surgery, University of Insubria, Varese, Como, Italy
| | | | - Luigina Guasti
- Department of Medicine and Surgery, University of Insubria, Varese, Como, Italy
| | | |
Collapse
|
19
|
Muhlestein JB, Kammerer J, Bair TL, Knowlton KU, Le VT, Anderson JL, Lappé DL, May HT. Frequency and clinical impact of hyperkalaemia within a large, modern, real-world heart failure population. ESC Heart Fail 2020; 8:691-696. [PMID: 33331114 PMCID: PMC7835576 DOI: 10.1002/ehf2.13164] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/12/2020] [Accepted: 11/24/2020] [Indexed: 11/07/2022] Open
Abstract
AIMS This analysis qualitatively describes the impact of hyperkalaemia (HK) and renin-angiotensin-aldosterone system inhibitor (RAASi) use on clinical outcomes in patients with heart failure (HF). METHODS AND RESULTS Patients were included if they were ≥18 years old; had a serum potassium result between 1 January 2003 and 3 December 2018; had ≥2 separate, non-urgent care or emergency department encounters; and had an HF diagnosis. Criteria were met by 52 253 patients; 48 333 had sufficient follow-up for analysis. Patients were stratified by the presence/absence of HK (serum potassium >5.0 mmol/L) (n = 31 619 and n = 20 634, respectively) and by baseline left ventricular ejection fraction (LVEF) ≤40% or >40%. Compared with patients without HK (no-HK), those with HK had significantly higher rates of baseline cardiovascular risk factors, prior diagnoses, and greater RAASi use in both baseline and follow-up periods. Assessed outcomes included RAASi use, rate of 3 year major adverse cardiovascular events (MACE), and individual component rates. Between baseline and follow-up analyses, the proportion of patients on RAASi decreased by 5% in patients with HK but increased by 20% in no-HK patients. Overall, MACE and death were consistently highest in the presence of HK without RAASi treatment (63% and 62%, respectively) and lowest in no-HK but on RAASi (25% and 21%, respectively). After complete multivariable adjustment, these trends were consistent regardless of baseline LVEF. CONCLUSIONS In this large, real-world HF population, HK was common and linked to baseline clinical risk factors, declining use of RAASi treatment, and an increase in future MACE, regardless of baseline LVEF. Both HK and reduced RAASi use were independent predictors of future MACE.
Collapse
Affiliation(s)
- Joseph B. Muhlestein
- Department of CardiologyIntermountain Medical Center Heart Institute5121 S. Cottonwood StreetSalt Lake CityUT84157USA
- Department of CardiologyUniversity of UtahSalt Lake CityUTUSA
| | - Jennifer Kammerer
- Managed Care Health OutcomesRelypsa, Inc., a Vifor Pharma Group CompanyRedwood CityCAUSA
| | - Tami L. Bair
- BioinformaticsIntermountain Medical Center Heart InstituteSalt Lake CityUTUSA
| | - Kirk U. Knowlton
- Department of CardiologyIntermountain Medical Center Heart Institute5121 S. Cottonwood StreetSalt Lake CityUT84157USA
- Department of CardiologyUniversity of UtahSalt Lake CityUTUSA
| | - Viet T. Le
- Department of CardiologyIntermountain Medical Center Heart Institute5121 S. Cottonwood StreetSalt Lake CityUT84157USA
| | - Jeffrey L. Anderson
- Department of CardiologyIntermountain Medical Center Heart Institute5121 S. Cottonwood StreetSalt Lake CityUT84157USA
- Department of CardiologyUniversity of UtahSalt Lake CityUTUSA
| | - Donald L. Lappé
- Department of CardiologyIntermountain Medical Center Heart Institute5121 S. Cottonwood StreetSalt Lake CityUT84157USA
| | - Heidi T. May
- EpidemiologyIntermountain Medical Center Heart InstituteSalt Lake CityUTUSA
| |
Collapse
|
20
|
Triposkiadis F, Boudoulas KD, Xanthopoulos A, Boudoulas H. Fallacies in medical practice: Renin-angiotensin-aldosterone system inhibition and COVID-19 as a Paradigm. Hellenic J Cardiol 2021; 62:185-9. [PMID: 33186672 DOI: 10.1016/j.hjc.2020.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/21/2020] [Accepted: 10/27/2020] [Indexed: 12/20/2022] Open
Abstract
In emergency situations, such as during the coronavirus disease 2019 (COVID-19) pandemic, medical community looks for quick answers and guidance. Under these circumstances, experts instead of admitting ignorance, feel obliged to give an answer, often pressurized by political or other authorities, even when such an answer is unavailable. Under these circumstances, publications based on fallacious reasoning are virtually unavoidable. In the present review, we summarize examples underlying fallacious reasoning recommendations regarding treatment with Renin-Angiotensin-Aldosterone inhibitors (RAASi) in the COVID-19 context. Most scientific societies emphasize that RAASi use is safe and that these agents should not be discontinued, based mainly on the results of observational studies (OSs) and occasionally preprints, as relevant randomized controlled trials (RCTs) are currently lacking. However, over the past 4 decades, results from successful RCTs have repeatedly proved that practices based on OSs were wrong. Lack of RCTs results in uncertainty. In this setting, the physician's wisdom and knowledge related to pathophysiologic mechanisms and effect of pharmacologic agents become even more important as they may limit fallacies. Based on these principles, in diseases (e.g., mild, or moderate arterial hypertension, etc.) where equally effective alternative therapies to RAASi are available, these therapies should be applied, whereas in diseases (e.g., heart failure, diabetic kidney disease, etc.), where equally effective alternative therapy compared to RAASi is not available, RAASi should be used. Admittedly this strategy, like all the other recommendations, is not based on solid evidence but is intended to be individualized and follows the Hippocratic "Primum non nocere".
Collapse
|
21
|
Sharma A, Alvarez PJ, Woods SD, Dai D. A Model to Predict Risk of Hyperkalemia in Patients with Chronic Kidney Disease Using a Large Administrative Claims Database. Clinicoecon Outcomes Res 2020; 12:657-667. [PMID: 33204127 PMCID: PMC7665575 DOI: 10.2147/ceor.s267063] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 07/07/2020] [Accepted: 10/22/2020] [Indexed: 12/14/2022] Open
Abstract
Background Chronic kidney disease (CKD) is responsible for substantial clinical and economic burden. Drugs that inhibit the renin-angiotensin-aldosterone system inhibitors (RAASi) slow CKD progression in many common clinical scenarios. Guideline-directed medical therapy requires maximal recommended doses of RAASi, which clinicians are often reluctant to prescribe because of the associated risk of hyperkalemia (HK). Objective This study aims to develop and validate a model to identify individuals with CKD at elevated risk for developing HK over a 12-month period on the basis of lab, medical, and pharmacy claims. Methods Using claims from a large US healthcare payer, we developed a model to predict the probability of individuals identified with CKD but not HK in 2016 (baseline year [BY]) who developed HK in 2017 (prediction year [PY]). The study population was comprised of members continuously enrolled with medical and pharmacy benefits and CKD (BY). Members were excluded from the analysis if they had HK (by lab results or diagnosis code) or dialysis (BY). Prediction model performance measures included area under the receiver operating characteristic curve (AUROC), calibration, and gain and lift charts. Results Of 435,512 members identified with CKD but not HK (BY), 6235 (1.43%) showed incident HK (PY). Compared with individuals without incident HK (PY), these members had a higher comorbidity burden, use of RAASi, and healthcare utilization. The AUROC and calibration analyses showed good predictive accuracy (area under the curve [AUC]=0.843 and calibration). The top 2 HK-prediction deciles identified 75.94% of members who went on to develop HK (PY). Conclusion Guideline-recommended doses of RAASi therapy can be limited by the risk of HK. Novel potassium binders may permit more patients at risk to benefit from these maximal RAASi doses. This predictive model successfully identified the risk of developing HK up to 1 year in advance.
Collapse
Affiliation(s)
- Ajay Sharma
- Healthagen, An Affiliate of Aetna Inc., A Part of the CVS Health Family of Companies, New York, NY, USA
| | - Paula J Alvarez
- Managed Care Health Outcomes, Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, CA, USA
| | - Steven D Woods
- Managed Care Health Outcomes, Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, CA, USA
| | - Dingwei Dai
- Healthagen, An Affiliate of Aetna Inc., A Part of the CVS Health Family of Companies, New York, NY, USA
| |
Collapse
|
22
|
Wang JJ, Edin ML, Zeldin DC, Li C, Wang DW, Chen C. Good or bad: Application of RAAS inhibitors in COVID-19 patients with cardiovascular comorbidities. Pharmacol Ther 2020; 215:107628. [PMID: 32653530 DOI: 10.1016/j.pharmthera.2020.107628] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2020] [Indexed: 02/06/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is caused by a newly emerged coronavirus (CoV) called Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2). COVID-19 patients with cardiovascular disease (CVD) comorbidities have significantly increased morbidity and mortality. The use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor type 1 blockers (ARBs) improve CVD outcomes; however, there is concern that they may worsen the prognosis of CVD patients that become infected with SARS-CoV-2 because the virus uses the ACE2 receptor to bind to and subsequently infect host cells. Thus, some health care providers and media sources have questioned the continued use of ACE inhibitors and ARBs. In this brief review, we discuss the effect of ACE inhibitor-induced bradykinin on the cardiovascular system, on the renin-angiotensin-aldosterone system (RAAS) regulation in COVID-19 patients, and analyze recent clinical studies regarding patients treated with RAAS inhibitors. We propose that the application of RAAS inhibitors for COVID-19 patients with CVDs may be beneficial rather than harmful.
Collapse
|
23
|
Chen R, Yang J, Gao X, Ding X, Yang Y, Shen Y, He C, Xiang H, Ke J, Yuan F, Cheng R, Lv H, Li P, Zhang L, Liu C, Tan H, Huang L. Influence of blood pressure control and application of renin-angiotensin-aldosterone system inhibitors on the outcomes in COVID-19 patients with hypertension. J Clin Hypertens (Greenwich) 2020; 22:1974-1983. [PMID: 33006442 PMCID: PMC7537535 DOI: 10.1111/jch.14038] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [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: 07/23/2020] [Revised: 08/05/2020] [Accepted: 08/07/2020] [Indexed: 01/08/2023]
Abstract
Hypertension is proved to be associated with severity and mortality in coronavirus disease 2019 (COVID‐19). However, little is known about the effects of pre‐admission and/or in‐hospital antihypertension treatments on clinical outcomes. Thus, this study aimed to investigate the association between in‐hospital blood pressure (BP) control and COVID‐19–related outcomes and to compare the effects of different antihypertension treatments. This study included 2864 COVID‐19 patients and 1628 were hypertensive. Patients were grouped according to their BP during hospitalization and records of medication application. Patients with higher BP showed worse cardiac and renal functions and clinical outcomes. After adjustment, subjects with pre‐admission usage of renin‐angiotensin‐aldosterone system (RAAS) inhibitors (HR = 0.35, 95%CI 0.14‐0.86, P = .022) had a lower risk of adverse clinical outcomes, including death, acute respiratory distress syndrome, respiratory failure, septic shock, mechanical ventilation, and intensive care unit admission. Particularly, hypertension patients receiving RAAS inhibitor treatment either before (HR = 0.35, 95%CI 0.13‐0.97, P = .043) or after (HR = 0.18, 95%CI 0.04‐0.86, P = .031) admission showed a significantly lower risk of adverse clinical outcomes than those receiving application of other antihypertensive medicines. Furthermore, consecutive application of RAAS inhibitors in COVID‐19 patients with hypertension showed better clinical outcomes (HR = 0.10, 95%CI 0.01‐0.83, P = .033) than non‐RAAS inhibitors users. We revealed that COVID‐19 patients with poor BP control during hospitalization had worse clinical outcomes. Compared with other antihypertension medicines, RAAS inhibitors were beneficial for improving clinical outcomes in COVID‐19 patients with hypertension. Our findings provide direct evidence to support the administration of RAAS inhibitors to COVID‐19 patients with hypertension before and after admission.
Collapse
Affiliation(s)
- Renzheng Chen
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Jie Yang
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Xubin Gao
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Xiaohan Ding
- Department of Health Care and Geriatrics, The 940th Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou, China.,Department of Infectious Diseases, Huo Shen Shan Hospital, Wuhan, China
| | - Yuanqi Yang
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Yang Shen
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Chunyan He
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Hedong Xiang
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Jingbin Ke
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Fangzhengyuan Yuan
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Ran Cheng
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Hailin Lv
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Ping Li
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Army Medical University, Chongqing, China.,Department of Infectious Diseases, Huo Shen Shan Hospital, Wuhan, China
| | - Limin Zhang
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Army Medical University, Chongqing, China.,Department of Infectious Diseases, Huo Shen Shan Hospital, Wuhan, China
| | - Chuan Liu
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Hu Tan
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Army Medical University, Chongqing, China.,Department of Infectious Diseases, Huo Shen Shan Hospital, Wuhan, China
| | - Lan Huang
- Institute of Cardiovascular Diseases of PLA, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| |
Collapse
|
24
|
Balogh DB, Molnar A, Hosszu A, Lakat T, Hodrea J, Szabo AJ, Lenart L, Fekete A. Antidepressant effect in diabetes-associated depression: A novel potential of RAAS inhibition. Psychoneuroendocrinology 2020; 118:104705. [PMID: 32447176 DOI: 10.1016/j.psyneuen.2020.104705] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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] [Received: 01/29/2020] [Revised: 04/22/2020] [Accepted: 05/03/2020] [Indexed: 12/29/2022]
Abstract
The incidence of depression doubles in diabetic patients and is associated with poor outcomes. Studies indicate that renin-angiotensin-aldosterone system inhibitors (RAASi) might relieve depression, however the mechanism of action is not well understood. We recently showed that angiotensin receptor blockers have antidepressant effects in experimental diabetes comorbid depression. Here we investigated whether all types of RAASi exhibit antidepressant and neuroprotective properties. Diabetes was induced by streptozotocin in adult male Wistar rats. After 5 weeks of diabetes, rats were treated per os with non-pressor doses of enalapril, ramipril, spironolactone or eplerenone for 2 weeks. Behavior was evaluated using forced swim test and open field test. Inflammatory response and brain-derived neurotrophic factor (BDNF) signaling were investigated in the hippocampus. Both ACEi and MR antagonists reversed diabetes-induced behavioral despair confirming their antidepressant-like effect. This may occur via alterations in hippocampal cytokine-mediated inflammatory response. Repressed BDNF production was restored by RAASi. Both ACEi and MR antagonists facilitated the BDNF-tropomyosin receptor kinase B-cAMP response element-binding protein signaling pathway as part of their neuroprotective effect. These data highlight the important benefits of ACEi and MR antagonists in the treatment of diabetes-associated depressive symptoms. Our novel findings support the link between diabetes comorbid depression, inflammation and repressed BDNF signaling. RAASi could provide new therapeutic options to improve the outcomes of both disorders.
Collapse
Affiliation(s)
- Dora B Balogh
- MTA-SE "Lendület" Diabetes Research Group, Hungarian Academy of Sciences, 54 Bokay Janos, H-1083 Budapest, Hungary; 1st Department of Pediatrics, Semmelweis University, 53-54 Bokay Janos, H-1083 Budapest, Hungary
| | - Agnes Molnar
- MTA-SE "Lendület" Diabetes Research Group, Hungarian Academy of Sciences, 54 Bokay Janos, H-1083 Budapest, Hungary; 1st Department of Pediatrics, Semmelweis University, 53-54 Bokay Janos, H-1083 Budapest, Hungary
| | - Adam Hosszu
- MTA-SE "Lendület" Diabetes Research Group, Hungarian Academy of Sciences, 54 Bokay Janos, H-1083 Budapest, Hungary; 1st Department of Pediatrics, Semmelweis University, 53-54 Bokay Janos, H-1083 Budapest, Hungary
| | - Tamas Lakat
- MTA-SE "Lendület" Diabetes Research Group, Hungarian Academy of Sciences, 54 Bokay Janos, H-1083 Budapest, Hungary; 1st Department of Pediatrics, Semmelweis University, 53-54 Bokay Janos, H-1083 Budapest, Hungary
| | - Judit Hodrea
- MTA-SE "Lendület" Diabetes Research Group, Hungarian Academy of Sciences, 54 Bokay Janos, H-1083 Budapest, Hungary; 1st Department of Pediatrics, Semmelweis University, 53-54 Bokay Janos, H-1083 Budapest, Hungary
| | - Attila J Szabo
- 1st Department of Pediatrics, Semmelweis University, 53-54 Bokay Janos, H-1083 Budapest, Hungary; MTA-SE Pediatrics and Nephrology Research Group, Hungarian Academy of Sciences and Semmelweis University, 54 Bokay Janos, Budapest H-1083, Hungary
| | - Lilla Lenart
- MTA-SE "Lendület" Diabetes Research Group, Hungarian Academy of Sciences, 54 Bokay Janos, H-1083 Budapest, Hungary; 1st Department of Pediatrics, Semmelweis University, 53-54 Bokay Janos, H-1083 Budapest, Hungary.
| | - Andrea Fekete
- MTA-SE "Lendület" Diabetes Research Group, Hungarian Academy of Sciences, 54 Bokay Janos, H-1083 Budapest, Hungary; 1st Department of Pediatrics, Semmelweis University, 53-54 Bokay Janos, H-1083 Budapest, Hungary.
| |
Collapse
|
25
|
Pirola CJ, Sookoian S. Estimation of Renin-Angiotensin-Aldosterone-System (RAAS)-Inhibitor effect on COVID-19 outcome: A Meta-analysis. J Infect 2020; 81:276-281. [PMID: 32474043 PMCID: PMC7255761 DOI: 10.1016/j.jinf.2020.05.052] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [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: 05/19/2020] [Accepted: 05/24/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND RATIONALE Some studies of hospitalized patients suggested that the risk of death and/or severe illness due to COVID-19 is not associated with the use of angiotensin-converting enzyme inhibitors (ACEIs) and/or angiotensin II receptor type 1 blockers (ARBs). Nevertheless, some controversy still exists and there is limited information of the ACEIs/ARBs effect size on COVID-19 prognosis. AIM AND METHODS We aimed to measure the effect of ACEIs and/or ARBs on COVID-19 severe clinical illness by a meta-analysis. Literature search included all studies published since the COVID-19 outbreak began (December 2019) until May 9, 2020. We analyzed information from studies that included tested COVID-19 patients with arterial hypertension as comorbidity prior to hospital admission and history of taking ACEIs, ARBs, or ACEIs/ARBs. RESULTS We included 16 studies that involved 24,676 COVID-19 patients, and we compared patients with critical (n = 4134) vs. non-critical (n = 20,542) outcomes. The overall assessment by estimating random effects shows that the use of ACEIs/ARBs is not associated with higher risk of in-hospital-death and/or severe illness among hypertensive patients with COVID-19 infection. On the contrary, effect estimate shows an overall protective effect of RAAS inhibitors/blockers (ACEIs, ARBs, and/or ACEIs/ARBs) with ∼ 23 % reduced risk of death and/or critical disease (OR: 0.768, 95%CI: 0.651-0.907, p=0.0018). The use of ACEIs (OR:0.652, 95%CI:0.478-0.891, p=0.0072) but not ACEIs/ARBs (OR:0.867, 95%CI:0.638-1.179, p =NS) or ARBs alone (OR:0.810, 95%CI:0.629-1.044, p=NS) may explain the overall protection displayed by RAAS intervention combined. CONCLUSION RAAS inhibitors might be associated with better COVID-19 prognosis.
Collapse
Affiliation(s)
- Carlos J Pirola
- University of Buenos Aires, School of Medicine, Institute of Medical Research A Lanari, Ciudad Autónoma de Buenos Aires, Argentina; National Scientific and Technical Research Council (CONICET)-University of Buenos Aires, Institute of Medical Research (IDIM), Department of Molecular Genetics and Biology of Complex Diseases, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Silvia Sookoian
- University of Buenos Aires, School of Medicine, Institute of Medical Research A Lanari, Ciudad Autónoma de Buenos Aires, Argentina; National Scientific and Technical Research Council (CONICET)-University of Buenos Aires, Institute of Medical Research (IDIM), Department of Clinical and Molecular Hepatology, Ciudad Autónoma de Buenos Aires, Argentina.
| |
Collapse
|
26
|
Paolisso P, Bergamaschi L, Saturi G, D'Angelo EC, Magnani I, Toniolo S, Stefanizzi A, Rinaldi A, Bartoli L, Angeli F, Donati F, Rucci P, Mattioli AV, Taglieri N, Pizzi C, Galiè N. Secondary Prevention Medical Therapy and Outcomes in Patients With Myocardial Infarction With Non-Obstructive Coronary Artery Disease. Front Pharmacol 2020; 10:1606. [PMID: 32082147 PMCID: PMC7005107 DOI: 10.3389/fphar.2019.01606] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [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: 11/07/2019] [Accepted: 12/10/2019] [Indexed: 01/01/2023] Open
Abstract
Background Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous entity with relevant long-term major cardiovascular events. Several trials have demonstrated that dual antiplatelet therapy (DAPT), β-blocker, renin-angiotensin-aldosterone system (RAAS) inhibitor and statin therapy improve the prognosis in patients with obstructive myocardial infarction (ob-MI). However, evidence on the best medical therapy for secondary prevention in MINOCA patients is lacking. Purpose To investigate the effects of secondary prevention treatments at discharge on mid-term outcomes in MINOCA. Methods Patients with acute myocardial infarction (MI) undergoing early coronary angiography between 2016 and 2018 were extracted from a clinical database. The diagnosis of MINOCA was made according to 2016 ESC MINOCA Position Paper criteria. Second-level diagnostic work-up including cardiac magnetic resonance was performed to exclude non-ischemic troponin elevation cause. The relationship between treatments and outcomes was evaluated by using Kaplan-Meier survival analysis and Cox regression models. All confirmed MINOCA were followed in our outpatient clinics. The primary end-points were all-cause mortality, re-hospitalization for MI and a composite outcome including all-cause mortality, hospitalization for MI and ischemic stroke (MACE). Results Out of 1,141 AMI who underwent coronary angiography, 134 were initially diagnosed as MINOCA. Patients with MINOCA were less likely to receive secondary prevention treatments than patients with obstructive coronary artery disease (CAD) MI (respectively, 42.1% vs 81.8% for DAPT; 75.5% vs 89.6% for β-blockers; 64.7% vs 80.3% for RAAS inhibitor and 63.9% vs 83% for statins). Based on the diagnostic work-up completed during the first month after discharge, a final sample of 88 patients had confirmed MINOCA. During an average follow-up of 19.35 ± 10.65 months, all-cause mortality occurred in 11 (12.5%) patients, recurrence of MI in 4 (4.5%), and MACE in 15 (17.0%) patients. Patients treated with RAAS inhibitors and statins had a significantly longer survival. On the contrary, no increase in survival was found in patients treated with β-blockers or DAPT. Cox multivariable analysis, including all secondary prevention drugs, showed that only RAAS inhibitors were associated with reduced all cause-mortality and MACE. Conclusion This prospective study suggests that RAAS inhibitor therapy provides mid-term beneficial effects on outcomes in MINOCA patients; in contrast, dual antiplatelet, β-blocker and statin therapy had no effects on mortality and MACE. These results should be considered preliminary and warrant confirmation from larger studies.
Collapse
Affiliation(s)
- Pasquale Paolisso
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Luca Bergamaschi
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Giulia Saturi
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Emanuela Concetta D'Angelo
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Ilenia Magnani
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Sebastiano Toniolo
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Andrea Stefanizzi
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Andrea Rinaldi
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Lorenzo Bartoli
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Francesco Angeli
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Francesco Donati
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Paola Rucci
- Division of Hygiene and Biostatistics, Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Anna Vittoria Mattioli
- Department of Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Nevio Taglieri
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Carmine Pizzi
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Nazzareno Galiè
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| |
Collapse
|
27
|
Desai NR, Reed P, Alvarez PJ, Fogli J, Woods SD, Owens MK. The Economic Implications of Hyperkalemia in a Medicaid Managed Care Population. Am Health Drug Benefits 2019; 12:352-361. [PMID: 32055283 PMCID: PMC6996620] [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] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/12/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Hyperkalemia, defined as a serum potassium level >5 mEq/L that results from multiple mechanisms, is a serious medical condition that can lead to life-threatening arrhythmias and sudden cardiac death. The coexistence of cardiac and renal diseases (ie, cardiorenal syndrome) significantly increases the complexity of care, but its economic impact is not well-characterized in this understudied Medicaid managed care population with hyperkalemia. OBJECTIVE To calculate the economic impact of hyperkalemia on patients with cardiorenal syndrome in a Medicaid managed care population in the United States using real-world data. METHODS In this retrospective cohort study, we used a proprietary Medicaid managed care database from 1 southern state. The total study population included 3563 patients, including 973 patients with hyperkalemia and 2590 controls (without hyperkalemia), who were matched based on age, comorbidities, and Medicaid eligibility status and duration, during a 30-month period between 2013 and 2016. The inclusion criteria for the hyperkalemia cohort were age ≥18 years, Medicaid-only insurance status, coded cardiorenal diagnosis, and a claim for hyperkalemia during the study period. The cost was determined using paid claims data. RESULTS The mean healthcare costs (medical and pharmacy per member per year [PMPY] for patients with hyperkalemia was higher than that for the control cohort without hyperkalemia ($56,002 vs $23,653, respectively). These cost differences were driven by medical costs accrued in the hyperkalemia and in the control cohorts ($49,648 and $18,399 PMPY, respectively). Two of the largest drivers of the medical cost variance were inpatient costs ($33,116 vs $10,629 PMPY for the hyperkalemia and control cohorts, respectively) and dialysis costs ($2716 vs $810 PMPY, respectively). The medical loss ratios were 552% for the hyperkalemia cohort and 260% for the control cohort. Both cohorts had revenue deficits to the health plan, but the hyperkalemia cohort had double the medical loss ratio compared with the control cohort. CONCLUSIONS The findings from this Medicaid managed care population suggest that hyperkalemia increases healthcare utilization and costs, which were primarily driven by the costs associated with inpatient care and dialysis. Our findings demonstrate that the Medicaid beneficiaries who have cardiorenal comorbidities accrue high costs to the Medicaid health plan, and these costs are even higher if a hyperkalemia diagnosis is present. The very high medical loss ratio for the hyperkalemia cohort in our analysis indicates that enhanced monitoring and management of patients with hyperkalemia should be considered.
Collapse
Affiliation(s)
- Nihar R Desai
- Assistant Professor of Medicine, Yale School of Medicine, New Haven, CT
| | - Pamala Reed
- Senior Director, Outcomes Research and Analysis, Intelligent Health Analytics, Tallahassee, FL
| | - Paula J Alvarez
- Senior Director, Managed Care Health Outcomes, Relypsa, a Vifor Pharma Group Company, Redwood City, CA
| | - Jeanene Fogli
- Executive Director, Medical Affairs, Relypsa, a Vifor Pharma Group Company, Redwood City, CA
| | - Steven D Woods
- Senior Director, Managed Care Health Outcomes, Relypsa, a Vifor Pharma Group Company, Redwood City, CA
| | - Mary Kay Owens
- President and Chief Executive Officer, Intelligent Health Analytics
| |
Collapse
|
28
|
Bonino B, Leoncini G, De Cosmo S, Greco E, Russo GT, Giandalia A, Viazzi F, Pontremoli R. Antihypertensive Treatment in Diabetic Kidney Disease: The Need for a Patient-Centered Approach. ACTA ACUST UNITED AC 2019; 55:E382. [PMID: 31315312 DOI: 10.3390/medicina55070382] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/02/2019] [Accepted: 07/12/2019] [Indexed: 12/22/2022]
Abstract
Diabetic kidney disease affects up to forty percent of patients with diabetes during their lifespan. Prevention and treatment of diabetic kidney disease is currently based on optimal glucose and blood pressure control. Renin–angiotensin aldosterone inhibitors are considered the mainstay treatment for hypertension in diabetic patients, especially in the presence of albuminuria. Whether strict blood pressure reduction entails a favorable renal outcome also in non-albuminuric patients is at present unclear. Results of several clinical trials suggest that an overly aggressive blood pressure reduction, especially in the context of profound pharmacologic inhibition of the renin–angiotensin–aldosterone system may result in a paradoxical worsening of renal function. On the basis of this evidence, it is proposed that blood pressure reduction should be tailored in each individual patient according to renal phenotype.
Collapse
|
29
|
Fici F, Bakir EA, Beyaz S, Makel W, Robles NR. PAIT-survey-Prevalence of albuminuria in patients with diabetes and hypertension in Turkey. Prim Care Diabetes 2018; 12:558-564. [PMID: 30327190 DOI: 10.1016/j.pcd.2018.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 12/09/2017] [Revised: 07/25/2018] [Accepted: 08/02/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Albuminuria is an early marker of kidney disease in patients with diabetes and/or hypertension undetected or untreated albuminuria is a leading cause of chronic kidney disease and cardiovascular events, The purpose of the present survey was to assess the prevalence of albuminuria in patients with diabetes and hypertension, treated with a combinations of renin angiotensin aldosterone system inhibitors and dihydropyridine calcium channel blockers. METHODS The survey was performed in 105 Primary Care Units in Turkey and involved outpatients, routinely visited by either a specialist or a non-specialist physician. Albuminuria was evaluated in a spot morning urine sample, as albumin-creatinine ratio, using the Multistic-Clinitek-device analyzer (Siemens), that has a strong correlation with 24-h urinary albumin excretion. Microalbuminuria was defined as a loss of 3.4-33.9mg albumin/mmol creatinine and macroalbuminuria as a loss of >33.9mg albumin/mmol creatinine. Diabetes was assessed through documented blood glucose concentration or use antidiabetic drugs, whereas hypertension through blood pressure measurement and current antihypertensive treatment. RESULTS The survey enrolled 1708 subjects with a prevalence of type 2 diabetes (87.6%). Albuminuria was detected in 52.0% of patients. Blood pressure was controlled in 37.0% and diabetes in 56.7%. The risk of albuminuria was significantly high in patients with uncontrolled diabetes (p<0.001) and blood pressure (p=0.009). CONCLUSIONS In a large cohort of treated hypertensive patients with diabetes, albuminuria was present in about 50% and was correlated with poor diabetes and blood pressure control. Systematic screening of albuminuria, particularly in Primary Care, is an important tool for the early diagnosis of nephropathy.
Collapse
Affiliation(s)
- Francesco Fici
- Catedra de Riesgo Cardiovascular, Universidad de Salamanca, Salamanca, Spain
| | - Elif Ali Bakir
- Department of Nephrology, Kartal Training Hpt, Kartal, Turkey
| | | | - Wim Makel
- Clinical Research Facilities International B.V., Schaijk,The Netherlands
| | | |
Collapse
|
30
|
Zagkotsis G, Markou M, Paschou E, Papanikolaou P, Sabanis N. Preventing the development and progression of diabetic kidney disease: Where do we stand? Diabetes Metab Syndr 2018; 12:585-590. [PMID: 29602760 DOI: 10.1016/j.dsx.2018.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 01/16/2018] [Accepted: 03/15/2018] [Indexed: 01/07/2023]
Abstract
Diabetic kidney disease (DKD) is a major factor associated with increased cardiovascular (CV) and all-cause mortality and morbidity in patients with diabetes. Current standard therapy includes intensive management of hyperglycemia and blood pressure control with renin-angiotensin-aldosterone system (RAAS) blockers. Despite the implementation of this strategy, DKD remains the leading cause of end-stage renal disease (ESRD), mainly because of the increasing burden of diabetes mellitus. The aim of this review is to evaluate the available evidence, focusing on the benefit of current treatment in the development and progression of DKD.
Collapse
Affiliation(s)
- Georgios Zagkotsis
- Department of Nephrology, General Hospital of Livadeia, Livadeia, Greece.
| | - Maria Markou
- Department of Endocrinology, "Evaggelismos" General Hospital of Athens, Athens, Greece.
| | | | | | - Nikos Sabanis
- Department of Nephrology, General Hospital of Livadeia, Livadeia, Greece.
| |
Collapse
|
31
|
Abstract
Proteinuria and decline of renal function are associated with progression of kidney disease. The Renin Angiotensin Aldosterone System (RAAS) plays an important role in blood pressure regulation, fluid volume, and sodium balance. Overactivity of RAAS contributes to the pathogenesis of a variety of clinical conditions including progress of chronic kidney disease (CKD). This review summarizes the use of RAAS inhibitors as dual therapy or monotherapy in different stages of kidney disease. Experimental and clinical studies have demonstrated RAAS inhibitors prevent proteinuria, kidney fibrosis and slow decline of renal function and thus play a protective role in both early and end stages of kidney disease. While combination use of RAAS inhibitors showed higher efficiency compared with monotherapy, it is also associated with higher incidence of adverse events. Besides ACEI/ARBs, more mechanism research of mineralocorticoid receptor antagonists in kidney disease should be performed.
Collapse
|
32
|
Epstein M, Lifschitz MD. Potassium homeostasis and dyskalemias: the respective roles of renal, extrarenal, and gut sensors in potassium handling. Kidney Int Suppl (2011) 2016; 6:7-15. [PMID: 30675414 PMCID: PMC6340905 DOI: 10.1016/j.kisu.2016.01.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [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: 12/18/2015] [Revised: 01/08/2016] [Accepted: 01/08/2016] [Indexed: 12/11/2022] Open
Abstract
Integrated mechanisms controlling the maintenance of potassium homeostasis are well established and are defined by the classic "feedback control" of potassium balance. Recently, increasing investigative attention has focused on novel physiological paradigms that increase the complexity and precision of homeostasis. This review briefly considers the classic and well-established feedback control of potassium and then considers subsequent investigations that inform on an intriguing and not widely recognized complementary paradigm: the "feed-forward control of potassium balance." Feed-forward control refers to a pathway in a homeostatic system that responds to a signal in the environment in a predetermined manner, without responding to how the system subsequently reacts (i.e., without responding to feedback). Studies in several animal species, and recently in humans, have confirmed the presence of a feed-forward control mechanism that is capable of mediating potassium excretion independent of changes in serum potassium concentration and aldosterone. Knowledge imparted by this update of potassium homeostasis hopefully will facilitate the clinical management of hyperkalemia in patients with chronic and recurrent hyperkalemia. Awareness of this updated integrative control mechanism for potassium homeostasis is more relevant today when the medical community is increasingly focused on leveraging and expanding established renin-angiotensin-aldosterone system inhibitor treatment regimens and on successfully coping with the challenges of managing hyperkalemia provoked by renin-angiotensin-aldosterone system inhibitors. These new insights are relevant to the future design of clinical trials delineating renal potassium handling.
Collapse
Affiliation(s)
- Murray Epstein
- Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Meyer D. Lifschitz
- Adult Nephrology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| |
Collapse
|
33
|
Mollace V, Gliozzi M, Capuano A, Rossi F. Modulation of RAAS-natriuretic peptides in the treatment of HF: Old guys and newcomers. Int J Cardiol 2016; 226:126-131. [PMID: 27075034 DOI: 10.1016/j.ijcard.2016.03.085] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [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] [Received: 02/02/2016] [Accepted: 03/19/2016] [Indexed: 01/10/2023]
Abstract
The use of renin-angiotensin-aldosterone system (RAAS) inhibitors in the treatment of chronic heart failure (HF) and arterial hypertension is recommended by the European Society of Cardiology Guidelines on the basis of consolidated evidence supporting their efficacy in the development of such a disease. However, the high incidence of re-hospitalization and mortality in patients undergoing chronic HF, leads to the need for the development of novel RAAS inhibitors possessing a better pharmacokinetic/pharmacodynamics profile in approaching hemodynamic imbalance and myocardial dysfunction associated with the development of chronic HF. Here we summarize some of the recent advances in the area of RAAS-modulators, including novel renin inhibitors, mineralcorticoid receptor antagonists and novel AT1 and AT2-receptor modulators. In addition, the pharmacology of a new class of compounds which display both AT1-receptor blocking properties combined with inhibition of neprilysin, the vasopeptidase enzyme degradating natriuretic peptide (ARNi), will be reviewed, alongside with their impact in the pathophysiology of chronic HF.
Collapse
Affiliation(s)
- Vincenzo Mollace
- Institute of Research for Food Safety & Health (IRC-FSH), University "Magna Graecia" of Catanzaro, Italy
| | - Micaela Gliozzi
- Institute of Research for Food Safety & Health (IRC-FSH), University "Magna Graecia" of Catanzaro, Italy.
| | - Annalisa Capuano
- Second University of Naples, Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Department of Experimental Medicine, Section of Pharmacology L. Donatelli of Medicine and Surgery, Napoli, Italy
| | - Francesco Rossi
- Second University of Naples, Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Department of Experimental Medicine, Section of Pharmacology L. Donatelli of Medicine and Surgery, Napoli, Italy
| |
Collapse
|
34
|
Weir MR. Current and future treatment options for managing hyperkalemia. Kidney Int Suppl (2011) 2016; 6:29-34. [PMID: 30675417 DOI: 10.1016/j.kisu.2016.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 01/11/2016] [Accepted: 01/11/2016] [Indexed: 12/23/2022] Open
Abstract
Hyperkalemia is associated with life-threatening cardiac arrhythmias and increased mortality. Hyperkalemia is most often observed in patients with chronic kidney disease and/or in those with congestive heart failure being treated with drugs that limit renal potassium excretion, especially drugs that inhibit the renin-angiotensin-aldosterone system. Treatment of hyperkalemia may be either acute, as needed during rapid changes in serum potassium, which are associated with cardiac arrhythmia, or chronic, which stabilizes serum potassium levels and limits the development of life-threatening arrhythmias. There are a number of both acute and chronic treatments available for the treatment of hyperkalemia, but some are limited by complex administration requirements and/or serious side effects. Hyperkalemia remains a vexing problem for clinicians, particularly in the care of patients with chronic kidney disease and cardiovascular disease.
Collapse
|
35
|
Damman K, Lambers-Heerspink HJ. Are renin-angiotensin-aldosterone system inhibitors lifesaving in chronic kidney disease? J Am Coll Cardiol 2014; 63:659-660. [PMID: 24269361 DOI: 10.1016/j.jacc.2013.10.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 10/22/2013] [Indexed: 01/13/2023]
Affiliation(s)
- Kevin Damman
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands.
| | - Hiddo J Lambers-Heerspink
- University of Groningen, Department of Clinical Pharmacology, University Medical Center Groningen, Groningen, the Netherlands
| |
Collapse
|
36
|
Fulop T, Rule AD, Schmidt DW, Wiste HJ, Bailey KR, Kullo IJ, Schwartz GL, Mosley TH, Boerwinkle E, Turner ST. C-reactive Protein among Community-Dwelling Hypertensives on Single-agent Antihypertensive Treatment. ACTA ACUST UNITED AC 2009; 3:260-6. [PMID: 20161163 DOI: 10.1016/j.jash.2009.03.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND C-reactive protein is a predictor of adverse cardiovascular outcomes. The effect of antihypertensive therapy on C-reactive protein levels is largely unknown. METHOD We undertook a cross-sectional study of CRP levels among participants with primary hypertension on single-agent anti-hypertensive therapy in the community-based biracial Genetic Epidemiology Network of Arteriopathy cohort. Linear regression models were used to assess the association of anti-hypertensive medication class with log-transformed C-reactive protein after adjustment for age, gender, ethnicity, body mass index, smoking, diabetes, HMG-Co-A reductase inhibitor use, achieved blood pressure control (<140/90 mmHg), serum creatinine and urine albumin-to-creatinine ratios. RESULTS There were 662 participants in the cohort taking single-agent therapy for hypertension. Median C-reactive protein levels differed across participants: 0.40 mg/dL for those on diuretics, 0.34 mg/dL on calcium channel blockers, 0.25 mg/dL on beta blockers and 0.27 mg/dL on renin-angiotensin-aldosterone system inhibitors (p<0.001). With multivariable adjustment, the group on renin-angiotensin-aldosterone system inhibitors had a 20% lower mean CRP on average than the group on diuretics (p=0.044), differences between other medication classes were not apparent. Heart rate had a strong association with C-reactive protein (p < 0.001). CONCLUSIONS Antihypertensive medication class may influence inflammation, particularly in patients on RAAS inhibitors.
Collapse
|