Effect of renin-angiotensin system inhibitors on cardiovascular events in hemodialysis patients with hyperphosphatemia: A post hoc analysis of the LANDMARK trial

INTRODUCTION

The clinical benefits of renin-angiotensin system inhibitors (RASi) in patients undergoing hemodialysis remain obscure.

METHODS

This is a post hoc cohort analysis of the LANDMARK trial investigate whether RASi use was associated with cardiovascular events (CVEs) and all-cause mortality. A total of 2135 patients at risk for vascular calcification were analyzed using a Cox proportional hazards model with propensity-score matching.

RESULTS

The risk of CVEs was similar between participants with RASi use at baseline and those without RASi use at baseline and between participants with RASi use during the study period and those without RASi use during the study period. No clinical benefits of RASi use on all-cause mortality were observed. Serum phosphate levels were significantly associated with the effect of RASi on CVEs.

CONCLUSIONS

RASi use was not significantly associated with a lower risk of CVEs or all-cause mortality in hemodialysis patients at risk of vascular calcification.

Renin-Angiotensin-System Inhibitors for the Prevention of Chemotherapy-Induced Peripheral Neuropathy: OncoToxSRA, a Preliminary Cohort Study

Chemotherapy-induced peripheral neuropathy (CIPN) is a frequent and dose-limiting adverse side effect of treatment. CIPN affects the oncological prognosis of patients, as well as their quality of life. To date, no specific pharmacological therapy has demonstrated effectiveness in preventing CIPN. Accumulating preclinical evidence suggests that renin-angiotensin system (RAS) inhibitors may have neuroprotective effects. One hundred and twenty patients were included in this observational study and were followed from the beginning of their neurotoxic chemotherapy schedule until their final assessment, at least one month after its cessation. The National Cancer Institute's common toxicity criteria 4.0 (NCI-CTC 4.0) were used to grade the severity of adverse events. Follow-ups also included electrochemical skin conductance and scales for pain, quality of life and disability. Among patients receiving a platinum-based regimen, the mean grade of sensory neuropathy (NCI-CTC 4.0) was significantly lower in the RAS inhibitor group after the end of their anticancer treatment schedule. Because of the observational design of the study, patients in the RAS inhibitor group cumulated comorbidities at risk of developing CIPN. Randomized controlled trials in platinum-based regimens would be worth conducting in the future to confirm the neuroprotective potential of RAS inhibitors during chemotherapy.

The Efficacy of Triptolide in Preventing Diabetic Kidney Diseases: A Systematic Review and Meta-Analysis

Ethnopharmacological Relevance: Triptolide (TP), the primary biologically active ingredient of Tripterygium wilfordii Hook F (TWHF), possesses the potential to solve the shortcomings of TWHF in treating diabetic kidney disease (DKD) in the clinic.

Aim of the Study: We conducted a meta-analysis to evaluate the efficacy of TP in treating DKD and offer solid evidence for further clinical applications of TP.

Materials and Methods: Eight databases (CNKI, VIP, CBM, WanFang, PubMed, Web of Science, EMBASE, and Cochrane library) were electronically searched for eligible studies until October 17, 2020. We selected animal experimental studies using TP versus renin–angiotensin system inhibitors or nonfunctional liquids to treat DKD by following the inclusion and exclusion criteria. Two researchers independently extracted data from the included studies and assessed the risk of bias with the Systematic Review Centre for Laboratory Animal Experimentation Risk of Bias tool. Fixed-effects meta-analyses, subgroup analyses, and meta-regression were conducted using RevMan 5.3 software. Inplasy registration number: INPLASY2020100042.

Results: Twenty-six studies were included. Meta-analysis showed that TP significantly reduced albuminuria (14 studies; standardized mean difference SMD: −1.44 [−1.65, −1.23], I² = 87%), urine albumin/urine creatinine ratio (UACR) (8 studies; SMD: –5.03 [–5.74, −4.33], I² = 84%), total proteinuria (4 studies; SMD: –3.12 [–3.75, −2.49], I² = 0%), serum creatinine (18 studies; SMD: –0.30 [–0.49, −0.12], I² = 76%), and blood urea nitrogen (12 studies; SMD: –0.40 [–0.60, −0.20], I² value = 55%) in DKD animals, compared to the vehicle control. However, on comparing TP to the renin–angiotensin system (RAS) inhibitors in DKD treatment, there was no marked difference in ameliorating albuminuria (3 studies; SMD: –0.35 [–0.72, 0.02], I² = 41%), serum creatinine (3 studies; SMD: –0.07 [–0.62, 0.48], I² = 10%), and blood urea nitrogen (2 studies; SMD: –0.35 [–0.97, 0.28], I² = 0%). Of note, TP exhibited higher capacities in reducing UACR (2 studies; SMD: –0.66 [–1.31, −0.01], I² = 0%) and total proteinuria (2 studies; SMD: –1.18 [–1.86, −2049], I² = 0%). Meta-regression implicated that the efficacy of TP in reducing DKD albuminuria was associated with applied dosages. In addition, publication bias has not been detected on attenuating albuminuria between TP and RAS inhibitors after the diagnosis of DKD.

Systematic Review Registration:https://clinicaltrials.gov/, identifier INPLASY2020100042

Chronotherapy with a Renin-angiotensin System Inhibitor Ameliorates Renal Damage by Suppressing Intrarenal Renin-angiotensin System Activation

Objective The intrarenal renin-angiotensin system (RAS) is activated in chronic kidney disease (CKD) patients and is not suppressed at night in CKD patients showing nocturnal hypertension, contributing to renal damage. Furthermore, changes in RAS inhibitor administration from morning to evening, namely chronotherapy, ameliorates renal damage at night. We attempted to clarify whether or not chronotherapy ameliorates renal damage by suppressing the intrarenal RAS activity. Methods We recruited 34 CKD patients with RAS inhibitors in the morning. We conducted ambulatory blood pressure (BP) monitoring and urine collection and evaluated urinary albumin (Alb) and angiotensinogen (AGT), which are surrogate markers for intrarenal RAS activity during the day and at night, respectively. The same experiments were conducted after changing the administration time. The ratio of values associated with morning versus evening dosing was defined as the morning to evening (M/E) ratio. Results The M/E ratio of urinary Alb had a significant and positive relationship with that of urinary AGT during the day and at night in all CKD patients. However, no significant relationships were found between the M/E ratios of urinary Alb and AGT using multiple linear regression analyses. Conversely, there was a significant and positive relationship between the M/E ratios of urinary Alb and AGT at night but not during the day in CKD patients whose estimated glomerular filtration rate was <45 mL/min/1.73 m² and whose night-to-day ratio of systolic BP was >0.90, even after adjustment. Conclusion This study indicated that chronotherapy with RAS inhibitors improved the renal damage via intrarenal RAS suppression, especially in CKD patients with an impaired renal function and nocturnal hypertension.

Utilization of antihypertensive drugs among chronic kidney disease patients: Results from the Chinese cohort study of chronic kidney disease (C-STRIDE)

The utilization of antihypertensive drugs plays an important role in blood pressure control among chronic kidney disease (CKD) patients. Limited information was available on how antihypertensive drugs were used among Chinese CKD patients. In the present study, the utilization of antihypertensive drugs among a subgroup of hypertensive participants with a complete record of antihypertensive drug information from the Chinese Cohort Study of Chronic Kidney Disease was analyzed. Among 2213 subjects, 61.7% and 26.5% had their blood pressure controlled to <140/90 mmHg and <130/80 mmHg, respectively. In total, 38.5% were on monotherapy. Of those patients who received combination therapy, 57.8% were treated with a two-drug combination. Renin-angiotensin system inhibitors (RASIs) were the most commonly prescribed drugs (71.2%). Only 10.2% of the patients were prescribed diuretics. After multivariable adjustment, participants taking RASI were more likely to have their blood pressure controlled to <140/90 mmHg (prevalence ratio (PR) 1.153, 95% confidence interval (CI): 1.071-1.240). CKD stage 4 (PR 0.548, 95% CI: 0.434-0.692) was associated with RASIs treatment. Additionally, diabetes (PR 1.498, 95% CI: 1.120-2.004), albumin/creatinine ratio ≥300 mg/g (PR 1.547, 95% CI: 1.020-2.344), and CKD stage 4 (PR 2.022, 95% CI: 1.223-3.343) were associated with diuretic use. The results suggested that combination therapy, diuretics use in general, and utilization of RASIs in advanced CKD stage were insufficient in the current treatment of Chinese hypertensive CKD patients.

Renin-angiotensin system inhibitor attenuates oxidative stress induced human coronary artery endothelial cell dysfunction via the PI3K/AKT/mTOR pathway

INTRODUCTION

The renin-angiotensin system is associated with blood pressure regulation, inflammation, oxidative stress and insulin resistance. It can decrease intracellular oxidative stress. Stimulation with H₂O₂ leads to increased oxidative stress and activation of the AKT/mTOR pathway. However, the role of renin-angiotensin system inhibitors in oxidative stress-induced endothelial cell dysfunction and H₂O₂-induced AKT activation remains unclear.

MATERIAL AND METHODS

Human coronary artery endothelial cells (HCAECs) were used. The cells were treated with H₂O₂, captopril, the AKT inhibitor MK-2206, and the AKT activator SC79, either separately, or in combination. p53 and ICAM-1 expression, and p-eNOS, p-Akt and mTOR activation were measured by Western blot. Cell viability was assessed by MTT assay. Levels of reactive oxygen species (ROS) were assayed by flow cytometry. Proliferation was monitored by BrdU labeling, while cell migration and invasion were determined by wound healing and Transwell assays, respectively.

RESULTS

The renin-angiotensin system inhibitor captopril reversed H₂O₂-induced oxidative stress and apoptosis in HCAECs. Co-treatment with captopril and the AKT inhibitor MK-2206 reduced the H₂O₂-induced P53 and ICAM-1 protein expression (p < 0.05). The proliferation, migration and invasion of HCAECs were significantly enhanced by co-treatment with captopril and MK-2206 (p < 0.05).

CONCLUSIONS

The study revealed the protective effect of captopril against H₂O₂-induced endothelial cell dysfunction through the AKT/mTOR pathway, and its enhancement of cell survival. These findings provide new insights into the protective effects of captopril and novel therapeutic approaches to treatment of cardiovascular disease.

Inhibition of renin-angiotensin axis reduces the risk of thrombus formation in the left atrial appendage in patients with hypertension complicated by atrial fibrillation

Aims:

We examined whether the use of a renin-angiotensin-aldosterone system (RAS) inhibitor plays a role in protecting against left atrial appendage thrombus (LAAT) in patients with hypertension complicated by atrial fibrillation (AF).

Methods:

Two observational studies were conducted on patients with diagnoses of hypertension and AF, who were categorized into RAS inhibitor user or nonuser groups. Demographic characteristics, clinical characteristics, echocardiographic parameters and hemostatic markers were examined and the occurrence of LAAT during follow-up were recorded.

Results:

In the first study (n = 131), LA peak systolic strain and LAA emptying flow velocity (LAA eV) were significantly increased in patients on RAS inhibitors compared with the nonuser group (p < 0.05). Lower D-dimer and fibrinogen levels were observed in patients on RAS inhibitors (p < 0.05). In the second study (n = 99), 25.9% (n = 11) of patients on RAS inhibitors developed LAAT, compared with 46.7% (n = 21) in the nonuser group (p < 0.05). After controlling for risk factors related to LAAT, use of RAS inhibitors remained associated with a significantly lower risk of developing LAAT (HR, 0.406; 95% CI, 0.191–0.862; p = 0.019).

Conclusions:

RAS inhibitors use was associated with a significant reduction in the risk of LAAT in patients with hypertension and AF.

Evidence-based pharmacotherapies used in the postdischarge phase are associated with improved one-year survival in senior patients hospitalized with heart failure

AIM

Hospitalized heart failure (HF) patients have a poor prognosis postdischarge. We determined whether renin-angiotensin system inhibitors (RASI) and β-blockers dispensed to patients within 60 days post-HF hospital discharge are associated with improved 1-year survival.

METHODS

A retrospective population-based study was conducted in 4897 seniors, aged 65-84 years, alive at 60 days postindex HF hospitalization in Western Australia over 2003-2008. Dispensing of RASI and β-blocker dispensing was identified from the Pharmaceutical Benefits Scheme claims database linked to hospital admission and death records.

RESULTS

At 1-year posthospital discharge, the all-cause mortality and all-cause death or HF rehospitalization rate was 13.5% (n = 663) and 24.4% (n = 1193), respectively. Postdischarge RASI and β-blocker were dispensed in 77.4% and 53.0% of patients, respectively. Their use was associated with a lower inverse probability treatment weighted (IPTW) HR for 1-year mortality of 0.70, 95% CI 0.61-0.81 and 0.79, 95% CI 0.68-0.92, respectively (both P < 0.0001), with a survival advantage most evident in the subgroup (70.1%) of patients with ischemic HF. In the overall cohort, these therapies were also associated with reduced IPTW HRs for all-cause death or HF rehospitalization (both P < 0.005) but not for HF rehospitalization exclusively. Use of a β-blocker was associated with a reduced IPTW HR for HF rehospitalization in the ischemic HF subgroup only.

CONCLUSIONS

In a cohort of senior patients hospitalized with HF, dispensing of a RASI or β-blocker within 60 days postdischarge is associated with a 1-year survival benefit. Early postdischarge support programs after recent HF hospitalization should include measures to optimize adherence to evidence-based medications.

A review of the benefits of early treatment initiation with single-pill combinations of telmisartan with amlodipine or hydrochlorothiazide

This review discusses the rationale for earlier use of single-pill combinations (SPCs) of antihypertensive drugs, with a focus on telmisartan/amlodipine (T/A) and telmisartan/hydrochlorothiazide (T/H) SPCs. Compared with the respective monotherapies, the once-daily T/A and T/H SPCs have been shown to result in significantly higher blood pressure (BP) reductions, BP goal rates, and response rates in patients at all stages of hypertension. As expected, BP reductions are highest with the highest dose (T80/A10 and T80/H25) SPCs. Subgroup analyses of the telmisartan trials have reported the efficacy of both SPCs to be consistent, regardless of the patients' age, race, and coexisting diabetes, obesity, or renal impairment. In patients with mild-to-moderate hypertension, the T/A combination provides superior 24-hour BP-lowering efficacy compared with either treatment administered as monotherapy. Similarly, the T/H SPC treatment provides superior 24-hour BP-lowering efficacy, especially in the last 6 hours relative to other renin-angiotensin system inhibitor-based SPCs. The T/A SPC is associated with a lower incidence of edema than amlodipine monotherapy, and the T/H SPC with a lower incidence of hypokalemia than hydrochlorothiazide monotherapy. Existing evidence supports the use of the T/A SPC for the treatment of hypertensive patients with prediabetes, diabetes, or metabolic syndrome, due to the metabolic neutrality of both component drugs, and the use of the T/H SPC for those patients with edema or in need of volume reduction.