Renoprotective effects

ACE inhibitors and angiotensin-receptor blockers (ARB) have definite benefits in patients with nephropathy and are believed to have renoprotective effects in most patients. Due to their ability to cause an initial bump in serum creatinine, these agents should be used cautiously when employed in combination with the calcineurin inhibitors. The dihydropyridine calcium channel blockers have demonstrated an ability to reverse the nephrotoxicity associated with cyclosporine and tacrolimus (Table 52-8). In general, antihypertensive therapy should focus on agents with proven benefit in reducing the progression of cardiovascular disease and should be chosen on a patient-specific basis.55 See Chapter 2 for further recommendations for treating HTN. 

Kurata, H., Fujii, T., Tsutsui, H., Katayama, T., Ohkita, M., Takaoka, M., Tsuruoka, N., Kiso, Y., Ohno, Y., Fujisawa, Y., Shokoji, T., Nishiyama, A., et al. (2006). Renoprotective effects of L-carnosine on ischemia/reperfusion-induced renal injury in rats. ]. Pharmacol. Exp. Ther. 319, 640-647. 

Renal insufficiency is a late complication of hypertension (354). This is why the choice of the antihypertensive drug selected as the firs (dine treatment of a condition that will persist for many years is so important. From this viewpoint, the fall in blood pressure induced by ACE inhibitors might have beneficial renal effects, in addition to those induced by any decrease in perfusion pressure of the kidneys, especially in diabetic patients (222, 355-358). It is unknown if, independendy of the hemodynamic effect, at an early stage of hypertension and before the initiation of a progressive decrease in renal function, a local decrease in angiotensin II (or increase in bradykinin) explains or direcdy participates in a so-called renoprotective effect (359). 

Lewis EJ, Hunsicker LG, Clarke WR et al. (2001) Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to Type 2 diabetes. New England journal of Medicine 345 851-860. 

Angiotensinogen ACE inhibitors regression of left ventricular hypertrophy, renoprotective effects, drug-induced cough Blood pressure reduction ... 

Lassnigg A, Donner E, Grubhofer G, et al. Lack of renoprotective effects of dopamine and furosemide during cardiac surgery. J Am Soc Nephrol 2000 11 97-104. 

TylickiL, Rutkowski P, Renke M, Rutkowski B. Renoprotective effect of small doses of losartan and enalapril in patients with primary glomerulonephritis. Short-term observation. Am J Nephrol 2002 22 356-362. 

Recently, cyclooxygenase-2 inhibitors have been shown to have proteinnria-lowering and renoprotective effects in animal models. If such benehcial effects are confirmed in humans, cyclooxygenase-2 inhibitors may become useful renoprotective agents for those patients whose low blood pressure preclude further use of drugs for ACE inhibition. ... 

Initial therapy choices for hypertension in diabetes mellitus usually include angiotensin-converting enzyme inhibitors or an angiotensin receptor blocker due to their well documented renoprotective effects. Currently, angiotensin receptor blockers have less robust data to support cardiovascular reduction compared to other therapeutic choices, yet the data that exists appears to be positive in patients with type 2 DM. Also, diuretics have shown superior results to an ACE inhibitor in the ALLHAT trial. The ADA currently recommends the use of any class (ACE inhibitors, angiotensin receptor blockers, /3-blockers, diuretics, or calcium channel blockers) of antihypertensive medication that has shown benefit in prevention of poor cardiovascular outcomes. Choice of monotherapy may not be important, as an average of two to three antihypertensive medications are needed to reach blood pressure goals. 

Angiotensin-converting enzyme (ACE) ACE inhibitors e.g., enalapiil) Renoprotective effects, hypotension, left ventricular mass reduction, cough... 

Yoshrmoto T, Naruse M, Nishikawa M, et al. Antihypertensive and vasculo- and renoprotective effects of pioglitazone in genetically obese diabetic rats. Am J Physiol. 1997 272(6) E989-E996. 

Intervention in the RAS System Additive Renoprotective Effect Independent of Blood Pressure ... 

Table 1. Evaluation of specific BP-independent renoprotective effects Possible strategies.

In conclusion, BP reduction independent from the class of drugs used is essential in conserving renal function. Detection of specific BP-independent renoprotective effects of ACE-I or ARB is difficult from a design point of view. There is, however, at least one well-designed randomized double-blind clinical trial clearly suggesting BP independence... 

In a recent randomized, nonblinded study in 68 nondiabetic patients, the renoprotective effects of ACE-1 (benazepril 1.25-5 mg daily or trandolapril... 

Rossing, K, SchjoedL KJ, Jensen, BR, Boomsma, F, Parving, HH Enhanced renoprotective effects of ultrahigh doses of irbesartan in patients with type 2 diabetes and microalbuminuria. Kidney Int. 68 1190-1198, 2005. 

Rossing, K, Jacobsen, P, Pietraszek, L, Parving, HH Renoprotective effects of adding angiotensin II receptor blocker to maximal recommended doses of ACE inhibitor in diabetic nephropathy a randomized... 

Forbes JM, 8oulis T, Thallas V, et al. Renoprotective effects of a novel inhibitor of advanced glycation. Diabetologia 2001 44 108-114. 

The elevated urinary protein excretion and plasma creatinine due to the induction of Heymann nephritis were significantly reduced by fucoidan from L. japonica by oral intubation. This indicated that fucoidan has a renoprotective effect on active Heymaim nephritis and is a promising therapeutic agent for nephritis (Zhang et ah, 2005). 

Morales E, Millet VG, Rojas-Rivera J, Huerta A, Gutierrez E, Gufierrez-Solis E, et al. Renoprotective effects of mineralocorficoid receptor blockers in patients with proteinuric kidney diseases. Nephrol Dial Transplant Official Publication of the European Dialysis and Transplant Association - European Renal Association 2013 28(2) 405-12. 

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