Real-world use of finerenone in patients with chronic kidney disease and type 2 diabetes based on large-scale clinical studies: FIDELIO-DKD and FIGARO-DKD.

IF 4.3 2区 医学 Q1 PERIPHERAL VASCULAR DISEASE
Atsuhisa Sato, Mitsuhiro Nishimoto
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引用次数: 0

Abstract

Finerenone is a new mineralocorticoid receptor antagonist that does not have a steroid skeleton, and in two large-scale clinical studies targeting patients with chronic kidney disease (CKD) complicated with type 2 diabetes (FIDELIO-DKD and FIGARO-DKD), it significantly reduced the composite endpoints due to the progression of renal disease, and the composite endpoints of cardiovascular disease. Recently, we published two databases summarizing how finerenone is used in clinical practice in Japan (FINEROD). In this paper, we examines how best to use finerenone to get the most out of its effects. The most important side effect of finerenone is hyperkalemia, and the risk of hyperkalemia increases as renal function declines. By starting treatment early when eGFR is maintained, it is expected that side effects will be reduced. Furthermore, the FIDELITY analysis (a pooled analysis of FIDELIO-DKD and FIGARO-DKD) has shown that the clinical effect is stronger when finerenone treatment is started at an early stage of CKD. The simultaneous use of RAS inhibitors (ACE inhibitor or ARB), finerenone, and SGLT2 inhibitors appears to be a promising treatment. Further, it is important to continue the medications of RAS inhibitors and MR antagonists as long as possible. To prevent hyperkalemia, the most reliable and safest method is to use a new oral potassium adsorbent. It is important to think of a new oral potassium adsorbent not as something that will lower serum potassium levels, but as something that will allow you to avoid discontinuing or increase the dose of RAS inhibitors or MR antagonists. Differences between steroidal and non-steroidal mineralocorticoid receptor (MR) antagonists. Mineralocorticoid receptors (MR) are present in epithelial tissues such as renal tubules and intestinal epithelium, as well as in non-epithelial tissues such as the brain, heart, and blood vessel walls. Although the MR itself is exactly the same in both tissues, its physiological actions are completely different. In epithelial tissues, cortisol is inactivated by the enzyme 11β-hydroxysteroid dehydrogenase type 2 (11 β-HSD2), and aldosterone selectively binds to the MR. On the other hand, in non-epithelial tissues, 11 β-HSD2 is almost nonexistent or is only weakly active, so that cortisol, which outnumbers it, binds to almost all the MR, and aldosterone binds to the very few remaining MR. Spironolactone, a representative MR antagonist with a steroid skeleton, has a high affinity for renal tubules, and concentrates there, where it is highly effective. Therefore, it is classified as a potassium-sparing diuretic. However, if it does not have a steroid skeleton, its affinity for epithelial and non-epithelial tissues is equal. In other words, its effect on epithelial tissues is relatively weak, and its effect on non-epithelial tissues is relatively strong. Finerenone does not cross the blood-brain barrier (BBB), and does not reach the central nervous system. The central MR, especially the periventricular MR, is strongly involved in hypertension, and esaxerenone, another nonsteroidal MR antagonist, which can cross the BBB although only to a small extent and reach the central nervous system, has a strong antihypertensive effect.

基于大规模临床研究的芬尼酮在慢性肾病和2型糖尿病患者中的实际应用:FIDELIO-DKD和FIGARO-DKD
非芬烯酮是一种新型的不具有类固醇骨架的矿皮质激素受体拮抗剂,在两项针对慢性肾脏疾病(CKD)合并2型糖尿病患者的大规模临床研究(FIDELIO-DKD和FIGARO-DKD)中,它显著降低了由于肾脏疾病进展导致的复合终点,以及心血管疾病的复合终点。最近,我们发表了两个数据库,总结了日本在临床实践中如何使用芬烯酮(FINEROD)。在本文中,我们研究了如何最好地利用细烯酮以最大限度地发挥其作用。芬尼酮最重要的副作用是高钾血症,高钾血症的风险随着肾功能下降而增加。在维持eGFR时尽早开始治疗,预期副作用将会减少。此外,FIDELITY分析(FIDELIO-DKD和FIGARO-DKD的汇总分析)表明,在CKD早期开始芬烯酮治疗的临床效果更强。同时使用RAS抑制剂(ACE抑制剂或ARB)、芬烯酮和SGLT2抑制剂似乎是一种有希望的治疗方法。此外,尽可能长时间地继续使用RAS抑制剂和MR拮抗剂也很重要。为了预防高钾血症,最可靠和最安全的方法是使用一种新的口服钾吸附剂。重要的是要考虑一种新的口服钾吸附剂不是降低血清钾水平,而是让你避免停止或增加RAS抑制剂或MR拮抗剂的剂量。甾体和非甾体矿物皮质激素受体(MR)拮抗剂的差异。矿化皮质激素受体(MR)存在于上皮组织,如肾小管和肠上皮,以及非上皮组织,如脑、心脏和血管壁。尽管MR本身在两种组织中完全相同,但其生理作用却完全不同。在上皮组织,皮质醇是由酶灭活11β-hydroxysteroid脱氢酶2型(11β-HSD2),和醛固酮选择性地结合,另一方面,在non-epithelial组织11β-HSD2几乎是不存在的或者仅仅是弱活跃,皮质醇,这恩典,绑定到几乎所有的先生,和醛固酮结合剩余很少安体舒通先生,先生代表拮抗剂类固醇骨架,对肾小管具有高度的亲和力,集中在那里,在那里它是非常有效的。因此,它被归类为保钾利尿剂。然而,如果它没有类固醇骨架,它对上皮组织和非上皮组织的亲和力是相等的。也就是说,它对上皮组织的作用相对较弱,而对非上皮组织的作用相对较强。芬烯酮不能穿过血脑屏障(BBB),也不能到达中枢神经系统。中枢MR,尤其是心室周围MR与高血压密切相关,而另一种非甾体MR拮抗剂依沙塞隆虽能小范围穿过血脑屏障,但能到达中枢神经系统,具有较强的降压作用。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Hypertension Research
Hypertension Research 医学-外周血管病
CiteScore
7.40
自引率
16.70%
发文量
249
审稿时长
3-8 weeks
期刊介绍: Hypertension Research is the official publication of the Japanese Society of Hypertension. The journal publishes papers reporting original clinical and experimental research that contribute to the advancement of knowledge in the field of hypertension and related cardiovascular diseases. The journal publishes Review Articles, Articles, Correspondence and Comments.
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