Кардиоренальные эффекты финеренона и его место в терапии хронической болезни почек у пациентов с сахарным диабетом 2-го типа - Журнал Терапевтический архив №3 Вопросы пульмонологии 2023

Кардиоренальные эффекты финеренона и его место в терапии хронической болезни почек у пациентов с сахарным диабетом 2-го типа

Салухов В.В., Шамхалова М.Ш., Дуганова А.В. Кардиоренальные эффекты финеренона и его место в терапии хронической болезни почек у пациентов с сахарным диабетом 2-го типа. Терапевтический архив. 2023;95(3):261–273. DOI: 10.26442/00403660.2023.03.202152

© ООО «КОНСИЛИУМ МЕДИКУМ», 2023 г.

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Salukhov VV, Shamkhalova MS, Duganova AV. Finerenone cardiorenal effects and its placement in treatment of chronic kidney disease in patients with type 2 diabetes mellitus: A review. Terapevticheskii Arkhiv (Ter. Arkh.). 2023;95(3):261–273. DOI: 10.26442/00403660.2023.03.202152

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Аннотация

Хроническая болезнь почек (ХБП) – одно из самых частых осложнений сахарного диабета (СД) и независимый фактор риска сердечно-сосудистых заболеваний. Несмотря на терапию ХБП у пациентов с СД 2-го типа (СД 2) в соответствии с действующими рекомендациями, риск развития у них почечной недостаточности и сердечно-сосудистых осложнений остается высоким. До настоящего времени средства лечения ХБП у пациентов с СД 2 не устраняли остаточный риск прогрессирования поражения почек, связанный с воспалением и фиброзом. В обзоре представлены результаты исследований FIDELIO-DKD, FIGARO-DKD и их объединенного анализа FIDELITY, посвященных оценке эффективности и безопасности селективного нестероидного антагониста минералокортикоидных рецепторов финеренона в лечении больных СД 2 с ХБП различных стадий. Рассмотрены современные патофизиологические аспекты гиперактивации минералокортикоидных рецепторов и особенности их блокады стероидными и нестероидными антагонистами минералокортикоидных рецепторов, различия их фармакологических эффектов, преимущества и нежелательные явления финеренона в рандомизированных исследованиях. Приведены вероятные механизмы ранних и отсроченных эффектов финеренона, которые реализовались в благотворном влиянии на сердечно-сосудистые и почечные исходы у больных СД 2 с ХБП. Предложен практический протокол инициации и титрации финеренона, нацеленный на уменьшение риска гиперкалиемии. Проанализированы современные рекомендации, касающиеся терапии ХБП у больных СД 2, определено место финеренона в нефропротективной комбинированной терапии.

Ключевые слова: сахарный диабет 2-го типа, хроническая болезнь почек, диабетическая болезнь почек, сердечно-сосудистый риск, воспаление, фиброз, антагонисты минералокортикоидных рецепторов, финеренон, спиронолактон, эплеренон

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Chronic kidney disease (CKD) is one of the most common complications of diabetes mellitus and an independent risk factor for cardiovascular disease. Despite guideline-directed therapy of CKD in patients with type 2 diabetes, the risk of renal failure and cardiovascular events still remains high. To date, current medications for CKD haven’t reduced enough the residual risk associated with inflammation and fibrosis in patients with type 2 diabetes. Here, in this review we present the results of FIDELIO-DKD, FIGARO-DKD trials and their pooled analysis FIDELITY, aimed to evaluate the effectiveness and safety of selective non-steroidal mineralocorticoid receptor antagonist finerenone in patients with type 2 diabetes with wide range stages of CKD. Modern pathophysiological aspects of mineralocorticoid receptor hyperactivation and features of their blockade by steroidal and nonsteroidal mineralocorticoid receptor antagonists are considered, differences in pharmacological effects between them are also discussed, finerenone benefits and its adverse events, demonstrated in randomized clinical trials are considered here. The probable mechanisms of early and delayed action of finerenone, which were realized in beneficial cardiovascular and renal outcomes in patients with type 2 diabetes with CKD, are presented here. Practical points for finerenone initiation and titration are indicated, aimed to minimize the hyperkalemia risk. Current guidelines for CKD treatment in patients with type 2 diabetes are analyzed, the finerenone placement in combined nephroprotective therapy is determined.

Keywords: type 2 diabetes mellitus, chronic kidney disease, diabetic kidney disease, cardiovascular risk, inflammation, fibrosis, mineralocorticoid receptor antagonists, finerenone, spironolactone, eplerenone

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23. Bakris GL, Agarwal R, Anker SD, et al; FIDELIO-DKD study investigators. Design and Baseline Characteristics of the Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease Trial. Am J Nephrol. 2019;50(5):333-44. DOI:10.1159/000503713
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1. Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int. 2022;102(5S):S1-127. DOI:10.1016/j.kint.2022.06.008
2. Fox CS, Matsushita K, Woodward M, et al. Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without diabetes: a meta-analysis. Lancet. 2012;380(9854):1662-73. DOI:10.1016/S0140-6736(12)61350-6
3. Clinical recommendations. Chronic kidney disease (CKD). Nephrology (Saint-Petersburg). 2021;25(5):10-82 (in Russian).
4. Shenoy SV, Nagaraju SP, Bhojaraja MV, et al. Sodium-glucose cotransporter-2 inhibitors and non-steroidal mineralocorticoid receptor antagonists: Ushering in a new era of nephroprotection beyond renin-angiotensin system blockade. Nephrology (Carlton). 2021;26(11):858-71. DOI:10.1111/nep.13917
5. Salukhov VV, Khalimov YuSh, Shustov SB, Popov SI. SGLT2 inhibitors and kidneys: mechanisms and main effects in diabetes mellitus patients. Diabetes mellitus. 2020;23(5):475-91 (in Russian). DOI:10.14341/DM12123
6. Shamkhalova MSh, Sklyanik IA, Shestakova MV. Nephroprotective potential of glucagon-like peptide-1 receptor agonists. Diabetes mellitus. 2020;23(1):56-64 (in Russian). DOI:10.14341/DM12286
7. Salukhov VV, Kovalevskaya EA. Rethinking the role of pioglitazone in modern diabetology as a cardiorenoprotective agent. Meditsinskiy sovet=Medical Council. 2022;10:10-21 (in Russian). DOI:10.21518/2079-701X-2022-16-10-10-21
8. Bolignano D, Palmer SC, Navaneethan SD, Strippoli GFM. Aldosterone antagonists for preventing the progression of chronic kidney disease. Cochrane Database Syst Rev. 2014;4:CD007004. DOI:10.1002/14651858.CD007004.pub3
9. Alicic RZ, Johnson EJ, Tuttle KR. Inflammatory Mechanisms as New Biomarkers and Therapeutic Targets for Diabetic Kidney Disease. Adv Chronic Kidney Dis. 2018;25(2):181-91. DOI:10.1053/j.ackd.2017.12.002
10. Epstein M. Aldosterone and Mineralocorticoid Receptor Signaling as Determinants of Cardiovascular and Renal Injury: From Hans Selye to the Present. Am J Nephrol. 2021;52(3):209-16. DOI:10.1159/000515622
11. Trubitsyna NP, Zaitseva NV, Severina AS, Shamkhalova MS. Chronic kidney disease in patients with type 2 diabetes: new targets of medicine action. Diabetes mellitus. 2022;25(5):492-8 (in Russian). DOI:10.14341/DM12944
12. Bertocchio JP, Warnock DG, Jaisser F. Mineralocorticoid receptor activation and blockade: an emerging paradigm in chronic kidney disease. Kidney Int. 2011;79(10):1051-60. DOI:10.1038/ki.2011.48
13. Lytvyn Y, Godoy LC, Scholtes RA, et al. Mineralocorticoid Antagonism and Diabetic Kidney Disease. Curr Diab Rep. 2019;19(1):4. DOI:10.1007/s11892-019-1123-8
14. Kolkhof P, Joseph A, Kintscher U. Nonsteroidal mineralocorticoid receptor antagonism for cardiovascular and renal disorders – New perspectives for combination therapy. Pharmacol Res. 2021;172:105859. DOI:10.1016/j.phrs.2021.105859
15. Barrera-Chimal J, Bonnard B, Jaisser F. Roles of Mineralocorticoid Receptors in Cardiovascular and Cardiorenal Diseases. Annu Rev Physiol. 2022;84:585-610.
DOI:10.1146/annurev-physiol-060821-013950
16. Lerma EV, Wilson DJ. Finerenone: a mineralocorticoid receptor antagonist for the treatment of chronic kidney disease associated with type 2 diabetes. Exp Rev Clin Pharmacol. 2022;15(5):501-13. DOI:10.1080/17512433.2022.2094770
17. Le Billan F, Perrot J, Carceller E, et al. Antagonistic effects of finerenone and spironolactone on the aldosterone-regulated transcriptome of human kidney cells. FASEB J. 2021;35(2):e21314. DOI:10.1096/fj.202002043RR
18. Abedini A, Wu J, Ma Z, et al. Revealing the antifibrotic mechanism of finerenone in the DOCA-salt nephropathy rat model using single nuclei and bulk transcriptomics. J Am Soc Nephrol. 2021;32:765
19. González-Blázquez R, Somoza B, Gil-Ortega M, et al. Finerenone Attenuates Endothelial Dysfunction and Albuminuria in a Chronic Kidney Disease Model by a Reduction in Oxidative Stress. Front Pharmacol. 2018;9:1131. DOI:10.3389/fphar.2018.01131
20. Alexandrou ME, Theodorakopoulou MP, Sarafidis PA. Role of Mineralocorticoid Receptor Antagonists in Diabetic Kidney Disease. Kidney Dial. 2022;2(2):163-82. DOI:10.3390/kidneydial2020019
21. Grune J, Beyhoff N, Smeir E, et al. Selective Mineralocorticoid Receptor Cofactor Modulation as Molecular Basis for Finerenone's Antifibrotic Activity. Hypertension. 2018;71(4):599-608. DOI:10.1161/HYPERTENSIONAHA.117.10360
22. Bakris GL, Agarwal R, Anker SD, et al. Effect of finerenone on chronic kidney disease outcomes in type 2 diabetes. N Engl J Med. 2020;383(23):2219-29. DOI:10.1056/NEJMoa2025845
23. Bakris GL, Agarwal R, Anker SD, et al; FIDELIO-DKD study investigators. Design and Baseline Characteristics of the Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease Trial. Am J Nephrol. 2019;50(5):333-44. DOI:10.1159/000503713
24. Filippatos G, Bakris GL, Pitt B, et al; FIDELIO-DKD Investigators. Finerenone Reduces New-Onset Atrial Fibrillation in Patients With Chronic Kidney Disease and Type 2 Diabetes. J Am Coll Cardiol. 2021;78(2):142-52. DOI:10.1016/j.jacc.2021.04.079
25. Leon SJ, Tangri N. Balancing Hyperkalemia Risks with Clinical Benefits of Renin-Angiotensin-Aldosterone Inhibitors/Mineralocorticoid Receptor Antagonists Blockade: It's Apples and Oranges. Kidney360. 2022;3(8):1442-4. DOI:10.34067/KID.0000952022
26. Pitt B, Filippatos G, Agarwal R, et al; FIGARO-DKD Investigators. Cardiovascular Events with Finerenone in Kidney Disease and Type 2 Diabetes. N Engl J Med. 2021;385(24):2252-63. DOI:10.1056/NEJMoa2110956
27. Ruilope LM, Agarwal R, Anker SD, et al; FIGARO-DKD study investigators. Design and Baseline Characteristics of the Finerenone in Reducing Cardiovascular Mortality and Morbidity in Diabetic Kidney Disease Trial. Am J Nephrol. 2019;50(5):345-56. DOI:10.1159/000503712
28. Ruilope LM, Pitt B, Anker SD, et al. Kidney outcomes with finerenone: An analysis from the FIGARO-DKD study. Nephrol Dial Transplant. 2023;38(2):372-83. DOI:10.1093/ndt/gfac157
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Авторы

В.В. Салухов*1, М.Ш. Шамхалова2, А.В. Дуганова1

1 ФГБВОУ ВО «Военно-медицинская академия им. С.М. Кирова» Минобороны России, Санкт-Петербург, Россия;
2 ФГБУ «Национальный медицинский исследовательский центр эндокринологии» Минздрава России, Москва, Россия
*vlasaluk@yandex.ru

________________________________________________

Vladimir V. Salukhov*1, Minara S. Shamkhalova2, Alla V. Duganova1

1 Kirov Military Medical Academy, Saint Petersburg, Russia;
2 Endocrinology Research Centre, Moscow, Russia
*vlasaluk@yandex.ru

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