Enfermedad renal diabética: pilares en el tratamiento / Diabetic kidney disease: pillars in treatment

Introducción: La diabetes mellitus (DM) es una enfermedad crónica inflamatoria muy frecuente y por ende una de las emergencias sanitarias mundiales de más rápido crecimiento en las últimas décadas. Hay tres ejes que impactan en la progresión del compromiso renal del paciente diabético. El eje hemodinámico, metabólico e inflamatorio. Resaltamos la importancia del componente inflamatorio como actor protagónico en el desarrollo de la Enfermedad renal diabética (ERD). El manejo del paciente con ERD debe ser holístico, con tres objetivos claros: buen control metabólico, disminuir progresión de la enfermedad renal y disminuir los desenlaces cardiovasculares adversos. Actualmente además de las intervenciones no farmacológicas, el control de los factores de riesgo, el uso de los IECAS/ARA II hay nuevos pilares en el tratamiento de la ERD. Objetivos: El objetivo de esta comunicación es revisar los nuevos pilares en el manejo de la ERD. En la revisión bibliográfica que se hizo, encontramos que hay tres nuevos pilares en el tratamiento. Los inhibidores SGLT-2, los agonistas del receptor GLP-1 y por último finerenona, que es un antagonista selectivo no esteroideo del receptor mineralocorticoide (ARM), no es un antidiabético. Con estas nuevas terapias el manejo actual de estos pacientes ha cambiado considerablemente. Conclusión: Hay nuevos pilares en el tratamiento de la ERD. Los inhibidores SGLT-2, los Agonistas del receptor GLP-1 y el uso de ARM como finerenona, que nos brindan beneficios cardio­renales y que hacen que hoy en día el tratamiento de la ERD tenga un mejor panorama.

Introduction: Diabetes mellitus (DM) is a very common chronic inflammatory disease and finally one of the fastest-growing global health emergencies in recent decades. Three axes impact the progression of renal compromise in diabetic patients. The hemodynamic, metabolic, and inflammatory axis. We highlight the importance of the inflammatory component as a leading actor in developing Diabetic Kidney Disease (DKD). The management of the patient with CKD must be holistic, with three clear objectives: reasonable metabolic control, slowing the progression of kidney disease, and reducing adverse cardiovascular outcomes. Currently, in addition to non-pharmacological interventions, the control of risk factors, and the use of ACE inhibitors/ARA II, there are new pillars in the treatment of CKD. Objectives: The objective of this communication is to review the new pillars in the management of DKD. In the bibliographic review that was carried out, we found that there are three new pillars in the treatment. SGLT-2 inhibitors, GLP-1 receptor agonists, and finally finerenone, which is a selective non-steroidal antagonist of the mineralocorticoid receptor (MRA), not an antidiabetic. With these new therapies, the current management of these patients has changed considerably. Conclusion: There are new pillars in the treatment of DKD. The SGLT-2 inhibitors, the GLP-1 receptor agonists, and the use of MRAs such as finerenone provide us with cardio-renal benefits and which today make the treatment of CKD have a better outlook.

Nueva evidencia en el tratamiento de la enfermedad renal diabética: ¿qué aporta la finerenona?

Contexto: la enfermedad renal diabética (ERD) es la primera causa a nivel mundial de enfermedad renal crónica (ERC) e impacta directamente en el riesgo cardiovascular y mortalidad de los pacientes con diabetes mellitus (DM). La finerenona, un antagonista selectivo del receptor mineralocorticoide (ARM), ha sido descrito en diversos estudios recientes como un fármaco que contribuye a la reducción de la progresión de la ERD y la disminución del riesgo cardiovascular, con un adecuado perfil de seguridad. Objetivo: realizar una revisión de la literatura sobre el impacto de la finerenona en la progresión del daño renal y el riesgo cardiovascular en los pacientes con ERD. Metodología: se realizó una búsqueda sistemática en diversas fuentes: PubMed (Medline, Biblioteca del Congreso de los Estados Unidos), Science Direct, Scopus, Embase y Lilacs; la búsqueda fue restringida a referencias en idioma español e inglés, sin límites en la fecha de publicación. Se utilizaron las siguientes palabras clave en el idioma inglés: diabetic renal disease, chronic kidney disease, diabetes mellitus, spironolactone, eplerenone, finerenone, mineralocorticoid receptor antagonist y sus correspondientes versiones en español. Resultados: Las referencias encontradas en la búsqueda fueron revisadas entre los diferentes autores para, posteriormente, proceder a realizar la elaboración del documento. Conclusiones: la finerenona es un medicamento que brinda cardio y nefroprotección en pacientes con ERD de fenotipo albuminúrico.

Background: Diabetic kidney disease (DKD) is the leading cause of chronic kidney disease (CKD) worldwide and has a direct impact on cardiovascular risk and mortality in patients with diabetes mellitus (DM). Finerenone, a selective mineralocorticoid receptor (MRA) antagonist, has been described in several recent studies as a drug that contributes to slowing the progression of CKD and reducing cardiovascular risk, with an adequate safety profile. Purpose: To carry out a review of the literature on the impact of finerenone on the progression of renal damage and cardiovascular risk in patients with DKD. Methodology: A systematic search were carried out in various sources: PubMed (Medline, United States Library of Congress), Science Direct, Scopus, Embase and Lilacs; the search was restricted to references in Spanish and English, with no limits on publication date. The following keywords in the English language were used: diabetic renal disease, chronic kidney disease, diabetes mellitus, spironolactone, eplerenone, finerenone, mineralocorticoid receptor antagonist and their corresponding Spanish versions. Results: The references found in the search were reviewed among the different authors to subsequently proceed to prepare the document. Conclusions: Finerenone is a drug that provides cardio and nephroprotection in patients with DKD albuminuric phenotype.

New progress in research and application of fenneridone / 中国临床药理学与治疗学

Aldosterone is a mineralocorticoid hormone produced by the adrenal cortex, which acts on receptors in the distal and collecting tubules of the nephron, causing reabsorption of sodium and secretion of potassium. Aldosterone can promote inflammatory response and lead to myocardial remodeling and fibrosis. Aldosterone acts through mineralocorticoid receptor (MR), which is mainly expressed in heart, kidney and blood vessels. Excessive activation of MR can cause endothelial dysfunction, fibrinolysis disorder, oxidative stress, cardiovascular and renal fibrosis, and eventually lead to organ injury, dysfunction and even organ failure. Mineralocorticoid receptor antagonist (MRA) can achieve cardiorenal protection by inhibiting inflammation and fibrosis caused by MR activation. The novel nonsteroidal MRA fenneridone can effectively block MR with its high selectivity and bring definite cardiac and renal protective effects.

Progress of pharmacotherapy for heart failure / 中国临床药理学与治疗学

Heart failure is the terminal stage of all kinds of heart diseases. Despite the use of a variety of traditional drug standard treatment, the prognosis is still not ideal, and there is an urgent need for the update and improvement of new drugs and treatment methods. In recent years, angiotensin receptor-enkephalase inhibitors (Sacubitril/Valsartan), sodium-glucose cotransporter 2 inhibitors (SGLT-2i), soluble guanoside cyclase agonists (Vericiguat) and myocardial myosin activators omecamtiv mecarbil have been developed successively. SGLT2 inhibitors can improve ventricular load, reduce fibrosis and affect myocardial metabolism. sGC agonists play an anti-heart failure role by enhancing l-ARg-No-SGC-CGMP signaling pathway, improving myocardial and vascular function, reversing ventricular hypertrophy and fibrosis, slowing ventricular remodeling, and reducing ventricular afterload through systemic and pulmonary vasodilation. In addition, fineridone, a novel salt corticosteroid receptor antagonist, has also been reported in clinical studies in the field of heart failure. Therefore, it is the direction and hope for the development of heart failure in the future to select appropriate drugs for different types of patients with heart failure and carry out individualized treatment according to the optimized process of heart failure.

Research progress of finerenone in the treatment of type 2 diabetes mellitus complicated with chronic kidney disease / 中国临床药理学与治疗学

Finerenone is a new non-steroidal mineralocorticoid receptor antagonists, which can prevent and treat type 2 diabetes mellitus complicated with chronic kidney disease through antioxidant, anti-inflammatory and anti-fibrosis effects, and has a significant cardiovascular protection effect. Compared with traditional mineralocorticoid receptor antagonists, finerenone has a higher selectivity. In this review, the basic introduction, basic research, clinical research and limitations of finerenone were reviewed in order to provide more ideas and options for the treatment of type 2 diabetes mellitus complicated with chronic kidney disease.