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Verapamil and Losartan Provide Renal Protection Against ESWL-Induced Renal Injury
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This study sought to determine whether pharmacologic agents or antioxidants confer protection against renal injury associated with extracorporeal shockwave lithotripsy (ESWL). A total of 160 patients were randomized to control, selenium, losartan, or verapamil. Urine markers of renal injury and renal perfusion were measured using dynamic contrast-enhanced MRI imaging following ESWL. Investigators found improvement in the degree of albuminuria among patients receiving losartan and improvement in renal perfusion among patients with ureteral obstruction receiving either losartan or verapamil.
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These data suggest that there may be a role for pharmacologic prophylaxis before ESWL. Whether observed improvements in albuminuria or renal perfusion translate into clinical improvements remains unknown.
– Matthew Resnick, MD
abstract
This abstract is available on the publisher's site.
Access this abstract nowOBJECTIVE
To evaluate the protective effects of selenium with vitamins A, C and E (selenium ACE, i.e. antioxidants), verapamil (calcium channel blocker), and losartan (angiotensin receptor blocker) against extracorporeal shockwave lithotripsy (ESWL)-induced renal injury.
PATIENTS AND METHODS
A randomised controlled trial was conducted between August 2012 and February 2015. Inclusion criteria were adult patients with a single renal stone (<2 cm) suitable for ESWL. Patients with diabetes, hypertension, congenital renal anomalies, moderate or marked hydronephrosis, or preoperative albuminuria (>300 mg/L) were excluded. ESWL was performed using the electromagnetic DoLiS lithotripter. Eligible patients were randomised into one of four groups using sealed closed envelopes: Group1, control; Group 2, selenium ACE; Group 3, losartan; and Group 4, verapamil. Albuminuria and urinary neutrophil gelatinase-associated lipocalin (uNGAL) were estimated after 2-4 h and 1 week after ESWL. The primary outcome was differences between albuminuria and uNGAL. Dynamic contrast-enhanced magnetic resonance imaging was performed before ESWL, and at 2-4 h and 1 week after ESWL to compare changes in renal perfusion.
RESULTS
Of 329 patients assessed for eligibility, the final analysis comprised 160 patients (40 in each group). Losartan was the only medication that showed significantly lower levels of albuminuria after 1 week (P < 0.001). For perfusion changes, there was a statistically significant decrease in the renal perfusion in patients with obstructed kidneys in comparison to before ESWL (P = 0.003). These significant changes were present in the control or antioxidant group, whilst in the losartan and verapamil groups renal perfusion was not significantly decreased.
CONCLUSIONS
Losartan was found to protect the kidney against ESWL-induced renal injury by significantly decreasing post-ESWL albuminuria. Verapamil and losartan maintained renal perfusion in patients with post-ESWL renal obstruction.
Additional Info
A Randomised Controlled Trial Evaluating Renal Protective Effects of Selenium With Vitamins A, C, E, Verapamil, and Losartan Against Extracorporeal Shockwave Lithotripsy-Induced Renal Injury
BJU Int 2017 Jan 01;119(1)142-147, AR El-Nahas, MM Elsaadany, DE Taha, AM Elshal, MA El-Ghar, AM Ismail, EA Elsawy, HH Saleh, EW Wafa, A Awadalla, TS Barakat, KZ SheirFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Various medications have been tested to evaluate for peri-procedural protective effects during shock wave lithotripsy (SWL), with this study now adding new medications to the list of potential treatments. The current study demonstrates a reduction in urinary inflammatory markers with the use of losartan, although this trial only started administration of the study medication a few hours prior to the procedure. Although one would expect larger differences with more patients and a longer pre-procedural treatment course, we would caution against making treatment decisions based on this study alone. While losartan may be a feasible reno-protective medication during SWL, additional comparative studies are needed to determine if this medication is the strongest contender.