IU Indianapolis ScholarWorks :: Browsing by Author "Georgianos, Panagiotis I."

Browsing by Author "Georgianos, Panagiotis I."

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Advances in the area of cardiorenal medicine: clinical research highlights from selected papers published in NDT
(Oxford University Press, 2022) Georgianos, Panagiotis I.; Agarwal, Rajiv; Medicine, School of Medicine
Ambulatory Blood Pressure Reduction With SGLT-2 Inhibitors: Dose-Response Meta-analysis and Comparative Evaluation With Low-Dose Hydrochlorothiazide
(American Diabetes Association, 2019-04) Georgianos, Panagiotis I.; Agarwal, Rajiv; Medicine, School of Medicine
Objective: Sodium-glucose cotransporter (SGLT)-2 inhibitors lower clinic and ambulatory blood pressure (BP), possibly through their natriuretic action. However, it remains unclear whether this BP-lowering effect is dose dependent and different from that of low-dose hydrochlorothiazide. The purpose of this meta-analysis was to quantify the association of the dose with response of ambulatory BP to SGLT-2 inhibition and to provide comparative evaluation with low-dose hydrochlorothiazide. Research design and methods: PubMed/MEDLINE, Embase, and Cochrane database of clinical trials from inception of each database through 22 August 2018. Randomized controlled trials (RCTs) reporting treatment effects of SGLT-2 inhibitors on ambulatory BP. We extracted data on the mean difference between the active treatment and placebo groups in change from baseline (CFB) of ambulatory systolic and diastolic BP. Results: We identified seven RCTs (involving 2,381 participants) comparing SGLT-2 inhibitors with placebo. Of these, two RCTs included low-dose hydrochlorothiazide as active comparator. CFB in 24-h systolic BP between SGLT-2 inhibitor and placebo groups was -3.62 mmHg (95% CI -4.29, -2.94) and in diastolic BP was -1.70 mmHg (95% CI -2.13, -1.26). BP lowering with SGLT-2 inhibition was more potent during daytime than during nighttime. The CFB in ambulatory BP was comparable between low-dose and high-dose subgroups and was similar to that for low-dose hydrochlorothiazide. Eligible RCTs did not evaluate cardiovascular outcomes/mortality. Conclusions: This meta-analysis shows that SGLT-2 inhibitors provoke an average reduction of systolic/diastolic BP 3.62/1.70 mmHg in 24-h ambulatory BP. This BP-lowering effect remains unmodified regardless of the dose of SGLT-2 inhibitor and is comparable with BP-lowering efficacy of low-dose hydrochlorothiazide.
Ambulatory BP Phenotypes and Their Association with Target Organ Damage and Clinical Outcomes in CKD
(American Society of Nephrology, 2020-04-07) Georgianos, Panagiotis I.; Agarwal, Rajiv; Medicine, School of Medicine
Assessment and Management of Hypertension among Patients on Peritoneal Dialysis
(American Society of Nephrology., 2019-02-07) Vaios, Vasilios; Georgianos, Panagiotis I.; Liakopoulos, Vassilios; Agarwal, Rajiv; Medicine, School of Medicine
Approximately 7%-10% of patients with ESKD worldwide undergo peritoneal dialysis (PD) as kidney replacement therapy. The continuous nature of this dialytic modality and the absence of acute shifts in pressure and volume parameters is an important differentiation between PD and in-center hemodialysis. However, the burden of hypertension and prognostic association of BP with mortality follow comparable patterns in both modalities. Although management of hypertension uses similar therapeutic principles, long-term preservation of residual diuresis and longevity of peritoneal membrane function require particular attention in the prescription of the appropriate dialysis regimen among those on PD. Dietary sodium restriction, appropriate use of icodextrin, and limited exposure of peritoneal membrane to bioincompatible solutions, as well as adaptation of the PD regimen to the peritoneal transport characteristics, are first-line therapeutic strategies to achieve adequate volume control with a potential long-term benefit on technique survival. Antihypertensive drug therapy is a second-line therapeutic approach, used when BP remains unresponsive to the above volume management strategies. In this article, we review the available evidence on epidemiology, diagnosis, and treatment of hypertension among patients on PD and discuss similarities and differences between PD and in-center hemodialysis. We conclude with a call for randomized trials aiming to elucidate several areas of uncertainty in management of hypertension in the PD population.
Blood pressure control in conventional hemodialysis
(Wiley, 2018-11) Georgianos, Panagiotis I.; Agarwal, Rajiv; Medicine, School of Medicine
Hypertension among patients on hemodialysis is common, difficult to diagnose and often inadequately controlled. Although specific blood pressure (BP) targets in this particular population are not yet established, meta-analyses of randomized trials showed that deliberate BP-lowering with antihypertensive drugs improves clinical outcomes in hemodialysis patients. BP-lowering in these individuals should initially utilize nonpharmacological strategies aiming to control sodium and volume overload. Accordingly, restricting dietary sodium intake, eliminating intradialytic sodium gain via individualized dialysate sodium prescription, optimally assessing and managing dry-weight and providing a sufficient duration of dialysis are first-line treatment considerations to control BP. If BP remains uncontrolled despite the adequate management of volume, antihypertensive therapy is the next consideration. Contrary to nonhemodialysis populations, emerging clinical-trial evidence suggests that among those on hemodialysis, β-blockers are more effective than agents blocking the renin-angiotensin-system (RAS) in reducing BP levels and protecting from serious adverse cardiovascular complications. Accordingly, β-blockade is our first-line approach in pharmacotherapy of hypertension. Long-acting calcium-channel-blockers and RAS-blockers are our next considerations, taking into account the comorbidities and the overall risk profile of each individual patient. Additional research efforts, mainly randomized trials, are clearly warranted in order to elucidate aspects of management that remain elusive in hypertensive dialysis patients.
Blood pressure in hemodialysis: targets?
(Wolters Kluwer, 2017-11) Georgianos, Panagiotis I.; Agarwal, Rajiv; Medicine, School of Medicine
Purpose of review In the absence of ‘hard’ clinical-trial evidence to define optimal blood pressure (BP) targets and validate different BP measurement techniques, management of hypertension in hemodialysis is based on expert opinions. In this review, we provide a comparative evaluation of out-of-dialysis BP monitoring versus dialysis-unit BP recordings in diagnosing hypertension, guiding its management and prognosticating mortality risk. Recent findings Owing to their high variability and poor reproducibility, predialysis and postdialysis BP recordings provide inaccurate reflection of the actual BP load outside of dialysis. Contrary to the reverse association of peridialytic BP with mortality, elevated home and ambulatory BP provides a direct mortality signal. Out-of-dialysis BP monitoring, even when done in the clinic, is a reliable approach to manage hypertension in the dialysis unit. Whenever none of these measures are available, median intradialytic SBP can provide a better estimate of interdialytic BP levels compared with peridialytic BP measurements. Summary Although out-of-dialysis BP monitoring have better diagnostic accuracy and prognostic validity, randomized trials are needed to ascertain BP targets for managing hypertension in hemodialysis patients.
Cardiorenal protection in advanced chronic kidney disease: research highlights from landmark papers published in Nephrology Dialysis Transplantation during 2018
(Oxford Academic, 2020-03) Georgianos, Panagiotis I.; Agarwal, Rajiv; Medicine, School of Medicine
Chronic kidney disease (CKD) and cardiovascular disease go hand-in-hand and an inverse, strong and independent relationship exists between estimated glomerular filtration rate (eGFR) and the risk of cardiovascular morbidity and mortality [1, 2]. In fact, the mortality hazard attributable to CKD is even higher than the mortality risk arising from diabetes mellitus (DM) and comparable with that of established coronary artery disease, thus CKD is considered a coronary disease equivalent [3]. The burden of cardiovascular disease, particularly due to heart failure or the development of cardiac arrhythmias, is multiplied in those with end-stage renal disease (ESRD) on chronic dialysis. It has to be noted, however, that clinical trial evidence to guide the management of cardiovascular disease in these high-risk patients is scant [4]. This lack of evidence is at least partly attributable to the fact that advanced CKD/ESRD was systematically an exclusion criterion in the majority of large outcome trials that have demonstrated the safety and efficacy of several cardioprotective therapies in earlier stages of CKD or in the general population [4]. In this editorial we discuss therapeutic strategies to optimize cardiovascular and/or renal protection in advanced CKD based on research highlights from ‘landmark’ papers published in Nephrology Dialysis Transplantation during 2018. We provide ‘take-home messages’ from these studies and directions for future research in these important areas.
Con: Nutritional vitaminDreplacement in chronic kidney disease and end-stage renal disease
(Oxford, 2016) Agarwal, Rajiv; Georgianos, Panagiotis I.; Department of Medicine, IU School of Medicine
Insufficiency of 25-hydroxyvitamin D [25(OH)D] is highly prevalent among patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD) and is a critical component in the pathogenesis of secondary hyperparathyroidism. Accordingly, current National Kidney Foundation—Kidney Disease Outcomes Quality Initiative and Kidney Disease: Improving Global Outcomes guidelines recommend the correction of hypovitaminosis D through nutritional vitamin D replacement as a first-step therapeutic approach targeting secondary hyperparathyroidism. In this Polar Views debate, we summarize the existing evidence, aiming to defend the position that nutritional vitamin D replacement is not evidence-based and should not be applied to patients with CKD. This position is supported by the following: (i) our meta-analysis of randomized controlled trials shows that whereas nutritional vitamin D significantly increases serum 25(OH)D levels relative to placebo, there is no evidence either in predialysis CKD or in ESRD that parathyroid hormone (PTH) is lowered; (ii) on the other hand, in randomized head-to-head comparisons, nutritional vitamin D is shown to be inferior to activated vitamin D analogs in reducing PTH levels; (iii) nutritional vitamin D is reported to exert minimal to no beneficial actions in a series of surrogate risk factors, including aortic stiffness, left ventricular mass index (LVMI), epoetin utilization and immune function among others; and (iv) there is no evidence to support a benefit of nutritional vitamin D on survival and other ‘hard’ clinical outcomes. Whereas nutritional vitamin D replacement may restore 25(OH)D concentration to near normal, the real target of treating vitamin D insufficiency is to treat secondary hyperparathyroidism, which is untouched by nutritional vitamin D. Furthermore, the pleotropic benefits of nutritional vitamin D remain to be proven. Thus, there is little, if any, benefit of nutritional vitamin D replacement in CKD.
Effect of lisinopril and atenolol on aortic stiffness in patients on hemodialysis
(American Society of Nephrology (ASN), 2015-04-07) Georgianos, Panagiotis I.; Agarwal, Rajiv; Department of Medicine, IU School of Medicine
BACKGROUND AND OBJECTIVES: Whether improvements in arterial compliance with BP lowering are because of BP reduction alone or if pleiotropic effects of antihypertensive agents contribute remains unclear. It was hypothesized that, among patients on hemodialysis, compared with a β-blocker (atenolol), a lisinopril-based therapy will better reduce arterial stiffness. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Among 200 participants of the Hypertension in Hemodialysis Patients Treated with Atenolol or Lisinopril Trial, 179 patients with valid assessment of aortic pulse wave velocity at baseline (89 patients randomly assigned to open-label lisinopril and 90 patients randomly assigned to atenolol three times a week after dialysis) were included in the secondary analysis. Among them, 109 patients had a valid pulse wave velocity measurement at 6 months. Monthly measured home BP was targeted to <140/90 mmHg by addition of antihypertensive drugs and dry weight adjustment. The difference between drugs in percentage change of aortic pulse wave velocity from baseline to 6 months was analyzed. RESULTS: Contrary to the hypothesis, atenolol-based treatment induced greater reduction in aortic pulse wave velocity relative to lisinopril (between drug difference, 14.8%; 95% confidence interval, 1.5% to 28.5%; P=0.03). Reduction in 44-hour ambulatory systolic and diastolic BP was no different between groups (median [25th, 75th percentile]; atenolol: -21.5 [-37.7, -7.6] versus lisinopril: -15.8 [-28.8, -1.5] mmHg; P=0.27 for systolic BP; -14.1 [-22.6, -5.3] versus -10.9 [-18.4, -0.9] mmHg, respectively; P=0.30 for diastolic BP). Between-drug difference in change of aortic pulse wave velocity persisted after adjustments for age, sex, race, other cardiovascular risk factors, and baseline ambulatory systolic BP but disappeared after adjustment for change in ambulatory systolic BP (11.8%; 95% confidence interval, -2.3% to 25.9%; P=0.10). CONCLUSIONS: Among patients on dialysis, atenolol was superior in improving arterial stiffness. However, differences between atenolol and lisinopril in improving aortic stiffness among patients on hemodialysis may be explained by BP-lowering effects of drugs.
Every obstruction does not need a stent: an important lesson from the ISCHEMIA-CKD trial for kidney-transplant surgeons
(Oxford University Press, 2021-01-01) Georgianos, Panagiotis I.; Agarwal, Rajiv; Medicine, School of Medicine

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