Prognostic value of plasma renin activity/concentration
Several studies have been published examining the association of renin with cardiovascular disease. In interpreting these results, it is important to consider the background medication, since these have a strong influence on renin levels and can obscure the results, but also the technique used to measure renin differs in the various studies. The first major prospective study on the association between renin and the incidence of cardiovascular disease has been conducted by Alderman et al. in 1991. They measured PRA and sodium excretion in 1,717 patients with an untreated systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥95 mmHg or on antihypertensive medication. Patients had not taken their antihypertensive drugs 4 weeks prior to the PRA and sodium measurements. Comparison of the high- versus low-renin group showed that high PRA was associated with increased risk for incident myocardial infarction even after adjustment for age, sex, race, cholesterol, smoking, glucose, blood pressure, and use of beta-blockers [
54]. Several years later, Meade et al. conducted a study in 803 untreated normotensive patients. In this cohort, however, the relationship between renin (here:ARC) and CV events could not be confirmed [
56]. A recent report from the Framingham Heart Study has shown an association of renin (here: PRA) with short-term all-cause mortality <3 years, but not long-term mortality or CV disease (myocardial infarction, unstable angina pectoris, stroke, or congestive heart failure). [
55] The relationship may have been obscured, however, by the use of various antihypertensive drugs, including ACEi, diuretics, and beta-blockers. Another study described patients with coronary artery disease and reported that high renin (PRA > 2,30 ng/ml/h) was associated with cardiac morbidity and mortality [
57]. In interpreting these epidemiological data, ANG II was generally thought to be the main culprit [
58]; however, in heart failure patients, high PRA was also associated with mortality in both patients on ACEi or ARB [
4,
53]. Part of the observed associations may be explained by ANG II and aldosterone breakthrough [
59,
60], but it is important notice that other mechanisms may play a role, such as direct effects of renin through the (P)RR.
This distinction is crucial in the development of new treatment for CV disease. Although the classical RAAS may (temporarily) be blocked by ACEi, ARB, and ARAs and has been shown to improve prognosis, the subsequent rise of renin levels is worrisome, considering it is associated with adverse prognosis. Unfortunately, the aforementioned studies by their observational design cannot answer the question whether renin is a risk factor or indicator reflecting neurohormonal activation due to compromised circulation. Hopefully, interventional studies with direct renin inhibitors and renin receptor blockers will provide the answer.
Renin in cardiorenal interaction
Heart failure (HF) is often complicated by decreased renal blood flow and a subsequent decrease in glomerular filtration rate (GFR) [
61,
62]. Decreased renal function is one of the strongest predictors of mortality in patients with advanced HF [
61] In these patients, RAAS is not only activated to maintain systemic circulatory volume, but mainly to maintain GFR [
63]. Initiation of RAAS blockade is therefore often associated with an initial decrease in GFR. Long-term RAAS activation, however, negatively influences renal function, among others through fluid and salt retention and subsequent increase in congestion [
62] This is supported by the bidirectional relationship that is observed between renin levels and renal function. In addition, ANG II exerts various potentially harmful effects including proliferative and profibrotic effects. Activation of RAAS may therefore lead to a downward spiral, which can potentially be stopped by RAAS blockade. The potential benefit of interfering in the RAAS is supported by the observation in the Val-Heft trial that double RAAS blockade in patients with heart failure is especially beneficial in patients with kidney disease [
64]. PRA and APRC often are increased in patients with HF and renal dysfunction [
61,
65]. Caution has to be taken, however, to extrapolate these results to all patients with kidney disease, since the ONTARGET and VALIANT trial showed harmful effects of double RAAS blockade in patients with resp. atherosclerotic vascular disease and left ventricular dysfunction directly after myocardial infarction [
66,
67]. Here, some RAAS activation may well be a necessary compensatory mechanism. Interesting to notice is that in contrast to patients with an estimated GFR (eGFR) < 60 ml/min/1,73 m
2, patients with proteinuria had decreased PRA levels.
The aforementioned trials however interfered downstream of ANG I and did not target renin activity or concentration, since heart failure and kidney disease are associated with increased renin levels, especially in the presence of ACEi or ARB. Targeting PRA may prove especially effective in these patients. The role of RAAS in cardiorenal interaction however is complex. According to the primary injury, as well as the stage of disease, activation can be either compensatory or harmful. Therapies targeting PRA or PRC may provide important additional evidence.
The (pro-) renin receptor in cardiorenal disease
Evidence regarding the role of the (P)RR in CV and kidney disease is slowly becoming available. Studies with transgenic animals have shown evidence that (P)RR might be related to CV and renal diseases. Rats with a ubiquitous, yet moderate overexpression of (P)RR develop proteinuria and progressive nephropathy, despite normal blood pressure, suggesting a direct pathological role of (P)RR in renal damage [
68]. Rat models with a strong overexpression of human (P)RR in vascular smooth muscle cells showed a progressive increase in systolic blood pressure and heart rate at 4 months of age, although kidney function remained normal [
69].
Mice that lack the gene encoding the (P)RR are not viable. Recently, mice were generated with cardiorestricted deletion of (P)RR; these mice died because of cardiomyocyte cell death due to acidification. This does not come as a complete surprise as the (P)RR not only binds renin and prorenin, but also exerts other functions, notably acting as a vacuolar ATPase and regulator of cellular pH [
70]. Furthermore, (P)RR also plays an important role in neural development through renin-independent mediation of wnt signaling [
71] Pharmacological inhibition of the (P)RR with a (P)RR-blocker could therefore have provided conclusive evidence on the role of the receptor in cardiac and renal disease. Development of a drug blocking the activation of (P)RR by renin proved to be very difficult, since structure–function studies and crystallographic data are lacking. Recently, a ‘handle region peptide’ (HRP) has been discovered, which allegedly blocks the (P)RR [
72]. Several studies have suggested that HRP may prevent and even reverse diabetic nephropathy in diabetic rodents and diminish cardiac fibrosis in stroke-prone spontaneously hypertensive rats [
73,
74]. However, other studies have shown less promising results: HRP did not show any beneficial effect in high-renin low-prorenin Goldblatt rats [
75] or mice overexpressing prorenin [
76]. The effectiveness of the HRP in blocking the prorenin receptor is questioned, since in vitro studies showed that prorenin binding to (P)RR was not prevented by HRP [
77]. In summary, although in the future, the (P)RR may provide a novel opportunity to treat CV and renal disease, and at this point, the exact function of the (P)RR in CV and kidney disease remains to be elucidated. In addition, caution has to be taken in blocking (P)RR, since it appears to exerts renin-independent effects beyond the cardiorenal system.
Renin blockade
As mentioned above, both ACEi and ARB increase renin levels due to the loss of negative feedback of ANG II on renin release. Despite the aforementioned clues that high PRA might play a role in the progression of cardiac disease in patients on RAAS blockade, conclusive evidence is missing. Directly blocking the active site of renin may provide important information. It was already in 1980 that the first studies were performed with a renin inhibitor [
78]; however, the effectiveness of this renin inhibitor was poor, mainly due to lack of specificity [
79]. Recently, an orally active renin inhibitor, aliskiren, has become commercially available, and several other direct renin inhibitors are in development. Numerous studies are now trying to establish the potentials for this treatment in CV and renal disease. Despite low bioavailability, aliskiren blocks the active site of renin and effectively lowers PRA [
80], thus providing very useful information on the role of PRA outside the classical RAAS pathway.
Since aliskiren blocks PRA, it acts upstream of ACEi, ARB of ARA and is believed to block the RAAS more completely. Its exact effects on ANG 1–7, ANG 1–9, ANG 1–5, ANG III, and ANG IV formation, however, have not been studied in detail. Aliskiren blocks the active site of renin and can thus block both renin and non-proteolitically activated prorenin. Therefore, it has the potential to block both circulating and tissue RAAS. This has been supported by the observation that aliskiren blocks tissue RAAS more effectively that ACEi and ARB [
81].
These assumptions have been supported by the observation that 3 months of aliskiren 150 mg once daily provided additional blood pressure lowering on top op of an ACEi, ARB, or diuretic [
82], and it reduced PRA, urinary aldosterone, and BNP on top of ‘optimal’ therapy in stable HF patients in the ALOFT trial [
83]. Furthermore, aliskiren reduced LV mass as much as Losartan, and the combination reduced LV mass slightly more, however not statistically significant in patients with hypertension and left ventricular hypertrophy [
84]. Unfortunately, the ASPIRE study did not show any improvement in echocardiographic measurements in patients with left ventricular dysfunction after myocardial infarction when treated with aliskiren on top of beta-blockers and ACEi or ARB [
85], neither did the ALOFT trial in stable HF patients. This may however be due to the short follow-up time.
Blocking PRA results in an increase in PRC. In diabetic TG(mRen-2)27 rats, aliskiren did not prevent renin binding of (pro-) renin to the (P)RR nor did it block the intracellular cascades, and therefore, the intracellular cascades may even increase due to higher PRC. Although an aliskiren-induced suppression of gene expression of (P)RR was observed in vivo, this was not observed in human mesangial cells in vitro. The most likely explanation is that in vivo high-(pro) renin levels inhibit (P)RR expression via negative feedback [
86]. The exact mechanism, however, remains to be elucidated, and whether the increased PRC results in harmful effects is still subject of debate [
87].
Several studies are now on the way evaluating the effects of aliskiren in patients with both systolic and diastolic heart failure. The Atmosphere [
88] is currently investigating the effects of aliskiren compared to and on top of Enalapril on morbidity and mortality in patients with systolic heart failure, and the ASTRONAUT study is investigating the effect of aliskiren in the acute HF setting [
89]. Studies on patients with diastolic heart failure are on their way as well. The evidence for a potential effect of renin blockade in diastolic heart failure is, however, scarce. Patients with diastolic heart failure tend to have a higher PRA than healthy controls, although not as high as patients with systolic HF [
90]; however, this may be due to concomitant medication. Moreover, ACEi and ARB have proven little benefit in these patients so far [
91‐
93]. The effects of direct renin inhibition remain to be investigated.
There is also some evidence that direct renin inhibition may improve renal function in patients with heart failure by improving effective renal plasma flow (ERPF). In a normotensive population, direct renin inhibition has been shown to have stronger beneficial effects on renal hemodynamics in comparison with ACEi [
94]. There was also an increase in ERPF observed in patients with diabetes type I treated with direct renin inhibitors [
95]. Whether these results can be achieved in patients with heart failure and decreased renal function is currently under investigation in the ARIANA-CHF-RD trial (clinicaltrials.gov id NCT00881439). As mentioned above, the reactive rise of PRC in patients on direct renin inhibition raises some concern. Its effects, however, are unknown, since medication specifically lowering TPRC is missing.
There are a few agents that in addition to other effects lower renin. First, beta-blockers have been proven beneficial in treatment of the entire spectrum of CV disease. Part of their beneficial effect is attributed to the decrease in TPRC and PRA as a consequence of inhibition of the beta1-adrenergic receptors in the JG cells [
96]. Indeed, several post hoc analyses of beta-blocker trials in patients with heart failure showed that the beta-blockers lower PRA [
97].
Another therapy aimed to lower PRA and/or TPRC is activation of the VDR. Several experimental studies show that the selective vitamin D receptor activator paricalcitol effectively reduces renin transcript levels and PRA in mice [
40,
98]. Furthermore, in Dahlt-salt sensitive rats [
99] and in Spontaneously Hypertensive Rats (SHR) [
100], paricalcitol treatment attenuated the development of hypertensive cardiomyopathy, which was ascribed at least in part due to lower renin levels. In rat model of nephropathy, paricalcitol lowered proteinuria associated with the inhibition of the RAAS [
101]. These promising experimental results have been backed-up by small-scale clinical observations. In small-scale clinical studies, administration of 1,25(OH)2D3 showed reductions in PRA, ANG II levels, BP, and myocardial hypertrophy [
41,
102]. Kong et al. also showed in a human pilot study in chronic hemodialysis patients that treatment with VDR activators lowered PRA in human subjects. The recently published VITAL study [
103] confirmed the antiproteinuric effects of paricalcitol in patients with CKD stage 3 and 4. The authors did not observe changes in aldosterone and PRA, but stated that the trial was not designed to measure effects on the RAAS. Currently, the “Study to Investigate the Effects of Vitamin D Administration on Plasma Renin Activity in Patients With Stable Chronic Heart Failure (Vit D-CHF)” trial investigates the effect of high-dose vitamin D on plasma renin activity in chronic heart failure patients (clinicaltrials.gov id: NCT01092130).
Finally, more experimental approaches like gene therapy with antisense oligos directed against renin are tested for their value to reduce renin levels [
104].