Patient characteristics and initiation of mineralocorticoid receptor antagonists in patients with chronic kidney disease in routine clinical practice in the US: a retrospective cohort study.

BACKGROUND: Steroidal mineralocorticoid receptor antagonists (MRAs) are recommended for the treatment of heart failure (HF) and resistant hypertension, both common comorbidities in patients with diabetes and chronic kidney disease (CKD). This study explored the clinical characteristics of, and steroidal MRA use in, patients with CKD with and without type 2 diabetes mellitus (T2D) and/or HF. METHODS: This retrospective cohort study used PharMetrics Plus US claims database data (October 2009-September 2014) to identify two patient populations aged ≥18 years with a first diagnosis of CKD or a first prescription for steroidal MRAs. Demographic characteristics, comorbidities, clinical events, medication use and healthcare costs were reported by population and stratified by diagnosis: CKD, CKD + T2D (DKD), CKD + HF and DKD + HF. The CKD population cohorts were further stratified by steroidal MRA treatment duration (no MRAs, < 6 and ≥ 6 months' treatment). RESULTS: The CKD and MRA populations comprised 229,004 patients and 5899 patients, respectively. Median age and the proportion of men were similar in the CKD and MRA populations across disease cohorts. Disease burden increased across the cohorts as comorbidity and clinical event incidences increased. Hypertension was reported in 70-92% of patients, irrespective of disease cohort or population. In the CKD population, MRA use was low but increased with disease burden: CKD, 1.2%; DKD, 1.8%; CKD + HF, 6.5%; and DKD + HF, 6.6%. Moreover, MRA users presented with higher rates of comorbidities and medication use, and higher healthcare costs than MRA non-users. Longer MRA treatment duration was associated with reduced polypharmacy, lower event rates and lower healthcare costs. In the MRA population, patients almost exclusively received spironolactone (≥ 96%; median dose across all groups 25 mg; one-year persistence, ≤ 43%); up to 16% of patients had end-stage renal disease at baseline despite steroidal MRAs being contraindicated. CONCLUSIONS: Steroidal MRA use was low across all cohorts, but increased with disease severity, driven particularly by HF. Steroidal MRAs were used in patients with advanced CKD, despite being contraindicated. The persistent morbidity and clinical event rates in CKD and DKD patients highlight the disease burden and the need for treatments that effectively target both cardio-vascular and kidney-related events.

Post-transcriptional control of executioner caspases by RNA-binding proteins.

Caspases are key components of apoptotic pathways. Regulation of caspases occurs at several levels, including transcription, proteolytic processing, inhibition of enzymatic function, and protein degradation. In contrast, little is known about the extent of post-transcriptional control of caspases. Here, we describe four conserved RNA-binding proteins (RBPs)-PUF-8, MEX-3, GLD-1, and CGH-1-that sequentially repress the CED-3 caspase in distinct regions of the Caenorhabditis elegans germline. We demonstrate that GLD-1 represses ced-3 mRNA translation via two binding sites in its 3' untranslated region (UTR), thereby ensuring a dual control of unwanted cell death: at the level of p53/CEP-1 and at the executioner caspase level. Moreover, we identified seven RBPs that regulate human caspase-3 expression and/or activation, including human PUF-8, GLD-1, and CGH-1 homologs PUM1, QKI, and DDX6. Given the presence of unusually long executioner caspase 3' UTRs in many metazoans, translational control of executioner caspases by RBPs might be a strategy used widely across the animal kingdom to control apoptosis.