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El-Nahas AR et al, 2016: A randomized controlled trial evaluating renal protective effects of selenium with vitamins A, C, E, verapamil, and losartan against extracorporeal shockwave lithotripsy-induced renal injury.

El-Nahas AR, Elsaadany MM, Taha DE, Elshal AM, El-Ghar MA, Ismail AM, Elsawy EA, Saleh HH, Wafa EW, Awadalla A, Barakat TS, Sheir KZ.
Department of Urology, Urology and Nephrology Center, Department of Radiology, Department of Clinical Pathology, Department of Microbiology, Department of Nephrology, Department of Molecular Biology Laboratory, Mansoura University, Mansoura, Egypt.

Abstract

OBJECTIVE: 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. 

BJU Int. 2017 Jan;119(1):142-147. doi: 10.1111/bju.13667.
PMID: 27686059

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Comments 1

Hans-Göran Tiselius on Friday, 26 May 2017 11:10

Protection against SWL induced renal injury is desirable for successful and safe non-invasive stone removal. This report is a randomized trial with three medical treatment options: selenium + vitamin A,C and E, verapamil (calcium channel blocker) and losartan (angiotensin receptor blocker). A control group of patients was treated without medical supplements.

Analysis of albuminuria (indicator of glomerular damage) and NGAL (indicator of kidney damage) were analysed. MRI was carried out after 2-4 h and after 1 week.

Urinary levels of NGAL did not differ from that in controls. Increased excretion of albumin was observed as an effect of SWL but it was only with losartan that lower levels of albumin were observed after 1 week. Both verapamil and losartan had positive effects on renal perfusion in patients with urinary obstruction as a result of SWL.

MRI disclosed small hematomas in 13 patients, not different between the groups.

The bottom-line of this study is that administration of 50 mg of losartan (Cozaar) 2-4 h before SWL and once daily during the following week might be a useful medical adjunct to SWL in order to minimize tissue damage in selected patients.

Protection against SWL induced renal injury is desirable for successful and safe non-invasive stone removal. This report is a randomized trial with three medical treatment options: selenium + vitamin A,C and E, verapamil (calcium channel blocker) and losartan (angiotensin receptor blocker). A control group of patients was treated without medical supplements. Analysis of albuminuria (indicator of glomerular damage) and NGAL (indicator of kidney damage) were analysed. MRI was carried out after 2-4 h and after 1 week. Urinary levels of NGAL did not differ from that in controls. Increased excretion of albumin was observed as an effect of SWL but it was only with losartan that lower levels of albumin were observed after 1 week. Both verapamil and losartan had positive effects on renal perfusion in patients with urinary obstruction as a result of SWL. MRI disclosed small hematomas in 13 patients, not different between the groups. The bottom-line of this study is that administration of 50 mg of losartan (Cozaar) 2-4 h before SWL and once daily during the following week might be a useful medical adjunct to SWL in order to minimize tissue damage in selected patients.
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