Systematic review: Renin-angiotensin system inhibitors in chemoprevention of hepatocellular carcinoma

Table 1 Clinical studies on the effect of angiotensin-converting enzyme inhibitors or angiotensin II type 1 receptor blockers exposure in patients affected or at high risk of hepatocellular carcinoma

Interventional studies
Authors	Patients	Treatment	HCC recurrence after 42-54 mo	P value
Yoshiji et al[13]	87 with RFA for prior HCC	I. Control	18/25	I vs II; < 0.01
		II. ACE-I + vit. K2	9/25
			19/19	I vs III, NS
		III. ACE-I	18/18
		IV. vit. K2		I vs IV; NS
Yoshiji et al[14]	89 with Insulin resistance and RFA for prior HCC	I. Control	16/26	I vs II; < 0.01
		II. ACE-I + BCAA	9/28
				I vs III, NS
			11/19
		III. ACE-I	9/16
		IV. BCAA		I vs IV; NS
Yoshiji et al[15]	54 with HCC randomized in 2 groups, before treatment	I. HCC treatment	77%	I vs II < 0.01
		II. HCC treatment + ACE-I and Vit. K
			40%
Observational studies
Authors	Patients	Treatment	OS, HR, OR	P value
Ho et al[16]	7724 HBV-patients	ACE-I or ARB (46.3% in HBV and 42.5% in HCV) within 6 mo after initiating DAAs	HCC risk after ACE-I and ARB exposure	NS1
	7873 HCV- patients		HR = 0.97, 95%CI: 0.81-1.16
	at high-risk of HCC development
			HR = 0.96, 95%CI: 0.80-1.16
			respectively
Hagberg et al[17]	490 HCC	ACE-I or ARBs	OR = 1.14, 95%CI: 0.85-1.55	NS2
	1909 controls		users vs non- users
Walker et al[18]	224 HCC	7% ACE-I users in HCC group	OR = 1.29, 95%CI: 0.88-1.88	NS3
		5.9% ACE-I users in control group
	2313 controls		unexposed vs exposed
Pinter et al[19]	156, with Sorafenib or supportive therapy	ACE-I or ARBs in 43 pts.	OS = 11.9 mo vs 6.8 mo	P = 0.014
				P = 0.011
			HR = 0.6, 95%CI: 0.4-0.9	P = 0.043
				P = 0.038
	76, (confirmation cohort) with sorafenib or supportive therapy
		ACE-I or ARBs in 38 pts.	OS = 19.5 mo vs 10.9 mo
			HR = 0.5, 95%CI: 0.3-1.0
Facciorusso et al[20]	153 with RFA for prior HCC	I: Control,73 pts	OS = 48 mo	I vs II, NS
		II: ACE-I, 49 pts	OS = 72 mo
			OS = 84 mo
				I < III, P < 0.002
		III. ARBs, 31 pts	HR4 = 0.39, 95%CI: 0.22-0.66
Kabori et al[21]	185 HCV-HCC pts. without cirrhosis	I. No hypert.	OS at 5 yr (76/106)	I vs II, NS
		II. Hypert. + ACE/ARB	OS at 5 yr (30/37)
				I > III, P < 0.001
			OS at 5 yr (11/42)
				II > III, P < 0.001
		III. Hypert. + other
		anti-hypertensives
	141 HCV-HCC pts. with cirrhosis	I. No hypertension	OS at 5 yr 51.6%	I and II > III, P = 0.029
			OS at 5 yr 76.7%
		II. Hypert. + ACE/ARB
			OS at 5 yr 37.3%
		III. Hypert. + other
	143 pts. with HCC related to other etiologies	I. No hypertension	OS at 5 yr 59%-74%	NS
			OS at 5 yr 60%-62%
		II. Hypertension

¹Adjusted for sex, age, liver cirrhosis, diabetes mellitus, alcohol consumption, hyperlipidemia, malignancies other than hepatocellular carcinoma (HCC), chronic obstructive pulmonary disease, end-stage renal disease, transplantation, aspirin, metformin, and statins.

²Adjusted odds ratio for HCC risk factors (body mass index, smoking status, alcohol abuse, hepatitis B virus and/or hepatitis C virus, rare metabolic disorders, liver disease, diabetes, and use of statins and acetaminophen) and duration of hypertension. The analysis was also repeated to cases and controls without diabetes and to cases and controls without liver disease demonstrating no significant difference.

³Adjusted for alcohol use, smoking, cirrhosis, and hepatitis.

⁴Adjusted for age, gender, Child-Pugh class and α-fetoprotein. Time to recurrence was significantly reduced in patients receiving angiotensin II type 1 receptor blockers (P = 0.009). RFA: Radiofrequency ablation; OS: Overall survival; OR: Odds ratio; HR: Hazard ratio; ACE-Is: Angiotensin-converting enzyme inhibitors; ARBs: Angiotensin II type 1 receptor blockers; Vit.: Vitamine; CI: Confidence interval; HCC: Hepatocellular carcinoma; HBV: Hepatitis B virus; HCV: Hepatitis C virus; Pts.: Patients. NS: No significance.

Table 2 Studies on the effect of angiotensin-converting enzyme inhibitors or angiotensin II type 1 receptor blockers in diethylnitrosamine-induced hepatocellular carcinoma animal models

	Animal model	Treatment	Results	Comments
Saber et al[25]	DEN-induced HCC in mice	I. Sorafenib	Both treatments improved liver histology; II. reduced α-feto-protein and VEGF level	Inhibition of proliferation by involvement of NFкB pathway and cyclin D1
		vs
		II. ACEIs or ARBs
Saber et al[26]	DEN-induced HCC in mice	1 Sorafenib	ACE-Is and ARBs monotherapy or plus sorafenib improved liver histology with regression to grade 1, almost restoration of lobular architecture	No survival improvement
		2 ACE-I ± Sorafenib		No additional effect when combination therapy was used
		3 ARB ± Sorafenib
Nasr et al[27]	DEN-induced HCC in mice	Leflunomide Perindopril Curcumin	All drugs abrogated: hepatic microvessel density, elevated VEGF; only curcumin reduced HIF-1α. Nodules reduced or absent	Combination of these agents: further inhibited neovascularization
Mansour et al[29]	DEN + carbon tetra-chloride in rats	ACE-I ARBs	Significant reduction of tumor markers and hepatic growth factors	Liver histology amelioration correlated with VEGF, CD31 and FGF
Yanase et al[30]	DEN-treated rats	combined effect of ACE-I and 5-fluorouracil	Inhibition of HCC growth, neovascularization (VEGF and CD31+ vessels suppression), and marked increase of apoptosis	In vitro studies on EC tubular formation confirm the anti-angiogenetic effect
	Male BALB/c mice with injections of BNL-HCC cells.
Yoshiji et al[31]	DEN-treated mice	Vit. K and ACE-I used singularly or in combination	Inhibitory effects by each compound on hepato-carcinogenesis, more potent when used in combination	Increased apoptosis in the tumor, w/o any effect on tumor cell proliferation; CD31 mRNA suppression
	Male BALB/c mice with injections of BNL-HCC cells
Yoshiji et al[32]	DEN-treated rats and human HCC cell lines	Vit. K or ACE-I alone or in combination	Chemopreventive effect on pre-neoplastic foci formation by single compounds, more potent when combined.	Inhibition of endothelial cell proliferation and tubular formation; reduction of CD31 mRNA expression.
Yoshiji et al[33]	DEN-treated rats	Interferon, ACE-I used singularly or in combination	IFN or PE, when used singularly, significantly attenuated, in combination nearly abolished HCC	CD31 and VEGF mRNA expression were reduced; apoptosis was also reduced; no change of cell proliferation
Yoshiji et al[34]	DEN-treated rats	Perindopril (ACE-I)	Inhibition of neo-vascularization and VEGF expression	Suppression of VEGF-induced tubular formation; no effect on endothelial cell proliferation in vitro
	Endothelial cells in vitro

ACE-Is: Angiotensin-converting enzyme inhibitors; ARBs: Angiotensin II type 1 receptor blockers; Vit.: Vitamine; DEN: Diethylnitrosamine; HCC: Hepatocellular carcinoma; VEGF: Vascular endothelial growth factor; HIF: Hypoxia-inducible factor.

Table 3 Experimental studies on the effect of angiotensin-converting enzyme inhibitors or angiotensin II type 1 receptor blockers in different hepatocellular carcinoma animal models and in hepatocellular carcinoma cell lines

	Model	Treatment	Results	Comments
Fan et al[35]	1 Tumor cell lines	Candesartan	Angiotensin II up-regulated AT1R and promoted production of VEGF in vitro. Candesartan reversed this process and downregulated the expression of VEGF-A in tumor xenografts	AT1R expression was associated to angiogenic potential in HCC human tissues
	2 BALB/c nude mice with injections of HCC cell lines
	3 Human HCC specimens
Du et al[36]	1 Tumor cell lines	AT2R over- expression by AT2R recombinant adenoviral vector	Overexpression of AT2R in transduced HCC cell lines produced apoptosis and inhibited cell proliferation. Higher AT2R expression could increase the growth of HCC and the prolifera-tion of HCC cells in vivo	A moderate expression of AT2R could increase the growth of HCC and the proliferation of HCC cells in vivo. AT2R mechanisms remain to be elucidated
	2 BALB/c nude mice with intra-liver injections of human HCC cells
Noguchi et al[37]	BALB/c mice injected with HCC cell lines	ACE-I and interferon-beta	Combination therapy was effective even on established tumors. Suppression of VEGF and endothelial cell proliferation and tubular formation, increase of apoptosis;	No effect on HCC cell proliferation.
Yoshiji et al[38]	BALB/c mice injected with HCC cell lines. Endothelial cell cultures	Retroviral tetracycline up-regulated VEGF gene expression and Perindopril (ACE-I)	Perindopril significantly attenuated VEGF-mediated tumor growth and neovascularization. In vitro, VEGF-induced endothelial cell migration inhibition	Suppression of VEGF
Yoshiji et al[39]	BALB/c mice injected with HCC cell lines. BNL CL2 cell line	Captopril Perindopril Temocapril Losartan Candesartan	Reduction of tubular formation and microvessel density in the tumor. Higher VEGF mRNA expression reduction and HCC growth inhibition by perindopril compared to temocapril and captopril. Neither candesartan nor losartan significantly inhibited the tumor development	ACE-Is suppressed the tumor development mainly by a mechanism which was independent from AT1-R blockage.
Tamaki et al[40]	Male Wistar rats receiving modified choline-deficient low-methionine diet	Telmisartan	No HCC in telmisartan group vs 54.6% of HCC in control group. Telmisartan inhibited the dietary-induced up-regulation of VEGF, TGF-β1, CTGF, HIF1α and TNF-α mRNA levels	Telmisartan may prevent hepatocarcinogenesis through the inhibition of hepatic angiogenesis
Noguchi et al[41]	Male Fisher-344 rats receiving modified choline-deficient low-methionine diet	Perindopril Eplerenone (selective aldosterone blocker) Aldosterone	Significant inhibitory effects on the GST-P positive pre-neoplastic lesion development; reduction of VEGF expression tubule formation and neovascularization	Combination of Perindopril + Eplerenone exerted a stronger suppression than single treatment
Yoshiji et al[42]	Male OLETF rats (spontaneous development of insulin resistance) treated with Diethylnitrosamine	branched-chain amino acids perindopril	Number/size of preneoplastic foci were significantly suppressed by treatment of both drugs suppression of CD31- and VEGF-mRNA	In vitro suppression of tubule formation, regardless of drug concentration
Oura et al[43]	Five human HCC cell lines (HepG2, HLF, HLE, HuH-7 and PLC/PRF/5)	Telmisartan	Only telmisartan reduced proliferation in most of cell lines. Promotion of apoptosis, Enhancement of bFGF reduction of p-ErbB3	Arrest of cell cycle in G1, and S phase. Effect is dose-dependent and may be mediated by induction of MPK/mTOR signaling.
		Valsartan
		Irbesartan
		Losartan
Santhekadur et al[44]	Hep3B and QGY-7703 cell lines	Losartan	SND1 increases AT1R level by augmenting AT1R mRNA stability; Losartan inhibited both cell migration and invasion	SND1 induces TGF-β expression through AT1R signaling
Cook et al[45]	H4-II-E-C3 rat hepatoma cells transfected with Ang II	Losartan Candesartan	Losartan inhibits Angiotensin II-induced proliferation	Both losartan and candesartan are equally effective in competing with Ang II/AT1 receptor interactions on the cell surface

Ang II: Angiotensin receptor; AT2R: Angiotensin II type 2 receptor; ACE-Is: Angiotensin-converting enzyme inhibitors; ARBs: Angiotensin II type 1 receptor blockers; HCC: Hepatocellular carcinoma; VEGF: Vascular endothelial growth factor; TNF: Tumor necrosis factor; TGF: Transforming growth factor; OLETF: Otsuka Long-Evans Tokushima Fatty.