151
|
Delanaye P, Scheen AJ. The diuretic effects of SGLT2 inhibitors: A comprehensive review of their specificities and their role in renal protection. DIABETES & METABOLISM 2021; 47:101285. [PMID: 34597788 DOI: 10.1016/j.diabet.2021.101285] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/16/2021] [Indexed: 02/08/2023]
Abstract
Sodium-glucose cotransporter type 2 inhibitors (SGLT2is) are new oral glucose-lowering agents that provide cardiovascular and renal protection in both patients with and without type 2 diabetes. Because of their unique mechanism of action, increased glucosuria is associated with osmotic diuresis and some natriuresis, yet the latter seems mostly transient. The potential role of the diuretic effect in overall cardiovascular and renal protection by SGLT2is remains a matter of debate. Precise evaluation of the diuretic effect is not so easy and most studies relied upon indirect estimations that led to divergent results, presumably also explained by different study designs and population characteristics. Everybody agrees upon the fact that SGLT2is are different from other classical diuretics (thiazides and loop diuretics) as they present some favourable properties, i.e. reduced sympathetic activity, preserved potassium balance, lower risk of acute renal injury, decrease of serum uric acid level. The potential role of the diuretic effect of SGLT2is on renal outcomes is still unclear, yet their ability to reduce albuminuria and dampen the risk of heart failure may contribute to improve renal prognosis besides other complex underlying mechanisms. In this comprehensive review we first critically analyse the results obtained with indirect methods that assess a diuretic effect of SGLT2is, second we describe the specificities of the diuretic activity of SGLT2is compared with other classical diuretics, and third we discuss the potential mechanisms by which the diuretic effect of SGLT2is could contribute to the improvement of renal outcomes consistently reported with this innovative amazing pharmacological class.
Collapse
Affiliation(s)
- Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium; Department of Nephrology-Dialysis-Apheresis, Hôpital Universitaire Carémeau, Nimes, France
| | - Andre J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium; Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium.
| |
Collapse
|
152
|
Heerspink HJL, Cherney D, Postmus D, Stefánsson BV, Chertow GM, Dwyer JP, Greene T, Kosiborod M, Langkilde AM, McMurray JJV, Correa-Rotter R, Rossing P, Sjöström CD, Toto RD, Wheeler DC. A pre-specified analysis of the Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease (DAPA-CKD) randomized controlled trial on the incidence of abrupt declines in kidney function. Kidney Int 2021; 101:174-184. [PMID: 34560136 DOI: 10.1016/j.kint.2021.09.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/26/2021] [Accepted: 09/03/2021] [Indexed: 02/07/2023]
Abstract
This pre-specified analysis of DAPA-CKD assessed the impact of sodium-glucose cotransporter 2 inhibition on abrupt declines in kidney function in high-risk patients based on having chronic kidney disease (CKD) and substantial albuminuria. DAPA-CKD was a randomized, double-blind, placebo-controlled trial that had a median follow-up of 2.4 years. Adults with CKD (urinary albumin-to-creatinine ratio 200-5000 mg/g and estimated glomerular filtration rate 25-75 mL/min/1.73m2) were randomized to dapagliflozin 10 mg/day matched to placebo (2152 individuals each). An abrupt decline in kidney function was defined as a pre-specified endpoint of doubling of serum creatinine between two subsequent study visits. We also assessed a post-hoc analysis of investigator-reported acute kidney injury-related serious adverse events. Doubling of serum creatinine between two subsequent visits (median time-interval 100 days) occurred in 63 (2.9%) and 91 (4.2%) participants in the dapagliflozin and placebo groups, respectively (hazard ratio 0.68 [95% confidence interval 0.49, 0.94]). Accounting for the competing risk of mortality did not alter our findings. There was no heterogeneity in the effect of dapagliflozin on abrupt declines in kidney function based on baseline subgroups. Acute kidney injury-related serious adverse events were not significantly different and occurred in 52 (2.5%) and 69 (3.2%) participants in the dapagliflozin and placebo groups, respectively (0.77 [0.54, 1.10]). Thus, in patients with CKD and substantial albuminuria, dapagliflozin reduced the risk of abrupt declines in kidney function.
Collapse
Affiliation(s)
- Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands; The George Institute for Global Health, Sydney, Australia.
| | - David Cherney
- Department of Medicine, Division of Nephrology, University Health Network and University of Toronto, Toronto, Canada
| | - Douwe Postmus
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, the Netherlands
| | - Bergur V Stefánsson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Glenn M Chertow
- Department of Medicine and Epidemiology and Population Health, Stanford University School of Medicine, Stanford, USA
| | - Jamie P Dwyer
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tom Greene
- Study Design and Biostatistics Center, University of Utah Health Sciences, Salt Lake City, Utah, USA
| | - Mikhail Kosiborod
- The George Institute for Global Health, Sydney, Australia; Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City, Missouri, USA
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Ricardo Correa-Rotter
- The National Medical Science and Nutrition Institute Salvador Zubiran, Mexico City, Mexico
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - C David Sjöström
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Robert D Toto
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - David C Wheeler
- The George Institute for Global Health, Sydney, Australia; Department of Renal Medicine, University College London, London, UK
| | | |
Collapse
|
153
|
McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 1-- gadu] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
|
154
|
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 1-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
|
155
|
McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 8029-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
|
156
|
McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 8029-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
|
157
|
McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021; 42:3599-3726. [PMID: 34447992 DOI: 10.1093/eurheartj/ehab368] [Citation(s) in RCA: 5506] [Impact Index Per Article: 1835.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
|
158
|
McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 1-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
|
159
|
McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 and 1880=1880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
|
160
|
McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J, Adamo M, Baumbach A, Böhm M, Burri H, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gardner RS, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab368 order by 8029-- awyx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
|
161
|
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors improve blood glucose control by blocking renal glucose reabsorption with little subsequent risk of hypoglycemia. Consequently, there are decreases in plasma volume, body weight, and blood pressure. Additional putative benefits include improved cardiovascular energetics, decreased systemic inflammation, and less renal dysfunction. Multiple cardiovascular outcome trials in diabetic patients have demonstrated this drug class reduces the risk of adverse cardiovascular events. Reductions in heart failure (HF) hospitalization suggested that SGLT2 inhibitors might prove useful for the primary treatment of HF. Two large subsequent trials studying SGLT2 inhibitors in heart failure with reduced ejection fraction (HFrEF) demonstrated a reduction in cardiovascular mortality, HF hospitalizations, and renal-specific adverse events. This medication class is now recognized as a new pillar of therapy for patients with HFrEF. The cardiovascular and HF community await the results of ongoing trials of SGLT2 inhibition in patients with HF with preserved ejection fraction. Expected final online publication date for the Annual Review of Pharmacology and Toxicology, Volume 62 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
Collapse
Affiliation(s)
- Kevin S Shah
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, Utah 84132, USA; ,
| | - James C Fang
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, Utah 84132, USA; ,
| |
Collapse
|
162
|
Treatment Response to SGLT2 Inhibitors: From Clinical Characteristics to Genetic Variations. Int J Mol Sci 2021; 22:ijms22189800. [PMID: 34575958 PMCID: PMC8466905 DOI: 10.3390/ijms22189800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 12/12/2022] Open
Abstract
SGLT2 (sodium-glucose cotransporter 2) inhibitors are a new class of antihyperglycaemic drugs that act on the proximal tubules of the kidney. They have shown efficacy in the management of diabetes mellitus type 2 and their cardiovascular and renal safety have been extensively investigated and confirmed in clinical trials. However, inter-individual differences in response to treatment with SGLT2 inhibitors may present in everyday clinical practice, and good predictors of glycemic response and the risk for adverse events in an individual patient are lacking. As genetic variability of SGLT2 may influence the treatment response, pharmacogenetic information could support the choice of the most beneficial treatment strategy in an individual patient. This review focuses on the clinical and genetic factors that may influence the treatment response to SGLT2 inhibitors in type 2 diabetes patients with comorbid conditions.
Collapse
|
163
|
Affiliation(s)
- L Parker Gregg
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.,Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Houston, Texas
| | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas .,Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.,Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Houston, Texas.,Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
164
|
Chiang CE, Ueng KC, Chao TH, Lin TH, Wu YJ, Wang KL, Sung SH, Yeh HI, Li YH, Liu PY, Chang KC, Shyu KG, Huang JL, Tsai CD, Hung HF, Liu ME, Chao TF, Cheng SM, Cheng HM, Chu PH, Yin WH, Wu YW, Chen WJ, Lai WT, Lin SJ, Yeh SJ, Hwang JJ, Hou CJY. 2021 Consensus Pathway of the Taiwan Society of Cardiology on Novel Therapy for Type 2 Diabetes. JACC. ASIA 2021; 1:129-146. [PMID: 36338159 PMCID: PMC9627904 DOI: 10.1016/j.jacasi.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/28/2021] [Accepted: 08/09/2021] [Indexed: 06/16/2023]
Abstract
Type 2 diabetes is a major threat to human health in the 21st century. More than half a billion people may suffer from this pandemic disease in 2030, leading to a huge burden of cardiovascular complications. Recently, 2 novel antidiabetic agents, glucagon-like peptide 1 receptor agonists and sodium-glucose cotransporter 2 inhibitors, reduced cardiovascular complications in a number of randomized control trials. To integrate new information and to achieve a streamlined process for better patient care, a working group was appointed by the Taiwan Society of Cardiology to formulate a stepwise consensus pathway for these therapies to reduce cardiovascular events in patients with type 2 diabetes. This consensus pathway is complementary to clinical guidelines, acting as a reference to improve patient care.
Collapse
Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kwo-Chang Ueng
- Department of Internal Medicine, School of Medicine, Chung-Shan Medical University Hospital, Taichung, Taiwan
| | - Ting-Hsing Chao
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tsung-Hsien Lin
- Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yih-Jer Wu
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
- Cardiovascular Center, MacKay Memorial Hospital, Taipei, Taiwan
| | - Kang-Ling Wang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Hsien Sung
- Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Public Health and Community Medicine Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hung-I Yeh
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
- Cardiovascular Center, MacKay Memorial Hospital, Taipei, Taiwan
| | - Yi-Heng Li
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ping-Yen Liu
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Kuan-Cheng Chang
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung, Taiwan
- School of Medicine, China Medical University, Taichung, Taiwan
| | - Kou-Gi Shyu
- Division of Cardiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Jin-Long Huang
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Dao Tsai
- Department of Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Huei-Fong Hung
- Division of Cardiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Ming-En Liu
- Division of Cardiology, Department of Internal Medicine, Hsinchu Mackay Memorial Hospital, Hsinchu, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shu-Meng Cheng
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hao-Min Cheng
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Center for Evidence-Based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-Hsian Yin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Yen-Wen Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Cardiology, Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Department of Internal Medicine and Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Jone Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Ter Lai
- Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shing-Jong Lin
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - San-Jou Yeh
- Department of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Juey-Jen Hwang
- Cardiovascular Division, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | | |
Collapse
|
165
|
Savarese G, Butler J, Lund LH, Bhatt DL, Anker SD. CARDIOVASCULAR EFFECTS OF NON-INSULIN GLUCOSE-LOWERING AGENTS: A COMPREHENSIVE REVIEW OF TRIAL EVIDENCE AND POTENTIAL CARDIOPROTECTIVE MECHANISMS. Cardiovasc Res 2021; 118:2231-2252. [PMID: 34390570 DOI: 10.1093/cvr/cvab271] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/12/2021] [Indexed: 11/12/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is highly prevalent and associated with a 2-fold increased mortality, mostly explained by cardiovascular diseases. Trial evidence on older glucose-lowering agents such as metformin and sulfonylureas is limited in terms of cardiovascular efficacy. Since 2008, after rosiglitazone was observed to increase the risk of myocardial infarction and heart failure (HF), cardiovascular outcome trials (CVOT) have been required by regulators for licensing new glucose-lowering agents. In the following CVOTs, dipeptidyl peptidase 4 inhibitors (DPP4i) have been shown to be safe but not to improve morbidity/mortality, except for saxagliptin which increased the risk of HF. Several glucagon-like peptide-1 receptor agonists (GLP1-Ra) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been demonstrated to reduce the risk of cardiovascular morbidity and mortality. SGLT2i have shown a class effect for the reduction in risk of HF events in patients with T2DM, leading to trials testing their efficacy/safety in HF regardless of T2DM. In the DAPA-HF and the EMPEROR-Reduced trials dapagliflozin and empagliflozin, respectively, improved cardiovascular mortality/morbidity in patients with HF and reduced ejection fraction (HFrEF), with and without T2DM. Therefore, these drugs are now key part of HFrEF pharmacotherapy. In the SOLOIST-WHF, sotagliflozin reduced cardiovascular mortality/morbidity in patients with T2DM and a recent acute episode of HF regardless of EF. The DELIVER and the EMPEROR-Preserved are testing dapagliflozin and empagliflozin, respectively, in patients with HF with mildly reduced and preserved EF. A strong renal protective role of SGLT2i has also emerged in trials enrolling patients with and without T2DM.
Collapse
Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden. Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Javed Butler
- University of Mississippi School of Medicine, Jackson, MI, USA
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden. Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), and German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin Berlin, Germany
| |
Collapse
|
166
|
Abdin A, Bauersachs J, Frey N, Kindermann I, Link A, Marx N, Lainscak M, Slawik J, Werner C, Wintrich J, Böhm M. Timely and individualized heart failure management: need for implementation into the new guidelines. Clin Res Cardiol 2021; 110:1150-1158. [PMID: 33983472 PMCID: PMC8117452 DOI: 10.1007/s00392-021-01867-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/30/2021] [Indexed: 01/10/2023]
Abstract
Due to remarkable improvements in heart failure (HF) management over the last 30 years, a significant reduction in mortality and hospitalization rates in HF patients with reduced ejection fraction (HFrEF) has been observed. Currently, the optimization of guideline-directed chronic HF therapy remains the mainstay to further improve outcomes for patients with HFrEF to reduce mortality and HF hospitalization. This includes established device therapies, such as implantable defibrillators and cardiac resynchronization therapies, which improved patients' symptoms and prognosis. Over the last 10 years, new HF drugs have merged targeting various pathways, such as those that simultaneously suppress the renin-angiotensin-aldosterone system and the breakdown of endogenous natriuretic peptides (e.g., sacubitril/valsartan), and those that inhibit the If channel and, thus, reduce heart rate (e.g., ivabradine). Furthermore, the treatment of patient comorbidities (e.g., iron deficiency) has shown to improve functional capacity and to reduce hospitalization rates, when added to standard therapy. More recently, other potential treatment mechanisms have been explored, such as the sodium/glucose co-transporter inhibitors, the guanylate cyclase stimulators and the cardiac myosin activators. In this review, we summarize the novel developments in HFrEF pharmacological and device therapy and discuss their implementation strategies into practice to further improve outcomes.
Collapse
Affiliation(s)
- Amr Abdin
- Klinik Für Innere Medizin III-Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Kirrberger Strasse 100, 66421, Homburg, Germany.
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Norbert Frey
- Department of Internal Medicine III, University of Heidelberg, 69120, Heidelberg, Germany
| | - Ingrid Kindermann
- Klinik Für Innere Medizin III-Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Kirrberger Strasse 100, 66421, Homburg, Germany
| | - Andreas Link
- Klinik Für Innere Medizin III-Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Kirrberger Strasse 100, 66421, Homburg, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I, Cardiology, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia
| | - Jonathan Slawik
- Klinik Für Innere Medizin III-Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Kirrberger Strasse 100, 66421, Homburg, Germany
| | - Christian Werner
- Klinik Für Innere Medizin III-Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Kirrberger Strasse 100, 66421, Homburg, Germany
| | - Jan Wintrich
- Klinik Für Innere Medizin III-Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Kirrberger Strasse 100, 66421, Homburg, Germany
| | - Michael Böhm
- Klinik Für Innere Medizin III-Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Kirrberger Strasse 100, 66421, Homburg, Germany
| |
Collapse
|
167
|
Herrington WG, Savarese G, Haynes R, Marx N, Mellbin L, Lund LH, Dendale P, Seferovic P, Rosano G, Staplin N, Baigent C, Cosentino F. Cardiac, renal, and metabolic effects of sodium-glucose co-transporter 2 inhibitors: a position paper from the European Society of Cardiology ad-hoc task force on sodium-glucose co-transporter 2 inhibitors. Eur J Heart Fail 2021; 23:1260-1275. [PMID: 34184823 DOI: 10.1002/ejhf.2286] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 11/07/2022] Open
Abstract
In 2015, the first large-scale placebo-controlled trial designed to assess cardiovascular safety of glucose-lowering with sodium-glucose co-transporter 2 (SGLT2) inhibition in type 2 diabetes mellitus raised hypotheses that the class could favourably modify not only risk of atherosclerotic cardiovascular disease, but also hospitalization for heart failure, and the development or worsening of nephropathy. By the start of 2021, results from 10 large SGLT2 inhibitor placebo-controlled clinical outcome trials randomizing ∼71 000 individuals have confirmed that SGLT2 inhibitors can provide clinical benefits for each of these types of outcome in a range of different populations. The cardiovascular and renal benefits of SGLT2 inhibitors appear to be larger than their comparatively modest effect on glycaemic control or glycosuria alone would predict, with three trials recently reporting that clinical benefits extend to individuals without diabetes mellitus who are at risk due to established heart failure, or albuminuric chronic kidney disease. This European Society of Cardiology position paper summarizes reported results from these 10 large clinical outcome trials considering separately each of the different types of cardiorenal benefit, summarizes key molecular and pathophysiological mechanisms, and provides a synopsis of metabolic effects and safety. We also describe ongoing placebo-controlled trials among individuals with heart failure with preserved ejection fraction and among individuals with chronic kidney disease.
Collapse
Affiliation(s)
- William G Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, part of the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Oxford Kidney Unit, Churchill Hospital, Oxford, UK
| | - Gianluigi Savarese
- Cardiology Unit, Department of Medicine, Karolinska Institute: Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Richard Haynes
- Medical Research Council Population Health Research Unit at the University of Oxford, part of the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Oxford Kidney Unit, Churchill Hospital, Oxford, UK
| | - Nikolaus Marx
- Department of Internal Medicine, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Linda Mellbin
- Cardiology Unit, Department of Medicine, Karolinska Institute: Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lars H Lund
- Cardiology Unit, Department of Medicine, Karolinska Institute: Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Paul Dendale
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine & Life Sciences, Hasselt University, Hasselt, Belgium
| | - Petar Seferovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy
| | - Natalie Staplin
- Medical Research Council Population Health Research Unit at the University of Oxford, part of the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
| | - Colin Baigent
- Medical Research Council Population Health Research Unit at the University of Oxford, part of the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
| | - Francesco Cosentino
- Cardiology Unit, Department of Medicine, Karolinska Institute: Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
168
|
Possible Preventative/Rehabilitative Role of Gliflozins in OSA and T2DM. A Systematic Literature Review-Based Hypothesis. Adv Ther 2021; 38:4195-4214. [PMID: 34273093 PMCID: PMC8342338 DOI: 10.1007/s12325-021-01791-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/13/2021] [Indexed: 02/07/2023]
Abstract
Obstructive sleep apnoea (OSA) is characterized by frequent apnoea episodes during sleep due to upper airway obstruction. The present review summarizes current knowledge on inter-relationships between OSA and type 2 diabetes mellitus (T2DM) and suggests the former as a possible target for sodium-glucose co-transporter-2 inhibitors (SGLT-2i). Based on pathophysiological mechanisms underlying OSA onset and renal SGLT-2 effects, we suggest that SGLT-2i indications might expand beyond current ones, including glucose, lipids, uric acid, blood pressure, and body weight control as well as chronic heart failure and kidney disease prevention.
Collapse
|
169
|
Liu J, Tian J, Sodhi K, Shapiro JI. The Na/K-ATPase Signaling and SGLT2 Inhibitor-Mediated Cardiorenal Protection: A Crossed Road? J Membr Biol 2021; 254:513-529. [PMID: 34297135 PMCID: PMC8595165 DOI: 10.1007/s00232-021-00192-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/06/2021] [Indexed: 12/17/2022]
Abstract
In different large-scale clinic outcome trials, sodium (Na+)/glucose co-transporter 2 (SGLT2) inhibitors showed profound cardiac- and renal-protective effects, making them revolutionary treatments for heart failure and kidney disease. Different theories are proposed according to the emerging protective effects other than the original purpose of glucose-lowering in diabetic patients. As the ATP-dependent primary ion transporter providing the Na+ gradient to drive other Na+-dependent transporters, the possible role of the sodium–potassium adenosine triphosphatase (Na/K-ATPase) as the primary ion transporter and its signaling function is not explored.
Collapse
Affiliation(s)
- Jiang Liu
- Department of Biomedical Sciences, JCE School of Medicine, Marshall University, Huntington, WV, USA.
| | - Jiang Tian
- Department of Biomedical Sciences, JCE School of Medicine, Marshall University, Huntington, WV, USA
| | - Komal Sodhi
- Department of Surgery, JCE School of Medicine, Marshall University, Huntington, WV, USA
| | - Joseph I Shapiro
- Departments of Medicine, JCE School of Medicine, Marshall University, Huntington, WV, USA
| |
Collapse
|
170
|
Nakagaito M, Imamura T, Joho S, Ushijima R, Nakamura M, Kinugawa K. Renoprotective effects of sodium glucose cotransporter 2 inhibitors in type 2 diabetes patients with decompensated heart failure. BMC Cardiovasc Disord 2021; 21:347. [PMID: 34289813 PMCID: PMC8296582 DOI: 10.1186/s12872-021-02163-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/15/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitor (SGLT2i) reduces the risk of the composite renal endpoint and weakens the progressive decline in renal function in patients with chronic heart failure (HF). However, a detailed mechanism of SGLT2i on renal function and outcome remains uninvestigated. METHODS We prospectively included 40 type 2 diabetic mellitus (T2DM) patients (median 68 years old, 29 male) who were hospitalized for decompensated HF and received SGLT2i during the index hospitalization. Of them, 24 patients had increases in estimated glomerular filtration rate (eGFR) at 12-month follow-up and 16 had decreases in eGFR. We investigated the baseline factors associating with the improvement in renal function. RESULTS Lower plasma B-type natriuretic peptide (BNP) level and the use of renin-angiotensin system inhibitor (RASI) were independently associated with increases in eGFR during the follow-up period (p < 0.05 for both). Patients with both low plasma BNP levels and uses of RASI achieved significant increases in eGFR irrespective of the baseline HbA1c levels. CONCLUSIONS Lower plasma BNP level and the use of RASI at baseline were the key factors contributing to the renoprotective effects of SGLT2i among patients with decompensated HF and T2DM.
Collapse
Affiliation(s)
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan.
| | - Shuji Joho
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Ryuichi Ushijima
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| |
Collapse
|
171
|
Abstract
Inhibitoren des Natrium-Glukose-Kotransporters 2 (SGTL2i, Gliflozine) wurden ursprünglich zur Diabetestherapie entwickelt, zeigten jedoch in den Zulassungsstudien unerwartete positive Effekte auf Herz- und Nierenfunktion. Im vergangenen Jahr wurden die Ergebnisse mehrerer großer Phase-III-Studien publiziert, welche die Effekte dieser Medikamentenklasse bei chronischer Niereninsuffizienz und Herzinsuffizienz auch ohne diabetische Grunderkrankung untersuchten. Die überwiegend positiven Ergebnisse haben dazu geführt, dass sich der Einsatzbereich von SGLT2i stetig erweitert. Der vorliegende Artikel soll einen Überblick über die neuesten Endpunktstudien zu SGLT2i geben und Konsequenzen für die Praxis aufzeigen, den Wissensstand zu Risiken und Nebenwirkungen wiedergeben und aktuelle Hypothesen zum Wirkmechanismus dieser Medikamentenklasse zusammenfassen.
Collapse
Affiliation(s)
- Eva Dumann
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Deutschland
| | - Jan Menne
- Klinik für Nephrologie, Angiologie, Hypertensiologie und Rheumatologie, KRH Klinikum Siloah, Hannover, Deutschland
| |
Collapse
|
172
|
Affiliation(s)
- Kieran F Docherty
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| |
Collapse
|
173
|
Marcondes-Braga FG, Moura LAZ, Issa VS, Vieira JL, Rohde LE, Simões MV, Fernandes-Silva MM, Rassi S, Alves SMM, de Albuquerque DC, de Almeida DR, Bocchi EA, Ramires FJA, Bacal F, Rossi JM, Danzmann LC, Montera MW, de Oliveira MT, Clausell N, Silvestre OM, Bestetti RB, Bernadez-Pereira S, Freitas AF, Biolo A, Barretto ACP, Jorge AJL, Biselli B, Montenegro CEL, dos Santos EG, Figueiredo EL, Fernandes F, Silveira FS, Atik FA, Brito FDS, Souza GEC, Ribeiro GCDA, Villacorta H, de Souza JD, Goldraich LA, Beck-da-Silva L, Canesin MF, Bittencourt MI, Bonatto MG, Moreira MDCV, Avila MS, Coelho OR, Schwartzmann PV, Mourilhe-Rocha R, Mangini S, Ferreira SMA, de Figueiredo JA, Mesquita ET. Emerging Topics Update of the Brazilian Heart Failure Guideline - 2021. Arq Bras Cardiol 2021; 116:1174-1212. [PMID: 34133608 PMCID: PMC8288520 DOI: 10.36660/abc.20210367] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Fabiana G. Marcondes-Braga
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil.
| | - Lídia Ana Zytynski Moura
- Pontifícia Universidade Católica de CuritibaCuritibaPRBrasilPontifícia Universidade Católica de Curitiba, Curitiba, PR – Brasil.
| | - Victor Sarli Issa
- Universidade da AntuérpiaBélgicaUniversidade da Antuérpia, – Bélgica
| | - Jefferson Luis Vieira
- Hospital do Coração de MessejanaFortalezaCEBrasilHospital do Coração de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, CE – Brasil.
| | - Luis Eduardo Rohde
- Hospital de Clínicas de Porto AlegrePorto AlegeRSBrasilHospital de Clínicas de Porto Alegre, Porto Alege, RS – Brasil.
- Hospital Moinhos de VentoPorto AlegreRSBrasilHospital Moinhos de Vento, Porto Alegre, RS – Brasil.
- Universidade Federal do Rio Grande do SulPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS – Brasil.
| | - Marcus Vinícius Simões
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoSão PauloSPBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, São Paulo, SP – Brasil.
| | - Miguel Morita Fernandes-Silva
- Universidade Federal do ParanáCuritibaPRBrasilUniversidade Federal do Paraná (UFPR), Curitiba, PR – Brasil.
- Quanta Diagnóstico por ImagemCuritibaPRBrasilQuanta Diagnóstico por Imagem, Curitiba, PR – Brasil.
| | - Salvador Rassi
- Universidade Federal de GoiásHospital das ClínicasGoiâniaGOBrasilHospital das Clínicas da Universidade Federal de Goiás (UFGO), Goiânia, GO – Brasil.
| | - Silvia Marinho Martins Alves
- Pronto Socorro Cardiológico de PernambucoRecifePEBrasilPronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE – Brasil.
- Universidade de PernambucoRecifePEBrasilUniversidade de Pernambuco (UPE), Recife, PE – Brasil.
| | - Denilson Campos de Albuquerque
- Universidade do Estado do Rio de JaneiroRio de JaneiroRJBrasilUniversidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ – Brasil.
| | - Dirceu Rodrigues de Almeida
- Universidade Federal de São PauloSão PauloSPBrasilUniversidade Federal de São Paulo (UNIFESP), São Paulo, SP – Brasil.
| | - Edimar Alcides Bocchi
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil.
| | - Felix José Alvarez Ramires
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil.
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein, São Paulo, SP – Brasil.
| | - Fernando Bacal
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil.
| | - João Manoel Rossi
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil.
| | - Luiz Claudio Danzmann
- Universidade Luterana do BrasilCanoasRSBrasilUniversidade Luterana do Brasil, Canoas, RS – Brasil.
- Hospital São Lucas da PUC-RSPorto AlegreRSBrasilHospital São Lucas da PUC-RS, Porto Alegre, RS – Brasil.
| | | | - Mucio Tavares de Oliveira
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil.
| | - Nadine Clausell
- Hospital de Clínicas de Porto AlegrePorto AlegeRSBrasilHospital de Clínicas de Porto Alegre, Porto Alege, RS – Brasil.
| | - Odilson Marcos Silvestre
- Universidade Federal do AcreRio BrancoACBrasilUniversidade Federal do Acre, Rio Branco, AC – Brasil.
| | - Reinaldo Bulgarelli Bestetti
- Universidade de Ribeirão PretoDepartamento de MedicinaRibeirão PretoSPBrasilDepartamento de Medicina da Universidade de Ribeirão Preto (UNAERP), Ribeirão Preto, SP – Brasil.
| | | | - Aguinaldo F. Freitas
- Universidade Federal de GoiásHospital das ClínicasGoiâniaGOBrasilHospital das Clínicas da Universidade Federal de Goiás (UFGO), Goiânia, GO – Brasil.
| | - Andréia Biolo
- Hospital de Clínicas de Porto AlegrePorto AlegeRSBrasilHospital de Clínicas de Porto Alegre, Porto Alege, RS – Brasil.
| | - Antonio Carlos Pereira Barretto
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil.
| | - Antônio José Lagoeiro Jorge
- Universidade Federal FluminenseFaculdade de MedicinaNiteróiRJBrasilFaculdade de Medicina da Universidade Federal Fluminense (UFF), Niterói, RJ – Brasil.
| | - Bruno Biselli
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil.
| | - Carlos Eduardo Lucena Montenegro
- Pronto Socorro Cardiológico de PernambucoRecifePEBrasilPronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE – Brasil.
- Universidade de PernambucoRecifePEBrasilUniversidade de Pernambuco (UPE), Recife, PE – Brasil.
| | - Edval Gomes dos Santos
- Universidade Estadual de Feira de SantanaFeira de SantanaBABrasilUniversidade Estadual de Feira de Santana, Feira de Santana, BA – Brasil.
- Santa Casa de Misericórdia de Feira de SantanaFeira de SantanaBABrasilSanta Casa de Misericórdia de Feira de Santana, Feira de Santana, BA – Brasil.
| | - Estêvão Lanna Figueiredo
- Instituto OrizontiBelo HorizonteMGBrasilInstituto Orizonti, Belo Horizonte, MG – Brasil.
- Hospital Vera CruzBelo HorizonteMGBrasilHospital Vera Cruz, Belo Horizonte, MG – Brasil.
| | - Fábio Fernandes
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil.
| | - Fabio Serra Silveira
- Fundação Beneficência Hospital de CirurgiaAracajuSEBrasilFundação Beneficência Hospital de Cirurgia (FBHC-Ebserh), Aracaju, SE – Brasil.
- Centro de Pesquisa Clínica do CoraçãoAracajuSEBrasilCentro de Pesquisa Clínica do Coração, Aracaju, SE – Brasil.
| | - Fernando Antibas Atik
- Universidade de BrasíliaBrasíliaDFBrasilUniversidade de Brasília (UnB), Brasília, DF – Brasil.
| | - Flávio de Souza Brito
- Universidade Estadual Paulista Júlio de Mesquita FilhoSão PauloSPBrasilUniversidade Estadual Paulista Júlio de Mesquita Filho (UNESP), São Paulo, SP – Brasil.
| | - Germano Emílio Conceição Souza
- Hospital Alemão Oswaldo CruzSão PauloSPBrasilHospital Alemão Oswaldo Cruz, São Paulo, SP – Brasil.
- Hospital Regional de São José dos CamposSão PauloSPBrasilHospital Regional de São José dos Campos, São Paulo, SP – Brasil.
| | - Gustavo Calado de Aguiar Ribeiro
- Pontifícia Universidade Católica de CampinasCampinasSPBrasilPontifícia Universidade Católica de Campinas (PUCC), Campinas, SP – Brasil.
| | - Humberto Villacorta
- Universidade Federal FluminenseFaculdade de MedicinaNiteróiRJBrasilFaculdade de Medicina da Universidade Federal Fluminense (UFF), Niterói, RJ – Brasil.
| | - João David de Souza
- Hospital do Coração de MessejanaFortalezaCEBrasilHospital do Coração de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, CE – Brasil.
| | - Livia Adams Goldraich
- Hospital de Clínicas de Porto AlegrePorto AlegeRSBrasilHospital de Clínicas de Porto Alegre, Porto Alege, RS – Brasil.
| | - Luís Beck-da-Silva
- Hospital de Clínicas de Porto AlegrePorto AlegeRSBrasilHospital de Clínicas de Porto Alegre, Porto Alege, RS – Brasil.
- Universidade Federal do Rio Grande do SulPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS – Brasil.
| | - Manoel Fernandes Canesin
- Universidade Estadual de LondrinaHospital UniversitárioLondrinaPRBrasilHospital Universitário da Universidade Estadual de Londrina, Londrina, PR – Brasil.
| | - Marcelo Imbroinise Bittencourt
- Universidade do Estado do Rio de JaneiroRio de JaneiroRJBrasilUniversidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ – Brasil.
- Hospital Universitário Pedro ErnestoRio de JaneiroRJBrasilHospital Universitário Pedro Ernesto, Rio de Janeiro, RJ – Brasil.
| | - Marcely Gimenes Bonatto
- Hospital Santa Casa de Misericórdia de CuritibaCuritibaPRBrasilHospital Santa Casa de Misericórdia de Curitiba, Curitiba, PR – Brasil.
| | | | - Mônica Samuel Avila
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil.
| | - Otavio Rizzi Coelho
- Universidade Estadual de CampinasFaculdade de Ciências MédicasCampinasSPBrasilFaculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP – Brasil.
| | - Pedro Vellosa Schwartzmann
- Hospital Unimed Ribeirão PretoRibeirão PretoSPBrasilHospital Unimed Ribeirão Preto, Ribeirão Preto, SP – Brasil.
- Centro Avançado de PesquisaEnsino e Diagnóstico (CAPED)Ribeirão PretoSPBrasilCentro Avançado de Pesquisa, Ensino e Diagnóstico (CAPED), Ribeirão Preto, SP – Brasil.
| | - Ricardo Mourilhe-Rocha
- Universidade do Estado do Rio de JaneiroRio de JaneiroRJBrasilUniversidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ – Brasil.
| | - Sandrigo Mangini
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil.
| | - Silvia Moreira Ayub Ferreira
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil.
| | | | - Evandro Tinoco Mesquita
- Universidade Federal FluminenseFaculdade de MedicinaNiteróiRJBrasilFaculdade de Medicina da Universidade Federal Fluminense (UFF), Niterói, RJ – Brasil.
- Treinamento Edson de Godoy Bueno / UHGCentro de EnsinoRio de JaneiroRJBrasilCentro de Ensino e Treinamento Edson de Godoy Bueno / UHG, Rio de Janeiro, RJ – Brasil.
| |
Collapse
|
174
|
HFrEF: Dapaglifocin-Wirkung unabhängig von Nierenfunktion. AKTUELLE KARDIOLOGIE 2021. [DOI: 10.1055/a-1430-7372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
175
|
Packer M, McMurray JJ. Rapid evidence-based sequencing of foundational drugs for heart failure and a reduced ejection fraction. Eur J Heart Fail 2021; 23:882-894. [PMID: 33704874 PMCID: PMC8360176 DOI: 10.1002/ejhf.2149] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/18/2021] [Accepted: 03/09/2021] [Indexed: 12/11/2022] Open
Abstract
Foundational therapy for heart failure and a reduced ejection fraction consists of a combination of an angiotensin receptor-neprilysin inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist and a sodium-glucose co-transporter 2 (SGLT2) inhibitor. However, the conventional approach to the implementation is based on a historically-driven sequence that is not strongly evidence-based, typically requires ≥6 months, and frequently leads to major gaps in treatment. We propose a rapid sequencing strategy that is based on four principles. First, since drugs act rapidly to reduce morbidity and mortality, patients should be started on all four foundational treatments within 2-4 weeks. Second, since the efficacy of each foundational therapy is independent of treatment with the other drugs, priority can be determined by considerations of relative efficacy, safety and ease-of-use. Third, low starting doses of foundational drugs have substantial therapeutic benefits, and achievement of low doses of all four classes of drugs should take precedence over up-titration to target doses. Fourth, since drugs can influence the tolerability of other foundational agents, sequencing can be based on whether agents started earlier can enhance the safety of agents started simultaneously or later in the sequence. We propose an accelerated three-step approach, which consists of the simultaneous initiation of a beta-blocker and an SGLT2 inhibitor, followed 1-2 weeks later by the initiation of sacubitril/valsartan, and 1-2 weeks later by a mineralocorticoid receptor antagonist. The latter two steps can be re-ordered or compressed depending on patient circumstances. Rapid sequencing is a novel evidence-based strategy that has the potential to dramatically improve the implementation of treatments that reduce the morbidity and mortality of patients with heart failure and a reduced ejection fraction.
Collapse
Affiliation(s)
- Milton Packer
- Baylor University Medical CenterDallasTXUSA
- Imperial CollegeLondonUK
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
| |
Collapse
|
176
|
Mishra S, Kass DA. Cellular and molecular pathobiology of heart failure with preserved ejection fraction. Nat Rev Cardiol 2021; 18:400-423. [PMID: 33432192 PMCID: PMC8574228 DOI: 10.1038/s41569-020-00480-6] [Citation(s) in RCA: 183] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 01/30/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) affects half of all patients with heart failure worldwide, is increasing in prevalence, confers substantial morbidity and mortality, and has very few effective treatments. HFpEF is arguably the greatest unmet medical need in cardiovascular disease. Although HFpEF was initially considered to be a haemodynamic disorder characterized by hypertension, cardiac hypertrophy and diastolic dysfunction, the pandemics of obesity and diabetes mellitus have modified the HFpEF syndrome, which is now recognized to be a multisystem disorder involving the heart, lungs, kidneys, skeletal muscle, adipose tissue, vascular system, and immune and inflammatory signalling. This multiorgan involvement makes HFpEF difficult to model in experimental animals because the condition is not simply cardiac hypertrophy and hypertension with abnormal myocardial relaxation. However, new animal models involving both haemodynamic and metabolic disease, and increasing efforts to examine human pathophysiology, are revealing new signalling pathways and potential therapeutic targets. In this Review, we discuss the cellular and molecular pathobiology of HFpEF, with the major focus being on mechanisms relevant to the heart, because most research has focused on this organ. We also highlight the involvement of other important organ systems, including the lungs, kidneys and skeletal muscle, efforts to characterize patients with the use of systemic biomarkers, and ongoing therapeutic efforts. Our objective is to provide a roadmap of the signalling pathways and mechanisms of HFpEF that are being characterized and which might lead to more patient-specific therapies and improved clinical outcomes.
Collapse
Affiliation(s)
- Sumita Mishra
- Department of Medicine, Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David A. Kass
- Department of Medicine, Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pharmacology and Molecular Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,
| |
Collapse
|
177
|
Bueno H, Moura B, Lancellotti P, Bauersachs J. The year in cardiovascular medicine 2020: heart failure and cardiomyopathies. Eur Heart J 2021; 42:657-670. [PMID: 33388764 DOI: 10.1093/eurheartj/ehaa1061] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/26/2020] [Accepted: 12/22/2020] [Indexed: 12/22/2022] Open
Affiliation(s)
- Héctor Bueno
- Multidisciplinary Translational Cardiovascular Research Group. Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernández Almagro, 3, Madrid 28029, Spain.,Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital, 12 de Octubre (imas12), Madrid, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Plaza de Ramón y Cajal, s/n, 28040 Madrid, Spain
| | - Brenda Moura
- Cardiology Department, Military Hospital, Av. da Boavista S/N, 4050-115 Porto, Portugal.,CINTESIS-Center for Health Technology and Services Research, R. Dr. Plácido da Costa, 4200-450 Porto, Portugal
| | - Patrizio Lancellotti
- Department of Cardiology, CHU SartTilman, University of Liège Hospital, GIGA Cardiovascular Sciences, Avenue de L'Hôpital 1, 4000 Liège, Belgium.,Cardiology Departments, Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola Bari, Italy and Via Corriera, 1, 48033 Cotignola RA, Italy and Anthea Hospital, Via Camillo Rosalba, 35/37, 70124 Bari BA, Italy
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| |
Collapse
|
178
|
Santoro D, Torreggiani M, Pellicanò V, Cernaro V, Messina RM, Longhitano E, Siligato R, Gembillo G, Esposito C, Piccoli GB. Kidney Biopsy in Type 2 Diabetic Patients: Critical Reflections on Present Indications and Diagnostic Alternatives. Int J Mol Sci 2021; 22:5425. [PMID: 34063872 PMCID: PMC8196671 DOI: 10.3390/ijms22115425] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/11/2021] [Accepted: 05/18/2021] [Indexed: 12/15/2022] Open
Abstract
Roughly 3% of patients worldwide with a new diagnosis of type 2 diabetes mellitus (T2DM) already have an overt nephropathy at diagnosis and about 20-30% of the remaining ones develop a complication of this kind later in life. The early identification of kidney disease in diabetic patients is important as it slows its progression, which is important not only because this reduces the need for renal replacement therapy, but also because it decreases the high rate of mortality and morbidity associated with a reduction in kidney function. The increasing prevalence of type 2 diabetes and the consequent greater probability of finding different types of kidney diseases in diabetic patients frequently gives rise to overlapping diagnoses, a definition encompassing the differential diagnosis between diabetic and non-diabetic kidney disease. The issue is made more complex by the acknowledgement of the increasing frequency of presentations of what is termed "diabetic kidney disease" without relevant proteinuria, in particular in T2DM patients. Distinguishing between diabetes related and non-diabetes related forms of kidney disease in diabetic patients is not only a semantic question, as different diseases require different clinical management. However, while the urologic and macrovascular complications of diabetes, as well as overlapping parenchymal damage, can be diagnosed by means of imaging studies, often only a kidney biopsy will make a differential diagnosis possible. In fact, the coexistence of typical diabetic lesions, such as nodular glomerulopathy or glomerulosclerosis, with different glomerular, vascular and tubulo-interstitial alterations has been extensively described, and an analysis of the dominant histological pattern can contribute to determining what therapeutic approach should be adopted. However, due to the high frequency of kidney diseases, and to the fact that T2DM patients are often affected by multiple comorbidities, a kidney biopsy is not generally performed in T2DM patients. What follows is a review aiming to discuss the diagnostic work-up, on the base of clinical, laboratory and imaging criteria, and evaluate the present indications and alternatives to renal biopsy.
Collapse
Affiliation(s)
- Domenico Santoro
- Unit of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, 98124 Messina, Italy; (D.S.); (V.P.); (V.C.); (R.M.M.); (E.L.); (R.S.); (G.G.)
| | - Massimo Torreggiani
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France;
| | - Vincenzo Pellicanò
- Unit of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, 98124 Messina, Italy; (D.S.); (V.P.); (V.C.); (R.M.M.); (E.L.); (R.S.); (G.G.)
| | - Valeria Cernaro
- Unit of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, 98124 Messina, Italy; (D.S.); (V.P.); (V.C.); (R.M.M.); (E.L.); (R.S.); (G.G.)
| | - Roberta Maria Messina
- Unit of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, 98124 Messina, Italy; (D.S.); (V.P.); (V.C.); (R.M.M.); (E.L.); (R.S.); (G.G.)
| | - Elisa Longhitano
- Unit of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, 98124 Messina, Italy; (D.S.); (V.P.); (V.C.); (R.M.M.); (E.L.); (R.S.); (G.G.)
| | - Rossella Siligato
- Unit of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, 98124 Messina, Italy; (D.S.); (V.P.); (V.C.); (R.M.M.); (E.L.); (R.S.); (G.G.)
| | - Guido Gembillo
- Unit of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, 98124 Messina, Italy; (D.S.); (V.P.); (V.C.); (R.M.M.); (E.L.); (R.S.); (G.G.)
| | - Ciro Esposito
- Unit of Nephrology and Dialysis, Department of Internal Medicine, ICS Maugeri S.p.A. SB, University of Pavia, 27100 Pavia, Italy;
| | - Giorgina Barbara Piccoli
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France;
| |
Collapse
|
179
|
Rosano GMC, Moura B, Metra M, Böhm M, Bauersachs J, Ben Gal T, Adamopoulos S, Abdelhamid M, Bistola V, Čelutkienė J, Chioncel O, Farmakis D, Ferrari R, Filippatos G, Hill L, Jankowska EA, Jaarsma T, Jhund P, Lainscak M, Lopatin Y, Lund LH, Milicic D, Mullens W, Pinto F, Ponikowski P, Savarese G, Thum T, Volterrani M, Anker SD, Seferovic PM, Coats AJS. Patient profiling in heart failure for tailoring medical therapy. A consensus document of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2021; 23:872-881. [PMID: 33932268 DOI: 10.1002/ejhf.2206] [Citation(s) in RCA: 150] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/17/2021] [Accepted: 04/29/2021] [Indexed: 12/22/2022] Open
Abstract
Despite guideline recommendations and available evidence, implementation of treatment in heart failure (HF) is poor. The majority of patients are not prescribed drugs at target doses that have been proven to positively impact morbidity and mortality. Among others, tolerability issues related to low blood pressure, heart rate, impaired renal function or hyperkalaemia are responsible. Chronic kidney disease plays an important role as it affects up to 50% of patients with HF. Also, dynamic changes in estimated glomerular filtration rate may occur during the course of HF, resulting in inappropriate dose reduction or even discontinuation of decongestive or neurohormonal modulating therapy in clinical practice. As patients with HF are rarely naïve to pharmacologic therapies, the challenge is to adequately prioritize or select the most appropriate up-titration schedule according to patient profile. In this consensus document, we identified nine patient profiles that may be relevant for treatment implementation in HF patients with a reduced ejection fraction. These profiles take into account heart rate (<60 bpm or >70 bpm), the presence of atrial fibrillation, symptomatic low blood pressure, estimated glomerular filtration rate (<30 or >30 mL/min/1.73 m2 ) or hyperkalaemia. The pre-discharge patient, frequently still congestive, is also addressed. A personalized approach, adjusting guideline-directed medical therapy to patient profile, may allow to achieve a better and more comprehensive therapy for each individual patient than the more traditional, forced titration of each drug class before initiating treatment with the next.
Collapse
Affiliation(s)
| | - Brenda Moura
- Armed Forces Hospital, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - Marco Metra
- Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Tuvia Ben Gal
- Department of Cardiology, Rabin Medical Centre, Petah Tikva, Israel
| | | | - Magdy Abdelhamid
- Faculty of Medicine, Department of Cardiology, Cairo University, Giza, Egypt
| | - Vasiliki Bistola
- Department of Cardiology, Attikon University Hospital, University of Athens Medical School, Athens, Greece
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, State Research Institute Centre for Innovative Medicine, Vilnius, Lithuania
| | - Ovidiu Chioncel
- University of Medicine Carol Davila, Bucharest, Romania.,Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
| | | | - Roberto Ferrari
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy.,Centro Cardiologico Universitario di Ferrara, University of Ferrara, Ferrara, Italy
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, University Hospital Attikon, Athens, Greece
| | - Loreena Hill
- School of Nursing and Midwifery, Queen's University Belfast, Northern Ireland, UK
| | - Ewa A Jankowska
- Department of Heart Diseases, Wroclaw Medical University and Center for Heart Diseases, University Hospital in Wroclaw, Wroclaw, Poland
| | - Tiny Jaarsma
- Department of Health, Medicine and Caring Sciences, Linkoping University, Linköping, Sweden.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pardeep Jhund
- Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Yuri Lopatin
- Volgograd State Medical University, Regional Cardiology Centre Volgograd, Volgograd, Russian Federation
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Davor Milicic
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Wilfried Mullens
- Faculty of Medicine and Life Sciences, BIOMED - Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium.,Department of Cardiology, Ziekenhuis Oost, Genk, Belgium
| | - Fausto Pinto
- Cardiology Department, University Hospital Santa Maria (CHULN), CAML, CCUL, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Piotr Ponikowski
- Centre for Heart Diseases, Faculty of Health Sciences, Wroclaw Medical University, Wroclaw, Poland
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Thum
- Hannover Medical School, Institute of Molecular and Translational Therapeutic Strategies, Hannover, Germany
| | | | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Petar M Seferovic
- Department Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | | |
Collapse
|
180
|
Abstract
Despite multiple attempts to develop a unifying hypothesis that explains the pathophysiology of heart failure with a reduced ejection fraction (HFrEF), no single conceptual model has withstood the test of time. In the present review, we discuss how the results of recent successful phase III clinical development programs in HFrEF are built upon existing conceptual models for drug development. We will also discuss where recent successes in clinical trials do not fit existing models to identify areas where further refinement of current paradigms may be needed. To provide the necessary structure for this review, we will begin with a brief overview of the pathophysiology of HFrEF, followed by an overview of the current conceptual models for HFrEF, and end with an analysis of the scientific rationale and clinical development programs for 4 new therapeutic classes of drugs that have improved clinical outcomes in HFrEF. The 4 new therapeutic classes discussed are ARNIs, SGLT2 (sodium-glucose cotransporter 2) inhibitors, soluble guanylate cyclase stimulators, and myosin activators. With the exception of SGLT2 inhibitors, each of these therapeutic advances was informed by the insights provided by existing conceptual models of heart failure. Although the quest to determine the mechanism of action of SGLT2 inhibitors is ongoing, this therapeutic class of drugs may represent the most important advance in cardiovascular therapeutics of recent decades and may lead to rethinking or expanding our current conceptual models for HFrEF.
Collapse
Affiliation(s)
- Douglas L. Mann
- Center for Cardiovascular Research, Washington University School of Medicine, St. Louis, MO 63108
| | - G. Michael Felker
- Center for Cardiovascular Research, Washington University School of Medicine, St. Louis, MO 63108
| |
Collapse
|
181
|
Patel RB, Fonarow GC, Greene SJ, Zhang S, Alhanti B, DeVore AD, Butler J, Heidenreich PA, Huang JC, Kittleson MM, Joynt Maddox KE, McDermott JJ, Owens AT, Peterson PN, Solomon SD, Vardeny O, Yancy CW, Vaduganathan M. Kidney Function and Outcomes in Patients Hospitalized With Heart Failure. J Am Coll Cardiol 2021; 78:330-343. [PMID: 33989713 DOI: 10.1016/j.jacc.2021.05.002] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 04/28/2021] [Accepted: 05/03/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Few contemporary data exist evaluating care patterns and outcomes in heart failure (HF) across the spectrum of kidney function. OBJECTIVES This study sought to characterize differences in quality of care and outcomes in patients hospitalized for HF by degree of kidney dysfunction. METHODS Guideline-directed medical therapies were evaluated among patients hospitalized with HF at 418 sites in the GWTG-HF (Get With The Guidelines-Heart Failure) registry from 2014 to 2019 by discharge CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration)-derived estimated glomerular filtration rate (eGFR). We additionally evaluated the risk-adjusted association of admission eGFR with in-hospital mortality. RESULTS Among 365,494 hospitalizations (age 72 ± 15 years, left ventricular ejection fraction [EF]: 43 ± 17%), median discharge eGFR was 51 ml/min/1.73 m2 (interquartile range: 34 to 72 ml/min/1.73 m2), 234,332 (64%) had eGFR <60 ml/min/1.73 m2, and 18,869 (5%) were on dialysis. eGFR distribution remained stable from 2014 to 2019. Among 157,439 patients with HF with reduced EF (≤40%), discharge guideline-directed medical therapies, including beta-blockers, were lowest in discharge eGFR <30 mL/min/1.73 m2 or dialysis (p < 0.001). "Triple therapy" with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor + beta-blocker + mineralocorticoid receptor antagonist was used in 38%, 33%, 25%, 15%, 5%, and 3% for eGFR ≥90, 60 to 89, 45 to 59, 30 to 44, <30 ml/min/1.73 m2, and dialysis, respectively; p < 0.001. Mortality was higher in a graded fashion at lower admission eGFR groups (1.1%, 1.5%, 2.0%, 3.0%, 5.0%, and 4.2%, respectively; p < 0.001). Steep covariate-adjusted associations between admission eGFR and mortality were observed across EF subgroups, but was slightly stronger for HF with reduced EF compared with HF with mid-range or preserved EF (pinteraction = 0.045). CONCLUSIONS Despite facing elevated risks of mortality, patients with comorbid HF with reduced EF and kidney disease are not optimally treated with evidence-based medical therapies, even at levels of eGFR where such therapies would not be contraindicated by kidney dysfunction. Further efforts are required to mitigate risk in comorbid HF and kidney disease.
Collapse
Affiliation(s)
- Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA. https://twitter.com/RBPatelMD
| | - Gregg C Fonarow
- Ahmanson-University of California, Los Angeles Cardiomyopathy Center, University of California-Los Angeles, Los Angeles, California, USA.
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA. https://twitter.com/SJGreene_md
| | - Shuaiqi Zhang
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Brooke Alhanti
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Adam D DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA. https://twitter.com/_adevore
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA. https://twitter.com/JavedButler1
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | | | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, California, USA. https://twitter.com/MKIttlesonMD
| | - Karen E Joynt Maddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri, USA. https://twitter.com/kejoynt
| | | | - Anjali Tiku Owens
- Heart and Vascular Center, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA. https://twitter.com/tikuowens
| | - Pamela N Peterson
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA; Department of Medicine, Anschutz Medical Center, Aurora, Colorado, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/scottdsolomon
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, University of Minnesota, Minnesota, USA. https://twitter.com/orlyvardeny
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/mvaduganathan
| |
Collapse
|
182
|
Bai Y, Jin J, Zhou W, Zhang S, Xu J. The safety outcomes of sodium-glucose cotransporter 2 inhibitors in patients with different renal function: A systematic review and meta-analysis. Nutr Metab Cardiovasc Dis 2021; 31:1365-1374. [PMID: 33812735 DOI: 10.1016/j.numecd.2021.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/29/2020] [Accepted: 02/05/2021] [Indexed: 01/10/2023]
Abstract
AIMS We aimed to assess whether the safety outcomes exerted by sodium-glucose cotransporter 2 (SGLT2) inhibitors were associated with different renal function at baseline. DATA SYNTHESIS We searched randomized controlled trials comparing SGLT2 inhibitors with placebo in participants simultaneously involving the entire range of estimated glomerular filtration rate (eGFR) levels at baseline in one study. According to eGFR, we divided the population into two subgroups with eGFR <60 ml/min/1.73 m2 and eGFR≥60 ml/min/1.73 m2. Data from the CANVAS program, CREDENCE, EMPA-REG OUTCOME, DECLARE-TIMI 58, DAPA-HF, and EMPA-REG RENAL were included. SGLT2 inhibitors significantly reduced the risk of all serious adverse events (HR 0.91 [95% CI 0.87 to 0.95], p < 0.001) and acute kidney injury (HR 0.74 [95% CI 0.64 to 0.85], p < 0.001). Except for high risk of genital infection, SGLT2 inhibitors did not increase the risk of amputation, fracture, hyperkalemia, hypoglycemia, volume depletion, or urinary tract infection. Further analyses showed that these safety outcomes were similar between subgroups (p-interaction > 0.05). For osmotic diuresis, SGLT2 inhibitors significantly increased the risk by 75% (p = 0.036), and subgroup analyses showed that this effect was completely attributed to the increase in patients with eGFR ≥60 ml/min/1.73 m2 (p-interaction<0.001). CONCLUSION The indication of no risk of osmotic diuresis in patients with eGFR<60 ml/min/1.73 m2 and the consistency of other safety outcomes across different baseline renal function may allow additional individuals to safely use SGLT2 inhibitors.
Collapse
Affiliation(s)
- Yaling Bai
- Departments of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Jingjing Jin
- Departments of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Wei Zhou
- Departments of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Shenglei Zhang
- Departments of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Jinsheng Xu
- Departments of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, PR China.
| |
Collapse
|
183
|
Abstract
PURPOSE OF REVIEW Sodium-glucose cotransporter 2 (SGLT2) inhibitors have proven cardiorenal protection in patients with diabetes and chronic kidney disease (CKD) as seen in cardiovascular outcome trials (CVOTs) and CREDENCE. In this review, we aim to discuss the mechanisms of kidney protection with SGLT2 inhibition as well as review the results of multiple translational studies and clinical trials of SGLT2 inhibition in the nondiabetic kidney disease (non-DKD) population. RECENT FINDINGS The application of SGLT2 inhibitors as dedicated kidney-protective agents continues to evolve with the publication of the dapagliflozin in patients with chronic kidney disease (DAPA CKD) trial, which extends their cardiorenal protection to patients with nondiabetic CKD. This trial was preceded by CREDENCE, a dedicated kidney outcome study in participants with DKD that demonstrated a 30% reduction in the risk of the composite kidney outcome. From a physiological perspective, mechanistic benefits of SGLT2 inhibitors are independent of their glucose-lowering effects as demonstrated in preclinical studies and post hoc analyses of dedicated CVOTs in participants with type 2 diabetes. From a clinical perspective, there is a growing body of evidence for kidney protection in nondiabetes mellitus patients. SUMMARY There exists strong rationale for SGLT2 inhibition to be incorporated into standard of care for appropriate groups of patients with nondiabetic kidney disease.
Collapse
|
184
|
Sen T, Heerspink HJL. A kidney perspective on the mechanism of action of sodium glucose co-transporter 2 inhibitors. Cell Metab 2021; 33:732-739. [PMID: 33691091 DOI: 10.1016/j.cmet.2021.02.016] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/25/2020] [Accepted: 02/17/2021] [Indexed: 02/07/2023]
Abstract
Sodium glucose co-transporter (SGLT) 2 inhibitors reduce the risk of kidney failure in patients with and without type 2 diabetes (T2D). Although the precise underlying mechanisms for these nephroprotective effects are incompletely understood, various hypotheses have been proposed including reductions in intraglomerular pressure through restoration of tubuloglomerular feedback, blood pressure reduction and favorable effects on vascular function, reduction in tubular workload and hypoxia, and metabolic effects resulting in increased autophagy. Here, we review these mechanisms, which may also explain the beneficial effects of SGLT2 inhibitors on kidney function in patients without T2D.
Collapse
Affiliation(s)
- Taha Sen
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; The George Institute for Global Health, Sydney, Australia.
| |
Collapse
|
185
|
McDonald M, Virani S, Chan M, Ducharme A, Ezekowitz JA, Giannetti N, Heckman GA, Howlett JG, Koshman SL, Lepage S, Mielniczuk L, Moe GW, O'Meara E, Swiggum E, Toma M, Zieroth S, Anderson K, Bray SA, Clarke B, Cohen-Solal A, D'Astous M, Davis M, De S, Grant ADM, Grzeslo A, Heshka J, Keen S, Kouz S, Lee D, Masoudi FA, McKelvie R, Parent MC, Poon S, Rajda M, Sharma A, Siatecki K, Storm K, Sussex B, Van Spall H, Yip AMC. CCS/CHFS Heart Failure Guidelines Update: Defining a New Pharmacologic Standard of Care for Heart Failure With Reduced Ejection Fraction. Can J Cardiol 2021; 37:531-546. [PMID: 33827756 DOI: 10.1016/j.cjca.2021.01.017] [Citation(s) in RCA: 141] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/15/2021] [Accepted: 01/16/2021] [Indexed: 12/14/2022] Open
Abstract
In this update of the Canadian Cardiovascular Society heart failure (HF) guidelines, we provide comprehensive recommendations and practical tips for the pharmacologic management of patients with HF with reduced ejection fraction (HFrEF). Since the 2017 comprehensive update of the Canadian Cardiovascular Society guidelines for the management of HF, substantial new evidence has emerged that has informed the care of these patients. In particular, we focus on the role of novel pharmacologic therapies for HFrEF including angiotensin receptor-neprilysin inhibitors, sinus node inhibitors, sodium glucose transport 2 inhibitors, and soluble guanylate cyclase stimulators in conjunction with other long established HFrEF therapies. Updated recommendations are also provided in the context of the clinical setting for which each of these agents might be prescribed; the potential value of each therapy is reviewed, where relevant, for chronic HF, new onset HF, and for HF hospitalization. We define a new standard of pharmacologic care for HFrEF that incorporates 4 key therapeutic drug classes as standard therapy for most patients: an angiotensin receptor-neprilysin inhibitor (as first-line therapy or after angiotensin converting enzyme inhibitor/angiotensin receptor blocker titration); a β-blocker; a mineralocorticoid receptor antagonist; and a sodium glucose transport 2 inhibitor. Additionally, many patients with HFrEF will have clinical characteristics for which we recommended other key therapies to improve HF outcomes, including sinus node inhibitors, soluble guanylate cyclase stimulators, hydralazine/nitrates in combination, and/or digoxin. Finally, an approach to management that integrates prioritized pharmacologic with nonpharmacologic and invasive therapies after a diagnosis of HFrEF is highlighted.
Collapse
Affiliation(s)
- Michael McDonald
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.
| | - Sean Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael Chan
- University of Alberta, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Anique Ducharme
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | - George A Heckman
- Schlegel-University of Waterloo Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - Jonathan G Howlett
- Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | | | - Serge Lepage
- Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Lisa Mielniczuk
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Gordon W Moe
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Elizabeth Swiggum
- Royal Jubilee Hospital, University of British Columbia, Victoria, British Columbia, Canada
| | - Mustafa Toma
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Kim Anderson
- Dalhousie University QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Sharon A Bray
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Brian Clarke
- Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | | | | | - Margot Davis
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Sabe De
- London Health Sciences, Western University, London, Ontario, Canada
| | - Andrew D M Grant
- Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Adam Grzeslo
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jodi Heshka
- Ottawa Cardiovascular Centre, Ottawa, Ontario, Canada
| | - Sabina Keen
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Simon Kouz
- Centre Intégré de Santé et de Services Sociaux de Lanaudière - Centre Hospitalier de Lanaudière, Joliette, Québec, Canada
| | - Douglas Lee
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Robert McKelvie
- St Joseph's Health Care, Western University, London, Ontario, Canada
| | - Marie-Claude Parent
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Stephanie Poon
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Miroslaw Rajda
- Dalhousie University QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | | | | | - Kate Storm
- Dalhousie University QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Bruce Sussex
- Memorial University, St John's, Newfoundland, Canada
| | | | | |
Collapse
|
186
|
Lee JF, Berzan E, Sridhar VS, Odutayo A, Cherney DZ. Cardiorenal Protection in Diabetic Kidney Disease. Endocrinol Metab (Seoul) 2021; 36:256-269. [PMID: 33873265 PMCID: PMC8090466 DOI: 10.3803/enm.2021.987] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/26/2021] [Indexed: 12/21/2022] Open
Abstract
Over the last 5 years there have been many new developments in the management of diabetic kidney disease. Glucagon-like peptide-1 receptor agonists (GLP-1 RA) and sodium-glucose cotransporter-2 (SGLT2) inhibitors were initially used for glycemic control, but more recent studies have now shown that their benefits extend to cardiovascular and kidney outcomes. The recent addition of data on the novel mineralocorticoid receptor antagonist (MRA) gives us another approach to further decrease the residual risk of diabetic kidney disease progression. In this review we describe the mechanism of action, key studies, and possible adverse effects related to these three classes of medications. The management of type 2 diabetes now includes an increasing number of medications for the management of comorbidities in a patient population at significant risk of cardiovascular disease and progression of chronic kidney disease. It is from this perspective that we seek to outline the rationale for the sequential and/or combined use of SGLT2 inhibitors, GLP-1 RA and MRAs in patients with type 2 diabetes for heart and kidney protection.
Collapse
Affiliation(s)
- Jason F. Lee
- Toronto General Hospital Research Institute, University Health Network, ON, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
| | - Ecaterina Berzan
- Toronto General Hospital Research Institute, University Health Network, ON, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
| | - Vikas S. Sridhar
- Toronto General Hospital Research Institute, University Health Network, ON, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
- Banting and Best Diabetes Centre, University of Toronto, ON, Canada
| | - Ayodele Odutayo
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael’s Hospital, ON, Canada
| | - David Z.I. Cherney
- Toronto General Hospital Research Institute, University Health Network, ON, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
- Banting and Best Diabetes Centre, University of Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
187
|
|
188
|
Satoh K. Sirtuin-7 as a Novel Therapeutic Target in Vascular Smooth Muscle Cell Proliferation and Remodeling. Circ J 2021; 85:2241-2242. [PMID: 33762514 DOI: 10.1253/circj.cj-21-0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kimio Satoh
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| |
Collapse
|
189
|
Docherty KF, Curtain JP, Anand IS, Bengtsson O, Inzucchi SE, Køber L, Kosiborod MN, Langkilde AM, Martinez FA, Ponikowski P, Sabatine MS, Schou M, Sjöstrand M, Solomon SD, Jhund PS, McMurray JJV. Effect of dapagliflozin on anaemia in DAPA-HF. Eur J Heart Fail 2021; 23:617-628. [PMID: 33615642 DOI: 10.1002/ejhf.2132] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/13/2021] [Accepted: 02/15/2021] [Indexed: 01/29/2023] Open
Abstract
AIM Anaemia is common in heart failure and associated with worse outcomes. We examined the effect of dapagliflozin on correction of anaemia in patients with heart failure (HF) and reduced ejection fraction in DAPA-HF. We also analysed the effect of dapagliflozin on outcomes, according to anaemia status at baseline. METHODS AND RESULTS Anaemia was defined at baseline as a haematocrit <39% in men and <36% in women. Resolution of anaemia was defined as two consecutive haematocrit measurements above these thresholds at any time during follow-up. The primary outcome was a composite of worsening HF (hospitalization or urgent visit requiring intravenous therapy) or cardiovascular death. Of the 4744 patients randomized in DAPA-HF, 4691 had a haematocrit available at baseline, of which 1032 were anaemic (22.0%). The rate of the primary outcome was higher in patients with anaemia (16.1 per 100 person-years) compared with those without (12.9 per 100 person-years). Anaemia was corrected in 62.2% of patients in the dapagliflozin group, compared with 41.1% of patients in the placebo group. The effect of dapagliflozin on the primary outcome was consistent in anaemic compared with non-anaemic patients [hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.52-0.88 vs. HR 0.76, 95% CI 0.65-0.89; interaction P = 0.44]. Similar findings were observed for cardiovascular death, HF hospitalization, and all-cause mortality. Patients with resolution of anaemia had better outcomes than those in which anaemia persisted. CONCLUSION Patients with anaemia had worse outcomes in DAPA-HF. Dapagliflozin corrected anaemia more often than placebo and improved outcomes, irrespective of anaemia status at baseline.
Collapse
Affiliation(s)
- Kieran F Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - James P Curtain
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Inder S Anand
- Department of Cardiovascular Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | - Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | - Lars Køber
- Rigshospitalet Copenhagen, University Hospital, Copenhagen, Denmark
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, USA.,The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | | | | | | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Morten Schou
- Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark
| | | | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | |
Collapse
|
190
|
Sodium/glucose cotransporter 2 inhibitors in chronic kidney disease and heart failure: ready for prime time in patients without diabetes. Curr Opin Nephrol Hypertens 2021; 30:361-368. [PMID: 33767064 DOI: 10.1097/mnh.0000000000000703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW The benefits of sodium/glucose cotransporter 2 (SGLT2) inhibitors seem to extend beyond glycemic control. We review recent randomized trial evidence evaluating SGLT2 inhibition in nondiabetic settings, including in patients with chronic kidney disease (CKD) and heart failure (HF). RECENT FINDINGS DAPA-CKD, DAPA-HF and EMPEROR-Reduced compared SGLT2 inhibitors to placebo, enrolling 5868 patients without diabetes. In DAPA-CKD, patients with an estimated glomerular filtration rate (eGFR) of 25-75 ml/min/1.73 m2 and macroalbuminuria irrespective of kidney disease aetiology had improved cardiovascular and kidney outcomes if randomized to receive SGLT2 inhibitors (primary composite endpoint: hazard ratio [HR] 0.61, 95% CI 0.51-0.72; absolute risk reduction [ARR] 5.3%). In DAPA-HF and EMPEROR-Reduced, participants with reduced ejection fraction (HFrEF) had improved cardiovascular outcomes when an SGLT2 inhibitor was added to guideline-directed medical therapy, mainly through a reduction in HF hospitalizations (HR 0.70, 95% CI 0.59-0.83; ARR 3.7% and HR 0.69, 95% CI 0.59-0.81; ARR 5.1% with dapagliflozin and empagliflozin, respectively). In all 3 trials, the benefits were not modified by diabetes, baseline eGFR or proteinuria. SUMMARY SGLT2 inhibitors improve kidney and HF outcomes in patients with high-risk CKD and HFrEF, irrespective of diabetes. Clinicians should become more comfortable prescribing these medications as we await studies that may further broaden their indications.
Collapse
|
191
|
Abstract
Diabetes and heart failure (HF) are common diseases, each affecting large segments of the world population. Moreover, prevalence rates for both are expected to rise dramatically over coming decades. The high prevalence rates of both diseases and wellrecognized association of diabetes as a risk factor for HF make it inevitable that both diseases co-exist in a large number of patients, complicating their management and increasing the risk of a poor outcome. Management of diabetes has been shown to impact clinical events in patients with HF and there is emerging evidence that agents used to treat diabetes can reduce HF events, even in non-diabetic patients. In this review we summarize the clinical course and treatment of patients with type 2 diabetes mellitus (T2DM) and HF and review the efficacy and safety of pharmacological agents in patients with T2DM at risk for HF and those with established disease.
Collapse
Affiliation(s)
- Jia Shen
- Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Barry H. Greenberg
- Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
- Corresponding author: Barry H. Greenberg https://orcid.org/0000-0002-6605-9385 Division of Cardiology, Department of Medicine, UC San Diego Health Cardiovascular Institute, 9452 Medical Center Drive, La Jolla, CA 92037-7411, USA E-mail:
| |
Collapse
|
192
|
Affiliation(s)
- Amy Kang
- Renal and Metabolic Division, The George Institute for Global Health, UNSW Sydney, Sydney, Australia.,Prince of Wales Hospital, Sydney, Australia
| | - Meg J Jardine
- Renal and Metabolic Division, The George Institute for Global Health, UNSW Sydney, Sydney, Australia. .,NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia. .,Concord Repatriation General Hospital, Sydney, Australia.
| |
Collapse
|
193
|
Carnicelli AP, Mentz RJ. Sodium-Glucose Cotransporter 2 Inhibitors in Patients With Heart Failure With Reduced Ejection Fraction: The Heart and Kidney Working Better Together. Circulation 2021; 143:322-325. [PMID: 33493029 DOI: 10.1161/circulationaha.120.052048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Anthony P Carnicelli
- Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC
| | - Robert J Mentz
- Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC
| |
Collapse
|
194
|
Ferrari F, Martins VM, Scheffel RS, da Silveira AD, Motta MT, Moriguchi EH, Santos RD, Stein R. The Role of Sodium-Glucose Cotransporter-2 Inhibitors in Patients With Heart Failure, Regardless of Diabetes Status: Focus on Cardiovascular Disease. Ann Pharmacother 2021; 55:1267-1275. [PMID: 33401940 DOI: 10.1177/1060028020985111] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To provide clinical guidance and an overview of the available data on the use of sodium-glucose cotransporter-2 (SGLT2) inhibitors in patients with heart failure with reduced ejection fraction (HFrEF), regardless of the presence of type 2 diabetes mellitus (T2DM). DATA SOURCES We searched the MEDLINE database via PubMed (from January 2015 to November 2020) for the following key terms: SGLT2 inhibitors, sodium-glucose co-transporter-2 inhibitors, SGLT2i, heart failure, and heart failure with reduced ejection fraction. STUDY SELECTION AND DATA EXTRACTION To be included in the review, the articles needed to assess the effects of SGLT2 inhibitors in the heart failure (HF) scenario. DATA SYNTHESIS There is consistent evidence that SGLT2 inhibitors reduce the risk of major adverse cardiovascular (CV) events and hospitalization in patients with HFrEF, even in the absence of T2DM. On May 5, 2020, the U.S. Food and Drug Administration approved dapagliflozin for adults with HFrEF, regardless of the presence of T2DM, even in those patients on standard therapy, including an angiotensin receptor/neprilysin inhibitor. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE The SGLT2 inhibitors are well tolerated, and their once-daily dosing without the need for adjustments is convenient. These drugs can be considered a major breakthrough in pharmacotherapy for HF, providing physicians with a new treatment approach to reduce major clinical outcomes. CONCLUSIONS SGLT2 inhibitor therapy reduces CV death and hospitalizations in HFrEF patients regardless of T2DM. The decision to prescribe this class of drugs should not be determined by glycemic status.
Collapse
Affiliation(s)
- Filipe Ferrari
- Postgraduate Program in Cardiology and Cardiovascular Sciences, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul School of Medicine, Porto Alegre, RS, Brazil.,Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Vítor M Martins
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Rafael S Scheffel
- Department of Pharmacology, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul School of Medicine, Porto Alegre, RS, Brazil
| | - Anderson D da Silveira
- Postgraduate Program in Cardiology and Cardiovascular Sciences, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul School of Medicine, Porto Alegre, RS, Brazil.,Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Emilio H Moriguchi
- Postgraduate Program in Cardiology and Cardiovascular Sciences, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul School of Medicine, Porto Alegre, RS, Brazil.,School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Raul D Santos
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.,Lipid Clinic, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ricardo Stein
- Postgraduate Program in Cardiology and Cardiovascular Sciences, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul School of Medicine, Porto Alegre, RS, Brazil.,School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| |
Collapse
|
195
|
Wheeler DC, Stefánsson BV, Jongs N, Chertow GM, Greene T, Hou FF, McMurray JJV, Correa-Rotter R, Rossing P, Toto RD, Sjöström CD, Langkilde AM, Heerspink HJL. Effects of dapagliflozin on major adverse kidney and cardiovascular events in patients with diabetic and non-diabetic chronic kidney disease: a prespecified analysis from the DAPA-CKD trial. Lancet Diabetes Endocrinol 2021; 9:22-31. [PMID: 33338413 DOI: 10.1016/s2213-8587(20)30369-7] [Citation(s) in RCA: 266] [Impact Index Per Article: 88.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/16/2020] [Accepted: 10/16/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Dapagliflozin reduces the risk of kidney failure and heart failure in patients with chronic kidney disease. We aimed to investigate the effects of dapagliflozin on kidney, cardiovascular, and mortality outcomes according to presence or absence of type 2 diabetes and according to underlying cause of chronic kidney disease, reported as diabetic nephropathy, chronic glomerulonephritides, ischaemic or hypertensive chronic kidney disease, or chronic kidney disease of other or unknown cause. METHODS DAPA-CKD was a multicentre, double-blind, placebo-controlled, randomised trial done at 386 study sites in 21 countries, in which participants with a urinary albumin-to-creatinine ratio of 200-5000 mg/g and an estimated glomerular filtration rate (eGFR) of 25-75 mL/min per 1·73m2 were randomly assigned (1:1) to dapagliflozin 10 mg once daily or matching placebo, as an adjunct to standard care. The primary outcome was a composite of sustained decline in eGFR of at least 50%, end-stage kidney disease, or kidney-related or cardiovascular death. Secondary efficacy outcomes were a kidney-specific composite (the same as the primary outcome but excluding cardiovascular death), a composite of cardiovascular death or hospital admission for heart failure, and all-cause mortality. In this study, we conducted a prespecified subgroup analysis of the DAPA-CKD primary and secondary endpoints by presence or absence of type 2 diabetes and by aetiology of chronic kidney disease. DAPA-CKD is registered with ClinicalTrials.gov, NCT03036150. FINDINGS The study took place between Feb 2, 2017, and June 12, 2020. 4304 participants were randomly assigned (2152 to dapagliflozin and 2152 to placebo) and were followed up for a median of 2·4 years (IQR 2·0-2·7). Overall, 2906 (68%) participants had a diagnosis of type 2 diabetes, of whom 396 (14%) had chronic kidney disease ascribed to causes other than diabetic nephropathy. The relative risk reduction for the primary composite outcome with dapagliflozin was consistent in participants with type 2 diabetes (hazard ratio [HR] 0·64, 95% CI 0·52-0·79) and those without diabetes (0·50, 0·35-0·72; pinteraction=0·24). Similar findings were seen for the secondary outcomes: kidney-specific composite outcome (0·57 [0·45-0·73] vs 0·51 [0·34-0·75]; Pinteraction=0·57), cardiovascular death or hospital admission for heart failure (0·70 [0·53-0·92] vs 0·79 [0·40-1·55]; Pinteraction=0·78), and all-cause mortality (0·74 [0·56-0·98] vs 0·52 [0·29-0·93]; Pinteraction=0·25). The effect of dapagliflozin on the primary outcome was also consistent among patients with diabetic nephropathy (n=2510; HR 0·63, 95% CI 0·51-0·78), glomerulonephritides (n=695; 0·43, 0·26-0·71), ischaemic or hypertensive chronic kidney disease (n=687; 0·75, 0·44-1·26), and chronic kidney disease of other or unknown cause (n=412; 0·58, 0·29-1·19; Pinteraction=0·53), with similar consistency seen across the secondary outcomes. The proportions of participants in the dapagliflozin and placebo groups who had serious adverse events or discontinued study drug due to adverse events did not vary between those with and those without type 2 diabetes. INTERPRETATION Dapagliflozin reduces the risks of major adverse kidney and cardiovascular events and all-cause mortality in patients with diabetic and non-diabetic chronic kidney disease. FUNDING AstraZeneca.
Collapse
Affiliation(s)
- David C Wheeler
- Department of Renal Medicine, University College London, London, UK; The George Institute for Global Health, Sydney, NSW, Australia.
| | - Bergur V Stefánsson
- Late-Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Glenn M Chertow
- Departments of Medicine and Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Tom Greene
- Study Design and Biostatistics Center, University of Utah Health Sciences, Salt Lake City, UT, USA
| | - Fan Fan Hou
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, Guangzhou, China
| | - John J V McMurray
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Ricardo Correa-Rotter
- National Medical Science and Nutrition Institute Salvador Zubirán, Mexico City, Mexico
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Robert D Toto
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - C David Sjöström
- Late-Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Hiddo J L Heerspink
- The George Institute for Global Health, Sydney, NSW, Australia; Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | | |
Collapse
|
196
|
Packer M, Butler J, Filippatos G, Zannad F, Ferreira JP, Zeller C, Brueckmann M, Jamal W, Pocock SJ, Anker SD. Design of a prospective patient-level pooled analysis of two parallel trials of empagliflozin in patients with established heart failure. Eur J Heart Fail 2020; 22:2393-2398. [PMID: 33251659 PMCID: PMC7898542 DOI: 10.1002/ejhf.2065] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 11/20/2020] [Accepted: 11/25/2020] [Indexed: 12/15/2022] Open
Abstract
Aim The EMPEROR‐Reduced trial demonstrated that empagliflozin reduced the combined risk of cardiovascular death or hospitalization for heart failure in patients with a reduced ejection fraction, and the EMPEROR‐Preserved trial is currently evaluating the effect of the drug on the same endpoint in patients with an ejection fraction >40%. However, neither the trial was designed to have adequate statistical power to evaluate the effects of empagliflozin and dapagliflozin on major adverse renal outcomes or on mortality. Herein we describe the design of a prospective individual patient‐level pooled analysis of two large‐scale trials with empagliflozin (EMPEROR‐Reduced and EMPEROR‐Preserved) in patients with heart failure across the spectrum of ejection fraction. Methods The trials were carried out in parallel using the same administrative structure and committees, randomization procedure, schedule of study visits and adjudication criteria and similar groups of investigators and case report forms. The two component trials specified the same primary and key secondary endpoints and used an identical hierarchical testing procedure, which included a pooled analysis of the two trials as a key component of the hierarchy. Consequently, the pooled analysis has been prospectively assigned a false positive error rate, which is conditional on one or both trials first achieving success on their primary and one or both key secondary endpoints. The pooled analysis has its own statistical plan with its own endpoints, and this plan was finalized before either trial had begun recruitment of patients into either study. The primary endpoint of the pooled analysis is a composite of serious adverse renal outcomes, defined by chronic dialysis, renal transplantation and a profound or sustained decrease in glomerular filtration rate. All‐cause and cardiovascular mortality are specified as secondary endpoints. Conclusion The planned pooled analysis has an unusually high degree of statistical rigour that will allow it to address important questions that cannot be fully addressed by the individual trials.
Collapse
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA.,Imperial College, London, UK
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Faiez Zannad
- Université de Lorraine, Inserm INI-CRCT, CHRU, Nancy, France
| | | | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH and Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Waheed Jamal
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Stefan D Anker
- Department of Cardiology (CVK), and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | | |
Collapse
|
197
|
Cupisti A, Giannese D, Moriconi D, D'Alessandro C, Torreggiani M, Piccoli GB. Nephroprotection by SGLT2i in CKD Patients: May It Be Modulated by Low-Protein Plant-Based Diets? Front Med (Lausanne) 2020; 7:622593. [PMID: 33425967 PMCID: PMC7793896 DOI: 10.3389/fmed.2020.622593] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 11/16/2020] [Indexed: 01/10/2023] Open
Abstract
Sodium-glucose-transporter 2 inhibitors (SGLT2i) are a new class of anti-diabetic drugs that in large trials such as CREDENCE have shown also a reduction of glomerular hyperfiltration and albuminuria in type 2 diabetic patients. Hence, the interest toward SGLT2i is focused toward this potential nephroprotective effect, in order to reduce the progression to overt nephropathy, and it seems to be confirmed in the most recent DAPA-CKD trial. This is the reason why the indication for SGLT2i treatment has been extended to chronic kidney disease (CKD) patients with eGFR up to 30 ml/min, namely with CKD stage 1-3. In patients with CKD stage 3 to 5, the most recent KDIGO guidelines recommend low-protein diet and plant-based regimens to delay end-stage kidney disease (ESKD) and improve quality of life. Similarly to SGLT2i, low-protein diets exert renal-protective effects by reducing single nephron hyperfiltration and urinary protein excretion. Beyond the glomerular hemodynamic effects, both protein restriction and SGLT2i are able to restore autophagy and, through these mechanisms, they may exert protective effects on diabetic kidney disease. In this perspective, it is likely that diet may modulate the effect of SGLT2i in CKD patients. Unfortunately, no data are available on the outcomes of the association of SGLT2i and low-protein and/or vegan diets. It is therefore reasonable to investigate whether CKD patients receiving SGLT2i may have further advantages in terms of nephroprotection from the implementation of a low-protein and/or plant-based diet or whether this association does not result in an additive effect, especially in vascular nephropathies.
Collapse
Affiliation(s)
- Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Domenico Giannese
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Diego Moriconi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Claudia D'Alessandro
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Giorgina B Piccoli
- Néphrologie, Centre Hospitalier Le Mans, Le Mans, France.,Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, Torino, Italy
| |
Collapse
|