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Sridhar VS, Cosentino F, Dagogo-Jack S, McGuire DK, Pratley RE, Cater NB, Noyes Essex M, Mancuso JP, Zhao Y, Cherney DZI. Effects of ertugliflozin on uric acid and gout-related outcomes in persons with type 2 diabetes and cardiovascular disease: Post hoc analyses from VERTIS CV. Diabetes Obes Metab 2024. [PMID: 39219437 DOI: 10.1111/dom.15895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 08/06/2024] [Accepted: 08/06/2024] [Indexed: 09/04/2024]
Abstract
AIM To conduct post hoc analyses of the VERTIS CV (NCT01986881) trial to explore the effects of ertugliflozin on serum uric acid (UA) and gout-related outcomes. MATERIALS AND METHODS Participants with type 2 diabetes and atherosclerotic cardiovascular disease were randomised (1:1:1) to placebo, ertugliflozin 5 mg or ertugliflozin 15 mg. Mean UA over time (260 weeks) was evaluated for pooled ertugliflozin versus placebo overall, and by baseline quintile of UA (≤4.3 mg/dL [≤255.8 µmol/L], >4.3-5.1 mg/dL [>255.8-303.4 µmol/L], >5.1-5.8 mg/dL [>303.4-345.0 µmol/L], >5.8-6.9 mg/dL [>345.0-410.4 µmol/L] and >6.9 mg/dL [>410.4 µmol/L]), glycated haemoglobin level, albuminuria status, estimated glomerular filtration rate and KDIGO (Kidney Disease: Improving Global Outcomes in Chronic Kidney Disease) risk category. The effect of ertugliflozin on a composite of gout onset or initiation of anti-gout medication was assessed. RESULTS The mean UA levels at baseline were 5.67 and 5.62 mg/dL in the placebo and ertugliflozin groups, respectively. Ertugliflozin reduced UA over Weeks 6-260 compared with placebo, with least squares mean (LSM) changes (95% confidence interval [CI]) from baseline at Week 260 of 0.07 mg/dL (-0.02, 0.15) and -0.19 mg/dL (-0.25, -0.13) in the placebo and pooled ertugliflozin groups, respectively. At Week 260, placebo-adjusted LSM change (95% CI) from baseline in UA was -0.26 mg/dL (-0.36, -0.16) with ertugliflozin. Ertugliflozin was associated with reductions in UA across baseline UA quintiles compared with placebo. The incidence of the composite of gout-related outcomes was 84/2539 (3.3%) for placebo and 133/5091 (2.6%) for ertugliflozin (hazard ratio for the composite 0.76 [95% CI 0.580, 1.002]). CONCLUSIONS Ertugliflozin was generally associated with lowering UA overall and across subgroups compared with placebo, and numerically reduced rates of gout-related outcome events.
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Affiliation(s)
- Vikas S Sridhar
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Francesco Cosentino
- Unit of Cardiology, Karolinska Institute & Karolinska University Hospital, Stockholm, Sweden
| | | | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
- Parkland Health, Dallas, Texas, USA
| | - Richard E Pratley
- AdventHealth Translational Research Institute, Orlando, Florida, USA
| | | | | | | | - Yujie Zhao
- Merck & Co., Inc, Rahway, New Jersey, USA
| | - David Z I Cherney
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
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Girardi ACC, Polidoro JZ, Castro PC, Pio-Abreu A, Noronha IL, Drager LF. Mechanisms of heart failure and chronic kidney disease protection by SGLT2 inhibitors in nondiabetic conditions. Am J Physiol Cell Physiol 2024; 327:C525-C544. [PMID: 38881421 DOI: 10.1152/ajpcell.00143.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 06/11/2024] [Accepted: 06/11/2024] [Indexed: 06/18/2024]
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2is), initially developed for type 2 diabetes (T2D) treatment, have demonstrated significant cardiovascular and renal benefits in heart failure (HF) and chronic kidney disease (CKD), irrespective of T2D. This review provides an analysis of the multifaceted mechanisms underlying the cardiorenal benefits of SGLT2i in HF and CKD outside of the T2D context. Eight major aspects of the protective effects of SGLT2i beyond glycemic control are explored: 1) the impact on renal hemodynamics and tubuloglomerular feedback; 2) the natriuretic effects via proximal tubule Na+/H+ exchanger NHE3 inhibition; 3) the modulation of neurohumoral pathways with evidence of attenuated sympathetic activity; 4) the impact on erythropoiesis, not only in the context of local hypoxia but also systemic inflammation and iron regulation; 5) the uricosuria and mitigation of the hyperuricemic environment in cardiorenal syndromes; 6) the multiorgan metabolic reprogramming including the potential induction of a fasting-like state, improvement in glucose and insulin tolerance, and stimulation of lipolysis and ketogenesis; 7) the vascular endothelial growth factor A (VEGF-A) upregulation and angiogenesis, and 8) the direct cardiac effects. The intricate interplay between renal, neurohumoral, metabolic, and cardiac effects underscores the complexity of SGLT2i actions and provides valuable insights into their therapeutic implications for HF and CKD. Furthermore, this review sets the stage for future research to evaluate the individual contributions of these mechanisms in diverse clinical settings.
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Affiliation(s)
- Adriana C C Girardi
- Laboratório de Genética e Cardiologia Molecular, Faculdade de Medicina, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Juliano Z Polidoro
- Laboratório de Genética e Cardiologia Molecular, Faculdade de Medicina, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Paulo C Castro
- Laboratório de Genética e Cardiologia Molecular, Faculdade de Medicina, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Andrea Pio-Abreu
- Disciplina de Nefrologia, Faculdade de Medicina, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Irene L Noronha
- Disciplina de Nefrologia, Faculdade de Medicina, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Luciano F Drager
- Disciplina de Nefrologia, Faculdade de Medicina, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
- Unidade de Hipertensão, Faculdade de Medicina, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
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Wanner C, Nangaku M, Kraus BJ, Zinman B, Mattheus M, Hantel S, Schumacher M, Ohneberg K, Schmoor C, Inzucchi SE. How do SGLT2 inhibitors protect the kidney? A mediation analysis of the EMPA-REG OUTCOME trial. Nephrol Dial Transplant 2024; 39:1504-1513. [PMID: 38323492 PMCID: PMC11361804 DOI: 10.1093/ndt/gfae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Indexed: 02/08/2024] Open
Abstract
INTRODUCTION Mechanisms underlying kidney benefits with sodium-glucose cotransporter-2 (SGLT2) inhibition in heart failure and/or type 2 diabetes (T2D) with established cardiovascular disease are currently unclear. METHODS We evaluated post hoc the factors mediating the effect of empagliflozin on a composite kidney outcome (first sustained estimated glomerular filtration rate ≥40% reduction from baseline, initiation of renal replacement therapy or death due to kidney disease) in EMPA-REG OUTCOME (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients). Variables, calculated as change from baseline or updated mean, were evaluated as time-dependent covariates and using a landmark approach (at Week 12) in Cox regression analyses. In multivariable analyses, variables with the greatest mediating effect were added using a step-up procedure. RESULTS In univariable time-dependent updated mean covariate analyses, the strongest mediator was hematocrit (99.5% mediation). Hemoglobin, uric acid and urine albumin-to-creatinine ratio mediated 79.4%, 33.2% and 31.0%, respectively. Multivariable analyses were not performed due to the very strong mediation effect of hematocrit. In univariable Week 12 landmark change from baseline analyses, the strongest mediators included hematocrit (40.7%), glycated hemoglobin (28.3%), systolic blood pressure (16.8%) and free fatty acids (16.5%), which yielded a combined mediation of 78.9% in multivariable analysis. CONCLUSIONS Changes in hematocrit and hemoglobin were the strongest mediators of empagliflozin's kidney benefits in EMPA-REG OUTCOME participants with T2D and cardiovascular disease.
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Affiliation(s)
- Christoph Wanner
- Department of Medicine, Würzburg University Clinic, Würzburg, Germany
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, Department of Hemodialysis and Apheresis, The University of Tokyo Hospital, Tokyo, Japan
| | - Bettina J Kraus
- Medical Affairs, Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Michaela Mattheus
- Biostatistics, Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Stefan Hantel
- Biostatistics, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Martin Schumacher
- Institute for Medical Biometry and Statistics and Clinical Trials Unit, Faculty of Medicine, and Medical Center, University of Freiburg, Freiburg, Germany
| | - Kristin Ohneberg
- Institute for Medical Biometry and Statistics and Clinical Trials Unit, Faculty of Medicine, and Medical Center, University of Freiburg, Freiburg, Germany
| | - Claudia Schmoor
- Clinical Trials Unit, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT, USA
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Tesfaye H, Wang KM, Zabotka LE, Wexler DJ, Schmedt N, Koeneman L, Seman L, Paik JM, Patorno E. Empagliflozin and Risk of Incident Gout: Analysis from the EMPagliflozin Comparative Effectiveness and SafEty (EMPRISE) Cohort Study. J Gen Intern Med 2024; 39:1870-1879. [PMID: 38710868 PMCID: PMC11282041 DOI: 10.1007/s11606-024-08793-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 04/24/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Hyperuricemia is frequently observed in patients with type 2 diabetes (T2D) and is associated with increased risk of gout and cardiovascular disease (CVD). Empagliflozin lowers serum urate levels by enhancing its urinary excretion. OBJECTIVE To compare initiators of empagliflozin vs dipeptidyl peptidase-4 inhibitor (DPP4i) and initiators of empagliflozin vs glucagon-like peptide-1 receptor agonist (GLP-1RA) with respect to the risk of incident gout events. DESIGN AND PARTICIPANTS Using three claims-based datasets from 08/2014 to 09/2019, we generated two cohorts (cohort 1: empagliflozin vs DPP4i; cohort 2: empagliflozin vs GLP-1RA) of adult patients with T2D and without prior history of gout or gout-specific medication dispensing separately in each dataset. To assess the risk of incident gout, we estimated hazard ratios (HR) and rate differences (RD) per 1000 person-years (PY) with their 95% confidence intervals (CI) before and after 1:1 propensity score (PS) matching adjusting for 141 baseline covariates. KEY RESULTS We identified 102,262 pairs of 1:1 propensity score-matched adults in cohort 1 and 131,216 pairs in cohort 2. Over a mean follow-up period of 8 months on treatment, the risk of gout was lower in patients initiating empagliflozin compared to DPP4i (HR = 0.69: 95% CI (0.60-0.79); RD = - 2.27: 95% CI (- 3.08, 1.46)) or GLP-1RA (HR = 0.83: 95% CI (0.73-0.94); RD = - 0.99: 95% CI (- 1.66, - 0.32)). Results were consistent across subgroups (sex, age, body mass index, chronic kidney disease, heart failure, cardiovascular disease, and concurrent diuretic use) and sensitivity analyses. CONCLUSIONS Among adults with T2D, the initiation of empagliflozin vs a DPP4i or GLP-1RA was associated with lower risk of incident gout, complementing results from a post hoc analysis of the EMPA-REG OUTCOME trial and previously published observational research focusing on the sodium-glucose co-transporter-2 inhibitor class in more narrowly defined study populations.
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Affiliation(s)
- Helen Tesfaye
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Katherine M Wang
- Division of Renal (Kidney) Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Center for Healthcare Organization & Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - Luke E Zabotka
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Deborah J Wexler
- MGH Diabetes Center, Division of Endocrinology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Niklas Schmedt
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | | | - Leo Seman
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT, USA
| | - Julie M Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Division of Renal (Kidney) Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Center for Healthcare Organization & Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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Apperloo EM, Neuen BL, Fletcher RA, Jongs N, Anker SD, Bhatt DL, Butler J, Cherney DZI, Herrington WG, Inzucchi SE, Jardine MJ, Liu CC, Mahaffey KW, McGuire DK, McMurray JJV, Neal B, Packer M, Perkovic V, Sabatine MS, Solomon SD, Staplin N, Szarek M, Vaduganathan M, Wanner C, Wheeler DC, Wiviott SD, Zannad F, Heerspink HJL. Efficacy and safety of SGLT2 inhibitors with and without glucagon-like peptide 1 receptor agonists: a SMART-C collaborative meta-analysis of randomised controlled trials. Lancet Diabetes Endocrinol 2024; 12:545-557. [PMID: 38991584 DOI: 10.1016/s2213-8587(24)00155-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/15/2024] [Accepted: 05/20/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND SGLT2 inhibitors and GLP-1 receptor agonists both improve cardiovascular and kidney outcomes in patients with type 2 diabetes. We sought to evaluate whether the benefits of SGLT2 inhibitors are consistent in patients receiving and not receiving GLP-1 receptor agonists. METHODS We conducted a collaborative meta-analysis of trials included in the SGLT2 Inhibitor Meta-Analysis Cardio-Renal Trialists' Consortium, restricted to participants with diabetes. Treatment effects from individual trials were obtained from Cox regression models and pooled using inverse variance weighted meta-analysis. The two main cardiovascular outcomes assessed included major adverse cardiovascular events (nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death), and hospitalisation for heart failure or cardiovascular death. The main kidney outcomes assessed were chronic kidney disease progression (≥40% decline in estimated glomerular filtration rate [eGFR], kidney failure [eGFR <15 mL/min/1·73 m2, chronic dialysis, or kidney transplantation], or death due to kidney failure), and the rate of change in eGFR over time. Safety outcomes were also assessed. FINDINGS Across 12 randomised, double-blind, placebo-controlled trials, 3065 (4·2%) of 73 238 participants with diabetes were using GLP-1 receptor agonists at baseline. SGLT2 inhibitors reduced the risk of major adverse cardiovascular events in participants both receiving and not receiving GLP-1 receptor agonists (hazard ratio [HR] 0·81, 95% CI 0·63-1·03 vs 0·90, 0·86-0·94; p-heterogeneity=0·31). Effects on hospitalisation for heart failure or cardiovascular death (0·76, 0·57-1·01 vs 0·78, 0·74-0·82; p-heterogeneity=0·90) and chronic kidney disease progression (0·65, 0·46-0·94 vs 0·67, 0·62-0·72; p-heterogeneity=0·81) were also consistent regardless of GLP-1 receptor agonist use, as was the effect on the chronic rate of change in eGFR over time (heterogeneity=0·92). Fewer serious adverse events occurred with SGLT2 inhibitors compared with placebo, irrespective of GLP-1 receptor agonist use (relative risk 0·87, 95% CI 0·79-0·96 vs 0·91, 0·89-0·93; p-heterogeneity=0·41). INTERPRETATION The effects of SGLT2 inhibitors on cardiovascular and kidney outcomes are consistent regardless of the background use of GLP-1 receptor agonists. These findings suggest independent effects of these evidence-based therapies and support clinical practice guidelines recommending the use of these agents in combination to improve cardiovascular and kidney metabolic outcomes. FUNDING National Health and Medical Research Council of Australia and the Ramaciotti Foundation.
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Affiliation(s)
- Ellen M Apperloo
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Robert A Fletcher
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Stefan D Anker
- Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA; Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, ON, Canada
| | - William G Herrington
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale School of Medicine, New Haven, CT, USA
| | - Meg J Jardine
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia; Department of Renal Medicine, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | | | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Darren K McGuire
- University of Texas Southwestern Medical Center and Parkland Health, Dallas, TX, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Department of Epidemiology and Biostatistics, Imperial College London, London, UK
| | - Milton Packer
- Baylor University Medical Center, Dallas TX, USA; Imperial College, London, UK
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Marc S Sabatine
- TIMI Study Group, Boston, MA, USA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Scott D Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Natalie Staplin
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Michael Szarek
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA; Colorado Prevention Center Clinical Research, Aurora, CO, USA; State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Christoph Wanner
- Department of Clinical Research and Epidemiology, Comprehensive Heart Failure Centre, University Hospital, Würzburg, Germany
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Stephen D Wiviott
- TIMI Study Group, Boston, MA, USA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Faiez Zannad
- Université de Lorraine, Inserm, Center d'Investigations Cliniques, Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands; The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.
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Chen AX, Fletcher R, Neuen BL, Neal B, Arnott C. An overview of the CANVAS Program and CREDENCE trial: The primary outcomes and key clinical implications for those managing patients with type 2 diabetes. Diabetes Obes Metab 2024. [PMID: 39036974 DOI: 10.1111/dom.15751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/04/2024] [Accepted: 06/14/2024] [Indexed: 07/23/2024]
Abstract
AIMS To provide an overview of the primary outcomes and key clinical implications of the CANVAS Program and CREDENCE trial, which were event-driven, double-blind randomized controlled trials that established the efficacy and safety of canagliflozin in those with type 2 diabetes (T2D) and high cardiovascular risk (CV) or albuminuric chronic kidney disease (CKD). METHODS AND RESULTS The CANVAS programme (CANVAS and CANVAS-R trials) randomized 10 142 people with T2D and high CV risk to canagliflozin or placebo and followed them for a median of 126 weeks. The primary efficacy outcome was met, with canagliflozin treatment associated with a 14% reduction in major adverse CV events (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.75 to 0.97; p < 0.001) as compared to placebo. The CREDENCE trial randomized 4401 individuals with T2D and albuminuric CKD to canagliflozin or placebo and followed them for 109 weeks. The CREDENCE trial also met its primary endpoint; canagliflozin treatment was associated with a 30% reduction in the composite of kidney failure, sustained doubling of serum creatinine level, or death from kidney or CV causes (HR 0.70, 95% CI 0.59 to 0.82; p < 0.001). Substantial reductions in hospitalization for heart failure (CANVAS: HR 0.67, 95% CI 0.52 to 0.87; CREDENCE: HR 0.61, 95% CI 0.47 to 0.80) and other key CV and kidney outcomes were also identified. Relative clinical benefits were consistent across subgroups defined by baseline age, sex, kidney function and history of CV disease but absolute benefits were greatest in those at highest baseline risk. Total serious adverse events were less common with canagliflozin treatment. Concerns about amputation and fracture risk observed in the CANVAS Program were not seen in CREDENCE and appear to have been spurious chance findings. CONCLUSION Canagliflozin reduced important CV, kidney and mortality outcomes in those with T2D and high CV risk or CKD across diverse patient groups, with a good safety profile. Taken together with the other sodium-glucose cotransporter-2 inhibitor CV and renal outcomes trials, these landmark findings have changed the treatment landscape for patients worldwide.
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Affiliation(s)
- Angela X Chen
- Cardiovascular Program, The George Institute of Global Health, University of New South Wales, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
- Department of Endocrinology and Diabetes, Westmead Hospital, Sydney, Australia
| | - Robert Fletcher
- Cardiovascular Program, The George Institute of Global Health, University of New South Wales, Sydney, Australia
| | - Brendon L Neuen
- Cardiovascular Program, The George Institute of Global Health, University of New South Wales, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Bruce Neal
- Cardiovascular Program, The George Institute of Global Health, University of New South Wales, Sydney, Australia
| | - Clare Arnott
- Cardiovascular Program, The George Institute of Global Health, University of New South Wales, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
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Shi Y, Dong S, Xu Y, Ji D, Yang L, Zhao R. Acute kidney injury events in patients with diabetes using sodium glucose transporter 2 inhibitors: a meta-analysis of cohort studies. Acta Diabetol 2024; 61:755-764. [PMID: 38441621 DOI: 10.1007/s00592-024-02252-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 02/01/2024] [Indexed: 05/18/2024]
Abstract
AIMS To conduct a meta-analysis of cohort studies to explore the association between acute kidney injury (AKI) and the effect of sodium glucose transporter 2 inhibitors (SGLT2 inhibitors) in patients with type 2 diabetes mellitus (T2DM). MATERIALS AND METHODS PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were comprehensively searched for eligible studies until April 4, 2023 on the association between AKI and use of SGLT2 inhibitors in T2DM patients. Odds ratios (ORs) and their 95% confidence intervals (CIs) were pooled using the Mantel-Haenszel method. RESULTS A total of 10 cohort studies (20 cohorts) and 526,863 participants were included in the meta-analysis. Compared with other glucose-lowering drugs (oGLDs), SGLT2 inhibitors were associated with a decreased risk of AKI (OR = 0.50, 95% CI 0.38-0.66, I2 = 96%). Meanwhile, SGLT2 inhibitors demonstrated a significant reduction in the incidence of AKI hospitalization compared with oGLDs (OR = 0.54, 95% CI 0.43-0.68, I2 = 92.0%). The result was consistent across different subgroups, and was robust to sensitivity analysis. CONCLUSIONS Compared with oGLDs, SGLT2 inhibitors reduced the risk of suffering AKI and AKI hospitalization in the real-world setting. Vigilance to the occurrence of AKI should not be an obstacle to discourage clinicians from prescribing SGLT2 inhibitors.
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Affiliation(s)
- Yanjing Shi
- Department of Pharmacy, Peking University Third Hospital, No.49 Huayuan North Road, Haidian District, Beijing, 100191, China
- Department of Pharmacy, The Affiliated Hospital of Chengde Medical College, Chengde, Hebei Province, China
| | - Shujie Dong
- Department of Pharmacy, Peking University Third Hospital, No.49 Huayuan North Road, Haidian District, Beijing, 100191, China
| | - Yang Xu
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Dongze Ji
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Li Yang
- Department of Pharmacy, Peking University Third Hospital, No.49 Huayuan North Road, Haidian District, Beijing, 100191, China
| | - Rongsheng Zhao
- Department of Pharmacy, Peking University Third Hospital, No.49 Huayuan North Road, Haidian District, Beijing, 100191, China.
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Badura K, Janc J, Wąsik J, Gnitecki S, Skwira S, Młynarska E, Rysz J, Franczyk B. Anemia of Chronic Kidney Disease-A Narrative Review of Its Pathophysiology, Diagnosis, and Management. Biomedicines 2024; 12:1191. [PMID: 38927397 PMCID: PMC11200696 DOI: 10.3390/biomedicines12061191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/28/2024] Open
Abstract
Anemia is one of the most common chronic kidney disease (CKD) complications. It negatively affects patients' quality of life and clinical outcomes. The pathophysiology of anemia in CKD involves the interplay of various factors such as erythropoietin (EPO) deficiency, iron dysregulation, chronic inflammation, bone marrow dysfunction, and nutritional deficiencies. Despite recent advances in understanding this condition, anemia still remains a serious clinical challenge in population of patients with CKD. Several guidelines have been published with the aim to systematize the diagnostic approach and treatment of anemia; however, due to emerging data, many recommendations vary between publications. Recent studies indicate a potential of novel biomarkers to evaluate anemia and related conditions such as iron deficiency, which is often present in CKD patients. Our article aims to summarize the pathophysiology of anemia in CKD, as well as the diagnosis and management of this condition, including novel therapeutic approaches such as hypoxia-inducible factor-prolyl hydroxylase inhibitors (HIF-PHI). Understanding these complex subjects is crucial for a targeted approach to diagnose and treat patients with anemia in CKD effectively.
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Affiliation(s)
- Krzysztof Badura
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Jędrzej Janc
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Joanna Wąsik
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Szymon Gnitecki
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Sylwia Skwira
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Ewelina Młynarska
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Beata Franczyk
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
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Natale P, Tunnicliffe DJ, Toyama T, Palmer SC, Saglimbene VM, Ruospo M, Gargano L, Stallone G, Gesualdo L, Strippoli GF. Sodium-glucose co-transporter protein 2 (SGLT2) inhibitors for people with chronic kidney disease and diabetes. Cochrane Database Syst Rev 2024; 5:CD015588. [PMID: 38770818 PMCID: PMC11106805 DOI: 10.1002/14651858.cd015588.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Diabetes is associated with high risks of premature chronic kidney disease (CKD), cardiovascular diseases, cardiovascular death and impaired quality of life. People with diabetes are more likely to develop kidney impairment, and approximately one in three adults with diabetes have CKD. People with CKD and diabetes experience a substantially higher risk of cardiovascular outcomes. Sodium-glucose co-transporter protein 2 (SGLT2) inhibitors have shown potential effects in preventing kidney and cardiovascular outcomes in people with CKD and diabetes. However, new trials are emerging rapidly, and evidence synthesis is essential to summarising cumulative evidence. OBJECTIVES This review aimed to assess the benefits and harms of SGLT2 inhibitors for people with CKD and diabetes. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 17 November 2023 using a search strategy designed by an Information Specialist. Studies in the Register are continually identified through regular searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled studies were eligible if they evaluated SGLT2 inhibitors versus placebo, standard care or other glucose-lowering agents in people with CKD and diabetes. CKD includes all stages (from 1 to 5), including dialysis patients. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed the study risk of bias. Treatment estimates were summarised using random effects meta-analysis and expressed as a risk ratio (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The primary review outcomes were all-cause death, 3-point and 4-point major adverse cardiovascular events (MACE), fatal or nonfatal myocardial infarction (MI), fatal or nonfatal stroke, and kidney failure. MAIN RESULTS Fifty-three studies randomising 65,241 people with CKD and diabetes were included. SGLT2 inhibitors with or without other background treatments were compared to placebo, standard care, sulfonylurea, dipeptidyl peptidase-4 (DPP-4) inhibitors, or insulin. In the majority of domains, the risks of bias in the included studies were low or unclear. No studies evaluated the treatment in children or in people treated with dialysis. No studies compared SGLT2 inhibitors with glucagon-like peptide-1 receptor agonists or tirzepatide. Compared to placebo, SGLT2 inhibitors decreased the risk of all-cause death (20 studies, 44,397 participants: RR 0.85, 95% CI 0.78 to 0.94; I2 = 0%; high certainty) and cardiovascular death (16 studies, 43,792 participants: RR 0.83, 95% CI 0.74 to 0.93; I2 = 29%; high certainty). Compared to placebo, SGLT2 inhibitors probably make little or no difference to the risk of fatal or nonfatal MI (2 studies, 13,726 participants: RR 0.95, 95% CI 0.80 to 1.14; I2 = 24%; moderate certainty), and fatal or nonfatal stroke (2 studies, 13,726 participants: RR 1.07, 95% CI 0.88 to 1.30; I2 = 0%; moderate certainty). Compared to placebo, SGLT2 inhibitors probably decrease 3-point MACE (7 studies, 38,320 participants: RR 0.89, 95% CI 0.81 to 0.98; I2 = 46%; moderate certainty), and 4-point MACE (4 studies, 23,539 participants: RR 0.82, 95% CI 0.70 to 0.96; I2 = 77%; moderate certainty), and decrease hospital admission due to heart failure (6 studies, 28,339 participants: RR 0.70, 95% CI 0.62 to 0.79; I2 = 17%; high certainty). Compared to placebo, SGLT2 inhibitors may decrease creatinine clearance (1 study, 132 participants: MD -2.63 mL/min, 95% CI -5.19 to -0.07; low certainty) and probably decrease the doubling of serum creatinine (2 studies, 12,647 participants: RR 0.70, 95% CI 0.56 to 0.89; I2 = 53%; moderate certainty). SGLT2 inhibitors decrease the risk of kidney failure (6 studies, 11,232 participants: RR 0.70, 95% CI 0.62 to 0.79; I2 = 0%; high certainty), and kidney composite outcomes (generally reported as kidney failure, kidney death with or without ≥ 40% decrease in estimated glomerular filtration rate (eGFR)) (7 studies, 36,380 participants: RR 0.68, 95% CI 0.59 to 0.78; I2 = 25%; high certainty) compared to placebo. Compared to placebo, SGLT2 inhibitors incur less hypoglycaemia (16 studies, 28,322 participants: RR 0.93, 95% CI 0.89 to 0.98; I2 = 0%; high certainty), and hypoglycaemia requiring third-party assistance (14 studies, 26,478 participants: RR 0.75, 95% CI 0.65 to 0.88; I2 = 0%; high certainty), and probably decrease the withdrawal from treatment due to adverse events (15 studies, 16,622 participants: RR 0.94, 95% CI 0.82 to 1.08; I2 = 16%; moderate certainty). The effects of SGLT2 inhibitors on eGFR, amputation and fracture were uncertain. No studies evaluated the effects of treatment on fatigue, life participation, or lactic acidosis. The effects of SGLT2 inhibitors compared to standard care alone, sulfonylurea, DPP-4 inhibitors, or insulin were uncertain. AUTHORS' CONCLUSIONS SGLT2 inhibitors alone or added to standard care decrease all-cause death, cardiovascular death, and kidney failure and probably decrease major cardiovascular events while incurring less hypoglycaemia compared to placebo in people with CKD and diabetes.
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Affiliation(s)
- Patrizia Natale
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - David J Tunnicliffe
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Tadashi Toyama
- Department of Nephrology, Kanazawa University, Kanazawa, Japan
- Innovative Clinical Research Center, Kanazawa University, Kanazawa, Japan
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Valeria M Saglimbene
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Marinella Ruospo
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Letizia Gargano
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Loreto Gesualdo
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Maruhashi T, Tanaka A, Takahashi K, Higashi Y, Node K. Erythropoiesis and estimated fluid volume regulation following initiation of ipragliflozin treatment in patients with type 2 diabetes mellitus and chronic kidney disease: A post-hoc analysis of the PROCEED trial. Diabetes Obes Metab 2024; 26:1723-1730. [PMID: 38326092 DOI: 10.1111/dom.15481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/11/2024] [Accepted: 01/18/2024] [Indexed: 02/09/2024]
Abstract
AIMS To analyse the changes in erythropoietic and estimated fluid volume parameters after the initiation of ipragliflozin, a sodium-glucose co-transporter 2 inhibitor, in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). METHODS This was a post-hoc analysis of the PROCEED trial, which evaluated the effect of 24-week ipragliflozin treatment on endothelial dysfunction in patients with T2DM and CKD. We evaluated the changes in erythropoietic and estimated fluid volume parameters from baseline to 24 weeks post-treatment in 53 patients who received ipragliflozin (ipragliflozin group) and 55 patients with T2DM and CKD without sodium-glucose co-transporter 2 inhibitors (control group), a full analysis set of the PROCEED trial. RESULTS The increases in haemoglobin [estimated group difference, 0.5 g/dl; 95% confidence interval (CI), 0.3-0.8; p < .001], haematocrit (estimated group difference, 2.2%; 95% CI, 1.3-3.1; p < .001) and erythropoietin (estimated log-transformed group difference, 0.1; 95% CI, 0.01-0.3; p = .036) were significantly greater in the ipragliflozin group than those in the control group. Ipragliflozin treatment was significantly associated with an increase in erythropoietin, independent of the corresponding change in haemoglobin (β = 0.253, p < .001) or haematocrit (β = 0.278, p < .001). Reductions in estimated plasma volume (estimated group difference, -7.94%; 95% CI, -11.6 to -4.26%; p < .001) and estimated extracellular volume (estimated group difference, -181.6 ml; 95% CI, -275.7 to -87.48 ml; p < .001) were significantly greater in the ipragliflozin group than those in the control group. CONCLUSIONS Erythropoiesis was enhanced and estimated fluid volumes were reduced by ipragliflozin in patients with T2DM and CKD. CLINICAL TRIAL PROCEED trial (registration number: jRCTs071190054).
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Affiliation(s)
- Tatsuya Maruhashi
- Department of Regenerative Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Kanae Takahashi
- Department of Biostatistics, Hyogo Medical University, Nishinomiya, Japan
| | - Yukihito Higashi
- Department of Regenerative Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
- Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
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11
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Asahina Y, Sakaguchi Y, Oka T, Hattori K, Kawaoka T, Doi Y, Yamamoto R, Matsui I, Mizui M, Kaimori JY, Isaka Y. Association between urinary uric acid excretion and kidney outcome in patients with CKD. Sci Rep 2024; 14:5119. [PMID: 38429496 PMCID: PMC10907602 DOI: 10.1038/s41598-024-55809-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 02/28/2024] [Indexed: 03/03/2024] Open
Abstract
Inhibiting tubular urate reabsorption may protect the kidney from urate-induced tubular injury. However, this approach may promote intratubular uric acid crystallization, especially in acidified urine, which could be toxic to the kidney. To assess how tubular urate handling affects kidney outcomes, we conducted a retrospective cohort study including 1042 patients with estimated glomerular filtration rates (eGFR) of 15-60 mL/min/1.73 m2. The exposures were fractional excretion of uric acid (FEUA) and urinary uric acid-to-creatinine ratio (UUCR). The kidney outcome was defined as a halving of eGFR from baseline or initiating kidney replacement therapy. The median FEUA and UUCR were 7.2% and 0.33 g/gCre, respectively. During a median follow-up of 1.9 years, 314 kidney outcomes occurred. In a multivariate Cox model, the lowest FEUA quartile exhibited a 1.68-fold higher rate of kidney outcome than the highest FEUA quartile (95% confidence interval, 1.13-2.50; P = 0.01). Similarly, lower UUCR was associated with a higher rate of kidney outcome. Notably, patients in the highest quartile of FEUA and UUCR were at the lowest risk of kidney outcome even among those with aciduria. In conclusion, lower FEUA and UUCR were associated with a higher risk of kidney failure, suggesting that increased urate reabsorption is harmful to the kidney.
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Affiliation(s)
- Yuta Asahina
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yusuke Sakaguchi
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Tatsufumi Oka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Koki Hattori
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takayuki Kawaoka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yohei Doi
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Ryohei Yamamoto
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
- Health and Counseling Center, Osaka University, Toyonaka, Japan
| | - Isao Matsui
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masayuki Mizui
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Jun-Ya Kaimori
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
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12
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Cases A, Cigarrán S, Luis Górriz J, Nuñez J. Effect of SGLT2 inhibitors on anemia and their possible clinical implications. Nefrologia 2024; 44:165-172. [PMID: 38604895 DOI: 10.1016/j.nefroe.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/11/2023] [Indexed: 04/13/2024] Open
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have demonstrated cardiovascular and renal benefits in patients with type 2 diabetes mellitus, heart failure, or chronic kidney disease. Since the first studies with these drugs, an initial increase in hemoglobin/hematocrit levels was observed, which was attributed to an increase in hemoconcentration associated with its diuretic effect, although it was early appearent that these drugs increased erythropoietin levels and erythropoiesis, and improved iron metabolism. Mediation studies found that the increase in hemoglobin was strongly associated with the cardiorenal benefits of these drugs. In this review, we discuss the mechanisms for improving erythropoiesis and the implication of the increase in hemoglobin on the cardiorenal prognostic benefit of these drugs.
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Affiliation(s)
- Aleix Cases
- Servei de Nefrología, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain; Grupo de Anemia de la S.E.N., Spain
| | | | - José Luis Górriz
- Grupo de Anemia de la S.E.N., Spain; Servicio de Nefrología, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain.
| | - Julio Nuñez
- Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de València, CIBER Cardiovascular, Spain
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13
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Rodriguez‐Valadez JM, Tahsin M, Masharani U, Park M, Hunink MGM, Yeboah J, Li L, Weber E, Berkalieva A, Avezaat L, Max W, Fleischmann KE, Ferket BS. Potential Mediators for Treatment Effects of Novel Diabetes Medications on Cardiovascular and Renal Outcomes: A Meta-Regression Analysis. J Am Heart Assoc 2024; 13:e032463. [PMID: 38362889 PMCID: PMC11010086 DOI: 10.1161/jaha.123.032463] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/30/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND Prior research suggests clinical effects of glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is) are mediated by changes in glycated hemoglobin, body weight, systolic blood pressure, hematocrit, and urine albumin-creatinine ratio. We aimed to confirm these findings using a meta-analytic approach. METHODS AND RESULTS We updated a systematic review of 9 GLP-1RA and 13 SGLT2i trials and summarized longitudinal mediator data. We obtained hazard ratios (HRs) for cardiovascular, renal, and mortality outcomes. We performed linear mixed-effects modeling of LogHRs versus changes in potential mediators and investigated differences in meta-regression associations among drug classes using interaction terms. HRs generally became more protective with greater glycated hemoglobin reduction among GLP-1RA trials, with average HR improvements of 20% to 30%, reaching statistical significance for major adverse cardiovascular events (ΔHR, 23%; P=0.02). Among SGLT2i trials, associations with HRs were not significant and differed from GLP1-RA trials for major adverse cardiovascular events (Pinteraction=0.04). HRs for major adverse cardiovascular events, myocardial infarction, and stroke became less efficacious (ΔHR, -15% to -34%), with more weight loss for SGLT2i but not for GLP-1RA trials (ΔHR, 4%-7%; Pinteraction<0.05). Among 5 SGLT2i trials with available data, HRs for stroke became less efficacious with larger increases in hematocrit (ΔHR, 123%; P=0.09). No changes in HRs by systolic blood pressure (ΔHR, -11% to 9%) and urine albumin-creatinine ratio (ΔHR, -1% to 4%) were found for any outcome. CONCLUSIONS We confirmed increased efficacy findings for major adverse cardiovascular events with reduction in glycated hemoglobin for GLP1-RAs. Further research is needed on the potential loss of cardiovascular benefits with increased weight loss and hematocrit for SGLT2i.
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Affiliation(s)
- José M. Rodriguez‐Valadez
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Malak Tahsin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Umesh Masharani
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Meyeon Park
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
- Division of NephrologyUniversity of CaliforniaSan FranciscoCAUSA
| | - M. G. Myriam Hunink
- Department of EpidemiologyErasmus MCRotterdamthe Netherlands
- Department of RadiologyErasmus MCRotterdamthe Netherlands
- Center for Health Decision Sciences, Harvard TH Chan School of Public HealthBostonMAUSA
| | - Joseph Yeboah
- Section of Cardiovascular Medicine, Internal MedicineWake Forest University School of MedicineWinston SalemNCUSA
| | - Lihua Li
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Ellerie Weber
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Asem Berkalieva
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Luuk Avezaat
- Department of EpidemiologyErasmus MCRotterdamthe Netherlands
| | - Wendy Max
- Institute for Health & Aging and Department of Social and Behavioral SciencesUniversity of CaliforniaSan FranciscoCAUSA
| | - Kirsten E. Fleischmann
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
- Division of CardiologyUniversity of CaliforniaSan FranciscoCAUSA
| | - Bart S. Ferket
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
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14
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Dakroub A, Almarzooq ZI. Mediators of Cardiovascular and Renal Outcomes: How Do Novel Diabetes Medications Work? J Am Heart Assoc 2024; 13:e033863. [PMID: 38362888 PMCID: PMC11010108 DOI: 10.1161/jaha.124.033863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 01/11/2024] [Indexed: 02/17/2024]
Affiliation(s)
- Ali Dakroub
- St. Francis Hospital and Heart CenterRoslynNYUSA
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15
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Berezin AE, Berezina TA. Plausible prediction of renoprotective effects of sodium-glucose cotransporter-2 inhibitors in patients with chronic kidney diseases. J Int Med Res 2024; 52:3000605241227659. [PMID: 38329077 PMCID: PMC10854388 DOI: 10.1177/03000605241227659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 12/20/2023] [Indexed: 02/09/2024] Open
Abstract
This narrative review was conducted due to uncertainty in predicting the beneficial impact of sodium-glucose cotransporter-2 (SGLT2) inhibitors on a dip of estimated glomerular filtration rate (eGFR), regardless of albuminuria presence, with the aim of elucidating plausible predictors of kidney function outcome among patients treated with SGLT2 inhibitors. The PubMed and Web of Science databases were searched in May 2023 for relevant articles published in English between 2013 and 2023. A total of 25 full-length scientific publications (comprising 11 large randomized trials and two cohort studies) were included for analysis. The majority of studies demonstrated a limited value of conventional biomarkers, such as initial decline in eGFR, a trajectory of eGFR during SGLT2 inhibitor administration, and urine albumin-to-creatinine ratio (UACR), in prediction of renoprotection. Included studies showed that the tendency to decreased eGFR, UACR, hemoglobin, glycosylated hemoglobin, lipid profile, serum uric acid, inflammatory biomarkers and natriuretic peptides did not predict clinical outcomes in groups without heart failure (HF) treated with SGLT2 inhibitors. In HF groups, biomarkers of inflammation, kidney injury, oxidative stress, mitochondrial dysfunction, ketogenesis, energy metabolism, and adipose tissue dysfunction (adropin and irisin), were detected with the aim of finding potential biomarkers. Biomarkers of adipose tissue dysfunction and inflammation may be promising for predicting SGLT2 inhibitor benefit compared with N-terminal pro-B-type natriuretic peptide and energy metabolism indicators.
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Affiliation(s)
- Alexander E Berezin
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University, Salzburg, Austria
| | - Tetiana A Berezina
- Department of Internal Medicine and Nephrology, VitaCenter, Zaporozhye, Ukraine
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16
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Ferrannini E, Solini A, Baldi S, Scozzaro T, Polidori D, Natali A, Hansen MK. Role of Glycosuria in SGLT2 Inhibitor-Induced Cardiorenal Protection: A Mechanistic Analysis of the CREDENCE Trial. Diabetes 2024; 73:250-259. [PMID: 37939214 PMCID: PMC10796302 DOI: 10.2337/db23-0448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/16/2023] [Indexed: 11/10/2023]
Abstract
SGLT2 inhibitors have been shown to provide pronounced reductions in cardiorenal outcomes, including cardiovascular death, heart failure, and renal failure. The mechanisms underlying these benefits remain uncertain. We hypothesized that the effects could be attributed to the elevated glycosuria induced by these drugs. Urine concentrations of glucose, creatinine, and ketones were measured at baseline and after 1 year of treatment with either placebo or canagliflozin 100 mg/day, in approximately 2,600 individuals from the Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE) trial (enrolling patients with type 2 diabetes, chronic kidney disease (CKD), and albuminuria). Associations between glycosuria and the primary composite end point from CREDENCE, and secondary outcomes were assessed using Cox proportional hazards models. Canagliflozin treatment increased fractional urinary glucose excretion (± SD) from 3 ± 9% at baseline to 30 ± 26% at year 1 (vs. 5 ± 19% with placebo; P < 0.001). Patients in the canagliflozin arm and in the top quartile of urine glucose to creatinine ratio at year 1 were significantly protected for the primary end point (hazard ratio [HR] 0.42; 95% CI 0.30-0.61); similar results were seen for cases of hospitalized heart failure (HR 0.45; 95% CI 0.27-0.73) and all-cause death (HR 0.56; 95% CI 0.39-0.80). These associations persisted when adjustments were made for multiple conventional risk factors. Among patients with type 2 diabetes and CKD treated with canagliflozin, individuals with the highest glycosuria levels had the strongest protection against multiple cardiorenal outcomes. ARTICLE HIGHLIGHTS
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Affiliation(s)
| | - Anna Solini
- Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
| | - Simona Baldi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Tiziana Scozzaro
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Andrea Natali
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Packer M. Hyperuricemia and Gout Reduction by SGLT2 Inhibitors in Diabetes and Heart Failure: JACC Review Topic of the Week. J Am Coll Cardiol 2024; 83:371-381. [PMID: 38199714 DOI: 10.1016/j.jacc.2023.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/06/2023] [Accepted: 10/17/2023] [Indexed: 01/12/2024]
Abstract
Gout is characterized by increased production of purines (through the pentose phosphate pathway), which is coupled with reduced renal or intestinal excretion of urate. Concurrent upregulation of nutrient surplus signaling (mammalian target of rapamycin and hypoxia-inducible factor-1a) and downregulation of nutrient deprivation signaling (sirtuin-1 and adenosine monophosphate-activated protein kinase) redirects glucose toward anabolic pathways (rather than adenosine triphosphate production), thus promoting heightened oxidative stress and cardiomyocyte and proximal tubular dysfunction, leading to cardiomyopathy and kidney disease. Hyperuricemia is a marker (rather than a driver) of these cellular stresses. By inducing a state of starvation mimicry in a state of nutrient surplus, sodium-glucose cotransporter-2 inhibitors decrease flux through the pentose phosphate pathway (thereby attenuating purine and urate synthesis) while promoting renal urate excretion. These convergent actions exert a meaningful effect to lower serum uric acid by ≈0.6 to 1.5 mg/dL and to reduce the risk of gout by 30% to 50% in large-scale clinical trials.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Dallas, Texas, USA; Imperial College, London, United Kingdom.
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Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial. Lancet Diabetes Endocrinol 2024; 12:39-50. [PMID: 38061371 PMCID: PMC7615591 DOI: 10.1016/s2213-8587(23)00321-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial. METHODS EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110. FINDINGS Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001). INTERPRETATION Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor. FUNDING Boehringer Ingelheim and Eli Lilly.
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Sridhar VS, Limonte CP, Groop PH, Heerspink HJL, Pratley RE, Rossing P, Skyler JS, Cherney DZI. Chronic kidney disease in type 1 diabetes: translation of novel type 2 diabetes therapeutics to individuals with type 1 diabetes. Diabetologia 2024; 67:3-18. [PMID: 37801140 DOI: 10.1007/s00125-023-06015-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/21/2023] [Indexed: 10/07/2023]
Abstract
Current management of chronic kidney disease (CKD) in type 1 diabetes centres on glycaemic control, renin-angiotensin system inhibition and optimisation of risk factors including blood pressure, lipids and body weight. While these therapeutic approaches have significantly improved outcomes among people with type 1 diabetes and CKD, this population remains at substantial elevated risk for adverse kidney and cardiovascular events, with limited improvements over the last few decades. The significant burden of CKD and CVD in type 1 diabetes populations highlights the need to identify novel therapies with the potential for heart and kidney protection. Over the last decade, sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide 1 receptor agonists and non-steroidal mineralocorticoid receptor antagonists have emerged as potent kidney-protective and/or cardioprotective agents in type 2 diabetes. The consistent, substantial kidney and cardiovascular benefits of these agents has led to their incorporation into professional guidelines as foundational care for type 2 diabetes. Furthermore, introduction of these agents into clinical practice has been accompanied by a shift in the focus of diabetes care from a 'glucose-centric' to a 'cardiorenal risk-centric' approach. In this review, we evaluate the potential translation of novel type 2 diabetes therapeutics to individuals with type 1 diabetes with the lens of preventing the development and progression of CKD.
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Affiliation(s)
- Vikas S Sridhar
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada.
| | - Christine P Limonte
- Division of Nephrology, University of Washington, Seattle, WA, USA
- Kidney Research Institute, University of Washington, Seattle, WA, USA
| | - Per-Henrik Groop
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia
| | - 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
| | | | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jay S Skyler
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David Z I Cherney
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
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20
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Schwarz Y, Klein P, Lev-Shalem L. Masked anemia and hematocrit elevation under sodium glucose transporter inhibitors: findings from a large real-world study. Acta Diabetol 2024; 61:99-105. [PMID: 37698758 DOI: 10.1007/s00592-023-02174-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 08/07/2023] [Indexed: 09/13/2023]
Abstract
AIMS Sodium glucose transporter inhibitors (SGLT2i) therapy is associated with an increase in hematocrit as a class effect. There is a lack of information regarding the clinical magnitude and significance of hematocrit elevation, especially cardiovascular outcomes in patients with polycythemia and possible masking of lower hemoglobin levels as a sign of potential severe disease. METHODS A retrospective study utilizing large community healthcare provider electronic database. Hematocrit levels and variables with potential effect on hematocrit change were compared before and during SGLT2i treatment in adults with type 2 diabetes mellitus. RESULTS Study population included 9646 patients treated with Dapagliflozin or Empagliflozin between 01.2015 and 06.2019. Hematocrit levels were significantly higher after treatment initiation (2.1%), with higher median elevation among male vs female (2.3% vs. 1.8%). Anemia prevalence was significantly lower under treatment (20% vs. 31.6%). In multivariable model, gender, smoking status, SGLT2i type, pretreatment hematocrit, diabetes duration, body mass index and estimated glomerular filtration rate change significantly effected hematocrit change. CONCLUSIONS In the current study SGLT2i treatment was associated with significant hematocrit elevation, polycythemia and lower anemia prevalence. Further studies are needed to determine the clinical significance and approach to patients with pretreatment or on treatment polycythemia and the approach to patients with lower-normal hemoglobin levels under SGLT2i treatment.
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Affiliation(s)
- Yair Schwarz
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Derech Sheba 2, 5266202, Ramat Gan, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel.
| | - Pinchas Klein
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Derech Sheba 2, 5266202, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
- Maccabi Health Care Services, Tel-Avia-Jaffa, 6812509, Israel
| | - Liat Lev-Shalem
- Maccabi Health Care Services, Tel-Avia-Jaffa, 6812509, Israel
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21
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Speedtsberg ES, Tepel M. Narrative review investigating the nephroprotective mechanisms of sodium glucose cotransporter type 2 inhibitors in diabetic and nondiabetic patients with chronic kidney disease. Front Endocrinol (Lausanne) 2023; 14:1281107. [PMID: 38174341 PMCID: PMC10761498 DOI: 10.3389/fendo.2023.1281107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/16/2023] [Indexed: 01/05/2024] Open
Abstract
Background and aims Outcome trials using sodium glucose cotransporter type 2 inhibitors have consistently shown their potential to preserve kidney function in diabetic and nondiabetic patients. Several mechanisms have been introduced which may explain the nephroprotective effect of sodium glucose cotransporter type 2 inhibitors beyond lowering blood glucose. This current narrative review has the objective to describe main underlying mechanisms causing a nephroprotective effect and to show similarities as well as differences between proposed mechanisms which can be observed in patients with diabetic and nondiabetic chronic kidney disease. Methods We performed a narrative review of the literature on Pubmed and Embase. The research string comprised various combinations of items including "chronic kidney disease", "sodium glucose cotransporter 2 inhibitor" and "mechanisms". We searched for original research and review articles published until march, 2022. The databases were searched independently and the agreements by two authors were jointly obtained. Results Sodium glucose cotransporter type 2 inhibitors show systemic, hemodynamic, and metabolic effects. Systemic effects include reduction of blood pressure without compensatory activation of the sympathetic nervous system. Hemodynamic effects include restoration of tubuloglomerular feedback which may improve pathologic hyperfiltration observed in most cases with chronic kidney disease. Current literature indicates that SGLT2i may not improve cortical oxygenation and may reduce medullar oxygenation. Conclusion Sodium glucose cotransporter type 2 inhibitors cause nephroprotective effects by several mechanisms. However, several mediators which are involved in the underlying pathophysiology may be different between diabetic and nondiabetic patients.
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Affiliation(s)
- Emma S Speedtsberg
- Institute of Molecular Medicine, Cardiovascular and Renal Research, University of Southern Denmark, Odense, Denmark
- Institute of Clinical Medicine, University of Southern Denmark, Odense, Denmark
- Department of Nephrology, Odense University Hospital, Odense, Denmark
| | - Martin Tepel
- Institute of Molecular Medicine, Cardiovascular and Renal Research, University of Southern Denmark, Odense, Denmark
- Institute of Clinical Medicine, University of Southern Denmark, Odense, Denmark
- Department of Nephrology, Odense University Hospital, Odense, Denmark
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22
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Patoulias D, Eid AH, Rizzo M. Understanding the mechanisms mediating cardio-renal benefit of empagliflozin in type 2 diabetes mellitus. J Diabetes Complications 2023; 37:108630. [PMID: 39034649 DOI: 10.1016/j.jdiacomp.2023.108630] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/15/2023] [Indexed: 07/23/2024]
Affiliation(s)
- Dimitrios Patoulias
- Outpatient Department of Cardiometabolic Medicine, Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital "Hippokration", Thessaloniki, Greece.
| | - Ali H Eid
- Department of Basic Medical Sciences, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Manfredi Rizzo
- School of Medicine, Promise Department, University of Palermo, Italy; School of Medicine, Mohammed Bin Rashid University, Dubai, United Arab Emirates
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Koshino A, Neuen BL, Jongs N, Pollock C, Greasley PJ, Andersson EM, Hammarstedt A, Karlsson C, Langkilde AM, Wada T, Heerspink HJL. Effects of dapagliflozin and dapagliflozin-saxagliptin on erythropoiesis, iron and inflammation markers in patients with type 2 diabetes and chronic kidney disease: data from the DELIGHT trial. Cardiovasc Diabetol 2023; 22:330. [PMID: 38017482 PMCID: PMC10685512 DOI: 10.1186/s12933-023-02027-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/12/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND This post-hoc analysis of the DELIGHT trial assessed effects of the SGLT2 inhibitor dapagliflozin on iron metabolism and markers of inflammation. METHODS Patients with type 2 diabetes and albuminuria were randomized to dapagliflozin, dapagliflozin and saxagliptin, or placebo. We measured hemoglobin, iron markers (serum iron, transferrin saturation, and ferritin), plasma erythropoietin, and inflammatory markers (urinary MCP-1 and urinary/serum IL-6) at baseline and week 24. RESULTS 360/461 (78.1%) participants had available biosamples. Dapagliflozin and dapagliflozin-saxagliptin, compared to placebo, increased hemoglobin by 5.7 g/L (95%CI 4.0, 7.3; p < 0.001) and 4.4 g/L (2.7, 6.0; p < 0.001) and reduced ferritin by 18.6% (8.7, 27.5; p < 0.001) and 18.4% (8.7, 27.1; p < 0.001), respectively. Dapagliflozin reduced urinary MCP-1/Cr by 29.0% (14.6, 41.0; p < 0.001) and urinary IL-6/Cr by 26.6% (9.1, 40.7; p = 0.005) with no changes in other markers. CONCLUSIONS Dapagliflozin increased hemoglobin and reduced ferritin and urinary markers of inflammation, suggesting potentially important effects on iron metabolism and inflammation. TRIAL REGISTRATION ClinicalTrials.gov NCT02547935.
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Affiliation(s)
- Akihiko Koshino
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
| | - Carol Pollock
- Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, Australia
- Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Peter J Greasley
- BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Eva-Marie Andersson
- BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Ann Hammarstedt
- BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Cecilia Karlsson
- BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | | | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands.
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia.
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24
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Weingold R, Zinman B, Mattheus M, Ofstad AP, Steubl D, Wanner C, Inzucchi SE. Shifts in KDIGO CKD risk groups with empagliflozin: Kidney-protection from SGLT2 inhibition across the spectrum of risk. J Diabetes Complications 2023; 37:108628. [PMID: 37852075 DOI: 10.1016/j.jdiacomp.2023.108628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/30/2023] [Accepted: 10/08/2023] [Indexed: 10/20/2023]
Abstract
T2D is a well-established risk factor for development and progression of CKD. KDIGO recommends categorization of risk by likelihood of progression to ESKD. Compared to placebo, empagliflozin decreases likelihood of worsening (OR 0.70, 95 % CI 0.62-0.78) and increases likelihood of improvement (OR 1.56, 95 % CI 1.30-1.86) in KDIGO risk category.
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Affiliation(s)
| | - Bernard Zinman
- Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Michaela Mattheus
- Boehringer Ingelheim International GmbH & Co. KG, Ingelheim, Germany
| | - Anne Pernille Ofstad
- Boehringer Ingelheim Norway KS, Asker, Norway; Oslo Diabetes Research Center, Oslo, Norway
| | - Dominik Steubl
- Boehringer Ingelheim International GmbH & Co. KG, Ingelheim, Germany; Department of Nephrology, Hospital rechts der Isar, Technical University Munich, Munich, Germany
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Ku E, Del Vecchio L, Eckardt KU, Haase VH, Johansen KL, Nangaku M, Tangri N, Waikar SS, Więcek A, Cheung M, Jadoul M, Winkelmayer WC, Wheeler DC. Novel anemia therapies in chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2023; 104:655-680. [PMID: 37236424 DOI: 10.1016/j.kint.2023.05.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/11/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023]
Abstract
Anemia is common in patients with chronic kidney disease and is associated with a high burden of morbidity and adverse clinical outcomes. In 2012, Kidney Disease: Improving Global Outcomes (KDIGO) published a guideline for the diagnosis and management of anemia in chronic kidney disease. Since then, new data from studies assessing established and emerging therapies for the treatment of anemia and iron deficiency have become available. Beginning in 2019, KDIGO planned 2 Controversies Conferences to review the new evidence and its potential impact on the management of anemia in clinical practice. Here, we report on the second of these conferences held virtually in December 2021, which focused on a new class of agents-the hypoxia-inducible factor-prolyl hydroxylase inhibitors (HIF-PHIs). This report provides a review of the consensus points and controversies from this second conference and highlights areas that warrant prioritization for future research.
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Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California, USA; Division of Pediatric Nephrology, Department of Pediatrics, University of California San Francisco, San Francisco, California, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA.
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Volker H Haase
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Program in Cancer Biology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Kirsten L Johansen
- Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota, USA; Division of Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Navdeep Tangri
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Andrzej Więcek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK.
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Doi Y, Hamano T, Yamaguchi S, Sakaguchi Y, Kaimori JY, Isaka Y. Mediators between canagliflozin and renoprotection vary depending on patient characteristics: Insights from the CREDENCE trial. Diabetes Obes Metab 2023; 25:2944-2953. [PMID: 37385955 DOI: 10.1111/dom.15191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/31/2023] [Accepted: 06/08/2023] [Indexed: 07/01/2023]
Abstract
AIM To identify the mediators between canagliflozin and renoprotection in patients with type 2 diabetes at a high risk of end-stage kidney disease (ESKD). METHODS In this post hoc analysis of the CREDENCE trial, the effect of canagliflozin on potential mediators (42 biomarkers) at 52 weeks and the association between changes in mediators and renal outcomes were evaluated using mixed-effects and Cox models, respectively. The renal outcome was a composite of ESKD, serum creatinine doubling or renal death. The percentage of the mediating effect of each significant mediator was calculated based on changes in the hazard ratios of canagliflozin after additional adjustment of the mediator. RESULTS Changes in haematocrit, haemoglobin, red blood cell (RBC) count and urinary albumin-to-creatinine ratio (UACR) at 52 weeks significantly mediated 47%, 41%, 40% and 29% risk reduction with canagliflozin, respectively. Further, 85% mediation was attributed to the combined effect of haematocrit and UACR. A large variation in mediating effects by haematocrit change existed among the subgroups, ranging from 17% in those patients with a UACR of more than 3000 mg/g to 63% in patients with a UACR of 3000 mg/g or less. In the subgroups with a UACR of more than 3000 mg/g, UACR change was the highest mediating factor (37%), driven by the strong association between UACR decline and renal risk reduction. CONCLUSIONS The renoprotective effects of canagliflozin in patients at a high risk of ESKD can be significantly explained by changes in RBC variables and UACR. The complementary mediating effects of RBC variables and UACR may support the renoprotective effect of canagliflozin in different patient groups.
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Affiliation(s)
- Yohei Doi
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Takayuki Hamano
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Nephrology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Satoshi Yamaguchi
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Nephrology, Japan Community Health Care Organization Osaka Hospital, Osaka, Japan
| | - Yusuke Sakaguchi
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Jun-Ya Kaimori
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
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Gill M, Leung M, Luo CY, Cheung C, Beauchesne A, Chang D, Lan J, Johnston O. Erythrocytosis and thrombotic events in kidney transplant recipients prescribed a sodium glucose cotransport-2 inhibitor. Clin Transplant 2023; 37:e15013. [PMID: 37170711 DOI: 10.1111/ctr.15013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/24/2023] [Accepted: 04/29/2023] [Indexed: 05/13/2023]
Abstract
INTRODUCTION The safety and efficacy of sodium glucose cotransport-2 inhibitors (SGLT2i) in kidney transplant recipients remains uncertain. Transplant recipients may be at risk of thrombosis because of post-transplant erythrocytosis and SGLT2i are associated with an increase in hematocrit. METHODS We determined SGLT2i use, the change in hematocrit and incidence of thrombotic events in kidney transplant recipients in 1700 prevalent patients in our center. RESULTS Among the 42 patients treated with SGLT2i, the mean pre-transplant hematocrit was 31%, and none of the patients had a hematocrit ≥50%. The mean percent change in hematocrit measured at an average of 53 days after initiation of an SGLT2i was 11% and four patients (10%) had a hematocrit ≥ 50%. The mean hematocrit measured 3 months after treatment was 42% and two patients (5%) had a hematocrit ≥50%. One patient had a cerebellar stroke 14 months post-SGLT2i initiation when the hemoglobin was 173 grams/liter, and the hematocrit was 52%. CONCLUSIONS All patients had a sustained increase in hematocrit 3 months after SGLT2i treatment. Hematocrit ≥50% occurred in 10%, and one patient had a thrombotic event that may or may not have been related to an increase in hematocrit. Clinicians may consider monitoring for erythrocytosis after starting and SGLT2i in kidney transplant recipients.
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Affiliation(s)
- Maia Gill
- University of British Columbia, Division of Nephrology, Kidney Transplant program, Vancouver, Canada
| | - Marianna Leung
- University of British Columbia Faculty of Pharmaceutical Sciences, Vancouver, Canada
- Providence Healthcare, Seattle, USA
| | - Cindy Y Luo
- University of British Columbia, Division of Nephrology, Kidney Transplant program, Vancouver, Canada
- University of British Columbia Faculty of Pharmaceutical Sciences, Vancouver, Canada
| | - Catherine Cheung
- University of British Columbia Faculty of Pharmaceutical Sciences, Vancouver, Canada
- Fraser Health, Surrey, Canada
| | - Arielle Beauchesne
- University of British Columbia Faculty of Pharmaceutical Sciences, Vancouver, Canada
- Providence Healthcare, Seattle, USA
| | - Doris Chang
- University of British Columbia, Division of Nephrology, Kidney Transplant program, Vancouver, Canada
- Providence Health Research Institute, Seattle, USA
| | - James Lan
- University of British Columbia, Division of Nephrology, Kidney Transplant program, Vancouver, Canada
| | - Olwyn Johnston
- University of British Columbia, Division of Nephrology, Kidney Transplant program, Vancouver, Canada
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28
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Charytan DM, Mahaffey KW, Jardine MJ, Cannon CP, Neal B, Lambers Heerspink HJ, Agarwal R, Bakris GL, de Zeeuw D, Levin A, Pollock C, Zhang H, Zinman B, Rosenthal N, Perkovic V, Di Tanna GL, Yu J, Rogers K, Arnott C, Wheeler DC. Cardiorenal protective effects of canagliflozin in CREDENCE according to glucose lowering. BMJ Open Diabetes Res Care 2023; 11:e003270. [PMID: 37311602 DOI: 10.1136/bmjdrc-2022-003270] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 04/21/2023] [Indexed: 06/15/2023] Open
Abstract
INTRODUCTION Relationships between glycemic-lowering effects of sodium glucose co-transporter 2 inhibitors and impact on kidney and cardiovascular outcomes are uncertain. RESEARCH DESIGN AND METHODS We analyzed 4395 individuals with prebaseline and postbaseline hemoglobin A1c (HbA1c) randomized to canagliflozin (n=2193) or placebo (n=2202) in The Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation trial. Effects on HbA1c were assessed using mixed models. Mediation of treatment effects by achieved glycemic control was analyzed using proportional hazards regression with and without adjustment for achieved HbA1c. End points included combined kidney or cardiovascular death, end-stage kidney disease or doubling of serum creatinine (primary trial outcome), and individual end point components. RESULTS HbA1c lowering was modified by baseline estimated glomerular filtration rate (eGFR). For baseline eGFR 60-90, 45-59, and 30-44 mL/min/1.73 m2, overall HbA1c (canagliflozin vs placebo) decreased by -0.24%, -0.14%, and -0.08% respectively and likelihood of >0.5% decrease in HbA1c decreased with ORs of 1.47 (95% CI 1.27 to 1.67), 1.12 (0.94 to 1.33) and 0.99 (0.83 to 1.18), respectively. Adjustment for postbaseline HbA1c marginally attenuated canagliflozin effects on primary and kidney composite outcomes: unadjusted HR 0.67 (95% CI 0.57 to 0.80) and 0.66 (95% CI 0.53 to 0.81); adjusted for week 13 HbA1c, HR 0.71 (95% CI 0.060 to 0.84) and 0.68 (95% CI 0.55 to 0.83). Results adjusted for time-varying HbA1c or HbA1c as a cubic spline were similar and consistent with preserved clinical benefits across a range of excellent and poor glycemic control. CONCLUSIONS The glycemic effects of canagliflozin are attenuated at lower eGFR but effects on kidney and cardiac end points are preserved. Non-glycemic effects may be primarily responsible for the kidney and cardioprotective benefits of canagliflozin.22.
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Affiliation(s)
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Meg J Jardine
- The University of Sydney, Sydney, New South Wales, Australia
| | | | - Bruce Neal
- The University of Sydney, Sydney, New South Wales, Australia
| | | | | | | | - Dick de Zeeuw
- Clinical Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Adeera Levin
- Nephrology, St. Paul's Hospital, Newtown, New South Wales, Australia
| | - Carol Pollock
- Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Hong Zhang
- Renal Division of Peking University First Hospital, Beijing, China
| | | | | | - Vlado Perkovic
- George Institute for Global Health, Sydney, New South Wales, Australia
- Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | | | - Jie Yu
- George Institute for Global Health, Sydney, New South Wales, Australia
| | - Kris Rogers
- George Institute for Global Health, Sydney, New South Wales, Australia
| | - Clare Arnott
- The George Institute for Global Health, Newtown, New South Wales, Australia
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Tye S, Oshima M, Arnott C, Neuen BL, Fletcher RA, Neal B, Heerspink HJL. The importance of targeting multiple risk markers in patients with type 2 diabetes: A post-hoc study from the CANVAS programme. Diabetes Obes Metab 2023; 25:1638-1645. [PMID: 36782264 DOI: 10.1111/dom.15018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/31/2023] [Accepted: 02/07/2023] [Indexed: 02/15/2023]
Abstract
AIMS To investigate the extent to which improvements in multiple cardiovascular risk markers are associated with a lower risk of cardiovascular and kidney outcomes in patients with type 2 diabetes and high cardiovascular risk participating in the CANVAS programme. MATERIALS AND METHODS Clinically relevant improvements in cardiovascular risk factors were defined as a reduction in glycated haemoglobin ≥1.0%, systolic blood pressure ≥10 mmHg, body weight ≥3 kg, urinary-albumin-creatinine ratio ≥30%, uric acid ≥0.5 mg/dl, and an increase in haemoglobin of ≥1.0 g/dl from baseline to week 26. Participants were categorized according to the number of improvements in cardiovascular risk markers: zero, one, two, three, or four or more risk marker improvements. The Cox proportional hazard regression adjusted for treatment assignment, demographic variables and laboratory measurements was performed to determine the association between the number of risk marker improvements and risk of a composite cardiovascular, heart failure or kidney outcomes. RESULTS We included 9487 (93.5%) participants with available data at baseline and week 26. After week 26, 566 composite cardiovascular, 370 heart failure/cardiovascular death and 153 composite kidney outcomes occurred. The multivariable adjusted hazard ratios associated with four or more improvements in risk markers versus no risk marker improvement were 0.67 (95% CI 0.48, 0.92), 0.58 (95% CI 0.39, 0.87) and 0.49 (95% CI 0.25, 0.96) for the three outcomes respectively. We observed a trend of decreased hazard ratios across subgroups of increasing number of risk marker improvements (p for trend = .008, .02 and .047, respectively). CONCLUSIONS In patients with type 2 diabetes, improvements in multiple risk markers were associated with a reduced risk of cardiovascular and kidney outcomes as compared with no risk marker improvement.
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Affiliation(s)
- SokCin Tye
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Megumi Oshima
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Japan
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Clare Arnott
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Robert A Fletcher
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Bruce Neal
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - 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, UNSW Sydney, Sydney, New South Wales, Australia
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Sinha F, Federlein A, Biesold A, Schwarzfischer M, Krieger K, Schweda F, Tauber P. Empagliflozin increases kidney weight due to increased cell size in the proximal tubule S3 segment and the collecting duct. Front Pharmacol 2023; 14:1118358. [PMID: 37033639 PMCID: PMC10076569 DOI: 10.3389/fphar.2023.1118358] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/14/2023] [Indexed: 04/11/2023] Open
Abstract
The inhibition of renal SGLT2 glucose reabsorption has proven its therapeutic efficacy in chronic kidney disease. SGLT2 inhibitors (SGLTi) have been intensively studied in rodent models to identify the mechanisms of SGLT2i-mediated nephroprotection. So far, the overwhelming effects from clinical trials, could only partially be reproduced in rodent models of renal injury. However, a commonly disregarded observation from these studies, is the increase in kidney weight after SGLT2i administration. Increased kidney mass often relies on tubular growth in response to reabsorption overload during glomerular hyperfiltration. Since SGLT2i suppress hyperfiltration but concomitantly increase renal weight, it seems likely that SGLT2i have a growth promoting effect on the kidney itself, independent of GFR control. This study aimed to investigate the effect of SGLT2i on kidney growth in wildtype animals, to identify enlarged nephron segments and classify the size increase as hypertrophic/hyperplastic growth or cell swelling. SGLT2i empagliflozin increased kidney weight in wildtype mice by 13% compared to controls, while bodyweight and other organs were not affected. The enlarged nephron segments were identified as SGLT2-negative distal segments of proximal tubules and as collecting ducts by histological quantification of tubular cell area. In both segments protein/DNA ratio, a marker for hypertrophic growth, was increased by 6% and 12% respectively, while tubular nuclei number (hyperplasia) was unchanged by empagliflozin. SGLT2-inhibition in early proximal tubules induces a shift of NaCl resorption along the nephron causing compensatory NaCl and H2O reabsorption and presumably cell growth in downstream segments. Consistently, in collecting ducts of empagliflozin-treated mice, mRNA expression of the Na+-channel ENaC and the H2O-channels Aqp-2/Aqp-3 were increased. In addition, the hypoxia marker Hif1α was found increased in intercalated cells of the collecting duct together with evidence for increased proton secretion, as indicated by upregulation of carbonic anhydrases and acidified urine pH in empagliflozin-treated animals. In summary, these data show that SGLT2i induce cell enlargement by hypertrophic growth and possibly cell swelling in healthy kidneys, probably as a result of compensatory glucose, NaCl and H2O hyperreabsorption of SGLT2-negative segments. Particularly affected are the SGLT2-negative proximal tubules (S3) and the collecting duct, areas of low O2 availability.
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Aroda VR, Eckel RH. Reconsidering the role of glycaemic control in cardiovascular disease risk in type 2 diabetes: A 21st century assessment. Diabetes Obes Metab 2022; 24:2297-2308. [PMID: 35929480 PMCID: PMC9804800 DOI: 10.1111/dom.14830] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 01/09/2023]
Abstract
It is well known that the multiple factors contributing to the pathogenesis of type 2 diabetes (T2D) confer an increased risk of developing cardiovascular disease (CVD). Although the relationship between hyperglycaemia and increased microvascular risk is well established, the relative contribution of hyperglycaemia to macrovascular events has been strongly debated, particularly owing to the failure of attempts to reduce CVD risk through normalizing glycaemia with traditional therapies in high-risk populations. The debate has been further fuelled by the relatively recent discovery of the cardioprotective properties of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors. Further, as guidelines now recommend individualizing glycaemic targets, highlighting the importance of achieving glycated haemoglobin (HbA1c) goals safely, the previously observed negative influences of intensive therapy on CVD risk might not present if trials were repeated using current-day treatments and individualized HbA1c goals. Emerging longitudinal data illuminate the overall effect of excess glucose, the impacts of magnitude and duration of hyperglycaemia on disease progression and risk of CVD complications, and the importance of glycaemic control at or early after diagnosis of T2D for prevention of complications. Herein, we review the role of glucose as a modifiable cardiovascular (CV) risk factor, the role of microvascular disease in predicting macrovascular risk, and the deleterious impact of therapeutic inertia on CVD risk. We reconcile new and old data to offer a current perspective, highlighting the importance of effective, early treatment in reducing latent CV risk, and the timely use of appropriate therapy individualized to each patient's needs.
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Affiliation(s)
- Vanita R. Aroda
- Division of Endocrinology, Diabetes, and HypertensionBrigham and Women's HospitalBostonMassachusetts
| | - Robert H. Eckel
- Division of Endocrinology, Metabolism, and Diabetes, and the Division of CardiologyUniversity of Colorado School of MedicineAuroraColorado
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Matsubayashi Y, Yoshida A, Suganami H, Oe M, Sato T, Yaguchi Y, Fujihara K, Yamada T, Tanaka S, Kaku K, Sone H. Predictors of haemoglobin levels and of changes in these levels, focusing on anaemia and polycythaemia after administration of the sodium-glucose cotransporter-2 inhibitor tofogliflozin. Diabetes Obes Metab 2022; 24:2469-2473. [PMID: 35979908 PMCID: PMC9825934 DOI: 10.1111/dom.14836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/05/2022] [Accepted: 08/10/2022] [Indexed: 01/11/2023]
Affiliation(s)
- Yasuhiro Matsubayashi
- Department of Hematology, Endocrinology and Metabolism, Faculty of MedicineNiigata UniversityNiigataJapan
| | - Alkihiro Yoshida
- Department of Hematology, Endocrinology and Metabolism, Faculty of MedicineNiigata UniversityNiigataJapan
- Kowa Company, LtdTokyoJapan
| | | | - Momoko Oe
- Department of Hematology, Endocrinology and Metabolism, Faculty of MedicineNiigata UniversityNiigataJapan
- Kowa Company, LtdTokyoJapan
| | - Takaaki Sato
- Department of Hematology, Endocrinology and Metabolism, Faculty of MedicineNiigata UniversityNiigataJapan
| | - Yuta Yaguchi
- Department of Hematology, Endocrinology and Metabolism, Faculty of MedicineNiigata UniversityNiigataJapan
| | - Kazuya Fujihara
- Department of Hematology, Endocrinology and Metabolism, Faculty of MedicineNiigata UniversityNiigataJapan
| | - Takaho Yamada
- Department of Hematology, Endocrinology and Metabolism, Faculty of MedicineNiigata UniversityNiigataJapan
| | - Shiro Tanaka
- Department of Clinical BiostatisticsGraduate School of Medicine Kyoto University
| | | | - Hirohito Sone
- Department of Hematology, Endocrinology and Metabolism, Faculty of MedicineNiigata UniversityNiigataJapan
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Shamkhalova MS, Sukhareva OY, Shestakova MV. Sub-analyses of the DAPA-CKD study: new data on the use of sodium-glucose cotransporter type 2 inhibitor in the treatment of chronic kidney disease. TERAPEVT ARKH 2022; 94:1188-1196. [DOI: 10.26442/00403660.2022.10.201883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Indexed: 11/23/2022]
Abstract
Sodium-glucose cotransporter inhibitors updated their position in the therapy of patients with type 2 diabetes mellitus due to proven nephro- and cardioprotective effects. The DAPA-CKD study, performed among individuals with CKD of various etiologies, was also conducted in a mixed population, including patients without type 2 diabetes, showed the ability of dapagliflozin to reduce the risk of the primary combined endpoint (eGFR15 ml/min/1.73 m2, the need for chronic dialysis or kidney transplantation, time to renal or cardiovascular death), and certain secondary endpoints. Due to the inclusion of dapagliflozin into the treatment of the patients with CKD of not only the diabetic origin and the expected subsequent significant expansion of the patient population with indications for the use of this drug, the review of the results of the sub-analyses of DAPA-CKD study may be of interest to the clinicians.
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Gohda T, Murakoshi M. Sodium-Glucose Cotransporter-2 Inhibitors-Miracle Drugs for the Treatment of Chronic Kidney Disease Irrespective of the Diabetes Status: Lessons from the Dedicated Kidney Disease-Focused CREDENCE and DAPA-CKD Trials. Int J Mol Sci 2022; 23:ijms232213749. [PMID: 36430228 PMCID: PMC9696577 DOI: 10.3390/ijms232213749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/04/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022] Open
Abstract
Diabetic kidney disease (DKD) is the leading cause of chronic kidney disease (CKD) and end-stage kidney disease worldwide. In Japan, the proportion of new patients requiring dialysis due to DKD has remained unchanged over the past five years. Early diagnosis and treatment are extremely important for the prevention of DKD progression. Albuminuria is the most promising biomarker currently available for diagnosing DKD and predicting its prognosis at an early stage; however, it has relatively poor specificity and sensitivity for DKD. Measuring the serum levels of tumor necrosis factor receptors (TNFRs; TNFR1 and TNFR2) is an alternative for predicting the prognosis of patients with CKD, irrespective of their diabetes status. Cardiorenal risk factor management and renin-angiotensin system inhibitor usage are effective in slowing the DKD progression, although the residual risk remains high in patients with DKD. Recently, two classes of antihyperglycemic agents, sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists, in addition to nonsteroidal selective mineralocorticoid receptor antagonists, which are less potent blood pressure-lowering and potassium-sparing agents, have emerged as cardiorenal disease-modifying therapies for preventing the DKD progression. This review focused on the SGLT2 inhibitor-based therapeutic strategies that have demonstrated cardiorenal benefits in patients with type 2 diabetes.
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Packer M. Critical Reanalysis of the Mechanisms Underlying the Cardiorenal Benefits of SGLT2 Inhibitors and Reaffirmation of the Nutrient Deprivation Signaling/Autophagy Hypothesis. Circulation 2022; 146:1383-1405. [PMID: 36315602 PMCID: PMC9624240 DOI: 10.1161/circulationaha.122.061732] [Citation(s) in RCA: 139] [Impact Index Per Article: 69.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 08/10/2022] [Indexed: 02/06/2023]
Abstract
SGLT2 (sodium-glucose cotransporter 2) inhibitors produce a distinctive pattern of benefits on the evolution and progression of cardiomyopathy and nephropathy, which is characterized by a reduction in oxidative and endoplasmic reticulum stress, restoration of mitochondrial health and enhanced mitochondrial biogenesis, a decrease in proinflammatory and profibrotic pathways, and preservation of cellular and organ integrity and viability. A substantial body of evidence indicates that this characteristic pattern of responses can be explained by the action of SGLT2 inhibitors to promote cellular housekeeping by enhancing autophagic flux, an effect that may be related to the action of these drugs to produce simultaneous upregulation of nutrient deprivation signaling and downregulation of nutrient surplus signaling, as manifested by an increase in the expression and activity of AMPK (adenosine monophosphate-activated protein kinase), SIRT1 (sirtuin 1), SIRT3 (sirtuin 3), SIRT6 (sirtuin 6), and PGC1-α (peroxisome proliferator-activated receptor γ coactivator 1-α) and decreased activation of mTOR (mammalian target of rapamycin). The distinctive pattern of cardioprotective and renoprotective effects of SGLT2 inhibitors is abolished by specific inhibition or knockdown of autophagy, AMPK, and sirtuins. In the clinical setting, the pattern of differentially increased proteins identified in proteomics analyses of blood collected in randomized trials is consistent with these findings. Clinical studies have also shown that SGLT2 inhibitors promote gluconeogenesis, ketogenesis, and erythrocytosis and reduce uricemia, the hallmarks of nutrient deprivation signaling and the principal statistical mediators of the ability of SGLT2 inhibitors to reduce the risk of heart failure and serious renal events. The action of SGLT2 inhibitors to augment autophagic flux is seen in isolated cells and tissues that do not express SGLT2 and are not exposed to changes in environmental glucose or ketones and may be related to an ability of these drugs to bind directly to sirtuins or mTOR. Changes in renal or cardiovascular physiology or metabolism cannot explain the benefits of SGLT2 inhibitors either experimentally or clinically. The direct molecular effects of SGLT2 inhibitors in isolated cells are consistent with the concept that SGLT2 acts as a nutrient surplus sensor, and thus, its inhibition causes enhanced nutrient deprivation signaling and its attendant cytoprotective effects, which can be abolished by specific inhibition or knockdown of AMPK, sirtuins, and autophagic flux.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Dallas, TX. Imperial College, London, United Kingdom
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Sen T, Koshino A, Neal B, Bijlsma MJ, Arnott C, Li J, Hansen MK, Ix JH, Heerspink HJL. Mechanisms of action of the sodium-glucose cotransporter-2 (SGLT2) inhibitor canagliflozin on tubular inflammation and damage: A post hoc mediation analysis of the CANVAS trial. Diabetes Obes Metab 2022; 24:1950-1956. [PMID: 35635326 PMCID: PMC9546391 DOI: 10.1111/dom.14779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/09/2022] [Accepted: 05/25/2022] [Indexed: 01/10/2023]
Abstract
AIMS To test the hypothesis that the reduction in urinary kidney injury molecule-1 (KIM-1) observed with the sodium-glucose cotransporter-2 (SGLT2) inhibitor canagliflozin is mediated through its effects on urine albumin to creatinine ratio (UACR) and monocyte chemoattractant protein-1 (MCP-1) by assessing the proportion of the effect of canagliflozin on KIM-1 that is mediated through its effects on MCP-1 and UACR in patients with type 2 diabetes and albuminuric kidney disease. MATERIAL AND METHODS We measured KIM-1 and MCP-1 levels in urine samples from the CANVAS trial at baseline and Week 52 with the Mesoscale QuickPlex SQ 120 platform. KIM-1 and MCP-1 were standardized by urinary creatinine (Cr). The proportion of the effect of canagliflozin that is mediated through UACR and MCP-1/Cr on KIM-1/Cr was estimated with G-computation. RESULTS In total, 763 patients with micro- or macroalbuminuria (17.6% of the total cohort) were included. Baseline characteristics were well balanced between the canagliflozin and placebo group. At Year 1, canagliflozin compared to placebo reduced UACR, MCP-1/Cr and KIM-1/Cr by 40.4% (95% CI 31.0, 48.4), 18.1% (95% CI 8.9, 26.4) and 30.9% (95% CI 23.0, 38.0), respectively. The proportion of the effect of canagliflozin on KIM-1/Cr mediated by its effect on UACR and in turn on MCP-1/Cr was 15.2% (95% CI 9.4, 24.5). CONCLUSION Canagliflozin reduces urinary KIM-1, suggesting decreased tubular damage. This effect was partly mediated through a reduction in MCP-1, indicative of reduced tubular inflammation, which was in turn mediated by a reduction in UACR. This post hoc analysis suggests that urinary albumin leakage may lead to tubular inflammation and induction of injury, and provide mechanistic insight for how canagliflozin may ameliorate tubular damage, but further research is required to confirm these findings.
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Affiliation(s)
- Taha Sen
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
| | - Akihiko Koshino
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
- Department of Nephrology and Laboratory MedicineKanazawa UniversityKanazawaJapan
| | - Bruce Neal
- The George Institute for Global HealthUNSW SydneySydneyNew South WalesAustralia
| | - Maarten J. Bijlsma
- Unit PharmacoTherapy, Epidemiology, and Economics (PTEE), Groningen Research Institute of PharmacyUniversity of GroningenGroningenThe Netherlands
| | - Clare Arnott
- The George Institute for Global HealthUNSW SydneySydneyNew South WalesAustralia
| | - Jingwei Li
- The George Institute for Global HealthUNSW SydneySydneyNew South WalesAustralia
| | | | - Joachim H. Ix
- Nephrology SectionVeterans Affairs San Diego Healthcare SystemLa JollaCaliforniaUSA
- Division of Nephrology‐Hypertension, Department of MedicineUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Hiddo J. L. Heerspink
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
- The George Institute for Global HealthUNSW SydneySydneyNew South WalesAustralia
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Abstract
SGLT2 inhibitors can protect the kidneys of patients with and without type 2 diabetes from failing. This includes blood glucose dependent and independent mechanisms. SGLT2 inhibitors lower glomerular pressure and filtration, thereby reducing the physical stress on the filtration barrier and the oxygen demand for tubular reabsorption. This improves cortical oxygenation, which, together with lesser tubular glucotoxicity and improved mitochondrial function and autophagy, can reduce proinflammatory and profibrotic signaling and preserve tubular function and GFR in long term. By shifting transport downstream, SGLT2 inhibitors may mimic systemic hypoxia and stimulate erythropoiesis, which improves oxygen delivery to the kidney and other organs.
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Affiliation(s)
- Volker Vallon
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, CA, USA; Department of Pharmacology, University of California San Diego, La Jolla, CA, USA; VA San Diego Healthcare System, 3350 La Jolla Village Drive (9151), San Diego, CA 92161, USA.
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Docherty KF, Welsh P, Verma S, De Boer RA, O’Meara E, Bengtsson O, Køber L, Kosiborod MN, Hammarstedt A, Langkilde AM, Lindholm D, Little DJ, Sjöstrand M, Martinez FA, Ponikowski P, Sabatine MS, Morrow DA, Schou M, Solomon SD, Sattar N, Jhund PS, McMurray JJ. Iron Deficiency in Heart Failure and Effect of Dapagliflozin: Findings From DAPA-HF. Circulation 2022; 146:980-994. [PMID: 35971840 PMCID: PMC9508991 DOI: 10.1161/circulationaha.122.060511] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Iron deficiency is common in heart failure and associated with worse outcomes. We examined the prevalence and consequences of iron deficiency in the DAPA-HF trial (Dapagliflozin and Prevention of Adverse-Outcomes in Heart Failure) and the effect of dapagliflozin on markers of iron metabolism. We also analyzed the effect of dapagliflozin on outcomes, according to iron status at baseline. METHODS Iron deficiency was defined as a ferritin level <100 ng/mL or a transferrin saturation <20% and a ferritin level 100 to 299 ng/mL. Additional biomarkers of iron metabolism, including soluble transferrin receptor, erythropoietin, and hepcidin were measured at baseline and 12 months after randomization. The primary outcome was a composite of worsening heart failure (hospitalization or urgent visit requiring intravenous therapy) or cardiovascular death. RESULTS Of the 4744 patients randomized in DAPA-HF, 3009 had ferritin and transferrin saturation measurements available at baseline, and 1314 of these participants (43.7%) were iron deficient. The rate of the primary outcome was higher in patients with iron deficiency (16.6 per 100 person-years) compared with those without (10.4 per 100 person-years; P<0.0001). The effect of dapagliflozin on the primary outcome was consistent in iron-deficient compared with iron-replete patients (hazard ratio, 0.74 [95% CI, 0.58-0.92] versus 0.81 [95% CI, 0.63-1.03]; P-interaction=0.59). Similar findings were observed for cardiovascular death, heart failure hospitalization, and all-cause mortality. Transferrin saturation, ferritin, and hepcidin were reduced and total iron-binding capacity and soluble transferrin receptor increased with dapagliflozin compared with placebo. CONCLUSIONS Iron deficiency was common in DAPA-HF and associated with worse outcomes. Dapagliflozin appeared to increase iron use but improved outcomes, irrespective of iron status at baseline. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03036124.
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Affiliation(s)
- Kieran F. Docherty
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (K.F.D., P.W., N.S., P.S.J., J.J.V.M.)
| | - Paul Welsh
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (K.F.D., P.W., N.S., P.S.J., J.J.V.M.)
| | - Subodh Verma
- Division of Cardiac Surgery, St Michael’s Hospital, University of Toronto, Canada (S.V.)
| | - Rudolf A. De Boer
- Department of Cardiology, University Medical Center and University of Groningen, The Netherlands (R.A.D.B.)
| | - Eileen O’Meara
- Montreal Heart Institute, Université de Montréal, Canada (E.O.)
| | - Olof Bengtsson
- AstraZeneca R&D, Gothenburg, Sweden (O.B., A.H., A.M.L., D.L., D.J.L., M. Sjöstrand)
| | - Lars Køber
- Rigshospitalet Copenhagen University Hospital, Denmark (L.K.)
| | - Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute and University of Missouri-Kansas City (M.N.K.).,George Institute for Global Health, University of New South Wales, Sydney, Australia (M.N.K.)
| | - Ann Hammarstedt
- AstraZeneca R&D, Gothenburg, Sweden (O.B., A.H., A.M.L., D.L., D.J.L., M. Sjöstrand)
| | - Anna Maria Langkilde
- AstraZeneca R&D, Gothenburg, Sweden (O.B., A.H., A.M.L., D.L., D.J.L., M. Sjöstrand)
| | - Daniel Lindholm
- AstraZeneca R&D, Gothenburg, Sweden (O.B., A.H., A.M.L., D.L., D.J.L., M. Sjöstrand)
| | - Dustin J. Little
- AstraZeneca R&D, Gothenburg, Sweden (O.B., A.H., A.M.L., D.L., D.J.L., M. Sjöstrand)
| | - Mikaela Sjöstrand
- AstraZeneca R&D, Gothenburg, Sweden (O.B., A.H., A.M.L., D.L., D.J.L., M. Sjöstrand)
| | - Felipe A. Martinez
- George Institute for Global Health, University of New South Wales, Sydney, Australia (M.N.K.)
| | | | - Marc S. Sabatine
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Cardiovascular Division, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA (M.S.S., D.A.M.)
| | - David A. Morrow
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Cardiovascular Division, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA (M.S.S., D.A.M.)
| | - Morten Schou
- Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (M. Schou)
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (S.D.S.)
| | - Naveed Sattar
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (K.F.D., P.W., N.S., P.S.J., J.J.V.M.)
| | - Pardeep S. Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (K.F.D., P.W., N.S., P.S.J., J.J.V.M.)
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (K.F.D., P.W., N.S., P.S.J., J.J.V.M.)
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Segar MW, Kolkailah AA, Frederich R, Pong A, Cannon CP, Cosentino F, Dagogo‐Jack S, McGuire DK, Pratley RE, Liu C, Maldonado M, Liu J, Cater NB, Pandey A, Cherney DZI. Mediators of ertugliflozin effects on heart failure and kidney outcomes among patients with type 2 diabetes mellitus. Diabetes Obes Metab 2022; 24:1829-1839. [PMID: 35603908 PMCID: PMC9357198 DOI: 10.1111/dom.14769] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 05/06/2022] [Accepted: 05/10/2022] [Indexed: 11/28/2022]
Abstract
AIMS Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been shown to reduce the risk of hospitalization for heart failure (HHF) and composite kidney outcomes, but the mediators underlying these benefits are unknown. MATERIALS AND METHODS Among participants from VERTIS CV, a trial of patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease randomized to ertugliflozin versus placebo, Cox proportional hazards regression models were used to evaluate the percentage mediation of ertugliflozin efficacy on the first HHF and kidney composite outcome in 26 potential mediators. Time-dependent approaches were used to evaluate associations between early (change from baseline to the first post-baseline measurement) and average (weighted average of change from baseline using all post-baseline measurements) changes in covariates with clinical outcomes. RESULTS For the HHF analyses, early changes in four biomarkers (haemoglobin, haematocrit, serum albumin and urate) and average changes in seven biomarkers (early biomarkers + weight, chloride and serum protein) were identified as fulfilling the criteria as mediators of ertugliflozin effects on the risk of HHF. Similar results were observed for the composite kidney outcome, with early changes in four biomarkers (glycated haemoglobin, haemoglobin, haematocrit and urate), and average changes in five biomarkers [early biomarkers (not glycated haemoglobin) + weight, serum albumin] mediating the effects of ertugliflozin on the kidney outcome. CONCLUSIONS In these analyses from the VERTIS CV trial, markers of volume status and haemoconcentration and/or haematopoiesis were the strongest mediators of the effect of ertugliflozin on reducing risk of HHF and composite kidney outcomes in the early and average change periods. GOV IDENTIFIER NCT01986881.
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Affiliation(s)
| | - Ahmed A. Kolkailah
- Division of Cardiology, Department of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | | | - Annpey Pong
- Biostatistics and Research Decision SciencesMerck & Co., Inc.KenilworthNew JerseyUSA
| | - Christopher P. Cannon
- Cardiovascular Division, Brigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Francesco Cosentino
- Unit of CardiologyKarolinska Institute & Karolinska University HospitalStockholmSweden
| | - Samuel Dagogo‐Jack
- Department of MedicineUniversity of Tennessee Health Science CenterMemphisTennesseeUSA
| | - Darren K. McGuire
- Division of Cardiology, Department of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Parkland Health and Hospital SystemDallasTexasUSA
| | | | - Chih‐Chin Liu
- Biostatistics and Research Decision SciencesMerck & Co., Inc.KenilworthNew JerseyUSA
| | | | - Jie Liu
- Global Clinical Development ‐ Diabetes, Endocrinology & MetabolismMerck & Co., Inc.KenilworthNew JerseyUSA
| | | | - Ambarish Pandey
- Division of Cardiology, Department of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - David Z. I. Cherney
- Department of Medicine, Division of Nephrology, University Health NetworkUniversity of TorontoTorontoOntarioCanada
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40
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Zannad F, Ferreira JP, Butler J, Filippatos G, Januzzi JL, Sumin M, Zwick M, Saadati M, Pocock SJ, Sattar N, Anker SD, Packer M. Effect of empagliflozin on circulating proteomics in heart failure: mechanistic insights into the EMPEROR programme. Eur Heart J 2022; 43:4991-5002. [PMID: 36017745 PMCID: PMC9769969 DOI: 10.1093/eurheartj/ehac495] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/15/2022] [Accepted: 08/25/2022] [Indexed: 01/12/2023] Open
Abstract
AIMS Sodium-glucose co-transporter 2 (SGLT2) inhibitors improve cardiovascular outcomes in diverse patient populations, but their mechanism of action requires further study. The aim is to explore the effect of empagliflozin on the circulating levels of intracellular proteins in patients with heart failure, using large-scale proteomics. METHODS AND RESULTS Over 1250 circulating proteins were measured at baseline, Week 12, and Week 52 in 1134 patients from EMPEROR-Reduced and EMPEROR-Preserved, using the Olink® Explore 1536 platform. Statistical and bioinformatical analyses identified differentially expressed proteins (empagliflozin vs. placebo), which were then linked to demonstrated biological actions in the heart and kidneys. At Week 12, 32 of 1283 proteins fulfilled our threshold for being differentially expressed, i.e. their levels were changed by ≥10% with a false discovery rate <1% (empagliflozin vs. placebo). Among these, nine proteins demonstrated the largest treatment effect of empagliflozin: insulin-like growth factor-binding protein 1, transferrin receptor protein 1, carbonic anhydrase 2, erythropoietin, protein-glutamine gamma-glutamyltransferase 2, thymosin beta-10, U-type mitochondrial creatine kinase, insulin-like growth factor-binding protein 4, and adipocyte fatty acid-binding protein 4. The changes of the proteins from baseline to Week 52 were generally concordant with the changes from the baseline to Week 12, except empagliflozin reduced levels of kidney injury molecule-1 by ≥10% at Week 52, but not at Week 12. The most common biological action of differentially expressed proteins appeared to be the promotion of autophagic flux in the heart, kidney or endothelium, a feature of 6 proteins. Other effects of differentially expressed proteins on the heart included the reduction of oxidative stress, inhibition of inflammation and fibrosis, and the enhancement of mitochondrial health and energy, repair, and regenerative capacity. The actions of differentially expressed proteins in the kidney involved promotion of autophagy, integrity and regeneration, suppression of renal inflammation and fibrosis, and modulation of renal tubular sodium reabsorption. CONCLUSIONS Changes in circulating protein levels in patients with heart failure are consistent with the findings of experimental studies that have shown that the effects of SGLT2 inhibitors are likely related to actions on the heart and kidney to promote autophagic flux, nutrient deprivation signalling and transmembrane sodium transport.
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Affiliation(s)
- Faiez Zannad
- Corresponding author. Tel: +33 3 83 15 73 15, Fax: +33 3 83 15 73 24, Emails: ;
| | - João Pedro Ferreira
- Corresponding author. Tel: +33 3 83 15 73 15, Fax: +33 3 83 15 73 24, Emails: ;
| | - Javed Butler
- Heart and Vascular Research, Baylor Scott and White Research Institute, 34 Live Oak St Ste 501, Dallas, TX 75204, USA,University of Mississippi Medical Center, 2500 North State Street Jackson, MS 39216, USA
| | - Gerasimos Filippatos
- Heart Failure Unit, National and Kapodistrian University of Athens School of Medicine, Mikras Asias 75, Athina 115 27 Athens, Greece
| | - James L Januzzi
- Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114USA,The Baim Institute for Clinical Research, 930 Commonwealth Ave #3, Boston, MA 02215USA
| | - Mikhail Sumin
- Boehringer Ingelheim International GmbH, Binger Str. 173, 55218 Ingelheim am RheinGermany
| | - Matthias Zwick
- Boehringer Ingelheim Pharma GmbH & Co. KG, Birkendorfer Str. 65, 88400 Biberach an der RissGermany
| | - Maral Saadati
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KG, Birkendorfer Str. 65, 88400 Biberach an der Riss, Germany
| | - Stuart J Pocock
- London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HTUK
| | - Naveed Sattar
- BHF, UK School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TAUK
| | - Stefan D Anker
- Department of Cardiology (CVK) Berlin Institute of Health Center for Regenerative Therapies (BCRT) German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Charité, Campus Virchow-Klinikum, Augustenburger Platz 1, D-13353 Berlin, Germany,Institute of Heart Diseases, Wroclaw Medical University, Borowska Street 213, 50-556 Warsaw, Poland
| | - Milton Packer
- Baylor Heart and Vascular Hospital, Baylor University Medical Center, 621 N Hall St, Dallas, TX 75226, USA,Imperial College, London, Exhibition Rd, South Kensington, London SW7 2BX, UK
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41
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Gan T, Song Y, Guo F, Qin G. Emerging roles of Sodium-glucose cotransporter 2 inhibitors in Diabetic kidney disease. Mol Biol Rep 2022; 49:10915-10924. [PMID: 36002651 DOI: 10.1007/s11033-022-07758-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 06/27/2022] [Accepted: 06/30/2022] [Indexed: 10/15/2022]
Abstract
Diabetic kidney disease (DKD), a severe microvascular complication of diabetes mellitus, is the primary cause of end stage renal disease (ESRD). Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a class of novel anti-diabetic drugs for DKD, which have the potential to prevent renal function from failing. The involved mechanisms have garnered considerable attention. Besides hypoglycemic effect, it seems that various glucose-independent nephroprotective mechanisms also have a role. Among them, improvement in tubuloglomerular feedback is considered as the main reason, followed by reduced intraglomerular pressure and fluid load. In addition, reduced blood pressure, anti-inflammatory effects, nutrient deprivation signaling as well as improved endothelial function are also important. In the future, clinical trials and mechanistic studies might further complement the current knowledge on SGLT2 inhibitors and facilitate to translate these agents to clinical use. Here, we review these mechanisms of SGLT2 inhibitors with an emphasis on kidney protective effects.
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Affiliation(s)
- Tian Gan
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Zhengzhou University, 450052, Zhengzhou, China
| | - Yi Song
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Zhengzhou University, 450052, Zhengzhou, China
| | - Feng Guo
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Zhengzhou University, 450052, Zhengzhou, China
| | - Guijun Qin
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Zhengzhou University, 450052, Zhengzhou, China.
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42
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Li J, Arnott C, Heerspink HJL, MBiostat QL, Cannon CP, Wheeler DC, Charytan DM, Barraclough J, Figtree GA, Agarwal R, Bakris G, de Zeeuw D, Greene T, Levin A, Pollock C, Zhang H, Zinman B, Mahaffey KW, Perkovic V, Neal B, Jardine MJ. Effect of Canagliflozin on Total Cardiovascular Burden in Patients With Diabetes and Chronic Kidney Disease: A Post Hoc Analysis From the CREDENCE Trial. J Am Heart Assoc 2022; 11:e025045. [PMID: 35929472 PMCID: PMC9496296 DOI: 10.1161/jaha.121.025045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background The sodium‐glucose cotransporter 2 inhibitor canagliflozin reduced the risk of first cardiovascular composite events in the CREDENCE (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation) trial. In this post hoc analysis, we evaluated the effect of canagliflozin on total (first and recurrent) cardiovascular events. Methods and Results The CREDENCE trial compared canagliflozin or matching placebo in 4401 patients with type 2 diabetes, albuminuria, and estimated glomerular filtration rate of 30 to <90 mL/min per 1.73 m2, over a median of 2.6 years. The primary outcome was analyzed as a composite of any cardiovascular event including myocardial infarction, stroke, hospitalization for heart failure, hospitalization for unstable angina, and cardiovascular death. Negative binomial regression models were used to assess the effect of canagliflozin on the net burden of cardiovascular events. During the trial, 634 patients had 883 cardiovascular events, of whom 472 (74%) had just 1 cardiovascular event and 162 (26%) had multiple cardiovascular events. Canagliflozin reduced first cardiovascular events by 26% (hazard ratio, 0.74 [95% CI, 0.63–0.86]; P<0.001) and total cardiovascular events by 29% (incidence rate ratio, 0.71 [95% CI, 0.59–0.86]; P<0.001). The absolute risk difference per 1000 patients treated over 2.5 years was −44 (95% CI, −67 to −21) first cardiovascular events and −73 (95% CI, −114 to −33) total events. Conclusions Canagliflozin reduced cardiovascular events, with a larger absolute benefit for total cardiovascular than first cardiovascular events. These findings provide further support for the benefit of continuing canagliflozin therapy after an initial event to prevent recurrent cardiovascular events. Registration Information URL: https://www.clinicaltrials.gov; Unique Identifier: NCT02065791.
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Affiliation(s)
- Jing‐Wei Li
- The George Institute for Global HealthUNSW SydneySydneyAustralia
- Department of Cardiology, Xinqiao HospitalArmy Military Medical UniversityChongqingChina
| | - Clare Arnott
- The George Institute for Global HealthUNSW SydneySydneyAustralia
- Department of Cardiology, Royal Prince Alfred HospitalSydneyAustralia
- Sydney Medical SchoolThe University of SydneySydneyNew South Wales
| | - Hiddo J. L. Heerspink
- The George Institute for Global HealthUNSW SydneySydneyAustralia
- Department Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical CenterGroningenThe Netherlands
| | | | - Christopher P. Cannon
- Cardiovascular DivisionBrigham & Women’s Hospital and Baim Institute for Clinical ResearchBostonMA
| | - David C. Wheeler
- The George Institute for Global HealthUNSW SydneySydneyAustralia
- Department of Renal MedicineUCL Medical SchoolLondonUK
| | - David M. Charytan
- Nephrology DivisionNYU School of Medicine and NYU Langone Medical CenterNew YorkNY
- Baim Institute for Clinical ResearchBostonMA
| | - Jennifer Barraclough
- The George Institute for Global HealthUNSW SydneySydneyAustralia
- Department of Cardiology, Royal Prince Alfred HospitalSydneyAustralia
| | - Gemma A. Figtree
- The George Institute for Global HealthUNSW SydneySydneyAustralia
- Sydney Medical SchoolThe University of SydneySydneyNew South Wales
- Kolling InstituteRoyal North Shore Hospital and University of SydneySydneyAustralia
| | - Rajiv Agarwal
- Indiana University School of Medicine and VA Medical CenterIndianapolisIN
| | - George Bakris
- Department of MedicineUniversity of Chicago MedicineChicagoIL
| | - Dick de Zeeuw
- Department Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical CenterGroningenThe Netherlands
| | - Tom Greene
- Division of Biostatistics, Department of Population Health SciencesUniversity of UtahSalt Lake CityUT
| | - Adeera Levin
- Division of NephrologyUniversity of British ColumbiaVancouverBC
| | - Carol Pollock
- Kolling InstituteRoyal North Shore Hospital and University of SydneySydneyAustralia
| | - Hong Zhang
- Renal Division of Peking University First HospitalBeijingChina
| | - Bernard Zinman
- Lunenfeld‐Tanenbaum Research Institute, Mt Sinai HospitalUniversity of TorontoTorontoON
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research, Department of MedicineStanford University School of MedicineStanfordCA
| | - Vlado Perkovic
- The George Institute for Global HealthUNSW SydneySydneyAustralia
- The Royal North Shore HospitalSydneyAustralia
| | - Bruce Neal
- The George Institute for Global HealthUNSW SydneySydneyAustralia
- The Charles Perkins CentreUniversity of SydneySydneyNew South Wales
- Imperial College LondonLondonUK
| | - Meg J. Jardine
- The George Institute for Global HealthUNSW SydneySydneyAustralia
- NHMRC Clinical Trials CentreUniversity of SydneySydneyNew South Wales
- Concord Repatriation General HospitalSydneyNew South Wales
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43
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Heerspink HJL, Stack AG, Terkeltaub R, Greene TA, Inker LA, Bjursell M, Perl S, Rikte T, Erlandsson F, Perkovic V. Rationale, design, demographics and baseline characteristics of the randomized, controlled, Phase 2b SAPPHIRE study of verinurad plus allopurinol in patients with chronic kidney disease and hyperuricaemia. Nephrol Dial Transplant 2022; 37:1461-1471. [PMID: 34383954 PMCID: PMC9317164 DOI: 10.1093/ndt/gfab237] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Verinurad is a human uric acid (UA) transporter (URAT1) inhibitor known to decrease serum UA (sUA) levels and that may reduce albuminuria. In a Phase 2a study (NCT03118739), treatment with verinurad + febuxostat lowered urine albumin-to-creatinine ratio (UACR) at 12 weeks by 39% (90% confidence interval 4-62%) among patients with Type 2 diabetes mellitus, hyperuricaemia and albuminuria. The Phase 2b, randomized, placebo-controlled Study of verinurAd and alloPurinol in Patients with cHronic kIdney disease and hyperuRicaEmia (SAPPHIRE; NCT03990363) will examine the effect of verinurad + allopurinol on albuminuria and estimated glomerular filtration rate (eGFR) slope among patients with chronic kidney disease (CKD) and hyperuricaemia. METHODS Adults (≥18 years of age) with CKD, eGFR ≥25 mL/min/1.73 m2, UACR 30-5000 mg/g and sUA ≥6.0 mg/dL will be enrolled. Approximately 725 patients will be randomized 1:1:1:1:1 to 12, 7.5 or 3 mg verinurad + allopurinol, allopurinol or placebo. An 8-week dose-titration period will precede a 12-month treatment period; verinurad dose will be increased to 24 mg at Month 9 in a subset of patients in the 3 mg verinurad + allopurinol arm. The primary efficacy endpoint the is change from baseline in UACR at 6 months. Secondary efficacy endpoints include changes in UACR, eGFR and sUA from baseline at 6 and 12 months. CONCLUSIONS This study will assess the combined clinical effect of verinurad + allopurinol on kidney function in patients with CKD, hyperuricaemia and albuminuria, and whether this combination confers renoprotection beyond standard-of-care.
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Affiliation(s)
- 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
| | - Austin G Stack
- School of Medicine & Health Research Institute, University of Limerick, Limerick, Ireland
| | - Robert Terkeltaub
- San Francisco VA Health Care System, University of California San Diego, La Jolla, CA, USA
| | - Tom A Greene
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | | | | | - Tord Rikte
- AstraZeneca R&D Gothenburg, Mölndal, Sweden
| | | | - Vlado Perkovic
- The George Institute for Global Health, Sydney, Australia
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Ferrannini G, Rosenthal N, Hansen MK, Ferrannini E. Liver function markers predict cardiovascular and renal outcomes in the CANVAS Program. Cardiovasc Diabetol 2022; 21:127. [PMID: 35787704 PMCID: PMC9254689 DOI: 10.1186/s12933-022-01558-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/22/2022] [Indexed: 11/12/2022] Open
Abstract
Background Raised liver function tests (LFTs) have been correlated with multiple metabolic abnormalities and variably associated with cardiorenal outcomes. We sought to systematically test the relationship between LFT levels within the accepted range and major cardiorenal outcomes in a large clinical trial in type 2 diabetes, and the possible impact of placebo-controlled canagliflozin treatment. Methods We measured serum alanine aminotransferase (ALT), aspartic aminotransferase (AST), gamma-glutamyl transferase (γGT), alkaline phosphatase (ALP), and bilirubin concentrations in 10,142 patients, at baseline and repeatedly over follow-up. The relation of LFTs to first hospitalized heart failure (HHF), cardiovascular (CV) and all-cause mortality, and progression of renal impairment was investigated using multivariate proportional-hazards models. Results In univariate association, ALT was reciprocally predictive, and ALP was positively predictive, of all adjudicated outcomes; γGT also was directly associated with CV—but not renal—outcomes. In multivariate models including all 5 LFTs and 19 potential clinical confounders, ALT was independently associated with lower, and γGT with higher, CV outcomes risk. Canagliflozin treatment significantly reduced ALT, AST, and γGT over time. In a fully adjusted model including updated LFT levels and treatment, γGT was independently associated with CV and all-cause mortality, ALP with renal dysfunction progression, and canagliflozin treatment with significant reduction in HHF and renal risk. Conclusions Higher γGT levels are top LFT markers of risk of HHF and death in patients with diabetes and high CV risk, while ALT are protective. Canagliflozin lowers the risk of HHF and renal damage independently of LFTs and potential confounders. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-022-01558-w.
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Affiliation(s)
- Giulia Ferrannini
- Department of Medicine Solna, Karolinska Institutet, Norrbacka, S1:02, 171 76, Stockholm, Sweden.
| | - Norman Rosenthal
- Janssen Research & Development, LLC, 920 US-202, Raritan, NJ, 08869, USA
| | - Michael K Hansen
- Janssen Research & Development, LLC, Welsh & McKean Rds., Spring House, PA, 19477, USA
| | - Ele Ferrannini
- CNR Institute of Clinical Physiology, Via Savi 12, 56126, Pisa, Italy
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Kurata Y, Nangaku M. Dapagliflozin for the treatment of chronic kidney disease. Expert Rev Endocrinol Metab 2022; 17:275-291. [PMID: 35822873 DOI: 10.1080/17446651.2022.2099373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Sodium-dependent glucose cotransporter 2 (SGLT2) is a glucose transporter expressed on the proximal tubular cells, where it reabsorbs glucose from the glomerular filtrate. SGLT2 inhibitors (SGLT2is), initially developed as an antidiabetic drug, have recently attracted considerable attention because they have cardiorenal protective effects. Among SGLT2is, dapagliflozin was the first to demonstrate the renoprotective effect in patients with and without diabetes and has been approved for chronic kidney disease (CKD) treatment. AREAS COVERED This review covers the pharmacological characteristics and the clinical efficacy and safety profiles of dapagliflozin, including comparison with other SGLT2is and risk modification strategies. EXPERT OPINION In DAPA-CKD, dapagliflozin reduced the primary outcome (≥50% estimated glomerular filtration rate [eGFR] decline, end-stage kidney disease [ESKD], or renal or cardiovascular [CV] death) by 39% in CKD patients. This beneficial effect was consistent across prespecified subgroups, including those based on the presence of diabetes. Dapagliflozin also decreased the CV composite outcome and all-cause death by 29% and 31%, respectively. Although an increased risk of adverse events such as ketoacidosis and volume depletion has been reported, the robust renal and CV benefits of dapagliflozin are expected to outweigh potential risks. SGLT2is, including dapagliflozin, will constitute the mainstay of CKD treatment.
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Affiliation(s)
- Yu Kurata
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Bunkyo-ku, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Bunkyo-ku, Japan
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Liu H, Sridhar VS, Perkins BA, Rosenstock J, Cherney DZI. SGLT2 Inhibition in Type 1 Diabetes with Diabetic Kidney Disease: Potential Cardiorenal Benefits Can Outweigh Preventable Risk of Diabetic Ketoacidosis. Curr Diab Rep 2022; 22:317-332. [PMID: 35633439 DOI: 10.1007/s11892-022-01471-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to summarize existing research investigating the use of sodium glucose cotransporter-2 (SGLT2) inhibitors in patients with type 1 diabetes mellitus (T1DM) while highlighting potential strategies to mitigate the risk of diabetic ketoacidosis (DKA). RECENT FINDINGS SGLT2 inhibitors have been studied in patients with T1DM in phase 3 clinical trials such as the inTandem, DEPICT, and EASE trials, which demonstrated consistent reductions in HbA1c. Secondary analyses of these trials have also reported potential kidney protective effects that are independent of improved glycemic control. However, trials in patients with type 2 diabetes mellitus (T2DM) have found an increased risk of DKA with SGLT2 inhibitors, a serious concern in patients with T1DM. SGLT2 inhibitors provide cardiovascular benefits and kidney protection in patients with T2DM and are a promising therapeutic option for patients with T1DM due to overlapping pathophysiological mechanisms. However, SGLT2 inhibitors increase the risk of DKA, and there is currently a lack of research investigating the beneficial effects of SGLT2 inhibitors in patients with T1DM. Preventative measure for DKA would have to be implemented and the risks would need to be carefully balanced with the benefits offered by SGLT2 inhibitors. Additional research will also be required to determine the kidney protective effects of SGLT2 inhibitors in patients with T1DM and diabetic kidney disease and to quantify the risk of DKA after the implementation of preventative measures, proper patient education, and ketone monitoring.
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Affiliation(s)
- Hongyan Liu
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Vikas S Sridhar
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Julio Rosenstock
- Dallas Diabetes Research Center at Medical City, Dallas, TX, USA
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada.
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
- Toronto General Hospital, 585 University Ave, Toronto, ON, 8N-845M5G 2N2, Canada.
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47
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Oe Y, Vallon V. The Pathophysiological Basis of Diabetic Kidney Protection by Inhibition of SGLT2 and SGLT1. KIDNEY AND DIALYSIS 2022; 2:349-368. [PMID: 36380914 PMCID: PMC9648862 DOI: 10.3390/kidneydial2020032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
SGLT2 inhibitors can protect the kidneys of patients with and without type 2 diabetes mellitus and slow the progression towards end-stage kidney disease. Blocking tubular SGLT2 and spilling glucose into the urine, which triggers a metabolic counter-regulation similar to fasting, provides unique benefits, not only as an anti-hyperglycemic strategy. These include a low hypoglycemia risk and a shift from carbohydrate to lipid utilization and mild ketogenesis, thereby reducing body weight and providing an additional energy source. SGLT2 inhibitors counteract hyperreabsorption in the early proximal tubule, which acutely lowers glomerular pressure and filtration and thereby reduces the physical stress on the filtration barrier, the filtration of tubule-toxic compounds, and the oxygen demand for tubular reabsorption. This improves cortical oxygenation, which, together with lesser tubular gluco-toxicity and improved mitochondrial function and autophagy, can reduce pro-inflammatory, pro-senescence, and pro-fibrotic signaling and preserve tubular function and GFR in the long-term. By shifting transport downstream, SGLT2 inhibitors more equally distribute the transport burden along the nephron and may mimic systemic hypoxia to stimulate erythropoiesis, which improves oxygen delivery to the kidney and other organs. SGLT1 inhibition improves glucose homeostasis by delaying intestinal glucose absorption and by increasing the release of gastrointestinal incretins. Combined SGLT1 and SGLT2 inhibition has additive effects on renal glucose excretion and blood glucose control. SGLT1 in the macula densa senses luminal glucose, which affects glomerular hemodynamics and has implications for blood pressure control. More studies are needed to better define the therapeutic potential of SGLT1 inhibition to protect the kidney, alone or in combination with SGLT2 inhibition.
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Affiliation(s)
- Yuji Oe
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, CA 92161, USA
- VA San Diego Healthcare System, San Diego, CA 92161, USA
| | - Volker Vallon
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, CA 92161, USA
- VA San Diego Healthcare System, San Diego, CA 92161, USA
- Department of Pharmacology, University of California San Diego, La Jolla, CA 92161, USA
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48
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Sridhar VS, Ambinathan JPN, Gillard P, Mathieu C, Cherney DZI, Lytvyn Y, Singh SK. Cardiometabolic and Kidney Protection in Kidney Transplant Recipients With Diabetes: Mechanisms, Clinical Applications, and Summary of Clinical Trials. Transplantation 2022; 106:734-748. [PMID: 34381005 DOI: 10.1097/tp.0000000000003919] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Kidney transplantation is the therapy of choice for patients with end-stage renal disease. Preexisting diabetes is highly prevalent in kidney transplant recipients (KTR), and the development of posttransplant diabetes is common because of a number of transplant-specific risk factors such as the use of diabetogenic immunosuppressive medications and posttransplant weight gain. The presence of pretransplant and posttransplant diabetes in KTR significantly and variably affect the risk of graft failure, cardiovascular disease (CVD), and death. Among the many available therapies for diabetes, there are little data to determine the glucose-lowering agent(s) of choice in KTR. Furthermore, despite the high burden of graft loss and CVD among KTR with diabetes, evidence for strategies offering cardiovascular and kidney protection is lacking. Recent accumulating evidence convincingly shows glucose-independent cardiorenal protective effects in non-KTR with glucose-lowering agents, such as sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists. Therefore, our aim was to review cardiorenal protective strategies, including the evidence, mechanisms, and rationale for the use of these glucose-lowering agents in KTR with diabetes.
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Affiliation(s)
- Vikas S Sridhar
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- The Kidney Transplant Program and the Ajmera Tranplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jaya Prakash N Ambinathan
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- The Kidney Transplant Program and the Ajmera Tranplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Pieter Gillard
- Department of Endocrinology, University Hospitals Leuven, Catholic University Leuven, Leuven, Belgium
| | - Chantal Mathieu
- Department of Endocrinology, University Hospitals Leuven, Catholic University Leuven, Leuven, Belgium
| | - David Z I Cherney
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yuliya Lytvyn
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Sunita K Singh
- Division of Nephrology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- The Kidney Transplant Program and the Ajmera Tranplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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49
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Suijk D, van Baar M, van Bommel E, Iqbal Z, Krebber M, Vallon V, Touw D, Hoorn E, Nieuwdorp M, Kramer M, Joles J, Bjornstad P, van Raalte D. SGLT2 Inhibition and Uric Acid Excretion in Patients with Type 2 Diabetes and Normal Kidney Function. Clin J Am Soc Nephrol 2022; 17:663-671. [PMID: 35322793 PMCID: PMC9269569 DOI: 10.2215/cjn.11480821] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 03/17/2022] [Indexed: 11/23/2022]
Abstract
Background and objectives: Sodium glucose transporter 2 (SGLT2)-inhibitor-induced uric acid lowering may contribute to kidney protective effects of the drug-class in people with type 2 diabetes. This study investigates mechanisms of plasma uric acid lowering by SGLT2-inhibitors in people with type 2 diabetes with a focus on urate transporter (URAT)1. Methods: We conducted an analysis of two randomized, clinical trials. First, in the Renoprotective Effects of Dapagliflozin in Type 2 Diabetes (RED) study, 44 people with type 2 diabetes were randomized to dapagliflozin or gliclazide for 12 weeks. Plasma uric acid, fractional uric acid excretion and hemodynamic kidney function were measured in the fasted state and during clamped eu- or hyperglycemia. Second, in the Uric Acid Excretion study (UREX) study, 10 people with type 2 diabetes received 1-week empagliflozin, benzbromarone and their combination in a cross-over design and effects on plasma uric acid, fractional uric acid excretion and 24-hr uric acid excretion were measured. Results: In the RED study, compared to the fasted state (5.3±1.1mg/dL), acute hyperinsulinemia and hyperglycemia significantly reduced plasma uric acid by 0.2±0.3 and 0.4±0.3 mg/dL (both p<0.001), while increasing fractional uric acid excretion (by 3.2±3.1% and 8.9±4.5% respectively (both p<0.001). Dapagliflozin reduced plasma uric acid by 0.8±0.8mg/dL, 1.0±1.0mg/dL and by 0.8±0.7mg/dL during fasting, hyperinsulinemic-euglycemic and hyperglycemic conditions (p<0.001), whereas fractional uric acid excretion in 24-hr urine increased by 3.0±2.1% (p<0.001) and 2.6±4.5% during hyperinsulinemic-euglycemic conditions (p=0.003). Fractional uric acid excretion strongly correlated to fractional glucose excretion (r= 0.35, p=0.02). In the UREX study, empagliflozin and benzbromarone both significantly reduced plasma uric acid and increased fractional uric acid excretion. Effects of combination therapy did not differ from benzbromarone monotherapy. Conclusion: In conclusion, SGLT2-inhibitors induce uric acid excretion, which is strongly linked to urinary glucose excretion and which is attenuated during concomitant pharmacological blockade of URAT1.
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Affiliation(s)
- Danii Suijk
- D Suijk, Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, Netherlands
| | - Michaël van Baar
- M van Baar, Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, Netherlands
| | - Erik van Bommel
- E van Bommel, Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, Netherlands
| | - Zainab Iqbal
- Z Iqbal, Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, Netherlands
| | - Merle Krebber
- M Krebber, Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Volker Vallon
- V Vallon, Division of Nephrology and hypertension, Department of Medicine, University of California San Diego, La Jolla, United States
| | - Daan Touw
- D Touw, Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, Groningen, Netherlands
| | - Ewout Hoorn
- E Hoorn, Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, Netherlands
| | - Max Nieuwdorp
- M Nieuwdorp, Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, Netherlands
| | - Mark Kramer
- M Kramer, Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, Netherlands
| | - Jaap Joles
- J Joles, Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Petter Bjornstad
- P Bjornstad, Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, United States
| | - Daniël van Raalte
- D van Raalte, Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, Netherlands
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50
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Guedes M, Pecoits-Filho R. Can we cure diabetic kidney disease? Present and future perspectives from a nephrologist's point of view. J Intern Med 2022; 291:165-180. [PMID: 34914852 DOI: 10.1111/joim.13424] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Diabetic kidney disease (DKD) is the leading cause of chronic kidney disease (CKD) worldwide, contributing to a great burden across a variety of patient-reported and clinical outcomes. New interventions for DKD management have been established in recent years, unleashing a novel paradigm, in which kidney-dedicated trials yield informative and robust data to guide optimal clinical management. After unprecedented results from groundbreaking randomized controlled trials were released, a new scenario of evidence-based recommendations has evolved for the management of diabetic patients with CKD. The current guidelines place great emphasis on multidimensional and interdisciplinary approaches, but the challenges of implementation are just starting and will be pivotal to optimize clinical results and to understand the new threshold for residual risk in DKD. We thereby provide an updated review on recent advances in DKD management based on new guideline recommendations, summarizing recent evidence while projecting the landscape for innovative ongoing initiatives in the field. Specifically, we review current insights on the natural history, epidemiology, pathogenesis, and therapeutics of DKD, mapping the new scientific information into the recently released Kidney Disease - Improving Global Outcomes Guidelines translating results from major novel randomized controlled trials to the clinical practice. Additionally, we approach the landscape of new therapeutics in the field, summarizing ongoing phase IIb and III trials focused on DKD. Finally, reflecting on the past and looking into the future, we highlight unmet needs in the current DKD management based on real-world evidence and offer a nephrologist's perspective into the challenge of fostering continuous improvement on clinical and patient-reported outcomes for individuals living with DKD.
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Affiliation(s)
- Murilo Guedes
- School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Parana, Brazil
| | - Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Parana, Brazil.,DOPPS Program Area, Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
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