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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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Stocker SD, Kinsman BJ, Farquhar WB, Gyarmati G, Peti-Peterdi J, Sved AF. Physiological Mechanisms of Dietary Salt Sensing in the Brain, Kidney, and Gastrointestinal Tract. Hypertension 2024; 81:447-455. [PMID: 37671571 PMCID: PMC10915107 DOI: 10.1161/hypertensionaha.123.19488] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
Excess dietary salt (NaCl) intake is strongly correlated with cardiovascular disease and is a major contributing factor to the pathogenesis of hypertension. NaCl-sensitive hypertension is a multisystem disorder that involves renal dysfunction, vascular abnormalities, and neurogenically-mediated increases in peripheral resistance. Despite a major research focus on organ systems and these effector mechanisms causing NaCl-induced increases in arterial blood pressure, relatively less research has been directed at elucidating how NaCl is sensed by various tissues to elicit these downstream effects. The purpose of this review is to discuss how the brain, kidney, and gastrointestinal tract sense NaCl including key cell types, the role of NaCl versus osmolality, and the underlying molecular and electrochemical mechanisms.
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Affiliation(s)
- Sean D. Stocker
- Department of Neurobiology, University of Pittsburgh School of Medicine
| | - Brian J Kinsman
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital
| | | | - Georgina Gyarmati
- Department of Physiology and Neuroscience and Medicine, Zilkha Neurogenetic Institute, University of Southern California
| | - Janos Peti-Peterdi
- Department of Physiology and Neuroscience and Medicine, Zilkha Neurogenetic Institute, University of Southern California
| | - Alan F. Sved
- Department of Neuroscience, University of Pittsburgh
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Goligorsky MS. Glomerular microcirculation: Implications for diabetes, preeclampsia, and kidney injury. Acta Physiol (Oxf) 2023; 239:e14048. [PMID: 37688412 PMCID: PMC10615779 DOI: 10.1111/apha.14048] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023]
Abstract
This review outlines the features of tandem regulation of glomerular microcirculation by autoregulatory mechanisms and intraglomerular redistribution of blood flow. Multiple points of cooperation exist between autoregulatory and distributional mechanisms. Mutual interactions between myogenic and tubuloglomerular feedback (TGF) mechanisms regulating the inflow are briefly discussed. In addition to this, TGF operation involving purinergic, autocoid, and NO signaling affects, however, not only afferent arteriolar tone, but mesangial cell tone as well. The latter reversibly reconfigures the distribution of blood flow between the shorter and longer pathways in the glomerular tuft. I advance a hypothesis that blood flow in these pathways spontaneously alternates, and mesangial cell tonicity serves as a rheostatic shift between them. Furthermore, humoral messengers from macula densa cells, themselves dependent on myogenic mechanisms, fine-tune the secretion of renin and, subsequently, the local, intrarenal generation of angiotensin II, which, in turn, provides additional vasomotor signaling to glomerular capillaries through changing the tone of mesangial cells. This complex regulatory network may partially explain the phenomenon of renal functional reserve, as well as suggest implications for changes in renal function during pregnancy, early diabetes mellitus, and acute kidney injury.
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Affiliation(s)
- Michael S Goligorsky
- Department of Medicine, New York Medical College at the Touro University, Valhalla, New York, USA
- Department of Pharmacology, New York Medical College at the Touro University, Valhalla, New York, USA
- Department of Physiology, New York Medical College at the Touro University, Valhalla, New York, USA
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Koh ES, Kim GH, Chung S. Intrarenal Mechanisms of Sodium-Glucose Cotransporter-2 Inhibitors on Tubuloglomerular Feedback and Natriuresis. Endocrinol Metab (Seoul) 2023; 38:359-372. [PMID: 37482684 PMCID: PMC10475968 DOI: 10.3803/enm.2023.1764] [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: 06/21/2023] [Revised: 07/05/2023] [Accepted: 07/10/2023] [Indexed: 07/25/2023] Open
Abstract
When sodium-glucose cotransporter-2 (SGLT2) inhibitors were first introduced a decade ago, no one expected them to have substantial effects beyond their known glucose-lowering effects, until the emergence of evidence of their robust renal and cardiovascular benefits showing that they could attenuate progression of kidney disease, irrespective of diabetes, as well as prevent the development of acute kidney injury. Still, the precise and elaborate mechanisms underlying the major organ protection of SGLT2 inhibitors remain unclear. SGLT2 inhibitors inhibit the reabsorption of sodium and glucose in the proximal tubule of the kidney and then recovers tubuloglomerular feedback, whereby SGLT2 inhibitors reduce glomerular hyperfiltration. This simple demonstration of their beneficial effects has perplexed experts in seeking more plausible and as yet undisclosed explanations for the whole effects of SGLT2 inhibitors, including metabolism reprogramming and the modulation of hypoxia, inflammation, and oxidative stress. Given that the renal benefits of SGLT2 inhibitors in patients with kidney disease but without diabetes were comparable to those seen in patients with diabetes, it may be reasonable to keep the emphasis on their hemodynamic actions. In this context, the aim of the present review is to provide a comprehensive overview of renal hemodynamics in individuals with diabetes who are treated with SGLT2 inhibitors, with a focus on natriuresis associated with the regulation of tubuloglomerular feedback and potential aquaresis. Throughout the discussion of alterations in renal sodium and water transports, particular attention will be given to the potential enhancement of adenosine and its receptors following SGLT2 inhibition.
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Affiliation(s)
- Eun Sil Koh
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Gheun-Ho Kim
- Division of Nephrology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sungjin Chung
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Feng LL, Huang Z, Nong YY, Guo BJ, Wang QY, Qin JH, He Y, Zhu D, Guo HW, Qin YL, Zhong XY, Guo Y, Cheng B, Ou SF, Su ZH. Evaluation of aristolochic acid Ι nephrotoxicity in mice via 1H NMR quantitative metabolomics and network pharmacology approaches. Toxicol Res (Camb) 2023; 12:282-295. [PMID: 37125334 PMCID: PMC10141773 DOI: 10.1093/toxres/tfad020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 03/06/2023] [Accepted: 03/12/2023] [Indexed: 03/29/2023] Open
Abstract
Background Although many studies have shown that herbs containing aristolochic acids can treat various human diseases, AAΙ in particular has been implicated as a nephrotoxic agent. Methods and results Here, we detail the nephrotoxic effect of AAΙ via an approach that integrated 1H NMR-based metabonomics and network pharmacology. Our findings revealed renal injury in mice after the administration of AAΙ. Metabolomic data confirmed significant differences among the renal metabolic profiles of control and model groups, with significant reductions in 12 differential metabolites relevant to 23 metabolic pathways. Among them, there were seven important metabolic pathways: arginine and proline metabolism; glycine, serine, and threonine metabolism; taurine and hypotaurine metabolism; ascorbate and aldehyde glycolate metabolism; pentose and glucosinolate interconversion; alanine, aspartate, and glutamate metabolism; and glyoxylate and dicarboxylic acid metabolism. Relevant genes, namely, nitric oxide synthase 1 (NOS1), pyrroline-5-carboxylate reductase 1 (PYCR1), nitric oxide synthase 3 (NOS3) and glutamic oxaloacetic transaminase 2 (GOT2), were highlighted via network pharmacology and molecular docking techniques. Quantitative real-time PCR findings revealed that AAI administration significantly downregulated GOT2 and NOS3 and significantly upregulated NOS1 and PYCR1 expression and thus influenced the metabolism of arginine and proline. Conclusion This work provides a meaningful insight for the mechanism of AAΙ renal injury.
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Affiliation(s)
- Lin-Lin Feng
- Pharmaceutical College, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
| | - Zheng Huang
- Pharmaceutical College, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
| | - Yun-Yuan Nong
- Pharmaceutical College, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
| | - Bing-Jian Guo
- Pharmaceutical College, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
| | - Qian-Yi Wang
- Pharmaceutical College, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
| | - Jing-Hua Qin
- Pharmaceutical College, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
| | - Ying He
- First Clinical Medical College, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
| | - Dan Zhu
- Pharmaceutical College, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
| | - Hong-Wei Guo
- Pharmaceutical College, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
| | - Yue-Lian Qin
- Pharmaceutical College, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
| | - Xin-Yu Zhong
- Pharmaceutical College, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
| | - Yue Guo
- Pharmaceutical College, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
- Guangxi Key Laboratory of Traditional Chinese Medicine Quality Standards, Guangxi Institute of Traditional Medical and Pharmaceutical Sciences, No. 20-1 Dongge Road, Qingxiu District, Nanning 530022, China
| | - Bang Cheng
- Pharmaceutical College, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
| | - Song-Feng Ou
- Pharmaceutical College, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
| | - Zhi-Heng Su
- Pharmaceutical College, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
- Guangxi Key Laboratory of Bioactive Molecules Research and Evaluation, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
- Guangxi Beibu Gulf Marine Biomedicine Precision Development, High-value Utilization Engineering Research Center, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
- Guangxi Health Commission Key Laboratory of Basic Research on Antigeriatric Drugs, Guangxi Medical University, No. 22 Shuangyong Road, Qingxiu District, Nanning 530021, China
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Abstract
The sodium-glucose cotransporter 2 (SGLT2) inhibitors have become an integral part of clinical practice guidelines to slow the progression of CKD in patients with and without diabetes mellitus. Although initially developed as antihyperglycemic drugs, their effect on the kidney is multifactorial resulting from profuse glycosuria and natriuresis consequent to their primary site of action. Hemodynamic and metabolic changes ensue that mediate kidney-protective effects, including ( 1 ) decreased workload of proximal tubular cells and prevention of aberrant increases in glycolysis, contributing to a decreased risk of AKI; ( 2 ) lowering of intraglomerular pressure by activating tubular glomerular feedback and reductions in BP and tissue sodium content; ( 3 ) initiation of nutrient-sensing pathways reminiscent of starvation activating ketogenesis, increased autophagy, and restoration of carbon flow through the mitochondria without production of reactive oxygen species; ( 4 ) body weight loss without a reduction in basal metabolic rate due to increases in nonshivering thermogenesis; and ( 5 ) favorable changes in quantity and characteristics of perirenal fat leading to decreased release of adipokines, which adversely affect the glomerular capillary and signal increased sympathetic outflow. Additionally, these drugs stimulate phosphate and magnesium reabsorption and increase uric acid excretion. Familiarity with kidney-specific mechanisms of action, potential changes in kidney function, and/or alterations in electrolytes and volume status, which are induced by these widely prescribed drugs, will facilitate usage in the patients for whom they are indicated.
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Affiliation(s)
- Biff F. Palmer
- Division of Nephrology, Department of Medicine, Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Deborah J. Clegg
- Internal Medicine, Texas Tech Health Sciences Center, El Paso, Texas
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Liu R. Tubuloglomerular feedback: a key player in obesity-associated kidney injury. Am J Physiol Renal Physiol 2022; 322:F587-F588. [PMID: 35403452 PMCID: PMC9054322 DOI: 10.1152/ajprenal.00068.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 12/28/2022] Open
Affiliation(s)
- Ruisheng Liu
- Department of Molecular Pharmacology and Physiology, College of Medicine, University of South Florida, Tampa, Florida
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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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Yang Y, Xu G. Update on Pathogenesis of Glomerular Hyperfiltration in Early Diabetic Kidney Disease. Front Endocrinol (Lausanne) 2022; 13:872918. [PMID: 35663316 PMCID: PMC9161673 DOI: 10.3389/fendo.2022.872918] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
In the existing stages of diabetic kidney disease (DKD), the first stage of DKD is called the preclinical stage, characterized by glomerular hyperfiltration, an abnormally elevated glomerular filtration rate. Glomerular hyperfiltration is an independent risk factor for accelerated deterioration of renal function and progression of nephropathy, which is associated with a high risk for metabolic and cardiovascular disease. It is imperative to understand hyperfiltration and identify potential treatments to delay DKD progress. This paper summarizes the current mechanisms of hyperfiltration in early DKD. We pay close attention to the effect of glucose reabsorption mediated by sodium-glucose cotransporters and renal growth on hyperfiltration in DKD patients, as well as the mechanisms of nitric oxide and adenosine actions on renal afferent arterioles via tubuloglomerular feedback. Furthermore, we also focus on the contribution of the atrial natriuretic peptide, cyclooxygenase, renin-angiotensin-aldosterone system, and endothelin on hyperfiltration. Proposing potential treatments based on these mechanisms may offer new therapeutic opportunities to reduce the renal burden in this population.
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