Acute Kidney Injury Associated With Semaglutide

A review of serious adverse events linked with GLP-1 agonists in type 2 diabetes mellitus and obesity treatment

Glucagon-like peptide-1 (GLP-1) agonists play a crucial role in treating type 2 diabetes mellitus and obesity by providing glycemic control and aiding weight management. Despite their widespread use, concerns about serious adverse events have prompted extensive research. This review aims to describe the current understanding of serious adverse events associated with GLP-1 agonists. A comprehensive search of PubMed, Google Scholar and Embase databases was performed starting from 2010. Studies reporting evidence of an association between GLP-1 agonists and serious adverse events from 22 articles (5 case reports, 5 randomized controlled trials (RCTs), 9 real-world data cohort analyses, 2 meta-analyses and 1 systematic review and meta-analysis) were included and categorized by the type of adverse event. While some studies reported risks, including anaphylaxis, cardiovascular, gastrointestinal, psychiatric and thyroid-related events, others found no significant associations. The evidence remains mixed, necessitating further research to fully understand the safety profile of GLP-1 agonists and inform clinical practice.

Semaglutide-associated kidney injury

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are multipurpose agents effective in improving glycemic control in patients with type 2 diabetes while also achieving weight loss and risk reduction of major cardiovascular (CV) events and chronic kidney disease progression. With their increased utility in diabetes, obesity, CV health and renal protection, the use of GLP-1RAs has increased. However, with this increased use, there have also been increased reports of associated kidney adverse events, including case reports of acute interstitial nephritis (AIN) associated with GLP-1RA use. We report the data from the Food and Drug Administration adverse event reporting system (FAERS) in relation to GLP-1RA use and adverse kidney events, with acute kidney injury being the most common. In addition, we report two cases of semaglutide-associated biopsy-proven AIN and one with associated podocytopathy. To our knowledge, this is the first case of biopsy-proven AIN with podocytopathy associated with semaglutide use. Both patients experienced complete remission shortly after discontinuing semaglutide and undergoing immunosuppressive therapy. Further analysis of the FAERS database revealed 17 cases of proteinuria and 1 case of glomerulonephritis associated with semaglutide in the FAERS database, however no further information was available. While further research is needed to establish causality, this case series adds to the growing body of literature that semaglutide is associated with AIN and adds a new association, semaglutide with AIN and podocytopathies. While the overall clinical and mortality benefits of GLP-1RAs may outweigh the rarer risks, prescribers need to be aware of these associations, particularly as the use of GLP-1RAs continues to expand.

Safety of SGLT2 inhibitors, DPP-4 inhibitors, and GLP-1 receptor agonists in US veterans with and without chronic kidney disease: a population-based study

Background

We examined the real-world comparative safety of sodium-glucose cotransporter-2 inhibitors (SGLT2i) vs. other newer anti-glycemic medications (dipeptidyl peptidase-4 inhibitors [DPP4i], glucagon-like peptide-1 receptor agonists [GLP1a]) in patients with and without chronic kidney disease (CKD).

Methods

Among US Veterans with diabetes receiving care from the Veterans Affairs (VA) healthcare system over 2004-19, we identified incident users of SGLT2i vs. DPP4i vs. GLP1a monotherapy. In analyses stratified by CKD status, defined by estimated glomerular filtration rate and albuminuria, we examined associations of SGLT2i vs. DPP4i vs. GLP1a use with risk of infection-related (primary outcome) and genitourinary infection hospitalizations (secondary outcome) using multivariable Cox models.

Findings

Among 92,269 patients who met eligibility criteria, 52% did not have CKD, whereas 48% had CKD. In the overall and non-CKD cohorts, compared to DPP4i use, SGLT2i use was associated with lower infection-related hospitalization risk (HRs [95% CIs] 0.74 [0.67-0.81] and 0.77 [0.67, 0.88], respectively), whereas GLP1a use demonstrated comparable risk. However, in the CKD cohort SGLT2i and GLP1a use were each associated with lower risk (HRs [95% CIs] 0.70 [0.61, 0.81] and 0.91 [0.84, 0.99], respectively). Propensity score-matched analyses showed similar findings in the non-CKD and CKD cohorts. In the overall, non-CKD, and CKD cohorts, SGLT2i use was associated with lower genitourinary infection hospitalization risk whereas GLP1a use showed comparable risk vs. DPP4i use.

Interpretation

In a national cohort of Veterans with diabetes, compared with DPP4i use, SGLT2i use was associated with lower infection-related and genitourinary infection hospitalization risk.

Funding

VA Health Services Research and Development, USA.

Assessing the Renal Outcomes of Semaglutide in Diabetic Kidney Disease: A Systematic Review

Diabetic kidney disease (DKD) is a prevalent microvascular complication of diabetes, posing a significant health burden. Semaglutide, a glucagon-like peptide-1 receptor agonist, has shown promise in mitigating renal outcomes in DKD. This systematic review aimed to evaluate the renal effects of semaglutide in individuals with DKD. A comprehensive literature search identified six eligible studies, including two case reports and four cohorts, from diverse geographic locations. The primary outcomes assessed were changes in estimated glomerular filtration rate (eGFR) and albuminuria. Secondary outcomes included acute kidney injury (AKI) incidence and other renal biomarkers. The impact of semaglutide on eGFR was variable, with some studies reporting decreases and others showing improvements or no significant changes. Albuminuria, however, was more consistently reduced, particularly in patients with macroalbuminuria. Notably, the case reports described semaglutide-associated AKI, including acute interstitial nephritis, highlighting the need for careful monitoring during therapy. Beyond renal outcomes, semaglutide consistently improved glycemic control and promoted weight loss, with generally manageable gastrointestinal side effects. The findings suggest that semaglutide may effectively reduce albuminuria in DKD, potentially slowing disease progression. However, the risk of AKI and the variable impact on eGFR underscore the need for a personalized approach and vigilant monitoring, particularly in patients with advanced CKD. Future large-scale, long-term randomized controlled trials are warranted to definitively assess the renal benefits and risks of semaglutide in DKD.

Hemiplegic Migraines Exacerbated using an Injectable GLP-1 Agonist for Weight Loss

The widespread adoption of Glucagon-like peptide-1 (GLP-1) receptor agonists for the treatment of obesity and diabetes has raised concerns about their potential adverse effects, including the induction of depression and suicide ideation. We report on a male patient in his early 50s with a complex medical history, including adult Attention-Deficit/Hyperactive Disorder, narcolepsy with cataplexy, and major depressive disorder in remission, who experienced exacerbated hemiplegic migraines after initiating treatment with an injectable GLP-1 agonist (Saxenda) for weight loss. Despite a previous history of experiencing hemiplegic migraines once or twice a year, the patient reported daily occurrences of migraines, many of which were hemiplegic, during the 60 days of GLP-1 agonist treatment. The migraines abated only upon discontinuation of the medication. This case underscores the need to carefully consider patient history and potential genetic predispositions when prescribing GLP-1 agonists, highlighting the complex interactions between these medications, existing comorbidities, and the dopaminergic and calcitonin gene-related peptide pathways. Our findings suggest that GLP-1 agonists, while beneficial for some, may pose significant risks for patients with specific genetic backgrounds or neurological conditions, calling for personalized approaches to treatment and increased awareness of potential adverse effects.

Glucagon-Like Peptide-1 Receptor Agonist Cases Reported to United States Poison Centers, 2017-2022

INTRODUCTION

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are a class of medications for management of diabetes and obesity. The objective of this study is to characterize the epidemiology of GLP-1RA cases reported to US poison centers.

METHODS

We analyzed cases involving a GLP-1RA reported to the National Poison Data System during 2017-2022.

RESULTS

There were 5,713 single-substance exposure cases reported to US poison centers involving a GLP-1RA. Most cases were among females (71.3%) and attributable to therapeutic errors (79.9%). More than one-fifth (22.4%) of cases were evaluated in a healthcare facility, including 0.9% admitted to a critical care unit and 4.1% admitted to a non-critical care unit. Serious medical outcomes were described in 6.2% of cases, including one fatality. The rate of cases per one million US population increased from 1.16 in 2017 to 3.49 in 2021, followed by a rapid increase of 80.9% to 6.32 in 2022. Trends for rates of serious medical outcomes and admissions to a healthcare facility showed similar patterns with 129.9% and 95.8% increases, respectively, from 2021 to 2022.

CONCLUSIONS

Most GLP-1RA cases reported to US poison centers were associated with no or minimal effects and did not require referral for medical treatment; however, a notable minority of individuals experienced a serious medical outcome or healthcare facility admission. The rate of reported cases increased during the study period, including an 80.9% increase from 2021 to 2022. Opportunities exist to improve provider and patient awareness of the adverse effects of these medications.

What is the evidence regarding the safety of new obesity pharmacotherapies

The use of gut-hormone receptors agonists as new therapeutic options for obesity and some of its related comorbidities, such as type 2 diabetes, has resulted in an unprecedented efficacy in the medical management of people living with obesity (PLWO). Appraisal of the safety of these drugs is of utmost importance considering the large number of PLWO, and the potentially long exposure to these pharmacotherapies. In this narrative review we summarize the evidence on the safety of liraglutide, semaglutide, and tirzepatide as derived from randomized clinical trials conducted in adults living with obesity. Additionally, the safety of these drugs is put into perspective with that of other drugs currently approved for the treatment of PLWO. Overall, the available data support a favorable efficacy versus safety balance for gut-hormone hormone receptor analogues in the treatment of these subjects. Nonetheless, it should be acknowledged that in the context of a chronic disease that has reached epidemic proportions, data from randomized clinical trials aimed primarily at proving the efficacy of these drugs may have been insufficient to unveil all the safety issues. Thus, continuous surveillance on the adverse effects of liraglutide, semaglutide, and tirzepatide is required as we use these drugs in a broader population than that represented in currently available clinical trials.

Anti-obesity pharmacotherapy in adults with chronic kidney disease

Obesity is a leading risk factor for the development and progression of kidney disease and a major barrier to optimal management of patients with chronic kidney disease. While in the past anti-obesity drugs offered only modest weight loss efficacy in exchange for various safety and tolerability risks, a wave of safer, more tolerable, and more effective treatment options is transforming the management of obesity. This review evaluates current and future pharmacologic anti-obesity therapy in adults through a kidney-oriented lens. It also explores the goals of anti-obesity treatment, describes the underlying putative mechanisms of action, and raises important scientific questions that deserve further exploration in people with chronic kidney disease.

Eosinophil-related diseases during treatment with glucagon-like peptide one receptor (GLP-1 RA): a case report and review of the literature

Glucagon-like peptide one-receptor agonists (GLP-1 RA) are drugs that differ in their pharmacological composition and homology to human GLP-1 and are used most frequently for the treatment of type 2 diabetes and weight loss. There are isolated reports of eosinophilic adverse reactions associated with GLP-1 RA. We present the case of a 42-year-old female patient who, after starting weekly subcutaneous semaglutide, developed eosinophilic fasciitis with favorable clinical evolution after the discontinuation of semaglutide and the initiation of immunosuppression. A review of the eosinophilic adverse events that have been previously reported with GLP-1 RA is provided.

Meeting the Body Mass Index Requirement for Gender-affirming Surgery Using Antiobesity Medication

One-fourth of transgender and gender diverse (TGD) patients presenting for initial gender-affirming surgery (GAS) consult is denied surgery due to obesity. Many surgery centers enforce body mass index (BMI) requirements for GAS because of concerns about perioperative risks, cosmetic outcomes, and reoperation. TGD people experience gender minority stress and disparities in lifestyle factors that likely contribute to excess weight gain. Gender-affirming hormone therapy has also been associated with increased body weight. Effective and affirming weight management interventions for TGD patients with overweight and obesity are currently lacking. We report the case of a 40-year-old transgender woman with a BMI of 39.6 kg/m2 who presented for weight loss to qualify for gender-affirming bilateral breast augmentation, requiring BMI <35 kg/m2. In addition to lifestyle modification counseling, she was started on semaglutide with monthly dose escalation, leading to 13.9% weight loss with a BMI of 34.1 kg/m2 within 3 months. This case highlights the need for access to affirming weight management services for TGD patients pursuing GAS and the role of antiobesity medications in reaching presurgical BMI targets. Further studies should evaluate the needs of TGD patients in weight loss interventions and the effects of weight loss and antiobesity medications on gender-affirming hormone therapy.

Beyond the pancreas: contrasting cardiometabolic actions of GIP and GLP1

Glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide 1 (GLP1) exhibit incretin activity, meaning that they potentiate glucose-dependent insulin secretion. The emergence of GIP receptor (GIPR)-GLP1 receptor (GLP1R) co-agonists has fostered growing interest in the actions of GIP and GLP1 in metabolically relevant tissues. Here, we update concepts of how these hormones act beyond the pancreas. The actions of GIP and GLP1 on liver, muscle and adipose tissue, in the control of glucose and lipid homeostasis, are discussed in the context of plausible mechanisms of action. Both the GIPR and GLP1R are expressed in the central nervous system, wherein receptor activation produces anorectic effects enabling weight loss. In preclinical studies, GIP and GLP1 reduce atherosclerosis. Furthermore, GIPR and GLP1R are expressed within the heart and immune system, and GLP1R within the kidney, revealing putative mechanisms linking GIP and GLP1R agonism to cardiorenal protection. We interpret the clinical and mechanistic data obtained for different agents that enable weight loss and glucose control for the treatment of obesity and type 2 diabetes mellitus, respectively, by activating or blocking GIPR signalling, including the GIPR-GLP1R co-agonist tirzepatide, as well as the GIPR antagonist-GLP1R agonist AMG-133. Collectively, we update translational concepts of GIP and GLP1 action, while highlighting gaps, areas of uncertainty and controversies meriting ongoing investigation.

Clinical Insight on Semaglutide for Chronic Weight Management in Adults: Patient Selection and Special Considerations

Losses of 5-10% or more of initial body weight are associated with improvements in obesity-related comorbidities. However, attaining and sustaining this level of weight loss is challenging. The novel anti-obesity medication semaglutide 2.4 mg injected subcutaneously once weekly as an adjunct to a reduced-calorie diet and physical activity helps patients achieve average losses of 9.6-17.4% of initial body weight at week 68, as well as improvements in cardiometabolic and psychosocial indices. Despite these average benefits, prescribers should carefully assess the suitability of patients for this medication. In this paper, we discuss considerations for the selection of individuals who are candidates for semaglutide and special considerations related to the use of this medication. These include its efficacy and safety, as well as its contraindications, potential adverse effects, management of comorbidities and drug interactions, insurance coverage and cost, and patient preferences.

Progressive Cholestasis and Biliary Cirrhosis After Initiating Oral Semaglutide: Report From the Drug-Induced Liver Injury Network

Semaglutide has little hepatic metabolism and is deemed low risk for causing drug-induced liver injury (DILI). We present a case of DILI from the US DILI Network. The case involved a 51-year-old man with type 2 diabetes who presented with jaundice and acute-on-chronic kidney disease 6 months after starting oral semaglutide. His liver injury progressed to biliary cirrhosis, accompanied by nephritis that led to end-stage renal disease. Extensive evaluations including liver and kidney biopsies revealed no alternative etiologies. Cholestatic gene sequencing revealed heterozygosity for ABCC2 and DHCR7. He eventually underwent combined liver and kidney transplantation.

Advances in the management of diabetic kidney disease: beyond sodium-glucose co-transporter 2 inhibitors

Progress in the treatment of diabetic kidney disease (DKD) has been modest since the early trials on renin-angiotensin-aldosterone system inhibitors (RAASis). Although sodium-glucose co-transporter 2 inhibitors (SGLT2is) have revolutionized the management of DKD by lowering proteinuria and protecting organs, other novel treatment approaches with good evidence and efficacy that can be used in conjunction with a RAASi or SGLT2i in managing DKD have emerged in the past few years. This review discusses the evidence for glucagon-like peptide-1 receptor agonist, selective mineralocorticoid receptor antagonist, and selective endothelin A receptor antagonist, emerging treatment options for DKD beyond SGLT2 inhibition.

Akutes Nierenversagen

Das akute Nierenversagen oder die akute Nierenschädigung ist eine ernsthafte Erkrankung. Es gibt nur vage Zahlenangaben zum Auftreten. Im vorliegenden Beitrag wird versucht, die diabetologisch relevanten Aspekte dieser Erkrankung darzustellen. Die möglichen Ursachen werden aufgezeigt. Menschen mit Diabetes mellitus haben überwiegend ein höheres Risiko für ein akutes Nierenversagen als nicht von dieser Stoffwechselerkrankung Betroffene. Dies wird für diagnostische sowie klinisch relevante Risikokonstellationen dargestellt. Sowohl diagnostisch als auch therapeutisch ist die interdisziplinäre Kooperation insbesondere mit dem Fachgebiet Nephrologie erforderlich. Therapeutisch relevante Aspekte werden angerissen, auch medikamentöse Maßnahmen.

Contrast-Induced Acute Kidney Injury in Patients on SGLT2 Inhibitors Undergoing Percutaneous Coronary Interventions: A Propensity-Matched Analysis

Background

Contrast-induced acute kidney injury (CI-AKI) is a common complication of patients undergoing percutaneous coronary intervention (PCI). Data regarding the influence of sodium-glucose cotransporter-2 (SGLT2) inhibitor on the CI-AKI incidence and renal outcomes of patients undergoing PCI are limited. This study aimed to examine the real-world risk of CI-AKI in SGLT2 inhibitor users undergoing PCI.

Methods

We used longitudinal data from the medical records of the First Affiliated Hospital of Xi'an Jiaotong University. We selected SGLT inhibitor users and nonusers [patients with type 2 diabetes (T2D) without SGLT2 inhibitor prescription] undergoing PCI. We determined CI-AKI by the ESUR (European Society of Urogenital Radiology, AKI_ESUR) and KDIGO definition (Kidney Disease: Improving Global Outcomes, AKI_KDIGO). We performed 1:1 nearest-neighbor propensity matching and calculated unadjusted odds ratios (ORs) and adjusted ORs (aORs; accounting for covariates poorly balanced) for AKI in primary and sensitivity analyses. We compared the renal function indicators in users and nonusers at 24, 48, and 72 h post-PCI.

Results

We identified 242 SGLT2 inhibitor users and 242 nonusers in the cohort. The unadjusted ORs of CI-AKI_ESUR were 63% lower in users [OR: 0.37 (95% CI: 0.18–0.68); P = 0.01], which was unchanged [aOR: 0.37 (95% CI: 0.19–0.67); P < 0.01] post adjustment. These estimates did not qualitatively change across several sensitivity analyses. There was no significant difference in urea nitrogen, creatinine, and estimated glomerular filtration rate (eGFR) values between the two groups before PCI, and at 24 h, while the creatinine (48 and 72 h post-PCI) and CyC (24 and 48 h post-PCI) were significantly lower than those in the nonuser group (P < 0.05).

Conclusion

Our findings do not suggest an increased risk of CI-AKI associated with SGLT2 inhibitor use in patients with CAD and T2D undergoing PCI.

Adverse drug reactions of GLP-1 agonists: A systematic review of case reports

BACKGROUND AND AIM

The importance of glucagon-like peptide-1 (GLP-1) agonists is increasing because of its blood sugar controlling and weight loss properties. The data regarding safety of GLP-1 agonists are limited. This study aims to review case reports and case series on adverse drug reactions (ADRs) of GLP-1 agonist.

METHODOLOGY

A comprehensive search was performed in PubMed/Medline, Scopus and Embase to identify literatures. Bibliographic search and open search in Google, Google Scholar, SpringerLink and ResearchGate was performed to identify additional studies. Case reports and case series published the ADRs by the use of GLP-1 agonists in type 2 diabetes patients were included in the study. Reviews, experimental studies, observational studies, grey literature and non English studies were excluded.

RESULTS

The study identified 120 cases of GLP-1 agonists associated ADRs (liraglutide - 46, exenatide - 46, dulaglutide - 20, semaglutide - 4, albiglutide - 2, lixisenatide - 2). The major ADRs reported was gastrointestinal disorders (n = 40) followed by renal (n = 23), dermatologic (n = 14), hepatic (n = 10), immunologic (n = 13), endocrine/metabolic (n = 7), hematologic (n = 3), angioedema (n = 3), neurologic (n = 2), cardiovascular (n = 2) and 1 from each of psychiatric, reproductive, generalized edema problems.

CONCLUSION

Gastrointestinal problems, particularly pancreatitis was the more frequently reported adverse drug reaction associated with GLP-1 agonist. The most adverse drug reactions were observed with liraglutide and exenatide.

Can glucagon-like peptide-1 receptor agonists cause acute kidney injury? An analytical study based on post-marketing approval pharmacovigilance data

Clinical studies after marketing have shown that the use of glucagon-like peptide-1 receptor agonist(GLP-1RA) may lead to acute kidney injury(AKI). However, few epidemiological studies have investigated the risk, clinical features, and outcomes of AKI caused by different GLP-1RA. In this study, Adverse Event Reporting System (FAERS) data were used to compare the association between different GLP-1RA and AKI in the real world.

METHODS

FAERS data from January 2004 to December 2021 were mined using disproportionality analysis and Bayesian analysis to determine the correlation between different GLP-1RA and AKI, and the onset time, mortality, and hospitalization rate of different GLP-1RA were analyzed.

RESULTS

We identified 2670 cases of AKI events associated with GLP-1RA, of which liraglutide was the most commonly reported (34.98%). The patients with AKI were mainly males (47.94%), and the age group was mainly 45-84 years old (73.15%). obese patients with weight more than 99kg (24.42%) were more likely to have AKI. According to different signal mining methods, reporting odds ratio (ROR) (1.50, 95% confidence interval =1.41-1.60) and Bayesian confidence Propagation neural network (0.57, 95% confidence interval =0.54), liraglutide was more strongly associated with AKI than other GLP-1RA. The median time to onset of AKI was 63 days [quartile range (IQR): 15-458.5 days]. In addition, the hospitalization rate and fatality rate of patients with GLP-1RA-related AKI were 45.28% and 4.23% respectively.

CONCLUSIONS

Based on the data in the FAERS database, we analyzed the risk, onset time, and adverse reaction outcomes of GLP-1RA-induced AKI in detail. The results showed that liraglutide had the highest risk of AKI. From the early stage of treatment, we need to monitor patients' renal function regularly, especially for patients with high kidney risks such as obesity and age.