Dapagliflozin in Patients with Chronic Kidney Disease

Cost-utility analysis of empagliflozin on chronic kidney disease progression in Thailand

OBJECTIVE

The prevalence of chronic kidney disease (CKD) in Thailand is high and kidney disease progression remains a problem. Empagliflozin has been known to be used to slow CKD progression, but its accessibility remains limited. This study aimed to assess the cost-utility of empagliflozin for CKD progression in Thailand.

METHODS

A state-transition model was developed consisting of eight health states: five eGFR health states (G2, G3a, G3b, G4, and G5), dialysis, kidney transplantation, and death. Empagliflozin 10 mg was assessed as an add-on treatment to standard of care (SoC). The efficacy of empagliflozin was derived from the EMPA-KIDNEY trial, while other inputs were obtained from a comprehensive literature review. The incremental cost-effectiveness ratio (ICER) per quality-adjusted life year (QALY) was calculated. A probabilistic sensitivity analysis (PSA) was performed to explore uncertainties.

RESULTS

Empagliflozin could improve QALYs by 0.62 and 0.71 for patients with CKD without and with diabetes mellitus (DM) compared with SoC, respectively. However, it required higher total lifetime costs of 77,966 Thai baht (THB) and 59,454 THB for patients with CKD without and with DM, respectively. The ICER for CKD without DM was 126,201 THB/QALY, while the ICER for CKD with DM was 83,473 THB/QALY. The PSA indicated that empagliflozin had a 64.00% probability of being cost-effective for CKD without DM and an 89.18% probability for CKD with DM.

LIMITATIONS

An important limitation was that the treatment effects of empagliflozin were derived from the EMPA-KIDNEY, which was conducted in DM patients and assumed to be the same for non-DM patients because of the limited evidence in non-DM patients.

CONCLUSION

At the current willingness-to-pay threshold of 160,000 THB/QALY, empagliflozin was cost-effective for treating patients with CKD without or with DM.

Cost-effectiveness of finerenone therapy for patients with chronic kidney disease and type 2 diabetes in England & Wales: results of the FINE-CKD model

OBJECTIVE

Chronic kidney disease (CKD) is the leading cause of kidney failure, end-stage kidney disease (ESKD), and cardiovascular (CV) events in patients with type 2 diabetes (T2D). The FIDELIO-DKD trial demonstrated that finerenone lowered the risk of renal and CV events in patients with CKD and T2D, regardless of cardiovascular disease history. This study evaluated the cost-effectiveness of finerenone added to background treatment (finerenone + BT) versus background treatment (BT) alone in patients with CKD and T2D from the perspective of the National Health Service in England and Wales.

METHODS

A lifetime Markov model assessed the indicated usage of finerenone for the treatment of stage 3 or 4 CKD with albuminuria associated with T2D in adults, as per the relevant marketing authorization. The model structure considered kidney disease progression and CV risk, with health states encompassing patients' kidney disease stage and CV event profiles, using patient-level data from the FIDELIO-DKD trial. Model outcomes were life years, quality-adjusted life years (QALYs), per-patient costs, incremental costs, and incremental cost-effectiveness ratio (ICER). Sensitivity and scenario analysis were performed, including an analysis exploring the impact of real-world data which suggests more frequent sodium-glucose co-transporter-2 (SGLT2) inhibitor use in the United Kingdom since FIDELIO-DKD.

RESULTS

Patients receiving finerenone experienced kidney and CV benefits, including reduced rates of nonfatal CV events and CV deaths, translating to improvements in survival and quality-adjusted life years (QALYs) of 6.11 and 5.97 per patient for finerenone + BT versus BT, respectively. Total discounted per-patient costs were £48,940 for finerenone + BT and £47,716 for BT alone, resulting in an incremental cost-effectiveness ratio of £8,808 per QALY gained for finerenone + BT versus BT.

CONCLUSION

Sensitivity and scenario analyses, including more frequent SGLT2 inhibitor use consistent with real-world data, indicate a robust ICER that remains within the bounds of what is typically considered cost-effective.

Treatment of immunoglobulin A nephropathy: Current perspective and future prospects

Immunoglobulin (Ig) A nephropathy is the most common type of primary glomerulonephritis globally. It typically manifests with microscopic hematuria and a spectrum of proteinuria, although rapidly progressive glomerulonephritis may occur in rare instances. Deposition of IgA in the mesangium seems to be the underlying disease mechanism. Despite current treatment, IgA nephropathy may progress into end-stage renal disease, indicating the necessity for the development of new therapeutic agents. Lifestyle modifications and anti-proteinuric treatment are recommended, and steroids have shown to be beneficial to high risk groups. Nevertheless, other conventional immunosuppressive agents, such as cyclophosphamide and mycophenolate mofetil, may be considered, despite the lack of sufficient evidence to support their efficacy. A considerable proportion of cases remain unresponsive to these treatments, underscoring the need for novel therapeutic approaches. There are several promising immunosuppressive drugs, such as B-cell lineage depleting agents or complement system inhibitors, that are currently undergoing clinical trials. These therapies may be considered for use in selected cases.

Cardiovascular outcomes of SGLT-2 inhibitors' subtypes in type 2 diabetes; an updated systematic review and meta-analysis of randomized controlled trials

Introduction

The effects of Sodium-glucose cotransporter-2 (SGLT-2) inhibitors on cardiac outcomes, cardiovascular mortality (CVM), and all-cause mortality (ACM) in type 2 diabetes mellitus (T2DM) patients have been reported heterogeneously in different studies.

Methods

PubMed, Scopus, Embase, Cochrane Library, and Scholar databases were searched with relevant MeSH terms from January 1, 2010, to November 14, 2023. The study used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcomes in all trials included the risk of ACM, CVM, hospitalization for heart failure (HHF), myocardial infarction (MI), and cerebrovascular accidents (CVA) in T2DM patients who were treated with one of the SGLT-2 inhibitors. Heterogeneity between studies was evaluated using Cochran's Q and I2 tests. The Egger's test was used to check for publication bias.

Results

Eighteen studies, including 70,830 participants, were included. A pooled estimate showed that SGLT-2 inhibitor treatment was significantly associated with reduced ACM (OR: 0.82, 95% CI: 0.75-0.90, p-value: 0.001, I2: 35.1%), CVM (OR: 0.88, 95% CI: 0.80-0.96, p-value: 0.001, I2: 0%), MI (OR: 0.88, 95% CI: 0.79-0.98, p-value: 0.001, I2: 0%), and HHF (OR: 0.67, 95% CI: 0.58-0.77, p-value: 0.001). SGL-2 inhibitor treatment had no significant relationship with CVA (stroke) (OR: 0.95, 95% CI: 0.8-1.10, p-value: 0.896). Subgroup analysis showed that the effect of SGLT-2 inhibitor treatment on outcomes varied based on the type of SGLT-2 inhibitor.

Conclusion

SGLT-2 inhibitor treatment significantly reduced CVM, ACM, MI, and HHF. Empagliflozin, Canagliflozin, and Dapagliflozin significantly reduced ACM. Canagliflozin was significantly associated with a reduction in CVM. All SGLT-2 inhibitor treatments were associated with a reduction in HHF.

Empagliflozin attenuates renal damage in diabetic nephropathy by modulating mitochondrial quality control via Prdx3-PINK1 pathway

In clinical practice, sodium-glucose transporter 2 inhibitor (SGLT2i) reduces the composite renal outcomes in patients with diabetic kidney disease (DKD). However, its effect on regulating renal mitochondria remains unclear. Mitochondrial quality control (MQC) has been identified as a key factor in DKD. Peroxiredoxin3 (Prdx3) serves as a primary antioxidant protein in mitochondria. In this study, we investigated the expression of Prdx3 in patients with DKD, diabetic mice and HK-2 cells exposed to high glucose and explored SGLT2i potential mechanism of action. The results also showed that empagliflozin (Empa) treatment improved proteinuria and ameliorated renal pathological damage. We observed that Empa has an impact on the expression of Prdx3 in diabetic mice and HK-2 cells exposed to high glucose, so does the mitochondrial dynamic proteins and mitophagy-related proteins Mfn2, Drp1, PINK1, Parkin, LC3II, and P62. In vitro experiments after transfected with pcDNA3.1(+)-Prdx3 and siPrdx3 the expression of Mfn2, Drp1, PINK1, Parkin, LC3II, and P62 changed. The expression of PINK1 decreased after the knockdown of Prdx3. Furthermore, the knockdown of PINK1 accelerated the MQC damage and weakened the protective effect of Empa. Because Empa has impacts on Prdx3, which plays a protective role by influencing MQC, we investigated the latent impact of Prdx3 deficiency on renal injury and its molecular mechanism in vivo and in vitro in DKD. Herein, we demonstrate that Empa treatment modulates MQC potentially via Prdx3 through interacting with PINK1.

Racial and regional differences in efficacy of sodium-glucose cotransporter 2 inhibitors on cardiorenal outcomes: A systematic review and meta-analysis

BACKGROUND

To investigate the efficacy of SGLT2 inhibitors on multiple cardiorenal outcomes across different racial/ethnic groups and regions.

METHODS

We searched PubMed, Cochrane Library, Web of Science, and Embase databases in April 2024 for a systematic review and meta-analysis. Owing to inconsistencies in the reporting of the racial/ethnic and regional demographics, participants were grouped into three racial groups (Asian, Black, and White) and four regional (Asia, Central/South America, Europe, North America) groups. We compared the efficacy of SGLT2 inhibitors among these racial/ethnic and regional groups by calculating the ratio of hazard ratios (RHR). We evaluated the composite of cardiovascular death or hospitalization for heart failure (HHF), cardiovascular death, HHF, all-cause death, major adverse cardiac events, and cardiorenal composite outcomes.

RESULTS

We included 14 randomized placebo-controlled trials with 94,445 participants. Across the three racial/ethnic groups, SGLT2 inhibitors showed comparable efficacy. Compared with White patients, the efficacy of SGLT2 inhibitors on HHF was more pronounced in Black patients (RHR, 0.64; 95 % confidence interval [CI], 0.44-0.94), and a numerically lower risk was associated with Asian patients (RHR, 0.62; 95 % CI, 0.38-1.01). A consistent reduction in cardiovascular events with SGLT2 inhibitors was observed across all regions, while the efficacy of SGLT2 inhibitors on HHF was more pronounced in Asia than in other regions (RHR, 0.52; 95 % CI, 0.33-0.81).

CONCLUSIONS

SGLT2 inhibitors showed generally consistent efficacy across various racial/ethnic and regional groups, with some differences noted in specific populations. Ensuring adequate representation of diverse populations in clinical trials would be key to addressing healthcare disparities.

Renal macro- and microcirculatory perturbations in acute kidney injury and chronic kidney disease associated with heart failure and cardiac surgery

Chronic kidney disease (CKD) affects 50% of patients with heart failure. The pathophysiology of CKD in heart failure is proposed to be driven by macrocirculatory hemodynamic changes, including reduced cardiac output and elevated central venous pressure. However, our understanding of renal microcirculation in heart failure and CKD remains limited. This is largely due to the lack of noninvasive techniques to assess renal microcirculation in patients. Moreover, there is a lack of clinically relevant animal models of heart failure and CKD to advance our understanding of the timing and magnitude of renal microcirculatory dysfunction. Patients with heart failure and CKD commonly require cardiac surgery with cardiopulmonary bypass (CPB) to improve their prognosis. However, acute kidney injury (AKI) is a frequent unresolved clinical complication in these patients. There is emerging evidence that renal microcirculatory dysfunction, characterized by renal medullary hypoperfusion and hypoxia, plays a critical role in the pathogenesis of cardiac surgery-associated AKI. In this review, we consolidate the preclinical and clinical evidence of renal macro- and microcirculatory perturbations in heart failure and cardiac surgery requiring CPB. We also examine emerging biomarkers and therapies that may improve health outcomes for this vulnerable patient population by targeting the renal microcirculation.

Efficacy and Safety of Sodium-Glucose Cotransporter 2 Inhibitors for the Primary Prevention of Cardiovascular, Renal Events, and Safety Outcomes in Patients With Systemic Lupus Erythematosus and Comorbid Type 2 Diabetes: A Population-Based Target Trial Emulation

OBJECTIVE

Patients with systemic lupus erythematosus (SLE) were excluded from sodium-glucose cotransporter 2 inhibitors (SGLT2i) clinical trials. It is unknown whether the cardiorenal benefits of SGLT2i extend to patients with SLE and comorbid type 2 diabetes (T2D).

METHODS

We performed an emulated clinical trial in an insurance-based cohort in the United States, evaluating SGLT2i versus dipeptidyl peptidase-4 inhibitors (DPP4i) for primary prevention of cardiovascular, renal, and other clinical outcomes among patients with both SLE and comorbid T2D. SGLT2i initiators were matched to DPP4i initiators using propensity scores (PSs) based on clinical and demographic factors. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using Cox models.

RESULTS

Outcomes among 2,165 patients starting SGLT2i and 2,165 PS-matched patients starting DPP4i were compared. Over 753.1 (±479.2) mean days, SGLT2i recipients had significantly lower risks of incident acute kidney injury (HR 0.49, 95% CI 0.39-0.63), chronic kidney disease (HR 0.61, 95% CI 0.50-0.76), end-stage renal disease (HR 0.40, 95% CI 0.20-0.80), heart failure (HR 0.72, 95% CI 0.56-0.92), emergency department visits (HR 0.90, 0.82-0.99), and severe sepsis (HR 0.61, 95% CI 0.39-0.94). Risks of all-cause mortality (HR 0.89, 95% CI 0.65-1.21), lupus nephritis (HR 0.67, 95% CI 0.38-1.15), myocardial infarction (HR 0.81, 95% CI 0.54-1.23), stroke (HR 1.03, 95% CI 0.74-1.44), and hospitalizations (HR 0.76, 95% CI 0.51-1.12) did not differ. Genital infection risk (HR 1.31, 95% CI 1.07-1.61) was increased, but urinary tract infection risk (HR 0.90, 95% CI 0.79-1.03) did not differ. No significant difference was observed for diabetic ketoacidosis risk (HR 1.07, 95% CI 0.53-2.14) and fractures (HR 0.95, 95% CI 0.66-1.36).

CONCLUSION

In this emulated clinical trial, treatment with SGLT2i, compared to DPP4i therapy, was associated with significantly reduced risks of several cardiorenal complications among patients with both SLE and T2D.

Effects of sodium-glucose co-transporter inhibitors on individual clinical endpoints and quality of life

AIMS

Sodium-glucose co-transporter inhibitors (SGLTis) have cardiovascular protective effects. We aimed to assess the effects of SGLTis on individual hard clinical endpoints and quality of life (QoL) in patients with cardiovascular risk factors.

METHODS AND RESULTS

Data was searched in PubMed, Embase, Cochrane Library and clinicaltrials.gov databases up to February 2024. Randomized controlled trials (RCTs) comparing SGLTis with placebo were included. The primary outcomes were individual hard clinical endpoints (Subset A) and QoL (Subset B). For Subset A, 13 RCTs including 90 413 patients were enrolled (age 66 ± 10.1 years, 35.7% female, follow-up 2.4 ± 0.3 years); as compared with placebo, SGLTis were associated with significantly lower risk of all-cause mortality [risk ratio (RR): 0.90, 95% confidence interval (CI): 0.86-0.94, P < 0.01], cardiovascular mortality (RR: 0.87, 95% CI: 0.82-0.92, P < 0.01), hospitalization for heart failure (HF) (RR: 0.72, 95% CI: 0.68-0.76, P < 0.01), HF events (RR: 0.72, 95% CI: 0.68-0.75, P < 0.01), hospitalization for any cause (RR: 0.91, 95% CI: 0.88-0.93, P < 0.01) and myocardial infarction (MI) (RR: 0.92, 95% CI: 0.85-0.99, P = 0.03). Notably, the favourable effect of SGLTis on all-cause mortality was more pronounced in younger (<65 years) patients (RR: 0.86, 95% CI: 0.81-0.92) and in studies with less female (RR: 0.84, 95% CI: 0.79-0.90). The favourable effect of SGLTis on MI was only observed in patients who received sotagliflozin (RR: 0.47, 95% CI: 0.31-0.73). For Subset B, nine RCTs including 2552 HF patients were enrolled (age 67.8 ± 12.4 years, 36.4% female, follow-up 3.4 ± 1.9 months); SGLTis were associated with significant improvement in QoL as compared with placebo.

CONCLUSIONS

In patients with a broad spectrum of cardiovascular risk factors, SGLTis substantially improve individual hard clinical outcomes and QoL.

Evaluating the appropriateness and the factors associated with sodium-glucose co-transporter 2 inhibitors prescribing in a Middle Eastern country: a cross-sectional study

BACKGROUND

Sodium glucose co-transporter 2 inhibitors (SGLT2is) are a novel class of oral antidiabetic drugs (ADDs). Studies evaluating the appropriateness of SGLT2is prescribing, and the factors associated with their initiation in the Middle East region are lacking.

AIM

This study aimed to evaluate the appropriateness of prescribing SGLT2is based on indication, dosing, and contraindication and determine the factors associated with their initial prescribing.

METHOD

In this cross-sectional study, a cohort of 650 patients newly prescribed SGLT2is (n = 400) and/or any other oral ADDs (n = 250) during 2020 were included. Data were extracted from an electronic medical record system. Multivariate logistic regression was conducted to investigate factors associated with prescribing SGLT2is.

RESULTS

SGLT2is were prescribed for appropriate indication in 400 patients (100%), while inappropriately prescribed in relation to contraindication and dosing in 14 patients (3.5%). Male patients were more likely to be prescribed SGLT2is (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.02-2.82). Patients with a baseline glycated hemoglobin (HbA1c) above 7% and atherosclerotic cardiovascular disease (ASCVD) were more likely to be prescribed SGLT2is (OR, 3.22; 95% CI, 1.84-5.64) and (OR, 2.18; 95% CI, 1.05-4.52), respectively. Patients receiving metformin (OR, 7.56; 95% CI, 4.46-12.80), sulfonylureas (OR, 2.30; 95% CI, 1.16-4.56), and dipeptidyl peptidase 4 inhibitors (OR, 3.43; 95% CI, 2.00-5.87) were more likely to be prescribed SGLT2is.

CONCLUSION

SGLT2is were found to be typically prescribed for the appropriate indication. Among the most important factors associated with prescribing SGLT2is are having uncontrolled HbA1c, history of ASCVD, and using other ADDs.

Protocol and rationale for a randomized controlled SGLT2 inhibitor trial in paediatric and young adult populations with chronic kidney disease: DOUBLE PRO-TECT Alport

BACKGROUND

Clinical trials have demonstrated positive cardiovascular and kidney outcomes of sodium-glucose co-transporter 2 (SGLT2) inhibitors in adult patients with diabetic and other chronic kidney diseases (CKDs). Whether benefits extend to children, teenagers and young adults with early-stage CKD is unknown. For this reason, the DOUBLE PRO-TECT Alport trial (NCT05944016) will study the progression of albuminuria in young patients with Alport syndrome (AS), the most common hereditary CKD, to assess the safety and efficacy of the SGLT2 inhibitor dapagliflozin. Patients living with AS and chronically elevated albuminuria have a high risk of kidney failure before the age of 50 years.

METHODS

DOUBLE PRO-TECT Alport is a multicentre, randomized, double-blind, placebo-controlled trial. Participants (ages 10-39 years) must have a diagnosis of AS by genetic testing or kidney biopsy, be on a stable (>3 months) maximum tolerated dose of a renin-angiotensin system inhibitor and have a urinary albumin:creatinine ratio (UACR) of >300 mg/g (paediatric) or >500 mg/g (adult).Eligible participants will be randomly assigned at a 2:1 ratio to 48 weeks of treatment with dapaglifozin 10 mg/day or matched placebo. Most participants are expected to be children with a normal estimated glomerular filtration rate (eGFR). In addition to safety, the primary (change in UACR from baseline to week 48) and key secondary (eGFR change from baseline to week 52) efficacy outcomes will be analysed with a mixed model repeated measures approach. Efficacy analyses will be performed primarily in the full analysis set according to the intention-to-treat principle. A sensitivity analysis will be performed using reference-based multiple imputation.

CONCLUSION

DOUBLE PRO-TECT Alport will assess whether SGLT2 inhibitors can safely reduce the UACR change from baseline as a marker for progression of CKD in young patients living with AS.

SGLT2 inhibitors increase low serum magnesium levels in patients with chronic kidney disease immediately after treatment

BACKGROUND

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been shown in clinical trials to increase serum Mg2+ levels in patients with type 2 diabetes mellitus. However, it is unclear whether this effect is similarly observed in patients with chronic kidney disease (CKD) and whether such an increase is observed immediately after treatment.

METHODS

Our retrospective observational study included the 62 patients with CKD who started SGLT2 inhibitor therapy at our institution between 2017 and 2022 and who had complete data on serum Mg2+ measurements at baseline and at 1, 3, and 6 months after treatment. Patients were divided into three subgroups, stratified by serum Mg2+ levels at baseline. We evaluated the changes in serum Mg2+ levels from baseline to 6 months after treatment and the factors associated with these changes.

RESULTS

Median eGFR and mean serum Mg2+ at baseline were 33.5 mL/min/1.73 m2 and 2.03 mg/dL, respectively. Treatment with SGLT2 inhibitors significantly increased serum Mg2+ levels immediately from 1 month after treatment compared with those at baseline and persisted over 6 months, with an overall mean change of 0.13 mg/dL from baseline to 6 months. This increased effect was observed in the low and middle tertile subgroups, but not in the high tertile subgroup. Multivariate linear regression analysis revealed that baseline serum Mg2+ levels and sodium-chloride differences, as a parameter of acid-base status, were independently associated with these changes.

CONCLUSIONS

SGLT2 inhibitors increased serum Mg2+ levels in patients with CKD, particularly those with lower baseline Mg2+ levels, potentially improving their prognosis.

Dapagliflozin in diabetic kidney disease patients with different filtration status

BACKGROUND

Few studies have discussed the effects and mechanism of dapagliflozin on diabetic kidney disease (DKD) with different glomerular filtration rate (GFR) and systolic blood pressure (SBP). This study aimed to investigate the variation in the eGFR and proteinuria after dapagliflozin treatment in DKD patients with different filtration status and SBP levels.

METHODS

First, we conducted a cross-sectional study to determined hyperfiltration threshold for the DKD trial. Then, we enrolled 259 DKD patients with an eGFR greater than 70 mL/min/1.73m2 and an albumin-to-creatinine ratio (ACR) between 30 and 200 mg/g to receive treatment with dapagliflozin. Hyperfiltration was defined as the 95th percentile of eGFR above the age- and gender- specific in healthy subjects, DKD patients were divided into hyperfiltration and non-hyperfiltration groups, and SBP > 120 mmHg and ≤ 120 mmHg groups. The eGFR, ACR, and blood and urine electrolytes were measured before and after treatment.

RESULTS

The mean eGFR change at 2 weeks in the hyperfiltration with SBP > 120 mmHg group was greater than in the non-hyperfiltration with SBP ≤ 120 mmHg group (P = 0.048). The mean ACR reduction values were greater in the non-hyperfiltration with SBP ≤ 120 mmHg group than in the hyperfiltration with SBP > 120 mmHg group at 12 weeks (P = 0.042). There was no difference in other blood or urine electrolytes before and after treatment, except for the fractional excretion of sodium (FENa), which significantly increased after 2 weeks (P < 0.001) and recovered after 8 weeks (P = 0.305).

CONCLUSION

DKD with non-hyperfiltration with SBP ≤ 120 mmHg had a lower mean eGFR decline and greater decrease in the ACR after treatment. The initial increase in FENa and subsequent decrease after dapagliflozin treatment may be the main mechanism behind the eGFR variation.

Beyond glycated haemoglobin: Modelling contemporary management of type 2 diabetes with the updated Cardiff model

AIMS

Recommendations on the use of newer type 2 diabetes (T2D) treatments (e.g., SGLT2 inhibitors and GLP-1 receptor agonists [RA]) in contemporary clinical guidelines necessitate a change in how T2D models approach therapy selection and escalation. Dynamic, person-centric clinical decision-making considers factors beyond a patient's HbA1c and glycaemic targets, including cardiovascular (CV) risk, comorbidities and bodyweight. This study aimed to update the existing Cardiff T2D health economic model to reflect modern T2D management and to remain fit-for-purpose in supporting decision-making.

MATERIALS AND METHODS

The Cardiff T2D model's therapy selection/escalation module was updated from a conventional, glucose-centric to a holistic approach. Risk factor progression equations were updated based on UKPDS90; the cardio-kidney-metabolic benefits of SGLT2i and GLP-1 RA were captured via novel risk equations derived from relevant outcomes trial data. The significance of the updates was illustrated by comparing predicted outcomes and costs for a newly diagnosed T2D population between conventional and holistic approaches to disease management, where the latter represents recent treatment guidelines.

RESULTS

A holistic approach to therapy selection/escalation enables early introduction of SGLT2i and GLP-1 RA in modelled pathways in a manner aligned to guidelines and primarily due to elevated CV risk. Compared with a conventional approach, only considering HbA1c, patients experience fewer clinical events and gain additional health benefits.

CONCLUSIONS

Predictions based on a glucose-centric approach to therapy are likely to deviate from real-world observations. A holistic approach is more able to capture the nuances of contemporary clinical practice. T2D modelling must evolve to remain robust and relevant.

Cardiovascular, kidney and safety outcomes with canagliflozin in older adults: A combined analysis from the CANVAS Program and CREDENCE trial

AIM

SGLT2 inhibitors may be underused in older adults with type 2 diabetes due to concerns about safety and tolerability. This pooled analysis of the CANVAS Program and CREDENCE trial examined the efficacy and safety of canagliflozin according to age.

METHODS

Pooled individual participant data from the CANVAS Program (n = 10 142) and CREDENCE trial (n = 4401) were analysed by baseline age (<65 years, 65 to <75 years, and ≥75 years). A range of adjudicated clinical outcomes were assessed, including major adverse cardiovascular events and CKD progression, as well as safety outcomes. Cox proportional hazards models and Fine and Gray competing risk analysis were used.

RESULTS

Among the 14 543 participants, 7927 (54.5%) were <65 years, 5281 (36.3%) were 65 to <75 years and 1335 (9.2%) were ≥75 years. Older participants had higher rates of atherosclerotic cardiovascular disease and heart failure, longer diabetes duration and lower mean eGFR. Reductions in cardiovascular and kidney outcomes with canagliflozin were consistent across age categories (all p trend >0.10), although there was some evidence that effects on cardiovascular death and all-cause death were attenuated with older age (p trend = 0.02 and 0.03, respectively). Although the incidence of adverse events increased with age, effects of canagliflozin on safety outcomes including acute kidney injury, volume depletion, urinary tract infections and hypoglycaemia, were not modified by age (all p trend >0.10).

CONCLUSIONS

In patients with varying degrees of kidney function, canagliflozin reduced cardiovascular and kidney outcomes, regardless of age, with no additional safety concerns identified in older patients.

Longitudinal Determination of Diabetes Complications and Other Clinical Variables as Risk Factors for Diabetic Ketoacidosis in Type 1 Diabetes

OBJECTIVE

We aimed to determine whether diabetes complications, such as kidney disease that may impair acid-base buffering capacity, independently predict the risk of subsequent diabetic ketoacidosis (DKA).

RESEARCH DESIGN AND METHODS

We accessed previously collected 34-year data from the Diabetes Control and Complications Trial and Epidemiology of Diabetes Interventions and Complications study through public data access. Multivariable Cox proportional hazards models with time-varying exposures and covariates were used to examine the associations of macrovascular disease and early and late stages of neuropathy, nephropathy, and retinopathy, with subsequent DKA occurrence as the outcome.

RESULTS

Of 1,441 participants, 297 experienced 488 DKA events over follow-up. Major adverse cardiovascular events [hazard ratio (HR) 3.16, 95% CI 1.57-6.35, P = 0.001] and late-stage neuropathy, which comprised serious foot ulcer or amputation (HR 1.59, 95% CI 1.04-2.45, P = 0.03) were independently associated with higher DKA risk. Higher risk was also associated with shorter diabetes duration (HR 0.76, 95% CI 0.64-0.91, P = 0.002), female sex (HR 2.04, 95% CI 1.56-2.67, P < 0.001), current insulin pump use (HR 3.04, 95% CI 2.29-4.02, P < 0.001), higher time-updated HbA1c (per additional 1%: HR 1.39, 95% CI 1.29-1.50, P < 0.001), and higher current insulin dose (per 1 additional unit/kg/day: HR 2.32, 95% CI 1.62-3.33, P < 0.001).

CONCLUSIONS

A major cardiovascular event, foot ulcer, or amputation confers the greatest risk of future DKA independent of previously recognized risk factors, implying a need to target patients with these events for DKA prevention interventions, such as self-management skills for metabolic control, management of depression, and DKA education.

Implementation of guideline-recommended medical therapy for patients with heart failure in Europe

Physicians' adherence to guideline-recommended heart failure (HF) treatment remains suboptimal, especially regarding the target doses. In particular, there is evidence that non-cardiologists are less compliant with HF guideline recommendations. This is likely to have a detrimental impact on patients' survival, readmissions and quality of life. Thus, the present document aims to address the reasons underlying low implementation and under-dosing of guideline-directed medical therapy in HF and to update a guidance for the initiation and rapid titration of HF drugs. In particular, aim of this document is to provide practical indications for drug implementation, to be applied not only by cardiologists but also by GPs and internal medicine doctors.

Long-term cardiovascular outcomes after percutaneous coronary intervention in patients with systemic sclerosis

Background

Recent data have shown that systemic sclerosis (SSc) is a significant risk factor for coronary artery disease (CAD) and poorer cardiovascular outcomes in the setting of acute coronary syndrome. However, the morphological characteristics of CAD and the long-term cardiovascular outcomes in patients with concurrent SSc and CAD remain unclear.

Methods

We retrospectively investigated 3,300 patients with CAD who underwent percutaneous coronary intervention (PCI) without prior myocardial infarction or coronary artery revascularization. Laboratory, echocardiographic and angiographic characteristics, and clinical outcomes were compared between patients with and without SSc according to a 1:3 propensity score-matching analysis adjusted for patient demographics and comorbidities. The primary outcome was a composite of cardiac death, myocardial infarction, and stroke, and the secondary outcome was a composite of the primary outcome and heart failure hospitalization.

Results

Among all 3,300 patients, 17 (0.5 %) had SSc. The patients were classified into an SSc group (n = 17) and non-SSc group (n = 51) by propensity score matching. There were no significant differences in laboratory or echocardiographic parameters between the two groups. However, CAD tended to be more complex in the SSc group because of the higher proportion of left main trunk lesions (p = 0.100) and higher SYNergy between PCI with TAXUS™ and Cardiac Surgery (SYNTAX) score (p = 0.030). During a median follow-up of 3.1 years, patients with SSc more frequently experienced primary and secondary outcomes than those without SSc (both log-rank p < 0.02).

Conclusions

Among patients with CAD, long-term cardiovascular outcomes after PCI were poorer in those with than without SSc.

Effect of sotagliflozin on major adverse cardiovascular events: a prespecified secondary analysis of the SCORED randomised trial

BACKGROUND

Sodium-glucose co-transporter (SGLT)-2 inhibitors have shown consistent benefit in improving heart failure-related outcomes but not ischaemic cardiovascular events such as myocardial infarction or stroke. We assessed if the dual SGLT1/2 inhibitor sotagliflozin improves ischaemic outcomes.

METHODS

We did a prespecified secondary analysis of the SCORED trial, which was a double-blind, placebo-controlled, randomised clinical trial enrolling patients (aged ≥18 years) with type 2 diabetes, chronic kidney disease (estimated glomerular filtration rate [eGFR] 25-60 mL/min per 1·73 m2), and additional cardiovascular risk factors. Patients at 750 sites in 44 countries were randomly assigned (1:1) to oral sotagliflozin or placebo via an interactive response technology system (block size of four; stratified by heart failure-related criteria and geographical region), with participants, investigators, and study staff, including those who assessed outcomes, masked to group assignment. Sotagliflozin treatment was prescribed at 200 mg once a day, with the dose increased to 400 mg once a day within the first 6 months if tolerated. Matching placebo was prescribed at the same treatment frequency as the intervention regimen. A prespecified secondary outcome was total major adverse cardiovascular events (MACE), which was defined as a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke, assessed as first and subsequent events. Other outcomes included total myocardial infarction and total stroke (fatal and non-fatal events) as individual post-hoc endpoints. Outcomes were assessed by intention to treat with competing-risk proportional hazard models in the overall population, and, for total MACE, in prespecified subgroups stratified by baseline demographic and clinical features (sex, age, geographical region, heart failure-related criteria, eGFR, urine albumin-creatinine ratio, and cardiovascular disease history). The SCORED trial was registered at ClinicalTrials.gov, NCT03315143, and was ended early due to loss of funding.

FINDINGS

10 584 patients were enrolled and randomly assigned to sotagliflozin (n=5292 [50·0%]) or placebo (n=5292 [50·0%]) between Dec 8, 2017 and Jan 20, 2020 (median age 69 years [IQR 63-74]; 4754 [44·9%] female patients and 5830 [55·1%] male patients). 5144 (48·6%) patients had a history of cardiovascular disease, of whom 2108 (19·9% of the total population) had a history of myocardial infarction, 946 (8·9%) had a history of stroke, and 2375 (22·4%) had a history of coronary revascularisation. Patients in the sotagliflozin group had a significantly lower rate of total MACE than those in the placebo group (4·8 events per 100 person-years vs 6·3 events per 100 person-years; hazard ratio [HR] 0·77 [95% CI 0·65-0·91]; p=0·0020). Interaction analyses suggested a consistent effect of sotagliflozin on total MACE among stratified subgroups without evidence of heterogeneity. Additionally, sotagliflozin significantly reduced the rate of myocardial infarction (1·8 events per 100 person-years vs 2·7 events per 100 person-years; HR 0·68 [0·52-0·89]; p=0·0041) and stroke (1·2 events per 100 person-years vs 1·8 events per 100 person-years; HR 0·66 [0·48-0·91]; p=0·012) compared with placebo.

INTERPRETATION

Sotagliflozin reduced MACE, with independent reductions in myocardial infarction and stroke, among patients with type 2 diabetes, chronic kidney disease, and additional cardiovascular risk. The ischaemic benefit on both myocardial infarction and stroke has not been previously observed with other SGLT inhibitors and warrants investigation of combined SGLT1 and SGLT2 inhibition as a possible underlying mechanism.

FUNDING

Lexicon Pharmaceuticals.

Novel therapeutic agents for cardiometabolic risk mitigation in heart transplant recipients

Heart transplant (HT) recipients experience high rates of cardiometabolic disease. Novel therapies targeting hyperlipidemia, diabetes, and obesity, including proprotein convertase subtilisin/kexin inhibitors, sodium-glucose cotransporter-2 inhibitors, and glucagon-like peptide-1 agonists, are increasingly used for cardiometabolic risk mitigation in the general population. However, limited data exist to support the use of these agents in patients who have undergone heart transplantation. Herein, we describe the mechanisms of action and emerging evidence supporting the use of novel pharmacologic agents in the post-HT setting for cardiometabolic risk mitigation and review evidence supporting their ability to modulate immune pathways associated with atherogenesis, epicardial adipose tissue, and coronary allograft vasculopathy.

Bridging the Gap Between CKD Management Paradigms in Transplant and Nontransplant Settings: Published Evidence, Challenges, and Perspectives

Kidney transplantation (KT) is the best treatment for patients with kidney failure, associated with improved survival and quality of life compared with maintenance dialysis. However, despite constant improvements in the assessment and management of the alloimmune response, KT patients frequently demonstrate a reduced estimated glomerular filtration rate. Therefore, the usual complications of chronic kidney disease (CKD), such as anemia, hypertension, metabolic acidosis, hyperkalemia, or persistent secondary hyperparathyroidism, are highly prevalent after KT. However, their underlying mechanisms are different in the transplant setting (compared with the nontransplanted CKD population), and management recommendations are based on relatively poor-quality data. In recent years, new therapies have emerged, significantly improving kidney and cardiovascular outcomes of non-KT patients with CKD. Whether those new drugs could improve the outcomes of KT patients has largely been under investigated so far. In this review, we will address the challenges of the management of a KT patient with a reduced estimated glomerular filtration rate, cover the published evidence, and highlight the critical knowledge gaps.

Renal Tubule-Specific Angiotensinogen Deletion Attenuates SGLT2 Expression and Ameliorates Diabetic Kidney Disease in Murine Models of Type 1 Diabetes

ARTICLE HIGHLIGHTS

Renin-angiotensin system (RAS) activation plays an important role in the progression of diabetic kidney disease (DKD). However, systemic RAS blockade alone is insufficient to reverse DKD progression. We hypothesized that intrarenal renin-angiotensin system (iRAS) activation plays a crucial role in the progression of DKD. We sought to elucidate the role of the iRAS in DKD progression. Selective deletion of angiotensinogen in renal tubules ameliorated the pathological features of DKD. Our study indicates that iRAS inactivation may be a potential approach for preventing DKD disease severity and its progression.

Dapagliflozin in Patients Undergoing Transcatheter Aortic-Valve Implantation

BACKGROUND

Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk of heart-failure admission among high-risk patients. However, most patients with valvular heart disease, including those undergoing transcatheter aortic-valve implantation (TAVI), have been excluded from randomized trials.

METHODS

We conducted this randomized, controlled trial in Spain to evaluate the efficacy of dapagliflozin (at a dose of 10 mg once daily) as compared with standard care alone in patients with aortic stenosis who were undergoing TAVI. All the patients had a history of heart failure plus at least one of the following: renal insufficiency, diabetes, or left ventricular systolic dysfunction. The primary outcome was a composite of death from any cause or worsening of heart failure, defined as hospitalization or an urgent visit, at 1 year of follow-up.

RESULTS

A total of 620 patients were randomly assigned to receive dapagliflozin and 637 to receive standard care alone after TAVI; after exclusions, a total of 1222 patients were included in the primary analysis. A primary-outcome event occurred in 91 patients (15.0%) in the dapagliflozin group and in 124 patients (20.1%) in the standard-care group (hazard ratio, 0.72; 95% confidence interval [CI], 0.55 to 0.95; P = 0.02). Death from any cause occurred in 47 patients (7.8%) in the dapagliflozin group and in 55 (8.9%) in the standard-care group (hazard ratio, 0.87; 95% CI, 0.59 to 1.28). Worsening of heart failure occurred in 9.4% and 14.4% of the patients, respectively (subhazard ratio, 0.63; 95% CI, 0.45 to 0.88). Genital infection and hypotension were significantly more common in the dapagliflozin group.

CONCLUSIONS

Among older adults with aortic stenosis undergoing TAVI who were at high risk for heart-failure events, dapagliflozin resulted in a significantly lower incidence of death from any cause or worsening of heart failure than standard care alone. (Funded by Instituto de Salud Carlos III and others; ClinicalTrials.gov number, NCT04696185.).

Novel Antidiabetic Drugs and Risk of Venous Thromboembolism: A Literature Review

Novel antidiabetic drugs, particularly sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists, have significantly transformed the management landscape for type 2 diabetes mellitus, cardiovascular diseases, and chronic kidney diseases, owing to their well-established cardiorenal protective effects. Given the shared risk factors and comorbidities, it is relevant to consider the potential risk of venous thromboembolism (VTE) in individuals prescribed these novel antidiabetic medications. This literature review aims to summarize currently available evidence on VTE risk associated with novel antidiabetic drugs, including GLP-1 receptor agonists, dipeptidyl-peptidase IV (DPP-4) inhibitors, and SGLT2 inhibitors. Following a comprehensive search on PubMed using relevant keywords and backward reference searching, we identified 25 publications that directly reported on associations between these medications and VTE risk. Findings from these studies, including seven meta-analyses, reveal inconsistent results: some studies suggest that GLP-1 receptor agonists or DPP-4 inhibitors may be associated with increased risk of VTE, whereas SGLT2 inhibitors do not appear to be associated with VTE and may even be a protective factor. A notable limitation of the existing studies is the significant challenge posed by confounding in observational studies, while the randomized controlled trials (RCTs) often concluded with a limited number of VTE events, if it was studied. Furthermore, all identified studies focused on the risk of primary VTE, leaving an important knowledge gap regarding whether these novel antidiabetic drugs may influence the efficacy or safety of anticoagulants used for preventing VTE recurrence. Addressing these gaps presents an important avenue for future research.

The effects of empagliflozin on systemic haemodynamic function: three randomized, placebo-controlled trials

BACKGROUND

Sodium glucose cotransporter 2 inhibitors lower blood pressure. The underlying mechanisms are multifactorial and include effects on vascular function. We examined the systemic hemodynamic effects of empagliflozin in patients with type 2 diabetes mellitus (DM2) with and without chronic kidney disease (CKD) and in patients with nondiabetic CKD.

METHODS

Three double-blinded, randomized, placebo-controlled cross-over trials, including patients with DM2 and preserved renal function (n = 16), DM2 and CKD (n = 17) and nondiabetic CKD (n = 16). Participants were randomized to 4 weeks of empagliflozin 10 mg or placebo and crossed over after a 2-week washout. We measured brachial and central 24-h ambulatory blood pressure (ABP), pulse wave velocity (PWV), augmentation index (AIx@75), markers of nitric oxide and erythrocyte sodium sensitivity (ESS), a marker of endothelial glycocalyx function.

RESULTS

Empagliflozin reduced PWV [-0.16 m/s, 95% confidence interval (95% CI): -0.26; -0.06, P = 0.002], AIx@75 (-2.17%, 95% CI: -3.31; -1.02, P < 0.001) and brachial and central ABP in the combined study population (n = 49). Changes in PWV and AIx@75 correlated to changes in systolic brachial ABP. Markers of nitric oxide did not increase, but empagliflozin decreased ESS, which was correlated to an increase in haematocrit.

CONCLUSION

Empagliflozin decreased arterial stiffness, mediated partly by a decrease in brachial ABP. We found no increase in nitric oxide activity, but ESS decreased. While this may be explained partly by a change in haematocrit, it could indicate an improvement in endothelial glycocalyx function.

TRIAL REGISTRATION

EU Clinical Trials Register 2019-004303-12, 2019-004447-80 and 2019-004467-50.

Impact of Cardiorenal Anemia Syndrome on the Prognosis of Patients With Chronic Heart Failure in Japan - Insights From the KUNIUMI Registry Chronic Cohort

BACKGROUND

With the aging of the population, the number of patients with chronic heart failure (CHF) and comorbidities is increasing in Japan. Among the comorbidities, cardiorenal anemia syndrome (CRAS) is particularly important, but the age-specific prevalence and prognosis of CRAS remain unclear.

METHODS AND RESULTS

The KUNIUMI registry chronic cohort is a prospective observational study of CHF (Stages B-D) in Awaji Island. In this study, we analyzed 1,646 patients registered in the KUNIUMI registry and categorized them into 4 groups: Group 1 included patients without cardiac failure (Stage B); Group 2 consisted of patients with cardiac failure but without renal failure or anemia; Group 3 comprised patients with both cardiac failure and renal failure but without anemia; and Group 4 (CRAS) included patients with cardiac failure, renal failure, and anemia. The primary endpoint was composite of all-cause-death and heart failure hospitalization. The proportion of patients with CRAS increased with age. Furthermore, Group 4 showed a significantly worse prognosis than other groups (log-rank P<0.01). On Cox proportional hazard regression analysis, compared with patients without cardiac failure, renal failure, or anemia, the age- and sex-adjusted hazard ratio for the primary endpoint in those with CRAS was 8.94 (95% confidence interval: 5.36-14.92).

CONCLUSIONS

The prevalence of CRAS in CHF increases with age, and the prognosis associated with CRAS is generally worse compared with other comorbidities.

Providing care for kidney transplant recipients: An overview for generalists

Kidney transplantation is the preferred treatment for patients with advanced chronic kidney disease and end-stage kidney disease, offering superior quality of life and survival compared to dialysis. This manuscript provides an updated overview of post-transplant care, highlighting recent advancements and current practices to assist generalists in managing these patients. It covers key areas such as immunosuppression strategies, drug interactions, and the management of transplant-specific acute kidney injury. The focus includes the use of sodium-glucose cotransporter-2 inhibitors and cell-free DNA monitoring for evaluating allograft health and immune-mediated injury. The manuscript reviews the fundamentals of immunosuppression, including both induction and maintenance therapies, and underscores the importance of monitoring kidney function, as well as addressing hypertension, diabetes, and infections. It also provides recommendations for vaccinations and cancer screening tailored to kidney transplant recipients and emphasizes lifestyle management strategies, such as exercise and sodium intake, to reduce post-transplant complications.

Contribution of the glomerular filtration rate slope to the kidney hierarchical composite endpoint

INTRODUCTION

A recent chronic kidney disease (CKD) progression hierarchical composite endpoint (HCE) utilizes the glomerular filtration rate (GFR) slope for participants without a dichotomous event. Here, we evaluated clinical interpretations when HCE analyses are driven by GFR slope comparisons.

METHODS

Using CKD trial data, we calculated win odds using only GFR slope; dichotomous kidney events and GFR slope; all-cause mortality, dichotomous kidney events and GFR slope; and all-cause mortality with dichotomous kidney events.

RESULTS

Win odds (95% confidence interval) calculated from pairwise GFR slope only comparisons were 1.44 (1.34-1.55), 1.60 (1.49-1.72), 1.19 (1.10-1.28), and 0.82 (0.78-0.86) in the DAPA-CKD, CREDENCE, SONAR, and ALTITUDE trials, respectively. Win odds were similar for the GFR slope only and full kidney HCE with and without mortality.

CONCLUSIONS

These results support incorporation of GFR slope into the CKD progression HCE and help to interpret the magnitude of treatment effect on kidney HCE estimated with win odds.

Cardiovascular outcomes with semaglutide by severity of chronic kidney disease in type 2 diabetes: the FLOW trial

BACKGROUND AND AIMS

In the FLOW trial, semaglutide reduced the risks of kidney and cardiovascular (CV) outcomes and death in participants with type 2 diabetes and chronic kidney disease (CKD). These prespecified analyses assessed the effects of semaglutide on CV outcomes and death by CKD severity.

METHODS

Participants were randomized to subcutaneous semaglutide 1 mg or placebo weekly. The main outcome was a composite of CV death, non-fatal myocardial infarction (MI), or non-fatal stroke (CV death/MI/stroke) as well as death due to any cause by baseline CKD severity. CKD was categorized by estimated glomerular filtration rate < or ≥60 mL/min/1.73 m2, urine albumin-to-creatinine ratio < or ≥300 mg/g, or Kidney Disease Improving Global Outcomes (KDIGO) risk classification.

RESULTS

Three thousand, five hundred and thirty-three participants were randomized with a median follow-up of 3.4 years. Low/moderate KDIGO risk was present in 242 (6.8%), while 878 (24.9%) had high and 2412 (68.3%) had very high KDIGO risk. Semaglutide reduced CV death/MI/stroke by 18% [hazard ratio (HR) 0.82 (95% confidence interval 0.68-0.98); P = .03], with consistency across estimated glomerular filtration rate categories, urine albumin-to-creatinine ratio levels, and KDIGO risk classification (all P-interaction > .13). Death due to any cause was reduced by 20% [HR 0.80 (0.67-0.95); P = .01], with consistency across estimated glomerular filtration rate categories and KDIGO risk class (P-interaction .21 and .23, respectively). The P-interaction treatment effect for death due to any cause by urine albumin-to-creatinine ratio was .01 [<300 mg/g HR 1.17 (0.83-1.65); ≥300 mg/g HR 0.70 (0.57-0.85)].

CONCLUSIONS

Semaglutide significantly reduced the risk of CV death/MI/stroke regardless of baseline CKD severity in participants with type 2 diabetes.

Management of Diabetes in Patients with Chronic Kidney Disease

BACKGROUND

Patients with diabetes and chronic kidney disease (CKD) are at increased risk of kidney disease progression and cardiovascular events.

METHODS

In this article, we will summarize the 2022 consensus report by the ADA and KDIGO on diabetes management in CKD and include newly available evidence to assist health care professionals in providing optimal care to patients living with diabetes and CKD.

RESULTS

Comprehensive care strategies include lifestyle interventions, optimal glycemic, blood pressure, weight, and lipid management, and preferential use of therapies with proven heart and kidney beneficial effects.

CONCLUSIONS

This article offers a concise overview of the multiple strategies aimed at reducing cardiovascular and kidney risk among people with diabetes and CKD, as recommended by multiple societies.

The Impact of Sodium-Glucose Cotransporter-2 Inhibitors on Dialysis Risk and Mortality in Kidney Transplant Patients with Diabetes

Kidney transplantation is the optimal treatment for end-stage kidney disease, but many patients also have diabetes mellitus. This study compares long-term outcomes between new users of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and dipeptidyl peptidase-4 inhibitors (DPP-4i) in kidney transplant recipients with diabetes mellitus. Data from the TriNetX Collaborative Network, including 89,710 patients with diabetes mellitus who underwent kidney transplantation between January 1, 2015, and June 30, 2023, were analyzed. From this cohort, 1,410 matched pairs of SGLT2i and DPP-4i users were selected based on propensity scores. The results showed that SGLT2i users had a lower risk of dialysis (HR: 0.694) and all-cause mortality (HR: 0.687) compared to DPP-4i users. There were no significant differences in the risk of post-transplant infections, transplant rejection, or hospitalization between the two groups. Additionally, SGLT2i users had significantly lower cumulative incidences of dialysis and mortality. In conclusion, this study, utilizing data from TriNetX, demonstrates that SGLT2i treatment in kidney transplant recipients with diabetes mellitus is associated with lower risks of dialysis and mortality, suggesting it may help preserve kidney function and improve survival in this population.

Impact of Selective Peroxisome Proliferator-Activated Receptor (PPAR)-α Modulators and Fibrates on Microvascular Disease: Is There Still Room?

PURPOSE OF REVIEW

This review examines the role of fibrates and the selective PPAR-alpha modulators (SPPARM-α), pemafibrate, in diabetic microvascular disease. It reviews their potential to mitigate residual risk in retinopathy, nephropathy, neuropathy and peripheral vascular disease.

RECENT FINDINGS

These pharmacotherapies, beyond their lipid-lowering effects, may exert anti-inflammatory, antioxidant, and endothelial-protective actions. Secondary analyses of large clinical trials supports their efficacy in slowing retinopathy progression, reducing albuminuria, and preventing minor amputations. Recent analyses suggest that pemafibrate offers an enhanced efficacy and safety profile compared to conventional fibrate and may lower the incidence of diabetic foot ulcers and gangrene. Fibrates and SPPARM-α agonists represent promising therapies to prevent diabetic microvascular complications. Their benefits in reducing microvascular damage support their broader adoption in clinical practice. However, additional dedicated randomized trials are essential to validate the efficacy of those agents in contemporary diabetes care era and to address the growing burden of diabetes-related microvascular complications.

Applications and prospects of phosphoproteomics in renal disease research

Introduction

Phosphoproteomics, an advanced branch of molecular biology, utilizes specific techniques such as mass spectrometry, affinity chromatography, and bioinformatics analysis to explore protein phosphorylation, shedding light on the cellular mechanisms that drive various biological processes. This field has become instrumental in advancing our understanding of renal diseases, from identifying underlying mechanisms to pinpointing new therapeutic targets.

Areas covered

This review will discuss the evolution of phosphoproteomics from its early experimental observations to its current application in renal disease research using liquid chromatography-tandem mass spectrometry (LC-MS/MS). We will explore its role in the identification of disease biomarkers, the elucidation of pathogenic mechanisms, and the development of novel therapeutic strategies. Additionally, the potential of phosphoproteomics in enhancing drug discovery and improving treatment outcomes for renal diseases will be highlighted.

Expert opinion

Phosphoproteomics is rapidly transforming renal disease research by offering unprecedented insights into cellular processes. Utilizing techniques such as LC-MS/MS, it enables the identification of novel biomarkers and therapeutic targets, enhancing our understanding of drug mechanisms. This field promises significant advancements in the diagnosis and treatment of renal diseases, shifting towards more personalized and effective therapeutic strategies. As the technology evolves, its integration into clinical practice is pivotal for revolutionizing renal healthcare.

Need for life cycle assessment of pharmaceuticals for kidney healthcare

PURPOSE

Global warming is a known risk factor for chronic kidney disease (CKD), and both progression of the disease and its treatment place a burden on the environment. Life cycle assessment (LCA) is an established method for evaluating the global impact of manufactured products, from materials' procurement to disposal. We aimed to examine available reports of its application to pharmaceuticals.

METHODS

A narrative review focused on LCA studies of any pharmaceuticals according to disease area.

RESULTS

We identified the drug types used for treatment of 13 disease areas described in 51 previous LCA studies, classified using the MIDAS database. Among the drug types, anesthetics, inhalants, and antibiotics have received the most attention. However, LCA studies are lacking for the wide range of pharmaceuticals used in kidney healthcare, in the fields of dialysis therapy, treatment of end-stage kidney disease, and associated cardiovascular, metabolic, and endocrine diseases.

DISCUSSION

As the proportion of the population affected by CKD increases, there is a particular urgency for LCA research into drugs administered for their kidney protective effects, such as renin--angiotensin system inhibitors and sodium-glucose cotransporter 2 inhibitors. As sustainable practices in drug production and the ability to identify and choose effective drugs with low environmental impact require comprehensive LCA data, clinical physicians and pharmacists involved in kidney healthcare should collaborate with pharmaceutical companies to develop an LCA research system . Incorporating rating of environmental burden of each drug into daily practice is desirable for achieving sustainable kidney healthcare and reducing its environmental impacts.

Dapagliflozin effects on exercise, cardiac remodeling, biomarkers, and renal and pulmonary function in heart failure patients: not as good as expected?

Background

Sodium-glucose cotransporter-2 inhibitors (SGLT2-i) are standard therapy for heart failure (HF). We performed a holistic evaluation of dapagliflozin, including its effects on exercise performance, left ventricle (LV) reverse remodeling, cardiac biomarkers, fluid retention, and renal and pulmonary function.

Methods

We enrolled HF reduced ejection fraction (LVEF) outpatients (EF <40%) eligible for SGLT2-i and performed cardiopulmonary exercise tests (CPET), pulmonary function tests, bioelectrical impedance vector analysis, and laboratory and echocardiographic assessments at baseline (T = 0), after 2-4 weeks (T1), and after 6 months of treatment (T2).

Results

None of the patients interrupted SGLT2-i for adverse events albeit follow-up was completed by 67 of 75 enrolled patients. At T2, mean LVEF increased (from 34.6 ± 7.8 to 37.5 ± 9.2%; p < 0.001) while end-diastolic (EDV) and end-systolic (ESV) volumes decreased [EDV: 186 (145-232) vs. 177 (129-225) mL, ESV: 113 (87-163) vs. 110 (76-145) mL; p < 0.001]. Peak oxygen intake was unchanged [peakVO2: 16.2 (13.4-18.7) vs. 16.0 (13.3-18.9) mL/kg/min; p = 0.297], while exercise ventilatory efficiency (VE/VCO2 slope) improved [from 34.2 (31.1-39.2) to 33.7 (30.2-37.6); p = 0.006]. Mean hemoglobin increased (from 13.8 ± 1.5 to 14.6 ± 1.7 g/dL; p < 0.001), while renal function did not change after a transient worsening at T1. NT-proBNP, ST-2, and hs-TNI did not change as overall body fluids and quality of life assessed by KCCQ. NYHA class improved (p=0.002), paralleled by a decrease of MECKI (Metabolic Exercise test data combined with Cardiac and Kidney Indexes) score, from 3.3% (1.9-8.0) to 2.8% (1.2-5.7), suggestive of a positive impact on 2 years prognosis (p < 0.001).

Conclusions

Dapagliflozin induced positive LV remodeling, improvement of exercise ventilatory efficiency, and NYHA class but without peakVO2 fluid status and cardiac biomarkers changes.

SGLT2 Inhibitors and the Risk of Urogenital Infections: A Concise Review

Diabetes mellitus has become a major public health problem due to aspects such as an alarming increase in prevalence, the morbidity and mortality associated with its complications and, not least, the economic burden. SGLT2 inhibitors are a relatively new but valuable class of drugs that demonstrated multifaceted effects in addition to hypoglycemic action. Moreover, these drugs demonstrated cardiovascular and renal benefits, even in individuals without diabetes, being recommended by current guidelines to patients with a history of cardiovascular disease, or at high risk for it, as well as to patients with chronic kidney disease. The prescription of this class of drugs is limited by the risk of urogenital infections, despite their multiple demonstrated benefits. Data regarding the prevalence of SGLT2 inhibitors associated with urogenital infections depend on several factors related to the study carried out and to other additional conditions that could precipitate such infections. While SGLT2 inhibitors have a well-established association with the risk of genital infections, the association with urinary tract infections remains controversial and uncertain. This review will be focused on urogenital infections associated with the administration of SGLT2 inhibitors, highlighting their prevalence, risk factors, mechanisms involved, clinical relevance and particularities of management.

Kidney outcomes with SGLT2 inhibitors in patients with diabetes and an insulin-deficient phenotype: A real world analysis

AIM

Diabetic kidney disease (DKD) is a major complication of diabetes, including in insulin-deficient phenotypes, yet data on kidney outcomes with sodium-glucose cotransporter 2 inhibitors (SGLT2i) in this population are limited. This study investigates the impact of SGLT2i on kidney outcomes in patients with insulin-deficient diabetes using real world data.

MATERIALS AND METHODS

This retrospective cohort study utilized data from a large Health Maintenance Organization in Israel and included 12,530 propensity score-matched adults with insulin-deficient diabetes. Patients were categorized into SGLT2i users and non-users and followed for a median of 1657 days. The primary outcome was a composite of ≥50% decline in eGFR to <60 mL/min/1.73 m2 or progression to eGFR <15 mL/min/1.73 m2. Secondary outcomes included doubling of serum creatinine and changes in albuminuria category.

RESULTS

SGLT2i use was associated with a reduced incidence of the primary outcome (6.1% vs. 7.5%; HR 0.79, p < 0.001). Secondary analyses revealed significant reductions in serum creatinine doubling (HR 0.76, p < 0.001) and improvements in albuminuria, with 51% of SGLT2i users transitioning to normoalbuminuria. Benefits were consistent across subgroups. Although diabetic ketoacidosis (DKA) incidence was higher among SGLT2i users (2.81% vs. 2.19%, p = 0.03), the overall frequency was low.

CONCLUSIONS

SGLT2i demonstrated substantial kidney protection in insulin-deficient patients, extending benefits beyond type 2 diabetes. These findings highlight SGLT2i as a potential therapeutic option for mitigating DKD in high-risk populations.

Heart Failure in Older Patients: An Update

Heart failure (HF) is a clinical syndrome with high incidence and prevalence and high morbidity and death rate, even in the short term, representing a serious public health issue, mainly in older people. It is a growing cause for hospital admission in this age group, being frequently associated with several comorbidities, further aggravating the disease's course. Moreover, older HF patients are usually affected by clinical conditions, like frailty, malnutrition, and cachexia, which significantly impact the overall management of HF and need to be properly identified and treated. Diagnosing and managing HF in older patients may be very complicated and challenging. Although specific data on treatment of both acute and chronic HF in older subjects are limited and mainly extrapolated from large-scale clinical trials, the standard pharmacological management may be considered well-tolerated and generally safe. In any case, a personalized and tailored approach is mandatory and is based on severity of comorbidities, overall status, and prognosis, above all in frailer and more comorbid subjects, due to the higher rate of drug interactions, side effects, and therapy discontinuation in this population. In this scenario, palliative care has become a fundamental part of HF management in the elderly in order to improve their care and the quality of life. Moreover, an increasing number of promising pharmacological options deserve further investigation in order to support clinicians in optimizing management of comorbid and frailer patients. In this work, we provide detailed and updated insight into clinical, therapeutic, and prognostic features of both acute and chronic HF in the older population.

Effect of SGLT2i on kidney outcomes of individuals with type 2 diabetes according to body mass index: nationwide cohort study

AIMS

To investigate the clinical significance of the modification of the kidney protective effects of sodium-glucose cotransporter-2 (SGLT2) inhibitors by baseline body mass index (BMI).

METHODS AND RESULTS

We included individuals with SGLT2 inhibitors or dipeptidyl peptidase-4 (DPP4) inhibitors newly prescribed for type 2 diabetes using a nationwide epidemiological cohort and performed propensity score matching (1:2). The primary outcome was the annual eGFR decline, assessed using a linear mixed-effects model, compared between individuals with SGLT2 inhibitors and DPP4 inhibitors. We investigated the interaction effect of BMI at the time of prescription using a three-knot restricted cubic spline model. We analysed 2165 individuals with SGLT2 inhibitor prescriptions and 4330 individuals with DPP4 inhibitor prescriptions. Overall, the annual decline in eGFR was less pronounced in the group treated with SGLT2 inhibitors than in those treated with DPP4 inhibitors (-1.34 mL/min/1.73 m2 vs. -1.49 mL/min/1.73 m2). The advantage of SGLT2 inhibitors in mitigating eGFR decline was augmented in the individuals with higher BMI (P-value for interaction 0.0017). Furthermore, even upon adjusting the definition of outcomes to encompass a 30 or 40% reduction in eGFR, the potential advantages of SGLT2 inhibitors over DPP4 inhibitors persisted, with a trend of augmented effects with higher BMI. This interaction effect was evident in the individuals with preserved kidney function.

CONCLUSION

Our nationwide epidemiological study substantiated the improved kidney outcomes in the SGLT2 inhibitor users compared with the DPP4 inhibitor users across a wide range of BMI, which was pronounced for individuals with higher BMI.

Comparative cardiovascular effectiveness of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors in atherosclerotic cardiovascular disease phenotypes: a systematic review and meta-analysis

BACKGROUND

Atherosclerotic cardiovascular disease (ASCVD) encompasses various phenotypes with elevated risks of major adverse cardiovascular events (MACEs). This study aimed to assess the comparative cardiovascular effectiveness of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is) across diverse ASCVD phenotypes.

METHODS AND RESULTS

We conducted a systematic review and meta-analysis of randomized controlled trials evaluating GLP-1 RAs or SGLT2is against placebo or standard care in ASCVD patients. Primary outcomes included MACE, defined as cardiovascular mortality, non-fatal myocardial infarction, and non-fatal stroke. Risk ratios (RRs) with 95% confidence interval (CI) were calculated using a random-effects model.Twenty-six trials (151 789 patients) were included. Both GLP-1 RAs and SGLT2is significantly reduced MACE rates in ASCVD patients (RR 0.85; 95% CI 0.80-0.91 for both). GLP-1 RAs showed significant effectiveness in peripheral artery disease (RR 0.86; 95% CI 0.76-0.98) and post-acute cardiovascular events (RR 0.90; 95% CI 0.83-0.97). In ASCVD with heart failure, both drug classes reduced MACE (GLP-1 RAs: RR 0.73; 95% CI 0.63-0.84; SGLT2is: RR 0.86; 95% CI 0.78-0.95). SGLT2is significantly reduced MACE in ASCVD with chronic kidney disease (RR 0.84; 95% CI 0.72-0.99), particularly in severe albuminuria (RR 0.61; 95% CI 0.37-0.99).

CONCLUSION

GLP-1 RAs and SGLT2is exhibit distinct cardiovascular effectiveness profiles across ASCVD phenotypes. GLP-1 RAs show particular benefits in peripheral artery disease and post-acute cardiovascular events, while SGLT2is demonstrate unique advantages in ASCVD with comorbid chronic kidney disease. Both are effective in heart failure. These findings support tailored treatment strategies for diverse ASCVD participants based on specific comorbidities and risk factors.

Dapagliflozin in Chronic Kidney Disease: Insights from Network Pharmacology and Molecular Docking Simulation

Chronic kidney disease (CKD) involves inflammation, oxidative stress, and fibrosis, leading to renal dysfunction. Dapagliflozin, an SGLT2 inhibitor, shows renoprotective effects beyond glucose control, but its precise molecular mechanisms remain unclear. This study utilizes network pharmacology and molecular docking to elucidate its multi-target effects in CKD. Dapagliflozin's SMILES structure was analyzed for ADMET properties. Potential targets were identified via SwissTargetPrediction, GeneCards, and SEA, and common CKD-related targets were determined. A protein-protein interaction (PPI) network was constructed, and key pathways were identified using GO and KEGG enrichment analyses. Molecular docking was conducted to validate dapagliflozin's binding affinities with hub proteins. A total of 208 common targets were identified, including EGFR, GSK3β, and IL-6. GO and KEGG analyses highlighted key pathways, such as PI3K-Akt, MAPK, and AGE-RAGE, involved in inflammation, oxidative stress, and metabolic regulation. Molecular docking confirmed strong binding affinities with EGFR (-8.42 kcal/mol), GSK3β (-7.70 kcal/mol), and IL-6 (-6.83 kcal/mol). Dapagliflozin exhibits multi-target therapeutic potential in CKD by modulating inflammation, oxidative stress, and metabolic pathways. This integrative approach enhances the understanding of its mechanisms, supporting future experimental validation and clinical application in CKD management.

Nomenclature of renal involvement in diabetes mellitus: unify to manage diversity

Diabetes mellitus is the most common cause of chronic kidney disease leading to kidney failure and premature death. Over the years, the nomenclature of kidney involvement in diabetes mellitus has evolved, driven both by the understanding that the phenotype may be more diverse than initially thought and by pragmatism. In clinical practice, most patients with diabetes mellitus do not undergo a comprehensive work-up (including kidney biopsy and genetic testing) to exclude the presence or coexistence of additional factors or other kidney diseases. Furthermore, the inclusion criteria for successful kidney protection clinical trials that are the basis of current guidelines covered a wide range of kidney phenotypes under the label of "diabetes and kidney disease," without requiring proactive efforts to exclude other nephropathies. The aim of this review is to provide a critical review of the most common chronic kidney disease phenotypes in the context of diabetes mellitus and discuss the evolving nomenclature. Various topics are discuss diabetic kidney disease, classic diabetic nephropathy, regression of albuminuria, rapid progression, non-albuminuric and non-proteinuric kidney disease, the connections between and the impact of aging on these phenotypes and a glimpse into future phenotypes resulting from proactive prevention rather than reactive treatment of kidney disease in diabetes.

Albuminuria in Cardiovascular, Kidney, and Metabolic Disorders: A State-of-the-Art Review

Albuminuria-increased urine albumin excretion-is associated with cardiovascular mortality among patients with diabetes, hypertension, chronic kidney disease, or heart failure, as well as among adults with few cardiovascular risk factors. Many authors have hypothesized that albuminuria reflects widespread endothelial dysfunction, but additional work is needed to uncover whether albuminuria is directly pathologic or causative of cardiovascular disease. Urinary albumin-to-creatinine ratio is an attractive, unifying biomarker of cardiovascular, kidney, and metabolic conditions that may be useful for identifying and monitoring disease trajectory. However, albuminuria may develop through unique mechanisms across these distinct clinical phenotypes. This state-of-the-art review discusses the role of albuminuria in cardiovascular, kidney, and metabolic conditions; identifies potential pathways linking albuminuria to adverse outcomes; and provides practical approaches to screening and managing albuminuria for clinical cardiologists. Future research is needed to determine how broadly and how frequently to screen patients for albuminuria, whether it is cost-effective to treat low-grade albuminuria (10-30 mg/g), and how to equitably offer newer antiproteinuric therapies across the spectrum of cardiovascular-kidney-metabolic diseases.

Long-term trajectory of estimated glomerular filtration rate in ambulatory patients with type 2 diabetes and heart failure: clinical insights and prognostic implications

BACKGROUND

Although previous studies have evaluated renal function decline in patients with heart failure (HF), there is limited evidence on long-term renal trajectories, especially in patients with concomitant HF and type 2 diabetes (T2D). This study aims to provide a detailed analysis of renal function decline over an extended follow-up period in a well-characterized cohort of patients with HF and T2D.

METHODS

This is a post hoc subanalysis of a prospective registry involving ambulatory patients with HF and T2D referred to a specialized HF clinic. The estimated glomerular filtration rate (eGFR) was assessed at baseline and during scheduled follow-up visits every three months using the Chronic Kidney Disease Epidemiology Collaboration formula. Loess curves were plotted for predefined subgroups, and multivariable longitudinal Cox regression analyses were performed to evaluate the associations between eGFR trajectories and all-cause mortality.

RESULTS

A total of 1,114 patients with HF and T2D were included, with a mean age of 69.3 ± 10.3 years, and 68.2% were men. In total, 10,830 scheduled creatinine measurements were analysed, with a mean of 15.8 ± 9.4 measurements per patient. A significant progressive decline in the eGFR was observed, with an average annual rate of - 2.05 (95% CI - 2.11 to - 1.95, p < 0.001) ml/min/1.73 m2. Subgroup analysis indicated that older age, nonischaemic HF aetiology, HFpEF or HFmrEF, poor glycaemic control, and higher baseline eGFRs were associated with a more pronounced decline in renal function. Furthermore, a decrease in the eGFR was independently associated with an increased risk of all-cause mortality.

CONCLUSIONS

This study offers novel insights into long-term renal function trajectories in patients with HF and T2D and identifies key clinical factors associated with accelerated renal decline. Future research is warranted to validate these results in larger, more diverse cohorts and to explore potential therapeutic interventions.

Impact of hospital-based early detection on management in chronic kidney disease: the CKD Stewardship study (CKD-S) - protocol for a prospective, multicentre, observational cohort study

INTRODUCTION

Chronic kidney disease (CKD) causes significant morbidity and mortality. Medical therapies can reduce the progression of disease by up to 50%. CKD is undiagnosed in the majority of people who have it, resulting in undertreatment. CKD Stewardship (CKD-S) aims to identify hospital inpatients with undiagnosed mid-stage to late-stage CKD with the goal of facilitating diagnosis and initiating guideline-based therapies.

METHODS AND ANALYSIS

This prospective, multicentre, cohort study compares two models of care, CKD-S and standard care, for identification and management of CKD, across six public hospitals in metropolitan Sydney, Australia. CKD-S entails active case finding using the electronic medical record, with nephrologist outreach to admitting teams and kidney nurse provided patient education. Adult inpatients with an admission estimated glomerular filtration rate (eGFR)<45 mL/min/1.73 m2 and not known to a nephrologist will be eligible, excluding those with short life expectancy or advanced age (>80 years). Participants will be enrolled between 1 March 2024 and 1 March 2025. Baseline and demographic data will be collected after discharge from the hospital. Participants will be followed up 12 months after discharge using Pharmaceutical Benefits Schedule and Medical Benefits Schedule data, linked via the Australian Institute of Health and Welfare Hub. We will report the proportion of all adults admitted to the hospital who are not already known to a nephrologist, in which a diagnosis of stage 3b-5 CKD is recognised by the CKD-S intervention team, compared with standard care. We will then compare the proportion in each cohort who have an eGFR or urine albumin:creatinine ratio measured, are referred to a nephrologist, and are prescribed guideline-directed therapies over the 12 months following discharge from the hospital.

ETHICS AND DISSEMINATION

The study has ethics approval from the Sydney Local Health District's Ethics Committee (Concord Hospital Zone). The results of the CKD-S study will be published in peer-reviewed journals and presented at academic conferences.

TRIAL REGISTRATION NUMBER

ACTRN12624000452594.