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Lee OYA, Wong ANN, Ho CY, Tse KW, Chan AZ, Leung GPH, Kwan YW, Yeung MHY. Potentials of Natural Antioxidants in Reducing Inflammation and Oxidative Stress in Chronic Kidney Disease. Antioxidants (Basel) 2024; 13:751. [PMID: 38929190 PMCID: PMC11201162 DOI: 10.3390/antiox13060751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 06/13/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
Chronic kidney disease (CKD) presents a substantial global public health challenge, with high morbidity and mortality. CKD patients often experience dyslipidaemia and poor glycaemic control, further exacerbating inflammation and oxidative stress in the kidney. If left untreated, these metabolic symptoms can progress to end-stage renal disease, necessitating long-term dialysis or kidney transplantation. Alleviating inflammation responses has become the standard approach in CKD management. Medications such as statins, metformin, and GLP-1 agonists, initially developed for treating metabolic dysregulation, demonstrate promising renal therapeutic benefits. The rising popularity of herbal remedies and supplements, perceived as natural antioxidants, has spurred investigations into their potential efficacy. Notably, lactoferrin, Boerhaavia diffusa, Amauroderma rugosum, and Ganoderma lucidum are known for their anti-inflammatory and antioxidant properties and may support kidney function preservation. However, the mechanisms underlying the effectiveness of Western medications and herbal remedies in alleviating inflammation and oxidative stress occurring in renal dysfunction are not completely known. This review aims to provide a comprehensive overview of CKD treatment strategies and renal function preservation and critically discusses the existing literature's limitations whilst offering insight into the potential antioxidant effects of these interventions. This could provide a useful guide for future clinical trials and facilitate the development of effective treatment strategies for kidney functions.
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Affiliation(s)
- On Ying Angela Lee
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong SAR, China; (O.Y.A.L.)
| | - Alex Ngai Nick Wong
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong SAR, China; (O.Y.A.L.)
| | - Ching Yan Ho
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong SAR, China; (O.Y.A.L.)
| | - Ka Wai Tse
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong SAR, China; (O.Y.A.L.)
| | - Angela Zaneta Chan
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - George Pak-Heng Leung
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China;
| | - Yiu Wa Kwan
- The School of Biomedical Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Martin Ho Yin Yeung
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong SAR, China; (O.Y.A.L.)
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
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Shiau CH, Tsau LY, Kao CC, Peng YC, Bai CH, Wu JC, Hou WH. Efficacy and safety of sodium-glucose cotransporter-2 inhibitors in patients with chronic kidney disease: a systematic review and meta-analysis. Int Urol Nephrol 2024; 56:1359-1381. [PMID: 37752340 DOI: 10.1007/s11255-023-03789-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 08/24/2023] [Indexed: 09/28/2023]
Abstract
PURPOSE Owing to the pharmacological mechanism, sodium-glucose cotransporter 2 inhibitors (SGLT2is) may be less effective in patients with reduced renal functions, but no systematic review or meta-analysis addressed chronic kidney disease (CKD) patients specifically. We aimed to assess the efficacy and safety of SGLT2is in CKD patients. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials. Mean difference (MD) were pooled for the decline of glomerular filtration rate (eGFR) and change in urine albumin-to-creatinine ratio (uACR). Hazard ratio (HR) and rate ratio (RR) were pooled for composite of renal outcomes and adverse effects. RESULTS Thirty articles were identified. Overall MD in rate of eGFR decline was 0.02 (P = 0.05), with a borderline significant difference favoring SGLT2is, while the change in uACR from baseline was - 141.34 mg/g and hazard ratio of composite renal outcomes was 0.64 significantly favoring SGLT2is. Subgroup analyses showed that the long-term renal function, participants with baseline macroalbuminuria, and stage 4 CKD patients had significantly slower eGFR decline rate in SGLT2is compared to the placebo group. Risks of genital mycotic infection and ketoacidosis were significantly higher among the SGLT2is group than placebo. CONCLUSION For CKD patients, no matter diabetic or non-diabetic, our study showed potential renoprotective effects favoring SGLT2is in overall and long-term phase, and in patients with macroalbuminuria or stage 4 CKD. However, only slight increased risk of adverse effects among the SGLT2is group is observed. Therefore, we concluded that in CKD patients, prescribing SGLT2is was safe and had renal benefits.
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Affiliation(s)
- Chu-Hsuan Shiau
- Department of Education, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Urology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Li-Yun Tsau
- Graduate Institute of Clinical Medicine, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chih-Chin Kao
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Yu-Ching Peng
- Department of Education, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chyi-Huey Bai
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Jeng-Cheng Wu
- Department of Education, Taipei Medical University Hospital, Taipei, Taiwan.
- Department of Urology, Taipei Medical University Hospital, Taipei, Taiwan.
- Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan.
- Department of Education and Humanities in Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| | - Wen-Hsuan Hou
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
- International Ph.D. Program in Gerontology and Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan.
- Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei, Taiwan.
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Hegde NC, Kumar A, Patil AN, Bhattacharjee S, Gamad N, Kasudhan KS, Kumar V, Rastogi A. Dose-dependent renoprotection efficacy of sglt2 inhibitors in type 2 diabetes: systematic review and network meta-analysis. Acta Diabetol 2023; 60:1311-1331. [PMID: 37322184 DOI: 10.1007/s00592-023-02126-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/31/2023] [Indexed: 06/17/2023]
Abstract
AIM To compare the relative effects of different dosages of sodium-glucose cotransport inhibitors (SGLT2i) for renoprotection in Type 2 diabetes mellitus. METHODS The study searched different databases (PubMed, Embase, Scopus, and Web of Science) for studies comparing dose-dependent renoprotective efficacy defined as a decline in eGFR with the different "-flozins namely Empagliflozin, Canagliflozin, Dapagliflozin, Ertugliflozin, Ipragliflozin, Luseogliflozin, Remogliflozin and Sotagliflozin. The studies were compared with the Bayesian approach of network meta-analysis coupled with the random-effect model using the Cochrane risk of bias tool (RoB 2.0), and the surface under the cumulative ranking curve (SUCRA) score was allotted to each dosage of different SGLT-2i. RESULTS A total of 43,434 citations were identified, out of which forty-five randomized trials with 48,067 patients, mentioning the flozin dose and eGFR as an endpoint, were found to be eligible for further analysis. The median duration of the follow-up in the trials was 12 months (IQR 5.5-16 months). Canagliflozin 100 mg demonstrated distinct eGFR benefit with an odds ratio of 2.3 (CI 0.72-3.9) compared to placebo. A statistically non-significant eGFR benefit was observed with all other "-flozins." Canagliflozin 100 mg drug dose category showed the highest sucra rank probability score of 93%, followed by the Canagliflozin 300 mg and Dapagliflozin 5 mg with sucra rank probability scores of 69% and 65%, respectively. The Flozin-dose assessment against eGFR was similar to the albumin-creatinine ratios as the secondary endpoint in the SUCRA ranking. CONCLUSION The renoprotective efficacy of SGLT2i is independent of the incremental doses suggesting lower doses may suffice for renal outcomes.
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Affiliation(s)
- Naveen C Hegde
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankit Kumar
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amol N Patil
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Samiksha Bhattacharjee
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nanda Gamad
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kripa Shanker Kasudhan
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivek Kumar
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashu Rastogi
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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Feng B, Yang F, Liu J, Sun Q, Meng R, Zhu D. Amelioration of diabetic kidney injury with dapagliflozin is associated with suppressing renal HMGB1 expression and restoring autophagy in obese mice. J Diabetes Complications 2023; 37:108409. [PMID: 36731146 DOI: 10.1016/j.jdiacomp.2023.108409] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 01/12/2023] [Accepted: 01/23/2023] [Indexed: 01/29/2023]
Abstract
Diabetic kidney disease (DKD) is a major cause of chronic and end-stage renal disease in diabetic patients. Here, we investigated protective effects and possible mechanisms of dapagliflozin on renal injury in diabetic mice. DKD mice were established by high fat diet (HFD) feeding. Half of DKD mice were randomly assigned to receive dapagliflozin treatment (200 μg/day) for 8 weeks. Renal lipid droplets, fibrosis, oxidative and endoplasmic reticulum stress were evaluated. Glomerular injury was assessed by immunohistochemistry and transmission electron microscopy. Dapagliflozin led to marked inhibition of ROS levels and endoplasmic reticulum stress in diabetic mice. HFD-induced loss of Podocin and Nephrin, and impaired podocytes were also improved with the treatment. Importantly, overexpression of HMGB1 and suppressed autophagy in the kidney were partly reversed by dapagliflozin. Therefore, we speculate that protective effects of dapagliflozin on DKD may be associated with suppression of HMGB1 expression and restoration of autophagy in the kidney.
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Affiliation(s)
- Bin Feng
- Department of Endocrinology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Fan Yang
- Department of Endocrinology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Jie Liu
- Department of Endocrinology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Qichao Sun
- Department of Endocrinology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Ran Meng
- Department of Endocrinology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China.
| | - Dalong Zhu
- Department of Endocrinology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China.
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Repurposing SGLT-2 Inhibitors to Target Aging: Available Evidence and Molecular Mechanisms. Int J Mol Sci 2022; 23:ijms232012325. [PMID: 36293181 PMCID: PMC9604287 DOI: 10.3390/ijms232012325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/04/2022] [Accepted: 10/13/2022] [Indexed: 11/13/2022] Open
Abstract
Caloric restriction promotes longevity in multiple animal models. Compounds modulating nutrient-sensing pathways have been suggested to reproduce part of the beneficial effect of caloric restriction on aging. However, none of the commonly studied caloric restriction mimetics actually produce a decrease in calories. Sodium-glucose cotransporter 2 inhibitors (SGLT2-i) are a class of drugs which lower glucose by promoting its elimination through urine, thus inducing a net loss of calories. This effect promotes a metabolic shift at the systemic level, fostering ketones and fatty acids utilization as glucose-alternative substrates, and is accompanied by a modulation of major nutrient-sensing pathways held to drive aging, e.g., mTOR and the inflammasome, overall resembling major features of caloric restriction. In addition, preliminary experimental data suggest that SGLT-2i might also have intrinsic activities independent of their systemic effects, such as the inhibition of cellular senescence. Consistently, evidence from both preclinical and clinical studies have also suggested a marked ability of SGLT-2i to ameliorate low-grade inflammation in humans, a relevant driver of aging commonly referred to as inflammaging. Considering also the amount of data from clinical trials, observational studies, and meta-analyses suggesting a tangible effect on age-related outcomes, such as cardiovascular diseases, heart failure, kidney disease, and all-cause mortality also in patients without diabetes, here we propose a framework where at least part of the benefit provided by SGLT-2i is mediated by their ability to blunt the drivers of aging. To support this postulate, we synthesize available data relative to the effect of this class on: 1- animal models of healthspan and lifespan; 2- selected molecular pillars of aging in preclinical models; 3- biomarkers of aging and especially inflammaging in humans; and 4- COVID-19-related outcomes. The burden of evidence might prompt the design of studies testing the potential employment of this class as anti-aging drugs.
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SGLT2 Inhibitors in Chronic Kidney Disease: From Mechanisms to Clinical Practice. Biomedicines 2022; 10:biomedicines10102458. [PMID: 36289720 PMCID: PMC9598622 DOI: 10.3390/biomedicines10102458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/22/2022] [Accepted: 09/27/2022] [Indexed: 11/29/2022] Open
Abstract
In recent years, sodium-glucose co-transporter 2 inhibitors (SGLT2i) have demonstrated beneficial renoprotective effects, which culminated in the recent approval of their use for patients with chronic kidney disease (CKD), following a similar path to one they had already crossed due to their cardioprotective effects, meaning that SGLT2i represent a cornerstone of heart failure therapy. In the present review, we aimed to discuss the pathophysiological mechanisms operating in CKD that are targeted with SGLT2i, either directly or indirectly. Furthermore, we presented clinical evidence of SGLT2i in CKD with respect to the presence of diabetes mellitus. Despite initial safety concerns with regard to euglycemic diabetic ketoacidosis and transient decline in glomerular filtration rate, the accumulating clinical data are reassuring. In summary, although SGLT2i provide clinicians with an exciting new treatment option for patients with CKD, further research is needed to determine which subgroups of patients with CKD will benefit the most, and which the least, from this therapeutical option.
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Kansara A, Mubeen F, Shakil J. SGLT2 Inhibitors in Patients with Chronic Kidney Disease and Heart Disease: A Literature Review. Methodist Debakey Cardiovasc J 2022; 18:62-72. [PMID: 36132575 PMCID: PMC9461689 DOI: 10.14797/mdcvj.1120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/28/2022] [Indexed: 11/11/2022] Open
Abstract
Sodium-glucose transport protein 2 inhibitors, commonly referred to as SGLT2i, are a group of prescription pharmaceuticals that are approved by the United States Food and Drug Administration for use with diet and exercise to lower blood glucose in adults with type 2 diabetes. Diabetes is a well-recognized major contributor to cardiovascular and renal disease burden. In addition to blood glucose control, SGLT2i have been shown to provide significant cardiovascular and renoprotective benefits in patients with and without diabetes. In this review, we describe current evidence related to the renal and cardiovascular benefits of using SGLT2i.
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Affiliation(s)
- Abhishek Kansara
- Houston Methodist Hospital, Houston, Texas, US
- Weill Cornell College of Medicine, Ithaca, New York, US
- Texas A&M College of Medicine, Houston, Texas, US
| | | | - Jawairia Shakil
- Houston Methodist Hospital, Houston, Texas, US
- Weill Cornell College of Medicine, Ithaca, New York, US
- Texas A&M College of Medicine, Houston, Texas, US
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Shityakov S, Nagai M, Ergün S, Braunger BM, Förster CY. The Protective Effects of Neurotrophins and MicroRNA in Diabetic Retinopathy, Nephropathy and Heart Failure via Regulating Endothelial Function. Biomolecules 2022; 12:biom12081113. [PMID: 36009007 PMCID: PMC9405668 DOI: 10.3390/biom12081113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 12/15/2022] Open
Abstract
Diabetes mellitus is a common disease affecting more than 537 million adults worldwide. The microvascular complications that occur during the course of the disease are widespread and affect a variety of organ systems in the body. Diabetic retinopathy is one of the most common long-term complications, which include, amongst others, endothelial dysfunction, and thus, alterations in the blood-retinal barrier (BRB). This particularly restrictive physiological barrier is important for maintaining the neuroretina as a privileged site in the body by controlling the inflow and outflow of fluid, nutrients, metabolic end products, ions, and proteins. In addition, people with diabetic retinopathy (DR) have been shown to be at increased risk for systemic vascular complications, including subclinical and clinical stroke, coronary heart disease, heart failure, and nephropathy. DR is, therefore, considered an independent predictor of heart failure. In the present review, the effects of diabetes on the retina, heart, and kidneys are described. In addition, a putative common microRNA signature in diabetic retinopathy, nephropathy, and heart failure is discussed, which may be used in the future as a biomarker to better monitor disease progression. Finally, the use of miRNA, targeted neurotrophin delivery, and nanoparticles as novel therapeutic strategies is highlighted.
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Affiliation(s)
- Sergey Shityakov
- Division of Chemoinformatics, Infochemistry Scientific Center, Lomonosova Street 9, 191002 Saint-Petersburg, Russia
| | - Michiaki Nagai
- Department of Cardiology, Hiroshima City Asa Hospital, 2-1-1 Kabeminami, Aaskita-ku, Hiroshima 731-0293, Japan
| | - Süleyman Ergün
- Institute of Anatomy and Cell Biology, Julius-Maximilians-University Würzburg, 97070 Würzburg, Germany
| | - Barbara M. Braunger
- Institute of Anatomy and Cell Biology, Julius-Maximilians-University Würzburg, 97070 Würzburg, Germany
- Correspondence: (B.M.B.); (C.Y.F.)
| | - Carola Y. Förster
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg University, 97080 Würzburg, Germany
- Correspondence: (B.M.B.); (C.Y.F.)
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Hung WT, Chen YJ, Cheng CY, Ovbiagele B, Lee M, Hsu CY. Metformin plus a low hypoglycemic risk antidiabetic drug vs. metformin monotherapy for untreated type 2 diabetes mellitus: A meta-analysis of randomized controlled trials. Diabetes Res Clin Pract 2022; 189:109937. [PMID: 35662614 DOI: 10.1016/j.diabres.2022.109937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/26/2022] [Accepted: 05/28/2022] [Indexed: 11/03/2022]
Abstract
AIMS The aim of the meta-analysis of randomized controlled trials (RCTs) was to compare the effectiveness of glycemic control and hypoglycemia risk of combination therapy (metformin plus a low hypoglycemic risk antidiabetic drug) vs. standard metformin monotherapy, in patients with untreated type 2 diabetes mellitus (T2DM). METHODS We searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials through October 31, 2021 to find relevant RCTs. Efficacy outcomes were changes in hemoglobulin A1c (HbA1c) and fast plasma glucose (FPG) from baseline as well as proportion of patients achieving HbA1c < 7%; the safety outcome was hypoglycemia risk. RESULTS We identified 14 RCTs comprising 5326 patients with untreated T2DM. Mean treatment duration was 28.1 weeks. Pooled results showed that compared to metformin monotherapy, combination therapy was associated with a reduction in HbA1c (mean difference: -0.48 %, -0.58 to - 0.38) and FPG (mean difference: -0.92 mmol/L, -1.14 to - 0.69), and more patients achieving HbA1c < 7% (odds ratio: 2.21, 1.87 to 2.60). Hypoglycemic events and people experiencing hypoglycemia were not different between 2 groups. CONCLUSIONS Initial combination of metformin plus a low hypoglycemic risk antidiabetic drug may achieve better glycemic control, without a rise in hypoglycemia, in patients with untreated T2DM.
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Affiliation(s)
- Wei-Tse Hung
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yuan-Jung Chen
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chun-Yu Cheng
- Department of Neurosurgery, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Bruce Ovbiagele
- Departments of Neurology, University of California, San Francisco, California, USA
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chia-Yu Hsu
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan.
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Brodosi L, Petta S, Petroni ML, Marchesini G, Morelli MC. Management of Diabetes in Candidates for Liver Transplantation and in Transplant Recipients. Transplantation 2022; 106:462-478. [PMID: 34172646 PMCID: PMC9904447 DOI: 10.1097/tp.0000000000003867] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 11/25/2022]
Abstract
Diabetes is common in patients waitlisted for liver transplantation because of end-stage liver disease or hepatocellular cancer as well as in posttransplant phase (posttransplantation diabetes mellitus). In both conditions, the presence of diabetes severely affects disease burden and long-term clinical outcomes; careful monitoring and appropriate treatment are pivotal to reduce cardiovascular events and graft and recipients' death. We thoroughly reviewed the epidemiology of diabetes in the transplant setting and the different therapeutic options, from lifestyle intervention to antidiabetic drug use-including the most recent drug classes available-and to the inclusion of bariatric surgery in the treatment cascade. In waitlisted patients, the old paradigm that insulin should be the treatment of choice in the presence of severe liver dysfunction is no longer valid; novel antidiabetic agents may provide adequate glucose control without the risk of hypoglycemia, also offering cardiovascular protection. The same evidence applies to the posttransplant phase, where oral or injectable noninsulin agents should be considered to treat patients to target, limiting the impact of disease on daily living, without interaction with immunosuppressive regimens. The increasing prevalence of liver disease of metabolic origin (nonalcoholic fatty liver) among liver transplant candidates, also having a higher risk of noncirrhotic hepatocellular cancer, is likely to accelerate the acceptance of new drugs and invasive procedures, as suggested by international guidelines. Intensive lifestyle intervention programs remain however mandatory, both before and after transplantation. Achievement of adequate control is mandatory to increase candidacy, to prevent delisting, and to improve long-term outcomes.
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Affiliation(s)
- Lucia Brodosi
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater University, Bologna, Italy
| | - Salvatore Petta
- Section of Gastroenterology and Hepatology, PROMISE, University of Palermo, Palermo, Italy
| | - Maria L. Petroni
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater University, Bologna, Italy
| | - Giulio Marchesini
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater University, Bologna, Italy
| | - Maria C. Morelli
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Comparative efficacy of empagliflozin versus placebo in the treatment of type 1 diabetes mellitus: a meta-analysis of randomized controlled trials. CURRENT ISSUES IN PHARMACY AND MEDICAL SCIENCES 2021. [DOI: 10.2478/cipms-2021-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
The objective of this meta-analysis study was to evaluate the comparative efficacy of empagliflozin (25 mg) with placebo in the treatment and management of type 1 diabetes mellitus. This study is a meta-analysis, so an ethical statement is not required. Different databases and individual journal websites like SCOPUS, Science direct, Cochrane review library etc. were used. The articles were evaluated based on the search and eligibility criteria. A total of five RCTs were incorporated in this meta-analysis. These studies contained a total of 1058 patients, including 526 patients with placebo (or control-treated patients), and 532 patients with empagliflozin (25 mg) treated combination. The mean follow-up time ranged from 7 days to 6 months. Overall, mean reduction in placebo was -0.50% and empa-treated was -0.85%, while the pooled WMD was 3.82 995% CI 1.20 – 5.88, p=0.0001). Regarding urinary glucose excretion, that the pooled WMD was 6.67 (95% CI 4.87-10.14, p=0.001) indicated a significant increase in empa-arm compared to placebo. No heterogeneity was found (I2 – 15.03%). This meta-analysis underlined the therapeutic benefit of empagliflozin as an adjunctive therapy for patients with type 1 diabetes.
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Augusto GA, Cassola N, Dualib PM, Saconato H, Melnik T. Sodium-glucose cotransporter-2 inhibitors for type 2 diabetes mellitus in adults: An overview of 46 systematic reviews. Diabetes Obes Metab 2021; 23:2289-2302. [PMID: 34142426 DOI: 10.1111/dom.14470] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 06/02/2021] [Accepted: 06/14/2021] [Indexed: 12/11/2022]
Abstract
AIMS To summarize the evidence from systematic reviews (SRs) of randomized controlled trials (RCTs) evaluating the efficacy and safety of sodium-glucose cotransporter-2 (SGLT2) inhibitors versus placebo or active comparators for type 2 diabetes mellitus. MATERIALS AND METHODS We searched six databases between 2014 and 2021. We assessed the quality of evidence using Assessment of Multiple Systematic Reviews (AMSTAR 2) and Grading of Recommendations Assessment, Development and Evaluation (GRADE) and summarized the main outcome results according to their evidence of benefit (PROSPERO ID: CRD42019132431). RESULTS We included 46 SRs, comprising 175 RCTs and 136 096 participants. The results showed "clear evidence of benefit" in relation to: myocardial infarction (odds ratio [OR]/hazard ratio [HR] 0.85 to 0.91); cardiovascular mortality (OR/HR 0.67 to 0.86); heart failure (OR/HR 0.64 to 0.69); albuminuria progression and composite renal outcome (relative risk [RR]/HR 0.55 to 0.63); glycated haemoglobin (HbA1c) versus placebo (mean difference [MD] -0.49% to -0.77% [5.4 to 8.4 mmol/mol]); and weight versus placebo (MD -1.09 kg to -2.99 kg). "Possible benefit" was observed in relation to major adverse cardiovascular events (OR/HR 0.80 to 0.89), all-cause mortality and nonalcoholic fatty liver disease. SGLT2 inhibitors showed "clear evidence of no effect or equivalence" in relation to stroke and fractures. "Clear evidence of harm" was observed in relation to genital infections (RR/OR 2.06 to 5.25) and ketoacidosis (HR/OR 1.36 to 2.20). Regarding amputation risk and urinary tract infections, we found "no conclusions possible due to lack of evidence". CONCLUSIONS Our results showed that SGLT2 inhibitors have beneficial effects in relation to renal and cardiovascular outcomes (except for stroke), HbA1c and weight. Further studies are needed to assess urinary infections and amputation risk.
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Affiliation(s)
- Gustavo A Augusto
- Brazilian Cochrane Centre, Universidade Federal de São Paulo (UNIFESP), Sao Paulo, Brazil
| | - Nicolle Cassola
- Brazilian Cochrane Centre, Universidade Federal de São Paulo (UNIFESP), Sao Paulo, Brazil
| | - Patrícia M Dualib
- Diabetes Centre of the Endocrinology Division, Universidade Federal de São Paulo (UNIFESP), Sao Paulo, Brazil
| | - Humberto Saconato
- Brazilian Cochrane Centre, Universidade Federal de São Paulo (UNIFESP), Sao Paulo, Brazil
| | - Tamara Melnik
- Brazilian Cochrane Centre, Universidade Federal de São Paulo (UNIFESP), Sao Paulo, Brazil
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13
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Aziz S, Ghadzi SMS, Sulaiman SAS, Hanafiah NHM, Harun SN. Can Newer Anti-Diabetic Therapies Delay the Development of Diabetic Nephropathy? JOURNAL OF PHARMACY AND BIOALLIED SCIENCES 2021; 13:341-351. [PMID: 35399797 PMCID: PMC8985833 DOI: 10.4103/jpbs.jpbs_497_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/08/2021] [Accepted: 09/08/2021] [Indexed: 11/25/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is progressive in nature and leads to hyperglycemia-associated microvascular and macrovascular complications. Diabetic nephropathy (DN) is one of the most prominent microvascular complication induced by T2DM and is characterized by albuminuria and progressive loss of kidney function. Aggressive management of hyperglycemia and hypertension has been found effective in delaying the development and progression of DN. Although the conventional antidiabetic treatment is effective in the earlier management of hyperglycemia, the progressive loss of beta cells ultimately needs the addition of insulin to the therapy. The emergence of newer antidiabetic agents may address the limitations associated with conventional antidiabetic therapies, which not only improve the glycemic status but also effective in improving cardio-renal outcomes. Nevertheless, the exact role of these agents and their role in minimizing diabetes progression to DN still needs elaboration. The present review aimed to highlights the impact of these newer antidiabetic agents in the management of hyperglycemia and their role in delaying the progression of diabetes to DN/management of DN in patients with T2DM.
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Affiliation(s)
- Sohail Aziz
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | | | - Syed Azhar Syed Sulaiman
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
- Advanced Medical and Dental Institute, Universiti Sains Malaysia, Penang, Malaysia
| | - Nur Hafzan Md Hanafiah
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Sabariah Noor Harun
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
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14
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Mitchell NS, Batch BC, Tyson CC. Retrospective cohort study of changes in estimated glomerular filtration rate for patients prescribed a low carb diet. Curr Opin Endocrinol Diabetes Obes 2021; 28:480-487. [PMID: 34392262 DOI: 10.1097/med.0000000000000673] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE OF REVIEW Obesity and diabetes contribute to chronic kidney disease (CKD) and accelerate the loss of kidney function. Low carbohydrate diets (LCDs) are associated with weight loss and improved diabetes control. Compared to the typical Western diet, LCDs contain more protein, so individuals with CKD are not included in studies of LCDs. Therefore, there are no studies of LCDs for weight loss and their effects on kidney function. RECENT FINDINGS Obesity, hyperglycemia, and hyperinsulinemia can be detrimental to kidney function. LCDs may improve kidney function in patients with obesity and diabetes because they are associated with weight loss, improve blood sugar control, and decrease endogenous insulin production and exogenous insulin requirements. SUMMARY In this study, for patients with mildly reduced and moderately to severely reduced kidney function who were prescribed an LCD, their estimated glomerular filtration rate (eGFR) was either unchanged or improved. For those with normal or elevated eGFR, their kidney function was slightly decreased. For those without diabetes, greater weight loss was associated with improved eGFR. Future studies should prospectively measure low carbohydrate dietary adherence and physical activity and directly measure changes in GFR and albuminuria for participants with CKD before and during that diet.
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Affiliation(s)
- Nia S Mitchell
- Duke University Department of Medicine, Division of General Internal Medicine
| | - Bryan C Batch
- Duke University Department of Medicine, Division of Endocrinology, Metabolism, and Nutrition
| | - Crystal C Tyson
- Duke University Department of Medicine, Division of Nephrology, Durham, North Carolina, USA
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15
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Srinivas N, Sarnaik MK, Modi S, Pisipati Y, Vaidya S, Syed Gaggatur N, Sange AH, Sange I. Sodium-Glucose Cotransporter 2 (SGLT-2) Inhibitors: Delving Into the Potential Benefits of Cardiorenal Protection Beyond the Treatment of Type-2 Diabetes Mellitus. Cureus 2021; 13:e16868. [PMID: 34513443 PMCID: PMC8414630 DOI: 10.7759/cureus.16868] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2021] [Indexed: 12/14/2022] Open
Abstract
Diabetes mellitus is a leading cause of morbidity and mortality and a significant risk factor for the early onset of chronic kidney disease and heart disease. Hyperglycemia and insulin resistance are key factors that play a role in the pathogenesis of type 2 diabetes. Renal glucose reabsorption is a critical component of glycemic regulation. Sodium-glucose cotransporter 2 (SGLT2) inhibitors, commonly known as gliflozins, lower blood sugar levels by inhibiting glucose absorption in the proximal tubule of the kidney. SGLT2 inhibitors are currently used primarily as antidiabetic medications; however, their advantages go well beyond just glycemic control. This article has reviewed the mechanisms behind cardiac and renal involvement in type 2 diabetes and their inseparable interconnections. This article has also discussed the pharmacokinetic and pharmacodynamic profile of different SGLT2 inhibitors available in the market. Finally, this review has provided a perspective on the outcome trials, which provide evidence supporting a potential benefit of SGLT2 inhibitors in reducing cardiovascular and renal risks and possible mechanisms that mediate the renal and cardiovascular protection conferred.
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Affiliation(s)
- Natasha Srinivas
- Research, BGS Global Institute of Medical Sciences, Bangalore, IND
| | | | - Srimy Modi
- Research, KJ Somaiya Medical College, Mumbai, IND
| | | | - Sarayoo Vaidya
- Internal Medicine, MS Ramaiah Medical College, Bengaluru, IND
| | | | | | - Ibrahim Sange
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Medicine, KJ Somaiya Medical College, Mumbai, IND
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16
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Bai Y, Jin J, Zhou W, Zhang S, Xu J. The safety outcomes of sodium-glucose cotransporter 2 inhibitors in patients with different renal function: A systematic review and meta-analysis. Nutr Metab Cardiovasc Dis 2021; 31:1365-1374. [PMID: 33812735 DOI: 10.1016/j.numecd.2021.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/29/2020] [Accepted: 02/05/2021] [Indexed: 01/10/2023]
Abstract
AIMS We aimed to assess whether the safety outcomes exerted by sodium-glucose cotransporter 2 (SGLT2) inhibitors were associated with different renal function at baseline. DATA SYNTHESIS We searched randomized controlled trials comparing SGLT2 inhibitors with placebo in participants simultaneously involving the entire range of estimated glomerular filtration rate (eGFR) levels at baseline in one study. According to eGFR, we divided the population into two subgroups with eGFR <60 ml/min/1.73 m2 and eGFR≥60 ml/min/1.73 m2. Data from the CANVAS program, CREDENCE, EMPA-REG OUTCOME, DECLARE-TIMI 58, DAPA-HF, and EMPA-REG RENAL were included. SGLT2 inhibitors significantly reduced the risk of all serious adverse events (HR 0.91 [95% CI 0.87 to 0.95], p < 0.001) and acute kidney injury (HR 0.74 [95% CI 0.64 to 0.85], p < 0.001). Except for high risk of genital infection, SGLT2 inhibitors did not increase the risk of amputation, fracture, hyperkalemia, hypoglycemia, volume depletion, or urinary tract infection. Further analyses showed that these safety outcomes were similar between subgroups (p-interaction > 0.05). For osmotic diuresis, SGLT2 inhibitors significantly increased the risk by 75% (p = 0.036), and subgroup analyses showed that this effect was completely attributed to the increase in patients with eGFR ≥60 ml/min/1.73 m2 (p-interaction<0.001). CONCLUSION The indication of no risk of osmotic diuresis in patients with eGFR<60 ml/min/1.73 m2 and the consistency of other safety outcomes across different baseline renal function may allow additional individuals to safely use SGLT2 inhibitors.
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Affiliation(s)
- Yaling Bai
- Departments of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Jingjing Jin
- Departments of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Wei Zhou
- Departments of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Shenglei Zhang
- Departments of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Jinsheng Xu
- Departments of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, PR China.
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17
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Tuttle KR, Brosius FC, Cavender MA, Fioretto P, Fowler KJ, Heerspink HJ, Manley T, McGuire DK, Molitch ME, Mottl AK, Perreault L, Rosas SE, Rossing P, Sola L, Vallon V, Wanner C, Perkovic V. SGLT2 Inhibition for CKD and Cardiovascular Disease in Type 2 Diabetes: Report of a Scientific Workshop Sponsored by the National Kidney Foundation. Am J Kidney Dis 2021; 77:94-109. [DOI: 10.1053/j.ajkd.2020.08.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/04/2020] [Indexed: 12/25/2022]
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18
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D'Marco L, Morillo V, Gorriz JL, Suarez MK, Nava M, Ortega Á, Parra H, Villasmil N, Rojas-Quintero J, Bermúdez V. SGLT2i and GLP-1RA in Cardiometabolic and Renal Diseases: From Glycemic Control to Adipose Tissue Inflammation and Senescence. J Diabetes Res 2021; 2021:9032378. [PMID: 34790827 PMCID: PMC8592766 DOI: 10.1155/2021/9032378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/01/2021] [Accepted: 10/18/2021] [Indexed: 12/16/2022] Open
Abstract
Background. Over the last few years, the use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1RA) has increased substantially in medical practice due to their documented benefits in cardiorenal and metabolic health. In this sense, and in addition to being used for glycemic control in diabetic patients, these drugs also have other favorable effects such as weight loss and lowering blood pressure, and more recently, they have been shown to have cardio and renoprotective effects with anti-inflammatory properties. Concerning the latter, the individual or associated use of these antihyperglycemic agents has been linked with a decrease in proinflammatory cytokines and with an improvement in the inflammatory profile in chronic endocrine-metabolic diseases. Hence, these drugs have been positioned as first-line therapy in the management of diabetes and its multiple comorbidities, such as obesity, which has been associated with persistent inflammatory states that induce dysfunction of the adipose tissue. Moreover, other frequent comorbidities in long-standing diabetic patients are chronic complications such as diabetic kidney disease, whose progression can be slowed by SGLT2i and/or GLP-1RA. The neuroendocrine and immunometabolism mechanisms underlying adipose tissue inflammation in individuals with diabetes and cardiometabolic and renal diseases are complex and not fully understood. Summary. This review intends to expose the probable molecular mechanisms and compile evidence of the synergistic or additive anti-inflammatory effects of SGLT2i and GLP-1RA and their potential impact on the management of patients with obesity and cardiorenal compromise.
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Affiliation(s)
- Luis D'Marco
- Hospital Clínico Universitario de Valencia, INCLIVA, Valencia 46010, Spain
- CEU Cardenal Herrera University, Valencia 46115, Spain
| | - Valery Morillo
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo 4004, Venezuela
| | - José Luis Gorriz
- Hospital Clínico Universitario de Valencia, INCLIVA, Valencia 46010, Spain
| | - María K. Suarez
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo 4004, Venezuela
| | - Manuel Nava
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo 4004, Venezuela
| | - Ángel Ortega
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo 4004, Venezuela
| | - Heliana Parra
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo 4004, Venezuela
| | - Nelson Villasmil
- School of Medicine, University of Zulia, Maracaibo 4004, Venezuela
| | - Joselyn Rojas-Quintero
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 77054, USA
| | - Valmore Bermúdez
- Universidad Simón Bolívar, Facultad de Ciencias de la Salud, Barranquilla 080002, Colombia
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19
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Zhao LM, Zhan ZL, Qiu M. Effects of SGLT2 inhibitors on cardiovascular death and all-cause death in patients with type 2 diabetes and chronic kidney disease: an updated meta-analysis including the SCORED trial. Ther Adv Endocrinol Metab 2021; 12:20420188211044945. [PMID: 34589202 PMCID: PMC8474301 DOI: 10.1177/20420188211044945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/06/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The effects of sodium-glucose transporter 2 (SGLT2) inhibitors on cardiovascular death (CV death) and all-cause death (AC death) in patients with type 2 diabetes (T2D) and chronic kidney disease (CKD) are currently under intensive investigation. We intended to conduct an updated meta-analysis including the SCORED trial to evaluate the effects of SGLT2 inhibitors on death and cardiorenal events in this vulnerable population. METHODS Cardiorenal outcome trials of SGLT2 inhibitors were included. Primary outcomes were CV death and AC death, while secondary outcomes were hospitalization for heart failure (HHF), myocardial infarction (MI), CKD progression, cardiovascular death or hospitalization for heart failure (CV death or HHF), major adverse cardiovascular events (MACE), and stroke. Meta-analysis was conducted for each outcome. RESULTS Eight trials were included for meta-analysis. Compared with placebo, SGLT2 inhibitors significantly lowered the risk of CV death (HR = 0.86, 95% CI = 0.75-0.98), AC death (HR = 0.87, 95% CI = 0.79-0.96), HHF (HR = 0.64, 95% CI = 0.56-0.74), MI (HR = 0.76, 95% CI = 0.65-0.89), CKD progression (HR = 0.62, 95% CI = 0.54-0.72), and CV death or HHF (HR = 0.73, 95% CI = 0.67-0.80). No heterogeneity existed in the above meta-analyses (all I2 values = 0%), whereas moderate heterogeneity existed in the meta-analyses for MACE and stroke (I2 = 31.6% and 44.5%, respectively). CONCLUSIONS Our findings suggest that SGLT2 inhibitors versus placebo significantly lower death, heart failure, renal failure, and MI events in patients with T2D and CKD. Head-to-head trials are needed to examine the possible differences in the effects of various gliflozins on MACE and stroke.
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Affiliation(s)
- Li-Min Zhao
- Department of Endocrinology, Shenzhen Longhua District
Central Hospital, Shenzhen, China
| | - Ze-Lin Zhan
- Class 3, Clinical medicine, Grade 2019, The Second
Clinical Medical College, Southern Medical University, Guangzhou, China
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20
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Zhou Y, Chi J, Huang Y, Dong B, Lv W, Wang YG. Efficacy and safety of endothelin receptor antagonists in type 2 diabetic kidney disease: A systematic review and meta-analysis of randomized controlled trials. Diabet Med 2021; 38:e14411. [PMID: 33000477 DOI: 10.1111/dme.14411] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/10/2020] [Accepted: 09/22/2020] [Indexed: 01/01/2023]
Abstract
AIM To analyse the efficacy and safety of endothelin receptor antagonists for people with diabetic kidney disease. METHODS Randomized controlled trials comparing endothelin receptor antagonists with placebo in people with diabetic kidney disease were identified through PubMed, Embase and the Cochrane Library. We used a random-effect model to calculate the mean difference or risk ratio with the 95% CI. RESULTS Seven studies with a total of 4730 participants were included. Overall, endothelin receptor antagonists significantly reduced albuminuria compared with placebo (standardized mean difference -0.48, 95% CI -0.64 to -0.33). Atrasentan, in particular, effectively reduced albuminuria (standardized mean difference -0.58, 95% CI -1.00 to -0.17) and the risk of composite renal endpoints (risk ratio 0.65; 95% CI 0.49 to 0.88), with insignificant change in the rate of congestive heart failure (risk ratio 1.40, 95% CI 0.76 to 2.56) and mortality (risk ratio 1.11, 95% CI 0.77 to 1.61). In contrast, although avosentan reduced albuminuria (standardized mean difference -0.47, 95% CI -0.57 to -0.36) and the risk of composite renal endpoints (risk ratio 0.63, 95% CI 0.42 to 0.94), it was associated with a significant increase in congestive heart failure risk (risk ratio 2.61, 95% CI 1.36 to 5.00) and an insignificant increase in mortality risk (risk ratio 1.50, 95% CI 0.81, 2.78). No significant change in efficacy or safety outcomes with bosentan was detected. Dose-response analysis indicated that 0.75 mg/day atrasentan is expected to be optimal for renoprotection, with maximal albuminuria reduction and minimal fluid retention events. CONCLUSIONS Among the endothelin receptor antagonists, atrasentan and avosentan, but not bosentan, are effective for renoprotection in people with diabetic kidney disease. Compared with other types and doses, atrasentan 0.75 mg/day is the most promising, with maximal albuminuria reduction and minimal fluid retention. Vigilant monitoring of congestive heart failure risk is needed in future clinical practice. (PROSPERO registration no. CRD42020169840).
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Affiliation(s)
- Y Zhou
- Department of Endocrinology, Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - J Chi
- Department of Endocrinology, Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - Y Huang
- Department of Endocrinology, Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - B Dong
- Department of Endocrinology, Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - W Lv
- Department of Endocrinology, Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - Y G Wang
- Department of Endocrinology, Affiliated Hospital of Medical College Qingdao University, Qingdao, China
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21
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Tuttle KR, Brosius FC, Cavender MA, Fioretto P, Fowler KJ, Heerspink HJL, Manley T, McGuire DK, Molitch ME, Mottl AK, Perreault L, Rosas SE, Rossing P, Sola L, Vallon V, Wanner C, Perkovic V. SGLT2 Inhibition for CKD and Cardiovascular Disease in Type 2 Diabetes: Report of a Scientific Workshop Sponsored by the National Kidney Foundation. Diabetes 2021; 70:1-16. [PMID: 33106255 PMCID: PMC8162454 DOI: 10.2337/dbi20-0040] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/04/2020] [Indexed: 12/24/2022]
Abstract
Diabetes is the most frequent cause of chronic kidney disease (CKD), leading to nearly half of all cases of kidney failure requiring replacement therapy. The principal cause of death among patients with diabetes and CKD is cardiovascular disease (CVD). Sodium/glucose cotransporter 2 (SGLT2) inhibitors were developed to lower blood glucose levels by inhibiting glucose reabsorption in the proximal tubule. In clinical trials designed to demonstrate the CVD safety of SGLT2 inhibitors in type 2 diabetes mellitus (T2DM), consistent reductions in risks for secondary kidney disease end points (albuminuria and a composite of serum creatinine doubling or 40% estimated glomerular filtration rate decline, kidney failure, or death), along with reductions in CVD events, were observed. In patients with CKD, the kidney and CVD benefits of canagliflozin were established by the CREDENCE (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation) trial in patients with T2DM, urinary albumin-creatinine ratio >300 mg/g, and estimated glomerular filtration rate of 30 to <90 mL/min/1.73 m2 To clarify and support the role of SGLT2 inhibitors for treatment of T2DM and CKD, the National Kidney Foundation convened a scientific workshop with an international panel of more than 80 experts. They discussed the current state of knowledge and unanswered questions in order to propose therapeutic approaches and delineate future research. SGLT2 inhibitors improve glomerular hemodynamic function and are thought to ameliorate other local and systemic mechanisms involved in the pathogenesis of CKD and CVD. SGLT2 inhibitors should be used when possible by people with T2DM to reduce risks for CKD and CVD in alignment with the clinical trial entry criteria. Important risks of SGLT2 inhibitors include euglycemic ketoacidosis, genital mycotic infections, and volume depletion. Careful consideration should be given to the balance of benefits and harms of SGLT2 inhibitors and risk mitigation strategies. Effective implementation strategies are needed to achieve widespread use of these life-saving medications.
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Affiliation(s)
- Katherine R Tuttle
- Providence Health Care and University of Washington School of Medicine, Spokane, WA
| | | | | | - Paola Fioretto
- Department of Medicine, University of Padua, Padua, Italy
| | | | | | - Tom Manley
- National Kidney Foundation, New York, NY
| | | | - Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern, University Feinberg School of Medicine, Chicago, IL
| | - Amy K Mottl
- University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Sylvia E Rosas
- Joslin Diabetes Center and Harvard Medical School, Boston, MA
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | - Laura Sola
- University of the Republic, Montevideo, Uruguay
| | | | - Christoph Wanner
- Division of Nephrology, University Hospital Würzburg, Würzburg, Germany
| | - Vlado Perkovic
- George Institute for Global Health, UNSW Sydney, Australia
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22
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Rainkie DC, Abedini ZS, Abdelkader NN. Reporting and methodological quality of systematic reviews and meta-analysis with protocols in Diabetes Mellitus Type II: A systematic review. PLoS One 2020; 15:e0243091. [PMID: 33326429 PMCID: PMC7743973 DOI: 10.1371/journal.pone.0243091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 11/15/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Systematic reviews with or without meta-analyses (SR/MAs) are strongly encouraged to work from a protocol to facilitate high quality, transparent methodology. The completeness of reporting of a protocol (PRISMA-P) and manuscript (PRISMA) is essential to the quality appraisal (AMSTAR-2) and appropriate use of SR/MAs in making treatment decisions. OBJECTIVES The objectives of this study were to describe the completeness of reporting and quality of SR/MAs, assess the correlations between PRISMA-P, PRISMA, and AMSTAR-2, and to identify reporting characteristics between similar items of PRISMA-P and PRISMA. METHODS We performed a systematic review of Type 2 Diabetes Mellitus SR/MAs of hypoglycemic agents with publicly available protocols. Cochrane reviews, guidelines, and specific types of MA were excluded. Two reviewers independently, (i) searched PubMed and Embase between 1/1/2015 to 20/3/2019; (ii) identified protocols of included studies by searching the manuscript bibliography, supplementary material, PROSPERO, and Google; (iii) completed PRISMA-P, PRISMA, and AMSTAR-2 tools. Data analysis included descriptive statistics, Pearson correlation, and multivariable linear regression. RESULTS Of 357 relevant SR/MAs, 51 had available protocols and were included. The average score for PRISMA-P was 15.8±3.3 (66%; maximum 24) and 25.2±1.1 (93%; maximum 27) for PRISMA. The quality of SR/MAs assessed using the AMSTAR-2 tool identified an overall poor quality (63% critically low, 18% low, 8% moderate, 12% high). The correlation between the PRISMA-P and PRISMA was not significant (r = 0.264; p = 0.06). Correlation was significant between PRISMA-P and AMSTAR-2 (r = 0.333; p = 0.02) and PRISMA and AMSTAR-2 (r = 0.555; p<0.01). Discrepancies in reporting were common between similar PRISMA-P and PRISMA items. CONCLUSION Adherence to protocol reporting guidance was poor while manuscript reporting was comprehensive. Protocol completeness is not associated with a completely reported manuscript. Independently, PRISMA-P and PRISMA scores were weakly associated with higher quality assessments but insufficient as a surrogate for quality. Critical areas for quality improvement include protocol description, investigating causes of heterogeneity, and the impact of risk of bias on the evidence synthesis.
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Wong CKH, Tang EHM, Man KKC, Chan EWY, Wong ICK, Lam CLK. SGLT2i as fourth-line therapy and risk of mortality, end-stage renal diseases and cardiovascular diseases in patients with type 2 diabetes mellitus. DIABETES & METABOLISM 2020; 47:101196. [PMID: 33039672 DOI: 10.1016/j.diabet.2020.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/21/2020] [Accepted: 09/19/2020] [Indexed: 01/29/2023]
Abstract
AIM Current guideline recommends insulin as fourth-line glucose-lowering medications. However, treatment effects of sodium glucose co-transporter-2 inhibitors (SGLT2i) on the risk of complications are uncertain. This study examines risks of all-cause mortality, cardiovascular diseases (CVD) and end-stage renal diseases (ESRD) in type 2 diabetes mellitus (T2DM) patients on triple oral glucose-lowering medications initiating SGLT2i, insulin or other oral medications. METHODS A population-based retrospective cohort of patients with T2DM between 2006-2017 was extracted from Hong Kong Hospital Authority database. Patients who were initiated a fourth-line therapy with SGLT2i, insulin or other oral medications were included. Hazard ratios (HRs) for all-cause mortality, CVD and ESRD were assessed using Cox proportional hazard models. RESULTS Over a median follow-up period of 18.5 months with 63,122 person-years, SGLT2i and insulin group had the lowest and highest incidence rate of all-cause mortality, CVD and ESRD (1.06, 0.65 and 0.61 vs 4.25, 5.58 and 4.39/100 person-years), respectively. Initiating SGLT2i as fourth-line medication had more benefits on CVD, in particular coronary heart disease and stroke. Insulin users had higher risks of CVD (HR=8.04, 95%CI=3.06-21.12) than SGLT2i users. SGLT2i was associated with insignificant reduction in ESRD (HR=4.62, 95%CI=0.73-29.09) and all-cause mortality (HR=3.06, 95%CI=0.75-12.45), and HF (HR=2.99, 95%CI=0.37-24.42) among patients without established HF. CONCLUSION Among T2DM patients initiating fourth-line therapy, SGLT2i users had significant benefits in lowering risk of CVD, and potential benefits in lowering risks of ESRD and all-cause mortality. SGLT2i was the preferred fourth-line glucose-lowering medication least likely to be associated with complication risks.
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Affiliation(s)
- C K H Wong
- Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.
| | - E H M Tang
- Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - K K C Man
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; Research Department of Policy and Practice, University College London School of Pharmacy, London, UK
| | - E W Y Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - I C K Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; Research Department of Policy and Practice, University College London School of Pharmacy, London, UK
| | - C L K Lam
- Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Matsuba I, Kawata T, Iemitsu K, Asakura T, Amemiya H, Ishikawa M, Ito S, Kaneshiro M, Kanamori A, Kubota A, Shinoda K, Takai M, Takuma T, Takihata M, Takeda H, Tanaka K, Matsuzawa Y, Machimura H, Minagawa F, Minami N, Mokubo A, Miyakawa M, Terauchi Y, Tanaka Y. Effects of ipragliflozin on the development and progression of kidney disease in patients with type 2 diabetes: An analysis from a multicenter prospective intervention study. J Diabetes Investig 2020; 11:1248-1257. [PMID: 32149469 PMCID: PMC7477528 DOI: 10.1111/jdi.13248] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/26/2020] [Accepted: 03/05/2020] [Indexed: 01/14/2023] Open
Abstract
AIMS/INTRODUCTION Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. METHODS This was an investigator-initiated multicenter prospective intervention study in which ipragliflozin (50 mg) was administered once daily, and glycemic control, estimated glomerular filtration rate (eGFR) and adverse events were evaluated until 104 weeks after starting research. RESULTS There were 407 patients analyzed. In the eGFR ≥90 group and eGFR ≥60 to <90 group, eGFR had significantly decreased compared with baseline at all time points from 4 to 104 weeks. There were significant increases in the eGFR ≥45 to <60 groups compared with baseline at 36 weeks (2.3 ± 1.0) and 52 weeks (2.6 ± 1.2). Comparison between the eGFR <60, urine albumin-to-creatinine ratio >300 group and the eGFR <60, urine albumin-to-creatinine ratio <300 group showed a greater reduction in eGFR in the former (-5.4 ± 2.4 vs 3.3 ± 1.1) at 12 weeks and was maintained to 104 weeks. In any group, eGFR did not significantly decrease until 104 weeks compared with 4 weeks. The urine albumin-to-creatinine ratio after 52 weeks and after 104 weeks was significantly decreased compared with baseline in the eGFR ≥90 group. CONCLUSIONS Ipragliflozin lowers eGFR and corrects hyperfiltration in patients with high eGFR (eGFR ≥60). In patients with low eGFR (eGFR ≥30 to <60), ipragliflozin has the possibility of increasing eGFR and exerting a renoprotective effect.
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Affiliation(s)
- Ikuro Matsuba
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Takehiro Kawata
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Kotaro Iemitsu
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Taro Asakura
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Hikaru Amemiya
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Masashi Ishikawa
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Syogo Ito
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Mizuki Kaneshiro
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Akira Kanamori
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Akira Kubota
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Kazuaki Shinoda
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Masahiko Takai
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Tetsuo Takuma
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Masahiro Takihata
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Hiroshi Takeda
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Keiji Tanaka
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Yoko Matsuzawa
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Hideo Machimura
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Fuyuki Minagawa
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Nobuaki Minami
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Atsuko Mokubo
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Masaaki Miyakawa
- The Study Group of the Diabetes CommitteeKanagawa Physicians AssociationYokohamaJapan
| | - Yasuo Terauchi
- Department of Endocrinology and MetabolismYokohama City UniversityYokohamaJapan
| | - Yasushi Tanaka
- Division of Metabolism and EndocrinologyDepartment of Internal MedicineSt. Marianna University School of MedicineKawasakiJapan
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Patel DK, Strong J. The Pleiotropic Effects of Sodium-Glucose Cotransporter-2 Inhibitors: Beyond the Glycemic Benefit. Diabetes Ther 2019; 10:1771-1792. [PMID: 31456166 PMCID: PMC6778563 DOI: 10.1007/s13300-019-00686-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Indexed: 12/25/2022] Open
Abstract
Type 2 diabetes (T2D) is associated with an increased risk of macro- and microvascular complications, including cardiovascular disease (CVD), heart failure (HF), and chronic kidney disease (CKD). Of the currently available glucose-lowering therapies, sodium-glucose cotransporter-2 inhibitors (SGLT-2is) are the only class to target the pathophysiologic increase in renal glucose reabsorption in patients with T2D. In CV outcomes trials of SGLT-2is in patients with T2D and established CVD or varying levels of CV risk, empagliflozin, canagliflozin, and dapagliflozin were associated with significant improvements in the risk of composite CV and renal outcomes compared with placebo that extended beyond their glycemic effects. Real-world observational studies have also reported improvements in CV outcomes with SGLT-2is compared with other glucose-lowering therapy in routine clinical practice. This review describes the pleiotropic effects of SGLT-2is and discusses the potential mechanisms for these effects as well as how they potentially provide benefits beyond glycemic control in patients with T2D. These favorable nonglycemic effects indicate that SGLT-2is may be of particular benefit in patients with diabetic complications, such as CVD, HF, or CKD. Ongoing large randomized trials in specific patient populations, including those with CVD, HF, or CKD (with or without T2D), may help to confirm the benefits of SGLT-2is in these patients and further elucidate the potential mechanisms of their pleiotropic effects. FUNDING: AstraZeneca.
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Affiliation(s)
- Dhiren K Patel
- VA Boston Healthcare System, Boston, Massachusetts, 02130, USA.
| | - Jodi Strong
- Ascension Medical Group, 824 Illinois Ave, Stevens Point, Wisconsin, 54481, USA
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26
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Weir MR. Renal effects of sodium-glucose cotransporter-2 inhibitors in patients with type 2 diabetes and renal impairment. Postgrad Med 2019; 131:367-375. [PMID: 31132013 DOI: 10.1080/00325481.2019.1624582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In patients with type 2 diabetes (T2D), microvascular changes in the kidney often result in diabetic kidney disease (DKD), the progression of which is associated with an increased risk of cardiovascular (CV) and all-cause mortality. Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) are a newer class of oral glucose-lowering therapies that were associated with significant reductions in the risk of major adverse CV events, CV death, and hospitalization for heart failure compared with placebo in CV outcomes trials (CVOTs) of patients with T2D and established CV disease or varying levels of CV risk. In addition, SGLT-2is reduced the risks of clinically relevant renal outcomes in these large randomized studies, indicating the potential for renoprotective effects in patients with T2D and DKD. This review discussed the non-glycemic effects of SGLT-2is in patients with T2D and renal impairment, including reductions in systolic and diastolic blood pressure, decreases in albuminuria and plasma uric acid, changes in estimated glomerular filtration rate, and minimal changes in electrolytes. Potential mechanisms for the renoprotective effects of SGLT-2is observed in CVOTs were considered, including the likely incremental benefits of SGLT-2is when added to renin-aldosterone-angiotensin system inhibitors (RAASis). The possibility of extending the use of SGLT-2is to patients with non-DKD was also discussed. Although the exact mechanisms by which SGLT-2is improve renal outcomes are not fully understood, they are likely to be multifactorial and additive when these drugs are used in combination with RAASis in patients with DKD.
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Affiliation(s)
- Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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