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Nogi K, Ueda T, Nogi M, Ishihara S, Nakada Y, Hashimoto Y, Nakagawa H, Nishida T, Seno A, Onoue K, Watanabe M, Saito Y, Hikoso S. Prognostic value of estimated plasma volume status at discharge in acute myocardial infarction. ESC Heart Fail 2024; 11:3222-3231. [PMID: 39322631 PMCID: PMC11424303 DOI: 10.1002/ehf2.14912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/15/2024] [Accepted: 06/07/2024] [Indexed: 09/27/2024] Open
Abstract
AIMS Congestive heart failure (HF) is a common complication in patients with acute myocardial infarction (AMI). The estimated plasma volume status [ePVS = (100 - haematocrit)/haemoglobin] is used as the blood plasma volume index to determine the presence of congestion in patients with HF. However, the clinical impact of ePVS at discharge in patients with AMI remains unclear. This study aimed to investigate whether ePVS at discharge could determine the long-term prognosis in patients with AMI. METHODS AND RESULTS We retrospectively identified patients with AMI with ePVS measured at discharge between January 2012 and December 2020. The primary endpoint was post-discharge all-cause death. The patients were divided into two groups according to an ePVS cut-off value of 5.5%, which is commonly used in HF. In total, 1012 patients with AMI were included. The median age was 70 years (range, 61-78 years), and 76.4% of the patients were male. The ePVS > 5.5% (high-ePVS) group included 365 patients (36.1%), and the all-cause mortality rate in the total cohort was 17.7%. The log-rank test revealed that the high-ePVS group had a significantly higher rate of all-cause death than the ePVS ≤ 5.5% (low-ePVS) group (P < 0.001). Multivariate Cox proportional hazards model analysis revealed that high ePVS was associated with post-discharge all-cause death, independent of other risk factors (hazard ratio = 1.879; 95% confidence interval = 1.343-2.629, P < 0.001). CONCLUSIONS High ePVS at discharge was independently associated with high post-discharge all-cause mortality in patients with AMI. Our study suggests that ePVS at discharge in patients with AMI could serve as a novel prognostic marker.
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Affiliation(s)
- Kazutaka Nogi
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Tomoya Ueda
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Maki Nogi
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Satomi Ishihara
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Yasuki Nakada
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Yukihiro Hashimoto
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Hitoshi Nakagawa
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Taku Nishida
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Ayako Seno
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Kenji Onoue
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Makoto Watanabe
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
- Department of Cardiovascular Medicine, Nara Prefecture Seiwa Medical Center, Sango, Japan
| | - Shungo Hikoso
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
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Kakzanov Y, Sevilya Z, Goldman A, Cipok M, Hershkovitz V, Bryk G, Lev EI. The Effect of SGLT2 Inhibitor Therapy on Endothelial Progenitor Cell Function in Patients With Heart Failure. J Cardiovasc Pharmacol 2024; 84:220-226. [PMID: 38922584 DOI: 10.1097/fjc.0000000000001581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 04/03/2024] [Indexed: 06/27/2024]
Abstract
ABSTRACT Sodium-glucose cotransporter-2 (SGLT-2) inhibitors have been shown to reduce the risk of cardiovascular mortality and hospitalizations in patients with heart failure (HF) with preserved or reduced ejection fraction (HFpEF or HFrEF). The mechanism for this benefit is not clear. Endothelial progenitor cells (EPCs) are bone marrow-derived cells able to differentiate into functional endothelial cells and participate in endothelial repair. The aim of this study was to evaluate the effect of SGLT-2 inhibitors on the level and function of EPCs in patients with HF. We enrolled 20 patients with symptomatic HF, 12 with HFrEF and 8 with HFpEF (aged 73.3 ± 10.2 years, 95% men). Blood samples were drawn at 2 time points: baseline and ≥3 months after initiation of SGLT-2 inhibitor therapy. Circulating EPC levels were evaluated by expression of vascular endothelial growth factor receptor-2 (VEGFR-2), CD34, and CD133 by flow cytometry. EPC colony forming units (CFUs) were quantified after 7 days in culture. The proportion of cells that coexpressed VEGFR-2 and CD34 or VEGFR-2 and CD133 was higher following 3 months of SGLT-2 inhibitors [0.26% (interquartile range, IQR 0.10-0.33) versus 0.55% (IQR 0.28-0.91), P = 0.002; 0.12% (IQR 0.07-0.15) versus 0.24% (IQR 0.15-0.39), P = 0.001, respectively]. EPC CFUs were also increased following SGLT-2 inhibitor treatment [23 (IQR 3.7-37.8) versus 79.4 (IQR 25.1-110.25) colonies/10 6 cells, P = 0.0039]. In patients with symptomatic HF, both HFpEF and HFrEF, treatment with SGLT-2 inhibitors is associated with an increase in the level and function of circulating EPCs. This augmentation in EPCs may be a contributing mechanism to the clinical benefit of SGLT-2 inhibitors in patients with HF.
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Affiliation(s)
- Yana Kakzanov
- Cardiology Department, Assuta Ashdod Medical Center, Ashdod, Israel
- Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Ziv Sevilya
- Cardiology Department, Assuta Ashdod Medical Center, Ashdod, Israel
- Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Alexander Goldman
- Cardiology Department, Assuta Ashdod Medical Center, Ashdod, Israel
- Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Michal Cipok
- Hematology Laboratory, Assuta Ashdod Medical Center, Ashdod, Israel; and
| | - Vera Hershkovitz
- Hematology Laboratory, Assuta Ashdod Medical Center, Ashdod, Israel; and
| | - Gabriel Bryk
- Biochemistry Laboratory, Assuta Ashdod Medical Center, Ashdod, Israel
| | - Eli I Lev
- Cardiology Department, Assuta Ashdod Medical Center, Ashdod, Israel
- Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
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Mani S, Balasubramanian A, Veluswami K, Rao S, Aggarwal S. Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors and Cardiovascular Outcomes: A Review of Literature. Cureus 2024; 16:e63796. [PMID: 39099905 PMCID: PMC11297731 DOI: 10.7759/cureus.63796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2024] [Indexed: 08/06/2024] Open
Abstract
Coronary arterial diseases are a major contributor to disease and death worldwide and are most often compounded by several other underlying medical conditions. A key concern is type 2 diabetes mellitus (T2DM). Despite progress in medical advancements, these life-threatening illnesses are still underdiagnosed and undermanaged. A relatively newer class of anti-diabetic drugs, the sodium-glucose cotransporter-2 inhibitors (SGL2-Is), also termed gliflozins, have shown promising results in reducing cardiovascular risk, regardless of diabetic status. These drugs have on-target (promoting renal glycosuria and diuresis by acting on the SGLT-2 channels in the proximal convoluted tubule) and off-target effects contributing to the reported cardiovascular benefit. Some emerging theories about its impact on myocardial energetics, calcium balance, and renal physiology exist. In this review article, we explored three major cardiovascular outcome trials: the Dapagliflozin Effect on Cardiovascular Events-Thrombolysis in Myocardial Infarction 58 (DECLARE-TIMI 58) trial, the CANagliflozin cardioVascular Assessment Study (CANVAS) program, and the Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients-Removing Excess Glucose (EMPA-REG OUTCOME) trial to evaluate the cardiovascular effects of SGLT2-Is.
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Affiliation(s)
- Sweatha Mani
- Internal Medicine, K.A.P. Viswanatham Government Medical College, Tiruchirappalli, IND
| | | | | | - Sudipta Rao
- Internal Medicine, JSS Medical College, Mysore, IND
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Taťána A, Filip M. Effect of Sodium-Glucose Co-Transporter-2 Inhibitor on Estimated Plasma Volume in a Patient With Heart Failure With Reduced Ejection Fraction and a Patient With Heart Failure With Preserved Ejection Fraction. Clin Cardiol 2024; 47:e24303. [PMID: 39031990 PMCID: PMC11259570 DOI: 10.1002/clc.24303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 05/15/2024] [Accepted: 05/23/2024] [Indexed: 07/22/2024] Open
Abstract
BACKGROUND The increased diuresis after sodium-glucose cotransporter 2 inhibitor (SGLT2i) was associated with a reduction of the estimated plasma volume (ePV) in type 2 diabetic patients. HYPOTHESIS We hypothesized that the early effect of SGLT2i on ePV may be monitored by the change of biomarkers of hemoconcentration. PATIENTS AND METHODS We analyzed the early- and long-term effect of SGLT2i empagliflozin on the ePV as assessed by biomarkers of hemoconcentration in a nondiabetic patient with heart failure and reduced ejection fraction (HFrEF) and a nondiabetic patient with heart failure and preserved ejection fraction (HFpEF). The ePV was calculated from hemoglobin and hematocrit levels by Duarte formula and ePV change was calculated by Strauss formula. RESULTS The ePV change was -22.56% between baseline and 1 month, and -37.60% between baseline and 12 months follow-up in a patient with HFrEF, and -6.18% and -16.40% in a patient with HFpEF, respectively. CONCLUSION The early effect of SGLT2i on ePV in patients with heart failure may be monitored by biomarkers of hemoconcentration.
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Affiliation(s)
- Andreasová Taťána
- Third Faculty of MedicineCharles UniversityPragueCzech Republic
- Center of Nuclear MedicineFaculty Hospital BulovkaPragueCzech Republic
| | - Málek Filip
- Third Faculty of MedicineCharles UniversityPragueCzech Republic
- Na Homolce HospitalPragueCzech Republic
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Asakura-Kinoshita M, Masuda T, Oka K, Ohara K, Miura M, Morinari M, Misawa K, Miyazawa Y, Akimoto T, Shimada K, Nagata D. Sodium-Glucose Cotransporter 2 Inhibitor Combined with Conventional Diuretics Ameliorate Body Fluid Retention without Excessive Plasma Volume Reduction. Diagnostics (Basel) 2024; 14:1194. [PMID: 38893720 PMCID: PMC11171863 DOI: 10.3390/diagnostics14111194] [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: 04/07/2024] [Revised: 05/28/2024] [Accepted: 06/04/2024] [Indexed: 06/21/2024] Open
Abstract
We previously reported that sodium-glucose cotransporter 2 (SGLT2) inhibitors exert sustained fluid homeostatic actions through compensatory increases in osmotic diuresis-induced vasopressin secretion and fluid intake. However, SGLT2 inhibitors alone do not produce durable amelioration of fluid retention. In this study, we examined the comparative effects of the SGLT2 inhibitor dapagliflozin (SGLT2i group, n = 53) and the combined use of dapagliflozin and conventional diuretics, including loop diuretics and/or thiazides (SGLT2i + diuretic group, n = 23), on serum copeptin, a stable, sensitive, and simple surrogate marker of vasopressin release and body fluid status. After six months of treatment, the change in copeptin was significantly lower in the SGLT2i + diuretic group than in the SGLT2i group (-1.4 ± 31.5% vs. 31.5 ± 56.3%, p = 0.0153). The change in the estimated plasma volume calculated using the Strauss formula was not significantly different between the two groups. Contrastingly, changes in interstitial fluid, extracellular water, intracellular water, and total body water were significantly lower in the SGLT2i + diuretic group than in the SGLT2i group. Changes in renin, aldosterone, and absolute epinephrine levels were not significantly different between the two groups. In conclusion, the combined use of the SGLT2 inhibitor dapagliflozin and conventional diuretics inhibited the increase in copeptin levels and remarkably ameliorated fluid retention without excessively reducing plasma volume and activating the renin-angiotensin-aldosterone and sympathetic nervous systems.
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Affiliation(s)
- Maki Asakura-Kinoshita
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke 3290498, Japan; (M.A.-K.); (K.O.); (K.O.); (K.M.); (T.A.); (D.N.)
| | - Takahiro Masuda
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke 3290498, Japan; (M.A.-K.); (K.O.); (K.O.); (K.M.); (T.A.); (D.N.)
- Department of Nephrology, Shin-Oyama City Hospital, Oyama 3230827, Japan;
| | - Kentaro Oka
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke 3290498, Japan; (M.A.-K.); (K.O.); (K.O.); (K.M.); (T.A.); (D.N.)
- Department of Nephrology, Shin-Oyama City Hospital, Oyama 3230827, Japan;
| | - Ken Ohara
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke 3290498, Japan; (M.A.-K.); (K.O.); (K.O.); (K.M.); (T.A.); (D.N.)
| | - Marina Miura
- Department of Nephrology, Shin-Oyama City Hospital, Oyama 3230827, Japan;
| | - Masato Morinari
- Department of Internal Medicine, Nasu Minami Hospital, Nasu-Karasuyama 3210621, Japan; (M.M.); (Y.M.)
| | - Kyohei Misawa
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke 3290498, Japan; (M.A.-K.); (K.O.); (K.O.); (K.M.); (T.A.); (D.N.)
- Department of Nephrology, Shin-Oyama City Hospital, Oyama 3230827, Japan;
| | - Yasuharu Miyazawa
- Department of Internal Medicine, Nasu Minami Hospital, Nasu-Karasuyama 3210621, Japan; (M.M.); (Y.M.)
| | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke 3290498, Japan; (M.A.-K.); (K.O.); (K.O.); (K.M.); (T.A.); (D.N.)
| | - Kazuyuki Shimada
- Department of Cardiology, Shin-Oyama City Hospital, Oyama 3230827, Japan;
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke 3290498, Japan; (M.A.-K.); (K.O.); (K.O.); (K.M.); (T.A.); (D.N.)
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Chatzianagnostou K, Gaggini M, Suman Florentin A, Simonini L, Vassalle C. New Molecules in Type 2 Diabetes: Advancements, Challenges and Future Directions. Int J Mol Sci 2024; 25:6218. [PMID: 38892417 PMCID: PMC11173177 DOI: 10.3390/ijms25116218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/30/2024] [Accepted: 06/02/2024] [Indexed: 06/21/2024] Open
Abstract
Although good glycemic control in patients with type 2 diabetes (T2D) can prevent cardiovascular complications, many diabetic patients still have poor optimal control. A new class of antidiabetic drugs (e.g., glucagon-like peptide-1-GLP-1 receptor agonists, sodium-glucose co-transporters-SGLT2 inhibitors), in addition to the low hypoglycemic effect, exert multiple beneficial effects at a metabolic and cardiovascular level, through mechanisms other than antihyperglycemic agents. This review aims to discuss the effects of these new antidiabetic drugs, highlighting cardiovascular and metabolic benefits, through the description of their action mechanisms as well as available data by preclinical and clinical studies. Moreover, new innovative tools in the T2D field will be described which may help to advance towards a better targeted T2D personalized care in future.
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Affiliation(s)
| | - Melania Gaggini
- Institute of Clinical Physiology, National Research Council, Via G. Moruzzi 1, 56124 Pisa, Italy; (M.G.); (A.S.F.)
| | - Adrian Suman Florentin
- Institute of Clinical Physiology, National Research Council, Via G. Moruzzi 1, 56124 Pisa, Italy; (M.G.); (A.S.F.)
| | - Ludovica Simonini
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, 56126 Pisa, Italy;
| | - Cristina Vassalle
- Fondazione CNR-Regione Toscana G Monasterio, Via G. Moruzzi 1, 56124 Pisa, Italy;
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Maruhashi T, Tanaka A, Takahashi K, Higashi Y, Node K. Erythropoiesis and estimated fluid volume regulation following initiation of ipragliflozin treatment in patients with type 2 diabetes mellitus and chronic kidney disease: A post-hoc analysis of the PROCEED trial. Diabetes Obes Metab 2024; 26:1723-1730. [PMID: 38326092 DOI: 10.1111/dom.15481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/11/2024] [Accepted: 01/18/2024] [Indexed: 02/09/2024]
Abstract
AIMS To analyse the changes in erythropoietic and estimated fluid volume parameters after the initiation of ipragliflozin, a sodium-glucose co-transporter 2 inhibitor, in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). METHODS This was a post-hoc analysis of the PROCEED trial, which evaluated the effect of 24-week ipragliflozin treatment on endothelial dysfunction in patients with T2DM and CKD. We evaluated the changes in erythropoietic and estimated fluid volume parameters from baseline to 24 weeks post-treatment in 53 patients who received ipragliflozin (ipragliflozin group) and 55 patients with T2DM and CKD without sodium-glucose co-transporter 2 inhibitors (control group), a full analysis set of the PROCEED trial. RESULTS The increases in haemoglobin [estimated group difference, 0.5 g/dl; 95% confidence interval (CI), 0.3-0.8; p < .001], haematocrit (estimated group difference, 2.2%; 95% CI, 1.3-3.1; p < .001) and erythropoietin (estimated log-transformed group difference, 0.1; 95% CI, 0.01-0.3; p = .036) were significantly greater in the ipragliflozin group than those in the control group. Ipragliflozin treatment was significantly associated with an increase in erythropoietin, independent of the corresponding change in haemoglobin (β = 0.253, p < .001) or haematocrit (β = 0.278, p < .001). Reductions in estimated plasma volume (estimated group difference, -7.94%; 95% CI, -11.6 to -4.26%; p < .001) and estimated extracellular volume (estimated group difference, -181.6 ml; 95% CI, -275.7 to -87.48 ml; p < .001) were significantly greater in the ipragliflozin group than those in the control group. CONCLUSIONS Erythropoiesis was enhanced and estimated fluid volumes were reduced by ipragliflozin in patients with T2DM and CKD. CLINICAL TRIAL PROCEED trial (registration number: jRCTs071190054).
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Affiliation(s)
- Tatsuya Maruhashi
- Department of Regenerative Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Kanae Takahashi
- Department of Biostatistics, Hyogo Medical University, Nishinomiya, Japan
| | - Yukihito Higashi
- Department of Regenerative Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
- Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
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Gajewska A, Wasiak J, Sapeda N, Młynarska E, Rysz J, Franczyk B. SGLT2 Inhibitors in Kidney Diseases-A Narrative Review. Int J Mol Sci 2024; 25:4959. [PMID: 38732178 PMCID: PMC11084583 DOI: 10.3390/ijms25094959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/27/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Some of the most common conditions affecting people are kidney diseases. Among them, we distinguish chronic kidney disease and acute kidney injury. Both entities pose serious health risks, so new drugs are still being sought to treat and prevent them. In recent years, such a role has begun to be assigned to sodium-glucose cotransporter-2 (SGLT2) inhibitors. They increase the amount of glucose excreted in the urine. For this reason, they are currently used as a first-line drug in type 2 diabetes mellitus. Due to their demonstrated cardioprotective effect, they are also used in heart failure treatment. As for the renal effects of SGLT2 inhibitors, they reduce intraglomerular pressure and decrease albuminuria. This results in a slower decline in glomelular filtration rate (GFR) in patients with kidney disease. In addition, these drugs have anti-inflammatory and antifibrotic effects. In the following article, we review the evidence for the effectiveness of this group of drugs in kidney disease and their nephroprotective effect. Further research is still needed, but meta-analyses indicate SGLT2 inhibitors' efficacy in kidney disease, especially the one caused by diabetes. Development of new drugs and clinical trials on specific patient subgroups will further refine their nephroprotective effects.
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Affiliation(s)
- Agata Gajewska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland; (A.G.); (J.W.); (N.S.)
| | - Jakub Wasiak
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland; (A.G.); (J.W.); (N.S.)
| | - Natalia Sapeda
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland; (A.G.); (J.W.); (N.S.)
| | - Ewelina Młynarska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland; (A.G.); (J.W.); (N.S.)
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Beata Franczyk
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland; (A.G.); (J.W.); (N.S.)
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Aoun M, Jadoul M, Anders HJ. Erythrocytosis and CKD: A Review. Am J Kidney Dis 2024:S0272-6386(24)00715-7. [PMID: 38621632 DOI: 10.1053/j.ajkd.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 02/18/2024] [Accepted: 02/21/2024] [Indexed: 04/17/2024]
Abstract
Erythrocytosis or polycythemia is defined as an increase in red blood cell concentration above the age- and sex-specific normal levels. Unlike anemia, which is very common in patients with chronic kidney disease (CKD), erythrocytosis is less frequent but requires specific understanding by health care professionals in order to provide the best care. Erythrocytosis, especially when undiagnosed and untreated, can lead to serious thrombotic events and higher mortality. Classic causes of erythrocytosis associated with CKD include cystic kidney diseases, kidney or other erythropoietin-secreting neoplasms, high-altitude renal syndrome, overdosage of erythropoietin-stimulating agents, androgen therapy, heavy smoking, chronic lung disease, obstructive sleep apnea, IgA nephropathy, post-kidney transplant erythrocytosis, renal artery stenosis, and congenital etiologies. After ruling out the common acquired causes of erythrocytosis and/or in the presence of suggestive parameters, primary erythrocytosis or polycythemia vera (PV) should be considered, and patients should be screened for JAK2V617F somatic mutation. The newest entity inducing erythrocytosis is linked to the use of sodium/glucose cotransporter 2 (SGLT2) inhibitors that hypothetically activate hypoxia-inducible factor 2α (HIF-2α) and in some cases unmask PV. This Review focuses on the pathogenesis, renal manifestations and management of PV, the pathophysiology of erythrocytosis induced by SGLT2 inhibitors and the relevance of timely JAK2 mutation screening in these patients.
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Affiliation(s)
- Mabel Aoun
- Fondation AUB Santé, Lorient, France; Faculty of Medicine, Saint Joseph University of Beirut, Beirut, Lebanon.
| | - Michel Jadoul
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Hans-Joachim Anders
- Division of Nephrology, Department of Medicine IV, Hospital of the Ludwig-Maximilians University, Munich, Germany
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Shan B, Li J, Shi Z, Han C, Zhang J, Zhao J, Hu R, Liu L, Ta S. Predictive value of estimated plasma volume for postoperative hypotension in percutaneous intramyocardial septal radiofrequency ablation treating for hypertrophic obstructive cardiomyopathy. BMC Cardiovasc Disord 2024; 24:177. [PMID: 38519968 PMCID: PMC10958927 DOI: 10.1186/s12872-024-03844-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/13/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Estimated plasma volume status (ePVS) estimated by the Duarte formula is associated with clinical outcomes in patients with heart failure. It remains unclear the predictive value of the ePVS to the postoperative hypotension (POH) in percutaneous intramyocardial septal radiofrequency ablation (PIMSRA) treating hypertrophic obstructive cardiomyopathy (HOCM). METHODS Data of HOCM patients who underwent PIMSRA were retrospectively collected. Preoperative ePVS was calculated using the Duarte formulas which derived from hemoglobin and hematocrit ratios. Clinical variables including physical assessment, biological and echocardiographic parameters were recorded. Patients were labeled with or without POH according to the medical record in the hospital. Univariable and multivariable logistic regression were performed to evaluate the association between ePVS and POH. Using different thresholds derived from quartiles and the best cutoff value of the receiver operating characteristic curve, the diagnostic performance of ePVS was quantified. RESULTS Among the 405 patients included in this study, 53 (13.1%) patients were observed with symptomatic POH. Median (IQR) of ePVS in overall patients was 3.77 (3.27~4.40) mL/g and in patients with POH were higher than those without POH. The ePVS was associated with POH, with the odds ratio of 1.669 (95% CI 1.299 ~ 2.144) per mL/g. After adjusted by potential confounders, ePVS remained independently associated with POH, with the approximate odds ratio in different models. CONCLUSION The preoperative ePVS derived from the Duarte formulas was independently associated with postoperative hypotension in HOCM patients who underwent PIMSRA and showed prognostic value to the risk stratification of postoperative management. TRIAL REGISTRATION NCT06003478 (22/08/2023).
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Affiliation(s)
- Bo Shan
- Department of Ultrasound, Hypertrophic Cardiomyopathy Center, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Jing Li
- Department of Ultrasound, Hypertrophic Cardiomyopathy Center, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Zhangwei Shi
- Department of Cardiology, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Chao Han
- Department of Ultrasound, Hypertrophic Cardiomyopathy Center, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Juan Zhang
- Department of Ultrasound, Hypertrophic Cardiomyopathy Center, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Jia Zhao
- Department of Ultrasound, Hypertrophic Cardiomyopathy Center, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Rui Hu
- Department of Ultrasound, Hypertrophic Cardiomyopathy Center, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Liwen Liu
- Department of Ultrasound, Hypertrophic Cardiomyopathy Center, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China.
| | - Shengjun Ta
- Department of Ultrasound, Hypertrophic Cardiomyopathy Center, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China.
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11
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Hasan I, Rashid T, Jaikaransingh V, Heilig C, Abdel-Rahman EM, Awad AS. SGLT2 inhibitors: Beyond glycemic control. J Clin Transl Endocrinol 2024; 35:100335. [PMID: 38525377 PMCID: PMC10957445 DOI: 10.1016/j.jcte.2024.100335] [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: 02/08/2024] [Revised: 03/08/2024] [Accepted: 03/11/2024] [Indexed: 03/26/2024] Open
Abstract
Multiple randomized controlled trials have extensively examined the therapeutic effectiveness of sodium-glucose cotransporter 2 (SGLT2) inhibitors, ushering in a transformative approach to treating individuals with type 2 diabetes mellitus (DM). Notably, emerging reports have drawn attention to the potential positive impacts of SGLT2 inhibitors in nondiabetic patients. In an effort to delve into this phenomenon, a comprehensive systematic literature review spanning PubMed (NLM), Medline (Ovid), and Cochrane Library, covering publications from 2000 to 2024 was undertaken. This systematic review encompassed twenty-six randomized control trials (RCTs) involving 35,317 participants. The findings unveiled a multifaceted role for SGLT2 inhibitors, showcasing their ability to enhance metabolic control and yield cardioprotective effects through a reduction in cardiovascular death (CVD) and hospitalization related to heart failure (HF). Additionally, a renalprotective effect was observed, evidenced by a slowdown in chronic kidney disease (CKD) progression and a decrease in albuminuria. Importantly, these benefits were coupled with an acceptable safety profile. The literature also points to various biological plausibility and underlying mechanistic pathways, offering insights into the association between SGLT2 inhibitors and these positive outcomes in nondiabetic individuals. Current research trends indicate a continual exploration of additional role for SGLT2 inhibitors in. Nevertheless, further research is imperative to fully elucidate the mechanisms and long-term outcomes associated with the nondiabetic use of SGLT2 inhibitors.
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Affiliation(s)
- Irtiza Hasan
- University of Florida College of Medicine-Jacksonville, FL, USA
| | - Tasnuva Rashid
- University of Florida College of Medicine-Jacksonville, FL, USA
| | | | - Charles Heilig
- University of Florida College of Medicine-Jacksonville, FL, USA
| | | | - Alaa S. Awad
- University of Florida College of Medicine-Jacksonville, FL, USA
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12
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Palmer BF, Clegg DJ. SGLT2 Inhibition and Kidney Potassium Homeostasis. Clin J Am Soc Nephrol 2024; 19:399-405. [PMID: 37639260 PMCID: PMC10937025 DOI: 10.2215/cjn.0000000000000300] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/20/2023] [Indexed: 08/29/2023]
Abstract
Pharmacologic inhibition of the sodium-glucose transporter 2 (SGLT2) in the proximal tubule brings about physiologic changes predicted to both increase and decrease kidney K + excretion. Despite these effects, disorders of plasma K + concentration are an uncommon occurrence. If anything, these drugs either cause no effect or a slight reduction in plasma K + concentration in patients with normal kidney function but seem to exert a protective effect against hyperkalemia in the setting of reduced kidney function or when given with drugs that block the renin-angiotensin-aldosterone axis. In this review, we discuss the changes in kidney physiology after the administration of SGLT2 inhibitors predicted to cause both hypokalemia and hyperkalemia. We conclude that these factors offset one another, explaining the uncommon occurrence of dyskalemias with these drugs. Careful human studies focusing on the determinants of kidney K + handling are needed to fully understand how these drugs attenuate the risk of hyperkalemia and yet rarely cause hypokalemia.
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Affiliation(s)
- Biff F. Palmer
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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13
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Gullaksen S, Vernstrøm L, Sørensen SS, Ringgaard S, Laustsen C, Birn H, Funck KL, Poulsen PL, Laugesen E. The effects of semaglutide, empagliflozin and their combination on the kidney sodium signal from magnetic resonance imaging: A prespecified, secondary analysis from a randomized, clinical trial. J Diabetes Complications 2024; 38:108673. [PMID: 38219335 DOI: 10.1016/j.jdiacomp.2023.108673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/17/2023] [Accepted: 12/24/2023] [Indexed: 01/16/2024]
Abstract
AIMS To evaluate the effect of treatment with semaglutide and empagliflozin on the cortico-medullary sodium gradient (MCR; medulla/cortex ratio), urine sodium/creatinine ratio (UNACR), and estimated plasma volume (ePV) and to compare the MCR between persons with and without type 2 diabetes. METHODS Using the 23Na magnetic resonance imaging (23Na-MRI) technique, we investigated the effects of 32 weeks of treatment with semaglutide, empagliflozin or their combination on MCR in 65 participants with type 2 diabetes and high risk of cardiovascular disease. The participants were recruited from a randomized, controlled interventional trial and further characterized by UNACR and ePV. In addition, in a cross-sectional design, we compared MCR by 23Na-MRI in 12 persons with type 2 diabetes and 17 matched controls. Data from the interventional trial were analyzed using a single, multivariate linear mixed model strategy for repeated measurements. Data from the cross-sectional study were analyzed by fitting a linear regression model adjusted for age and sex. RESULTS Compared to placebo, semaglutide, but not empagliflozin, significantly decreased the MCR (-9 %, 95%CI (-18, -0.06)%, p = 0.035 and -0.05 %, 95%CI(-0.15, 0.05)%, p = 0.319, respectively). The UNACR decreased in the semaglutide group(-35 %, 95 % CI(-52, -14) %, p = 0.003) but not in the empagliflozin group (7 %, 95 % CI(-21, 44)%, p = 0.657), whereas the ePV decreased in the combination group. The MCR was not different between persons with and without type 2 diabetes. CONCLUSION 23Na magnetic resonance imaging can identify drug induced changes in the MCR in persons with type 2 diabetes, and 32 weeks of semaglutide decreases the MCR in such persons. There is no difference in the MCR between persons with and without type 2 diabetes. TRIAL NUMBER AND REGISTRY EUDRACT 2019-000781-38, clinicaltrialsregister.eu.
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Affiliation(s)
- Søren Gullaksen
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark; Department of Internal Medicine & Endocrinology, Aarhus University Hospital, 8200 Aarhus N, Denmark; Department of Medicine, Regional Hospital Horsens, 8700 Horsens, Denmark.
| | - Liv Vernstrøm
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark; Department of Internal Medicine & Endocrinology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Steffen S Sørensen
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark; Department of Internal Medicine & Endocrinology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | | | | | - Henrik Birn
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark; Department of Renal Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark; Department of Biomedicine, Aarhus University, 8000 Aarhus C, Denmark
| | - Kristian L Funck
- Department of Internal Medicine & Endocrinology, Aarhus University Hospital, 8200 Aarhus N, Denmark; Steno Diabetes Center, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Per L Poulsen
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark; Steno Diabetes Center, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Esben Laugesen
- Diagnostic Centre, Silkeborg Regional Hospital, 8600 Silkeborg, Denmark; Steno Diabetes Center, Aarhus University Hospital, 8200 Aarhus N, Denmark
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14
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Sabbar R, Kadhim SAA, Fawzi HA, Flayih A, Mohammad B, Swadi A. The impact of empagliflozin and metformin on cardiac parameters in patients with mid-range ejection fraction heart failure without diabetes. J Med Life 2024; 17:57-62. [PMID: 38737651 PMCID: PMC11080507 DOI: 10.25122/jml-2023-0340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/17/2023] [Indexed: 05/14/2024] Open
Abstract
Heart failure (HF) remains a significant problem for healthcare systems, requiring the use of intervention and multimodal management strategies. We aimed to assess the short-term effect of empagliflozin (EMPA) and metformin on cardiac function parameters, including ventricular dimension-hypertrophy, septal thickness, ejection fraction (EF), and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels in patients with HF and mildly reduced EF. A case-control study included 60 newly diagnosed patients with HF. Patients were divided into two groups: Group E received standard HF treatment (carvedilol, bumetanide, sacubitril-valsartan, spironolactone) plus EMPA 10 mg daily, and Group M received standard HF treatment plus metformin 500 mg daily. After three months of treatment, Group E had a significantly higher EF than Group M compared to initial measurements (a change of 9.2% versus 6.1%, respectively). We found similar results in the left ventricular end-systolic dimension (LVESD), with mean reductions of 0.72 mm for Group E and 0.23 mm for Group M. Regarding cardiac indicators, the level of NT-proBNP was considerably decreased in both groups. However, the reduction was significantly greater in group E than in group M compared to the initial level (mean reduction: 719.9 vs. 973.6, respectively). When combined with quadruple anti-heart failure therapy, metformin enhanced several echocardiographic parameters, showing effects similar to those of EMPA when used in the same treatment regimen. However, the benefits of EMPA were more pronounced, particularly regarding improvements in EF and LVESD.
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Affiliation(s)
- Reeman Sabbar
- Department of Pharmacology, College of Medicine, University of Al-Qadisiyah, Al-Qadisiyah, Iraq
| | - Sinaa Abdul Amir Kadhim
- Department of Pharmacology, College of Medicine, University of Al-Qadisiyah, Al-Qadisiyah, Iraq
| | | | - Ali Flayih
- Department of Pharmacology, College of Medicine, University of Al-Qadisiyah, Al-Qadisiyah, Iraq
| | - Bassim Mohammad
- Department of Pharmacology, College of Medicine, University of Al-Qadisiyah, Al-Qadisiyah, Iraq
| | - Asma Swadi
- Department of Pharmacology, College of Medicine, University of Al-Qadisiyah, Al-Qadisiyah, Iraq
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15
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Verma S, Mudaliar S, Greasley PJ. Potential Underlying Mechanisms Explaining the Cardiorenal Benefits of Sodium-Glucose Cotransporter 2 Inhibitors. Adv Ther 2024; 41:92-112. [PMID: 37943443 PMCID: PMC10796581 DOI: 10.1007/s12325-023-02652-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/17/2023] [Indexed: 11/10/2023]
Abstract
There is a bidirectional pathophysiological interaction between the heart and the kidneys, and prolonged physiological stress to the heart and/or the kidneys can cause adverse cardiorenal complications, including but not limited to subclinical cardiomyopathy, heart failure and chronic kidney disease. Whilst more common in individuals with Type 2 diabetes, cardiorenal complications also occur in the absence of diabetes. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) were initially approved to reduce hyperglycaemia in patients with Type 2 diabetes. Recently, these agents have been shown to significantly improve cardiovascular and renal outcomes in patients with and without Type 2 diabetes, demonstrating a robust reduction in hospitalisation for heart failure and reduced risk of progression of chronic kidney disease, thus gaining approval for use in treatment of heart failure and chronic kidney disease. Numerous potential mechanisms have been proposed to explain the cardiorenal effects of SGLT2i. This review provides a simplified summary of key potential cardiac and renal mechanisms underlying the cardiorenal benefits of SGT2i and explains these mechanisms in the clinical context. Key mechanisms related to the clinical effects of SGLT2i on the heart and kidneys explained in this publication include their impact on (1) tissue oxygen delivery, hypoxia and resultant ischaemic injury, (2) vascular health and function, (3) substrate utilisation and metabolic health and (4) cardiac remodelling. Knowing the mechanisms responsible for SGLT2i-imparted cardiorenal benefits in the clinical outcomes will help healthcare practitioners to identify more patients that can benefit from the use of SGLT2i.
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Affiliation(s)
- Subodh Verma
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.
| | - Sunder Mudaliar
- Endocrinology/Diabetes Section, Veterans Affairs Medical Centre, San Diego, CA, USA
- Department of Medicine, University of California, San Diego, CA, USA
| | - Peter J Greasley
- Early Discovery and Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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16
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Otaki Y, Watanabe T, Yamaguchi R, Tachibana S, Sato J, Kato S, Tamura H, Nishiyama S, Arimoto T, Takahashi H, Watanabe M. Hypokalemia, Kidney Function, and Clinical Outcomes in Heart Failure With Preserved Ejection Fraction. Circ J 2023; 88:117-126. [PMID: 37981326 DOI: 10.1253/circj.cj-23-0562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) is an increasing health problem associated with high morbidity and mortality rates. Several reports have shown an association between hypokalemia and clinical outcomes in patients with heart failure (HF). However, the association of hypokalemia with kidney function and clinical outcomes in patients with HFpEF remains unclear. METHODS AND RESULTS We measured serum potassium levels and kidney function in 454 patients with HFpEF (mean age 76 years; 55% men) at admission. Hypokalemia (K+<3.5 mmol/L) and hyperkalemia (K+>5.0 mmol/L) were identified in 58 (12.7%) and 11 (2.4%) patients, respectively. Patients with hypokalemia showed renal tubular damage (RTD), defined as a urinary β2-microglobulin to creatinine ratio ≥300 μg/gCr, preserved estimated glomerular filtration rate (eGFR), and plasma volume expansion. Multivariate logistic analysis demonstrated that RTD, preserved eGFR, and plasma volume expansion were significantly associated with hypokalemia. During the median follow-up period of 1,000 days, 82 HF-related events occurred. Kaplan-Meier analysis showed that patients with hypokalemia had a higher rate of HF-related events than those without hypokalemia. Multivariate Cox proportional hazard regression analysis demonstrated that hypokalemia was significantly associated with HF-related events after adjusting for confounding factors. CONCLUSIONS Hypokalemia is affected by kidney function, notably RTD, in patients with HFpEF. Hypokalemia is a risk factor for HF-related events in patients with HFpEF.
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Affiliation(s)
- Yoichiro Otaki
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Ryuhei Yamaguchi
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Shingo Tachibana
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Junya Sato
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Shigehiko Kato
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Harutoshi Tamura
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Satoshi Nishiyama
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Takanori Arimoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Hiroki Takahashi
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
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17
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Oka K, Masuda T, Ohara K, Miura M, Morinari M, Misawa K, Miyazawa Y, Akimoto T, Shimada K, Nagata D. Fluid homeostatic action of dapagliflozin in patients with chronic kidney disease: the DAPA-BODY Trial. Front Med (Lausanne) 2023; 10:1287066. [PMID: 38155663 PMCID: PMC10753517 DOI: 10.3389/fmed.2023.1287066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/30/2023] [Indexed: 12/30/2023] Open
Abstract
Sodium glucose cotransporter 2 (SGLT2) inhibitors have both glucose-lowering and diuretic effects. We recently reported that the SGLT2 inhibitor dapagliflozin exerts short-term fluid homeostatic action in patients with chronic kidney disease (CKD). However, the long-term effects of SGLT2 inhibitors on body fluid status in patients with CKD remain unclear. This was a prospective, non-randomized, open-label study that included a dapagliflozin treatment group (n = 73) and a control group (n = 24) who were followed for 6 months. Body fluid volume was measured using a bioimpedance analysis device. The extracellular water-to-total body water ratio (ECW/TBW), a predictor of renal outcomes, was used as a parameter for body fluid status (fluid retention, 0.400 ≤ ECW/TBW). Six-month treatment with dapagliflozin significantly decreased ECW/TBW compared with the control group (-0.65% ± 2.03% vs. 0.97% ± 2.49%, p = 0.0018). Furthermore, dapagliflozin decreased the ECW/TBW in patients with baseline fluid retention, but not in patients without baseline fluid retention (-1.47% ± 1.93% vs. -0.01% ± 1.88%, p = 0.0017). Vasopressin surrogate marker copeptin levels were similar between the control and dapagliflozin groups at 6 months (32.3 ± 33.4 vs. 30.6 ± 30.1 pmol/L, p = 0.8227). However, dapagliflozin significantly increased the change in copeptin levels at 1 week (39.0% ± 41.6%, p = 0.0010), suggesting a compensatory increase in vasopressin secretion to prevent hypovolemia. Renin and aldosterone levels were similar between the control and dapagliflozin groups at 6 months, while epinephrine and norepinephrine (markers of sympathetic nervous system activity) were significantly lower in the dapagliflozin group than in the control group. In conclusion, the SGLT2 inhibitor dapagliflozin ameliorated fluid retention and maintained euvolemic fluid status in patients with CKD, suggesting that SGLT2 inhibitors exert sustained fluid homeostatic actions in patients with various fluid backgrounds. Clinical trial registration: https://www.umin.ac.jp/ctr/, identifier [UMIN000048568].
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Affiliation(s)
- Kentaro Oka
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
- Department of Nephrology, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
| | - Takahiro Masuda
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
- Department of Nephrology, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
| | - Ken Ohara
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Marina Miura
- Department of Nephrology, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
| | - Masato Morinari
- Department of Internal Medicine, Nasu Minami Hospital, Nasukarasuyama, Tochigi, Japan
| | - Kyohei Misawa
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
- Department of Nephrology, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
| | - Yasuharu Miyazawa
- Department of Internal Medicine, Nasu Minami Hospital, Nasukarasuyama, Tochigi, Japan
| | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Kazuyuki Shimada
- Department of Cardiology, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
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18
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Koutentakis M, Kuciński J, Świeczkowski D, Surma S, Filipiak KJ, Gąsecka A. The Ketogenic Effect of SGLT-2 Inhibitors-Beneficial or Harmful? J Cardiovasc Dev Dis 2023; 10:465. [PMID: 37998523 PMCID: PMC10672595 DOI: 10.3390/jcdd10110465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/09/2023] [Accepted: 11/14/2023] [Indexed: 11/25/2023] Open
Abstract
Sodium-glucose cotransporter-2 (SGLT-2) inhibitors, also called gliflozins or flozins, are a class of drugs that have been increasingly used in the management of type 2 diabetes mellitus (T2DM) due to their glucose-lowering, cardiovascular (CV), and renal positive effects. However, recent studies suggest that SGLT-2 inhibitors might also have a ketogenic effect, increasing ketone body production. While this can be beneficial for some patients, it may also result in several potential unfavorable effects, such as decreased bone mineral density, infections, and ketoacidosis, among others. Due to the intricate and multifaceted impact caused by SGLT-2 inhibitors, this initially anti-diabetic class of medications has been effectively used to treat both patients with chronic kidney disease (CKD) and those with heart failure (HF). Additionally, their therapeutic potential appears to extend beyond the currently investigated conditions. The objective of this review article is to present a thorough summary of the latest research on the mechanism of action of SGLT-2 inhibitors, their ketogenesis, and their potential synergy with the ketogenic diet for managing diabetes. The article particularly discusses the benefits and risks of combining SGLT-2 inhibitors with the ketogenic diet and their clinical applications and compares them with other anti-diabetic agents in terms of ketogenic effects. It also explores future directions regarding the ketogenic effects of SGLT-2 inhibitors.
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Affiliation(s)
- Michail Koutentakis
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland;
| | - Jakub Kuciński
- Central Clinical Hospital, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland;
| | - Damian Świeczkowski
- Department of Toxicology, Faculty of Pharmacy, Medical University of Gdansk, 80-416 Gdańsk, Poland;
| | - Stanisław Surma
- Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland;
| | - Krzysztof J. Filipiak
- Department of Clinical Sciences, Maria Sklodowska-Curie Medical Academy, 00-001 Warsaw, Poland;
- Department of Hypertensiology, Angiology and Internal Medicine, Poznań University of Medical Sciences, 61-848 Poznań, Poland
| | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland;
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19
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Guan X, Zhang J, Chen G, Zhang G, Chang S, Nie Z, Liu W, Guo T, Zhao Y, Li B. MRAs may have lost their cornerstone position for heart failure treatment in the age of SGLT-2 inhibitors: A meta-analysis of randomized controlled trials. Heart Fail Rev 2023; 28:1427-1436. [PMID: 37369935 DOI: 10.1007/s10741-023-10330-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 06/29/2023]
Abstract
Mineralocorticoid receptor antagonists (MRAs) are a cornerstone drug class for heart failure therapy. Several clinical studies have demonstrated its role in heart failure therapy. However, due to the recommendation of sodium-glucose cotransporter-2 (SGLT-2) inhibitors for the treatment of heart failure, there is a lack of sufficient evidence regarding whether MRAs can continue to play a cornerstone role in heart failure treatment. A meta-analysis was performed on subgroups of the DAPA-HF and EMPEROR-Reduced trials. Using trial-level data, we performed a meta-analysis to assess the effects of SGLT-2 inhibitors and MRAs on various clinical endpoints of heart failure. The incidence of cardiovascular-related death or heart failure hospitalization was the primary outcome. In addition, we assessed cardiovascular death, all-cause death, heart failure hospitalization, renal outcomes, and hyperkalemia. This study has already been registered with PROSPERO, CRD42022385023. Compared with SGLT-2 inhibitor monotherapy, combined treatment did not demonstrate more significant advantages in terms of heart failure or cardiovascular death (RR = 1.00; 95% CI: 0.78-1.28), cardiovascular death (RR = 0.96; 95% CI: 0.61-1.52), heart failure hospitalization (RR = 0.92; 95% CI: 0.79-1.07), all-cause death (RR = 1.00; 95% CI: 0.63-1.59) and composite kidney endpoint (RR = 0.85; 95% CI: 0.49-1.46). Moreover, in comparison to SGLT-2 inhibitors, combined therapy increased the risk of moderate-severe hyperkalemia (blood potassium > 6.0 mmol/l) (RR = 4.13; 95% CI: 2.23-7.65). In patients with HFrEF who have started MRAs treatment, the addition of an SGLT-2 inhibitor provides significant clinical benefit. However, the addition of MRAs to SGLT-2 inhibitors to treat heart failure is not essential.
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Affiliation(s)
- Xiangfeng Guan
- School of Clinical Medicine, Affiliated Hospital of Weifang Medical University, Weifang Medical University, Weifang, 261053, China
| | - Ju Zhang
- School of Clinical Medicine, Affiliated Hospital of Weifang Medical University, Weifang Medical University, Weifang, 261053, China
| | - Guangxin Chen
- Department of Emergency, Zibo Central Hospital Affiliated to Binzhou Medical College, No. 10, South Shanghai Road, Zibo, 255000, China
| | - Guanzhao Zhang
- Department of Cardiology, Zibo Central Hospital Affiliated to Binzhou Medical College, No. 10, South Shanghai Road, Zibo, 255000, China
| | - Shuting Chang
- School of Clinical Medicine, Affiliated Hospital of Weifang Medical University, Weifang Medical University, Weifang, 261053, China
| | - Zifan Nie
- Department of Cardiology, Zibo Central Hospital Affiliated to Binzhou Medical College, No. 10, South Shanghai Road, Zibo, 255000, China
| | - Wenhao Liu
- Department of Cardiology, Zibo Central Hospital Affiliated to Binzhou Medical College, No. 10, South Shanghai Road, Zibo, 255000, China
| | - Tianlong Guo
- School of Clinical Medicine, Affiliated Hospital of Weifang Medical University, Weifang Medical University, Weifang, 261053, China
| | - Yunhe Zhao
- Department of Cardiology, Zibo Central Hospital Affiliated to Binzhou Medical College, No. 10, South Shanghai Road, Zibo, 255000, China.
| | - Bo Li
- Department of Cardiology, Zibo Central Hospital Affiliated to Binzhou Medical College, No. 10, South Shanghai Road, Zibo, 255000, China.
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20
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Heusser K, Tank J, Diedrich A, Fischer A, Heise T, Jordan J. Randomized Trial Comparing SGLT2 Inhibition and Hydrochlorothiazide on Sympathetic Traffic in Type 2 Diabetes. Kidney Int Rep 2023; 8:2254-2264. [PMID: 38025218 PMCID: PMC10658269 DOI: 10.1016/j.ekir.2023.08.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/24/2023] [Accepted: 08/28/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Reductions in sympathetic nervous system activity may contribute to beneficial effects of sodium glucose cotransporter 2 (SGLT2) inhibition on cardiovascular outcomes. Therefore, we tested the hypothesis that SGLT2 inhibition with empagliflozin (Empa) lowers muscle sympathetic nerve activity (MSNA) in patients with type 2 diabetes mellitus (T2DM) compared with hydrochlorothiazide (HCT) to discern SGLT2-specific actions from responses to increased natriuresis. Methods We randomized patients with T2DM on metformin monotherapy to either 25 mg/d Empa (n = 20) or 25 mg/d HCT (n = 21) for 6 weeks in a parallel, double-blind fashion. We assessed MSNA by peroneal microneurography, blood pressure, cardiovascular and metabolic biomarkers at baseline and at the end of treatment. Results Both drugs elicited volume depletion, as indicated by increased thoracic impedance. Compared with HCT, Empa caused 1.23 kg more body weight loss (P = 0.011) and improved glycemic control. Seated systolic blood pressure decreased with both treatments (P < 0.002). MSNA did not change significantly with either treatment; however, MSNA changes were negatively correlated with changes in body weight on Empa (P = 0.042) and on HCT(P = 0.001). The relationship was shifted to lower MSNA on Empa compared with HCT (P = 0.002). Conclusion Increased renal sodium excretion eliciting body weight loss may promote sympathetic activation. However, sympathetic excitation in the face of increased sodium loss may be attenuated by SGLT2 inhibitor-specific actions.
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Affiliation(s)
- Karsten Heusser
- Institute of Aerospace Medicine, German Aerospace Center, Cologne Germany
| | - Jens Tank
- Institute of Aerospace Medicine, German Aerospace Center, Cologne Germany
| | - André Diedrich
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Engineering, School of Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | | | | | - Jens Jordan
- Institute of Aerospace Medicine, German Aerospace Center, Cologne Germany
- Medical Faculty, University of Cologne, Cologne, Germany
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21
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Jürgens M, Schou M, Hasbak P, Kjaer A, Wolsk E, Zerahn B, Brandt-Jacobsen NH, Gaede P, Rossing P, Faber J, Inzucchi SE, Gustafsson F, Kistorp C. The effects of empagliflozin on measured glomerular filtration rate and estimated extracellular and plasma volumes in patients with type 2 diabetes. Diabetes Obes Metab 2023; 25:2888-2896. [PMID: 37395341 DOI: 10.1111/dom.15183] [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: 02/15/2023] [Revised: 05/22/2023] [Accepted: 06/02/2023] [Indexed: 07/04/2023]
Abstract
AIMS To investigate the effects of empagliflozin on measured glomerular filtration rate (mGFR), estimated plasma volume (PV) and estimated extracellular volume (ECV) in a cohort of patients with type 2 diabetes (T2D) and high risk of cardiovascular events. MATERIALS AND METHODS In this prespecified substudy of the randomized, placebo-controlled SIMPLE trial, patients with T2D at high risk of cardiovascular events were allocated to either empagliflozin 25 mg or placebo once daily for 13 weeks. The prespecified outcome was between-group change in mGFR, measured by the 51 Cr-EDTA method after 13 weeks; changes in estimated PV and estimated ECV were included. RESULTS From April 4, 2017 to May 11, 2020, 91 participants were randomized. Of these, 45 patients from the empagliflozin group and 45 patients from the placebo group were included in the intention-to-treat analysis. Treatment with empagliflozin reduced mGFR by -7.9 mL/min (95% confidence interval [CI] -11.1 to -4.7; P < 0.001), estimated ECV by -192.5 mL (95% CI -318.0 to -66.9; P = 0.003) and estimated PV by -128.9 mL (95% CI -218.0 to 39.8; P = 0.005) at Week 13. CONCLUSIONS Treatment with empagliflozin for 13 weeks reduced mGFR, estimated ECV and estimated PV in patients with T2D and high risk of cardiovascular events.
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Affiliation(s)
- Mikkel Jürgens
- Department of Endocrinology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Philip Hasbak
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Department of Biomedical Sciences, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Andreas Kjaer
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Department of Biomedical Sciences, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Emil Wolsk
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Bo Zerahn
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Niels H Brandt-Jacobsen
- Department of Endocrinology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Peter Gaede
- Slagelse Hospital, Slagelse, Denmark, University of Southern Denmark, Odense, Denmark
| | - Peter Rossing
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Jens Faber
- Department of Endocrinology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Silvio E Inzucchi
- Yale Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Finn Gustafsson
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Caroline Kistorp
- Department of Endocrinology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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22
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Kurokawa T, Otaki Y, Takahashi H, Watanabe T, Shikama T, Tamura H, Kato S, Nishiyama S, Arimoto T, Watanabe M. Impact of estimated plasma volume status on clinical outcomes in patients with lower extremity artery disease who underwent endovascular therapy. Hypertens Res 2023; 46:2005-2015. [PMID: 37286869 DOI: 10.1038/s41440-023-01315-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/21/2023] [Accepted: 04/28/2023] [Indexed: 06/09/2023]
Abstract
Lower extremity artery disease (LEAD) is an arterial occlusive disease associated with high morbidity and mortality. Estimated plasma volume status (ePVS), a marker of plasma volume expansion and contraction, is gaining attention in the field of cardiovascular diseases. However, the impact of ePVS on the clinical outcomes of patients with LEAD remains unclear. We calculated ePVS using two different formulas, Kaplan-Hakim (KH-ePVS) and Duarte (D-ePVS), in 288 patients (mean age, 73 years; 77% male) with LEAD who underwent the first endovascular therapy (EVT), and prospectively followed them up between 2014 and 2019. All patients were divided into two groups based on the median ePVS values. The primary endpoints were composite events, including all-cause death and major adverse limb events (death/MALE). The median follow-up duration was 672 days. There were 183, 40 and 65 patients in Fontaine classes II, III, and IV, respectively. The median KH-ePVS and D-ePVS was 5.96 and 5.09, respectively. The ePVS significantly increased with advancing Fontaine classes. Kaplan-Meier analysis demonstrated that the high ePVS group had higher rates of death/MALE than the low ePVS group. Multivariate Cox proportional hazard analysis revealed that each ePVS was an independent predictor for death/MALE after adjusting for confounding risk factors. The prognostic ability for death/MALE was significantly improved by adding ePVS to the basic predictors. ePVS was associated with LEAD severity and clinical outcomes, suggesting that ePVS could be an additional risk factor for death/MALE in patients with LEAD who underwent EVT. We demonstrated that the association between ePVS and the clinical outcomes of patients with LEAD. The prognostic ability for death/MALE was significantly improved by adding ePVS to the basic predictors. LEAD lower extremity artery disease, MALE major adverse limb events, PVS plasma volume status.
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Affiliation(s)
- Tasuku Kurokawa
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Yoichiro Otaki
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan.
| | - Hiroki Takahashi
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Taku Shikama
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Harutoshi Tamura
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Shigehiko Kato
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Satoshi Nishiyama
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Takanori Arimoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
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23
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Packer M, Wilcox CS, Testani JM. Critical Analysis of the Effects of SGLT2 Inhibitors on Renal Tubular Sodium, Water and Chloride Homeostasis and Their Role in Influencing Heart Failure Outcomes. Circulation 2023; 148:354-372. [PMID: 37486998 PMCID: PMC10358443 DOI: 10.1161/circulationaha.123.064346] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/25/2023] [Indexed: 07/26/2023]
Abstract
SGLT2 (sodium-glucose cotransporter 2) inhibitors interfere with the reabsorption of glucose and sodium in the early proximal renal tubule, but the magnitude and duration of any ensuing natriuretic or diuretic effect are the result of an interplay between the degree of upregulation of SGLT2 and sodium-hydrogen exchanger 3, the extent to which downstream compensatory tubular mechanisms are activated, and (potentially) the volume set point in individual patients. A comprehensive review and synthesis of available studies reveals several renal response patterns with substantial variation across studies and clinical settings. However, the common observation is an absence of a large acute or chronic diuresis or natriuresis with these agents, either when given alone or combined with other diuretics. This limited response results from the fact that renal compensation to these drugs is rapid and nearly complete within a few days or weeks, preventing progressive volume losses. Nevertheless, the finding that fractional excretion of glucose and lithium (the latter being a marker of proximal sodium reabsorption) persists during long-term treatment with SGLT2 inhibitors indicates that pharmacological tolerance to the effects of these drugs at the level of the proximal tubule does not meaningfully occur. This persistent proximal tubular effect of SGLT2 inhibitors can be hypothesized to produce a durable improvement in the internal set point for volume homeostasis, which may become clinically important during times of fluid expansion. However, it is difficult to know whether a treatment-related change in the volume set point actually occurs or contributes to the effect of these drugs to reduce the risk of major heart failure events. SGLT2 inhibitors exert cardioprotective effects by a direct effect on cardiomyocytes that is independent of the presence of or binding to SGLT2 or the actions of these drugs on the proximal renal tubule. Nevertheless, changes in the volume set point mediated by SGLT2 inhibitors might potentially act cooperatively with the direct favorable molecular and cellular effects of these drugs on cardiomyocytes to mediate their benefits on the development and clinical course of heart failure.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Dallas, TX (M.P.)
- Imperial College London, United Kingdom (M.P.)
| | - Christopher S. Wilcox
- Division of Nephrology and Hypertension, Kidney, and Vascular Research Center, Georgetown University, Washington, DC (C.S.W.)
| | - Jeffrey M. Testani
- Section of Cardiovascular Medicine, Yale University, New Haven, CT (J.M.T.)
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24
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Tanaka A, Imai T, Toyoda S, Sugimoto K, Yoshida R, Furuta M, Node K. Long-term observation of estimated fluid volume reduction after the initiation of ipragliflozin in patients with type 2 diabetes mellitus: a sub-analysis from a randomized controlled trial (PROTECT). Diabetol Metab Syndr 2023; 15:152. [PMID: 37415229 DOI: 10.1186/s13098-023-01129-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 07/01/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUNDS/AIM Recent studies have shown that the addition of sodium-glucose co-transporter 2 (SGLT2) inhibitors gradually reduces the estimated fluid volume parameters in a broad range of patient populations, suggesting that this mediates the clinical benefits of SGLT2 inhibitors in preventing heart failure. Here, we sought to examine the long-term (24 months) effect of the SGLT2 inhibitor ipragliflozin on the estimated fluid volume parameters in patients with type 2 diabetes mellitus (T2DM). METHODS In this prespecified sub-analysis of the PROTECT (Prevention of Atherosclerosis by SGLT2 Inhibitor: Multicenter, Randomized Controlled Study) trial, which was an investigator-initiated, multicenter, prospective, randomized, open-label, clinical trial primarily designed to evaluate the effect of ipragliflozin treatment administered for 24 months on carotid atherosclerosis in patients with T2DM, we evaluated serial changes in estimated plasma volume (ePV, %) calculated using the Straus formula and estimated extracellular volume (eEV, mL) calculated by the body surface area by 24 months following the initiation of 50-mg ipragliflozin once daily and compared them with those following standard care for T2DM (non-SGLT2 inhibitor use). RESULTS This sub-analysis included 464 patients (ipragliflozin, n = 232; control, n = 232), a full analysis set of the PROTECT trial. In an analysis using mixed-effects models for repeated measures, relative to the control group, ipragliflozin significantly reduced ePV by - 10.29% (95% confidence interval [CI] - 12.47% to - 8.11%; P < 0.001) at 12 months and - 10.76% (95% CI - 12.86% to - 8.67%; P < 0.001) at 24 months. Additionally, ipragliflozin significantly reduced eEV by - 190.44 mL (95% CI - 249.09 to - 131.79 mL; P < 0.001) at 12 months and - 176.90 mL (95% CI - 233.36 to - 120.44 mL; P < 0.001) at 24 months. The effects of ipragliflozin on these parameters over 24 months were mostly consistent across various patient clinical characteristics. CONCLUSIONS This prespecified sub-analysis from the PROTECT trial demonstrated that ipragliflozin treatment, compared with the standard care for T2DM, reduced two types of estimated fluid volume parameters in patients with T2DM, and the effect was maintained for 24 months. Our findings suggest that SGLT2 inhibitor treatment regulates clinical parameters incorporated into the calculating formulas analyzed and consequently fluid volume status for the long-term, and this may be at least partly associated with clinical benefits from chronic use of SGLT2 inhibitors. Trial registration Japan Registry of Clinical Trials, ID jRCT1071220089.
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Affiliation(s)
- Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, 5-5-1 Nabeshima, Saga, 849-8501, Japan.
| | - Takumi Imai
- Department of Medical Statistics, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Shigeru Toyoda
- Department of Cardiovascular Medicine, Dokkyo Medical University School of Medicine, Mibu, Japan
| | | | - Ruka Yoshida
- Department of Cardiology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Machi Furuta
- Department of Clinical Laboratory Medicine, Wakayama Medical University, Wakayama, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, 5-5-1 Nabeshima, Saga, 849-8501, Japan.
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25
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Ji L, Mishra M, De Geest B. The Role of Sodium-Glucose Cotransporter-2 Inhibitors in Heart Failure Management: The Continuing Challenge of Clinical Outcome Endpoints in Heart Failure Trials. Pharmaceutics 2023; 15:1092. [PMID: 37111578 PMCID: PMC10140883 DOI: 10.3390/pharmaceutics15041092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
The introduction of sodium-glucose cotransporter-2 (SGLT2) inhibitors in the management of heart failure with preserved ejection fraction (HFpEF) may be regarded as the first effective treatment in these patients. However, this proposition must be evaluated from the perspective of the complexity of clinical outcome endpoints in heart failure. The major goals of heart failure treatment have been categorized as: (1) reduction in (cardiovascular) mortality, (2) prevention of recurrent hospitalizations due to worsening heart failure, and (3) improvement in clinical status, functional capacity, and quality of life. The use of the composite primary endpoint of cardiovascular death and hospitalization for heart failure in SGLT2 inhibitor HFpEF trials flowed from the assumption that hospitalization for heart failure is a proxy for subsequent cardiovascular death. The use of this composite endpoint was not justified since the effect of the intervention on both components was clearly distinct. Moreover, the lack of convincing and clinically meaningful effects of SGLT2 inhibitors on metrics of heart failure-related health status indicates that the effect of this class of drugs in HFpEF patients is essentially restricted to an effect on hospitalization for heart failure. In conclusion, SGLT2 inhibitors do not represent a substantial breakthrough in the management of HFpEF.
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Affiliation(s)
| | | | - Bart De Geest
- Centre for Molecular and Vascular Biology, Catholic University of Leuven, 3000 Leuven, Belgium; (L.J.); (M.M.)
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26
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Farooq M, Jorde UP. Impact of Sodium-Glucose Cotransporter-2 Inhibitors on Cardiac Bioenergetic Properties and Cardiorespiratory Fitness: A Special Effect of SGLT2i In Heart Failure? Cardiol Rev 2023; 31:65-69. [PMID: 35191660 DOI: 10.1097/crd.0000000000000424] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Recent clinical trials have highlighted the profound benefits of sodium-glucose linked transporter 2 inhibitors (SGLT2i) on cardiovascular mortality and hospitalization for heart failure patients. Modest improvements in glycemic, lipid, or blood pressure control are unlikely to contribute to these significant beneficial outcomes, generating much interest in the relevant mechanisms leading to outcome improvements. In this review, we discuss the current evidence supporting a shift in myocardial substrate utilization from carbohydrates and fat oxidation toward energy efficient ketone bodies in the failing heart and the role of SGLT2i in this key metabolic adaptation to optimize myocardial fuel energetics. Further insights into the effect of SGLT2i on the indices of cardiorespiratory fitness are outlined and provide important clues into their mechanism of benefit. This mechanistic discussion in the context of recent trials of SGLT2i denotes a promising treatment paradigm of heart failure in individuals with and without diabetes.
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Affiliation(s)
- Muhammad Farooq
- From the Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY
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27
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Shiina K, Tomiyama H, Tanaka A, Imai T, Hisauchi I, Taguchi I, Sezai A, Toyoda S, Dohi K, Kamiya H, Kida K, Anzai T, Chikamori T, Node K, Ako J, Amano R, Asai M, Eguchi K, Eshima K, Fujiki S, Fujita M, Hikoso S, Hiramitsu S, Hoshide S, Hoshino A, Ikeda Y, Ikehara Y, Inomata T, Inoue T, Ishii K, Ishizaka N, Ito M, Iwahashi N, Iwakura K, Kadokami T, Kanbara T, Kanzaki Y, Kashimura K, Kimura K, Kishi S, Kitada S, Kitakaze M, Kiyosue A, Kodama K, Kojima T, Kondo T, Kubota Y, Kusunose K, Machii N, Matsunaga K, Matsuo Y, Matsuzawa Y, Mikami T, Minamino T, Murohara T, Nagai T, Nagano Y, Nagumo M, Nakamura I, Nakamura K, Nakatani D, Nanasato M, Naruse H, Nishino M, Niwano S, Oguri M, Ohte N, Oikawa M, Okumura T, Okumura M, Onishi K, Oyama JI, Ozaki Y, Saito K, Sakamoto T, Sakata Y, Sakuma M, Sata M, Sekino H, Shimabukuro M, Shimizu W, Suzuki M, Suzuki K, Takahama H, Takahashi N, Takeishi Y, Tamaki S, Tanaka A, Tanimoto S, Teragawa H, Tobushi T, Toita T, Tokuda K, Tsutsui H, Ueda S, Uehara H, Uematsu M, Watada H, Yahagi K, Yamada T, Yamada H, Yoshida T, Yoshihisa A. Canagliflozin independently reduced plasma volume from conventional diuretics in patients with type 2 diabetes and chronic heart failure: a subanalysis of the CANDLE trial. Hypertens Res 2023; 46:495-506. [PMID: 36380202 DOI: 10.1038/s41440-022-01085-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 09/24/2022] [Accepted: 10/03/2022] [Indexed: 11/16/2022]
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2is) reduce the risk of heart failure progression and mortality rates. Moreover, osmotic diuresis induced by SGLT2 inhibition may result in an improved heart failure prognosis. Independent of conventional diuretics in patients with type 2 diabetes (T2D) and chronic heart failure, especially in patients with heart failure with preserved ejection fraction (HFpEF), it is unclear whether SGLT2i chronically reduces estimated plasma volume (ePV). As a subanalysis of the CANDLE trial, which assessed the effect of canagliflozin on N-terminal pro-brain natriuretic peptide (NT-proBNP), we examined the change (%) in ePV over 24 weeks of treatment based on the baseline level associated with diuretic usage. In the CANDLE trial, nearly all patients were clinically stable (NYHA class I-II), with approximately 70% of participants presenting a baseline phenotype of HFpEF. A total of 99 (42.5%) patients were taking diuretics (mostly furosemide) at baseline, while 134 (57.5%) were not. Relative to glimepiride, canagliflozin significantly reduced ePV without worsening renal function in patients in both groups: -4.00% vs. 1.46% (p = 0.020) for the diuretic group and -6.14% vs. 1.28% (p < 0.001) for the nondiuretic group. Furthermore, canagliflozin significantly reduced serum uric acid without causing major electrolyte abnormalities in patients in both subgroups. The long-term beneficial effect of SGLT2i on intravascular congestion could be independent of conventional diuretic therapy without worsening renal function in patients with T2D and HF (HFpEF predominantly). In addition, the beneficial effects of canagliflozin are accompanied by improved hyperuricemia without causing major electrolyte abnormalities.
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Affiliation(s)
- Kazuki Shiina
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan.
| | | | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Takumi Imai
- Department of Medical Statistics, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Itaru Hisauchi
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Isao Taguchi
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Akira Sezai
- The Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Shigeru Toyoda
- Department of Cardiovascular Medicine, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Haruo Kamiya
- Department of Cardiology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Keisuke Kida
- Department of Pharmacology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Hokkaido University, Sapporo, Japan
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
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Chen X, Lin G, Dai C, Xu K. Effect of estimated plasma volume status and left atrial diameter on prognosis of patients with acute heart failure. Front Cardiovasc Med 2023; 10:1069864. [PMID: 36760561 PMCID: PMC9905108 DOI: 10.3389/fcvm.2023.1069864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 01/06/2023] [Indexed: 01/26/2023] Open
Abstract
Objective Acute heart failure (AHF) is a frequent cardiovascular emergency presenting with high mortality as well as readmission rates. The aim was to investigate the predictive value of estimated plasma volume status (ePVs) and left atrial diameter (LAD) for the prognosis of patients with AHF. Methods Clinical profiles were collected from 259 cases of AHF patients at the Affiliated Hospital of Putian University between September 2019 and October 2021. Results Six patients lost follow-up, resulting in 253 patients enrolled. Cardiogenic death and heart failure readmission during follow-up were defined as major cardiovascular events (MACE) group, other patients were defined as Non-MACE group. Apart from age, no significant differences were found between the two groups in demographics and comorbidities. The comparison between the two groups was statistically significant in terms of ePVs, LAD, and N-terminal-pro B-type natriuretic peptide (Nt-pro-BNP). On binary logistic regression analysis, ePVs (OR = 2.061, 95% CI 1.322∼3.214, P = 0.001), LAD (OR = 1.054, 95% CI 1.012∼1.098, P = 0.011), and Nt-pro-bnp (OR = 1.006, 95% CI 1.003∼1.010, P = 0.036) as predicting factors for MACE. Kaplan-Meier analysis indicated that the risk for cardiogenic death increasing with ePVs (p < 0.05). Conclusion Estimated plasma volume status and LADs have some predictive value in assessing cardiogenic death and heart failure readmission in patients with AHF.
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29
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Hasan MT, Awad AK, Shih M, Attia AN, Aboeldahab H, Bendary M, Bendary A. Meta-Analysis on the Safety and Efficacy of Sodium Glucose Cotransporters 2 Inhibitors in Patients With Heart Failure With and Without Diabetes. Am J Cardiol 2023; 187:93-99. [PMID: 36459753 DOI: 10.1016/j.amjcard.2022.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 10/04/2022] [Accepted: 10/13/2022] [Indexed: 12/02/2022]
Abstract
Heart failure (HF) is the most common cardiovascular cause of hospitalization in patients over 60 years, affecting about 64.3 million patients worldwide. Few studies have investigated the role of sodium glucose cotransporter inhibitors (SGLT2Is) in patients with HF without and without diabetes. Thus, we conducted our meta-analysis to further investigate the role of SGLT2I role in patients with HF without and without diabetes. PubMed, Scopus, Web of Science, and Embase were searched. All clinical trials that compared the effect of SGLT2Is versus placebo on patients with HF were included. Dichotomous data were extracted, pooled as risk ratio (RR) with 95% confidence interval (CI), and analyzed using RevMan version 5.3 for windows using the Mantel-Haenszel method. A total of 13 randomized clinical trials were included for analysis, with a total number of 75,287 patients. SGLT2Is significantly lowered the risk of hospitalization for HF in patients with (RR = 0.68, 95% CI 0.63 to 0.74) and without diabetes (RR = 0.75, 95% CI 0.62 to 0.89). Furthermore, they lowered the mortality risk in both patients with diabetes with statistical significance (RR = 0.87, 95% CI 0.77 to 0.99), yet without statistical significance in patients without diabetes (RR = 0.93, 95% CI 0.70 to 1.23). Further analyses for serious adverse events were conducted, and SGLT2I showed a significant lower risk in patients with diabetes (RR = 0.94, 95% CI 0.90 to 0.98) and without diabetes (RR = 0.72, 95% CI 0.38 to 1.39). in patients with diabetes, SGLT2Is significantly reduced cardiovascular mortality, HHF, and serious adverse events. However, in patients without, despite showing a significant reduction in HHF, SGLT2I reduced cardiovascular mortality or serious adverse events but without statistical significance.
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Affiliation(s)
| | - Ahmed K Awad
- Faculty of Medicine, Ain-Shams University, Cairo, Egypt.
| | | | | | - Heba Aboeldahab
- Biomedical Informatics and Medical Statistics Department, Medical Research Institute, Alexandria University, Egypt
| | - Mohamed Bendary
- Epidemiology and Biostatistics Department, Cairo University, Cairo, Egypt
| | - Ahmed Bendary
- Cardiology Department, Benha University, Cairo, Egypt
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Kubica J, Kubica A, Grzelakowska K, Stolarek W, Grąbczewska Z, Michalski P, Niezgoda P, Bartuś S, Budaj A, Dąbrowski M, Drożdż J, Gellert R, Jaguszewski MJ, Jankowski P, Legutko J, Lesiak M, Leszek P, Małyszko J, Mitkowski P, Nessler J, Pawlaczyk K, Siller-Matula J, Stompór T, Wolnik B, Navarese EP. Inhibitors of sodium-glucose transport protein 2: A new multidirectional therapeutic option for heart failure patients. Cardiol J 2023; 30:143-149. [PMID: 34708866 PMCID: PMC9987542 DOI: 10.5603/cj.a2021.0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/06/2021] [Indexed: 11/25/2022] Open
Abstract
Several mechanisms have been suggested to explain positive cardiovascular effects observed in studies with sodium-glucose co-transporter 2 (SGLT2) inhibitors. The reduction in glucose reabsorption in proximal tubuli induced by SGLT2 inhibitors increases urinary glucose and sodium excretion resulting in increased osmotic diuresis and consequently in decreased plasma volume, followed by reduced preload. In addition, the hemodynamic effects of SGLT2 inhibition were observed in both hyper and euglycemic patients. Due to the complex and multidirectional effects induced by SGLT2 inhibitors, this originally antidiabetic group of drugs has been successfully used to treat patients with heart failure as well as for subjects with chronic kidney disease. Moreover, their therapeutic potential seems to be even broader than the indications studied to date.
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Affiliation(s)
- Jacek Kubica
- Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Aldona Kubica
- Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | - Wioleta Stolarek
- Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Zofia Grąbczewska
- Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Piotr Michalski
- Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Piotr Niezgoda
- Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.
| | - Stanisław Bartuś
- 2nd Department of Cardiology, Collegium Medicum, Jagiellonian University, Krakow, Poland
| | - Andrzej Budaj
- Center of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | | | - Jarosław Drożdż
- 2nd Department of Cardiology, Chair of Cardiology, Cardiac Surgery and Vascular Diseases, Medical University of Lodz, Poland
| | - Ryszard Gellert
- Department of Nephrology and Internal Medicine, Center of Postgraduate Medical Education, Warsaw, Poland
| | | | - Piotr Jankowski
- 1st Department of Cardiology, Collegium Medicum, Jagiellonian University, Krakow, Poland
| | - Jacek Legutko
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Poland
| | - Maciej Lesiak
- Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Przemysław Leszek
- Department of Heart Failure and Transplantology, National Institute of Cardiology, Warsaw, Poland
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Poland
| | | | - Jadwiga Nessler
- Department of Coronary Artery Disease and Heart Failure, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Krzysztof Pawlaczyk
- Department of Nephrology, Transplantology and Internal Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Jolanta Siller-Matula
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Poland.,Department of Cardiology, Medical University of Vienna, Austria
| | - Tomasz Stompór
- Chair of Internal Medicine Department of Nephrology, Hypertension and Internal Medicine, Medical Faculty, University of Warmia and Mazury in Olsztyn, Poland
| | - Bogumił Wolnik
- Department of Hypertension and Diabetology, Faculty of Medicine, Medical University of Gdansk, Poland
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Fujiki S, Tanaka A, Imai T, Shimabukuro M, Uehara H, Nakamura I, Matsunaga K, Suzuki M, Kashimura T, Minamino T, Inomata T, Node K. Body fluid regulation via chronic inhibition of sodium-glucose cotransporter-2 in patients with heart failure: a post hoc analysis of the CANDLE trial. Clin Res Cardiol 2023; 112:87-97. [PMID: 35729430 DOI: 10.1007/s00392-022-02049-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 05/31/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND In patients with chronic heart failure (CHF) and type 2 diabetes (T2D), sodium-glucose cotransporter-2 (SGLT2) inhibition improves cardiorenal outcomes, but details of the effects on distinct subsets of body fluid volume remain incomplete. METHODS This was a post hoc analysis of patients with CHF and T2D in the CANDLE trial (UMIN000017669), an investigator-initiated, multi-center, randomized open-label trial that compared the effect of canagliflozin (100 mg, n = 113) with glimepiride (starting dose: 0.5 mg, n = 120) on changes in N-terminal pro-brain natriuretic peptide. The estimated plasma volume (ePV, calculated with the Straus formula) and estimated extracellular volume (eEV, determined by the body surface area) were compared between treatment groups at weeks 4, 12, and 24. RESULTS Among 233 patients analyzed, 166 (71.2%) had an ejection fraction (EF) > 50%. Reductions in ePV and eEV were observed only in the canagliflozin group until week 12 (change from baseline at week 12, ePV; - 7.63%; 95% confidence interval [CI], - 10.71 to - 4.55%, p < 0.001, eEV; - 123.15 mL; 95% CI, - 190.38 to - 55.92 mL, p < 0.001). While ePV stopped falling after week 12, eEV continued to fall until week 24 ([change from baseline at week 24] - [change from baseline at week 12], ePV; 1.01%; 95%CI, - 2.30-4.32%, p = 0.549, eEV; - 125.15 mL; 95% CI, - 184.35 to - 65.95 mL, p < 0.001). CONCLUSIONS Maintenance of a modest reduction in ePV and continuous removal of eEV via chronic SGLT2 inhibition suggests that favorable body fluid regulation contributes to the cardiorenal benefits of SGLT2 inhibitors in patients with CHF, irrespective of EF. TRIAL REGISTRATION UMIN000017669.
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Affiliation(s)
- Shinya Fujiki
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan.
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Takumi Imai
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Osaka, Japan
| | - Michio Shimabukuro
- Department of Diabetes, Endocrinology, and Metabolism, Fukushima Medical University, Fukushima, Japan
| | - Hiroki Uehara
- Division of Cardiology, Urasoe General Hospital, Urasoe, Japan
| | - Ikuko Nakamura
- Department of Cardiovascular Medicine, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Kazuo Matsunaga
- Department of Internal Medicine, Imari-Arita Kyoritsu Hospital, Matsuura, Japan
| | - Makoto Suzuki
- Department of Cardiology, Yokohama Minami Kyosai Hospital, Yokohama, Japan
| | - Takeshi Kashimura
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
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Jamil S, Zainab A, Arora AKMS, Shaik TA, Khemani V, Mekowulu FC, Aschalew YN, Khan S. Efficacy and Safety of Sodium Glucose Cotransporter-2 (SGLT2) Inhibitors in Patients With Diabetes and Chronic Kidney Disease (CKD): A Meta-analysis of Randomized Control Trials. Cureus 2022; 14:e31898. [PMID: 36579248 PMCID: PMC9791678 DOI: 10.7759/cureus.31898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2022] [Indexed: 11/27/2022] Open
Abstract
The current meta-analysis aims to assess the efficacy and safety of sodium glucose cotransporter 2 (SGLT2) inhibitors in individuals with diabetes and chronic kidney disease (CKD). The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search was conducted to identify all relevant studies related to the efficacy and safety of SGLT2 inhibitors in individuals with diabetes and CKD. The search was undertaken in PubMed, EMBASE, and Cochrane Library from January 2000 to September 2022. The primary efficacy outcome assessed in the current meta-analysis included major adverse cardiovascular events (MACE). Other efficacy outcomes included all-cause mortality and change in hemoglobin A1c (HbA1c) (%). Safety outcomes included serious adverse events, acute kidney injury, hypoglycemia, and hyperkalemia. In total 11 articles met the inclusion criteria and were included in the final analysis enrolling 27520 patients (14491 in the SGLT2 inhibitors and 13029 in the placebo group). The findings of this meta-analysis have shown that the risk of MACE and all-cause mortality was significantly lower in patients receiving SGLT2 inhibitors. Additionally, Hb1AC change was also significantly greater in SGLT2 inhibitors group. In relation to safety outcomes, serious adverse events, risk of acute kidney injury, and hyperkalemia were significantly lower in the SGLT2 inhibitors group. The SGLT2 inhibitors significantly decreased the risk of major cardiovascular events and all-cause mortality in patients with CKD and diabetes. Furthermore, SGLT2 inhibitor is also effective in reducing Hb1Ac levels in patients.
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Affiliation(s)
- Sidra Jamil
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Arfa Zainab
- Medicine, Mohammad ud din Islamic Medical College, Mir Pur, PAK
| | - Avneet Kaur Manjeet Singh Arora
- Public Health, Epidemiology, University of California Berkeley, Berkeley, USA
- Internal Medicine, Mahatma Gandhi Mission's Medical College, Navi Mumbai, IND
| | - Tanveer Ahamad Shaik
- Cardiovascular Medicine, University of Louisville School of Medicine, Louisville, USA
| | - Vimal Khemani
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Favour C Mekowulu
- Internal Medicine, V.N. Karazin Kharkiv National University, Kharkiv, UKR
| | | | - Saima Khan
- Internal Medicine, Sir Syed College of Medical Sciences for Girls, Waterbury, USA
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Xu Y, Zhang C, Jiang K, Yang X, Chen F, Cheng Z, Zhao J, Cheng J, Li X, Chen X, Zhou L, Duan H, Huang Y, Xiang Y, Li J. Structural repurposing of SGLT2 inhibitor empagliflozin for strengthening anti-heart failure activity with lower glycosuria. Acta Pharm Sin B 2022; 13:1671-1685. [PMID: 37139418 PMCID: PMC10149898 DOI: 10.1016/j.apsb.2022.08.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/17/2022] [Accepted: 08/25/2022] [Indexed: 11/15/2022] Open
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been reapproved for heart failure (HF) therapy in patients with and without diabetes. However, the initial glucose-lowering indication of SGLT2i has impeded their uses in cardiovascular clinical practice. A challenge of SGLT2i then becomes how to separate their anti-HF activity from glucose-lowering side-effect. To address this issue, we conducted structural repurposing of EMPA, a representative SGLT2 inhibitor, to strengthen anti-HF activity and reduce the SGLT2-inhibitory activity according to structural basis of inhibition of SGLT2. Compared to EMPA, the optimal derivative JX01, which was produced by methylation of C2-OH of the glucose ring, exhibited weaker SGLT2-inhibitory activity (IC50 > 100 nmol/L), and lower glycosuria and glucose-lowering side-effect, better NHE1-inhibitory activity and cardioprotective effect in HF mice. Furthermore, JX01 showed good safety profiles in respect of single-dose/repeat-dose toxicity and hERG activity, and good pharmacokinetic properties in both mouse and rat species. Collectively, the present study provided a paradigm of drug repurposing to discover novel anti-HF drugs, and indirectly demonstrated that SGLT2-independent molecular mechanisms play an important role in cardioprotective effects of SGLT2 inhibitors.
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Affiliation(s)
- Yixiang Xu
- State Key Laboratory of Bioreactor Engineering, Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, Frontiers Science Center for Materiobiology and Dynamic Chemistry, Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai 200237, China
| | - Chao Zhang
- State Key Laboratory of Bioreactor Engineering, Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, Frontiers Science Center for Materiobiology and Dynamic Chemistry, Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai 200237, China
| | - Kai Jiang
- Shanghai East Hospital, School of Life Sciences and Technology, Tongji University, Shanghai 200092, China
| | - Xinchun Yang
- East China University of Science and Technology-Tengbai Pharmaceutical Innovative Drugs Joint Research Institute, Zhuhai Tengbai Pharmaceutical Co., Ltd., Zhuhai 519000, China
| | - Feng Chen
- Shanghai East Hospital, School of Life Sciences and Technology, Tongji University, Shanghai 200092, China
| | - Zhiyang Cheng
- Shanghai East Hospital, School of Life Sciences and Technology, Tongji University, Shanghai 200092, China
| | - Jinlong Zhao
- East China University of Science and Technology-Tengbai Pharmaceutical Innovative Drugs Joint Research Institute, Zhuhai Tengbai Pharmaceutical Co., Ltd., Zhuhai 519000, China
| | - Jiaxing Cheng
- East China University of Science and Technology-Tengbai Pharmaceutical Innovative Drugs Joint Research Institute, Zhuhai Tengbai Pharmaceutical Co., Ltd., Zhuhai 519000, China
| | - Xiaokang Li
- State Key Laboratory of Bioreactor Engineering, Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, Frontiers Science Center for Materiobiology and Dynamic Chemistry, Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai 200237, China
| | - Xin Chen
- State Key Laboratory of Bioreactor Engineering, Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, Frontiers Science Center for Materiobiology and Dynamic Chemistry, Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai 200237, China
| | - Luoyifan Zhou
- State Key Laboratory of Bioreactor Engineering, Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, Frontiers Science Center for Materiobiology and Dynamic Chemistry, Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai 200237, China
| | - Hao Duan
- State Key Laboratory of Bioreactor Engineering, Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, Frontiers Science Center for Materiobiology and Dynamic Chemistry, Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai 200237, China
| | - Yunyuan Huang
- Hubei Key Laboratory of Genetic Regulation and Integrative Biology, School of Life Sciences, Central China Normal University, Wuhan 430079, China
- Corresponding authors. Tel./fax: +86 21 64252584 (Jian Li and Yunyuan Huang), +86 21 65981041 (Yaozu Xiang).
| | - Yaozu Xiang
- Shanghai East Hospital, School of Life Sciences and Technology, Tongji University, Shanghai 200092, China
- Corresponding authors. Tel./fax: +86 21 64252584 (Jian Li and Yunyuan Huang), +86 21 65981041 (Yaozu Xiang).
| | - Jian Li
- State Key Laboratory of Bioreactor Engineering, Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, Frontiers Science Center for Materiobiology and Dynamic Chemistry, Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai 200237, China
- Yunnan Key Laboratory of Screening and Research on Anti-pathogenic Plant Resources from West Yunnan, College of Pharmacy, Dali University, Dali 671000, China
- Clinical Medicine Scientific and Technical Innovation Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200092, China
- Key Laboratory of Tropical Biological Resources of Ministry of Education, College of Pharmacy, Hainan University, Haikou 570228, China
- Corresponding authors. Tel./fax: +86 21 64252584 (Jian Li and Yunyuan Huang), +86 21 65981041 (Yaozu Xiang).
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Masuda T, Ohara K, Vallon V, Nagata D. SGLT2 inhibitor and loop diuretic induce different vasopressin and fluid homeostatic responses in nondiabetic rats. Am J Physiol Renal Physiol 2022; 323:F361-F369. [PMID: 35900341 PMCID: PMC9423725 DOI: 10.1152/ajprenal.00070.2022] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/20/2022] [Accepted: 07/20/2022] [Indexed: 12/12/2022] Open
Abstract
Loop diuretics are commonly used diuretics in the treatment of fluid retention but induce hypovolemia-related renal dysfunction. Na+-glucose cotransporter 2 (SGLT2) inhibitors induce osmotic diuresis, but body fluid volume is maintained by stimulating vasopressin-induced fluid intake and collecting duct water reabsorption as previously reported in diabetic rats. We aimed to test the hypothesis that unlike SGLT2 inhibitors, loop diuretics lack activation of similar fluid homeostatic mechanisms. Nondiabetic male Sprague-Dawley rats were treated daily by oral gavage with vehicle, the SGLT2 inhibitor ipragliflozin (5 mg/kg), or the loop diuretic furosemide (50 mg/kg) and monitored in metabolic cages for 2 or 7 days. Ipragliflozin and furosemide similarly increased urine volume on day 2. This was associated with increased serum Na+ concentration, urine vasopressin excretion, fluid intake, and solute-free water reabsorption in response to ipragliflozin but not to furosemide. Ipragliflozin maintained fluid balance (fluid intake - urine volume) on day 2 and total body water measured by bioimpedance spectroscopy and serum creatinine on day 7. In comparison, furosemide decreased fluid balance on day 2 and decreased total body water and increased serum creatinine on day 7. Furosemide, but not ipragliflozin, increased plasma renin activity, and systolic blood pressure was similar among the groups. In conclusion, the osmotic diuresis of the SGLT2 inhibitor increased serum Na+ concentration and the vasopressin-related stimulation of fluid intake and renal water retention maintained fluid balance, whereas the loop diuretic did not engage the compensatory vasopressin system. The data suggest differences in vasopressin and fluid homeostatic responses between SGLT2 inhibitors and loop diuretics.NEW & NOTEWORTHY In nondiabetic rats, the Na+-glucose cotransporter 2 (SGLT2) inhibitor ipragliflozin increased vasopressin-related stimulation of fluid intake and free water reabsorption and maintained fluid balance and serum creatinine, whereas the loop diuretic furosemide reduced vasopressin and induced a negative fluid balance followed by a subsequent increase in serum creatinine. This study suggests that differences in vasopressin secretion in response to a SGLT2 inhibitor or loop diuretic may contribute to differences in body fluid status and subsequent renal function.
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Affiliation(s)
- Takahiro Masuda
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Ken Ohara
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Volker Vallon
- Division of Nephrology and Hypertension, Departments of Medicine and Pharmacology, University of California-San Diego and Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
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Tanaka A, Imai T, Shimabukuro M, Taguchi I, Sezai A, Toyoda S, Watada H, Ako J, Node K. Association between serum insulin levels and heart failure-related parameters in patients with type 2 diabetes and heart failure treated with canagliflozin: a post-hoc analysis of the randomized CANDLE trial. Cardiovasc Diabetol 2022; 21:151. [PMID: 35941584 PMCID: PMC9358857 DOI: 10.1186/s12933-022-01589-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 08/01/2022] [Indexed: 11/10/2022] Open
Abstract
Background Insulin resistance and hyperinsulinemia in patients with type 2 diabetes (T2D) are adversely associated with the development and worsening of heart failure (HF). Herein, we sought to investigate the effect of canagliflozin on insulin concentrations and the associations of changes in insulin concentrations with HF-related clinical parameters in patients with T2D and HF. Methods This was a post-hoc analysis of the investigator-initiated, multicenter, open-label, randomized, controlled CANDLE trial for patients with T2D and chronic HF (UMIN000017669). The endpoints were the effects of 24 weeks of canagliflozin treatment, relative to glimepiride treatment, on insulin concentrations and the relationship between changes in insulin concentrations and clinical parameters of interest, including New York Heart Association (NYHA) classification. The effects of canagliflozin on those parameters were also analyzed by baseline insulin level. Results Among the participants in the CANDLE trial, a total of 129 patients (canagliflozin, n = 64; glimepiride, n = 65) who were non-insulin users with available serum insulin data both at baseline and week 24 were included in this analysis. Overall, the mean age was 69.0 ± 9.4 years; 75% were male; the mean HbA1c was 6.8 ± 0.7%; and the mean left ventricular ejection fraction was 59.0 ± 14.1%, with parameters roughly balanced between treatment groups. Canagliflozin treatment significantly reduced insulin concentrations at week 24 (p < 0.001), and the between-group difference (canagliflozin minus glimepiride) in those changes was − 3.52 mU/L (95% confidence interval, − 4.85 to − 2.19; p < 0.001). Decreases in insulin concentrations, irrespective of baseline insulin level, were significantly associated with improvement in NYHA class in patients treated with canagliflozin. Conclusion Our findings suggest that canagliflozin treatment in patients with T2D and HF ameliorated excess insulin overload, contributing to the improvement of clinical HF status. Trial registration: University Medical Information Network Clinical Trial Registry, number 000017669, Registered on May 25, 2015. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-022-01589-3.
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Affiliation(s)
- Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan.
| | - Takumi Imai
- Department of Medical Statistics, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Michio Shimabukuro
- Department of Diabetes, Endocrinology, and Metabolism, Fukushima Medical University, Fukushima, Japan
| | - Isao Taguchi
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Akira Sezai
- Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Shigeru Toyoda
- Department of Cardiovascular Medicine, Dokkyo Medical University School of Medicine, Mibu, Japan
| | - Hirotaka Watada
- Department of Metabolism & Endocrinology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan.
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Shen X, Shen X. Promise of sodium-glucose co-transporter-2 inhibitors in heart failure with mildly reduced ejection fraction. ESC Heart Fail 2022; 9:2239-2248. [PMID: 35642772 PMCID: PMC9288809 DOI: 10.1002/ehf2.14005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/14/2022] [Accepted: 05/19/2022] [Indexed: 12/03/2022] Open
Abstract
Heart failure with mildly reduced ejection fraction (HFmrEF) is associated with comparable poor outcomes as other subtypes of heart failure and remains a medical unmet need due to the paucity of effective therapies. According to large cardiovascular (CV) outcome trials in patients with heart failure, sodium-glucose co-transporter-2 inhibitors (SGLT2is) reduce CV mortality and hospitalizations for heart failure in patients with heart failure across the spectrum of left ventricular ejection fraction (LVEF). There has been a lack of dedicated trials in HFmrEF. However, several large outcome trials in heart failure that enrolled patients with HFmrEF could provide a hint on the role of SGLT2is in this subgroup. This review focuses on CV effects of three major SGLT2is-dapagliflozin, empagliflozin, and sotagliflozin-in patients with HFmrEF. A narrative review of trials investigating the efficacy of each medication in treating heart failure with LVEF > 40% is provided with a focus on their LVEF subgroup analyses. The purpose of this review is to discuss the current state of evidence regarding the potential of SGLT2is in HFmrEF management. Current limited evidence suggests that SGLT2is might be a favourable treatment modality for patients with HFmrEF to reduce hospitalization for heart failure and CV mortality. This conclusion needs to be further supported by clear HFmrEF subgroup analysis of the existing trials. Further outcome trials involving sufficient patients with different subtypes of HFmrEF are needed to confirm and assess CV benefits of SGLT2is in HFmrEF. Possible mechanisms by which SGLT2is exert their cardioprotective effect are also described briefly.
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Affiliation(s)
- Xizi Shen
- Faculty of MedicineThe University of QueenslandBrisbaneAustralia
| | - Xingping Shen
- Department of EndocrinologyZhongshan Hospital of Xiamen University, School of Medicine, Xiamen UniversityXiamenChina
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van Ruiten CC, Smits MM, Kok MD, Serné EH, van Raalte DH, Kramer MHH, Nieuwdorp M, IJzerman RG. Mechanisms underlying the blood pressure lowering effects of dapagliflozin, exenatide, and their combination in people with type 2 diabetes: a secondary analysis of a randomized trial. Cardiovasc Diabetol 2022; 21:63. [PMID: 35484607 PMCID: PMC9052512 DOI: 10.1186/s12933-022-01492-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/08/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) lower blood pressure (BP). When SGLT2i and GLP-1RA are combined, synergistic effects on BP have been observed. The mechanisms underlying these BP reductions are incompletely understood. The aim of this study was to assess the mechanisms underlying the BP reduction with the SGLT2i dapagliflozin, GLP-1RA exenatide, and dapagliflozin-exenatide compared with placebo in people with obesity and type 2 diabetes. METHODS Sixty-six people with type 2 diabetes were randomized to 16 weeks of dapagliflozin 10 mg/day, exenatide 10 µg twice daily, dapagliflozin-exenatide, or placebo treatment. The effect of treatments on estimates of: (1) plasma volume (calculated by Strauss formula, bioimpedance spectroscopy, hematocrit, (2) autonomic nervous system activity (heart rate variability), (3) arterial stiffness (pulse wave applanometry), (4) systemic hemodynamic parameters including peripheral vascular resistance, cardiac output and stroke volume (all derived from non-invasively systemic hemodynamic monitoring), and (5) natriuresis (24-hour urine collection) were assessed after 10 days and 16 weeks of treatment. RESULTS After 10 days, dapagliflozin reduced systolic BP (SBP) by - 4.7 mmHg, and reduced plasma volume. After 16 weeks, dapagliflozin reduced SBP by - 4.4 mmHg, and reduced sympathetic nervous system (SNS) activity. Exenatide had no effect on SBP, but reduced parasympathetic nervous system activity after 10 days and 16 weeks. After 10 days, dapagliflozin-exenatide reduced SBP by - 4.2 mmHg, and reduced plasma volume. After 16 weeks, dapagliflozin-exenatide reduced SBP by - 6.8 mmHg, and the reduction in plasma volume was still observed, but SNS activity was unaffected. CONCLUSIONS The dapagliflozin-induced plasma volume contraction may contribute to the initial SBP reduction, while a reduction in SNS activity may contribute to the persistent SBP reduction. Dapagliflozin-exenatide resulted in the largest decrease in SBP. The effect on plasma volume was comparable to dapagliflozin monotherapy, and SNS activity was not reduced, therefore other mechanisms are likely to contribute to the blood pressure lowering effect of this combination, which need further investigation. Trial registration Clinicaltrials.gov, NCT03361098.
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Affiliation(s)
- Charlotte C van Ruiten
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands.
- Department of Internal Medicine, Amsterdam Diabetes Center, Amsterdam University Medical Centers (Amsterdam UMC), Location VU University Medical Center (VUMC), De Boelelaan 1117 (room ZH 4A63), 1081 HV, Amsterdam, The Netherlands.
| | - Mark M Smits
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands
| | - Megan D Kok
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands
| | - Erik H Serné
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands
- Department of Vascular Medicine, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands
| | - Daniël H van Raalte
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands
| | - Mark H H Kramer
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands
| | - Max Nieuwdorp
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands
- Department of Vascular Medicine, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Richard G IJzerman
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands
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Chrysant SG, Chrysant GS. Beneficial cardiovascular and remodeling effects of SGLT2 inhibitors: pathophysiologic mechanisms. Expert Rev Cardiovasc Ther 2022; 20:223-232. [PMID: 35320057 DOI: 10.1080/14779072.2022.2057949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The intent of this paper is to review the data regarding the multipotential effects of the sodium-glucose cotransporter 2 (SGLT 2) inhibitors, their cardiovascular protective effects, and their mechanism of action. AREAS COVERED The SGLT2 inhibitors exert their beneficial antidiabetic and cardioprotective effects through increased glucose excretion from the kidneys, blood pressure and weight lowering, vasodilation and other potential beneficial effects. They have been used for the treatment of patients with type 2 diabetes mellitus (T2DM) as well as in patients with cardiovascular disease (CVD), coronary artery disease (CAD),and heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). In order to get a better understanding of their mechanism of action for their multiple cardiovascular protective effects, a Medline search of the English language literature was conducted between 2015 and February 2022 and 46 pertinent papers were selected. EXPERT OPINION The analysis of data clearly demonstrated that the use of the SGLT2 inhibitors besides their antidiabetic effects, provide additional protection against CVD, CAD, and HFrEF and HFpEF, and death, but not stroke, in both diabetic and non-diabetic patients. Therefore, they should be preferably used for the treatment of patients with T2DM with preexisting CVD, CAD, and HFrEF and HFpEF.
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Affiliation(s)
- Steven G Chrysant
- Department of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
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Nakashima M, Miyoshi T, Ejiri K, Kihara H, Hata Y, Nagano T, Takaishi A, Toda H, Nanba S, Nakamura Y, Akagi S, Sakuragi S, Minagawa T, Kawai Y, Nishii N, Fuke S, Yoshikawa M, Nakamura K, Ito H. Effects of luseogliflozin on estimated plasma volume in patients with heart failure with preserved ejection fraction. ESC Heart Fail 2022; 9:712-720. [PMID: 35267246 PMCID: PMC8787977 DOI: 10.1002/ehf2.13683] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/05/2021] [Indexed: 12/11/2022] Open
Abstract
AIMS Sodium glucose co-transporter 2 inhibitors have diuretic effects in both patients with glycosuria and with natriuresis. We sought to assess the effect of luseogliflozin on estimated plasma volume (ePV) in patients with type 2 diabetes and heart failure with preserved ejection fraction (HFpEF). METHODS AND RESULTS This study was a post-hoc analysis of the MUSCAT-HF trial (UMIN000018395), a multicentre, prospective, open-label, randomized controlled trial that assessed the effect of 12 weeks of luseogliflozin (2.5 mg, once daily, n = 83) as compared with voglibose (0.2 mg, three times daily, n = 82) on the reduction in brain natriuretic peptide (BNP) in patients with type 2 diabetes and HFpEF. The analysis compared the change in ePV calculated by the Straus formula from baseline to Weeks 4, 12, and 24, using a mixed-effects model for repeated measures. We also estimated the association between changes in ePV and changes in other clinical parameters, including BNP levels. Luseogliflozin significantly reduced ePV as compared to voglibose at Week 4 {adjusted mean group-difference -6.43% [95% confidence interval (CI): -9.11 to -3.74]}, at Week 12 [-8.73% (95%CI: -11.40 to -6.05)], and at Week 24 [-11.02% (95%CI: -13.71 to -8.33)]. The effect of luseogliflozin on these parameters was mostly consistent across various patient clinical characteristics. The change in ePV at Week 12 was significantly associated with log-transformed BNP (r = 0.197, P = 0.015) and left atrial volume index (r = 0.283, P = 0.019). CONCLUSIONS Luseogliflozin significantly reduced ePV in patients with type 2 diabetes and HFpEF, as compared with voglibose. The reduction of intravascular volume by luseogliflozin may provide clinical benefits to patients with type 2 diabetes and HFpEF.
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Affiliation(s)
- Mitsutaka Nakashima
- Department of Cardiovascular MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences2‐5‐1 Shikata‐cho, Kita‐kuOkayama700‐8558Japan
| | - Toru Miyoshi
- Department of Cardiovascular MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences2‐5‐1 Shikata‐cho, Kita‐kuOkayama700‐8558Japan
| | - Kentaro Ejiri
- Department of Cardiovascular MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences2‐5‐1 Shikata‐cho, Kita‐kuOkayama700‐8558Japan
- Department of Internal MedicineTamano City HospitalOkayamaJapan
| | - Hajime Kihara
- Department of Internal MedicineKihara Cardiovascular ClinicAsahikawaJapan
| | - Yoshiki Hata
- Department of CardiologyMinamino Cardiovascular HospitalHachiojiJapan
| | | | | | - Hironobu Toda
- Department of Cardiovascular MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences2‐5‐1 Shikata‐cho, Kita‐kuOkayama700‐8558Japan
- Department of Internal MedicineOkayama East Neurosurgery HospitalOkayamaJapan
| | - Seiji Nanba
- Department of CardiologyOkayama Rosai HospitalOkayamaJapan
| | - Yoichi Nakamura
- Department of Cardiovascular MedicineSpecified Clinic of Soyokaze CardioVascular Medicine and Diabetes CareMatsuyamaJapan
| | - Satoshi Akagi
- Department of Internal MedicineAkaiwa Medical Association HospitalOkayamaJapan
| | - Satoru Sakuragi
- Department of Cardiovascular MedicineIwakuni Clinical CenterIwakuniJapan
| | - Taro Minagawa
- Department of Internal MedicineMinagawa Cardiovascular ClinicGifuJapan
| | - Yusuke Kawai
- Department of Cardiovascular MedicineOkayama City HospitalOkayamaJapan
| | - Nobuhiro Nishii
- Department of Cardiovascular MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences2‐5‐1 Shikata‐cho, Kita‐kuOkayama700‐8558Japan
- Department of Internal MedicineYoshinaga HospitalBizenJapan
| | - Soichiro Fuke
- Department of Cardiovascular MedicineJapanese Red Cross Okayama HospitalOkayamaJapan
| | | | - Kazufumi Nakamura
- Department of Cardiovascular MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences2‐5‐1 Shikata‐cho, Kita‐kuOkayama700‐8558Japan
| | - Hiroshi Ito
- Department of Cardiovascular MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences2‐5‐1 Shikata‐cho, Kita‐kuOkayama700‐8558Japan
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Kobayashi M, Douair A, Coiro S, Giacomin G, Bassand A, Jaeger D, Duarte K, Huttin O, Zannad F, Rossignol P, Chouihed T, Girerd N. A Combination of Chest Radiography and Estimated Plasma Volume May Predict In-Hospital Mortality in Acute Heart Failure. Front Cardiovasc Med 2022; 8:752915. [PMID: 35087878 PMCID: PMC8787280 DOI: 10.3389/fcvm.2021.752915] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/16/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Patients with heart failure (HF) often display dyspnea associated with pulmonary congestion, along with intravascular congestion, both may result in urgent hospitalization and subsequent death. A combination of radiographic pulmonary congestion and plasma volume might screen patients with a high risk of in-hospital mortality in the emergency department (ED). Methods: In the pathway of dyspneic patients in emergency (PARADISE) cohort, patients admitted for acute HF were stratified into 4 groups based on high or low congestion score index (CSI, ranging from 0 to 3, high value indicating severe congestion) and estimated plasma volume status (ePVS) calculated from hemoglobin/hematocrit. Results: In a total of 252 patients (mean age, 81.9 years; male, 46.8%), CSI and ePVS were not correlated (Spearman rho <0 .10, p > 0.10). High CSI/high ePVS was associated with poorer renal function, but clinical congestion markers (i.e., natriuretic peptide) were comparable across CSI/ePVS categories. High CSI/high ePVS was associated with a four-fold higher risk of in-hospital mortality (adjusted-OR, 95%CI = 4.20, 1.10-19.67) compared with low CSI/low ePVS, whereas neither high CSI nor ePVS alone was associated with poor prognosis (all-p-value > 0.10; Pinteraction = 0.03). High CSI/high ePVS improved a routine risk model (i.e., natriuretic peptide and lactate)(NRI = 46.9%, p = 0.02), resulting in high prediction of risk of in-hospital mortality (AUC = 0.85, 0.82-0.89). Conclusion: In patients hospitalized for acute HF with relatively old age and comorbidity burdens, a combination of CSI and ePVS was associated with a risk of in-hospital death, and improved prognostic performance on top of a conventional risk model.
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Affiliation(s)
- Masatake Kobayashi
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM 1116, Nancy, France
- F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists Network, Nancy, France
- CHRU Nancy, F-CRIN INI-CRCT, Nancy, France
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Amine Douair
- Emergency Department, University Hospital of Nancy, Nancy, France
| | - Stefano Coiro
- Division of Cardiology, University of Perugia, Perugia, Italy
| | - Gaetan Giacomin
- Emergency Department, University Hospital of Nancy, Nancy, France
| | - Adrien Bassand
- Emergency Department, University Hospital of Nancy, Nancy, France
| | - Déborah Jaeger
- Emergency Department, University Hospital of Nancy, Nancy, France
| | - Kevin Duarte
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM 1116, Nancy, France
- F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists Network, Nancy, France
- CHRU Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Olivier Huttin
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM 1116, Nancy, France
- F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists Network, Nancy, France
- CHRU Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Faiez Zannad
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM 1116, Nancy, France
- F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists Network, Nancy, France
- CHRU Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Patrick Rossignol
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM 1116, Nancy, France
- F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists Network, Nancy, France
- CHRU Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Tahar Chouihed
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM 1116, Nancy, France
- F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists Network, Nancy, France
- CHRU Nancy, F-CRIN INI-CRCT, Nancy, France
- Emergency Department, University Hospital of Nancy, Nancy, France
| | - Nicolas Girerd
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM 1116, Nancy, France
- F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists Network, Nancy, France
- CHRU Nancy, F-CRIN INI-CRCT, Nancy, France
- *Correspondence: Nicolas Girerd
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Lin KJ, Wang TJ, Chen SD, Lin KL, Liou CW, Lan MY, Chuang YC, Chuang JH, Wang PW, Lee JJ, Wang FS, Lin HY, Lin TK. Two Birds One Stone: The Neuroprotective Effect of Antidiabetic Agents on Parkinson Disease-Focus on Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors. Antioxidants (Basel) 2021; 10:antiox10121935. [PMID: 34943038 PMCID: PMC8750793 DOI: 10.3390/antiox10121935] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 11/25/2021] [Accepted: 11/29/2021] [Indexed: 12/13/2022] Open
Abstract
Parkinson's disease (PD) is the second most common neurodegenerative disease after Alzheimer's disease affecting more than 1% of the population over 65 years old. The etiology of the disease is unknown and there are only symptomatic managements available with no known disease-modifying treatment. Aging, genes, and environmental factors contribute to PD development and key players involved in the pathophysiology of the disease include oxidative stress, mitochondrial dysfunction, autophagic-lysosomal imbalance, and neuroinflammation. Recent epidemiology studies have shown that type-2 diabetes (T2DM) not only increased the risk for PD, but also is associated with PD clinical severity. A higher rate of insulin resistance has been reported in PD patients and is suggested to be a pathologic driver in this disease. Oral diabetic drugs including sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and dipeptidyl peptidase-4 (DPP-4) inhibitors have been shown to provide neuroprotective effects in both PD patients and experimental models; additionally, antidiabetic drugs have been demonstrated to lower incidence rates of PD in DM patients. Among these, the most recently developed drugs, SGLT2 inhibitors may provide neuroprotective effects through improving mitochondrial function and antioxidative effects. In this article, we will discuss the involvement of mitochondrial-related oxidative stress in the development of PD and potential benefits provided by antidiabetic agents especially focusing on sglt2 inhibitors.
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Affiliation(s)
- Kai-Jung Lin
- Center for Mitochondrial Research and Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Department of Family Medicine, National Taiwan University Hospital, Taipei 100225, Taiwan
| | - Tzu-Jou Wang
- Center for Mitochondrial Research and Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Department of Pediatric, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Shang-Der Chen
- Center for Mitochondrial Research and Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Center of Parkinson's Disease, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Kai-Lieh Lin
- Center for Mitochondrial Research and Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Chia-Wei Liou
- Center for Mitochondrial Research and Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Center of Parkinson's Disease, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Min-Yu Lan
- Center for Mitochondrial Research and Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Center of Parkinson's Disease, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Yao-Chung Chuang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Center of Parkinson's Disease, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Jiin-Haur Chuang
- Center for Mitochondrial Research and Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Department of Pediatric Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Pei-Wen Wang
- Center for Mitochondrial Research and Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Department of Metabolism, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Jong-Jer Lee
- Center for Mitochondrial Research and Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Department of Ophthalmology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Feng-Sheng Wang
- Center for Mitochondrial Research and Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Department of Medical Research, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
| | - Hung-Yu Lin
- Center for Mitochondrial Research and Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Research Assistant Center, Show Chwan Memorial Hospital, Changhua 500, Taiwan
| | - Tsu-Kung Lin
- Center for Mitochondrial Research and Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Center of Parkinson's Disease, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
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Matsuba I, Takihata M, Takai M, Maeda H, Kubota A, Iemitsu K, Umezawa S, Obana M, Kaneshiro M, Kawata T, Takuma T, Takeda H, Machimura H, Mokubo A, Motomiya T, Asakura T, Kikuchi T, Matsuzawa Y, Ito S, Miyakawa M, Terauchi Y, Kanamori A. Effects of 1-year treatment with canagliflozin on body composition and total body water in patients with type 2 diabetes. Diabetes Obes Metab 2021; 23:2614-2622. [PMID: 34338409 DOI: 10.1111/dom.14508] [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: 06/17/2021] [Revised: 07/22/2021] [Accepted: 07/28/2021] [Indexed: 01/14/2023]
Abstract
AIM To characterize the long-term changes in body composition associated with sodium-glucose cotransporter-2 (SGLT2) inhibitors. MATERIALS AND METHODS In this multicentre, single-arm, open-label study, 107 patients with type 2 diabetes were treated with canagliflozin 100 mg, as add-on therapy, for 12 months. Body composition was measured with a body composition analyser (T-SCAN PLUS) using the impedance method to prospectively analyse changes in body components, including percentage of body fat, body fat mass, total body water, muscle mass and mineral mass. Estimated plasma volume (PV) was calculated using the Kaplan formula. RESULTS Body weight showed a significant decrease from 1 month to 12 months of treatment with canagliflozin, with a higher rate of decrease in body fat in body composition. A significant decrease in mineral mass was also observed, but its rate was low. Following treatment with canagliflozin, changes in total body water did not affect intracellular water, and a significant decrease in extracellular water, including plasma components, was observed early and was sustained up to 12 months. Protein mass, a component of muscle mass, was not affected, with only a slight decrease in water volume observed. CONCLUSIONS Canagliflozin decreased extracellular fluid and PV in addition to decreasing fat in the body via calorie loss resulting from urinary glucose excretion. This study suggested that SGLT2 inhibitors might reduce body weight by regulating fat mass or water distribution in the body and might have cardiac and renal protective effects by resetting the homeostasis of fluid balance.
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Affiliation(s)
- Ikuro Matsuba
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Masahiro Takihata
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Masahiko Takai
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Hajime Maeda
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Akira Kubota
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Kotaro Iemitsu
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Shinichi Umezawa
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Mitsuo Obana
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Mizuki Kaneshiro
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Takehiro Kawata
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Tetsuo Takuma
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Hiroshi Takeda
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Hideo Machimura
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Atsuko Mokubo
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Tetsuya Motomiya
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Taro Asakura
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Taisuke Kikuchi
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Yoko Matsuzawa
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Shogo Ito
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Masaaki Miyakawa
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Yasuo Terauchi
- Department of Endocrinology and Metabolism, Yokohama City University, Yokohama, Japan
| | - Akira Kanamori
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
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Lund SS, Sattar N, Salsali A, Neubacher D, Ginsberg HN. Potential contribution of haemoconcentration to changes in lipid variables with empagliflozin in patients with type 2 diabetes: A post hoc analysis of pooled data from four phase 3 randomized clinical trials. Diabetes Obes Metab 2021; 23:2763-2774. [PMID: 34463415 PMCID: PMC9290508 DOI: 10.1111/dom.14534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/10/2021] [Accepted: 08/24/2021] [Indexed: 01/24/2023]
Abstract
AIM To examine the association between changes in lipids and markers of haemoconcentration (haematocrit and serum albumin) with empagliflozin, a sodium-glucose co-transporter-2 inhibitor, in patients with type 2 diabetes (T2D) using pooled data from four phase 3 randomized trials. MATERIALS AND METHODS Patients with T2D received placebo (n = 825), empagliflozin 10 mg (n = 830) or 25 mg (n = 822) for 24 weeks. In post hoc mediation analyses, we assessed total changes in LDL-cholesterol, HDL-cholesterol, triglycerides, apolipoprotein (Apo) B, and Apo A-I, and changes in these variables associated with, and independent of, changes in haematocrit and serum albumin at week 24 using ANCOVA models. RESULTS Empagliflozin versus placebo increased serum LDL-cholesterol, HDL-cholesterol, and Apo A-I, decreased triglycerides (empagliflozin 10 mg only), and (non-significantly) increased Apo B. Empagliflozin modestly increased haematocrit and serum albumin. In mediation analyses, haematocrit changes (increases) with empagliflozin were associated with significant changes (increases) in all lipid variables, including Apo B. Except for triglycerides (non-significant), similar lipid variable associations were observed with serum albumin changes. Haematocrit- and serum albumin-independent changes in lipids with empagliflozin were significant for HDL-cholesterol (increases), mostly significant for triglycerides (decreases), and less so for other lipid fractions. CONCLUSION Haematocrit and serum albumin increases were associated with increases in lipid fractions with empagliflozin. Empagliflozin-associated changes in serum lipids, particularly LDL-cholesterol increases, may be partly attributable to haemoconcentration resulting from increased urinary volume and subsequent volume contraction.
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Affiliation(s)
- Søren S. Lund
- Boehringer Ingelheim International GmbHIngelheimGermany
| | | | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, IncRidgefieldConnecticutUSA
| | | | - Henry N. Ginsberg
- Vagelos College of Physicians and Surgeons of Columbia UniversityNew YorkNew YorkUSA
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Afzal M, Al-Abbasi FA, Nadeem MS, Alshehri S, Ghoneim MM, Imam SS, Almalki WH, Kazmi I. Sodium-Glucose Cotransporter-2 Inhibitors Improve Cardiovascular Dysfunction in Type 2 Diabetic East Asians. Metabolites 2021; 11:794. [PMID: 34822452 PMCID: PMC8622829 DOI: 10.3390/metabo11110794] [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: 09/29/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 11/22/2022] Open
Abstract
In East Asians, the incidence of type 2 DM (T2DM) has increased as a result of major alterations in life. Cardiovascular problems are more likely in those with T2DM. Sodium-glucose cotransporter-2 (SGLT2) inhibitors are novel insulin-independent antihyperglycemic drugs that limit renal glucose reabsorption and thereby improve glycemic control. They are used alone or in combination with insulin and other antihyperglycemic medications to treat diabetes, and they are also helpful in protecting against the progression of complications. This review has evaluated the available evidence not only on the efficacy of SGLT2 inhibitors in T2DM, but also on their favourable cardiovascular events in East Asians. DM is an independent risk factor for cardiovascular diseases. As a result, in addition to glycemic control in diabetes management, the therapeutic goal in East Asian diabetic patients should be to improve adverse cardiovascular outcomes. Besides establishing antidiabetic effects, several studies have reported cardioprotective benefits of SGLT2 inhibitors via numerous pathways. SGLT2 inhibitors show promising antidiabetic drugs with potential cardiovascular advantages, given that a high number of diabetic patients in East Asia have co-existing cardiovascular disorders. Despite significant positive results in favour of SGLT2, more research is needed to determine how SGLT2 inhibitors exert these impressive cardiovascular effects.
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Affiliation(s)
- Muhammad Afzal
- Department of Pharmacology, College of Pharmacy, Jouf University, Sakaka 72341, Saudi Arabia;
| | - Fahad A. Al-Abbasi
- Department of Biochemistry, Faculty of Science, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (F.A.A.-A.); (M.S.N.)
| | - Muhammad Shahid Nadeem
- Department of Biochemistry, Faculty of Science, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (F.A.A.-A.); (M.S.N.)
| | - Sultan Alshehri
- Department of Pharmaceutics, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia; (S.A.); (S.S.I.)
| | - Mohammed M. Ghoneim
- Department of Pharmacy Practice, College of Pharmacy, AlMaarefa University, Ad Diriyah 13713, Saudi Arabia;
| | - Syed Sarim Imam
- Department of Pharmaceutics, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia; (S.A.); (S.S.I.)
| | - Waleed Hassan Almalki
- Department of Pharmacology, College of Pharmacy, Umm Al-Qura University, Makkah 21955, Saudi Arabia;
| | - Imran Kazmi
- Department of Pharmacology, College of Pharmacy, Jouf University, Sakaka 72341, Saudi Arabia;
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Abstract
Patients with type 2 diabetes mellitus (T2D) are at increased risk of cardiovascular (CV) disease. Sodium glucose cotransporter 2 (SGLT2) inhibitors, also known as gliflozins, are a class of medications used to treat T2D by preventing the reabsorption of glucose filtered through the kidney and thereby facilitating glucose excretion in the urine. Over the past 5 years, many cardiovascular outcome trials (CVOTs) have evaluated the safety and efficacy of SGLT2 inhibitors in preventing CV events. The results of 7 CVOTs have provided solid evidence that the use of SGLT2 in patients with T2D and at high CV risk significantly reduced the risk of death from CV causes. Moreover, in patient with heart failure with reduced ejection fraction, regardless of the presence or absence of T2D, SGLT2 inhibitors use significantly reduced the risk of worsening heart failure and death from CV causes. Although the exact mechanism of the cardiorenal benefit of SGLT2 inhibitors is still unknown, studies have shown that the beneficial effect of these drugs cannot be exclusively explained by their glucose lowering effect, and several possible mechanisms have been proposed. This review will explore the changing role of SGLT2 inhibitors from a diabetes drug to clinical practice guideline-supported therapy for the prevention and treatment of CV diseases, including heart failure.
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Affiliation(s)
- Reza Mohebi
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - James L Januzzi
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Baim Institute for Clinical Research, Boston, MA, USA
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Chen J, Shen J, Cai D, Wei T, Qian R, Zeng C, Lyu L. Estimated plasma volume status (ePVS) is a predictor for acute myocardial infarction in-hospital mortality: analysis based on MIMIC-III database. BMC Cardiovasc Disord 2021; 21:530. [PMID: 34749646 PMCID: PMC8573972 DOI: 10.1186/s12872-021-02338-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 10/20/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Estimated plasma volume status (ePVS) has been reported that associated with poor prognosis in heart failure patients. However, no researchinvestigated the association of ePVS and prognosis in patients with acute myocardial infarction (AMI). Therefore, we aimed to determine the association between ePVS and in-hospital mortality in AMI patients. METHODS AND RESULTS We extracted AMI patients data from MIMIC-III database. A generalized additive model and logistic regression model were used to demonstrate the association between ePVS levels and in-hospital mortality in AMI patients. Kaplan-Meier survival analysis was used to pooled the in-hospital mortality between the various group. ROC curve analysis were used to assessed the discrimination of ePVS for predicting in-hospital mortality. 1534 eligible subjects (1004 males and 530 females) with an average age of 67.36 ± 0.36 years old were included in our study finally. 136 patients (73 males and 63 females) died in hospital, with the prevalence of in-hospital mortality was 8.9%. The result of the Kaplan-Meier analysis showed that the high-ePVS group (ePVS ≥ 5.28 mL/g) had significant lower survival possibility in-hospital admission compared with the low-ePVS group (ePVS < 5.28 mL/g). In the unadjusted model, high-level of ePVS was associated with higher OR (1.09; 95% CI 1.06-1.12; P < 0.001) compared with low-level of ePVS. After adjusted the vital signs data, laboratory data, and treatment, high-level of ePVS were also associated with increased OR of in-hospital mortality, 1.06 (95% CI 1.03-1.09; P < 0.001), 1.05 (95% CI 1.01-1.08; P = 0.009), 1.04 (95% CI 1.01-1.07; P = 0.023), respectively. The ROC curve indicated that ePVS has acceptable discrimination for predicting in-hospital mortality. The AUC value was found to be 0.667 (95% CI 0.653-0.681). CONCLUSION Higher ePVS values, calculated simply from Duarte's formula (based on hemoglobin/hematocrit) was associated with poor prognosis in AMI patients. EPVS is a predictor for predicting in-hospital mortality of AMI, and could help refine risk stratification.
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Affiliation(s)
- Jun Chen
- Zhejiang Chinese Medical University, Hangzhou, 310000 Zhejiang China
| | - Jiayi Shen
- Lishui Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical College, Lishui, 323000 Zhejiang China
| | - Dongsheng Cai
- Zhejiang University of Medical College, Hangzhou, 310000 Zhejiang China
| | - Tiemin Wei
- Lishui Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical College, Lishui, 323000 Zhejiang China
| | - Renyi Qian
- Lishui Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical College, Lishui, 323000 Zhejiang China
| | - Chunlai Zeng
- Lishui Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical College, Lishui, 323000 Zhejiang China
| | - Lingchun Lyu
- Lishui Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical College, Lishui, 323000 Zhejiang China
- Department of Cardiology, Lishui Central Hospital and The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, 323000 China
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Delanaye P, Scheen AJ. The diuretic effects of SGLT2 inhibitors: A comprehensive review of their specificities and their role in renal protection. DIABETES & METABOLISM 2021; 47:101285. [PMID: 34597788 DOI: 10.1016/j.diabet.2021.101285] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/16/2021] [Indexed: 02/08/2023]
Abstract
Sodium-glucose cotransporter type 2 inhibitors (SGLT2is) are new oral glucose-lowering agents that provide cardiovascular and renal protection in both patients with and without type 2 diabetes. Because of their unique mechanism of action, increased glucosuria is associated with osmotic diuresis and some natriuresis, yet the latter seems mostly transient. The potential role of the diuretic effect in overall cardiovascular and renal protection by SGLT2is remains a matter of debate. Precise evaluation of the diuretic effect is not so easy and most studies relied upon indirect estimations that led to divergent results, presumably also explained by different study designs and population characteristics. Everybody agrees upon the fact that SGLT2is are different from other classical diuretics (thiazides and loop diuretics) as they present some favourable properties, i.e. reduced sympathetic activity, preserved potassium balance, lower risk of acute renal injury, decrease of serum uric acid level. The potential role of the diuretic effect of SGLT2is on renal outcomes is still unclear, yet their ability to reduce albuminuria and dampen the risk of heart failure may contribute to improve renal prognosis besides other complex underlying mechanisms. In this comprehensive review we first critically analyse the results obtained with indirect methods that assess a diuretic effect of SGLT2is, second we describe the specificities of the diuretic activity of SGLT2is compared with other classical diuretics, and third we discuss the potential mechanisms by which the diuretic effect of SGLT2is could contribute to the improvement of renal outcomes consistently reported with this innovative amazing pharmacological class.
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Affiliation(s)
- Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium; Department of Nephrology-Dialysis-Apheresis, Hôpital Universitaire Carémeau, Nimes, France
| | - Andre J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium; Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium.
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48
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Sen T, Li J, Neuen BL, Neal B, Arnott C, Parikh CR, Coca SG, Perkovic V, Mahaffey KW, Yavin Y, Rosenthal N, Hansen MK, Heerspink HJL. Effects of the SGLT2 inhibitor canagliflozin on plasma biomarkers TNFR-1, TNFR-2 and KIM-1 in the CANVAS trial. Diabetologia 2021; 64:2147-2158. [PMID: 34415356 PMCID: PMC8423682 DOI: 10.1007/s00125-021-05512-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/19/2021] [Indexed: 01/08/2023]
Abstract
AIMS/HYPOTHESIS Higher plasma concentrations of tumour necrosis factor receptor (TNFR)-1, TNFR-2 and kidney injury molecule-1 (KIM-1) have been found to be associated with higher risk of kidney failure in individuals with type 2 diabetes in previous studies. Whether drugs can reduce these biomarkers is not well established. We measured these biomarkers in samples of the CANVAS study and examined the effect of the sodium-glucose cotransporter 2 inhibitor canagliflozin on these biomarkers and assessed whether the early change in these biomarkers predict cardiovascular and kidney outcomes in individuals with type 2 diabetes in the CANagliflozin cardioVascular Assessment Study (CANVAS). METHODS Biomarkers were measured with immunoassays (proprietary multiplex assay performed by RenalytixAI, New York, NY, USA) at baseline and years 1, 3 and 6. Mixed-effects models for repeated measures assessed the effect of canagliflozin vs placebo on the biomarkers. Associations of baseline levels and the early change (baseline to year 1) for each biomarker with the kidney outcome were assessed using multivariable-adjusted Cox regression. RESULTS In total, 3523/4330 (81.4%) of the CANVAS participants had available samples at baseline. Each doubling in baseline TNFR-1, TNFR-2 and KIM-1 was associated with a higher risk of kidney outcomes, with corresponding HRs of 3.7 (95% CI 2.3, 6.1; p < 0.01), 2.7 (95% CI 2.0, 3.6; p < 0.01) and 1.5 (95% CI 1.2, 1.8; p < 0.01), respectively. Canagliflozin reduced the level of the plasma biomarkers with differences in TNFR-1, TNFR-2 and KIM-1 between canagliflozin and placebo during follow-up of 2.8% (95% CI 3.4%, 1.3%; p < 0.01), 1.9% (95% CI 3.5%, 0.2%; p = 0.03) and 26.7% (95% CI 30.7%, 22.7%; p < 0.01), respectively. Within the canagliflozin treatment group, each 10% reduction in TNFR-1 and TNFR-2 at year 1 was associated with a lower risk of the kidney outcome (HR 0.8 [95% CI 0.7, 1.0; p = 0.02] and 0.9 [95% CI 0.9, 1.0; p < 0.01] respectively), independent of other patient characteristics. The baseline and 1 year change in biomarkers did not associate with cardiovascular or heart failure outcomes. CONCLUSIONS/INTERPRETATION Canagliflozin decreased KIM-1 and modestly reduced TNFR-1 and TNFR-2 compared with placebo in individuals with type 2 diabetes in CANVAS. Early decreases in TNFR-1 and TNFR-2 during canagliflozin treatment were independently associated with a lower risk of kidney disease progression, suggesting that TNFR-1 and TNFR-2 have the potential to be pharmacodynamic markers of response to canagliflozin.
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Affiliation(s)
- Taha Sen
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
| | - Jingwei Li
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Bruce Neal
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Clare Arnott
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | | | - Steven G Coca
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Yshai Yavin
- Janssen Research & Development LLC, Spring House, PA, USA
| | | | | | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands.
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia.
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Rasalam R, Atherton JJ, Deed G, Molloy‐Bland M, Cohen N, Sindone A. Sodium-glucose cotransporter 2 inhibitor effects on heart failure hospitalization and cardiac function: systematic review. ESC Heart Fail 2021; 8:4093-4118. [PMID: 34219407 PMCID: PMC8497341 DOI: 10.1002/ehf2.13483] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/07/2021] [Indexed: 12/17/2022] Open
Abstract
AIMS To systematically review randomized controlled trials assessing effects of sodium-glucose cotransporter 2 inhibitors (SGLT2is) on hospitalization for heart failure (HHF) and cardiac structure/function and explore randomized controlled trial (RCT)-derived evidence for SGLT2i efficacy mechanisms in heart failure (HF). METHODS AND RESULTS Systematic searches of Medline and Embase were performed. In seven trials [3730-17 160 patients; low risk of bias (RoB)], SGLT2is significantly reduced the relative risk of HHF by 27-39% vs. placebo, including in two studies in patients with HF with reduced ejection fraction with or without type-2 diabetes mellitus (T2DM). Improvements in conventional cardiovascular risk factors, including glycaemic levels, cannot account for these effects. Five trials (56-105 patients; low RoB) assessed the effects of 6-12 months of SGLT2i treatment on left ventricular structure/function; four reported significant improvements vs. placebo, and one did not. Five trials (low RoB) assessed SGLT2i treatment effects on serum N-terminal pro B-type natriuretic peptide levels; significant reductions vs. placebo were reported after 8-12 months (two studies; 3730-4744 patients) but not ≤12 weeks (three studies; 80-263 patients). Limited available RCT-derived evidence suggests various possible cardioprotective SGLT2i mechanisms, including improved haemodynamics (natriuresis and reduced interstitial fluid without blood volume contraction/neurohormonal activation) and vascular function, enhanced erythropoiesis, reduced tissue sodium and epicardial fat/inflammation, decreased sympathetic tone, and beneficial changes in cellular energetics. CONCLUSIONS Sodium-glucose cotransporter 2 inhibitors reduce HHF regardless of T2DM status, and reversal of adverse left ventricular remodelling likely contributes to this efficacy. Hypothesis-driven mechanistic trials remain sparse, although numerous trials are planned or ongoing.
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Affiliation(s)
- Roy Rasalam
- College of Medicine & DentistryJames Cook UniversityTownsvilleQLDAustralia
| | - John J. Atherton
- Royal Brisbane and Women's Hospital, Faculty of MedicineUniversity of QueenslandHerstonQLDAustralia
| | - Gary Deed
- Mediwell Medical ClinicCoorparooQLDAustralia
| | | | - Neale Cohen
- Baker Heart and Diabetes InstituteMelbourneVICAustralia
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Effect of canagliflozin on N-terminal pro-brain natriuretic peptide in patients with type 2 diabetes and chronic heart failure according to baseline use of glucose-lowering agents. Cardiovasc Diabetol 2021; 20:175. [PMID: 34479543 PMCID: PMC8417990 DOI: 10.1186/s12933-021-01369-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/21/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk of a deterioration in heart failure (HF) and mortality in patients with a broad range of cardiovascular risks. Recent guidelines recommend considering the use of SGLT2 inhibitors in patients with type 2 diabetes (T2D) and HF, irrespective of their glycemic control status and background use of other glucose-lowering agents including metformin. However, only a small number of studies have investigated whether the effects of SGLT2 inhibitor in these patients differ by the concomitant use of other glucose-lowering agents. METHODS This was a post-hoc analysis of the CANDLE trial (UMIN000017669), an investigator-initiated, multicenter, open-label, randomized, controlled trial. The primary aim of the analysis was to assess the effect of 24 weeks of treatment with canagliflozin, relative to glimepiride, on N-terminal pro-brain natriuretic peptide (NT-proBNP) concentration in patients with T2D and clinically stable chronic HF. In the present analysis, the effect of canagliflozin on NT-proBNP concentration was assessed in the patients according to their baseline use of other glucose-lowering agents. RESULTS Almost all patients in the CANDLE trial presented as clinically stable (New York Heart Association class I to II), with about 70% of participants having HF with a preserved ejection fraction phenotype (defined as a left ventricular ejection fraction ≥ 50%) at baseline. Of the 233 patients randomized to either canagliflozin (100 mg daily) or glimepiride (starting dose 0.5 mg daily), 85 (36.5%) had not been taking any glucose-lowering agents at baseline (naïve). Of the 148 patients who had been taking at least one glucose-lowering agent at baseline (non-naïve), 44 (29.7%) and 127 (85.8%) had received metformin or a dipeptidyl dipeptidase-4 (DPP-4) inhibitor, respectively. The group ratio (canagliflozin vs. glimepiride) of proportional changes in the geometric means of NT-proBNP concentration was 0.95 (95% confidence interval [CI] 0.76 to 1.18, p = 0.618) for the naïve subgroup, 0.92 (95% CI 0.79 to1.07, p = 0.288) for the non-naïve subgroup, 0.90 (95% CI 0.68 to 1.20, p = 0.473) for the metformin-user subgroup, and 0.91 (95% CI 0.77 to 1.08, p = 0.271) for the DPP-4 inhibitor-user subgroup. No heterogeneity in the effect of canagliflozin, relative to glimepiride, on NT-proBNP concentration was observed in the non-naïve subgroups compared to that in the naïve subgroup. CONCLUSION The impact of canagliflozin treatment on NT-proBNP concentration appears to be independent of the background use of diabetes therapy in the patient population examined. Trial registration University Medical Information Network Clinical Trial Registry, number 000017669. Registered on May 25, 2015.
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