Effects of phlorizin on glucose, water and sodium handling by the rat kidney

Cardiovascular benefit of SGLT2 inhibitors

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.

Development and potential role of type-2 sodium-glucose transporter inhibitors for management of type 2 diabetes

There is a recognized need for new treatment options for type 2 diabetes mellitus (T2DM). Recovery of glucose from the glomerular filtrate represents an important mechanism in maintaining glucose homeostasis and represents a novel target for the management of T2DM. Recovery of glucose from the glomerular filtrate is executed principally by the type 2 sodium-glucose cotransporter (SGLT2). Inhibition of SGLT2 promotes glucose excretion and normalizes glycemia in animal models. First reports of specifically designed SGLT2 inhibitors began to appear in the second half of the 1990s. Several candidate SGLT2 inhibitors are currently under development, with four in the later stages of clinical testing. The safety profile of SGLT2 inhibitors is expected to be good, as their target is a highly specific membrane transporter expressed almost exclusively within the renal tubules. One safety concern is that of glycosuria, which could predispose patients to increased urinary tract infections. So far the reported safety profile of SGLT2 inhibitors in clinical studies appears to confirm that the class is well tolerated. Where SGLT2 inhibitors will fit in the current cascade of treatments for T2DM has yet to be established. The expected favorable safety profile and insulin-independent mechanism of action appear to support their use in combination with other antidiabetic drugs. Promotion of glucose excretion introduces the opportunity to clear calories (80-90 g [300-400 calories] of glucose per day) in patients that are generally overweight, and is expected to work synergistically with weight reduction programs. Experience will most likely lead to better understanding of which patients are likely to respond best to SGLT2 inhibitors, and under what circumstances.

Phlorizin prevents glomerular hyperfiltration but not hypertrophy in diabetic rats

The relationships of renal and glomerular hypertrophies to development of hyperfiltration and proteinuria early in streptozotocin-induced diabetes were explored. Control, diabetic, phlorizin-treated controls, and diabetic male Fischer rats were used. Phlorizin (an Na⁺-glucose cotransport inhibitor) was given at a dose sufficient to normalize blood glucose. Inulin clearance (C_inulin) and protein excretion rate (PER) were measured. For morphometry, kidney sections were stained with periodic acid Schiff. At one week, diabetes PER increased 2.8-folds (P < .001), C_inulin increased 80% (P < .01). Kidney wet and dry weights increased 10%–12% (P < .05), and glomerular tuft area increased 9.3% (P < .001). Phlorizin prevented proteinuria, hyperfiltration, and kidney hypertrophy, but not glomerular hypertrophy. Thus, hyperfiltration, proteinuria, and whole kidney hypertrophy were related to hyperglycemia but not to glomerular growth. Diabetic glomerular hypertrophy constitutes an early event in the progression of glomerular pathology which occurs in the absence of mesangial expansion and persists even after changes in protein excretion and GFR are reversed through glycemic control.

Phlorizin-induced glycosuria does not prevent gentamicin nephrotoxicity in rats

Because rats with streptozotocin-induced diabetes mellitus (DM) have a high solute diuresis (glycosuria of 10 to 12 g/day), we have suggested that this may in part be responsible for their resistance to gentamicin-induced acute renal failure (ARF). The protection from gentamicin nephrotoxicity was studied in non-diabetic rats with chronic solute diuresis induced by blockage of tubular glucose reabsorption with phlorizin (P). DM rats with mild glycosuria (similar in degree to that of the P treated animals) were also studied. Unanesthetized adult female, Sprague-Dawley rats were divided in four groups and studied for 15 days. Group 1 (P alone) received P, 360 mg/day, for 15 days; Group II (P + gentamicin); Group III (gentamicin alone) and Group IV (mild DM + gentamicin). Nephrotoxic doses (40 mg/kg body wt/day) of gentamicin were injected during the last nine days of study to the animals of groups II to IV. In Group I, P induced a moderate and stable glycosuria (3.9 +/- 0.1 g/day, SE), and no functional or morphologic evidence of renal dysfunction (baseline CCr 2.1 +/- 0.1 ml/min, undetectable lysozymuria) or damage (tubular necrosis score [maximum 4], zero). In Group II, P did not prevent gentamicin-ARF (maximal decrease in CCr at day 9.89%, P less than 0.001; peak lysozymuria, 1863 +/- 321 micrograms/day; and tubular necrosis score, 3.9 +/- 0.1). These values were not different from those of Group III: maximal decrease in CCr 73% (P less than 0.001); lysozymuria, 2147 +/- 701 micrograms/day; tubular necrosis score, 3.8 +/- 0.1.(ABSTRACT TRUNCATED AT 250 WORDS)

The contribution of gluconeogenesis to glycogen repletion during glucose infusion in endotoxemia

Glycogen repletion rates in liver and skeletal muscle were quantitated, and the contribution of gluconeogenesis to hepatic glycogen repletion and glucose output were determined during glucose infusion in hemodynamically stable endotoxemic animals. Four hours after the injection of endotoxin (or saline), rats were infused with 235 mumol/min/kg of glucose (or saline) containing [6-3H]-glucose for up to four additional hours. Glucose infusion increased the plasma glucose concentration, which plateaued between 14 to 17 mmol/L, in the control rats. The glucose concentration of the endotoxin group receiving glucose was consistently greater than in control rats and failed to reach a plateau. The rate of muscle glycogen synthesis was not altered after endotoxin, but hepatic glycogen repletion was decreased by 55%. The percentage of glycogen repletion derived directly from blood glucose in liver and muscle was similar in control and endotoxin-treated rats receiving glucose. Therefore, the direct incorporation of glucose into glycogen appeared to predominate over the contribution by gluconeogenesis. However, gluconeogenesis continued during the glucose infusion in both control and endotoxemic animals. The calculated rate of total gluconeogenesis was 160% higher in the endotoxin glucose-infused rats compared to the control animals receiving glucose. This increase was due primarily to the attenuated suppression of hepatic glucose output in the endotoxin group (52 +/- 4%) compared to controls (84 +/- 3%). Thus, gluconeogenically derived glucose-6-phosphate appears to be diverted from hepatic glycogen storage to glucose output in endotoxin-treated rats during glucose infusion.

Glucose transport by short loops of Henle in the rat

1. Short loops of Henle were artificially perfused with saline solutions containing 5 or 0 mM-glucose in the presence and absence of phlorizin. 2. Net fluid reabsorption was greater when glucose but no phlorizin was present than in all other series. 3. Glucose was reabsorbed from glucose-containing perfusate and this was abolished by phlorizin. Secretion of glucose occurred into the perfusate which initially contained no glucose and this secretion was enhanced by phlorizin. 4. Sodium reabsorption was inhibited by phlorizin, when glucose was present, but enhanced by phlorizin when glucose was absent. 5. It can be shown that there is secretion of some osmotically active solute in all series. Its secretion is enhanced by phlorizin in the absence of glucose.

Effects of pregnancy on glucose handling by rat kidneys

1. Glomerular filtration rate (g.f.r.), and renal reabsorption and excretion of glucose, sodium and potassium were measured in 7-8 day pregnant rats and age-matched (12-13 week old) virgin controls undergoing saline and glucose infusions. 2. Pregnancy was associated with an increased g.f.r. and a decreased urine flow rate during both infusions. 3. During saline infusion, more glucose was excreted in pregnant animals than in virgins but with no significant difference in fractional reabsorption. During glucose infusion, pregnant animals excreted less glucose than virgins, owing to a decrease in the filtered load but with no significant difference in fractional reabsorption. 4. During both saline and glucose infusion, pregnant animals excreted less sodium than virgin controls. 5. During saline infusion, pregnant animals excreted more potassium. During glucose infusion, pregnant animals excreted less potassium than control animals.

Free-flow reabsorption of glucose, sodium, osmoles and water in rat proximal convoluted tubule

1. Reabsorption of glucose, sodium, total solute (osmoles) and water in the rat proximal tubule (pars convoluta) were studied by free-flow micropuncture at normal (saline-infused), suppressed (saline with phlorizin) and elevated (glucose infusion) glucose reabsorption rates. 2. Phlorizin completely inhibited net glucose reabsorption, approximately halved reabsorption of sodium, total solutes and water, and reduced single nephron glomerular filtration rate (SNGFR). 3. In saline and glucose-infused groups, there were no significant differences between SNGFR nor between reabsorptions (fractional and absolute) of either sodium, total solute or water, which were uniformly distributed along segments assessible to micropuncture. 4. Glucose reabsorptive capacity existed along the entire pars convoluta, with highest reabsorptive rates in convolutions closest to the glomerulus (in saline-infused rats, 90% fractional reabsorption at 2 mm, over 95% at end pars convoluta; in glucose-infused rats, 55 and 90%, respectively). 5. In saline and glucose infused rats, a significant correlation existed between net glucose and sodium reabsorption, but the regression slopes differed and correlations became non-significant when the reabsorptive fluxes were factored by SNGFR. 6. For all groups, the majority of tubular fluid (TF) concentrations of osmoles and sodium were lower than those in plasma (over-all mean TFosm)Posm = 0.973 +/- 0.004, P less than 0.001; TFNa /PNa = 0.964 +/- 0.005, P less than 0.001). 7. Correspondingly, calculated osmolal and sodium concentrations in the reabsorbate were greater than those in plasma, and were significantly correlated with distance to puncture site with maximal values in the most proximal convolutions (for osmolality, approximately +79 m-osmole kg-1 water at 1 mm).

Effects of glucose on water and sodium reabsorption in the proximal convoluted tubule of rat kidney

1. The effects of glucose on sodium and water reabsorption by rat renal proximal tubules was investigated by in situ microperfusion of segments of proximal tubules with solutions containing glucose or no glucose, with and without phlorizin. 2. Absence of glucose did not significantly alter net water flux. Sodium flux was reduced by about 10% but this was not statistically significant. 3. In the absence of glucose in the perfusion fluid net secretion of glucose occurred. 4. Phlorizin reduced either net reabsorption or net secretion of glucose; and net water flux. 5. The data suggest that in later parts of the proximal convoluted tubule some sodium may be co-transported with glucose, but that this represents only a small fraction of the total sodium reabsorption. 6. It is suggested that the glucose carrier is reversible and in appropriate circumstances could cause glucose secretion. 7. Although phlorizin alters net water flux the underlying mechanisms are not clear. 8. The calculated osmolality of the reabsorbate was significantly greater than the perfusate osmolality and greater than plasma osmolality although this was not quite significant statistically.