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Edwards A. Renal handling of albumin in rats with early stage diabetes: A theoretical analysis. J Physiol 2024. [PMID: 38857419 DOI: 10.1113/jp286245] [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: 01/08/2024] [Accepted: 05/20/2024] [Indexed: 06/12/2024] Open
Abstract
In early diabetic nephropathy (DN), recent studies have shown that albuminuria stems mostly from alterations in tubular function rather than from glomerular damage. Several factors in DN, including hyperfiltration, hypertrophy and reduced abundance of the albumin receptors megalin and cubilin, affect albumin endocytosis in the proximal tubule (PT). To assess their respective contribution, we developed a model of albumin handling in the rat PT that couples the transport of albumin to that of water and solutes. Our simulations suggest that, under basal conditions, ∼75% of albumin is retrieved in the S1 segment. The model predicts negligible uptake in S3, as observed experimentally. It also accurately predicts the impact of acute hyperglycaemia on urinary albumin excretion. Simulations reproduce observed increases in albumin excretion in early DN by considering the combined effects of increased glomerular filtration rate (GFR), osmotic diuresis, hypertrophy, and megalin and cubilin downregulation, without stipulating changes in glomerular permselectivity. The results indicate that in isolation, glucose-elicited osmotic diuresis and glucose transporter upregulation raise albumin excretion only slightly. Enlargement of PT diameter not only augments uptake via surface area expansion, but also reduces fluid velocity and thus shear stress-induced stimulation of endocytosis. Overall, our model predicts that downregulation of megalin and cubilin and hyperfiltration both contribute significantly to increasing albumin excretion in rats with early-stage diabetes. The results also suggest that acute sodium-glucose cotransporter 2 inhibition lowers albumin excretion only if GFR decreases sufficiently, and that angiotensin II receptor blockers mitigate urinary albumin loss in early DN in large part by upregulating albumin receptor abundance. KEY POINTS: The urinary excretion of albumin is increased in early diabetic nephropathy (DN). It is difficult to experimentally disentangle the multiple factors that affect the renal handling of albumin in DN. We developed a mathematical model of albumin transport in the rat proximal tubule (PT) to examine the impact of elevated plasma glucose, hyperfiltration, PT hypertrophy and reduced abundance of albumin receptors on albumin uptake and excretion in DN. Our model predicts that glucose-elicited osmotic diuresis per se raises albumin excretion only slightly. Conversely, increases in PT diameter and length favour reduced albumin excretion. Our results suggest that downregulation of the receptors megalin and cubilin in PT cells and hyperfiltration both contribute significantly to increasing albumin excretion in DN. The model helps to better understand the mechanisms underlying urinary loss of albumin in early-stage diabetes, and the impact of specific treatments thereupon.
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Affiliation(s)
- Aurélie Edwards
- Department of Biomedical Engineering, Boston University, Boston, MA, USA
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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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Albalawy WN, Youm EB, Shipman KE, Trull KJ, Baty CJ, Long KR, Rbaibi Y, Wang XP, Fagunloye OG, White KA, Jurczak MJ, Kashlan OB, Weisz OA. SGLT2-independent effects of canagliflozin on NHE3 and mitochondrial complex I activity inhibit proximal tubule fluid transport and albumin uptake. Am J Physiol Renal Physiol 2024; 326:F1041-F1053. [PMID: 38660713 DOI: 10.1152/ajprenal.00005.2024] [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: 01/03/2024] [Revised: 04/03/2024] [Accepted: 04/18/2024] [Indexed: 04/26/2024] Open
Abstract
Beyond glycemic control, SGLT2 inhibitors (SGLT2is) have protective effects on cardiorenal function. Renoprotection has been suggested to involve inhibition of NHE3 leading to reduced ATP-dependent tubular workload and mitochondrial oxygen consumption. NHE3 activity is also important for regulation of endosomal pH, but the effects of SGLT2i on endocytosis are unknown. We used a highly differentiated cell culture model of proximal tubule (PT) cells to determine the direct effects of SGLT2i on Na+-dependent fluid transport and endocytic uptake in this nephron segment. Strikingly, canagliflozin but not empagliflozin reduced fluid transport across cell monolayers and dramatically inhibited endocytic uptake of albumin. These effects were independent of glucose and occurred at clinically relevant concentrations of drug. Canagliflozin acutely inhibited surface NHE3 activity, consistent with a direct effect, but did not affect endosomal pH or NHE3 phosphorylation. In addition, canagliflozin rapidly and selectively inhibited mitochondrial complex I activity. Inhibition of mitochondrial complex I by metformin recapitulated the effects of canagliflozin on endocytosis and fluid transport, whereas modulation of downstream effectors AMPK and mTOR did not. Mice given a single dose of canagliflozin excreted twice as much urine over 24 h compared with empagliflozin-treated mice despite similar water intake. We conclude that canagliflozin selectively suppresses Na+-dependent fluid transport and albumin uptake in PT cells via direct inhibition of NHE3 and of mitochondrial function upstream of the AMPK/mTOR axis. These additional targets of canagliflozin contribute significantly to reduced PT Na+-dependent fluid transport in vivo.NEW & NOTEWORTHY Reduced NHE3-mediated Na+ transport has been suggested to underlie the cardiorenal protection provided by SGLT2 inhibitors. We found that canagliflozin, but not empagliflozin, reduced NHE3-dependent fluid transport and endocytic uptake in cultured proximal tubule cells. These effects were independent of SGLT2 activity and resulted from inhibition of mitochondrial complex I and NHE3. Studies in mice are consistent with greater effects of canagliflozin versus empagliflozin on fluid transport. Our data suggest that these selective effects of canagliflozin contribute to reduced Na+-dependent transport in proximal tubule cells.
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Affiliation(s)
- Wafaa N Albalawy
- Department of Human Genetics, Pitt Public Health, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Elynna B Youm
- Department of Human Genetics, Pitt Public Health, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Katherine E Shipman
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Keelan J Trull
- Department of Chemistry and Biochemistry, University of Notre Dame, South Bend, Indiana, United States
| | - Catherine J Baty
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Kimberly R Long
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Youssef Rbaibi
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Xue-Ping Wang
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Olayemi G Fagunloye
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Katharine A White
- Department of Chemistry and Biochemistry, University of Notre Dame, South Bend, Indiana, United States
| | - Michael J Jurczak
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Ossama B Kashlan
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Ora A Weisz
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
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Castro PC, Santos-Rios TM, Martins FL, Crajoinas RO, Caetano MV, Lessa LMA, Luchi WM, McCormick JA, Girardi ACC. Renal upregulation of NCC counteracts empagliflozin-mediated NHE3 inhibition in normotensive but not in hypertensive male rat. Am J Physiol Cell Physiol 2024; 326:C1573-C1589. [PMID: 38557357 DOI: 10.1152/ajpcell.00351.2023] [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: 07/31/2023] [Revised: 03/21/2024] [Accepted: 03/21/2024] [Indexed: 04/04/2024]
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce blood pressure (BP) in patients with hypertension, yet the precise molecular mechanisms remain elusive. SGLT2i inhibits proximal tubule (PT) NHE3-mediated sodium reabsorption in normotensive rodents, yet no hypotensive effect is observed under this scenario. This study examined the effect of empagliflozin (EMPA) on renal tubular sodium transport in normotensive and spontaneously hypertensive rats (SHRs). It also tested the hypothesis that EMPA-mediated PT NHE3 inhibition in normotensive rats is associated with upregulation of distal nephron apical sodium transporters. EMPA administration for 14 days reduced BP in 12-wk-old SHRs but not in age-matched Wistar rats. PT NHE3 activity was inhibited by EMPA treatment in both Wistar and SHRs. In Wistar rats, EMPA increased NCC activity, mRNA expression, protein abundance, and phosphorylation levels, but not in SHRs. SHRs showed higher NKCC2 activity and an abundance of cleaved ENaC α and γ subunits compared with Wistar rats, none of which were affected by EMPA. Another set of male Wistar rats was treated with EMPA, the NCC inhibitor hydrochlorothiazide (HCTZ), and EMPA combined with HCTZ or vehicle for 14 days. In these rats, BP reduction was observed only with combined EMPA and HCTZ treatment, not with either drug alone. These findings suggest that NCC upregulation counteracts EMPA-mediated inhibition of PT NHE3 in male normotensive rats, maintaining their baseline BP. Moreover, the reduction of NHE3 activity without further upregulation of major apical sodium transporters beyond the PT may contribute to the BP-lowering effect of SGLT2i in experimental models and patients with hypertension.NEW & NOTEWORTHY This study suggests that reduced NHE3-mediated sodium reabsorption in the renal proximal tubule may account, at least in part, for the BP-lowering effect of SGLT2 inhibitors in the setting of hypertension. It also demonstrates that chronic treatment with SGLT2 inhibitors upregulates NCC activity, phosphorylation, and expression in the distal tubule of normotensive but not hypertensive rats. SGLT2 inhibitor-mediated upregulation of NCC seems crucial to counteract proximal tubule natriuresis in subjects with normal BP.
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Affiliation(s)
- Paulo C Castro
- Laboratório de Genética e Cardiologia Molecular, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, São Paulo, Brazil
| | - Thiago M Santos-Rios
- Laboratório de Genética e Cardiologia Molecular, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, São Paulo, Brazil
| | - Flavia L Martins
- Laboratório de Genética e Cardiologia Molecular, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, São Paulo, Brazil
| | - Renato O Crajoinas
- Laboratório de Genética e Cardiologia Molecular, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, São Paulo, Brazil
| | - Marcos V Caetano
- Laboratório de Genética e Cardiologia Molecular, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, São Paulo, Brazil
| | - Lucília M A Lessa
- Instituto Superior de Ciências Biomédicas, Universidade Estadual do Ceará, Fortaleza, Brazil
| | - Weverton M Luchi
- Hospital Universitário Cassiano Antonio Moraes, Universidade Federal do Espírito Santo (HUCAM-UFES), Vitória, Brazil
| | - James A McCormick
- Division of Nephrology and Hypertension, Department of Medicine, Oregon Health and Science University, Portland, Oregon, United States
| | - Adriana C C Girardi
- Laboratório de Genética e Cardiologia Molecular, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, São Paulo, Brazil
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Raphael KL. Metabolic Acidosis in CKD: Pathogenesis, Adverse Effects, and Treatment Effects. Int J Mol Sci 2024; 25:5187. [PMID: 38791238 PMCID: PMC11121226 DOI: 10.3390/ijms25105187] [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: 12/29/2023] [Revised: 04/28/2024] [Accepted: 05/05/2024] [Indexed: 05/26/2024] Open
Abstract
Metabolic acidosis is a frequent complication of chronic kidney disease and is associated with a number of adverse outcomes, including worsening kidney function, poor musculoskeletal health, cardiovascular events, and death. Mechanisms that prevent metabolic acidosis detrimentally promote further kidney damage, creating a cycle between acid accumulation and acid-mediated kidney injury. Disrupting this cycle through the provision of alkali, most commonly using sodium bicarbonate, is hypothesized to preserve kidney function while also mitigating adverse effects of excess acid on bone and muscle. However, results from clinical trials have been conflicting. There is also significant interest to determine whether sodium bicarbonate might improve patient outcomes for those who do not have overt metabolic acidosis. Such individuals are hypothesized to be experiencing acid-mediated organ damage despite having a normal serum bicarbonate concentration, a state often referred to as subclinical metabolic acidosis. Results from small- to medium-sized trials in individuals with subclinical metabolic acidosis have also been inconclusive. Well-powered clinical trials to determine the efficacy and safety of sodium bicarbonate are necessary to determine if this intervention improves patient outcomes.
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Affiliation(s)
- Kalani L. Raphael
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT 84112, USA;
- Medicine Section, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT 84148, USA
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Kao YW, Chao TF, Chen SW, Cheng YW, Chan YH, Chu PH. Initial eGFR Changes with SGLT2 Inhibitor in Patients With Type 2 Diabetes and Associations With the Risk of Abnormal Serum Potassium Level. J Am Heart Assoc 2024; 13:e033236. [PMID: 38686902 PMCID: PMC11179933 DOI: 10.1161/jaha.123.033236] [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: 10/25/2023] [Accepted: 03/27/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Both high and low levels of serum potassium measurements are linked with a higher risk of adverse clinical events among patients with type 2 diabetes. The study was aimed at evaluating the implications of the various degrees of initial estimated glomerular filtration rate (eGFR) change on subsequent serum potassium homeostasis following sodium-glucose cotransporter-2 inhibitor (SGLT2i) initiation among patients with type 2 diabetes. METHODS AND RESULTS We used medical data from a multicenter health care provider in Taiwan and recruited 5529 patients with type 2 diabetes with baseline/follow-up eGFR data available after 4 to 12 weeks of SGLT2i treatment from June 1, 2016, to December 31, 2018. SGLT2i treatment was associated with an initial mean (SEM) eGFR decline of -3.5 (0.2) mL/min per 1.73 m2 in overall study participants. A total of 36.7% (n=2028) of patients experienced no eGFR decline, and 57.9% (n=3201) and 5.4% (n=300) of patients experienced an eGFR decline of 0% to 30% and >30%, respectively. Patients with an initial eGFR decline of >30% were associated with higher variability in consequent serum potassium measurement when compared with those without an initial eGFR decline. Participants with a pronounced eGFR decline of >30% were associated with a higher risk of hyperkalemia ≥5.5 (adjusted hazard ratio,4.59 [95% CI, 2.28-9.26]) or use of potassium binder (adjusted hazard ratio, 2.65 [95% CI, 1.78-3.95]) as well as hypokalemia events <3.0 mmol/L (adjusted hazard ratio, 3.21 [95% CI, 1.90-5.42]) or use of potassium supplement (adjusted hazard ratio, 1.87 [95% CI, 1.37-2.56]) following SGLT2i treatment after multivariate adjustment. CONCLUSIONS Physicians should be aware that the eGFR trough occurs shortly, and consequent serum potassium changes following SGLT2i initiation.
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Affiliation(s)
- Yi-Wei Kao
- Department of Applied Statistics and Information Science Ming Chuan University Taoyuan City Taiwan
- Artificial Intelligence Development Center Fu Jen Catholic University Taipei Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine Taipei Veterans General Hospital Taiwan
- Institute of Clinical Medicine, Cardiovascular Research Center National Yang Ming Chiao Tung University Taipei Taiwan
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center Chang Gung University Taoyuan City Taiwan
- Center for Big Data Analytics and Statistics Chang Gung Memorial Hospital Taoyuan Taiwan
| | - Yu-Wen Cheng
- The Cardiovascular Department Chang Gung Memorial Hospital Taoyuan Taiwan
| | - Yi-Hsin Chan
- The Cardiovascular Department Chang Gung Memorial Hospital Taoyuan Taiwan
- College of Medicine Chang Gung University Taoyuan Taiwan
- School of Traditional Chinese Medicine, College of Medicine Chang-Gung University Taoyuan City Taiwan
- Microscopy Core Laboratory Chang Gung Memorial Hospital Taoyuan Taiwan
| | - Pao-Hsien Chu
- The Cardiovascular Department Chang Gung Memorial Hospital Taoyuan Taiwan
- College of Medicine Chang Gung University Taoyuan Taiwan
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Upadhyay A. SGLT2 Inhibitors and Kidney Protection: Mechanisms Beyond Tubuloglomerular Feedback. KIDNEY360 2024; 5:771-782. [PMID: 38523127 PMCID: PMC11146657 DOI: 10.34067/kid.0000000000000425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 03/19/2024] [Indexed: 03/26/2024]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk for kidney failure and are a key component of guideline-directed therapy for CKD. While SGLT2 inhibitors' ability to activate tubuloglomerular feedback and reduce hyperfiltration-mediated kidney injury is considered to be the central mechanism for kidney protection, recent data from experimental studies raise questions on the primacy of this mechanism. This review examines SGLT2 inhibitors' role in tubuloglomerular feedback and summarizes emerging evidence on following of SGLT2 inhibitors' other putative mechanisms for kidney protection: optimization of kidney's energy substrate utilization and delivery, regulation of autophagy and maintenance of cellular homeostasis, attenuation of sympathetic hyperactivity, and improvement in vascular health and microvascular function. It is imperative to examine the effect of SGLT2 inhibition on these different physiologic processes to help our understanding of mechanisms underpinning kidney protection with this important class of drugs.
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Affiliation(s)
- Ashish Upadhyay
- Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
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Zheng K, Layton AT. Predicting sex differences in the effects of diuretics in renal epithelial transport during angiotensin II-induced hypertension. Am J Physiol Renal Physiol 2024; 326:F737-F750. [PMID: 38482554 DOI: 10.1152/ajprenal.00398.2023] [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: 12/11/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 04/26/2024] Open
Abstract
Chronic angiotensin II (ANG II) infusion is an experimental model that induces hypertension in rodents. The natriuresis, diuresis, and blood pressure responses differ between males and females. This is perhaps not unexpected, given the rodent kidney, which plays a key role in blood pressure regulation, exhibits marked sex differences. Under normotensive conditions, compared with males, the female rat nephron exhibits lower Na+/H+ exchanger 3 (NHE3) activity along the proximal tubule but higher Na+ transporter activities along the distal segments. ANG II infusion-induced hypertension induces a pressure natriuretic response that reduces NHE3 activity and shifts Na+ transport capacity downstream. The goals of this study were to apply a computational model of epithelial transport along a rat nephron 1) to understand how a 14-day ANG II infusion impacts segmental electrolyte transport in male and female rat nephrons and 2) to identify and explain any sex differences in the effects of loop diuretics, thiazide diuretics, and K+-sparing diuretics. Model simulations suggest that the NHE3 downregulation in the proximal tubule is a major contributor to natriuresis and diuresis in hypertension, with the effects stronger in males. All three diuretics are predicted to induce stronger natriuretic and diuretic effects under hypertension compared with normotension, with relative increases in sodium excretion higher in hypertensive females than in males. The stronger natriuretic responses can be explained by the downstream shift of Na+ transport load in hypertension and by the larger distal transport load in females, both of which limit the ability of the distal segments to further elevate their Na+ transport.NEW & NOTEWORTHY Sex differences in the prevalence of hypertension are found in human and animal models. The kidney, which regulates blood pressure, exhibits sex differences in morphology, hemodynamics, and membrane transporter distributions. This computational modeling study provides insights into how the sexually dimorphic responses to a 14-day angiotensin II infusion differentially impact segmental electrolyte transport in rats. Simulations of diuretic administration explain how the natriuretic and diuretic effects differ between normotension and hypertension and between the sexes.
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Affiliation(s)
- Kaixin Zheng
- Department of Applied Mathematics, University of Waterloo, Waterloo, Ontario, Canada
| | - Anita T Layton
- Department of Applied Mathematics, University of Waterloo, Waterloo, Ontario, Canada
- Department of Biology, Cheriton School of Computer Science, and School of Pharmacology, University of Waterloo, Waterloo, Ontario, Canada
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9
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Preda A, Montecucco F, Carbone F, Camici GG, Lüscher TF, Kraler S, Liberale L. SGLT2 inhibitors: from glucose-lowering to cardiovascular benefits. Cardiovasc Res 2024; 120:443-460. [PMID: 38456601 DOI: 10.1093/cvr/cvae047] [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: 10/19/2023] [Revised: 01/03/2024] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
An increasing number of individuals are at high risk of type 2 diabetes (T2D) and its cardiovascular complications, including heart failure (HF), chronic kidney disease (CKD), and eventually premature death. The sodium-glucose co-transporter-2 (SGLT2) protein sits in the proximal tubule of human nephrons to regulate glucose reabsorption and its inhibition by gliflozins represents the cornerstone of contemporary T2D and HF management. Herein, we aim to provide an updated overview of the pleiotropy of gliflozins, provide mechanistic insights and delineate related cardiovascular (CV) benefits. By discussing contemporary evidence obtained in preclinical models and landmark randomized controlled trials, we move from bench to bedside across the broad spectrum of cardio- and cerebrovascular diseases. With landmark randomized controlled trials confirming a reduction in major adverse CV events (MACE; composite endpoint of CV death, non-fatal myocardial infarction, and non-fatal stroke), SGLT2 inhibitors strongly mitigate the risk for heart failure hospitalization in diabetics and non-diabetics alike while conferring renoprotection in specific patient populations. Along four major pathophysiological axes (i.e. at systemic, vascular, cardiac, and renal levels), we provide insights into the key mechanisms that may underlie their beneficial effects, including gliflozins' role in the modulation of inflammation, oxidative stress, cellular energy metabolism, and housekeeping mechanisms. We also discuss how this drug class controls hyperglycaemia, ketogenesis, natriuresis, and hyperuricaemia, collectively contributing to their pleiotropic effects. Finally, evolving data in the setting of cerebrovascular diseases and arrhythmias are presented and potential implications for future research and clinical practice are comprehensively reviewed.
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Affiliation(s)
- Alberto Preda
- Department of Clinical Cardiology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Federico Carbone
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Giovanni G Camici
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Department of Research and Education, University Hospital Zurich, Zurich, Switzerland
| | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Royal Brompton and Harefield Hospitals and Imperial College and King's College, London, United Kingdom
| | - Simon Kraler
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Department of Internal Medicine, Cantonal Hospital Baden, Baden, Switzerland
| | - Luca Liberale
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
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10
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Cox ZL, Collins SP, Hernandez GA, McRae AT, Davidson BT, Adams K, Aaron M, Cunningham L, Jenkins CA, Lindsell CJ, Harrell FE, Kampe C, Miller KF, Stubblefield WB, Lindenfeld J. Efficacy and Safety of Dapagliflozin in Patients With Acute Heart Failure. J Am Coll Cardiol 2024; 83:1295-1306. [PMID: 38569758 DOI: 10.1016/j.jacc.2024.02.009] [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: 12/12/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND The primary goals during acute heart failure (AHF) hospitalization are decongestion and guideline-directed medical therapy (GDMT) optimization. Unlike diuretics or other GDMT, early dapagliflozin initiation could achieve both AHF goals. OBJECTIVES The authors aimed to assess the diuretic efficacy and safety of early dapagliflozin initiation in AHF. METHODS In a multicenter, open-label study, 240 patients were randomized within 24 hours of hospital presentation for hypervolemic AHF to dapagliflozin 10 mg once daily or structured usual care with protocolized diuretic titration until day 5 or hospital discharge. The primary outcome, diuretic efficiency expressed as cumulative weight change per cumulative loop diuretic dose, was compared across treatment assignment using a proportional odds model adjusted for baseline weight. Secondary and safety outcomes were adjudicated by a blinded committee. RESULTS For diuretic efficiency, there was no difference between dapagliflozin and usual care (OR: 0.65; 95% CI: 0.41-1.02; P = 0.06). Dapagliflozin was associated with reduced loop diuretic doses (560 mg [Q1-Q3: 260-1,150 mg] vs 800 mg [Q1-Q3: 380-1,715 mg]; P = 0.006) and fewer intravenous diuretic up-titrations (P ≤ 0.05) to achieve equivalent weight loss as usual care. Early dapagliflozin initiation did not increase diabetic, renal, or cardiovascular safety events. Dapagliflozin was associated with improved median 24-hour natriuresis (P = 0.03) and urine output (P = 0.005), expediting hospital discharge over the study period. CONCLUSIONS Early dapagliflozin during AHF hospitalization is safe and fulfills a component of GDMT optimization. Dapagliflozin was not associated with a statistically significant reduction in weight-based diuretic efficiency but was associated with evidence for enhanced diuresis among patients with AHF. (Efficacy and Safety of Dapagliflozin in Acute Heart Failure [DICTATE-AHF]; NCT04298229).
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Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee, USA; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center, Nashville, Tennessee, USA
| | - Gabriel A Hernandez
- Division of Cardiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - A Thomas McRae
- TriStar Centennial Medical Center, Nashville, Tennessee, USA
| | - Beth T Davidson
- TriStar Centennial Medical Center, Nashville, Tennessee, USA
| | - Kirkwood Adams
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Mark Aaron
- Department of Cardiac Sciences, Saint Thomas West Hospital, Nashville, Tennessee, USA
| | - Luke Cunningham
- Department of Cardiology, INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma, USA
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christina Kampe
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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11
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Sarzani R, Landolfo M, Di Pentima C, Ortensi B, Falcioni P, Sabbatini L, Massacesi A, Rampino I, Spannella F, Giulietti F. Adipocentric origin of the common cardiometabolic complications of obesity in the young up to the very old: pathophysiology and new therapeutic opportunities. Front Med (Lausanne) 2024; 11:1365183. [PMID: 38654832 PMCID: PMC11037084 DOI: 10.3389/fmed.2024.1365183] [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: 01/03/2024] [Accepted: 03/26/2024] [Indexed: 04/26/2024] Open
Abstract
Obesity is a multifactorial chronic disease characterized by an excess of adipose tissue, affecting people of all ages. In the last 40 years, the incidence of overweight and obesity almost tripled worldwide. The accumulation of "visceral" adipose tissue increases with aging, leading to several cardio-metabolic consequences: from increased blood pressure to overt arterial hypertension, from insulin-resistance to overt type 2 diabetes mellitus (T2DM), dyslipidemia, chronic kidney disease (CKD), and obstructive sleep apnea. The increasing use of innovative drugs, namely glucagon-like peptide-1 receptor agonists (GLP1-RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2-i), is changing the management of obesity and its related cardiovascular complications significantly. These drugs, first considered only for T2DM treatment, are now used in overweight patients with visceral adiposity or obese patients, as obesity is no longer just a risk factor but a critical condition at the basis of common metabolic, cardiovascular, and renal diseases. An adipocentric vision and approach should become the cornerstone of visceral overweight and obesity integrated management and treatment, reducing and avoiding the onset of obesity-related multiple risk factors and their clinical complications. According to recent progress in basic and clinical research on adiposity, this narrative review aims to contribute to a novel clinical approach focusing on pathophysiological and therapeutic insights.
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Affiliation(s)
- Riccardo Sarzani
- Internal Medicine and Geriatrics, European Society of Hypertension (ESH) “Hypertension Excellence Centre”, Società Italiana per lo Studio dell'Aterosclerosi (SISA) LIPIGEN Centre, IRCCS INRCA, Ancona, Italy
- Centre for Obesity, Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Matteo Landolfo
- Internal Medicine and Geriatrics, European Society of Hypertension (ESH) “Hypertension Excellence Centre”, Società Italiana per lo Studio dell'Aterosclerosi (SISA) LIPIGEN Centre, IRCCS INRCA, Ancona, Italy
- Centre for Obesity, Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Chiara Di Pentima
- Internal Medicine and Geriatrics, European Society of Hypertension (ESH) “Hypertension Excellence Centre”, Società Italiana per lo Studio dell'Aterosclerosi (SISA) LIPIGEN Centre, IRCCS INRCA, Ancona, Italy
| | - Beatrice Ortensi
- Internal Medicine and Geriatrics, European Society of Hypertension (ESH) “Hypertension Excellence Centre”, Società Italiana per lo Studio dell'Aterosclerosi (SISA) LIPIGEN Centre, IRCCS INRCA, Ancona, Italy
- Centre for Obesity, Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Paolo Falcioni
- Internal Medicine and Geriatrics, European Society of Hypertension (ESH) “Hypertension Excellence Centre”, Società Italiana per lo Studio dell'Aterosclerosi (SISA) LIPIGEN Centre, IRCCS INRCA, Ancona, Italy
- Centre for Obesity, Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Lucia Sabbatini
- Internal Medicine and Geriatrics, European Society of Hypertension (ESH) “Hypertension Excellence Centre”, Società Italiana per lo Studio dell'Aterosclerosi (SISA) LIPIGEN Centre, IRCCS INRCA, Ancona, Italy
- Centre for Obesity, Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Adriano Massacesi
- Internal Medicine and Geriatrics, European Society of Hypertension (ESH) “Hypertension Excellence Centre”, Società Italiana per lo Studio dell'Aterosclerosi (SISA) LIPIGEN Centre, IRCCS INRCA, Ancona, Italy
- Centre for Obesity, Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Ilaria Rampino
- Internal Medicine and Geriatrics, European Society of Hypertension (ESH) “Hypertension Excellence Centre”, Società Italiana per lo Studio dell'Aterosclerosi (SISA) LIPIGEN Centre, IRCCS INRCA, Ancona, Italy
- Centre for Obesity, Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Francesco Spannella
- Internal Medicine and Geriatrics, European Society of Hypertension (ESH) “Hypertension Excellence Centre”, Società Italiana per lo Studio dell'Aterosclerosi (SISA) LIPIGEN Centre, IRCCS INRCA, Ancona, Italy
- Centre for Obesity, Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Federico Giulietti
- Internal Medicine and Geriatrics, European Society of Hypertension (ESH) “Hypertension Excellence Centre”, Società Italiana per lo Studio dell'Aterosclerosi (SISA) LIPIGEN Centre, IRCCS INRCA, Ancona, Italy
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12
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Dominguez Rieg JA, Rieg T. New functions and roles of the Na +-H +-exchanger NHE3. Pflugers Arch 2024; 476:505-516. [PMID: 38448727 DOI: 10.1007/s00424-024-02938-9] [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: 02/05/2024] [Revised: 02/22/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
The sodium/proton exchanger isoform 3 (NHE3) is expressed in the intestine and the kidney, where it contributes to hydrogen secretion and sodium (re)absorption. The roles of this transporter have been studied by the use of the respective knockout mice and by using pharmacological inhibitors. Whole-body NHE3 knockout mice suffer from a high mortality rate (with only ∼30% of mice surviving into adulthood), and based on the expression of NHE3 in both intestine and kidney, some conclusions that were originally derived were based on this rather complex phenotype. In the last decade, more refined models have been developed that added temporal and spatial control of NHE3 expression. For example, novel mouse models have been developed with a knockout of NHE3 in intestinal epithelial cells, tubule/collecting duct of the kidney, proximal tubule of the kidney, and thick ascending limb of the kidney. These refined models have significantly contributed to our understanding of the role of NHE3 in a tissue/cell type-specific manner. In addition, tenapanor was developed, which is a non-absorbable, intestine-specific NHE3 inhibitor. In rat and human studies, tenapanor lowered intestinal Pi uptake and was effective in lowering plasma Pi levels in patients on hemodialysis. Of note, diarrhea is seen as a side effect of tenapanor (with its indication for the treatment of constipation) and in intestine-specific NHE3 knockout mice; however, effects on plasma Pi were not supported by this mouse model which showed enhanced and not reduced intestinal Pi uptake. Further studies indicated that the gut microbiome in mice lacking intestinal NHE3 resembles an intestinal environment favoring the competitive advantage of inflammophilic over anti-inflammatory species, something similar seen in patients with inflammatory bowel disease. This review will highlight recent developments and summarize newly gained insight from these refined models.
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Affiliation(s)
- Jessica A Dominguez Rieg
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
- James A. Haley Veterans' Hospital, Tampa, FL, 33612, USA
- Hypertension and Kidney Research Center, University of South Florida, Tampa, FL, 33602, USA
| | - Timo Rieg
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA.
- James A. Haley Veterans' Hospital, Tampa, FL, 33612, USA.
- Hypertension and Kidney Research Center, University of South Florida, Tampa, FL, 33602, USA.
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13
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Shepard BD, Chau J, Kurtz R, Rosenberg AZ, Sarder P, Border SP, Ginley B, Rodriguez O, Albanese C, Knoer G, Greene A, De Souza AMA, Ranjit S, Levi M, Ecelbarger CM. Nascent shifts in renal cellular metabolism, structure, and function due to chronic empagliflozin in prediabetic mice. Am J Physiol Cell Physiol 2024; 326:C1272-C1290. [PMID: 38602847 PMCID: PMC11193535 DOI: 10.1152/ajpcell.00446.2023] [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: 09/14/2023] [Revised: 02/21/2024] [Accepted: 02/21/2024] [Indexed: 04/13/2024]
Abstract
Sodium-glucose cotransporter, type 2 inhibitors (SGLT2i) are emerging as the gold standard for treatment of type 2 diabetes (T2D) with renal protective benefits independent of glucose lowering. We took a high-level approach to evaluate the effects of the SGLT2i, empagliflozin (EMPA) on renal metabolism and function in a prediabetic model of metabolic syndrome. Male and female 12-wk-old TallyHo (TH) mice, and their closest genetic lean strain (Swiss-Webster, SW) were treated with a high-milk-fat diet (HMFD) plus/minus EMPA (@0.01%) for 12-wk. Kidney weights and glomerular filtration rate were slightly increased by EMPA in the TH mice. Glomerular feature analysis by unsupervised clustering revealed sexually dimorphic clustering, and one unique cluster relating to EMPA. Periodic acid Schiff (PAS) positive areas, reflecting basement membranes and mesangium were slightly reduced by EMPA. Phasor-fluorescent life-time imaging (FLIM) of free-to-protein bound NADH in cortex showed a marginally greater reliance on oxidative phosphorylation with EMPA. Overall, net urine sodium, glucose, and albumin were slightly increased by EMPA. In TH, EMPA reduced the sodium phosphate cotransporter, type 2 (NaPi-2), but increased sodium hydrogen exchanger, type 3 (NHE3). These changes were absent or blunted in SW. EMPA led to changes in urine exosomal microRNA profile including, in females, enhanced levels of miRs 27a-3p, 190a-5p, and 196b-5p. Network analysis revealed "cancer pathways" and "FOXO signaling" as the major regulated pathways. Overall, EMPA treatment to prediabetic mice with limited renal disease resulted in modifications in renal metabolism, structure, and transport, which may preclude and underlie protection against kidney disease with developing T2D.NEW & NOTEWORTHY Renal protection afforded by sodium glucose transporter, type 2 inhibitors (SGLT2i), e.g., empagliflozin (EMPA) involves complex intertwined mechanisms. Using a novel mouse model of obesity with insulin resistance, the TallyHo/Jng (TH) mouse on a high-milk-fat diet (HMFD), we found subtle changes in metabolism including altered regulation of sodium transporters that line the renal tubule. New potential epigenetic determinants of metabolic changes relating to FOXO and cancer signaling pathways were elucidated from an altered urine exosomal microRNA signature.
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Affiliation(s)
- Blythe D Shepard
- Department of Human Science, Georgetown University, Washington, District of Columbia, United States
| | - Jennifer Chau
- Department of Medicine,Georgetown University, Washington, District of Columbia, United States
| | - Ryan Kurtz
- Department of Human Science, Georgetown University, Washington, District of Columbia, United States
| | - Avi Z Rosenberg
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, United States
| | - Pinaki Sarder
- J Crayton Pruitt Department of Biomedical Engineering, University of Florida, Gainesville, Florida, United States
| | - Samuel P Border
- J Crayton Pruitt Department of Biomedical Engineering, University of Florida, Gainesville, Florida, United States
| | - Brandon Ginley
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, United States
- Department of Computational Cell Biology, Anatomy, and Pathology, State University of New York at Buffalo, Buffalo, New York, United States
| | - Olga Rodriguez
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, United States
- Center for Translational Imaging, Georgetown University, Washington, District of Columbia, United States
| | - Chris Albanese
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, United States
- Center for Translational Imaging, Georgetown University, Washington, District of Columbia, United States
- Department of Radiology, Georgetown University, Washington, District of Columbia, United States
| | - Grace Knoer
- Center for Translational Imaging, Georgetown University, Washington, District of Columbia, United States
| | - Aarenee Greene
- Department of Medicine,Georgetown University, Washington, District of Columbia, United States
| | - Aline M A De Souza
- Department of Medicine,Georgetown University, Washington, District of Columbia, United States
| | - Suman Ranjit
- Department of Biochemistry and Molecular & Cellular Biology, Georgetown University, Washington, District of Columbia, United States
- Microscopy & Imaging Shared Resources, Georgetown University, Washington, District of Columbia, United States
| | - Moshe Levi
- Department of Biochemistry and Molecular & Cellular Biology, Georgetown University, Washington, District of Columbia, United States
| | - Carolyn M Ecelbarger
- Department of Medicine,Georgetown University, Washington, District of Columbia, United States
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14
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Billing AM, Kim YC, Gullaksen S, Schrage B, Raabe J, Hutzfeldt A, Demir F, Kovalenko E, Lassé M, Dugourd A, Fallegger R, Klampe B, Jaegers J, Li Q, Kravtsova O, Crespo-Masip M, Palermo A, Fenton RA, Hoxha E, Blankenberg S, Kirchhof P, Huber TB, Laugesen E, Zeller T, Chrysopoulou M, Saez-Rodriguez J, Magnussen C, Eschenhagen T, Staruschenko A, Siuzdak G, Poulsen PL, Schwab C, Cuello F, Vallon V, Rinschen MM. Metabolic Communication by SGLT2 Inhibition. Circulation 2024; 149:860-884. [PMID: 38152989 PMCID: PMC10922673 DOI: 10.1161/circulationaha.123.065517] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 11/22/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND SGLT2 (sodium-glucose cotransporter 2) inhibitors (SGLT2i) can protect the kidneys and heart, but the underlying mechanism remains poorly understood. METHODS To gain insights on primary effects of SGLT2i that are not confounded by pathophysiologic processes or are secondary to improvement by SGLT2i, we performed an in-depth proteomics, phosphoproteomics, and metabolomics analysis by integrating signatures from multiple metabolic organs and body fluids after 1 week of SGLT2i treatment of nondiabetic as well as diabetic mice with early and uncomplicated hyperglycemia. RESULTS Kidneys of nondiabetic mice reacted most strongly to SGLT2i in terms of proteomic reconfiguration, including evidence for less early proximal tubule glucotoxicity and a broad downregulation of the apical uptake transport machinery (including sodium, glucose, urate, purine bases, and amino acids), supported by mouse and human SGLT2 interactome studies. SGLT2i affected heart and liver signaling, but more reactive organs included the white adipose tissue, showing more lipolysis, and, particularly, the gut microbiome, with a lower relative abundance of bacteria taxa capable of fermenting phenylalanine and tryptophan to cardiovascular uremic toxins, resulting in lower plasma levels of these compounds (including p-cresol sulfate). SGLT2i was detectable in murine stool samples and its addition to human stool microbiota fermentation recapitulated some murine microbiome findings, suggesting direct inhibition of fermentation of aromatic amino acids and tryptophan. In mice lacking SGLT2 and in patients with decompensated heart failure or diabetes, the SGLT2i likewise reduced circulating p-cresol sulfate, and p-cresol impaired contractility and rhythm in human induced pluripotent stem cell-derived engineered heart tissue. CONCLUSIONS SGLT2i reduced microbiome formation of uremic toxins such as p-cresol sulfate and thereby their body exposure and need for renal detoxification, which, combined with direct kidney effects of SGLT2i, including less proximal tubule glucotoxicity and a broad downregulation of apical transporters (including sodium, amino acid, and urate uptake), provides a metabolic foundation for kidney and cardiovascular protection.
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Affiliation(s)
- Anja M. Billing
- Departments of Biomedicine (A.M.B., F.D., E.K., J.J., R.A.F., M.C., M.M.R.), Aarhus University, Denmark
| | - Young Chul Kim
- Departments of Medicine and Pharmacology, University of California San Diego, La Jolla (Y.C.K., M.C.-M., V.V.)
- VA San Diego Healthcare System, CA (Y.C.K., M.C.-M., V.V.)
| | - Søren Gullaksen
- Clinical Medicine (S.G., P.L.P.), Aarhus University, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Denmark (S.G., E.L.)
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (B.S., S.B., P.K., T.Z., C.M.)
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (B.S., J.R., S.B., P.K., T.Z., C.M., T.E., F.C.)
| | - Janice Raabe
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (B.S., J.R., S.B., P.K., T.Z., C.M., T.E., F.C.)
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (J.R., B.K., T.E., F.C.)
| | - Arvid Hutzfeldt
- III Department of Medicine and Hamburg Center for Kidney Health, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (A.H., M.L., E.H., T.B.H., M.M.R.)
| | - Fatih Demir
- Departments of Biomedicine (A.M.B., F.D., E.K., J.J., R.A.F., M.C., M.M.R.), Aarhus University, Denmark
| | - Elina Kovalenko
- Departments of Biomedicine (A.M.B., F.D., E.K., J.J., R.A.F., M.C., M.M.R.), Aarhus University, Denmark
| | - Moritz Lassé
- III Department of Medicine and Hamburg Center for Kidney Health, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (A.H., M.L., E.H., T.B.H., M.M.R.)
| | - Aurelien Dugourd
- Heidelberg University, Faculty of Medicine, and Heidelberg University Hospital, Institute for Computational Biomedicine, BioQuant, Heidelberg, Germany (A.D., R.F., J.S.-R.)
| | - Robin Fallegger
- Heidelberg University, Faculty of Medicine, and Heidelberg University Hospital, Institute for Computational Biomedicine, BioQuant, Heidelberg, Germany (A.D., R.F., J.S.-R.)
| | - Birgit Klampe
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (J.R., B.K., T.E., F.C.)
| | - Johannes Jaegers
- Departments of Biomedicine (A.M.B., F.D., E.K., J.J., R.A.F., M.C., M.M.R.), Aarhus University, Denmark
| | - Qing Li
- Engineering (Q.L., C.S.), Aarhus University, Denmark
| | - Olha Kravtsova
- Departments of Biomedicine (A.M.B., F.D., E.K., J.J., R.A.F., M.C., M.M.R.), Aarhus University, Denmark
| | - Maria Crespo-Masip
- Departments of Medicine and Pharmacology, University of California San Diego, La Jolla (Y.C.K., M.C.-M., V.V.)
- VA San Diego Healthcare System, CA (Y.C.K., M.C.-M., V.V.)
| | - Amelia Palermo
- Scripps Research, Center for Metabolomics, San Diego, CA (A.P., G.S., M.M.R.)
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California, Los Angeles (A.P.)
| | - Robert A. Fenton
- Departments of Biomedicine (A.M.B., F.D., E.K., J.J., R.A.F., M.C., M.M.R.), Aarhus University, Denmark
| | - Elion Hoxha
- III Department of Medicine and Hamburg Center for Kidney Health, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (A.H., M.L., E.H., T.B.H., M.M.R.)
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (B.S., S.B., P.K., T.Z., C.M.)
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (B.S., J.R., S.B., P.K., T.Z., C.M., T.E., F.C.)
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (B.S., S.B., P.K., T.Z., C.M.)
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (B.S., J.R., S.B., P.K., T.Z., C.M., T.E., F.C.)
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (P.K.)
| | - Tobias B. Huber
- III Department of Medicine and Hamburg Center for Kidney Health, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (A.H., M.L., E.H., T.B.H., M.M.R.)
| | - Esben Laugesen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Denmark (S.G., E.L.)
- Diagnostic Centre, Silkeborg Regional Hospital, Denmark (E.L.)
| | - Tanja Zeller
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (B.S., S.B., P.K., T.Z., C.M.)
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (B.S., J.R., S.B., P.K., T.Z., C.M., T.E., F.C.)
| | - Maria Chrysopoulou
- Departments of Biomedicine (A.M.B., F.D., E.K., J.J., R.A.F., M.C., M.M.R.), Aarhus University, Denmark
| | - Julio Saez-Rodriguez
- Heidelberg University, Faculty of Medicine, and Heidelberg University Hospital, Institute for Computational Biomedicine, BioQuant, Heidelberg, Germany (A.D., R.F., J.S.-R.)
| | - Christina Magnussen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (B.S., S.B., P.K., T.Z., C.M.)
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (B.S., J.R., S.B., P.K., T.Z., C.M., T.E., F.C.)
| | - Thomas Eschenhagen
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (B.S., J.R., S.B., P.K., T.Z., C.M., T.E., F.C.)
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (J.R., B.K., T.E., F.C.)
| | - Alexander Staruschenko
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa (O.K., A.S.)
| | - Gary Siuzdak
- Scripps Research, Center for Metabolomics, San Diego, CA (A.P., G.S., M.M.R.)
| | - Per L. Poulsen
- Clinical Medicine (S.G., P.L.P.), Aarhus University, Denmark
- Steno Diabetes Center (P.L.P.), Aarhus University, Denmark
| | | | - Friederike Cuello
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (B.S., J.R., S.B., P.K., T.Z., C.M., T.E., F.C.)
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (J.R., B.K., T.E., F.C.)
| | - Volker Vallon
- Departments of Medicine and Pharmacology, University of California San Diego, La Jolla (Y.C.K., M.C.-M., V.V.)
- VA San Diego Healthcare System, CA (Y.C.K., M.C.-M., V.V.)
| | - Markus M. Rinschen
- Departments of Biomedicine (A.M.B., F.D., E.K., J.J., R.A.F., M.C., M.M.R.), Aarhus University, Denmark
- Aarhus Institute of Advanced Studies (M.M.R.), Aarhus University, Denmark
- III Department of Medicine and Hamburg Center for Kidney Health, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (A.H., M.L., E.H., T.B.H., M.M.R.)
- Scripps Research, Center for Metabolomics, San Diego, CA (A.P., G.S., M.M.R.)
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15
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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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16
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Paik JM, Tesfaye H, Curhan GC, Zakoul H, Wexler DJ, Patorno E. Sodium-Glucose Cotransporter 2 Inhibitors and Nephrolithiasis Risk in Patients With Type 2 Diabetes. JAMA Intern Med 2024; 184:265-274. [PMID: 38285598 PMCID: PMC10825784 DOI: 10.1001/jamainternmed.2023.7660] [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: 08/30/2023] [Accepted: 11/21/2023] [Indexed: 01/31/2024]
Abstract
Importance Type 2 diabetes (T2D) is associated with an increased risk of kidney stones. Sodium-glucose cotransporter 2 inhibitors (SGLT2is) might lower the risk of nephrolithiasis by altering urine composition. However, no studies have investigated the association between SGLT2i use and nephrolithiasis risk in patients receiving routine care in the US. Objective To investigate the association between SGLT2i use and nephrolithiasis risk in clinical practice. Design, Setting, and Participants This new-user, active comparator cohort study used data from commercially insured adults (aged ≥18 years) with T2D who initiated treatment with SGLT2is, glucagon-like peptide 1 receptor agonists (GLP-1RAs), or dipeptidyl peptidase 4 inhibitors (DPP4is) between April 1, 2013, and December 31, 2020. The data were analyzed from July 2021 through June 2023. Exposure New initiation of an SGLT2i, GLP-1RA, or DPP4i. Main Outcomes and Measures The primary outcome was nephrolithiasis diagnosed by International Classification of Diseases codes in the inpatient or outpatient setting. New SGLT2i users were 1:1 propensity score matched to new users of a GLP-1RA or DPP4i in pairwise comparisons. Incidence rates, rate differences (RDs), and estimated hazard ratios (HRs) with 95% CIs were calculated. Results After 1:1 propensity score matching, a total of 716 406 adults with T2D (358 203 pairs) initiating an SGLT2i or a GLP-1RA (mean [SD] age, 61.4 [9.7] years for both groups; 51.4% vs 51.2% female; 48.6% vs 48.5% male) and 662 056 adults (331 028 pairs) initiating an SGLT2i or a DPP4i (mean [SD] age, 61.8 [9.3] vs 61.7 [10.1] years; 47.4% vs 47.3% female; 52.6% vs 52.7% male) were included. Over a median follow-up of 192 (IQR, 88-409) days, the risk of nephrolithiasis was lower in patients initiating an SGLT2i than among those initiating a GLP-1RA (14.9 vs 21.3 events per 1000 person-years; HR, 0.69 [95% CI, 0.67-0.72]; RD, -6.4 [95% CI, -7.1 to -5.7]) or a DPP4i (14.6 vs 19.9 events per 1000 person-years; HR, 0.74 [95% CI, 0.71-0.77]; RD, -5.3 [95% CI, -6.0 to -4.6]). The association between SGLT2i use and nephrolithiasis risk was similar by sex, race and ethnicity, history of chronic kidney disease, and obesity. The magnitude of the risk reduction with SGLT2i use was larger among adults aged younger than 70 years vs aged 70 years or older (HR, 0.85 [95% CI, 0.79-0.91]; RD, -3.46 [95% CI, -4.87 to -2.05] per 1000 person-years; P for interaction <.001). Conclusions and Relevance These findings suggest that in adults with T2D, SGLT2i use may lower the risk of nephrolithiasis compared with GLP-1RAs or DPP4is and could help to inform decision-making when prescribing glucose-lowering agents for patients who may be at risk for developing nephrolithiasis.
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Affiliation(s)
- Julie M. Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Renal (Kidney) Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- New England Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Helen Tesfaye
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Gary C. Curhan
- Division of Renal (Kidney) Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Heidi Zakoul
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Deborah J. Wexler
- Harvard Medical School, Boston, Massachusetts
- Diabetes Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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17
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Kanoo S, Goodluck H, Kim YC, Garrido AN, Crespo-Masip M, Lopez N, Zhang H, Gonzalez-Villalobos RA, Ma LJ, Vallon V. Deletion, but not heterozygosity, of eNOS raises blood pressure and aggravates nephropathy in BTBR ob/ob mice. Nephron Clin Pract 2024:000536522. [PMID: 38301618 DOI: 10.1159/000536522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 01/20/2024] [Indexed: 02/03/2024] Open
Abstract
INTRODUCTION ob/ob mice are a leptin-deficient type 2 diabetes mellitus model, which, on a BTBR background, mimics glomerular pathophysiology of diabetic nephropathy (DN). Since leptin deficiency reduces blood pressure (BP), and endothelial nitric oxide synthase (eNOS) lowers BP and is kidney protective, we attempted to develop a more robust DN model by introducing eNOS deficiency in BTBR ob/ob mice. METHODS Six experimental groups included littermate male and female BTBR ob/ob or wild-type for ob (control) as well as wild-type (WT), heterozygote (HET) or knockout (KO) for eNOS. Systolic BP (by automated tail-cuff) and GFR (by FITC sinistrin plasma kinetics) were determined in awake mice at 27-30 weeks of age followed by molecular and histological kidney analyses. RESULTS Male and female ob/ob WT presented hyperglycemia and larger body and kidney weight, GFR, glomerular injury, and urine albumin to creatinine ratio (UACR) despite modestly lower BP vs control WT. These effects were associated with higher tubular injury score and renal mRNA expression of NGAL only in males, whereas female ob/ob WT unexpectedly had lower KIM-1 and COL1A1 expression vs control WT, indicating sex differences. HET for eNOS did not consistently alter BP or renal outcome in control or ob/ob. In comparison, eNOS KO increased BP (15-25 mmHg) and worsened renal markers of injury, inflammation and fibrosis, GFR, UACR, and survival rates, as observed in control and, more pronounced, in ob/ob mice and independent of sex. CONCLUSIONS Deletion, but not heterozygosity, of eNOS raises blood pressure and aggravates nephropathy in BTBR ob/ob mice.
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18
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Oe Y, Kim YC, Sidorenko VS, Zhang H, Kanoo S, Lopez N, Goodluck HA, Crespo-Masip M, Vallon V. SGLT2 inhibitor dapagliflozin protects the kidney in a murine model of Balkan nephropathy. Am J Physiol Renal Physiol 2024; 326:F227-F240. [PMID: 38031729 PMCID: PMC11198975 DOI: 10.1152/ajprenal.00228.2023] [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: 08/08/2023] [Revised: 11/06/2023] [Accepted: 11/27/2023] [Indexed: 12/01/2023] Open
Abstract
Proximal tubular uptake of aristolochic acid (AA) forms aristolactam (AL)-DNA adducts, which cause a p53/p21-mediated DNA damage response and acute tubular injury. Recurrent AA exposure causes kidney function loss and fibrosis in humans (Balkan endemic nephropathy) and mice and is a model of (acute kidney injury) AKI to chronic kidney disease (CKD) transition. Inhibitors of the proximal tubule sodium-glucose transporter SGLT2 can protect against CKD progression, but their effect on AA-induced kidney injury remains unknown. C57BL/6J mice (15-wk-old) were administered vehicle or AA every 3 days for 3 wk (10 and 3 mg/kg ip in females and males, respectively). Dapagliflozin (dapa, 0.01 g/kg diet) or vehicle was initiated 7 days prior to AA injections. All dapa effects were sex independent, including a robust glycosuria. Dapa lowered urinary kidney-injury molecule 1 (KIM-1) and albumin (both normalized to creatinine) after the last AA injection and kidney mRNA expression of early DNA damage response markers (p53 and p21) 3 wk later at the study end. Dapa also attenuated AA-induced increases in plasma creatinine as well as AA-induced up-regulation of renal pro-senescence, pro-inflammatory and pro-fibrotic genes, and kidney collagen staining. When assessed 1 day after a single AA injection, dapa pretreatment attenuated AL-DNA adduct formation by 10 and 20% in kidney and liver, respectively, associated with reduced p21 expression. Initiating dapa application after the last AA injection also improved kidney outcome but in a less robust manner. In conclusion, the first evidence is presented that pretreatment with an SGLT2 inhibitor can attenuate the AA-induced DNA damage response and subsequent nephropathy.NEW & NOTEWORTHY Recurrent exposure to aristolochic acid (AA) causes kidney function loss and fibrosis in mice and in humans, e.g., in the form of the endemic Balkan nephropathy. Inhibitors of the proximal tubule sodium-glucose transporter SGLT2 can protect against CKD progression, but their effect on AA-induced kidney injury remains unknown. Here we provide the first evidence in a murine model that pretreatment with an SGLT2 inhibitor can attenuate the AA-induced DNA damage response and subsequent nephropathy.
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Affiliation(s)
- Yuji Oe
- Department of Medicine, University of California-San Diego, La Jolla, California, United States
- Veterans Affairs San Diego Healthcare System, San Diego, California, United States
| | - Young Chul Kim
- Department of Medicine, University of California-San Diego, La Jolla, California, United States
- Veterans Affairs San Diego Healthcare System, San Diego, California, United States
| | - Viktoriya S Sidorenko
- Department of Pharmacological Sciences, Stony Brook University, Stony Brook, New York, United States
| | - Haiyan Zhang
- Department of Pathology, University of California-San Diego, San Diego, California, United States
| | - Sadhana Kanoo
- Veterans Affairs San Diego Healthcare System, San Diego, California, United States
| | - Natalia Lopez
- Veterans Affairs San Diego Healthcare System, San Diego, California, United States
| | - Helen A Goodluck
- Veterans Affairs San Diego Healthcare System, San Diego, California, United States
| | - Maria Crespo-Masip
- Veterans Affairs San Diego Healthcare System, San Diego, California, United States
| | - Volker Vallon
- Department of Medicine, University of California-San Diego, La Jolla, California, United States
- Veterans Affairs San Diego Healthcare System, San Diego, California, United States
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19
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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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20
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Palmer BF, Clegg DJ. SGLT2 Inhibition and Tubular Sodium Handling. J Am Soc Nephrol 2024; 35:131-133. [PMID: 38129943 PMCID: PMC10843184 DOI: 10.1681/asn.0000000000000280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Affiliation(s)
- Biff F. Palmer
- Internal Medicine, Department of Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Deborah J. Clegg
- Internal Medicine, Vice President for Research, Texas Tech Health Sciences Center, El Paso, Texas
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21
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Rao VS, Ivey-Miranda JB, Cox ZL, Moreno-Villagomez J, Maulion C, Bellumkonda L, Chang J, Field MP, Wiederin DR, Butler J, Collins SP, Turner JM, Wilson FP, Inzucchi SE, Wilcox CS, Ellison DH, Testani JM. Empagliflozin in Heart Failure: Regional Nephron Sodium Handling Effects. J Am Soc Nephrol 2024; 35:189-201. [PMID: 38073038 PMCID: PMC10843196 DOI: 10.1681/asn.0000000000000269] [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: 04/06/2023] [Accepted: 10/25/2023] [Indexed: 02/02/2024] Open
Abstract
SIGNIFICANCE STATEMENT The effect of sodium-glucose cotransporter-2 inhibitors (SGLT2i) on regional tubular sodium handling is poorly understood in humans. In this study, empagliflozin substantially decreased lithium reabsorption in the proximal tubule (PT) (a marker of proximal tubular sodium reabsorption), a magnitude out of proportion to that expected with only inhibition of sodium-glucose cotransporter-2. This finding was not driven by an "osmotic diuretic" effect; however, several parameters changed in a manner consistent with inhibition of the sodium-hydrogen exchanger 3. The large changes in proximal tubular handling were acutely buffered by increased reabsorption in both the loop of Henle and the distal nephron, resulting in the observed modest acute natriuresis with these agents. After 14 days of empagliflozin, natriuresis waned due to increased reabsorption in the PT and/or loop of Henle. These findings confirm in humans that SGLT2i have complex and important effects on renal tubular solute handling. BACKGROUND The effect of SGLT2i on regional tubular sodium handling is poorly understood in humans but may be important for the cardiorenal benefits. METHODS This study used a previously reported randomized, placebo-controlled crossover study of empagliflozin 10 mg daily in patients with diabetes and heart failure. Sodium handling in the PT, loop of Henle (loop), and distal nephron was assessed at baseline and day 14 using fractional excretion of lithium (FELi), capturing PT/loop sodium reabsorption. Assessments were made with and without antagonism of sodium reabsorption through the loop using bumetanide. RESULTS Empagliflozin resulted in a large decrease in sodium reabsorption in the PT (increase in FELi=7.5%±10.6%, P = 0.001), with several observations suggesting inhibition of PT sodium hydrogen exchanger 3. In the absence of renal compensation, this would be expected to result in approximately 40 g of sodium excretion/24 hours with normal kidney function. However, rapid tubular compensation occurred with increased sodium reabsorption both in the loop ( P < 0.001) and distal nephron ( P < 0.001). Inhibition of sodium-glucose cotransporter-2 did not attenuate over 14 days of empagliflozin ( P = 0.14). However, there were significant reductions in FELi ( P = 0.009), fractional excretion of sodium ( P = 0.004), and absolute fractional distal sodium reabsorption ( P = 0.036), indicating that chronic adaptation to SGLT2i results primarily from increased reabsorption in the loop and/or PT. CONCLUSIONS Empagliflozin caused substantial redistribution of intrarenal sodium delivery and reabsorption, providing mechanistic substrate to explain some of the benefits of this class. Importantly, the large increase in sodium exit from the PT was balanced by distal compensation, consistent with SGLT2i excellent safety profile. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER ClinicalTrials.gov ( NCT03027960 ).
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Affiliation(s)
- Veena S. Rao
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Juan B. Ivey-Miranda
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Zachary L. Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Julieta Moreno-Villagomez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Facultad de Estudios Superiores Iztacala, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Christopher Maulion
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Lavanya Bellumkonda
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - John Chang
- Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | | | | | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas
| | - Sean P. Collins
- Department of Emergency Medicine, Geriatric Research, Education and Clinical Center (GRECC), Vanderbilt University Medical Center and Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Jeffrey M. Turner
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - F. Perry Wilson
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut
| | - Silvio E. Inzucchi
- Section of Endocrinology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Christopher S. Wilcox
- Division of Nephrology and Hypertension Center, Georgetown University, Washington, DC
| | - David H. Ellison
- Oregon Clinical and Translational Research Institute, Oregon Health and Science University, Portland, Oregon
| | - Jeffrey M. Testani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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22
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Basham HA, Keswani S, Kumar A, Rahol Rai SKA, Surkasha F, Kumari A, Malik J. Role of Sodium-Glucose Co-Transporter-2 Inhibitor During Anthracycline Use: An Updated Review. Cardiol Rev 2024:00045415-990000000-00187. [PMID: 38189378 DOI: 10.1097/crd.0000000000000638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
The coalescence of anthracycline-induced cardiotoxicity and the evolving role of sodium-glucose co-transporter-2 (SGLT-2) inhibitors in oncology and cardiology has prompted a comprehensive review of their mechanisms, clinical implications, and future directions. Anthracyclines, potent chemotherapeutic agents, have been integral in cancer treatment, yet their potential for cardiac harm necessitates careful monitoring and management. We explore the multifactorial nature of anthracycline-induced cardiotoxicity, encompassing diverse patient populations, cumulative doses, and interplay with other treatments. While advancements in imaging and biomarker assessments aid in early detection, the lack of standardized criteria poses challenges. The emergent role of SGLT-2 inhibitors, initially developed for diabetes management, presents a novel avenue for cardioprotection. Beyond glycemic control, these inhibitors exhibit pleiotropic effects, including enhanced diuresis, anti-inflammatory actions, and modulation of energy sources. Consequently, SGLT-2 inhibitors are being investigated for their potential to mitigate cardiotoxic effects, promising an innovative approach in cardio-oncology. Despite these advancements, limitations in data interpretation and patient-specific considerations persist. The future of anthracycline-induced cardiotoxicity research lies in predictive biomarkers, precision medicine, multidisciplinary collaboration, and tailored treatment regimens. By navigating these challenges and harnessing emerging strategies, we aim to optimize cancer treatment efficacy while safeguarding cardiovascular health, ultimately paving the way for a new era of personalized and comprehensive oncologic care.
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Affiliation(s)
- Humzala Ali Basham
- From the Department of Cardiovascular Medicine, Cardiovascular Analytics Group, Islamabad, Pakistan
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23
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Duan XP, Xiao Y, Su XT, Zheng JY, Gurley S, Emathinger J, Yang CL, McCormick J, Ellison DH, Lin DH, Wang WH. Role of Angiotensin II Type 1a Receptor (AT1aR) of Renal Tubules in Regulating Inwardly Rectifying Potassium Channels 4.2 (Kir4.2), Kir4.1, and Epithelial Na + Channel (ENaC). Hypertension 2024; 81:126-137. [PMID: 37909221 PMCID: PMC10842168 DOI: 10.1161/hypertensionaha.123.21389] [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: 04/19/2023] [Accepted: 10/12/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Kir4.2 and Kir4.1 play a role in regulating membrane transport in the proximal tubule (PT) and in the distal-convoluted-tubule (DCT), respectively. METHODS We generated kidney-tubule-specific-AT1aR-knockout (Ks-AT1aR-KO) mice to examine whether renal AT1aR regulates Kir4.2 and Kir4.1. RESULTS Ks-AT1aR-KO mice had a lower systolic blood pressure than Agtr1aflox/flox (control) mice. Ks-AT1aR-KO mice had a lower expression of NHE3 (Na+/H+-exchanger 3) and Kir4.2, a major Kir-channel in PT, than Agtr1aflox/flox mice. Whole-cell recording also demonstrated that the membrane potential in PT of Ks-AT1aR-KO mice was lesser negative than Agtr1aflox/flox mice. The expression of Kir4.1 and Kir5.1, Kir4.1/Kir5.1-mediated K+ currents of DCT and DCT membrane potential in Ks-AT1aR-KO mice, were similar to Agtr1aflox/flox mice. However, angiotensin II perfusion for 7 days hyperpolarized the membrane potential in PT and DCT of the control mice but not in Ks-AT1aR-KO mice, while angiotensin II perfusion did not change the expression of Kir4.1, Kir4.2, and Kir5.1. Deletion of AT1aR did not significantly affect the expression of αENaC (epithelial Na+ channel) and βENaC but increased cleaved γENaC expression. Patch-clamp experiments demonstrated that deletion of AT1aR increased amiloride-sensitive Na+-currents in the cortical-collecting duct but not in late-DCT. However, tertiapin-Q sensitive renal outer medullary potassium channel currents were similar in both genotypes. CONCLUSIONS AT1aR determines the baseline membrane potential of PT by controlling Kir4.2 expression/activity but AT1aR is not required for determining the baseline membrane potential of the DCT and Kir4.1/Kir5.1 activity/expression. However, AT1aR is required for angiotensin II-induced hyperpolarization of basolateral membrane of PT and DCT. Deletion of AT1aR had no effect on baseline renal outer medullary potassium channel activity but increased ENaC activity in the CCD.
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Affiliation(s)
- Xin-Peng Duan
- Department of Physiology, Xuzhou Medical University, Xuzhou, China
- Department of Pharmacology, New York Medical College, Valhalla, NY
| | - Yu Xiao
- Department of Physiology, Qiqihar Medical College, Heilongjiang, China
- Department of Pharmacology, New York Medical College, Valhalla, NY
| | - Xiao-Tong Su
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jun-Ya Zheng
- Department of Pharmacology, New York Medical College, Valhalla, NY
| | - Susan Gurley
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Chao-Ling Yang
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - James McCormick
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - David H. Ellison
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Dao-Hong Lin
- Department of Pharmacology, New York Medical College, Valhalla, NY
| | - Wen-Hui Wang
- Department of Pharmacology, New York Medical College, Valhalla, NY
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Edwards A, Ralph DL, Mercado A, McDonough AA. Angiotensin II hypertension along the female rat tubule: predicted impact on coupled transport of Na + and K . Am J Physiol Renal Physiol 2023; 325:F733-F749. [PMID: 37823196 PMCID: PMC10878725 DOI: 10.1152/ajprenal.00232.2023] [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: 08/08/2023] [Revised: 10/05/2023] [Accepted: 10/05/2023] [Indexed: 10/13/2023] Open
Abstract
Chronic infusion of subpressor level of angiotensin II (ANG II) increases the abundance of Na+ transporters along the distal nephron, balanced by suppression of Na+ transporters along the proximal tubule and medullary thick ascending limb (defined as "proximal nephron"), which impacts K+ handling along the entire renal tubule. The objective of this study was to quantitatively assess the impact of chronic ANG II on the renal handling of Na+ and K+ in female rats, using a computational model of the female rat renal tubule. Our results indicate that the downregulation of proximal nephron Na+ reabsorption (TNa), which occurs in response to ANG II-triggered hypertension, involves changes in both transporter abundance and trafficking. Our model suggests that substantial (∼30%) downregulation of active NHE3 in proximal tubule (PT) microvilli is needed to reestablish the Na+ balance at 2 wk of ANG II infusion. The 35% decrease in SGLT2, a known NHE3 regulator, may contribute to this downregulation. Both depression of proximal nephron TNa and stimulation of distal ENaC raise urinary K+ excretion in ANG II-treated females, while K+ loss is slightly mitigated by cortical NKCC2 and NCC upregulation. Our model predicts that K+ excretion may be more significantly limited during ANG II infusion by ROMK inhibition in the distal nephron and/or KCC3 upregulation in the PT, which remain open questions for experimental validation. In summary, our analysis indicates that ANG II hypertension triggers a series of events from distal TNa stimulation followed by compensatory reduction in proximal nephron TNa and accompanying adjustments to limit excessive K+ secretion.NEW & NOTEWORTHY We used a computational model of the renal tubule to assess the impact of 2-wk angiotensin II (ANG II) infusion on the handling of Na+ and K+ in female rats. ANG II strongly stimulates distal Na+ reabsorption and K+ secretion. Simulations indicate that substantial downregulation of proximal tubule NHE3 is needed to reestablish Na+ balance at 2 wk. Proximal adaptations challenge K+ homeostasis, and regulation of distal NCC and specific K+ channels likely limit urinary K+ losses.
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Affiliation(s)
- Aurélie Edwards
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts, United States
| | - Donna L Ralph
- Department of Physiology and Neuroscience, Keck School of Medicine, University of Southern California, Los Angeles, California, United States
| | - Adriana Mercado
- Departamento de Bioquímica, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Alicia A McDonough
- Department of Physiology and Neuroscience, Keck School of Medicine, University of Southern California, Los Angeles, California, United States
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25
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Bilen Y, Almoushref A, Alkwatli K, Osman O, Mehdi A, Sawaf H. Treatment and practical considerations of diabetic kidney disease. Front Med (Lausanne) 2023; 10:1264497. [PMID: 38105902 PMCID: PMC10722293 DOI: 10.3389/fmed.2023.1264497] [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: 07/20/2023] [Accepted: 10/19/2023] [Indexed: 12/19/2023] Open
Abstract
Diabetic kidney disease (DKD) is a complication of diabetes that can lead to kidney failure. Over the years, several drugs have been developed to combat this disease. In the early 90s, angiotensin blockade (ACEi and ARBs) was introduced, which revolutionized the treatment of DKD. In recent years, newer drugs such as sodium-glucose co-transporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, endothelin antagonists, and mineralocorticoid receptor antagonists (MRA) have shown great promise in reducing albuminuria and protecting the kidneys. These drugs are being used in combination with lifestyle modifications, patient education, and risk factor modification to effectively manage DKD. In this review, we will explore the latest pharmacological options, their efficacy, and their potential to revolutionize the management of this debilitating disease.
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Affiliation(s)
- Yara Bilen
- Cleveland Clinic, Department of Internal Medicine, Cleveland, OH, United States
| | - Allaa Almoushref
- Cleveland Clinic, Department of Kidney Medicine, Cleveland, OH, United States
| | - Kenda Alkwatli
- Cleveland Clinic, Department of Endocrinology, Cleveland, OH, United States
| | - Omar Osman
- Cleveland Clinic, Department of Kidney Medicine, Cleveland, OH, United States
| | - Ali Mehdi
- Cleveland Clinic, Department of Kidney Medicine, Cleveland, OH, United States
| | - Hanny Sawaf
- Cleveland Clinic, Department of Kidney Medicine, Cleveland, OH, United States
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26
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Beal B, Schutte AE, Neuen BL. Blood Pressure Effects of SGLT2 Inhibitors: Mechanisms and Clinical Evidence in Different Populations. Curr Hypertens Rep 2023; 25:429-435. [PMID: 37948021 DOI: 10.1007/s11906-023-01281-1] [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] [Accepted: 10/26/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE OF REVIEW Sodium glucose transporter 2 inhibitors (SGLT2 inhibitors) are increasingly prescribed due to their considerable benefits on clinical outcomes in people with diabetes, heart failure, and chronic kidney disease (CKD). Hypertension is a common comorbidity in each of these disease states, increasing risk of cardiovascular morbidity and mortality. We herein review the effects of SGLT2 inhibitors on blood pressure in different populations, proposed mechanisms of action, and the contribution of blood pressure lowering to end-organ protection. RECENT FINDINGS A recognised effect of SGLT2 inhibitors in recent clinical trials is blood pressure lowering, with multiple postulated mechanisms. This advantageous effect was first identified in populations with type 2 diabetes mellitus, prior to expansion of these trials to broader cohorts. On our review, we identified that the blood pressure lowering effect of SGLT2 inhibitors appears to be a dose-independent class-effect, with a magnitude of effect comparable to that seen with a low dose hydrochlorothiazide. There is considerable evidence demonstrating that this effect is observed across populations including those with type 2 diabetes mellitus, chronic kidney disease, and resistant hypertension.
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Affiliation(s)
- Bryony Beal
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Aletta E Schutte
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Level 5, 1 King St Newtown 2042, Sydney, Australia
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Brendon L Neuen
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia.
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Level 5, 1 King St Newtown 2042, Sydney, Australia.
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27
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Reyes-Farias CI, Reategui-Diaz M, Romani-Romani F, Prokop L. The effect of sodium-glucose cotransporter 2 inhibitors in patients with chronic kidney disease with or without type 2 diabetes mellitus on cardiovascular and renal outcomes: A systematic review and meta-analysis. PLoS One 2023; 18:e0295059. [PMID: 38019892 PMCID: PMC10686459 DOI: 10.1371/journal.pone.0295059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransporter 2 (SGLT-2) inhibitors have shown a favorable effect on cardiovascular and renal outcomes in patients with type 2 diabetes mellitus (T2DM). However, their efficacy in patients with chronic kidney disease (CKD) with or without T2DM has not yet been analyzed. OBJECTIVE To assess the cardiovascular and renal effects of SGLT-2 inhibitors in patients with CKD with and without T2DM, including all CKD patients in the current literature. METHODS We searched MEDLINE, EMBASE, CENTRAL and Scopus for randomized controlled trials of SGLT-2 inhibitors that evaluated cardiovascular and kidney outcomes in patients with CKD, or trials in which these patients were a subgroup. We defined 2 primary outcomes: a composite of cardiovascular death or hospitalization for heart failure, and a composite renal outcome. For each outcome, we obtained overall hazard ratios with 95% confidence intervals by using a random effects model. RESULTS We included 14 randomized controlled trials. SGLT-2 inhibitors decreased the hazard for the primary cardiovascular outcome (HR 0.76; [95% CI 0.72-0.79]) and the primary renal outcome (HR 0.69; [95% CI 0.61-0.79]) in patients with CKD with or without T2DM. We did not find significant differences in the subgroup analyses according to diabetes status, baseline eGFR values or the type of SGLT-2 inhibitor used. CONCLUSION In patients with CKD, treatment with SGLT-2 inhibitors in addition to standard therapy conferred protection against cardiovascular and renal outcomes. Further research on patients with non-diabetic CKD should be done to confirm the utility of these medications in this population. (PROSPERO ID: CRD42021275012).
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Affiliation(s)
| | | | | | - Larry Prokop
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, United States of America
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Mark PB, Sarafidis P, Ekart R, Ferro CJ, Balafa O, Fernandez-Fernandez B, Herrington WG, Rossignol P, Del Vecchio L, Valdivielso JM, Mallamaci F, Ortiz A, Nistor I, Cozzolino M. SGLT2i for evidence-based cardiorenal protection in diabetic and non-diabetic chronic kidney disease: a comprehensive review by EURECA-m and ERBP working groups of ERA. Nephrol Dial Transplant 2023; 38:2444-2455. [PMID: 37230946 PMCID: PMC10615631 DOI: 10.1093/ndt/gfad112] [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: 09/30/2022] [Indexed: 05/27/2023] Open
Abstract
Chronic kidney disease (CKD) is a major public health issue affecting an estimated 850 million people globally. The leading causes of CKD is diabetes and hypertension, which together account for >50% of patients with end-stage kidney disease. Progressive CKD leads to the requirement for kidney replacement therapy with transplantation or dialysis. In addition, CKD, is a risk factor for premature cardiovascular disease, particularly from structural heart disease and heart failure (HF). Until 2015, the mainstay of treatment to slow progression of both diabetic and many non-diabetic kidney diseases was blood pressure control and renin-angiotensin system inhibition; however, neither angiotensin-converting enzyme inhibitors (ACEIs) nor angiotensin receptor blockers (ARBs) reduced cardiovascular events and mortality in major trials in CKD. The emergence of cardiovascular and renal benefits observed with sodium-glucose cotransporter-2 inhibitors (SGLT2i) from clinical trials of their use as anti-hyperglycaemic agents has led to a revolution in cardiorenal protection for patients with diabetes. Subsequent clinical trials, notably DAPA-HF, EMPEROR, CREDENCE, DAPA-CKD and EMPA-KIDNEY have demonstrated their benefits in reducing risk of HF and progression to kidney failure in patients with HF and/or CKD. The cardiorenal benefits-on a relative scale-appear similar in patients with or without diabetes. Specialty societies' guidelines are continually adapting as trial data emerges to support increasingly wide use of SGLT2i. This consensus paper from EURECA-m and ERBP highlights the latest evidence and summarizes the guidelines for use of SGLT2i for cardiorenal protection focusing on benefits observed relevant to people with CKD.
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Affiliation(s)
- Patrick B Mark
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Robert Ekart
- Faculty of Medicine, University of Maribor, Taborska 8, Maribor, Slovenia
| | - Charles J Ferro
- Renal Unit, University Hospitals Birmingham and Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK
| | - Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Beatriz Fernandez-Fernandez
- Division of Nephrology and Hypertension, IIS-Fundación Jiménez Díaz-Universidad Autónoma Madrid. Spain, Spain
| | - William G Herrington
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Patrick Rossignol
- Université de Lorraine, INSERM CIC-P 1433, CHRU de Nancy, INSERM U1116, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
- Service de Spécialités Médicales et de Néphrologie-Hémodialyse Centre Hospitalier Princesse Grace de Monaco, Monaco, Monaco
| | | | - Jose M Valdivielso
- Vascular and Renal Translational Research Group and UDETMA, IRBLleida, Lleida, Spain
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Alberto Ortiz
- Division of Nephrology and Hypertension, IIS-Fundación Jiménez Díaz-Universidad Autónoma Madrid. Spain, Spain
| | - Ionut Nistor
- Faculty of Medicine, University of Medicine and Pharmacy ‘Grigore T. Popa’, Iași, Romania
| | - Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
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Vogt L, Marques FZ, Fujita T, Hoorn EJ, Danser AHJ. Novel mechanisms of salt-sensitive hypertension. Kidney Int 2023; 104:690-697. [PMID: 37454911 DOI: 10.1016/j.kint.2023.06.035] [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: 05/24/2023] [Revised: 06/08/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023]
Abstract
A high dietary sodium-consumption level is considered the most important lifestyle factor that can be modified to help prevent an increase in blood pressure and the development of hypertension. Despite numerous studies over the past decades, the pathophysiology explaining why some people show a salt-sensitive blood pressure response and others do not is incompletely understood. Here, a brief overview of the latest mechanistic insights is provided, focusing on the mononuclear phagocytic system and inflammation, the gut-kidney axis, and epigenetics. The article also discusses the effects of 3 types of novel drugs on salt-sensitive hypertension-sodium-glucose cotransporter 2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists, and aldosterone synthase inhibitors. The conclusion is that besides kidney-centered mechanisms, vasoconstrictor mechanisms are also relevant for both the understanding and treatment of this blood pressure phenotype.
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Affiliation(s)
- Liffert Vogt
- Department of Internal Medicine, Section of Nephrology, Amsterdam University Medical Centers, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, Netherlands
| | - Francine Z Marques
- Hypertension Research Laboratory, School of Biological Sciences, and Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia; Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Toshiro Fujita
- Research Center for Advanced Science and Technology (RCAST), The University of Tokyo, Tokyo, Japan
| | - Ewout J Hoorn
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - A H Jan Danser
- Department of Internal Medicine, Division of Pharmacology and Vascular Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands.
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30
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Packer M, Butler J, Zeller C, Pocock SJ, Brueckmann M, Ferreira JP, Filippatos G, Usman MS, Zannad F, Anker SD. Blinded Withdrawal of Long-Term Randomized Treatment With Empagliflozin or Placebo in Patients With Heart Failure. Circulation 2023; 148:1011-1022. [PMID: 37621153 PMCID: PMC10516173 DOI: 10.1161/circulationaha.123.065748] [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: 05/26/2023] [Accepted: 08/03/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND It is not known whether the benefits of sodium-glucose cotransporter 2 inhibitors in heart failure persist after years of therapy. METHODS In the EMPEROR-Reduced (Empagliflozin Outcome Trials in Chronic Heart Failure With Reduced Ejection Fraction) and EMPEROR-Preserved (Empagliflozin Outcome Trials in Chronic Heart Failure With Preserved Ejection Fraction) trials, patients with heart failure were randomly assigned (double-blind) to placebo or empagliflozin 10 mg/day for a median of 16 and 26 months, respectively. At the end of the trials, 6799 patients (placebo 3381, empagliflozin 3418) were prospectively withdrawn from treatment in a blinded manner, and, of these, 3981 patients (placebo 2020, empagliflozin 1961) underwent prespecified in-person assessments after ≈30 days off treatment. RESULTS From 90 days from the start of closeout to the end of double-blind treatment, the annualized risk of cardiovascular death or hospitalization for heart failure was lower in empagliflozin-treated patients than in placebo-treated patients (10.7 [95% CI, 9.0-12.6] versus 13.5 [95% CI, 11.5-15.6] events per 100 patient-years, respectively; hazard ratio 0.76 [95% CI, 0.60-0.96]). When the study drugs were withdrawn for ≈30 days, the annualized risk of cardiovascular death or hospitalization for heart failure increased in patients withdrawn from empagliflozin but not in those withdrawn from placebo (17.0 [95% CI, 12.6-22.1] versus 14.1 [95% CI, 10.1-18.8] events per 100 patient-years for empagliflozin and placebo, respectively). The hazard ratio for the change in risk in the patients withdrawn from empagliflozin was 1.75 (95% CI, 1.20-2.54), P=0.0034, whereas the change in the risk in patients withdrawn from placebo was not significant (hazard ratio 1.12 [95% CI, 0.76-1.66]); time period-by-treatment interaction, P=0.068. After withdrawal, the Kansas City Cardiomyopathy Questionnaire Clinical Summary Score declined by 1.6±0.4 in patients withdrawn from empagliflozin versus placebo (P<0.0001). Furthermore, withdrawal of empagliflozin was accompanied by increases in fasting glucose, body weight, systolic blood pressure, estimated glomerular filtration rate, N-terminal pro-hormone B-type natriuretic peptide, uric acid, and serum bicarbonate and decreases in hemoglobin and hematocrit (all P<0.01). These physiological and laboratory changes were the inverse of the effects of the drug seen at the start of the trials during the initiation of treatment (≈1-3 years earlier) in the same cohort of patients. CONCLUSIONS These observations demonstrate a persistent effect of empagliflozin in patients with heart failure even after years of treatment, which dissipated rapidly after withdrawal of the drug. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifiers: NCT03057977 and NCT03057951.
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Affiliation(s)
- Milton Packer
- Baylor University Medical Center, Dallas, TX (M.P.)
- Imperial College, London, United Kingdom (M.P.)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX (J.B.)
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS (J.B.)
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH and Co KG, Biberach, Germany (C.Z.)
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, United Kingdom (S.J.P.)
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (M.B.)
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Germany (M.B.)
| | - João Pedro Ferreira
- Cardiovascular Research and Development Center, Faculty of Medicine of the University of Porto, Portugal (J.P.F.)
- Centre d'Investigations Cliniques Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France (J.P.F., F.Z.)
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece (G.F.)
| | - Muhammad Shariq Usman
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (M.S.U.)
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France (J.P.F., F.Z.)
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin (S.D.A.)
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31
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Dai ZC, Chen JX, Zou R, Liang XB, Tang JX, Yao CW. Role and mechanisms of SGLT-2 inhibitors in the treatment of diabetic kidney disease. Front Immunol 2023; 14:1213473. [PMID: 37809091 PMCID: PMC10552262 DOI: 10.3389/fimmu.2023.1213473] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/06/2023] [Indexed: 10/10/2023] Open
Abstract
Diabetic kidney disease (DKD) is a chronic inflammatory condition that affects approximately 20-40% of individuals with diabetes. Sodium-glucose co-transporter 2 (SGLT-2) inhibitors, emerging as novel hypoglycemic agents, have demonstrated significant cardiorenal protective effects in patients with DKD. Initially, it was believed that the efficacy of SGLT-2 inhibitors declined as the estimated glomerular filtration rate (eGFR) decreased, which led to their preferential use in DKD patients at G1-G3 stages. However, recent findings from the DAPA-CKD and EMPA-KIDNEY studies have revealed equally beneficial cardiorenal effects of SGLT-2 inhibitors in individuals at stage G4 DKD, although the underlying mechanism behind this phenomenon remains unclear. In this comprehensive analysis, we provide a systematic review of the mechanisms and functioning of SGLT-2 inhibitors, potential renal protection mechanisms, and the therapeutic efficacy and safety of SGLT-2 inhibitors in kidney diseases, with a particular focus on stage G4 DKD. Gaining a deeper understanding of the renal protective effect of SGLT-2 inhibitors and their underlying mechanisms is highly significance for the successful utilization of these inhibitors in the treatment of diverse kidney disorders.
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Affiliation(s)
| | | | | | | | - Ji-Xin Tang
- Guangdong Provincial Key Laboratory of Autophagy and Major Chronic Non-communicable Diseases, Key Laboratory of Prevention and Management of Chronic Kidney Diseases of Zhanjiang City, Institute of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Cui-Wei Yao
- Guangdong Provincial Key Laboratory of Autophagy and Major Chronic Non-communicable Diseases, Key Laboratory of Prevention and Management of Chronic Kidney Diseases of Zhanjiang City, Institute of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
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32
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Song J, Li X, Ni J. A Role for Sodium-Glucose Cotransporter 2 Inhibitors in the Treatment of Chronic Kidney Disease: A Mini Review. Kidney Blood Press Res 2023; 48:599-610. [PMID: 37717569 PMCID: PMC10614480 DOI: 10.1159/000534174] [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: 05/18/2023] [Accepted: 09/14/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransport protein 2 (SGLT2) inhibitors, a new type of glucose-lowering drug, have been well proved in several clinical studies for their glucose-lowering and nephroprotective effects, and the nephroprotective effects include both indirect effects of metabolic improvement and direct effects, independent of glucose-lowering effects. SUMMARY In patients with diabetic kidney disease (DKD), several studies have demonstrated the potential nephroprotective mechanisms of SGLT2 inhibitors, and evidence of nephroprotective mechanisms in the non-DKD population is accumulating. Although the nephroprotective mechanism of SGLT2 inhibitors has not been fully elucidated, several laboratory studies have illustrated the mechanism underlying the effects of SGLT2 inhibitors at various aspects. KEY MESSAGES The purpose of this article is to review the mechanism of nephroprotective effect of SGLT2 inhibitors and to look forward to promising research in the future.
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Affiliation(s)
- Jinfang Song
- Department of Clinical Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, Xuzhou Medical University, Xuzhou, China
| | - Xia Li
- Department of Clinical Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
- Wuxi School of Medicine, Jiangnan University, Jiangsu Province, Wuxi, China
| | - Jiang Ni
- Department of Clinical Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
- Wuxi School of Medicine, Jiangnan University, Jiangsu Province, Wuxi, China
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33
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Biegus J, Fudim M, Salah HM, Heerspink HJL, Voors AA, Ponikowski P. Sodium-glucose cotransporter-2 inhibitors in heart failure: Potential decongestive mechanisms and current clinical studies. Eur J Heart Fail 2023; 25:1526-1536. [PMID: 37477086 DOI: 10.1002/ejhf.2967] [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: 05/21/2023] [Revised: 06/19/2023] [Accepted: 07/01/2023] [Indexed: 07/22/2023] Open
Abstract
Congestion is a key pathophysiological feature of heart failure (HF) syndrome that drives most of the clinical manifestations of acute HF and is related with poor quality of life and outcomes. Therefore, safe and effective decongestion is an important therapeutic target in the management of acute HF and despite the use of guideline-recommended loop diuretics, adequate decongestion is not always achieved in patients with acute HF. Recently, sodium-glucose cotransporter-2 (SGLT-2) inhibitors have been shown to provide clinical benefits across a broad spectrum of patients with HF, including consistent reduction in the risk of acute HF episodes. While the exact mechanisms underlying these benefits remain a matter of debate, a growing body of evidence suggests that effective decongestion may be partly responsible, especially in the setting of acute HF. In this review, we discuss the potential decongestive mechanisms of SGLT-2 inhibitors, such as osmotic diuresis, natriuresis, preservation of glomerular filtration and facilitation of interstitial drainage, which can collectively translate into effective and safe decongestion. Furthermore, we provide a comprehensive review of up-to-date clinical data of SGLT-2 inhibitor use in the acute HF population.
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Affiliation(s)
- Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Marat Fudim
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Medicine, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Husam M Salah
- Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
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34
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Santulli G, Varzideh F, Forzano I, Wilson S, Salemme L, de Donato A, Lombardi A, Rainone A, Nunziata L, Jankauskas SS, Tesorio T, Guerra G, Kansakar U, Mone P. Functional and Clinical Importance of SGLT2-inhibitors in Frailty: From the Kidney to the Heart. Hypertension 2023; 80:1800-1809. [PMID: 37403685 PMCID: PMC10529735 DOI: 10.1161/hypertensionaha.123.20598] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
SGLT2 (sodium-glucose cotransporter 2) enables glucose and sodium reabsorption in the kidney. SGLT2-inhibitors (also known as gliflozins, which include canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin) act by increasing glycosuria, thereby reducing glycemia. These drugs are critical to reach and keep glycemic control, a crucial feature, especially in patients with comorbidities, like frail individuals. Several studies evaluated the effects of SGLT2-inhibitors in different settings beyond diabetes, revealing that they are actually pleiotropic drugs. We recently evidenced the favorable effects of SGLT2-inhibition on physical and cognitive impairment in frail older adults with diabetes and hypertension. In the present overview, we summarize the latest clinical and preclinical studies exploring the main effects of SGLT2-inhibitors on kidney and heart, emphasizing their potential beneficial actions in frailty.
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Affiliation(s)
- Gaetano Santulli
- Department of Medicine, Einstein College, New York, USA
- Naples University “Federico II”
| | | | | | - Scott Wilson
- Department of Medicine, Einstein College, New York, USA
| | | | | | | | | | | | | | | | | | - Urna Kansakar
- Department of Medicine, Einstein College, New York, USA
| | - Pasquale Mone
- Department of Medicine, Einstein College, New York, USA
- Department of Medicine, Molise University
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Ashfaq A, Meineck M, Pautz A, Arioglu-Inan E, Weinmann-Menke J, Michel MC. A systematic review on renal effects of SGLT2 inhibitors in rodent models of diabetic nephropathy. Pharmacol Ther 2023; 249:108503. [PMID: 37495021 DOI: 10.1016/j.pharmthera.2023.108503] [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: 05/18/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 07/28/2023]
Abstract
We have performed a systematic review of studies reporting on the renal effects of SGLT2 inhibitors in rodent models of diabetes. In 105 studies, SGLT2 inhibitors improved not only the glycemic control but also various aspects of renal function in most cases. These nephroprotective effects were similarly reported whether treatment with the SGLT2 inhibitor started concomitant with the onset of diabetes (within 1 week), early after onset (1-4 weeks) or after nephropathy had developed (>4 weeks after onset) with the latter probably having the greatest translational value. They were observed across various animal models of type 1 and type 2 diabetes/obesity (4 and 23 models, respectively), although studies in the type 2 diabetes model of db/db mice more often had negative data than in other models. Among possibly underlying pathophysiological mechanisms of nephroprotection, treatment with SGLT2 inhibitors had beneficial effects on lipid metabolism, blood pressure, glomerulosclerosis as well as renal tubular fibrosis, apoptosis, oxidative stress, and inflammation. These pathomechanisms highly influence atherosclerosis and renal health, which are two major factors that lead to an enhanced mortality in patients with diabetes and/or chronic kidney disease. Interestingly, renal SGLT2 inhibitor effects did not always correlate with those on glucose homeostasis, particularly in a limited number of direct comparative studies with other anti-diabetic treatments, indicating that nephroprotection may at least partly occur by mechanisms other than improving glycemic control. Our analyses did not provide evidence for different nephroprotective efficacy between SGLT2 inhibitors. Importantly, only four of 105 studies reported on female animals, and none provided direct comparative data between sexes. We conclude that more data on female animals and more direct comparative studies with other anti-diabetic compounds and combinations of treatments are needed.
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Affiliation(s)
- Aqsa Ashfaq
- Dept. of Pharmacology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Myriam Meineck
- 1(st) Dept. of Medicine, Div. of Nephrology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Andrea Pautz
- Dept. of Pharmacology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Ebru Arioglu-Inan
- Dept. of Pharmacology, Faculty of Pharmacy, Ankara University, Ankara, Turkey
| | - Julia Weinmann-Menke
- 1(st) Dept. of Medicine, Div. of Nephrology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Martin C Michel
- Dept. of Pharmacology, University Medical Center, Johannes Gutenberg University, Mainz, Germany.
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Packer M. Lack of durable natriuresis and objective decongestion following SGLT2 inhibition in randomized controlled trials of patients with heart failure. Cardiovasc Diabetol 2023; 22:197. [PMID: 37533009 PMCID: PMC10399057 DOI: 10.1186/s12933-023-01946-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/28/2023] [Indexed: 08/04/2023] Open
Abstract
Patients with heart failure have increased cardiac filling pressures, circulating natriuretic peptides, and physical signs of fluid retention, which are related to sodium retention by the kidneys and are alleviated by conventional diuretics. Sodium-glucose cotransporter 2 (SGLT2) inhibitors interfere with sodium and glucose reabsorption in the proximal renal tubule, but they evoke a marked counterregulatory activation of sodium and water reabsorption in distal nephron segments, which opposes and negates any diuretic effect. Nevertheless, it has been postulated that SGLT2 inhibitors modulate the volume set point, leading selectively to decongestion in patients with fluid overload. This hypothesis was tested in a review of 15 randomized controlled trials of SGLT2 inhibitors in patients with heart failure, with 7 trials focusing on urinary volume within the first week, and 8 trials focusing on objective decongestion at 12 weeks. In trials < 1 week, SGLT2 inhibition increased urine volume in the first 24 h, but typically without a change in urinary sodium excretion, and this diuresis was not sustained. In 8 trials of 12 weeks' duration, none reported alleviation of edema, ascites or pulmonary rales. The 2 trials that evaluated changes in left ventricular filling pressure noted no or small changes (1-2 mm Hg); the two trials that measured interstitial lung water or total blood volume found no effect; and 6 of the 7 trials found no decrease in circulating natriuretic peptides. Therefore, randomized controlled trials do not indicate that SGLT2 inhibitors produce a durable natriuresis or objective decongestion in patients with heart failure.
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Affiliation(s)
- Milton Packer
- Heart and Vascular Institute, Baylor University Medical Center, 621 North Hall Street, Dallas, TX, 75226, USA.
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Layton AT, Vallon V. Did you know how SGLT2 inhibitors protect the kidney? Acta Physiol (Oxf) 2023; 238:e14011. [PMID: 37288493 DOI: 10.1111/apha.14011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 05/22/2023] [Accepted: 05/24/2023] [Indexed: 06/09/2023]
Affiliation(s)
- Anita T Layton
- Departments of Applied Mathematics and Biology, University of Waterloo, Waterloo, Ontario, Canada
- Cheriton School of Computer Science, School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Volker Vallon
- Departments of Medicine and Pharmacology, University of California, San Diego, La Jolla, California, USA
- San Diego Veterans Affairs Healthcare System, San Diego, California, USA
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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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Biancalana E, Rossi C, Raggi F, Distaso M, Tricò D, Baldi S, Ferrannini E, Solini A. Empagliflozin and Renal Sodium-Hydrogen Exchange in Healthy Subjects. J Clin Endocrinol Metab 2023; 108:e567-e573. [PMID: 36794422 PMCID: PMC10348461 DOI: 10.1210/clinem/dgad088] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/25/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023]
Abstract
CONTEXT Sodium glucose co-transporter-2 inhibitors exert clinically relevant cardiorenal protection. Among several mechanisms, inhibition of sodium-hydrogen exchanger-3 (NHE3) in proximal renal tubules has been proposed in rodents. Demonstration of this mechanism with the associated electrolyte and metabolic changes in humans is lacking. OBJECTIVE The present proof-of-concept study was designed to explore the involvement of NHE3 in modulating the response to sodium glucose co-transporter-2 inhibitors in humans. METHODS Twenty healthy male volunteers received 2 tablets of empagliflozin 25 mg during a standardized hydration scheme; freshly voided urines and blood samples were collected at timed intervals for 8 hours. Protein expression of relevant transporters was examined in exfoliated tubular cells. RESULTS Urine pH levels increased after empagliflozin (from 5.81 ± 0.5 to 6.16 ± 0.6 at 6 hours, P = .008) as did urinary output (from median, 1.7; interquartile range [IQR, 0.6; 2.5] to 2.5 [IQR, 1.7; 3.5] mL/min-1, P = .008) and glucose (from median, 0.03 [IQR, 0.02; 0.04] to 34.8 [IQR, 31.6; 40.2] %, P < .0001), and sodium fractional excretion rates (from median, 0.48 [IQR, 0.34; 0.65] to 0.71 [IQR, 0.55; 0.85] %, P = .0001), whereas plasma glucose and insulin concentrations decreased and plasma and urinary ketones increased. Nonsignificant changes in NHE3, phosphorylated NHE3, and membrane-associated protein 17 protein expression were detected in urinary exfoliated tubular cells. In a time-control study in 6 participants, neither urine pH nor plasma and urinary parameters changed. CONCLUSIONS In healthy young volunteers, empagliflozin acutely increases urinary pH while inducing a substrate shift toward lipid utilization and ketogenesis, without significant changes in renal NHE3 protein expression.
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Affiliation(s)
- Edoardo Biancalana
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa I-56126, Italy
| | - Chiara Rossi
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa I-56126, Italy
| | - Francesco Raggi
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa I-56126, Italy
| | - Mariarosaria Distaso
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa I-56126, Italy
| | - Domenico Tricò
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa I-56126, Italy
| | - Simona Baldi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa I-56126, Italy
| | - Ele Ferrannini
- Consiglio Nazionale delle Ricerche (CNR) Institute of Clinical Physiology, Pisa I-56126, Italy
| | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa I-56126, Italy
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Gronda E, Palazzuoli A, Iacoviello M, Benevenuto M, Gabrielli D, Arduini A. Renal Oxygen Demand and Nephron Function: Is Glucose a Friend or Foe? Int J Mol Sci 2023; 24:9957. [PMID: 37373108 DOI: 10.3390/ijms24129957] [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: 04/26/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
The kidneys and heart work together to balance the body's circulation, and although their physiology is based on strict inter dependence, their performance fulfills different aims. While the heart can rapidly increase its own oxygen consumption to comply with the wide changes in metabolic demand linked to body function, the kidneys physiology are primarily designed to maintain a stable metabolic rate and have a limited capacity to cope with any steep increase in renal metabolism. In the kidneys, glomerular population filters a large amount of blood and the tubular system has been programmed to reabsorb 99% of filtrate by reabsorbing sodium together with other filtered substances, including all glucose molecules. Glucose reabsorption involves the sodium-glucose cotransporters SGLT2 and SGLT1 on the apical membrane in the proximal tubular section; it also enhances bicarbonate formation so as to preserve the acid-base balance. The complex work of reabsorption in the kidney is the main factor in renal oxygen consumption; analysis of the renal glucose transport in disease states provides a better understanding of the renal physiology changes that occur when clinical conditions alter the neurohormonal response leading to an increase in glomerular filtration pressure. In this circumstance, glomerular hyperfiltration occurs, imposing a higher metabolic demand on kidney physiology and causing progressive renal impairment. Albumin urination is the warning signal of renal engagement over exertion and most frequently heralds heart failure development, regardless of disease etiology. The review analyzes the mechanisms linked to renal oxygen consumption, focusing on sodium-glucose management.
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Affiliation(s)
- Edoardo Gronda
- Medicine and Medicine Sub-Specialties Department, Cardio Renal Program, U.O.C. Nephrology, Dialysis and Adult Renal Transplant Program, IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, 20122 Milano, Italy
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, S. Maria alle Scotte Hospital University of Siena, 53100 Siena, Italy
| | - Massimo Iacoviello
- Department of Medical and Surgical Sciences, University of Foggia, 71100 Foggia, Italy
| | - Manuela Benevenuto
- Unità Operativa Complessa Cardiologia-UTIC-Emodinamica, PO Giuseppe Mazzini, 64100 Teramo, Italy
| | - Domenico Gabrielli
- Unità Operativa Complessa Cardiologia-UTIC, Azienda Ospedaliera San Camillo Forlanini, 00152 Rome, Italy
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41
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Campbell RT, Docherty KF. Serum bicarbonate and congestion: a potential biomarker for identifying and guiding management in diuretic resistance? Eur Heart J 2023; 44:2006-2008. [PMID: 37160825 DOI: 10.1093/eurheartj/ehad209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023] Open
Affiliation(s)
- Ross T Campbell
- School of Cardiovascular and Metabolic Health, BHF Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
| | - Kieran F Docherty
- School of Cardiovascular and Metabolic Health, BHF Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
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42
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Buliga-Finis ON, Ouatu A, Tanase DM, Gosav EM, Seritean Isac PN, Richter P, Rezus C. Managing Anemia: Point of Convergence for Heart Failure and Chronic Kidney Disease? Life (Basel) 2023; 13:1311. [PMID: 37374094 DOI: 10.3390/life13061311] [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: 04/30/2023] [Revised: 05/23/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
The pathologic triangle formed by chronic heart failure (HF), chronic kidney disease (CKD), and anemia carries high morbidity and mortality rates and decreases quality of life. Anemia represents a common condition in patients with advanced HF and CKD, with a total prevalence in cardiorenal syndrome (CRS) ranging from 5% to 55%. Searching for a pragmatic approach for these patients with guided and disease-specific recommendations beyond just targeted hemoglobin therapeutic behavior represents the core of research for ongoing clinical trials. It is well known that the prevalence of anemia increases with the advancement of CKD and HF. The physiopathological mechanisms of anemia, such as the reduction of endogenous erythropoietin and the decrease in oxygen transport, are leading to tissue hypoxia, peripheral vasodilation, stimulating neurohormonal activity, and maintenance of the progressive renal and cardiac dysfunction. Given the challenges with the treatment options for patients with cardiorenal anemia syndrome (CRSA), new therapeutic agents such as hypoxia-inducible factor-prolyl hydroxylase domain inhibitors (HIF-PH) or hepcidin antagonists are emerging in the light of recent research. This review summarizes the potential therapeutic tools for anemia therapy in the cardiorenal population.
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Affiliation(s)
- Oana Nicoleta Buliga-Finis
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Anca Ouatu
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Daniela Maria Tanase
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Evelina Maria Gosav
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Petronela Nicoleta Seritean Isac
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Patricia Richter
- Department of Rheumatology and Physiotherapy, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Rheumatology Clinic, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
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43
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Kim YC, Fattah H, Fu Y, Nespoux J, Vallon V. Expression of leptin receptor in renal tubules is sparse but implicated in leptin-dependent kidney gene expression and function. Am J Physiol Renal Physiol 2023; 324:F544-F557. [PMID: 37102688 PMCID: PMC10228677 DOI: 10.1152/ajprenal.00279.2022] [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: 11/11/2022] [Revised: 03/30/2023] [Accepted: 04/16/2023] [Indexed: 04/28/2023] Open
Abstract
Leptin regulates energy balance via leptin receptors expressed in central and peripheral tissues, but little is known about leptin-sensitive kidney genes and the role of the tubular leptin receptor (Lepr) in response to a high-fat diet (HFD). Quantitative RT-PCR analysis of Lepr splice variants A, B, and C revealed a ratio of ∼100:10:1 in the mouse kidney cortex and medulla, with medullary levels being ∼10 times higher. Leptin replacement in ob/ob mice for 6 days reduced hyperphagia, hyperglycemia, and albuminuria, associated with normalization of kidney mRNA expression of molecular markers of glycolysis, gluconeogenesis, amino acid synthesis, and megalin. Normalization of leptin for 7 h in ob/ob mice did not normalize hyperglycemia or albuminuria. Tubular knockdown of Lepr [Pax8-Lepr knockout (KO)] and in situ hybridization revealed a minor fraction of Lepr mRNA in tubular cells compared with endothelial cells. Nevertheless, Pax8-Lepr KO mice had lower kidney weight. Moreover, while HFD-induced hyperleptinemia, increases in kidney weight and glomerular filtration rate, and a modest blood pressure lowering effect were similar compared with controls, they showed a blunted rise in albuminuria. Use of Pax8-Lepr KO and leptin replacement in ob/ob mice identified acetoacetyl-CoA synthetase and gremlin 1 as tubular Lepr-sensitive genes that are increased and reduced by leptin, respectively. In conclusion, leptin deficiency may increase albuminuria via systemic metabolic effects that impinge on kidney megalin expression, whereas hyperleptinemia may induce albuminuria by direct tubular Lepr effects. Implications of Lepr variants and the novel tubular Lepr/acetoacetyl-CoA synthetase/gremlin 1 axis remain to be determined.NEW & NOTEWORTHY This study provides new insights into kidney gene expression of leptin receptor splice variants, leptin-sensitive kidney gene expression, and the role of the leptin receptor in renal tubular cells for the response to diet-induced hyperleptinemia and obesity including albuminuria.
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Affiliation(s)
- Young Chul Kim
- Division of Nephrology and Hypertension, Department of Medicine, University of California-San Diego, La Jolla, California, United States
- Veterans Affairs San Diego Healthcare System, San Diego, California, United States
| | - Hadi Fattah
- Division of Nephrology and Hypertension, Department of Medicine, University of California-San Diego, La Jolla, California, United States
- Veterans Affairs San Diego Healthcare System, San Diego, California, United States
| | - Yiling Fu
- Veterans Affairs San Diego Healthcare System, San Diego, California, United States
| | - Josselin Nespoux
- Veterans Affairs San Diego Healthcare System, San Diego, California, United States
| | - Volker Vallon
- Division of Nephrology and Hypertension, Department of Medicine, University of California-San Diego, La Jolla, California, United States
- Veterans Affairs San Diego Healthcare System, San Diego, California, United States
- Department of Pharmacology, University of California-San Diego, La Jolla, California, United States
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Moady G, Ben Gal T, Atar S. Sodium-Glucose Co-Transporter 2 Inhibitors in Heart Failure-Current Evidence in Special Populations. Life (Basel) 2023; 13:1256. [PMID: 37374037 PMCID: PMC10301138 DOI: 10.3390/life13061256] [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: 04/20/2023] [Revised: 05/17/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
Sodium-glucose co-transporter 2 (SGLT2) inhibitors, originally used for diabetes mellitus, are gaining more popularity for other indications, owing to their positive cardiovascular and renal effects. SGLT2 inhibitors reduce heart failure (HF) hospitalization and improve cardiovascular outcomes in patients with type 2 diabetes. Later, SGLT2 inhibitors were evaluated in patients with HF with reduced ejection fraction (HFREF) and had beneficial effects independent of the presence of diabetes. Recently, reductions in cardiovascular outcomes were also observed in patients with HF with preserved ejection fraction (HFPEF). SGLT2 inhibitors also reduced renal outcomes in patients with chronic kidney disease. Overall, these drugs have an excellent safety profile with a negligible risk of genitourinary tract infections and ketoacidosis. In this review, we discuss the current data on SGLT2 inhibitors in special populations, including patients with acute myocardial infarction, acute HF, right ventricular (RV) failure, left ventricular assist device (LVAD), and type 1 diabetes. We also discuss the potential mechanisms behind the cardiovascular benefits of these medications.
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Affiliation(s)
- Gassan Moady
- Department of Cardiology, Galilee Medical Center, Nahariya 2210001, Israel;
- Azrieli Faculty of Medicine, Bar Ilan University, Safed 5290002, Israel
| | - Tuvia Ben Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Petah Tikva 4941492, Israel;
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Shaul Atar
- Department of Cardiology, Galilee Medical Center, Nahariya 2210001, Israel;
- Azrieli Faculty of Medicine, Bar Ilan University, Safed 5290002, Israel
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45
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Mårtensson J, Cutuli SL, Osawa EA, Yanase F, Toh L, Cioccari L, Luethi N, Maeda A, Bellomo R. Sodium glucose co-transporter-2 inhibitors in intensive care unit patients with type 2 diabetes: a pilot case control study. Crit Care 2023; 27:189. [PMID: 37194077 DOI: 10.1186/s13054-023-04481-y] [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: 03/17/2023] [Accepted: 05/08/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Sodium glucose co-transporter-2 (SGLT2) inhibitors improve long-term cardiovascular and renal outcomes in individuals with type 2 diabetes. However, the safety of SGLT2 inhibitors in ICU patients with type 2 diabetes is uncertain. We aimed to perform a pilot study to assess the relationship between empagliflozin therapy and biochemical, and clinical outcomes in such patients. METHODS We included 18 ICU patients with type 2 diabetes receiving empagliflozin (10 mg daily) and insulin to target glucose range of 10-14 mmol/l according to our liberal glucose control protocol for patients with diabetes (treatment group). Treatment group patients were matched on age, glycated hemoglobin A1c, and ICU duration with 72 ICU patients with type 2 diabetes exposed to the same target glucose range but who did not receive empagliflozin (control group). We compared changes in electrolyte and acid-base parameters, hypoglycemia, ketoacidosis, worsening kidney function, urine culture findings, and hospital mortality between the groups. RESULTS Median (IQR) maximum increase in sodium and chloride levels were 3 (1-10) mmol/l and 3 (2-8) mmol/l in the control group and 9 (3-12) mmol/l and 8 (3-10) mmol/l in the treatment group (P = 0.045 for sodium, P = 0.059 for chloride). We observed no differences in strong ion difference, pH or base excess. Overall, 6% developed hypoglycemia in each group. No patient in the treatment group and one patient in the control group developed ketoacidosis. Worsening kidney function occurred in 18% and 29% of treatment and control group patients, respectively (P = 0.54). Urine cultures were positive in 22% of treatment group patients and 13% of control group patients (P = 0.28). Overall, 17% of treatment group patients and 19% of control group patients died in hospital (P = 0.79). CONCLUSIONS In our pilot study of ICU patients with type 2 diabetes, empagliflozin therapy was associated with increases in sodium and chloride levels but was not significantly associated with acid-base changes, hypoglycemia, ketoacidosis, worsening kidney function, bacteriuria, or mortality.
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Affiliation(s)
- Johan Mårtensson
- Department of Physiology and Pharmacology, Section of Anaesthesia and Intensive Care, Karolinska Institutet, Stockholm, Sweden.
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Salvatore Lucio Cutuli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, L.Go F. Vito 1, 00168, Rome, Italy
| | - Eduardo A Osawa
- Cardiology Intensive Care Unit, Hospital DF-Star, Brasília, Brazil
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Lisa Toh
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Luca Cioccari
- Department of Intensive Care Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Nora Luethi
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Akinori Maeda
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, Melbourne University, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
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46
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Tang H, Xu C, Zhang P, Luo T, Huang Y, Yang X. A profile of SGLT-2 inhibitors in hyponatremia: The evidence to date. Eur J Pharm Sci 2023; 184:106415. [PMID: 36870579 DOI: 10.1016/j.ejps.2023.106415] [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: 11/27/2022] [Revised: 02/14/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023]
Abstract
Hyponatremia is the most common electrolyte disorder in clinical practice, which may lead to life-threatening complications. Several lines of evidence suggest that hyponatremia is associated not only with significant increases in length of stay, cost, and financial burden, but also with increased morbidity and mortality. Hyponatremia is also considered to be a negative prognostic factor in patients with heart failure and cancer. Although multiple therapeutic methods are available for treating hyponatremia, most have some limitations, such as poor compliance, rapid correction of serum Na+, other negative side effects and high cost. Given these limitations, identifying novel therapies for hyponatremia is essential. Recent clinical studies have shown that SGLT-2 inhibitors (SGLT 2i) significantly increased serum Na+ levels and were well tolerated by patients who underwent this treatment. Therefore, oral administration of SGLT 2i appears to be an effective treatment for hyponatremia. This article will briefly review the etiology of hyponatremia and integrated control of sodium within the kidney, current therapies for hyponatremia, potential mechanisms and efficacy of SGLT 2i for hyponatremia, and the benefits in cardiovascular, cancer, and kidney disease by regulating sodium and water balance.
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Affiliation(s)
- Hui Tang
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; School of Pharmacy, Southwest Medical University, Luzhou 646000, China
| | - Changjing Xu
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Piao Zhang
- Department of Pharmacy, Ya 'an People's Hospital, Ya 'an, Sichuan 646000, China
| | - Taimin Luo
- Department of pharmacy, Chengdu Seventh People's Hospital, Chengdu, Sichuan 610000, China
| | - Yilan Huang
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; School of Pharmacy, Southwest Medical University, Luzhou 646000, China.
| | - Xuping Yang
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; School of Pharmacy, Southwest Medical University, Luzhou 646000, China.
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47
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Sitina M, Lukes M, Sramek V. Empagliflozin-associated postoperative mixed metabolic acidosis. Case report and review of pathogenesis. BMC Endocr Disord 2023; 23:81. [PMID: 37060078 PMCID: PMC10103020 DOI: 10.1186/s12902-023-01339-w] [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: 11/24/2022] [Accepted: 04/10/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Euglycemic diabetic ketoacidosis associated with SGLT2 inhibitors is a rare, relatively new and potentially fatal clinical entity, characterized by metabolic acidosis with normal or only moderately elevated glycemia. The mechanisms are not fully understood but involve increased ketogenesis and complex renal metabolic dysfunction, resulting in both ketoacidosis and hyperchloremic acidosis. We report a rare case of fatal empagliflozin-associated acidosis with profound hyperchloremia and review its pathogenesis. CASE PRESENTATION A patient with type 2 diabetes mellitus treated with empagliflozin underwent an elective hip replacement surgery. Since day 4 after surgery, he felt generally unwell, leading to cardiac arrest on the day 5. Empagliflozin-associated euglycemic diabetic ketoacidosis with severe hyperchloremic acidosis was identified as the cause of the cardiac arrest. CONCLUSIONS This unique case documents the possibility of severe SGLT2 inhibitor-associated mixed metabolic acidosis with a predominant hyperchloremic component. Awareness of this possibility and a high index of suspicion are crucial for correct and early diagnosis.
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Affiliation(s)
- Michal Sitina
- Department of anesthesiology and intensive care medicine, St. Anne´s University Hospital, Pekarska 664/53, Brno, 656 91, Czech Republic.
- Department of Biostatistics, International Clinical Research Center, St. Anne´s University Hospital, Pekarska 664/53, Brno, 656 91, Czech Republic.
- Faculty of Medicine, Masaryk University, Kamenice 5, Brno, 625 00, Czech Republic.
| | - Marek Lukes
- Department of anesthesiology and intensive care medicine, St. Anne´s University Hospital, Pekarska 664/53, Brno, 656 91, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 5, Brno, 625 00, Czech Republic
| | - Vladimir Sramek
- Department of anesthesiology and intensive care medicine, St. Anne´s University Hospital, Pekarska 664/53, Brno, 656 91, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 5, Brno, 625 00, Czech Republic
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Abstract
ABSTRACT The incidence of abdominal aortic aneurysm (AAA) in the elderly is increasing year by year with high mortality. Current treatment is mainly through surgery or endovascular intervention, which is not sufficient to reduce future risk. Therefore, we still need to find an effective conservative measure as an adjunct therapy or early intervention to prevent AAA progression. Traditional therapeutic agents, such as β-receptor blockers, calcium channel blockers, and statins, have been shown to have limited effects on the growth of AAA. Recently, sodium-glucose cotransport proteins inhibitors (SGLT2is), a new class hypoglycemic drug, have shown outstanding beneficiary effects on cardiovascular diseases by plasma volume reduction, vascular tone regulation, and various unidentified mechanisms. It has been demonstrated that SGLT2i is abundantly expressed in the aorta, and some studies also showed promising results of SGLT2i in treating animal AAA models. This article aims to summarize the recent progress of AAA studies and look forward to the application of SGLT2i in AAA treatment for early intervention or adjunct therapy after surgical repair or stent graft.
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Affiliation(s)
- Zhongtiao Jin
- Master of Medicine, Department of Endocrinology, Renmin Hospital of Wuhan University, 430060, China; and
| | - Hongping Deng
- Department of Vascular Surgery, Renmin Hospital of Wuhan University, 430060, China.
| | - Sizheng Xiong
- Department of Vascular Surgery, Renmin Hospital of Wuhan University, 430060, China.
| | - Ling Gao
- Master of Medicine, Department of Endocrinology, Renmin Hospital of Wuhan University, 430060, China; and
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49
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The protective effects of SGLT-2 inhibitors, GLP-1 receptor agonists, and RAAS blockers against renal injury in patients with type 2 diabetes. Int Urol Nephrol 2023; 55:617-629. [PMID: 36036316 DOI: 10.1007/s11255-022-03355-6] [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: 02/03/2022] [Accepted: 08/21/2022] [Indexed: 10/15/2022]
Abstract
Diabetic kidney disease is one of the most severe complications of type 2 diabetes mellitus. Patients with diabetic kidney disease have a worse prognosis in terms of mortality and morbidity, compared with patients who have diabetes alone. Strict control of blood pressure and blood glucose is the primary method for prevention of initial kidney damage and delaying further progression of existing damage. Other management approaches include the use of exogenous drugs that can effectively protect the kidneys from diabetes, such as sodium-glucose transporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and renin-angiotensin-aldosterone system blockers. These drugs may protect against kidney injury through various molecular mechanisms. This review focuses on renal impairment in patients with type 2 diabetes; it discusses the direct and indirect effects of sodium-glucose transporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and renin-angiotensin-aldosterone system blockers on diabetic kidney disease. Finally, it discusses the effects of combination treatment with two or three types of drugs in patients with chronic kidney disease.
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50
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Anan G, Kikuchi D, Hirose T, Ito H, Nakayama S, Mori T. In Reply to “Letter Regarding ‘Impact of sodium-glucose cotransporter-2 inhibitors on urolithiasis’”. Kidney Int Rep 2023. [DOI: 10.1016/j.ekir.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
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