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Li H, Xia Y, Zha H, Zhang Y, Shi L, Wang J, Huang H, Yue R, Hu B, Zhu J, Song Z. Dapagliflozin attenuates AKI to CKD transition in diabetes by activating SIRT3/PGC1-α signaling and alleviating aberrant metabolic reprogramming. Biochim Biophys Acta Mol Basis Dis 2024; 1870:167433. [PMID: 39067538 DOI: 10.1016/j.bbadis.2024.167433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 07/07/2024] [Accepted: 07/17/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Patients with diabetes are prone to acute kidney injury (AKI) with a high mortality rate, poor prognosis, and a higher risk of progression to chronic kidney disease than non-diabetic patients. METHODS Streptozotocin (STZ)-treated type 1 and db/db type 2 diabetes model were established, AKI model was induced in mice by ischemia-reperfusion injury(IRI). Mouse proximal tubular cell cells were subjected to high glucose and hypoxia-reoxygenation in vitro. Transcriptional RNA sequencing was performed for clustering analysis and target gene screening. Renal structural damage was determined by histological staining, whereas creatinine and urea nitrogen levels were used to measure renal function. RESULTS Deteriorated renal function and renal tissue damage were observed in AKI mice with diabetic background. RNA sequencing showed a decrease in fatty acid oxidation (FAO) pathway and an increase in abnormal glycolysis. Treatment with Dapa, Sitagliptin(a DPP-4 inhibitor)and insulin reduced blood glucose levels in mice, and improved renal function. However, Dapa had a superior therapeutic effect and alleviated aberrant FAO and glycosis. Dapa reduced cellular death in cultured cells under high glucose hypoxia-reoxygenation conditions, alleviated FAO dysfunction, and reduced abnormal glycolysis. RNA sequencing showed that SIRT3 expression was reduced in diabetic IRI, which was largely restored by Dapa intervention. 3-TYP, a SIRT3 inhibitor, reversed the renal protective effects of Dapa and mediated abnormal FAO and glycolysis in mice and tubular cells. CONCLUSION Our study provides experimental evidence for the use of Dapa as a means to reduce diabetic AKI by ameliorating metabolic reprogramming in renal tubular cells.
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MESH Headings
- Animals
- Male
- Mice
- Acute Kidney Injury/metabolism
- Acute Kidney Injury/drug therapy
- Acute Kidney Injury/pathology
- Acute Kidney Injury/etiology
- Diabetes Mellitus, Experimental/complications
- Diabetes Mellitus, Experimental/metabolism
- Diabetes Mellitus, Experimental/drug therapy
- Diabetes Mellitus, Experimental/pathology
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/metabolism
- Diabetes Mellitus, Type 2/drug therapy
- Diabetes Mellitus, Type 2/pathology
- Diabetic Nephropathies/metabolism
- Diabetic Nephropathies/drug therapy
- Diabetic Nephropathies/pathology
- Glucosides/pharmacology
- Glucosides/therapeutic use
- Metabolic Reprogramming/drug effects
- Mice, Inbred C57BL
- Peroxisome Proliferator-Activated Receptor Gamma Coactivator 1-alpha/metabolism
- Peroxisome Proliferator-Activated Receptor Gamma Coactivator 1-alpha/genetics
- Renal Insufficiency, Chronic/metabolism
- Renal Insufficiency, Chronic/drug therapy
- Renal Insufficiency, Chronic/pathology
- Signal Transduction/drug effects
- Sirtuin 3/metabolism
- Sirtuin 3/genetics
- Benzhydryl Compounds/pharmacology
- Benzhydryl Compounds/therapeutic use
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Affiliation(s)
- Huimin Li
- Department of Nephrology, The First Clinical Medical College of Three Gorges University, Center People's Hospital of Yichang, Yichang, Hubei 443000, China; Institute of Kidney Disease, Three Gorges University, Yichang, Hubei 443000, China; Department of Nephrology, Affiliated Renhe Hospital of China Three Gorges University, Yichang City 443001, Hubei Province, China
| | - Yao Xia
- Department of Nephrology, The First Clinical Medical College of Three Gorges University, Center People's Hospital of Yichang, Yichang, Hubei 443000, China; Institute of Kidney Disease, Three Gorges University, Yichang, Hubei 443000, China
| | - Hongchu Zha
- Department of Nephrology, The First Clinical Medical College of Three Gorges University, Center People's Hospital of Yichang, Yichang, Hubei 443000, China; Institute of Kidney Disease, Three Gorges University, Yichang, Hubei 443000, China
| | - Yafei Zhang
- Department of Nephrology, The First Clinical Medical College of Three Gorges University, Center People's Hospital of Yichang, Yichang, Hubei 443000, China; Institute of Kidney Disease, Three Gorges University, Yichang, Hubei 443000, China
| | - Lang Shi
- Institute of Kidney Disease, Three Gorges University, Yichang, Hubei 443000, China; Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, China
| | - JiaYi Wang
- Department of Anesthesiology, the Second Xiangya Hospital, Changsha, Hunan Province, China
| | - Hua Huang
- Department of Nephrology, The First Clinical Medical College of Three Gorges University, Center People's Hospital of Yichang, Yichang, Hubei 443000, China; Institute of Kidney Disease, Three Gorges University, Yichang, Hubei 443000, China
| | - Ruchi Yue
- Department of Nephrology, The First Clinical Medical College of Three Gorges University, Center People's Hospital of Yichang, Yichang, Hubei 443000, China; Institute of Kidney Disease, Three Gorges University, Yichang, Hubei 443000, China; Department of Nephrology, Affiliated Renhe Hospital of China Three Gorges University, Yichang City 443001, Hubei Province, China
| | - Bin Hu
- Department of Nephrology, Affiliated Renhe Hospital of China Three Gorges University, Yichang City 443001, Hubei Province, China
| | - Jiefu Zhu
- Institute of Kidney Disease, Three Gorges University, Yichang, Hubei 443000, China; Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Zhixia Song
- Department of Nephrology, the Longhua District People's Hospital of Shenzhen, Shenzhen, Guangdong 518000, China.
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2
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Spasovski G. Hyponatraemia-treatment standard 2024. Nephrol Dial Transplant 2024; 39:1583-1592. [PMID: 39009016 DOI: 10.1093/ndt/gfae162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Indexed: 07/17/2024] Open
Abstract
Hyponatraemia is the most common electrolyte disorder in hospital patients associated with increased morbidity, mortality, hospital stay and financial burden. The speed of a correction with 3% sodium chloride as a 100- to 150-ml intravenous bolus or continuous infusion depends on the severity and persistence of the symptoms and needs frequent biochemical monitoring. The rapid intermittent administration of hypertonic saline is preferred for treatment of symptomatic hyponatraemia. In asymptomatic mild hyponatraemia, an adequate solute intake with an initial fluid restriction (FR) of 500 ml/day adjusted according to the serum sodium (sNa) levels is preferred. Almost half of the syndrome of inappropriate antidiuretic hormone (SIADH) patients do not respond to FR as first-line therapy. At present, urea and tolvaptan are considered the most effective second-line therapies in SIADH. However, the evidence for guidance on the choice of second-line therapy of hypotonic hyponatraemia is lacking. Oral urea is considered to be a very effective and safe treatment. Mild and asymptomatic hyponatraemia is treated with adequate solute intake (salt and protein) and initial FR with adjustments based on sNa levels. Specific treatment with vaptans may be considered in either euvolaemic or hypervolaemic patients with high ADH activity. In order to ensure optimal patient outcome, close monitoring and readiness for administration of either hypotonic fluids or desmopressin may be crucial in the decision-making process for specific treatment and eventual overcorrection consequences. According to the guidelines, gradual correction and clinical evaluation is preferable over rapid normalization of sNa towards the laboratory reference ranges.
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Affiliation(s)
- Goce Spasovski
- Department of Nephrology, University of Skopje, Sts. Cyril and Methodius, Skopje, N. Macedonia
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3
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Lamback E, Filho FDC, Ventura N, Chimelli L, Christ-Crain M, Gadelha MR. Extraventricular Neurocytoma of the Sellar Region Presenting With Syndrome of Inappropriate Antidiuresis. JCEM CASE REPORTS 2024; 2:luae099. [PMID: 39156001 PMCID: PMC11327119 DOI: 10.1210/jcemcr/luae099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Indexed: 08/20/2024]
Abstract
Neurocytomas are neuronal tumors that are usually intraventricular. Rare cases can arise from extraventricular sites. To our knowledge, only 29 cases of extraventricular neurocytoma of the sellar region (EVNSR) have been reported in the literature. We describe a case of a 39-year-old woman who presented with a one-month history of refractory headache, nausea and vomiting. Magnetic resonance imaging (MRI) showed a 5.1 × 3.1 × 2.2 cm sellar and suprasellar mass, suggestive of a pituitary adenoma (PA). She had hyponatremia, obstructive hydrocephalus, and panhypopituitarism at presentation (hypogonadism, adrenal insufficiency). After glucocorticoid replacement therapy and ventriculoperitoneal shunt, the vomiting and headache resolved, but she remained with nausea and hyponatremia. She was submitted to surgery, and histopathological analysis revealed a neurocytoma with positive immunostaining for arginine vasopressin. Syndrome of inappropriate antidiuresis (SIAD) was diagnosed but did not resolve after surgery due to residual tumor, despite fluid restriction and saline replacement. SIAD later resolved with empagliflozin. In conclusion, EVNSR is extremely rare and can be misdiagnosed as PA on MRI. In the context of SIAD and extraventricular neurocytoma, a secreting arginine vasopressin tumor must be considered. SIAD can be challenging to treat, with excision of the EVNSR the treatment choice and, alternatively, empagliflozin associated with fluid restriction.
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Affiliation(s)
- Elisa Lamback
- Neuroendocrinology Research Center, Endocrinology Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-617, Brazil
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro 20231-092, Brazil
- Neuroendocrine Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro 20231-092, Brazil
| | - Ferdinand Duenas Cabrera Filho
- Neuroradiology Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro 20231-092, Brazil
| | - Nina Ventura
- Neuroradiology Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro 20231-092, Brazil
| | - Leila Chimelli
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro 20231-092, Brazil
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel 4001, Switzerland
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel 4001, Switzerland
| | - Mônica R Gadelha
- Neuroendocrinology Research Center, Endocrinology Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-617, Brazil
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro 20231-092, Brazil
- Neuroendocrine Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro 20231-092, Brazil
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Tao S, Guo S, Tong N. Update on the clinical applications of SGLTis: Insight to benefits beyond hypoglycemic and cardiorenal protection. Pharmacotherapy 2024; 44:642-657. [PMID: 38973479 DOI: 10.1002/phar.2952] [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: 02/28/2024] [Revised: 06/03/2024] [Accepted: 06/12/2024] [Indexed: 07/09/2024]
Abstract
Sodium glucose cotransporter inhibitor (SGLTi) drugs have been widely used in clinical practice. In addition to their benefits in hyperglycemia, heart failure (HF), and kidney disease, their effects on obesity, metabolic dysfunction-associated steatotic liver disease (MASLD, formerly named nonalcoholic fatty liver disease [NAFLD]), polycystic ovarian syndrome (PCOS), abnormal lipid metabolism, hyperuricemia, obstructive sleep apnea syndrome (OSAS), anemia, and syndrome of inappropriate antidiuresis (SIAD, formerly named syndrome of inappropriate antidiuretic hormone [SIADH]) have been explored. In this review, we searched the data of clinical randomized controlled trials (RCTs) and meta-analyses of SGLTis in patients with diabetes from the PubMed library between January 1, 2020, and February 1, 2024. According to our review, certain SGLTis exhibit relatively superior clinical safety and effectiveness for treating the abovementioned diseases. Proper utilization of SGLTis in these patients can provide additional medication options for patients with different disease scenarios. However, studies of SGLTis in these diseases are relatively rare, with shortcomings such as small sample sizes and short intervention periods. Therefore, further large-scale, long-term, well-designed studies are needed to clarify the findings.
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Affiliation(s)
- Shibing Tao
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, China
- Research Centre for Diabetes and Metabolism, West China Hospital of Sichuan University, Chengdu, China
- Department of Endocrinology and Metabolism, Ziyang Central Hospital, Ziyang, Sichuan Province, China
| | - Shanlan Guo
- Department of Pathology, Ziyang Central Hospital, Ziyang, Sichuan Province, China
| | - Nanwei Tong
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, China
- Research Centre for Diabetes and Metabolism, West China Hospital of Sichuan University, Chengdu, China
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5
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Luo J, Tu L, Zhou C, Li G, Shi L, Hu S. SGLT2 inhibition, circulating proteins, and insomnia: A mendelian randomization study. Sleep Med 2024; 119:480-487. [PMID: 38795402 DOI: 10.1016/j.sleep.2024.05.036] [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: 01/30/2024] [Revised: 04/11/2024] [Accepted: 05/16/2024] [Indexed: 05/27/2024]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors (SGLT2i) initially emerged as oral antidiabetic medication but were subsequently discovered to exhibit pleiotropic actions. Insomnia is a prevalent and debilitating sleep disorder. To date, the causality between SGLT2 inhibitors and insomnia remains unclear. This study aims to evaluate the causality between SGLT2 inhibitors and insomnia and identify potential plasma protein mediators. METHODS Using a two-sample Mendelian Randomization (MR) analysis, we estimated the causality of SGLT2 inhibition on insomnia and sleep duration. Additionally, employing a two-step and proteome-wide MR analysis, we evaluated the causal link of SGLT2 inhibition on 4907 circulating proteins and the causality of SGLT2 inhibition-driven plasma proteins on insomnia. We applied a false discovery rate (FDR) correction for multiple comparisons. Furthermore, mediation analyses were used to identify plasma proteins that mediate the effects of SGLT2 inhibition on insomnia. RESULTS SGLT2 inhibition was negatively correlated with insomnia (odds ratio [OR] = 0.791, 95 % confidence interval [CI] [0.715, 0.876], P = 5.579*10^-6) and positively correlated with sleep duration (β = 0.186, 95 % CI [0.059, 0.314], P = 0.004). Among the 4907 circulating proteins, diadenosine tetraphosphatase (Ap4A) was identified as being linked to both SGLT2 inhibition and insomnia. Mediation analysis indicated that the effect of SGLT2 inhibition on insomnia partially operates through Ap4A (β = -0.018, 95 % CI [-0.036, -0.005], P = 0.023), with a mediation proportion of 7.7 %. CONCLUSION The study indicated a causality between SGLT2 inhibition and insomnia, with plasma Ap4A potentially serving as a mediator.
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Affiliation(s)
- Jinlan Luo
- Department of Geriatric Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China; Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Ling Tu
- Department of Geriatric Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China; Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, 430030, China
| | - Chenchen Zhou
- Department of Emergency Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Gen Li
- Department of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Lili Shi
- Department of Geriatric Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Shuiqing Hu
- Division of Cardiology, Department of Internal Medicine and Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430000, China.
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6
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Monnerat S, Drivakos N, Chapman FA, Dhaun N, Refardt J, Christ-Crain M. Apelin and Copeptin Levels in Patients With Chronic SIAD Treated With Empagliflozin. J Endocr Soc 2024; 8:bvae106. [PMID: 38872994 PMCID: PMC11170659 DOI: 10.1210/jendso/bvae106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Indexed: 06/15/2024] Open
Abstract
Background Empagliflozin increases sodium levels in patients with a chronic syndrome of inappropriate antidiuresis (SIAD), and dapagliflozin increases apelin levels in patients with diabetes mellitus. Exogenous apelin increases sodium levels in rats with SIAD. We aimed to investigate whether an increase in plasma apelin concentration may contribute to the efficacy of empagliflozin in SIAD. Methods Post hoc secondary analysis of a double-blind, crossover, placebo-controlled trial performed from December 2017 to August 2021 at the University Hospital Basel, Switzerland, investigating the effect of 4-week treatment with empagliflozin 25 mg/day as compared to placebo in 14 outpatients with chronic SIAD (NCT03202667). The objective was to investigate the effect of empagliflozin on plasma apelin and copeptin concentrations and their ratio. Results Fourteen patients, 50% female, with a median [interquartile range] age of 72 years [65-77] were analyzed. Median apelin concentration was 956 pmol/L [853, 1038] at baseline. Median [interquartile range] apelin relative changes were +11% [0.7, 21] and +8% [-5, 25] (P = .672) at the end of the placebo and empagliflozin phases, respectively. Median copeptin concentration was 2.6 [2.2, 4.5] pmol/L at baseline and had a relative change of +5 [-2. 11]% and +25% [10, 28] (P = .047) over the placebo and empagliflozin phases, respectively. Conclusion Empagliflozin did not lead to significant changes in apelin or the apelin/copeptin ratio in patients with chronic SIAD but led to an increase in copeptin. This suggests that the efficacy of empagliflozin in SIAD is independent of apelin and is not blunted by the adaptative increase in copeptin.
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Affiliation(s)
- Sophie Monnerat
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
| | - Nikolaos Drivakos
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
- Department of Nephrology, Hospital Center of Biel, 2501 Biel, Switzerland
| | - Fiona A Chapman
- BHF/University of Edinburgh Centre for Cardiovascular Science, Queen's Medical Research Institute, Edinburgh EH16 4TJ, UK
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
| | - Neeraj Dhaun
- BHF/University of Edinburgh Centre for Cardiovascular Science, Queen's Medical Research Institute, Edinburgh EH16 4TJ, UK
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
| | - Julie Refardt
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
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Chen JJ, Lee TH, Yang HY. Exploring nontraditional cardiorenal advantages of SGLT-2 inhibitors and GLP-1 receptor agonists. Kidney Int 2024; 105:442-444. [PMID: 38388145 DOI: 10.1016/j.kint.2024.01.002] [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: 12/06/2023] [Accepted: 01/02/2024] [Indexed: 02/24/2024]
Abstract
This commentary provides an analysis of the study by Fu et al. in Kidney International, which employs 3 administrative databases to investigate the hyperkalemia protective effects of sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists, and dipeptidyl peptidase-4 inhibitors. It emphasizes the methodological approach, notably the use of a fixed-effect model to aggregate pairwise comparisons from 3 data sets. In addition, we explored the broader cardiorenal and potential nonrenal benefits of these drug classes, underscoring the imperative for continued research in this domain.
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Affiliation(s)
- Jia-Jin Chen
- Kidney Research Center, Nephrology Department, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Tao-Han Lee
- Department of Nephrology, Chansn Hospital, Taoyuan City, Taiwan
| | - Huang-Yu Yang
- Kidney Research Center, Nephrology Department, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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Zandifar A, Panahi M, Badrfam R, Qorbani M. Efficacy of empagliflozin as adjunctive therapy to citalopram in major depressive disorder: a randomized double-blind, placebo-controlled clinical trial. BMC Psychiatry 2024; 24:163. [PMID: 38408937 PMCID: PMC10895773 DOI: 10.1186/s12888-024-05627-0] [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: 09/03/2023] [Accepted: 02/20/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Major depressive disorder is one of the most common psychiatric disorders, which is associated with a high disease burden. Current treatments using antidepressants have limitations, so using medication with neuromodulating and anti-inflammatory properties alongside them could be helpful. In a clinical trial, we studied the effectiveness of empagliflozin, a blood sugar-lowering drug, as an adjunctive therapy to reduce the severity of depression symptoms. METHODS A number of outpatients with moderate to severe depression (Hamilton Depression Rating Scale (HDRS) > = 17) who were not under related medication or had not taken medication for at least the last two months, had an age range of 18-60 years and had written informed consent to enter the study (N = 90) were randomly divided into two groups receiving placebo or empagliflozin (10 mg daily) combined with citalopram (40 mg daily) based on permuted block randomization method in an 8-week randomized, double-blind, placebo-controlled clinical trial. They were evaluated using the HDRS in weeks 0, 4, and 8. RESULTS HDRS scores were equal to 28.42(± 3.83), 20.20(± 3.82), and 13.42(± 3.42) in the placebo group during weeks 0,4, and 8, respectively. These scores were 27.36(± 3.77), 13.76(± 1.40), and 7.00(± 1.13), respectively, for the group treated with empagliflozin. Compared to the control group, patients treated with empagliflozin using repeated-measures ANOVA showed greater improvement in reducing the severity of depression symptoms over time (p value = 0.0001). CONCLUSIONS Considering the promising findings in this clinical trial, further study of empagliflozin as adjunctive therapy in MDD with larger sample sizes and longer follow-ups is recommended.
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Affiliation(s)
- Atefeh Zandifar
- Social Determinants of Health Research Center, Alborz University of Medical Sciences, Karaj, Iran
- Department of Psychiatry, Imam Hossein Hospital, Alborz University of Medical Sciences, Karaj, Alborz, Iran
| | - Maryam Panahi
- Faculty of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Rahim Badrfam
- Department of Psychiatry, Imam Hossein Hospital, Alborz University of Medical Sciences, Karaj, Alborz, Iran.
| | - Mostafa Qorbani
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
- Chronic Diseases Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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9
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Kettritz R. [Dysnatremias - concepts and clinical work-up]. Dtsch Med Wochenschr 2024; 149:86-92. [PMID: 38262402 DOI: 10.1055/a-2055-3486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Osmotic gradients over cell membranes lead to water movement into or out of cells. An intact osmoregulation prevents osmotic gradients, thereby protecting cells from swelling or shrinking. Na+ is the major cation in the extracellular fluid (ECF) and the major determinant of the osmolarity in the ECF, including plasma. Therefore, the plasma-Na+ concentration needs to be tightly regulated. An excess of electrolyte-free water decreases the concentration of osmolytes leading to hyponatremia. In contrast, a free water deficit increases the osmolyte concentration leading to hypernatremia. Pathophysiology-oriented approaches to dysnatremic patients help both clinicians and patients. Therapeutic interventions depend on the differentiation between acute and chronic, asymptomatic, and symptomatic dysnatremia, and on the patient's extracellular volume status. The therapeutic armamentarium for hyponatremia consists of water restriction, hypertonic infusions, urea, V2 receptor-blockers, and sodium-glucose cotransporter 2 (SGLT2) inhibitors. Patients with hypernatremia are treated with electrolyte-free water or hypotonic sodium-containing solutions depending on their volume status. Basic concepts in the management of dysnatremic patients are discussed.
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10
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Sugiyama J, Ryuge A, Mitsubayashi K, Ito M, Matsumoto N, Takeuchi R, Azuma K, Hachiya A, Asano M, Nakamura T. Dapagliflozin induced hypernatremia via osmotic diuresis: a case report. CEN Case Rep 2024; 13:9-13. [PMID: 37074627 PMCID: PMC10834893 DOI: 10.1007/s13730-023-00790-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/09/2023] [Indexed: 04/20/2023] Open
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been widely used. They inhibit proximal tubular glucose reabsorption, resulting in glycosuria. Herein, we report the case of a 65-year-old woman who presented with hypernatremia during the perioperative period of a subarachnoid hemorrhage. The patient continued to take dapagliflozin postoperatively and subsequently developed severe hypernatremia. Based on the urinalysis findings, we diagnosed osmotic diuresis due to glycosuria as contributing to hypernatremia. Hypernatremia improved with the discontinuation of dapagliflozin and the administration of a hypotonic infusion. In the perioperative period, physicians should discontinue SGLT2 inhibitors owing to concerns about the development of hypernatremia.
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Affiliation(s)
- Juri Sugiyama
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, 1-1 Sannomaru, Naka-Ku, Nagoya, Aichi, 460-0001, Japan
| | - Akihiro Ryuge
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, 1-1 Sannomaru, Naka-Ku, Nagoya, Aichi, 460-0001, Japan.
| | - Kenta Mitsubayashi
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, 1-1 Sannomaru, Naka-Ku, Nagoya, Aichi, 460-0001, Japan
| | - Masashi Ito
- Department of Neurosurgery, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Naoki Matsumoto
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, 1-1 Sannomaru, Naka-Ku, Nagoya, Aichi, 460-0001, Japan
| | - Riku Takeuchi
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, 1-1 Sannomaru, Naka-Ku, Nagoya, Aichi, 460-0001, Japan
| | - Kiho Azuma
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, 1-1 Sannomaru, Naka-Ku, Nagoya, Aichi, 460-0001, Japan
| | - Asaka Hachiya
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, 1-1 Sannomaru, Naka-Ku, Nagoya, Aichi, 460-0001, Japan
| | - Marina Asano
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, 1-1 Sannomaru, Naka-Ku, Nagoya, Aichi, 460-0001, Japan
| | - Tomonobu Nakamura
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, 1-1 Sannomaru, Naka-Ku, Nagoya, Aichi, 460-0001, Japan
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11
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Schwarz C, Lindner G, Windpessl M, Knechtelsdorfer M, Saemann MD. [Consensus recommendations on the diagnosis and treatment of hyponatremia from the Austrian Society for Nephrology 2024]. Wien Klin Wochenschr 2024; 136:1-33. [PMID: 38421476 PMCID: PMC10904443 DOI: 10.1007/s00508-024-02325-5] [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: 01/03/2024] [Indexed: 03/02/2024]
Abstract
Hyponatremia is a disorder of water homeostasis. Water balance is maintained by the collaboration of renal function and cerebral structures, which regulate thirst mechanisms and secretion of the antidiuretic hormone. Measurement of serum-osmolality, urine osmolality and urine-sodium concentration help to diagnose the different reasons for hyponatremia. Hyponatremia induces cerebral edema and might lead to severe neurological symptoms, which need acute therapy. Also, mild forms of hyponatremia should be treated causally, or at least symptomatically. An inadequate fast increase of the serum sodium level should be avoided, because it raises the risk of cerebral osmotic demyelination. Basic pathophysiological knowledge is necessary to identify the different reasons for hyponatremia which need different therapeutic procedures.
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Affiliation(s)
- Christoph Schwarz
- Innere Medizin 1, Pyhrn-Eisenwurzenklinikum, Sierningerstr. 170, 4400, Steyr, Österreich.
| | - Gregor Lindner
- Zentrale Notaufnahme, Kepler Universitätsklinikum GmbH, Johannes-Kepler-Universität, Linz, Österreich
| | | | | | - Marcus D Saemann
- 6.Medizinische Abteilung mit Nephrologie und Dialyse, Klinik Ottakring, Wien, Österreich
- Medizinische Fakultät, Sigmund-Freud Universität, Wien, Österreich
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12
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Arecco A, Demontis D, Della Sala L, Musso N, Gay S, Boschetti M, Ferone D, Gatto F. Case report: Twice-daily tolvaptan dosing regimen in a challenging case of hyponatremia due to SIAD. Front Endocrinol (Lausanne) 2024; 14:1309657. [PMID: 38288467 PMCID: PMC10822982 DOI: 10.3389/fendo.2023.1309657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/27/2023] [Indexed: 02/01/2024] Open
Abstract
Background Syndrome of inappropriate antidiuresis (SIAD) is one of the most frequent causes of euvolemic hyponatremia (serum sodium levels < 135 mEq/L) and it represents more than 35% of hyponatremia cases in hospitalized patients. It is characterized by an inappropriate vasopressin (AVP)/antidiuretic hormone (ADH) secretion, which occurs independently from effective serum osmolality or circulating volume, leading to water retention via its action on type 2 vasopressin receptor in the distal renal tubules. Corpus callosum agenesis (CCA) is one of the most common congenital brain defects, which can be associated to alterations in serum sodium levels. This report presents a rare case of chronic hyponatremia associated with SIAD in a woman with CCA, whose correction of serum sodium levels only occurred following twice-daily tolvaptan administration. Case presentation A 30-year-old female was admitted to our hospital for non-acute hyponatremia with dizziness, headache, distal tremors, and concentration deficits. She had profound hyponatremia (Na 121 mmol/L) with measured plasma hypo-osmolality (259 mOsm/Kg) and urinary osmolality greater than 100 mOsm/Kg (517 mOsm/Kg). She presented clinically as normovolemic. After the exclusion of other causes of normovolemic hyponatremia, such as hypothyroidism and adrenal insufficiency, a diagnosis of SIAD was established. We have ruled out paraneoplastic, inflammatory, and infectious causes, as well as ischemic events. Her medical history showed a CCA and frontal teratoma. We administered tolvaptan initially at a low dosage (15 mg once a day) with persistence of hyponatremia. Therefore, the dosage was first doubled (30 mg once a day) and then increased to 45 mg once a day with an initial improvement in serum sodium levels, although not long-lasting. We therefore tried dividing the 45 mg tolvaptan administration into two doses of 30 mg and 15 mg respectively, using an off-label treatment schedule, thus achieving long-lasting serum sodium levels in the low-normal range associated with a general clinical improvement. Conclusions This report underlines the importance of the correct diagnosis, management and treatment of SIAD, as well as the need for further studies about the pharmacokinetics and pharmacodynamics of vasopressin receptor antagonists.
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Affiliation(s)
- Anna Arecco
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
| | - Davide Demontis
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
| | - Leonardo Della Sala
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
| | - Natale Musso
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Stefano Gay
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Mara Boschetti
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Diego Ferone
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Federico Gatto
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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13
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Buchkremer F, Schuetz P, Mueller B, Segerer S. Classifying Hypotonic Hyponatremia by Projected Treatment Effects - A Quantitative 3-Dimensional Framework. Kidney Int Rep 2023; 8:2720-2732. [PMID: 38106585 PMCID: PMC10719653 DOI: 10.1016/j.ekir.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 08/29/2023] [Accepted: 09/04/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction The diagnostic algorithms currently used for hypotonic hyponatremia focus primarily on impaired urinary dilution and often neglect the influence of free water intake and solute excretion. We hypothesized that, in each case of hypotonic hyponatremia different pathophysiological mechanisms play a role simultaneously. Methods Using clinical data of the previous observational Co-Med study, we defined each case of hypotonic hyponatremia concurrently in 3 dimensions as follows: (i) high net free water intake (HNFWI), (ii) impaired dilution of the urine (IDU), and (iii) low nonelectrolyte solute excretion (LNESE). For each dimension, a "standard delta sodium" (sdna) was calculated reflecting the expected difference to the serum sodium concentration, that would result from changing a dimension to a specific and equivalent target level. Results Results from 279 patients were used for this analysis. With target levels of free water intake and urine osmolality at the fifth percentile, and nonelectrolyte solute excretion at the 95th percentile, median (interquartile range) sdna values were 7.1 (4.8-10.2) for HNFWI, 11.8 (7.0-18.6) for IDU and 2.6 (1.6-4.2) mmol/l per 24 hours for LNESE. Sdna results in individual patients were highest with IDU in 68.5%, HNFWI in 30.8% and 0.7% with LNESE. At an sdna-level of at least 4mmol/l per 24 hours, the prevalence of HNFWI was 78.9%, IDU 87.1%, and LNESE 26.5%. 77.5% of patients had 2 or all 3 mechanisms present. Hyponatremia was mostly multifactorial in subgroups according to classic categories of hyponatremia and typical comorbidities as well. Conclusion Hypotonic hyponatremia can be quantitatively defined by 3 dimensions. Most cases should be considered multifactorial.
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Affiliation(s)
| | - Philipp Schuetz
- Division of General Internal and Emergency Medicine, Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | - Beat Mueller
- Medical Faculty of the University of Basel, Basel, Switzerland
- Division of General Internal and Emergency Medicine, Department of Endocrinology, Diabetology & Metabolism, Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | - Stephan Segerer
- Division of Nephrology, Kantonsspital Aarau, Aarau, Switzerland
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14
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Pelouto A, Zandbergen AAM, Hoorn EJ. Food for thought: protein supplementation for the treatment of the syndrome of inappropriate antidiuresis. Eur J Endocrinol 2023; 189:R11-R14. [PMID: 37930818 DOI: 10.1093/ejendo/lvad145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 11/08/2023]
Affiliation(s)
- Anissa Pelouto
- Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Adrienne A M Zandbergen
- Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ewout J Hoorn
- Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
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15
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Affiliation(s)
- Horacio J Adrogué
- From the Department of Medicine, Section of Nephrology, Baylor College of Medicine, and the Department of Medicine, Division of Nephrology, Houston Methodist Hospital - both in Houston (H.J.A.); and the Department of Medicine, Tufts University School of Medicine, and the Department of Medicine, Division of Nephrology, St. Elizabeth's Medical Center - both in Boston (N.E.M.)
| | - Nicolaos E Madias
- From the Department of Medicine, Section of Nephrology, Baylor College of Medicine, and the Department of Medicine, Division of Nephrology, Houston Methodist Hospital - both in Houston (H.J.A.); and the Department of Medicine, Tufts University School of Medicine, and the Department of Medicine, Division of Nephrology, St. Elizabeth's Medical Center - both in Boston (N.E.M.)
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16
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Monnerat S, Christ-Crain M, Refardt J. One Liter a Day, Keeps the Doctor Away. J Clin Endocrinol Metab 2023; 108:e1452-e1453. [PMID: 37061807 DOI: 10.1210/clinem/dgad217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/28/2023] [Accepted: 04/12/2023] [Indexed: 04/17/2023]
Affiliation(s)
- Sophie Monnerat
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
| | - Julie Refardt
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
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17
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Monnerat S, Refardt J, Potasso L, Meier C, Christ-Crain M. An Increase in Plasma Sodium Levels Is Associated With an Increase in Osteoblast Function in Chronic SIAD. J Clin Endocrinol Metab 2023; 108:e1027-e1033. [PMID: 37098131 PMCID: PMC10505522 DOI: 10.1210/clinem/dgad238] [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: 02/06/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 04/27/2023]
Abstract
CONTEXT Hyponatremia is associated with increased risk for osteoporosis. Preclinical studies in untreated hyponatremia suggest osteoclast upregulation, whereas a clinical study showed improved osteoblast function after hyponatremia normalization in hospitalized patients with syndrome of inappropriate antidiuresis (SIAD). OBJECTIVE This work aimed to investigate the effect of an increase in sodium on bone turnover, that is, the ratio of the osteoblast marker procollagen type 1 N-terminal propeptide (P1NP) to the osteoclast marker cross-linked C-terminal telopeptide of type 1 collagen (CTX), in outpatients with chronic SIAD. METHODS A predefined secondary analysis was conducted of the 2-month double-blind, crossover, placebo-controlled SANDx Trial (NCT03202667) performed from December 2017 to August 2021. Participants included 11 outpatients with chronic SIAD: 6 women, median age 73 years, who received a 4-week treatment with 25-mg empagliflozin or placebo. Main outcome measures included the relationship between the change in bone formation index (BFI), defined as P1NP/CTX, and the change in plasma sodium levels. RESULTS Changes in sodium were positively correlated with changes in BFI and P1NP (BFI: ρ=.55; P < .001; P1NP: ρ=.45; P = .004) but not with CTX (P = .184) and osteocalcin (P = .149). A sodium increase of 1 mmol/l was associated with an increase of 5.21 in BFI (95% CI, 1.41-9.00; P = .013) and with an increase of 1.48 µg/l in P1NP (95% CI, .26-2.62; P = .03). The effect of sodium change on bone markers was independent of the study medication empagliflozin. CONCLUSION An increase in plasma sodium levels in outpatients with chronic hyponatremia due to SIAD, even when mild, was associated with an increase in bone formation index (P1NP/CTX) triggered by an increase in P1NP, a surrogate marker of osteoblast function.
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Affiliation(s)
- Sophie Monnerat
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
- Department of Clinical Research, University of Basel, 4056 Basel, Switzerland
| | - Julie Refardt
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
| | - Laura Potasso
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
| | - Christian Meier
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
- Department of Clinical Research, University of Basel, 4056 Basel, Switzerland
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
- Department of Clinical Research, University of Basel, 4056 Basel, Switzerland
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18
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Tzoulis P, Yavropoulou MP. Association of hyponatremia with bone mineral density and fractures: a narrative review. Ther Adv Endocrinol Metab 2023; 14:20420188231197921. [PMID: 37736657 PMCID: PMC10510353 DOI: 10.1177/20420188231197921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 07/13/2023] [Indexed: 09/23/2023] Open
Abstract
Recent studies suggest a possible association of hyponatremia with osteoporosis, falls and bone fractures. The objectives of this narrative review were to further explore this association and the related pathophysiological mechanisms and to suggest a practical approach to patients with osteoporosis or chronic hyponatremia in clinical practice. We conducted an extensive PubMed search until October 2022 with the combination of the following keywords: 'hyponatremia' or 'sodium' or 'SIADH' and 'fractures' or 'bone' or 'osteoporosis', as MeSH Terms. Review of numerous observational studies confirms a significant independent association of, even mild, hyponatremia with two- to three-fold increase in the occurrence of bone fractures. Hyponatremia is a risk factor for osteoporosis with a predilection to affect the hip, while the magnitude of association depends on the severity and chronicity of hyponatremia. Chronic hyponatremia also increases the risk for falls by inducing gait instability and neurocognitive deficits. Besides the detrimental impact of hyponatremia on bone mineral density and risk of falls, it also induces changes in bone quality. Emerging evidence suggests that acute hyponatremia shifts bone turnover dynamics towards less bone formation, while hyponatremia correction increases bone formation. The key unanswered question whether treatment of hyponatremia could improve osteoporosis and lower fracture risk highlights the need for prospective studies, evaluating the impact of sodium normalization on bone metabolism and occurrence of fractures. Recommendations for clinical approach should include measurement of serum sodium in all individuals with fracture or osteoporosis. Also, hyponatremia, as an independent risk factor for fracture, should be taken into consideration when estimating the likelihood for future fragility fracture and in clinical decision-making about pharmacological therapy of osteoporosis. Until it is proven that normalization of sodium can lower fracture occurrence, correcting hyponatremia cannot be universally recommended on this basis, but should be decided on a case-by-case basis.
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Affiliation(s)
- Ploutarchos Tzoulis
- Department of Metabolism & Experimental Therapeutics, Division of Medicine, University College London Medical School, Gower Street, London, WC1E6BT, UK
| | - Maria P. Yavropoulou
- Department of Propaedeutic and Internal Medicine, Medical School of University of Athens, Endocrinology Unit, Athens, Attica, Greece
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19
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Warren AM, Grossmann M, Christ-Crain M, Russell N. Syndrome of Inappropriate Antidiuresis: From Pathophysiology to Management. Endocr Rev 2023; 44:819-861. [PMID: 36974717 PMCID: PMC10502587 DOI: 10.1210/endrev/bnad010] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 02/19/2023] [Accepted: 03/27/2023] [Indexed: 03/29/2023]
Abstract
Hyponatremia is the most common electrolyte disorder, affecting more than 15% of patients in the hospital. Syndrome of inappropriate antidiuresis (SIAD) is the most frequent cause of hypotonic hyponatremia, mediated by nonosmotic release of arginine vasopressin (AVP, previously known as antidiuretic hormone), which acts on the renal V2 receptors to promote water retention. There are a variety of underlying causes of SIAD, including malignancy, pulmonary pathology, and central nervous system pathology. In clinical practice, the etiology of hyponatremia is frequently multifactorial and the management approach may need to evolve during treatment of a single episode. It is therefore important to regularly reassess clinical status and biochemistry, while remaining alert to potential underlying etiological factors that may become more apparent during the course of treatment. In the absence of severe symptoms requiring urgent intervention, fluid restriction (FR) is widely endorsed as the first-line treatment for SIAD in current guidelines, but there is considerable controversy regarding second-line therapy in instances where FR is unsuccessful, which occurs in around half of cases. We review the epidemiology, pathophysiology, and differential diagnosis of SIAD, and summarize recent evidence for therapeutic options beyond FR, with a focus on tolvaptan, urea, and sodium-glucose cotransporter 2 inhibitors.
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Affiliation(s)
- Annabelle M Warren
- Department of Medicine, University of Melbourne, Victoria 3010, Australia
- Department of Endocrinology, The Austin Hospital, Victoria 3084, Australia
| | - Mathis Grossmann
- Department of Medicine, University of Melbourne, Victoria 3010, Australia
- Department of Endocrinology, The Austin Hospital, Victoria 3084, Australia
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel 4031, Switzerland
- Department of Clinical Research, University of Basel and University Hospital Basel, Basel 4031, Switzerland
| | - Nicholas Russell
- Department of Medicine, University of Melbourne, Victoria 3010, Australia
- Department of Endocrinology, The Austin Hospital, Victoria 3084, Australia
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20
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Koufakis T, Tsimihodimos V, Metallidis S, Kotsa K, Doumas M. The effects of sodium-glucose cotransporter 2 inhibitors beyond the cardio-renal-metabolic spectrum: will gliflozins have a different fate than statins? Expert Opin Pharmacother 2023; 24:1753-1756. [PMID: 37594789 DOI: 10.1080/14656566.2023.2250255] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 08/19/2023]
Affiliation(s)
- Theocharis Koufakis
- Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Vasilis Tsimihodimos
- Department of Internal Medicine, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Symeon Metallidis
- Infectious Diseases Division, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Michael Doumas
- Second Propedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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21
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Monnerat S, Atila C, Baur F, Santos de Jesus J, Refardt J, Dickenmann M, Christ-Crain M. Effect of protein supplementation on plasma sodium levels in the syndrome of inappropriate antidiuresis: a monocentric, open-label, proof-of-concept study-the TREASURE study. Eur J Endocrinol 2023; 189:252-261. [PMID: 37540987 DOI: 10.1093/ejendo/lvad108] [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: 06/07/2023] [Revised: 07/07/2023] [Accepted: 07/12/2023] [Indexed: 08/06/2023]
Abstract
IMPORTANCE The syndrome of inappropriate antidiuresis (SIAD) can be treated with oral urea; however, compliance is impaired by its poor palatability. OBJECTIVE To investigate whether dietary proteins could increase plasma sodium levels through urea-induced osmotic diuresis. DESIGN An open-label, proof-of-concept trial. SETTING University Hospital of Basel, Switzerland, between October 2021 and February 2023. PARTICIPANTS Outpatients with chronic SIAD. INTERVENTIONS OR EXPOSURES Ninety grams of protein daily for 7 days in the form of protein powder, followed by 30 g of oral urea daily for 7 days after a wash-out period of ≥1 week. MAIN OUTCOMES AND MEASURES The increase in sodium levels from baseline to the end of the 7-day protein supplementation. RESULTS Seventeen patients were included. After 7 days of 90 g daily protein supplementation (n = 17), plasma sodium levels increased from 131 (129-133) to 133 (132-137), that is, by a median of 3 mmol L-1 (0-5) (P = .01). Plasma urea levels increased by 3 mmol L-1 (1.7-4.9) (P < .01), and urine urea to creatinine ratio increased by 21.2 mmol mmol-1 (6.2-29.1) (P < .01). After 7 days of 30 g oral urea (n = 10), plasma sodium levels increased from 132 (130-133) to 134 (131-136), that is, by a median of 2 mmol L-1 (1-3) (P = .06). Plasma urea levels increased by 5.8 mmol L-1 (2.7-9.2) (P < .01), and urine urea to creatinine ratio increased by 31.0 mmol mmol-1 (18.7-45.1) (P < .01). CONCLUSIONS AND RELEVANCE Our findings suggest that protein powder increases plasma sodium levels in patients with chronic SIAD through protein-induced ureagenesis and osmotic diuresis. The effects are comparable with oral urea.
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Affiliation(s)
- Sophie Monnerat
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Cihan Atila
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Fabienne Baur
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Joyce Santos de Jesus
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
| | - Julie Refardt
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
| | - Michael Dickenmann
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
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22
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Koh ES, Kim GH, Chung S. Intrarenal Mechanisms of Sodium-Glucose Cotransporter-2 Inhibitors on Tubuloglomerular Feedback and Natriuresis. Endocrinol Metab (Seoul) 2023; 38:359-372. [PMID: 37482684 PMCID: PMC10475968 DOI: 10.3803/enm.2023.1764] [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: 06/21/2023] [Revised: 07/05/2023] [Accepted: 07/10/2023] [Indexed: 07/25/2023] Open
Abstract
When sodium-glucose cotransporter-2 (SGLT2) inhibitors were first introduced a decade ago, no one expected them to have substantial effects beyond their known glucose-lowering effects, until the emergence of evidence of their robust renal and cardiovascular benefits showing that they could attenuate progression of kidney disease, irrespective of diabetes, as well as prevent the development of acute kidney injury. Still, the precise and elaborate mechanisms underlying the major organ protection of SGLT2 inhibitors remain unclear. SGLT2 inhibitors inhibit the reabsorption of sodium and glucose in the proximal tubule of the kidney and then recovers tubuloglomerular feedback, whereby SGLT2 inhibitors reduce glomerular hyperfiltration. This simple demonstration of their beneficial effects has perplexed experts in seeking more plausible and as yet undisclosed explanations for the whole effects of SGLT2 inhibitors, including metabolism reprogramming and the modulation of hypoxia, inflammation, and oxidative stress. Given that the renal benefits of SGLT2 inhibitors in patients with kidney disease but without diabetes were comparable to those seen in patients with diabetes, it may be reasonable to keep the emphasis on their hemodynamic actions. In this context, the aim of the present review is to provide a comprehensive overview of renal hemodynamics in individuals with diabetes who are treated with SGLT2 inhibitors, with a focus on natriuresis associated with the regulation of tubuloglomerular feedback and potential aquaresis. Throughout the discussion of alterations in renal sodium and water transports, particular attention will be given to the potential enhancement of adenosine and its receptors following SGLT2 inhibition.
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Affiliation(s)
- Eun Sil Koh
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Gheun-Ho Kim
- Division of Nephrology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sungjin Chung
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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23
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Tzoulis P, Kaltsas G, Baldeweg SE, Bouloux PM, Grossman AB. Tolvaptan for the treatment of the syndrome of inappropriate antidiuresis (SIAD). Ther Adv Endocrinol Metab 2023; 14:20420188231173327. [PMID: 37214762 PMCID: PMC10192810 DOI: 10.1177/20420188231173327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/15/2023] [Indexed: 05/24/2023] Open
Abstract
The syndrome of inappropriate antidiuresis (SIAD), the commonest cause of hyponatraemia, is associated with significant morbidity and mortality. Tolvaptan, an oral vasopressin V2-receptor antagonist, leads through aquaresis to an increase in serum sodium concentration and is the only medication licenced in Europe for the treatment of euvolaemic hyponatraemia. Randomised controlled trials have shown that tolvaptan is highly efficacious in correcting SIAD-related hyponatraemia. Real-world data have confirmed the marked efficacy of tolvaptan, but they have also reported a high risk of overly rapid sodium increase in patients with a very low baseline serum sodium. The lower the baseline serum sodium, the higher the tolvaptan-induced correction rate occurs. Therefore, a lower starting tolvaptan dose of 7.5 mg has been evaluated in small cohort studies, demonstrating its efficacy, but it still remains unclear as to whether it can reduce the risk of overcorrection. Most international guidelines, except for the European ones, recommend tolvaptan as second-line treatment for SIAD after fluid restriction. However, the risk of unduly rapid sodium correction in combination with its high cost have limited its routine use. Prospective controlled studies are warranted to evaluate whether tolvaptan-related sodium increase can improve patient-related clinical outcomes, such as mortality and length of hospital stay in the acute setting or neurocognitive symptoms and quality of life in the chronic setting. In addition, the potential role of a low tolvaptan starting dose needs to be further explored. Until then, tolvaptan should mainly be used as second-line treatment for SIAD, especially when there is a clinical need for prompt restoration of normonatraemia. Tolvaptan should be used with specialist input according to a structured clinical pathway, including rigorous monitoring of electrolyte and fluid balance and, if needed, implementation of appropriate measures to prevent, or when necessary reverse, overly rapid hyponatraemia correction.
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Affiliation(s)
| | - Gregory Kaltsas
- First Department of Propaedeutic and Internal
Medicine, Laiko University Hospital, National and Kapodistrian University of
Athens, Athens, Greece
| | - Stephanie E. Baldeweg
- Department of Diabetes & Endocrinology,
University College London Hospitals NHS Foundation Trust, London, UK
- Division of Medicine, University College
London, London, UK
| | | | - Ashley B. Grossman
- Green Templeton College, University of Oxford,
Oxford, UK
- Neuroendocrine Tumour Unit, Royal Free
Hospital, London, UK
- Centre for Endocrinology, Barts and the London
School of Medicine, Queen Mary University of London, London, UK
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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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Monnerat S, Atila C, Refardt J, Christ-Crain M. Prevalence of Admission Hyponatremia in Patients With Diabetes Treated With and Without an SGLT2 inhibitor. J Endocr Soc 2023; 7:bvad011. [PMID: 36819457 PMCID: PMC9933898 DOI: 10.1210/jendso/bvad011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Indexed: 01/25/2023] Open
Abstract
Context Hyponatremia often reflects a free water excess. Sodium/glucose cotransporter 2 (SGLT2) inhibitors increase free water excretion through glucose-induced osmotic diuresis. In 2 randomized double-blind, placebo-controlled trials in patients with the syndrome of inappropriate antidiuresis (SIAD), we showed that empagliflozin increased plasma sodium concentration more effectively than placebo. Objective We hypothesized that long-term therapy with SGLT2 inhibitors might reduce the prevalence of hyponatremia on hospital admission. Methods In this retrospective analysis, we extracted data from adult patients with type 2 diabetes (T2DM) hospitalized at the University Hospital Basel between 2015 and 2020. Patients with an SGLT2 inhibitor on admission were matched 1:1 according to age, gender, diagnosis of heart failure, and principal diagnosis to patients without an SGLT2 inhibitor on admission. The primary outcome was the prevalence of hyponatremia (plasma sodium concentration corrected for glycemia <135 mmol/L) on admission. Results We analyzed 821 patients with T2DM treated with and 821 patients with T2DM without an SGLT2 inhibitor on admission. Hyponatremia prevalence on admission was 9.9% in the treated group, and 8.9% in the matched control group (P = .554), in other words, the risk for hyponatremia did not differ (multivariable adjusted odds ratio 1.08, 95% CI 0.72-1.44, P = .666). There was no difference in the median (interquartile range) plasma sodium concentration between the groups (treated 140 mmol/L [138-142], controls 140 mmol/L [138-142]; P = .1017). Conclusion Based on these retrospective findings, treatment with SGLT2 inhibitors does not prevent hyponatremia. However, prospective randomized data suggest their efficacy at a higher dosage in overt SIAD.
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Affiliation(s)
- Sophie Monnerat
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel 4031, Switzerland
- Department of Clinical Research, University of Basel, Basel 4031, Switzerland
| | - Cihan Atila
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel 4031, Switzerland
- Department of Clinical Research, University of Basel, Basel 4031, Switzerland
| | - Julie Refardt
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel 4031, Switzerland
- Department of Clinical Research, University of Basel, Basel 4031, Switzerland
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel 4031, Switzerland
- Department of Clinical Research, University of Basel, Basel 4031, Switzerland
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Carney EF. Efficacy of empagliflozin for syndrome of inappropriate antidiuresis. Nat Rev Nephrol 2023; 19:73. [PMID: 36513846 DOI: 10.1038/s41581-022-00673-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Bioletto F, Varaldo E, Prencipe N, Benso A, Berton AM. Long-term efficacy of empagliflozin as an add-on treatment for chronic SIAD: a case report and literature review. Hormones (Athens) 2023; 22:343-347. [PMID: 36656532 DOI: 10.1007/s42000-023-00430-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/12/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND SLGT-2 inhibitors have recently been investigated as a promising therapy for syndrome of inappropriate antidiuresis (SIAD). However, to our knowledge, no report has been published about their use for this indication in the long term. CASE PRESENTATION We report the case of a 68-year-old male with type 2 diabetes and chronic SIAD, in whom serum sodium levels were not adequately controlled by urea monotherapy. Other treatment options were not viable due to inefficacy or adverse effects. The initiation of empagliflozin, in addition to urea, led to the full normalization of serum sodium. Reduction and subsequent discontinuation of urea were attempted upon patient request, but this resulted in a relapse of hyponatremia. Nevertheless, stable normonatremia was again achieved and maintained for more than 6 months after re-establishing a combination therapy with empagliflozin and urea. CONCLUSIONS SGLT2 inhibitors might represent an effective treatment for SIAD, even in the long term. Specific clinical trials are needed to confirm this result.
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Affiliation(s)
- Fabio Bioletto
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti, 14, 10126, Turin, Italy
| | - Emanuele Varaldo
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti, 14, 10126, Turin, Italy
| | - Nunzia Prencipe
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti, 14, 10126, Turin, Italy
| | - Andrea Benso
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti, 14, 10126, Turin, Italy
| | - Alessandro Maria Berton
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti, 14, 10126, Turin, Italy.
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28
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Tzoulis P. Therapy for SIAD: what does the future hold? Ther Adv Endocrinol Metab 2023; 14:20420188231166493. [PMID: 37101722 PMCID: PMC10123912 DOI: 10.1177/20420188231166493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
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