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Minami K, Sakuma Y, Ogawa K, Takemura K, Takahashi H, Inoue T, Suzuki Y, Takahashi H, Shimura H, Sato Y, Watanabe S, Yoshida S, Ogino J, Hashimoto N. Risk factors for chronic kidney disease progression over 20 years for primary prevention in Japanese individuals at a preventive medicine research center: Focus on the influence of plasma glucose levels. J Diabetes Investig 2024. [PMID: 38953868 DOI: 10.1111/jdi.14259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 06/06/2024] [Accepted: 06/11/2024] [Indexed: 07/04/2024] Open
Abstract
AIMS/INTRODUCTION Chronic kidney disease (CKD) is a very important issue globally because of the risk of its progressing to end-stage renal disease. We aimed to identify factors contributing to long-term estimated glomerular filtration rate (eGFR) decline to determine an early diagnosis and prevent CKD progression. MATERIALS AND METHODS From January 2003 to December 2006, 5,507 individuals underwent health checkups at our hospital's Preventive Medicine Research Center. We ultimately enrolled 2,175 individuals. The eGFR was ≥60 mL/min/1.73 m2 at the start of observation period, which was 20 years. The event onset time was the day that the eGFR became <30 mL/min during the 20-year period. Baseline risk factors - in particular, the effect of plasma glucose levels on the eGFR - were extracted and evaluated by using Fine and Gray analysis. RESULTS During the 20-year observation, the hazard ratio (HR) of CKD progression was examined. A fasting plasma glucose (FPG) level ≥105 mg/dL was significantly associated with the risk of CKD progressing to an eGFR <30 mL/min. This trend was similar in the slope of eGFR. An FPG ≥105 mg/dL or an glycated hemoglobin level ≥6.5% was useful for intervening in CKD progression. Multivariate analysis showed that independent risk factors were an FPG level ≥105 mg/dL (HR 1.9; P < 0.001), age ≥60 years (HR 3.86; P < 0.001), obesity (HR 1.61; P < 0.01) and urinary protein (HR 1.55; P < 0.01). CONCLUSIONS For early intervention against a reduction in the eGFR, detecting mild increases in FPG ≥105 mg/dL in patients with CKD with or without diabetes is useful.
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Affiliation(s)
- Kento Minami
- Department of Diabetes and Metabolic Diseases, Asahi General Hospital, Asahi, Chiba, Japan
| | - Yukie Sakuma
- Clinical Research Support Center, Asahi General Hospital, Asahi, Chiba, Japan
| | - Kaoru Ogawa
- Department of Diabetes and Metabolic Diseases, Asahi General Hospital, Asahi, Chiba, Japan
| | - Koji Takemura
- Department of Diabetes and Metabolic Diseases, Asahi General Hospital, Asahi, Chiba, Japan
| | - Haruo Takahashi
- Clinical Research Support Center, Asahi General Hospital, Asahi, Chiba, Japan
| | - Takeshi Inoue
- Clinical Research Support Center, Asahi General Hospital, Asahi, Chiba, Japan
| | - Yoshifumi Suzuki
- Department of Diabetes and Metabolic Diseases, Asahi General Hospital, Asahi, Chiba, Japan
| | - Hidenori Takahashi
- Preventive Medicine Research Center, Asahi General Hospital, Asahi, Chiba, Japan
| | - Haruhisa Shimura
- Department of Internal Medicine, Asahi General Hospital, Asahi, Chiba, Japan
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Saburo Watanabe
- Clinical Research Support Center, Asahi General Hospital, Asahi, Chiba, Japan
| | - Shouji Yoshida
- Department of Internal Medicine, Asahi General Hospital, Asahi, Chiba, Japan
| | - Jun Ogino
- Department of Diabetes and Metabolic Diseases, Asahi General Hospital, Asahi, Chiba, Japan
| | - Naotake Hashimoto
- Preventive Medicine Research Center, Asahi General Hospital, Asahi, Chiba, Japan
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Lamb EJ, Barratt J, Brettell EA, Cockwell P, Dalton RN, Deeks JJ, Eaglestone G, Pellatt-Higgins T, Kalra PA, Khunti K, Loud FC, Ottridge RS, Potter A, Rowe C, Scandrett K, Sitch AJ, Stevens PE, Sharpe CC, Shinkins B, Smith A, Sutton AJ, Taal MW. Accuracy of glomerular filtration rate estimation using creatinine and cystatin C for identifying and monitoring moderate chronic kidney disease: the eGFR-C study. Health Technol Assess 2024; 28:1-169. [PMID: 39056437 DOI: 10.3310/hyhn1078] [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] [Indexed: 07/28/2024] Open
Abstract
Background Estimation of glomerular filtration rate using equations based on creatinine is widely used to manage chronic kidney disease. In the UK, the Chronic Kidney Disease Epidemiology Collaboration creatinine equation is recommended. Other published equations using cystatin C, an alternative marker of kidney function, have not gained widespread clinical acceptance. Given higher cost of cystatin C, its clinical utility should be validated before widespread introduction into the NHS. Objectives Primary objectives were to: (1) compare accuracy of glomerular filtration rate equations at baseline and longitudinally in people with stage 3 chronic kidney disease, and test whether accuracy is affected by ethnicity, diabetes, albuminuria and other characteristics; (2) establish the reference change value for significant glomerular filtration rate changes; (3) model disease progression; and (4) explore comparative cost-effectiveness of kidney disease monitoring strategies. Design A longitudinal, prospective study was designed to: (1) assess accuracy of glomerular filtration rate equations at baseline (n = 1167) and their ability to detect change over 3 years (n = 875); (2) model disease progression predictors in 278 individuals who received additional measurements; (3) quantify glomerular filtration rate variability components (n = 20); and (4) develop a measurement model analysis to compare different monitoring strategy costs (n = 875). Setting Primary, secondary and tertiary care. Participants Adults (≥ 18 years) with stage 3 chronic kidney disease. Interventions Estimated glomerular filtration rate using the Chronic Kidney Disease Epidemiology Collaboration and Modification of Diet in Renal Disease equations. Main outcome measures Measured glomerular filtration rate was the reference against which estimating equations were compared with accuracy being expressed as P30 (percentage of values within 30% of reference) and progression (variously defined) studied as sensitivity/specificity. A regression model of disease progression was developed and differences for risk factors estimated. Biological variation components were measured and the reference change value calculated. Comparative costs of monitoring with different estimating equations modelled over 10 years were calculated. Results Accuracy (P30) of all equations was ≥ 89.5%: the combined creatinine-cystatin equation (94.9%) was superior (p < 0.001) to other equations. Within each equation, no differences in P30 were seen across categories of age, gender, diabetes, albuminuria, body mass index, kidney function level and ethnicity. All equations showed poor (< 63%) sensitivity for detecting patients showing kidney function decline crossing clinically significant thresholds (e.g. a 25% decline in function). Consequently, the additional cost of monitoring kidney function annually using a cystatin C-based equation could not be justified (incremental cost per patient over 10 years = £43.32). Modelling data showed association between higher albuminuria and faster decline in measured and creatinine-estimated glomerular filtration rate. Reference change values for measured glomerular filtration rate (%, positive/negative) were 21.5/-17.7, with lower reference change values for estimated glomerular filtration rate. Limitations Recruitment of people from South Asian and African-Caribbean backgrounds was below the study target. Future work Prospective studies of the value of cystatin C as a risk marker in chronic kidney disease should be undertaken. Conclusions Inclusion of cystatin C in glomerular filtration rate-estimating equations marginally improved accuracy but not detection of disease progression. Our data do not support cystatin C use for monitoring of glomerular filtration rate in stage 3 chronic kidney disease. Trial registration This trial is registered as ISRCTN42955626. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 11/103/01) and is published in full in Health Technology Assessment; Vol. 28, No. 35. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Edmund J Lamb
- Clinical Biochemistry, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Elizabeth A Brettell
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Paul Cockwell
- Renal Medicine, Queen Elizabeth Hospital Birmingham and Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - R Nei Dalton
- WellChild Laboratory, Evelina London Children's Hospital, St. Thomas' Hospital, London, UK
| | - Jon J Deeks
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gillian Eaglestone
- Kent Kidney Care Centre, East Kent Hospitals University NHS Foundation Trust, Kent, UK
| | | | - Philip A Kalra
- Department of Renal Medicine, Salford Royal Hospital Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | | | - Ryan S Ottridge
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Aisling Potter
- Clinical Biochemistry, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - Ceri Rowe
- Clinical Biochemistry, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - Katie Scandrett
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Alice J Sitch
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paul E Stevens
- Kent Kidney Care Centre, East Kent Hospitals University NHS Foundation Trust, Kent, UK
| | - Claire C Sharpe
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Bethany Shinkins
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Alison Smith
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Andrew J Sutton
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Maarten W Taal
- Department of Renal Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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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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van der Pluijm LA, Koudijs A, Stam W, Roelofs JJ, Danser AJ, Rotmans JI, Gross KW, Pieper MP, van Zonneveld AJ, Bijkerk R. SGLT2 inhibition promotes glomerular repopulation by cells of renin lineage in experimental kidney disease. Acta Physiol (Oxf) 2024; 240:e14108. [PMID: 38314444 PMCID: PMC10923162 DOI: 10.1111/apha.14108] [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: 09/13/2023] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 02/06/2024]
Abstract
AIM Sodium glucose co-transporter-2 (SGLT2) inhibitors stimulate renal excretion of sodium and glucose and exert renal protective effects in patients with (non-)diabetic chronic kidney disease (CKD) and may as well protect against acute kidney injury (AKI). The mechanism behind this kidney protective effect remains unclear. Juxtaglomerular cells of renin lineage (CoRL) have been demonstrated to function as progenitors for multiple adult glomerular cell types in kidney disease. This study assesses the impact of SGLT2 inhibition on the repopulation of glomerular cells by CoRL and examines their phenotypic commitment. METHODS Experiments were performed in Ren1cre-tdTomato lineage-trace mice. Either 5/6 nephrectomy (5/6NX) modeling CKD or bilateral ischaemia reperfusion injury (bIRI) mimicking AKI was applied, while the SGLT2 inhibitor empagliflozin (10 mg/kg) was administered daily via oral gavage for 14 days. RESULTS Both 5/6NX and bIRI-induced kidney injury increased the number of glomerular CoRL-derived cells. SGLT2 inhibition improved kidney function after 5/6NX, indicated by decreased blood creatinine and urea levels, but not after bIRI. In line with this, empagliflozin in 5/6NX animals resulted in less glomerulosclerosis, while it did not affect histopathological features in bIRI. Treatment with empagliflozin resulted in an increase in the number of CoRL-derived glomerular cells in both 5/6NX and bIRI conditions. Interestingly, SGLT2 inhibition led to more CoRL-derived podocytes in 5/6NX animals, whereas empagliflozin-treated bIRI mice presented with increased levels of parietal epithelial and mesangial cells derived from CoRL. CONCLUSION We conclude that SGLT2 inhibition by empagliflozin promotes CoRL-mediated glomerular repopulation with selective CoRL-derived cell types depending on the type of experimental kidney injury. These findings suggest a previously unidentified mechanism that could contribute to the renoprotective effect of SGLT2 inhibitors.
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Affiliation(s)
- Loïs A.K. van der Pluijm
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Angela Koudijs
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Wendy Stam
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Joris J.T.H. Roelofs
- Department of Pathology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, the Netherlands
| | - A.H. Jan Danser
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Joris I. Rotmans
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Kenneth W. Gross
- Department of Molecular and Cellular Biology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Michael P. Pieper
- CardioMetabolic Diseases Research, Boehringer Ingelheim Pharma GmbH & Co KG, Biberach an der Riss, Germany
| | - Anton Jan van Zonneveld
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Roel Bijkerk
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Centre, Leiden, the Netherlands
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Abdelrahman AM, Awad AS, Abdel-Rahman EM. Sodium-Glucose Co-Transporter 2 Inhibitors: Mechanism of Action and Efficacy in Non-Diabetic Kidney Disease from Bench to Bed-Side. J Clin Med 2024; 13:956. [PMID: 38398269 PMCID: PMC10888733 DOI: 10.3390/jcm13040956] [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: 01/08/2024] [Revised: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 02/25/2024] Open
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are currently available for the management of type 2 diabetes mellitus. SGLT2i acts by inhibiting renal SGLT2, thereby increasing glucosuria and lowering serum glucose. Recent trials are emerging supporting a role for SGLT2i irrespective of the diabetic status pointing towards that SGLT2i have other mechanisms of actions beyond blood sugar control. In this review, we will shed light on the role of this group of medications that act as SGLT2i in non-diabetics focusing on pre-clinical and clinical data highlighting the mechanism of renoprotection and effects of SGLT2i in the non-diabetic kidneys.
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Affiliation(s)
- Aly M. Abdelrahman
- Department of Pharmacology & Clinical Pharmacy, College of Medicine and Health Sciences, Sultan Qaboos University, Alkhod 123, Oman;
| | - Alaa S. Awad
- Division of Nephrology, University of Florida, Jacksonville, FL 32209, USA;
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Neuen BL, Heerspink HJL, Vart P, Claggett BL, Fletcher RA, Arnott C, de Oliveira Costa J, Falster MO, Pearson SA, Mahaffey KW, Neal B, Agarwal R, Bakris G, Perkovic V, Solomon SD, Vaduganathan M. Estimated Lifetime Cardiovascular, Kidney, and Mortality Benefits of Combination Treatment With SGLT2 Inhibitors, GLP-1 Receptor Agonists, and Nonsteroidal MRA Compared With Conventional Care in Patients With Type 2 Diabetes and Albuminuria. Circulation 2024; 149:450-462. [PMID: 37952217 DOI: 10.1161/circulationaha.123.067584] [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: 10/12/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Sodium glucose cotransporter 2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1 RA), and the nonsteroidal mineralocorticoid receptor antagonist (ns-MRA) finerenone all individually reduce cardiovascular, kidney, and mortality outcomes in patients with type 2 diabetes and albuminuria. However, the lifetime benefits of combination therapy with these medicines are not known. METHODS We used data from 2 SGLT2i trials (CANVAS [Canagliflozin Cardiovascular Assessment] and CREDENCE [Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation]), 2 ns-MRA trials (FIDELIO-DKD [Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease] and FIGARO-DKD [Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and the Clinical Diagnosis of Diabetic Kidney Disease]), and 8 GLP-1 RA trials to estimate the relative effects of combination therapy versus conventional care (renin-angiotensin system blockade and traditional risk factor control) on cardiovascular, kidney, and mortality outcomes. Using actuarial methods, we then estimated absolute risk reductions with combination SGLT2i, GLP-1 RA, and ns-MRA in patients with type 2 diabetes and at least moderately increased albuminuria (urinary albumin:creatinine ratio ≥30 mg/g) by applying estimated combination treatment effects to participants receiving conventional care in CANVAS and CREDENCE. RESULTS Compared with conventional care, the combination of SGLT2i, GLP-1 RA, and ns-MRA was associated with a hazard ratio of 0.65 (95% CI, 0.55-0.76) for major adverse cardiovascular events (nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death). The corresponding estimated absolute risk reduction over 3 years was 4.4% (95% CI, 3.0-5.7), with a number needed to treat of 23 (95% CI, 18-33). For a 50-year-old patient commencing combination therapy, estimated major adverse cardiovascular event-free survival was 21.1 years compared with 17.9 years for conventional care (3.2 years gained [95% CI, 2.1-4.3]). There were also projected gains in survival free from hospitalized heart failure (3.2 years [95% CI, 2.4-4.0]), chronic kidney disease progression (5.5 years [95% CI, 4.0-6.7]), cardiovascular death (2.2 years [95% CI, 1.2-3.0]), and all-cause death (2.4 years [95% CI, 1.4-3.4]). Attenuated but clinically relevant gains in event-free survival were observed in analyses assuming 50% additive effects of combination therapy, including for major adverse cardiovascular events (2.4 years [95% CI, 1.1-3.5]), chronic kidney disease progression (4.5 years [95% CI, 2.8-5.9]), and all-cause death (1.8 years [95% CI, 0.7-2.8]). CONCLUSIONS In patients with type 2 diabetes and at least moderately increased albuminuria, combination treatment of SGLT2i, GLP-1 RA, and ns-MRA has the potential to afford relevant gains in cardiovascular and kidney event-free and overall survival.
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Affiliation(s)
- Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia (B.L.N.)
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.L.N., B.L.C., S.D.S., M.V.)
| | - Hiddo J L Heerspink
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, The Netherlands (H.J.L.H., P.V.)
| | - Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, The Netherlands (H.J.L.H., P.V.)
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.L.N., B.L.C., S.D.S., M.V.)
| | - Robert A Fletcher
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
| | - Clare Arnott
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (C.A.)
| | - Julianna de Oliveira Costa
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Australia (J.d.O.C., M.O.F., S.-A.P.)
| | - Michael O Falster
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Australia (J.d.O.C., M.O.F., S.-A.P.)
| | - Sallie-Anne Pearson
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Australia (J.d.O.C., M.O.F., S.-A.P.)
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Stanford University School of Medicine, CA (K.W.M.)
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
- Department of Epidemiology and Biostatistics, Imperial College London, United Kingdom (B.N.)
| | - Rajiv Agarwal
- Indiana University School of Medicine and VA Medical Center, Indianapolis (R.A.)
| | - George Bakris
- Department of Medicine, University of Chicago, IL (G.B.)
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.L.N., B.L.C., S.D.S., M.V.)
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.L.N., B.L.C., S.D.S., M.V.)
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7
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Adler S. [Immunoglobulin A vasculitis]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:114-121. [PMID: 38236411 DOI: 10.1007/s00108-023-01650-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/14/2023] [Indexed: 01/19/2024]
Abstract
The immune-mediated small vessel vasculitis is known as Schoenlein-Henoch purpura predominantly from pediatrics and in these cases occurs more frequently after infections of the upper airways. In adults, immunoglobulin A (IgA) vasculitis often proceeds more severely und recurrently with the classical tetrad of skin manifestations in the sense of leukocytoclastic vasculitis, joint affection, gastrointestinal involvement and IgA nephritis, in contrast to the mostly mild and self-limiting course in children. The background of this systemic vasculitis with formation of IgA immune complexes is considered to be an altered glycosylation of IgA, as this causes the exposure of binding sites for autoantibodies so that an immune complex reaction can be elicited. This ultimately leads to perivascular deposition of IgA and a further activation of neutrophils. Groundbreaking in the diagnostics is the histological detection of leukocytoclastic vasculitis and in cases of renal manifestations a kidney biopsy with characteristic deposits of immune complexes, which cannot be clearly differentiated from IgA nephropathy. The treatment is aimed at the respective manifestation and is mostly based on consensus recommendations due to the lack of randomized studies. In addition to immunosuppressive medication, in the presence of a chronic kidney disease general nephroprotection is becoming increasingly more important also by inhibition of sodium-glucose transporter 2 (SGLT2). The type and extent of kidney involvement and also rare cardiac manifestations are the main determinants of the prognosis. Continuous medical accompaniment of those affected is necessary due to the possible progression of the disease and the risk of recurrence.
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Affiliation(s)
- Sabine Adler
- Rheumatologie und Immunologie, Kantonsspital Aarau, Tellstraße 25, 5001, Aarau, Schweiz.
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8
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Fages V, Jannin A, Maanaoui M, Glowacki F, Do Cao C. Proteinuria reduction with SGLT2 inhibitors in a patient treated with tyrosine kinase inhibitor lenvatinib. J Nephrol 2024; 37:187-189. [PMID: 37418091 DOI: 10.1007/s40620-023-01701-0] [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: 04/29/2023] [Accepted: 06/09/2023] [Indexed: 07/08/2023]
Abstract
We describe the case of a 66-year-old woman treated with tyrosine kinase inhibitor Lenvatinib for thyroid carcinoma who had persistent proteinuria above 2 g/24 h despite maximal dose of angiotensin-converting enzyme inhibitor. We initiated a treatment with SGLT2 inhibitor Dapagliflozin. Three months after Dapagliflozin initiation, her proteinuria decreased to 1 g/24 h, and after 6 months of follow-up was 0.6 g/24 h. To our knowledge, this is the first case of successful proteinuria reduction with SGLT2i in a patient treated with Lenvatinib. Specific renal effects of SGLT2i seem promising and their effects on tyrosine kinase inhibitor renal adverse effects need to be validated in clinical trials involving cancer patients.
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Affiliation(s)
- Victor Fages
- Service de Néphrologie, CHRU Lille, Hôpital Huriez, Rue Michel Polonowski, 59037, Lille, France.
| | - Arnaud Jannin
- Department of Diabetology, Endocrinology, Metabolism and Nutrition, Centre Hospitalier Regional Universitaire de Lille, Lille University Hospital, Lille, France
| | - Mehdi Maanaoui
- Service de Néphrologie, CHRU Lille, Hôpital Huriez, Rue Michel Polonowski, 59037, Lille, France
| | - François Glowacki
- Service de Néphrologie, CHRU Lille, Hôpital Huriez, Rue Michel Polonowski, 59037, Lille, France
| | - Christine Do Cao
- Department of Diabetology, Endocrinology, Metabolism and Nutrition, Centre Hospitalier Regional Universitaire de Lille, Lille University Hospital, Lille, France
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9
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Song B, Zhang H, Zhou B. RETRACTED ARTICLE: Effects of Dapagliflozin on myocardial remodeling, inflammatory factors, and cardiac events in heart failure with preserved ejection fraction. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:629. [PMID: 37368031 DOI: 10.1007/s00210-023-02590-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 06/17/2023] [Indexed: 06/28/2023]
Affiliation(s)
- BoFan Song
- Department of Cardiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Shushan District, Anhui, 230022, Hefei, People's Republic of China
| | - Hao Zhang
- Department of Cardiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Shushan District, Anhui, 230022, Hefei, People's Republic of China
| | - Birong Zhou
- Department of Cardiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Shushan District, Anhui, 230022, Hefei, People's Republic of China.
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10
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Chen TK, Hoenig MP, Nitsch D, Grams ME. Advances in the management of chronic kidney disease. BMJ 2023; 383:e074216. [PMID: 38052474 DOI: 10.1136/bmj-2022-074216] [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] [Indexed: 12/07/2023]
Abstract
Chronic kidney disease (CKD) represents a global public health crisis, but awareness by patients and providers is poor. Defined as persistent abnormalities in kidney structure or function for more than three months, manifested as either low glomerular filtration rate or presence of a marker of kidney damage such as albuminuria, CKD can be identified through readily available blood and urine tests. Early recognition of CKD is crucial for harnessing major advances in staging, prognosis, and treatment. This review discusses the evidence behind the general principles of CKD management, such as blood pressure and glucose control, renin-angiotensin-aldosterone system blockade, statin therapy, and dietary management. It additionally describes individualized approaches to treatment based on risk of kidney failure and cause of CKD. Finally, it reviews novel classes of kidney protective agents including sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists, non-steroidal selective mineralocorticoid receptor antagonists, and endothelin receptor antagonists. Appropriate, widespread implementation of these highly effective therapies should improve the lives of people with CKD and decrease the worldwide incidence of kidney failure.
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Affiliation(s)
- Teresa K Chen
- Kidney Health Research Collaborative and Division of Nephrology, Department of Medicine, University of California San Francisco; and San Francisco VA Health Care System, San Francisco, CA, USA
| | - Melanie P Hoenig
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Morgan E Grams
- Department of Medicine, New York University Langone School of Medicine, New York, NY, USA
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11
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Anders HJ, Fernandez-Juarez GM, Vaglio A, Romagnani P, Floege J. CKD therapy to improve outcomes of immune-mediated glomerular diseases. Nephrol Dial Transplant 2023; 38:ii50-ii57. [PMID: 37218706 DOI: 10.1093/ndt/gfad069] [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: 12/06/2022] [Indexed: 05/24/2023] Open
Abstract
The management of immunoglobulin A nephropathy, membranous nephropathy, lupus nephritis, anti-neutrophil cytoplasmic antibody-associated vasculitis, C3 glomerulonephritis, autoimmune podocytopathies and other immune-mediated glomerular disorders is focused on two major treatment goals, preventing overall mortality and the loss of kidney function. Since minimizing irreversible kidney damage best serves both goals, the management of immune-mediated kidney disorders must focus on the two central pathomechanisms of kidney function decline, i.e., controlling the underlying immune disease process (e.g. with immunotherapies) and controlling the non-immune mechanisms of chronic kidney disease (CKD) progression. Here we review the pathophysiology of these non-immune mechanisms of CKD progression and discuss non-drug and drug interventions to attenuate CKD progression in immune-mediated kidney disorders. Non-pharmacological interventions include reducing salt intake, normalizing body weight, avoiding superimposed kidney injuries, smoking cessation and regular physical activity. Approved drug interventions include inhibitors of the renin-angiotensin-aldosterone system and sodium-glucose cotransporter-2. Numerous additional drugs to improve CKD care are currently being tested in clinical trials. Here we discuss how and when to use these drugs in the different clinical scenarios of immune-mediated kidney diseases.
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Affiliation(s)
- Hans-Joachim Anders
- Division of Nephrology, Department of Internal Medicine IV, Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | | | - Augusto Vaglio
- Nephrology Unit, Anna Meyer Children's Hospital, Florence, Italy
| | - Paola Romagnani
- Nephrology Unit, Anna Meyer Children's Hospital, Florence, Italy
- Department of Clinical and Experimental Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
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12
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Heerspink HJL, Vart P, Jongs N, Neuen BL, Bakris G, Claggett B, Vaduganathan M, McCausland F, Docherty KF, Jhund PS, Solomon SD, Perkovic V, McMurray JJV. Estimated lifetime benefit of novel pharmacological therapies in patients with type 2 diabetes and chronic kidney disease: A joint analysis of randomized controlled clinical trials. Diabetes Obes Metab 2023; 25:3327-3336. [PMID: 37580309 DOI: 10.1111/dom.15232] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 07/07/2023] [Accepted: 07/19/2023] [Indexed: 08/16/2023]
Abstract
AIM To estimate the lifetime benefit of a combination treatment of sodium-glucose co-transporter 2 (SGLT2) inhibitors and mineralocorticoid-receptor antagonists (MRA) in patients with type 2 diabetes and chronic kidney disease (CKD). MATERIALS AND METHODS The cumulative effect of combination treatment was derived from trial-level estimates of the effect of an SGLT2 inhibitor (canagliflozin) and MRA (finerenone) from the CREDENCE (N = 4401) and FIDELIO (N = 5734) trials, respectively. The cumulative effect was applied to the control group of patients with type 2 diabetes in the DAPA-CKD trial (N = 1451) to estimate long-term gains in event-free and overall survival. The analysis was repeated in an observational study. The primary outcome was a composite endpoint of doubling of serum creatinine, end-stage kidney disease or death because of kidney failure. RESULTS The hazard ratio of combination treatment for the primary outcome was 0.50 [95% confidence interval (CI): 0.44, 0.57]. At age 50 years, the estimated event-free survival from the primary outcome was 16.7 years (95% CI: 18.1, 21.0) with combination treatment versus 10.0 years (95% CI: 6.8, 12.3) with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers resulting in an incremental gain of 6.7 years (95% CI: 5.5, 7.9). In an observational study, the estimated gain in event-free survival regarding primary outcome was 6.3 years (95% CI: 5.2, 7.3). In a conservative scenario, assuming low adherence (70% of the observed adherence) and less pronounced efficacy (70% of the observed efficacy with 2% yearly decline) of combination therapy, gain in event-free survival regarding primary outcome was 2.5 years (95% CI: 2.0, 2.9). CONCLUSIONS Combined disease-modifying treatment with an SGLT2 inhibitor and MRA in patients with type 2 diabetes and CKD may substantially increase the number of years free from kidney failure and mortality.
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Affiliation(s)
- Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
- The George Institute for Global Health, Sydney, Australia
| | - Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | | | - George Bakris
- American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Finnian McCausland
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kieran F Docherty
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vlado Perkovic
- The George Institute for Global Health, Sydney, Australia
- University of New South Wales, Sydney, Australia
| | - John J V McMurray
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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13
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Zhang Y, Hu YT, Lv JC, Zhang H. Corticosteroids in the treatment of IgA nephropathy: lessons from the TESTING trial. Pediatr Nephrol 2023; 38:3211-3220. [PMID: 36881171 DOI: 10.1007/s00467-023-05919-9] [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: 10/10/2022] [Revised: 01/22/2023] [Accepted: 02/14/2023] [Indexed: 03/08/2023]
Abstract
IgA nephropathy (IgAN), the most common form of primary glomerulonephritis, is mainly observed in young adults and children. Clinical and basic studies indicate the role of immunity in IgAN pathogenesis; however, corticosteroid therapy has been controversial in past decades. The TESTING study, initiated in 2012, is an international, multicenter, double-blinded, randomized, placebo-controlled trial that aimed to evaluate oral methylprednisolone's safety and long-term efficacy under conditions of optimized supportive treatment in patients with IgAN whose risk of progression is high. After a decade of effort, the successful completion of the TESTING study showed that a 6- to 9-month course of oral methylprednisolone is an effective regimen to protect kidney function in high-risk patients with IgAN, but also demonstrated safety concerns. Compared with the full-dose regimen, the reduced-dose regimen was reported to be beneficial, with successfully increased safety. Overall, the TESTING trial provided more data regarding the treatment dosage and safety of corticosteroids, a cost-effective therapy, in IgAN, which have important implications for pediatric patients with IgAN. With a deeper understanding of the disease pathogenesis of IgAN, ongoing studies of novel therapeutic regimens would help further optimize the benefit-risk ratio.
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Affiliation(s)
- Yuemiao Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, People's Republic of China
| | - Yi-Tong Hu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, People's Republic of China
- Peking University Health Science Center, Xue Yuan Road 38, Beijing, 100191, People's Republic of China
| | - Ji-Cheng Lv
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, People's Republic of China
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, People's Republic of China.
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14
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Oiwa A, Hiwatashi D, Takeda T, Miyamoto T, Kawata I, Koinuma M, Yamazaki M, Komatsu M. Efficacy and Safety of Low-dose Spironolactone for Chronic Kidney Disease in Type 2 Diabetes. J Clin Endocrinol Metab 2023; 108:2203-2210. [PMID: 36916985 DOI: 10.1210/clinem/dgad144] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/02/2023] [Accepted: 03/09/2023] [Indexed: 03/16/2023]
Abstract
CONTEXT Although adding spironolactone to renin-angiotensin system blockers reduces albuminuria in adults with chronic kidney disease and type 2 diabetes, it increases the risk of hyperkalemia. OBJECTIVE To assess whether a lower dose of spironolactone (12.5 mg/d) reduces the risk of hyperkalemia while maintaining its effect on reducing albuminemia. DESIGN Multicenter, open-label, randomized controlled trial. SETTING This study was conducted from July 2016 to November 2020 in ambulatory care at 3 diabetes medical institutions in Japan. PATIENTS We enrolled 130 Japanese adults with type 2 diabetes and albuminuria (≥30 mg/gCre), estimated glomerular filtration rate ≥30 mL/min/1.73 m2, and serum potassium level <5.0 mEq/L. INTERVENTIONS The participants were randomly assigned to the spironolactone-administered and control groups. MAIN OUTCOME MEASURES Changes in urine albumin-to-creatinine ratio (UACR) from baseline over the 24-week interventional period. RESULTS The spironolactone group showed a significant reduction in UACR from baseline (mean decrease, 103.47 ± 340.80 mg/gCre) compared with the control group, which showed an increased UACR (mean increase, 63.93 ± 310.14 mg/gCre; P = .0007, Wilcoxon rank-sum test and t test). Although the spironolactone group had a statistically significant increase in serum potassium levels, none of the participants had a potassium level ≥5.5 mEq/L at 24 weeks. Further, participants with a higher initial serum potassium level tended to have a smaller increase (estimate, -0.37, analysis of covariance). CONCLUSIONS Low-dose spironolactone administration reduced albuminuria without causing hyperkalemia. Spironolactone administration, the oldest known and most cost-effective mineralocorticoid receptor antagonist, at lower doses should be reconsidered.
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Affiliation(s)
- Ako Oiwa
- Department of Diabetes, Endocrinology and Metabolism, Division of Internal Medicine, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Dai Hiwatashi
- Department of Diabetes, Endocrinology and Metabolism, Division of Internal Medicine, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Teiji Takeda
- Takeda Internal Medicine Clinic, Azumino 399-8304, Japan
| | | | - Iori Kawata
- Department of Diabetes, Endocrinology and Metabolism, Division of Internal Medicine, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Masayoshi Koinuma
- Center for Clinical Research, Shinshu University Hospital, Matsumoto 390-8621, Japan
- Faculty of Pharmaceutical Sciences, Teikyo Heisei University, Nakano 164-8530, Japan
| | - Masanori Yamazaki
- Department of Diabetes, Endocrinology and Metabolism, Division of Internal Medicine, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Mitsuhisa Komatsu
- Department of Diabetes, Endocrinology and Metabolism, Division of Internal Medicine, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
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15
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Jourde-Chiche N, Bobot M, Burtey S, Chiche L, Daugas E. Weaning Maintenance Therapy in Lupus Nephritis: For Whom, When, and How? Kidney Int Rep 2023; 8:1481-1488. [PMID: 37547513 PMCID: PMC10403675 DOI: 10.1016/j.ekir.2023.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/21/2023] [Accepted: 05/16/2023] [Indexed: 08/08/2023] Open
Abstract
Lupus nephritis (LN) is one of the main determinants of the severity of systemic lupus erythematosus (SLE). LN flares can lead to organ damage with chronic kidney disease (CKD) or even end-stage kidney disease (ESKD) and impair patients' survival. The "treat-to-target" strategy, which aims at obtaining and maintaining remission or low disease activity of SLE to alleviate symptoms and prevent organ damage, also refers to the control of residual activity in the kidney. But damage in SLE can also come from treatments, and toxicities related to long-term use of treatments should be prevented. This may contribute to the frequent nonadherence in patients with SLE. The de-escalation or even weaning of treatments whenever possible, or "think-to-untreat" (T2U) strategy, is to be considered in patients with LN. This possibility of treatment weaning in LN was explored in retrospective cohorts, on the basis of long-term clinical remission. It was also proposed prospectively with a kidney-biopsy-based approach, combining clinical and pathologic remission to secure treatment weaning. The WIN-Lupus trial was the first randomized controlled trial comparing the continuation to the discontinuation of maintenance immunosuppressive therapy (IST) after 2 to 3 years in patients with LN in remission. It showed a higher risk of severe SLE flares in patients who discontinued treatment, but also a possibility of weaning without flare in some patients, who need to be better identified. We propose here a narrative review of the available literature on the weaning of treatment in LN and discuss how to secure a T2U strategy.
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Affiliation(s)
- Noémie Jourde-Chiche
- Aix-Marseille Université, C2VN, INSERM, INRAE, Marseille, France
- AP-HM, CHU Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
| | - Mickaël Bobot
- Aix-Marseille Université, C2VN, INSERM, INRAE, Marseille, France
- AP-HM, CHU Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
- Aix-Marseille Université, CERIMED, Marseille, France
| | - Stéphane Burtey
- Aix-Marseille Université, C2VN, INSERM, INRAE, Marseille, France
- AP-HM, CHU Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
| | - Laurent Chiche
- Hôpital Européen de Marseille, Service de Médecine interne, Marseille, France
| | - Eric Daugas
- AP-HP, Service de Néphrologie, Hôpital Bichat, Paris, France
- Université Paris Cité, INSERM U1149, Paris, France
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16
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Alshahrani S. Renin-angiotensin-aldosterone pathway modulators in chronic kidney disease: A comparative review. Front Pharmacol 2023; 14:1101068. [PMID: 36860293 PMCID: PMC9970101 DOI: 10.3389/fphar.2023.1101068] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/10/2023] [Indexed: 02/16/2023] Open
Abstract
Chronic kidney disease presents a health challenge that has a complex underlying pathophysiology, both acquired and inherited. The pharmacotherapeutic treatment options available today lower the progression of the disease and improve the quality of life but cannot completely cure it. This poses a challenge to the healthcare provider to choose, from the available options, the best way to manage the disease as per the presentation of the patient. As of now, the recommended first line of treatment to control the blood pressure in chronic kidney disease is the administration of renin-angiotensin-aldosterone system modulators. These are represented mainly by the direct renin inhibitor, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers. These modulators are varied in their structure and mechanisms of action, hence showing varying treatment outcomes. The choice of administration of these modulators is determined by the presentation and the co-morbidities of the patient, the availability and affordability of the treatment option, and the expertise of the healthcare provider. A direct head-to-head comparison between these significant renin-angiotensin-aldosterone system modulators is lacking, which can benefit healthcare providers and researchers. In this review, a comparison has been drawn between the direct renin inhibitor (aliskiren), angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers. This can be of significance for healthcare providers and researchers to find the particular loci of interest, either in structure or mechanism, and to intervene as per the case presentation to obtain the best possible treatment option.
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Affiliation(s)
- Saeed Alshahrani
- Department of Pharmacology and Toxicology, College of Pharmacy, Jazan University, Jizan, Saudi Arabia
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17
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SGLT2 Inhibitors in Diabetic and Non-Diabetic Chronic Kidney Disease. Biomedicines 2023; 11:biomedicines11020279. [PMID: 36830815 PMCID: PMC9953060 DOI: 10.3390/biomedicines11020279] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/15/2023] [Accepted: 01/18/2023] [Indexed: 01/20/2023] Open
Abstract
Results from recent randomized controlled trials on inhibitors of the sodium-glucose cotransporter 2 (SGLT2) have determined a paradigm shift in the treatment of patients with type 2 diabetes mellitus. These agents have been shown not only to ameliorate metabolic control, but also to independently protect from cardiovascular events and to reduce the progression of chronic kidney disease (CKD) in these patients. The magnitude of the nephroprotective effect observed in these studies is likely to make SGLT2 inhibitors the most impactful drug class for the treatment of diabetic patients with CKD since the discovery of renin-angiotensin system inhibitors. Even more surprisingly, SGLT2 inhibitors have also been shown to slow CKD progression in non-diabetic individuals with varying degrees of proteinuria, suggesting that activation of SGLT2 is involved in the pathogenesis of CKD independent of its etiology. As indications continue to expand, it is still unclear whether the observed benefits of SGLT2 inhibitors may extend to CKD patients at lower risk of progression and if their association with other agents may confer additional protection.
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18
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McEwan P, Hafner M, Jha V, Correa-Rotter R, Chernin G, De Nicola L, Villanueva R, Wheeler DC, Barone S, Nolan S, Garcia Sanchez JJ. Translating the efficacy of dapagliflozin in chronic kidney disease to lower healthcare resource utilization and costs: a medical care cost offset analysis. J Med Econ 2023; 26:1407-1416. [PMID: 37807895 DOI: 10.1080/13696998.2023.2264715] [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: 08/09/2023] [Accepted: 09/26/2023] [Indexed: 10/10/2023]
Abstract
AIMS Dapagliflozin was approved for use in patients with chronic kidney disease (CKD) based on results of the DAPA-CKD trial, demonstrating attenuation of CKD progression and reduced risk of cardio-renal outcomes and all-cause mortality (ACM) versus placebo, in addition to standard therapy. The study objective was to assess the potential medical care cost offsets associated with reduced rates of cardio-renal outcomes across 31 countries and regions. MATERIALS AND METHODS A comparative cost-determination framework estimated outcome-related costs of dapagliflozin plus standard therapy versus standard therapy alone over a 3-year horizon based on the DAPA-CKD trial. Incidence rates of end-stage kidney disease (ESKD), hospitalizations for heart failure (HHF), acute kidney injury (AKI), and ACM were estimated for a treated population of 100,000 patients. Associated medical care costs for non-fatal events were calculated using sources from a review of publicly available data specific to each considered setting. RESULTS Patients treated with dapagliflozin plus standard therapy experienced fewer incidents of ESKD (7,221 vs 10,767; number needed to treat, NNT: 28), HHF (2,370 vs 4,684; NNT: 43), AKI (4,110 vs. 5,819; NNT: 58), and ACM (6,383 vs 8,874; NNT: 40) per 100,000 treated patients versus those treated with standard therapy alone. Across 31 countries/regions, reductions in clinical events were associated with a 33% reduction in total costs, or a cumulative mean medical care cost offset of $264 million per 100,000 patients over 3 years. LIMITATIONS AND CONCLUSIONS This analysis is limited by the quality of country/region-specific data available for medical care event costs. Based on the DAPA-CKD trial, we show that treatment with dapagliflozin may prevent cardio-renal event incidence at the population level, which could have positive effects upon healthcare service delivery worldwide. The analysis was restricted to outcome-associated costs and did not consider the cost of drug treatments and disease management.
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Affiliation(s)
- Phil McEwan
- Health Economics and Outcomes Research Ltd, Cardiff, UK
| | - Marco Hafner
- Health Economics and Outcomes Research Ltd, Cardiff, UK
| | - Vivekenand Jha
- George Institute for Global Health India, New Delhi, India
| | - Ricardo Correa-Rotter
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Ciudad de Mexico, Mexico
| | | | - Luca De Nicola
- University L. Vanvitelli-Dept. Advanced Medical and Surgical Sciences, Naples, Italy
| | - Russell Villanueva
- Department of Adult Nephrology, National Kidney and Transplant Institute, Quezon City, Philippines
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Salvatore Barone
- Global Medical Affairs, AstraZeneca, Gaithersburg, Maryland, United States
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19
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Zeitler EM, Mottl AK. Toward Guideline-Directed Medical Therapy in Nephrology: Lifetime Benefit of RAAS and SGLT2 Inhibition in Nondiabetic Kidney Disease. Clin J Am Soc Nephrol 2022; 17:1710-1712. [PMID: 36414317 PMCID: PMC9718011 DOI: 10.2215/cjn.12401022] [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: 11/23/2022]
Affiliation(s)
- Evan M. Zeitler
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Amy K. Mottl
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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