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Narasaki Y, Kovesdy CP, You AS, Sumida K, Mallisetty Y, Surbhi S, Thomas F, Amin AN, Streja E, Kalantar-Zadeh K, Rhee CM. Safety of SGLT2 inhibitors, DPP-4 inhibitors, and GLP-1 receptor agonists in US veterans with and without chronic kidney disease: a population-based study. LANCET REGIONAL HEALTH. AMERICAS 2024; 36:100814. [PMID: 38993538 PMCID: PMC11237921 DOI: 10.1016/j.lana.2024.100814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 05/27/2024] [Accepted: 05/29/2024] [Indexed: 07/13/2024]
Abstract
Background We examined the real-world comparative safety of sodium-glucose cotransporter-2 inhibitors (SGLT2i) vs. other newer anti-glycemic medications (dipeptidyl peptidase-4 inhibitors [DPP4i], glucagon-like peptide-1 receptor agonists [GLP1a]) in patients with and without chronic kidney disease (CKD). Methods Among US Veterans with diabetes receiving care from the Veterans Affairs (VA) healthcare system over 2004-19, we identified incident users of SGLT2i vs. DPP4i vs. GLP1a monotherapy. In analyses stratified by CKD status, defined by estimated glomerular filtration rate and albuminuria, we examined associations of SGLT2i vs. DPP4i vs. GLP1a use with risk of infection-related (primary outcome) and genitourinary infection hospitalizations (secondary outcome) using multivariable Cox models. Findings Among 92,269 patients who met eligibility criteria, 52% did not have CKD, whereas 48% had CKD. In the overall and non-CKD cohorts, compared to DPP4i use, SGLT2i use was associated with lower infection-related hospitalization risk (HRs [95% CIs] 0.74 [0.67-0.81] and 0.77 [0.67, 0.88], respectively), whereas GLP1a use demonstrated comparable risk. However, in the CKD cohort SGLT2i and GLP1a use were each associated with lower risk (HRs [95% CIs] 0.70 [0.61, 0.81] and 0.91 [0.84, 0.99], respectively). Propensity score-matched analyses showed similar findings in the non-CKD and CKD cohorts. In the overall, non-CKD, and CKD cohorts, SGLT2i use was associated with lower genitourinary infection hospitalization risk whereas GLP1a use showed comparable risk vs. DPP4i use. Interpretation In a national cohort of Veterans with diabetes, compared with DPP4i use, SGLT2i use was associated with lower infection-related and genitourinary infection hospitalization risk. Funding VA Health Services Research and Development, USA.
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Affiliation(s)
- Yoko Narasaki
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Amy S You
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yamini Mallisetty
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Satya Surbhi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Fridtjof Thomas
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Alpesh N Amin
- Division of Hospital Medicine, Department of Medicine, University of California Irvine School of Medicine, Orange, CA, USA
| | - Elani Streja
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA, USA
- The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Connie M Rhee
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA, USA
- Nephrology Section, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, CA, USA
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Jia MJ, Chen L. Effect of trace elements and nutrients on diabetes and its complications: a Mendelian randomization study. Front Nutr 2024; 11:1439217. [PMID: 39149550 PMCID: PMC11324608 DOI: 10.3389/fnut.2024.1439217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 07/23/2024] [Indexed: 08/17/2024] Open
Abstract
Background Multiple clinical studies have observed a close relationship between serum trace elements and nutrients and diabetes and its complications, but it remains unclear whether there is a genetic causal effect between serum trace elements and nutrients and diabetes and its complications. Objective This study aims to investigate the causal effects of serum trace elements and nutrients on diabetes and its complications using Mendelian randomization methods. Methods The single nucleotide polymorphisms of serum trace elements and vitamins, as exposure factors, were sourced from the published UK Biobank database and public databases of genome-wide association studies. The genome-wide association study data of diabetes and its complications, as outcome events, were sourced from the FinnGen Biobank database. Mendelian randomization methods were employed to explore the causal relationships between 9 trace elements and 6 nutrients and diabetes and its complications. The causal relationships were inferred using inverse variance weighting, MR Egger, weighted median, simple model, and weighted model methods. Sensitivity analyses, including heterogeneity tests, horizontal pleiotropy tests, MR-PRESSO tests, and leave-one-out analysis, were conducted to evaluate the robustness of the study results. Finally, trace elements and nutrients with statistical significance in the IVW method and consistent Beta and OR directions in the five methods were selected as exposure factors with causal relationships with diabetes and its complications. This study also used multivariable Mendelian randomization methods to assess the combined effects of multiple exposure factors on the risk of diabetes and its complications. Results Mendelian randomization analysis revealed that selenium was linked to an elevated risk of T2D.Vitamin B6 was correlated with an increased risk of neurological complications in type 2 diabetes. Magnesium exhibited a negative causal relationship with the risk of T1D.Carotene was linked to a higher risk of renal complications in T1D.Vitamin B12 showed a negative causal relationship with renal complications in T1D.Carotene was connected to a higher risk of neurological complications in T1D.Potassium and vitamin B6 exhibited negative causal relationships with neurological complications in T1D.Vitamin E showed a negative causal relationship with peripheral circulation complications in T2D.Multivariable Mendelian randomization analysis suggested that vitamin B6 could independently influence neurological complications in both T1D and T2D, apart from other exposure factors. Vitamin B6 could also independently influence renal complications in T1D.Vitamin E could independently influence peripheral circulation complications in T1D, apart from other exposure factors. Conclusion The findings from univariable and multivariable Mendelian randomization studies substantiate the causal relationships between trace elements and nutrients and different subtypes of diabetes and their complications. These findings hold significant clinical implications for developing targeted prevention and treatment strategies for diabetes and its complications.
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Affiliation(s)
- Ming-Jie Jia
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Long Chen
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
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Chen XY, Lu F, Zhang J, Xu CX, Du XF, Liang MB, Chen LJ, Zhong JM. The effect of hyperuricemia and its interaction with hypertension towards chronic kidney disease in patients with type 2 diabetes: evidence from a cross- sectional study in Eastern China. Front Endocrinol (Lausanne) 2024; 15:1415459. [PMID: 39135624 PMCID: PMC11317236 DOI: 10.3389/fendo.2024.1415459] [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: 04/10/2024] [Accepted: 07/16/2024] [Indexed: 08/15/2024] Open
Abstract
Objectives This study aimed to explore the synergistic interaction effect between hyperuricemia and hypertension towards chronic kidney disease in patients with type 2 diabetes. Methods This research originates from a cross-sectional study performed in Zhejiang Province, Eastern China, between March and November 2018. The correlation between serum uric acid levels and the risk of chronic kidney disease was assessed using a restricted cubic spline model. An unconditional multivariable logistic regression model, along with an interaction table, was utilized to explore the potential interaction effect of hyperuricemia and hypertension towards chronic kidney disease. Results 1,756 patients with type 2 diabetes were included in this study, the prevalence of chronic kidney disease (CKD) was 27.62% in this population. A U-shaped non-linear pattern emerged correlating serum uric acid (SUA) levels and CKD risk, indicating that both low and high SUA levels were linked to an increased CKD risk. This risk achieved its lowest point (nadir) at SUA approximately equals to 285μmol/L (p for trend <0.05). Once adjustments for age, gender, education level, abnormal fasting plasma glucose (FPG), abnormal hemoglobin A1c (HbA1c), abnormal total cholesterol (TC), abnormal high-density lipoprotein cholesterol (HDL-C), alcohol consumption and duration of diabetes were factored in, it was found that patients with both hyperuricemia and hypertension demonstrated a 5.42-fold (95% CI: 3.72-7.90) increased CKD risk compared to the reference group. The additive interaction between hyperuricemia and hypertension was statistically significant, as manifested by the following values: a relative excess risk due to interaction (RERI) of 2.57 (95% CI: 0.71-4.71), an attributable proportion due to interaction (AP) of 0.47 (95% CI: 0.14-0.64), and a synergy index (SI) of 2.39 (95% CI: 1.24-4.58). In contrast, there was no significant interaction effect in multiplicative scale. Conclusion Hyperuricemia and hypertension may contribute additively to CKD, beyond their isolated impacts. Evaluating the risk of CKD in type 2 diabetes patients necessitates considering this potential interaction.
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Affiliation(s)
| | | | | | | | | | | | | | - Jie-ming Zhong
- Department of Non-Communicable Disease Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
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Polat F, Kaya Z, Süleymanoğlu C. Comparative analysis of the addition of empagliflozin versus doubling the furosemide dose in decompensated heart failure. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07593-x. [PMID: 38864970 DOI: 10.1007/s10557-024-07593-x] [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] [Accepted: 05/29/2024] [Indexed: 06/13/2024]
Abstract
INTRODUCTION This study aims to compare the addition of SGLT2 inhibitors or doubling the diuretic dose in patients receiving treatment with beta-blockers, angiotensin-converting enzyme inhibitors (ACEi), or angiotensin receptor blockers (ARB), as well as mineralocorticoid receptor antagonists (MRA), for heart failure with reduced ejection fraction (HFrEF) who present to the emergency department with decompensated heart failure. METHODS This study is a single-center and prospective analysis. A total of 980 decompensated heart failure (HFrEF) patients receiving optimal medical therapy (OMT) according to the 2021 European heart failure guidelines were randomized in a 2:1 ratio into the furosemide and empagliflozin treatment arms. The analysis includes patient clinical characteristics, laboratory results, and echocardiographic data. Factors influencing rehospitalization were identified through multivariate Cox regression analysis. Log-rank analysis was employed to assess factors affecting rehospitalization. RESULTS The mean age of the patients was 67.9 years, with 52.1% being men. There was no significant impact of demographic, clinical, or echocardiographic factors on rehospitalization at 1 month; only the effect of treatment subgroups on rehospitalization was observed (p = 0.039). Significant echocardiographic and clinical improvements were seen in both treatment arms. The empagliflozin group exhibited significant improvements in 6-min walk distance, heart rate, body weight, NT-pro BNP levels, and eGFR level compared to the furosemide group. The rate of rehospitalization in the first month was significantly lower in those receiving empagliflozin (28.7%) compared to those receiving a double dose of furosemide (40.2%) (log-rank p = 0.013). DISCUSSION AND CONCLUSION This study provides valuable insights into the management of decompensated HFrEF and demonstrates that SGLT2 inhibitors offer benefits beyond glycemic control in this patient group. The significant reduction in rehospitalization rates and improvements in echocardiographic parameters underscore the potential of SGLT2 inhibitors in reducing acute heart failure episodes.
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Affiliation(s)
- Fuat Polat
- Department of Cardiology, Health Sciences University Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey.
| | - Zeynettin Kaya
- Department of Cardiology, ASV Yaşam Hospital, Antalya, Turkey
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Huang Q, Chen J, Liao S, Long J, Fang R, He Y, Chen P, Liu D. The SGLT2 inhibitor empagliflozin inhibits skeletal muscle fibrosis in naturally aging male mice through the AMPKα/MMP9/TGF-β1/Smad pathway. Biogerontology 2024; 25:567-581. [PMID: 38403802 DOI: 10.1007/s10522-024-10093-y] [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: 12/06/2023] [Accepted: 01/03/2024] [Indexed: 02/27/2024]
Abstract
ABSTACT With advancing age, the incidence of sarcopenia increases, eventually leading to a cascade of adverse events. However, there is currently a lack of effective pharmacological treatment for sarcopenia. Sodium-glucose co-transporter 2 inhibitor (SGLT2i) empagliflozin demonstrates anti-fibrotic capabilities in various organs. This study aims to determine whether empagliflozin can improve skeletal muscle fibrosis induced by sarcopenia in naturally aging mice. A natural aging model was established by feeding male mice from 13 months of age to 19 months of age. A fibrosis model was created by stimulating skeletal muscle fibroblasts with TGF-β1. The Forelimb grip strength test assessed skeletal muscle function, and expression levels of COL1A1, COL3A1, and α-SMA were analyzed by western blot, qPCR, and immunohistochemistry. Additionally, levels of AMPKα/MMP9/TGFβ1/Smad signaling pathways were examined. In naturally aging mice, skeletal muscle function declines, expression of muscle fibrosis markers increases, AMPKα expression is downregulated, and MMP9/TGFβ1/Smad signaling pathways are upregulated. However, treatment with empagliflozin reverses this phenomenon. At the cellular level, empagliflozin exhibits similar anti-fibrotic effects, and these effects are attenuated by Compound C and siAMPKα. Empagliflozin exhibits anti-fibrotic effects, possibly associated with the AMPK/MMP9/TGFβ1/Smad signaling pathways.
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Affiliation(s)
- Qixuan Huang
- Department of Endocrinology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Jie Chen
- Department of Endocrinology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
- Department of Endocrinology, The Ninth People's Hospital of Chongqing, Chongqing, 400700, China
| | - Siqi Liao
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Jiangchuan Long
- Department of Endocrinology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Ronghua Fang
- Department of Endocrinology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Yusen He
- Department of Endocrinology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Peiyun Chen
- Department of Endocrinology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Dongfang Liu
- Department of Endocrinology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
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Natale P, Tunnicliffe DJ, Toyama T, Palmer SC, Saglimbene VM, Ruospo M, Gargano L, Stallone G, Gesualdo L, Strippoli GF. Sodium-glucose co-transporter protein 2 (SGLT2) inhibitors for people with chronic kidney disease and diabetes. Cochrane Database Syst Rev 2024; 5:CD015588. [PMID: 38770818 PMCID: PMC11106805 DOI: 10.1002/14651858.cd015588.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Diabetes is associated with high risks of premature chronic kidney disease (CKD), cardiovascular diseases, cardiovascular death and impaired quality of life. People with diabetes are more likely to develop kidney impairment, and approximately one in three adults with diabetes have CKD. People with CKD and diabetes experience a substantially higher risk of cardiovascular outcomes. Sodium-glucose co-transporter protein 2 (SGLT2) inhibitors have shown potential effects in preventing kidney and cardiovascular outcomes in people with CKD and diabetes. However, new trials are emerging rapidly, and evidence synthesis is essential to summarising cumulative evidence. OBJECTIVES This review aimed to assess the benefits and harms of SGLT2 inhibitors for people with CKD and diabetes. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 17 November 2023 using a search strategy designed by an Information Specialist. Studies in the Register are continually identified through regular searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled studies were eligible if they evaluated SGLT2 inhibitors versus placebo, standard care or other glucose-lowering agents in people with CKD and diabetes. CKD includes all stages (from 1 to 5), including dialysis patients. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed the study risk of bias. Treatment estimates were summarised using random effects meta-analysis and expressed as a risk ratio (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The primary review outcomes were all-cause death, 3-point and 4-point major adverse cardiovascular events (MACE), fatal or nonfatal myocardial infarction (MI), fatal or nonfatal stroke, and kidney failure. MAIN RESULTS Fifty-three studies randomising 65,241 people with CKD and diabetes were included. SGLT2 inhibitors with or without other background treatments were compared to placebo, standard care, sulfonylurea, dipeptidyl peptidase-4 (DPP-4) inhibitors, or insulin. In the majority of domains, the risks of bias in the included studies were low or unclear. No studies evaluated the treatment in children or in people treated with dialysis. No studies compared SGLT2 inhibitors with glucagon-like peptide-1 receptor agonists or tirzepatide. Compared to placebo, SGLT2 inhibitors decreased the risk of all-cause death (20 studies, 44,397 participants: RR 0.85, 95% CI 0.78 to 0.94; I2 = 0%; high certainty) and cardiovascular death (16 studies, 43,792 participants: RR 0.83, 95% CI 0.74 to 0.93; I2 = 29%; high certainty). Compared to placebo, SGLT2 inhibitors probably make little or no difference to the risk of fatal or nonfatal MI (2 studies, 13,726 participants: RR 0.95, 95% CI 0.80 to 1.14; I2 = 24%; moderate certainty), and fatal or nonfatal stroke (2 studies, 13,726 participants: RR 1.07, 95% CI 0.88 to 1.30; I2 = 0%; moderate certainty). Compared to placebo, SGLT2 inhibitors probably decrease 3-point MACE (7 studies, 38,320 participants: RR 0.89, 95% CI 0.81 to 0.98; I2 = 46%; moderate certainty), and 4-point MACE (4 studies, 23,539 participants: RR 0.82, 95% CI 0.70 to 0.96; I2 = 77%; moderate certainty), and decrease hospital admission due to heart failure (6 studies, 28,339 participants: RR 0.70, 95% CI 0.62 to 0.79; I2 = 17%; high certainty). Compared to placebo, SGLT2 inhibitors may decrease creatinine clearance (1 study, 132 participants: MD -2.63 mL/min, 95% CI -5.19 to -0.07; low certainty) and probably decrease the doubling of serum creatinine (2 studies, 12,647 participants: RR 0.70, 95% CI 0.56 to 0.89; I2 = 53%; moderate certainty). SGLT2 inhibitors decrease the risk of kidney failure (6 studies, 11,232 participants: RR 0.70, 95% CI 0.62 to 0.79; I2 = 0%; high certainty), and kidney composite outcomes (generally reported as kidney failure, kidney death with or without ≥ 40% decrease in estimated glomerular filtration rate (eGFR)) (7 studies, 36,380 participants: RR 0.68, 95% CI 0.59 to 0.78; I2 = 25%; high certainty) compared to placebo. Compared to placebo, SGLT2 inhibitors incur less hypoglycaemia (16 studies, 28,322 participants: RR 0.93, 95% CI 0.89 to 0.98; I2 = 0%; high certainty), and hypoglycaemia requiring third-party assistance (14 studies, 26,478 participants: RR 0.75, 95% CI 0.65 to 0.88; I2 = 0%; high certainty), and probably decrease the withdrawal from treatment due to adverse events (15 studies, 16,622 participants: RR 0.94, 95% CI 0.82 to 1.08; I2 = 16%; moderate certainty). The effects of SGLT2 inhibitors on eGFR, amputation and fracture were uncertain. No studies evaluated the effects of treatment on fatigue, life participation, or lactic acidosis. The effects of SGLT2 inhibitors compared to standard care alone, sulfonylurea, DPP-4 inhibitors, or insulin were uncertain. AUTHORS' CONCLUSIONS SGLT2 inhibitors alone or added to standard care decrease all-cause death, cardiovascular death, and kidney failure and probably decrease major cardiovascular events while incurring less hypoglycaemia compared to placebo in people with CKD and diabetes.
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Affiliation(s)
- Patrizia Natale
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - David J Tunnicliffe
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Tadashi Toyama
- Department of Nephrology, Kanazawa University, Kanazawa, Japan
- Innovative Clinical Research Center, Kanazawa University, Kanazawa, Japan
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Valeria M Saglimbene
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Marinella Ruospo
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Letizia Gargano
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Loreto Gesualdo
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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任 毅, 卢 金, 于 露, 李 宗, 王 高, 杨 菁. [Carnosine protects against diabetic nephropathy in rats by activating the AKT/mTOR pathway and restoring autophagy in the renal tissue]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2023; 43:1965-1970. [PMID: 38081616 PMCID: PMC10713464 DOI: 10.12122/j.issn.1673-4254.2023.11.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Indexed: 12/18/2023]
Abstract
OBJECTIVE To explore the mechanisms mediating the protective effect of carnosine against nephropathy in rats with diabetes mellitus (DM). METHODS Rat models of DM established by high-fat diet feeding and streptozotocin injection were randomized into DM group and 3 treatment groups with daily carnosine treatment at 100, 300, and 900 mg/kg. Body weight and blood glucose level changes of the rats were measured regularly. After the treatment, 24-h urine, serum samples and kidneys of the rats were collected to measure urine volume, urine protein content, blood creatinine, and kidney mass; renal pathology was observed using HE staining, and MDA content and SOD activity in the kidney tissues were detected. Western blotting was performed to detect the protein expressions of p-AKT, AKT, p-mTOR, mTOR, LC3 and p62 in the kidney tissues. RESULTS Compared with normal control rats, the diabetic rats exhibited dull and wet hair and showed decreased body weight, increased blood glucose, urinary protein content, 24-h urine volume, blood creatinine, and kidney mass with obvious swelling and deformation of the glomeruli, narrowing of the renal tubules, decreased SOD activity and increased MDA content, lowered p-mTOR/mTOR and p-AKT/AKT ratios and increased LC3 Ⅱ/Ⅰ ratio and p62 protein expression in the kidney tissue. The diabetic rats receiving carnosine treatments had dry hair with normal luster and showed increased body weight and slightly decreased blood glucose, urinary protein content, 24-h urine volume, blood creatinine, and kidney mass. The treatment also improved renal pathology, increased SOD activity, decreased MDA content, increased p-mTOR/mTOR and p-AKT/AKT ratios and lowered LC3 Ⅱ/Ⅰ ratio and p62 protein expression in renal tissue of the diabetic rats. CONCLUSION Carnosine offers protection against nephropathy in rats with DM possibly by inhibiting oxidative stress, activating the AKT/mTOR pathway, and restoring autophagy in the kidneys.
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Affiliation(s)
- 毅 任
- />锦州医科大学基础医学院生物化学与分子生物学教研室,辽宁 锦州 121001Department of Biochemistry and Molecular Biology, College of Basic Medical Sciences, Jinzhou Medical University, Jinzhou 121001, China
| | - 金莹 卢
- />锦州医科大学基础医学院生物化学与分子生物学教研室,辽宁 锦州 121001Department of Biochemistry and Molecular Biology, College of Basic Medical Sciences, Jinzhou Medical University, Jinzhou 121001, China
| | - 露 于
- />锦州医科大学基础医学院生物化学与分子生物学教研室,辽宁 锦州 121001Department of Biochemistry and Molecular Biology, College of Basic Medical Sciences, Jinzhou Medical University, Jinzhou 121001, China
| | - 宗泽 李
- />锦州医科大学基础医学院生物化学与分子生物学教研室,辽宁 锦州 121001Department of Biochemistry and Molecular Biology, College of Basic Medical Sciences, Jinzhou Medical University, Jinzhou 121001, China
| | - 高 王
- />锦州医科大学基础医学院生物化学与分子生物学教研室,辽宁 锦州 121001Department of Biochemistry and Molecular Biology, College of Basic Medical Sciences, Jinzhou Medical University, Jinzhou 121001, China
| | - 菁 杨
- />锦州医科大学基础医学院生物化学与分子生物学教研室,辽宁 锦州 121001Department of Biochemistry and Molecular Biology, College of Basic Medical Sciences, Jinzhou Medical University, Jinzhou 121001, China
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Chaterjee O, Sur D. Artificially induced in situ macrophage polarization: An emerging cellular therapy for immuno-inflammatory diseases. Eur J Pharmacol 2023; 957:176006. [PMID: 37611840 DOI: 10.1016/j.ejphar.2023.176006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/10/2023] [Accepted: 08/18/2023] [Indexed: 08/25/2023]
Abstract
Macrophages are the mature form of monocytes that have high plasticity and can shift from one phenotype to another by the process of macrophage polarization. Macrophage has several vital pharmacological tasks like eliminating microorganism invasion, clearing dead cells, causing inflammation, repairing damaged tissues, etc. The function of macrophages is based on their phenotype. M1 macrophages are mostly responsible for the body's immune responses and M2 macrophages have healing properties. Inappropriate activation of any one of the phenotypes often leads to ROS-induced tissue damage and affects wound healing and angiogenesis. Therefore, maintaining tissue macrophage homeostasis is necessary. Studies are being done to find techniques for macrophage polarization. But, the process of macrophage polarization is very complex as it involves multiple signalling pathways involving innate immunity. Thus, identifying the right pathways for macrophage polarization is essential to apply the polarizing technique for the treatment of various inflammatory diseases where macrophage physiology influences the disease pathology. In this review, we highlighted the various techniques so far used to change macrophage plasticity. We believe that soon macrophage targeting therapeutics will hit the market for the management of inflammatory disease. Hence this review will help macrophage researchers choose suitable methods and materials/agents to polarize macrophages artificially in various disease models.
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Affiliation(s)
- Oishani Chaterjee
- Division of Pharmacology, Guru Nanak Institute of Pharmaceutical Science & Technology, Panihati, Kolkata, 700114, India
| | - Debjeet Sur
- Division of Pharmacology, Guru Nanak Institute of Pharmaceutical Science & Technology, Panihati, Kolkata, 700114, India.
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9
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Marx N, Federici M, Schütt K, Müller-Wieland D, Ajjan RA, Antunes MJ, Christodorescu RM, Crawford C, Di Angelantonio E, Eliasson B, Espinola-Klein C, Fauchier L, Halle M, Herrington WG, Kautzky-Willer A, Lambrinou E, Lesiak M, Lettino M, McGuire DK, Mullens W, Rocca B, Sattar N. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J 2023; 44:4043-4140. [PMID: 37622663 DOI: 10.1093/eurheartj/ehad192] [Citation(s) in RCA: 210] [Impact Index Per Article: 210.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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10
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Kato S, Kuwatsuka Y, Ando M, Tatematsu Y, Nishibori N, Maruyama S. Rationale and study design of a randomized controlled trial to investigate the renoprotective effect of canagliflozin assessed by test of renal hemodynamics in diabetic kidney disease (the FAGOTTO study). BMC Nephrol 2023; 24:228. [PMID: 37537531 PMCID: PMC10401745 DOI: 10.1186/s12882-023-03277-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 07/20/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are considered to have the potential to maintain renal function by correcting glomerular hypertension in patients with diabetic kidney disease (DKD). The aim of this study is to demonstrate the renoprotective effect of SGLT2i by measuring renal hemodynamics, including glomerular filtration fraction (FF), in type 2 diabetic patients with moderate renal dysfunction. METHODS Renoprotective effect of canagliflozin derived from test of renal hemodynamics in diabetic kidney disease (FAGOTTO) study is a 12-week multicenter, open-label, randomized (1:1), parallel-group trial of type 2 diabetic patients with diabetic kidney disease (30 ≤ estimated glomerular filtration rate [eGFR] ≤ 60 mL/min/1.73 m2). A total of 110 patients are to be randomly allocated to receive once-daily canagliflozin 100 mg or control (standard therapy). FF will be calculated by dividing the measured GFR (mGFR) by the effective renal plasma flow (eRPF). mGFR and eRPF will be measured by the clearance of inulin and para-aminohippuric acid (PAH), respectively. The primary endpoint of this trial is the percentage change in FF after 4 weeks of treatment in the canagliflozin and control groups. DISCUSSION The FAGOTTO study will elucidate the mechanism of the renoprotective action of SGLT2i. The background, rationale, and study design of this trial are presented. To date, > 80 patients have been enrolled in this trial. The study will end in 2025. TRIAL REGISTRATION jRCT (Japan Registry Of Clinical Trials) jRCTs041200069. Date of registration: November 27, 2020.
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Affiliation(s)
- Sawako Kato
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65, Tsuruma-Cho, Showa-Ku, Nagoya, Aichi, 464-8550, Japan.
| | - Yachiyo Kuwatsuka
- Department of Advanced Medicine, Nagoya University Hospital, Aichi, Japan
| | - Masahiko Ando
- Department of Advanced Medicine, Nagoya University Hospital, Aichi, Japan
| | - Yoshitaka Tatematsu
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65, Tsuruma-Cho, Showa-Ku, Nagoya, Aichi, 464-8550, Japan
| | - Nobuhiro Nishibori
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65, Tsuruma-Cho, Showa-Ku, Nagoya, Aichi, 464-8550, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65, Tsuruma-Cho, Showa-Ku, Nagoya, Aichi, 464-8550, Japan
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11
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Thomas MC, Neuen BL, Twigg SM, Cooper ME, Badve SV. SGLT2 inhibitors for patients with type 2 diabetes and CKD: a narrative review. Endocr Connect 2023; 12:e230005. [PMID: 37159343 PMCID: PMC10448577 DOI: 10.1530/ec-23-0005] [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: 04/24/2023] [Accepted: 05/05/2023] [Indexed: 05/11/2023]
Abstract
Sodium-glucose co-transporter 2 (SGLT2) inhibitors have recently emerged as an effective means to protect kidney function in people with type 2 diabetes and chronic kidney disease (CKD). In this review, we explore the role of SGLT2 inhibition in these individuals. SGLT2 inhibitors specifically act to inhibit sodium and glucose reabsorption in the early proximal tubule of the renal nephron. Although originally developed as glucose-lowering agents through their ability to induce glycosuria, it became apparent in cardiovascular outcome trials that the trajectory of kidney function decline was significantly slowed and the incidence of serious falls in kidney function was reduced in participants receiving an SGLT2 inhibitor. These observations have recently led to specific outcome trials in participants with CKD, including DAPA-CKD, CREDENCE and EMPA-KIDNEY, and real-world studies, like CVD-REAL-3, that have confirmed the observation of kidney benefits in this setting. In response, recent KDIGO Guidelines have recommended the use of SGLT2 inhibitors as first-line therapy in patients with CKD, alongside statins, renin-angiotensin-aldosterone system inhibitors and multifactorial risk factor management as indicated. However, SGLT2 inhibitors remain significantly underutilized in the setting of CKD. Indeed, an inertia paradox exists, with patients with more severe disease less likely to receive an SGLT2 inhibitor. Concerns regarding safety appear unfounded, as acute kidney injury, hyperkalaemia, major acute cardiovascular events and cardiac death in patients with CKD appear to be lower following SGLT2 inhibition. The first-in-class indication of dapagliflozin for CKD may begin a new approach to managing kidney disease in type 2 diabetes.
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Affiliation(s)
- Merlin C Thomas
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Brendon L Neuen
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Stephen M Twigg
- The University of Sydney School of Medicine, Sydney, NSW, Australia
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Mark E Cooper
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Sunil V Badve
- The George Institute for Global Health, Sydney, NSW, Australia
- Department of Renal Medicine, St George Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
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12
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Cotton M, Hawley A. SGLT2 inhibitors; suggested mechanism of actions in supporting post-myocardial infarction patients. Future Cardiol 2023; 19:419-422. [PMID: 37702265 DOI: 10.2217/fca-2023-0066] [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: 09/14/2023] Open
Affiliation(s)
- Matthew Cotton
- Torbay Hospital & South Devon Foundation Trust, Lowes Bridge, Torquay, TQ2 7AA
| | - Alasdair Hawley
- Torbay Hospital & South Devon Foundation Trust, Lowes Bridge, Torquay, TQ2 7AA
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13
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Bueno Junior CR, Bano A, Tang Y, Sun X, Abate A, Hall E, Mitri J, Morieri ML, Shah H, Doria A. Rapid kidney function decline and increased risk of heart failure in patients with type 2 diabetes: findings from the ACCORD cohort : Rapid kidney function decline and heart failure in T2D. Cardiovasc Diabetol 2023; 22:131. [PMID: 37365586 PMCID: PMC10291814 DOI: 10.1186/s12933-023-01869-6] [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: 04/01/2023] [Accepted: 05/28/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Impaired kidney function and albuminuria are associated with increased risk of heart failure (HF) in patients with type 2 diabetes (T2D). We investigated whether rapid kidney function decline over time is an additional determinant of increased HF risk in patients with T2D, independent of baseline kidney function, albuminuria, and other HF predictors. METHODS Included in the study were 7,539 participants in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study with baseline urinary albumin-to-creatinine ratio (UACR) data, who had completed 4 years of follow-up and had ≥ 3 eGFR measurements during that period (median eGFR/year = 1.9, IQR 1.7-3.2). The association between rapid kidney function decline (eGFR loss ≥ 5 ml/min/1.73 m2/year) and odds of HF hospitalization or HF death during the first 4 years of follow-up was estimated by logistic regression. The improvement in risk discrimination provided by adding rapid kidney function decline to other HF risk factors was evaluated as the increment in the area under the Receiving Operating Characteristics curve (ROC AUC) and integrated discrimination improvement (IDI). RESULTS Over 4 years of follow-up, 1,573 participants (20.9%) experienced rapid kidney function decline and 255 (3.4%) experienced a HF event. Rapid kidney function decline was associated with a ~ 3.2-fold increase in HF odds (3.23, 95% CI, 2.51-4.16, p < 0.0001), independent of baseline CVD history. This estimate was not attenuated by adjustment for potential confounders, including eGFR and UACR at baseline as well as at censoring (3.74; 95% CI 2.63-5.31). Adding rapid kidney function decline during follow-up to other clinical predictors (WATCH-DM score, eGFR, and UACR at study entry and end of follow-up) improved HF risk classification (ROC AUC = + 0.02, p = 0.027; relative IDI = + 38%, p < 0.0001). CONCLUSIONS In patients with T2D, rapid kidney function decline is associated with a marked increase in HF risk, independent of starting kidney function and/or albuminuria. These findings highlight the importance of serial eGFR measurements over time to improve HF risk estimation in T2D.
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Affiliation(s)
- Carlos Roberto Bueno Junior
- Research Division, Joslin Diabetes Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- School of Physical Education and Sport, Medical School, College of Nursing of Ribeirao Preto, University of Sao Paulo (USP), Ribeirao Preto, Sao Paulo, Brazil
| | - Arjola Bano
- Research Division, Joslin Diabetes Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Yaling Tang
- Research Division, Joslin Diabetes Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Xiuqin Sun
- Research Division, Joslin Diabetes Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Endocrine and Metabolism, Peking University Shuang Hospital, Beijing, China
| | - Alex Abate
- Research Division, Joslin Diabetes Center, Boston, MA, USA
| | - Elizabeth Hall
- Research Division, Joslin Diabetes Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Joanna Mitri
- Research Division, Joslin Diabetes Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Mario Luca Morieri
- Department of Medicine, Metabolic Disease Unit, University of Padova, University Hospital of Padova, Padova, Italy
| | - Hetal Shah
- Research Division, Joslin Diabetes Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Alessandro Doria
- Research Division, Joslin Diabetes Center, Boston, MA, USA.
- Department of Medicine, Harvard Medical School, Boston, MA, USA.
- Research Division, Joslin Diabetes Center, One Joslin Place, Boston, MA, 02215, USA.
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14
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Biancalana E, Ceccarini G, Magno S, Ortenzi V, Giannese D, Santini F, Solini A. Canagliflozin on top of dual renin-angiotensin system blockade in a woman with partial acquired lipodystrophy, type 2 diabetes and severely proteinuric chronic kidney disease: a case report. Front Endocrinol (Lausanne) 2023; 14:1172468. [PMID: 37274321 PMCID: PMC10237351 DOI: 10.3389/fendo.2023.1172468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/26/2023] [Indexed: 06/06/2023] Open
Abstract
Sodium glucose cotransporter 2 inhibitors have proven strong efficacy in reducing end-stage renal disease in patients with type 2 diabetes. We are presenting here the case of a 40-year-old woman with acquired partial lipodystrophy, type 2 diabetes and essential hypertension complicated by chronic kidney disease and proteinuria in the nephrotic range. She first came to our attention in 2012; estimated glomerular filtration rate (eGFR) was 41.5 ml/min/1.73 m2 and total proteinuria was 375 mg/24h; she was treated with dual renin angiotensin system blocking. Proteinuria significantly increased during the following years, reaching a nephrotic range (>5 g/day). A kidney biopsy revealed a tubule-interstitial involvement compatible with type 2 diabetes. Leptin replacement therapy, started in 2018, improved glycaemic control and lipid profile, also determining a reduction in insulin total daily dose. In 2019, after the publication of the CREDENCE study, canagliflozin was started on top of losartan and ramipril. After an initial, expected eGFR drop, kidney function stabilized, and albuminuria significantly reduced (from 4120 to 984 mg/24h), while serum potassium showed only minimal increase. At last follow-up (2022) total proteinuria was still reducing (510 mg/24h), while kidney function was substantially unchanged (eGFR 40 ml/min/1.73 m2). This case report suggests that, despite not recommended in international guidelines, the use of SGLT2i in combination with dual renin angiotensin system blockade should be considered in specific conditions and under close clinical monitoring.
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Affiliation(s)
- Edoardo Biancalana
- Department of Clinical and Experimental Medicine University of Pisa, Pisa, Italy
| | - Giovanni Ceccarini
- Obesity and Lipodistrophy Center, University Hospital of Pisa, Pisa, Italy
| | - Silvia Magno
- Obesity and Lipodistrophy Center, University Hospital of Pisa, Pisa, Italy
| | - Valerio Ortenzi
- Section of Pathology, University Hospital of Pisa, Pisa, Italy
| | | | - Ferruccio Santini
- Obesity and Lipodistrophy Center, University Hospital of Pisa, Pisa, Italy
| | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
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15
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Su S, Ma Z, Wu H, Xu Z, Yi H. Oxidative stress as a culprit in diabetic kidney disease. Life Sci 2023; 322:121661. [PMID: 37028547 DOI: 10.1016/j.lfs.2023.121661] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/26/2023] [Accepted: 03/31/2023] [Indexed: 04/08/2023]
Abstract
Diabetic kidney disease (DKD) has become the leading cause of end-stage renal disease (ESRD), and the prevalence of DKD has increased worldwide during recent years. DKD is associated with poor therapeutic outcomes in most patients, but there is limited understanding of its pathogenesis. This review suggests that oxidative stress interacts with many other factors in causing DKD. Highly active mitochondria and NAD(P)H oxidase are major sources of oxidants, and they significantly affect the risk for DKD. Oxidative stress and inflammation may be considered reciprocal causes of DKD, in that each is a cause and an effect of DKD. Reactive oxygen species (ROS) can act as second messengers in various signaling pathways and as regulators of metabolism, activation, proliferation, differentiation, and apoptosis of immune cells. Epigenetic modifications, such as DNA methylation, histone modifications, and non-coding RNAs can modulate oxidative stress. The development of new technologies and identification of new epigenetic mechanisms may provide novel opportunities for the diagnosis and treatment of DKD. Clinical trials demonstrated that novel therapies which reduce oxidative stress can slow the progression of DKD. These therapies include the NRF2 activator bardoxolone methyl, new blood glucose-lowering drugs such as sodium-glucose cotransporter 2 inhibitors, and glucagon-like peptide-1 receptor agonists. Future studies should focus on improving early diagnosis and the development of more effective combination treatments for this multifactorial disease.
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16
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Fluid homeostasis induced by sodium-glucose cotransporter 2 inhibitors: novel insight for better cardio-renal outcomes in chronic kidney disease. Hypertens Res 2023; 46:1195-1201. [PMID: 36849579 DOI: 10.1038/s41440-023-01220-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/07/2023] [Accepted: 02/02/2023] [Indexed: 03/01/2023]
Abstract
Hypertension in chronic kidney disease (CKD) patients is a risk factor for end-stage renal disease, cardiovascular events, and mortality. Thus, the prevention and appropriate management of hypertension in these patients are essential strategies for better cardio-renal outcomes. In this review, we show novel risk factors for hypertension with CKD, several promising prognostic markers and treatment for cardio-renal outcomes. Of note, the clinical use of sodium-glucose cotransporter 2 (SGLT2) inhibitors has recently expanded to non-diabetic patients with CKD and heart failure as well as diabetic patients. SGLT2 inhibitors have an antihypertensive effect, but are also associated with a low risk of hypotension. This unique mechanism of blood pressure regulation by SGLT2 inhibitors may partially depend on body fluid homeostasis, which is mediated by the autoregulation property between "accelerator" (diuretic action) and "brake" (increase in anti-diuretic hormone vasopressin and fluid intake). Mineralocorticoid receptor (MR) blockers are used in the treatment of essential hypertension and hyperaldosteronism. Recently, a new MR blocker, finerenone, has been launched as a treatment for CKD with type 2 diabetes. These advances in relation to hypertension in CKD may contribute to the reduction of renal and cardiovascular events.
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Liu L, Xu J, Zhang Z, Ren D, Wu Y, Wang D, Zhang Y, Zhao S, Chen Q, Wang T. Metabolic Homeostasis of Amino Acids and Diabetic Kidney Disease. Nutrients 2022; 15:nu15010184. [PMID: 36615841 PMCID: PMC9823842 DOI: 10.3390/nu15010184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/16/2022] [Accepted: 12/27/2022] [Indexed: 01/03/2023] Open
Abstract
Diabetic kidney disease (DKD) occurs in 25-40% of patients with diabetes. Individuals with DKD are at a significant risk of progression to end-stage kidney disease morbidity and mortality. At present, although renal function-decline can be retarded by intensive glucose lowering and strict blood pressure control, these current treatments have shown no beneficial impact on preventing progression to kidney failure. Recently, in addition to control of blood sugar and pressure, a dietary approach has been recommended for management of DKD. Amino acids (AAs) are both biomarkers and causal factors of DKD progression. AA homeostasis contributes to renal hemodynamic response and glomerular hyperfiltration alteration in diabetic patients. This review discusses the links between progressive kidney dysfunction and the metabolic homeostasis of histidine, tryptophan, methionine, glutamine, tyrosine, and branched-chain AAs. In addition, we emphasize the regulation effects of special metabolites on DKD progression, with a focus on causality and potential mechanisms. This paper may offer an optimized protein diet strategy with concomitant management of AA homeostasis to reduce the risks of DKD in a setting of hyperglycemia.
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Affiliation(s)
- Luokun Liu
- State Key Laboratory of Component Based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, 10 Poyanghu Road, Jinghai District, Tianjin 301617, China
| | - Jingge Xu
- Haihe Laboratory of Modern Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, 10 Poyanghu Road, Jinghai District, Tianjin 301617, China
| | - Zhiyu Zhang
- State Key Laboratory of Component Based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, 10 Poyanghu Road, Jinghai District, Tianjin 301617, China
| | - Dongwen Ren
- Haihe Laboratory of Modern Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, 10 Poyanghu Road, Jinghai District, Tianjin 301617, China
| | - Yuzheng Wu
- State Key Laboratory of Component Based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, 10 Poyanghu Road, Jinghai District, Tianjin 301617, China
| | - Dan Wang
- State Key Laboratory of Component Based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, 10 Poyanghu Road, Jinghai District, Tianjin 301617, China
| | - Yi Zhang
- Haihe Laboratory of Modern Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, 10 Poyanghu Road, Jinghai District, Tianjin 301617, China
| | - Shuwu Zhao
- School of Intergrative Medicine, Tianjin University of Traditional Chinese Medicine, 10 Poyanghu Road, Jinghai District, Tianjin 301617, China
| | - Qian Chen
- State Key Laboratory of Component Based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, 10 Poyanghu Road, Jinghai District, Tianjin 301617, China
- Correspondence: (Q.C.); (T.W.); Tel.: +86-22-59596164 (Q.C.); +86-22-59596185 (T.W.)
| | - Tao Wang
- Haihe Laboratory of Modern Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, 10 Poyanghu Road, Jinghai District, Tianjin 301617, China
- Correspondence: (Q.C.); (T.W.); Tel.: +86-22-59596164 (Q.C.); +86-22-59596185 (T.W.)
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18
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Hao R, Myroniuk T, McGuckin T, Manca D, Campbell-Scherer D, Lau D, Yeung RO. Underuse of cardiorenal protective agents in high-risk diabetes patients in primary care: a cross-sectional study. BMC PRIMARY CARE 2022; 23:124. [PMID: 35606699 PMCID: PMC9128222 DOI: 10.1186/s12875-022-01731-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 05/10/2022] [Indexed: 12/03/2022]
Abstract
Background Sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) have shown benefits in patients with diabetes and cardiovascular disease (CVD), heart failure (HF), and chronic kidney disease (CKD). Objective We assessed benchmark outcomes (Hemoglobin A1c, LDL-C, and blood pressure), identified the prevalence of cardiorenal indications for SGLT2i and GLP-1RA, and compared prescribing rates of GLP1-RA and SGLT2i in those with and without cardiorenal indications. Methods We analyzed data from January 2018–June 2019 for 7168 patients with diabetes using electronic medical records from the Northern Alberta Primary Care Research Network, a regional network of the Canadian Primary Sentinel Surveillance Network (CPCSSN). Patients with and without cardiorenal comorbidities were compared using descriptive statistics and two proportion Z tests. Results Hemoglobin A1c ≤ 7.0% was met by 56.8%, blood pressure < 130/80 mmHg by 62.1%, LDL-C ≤ 2.0 mmol/L by 45.3% of patients. There were 4377 patients on glucose lowering medications; metformin was most common (77.7%), followed by insulin (24.6%), insulin secretagogues (23.6%), SGLT2i (19.7%), dipeptidyl peptidase-4 inhibitor (19.3%), and GLP-1RA (9.4%). A quarter of patients had cardiorenal indications for SGLT2i or GLP-1RA. Use of SGLT2i in these patients was lower than in patients without cardiorenal comorbidities (14.9% vs 21.2%, p < 0.05). GLP-1RA use in these patients was 4.6% compared with 11% in those without cardiorenal comorbidities (p < 0.05). Discussion Contrary to current evidence and recommendations, SGLT2i and GLP1-RA were less likely to be prescribed to patients with pre-existing CVD, HF, and/or CKD, revealing opportunities to improve prescribing for patients with diabetes at high-risk for worsening cardiorenal complications. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01731-w.
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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20
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de Boer IH, Khunti K, Sadusky T, Tuttle KR, Neumiller JJ, Rhee CM, Rosas SE, Rossing P, Bakris G. Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care 2022; 45:3075-3090. [PMID: 36189689 PMCID: PMC9870667 DOI: 10.2337/dci22-0027] [Citation(s) in RCA: 189] [Impact Index Per Article: 94.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 06/30/2022] [Indexed: 02/05/2023]
Abstract
People with diabetes and chronic kidney disease (CKD) are at high risk for kidney failure, atherosclerotic cardiovascular disease, heart failure, and premature mortality. Recent clinical trials support new approaches to treat diabetes and CKD. The 2022 American Diabetes Association (ADA) Standards of Medical Care in Diabetes and the Kidney Disease: Improving Global Outcomes (KDIGO) 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease each provide evidence-based recommendations for management. A joint group of ADA and KDIGO representatives reviewed and developed a series of consensus statements to guide clinical care from the ADA and KDIGO guidelines. The published guidelines are aligned in the areas of CKD screening and diagnosis, glycemia monitoring, lifestyle therapies, treatment goals, and pharmacologic management. Recommendations include comprehensive care in which pharmacotherapy that is proven to improve kidney and cardiovascular outcomes is layered on a foundation of healthy lifestyle. Consensus statements provide specific guidance on use of renin-angiotensin system inhibitors, metformin, sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and a nonsteroidal mineralocorticoid receptor antagonist. These areas of consensus provide clear direction for implementation of care to improve clinical outcomes of people with diabetes and CKD.
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Affiliation(s)
- Ian H. de Boer
- Kidney Research Institute, University of Washington, Seattle, WA
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, U.K
| | | | | | - Joshua J. Neumiller
- College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA
| | | | - Sylvia E. Rosas
- Joslin Diabetes Center and Harvard Medical School, Boston, MA
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Copenhagen, Demark
- University of Copenhagen, Copenhagen, Denmark
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21
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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22
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Lu YP, Wu HW, Zhu T, Li XT, Zuo J, Hasan AA, Reichetzeder C, Delic D, Yard B, Klein T, Krämer BK, Zhang ZY, Wang XH, Yin LH, Dai Y, Zheng ZH, Hocher B. Empagliflozin reduces kidney fibrosis and improves kidney function by alternative macrophage activation in rats with 5/6-nephrectomy. Biomed Pharmacother 2022; 156:113947. [DOI: 10.1016/j.biopha.2022.113947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/20/2022] [Accepted: 10/28/2022] [Indexed: 11/02/2022] Open
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23
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de Boer IH, Khunti K, Sadusky T, Tuttle KR, Neumiller JJ, Rhee CM, Rosas SE, Rossing P, Bakris G. Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2022; 102:974-989. [PMID: 36202661 DOI: 10.1016/j.kint.2022.08.012] [Citation(s) in RCA: 77] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 06/30/2022] [Indexed: 12/14/2022]
Abstract
People with diabetes and chronic kidney disease (CKD) are at high risk for kidney failure, atherosclerotic cardiovascular disease, heart failure, and premature mortality. Recent clinical trials support new approaches to treat diabetes and CKD. The 2022 American Diabetes Association (ADA) Standards of Medical Care in Diabetes and the Kidney Disease: Improving Global Outcomes (KDIGO) 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease each provide evidence-based recommendations for management. A joint group of ADA and KDIGO representatives reviewed and developed a series of consensus statements to guide clinical care from the ADA and KDIGO guidelines. The published guidelines are aligned in the areas of CKD screening and diagnosis, glycemia monitoring, lifestyle therapies, treatment goals, and pharmacologic management. Recommendations include comprehensive care in which pharmacotherapy that is proven to improve kidney and cardiovascular outcomes is layered on a foundation of healthy lifestyle. Consensus statements provide specific guidance on use of renin-angiotensin system inhibitors, metformin, sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide 1 receptor agonists, and a nonsteroidal mineralocorticoid receptor antagonist. These areas of consensus provide clear direction for implementation of care to improve clinical outcomes of people with diabetes and CKD.
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Affiliation(s)
- Ian H de Boer
- Kidney Research Institute, University of Washington, Seattle, Washington, USA.
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Tami Sadusky
- University of Washington, Seattle, Washington, USA
| | | | - Joshua J Neumiller
- College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington, USA
| | - Connie M Rhee
- University of California, Irvine, Orange, California, USA
| | - Sylvia E Rosas
- Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Copenhagen, Demark; University of Copenhagen, Copenhagen, Denmark
| | - George Bakris
- University of Chicago Medicine, Chicago, Illinois, USA
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24
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SGLT2 inhibitors for treating diabetes in people with chronic kidney disease. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2022; 2022:CD015588. [PMCID: PMC9534313 DOI: 10.1002/14651858.cd015588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: This review aims to assess the benefits and harms of SGLT2 inhibitors for lowering glucose levels in people with diabetes and CKD.
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25
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Alicic R, Nicholas SB. Diabetic Kidney Disease Back in Focus: Management Field Guide for Health Care Professionals in the 21st Century. Mayo Clin Proc 2022; 97:1904-1919. [PMID: 36202498 DOI: 10.1016/j.mayocp.2022.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 03/28/2022] [Accepted: 05/03/2022] [Indexed: 12/02/2022]
Abstract
Chronic kidney disease due to diabetes, or diabetic kidney disease (DKD), is a worldwide leading cause of chronic kidney disease and kidney failure and an increasingly important global public health issue. It is associated with poor quality of life, high burden of chronic diseases, and increased risk of premature death. Until recently, people with DKD had limited therapeutic options. Treatments have focused largely on glycemic and blood pressure control and renin-angiotensin system blockade, leaving patients with significant residual risk for progression of DKD. The availability of newer classes of glucose-lowering agents, namely, sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists, has changed the therapeutic landscape for these patients. These therapies have offered unprecedented opportunities to reduce the risk for progression of kidney disease and the risk of death that have led to recent updates to clinical guidelines. As such, the American Diabetes Association, the Kidney Disease: Improving Global Outcomes, and the European Association for the Study of Diabetes now recommend the use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists for patients with DKD to provide both kidney and cardiovascular protective benefits. This review highlights the importance of early detection of DKD and summarizes the latest recommendations in the clinical guidelines on management of patients with DKD with hope of facilitating their uptake into everyday clinical practice. An integrated approach to patient care with a multidisciplinary focus can help achieve the necessary shift in clinical care of patients with DKD.
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Affiliation(s)
- Radica Alicic
- Providence Medical Research Center, Providence Health Care, University of Washington, Spokane and Seattle
| | - Susanne B Nicholas
- David Geffen School of Medicine at University of California, Los Angeles.
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Ma Y, Zhang G, Kuang Z, Xu Q, Ye T, Li X, Qu N, Han F, Kan C, Sun X. Empagliflozin activates Sestrin2-mediated AMPK/mTOR pathway and ameliorates lipid accumulation in obesity-related nonalcoholic fatty liver disease. Front Pharmacol 2022; 13:944886. [PMID: 36133815 PMCID: PMC9483033 DOI: 10.3389/fphar.2022.944886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/11/2022] [Indexed: 12/03/2022] Open
Abstract
Empagliflozin (EMPA) therapy has led to improvements in patients with non-alcoholic fatty liver disease (NAFLD). Sestrin2 is a stress-inducible protein that controls the AMPK-mTOR pathway and inhibits oxidative damage in cells. This study investigated the functional implications of EMPA on the multifactorial pathogenesis of NAFLD and potential underlying molecular mechanisms of pathogenesis. An in vitro model of NAFLD was established by treating HepG2 cells with palmitic acid (PA); an in vivo model of NAFLD was generated by feeding C57BL/6 mice a high-fat diet. Investigations of morphology and lipid deposition in liver tissue were performed. Expression patterns of Sestrin2 and genes related to lipogenesis and inflammation were assessed by reverse transcription polymerase chain reaction. Protein levels of Sestrin2 and AMPK/mTOR pathway components were detected by Western blotting. NAFLD liver tissues and PA-stimulated HepG2 cells exhibited excessive lipid production and triglyceride secretion, along with upregulation of Sestrin2 and increased expression of lipogenesis-related genes. EMPA treatment reversed liver damage by upregulating Sestrin2 and activating the AMPK-mTOR pathway. Knockdown of Sestrin2 effectively increased lipogenesis and enhanced the mRNA expression levels of lipogenic and pro-inflammatory genes in PA-stimulated HepG2 cells; EMPA treatment did not affect these changes. Furthermore, Sestrin2 knockdown inhibited AMPK-mTOR signaling pathway activity. The upregulation of Sestrin2 after treatment with EMPA protects against lipid deposition-related metabolic disorders; it also inhibits lipogenesis and inflammation through activation of the AMPK-mTOR signaling pathway. These results suggest that Sestrin2 can be targeted by EMPA therapy to alleviate lipogenesis and inflammation in obesity-related NAFLD.
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Affiliation(s)
- Yuting Ma
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, Weifang, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Guangdong Zhang
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, Weifang, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Zenggguang Kuang
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, Weifang, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Qian Xu
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, Weifang, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Tongtong Ye
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, Weifang, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Xue Li
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
- Department of Pathology, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Na Qu
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
- Department of Pathology, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Fang Han
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
- Department of Pathology, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Chengxia Kan
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, Weifang, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
- *Correspondence: Chengxia Kan, ; Xiaodong Sun,
| | - Xiaodong Sun
- Department of Endocrinology and Metabolism, Affiliated Hospital of Weifang Medical University, Weifang, China
- Clinical Research Center, Affiliated Hospital of Weifang Medical University, Weifang, China
- *Correspondence: Chengxia Kan, ; Xiaodong Sun,
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Liu H, Sridhar VS, Perkins BA, Rosenstock J, Cherney DZI. SGLT2 Inhibition in Type 1 Diabetes with Diabetic Kidney Disease: Potential Cardiorenal Benefits Can Outweigh Preventable Risk of Diabetic Ketoacidosis. Curr Diab Rep 2022; 22:317-332. [PMID: 35633439 DOI: 10.1007/s11892-022-01471-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to summarize existing research investigating the use of sodium glucose cotransporter-2 (SGLT2) inhibitors in patients with type 1 diabetes mellitus (T1DM) while highlighting potential strategies to mitigate the risk of diabetic ketoacidosis (DKA). RECENT FINDINGS SGLT2 inhibitors have been studied in patients with T1DM in phase 3 clinical trials such as the inTandem, DEPICT, and EASE trials, which demonstrated consistent reductions in HbA1c. Secondary analyses of these trials have also reported potential kidney protective effects that are independent of improved glycemic control. However, trials in patients with type 2 diabetes mellitus (T2DM) have found an increased risk of DKA with SGLT2 inhibitors, a serious concern in patients with T1DM. SGLT2 inhibitors provide cardiovascular benefits and kidney protection in patients with T2DM and are a promising therapeutic option for patients with T1DM due to overlapping pathophysiological mechanisms. However, SGLT2 inhibitors increase the risk of DKA, and there is currently a lack of research investigating the beneficial effects of SGLT2 inhibitors in patients with T1DM. Preventative measure for DKA would have to be implemented and the risks would need to be carefully balanced with the benefits offered by SGLT2 inhibitors. Additional research will also be required to determine the kidney protective effects of SGLT2 inhibitors in patients with T1DM and diabetic kidney disease and to quantify the risk of DKA after the implementation of preventative measures, proper patient education, and ketone monitoring.
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Affiliation(s)
- Hongyan Liu
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Vikas S Sridhar
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Julio Rosenstock
- Dallas Diabetes Research Center at Medical City, Dallas, TX, USA
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada.
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
- Toronto General Hospital, 585 University Ave, Toronto, ON, 8N-845M5G 2N2, Canada.
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The non-steroidal mineralocorticoid receptor antagonist finerenone is a novel therapeutic option for patients with Type 2 diabetes and chronic kidney disease. Clin Sci (Lond) 2022; 136:1005-1017. [PMID: 35765983 DOI: 10.1042/cs20220212] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/01/2022] [Accepted: 06/16/2022] [Indexed: 11/17/2022]
Abstract
Despite strong preclinical data supporting the use of mineralocorticoid receptor antagonists (MRAs) to provide cardiorenal protection in rodent models of diabetes, the clinical evidence of their utility in treating chronic kidney disease (CKD) has been limited. Two major clinical trials (FIDELIO-DKD and FIGARO-DKD) including more than 13,000 patients with albuminuric CKD and Type 2 diabetes randomized to placebo or finerenone (MRA) have recently provided exciting results showing a significant risk reduction for kidney and cardiovascular outcomes. In this review, we will summarize the major findings of these trials, together with post-hoc and pooled analyses that have allowed evaluation of the efficacy and safety of finerenone across the spectrum of CKD, revealing significant protective effects of finerenone against kidney failure, new-onset atrial fibrillation or flutter, new-onset heart failure, cardiovascular death, and first and total heart-failure hospitalizations. Moreover, we will discuss the current evidence that supports the combined use of MRAs with sodium-glucose co-transporter-2 inhibitors, either by providing an additive cardiorenal benefit or by decreasing the risk of hyperkalemia. Although the mechanisms of protection by finerenone have only been partially explored in patients, rodent studies have shed light on its anti-inflammatory and anti-fibrotic effects in models of kidney disease, which is one of the main drivers for testing the efficacy of finerenone in non-diabetic CKD patients in the ongoing FIND-CKD trial.
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Renal Protective Mechanisms of Shenyuan Particle in Db/Db Mice: A Study Based on Network Pharmacology. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:9579179. [PMID: 35747379 PMCID: PMC9213133 DOI: 10.1155/2022/9579179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 05/01/2022] [Accepted: 05/18/2022] [Indexed: 11/18/2022]
Abstract
Aim The renal protective mechanisms of Shenyuan particle (SYP) in the treatment of diabetic kidney disease (DKD) were investigated, focusing on the main targets and pathways. Materials and Methods In this study, the potential targets of compounds identified in SYP were predicted by Traditional Chinese Medicine Systems Pharmacology Database and Analysis Platform (TCMSP), and a “herb-compound-target” network was constructed via Cytoscape. Next, the Gene Ontology (GO) terms and Kyoto Encyclopedia of Genes and Genomes (KEGG) functional enrichment analyses were dissected using R language. A protein-protein interaction network was fabricated using STRING to obtain the main target information. In addition, db/db mice were used as the DKD models to explore the renal protective effects of SYP. Transmission electron microscopy, western blot, pathological staining, TUNEL staining, and biochemical methods were used to identify the apoptotic pathways and establish the primary mechanism of SYP. Results Network pharmacology analysis revealed 67 potential targets based on the analysis of different databases. The targets of SYP were primarily associated with apoptosis. The network hub genes included caspase 3, caspase 7, caspase 8, caspase 9, Bax, and Bcl-2. In vivo, SYP materially improved renal function and inhibited apoptosis in the db/db mouse kidneys by improving the mitochondrial health. In addition, our results showed that SYP significantly decreased the expression of Bax, caspase 3, and Cyto-c and increased the expression of Bcl-2. Conclusions Network pharmacology analysis and experimental results suggest that SYP ameliorates DKD mediated via multiple components, targets, and pathways. Our study further demonstrates that SYP inhibits apoptosis in the kidneys of db/db mice by improving the mitochondrial health and thereby alleviating renal damage.
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Col4a3-/- Mice on Balb/C Background Have Less Severe Cardiorespiratory Phenotype and SGLT2 Over-Expression Compared to 129x1/SvJ and C57Bl/6 Backgrounds. Int J Mol Sci 2022; 23:ijms23126674. [PMID: 35743114 PMCID: PMC9223785 DOI: 10.3390/ijms23126674] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 01/27/2023] Open
Abstract
Alport syndrome (AS) is a hereditary renal disorder with no etiological therapy. In the preclinical Col4a3-/- model of AS, disease progression and severity vary depending on mouse strain. The sodium-glucose cotransporter 2 (SGLT2) is emerging as an attractive therapeutic target in cardiac/renal pathologies, but its application to AS remains untested. This study investigates cardiorespiratory function and SGLT2 renal expression in Col4a3-/- mice from three different genetic backgrounds, 129x1/SvJ, C57Bl/6 and Balb/C. male Col4a3-/- 129x1/SvJ mice displayed alterations consistent with heart failure with preserved ejection fraction (HFpEF). Female, but not male, C57Bl/6 and Balb/C Col4a3-/- mice exhibited mild changes in systolic and diastolic function of the heart by echocardiography. Male C57Bl/6 Col4a3-/- mice presented systolic dysfunction by invasive hemodynamic analysis. All strains except Balb/C males demonstrated alterations in respiratory function. SGLT2 expression was significantly increased in AS compared to WT mice from all strains. However, cardiorespiratory abnormalities and SGLT2 over-expression were significantly less in AS Balb/C mice compared to the other two strains. Systolic blood pressure was significantly elevated only in mutant 129x1/SvJ mice. The results provide further evidence for strain-dependent cardiorespiratory and hypertensive phenotype variations in mouse AS models, corroborated by renal SGLT2 expression, and support ongoing initiatives to develop SGLT2 inhibitors for the treatment of AS.
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Wong CKH, Lau KTK, Tang EHM, Lee CH, Lee CYY, Woo YC, Au ICH, Tan KCB, Lui DTW. Cardiovascular benefits of SGLT2 inhibitors in type 2 diabetes, interaction with metformin and role of erythrocytosis: a self-controlled case series study. Cardiovasc Diabetol 2022; 21:92. [PMID: 35658864 PMCID: PMC9166572 DOI: 10.1186/s12933-022-01520-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/05/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have proven cardiovascular benefits in patients with type 2 diabetes (T2D). This self-controlled case series study aims to evaluate whether metformin use and SGLT2i-associated erythrocytosis influence its cardiovascular benefits.
Methods
T2D patients with metformin and/or SGLT2i prescriptions between 2015 and 2020 were identified from the Hong Kong population. Study outcomes were composite cardiovascular diseases (CVD), coronary heart disease (CHD), hospitalisation for heart failure (HHF), stroke, and erythrocytosis. Risk periods were patient-time divided into four mutually exclusive windows: (i) ‘baseline period’ of metformin use without SGLT2i; (ii) pre-SGLT2i period; (iii) exposure to SGLT2i without metformin; and (iv) exposure to the drug combination. Another SCCS model was applied to evaluate the association between erythrocytosis and cardiovascular outcomes regarding SGLT2i exposure. Four mutually exclusive risk periods included (i) SGLT2i exposure with erythrocytosis; (ii) SGLT2i exposure without erythrocytosis; (iii) absence of SGLT2i exposure with erythrocytosis; and (iv) absence of SGLT2i exposure without erythrocytosis. Incidence rate ratios (IRR) of events at different risk periods were estimated using conditional Poisson regression model.
Results
Among 20,861 patients with metformin and/or SGLT2i prescriptions, 2575 and 1700 patients with events of composite CVD and erythrocytosis were identified, respectively. Compared to metformin use without SGLT2i, SGLT2i initiation was associated with lower risks of composite CVD, CHD, and HHF—regardless of the presence (CVD: IRR = 0.43, 95% CI 0.37–0.51; CHD: IRR = 0.44, 95% CI 0.37–0.53; HHF: IRR = 0.29, 95% CI 0.22–0.40; all p < 0.001) and absence of concomitant metformin (CVD: IRR = 0.31, 95% CI 0.20–0.48; CHD: IRR = 0.38, 95% CI 0.25–0.59; HHF: IRR = 0.17, 95% CI 0.09–0.31; all p < 0.001); while SGLT2i was neutral on stroke risk. Compared to metformin-SGLT2i combination, exposure to SGLT2i alone was associated with comparable risks of all cardiovascular outcomes (all p > 0.05). Incidence rates of erythrocytosis at baseline, SGLT2i without and with metformin use periods were 0.75, 3.06 and 3.27 per 100 person-years, respectively. SGLT2i users who developed erythrocytosis had lower risk of HHF (IRR = 0.38, 95% CI 0.14–0.99, p = 0.049) than those who did not.
Conclusions
Our real-world data suggested that SGLT2i-associated cardiovascular benefits were not attenuated by metformin use. Further studies will delineate the role of erythrocytosis as a surrogate marker of SGLT2i-associated cardiovascular benefit in reducing HHF.
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Evans M, Morgan AR, Bain SC, Davies S, Dashora U, Sinha S, Seidu S, Patel DC, Beba H, Strain WD. Defining the Role of SGLT2 Inhibitors in Primary Care: Time to Think Differently. Diabetes Ther 2022; 13:889-911. [PMID: 35349120 PMCID: PMC9076801 DOI: 10.1007/s13300-022-01242-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/23/2022] [Indexed: 11/30/2022] Open
Abstract
Disease burden in people with diabetes is mainly driven by long-term complications such as cardiovascular disease, heart failure and chronic kidney disease. This is a consequence of the interconnection between the cardiovascular, renal and metabolic systems, through a continuous chain of events referred to as 'the cardiorenal metabolic continuum'. Increasing evidence suggests that sodium-glucose cotransporter 2 inhibitors (SGLT2is) have beneficial effects across all stages of the cardiorenal metabolic continuum, reducing morbidity and mortality in a wide range of individuals, from those with diabetes and multiple risk factors to those with established heart failure and chronic kidney disease, regardless of the presence of diabetes. Despite this robust evidence base, the complexity of label indications and misconceptions concerning potential side effects have resulted in a lack of clear understanding in primary care regarding the implementation of SGLT2is in clinical practice. With this in mind, we provide an overview of the clinical and economic benefits of SGLT2is across the cardiorenal metabolic continuum together with practical considerations in order to help address some of these concerns and clearly define the role of SGLT2is in primary care as a holistic outcomes-driven treatment with the potential to reduce disease burden across the cardiorenal metabolic spectrum.
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Affiliation(s)
- Marc Evans
- Diabetes Resource Centre, University Hospital Llandough, Penlan Rd, Llandough, Penarth, Cardiff, CF64 2XX UK
| | - Angharad R. Morgan
- Health Economics and Outcomes Research Ltd., Unit A, Cardiff Gate Business Park, Copse Walk, Pontprennau, Cardiff, CF23 8RB UK
| | - Stephen C. Bain
- Diabetes Research Unit, Swansea University Medical School, Grove Building Swansea University, Swansea, SA2 8PP UK
| | - Sarah Davies
- Woodlands Medical Centre, 1 Green Farm Rd, Cardiff, CF5 4RG UK
| | - Umesh Dashora
- East Sussex Healthcare NHS Trust, Conquest Hospital, The Ridge, St Leonards-on-Sea, East Sussex, TN37 7RD UK
| | - Smeeta Sinha
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Stott Lane, Salford, M6 8HD UK
| | - Samuel Seidu
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, LE5 4PW UK
| | - Dipesh C. Patel
- Department of Diabetes, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF UK
| | - Hannah Beba
- NHS Leeds Clinical Commissioning Group, 2–4 Wira Business Park Ring Road, Leeds, LS16 6EB UK
| | - W. David Strain
- Diabetes and Vascular Research Centre, University of Exeter Medical School, Heavitree Road, Exeter, EX1 2LU UK
- The Academic Department of Healthcare for Older Adults, Royal Devon and Exeter Hospital, Exeter, UK
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Wilding JPH, Evans M, Fernando K, Gorriz JL, Cebrian A, Diggle J, Hicks D, James J, Newland-Jones P, Ali A, Bain S, Da Porto A, Patel D, Viljoen A, Wheeler DC, Del Prato S. The Place and Value of Sodium-Glucose Cotransporter 2 Inhibitors in the Evolving Treatment Paradigm for Type 2 Diabetes Mellitus: A Narrative Review. Diabetes Ther 2022; 13:847-872. [PMID: 35307801 PMCID: PMC8934539 DOI: 10.1007/s13300-022-01228-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/08/2022] [Indexed: 02/07/2023] Open
Abstract
Over recent years, the expanding evidence base for sodium-glucose cotransporter-2 inhibitor (SGLT2i) therapies has revealed benefits beyond their glucose-lowering efficacy in the treatment of Type 2 diabetes mellitus (T2DM), resulting in their recognition as cardiorenal medicines. While SGLT2is continue to be recommended among the second-line therapies for the treatment of hyperglycaemia, their true value now extends to the prevention of debilitating and costly cardiovascular and renal events for high-risk individuals, with particular benefit shown in reducing major adverse cardiac events and heart failure (HF) and slowing the progression of chronic kidney disease. However, SGLT2i usage is still suboptimal among groups considered to be at greatest risk of cardiorenal complications. The ongoing coronavirus disease 2019 (COVID-19) pandemic has intensified financial pressures on healthcare systems, which may hamper further investment in newer effective medicines. Emerging evidence indicates that glycaemic control should be prioritised for people with T2DM in the era of COVID-19 and practical advice on the use of T2DM medications during periods of acute illness remains important, particularly for healthcare professionals working in primary care who face multiple competing priorities. This article provides the latest update from the Improving Diabetes Steering Committee, including perspectives on the value of SGLT2is as cost-effective therapies within the T2DM treatment paradigm, with particular focus on the latest published evidence relating to the prevention or slowing of cardiorenal complications. The implications for ongoing and future approaches to diabetes care are considered in the light of the continuing coronavirus pandemic, and relevant aspects of international treatment guidelines are highlighted with practical advice on the appropriate use of SGLT2is in commonly occurring T2DM clinical scenarios. The 'SGLT2i Prescribing Tool for T2DM Management', previously published by the Steering Committee, has been updated to reflect the latest evidence and is provided in the Supplementary Materials to help support clinicians delivering T2DM care.
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Affiliation(s)
- John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Clinical Sciences Centre, University Hospital Aintree, Liverpool, UK.
| | - Marc Evans
- University Hospital Llandough, Cardiff, UK
| | | | - Jose Luis Gorriz
- University Hospital Clinic, University of Valencia, Valencia, Spain
| | - Ana Cebrian
- Spanish Diabetes Association, Catholic University of Murcia, Service Murciano de Salud, Cartagena, Murcia, Spain
- Centro de Salud Casco Antiguo Cartagena, Murcia, Spain
- Primary Care Research Group, Biomedical Research Institute of Murcia (IMIB), 30120, Murcia, Spain
| | - Jane Diggle
- College Lane Surgery, Ackworth, West Yorkshire, UK
| | | | - June James
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Amar Ali
- Royal Blackburn Hospital, Lancashire, UK
| | - Stephen Bain
- Swansea University and Diabetes Research Unit, Swansea, UK
| | | | | | - Adie Viljoen
- Cambridge University Hospitals NHS Foundation Trust, Stevenage, UK
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Tye SC, de Vries ST, Mann JFE, Schechter M, Mosenzon O, Denig P, Heerspink HJL. Prediction of the Effects of Liraglutide on Kidney and Cardiovascular Outcomes Based on Short-Term Changes in Multiple Risk Markers. Front Pharmacol 2022; 13:786767. [PMID: 35496307 PMCID: PMC9044907 DOI: 10.3389/fphar.2022.786767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/17/2022] [Indexed: 11/22/2022] Open
Abstract
Aims: The LEADER trial demonstrated that the glucagon-like peptide-1 receptor agonist (GLP1-RA) liraglutide reduces kidney and cardiovascular (CV) risk in patients with type 2 diabetes. We previously developed a Parameter Response Efficacy (PRE) score that translates multiple short-term risk marker changes, from baseline to first available follow-up measurement, into a predicted long-term drug effect on clinical outcomes. The objective of this study was to assess the accuracy of the PRE score in predicting the efficacy of liraglutide in reducing the risk of kidney and CV outcomes. Methods: Short-term changes in glycated hemoglobin (HbA1c), systolic blood pressure (BP), urinary-albumin-creatinine-ratio (UACR), hemoglobin, body weight, high-density-lipoprotein (HDL) cholesterol, low-density-lipoprotein (LDL) cholesterol, and potassium were monitored in the LEADER trial. Associations between risk markers and kidney or CV outcomes were established using a multivariable Cox proportional hazards model in a separate pooled database of 6,355 patients with type 2 diabetes. The regression coefficients were then applied to the short-term risk markers in the LEADER trial to predict the effects of liraglutide on kidney (defined as a composite of doubling of serum creatinine or end-stage kidney disease) and CV (defined as a composite of non-fatal myocardial infarction, non-fatal stroke, and CV death) outcomes. Results: Liraglutide compared to placebo reduced HbA1c (1.4%), systolic BP (3.0 mmHg), UACR (13.2%), body weight (2.3 kg), hemoglobin (2.6 g/L), and increased HDL-cholesterol (0.01 mmol/L) (all p-values <0.01). Integrating multiple risk marker changes in the PRE score resulted in a predicted relative risk reduction (RRR) of 16.2% (95% CI 13.7–18.6) on kidney outcomes which was close to the observed RRR of 15.5% (95% CI -9.0–34.6). For the CV outcome, the PRE score predicted a 7.6% (95% CI 6.8–8.3) RRR, which was less than the observed 13.2% (95% CI 3.2–22.2) RRR. Conclusion: Integrating multiple short-term risk markers using the PRE score adequately predicted the effect of liraglutide on the composite kidney outcome. However, the PRE score underestimated the effect of liraglutide for the composite CV outcome, suggesting that the risk markers included in the PRE score do not fully capture the CV benefit of liraglutide.
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Affiliation(s)
- Sok Cin Tye
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, Netherlands
| | - Sieta T. de Vries
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, Netherlands
| | - Johannes F. E. Mann
- KfH Kidney Center, Munich, Germany
- Department of Medicine, Friedrich Alexander University, Erlangen, Germany
| | - Meir Schechter
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Ofri Mosenzon
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, Netherlands
| | - Hiddo J. L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, Netherlands
- *Correspondence: Hiddo J. L. Heerspink,
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Tye SC, de Vries ST, Wanner C, Denig P, Heerspink HJL. Prediction of the Effects of Empagliflozin on Cardiovascular and Kidney Outcomes Based on Short-Term Changes in Multiple Risk Markers. Front Pharmacol 2022; 12:786706. [PMID: 35145402 PMCID: PMC8821652 DOI: 10.3389/fphar.2021.786706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/28/2021] [Indexed: 12/25/2022] Open
Abstract
Aims: The EMPA-REG OUTCOME trial demonstrated that the sodium-glucose cotransporter-2 inhibitor (SGLT2) empagliflozin reduces the risk of cardiovascular (CV) and kidney outcomes in patients with type 2 diabetes. We previously developed the parameter response efficacy (PRE) score, which translates drug effects on multiple short-term risk markers into a predicted long-term treatment effect on clinical outcomes. The main objective of this study was to assess the accuracy of the PRE score in predicting the efficacy of empagliflozin in reducing the risk of CV and kidney outcomes. Methods: Short-term (baseline to 6-months) changes in glycated hemoglobin (HbA1c), systolic blood pressure (SBP), urinary-albumin-creatinine-ratio (UACR), hemoglobin, body weight, high-density-lipoprotein (HDL) cholesterol, low-density-lipoprotein (LDL) cholesterol, uric acid, and potassium were determined among 7020 patients with type 2 diabetes and established CV disease in the EMPA-REG OUTCOME trial. The beta-coefficients, derived from a Cox proportional hazards model in a pooled database consisting of 6355 patients with type 2 diabetes, were applied to the short-term risk markers in the EMPA-REG OUTCOME trial to predict the empagliflozin-induced impact on CV (defined as a composite of non-fatal myocardial infarction, non-fatal stroke, or CV death) and kidney (defined as a composite of doubling of serum creatinine or end-stage kidney disease) outcomes. Results: Empagliflozin compared to placebo reduced HbA1c (0.6%), SBP (4.2 mmHg), UACR (13.0%), body weight (2.1 kg), uric acid (20.4 μmol/L), and increased hemoglobin (6.6 g/L), LDL-cholesterol (0.1 mmol/L) and HDL-cholesterol (0.04 mmol/L) (all p<0.01). Integrating these effects in the PRE score resulted in a predicted relative risk reduction (RRR) for the CV outcome of 6.4% (95% CI 1.4-11.7), which was less than the observed 14.7% (95% CI 1.3-26.4%) RRR. For the kidney outcome, the PRE score predicted a RRR of 33.4% (95% CI 26.2-39.8); the observed RRR was 46.9% (95% CI 26.8-61.5). In a subgroup of 2,811 patients with UACR ≥30 mg/g at baseline, the PRE score predicted RRR was 40.8% (95% CI 31.2-49.1) vs. the observed RRR of 40.8% (95% CI 12.4-60.0) for the kidney outcome. Conclusions: Integrating multiple short-term risk marker changes in the PRE score underestimated the effect of empagliflozin on CV and kidney outcomes, suggesting that the currently used risk markers do not fully capture the effect of empagliflozin. In patients with increased albuminuria, the PRE score adequately predicted the effect of empagliflozin on kidney outcomes.
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Affiliation(s)
- Sok Cin Tye
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, Groningen, Netherlands
| | - Sieta T. de Vries
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, Groningen, Netherlands
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, Würzburg University Clinic, Würzburg, Germany
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, Groningen, Netherlands
| | - Hiddo J. L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, Groningen, Netherlands
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Lee YT, Hsu CN, Fu CM, Wang SW, Huang CC, Li LC. Comparison of Adverse Kidney Outcomes With Empagliflozin and Linagliptin Use in Patients With Type 2 Diabetic Patients in a Real-World Setting. Front Pharmacol 2022; 12:781379. [PMID: 34992535 PMCID: PMC8724779 DOI: 10.3389/fphar.2021.781379] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/02/2021] [Indexed: 12/15/2022] Open
Abstract
Background: To compare the effects of empagliflozin and linagliptin use on kidney outcomes of type 2 diabetes mellitus (T2DM) patients in a real-world setting. Methods: The study involved a propensity score-matched cohort comprising new users of empagliflozin or linagliptin with T2DM between January 1, 2013 and December 31, 2018 from a large healthcare delivery system in Taiwan. Clinical outcomes assessed: acute kidney injury (AKI), post-AKI dialysis, and mortality. Cox proportional hazard model was used to estimate the relative risk of empagliflozin or linagliptin use; a linear mixed model was used to compare the average change in estimated glomerular filtration rate (eGFR) over time. Results: Of the 7,042 individuals, 67 of 3,521 (1.9%) in the empagliflozin group and 144 of 3,521 (4.1%) in the linagliptin group developed AKI during the 2 years follow-up. Patients in the empagliflozin group were at a 40% lower risk of developing AKI compared to those in the linagliptin group (adjusted hazard ratio [aHR], 0.60; 95% confidence interval [CI], 0.45-0.82, p = 0.001). Stratified analysis showed that empagliflozin users ≥65 years of age (aHR, 0.70; 95% CI, 0.43-1.13, p = 0.148), or with a baseline eGFR <60 ml/min/1.73 m2 (aHR, 0.97; 95% CI, 0.57-1.65, p = 0.899), or with a baseline glycohemoglobin ≦7% (aHR, 1.01; 95% CI, 0.51-2.00, p =0.973) experienced attenuated benefits with respect to AKI risk. A smaller decline in eGFR was observed in empagliflozin users compared to linagliptin users regardless of AKI occurrence (adjusted β = 1.51; 95% CI, 0.30-2.72 ml/min/1.73 m2, p = 0.014). Conclusion: Empagliflozin users were at a lower risk of developing AKI and exhibited a smaller eGFR decline than linagliptin users. Thus, empagliflozin may be a safer alternative to linagliptin for T2DM patients.
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Affiliation(s)
- Yueh-Ting Lee
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chung-Ming Fu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shih-Wei Wang
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chiang-Chi Huang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Lung-Chih Li
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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von Scholten BJ, Kreiner FF, Rasmussen S, Rossing P, Idorn T. The potential of GLP-1 receptor agonists in type 2 diabetes and chronic kidney disease: from randomised trials to clinical practice. Ther Adv Endocrinol Metab 2022; 13:20420188221112490. [PMID: 35874312 PMCID: PMC9301118 DOI: 10.1177/20420188221112490] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 06/13/2022] [Indexed: 01/10/2023] Open
Abstract
Chronic kidney disease (CKD) affects around 10% of the global population and is most often caused by diabetes. Diabetes with CKD (diabetic kidney disease, DKD) is a progressive condition that may cause kidney failure and which contributes significantly to the excess morbidity and mortality in these patients. DKD is treated with direct disease-targeting therapies like blockers of the renin-angiotensin system, sodium-glucose cotransporter-2 (SGLT-2) inhibitors and non-steroidal mineralocorticoid receptor antagonists as well as indirect therapies impacting hyperglycaemia, dyslipidaemia, obesity and hypertension, which all together reduce disease progression. While no glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) are currently indicated to improve kidney outcomes, accumulating evidence from cardiovascular outcomes trials (CVOTs) corroborates a kidney-protective effect in people with T2D and CKD, and GLP-1 RAs are now mentioned in international treatment guidelines for type 2 diabetes (T2D) with CKD. GLP-1 RAs are indicated to improve glycaemia in people with T2D; certain GLP-1 RAs are also approved for weight management and to reduce cardiovascular risk in T2D. Ongoing pivotal trials are assessing additional indications, including T2D with CKD. In this article, we review and discuss kidney outcomes from a multitude of completed clinical trials as well as real-world evidence and ongoing clinical trials.
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Affiliation(s)
| | | | | | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev,
Denmark
- Department of Clinical Medicine, University of
Copenhagen, Copenhagen, Denmark
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38
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Zhou W, Li J, Yuan X, Wang W, Zhou H, Zhang H, Ye S. Application of urine C-peptide creatinine ratio in type 2 diabetic patients with different levels of renal function. Front Endocrinol (Lausanne) 2022; 13:1052794. [PMID: 36465621 PMCID: PMC9712960 DOI: 10.3389/fendo.2022.1052794] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 10/28/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE This study aims to investigate the effect of single urine C peptide/creatinine (UCPCR) in assessing the islet β Cell function of type 2 diabetes mellitus (T2DM) patients with different renal function. METHODS A total of 85 T2DM patients were recruited in this study, all the patients were assigned to one group with estimated glomerular filtration rate (eGFR)≤60 ml·min-1·1.73 m-2 and another group complicated with eGFR>60 ml·min-1·1.73 m-2. Serum creatinine, urine creatinine, serum fasting C-peptide (FCP), fasting blood glucose (FBG), glycosylated hemoglobin (HbA1C) and 24-hour urinary C-peptide (24hUCP) were measured. The modified homeostasis model assessment-islet β cell function [HOMA-islet (CP-DM)], the modified homeostasis model assessment-insulin resistance [HOMA-IR(CP)] and UCPCR were calculated. RESULTS When compared with group eGFR ≤60 ml·min-1·1.73 m-2, the levels of UCPCR, FCP, the modified HOMA-IR(CP) and HOMA-islet (CP-DM) were promoted and the concentrations of HbA1C, FPG, creatinine were decreased in the patients of eGFR>60 ml·min-1·1.73 m-2 (P<0.05); FCP was uncorrelated with 24hUCP while associated with UCPCR in the patients of eGFR ≤ 60 ml·min-1·1.73 m-2; UCPCR was positively correlated with FCP and HOMA-IR(CP) in the T2DM patients with different levels of renal function; the cut-off (UCPCR ≤ 1.13 nmol/g) had 88.37% sensitivity and 95.24% specificity [95% confidence interval (CI):0.919-0.997] for identifying severe insulin deficiency in T2DM patients[area under the curve (AUC) 0.978]. CONCLUSION UCPCR can be used to evaluate islets β Cell function in T2DM patients with different renal function status.
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Affiliation(s)
- Wan Zhou
- Department of Endocrinology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- *Correspondence: Wan Zhou,
| | - Jie Li
- Anhui Provincial Hospital, Affiliated to Anhui Medical University, Hefei, China
| | - Xiaojing Yuan
- The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Wei Wang
- Department of Endocrinology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Huanran Zhou
- Department of Endocrinology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Haoqiang Zhang
- Department of Endocrinology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Shandong Ye
- Department of Endocrinology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
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Rhee CM, Kalantar-Zadeh K, Tuttle KR. Novel approaches to hypoglycemia and burnt-out diabetes in chronic kidney disease. Curr Opin Nephrol Hypertens 2022; 31:72-81. [PMID: 34750332 PMCID: PMC8684381 DOI: 10.1097/mnh.0000000000000756] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW Diabetes mellitus is a leading cause of chronic kidney disease (CKD) that confers faster kidney disease progression, higher mortality, and various metabolic derangements including hypoglycemia. RECENT FINDINGS Even in the absence of diabetes mellitus, growing research demonstrates that CKD patients are at heightened risk for hypoglycemia via multiple pathways. In CKD patients transitioning to end-stage renal disease (ESRD), spontaneous resolution of hyperglycemia and frequent hypoglycemia resulting in reduction and/or cessation of glucose-lowering medications are frequently observed in a phenomenon described as 'burnt-out diabetes'. In non-CKD patients, it is well established that hypoglycemia is causally associated with mortality, with pathways including arrhythmias, sudden cardiac death, stroke, and seizures. Increasing evidence shows that, in CKD and ESRD patients with and without diabetes mellitus, hypoglycemia is associated with cardiovascular complications and mortality risk. SUMMARY Given the high prevalence of hypoglycemia in CKD patients and the morbidity and mortality associated with this metabolic complication, a multimodal strategy is needed to prevent dysglycemia, including individualization of glycemic targets, selection of glucose-lowering medications less likely to induce hypoglycemia, medical nutrition therapy administered by trained dietitians, and accurate and precise hypoglycemia detection methods, such as self-monitored blood glucose or continuous glucose monitoring including during dialysis treatment.
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Affiliation(s)
- Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California
- Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, California
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California
- Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, California
| | - Katherine R. Tuttle
- Providence Health Care, Spokane, Washington
- Nephrology Division and Kidney Research Institute, University of Washington, Seattle, Washington
- Institute of Translational Health Sciences, University of Washington, Seattle, Washington
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Kim MN, Moon JH, Cho YM. Sodium-glucose cotransporter-2 inhibition reduces cellular senescence in the diabetic kidney by promoting ketone body-induced NRF2 activation. Diabetes Obes Metab 2021; 23:2561-2571. [PMID: 34318973 DOI: 10.1111/dom.14503] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 07/07/2021] [Accepted: 07/25/2021] [Indexed: 01/10/2023]
Abstract
AIMS To evaluate whether sodium-glucose cotransporter-2 (SGLT2) inhibition reduces cellular senescence in the kidney and to investigate the molecular pathways involved in the renoprotective effect. MATERIALS AND METHODS Dapagliflozin (1 mg/kg), glimepiride (2.5 mg/kg) or vehicle was administered daily via oral gavage for 8 weeks in db/db mice. Expression levels of ageing marker genes (p21, p16, and p53) and oxidative stress were measured in the kidney using real-time RT-PCR, immunohistochemistry, and Western blot analysis. For in vitro analysis, HK-2 cells, a human renal tubular epithelial cell line, were pretreated with H2 O2 to induce cellular senescence, and the levels of ageing markers were measured after treatment with β-hydroxybutyrate (β-HB) or NRF2-specific siRNA. RESULTS Expression levels of ageing marker genes (p21, p16 and p53) and senescence-associated secretory phenotypes of the kidney were increased in the vehicle-treated db/db (db/db + vehicle) group compared with the db/+ group, and this increase was markedly reversed in the dapagliflozin-treated db/db (db/db + SGLT2 inhibitor) group, but not in the glimepiride-treated db/db (db/db + sulphonylurea [SU]) group. In the kidneys of mice in the db/db + SGLT2 inhibitor group, oxidative stress and DNA damage were also reduced compared with those of mice in the db/db + vehicle and db/db + SU groups. Dapagliflozin increased plasma β-HB, which reduced H2 O2 -induced DNA damage and senescence in HK-2 cells. β-HB-induced NRF2 nuclear translocation mediated anti-senescent effects by inducing antioxidant pathways. CONCLUSIONS Dapagliflozin prevented the progression of diabetic kidney disease by inhibiting cellular senescence and oxidative stress via ketone-induced NRF2 activation.
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Affiliation(s)
- Mi Na Kim
- Department of Translational Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Joon Ho Moon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Young Min Cho
- Department of Translational Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Institute on Aging, Seoul National University, Seoul, South Korea
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Abstract
Hypertension has traditionally been the most common cardiovascular disease, and epidemiological studies suggest that the incidence continues to rise. Despite a plethora of antihypertensive agents, the management of blood pressure (BP) remains suboptimal. Addressing this issue is paramount to minimize hypertensive complications, including hypertensive nephropathy, a clinical entity whose definition has been challenged recently. Still, accumulating studies endorse poorly managed BP as an independent risk factor for both the onset of renal dysfunction and aggravation of baseline kidney disease. Nevertheless, current recommendations are not only discordant from one another but also offer inadequate evidence for the optimal BP control targets for renal protection, as since the cutoff values were primarily established on the premise of minimizing cardiovascular sequelae rather than kidney dysfunction. Although intense BP management was traditionally considered to compromise perfusion toward renal parenchyma, literature has gradually established that renal prognosis is more favorable as compared with the standard threshold. This review aims to elucidate the renal impact of poorly controlled hypertension, elaborate on contemporary clinical references for BP control, and propose future directions to improve the holistic care of hypertensive individuals.
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Affiliation(s)
- Ting-Wei Kao
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Chin-Chou Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Pharmacology, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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42
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Nguyen NTV, Chau HN, Le NH, Nguyen HH, Nguyen HA. Impact of Novel Guidelines on Multifactorial Control and Its Association with Mortality in Adult Patients with Hypertension and Newly Diagnosed Type 2 Diabetes: A 4-Year Prospective Multicenter Study. Int J Endocrinol 2021; 2021:9977840. [PMID: 34621312 PMCID: PMC8492251 DOI: 10.1155/2021/9977840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 09/01/2021] [Indexed: 11/18/2022] Open
Abstract
METHODS This prospective, observational study involved adult hypertensive patients with newly diagnosed type 2 diabetes mellitus at two university hospitals in Vietnam. The median time of follow-up was 4 years (August 2016-August 2020). The primary outcome was time to all-cause mortality. RESULTS 246 patients were included with a mean age of 64.5 ± 10.4. 58.5% were females. 64.2% were categorized as high risk. At baseline, ischemic heart disease, dyslipidemia, and chronic kidney disease (CKD) were present in 54.9%, 67.1%, and 41.1% of patients. Renin-angiotensin-aldosterone inhibitor, metformin, and statin were prescribed in 89.8%, 66.3%, and 67.1%. Among three risk factors, LDL-c control was the hardest to achieve, increasing from 5.7% to 8.5%. In contrast, blood pressure control decreased from 56.1% in 2016 to 30.2% in 2020, when the second wave of COVID-19 hit our nation. While contemporary targets resulted in persistently low simultaneous control at 1.2%, significant improvement was observed with conventional criteria (blood pressure < 140/90 mmHg, HbA1c < 7%, LDL-c < 70 mg/dl), increasing from 14.6% to 33.7%. During follow-up, the mortality rate was 24.4 events per 1000 patient-years, exclusively in patients with early newly diagnosed diabetes. Improving control overtime, not at baseline, was associated with less mortality. Conversely, age >75 years (HR = 2.6) and CKD (HR = 4.9) were associated with increased mortality. CONCLUSION These findings demonstrated real-world difficulties in managing hypertension and newly diagnosed diabetes, especially with stringent criteria from novel guidelines. High-risk profile, high mortality, and poor simultaneous control warrant more aggressive cardiorenal protection, focusing more on aging CKD patients with early newly diagnosed diabetes.
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Affiliation(s)
- Ngoc-Thanh-Van Nguyen
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City 700 000, Vietnam
- Cardiology Department, Nhan Dan Gia Dinh Hospital, Ho Chi Minh City 700 000, Vietnam
- Outpatient Department, University Medical Center, Ho Chi Minh City 700 000, Vietnam
| | - Hoa Ngoc Chau
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City 700 000, Vietnam
- Cardiology Department, Nhan Dan Gia Dinh Hospital, Ho Chi Minh City 700 000, Vietnam
- Outpatient Department, University Medical Center, Ho Chi Minh City 700 000, Vietnam
| | - Nam Hoai Le
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City 700 000, Vietnam
- Outpatient Department, University Medical Center, Ho Chi Minh City 700 000, Vietnam
| | - Hai Hoang Nguyen
- Cardiology Department, Nhan Dan Gia Dinh Hospital, Ho Chi Minh City 700 000, Vietnam
| | - Hoai-An Nguyen
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City 700 000, Vietnam
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Mohottige D, Manley HJ, Hall RK. Less is More: Deprescribing Medications in Older Adults with Kidney Disease: A Review. KIDNEY360 2021; 2:1510-1522. [PMID: 35373095 PMCID: PMC8786141 DOI: 10.34067/kid.0001942021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/08/2021] [Indexed: 02/04/2023]
Abstract
Due to age and impaired kidney function, older adults with kidney disease are at increased risk of medication-related problems and related hospitalizations. One proa ctive approach to minimize this risk is deprescribing. Deprescribing refers to the systematic process of reducing or stopping a medication. Aside from preventing harm, deprescribing can potentially optimize patients' quality of life by aligning medications with their goals of care. For some patients, deprescribing could involve less aggressive management of their diabetes and/or hypertension. In other instances, deprescribing targets may include potentially inappropriate medications that carry greater risk of harm than benefit in older adults, medications that have questionable efficacy, including medications that have varying efficacy by degree of kidney function, and that increase medication regimen complexity. We include a guide for clinicians to utilize in deprescribing, the List, Evaluate, Shared Decision-Making, Support (LESS) framework. The LESS framework provides key considerations at each step of the deprescribing process that can be tailored for the medications and context of individu al patients. Patient characteristics or clinical events that warrant consideration of deprescribing include limited life expectancy, cognitive impairment, and health status changes, such as dialysis initiation or recent hospitalization. We acknowledge patient-, clinician-, and system-level challenges to the depre scribing process. These include patient hesitancy and challenges to discussing goals of care, clinician time constraints and a lack of evidence-based guidelines, and system-level challenges of interoperable electronic health records and limited incentives for deprescribing. However, novel evidence-based tools designed to facilitate deprescribing and future evidence on effectiveness of deprescribing could help mitigate these barriers. This review provides foundational knowledge on deprescribing as an emerging component of clinical practice and research within nephrology.
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Affiliation(s)
- Dinushika Mohottige
- Renal Section, Durham Veterans Affairs Healthcare System, Durham, North Carolina,Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Rasheeda K. Hall
- Renal Section, Durham Veterans Affairs Healthcare System, Durham, North Carolina,Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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Rossing P, Persson F. What Have We Learned so Far From the Use of Sodium-Glucose Cotransporter 2 Inhibitors in Clinical Practice? Adv Chronic Kidney Dis 2021; 28:290-297. [PMID: 34922685 DOI: 10.1053/j.ackd.2021.06.002] [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: 03/04/2021] [Revised: 05/16/2021] [Accepted: 06/01/2021] [Indexed: 11/11/2022]
Abstract
Since the introduction of sodium-glucose cotransporter 2 (SGLT2) inhibitors, the aim of this therapy has expanded from being solely a glucose-lowering treatment into also being organ protective even in people without diabetes. In this review, we present this evolution of the treatment principle, from early studies over randomized controlled trials. We discuss available real-world evidence and summarize a number of recent post hoc analyses from the randomized controlled trials with kidney end points. As the use of sodium-glucose cotransporter 2 inhibitors becomes more widespread, new questions arise regarding initiation and follow-up, which we try to answer by providing the currently available data. For translation of study results to global effects, implementation becomes important. As is often the case, this does not happen without barriers, which must be addressed and handled. Finally, future studies and populations are discussed because it may well be that sodium-glucose cotransporter 2 inhibition are expanding into further areas.
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Neumiller JJ, Alicic RZ, Tuttle KR. Overcoming Barriers to Implementing New Therapies for Diabetic Kidney Disease: Lessons Learned. Adv Chronic Kidney Dis 2021; 28:318-327. [PMID: 34922688 DOI: 10.1053/j.ackd.2021.02.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/30/2020] [Accepted: 02/01/2021] [Indexed: 12/18/2022]
Abstract
As a result of the growing number of patients with type 2 diabetes mellitus, the prevalence of diabetic kidney disease (DKD) has proven to be one of the fastest growing health care challenges globally. Early detection and initiation of appropriate interventions to slow the progression of DKD are impeded by low awareness of the health consequences of DKD, high complexity of care that includes the need for lifestyle modifications, difficulties with adhering to increasingly complicated medication regimens, and low acceptance and application of guideline-directed management. After 2 decades of status quo in the care of patients with DKD, recently approved glucose-lowering agents are promising to transform care by demonstrating slowed DKD disease progression and improved survival. As has been learned over the last 2 decades, multiple barriers exist to the optimal integration and utilization of new therapies to improve kidney outcomes. The health care community, professional societies, and regulatory agencies must join efforts to develop implementation strategies for increasing DKD awareness, detection, and treatment.
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Neumiller JJ, Shubrook JH, Manley T, Alicic RZ, Tuttle KR. Optimizing use of SGLT2 inhibitors and other evidence-based therapies to improve outcomes in patients with type 2 diabetes and chronic kidney disease: An opportunity for pharmacists. Am J Health Syst Pharm 2021; 79:e65-e70. [PMID: 34185826 DOI: 10.1093/ajhp/zxab271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Joshua J Neumiller
- College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
| | - Jay H Shubrook
- Primary Care Department, Touro University, Vallejo, CA, USA
| | - Tom Manley
- National Kidney Foundation, New York, NY, USA
| | - Radica Z Alicic
- Providence Medical Research Center, Providence Health Care, Spokane, WA, and Division of Medicine, University of Washington, Spokane and Seattle, WA, USA
| | - Katherine R Tuttle
- Providence Medical Research Center, Providence Health Care, Spokane, WA, and Division of Nephrology, Kidney Research Institute, and Institute of Translational Health Sciences, University of Washington, Spokane and Seattle, WA, USA
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Østergaard MV, Secher T, Christensen M, Salinas CG, Roostalu U, Skytte JL, Rune I, Hansen HH, Jelsing J, Vrang N, Fink LN. Therapeutic effects of lisinopril and empagliflozin in a mouse model of hypertension-accelerated diabetic kidney disease. Am J Physiol Renal Physiol 2021; 321:F149-F161. [PMID: 34180715 DOI: 10.1152/ajprenal.00154.2021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hypertension is a critical comorbidity for progression of diabetic kidney disease (DKD). To facilitate the development of novel therapeutic interventions with the potential to control disease progression, there is a need to establish translational animal models that predict treatment effects in human DKD. The present study aimed to characterize renal disease and outcomes of standard of medical care in a model of advanced DKD facilitated by adeno-associated virus (AAV)-mediated renin overexpression in uninephrectomized (UNx) db/db mice. Five weeks after single AAV administration and 4 wk after UNx, female db/db UNx-ReninAAV mice received (PO, QD) vehicle, lisinopril (40 mg/kg), empagliflozin (20 mg/kg), or combination treatment for 12 wk (n = 17 mice/group). Untreated db/+ mice (n = 8) and vehicle-dosed db/db UNx-LacZAAV mice (n = 17) served as controls. End points included plasma, urine, and histomorphometric markers of kidney disease. Total glomerular numbers and individual glomerular volume were evaluated by whole kidney three-dimensional imaging analysis. db/db UNx-ReninAAV mice developed hallmarks of progressive DKD characterized by severe albuminuria, advanced glomerulosclerosis, and glomerular hypertrophy. Lisinopril significantly improved albuminuria, glomerulosclerosis, tubulointerstitial injury, and inflammation. Although empagliflozin alone had no therapeutic effect on renal endpoints, lisinopril and empagliflozin exerted synergistic effects on renal histological outcomes. In conclusion, the db/db UNx-ReninAAV mouse demonstrates good clinical translatability with respect to physiological and histological hallmarks of progressive DKD. The efficacy of standard of care to control hypertension and hyperglycemia provides a proof of concept for testing novel drug therapies in the model.NEW & NOTEWORTHY Translational animal models of diabetic kidney disease (DKD) are important tools in preclinical research and drug discovery. Here, we show that the standard of care to control hypertension (lisinopril) and hyperglycemia (empagliflozin) improves physiological and histopathological hallmarks of kidney disease in a mouse model of hypertension-accelerated progressive DKD. The findings substantiate hypertension and type 2 diabetes as essential factors in driving DKD progression and provide a proof of concept for probing novel drugs for potential nephroprotective efficacy in this model.
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Longato E, Fadini GP, Sparacino G, Avogaro A, Di Camillo B. Recurrent Neural Network to Predict Renal Function Impairment in Diabetic Patients via Longitudinal Routine Check-up Data. Artif Intell Med 2021. [DOI: 10.1007/978-3-030-77211-6_37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Tuttle KR. SGLT2 inhibition and chronic kidney disease outcomes: in diabetes and beyond. Lancet Diabetes Endocrinol 2021; 9:3-5. [PMID: 33338414 DOI: 10.1016/s2213-8587(20)30374-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Katherine R Tuttle
- Providence Medical Research Center, Providence Health Care, Spokane, WA 99204, USA; Institute of Translational Health Sciences, Kidney Research Institute, and Nephrology Division, University of Washington, Seattle, WA, USA.
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