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Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial. Lancet Diabetes Endocrinol 2024; 12:39-50. [PMID: 38061371 PMCID: PMC7615591 DOI: 10.1016/s2213-8587(23)00321-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial. METHODS EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110. FINDINGS Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001). INTERPRETATION Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor. FUNDING Boehringer Ingelheim and Eli Lilly.
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Yamada N, Yamagata K, Yamaguchi M, Yamaji Y, Yamamoto A, Yamamoto S, Yamamoto S, Yamamoto T, Yamanaka A, Yamano T, Yamanouchi Y, Yamasaki N, Yamasaki Y, Yamasaki Y, Yamashita C, Yamauchi T, Yan Q, Yanagisawa E, Yang F, Yang L, Yano S, Yao S, Yao Y, Yarlagadda S, Yasuda Y, Yiu V, Yokoyama T, Yoshida S, Yoshidome E, Yoshikawa H, Young A, Young T, Yousif V, Yu H, Yu Y, Yuasa K, Yusof N, Zalunardo N, Zander B, Zani R, Zappulo F, Zayed M, Zemann B, Zettergren P, Zhang H, Zhang L, Zhang L, Zhang N, Zhang X, Zhao J, Zhao L, Zhao S, Zhao Z, Zhong H, Zhou N, Zhou S, Zhu D, Zhu L, Zhu S, Zietz M, Zippo M, Zirino F, Zulkipli FH. Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial. Lancet Diabetes Endocrinol 2024; 12:51-60. [PMID: 38061372 DOI: 10.1016/s2213-8587(23)00322-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population. METHODS EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110. FINDINGS Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1). INTERPRETATION In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease. FUNDING Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.
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Sessa C, Zanoli L, Noto G, Alessandrello I, Galeano D, Giglio E, Giuffrida AE, Distefano G, Ficara V, Messina RM, Musumeci S, Scollo V, Zirino F, Zuppardo C, Morale W. [Contrast Media Toxicity and Its Prevention]. G Ital Nefrol 2023; 40:2023-vol5. [PMID: 38010244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Intravenous iodinated contrast media are commonly used in clinical practice, ranging from medical imaging to interventional radiology (IR) procedures and endovascular interventions. Compared with patients with normal renal function, nephropathic patients have an increased risk of acute kidney injury (AKI). Nevertheless, this condition cannot represent a limit to diagnostics or endovascular interventions. Despite the literature of the last five years, conflicting management and approaches for nephropathic patients persist, including the use of contrast agents and treatments replacing renal functions, which are often mistakenly considered as part of preventive strategies. Though the issue has been widely discussed, specialists often cope with uncertainty in handling properly the administration of contrast media and renal counselling requests. Furthermore, there is a general difficulty in distinguishing the Post-Contrast Acute Kidney Injury (PC-AKI) from the Contrast-Associated Acute Kidney Injury (CI-AKI). The present review aims to provide an update on the issue and examine strategies to reduce the acute kidney injury risk after the administration of contrast media. These strategies include the early identification of high-risk individuals, the choice of the contrast media and the proper dosage, the suspension of nephrotoxic drugs, the follow-up of the high-risk individuals, and the early identification of AKI.
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Affiliation(s)
- Concetto Sessa
- U.O.C. Nefrologia e Dialisi, P.O. Maggiore "Nino Baglieri", Modica, Ragusa (RG)
| | - Luca Zanoli
- Nefrologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Catania, Catania (CT)
| | - Giovanni Noto
- U.O.C. Medicina e Chirurgia d'Accettazione e Urgenza, P.O. Giovanni Paolo II, Ragusa (RG)
| | - Ivana Alessandrello
- U.O.C. Nefrologia e Dialisi, P.O. Maggiore "Nino Baglieri", Modica, Ragusa (RG)
| | - Dario Galeano
- U.O.C. Nefrologia e Dialisi, P.O. Maggiore "Nino Baglieri", Modica, Ragusa (RG)
| | - Elisa Giglio
- U.O.C. Nefrologia e Dialisi, P.O. Maggiore "Nino Baglieri", Modica, Ragusa (RG)
| | | | - Giulio Distefano
- U.O.C. Nefrologia e Dialisi, P.O. Maggiore "Nino Baglieri", Modica, Ragusa (RG)
| | - Vincenzo Ficara
- U.O.C. Nefrologia e Dialisi, P.O. Maggiore "Nino Baglieri", Modica, Ragusa (RG)
| | | | - Stella Musumeci
- U.O.C. Nefrologia e Dialisi, P.O. Maggiore "Nino Baglieri", Modica, Ragusa (RG)
| | - Viviana Scollo
- U.O.C. Nefrologia e Dialisi, P.O. Maggiore "Nino Baglieri", Modica, Ragusa (RG)
| | - Fortunata Zirino
- U.O.C. Nefrologia e Dialisi, P.O. Maggiore "Nino Baglieri", Modica, Ragusa (RG)
| | - Carmelo Zuppardo
- U.O.C. Nefrologia e Dialisi, P.O. Maggiore "Nino Baglieri", Modica, Ragusa (RG)
| | - Walter Morale
- U.O.C. Nefrologia e Dialisi, P.O. Maggiore "Nino Baglieri", Modica, Ragusa (RG)
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Vischi M, Moreschi B, Zanoni C, Raschioni E, Lanzi P, Orfeo NV, Cozzolino M, Zirino F. [Nephrological nutritional office: a transversal organization model and access flowchart]. G Ital Nefrol 2023; 40:40-02-2023-08. [PMID: 37179480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
The nutritional aspect has a critical relevance in the educational and care path of nephropathic patients. The Nephrology-Dietology synergy in the Hospital is conditioned by various factors, such as the difficulty for Dietology to provide capillary and personalized follow-up to nephropathic patients. Hence the experience of a transversal II level nephrological clinic, dedicated to nutritional aspects throughout the path of nephropathic patients, from the earliest stages of kidney disease to replacement treatment. The access flowchart provides a nephrological indication: from chronic kidney disease (CKD), kidney stones, immunopathology, hemodialysis, peritoneal dialysis, and transplantation clinics, from the nephrological department, patients are selected for evaluation. The clinic is conducted by an expert nephrologist and trained dietitians, and is divided into different settings: educational meetings in small groups (patients and caregivers); simultaneous dietary and nephrological visits to advanced CKD; nutritional-nephrological visits on specific problems: from metabolic screening of kidney stones to action on the intestinal microbiota in immunological pathologies, to the application of the ketogenic diet in obesity, metabolic syndrome, diabetes, and early kidney damage, to onconephrology. Submission to further dietological assessment is limited to critical and selected cases. The synergistic model between nephrology and dietetics offers clinical and organizational advantages: guarantees a capillary follow-up, reduces the number of hospital accesses, thus enhancing compliance and clinical outcomes, optimizes available resources, and overcomes the critical issues of a complex hospital with the advantage of the always profitable multidisciplinarity.
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Affiliation(s)
| | - Benedetta Moreschi
- SSD Servizio Dietetico e Nutrizione Clinica-ASST Santi Paolo e Carlo Milano
| | - Cristina Zanoni
- SSD Servizio Dietetico e Nutrizione Clinica-ASST Santi Paolo e Carlo Milano
| | - Enrica Raschioni
- SSD Servizio Dietetico e Nutrizione Clinica-ASST Santi Paolo e Carlo Milano
| | - Paola Lanzi
- SSD Servizio Dietetico e Nutrizione Clinica-ASST Santi Paolo e Carlo Milano
| | | | | | - Fortunata Zirino
- Dipartimento di Nefrologia, Dialisi e Trapianto Renale, Ospedale "San Bortolo", Vicenza
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Gechelin C, Milan Manani S, Virzì GM, Marturano D, Mattiotti M, Tantillo I, Ferrara A, Zirino F, Giuliani A, Ronco C, Zanella M. [Psychological support in anxiety management for patients affected by chronic kidney disease and treated by dialysis]. G Ital Nefrol 2023; 40:40-01-2023-08. [PMID: 36883924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Introduction: The quality of life of patients with chronic kidney disease stage V is strongly affected by the recommended therapies. Such a situation alters the state of anxiety, which expresses a perception connected to a specific context and it overlaps with trait anxiety, which evaluates relatively stable aspects of being prone to anxiety. The study aims to analyze the anxiety level of uremic patients and to demonstrate the benefit of psychological support either in person or online in order to mostly reduce the state of anxiety. Materials and methods: 23 patients treated at the Nephrology Unit of the San Bortolo Hospital in Vicenza have undergone at least 8 psychological sessions. The first and the eighth sessions have been held in person, while the others were either in person or online based on the patients' preference. The State-Trait Anxiety Inventory (STAI), which means to evaluate the current state of anxiety and aspects of being prone to anxiety, was submitted during the first and the eighth sessions. Results: Patients, before being submitted to psychological treatment, showed high rates of both State and Trait anxiety levels. After eight sessions the trait anxiety features and even better the state anxiety ones have significantly reduced both thanks to in-person or online treatments. Conclusions: A treatment of minimum eight sessions shows a significant improvement of the nephropathic patient's trait and, even better, state anxiety level and it also fosters the achievement of advanced adjustment levels compared to the new clinical status together with an improvement of the quality of life.
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Affiliation(s)
- Chiara Gechelin
- I.R.R.I.V. (International Renal Research Institute) Foundation, Vicenza
| | | | | | - Davide Marturano
- I.R.R.I.V. (International Renal Research Institute) Foundation, Vicenza
| | - Maria Mattiotti
- I.R.R.I.V. (International Renal Research Institute) Foundation, Vicenza
| | - Ilaria Tantillo
- I.R.R.I.V. (International Renal Research Institute) Foundation, Vicenza
| | - Alida Ferrara
- Dipartimento di Nefrologia, Dialisi e Trapianto Renale, Ospedale "San Bortolo", Vicenza
| | - Fortunata Zirino
- Dipartimento di Nefrologia, Dialisi e Trapianto Renale, Ospedale "San Bortolo", Vicenza
| | - Anna Giuliani
- Dipartimento di Nefrologia, Dialisi e Trapianto Renale, Ospedale "San Bortolo", Vicenza
| | - Claudio Ronco
- Dipartimento di Nefrologia, Dialisi e Trapianto Renale, Ospedale "San Bortolo", Vicenza
| | - Monica Zanella
- Dipartimento di Nefrologia, Dialisi e Trapianto Renale, Ospedale "San Bortolo", Vicenza
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Longhitano E, Zirino F, Calabrese V, Giuffrida A, Gembillo G, Cernaro V, Masturzo B, Attini R, Torreggiani M, Piccoli GB, Santoro D. Commonly used immunosuppressive drugs for kidney diseases and pregnancy: focus on open questions. Expert Rev Clin Pharmacol 2021; 14:1321-1323. [PMID: 34402354 DOI: 10.1080/17512433.2021.1968831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pregnancy is still a challenge in women with autoimmune diseases or kidney transplantation. In this context, management of the immunosuppressive therapy is critical, but, in spite of more than 60 years of experience, many issues remain open, also because of the difficulty in disentangling, in complex patients, the effect of the disease and of the frequent multiple treatments. For this purpose, we have tried to synthesize the existing knowledge and the unresolved issues, to support counseling and promote patient empowerment.
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Affiliation(s)
- Elisa Longhitano
- Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, A.o.u. "G. Martino," University of Messina, Messina, Italy
| | - Fortunata Zirino
- Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, A.o.u. "G. Martino," University of Messina, Messina, Italy
| | - Vincenzo Calabrese
- Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, A.o.u. "G. Martino," University of Messina, Messina, Italy
| | - Alfio Giuffrida
- Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, A.o.u. "G. Martino," University of Messina, Messina, Italy
| | - Guido Gembillo
- Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, A.o.u. "G. Martino," University of Messina, Messina, Italy
| | - Valeria Cernaro
- Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, A.o.u. "G. Martino," University of Messina, Messina, Italy
| | - Bianca Masturzo
- Department of Obstetrics and Gynecology SC2U, Città Della Salute E Della Scienza, Sant'Anna Hospital, Turin, Italy
| | - Rossella Attini
- Department of Obstetrics and Gynecology SC2U, Città Della Salute E Della Scienza, Sant'Anna Hospital, Turin, Italy
| | | | - Giorgina B Piccoli
- Néphrologie Et Dialyse, Centre Hospitalier Le Mans, Le Mans, France.,Department of Clinical and Biological Sciences, University of Torino, Turin, Italy
| | - Domenico Santoro
- Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, A.o.u. "G. Martino," University of Messina, Messina, Italy
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