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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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Grützmacher P, Öhm B, Szymczak S, Dorbath C, Brzoska M, Kleinert C. Primary and secondary prevention of cardiovascular disease in patients with hyperlipoproteinemia (a). Clin Res Cardiol Suppl 2017; 12:22-26. [PMID: 28233269 PMCID: PMC5352782 DOI: 10.1007/s11789-017-0090-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
General lipoprotein (Lp) (a) screening can help to identify patients at high risk for cardiovascular disease. Non-invasive methods allow early detection of clinically asymptomatic incipient atherosclerotic disease. Medical treatment options are still unsatisfactory. Lp(a) apheresis is an established treatment in Germany for secondary prevention of progressive cardiovascular disease. Statin-based lowering of LDL cholesterol and thrombocyte aggregation inhibitors still represent the basis of medical treatment. Target levels for LDL-cholesterol should be modified in patients with hyperlipoproteinemia (a).
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Affiliation(s)
- P Grützmacher
- 2nd Medical Clinic - Nephrology, Hypertension and Vascular Diseases, AGAPLESION Markus-Hospital, Frankfurt/Main, Germany.
| | - B Öhm
- 2nd Medical Clinic - Nephrology, Hypertension and Vascular Diseases, AGAPLESION Markus-Hospital, Frankfurt/Main, Germany
| | - S Szymczak
- 2nd Medical Clinic - Nephrology, Hypertension and Vascular Diseases, AGAPLESION Markus-Hospital, Frankfurt/Main, Germany
| | - C Dorbath
- 2nd Medical Clinic - Nephrology, Hypertension and Vascular Diseases, AGAPLESION Markus-Hospital, Frankfurt/Main, Germany
| | - M Brzoska
- 2nd Medical Clinic - Nephrology, Hypertension and Vascular Diseases, AGAPLESION Markus-Hospital, Frankfurt/Main, Germany
| | - C Kleinert
- 2nd Medical Clinic - Nephrology, Hypertension and Vascular Diseases, AGAPLESION Markus-Hospital, Frankfurt/Main, Germany
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Walker R, Ruderman I, Masterson R, Cohney S, Salvadori M, Conti P, Bertoni E, Durrbach A, Citterio F, Mulloy L, David-Neto E, Russ G, Vitko S, Zhang R, Xing J, Harler MB, Grinyo J, Rugiu C, Trubian A, Bernich P, Lupo A, Asbe-Vollkopf A, Pannu A, Hoefeld H, Gauer S, Gossmann J, Kachel HG, Froese S, Korom S, Geiger H, Hauser IA, Liefeldt L, Kluener C, Glander P, Giessing M, Gralla O, Neumayer HH, Budde K, Kroencke T, Liborio AB, Barros RM, Esmeraldo RM, Oliveira MLMB, Nogueira Paes FJV, Mendoza TR, Silva Junior GB, Daher EF, Siekierka-Harreis M, Bantis C, Kouri NM, Schwandt C, Rump LC, Ivens K, Slatinska J, Honsova E, Burgelova M, Slimackova E, Viklicky O, Tabernero G, Rivero K, Fernandez G, Canueto J, Garcia P, Fraile P, Lucas C, Tabernero JM, Bargnoux AS, Simon N, Garrigue V, Dupuy AM, Mourad G, Cristol JP, Yapici U, Kers J, Bemelman F, Roelofs J, Groothoff J, van der Loos C, van Donselaar-van der Pant K, Idu M, Claessen N, ten Berge I, Florquin S, Knap B, Dragonja Z, Dobnik S, Buturovic Ponikvar J, Ponikvar R, Kandus A, Bren A, Hauser IA, Kleemann J, Gauer S, Engel J, Winter S, Hoefeld H, Asbe-Vollkopf A, Brzoska M, Obermueller N, Geiger H, Schaeffeler E, Oldak M, Pazik J, Lewandowski Z, Sitarek E, Dabrowski M, Ploski R, Malejczyk J, Durlik M, Slubowska K, Urbanowicz A, Sadowska A, Lichodziejewska B, Kurnicka K, Galazka Z, Chmura A, Durlik M, Masin-Spasovska J, Spasovski G, Petrusevska G, Popov Z, Ivanovski N, Di Napoli A, Salvatori MF, Franco F, Di Lallo D, Guasticchi G, Sancho A, Gavela E, Beltran S, Kanter J, Alemany B, Crespo JF, Pallardo LM, Lionet A, Beuscart JB, Buob D, BenHenda A, Provot F, Hazzan M, Noel C, Galan-Sanchez F, Marin-Casanova P, Mazuecos A, Garcia-Alvarez T, Aznar E, Rodriguez-Iglesias M, Ossareh S, Salami M, Mohammad E, Hosseini M, Pawlik A, Chudek J, Kolonko A, Wilk J, Jalowiecki P, Wiecek A, Zyablitskaya E, Galkina E, Yushina E, Botelho C, Aires P, Santos L, Romaozinho C, Macario F, Alves R, Veiga P, Mota A, Yashi M, Yagisawa T, Kimura T, Nukui A, Fujiwara T, Sakuma Y, Ishikawa N, Iwabuchi T, Muraishi O, Glander P, Hambach P, Liefeldt L, Neumayer HH, Budde K, Esmen S, Keven K, Sengul S, Ozcan M, Ensari A, Tuzuner A, Calayoglu R, Nergizoglu G, Gullu Koca T, Koca N, Ersoy A, Faria B, Bustorff M, Barros F, Tavares I, Santos J, Ferreira I, Sampaio S, Pestana M, Keven K, Suvak B, Sengul S, Kurultak I, Calayoglu R, Tutkak H, Choi HM, Yang HN, Jo SK, Cho WY, Kim HK, Aybal Kutlugun A, Altun B, Akman U, Aki T, Turkmen E, Yildirim T, Altindal M, Yilmaz R, Yasavul U, Gullu Koca T, Koca N, Ersoy A, Thiem U, Heinze G, Gossler U, Perkmann T, Kainberger F, Muhlbacher F, Horl W, Borchhardt K, Sanchez-Escuredo A, Holgado S, Biosca C, Granada ML, Barluenga E, Lauzurica R, Romero R, Espinal A, Torregrossa V, Bayes B, Tomida K, Hamano T, Fujii N, Ichimaru N, Matsui I, Isaka Y, Rakugi H, Takahara S, Gavela E, Sancho A, Kanter J, Beltran S, Avila A, Crespo JF, Pallardo LM, Dor F, Massey E, Frunza M, Johnson R, Lennerling A, Loven C, Mamode N, Pascalev A, Sterckx S, Van Assche K, Zuidema W, Weimar W, Botelho C, Aires P, Santos L, Romaozinho C, Macario F, Alves R, Veiga P, Mota A, Allwin R, Gauer S, Roessel, Hoefeld H, Brzoska M, Buettner S, Gossmann J, Belwe V, Geiger H, Hauser IA, Apaza J, Gonzalez E, Polanco N, Bengoa I, Cadenillas C, Andres A, Morales JM, Rocha S, Fonseca I, Martins LS, Vidinha J, Dias L, Almeida M, Pedroso S, Henriques A, Cabrita A, Neretljak I, Mihovilovic K, Vidas Z, Jurenec F, Knotek M, Justa S, Minz R, Minz M, Anand S, Sharma A, Lacquaniti A, Donato V, Chirico V, Pettinato G, Buemi M, Galle J, Addison J, Perry P, Claes K, Farouk M, Guerin A, Kiss I, Winearls C, Di Giulio S, Basic-Jukic N, Slavicek J, Bubic-Filipi L, Kes P, Scholbach T, Wang HK, Yang AH, Loong CC, Wu TH, Abboud I, Antoine C, Serrato T, Lefaucheur C, Pillebout E, Gaudez F, Fieux F, Flamant M, Verine J, Viglietti D, Peraldi MN, Glotz D. Transplantation: clinical studies (2). Clin Kidney J 2011. [DOI: 10.1093/ndtplus/4.s2.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Baer PC, Bereiter-Hahn J, Missler C, Brzoska M, Schubert R, Gauer S, Geiger H. Conditioned medium from renal tubular epithelial cells initiates differentiation of human mesenchymal stem cells. Cell Prolif 2009; 42:29-37. [PMID: 19143761 DOI: 10.1111/j.1365-2184.2008.00572.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES Mesenchymal-epithelial interactions play a pivotal role in tubular morphogenesis and in maintaining the integrity of the kidney. During renal repair, similar mechanisms may regulate cellular reorganization and differentiation. We have hypothesized that soluble factors from proximal tubular epithelial cells (PTC) induce differentiation of adipose-derived adult mesenchymal stem cells (ASC). This hypothesis has been tested using cultured ASC and PTC. MATERIAL AND METHODS Conditioned medium was prepared from injured PTC and transferred to ASC cultures. ASC proliferation was analysed by a fluorometric and photometric assay. Signal transduction was analysed by phosphorylation of extracellular signal-regulated kinase 1 and 2 (ERK1/ERK2). Grade of ASC differentiation was assessed by morphological analysis and cell expression of characteristic markers. RESULTS Conditioned medium significantly induced proliferation and phosphorylation of ERK1/ERK2 of ASC. After 12 days of incubation, cell morphology changed to an epithelial-like monolayer. Expression of cytokeratin 18 was induced by conditioned medium, while alpha-smooth muscle actin, CD49a and CD90 expression decreased. These alterations strongly indicate onset of the differentiation process to the epithelial lineage. In summary, soluble factors from PTC induce signal transduction and differentiation of ASC. CONCLUSIONS Our study shows that conditioned medium from renal tubular epithelial cells provides a convenient source of inductive signals to initiate differentiation of ASC towards epithelial lineage. We deduce that these interactions may play an important role during renal repair mechanisms.
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Affiliation(s)
- P C Baer
- Division of Nephrology, Department of Internal Medicine III, John Wolfgang Goethe-University, Frankfurt, Germany.
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Brzoska M. [In vitro study of the suitability of nanoparticles as a vehicle for gene delivery into airway epithelium cells]. Pneumologie 2005; 59:715-6. [PMID: 16222584 DOI: 10.1055/s-2005-915560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- M Brzoska
- Klinikum der Johann Wolfgang Goethe-Universität, Medizinische Klinik I, Schwerpunkt Pneumologie/Allergologie, Frankfurt/Main.
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Brzoska M, Langer K, Coester C, Loitsch S, Wagner TOF, Mallinckrodt CV. Incorporation of biodegradable nanoparticles into human airway epithelium cells-in vitro study of the suitability as a vehicle for drug or gene delivery in pulmonary diseases. Biochem Biophys Res Commun 2004; 318:562-70. [PMID: 15120637 DOI: 10.1016/j.bbrc.2004.04.067] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2004] [Indexed: 10/26/2022]
Abstract
PURPOSE Nanoparticles are able to enhance drug or DNA stability for purposes of optimised deposition to targeted tissues. Surface modifications can mediate drug targeting. The suitability of nanoparticles synthesised out of porcine gelatin, human serum albumin, and polyalkylcyanoacrylate as drug and gene carriers for pulmonary application was investigated in vitro on primary airway epithelium cells and the cell line 16HBE14o-. METHODS The uptake of nanoparticles into these cells was examined by confocal laser scan microscopy (CLSM) and flow cytometry (FACS). Further the cytotoxicity of nanoparticles was evaluated by an LDH-release-test and the inflammatory potential of the nanoparticles was assessed by measuring IL-8 release. RESULTS CLSM and FACS experiments showed that the nanoparticles were incorporated into bronchial epithelial cells provoking little or no cytotoxicity and no inflammation as measured by IL-8 release. CONCLUSIONS Based on their low cytotoxicity and the missing inflammatory potential in combination with an efficient uptake in human bronchial epithelial cells, protein-based nanoparticles are suitable drug and gene carriers for pulmonary application.
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Affiliation(s)
- M Brzoska
- Department of Pulmonology, Medical Clinic of Johann-Wolfgang-Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany.
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