1
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Marton A, Saffari SE, Rauh M, Sun RN, Nagel AM, Linz P, Lim TT, Takase-Minegishi K, Pajarillaga A, Saw S, Morisawa N, Yam WK, Minegishi S, Totman JJ, Teo S, Teo LLY, Ng CT, Kitada K, Wild J, Kovalik JP, Luft FC, Greasley PJ, Chin CWL, Sim DKL, Titze J. Water Conservation Overrides Osmotic Diuresis During SGLT2 Inhibition in Patients With Heart Failure. J Am Coll Cardiol 2024; 83:1386-1398. [PMID: 38599715 DOI: 10.1016/j.jacc.2024.02.020] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/08/2024] [Accepted: 02/08/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors are believed to improve cardiac outcomes due to their osmotic diuretic potential. OBJECTIVES The goal of this study was to test the hypothesis that vasopressin-driven urine concentration overrides the osmotic diuretic effect of glucosuria induced by dapagliflozin treatment. METHODS DAPA-Shuttle1 (Hepato-renal Regulation of Water Conservation in Heart Failure Patients With SGLT-2 Inhibitor Treatment) was a single-center, double-blind, randomized, placebo-controlled trial, in which patients with chronic heart failure NYHA functional classes I/II and reduced ejection fraction were randomly assigned to receive dapagliflozin 10 mg daily or placebo (1:1) for 4 weeks. The primary endpoint was change from baseline in urine osmolyte concentration. Secondary endpoints included changes in copeptin levels and solute free water clearance. RESULTS Thirty-three randomized, sodium-glucose cotransporter 2 inhibitor-naïve participants completed the study, 29 of whom (placebo: n = 14; dapagliflozin: n = 15) provided accurate 24-hour urine collections (mean age 59 ± 14 years; left ventricular ejection fraction 31% ± 9%). Dapagliflozin treatment led to an isolated increase in urine glucose excretion by 3.3 mmol/kg/d (95% CI: 2.51-4.04; P < 0.0001) within 48 hours (early) which persisted after 4 weeks (late; 2.7 mmol/kg/d [95% CI: 1.98-3.51]; P < 0.0001). Dapagliflozin treatment increased serum copeptin early (5.5 pmol/L [95% CI: 0.45-10.5]; P < 0.05) and late (7.8 pmol/L [95% CI: 2.77-12.81]; P < 0.01), leading to proportional reductions in free water clearance (early: -9.1 mL/kg/d [95% CI: -14 to -4.12; P < 0.001]; late: -11.0 mL/kg/d [95% CI: -15.94 to -6.07; P < 0.0001]) and elevated urine concentrations (late: 134 mmol/L [95% CI: 39.28-229.12]; P < 0.01). Therefore, urine volume did not significantly increase with dapagliflozin (mean difference early: 2.8 mL/kg/d [95% CI: -1.97 to 7.48; P = 0.25]; mean difference late: 0.9 mL/kg/d [95% CI: -3.83 to 5.62]; P = 0.70). CONCLUSIONS Physiological-adaptive water conservation eliminated the expected osmotic diuretic potential of dapagliflozin and thereby prevented a glucose-driven increase in urine volume of approximately 10 mL/kg/d · 75 kg = 750 mL/kg/d. (Hepato-renal Regulation of Water Conservation in Heart Failure Patients With SGLT-2 Inhibitor Treatment [DAPA-Shuttle1]; NCT04080518).
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Affiliation(s)
- Adriana Marton
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore; Department of Internal Medicine 4-Nephrology and Hypertension, Paracelsus Private Medical School Nuremberg, Nuremberg, Germany.
| | | | - Manfred Rauh
- Research Laboratory, Division of Paediatrics, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Ruo-Ning Sun
- Clinical Imaging Research Centre, Centre for Translational Medicine, Singapore
| | - Armin M Nagel
- Institute of Radiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany; German Cancer Research Center (DKFZ), Division of Medical Physics in Radiology, Heidelberg, Germany
| | - Peter Linz
- Institute of Radiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Tzy Tiing Lim
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore
| | | | | | - Sharon Saw
- Department of Laboratory Medicine, National University Hospital, Singapore
| | - Norihiko Morisawa
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore
| | - Wan Keat Yam
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore
| | - Shintaro Minegishi
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore
| | - John J Totman
- Clinical Imaging Research Centre, Centre for Translational Medicine, Singapore; Radiography and Medical Imaging Department, Fatima College of Health Sciences, Abu Dhabi, United Arab Emirates
| | - Serena Teo
- Clinical Imaging Research Centre, Centre for Translational Medicine, Singapore
| | - Louis L Y Teo
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Choon Ta Ng
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Kento Kitada
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Johannes Wild
- Center for Cardiology, Cardiology I, Johannes Gutenberg-University, Mainz, Germany
| | - Jean-Paul Kovalik
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore
| | - Friedrich C Luft
- Experimental and Clinical Research Center, Max-Delbrück Center for Molecular Medicine, Medical Faculty of the Charité, Berlin, Germany
| | - Peter J Greasley
- Early Discovery and Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Calvin W L Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - David K L Sim
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Jens Titze
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore; III. Department of Medicine and Hamburg Center for Kidney Health (HCKH), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Nephrology, Duke University Medical Center, Durham, North Carolina, USA.
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2
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Heerspink HJL, Greasley PJ, Ahlström C, Althage M, Dwyer JP, Law G, Wijkmark E, Lin M, Mercier AK, Sunnåker M, Turton M, Wheeler DC, Ambery P. Efficacy and safety of zibotentan and dapagliflozin in patients with chronic kidney disease: study design and baseline characteristics of the ZENITH-CKD trial. Nephrol Dial Transplant 2024; 39:414-425. [PMID: 37632201 PMCID: PMC10899767 DOI: 10.1093/ndt/gfad183] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Sodium-glucose co-transporter 2 inhibitors (SGLT2is) are part of the standard of care for patients with chronic kidney disease (CKD), both with and without type 2 diabetes. Endothelin A (ETA) receptor antagonists have also been shown to slow progression of CKD. Differing mechanisms of action of SGLT2 and ETA receptor antagonists may enhance efficacy. We outline a study to evaluate the effect of combination zibotentan/dapagliflozin versus dapagliflozin alone on albuminuria and estimated glomerular filtration rate (eGFR). METHODS We are conducting a double-blind, active-controlled, Phase 2b study to evaluate the efficacy and safety of ETA receptor antagonist zibotentan and SGLT2i dapagliflozin in a planned 415 adults with CKD (Zibotentan and Dapagliflozin for the Treatment of CKD; ZENITH-CKD). Participants are being randomized (1:2:2) to zibotentan 0.25 mg/dapagliflozin 10 mg once daily (QD), zibotentan 1.5 mg/dapagliflozin 10 mg QD and dapagliflozin 10 mg QD alone, for 12 weeks followed by a 2-week off-treatment wash-out period. The primary endpoint is the change in log-transformed urinary albumin-to-creatinine ratio (UACR) from baseline to Week 12. Other outcomes include change in blood pressure from baseline to Week 12 and change in eGFR the study. The incidence of adverse events will be monitored. Study protocol-defined events of special interest include changes in fluid-related measures (weight gain or B-type natriuretic peptide). RESULTS A total of 447 patients were randomized and received treatment in placebo/dapagliflozin (n = 177), zibotentan 0.25 mg/dapagliflozin (n = 91) and zibotentan 1.5 mg/dapagliflozin (n = 179). The mean age was 62.8 years, 30.9% were female and 68.2% were white. At baseline, the mean eGFR of the enrolled population was 46.7 mL/min/1.73 m2 and the geometric mean UACR was 538.3 mg/g. CONCLUSION This study evaluates the UACR-lowering efficacy and safety of zibotentan with dapagliflozin as a potential new treatment for CKD. The study will provide information about an effective and safe zibotentan dose to be further investigated in a Phase 3 clinical outcome trial. CLINICAL TRIAL REGISTRATION NUMBER NCT04724837.
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Affiliation(s)
- Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Peter J Greasley
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Christine Ahlström
- DMPK, Research and Early Development Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Magnus Althage
- Translational Science & Experimental Medicine, Research and Early Development Cardiovascular, Renal, and Metabolism, Biopharmaceutical R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Jamie P Dwyer
- Division of Nephrology/Hypertension, University of Utah Health, Salt Lake City, UT, USA
| | - Gordon Law
- Early Biometrics & Statistical Innovation, Data Science and Artificial Intelligence, R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Emma Wijkmark
- Biometrics Late Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Min Lin
- Biometrics Late Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Anne-Kristina Mercier
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Mikael Sunnåker
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Michelle Turton
- Biopharma Clinical Operations, Early CVRM, AstraZeneca, Cambridge, UK
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Philip Ambery
- Clinical Late Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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3
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Verma S, Mudaliar S, Greasley PJ. Potential Underlying Mechanisms Explaining the Cardiorenal Benefits of Sodium-Glucose Cotransporter 2 Inhibitors. Adv Ther 2024; 41:92-112. [PMID: 37943443 PMCID: PMC10796581 DOI: 10.1007/s12325-023-02652-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/17/2023] [Indexed: 11/10/2023]
Abstract
There is a bidirectional pathophysiological interaction between the heart and the kidneys, and prolonged physiological stress to the heart and/or the kidneys can cause adverse cardiorenal complications, including but not limited to subclinical cardiomyopathy, heart failure and chronic kidney disease. Whilst more common in individuals with Type 2 diabetes, cardiorenal complications also occur in the absence of diabetes. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) were initially approved to reduce hyperglycaemia in patients with Type 2 diabetes. Recently, these agents have been shown to significantly improve cardiovascular and renal outcomes in patients with and without Type 2 diabetes, demonstrating a robust reduction in hospitalisation for heart failure and reduced risk of progression of chronic kidney disease, thus gaining approval for use in treatment of heart failure and chronic kidney disease. Numerous potential mechanisms have been proposed to explain the cardiorenal effects of SGLT2i. This review provides a simplified summary of key potential cardiac and renal mechanisms underlying the cardiorenal benefits of SGT2i and explains these mechanisms in the clinical context. Key mechanisms related to the clinical effects of SGLT2i on the heart and kidneys explained in this publication include their impact on (1) tissue oxygen delivery, hypoxia and resultant ischaemic injury, (2) vascular health and function, (3) substrate utilisation and metabolic health and (4) cardiac remodelling. Knowing the mechanisms responsible for SGLT2i-imparted cardiorenal benefits in the clinical outcomes will help healthcare practitioners to identify more patients that can benefit from the use of SGLT2i.
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Affiliation(s)
- Subodh Verma
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.
| | - Sunder Mudaliar
- Endocrinology/Diabetes Section, Veterans Affairs Medical Centre, San Diego, CA, USA
- Department of Medicine, University of California, San Diego, CA, USA
| | - Peter J Greasley
- Early Discovery and Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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4
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Lee NHC, Kiddle SJ, Chandankhede S, Agrawal S, Bean DM, Hunt PR, Parker VER, Greasley PJ, Ambery P. Evaluating clinical outcomes and prognosis in patients with cirrhosis and portal hypertension: a retrospective observational cohort study. BMJ Open Gastroenterol 2023; 10:e001234. [PMID: 38030407 PMCID: PMC10689413 DOI: 10.1136/bmjgast-2023-001234] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVE Cirrhosis describes the end-stage of chronic liver disease. Irreversible changes in the liver cause portal hypertension, which can progress to serious complications and death. Only a few studies with small sample sizes have investigated the prognosis of cirrhosis with portal hypertension. We used electronic healthcare records to examine liver-related outcomes in patients with diagnosed/suspected portal hypertension. DESIGN This retrospective observational cohort study used secondary health data between 1 January 2017 and 3 December 2020 from the TriNetX Network, a federated electronic healthcare records platform. Three patient groups with cirrhosis and diagnosed/suspected portal hypertension were identified ('most severe', 'moderate severity' and 'least severe'). Outcomes studied individually and as a composite were variceal haemorrhage, hepatic encephalopathy, complications of ascites and recorded mortality up to 24 months. RESULTS There were 13 444, 23 299, and 23 836 patients in the most severe, moderate severity and least severe groups, respectively. Mean age was similar across groups; most participants were white. The most common individual outcomes at 24 months were variceal haemorrhage in the most severe group, recorded mortality and hepatic encephalopathy in the moderate severity group, and recorded mortality in the least severe group. Recorded mortality rate was similar across groups. For the composite outcome, cumulative incidence was 59% in the most severe group at 6 months. Alcohol-associated liver disease and metabolic-associated steatohepatitis were significantly associated with the composite outcome across groups. CONCLUSION Our analysis of a large dataset from electronic healthcare records illustrates the poor prognosis of patients with diagnosed/suspected portal hypertension.
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Affiliation(s)
| | - Steven J Kiddle
- Data Science & Advanced Analytics, Data Science & Artificial Intelligence, R&D, AstraZeneca, Cambridge, UK
| | | | - Shubh Agrawal
- Real World Evidence, ZS Associates, Bangalore, India
| | - Daniel M Bean
- Data Science & Advanced Analytics, Data Science & Artificial Intelligence, R&D, AstraZeneca, Cambridge, UK
| | - Phillip R Hunt
- Medical Affairs, Cardiovascular, Renal and Metabolism, AstraZeneca, Gaithersburg, Maryland, USA
| | - Victoria E R Parker
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Peter J Greasley
- Early Clinical Development, Research and Early Development, Cardiovascular Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Philip Ambery
- Clinical Late Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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5
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Koshino A, Neuen BL, Jongs N, Pollock C, Greasley PJ, Andersson EM, Hammarstedt A, Karlsson C, Langkilde AM, Wada T, Heerspink HJL. Effects of dapagliflozin and dapagliflozin-saxagliptin on erythropoiesis, iron and inflammation markers in patients with type 2 diabetes and chronic kidney disease: data from the DELIGHT trial. Cardiovasc Diabetol 2023; 22:330. [PMID: 38017482 PMCID: PMC10685512 DOI: 10.1186/s12933-023-02027-8] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/12/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND This post-hoc analysis of the DELIGHT trial assessed effects of the SGLT2 inhibitor dapagliflozin on iron metabolism and markers of inflammation. METHODS Patients with type 2 diabetes and albuminuria were randomized to dapagliflozin, dapagliflozin and saxagliptin, or placebo. We measured hemoglobin, iron markers (serum iron, transferrin saturation, and ferritin), plasma erythropoietin, and inflammatory markers (urinary MCP-1 and urinary/serum IL-6) at baseline and week 24. RESULTS 360/461 (78.1%) participants had available biosamples. Dapagliflozin and dapagliflozin-saxagliptin, compared to placebo, increased hemoglobin by 5.7 g/L (95%CI 4.0, 7.3; p < 0.001) and 4.4 g/L (2.7, 6.0; p < 0.001) and reduced ferritin by 18.6% (8.7, 27.5; p < 0.001) and 18.4% (8.7, 27.1; p < 0.001), respectively. Dapagliflozin reduced urinary MCP-1/Cr by 29.0% (14.6, 41.0; p < 0.001) and urinary IL-6/Cr by 26.6% (9.1, 40.7; p = 0.005) with no changes in other markers. CONCLUSIONS Dapagliflozin increased hemoglobin and reduced ferritin and urinary markers of inflammation, suggesting potentially important effects on iron metabolism and inflammation. TRIAL REGISTRATION ClinicalTrials.gov NCT02547935.
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Affiliation(s)
- Akihiko Koshino
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
| | - Carol Pollock
- Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, Australia
- Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Peter J Greasley
- BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Eva-Marie Andersson
- BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Ann Hammarstedt
- BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Cecilia Karlsson
- BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | | | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands.
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia.
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6
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Heerspink HJL, Kiyosue A, Wheeler DC, Lin M, Wijkmark E, Carlson G, Mercier AK, Åstrand M, Ueckert S, Greasley PJ, Ambery P. Zibotentan in combination with dapagliflozin compared with dapagliflozin in patients with chronic kidney disease (ZENITH-CKD): a multicentre, randomised, active-controlled, phase 2b, clinical trial. Lancet 2023; 402:2004-2017. [PMID: 37931629 DOI: 10.1016/s0140-6736(23)02230-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND In patients with chronic kidney disease, SGLT2 inhibitors and endothelin A receptor antagonists (ERAs) can reduce albuminuria and glomerular filtration rate (GFR) decline. We assessed the albuminuria-lowering efficacy and safety of the ERA zibotentan combined with the SGLT2 inhibitor dapagliflozin. METHODS ZENITH-CKD was a multicentre, randomised, double-blind, active-controlled clinical trial, done in 170 clinical practice sites in 18 countries. Adults (≥18 to ≤90 years) with an estimated GFR (eGFR) of 20 mL/min per 1·73 m2 or greater and a urinary albumin-to-creatinine ratio (UACR) of 150-5000 mg/g were randomly assigned (2:1:2) to 12 weeks of daily treatment with zibotentan 1·5 mg plus dapagliflozin 10 mg, zibotentan 0·25 mg plus dapagliflozin 10 mg, or dapagliflozin 10 mg plus placebo, as adjunct to angiotensin-converting enzyme inhibitors or angiotensin receptor blockers if tolerated. The primary endpoint was a change from baseline in log-transformed UACR (zibotentan 1·5 mg plus dapagliflozin vs dapagliflozin plus placebo) at week 12. Fluid retention was an event of special interest, defined as an increase in bodyweight of at least 3% (at least 2·5% must have been from total body water) from baseline or an increase of at least 100% in B-type natriuretic peptide (BNP) and either a BNP concentration greater than 200 pg/mL if without atrial fibrillation or BNP greater than 400 pg/mL if with atrial fibrillation. This trial is registered with ClinicalTrials.gov, NCT04724837, and is completed. FINDINGS Between April 28, 2021, and Jan 17, 2023, we assessed 1492 participants for eligibility. For the main analysis, we randomly assigned 449 (30%) participants, 447 (99%) of whom (mean age 62·8 years [SD 12·1], 138 [31%] female, 309 [69%] male, 305 [68%] White, mean eGFR 46·7 mL/min per 1·73 m2 [SD 22·4], and median UACR 565·5 mg/g [IQR 243·0-1212·6]) received treatment with zibotentan 1·5 mg plus dapagliflozin (n=179 [40%]), zibotentan 0·25 mg plus dapagliflozin (n=91 [20%]), or dapagliflozin plus placebo (n=177 [40%]). Zibotentan 1·5 mg plus dapagliflozin and zibotentan 0·25 mg plus dapagliflozin reduced UACR versus dapagliflozin plus placebo throughout the treatment period of the study. At week 12, the difference in UACR versus dapagliflozin plus placebo was -33·7% (90% CI -42·5 to -23·5; p<0·0001) for zibotentan 1·5 mg plus dapagliflozin and -27·0% (90% CI -38·4 to -13·6; p=0·0022) for zibotentan 0·25 mg plus dapagliflozin. Fluid-retention events were observed in 33 (18%) of 179 participants in the zibotentan 1·5 mg plus dapagliflozin group, eight (9%) of 91 in the zibotentan 0·25 mg plus dapagliflozin group, and 14 (8%) of 177 in the dapagliflozin plus placebo group. INTERPRETATION Zibotentan combined with dapagliflozin reduced albuminuria with an acceptable tolerability and safety profile and is an option to reduce chronic kidney disease progression in patients already receiving currently recommended therapy. FUNDING AstraZeneca.
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Affiliation(s)
- Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands; The George Institute for Global Health, Sydney, NSW, Australia.
| | | | - David C Wheeler
- Department of Nephrology, University College London, London, UK
| | - Min Lin
- Biometrics Late Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Emma Wijkmark
- Biometrics Late Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Glenn Carlson
- Clinical Development, Late Cardiovascular, Renal and Metabolism, AstraZeneca, Gothenburg, Sweden
| | - Anne-Kristina Mercier
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Magnus Åstrand
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Sebastian Ueckert
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Peter J Greasley
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Phil Ambery
- Clinical Late Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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7
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Veenit V, Heerspink HJL, Ahlström C, Greasley PJ, Skritic S, van Zuydam N, Kohan DE, Hansen PBL, Menzies RI. The sodium glucose co-transporter 2 inhibitor dapagliflozin ameliorates the fluid-retaining effect of the endothelin A receptor antagonist zibotentan. Nephrol Dial Transplant 2023; 38:2289-2297. [PMID: 37102226 PMCID: PMC10539223 DOI: 10.1093/ndt/gfad078] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Endothelin A receptor antagonists (ETARA) slow chronic kidney disease (CKD) progression but their use is limited due to fluid retention and associated clinical risks. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) cause osmotic diuresis and improve clinical outcomes in CKD and heart failure. We hypothesized that co-administration of the SGLT2i dapagliflozin with the ETARA zibotentan would mitigate the fluid retention risk using hematocrit (Hct) and bodyweight as proxies for fluid retention. METHODS Experiments were performed in 4% salt fed WKY rats. First, we determined the effect of zibotentan (30, 100 or 300 mg/kg/day) on Hct and bodyweight. Second, we assessed the effect of zibotentan (30 or 100 mg/kg/day) alone or in combination with dapagliflozin (3 mg/kg/day) on Hct and bodyweight. RESULTS Hct at Day 7 was lower in zibotentan versus vehicle groups [zibotentan 30 mg/kg/day, 43% (standard error 1); 100 mg/kg/day, 42% (1); and 300 mg/kg/day, 42% (1); vs vehicle, 46% (1); P < .05], while bodyweight was numerically higher in all zibotentan groups compared with vehicle. Combining zibotentan with dapagliflozin for 7 days prevented the change in Hct [zibotentan 100 mg/kg/day and dapagliflozin, 45% (1); vs vehicle 46% (1); P = .44] and prevented the zibotentan-driven increase in bodyweight (zibotentan 100 mg/kg/day + dapagliflozin 3 mg/kg/day = -3.65 g baseline corrected bodyweight change; P = .15). CONCLUSIONS Combining ETARA with SGLT2i prevents ETARA-induced fluid retention, supporting clinical studies to assess the efficacy and safety of combining zibotentan and dapagliflozin in individuals with CKD.
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Affiliation(s)
- Vandana Veenit
- Bioscience Renal, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Christine Ahlström
- DMPK, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Peter J Greasley
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Stanko Skritic
- Innovation Strategies & External Liaison, Pharmaceutical Technologies & Development, AstraZeneca, Gothenburg, Sweden; Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Natalie van Zuydam
- Biostatistics Sweden, Data Science and Quantitative Biology, Discovery Sciences, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Donald E Kohan
- Division of Nephrology, University of Utah Health, Salt Lake City, UT, USA
| | - Pernille B L Hansen
- Bioscience Renal, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Robert I Menzies
- Bioscience Renal, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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8
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Carracedo M, Ericson E, Ågren R, Forslöw A, Madeyski-Bengtson K, Svensson A, Riddle R, Christoffersson J, González-King Garibotti H, Lazovic B, Hicks R, Buvall L, Fornoni A, Greasley PJ, Lal M. APOL1 promotes endothelial cell activation beyond the glomerulus. iScience 2023; 26:106830. [PMID: 37250770 PMCID: PMC10209455 DOI: 10.1016/j.isci.2023.106830] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/27/2023] [Accepted: 05/03/2023] [Indexed: 05/31/2023] Open
Abstract
Apolipoprotein L1 (APOL1) high-risk genotypes are associated with increased risk of chronic kidney disease (CKD) in people of West African ancestry. Given the importance of endothelial cells (ECs) in CKD, we hypothesized that APOL1 high-risk genotypes may contribute to disease via EC-intrinsic activation and dysfunction. Single cell RNA sequencing (scRNA-seq) analysis of the Kidney Precision Medicine Project dataset revealed APOL1 expression in ECs from various renal vascular compartments. Utilizing two public transcriptomic datasets of kidney tissue from African Americans with CKD and a dataset of APOL1-expressing transgenic mice, we identified an EC activation signature; specifically, increased intercellular adhesion molecule 1 (ICAM-1) expression and enrichment in leukocyte migration pathways. In vitro, APOL1 expression in ECs derived from genetically modified human induced pluripotent stem cells and glomerular ECs triggered changes in ICAM-1 and platelet endothelial cell adhesion molecule 1 (PECAM-1) leading to an increase in monocyte attachment. Overall, our data suggest the involvement of APOL1 as an inducer of EC activation in multiple renal vascular beds with potential effects beyond the glomerular vasculature.
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Affiliation(s)
- Miguel Carracedo
- Bioscience Renal, Research and Early Development, Cardiovascular , Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Elke Ericson
- Genome Engineering, Discovery Biology, Discovery Sciences, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Rasmus Ågren
- Translational Science and Experimental Medicine, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anna Forslöw
- Translational Genomics, Discovery Biology, Discovery Sciences, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Katja Madeyski-Bengtson
- Translational Genomics, Discovery Biology, Discovery Sciences, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anna Svensson
- Translational Genomics, Discovery Biology, Discovery Sciences, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Rebecca Riddle
- Department of Pharmacology, University of Cambridge, Cambridge, UK
| | - Jonas Christoffersson
- Bioscience Cardiovascular, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Hernán González-King Garibotti
- Bioscience Cardiovascular, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Bojana Lazovic
- Genome Engineering, Discovery Biology, Discovery Sciences, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
- BioPharmaceuticals R&D Cell Therapy, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), AstraZeneca, Gothenburg, Sweden
| | - Ryan Hicks
- BioPharmaceuticals R&D Cell Therapy, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), AstraZeneca, Gothenburg, Sweden
- School of Cardiovascular and Metabolic Medicine and Sciences, King’s College London, London, UK
| | - Lisa Buvall
- Bioscience Renal, Research and Early Development, Cardiovascular , Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Alessia Fornoni
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Peggy and Harold Katz Family Drug Discovery Center, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Peter J. Greasley
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Mark Lal
- Bioscience Renal, Research and Early Development, Cardiovascular , Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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9
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Ern Yeoh S, Docherty KF, Campbell RT, Jhund PS, Hammarstedt A, Heerspink HJL, Jarolim P, Køber L, Kosiborod MN, Martinez FA, Ponikowski P, Solomon SD, Sjöstrand M, Bengtsson O, Greasley PJ, Sattar N, Welsh P, Sabatine MS, Morrow DA, McMurray JJV. Endothelin-1, Outcomes in Patients With Heart Failure and Reduced Ejection Fraction, and Effects of Dapagliflozin: Findings From DAPA-HF. Circulation 2023; 147:1670-1683. [PMID: 37039015 DOI: 10.1161/circulationaha.122.063327] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
BACKGROUND ET-1 (endothelin-1) is implicated in the pathophysiology of heart failure and renal disease. Its prognostic importance and relationship with kidney function in patients with heart failure with reduced ejection fraction receiving contemporary treatment are uncertain. We investigated these and the efficacy of dapagliflozin according to ET-1 level in the DAPA-HF trial (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure). METHODS We investigated the incidence of the primary outcome (cardiovascular death or worsening heart failure), change in kidney function, and the effect of dapagliflozin according to baseline ET-1 concentration, adjusting in Cox models for other recognized prognostic variables in heart failure including NT-proBNP (N-terminal pro-B-type natriuretic peptide). We also examined the effect of dapagliflozin on ET-1 level. RESULTS Overall, 3048 participants had baseline ET-1 measurements of: tertile 1 (T1; ≤3.28 pg/mL; n=1016); T2 (>3.28-4.41 pg/mL; n=1022); and T3 (>4.41 pg/mL; n=1010). Patients with higher ET-1 were more likely male, more likely obese, and had lower left ventricular ejection fraction, lower estimated glomerular filtration rate, worse functional status, and higher NT-proBNP and hs-TnT (high-sensitivity troponin-T). In the adjusted Cox models, higher baseline ET-1 was independently associated with worse outcomes and steeper decline in kidney function (adjusted hazard ratio for primary outcome of 1.95 [95% CI, 1.53-2.50] for T3 and 1.36 [95% CI, 1.06-1.75] for T2; both versus T1; estimated glomerular filtration rate slope: T3, -3.19 [95% CI, -3.66 to -2.72] mL/min/1.73 m2/y, T2, -2.08 [95% CI, -2.52 to -1.63] and T1 -2.35 [95% CI, -2.79 to -1.91]; P=0.002). The benefit of dapagliflozin was consistent regardless of baseline ET-1, and the placebo-corrected decrease in ET-1 with dapagliflozin was 0.13 pg/mL (95% CI, 0.25-0.01; P=0.029). CONCLUSIONS Higher baseline ET-1 concentration was independently associated with worse clinical outcomes and more rapid decline in kidney function. The benefit of dapagliflozin was consistent across the range of ET-1 concentrations measured, and treatment with dapagliflozin led to a small decrease in serum ET-1 concentration. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03036124.
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Affiliation(s)
- Su Ern Yeoh
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (S.E.Y., K.F.D., R.T.C., P.S.J., N.S., P.W., J.J.V.M.)
| | - Kieran F Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (S.E.Y., K.F.D., R.T.C., P.S.J., N.S., P.W., J.J.V.M.)
| | - Ross T Campbell
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (S.E.Y., K.F.D., R.T.C., P.S.J., N.S., P.W., J.J.V.M.)
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (S.E.Y., K.F.D., R.T.C., P.S.J., N.S., P.W., J.J.V.M.)
| | - Ann Hammarstedt
- BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (A.H., M.S., O.B., P.J.G.)
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, The Netherlands (H.J.L.H.)
- George Institute for Global Health, University of New South Wales, Sydney, Australia (H.J.L.H.)
| | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital, Boston, MA. (P.J.)
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (L.K.)
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City (M.N.K.)
| | | | - Piotr Ponikowski
- Center for Heart Diseases, University Hospital, Wroclaw Medical University, Poland (P.P.)
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA. (S.D.S.)
| | - Mikaela Sjöstrand
- BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (A.H., M.S., O.B., P.J.G.)
| | - Olof Bengtsson
- BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (A.H., M.S., O.B., P.J.G.)
| | - Peter J Greasley
- BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (A.H., M.S., O.B., P.J.G.)
| | - Naveed Sattar
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (S.E.Y., K.F.D., R.T.C., P.S.J., N.S., P.W., J.J.V.M.)
| | - Paul Welsh
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (S.E.Y., K.F.D., R.T.C., P.S.J., N.S., P.W., J.J.V.M.)
| | - Marc S Sabatine
- TIMI Study Group, Brigham and Women's Hospital, Boston, MA. (M.S.S., D.A.M.)
| | - David A Morrow
- TIMI Study Group, Brigham and Women's Hospital, Boston, MA. (M.S.S., D.A.M.)
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (S.E.Y., K.F.D., R.T.C., P.S.J., N.S., P.W., J.J.V.M.)
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10
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Blundell H, Ambery P, Arnold M, Brookes-Smith I, Kiddle S, Greasley PJ, Berry C. Comorbidity and medication use in patients with angina due to a coronary vasomotion disorder. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Microvascular angina and vasospastic angina are disorders of coronary vasomotion. The associations between these conditions, comorbidity and medication use in relatively unselected populations is not well described.
Aim
To describe the proportions of patients with concomitant morbidity and related medication use in an international, contemporary, clinical database.
Methods
TriNetX, a global federated health research network with access to anonymized electronical medical records (EMRs) from participating healthcare organizations including academic medical centres, specialty physician practices, and community hospitals, predominantly in the USA was used. The ICD10 code (I20.1) representing “Angina pectoris with documented spasm” was used as a primary search term. ICD10 codes were also used for cardiorenal and metabolic conditions. Medication use was classified as occurring prior to or on the date of the angina episode. The time-period for defining the analysis population was 01.01.2017–31.12.2019. The population age was ≥18 years.
Results
Data were available on 12,200 individuals (mean (SD) age 63 (13) years; 63% female). The % of individuals with a concomitant diagnosis is described in Table 1. Hypertension occurred in almost two thirds of individuals, an anxiety disorder affected more than one quarter and type 2 diabetes and/or obesity occurred in one fifth. Medication use is described in Table 2. Half of patients received a calcium channel blocker therapy. Nitroglycerin, beta-blockers, and isosorbide mononitrate were less commonly used (45%, 45% and 23%, respectively). Most (58%) patients were prescribed an antacid. Half of patients received statin treatment (50% overall; 36% atorvastatin) and insulin (12%) and metformin (9%) were the most commonly prescribed antidiabetic medications.
Conclusions
Angina associated with coronary spasm associates with female sex and cardio-metabolic risk factors. Contemporary pharmacotherapy for diabetes and statins appear to be under-used.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): AstraZeneca
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Affiliation(s)
- H Blundell
- University of Oxford , Oxford , United Kingdom
| | - P Ambery
- AstraZeneca , Gothenburg , Sweden
| | - M Arnold
- AstraZeneca , Cambridge , United Kingdom
| | | | - S Kiddle
- AstraZeneca , Cambridge , United Kingdom
| | | | - C Berry
- University of Glasgow , Glasgow , United Kingdom
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11
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Squire IB, Gabrielsen A, Greasley PJ, Wernevik L, Hartleib‐Geschwindner J, Holden J, Johansson S, Rudvik A, Sánchez J, Bamberg K, Melin J, Whittaker A. Effect of AZD9977 and spironolactone on serum potassium in heart failure with preserved or mildly reduced ejection fraction, and renal impairment: A randomized trial. Clin Transl Sci 2022; 15:2493-2504. [PMID: 35971596 PMCID: PMC9579384 DOI: 10.1111/cts.13377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/23/2022] [Accepted: 07/13/2022] [Indexed: 01/25/2023] Open
Abstract
This phase Ib study compared the effects of AZD9977, a selective mineralocorticoid receptor modulator with predicted low hyperkalemia risk, with spironolactone on serum potassium (sK+ ) in patients with heart failure (HF) with preserved or mildly reduced ejection fraction (EF; ≥40%), and renal impairment. Patients with HF with EF greater than or equal to 40% and estimated glomerular filtration rate of 40-70 ml/min/1.73 m2 were randomized to once-daily AZD9977 100 mg or spironolactone 25 mg for 14 days, up-titrated to AZD9977 200 mg or spironolactone 50 mg for another 14 days. The primary end point was relative change (%) in sK+ for AZD9977 versus spironolactone (baseline to day 28). Serum/urinary electrolytes, fractional excretion (FE) of Na+ /K+ , plasma aldosterone, cortisol, and renin, and safety were also assessed. Sixty-eight patients were randomized (AZD9977, n = 33; spironolactone, n = 35). Mean (SD) age was 73.0 (8.5) years, 51.5% men. Mean sK+ change from baseline to day 28 was 5.7% (AZD9977) and 4.2% (spironolactone), and 1.5% and 4.2% at day 14. Relative change (95% confidence interval) in sK+ with AZD9977 versus spironolactone was -0.3% (-5.3% to 4.4%; day 28), and 3.4% (-0.8% to 7.5%; day 14). Median increase from baseline in plasma aldosterone at day 28 was 89.8 pmol/L for AZD9977 and 67.4 pmol/L for spironolactone. Median FE of K+ was 12.9% (AZD9977) and 10.1% (spironolactone). AZD9977 was well-tolerated. No discontinuations due to hyperkalemia occurred with either treatment. Evidence of target engagement for AZD9977 with a favorable safety profile, supports further evaluation of AZD9977 in patients with HF and renal impairment.
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Affiliation(s)
- Iain B. Squire
- NIHR Biomedical Research CentreGlenfield HospitalLeicesterUK,Department of Cardiovascular SciencesUniversity of LeicesterLeicesterUK
| | - Anders Gabrielsen
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and MetabolismBioPharmaceuticals R&D, AstraZenecaGothenburgSweden
| | - Peter J. Greasley
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and MetabolismBioPharmaceuticals R&D, AstraZenecaGothenburgSweden
| | - Linda Wernevik
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and MetabolismBioPharmaceuticals R&D, AstraZenecaGothenburgSweden
| | - Judith Hartleib‐Geschwindner
- Late‐stage Development, Cardiovascular, Renal, and MetabolismBioPharmaceuticals R&D, AstraZenecaGothenburgSweden
| | - Julie Holden
- Global Drug Safety, Oncology R&DAstraZenecaGaithersburgMarylandUSA
| | - Susanne Johansson
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and MetabolismBioPharmaceuticals R&D, AstraZenecaGothenburgSweden
| | - Anna Rudvik
- Early Biometrics and Statistical Innovation, Data Science and AIBioPharmaceuticals R&D, AstraZenecaGothenburgSweden
| | - José Sánchez
- Early Biometrics and Statistical Innovation, Data Science and AIBioPharmaceuticals R&D, AstraZenecaGothenburgSweden
| | - Krister Bamberg
- Translational Sciences and Experimental Medicines, Research and Early Development, Cardiovascular, Renal and MetabolismBioPharmaceuticals R&D, AstraZenecaGothenburgSweden
| | - Johanna Melin
- Clinical & Quantitative Pharmacology, Clinical Pharmacology and Safety SciencesR&D, AstraZenecaGothenburgSweden
| | - Andrew Whittaker
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and MetabolismBioPharmaceuticals R&D, AstraZenecaCambridgeUK
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12
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Adamson C, Cowan LM, de Boer RA, Diez M, Drożdż J, Dukát A, Inzucchi SE, Køber L, Kosiborod MN, Ljungman CE, Martinez FA, Ponikowski P, Sabatine MS, Lindholm D, Bengtsson O, Boulton DW, Greasley PJ, Langkilde AM, Sjöstrand M, Solomon SD, McMurray JJ, Jhund PS. Liver tests and outcomes in heart failure with reduced ejection fraction: findings from DAPA-HF. Eur J Heart Fail 2022; 24:1856-1868. [PMID: 36054568 PMCID: PMC9805158 DOI: 10.1002/ejhf.2649] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/22/2022] [Accepted: 07/31/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS Reflecting both increased venous pressure and reduced cardiac output, abnormal liver tests are common in patients with severe heart failure and are associated with adverse clinical outcomes. We aimed to investigate the prognostic significance of abnormal liver tests in ambulatory patients with heart failure with reduced ejection fraction (HFrEF), explore any treatment interaction between bilirubin and sodium-glucose cotransporter 2 (SGLT2) inhibitors and examine change in liver tests with SGLT2 inhibitor treatment. METHODS AND RESULTS We explored these objectives in the Dapagliflozin And Prevention of Adverse outcomes in Heart Failure (DAPA-HF) trial, with focus on bilirubin. We calculated the incidence of cardiovascular death or worsening heart failure by bilirubin tertile. Secondary cardiovascular outcomes were examined, along with the change in liver tests at the end-of-study visit. Baseline bilirubin was available in 4720 patients (99.5%). Participants in the highest bilirubin tertile (T3) have more severe HFrEF (lower left ventricular ejection fraction, higher N-terminal pro-B-type natriuretic peptide [NT-proBNP] and worse New York Heart Association class), had a greater burden of atrial fibrillation but less diabetes. Higher bilirubin (T3 vs. T1) was associated with worse outcomes even after adjustment for other predictive variables, including NT-proBNP and troponin T (adjusted hazard ratio for the primary outcome 1.73 [95% confidence interval 1.37-2.17], p < 0.001; and 1.52 [1.12-2.07], p = 0.01 for cardiovascular death). Baseline bilirubin did not modify the benefits of dapagliflozin. During follow-up, dapagliflozin had no effect on liver tests. CONCLUSION Bilirubin concentration was an independent predictor of worse outcomes but did not modify the benefits of dapagliflozin in HFrEF. Dapagliflozin was not associated with change in liver tests. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT03036124.
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Affiliation(s)
- Carly Adamson
- BHF Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
| | - Lorna M. Cowan
- BHF Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
| | - Rudolf A. de Boer
- Department of CardiologyUniversity Medical Center and University of GroningenGroningenThe Netherlands
| | - Mirta Diez
- Division of CardiologyInstitute Cardiovascular de Buenos AiresBuenos AiresArgentina
| | | | - Andre Dukát
- Fifth Department of Internal MedicineComenius University in BratislavaBratislavaSlovakia
| | | | - Lars Køber
- Department of Cardiology, RigshospitaletCopenhagen University HospitalCopenhagenDenmark
| | - Mikhail N. Kosiborod
- Saint Luke's Mid America Heart InstituteUniversity of MissouriKansas CityMOUSA
- The George Institute for Global HealthUniversity of New South WalesSydneyNSWAustralia
| | - Charlotta E.A. Ljungman
- Institute of Medicine, Department of Molecular and Clinical Medicine/Cardiology, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | | | - Piotr Ponikowski
- Center for Heart Diseases, University HospitalWroclaw Medical UniversityWroclawPoland
| | - Marc S. Sabatine
- TIMI Study Group, Division of Cardiovascular MedicineBrigham and Women's HospitalBostonMAUSA
| | - Daniel Lindholm
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Olof Bengtsson
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - David W. Boulton
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&DAstraZenecaGaithersburgMDUSA
| | - Peter J. Greasley
- Early Research and Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Anna Maria Langkilde
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Mikaela Sjöstrand
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Scott D. Solomon
- Division of Cardiovascular MedicineBrigham and Women's HospitalBostonMAUSA
| | | | - Pardeep S. Jhund
- BHF Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
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Sen T, Scholtes R, Greasley PJ, Cherney DZI, Dekkers CCJ, Vervloet M, Danser AHJ, Barbour SJ, Karlsson C, Hammarstedt A, Li Q, Laverman GD, Bjornstad P, van Raalte DH, Heerspink HJL. Effects of dapagliflozin on volume status and systemic haemodynamics in patients with chronic kidney disease without diabetes: Results from DAPASALT and DIAMOND. Diabetes Obes Metab 2022; 24:1578-1587. [PMID: 35478433 PMCID: PMC9262818 DOI: 10.1111/dom.14729] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/15/2022] [Accepted: 04/26/2022] [Indexed: 12/30/2022]
Abstract
AIMS To assess the effect of sodium-glucose cotransporter-2 inhibitor dapagliflozin on natriuresis, blood pressure (BP) and volume status in patients with chronic kidney disease (CKD) without diabetes. MATERIALS AND METHODS We performed a mechanistic open-label study (DAPASALT) to evaluate the effects of dapagliflozin on 24-hour sodium excretion, 24-hour BP, extracellular volume, and markers of volume status during a standardized sodium diet (150 mmol/d) in six patients with CKD. In parallel, in a placebo-controlled double-blind crossover trial (DIAMOND), we determined the effects of 6 weeks of dapagliflozin on markers of volume status in 53 patients with CKD. RESULTS In DAPASALT (mean age 65 years, mean estimated glomerular filtration rate [eGFR] 39.4 mL/min/1.73 m2 , median urine albumin:creatinine ratio [UACR] 111 mg/g), dapagliflozin did not change 24-hour sodium and volume excretion during 2 weeks of treatment. Dapagliflozin was associated with a modest increase in 24-hour glucose excretion on Day 4, which persisted at Day 14 and reversed to baseline after discontinuation. Mean 24-hour systolic BP decreased by -9.3 (95% confidence interval [CI] -19.1, 0.4) mmHg after 4 days and was sustained at Day 14 and at wash-out. Renin, angiotensin II, urinary aldosterone and copeptin levels increased from baseline. In DIAMOND (mean age 51 years, mean eGFR 59.0 mL/min/1.73 m2 , median UACR 608 mg/g), compared to placebo, dapagliflozin increased plasma renin (38.5 [95% CI 7.4, 78.8]%), aldosterone (19.1 [95% CI -5.9, 50.8]%), and copeptin levels (7.3 [95% CI 0.1, 14.5] pmol/L). CONCLUSIONS During a standardized sodium diet, dapagliflozin decreased BP but did not increase 24-hour sodium and volume excretion. The lack of increased natriuresis and diuresis may be attributed to activation of intra-renal compensatory mechanisms to prevent excessive water loss.
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Affiliation(s)
- Taha Sen
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
| | - Rosalie Scholtes
- Diabetes Centre, Department of Internal MedicineAmsterdam University Medical Centres, Location VU University Medical CenterAmsterdamThe Netherlands
| | - Peter J. Greasley
- Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - David Z. I. Cherney
- Division of Nephrology, Department of MedicineUniversity Health Network and University of TorontoTorontoOntarioCanada
| | - Claire C. J. Dekkers
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
| | - Marc Vervloet
- Department of Nephrology and Amsterdam Cardiovascular SciencesAmsterdam University Medical CenterAmsterdamThe Netherlands
| | - Alexander H. J. Danser
- Division of Pharmacology and Vascular Medicine, Department of Internal MedicineErasmus MCRotterdamThe Netherlands
| | - Sean J. Barbour
- Division of Nephrology, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Cecilia Karlsson
- Late‐stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Ann Hammarstedt
- Late‐stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Qiang Li
- The George Institute for Global HealthUNSW SydneySydneyNew South WalesAustralia
| | | | - Petter Bjornstad
- Department of Pediatrics, Division of EndocrinologyUniversity of Colorado School of MedicineAuroraColoradoUSA
- Department of Medicine, Division of NephrologyUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Daniel H. van Raalte
- Diabetes Centre, Department of Internal MedicineAmsterdam University Medical Centres, Location VU University Medical CenterAmsterdamThe Netherlands
| | - Hiddo J. L. Heerspink
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
- The George Institute for Global HealthUNSW SydneySydneyNew South WalesAustralia
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14
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Aoki Y, Cabrera CS, Ouwens M, Bamberg K, Nyström J, Raz I, Scirica BM, Hamrén B, Greasley PJ, Rekić D. Bilirubin levels and kidney function decline: An analysis of clinical trial and real world data. PLoS One 2022; 17:e0269970. [PMID: 35727760 PMCID: PMC9212140 DOI: 10.1371/journal.pone.0269970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/30/2022] [Indexed: 11/18/2022] Open
Abstract
Objective To evaluate if previously found associations between low serum bilirubin concentration and kidney function decline is independent of hemoglobin and other key confounders. Research design and methods Clinical trial data from the SAVOR-TIMI 53 trial as well as the UK primary care electronic healthcare records, Clinical Practice Research Datalink (CPRD), were used to construct three cohorts of patients at risk of chronic kidney disease (CKD). The randomized clinical trial (RCT) cohort from the subset of SAVOR-TIMI 53 trial consisted of 10,555 type-2 diabetic patients with increased risk of cardiovascular disease. The two observational data cohorts from CPRD consisted of 71,104 newly diagnosed type-2 diabetes (CPRD-DM2) and 82,065 newly diagnosed hypertensive (CPRD-HT) patients without diabetes. Cohorts were stratified according to baseline circulating total bilirubin levels to determine association on the primary end point of a 30% reduction from baseline in estimated glomerular filtration rate (eGFR) and the secondary end point of albuminuria. Results The confounder adjusted hazard ratios of the subpopulation with lower than median bilirubin levels compared to above median bilirubin levels for the primary end point were 1.18 (1.02–1.37), 1.12 (1.05–1.19) and 1.09 (1.01–1.17), for the secondary end point were 1.26 (1.06–1.52), 1.11 (1.01–1.21) and 1.18 (1.01–1.39) for SAVOR-TIMI 53, CPRD-DM2, CPRD-HT, respectively. Conclusion Our findings are consistent across all cohorts and endpoints: lower serum bilirubin levels are associated with a greater kidney function decline independent of hemoglobin and other key confounders. This suggests that increased monitoring of kidney health in patients with lower bilirubin levels may be considered, especially for diabetic patients.
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Affiliation(s)
- Yasunori Aoki
- Clinical Pharmacology and Safety Sciences, AstraZeneca, Gothenburg, Sweden
| | - Claudia S. Cabrera
- Real World Science and Digital, BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | - Mario Ouwens
- Biometrics Oncology, AstraZeneca, Gothenburg, Sweden
| | - Krister Bamberg
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal, and Metabolism (CVRM) BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Jenny Nyström
- The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Itamar Raz
- Hadassah University Hospital, Jerusalem, Israel
| | - Benjamin M. Scirica
- Brigham and Women’s Hospital Heart & Vascular Center, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Bengt Hamrén
- Clinical Pharmacology and Safety Sciences, AstraZeneca, Gothenburg, Sweden
| | - Peter J. Greasley
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal, and Metabolism (CVRM) BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Dinko Rekić
- Clinical Pharmacology and Safety Sciences, AstraZeneca, Gothenburg, Sweden
- * E-mail:
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15
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Abraham GR, Kuc RE, Althage M, Greasley PJ, Ambery P, Maguire JJ, Wilkinson IB, Hoole SP, Cheriyan J, Davenport AP. Endothelin-1 is increased in the plasma of patients hospitalised with Covid-19. J Mol Cell Cardiol 2022; 167:92-96. [PMID: 35339512 PMCID: PMC8941861 DOI: 10.1016/j.yjmcc.2022.03.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/25/2022] [Accepted: 03/19/2022] [Indexed: 12/03/2022]
Abstract
Virus induced endothelial dysregulation is a well-recognised feature of severe Covid-19 infection. Endothelin-1 (ET-1) is the most highly expressed peptide in endothelial cells and a potent vasoconstrictor, thus representing a potential therapeutic target. ET-1 plasma levels were measured in a cohort of 194 Covid-19 patients stratified according to the clinical severity of their illness. Hospitalised patients, including those who died and those developing acute myocardial or kidney injury, had significantly elevated ET-1 plasma levels during the acute phase of infection. The results support the hypothesis that endothelin receptor antagonists may provide clinical benefit for certain Covid-19 patients.
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Affiliation(s)
- George R Abraham
- Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK; Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.
| | - Rhoda E Kuc
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Magnus Althage
- Late-stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Peter J Greasley
- Late-stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Philip Ambery
- Late-stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Janet J Maguire
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Ian B Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Stephen P Hoole
- Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
| | - Joseph Cheriyan
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Clinical Pharmacology Department and Cardiovascular Office, Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Anthony P Davenport
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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16
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Yeoh SE, Docherty KF, Jhund PS, Petrie MC, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P, Sabatine MS, Bengtsson O, Boulton DW, Greasley PJ, Langkilde AM, Sjöstrand M, Solomon SD, McMurray JJV. Relationship of Dapagliflozin With Serum Sodium: Findings From the DAPA-HF Trial. JACC Heart Fail 2022; 10:306-318. [PMID: 35483792 DOI: 10.1016/j.jchf.2022.01.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVES This study aimed to assess the prognostic importance of hyponatremia and the effects of dapagliflozin on serum sodium in the DAPA-HF (Dapagliflozin And Prevention of Adverse outcomes in Heart Failure) trial. BACKGROUND Hyponatremia is common and prognostically important in hospitalized patients with heart failure with reduced ejection fraction, but its prevalence and importance in ambulatory patients are uncertain. METHODS We calculated the incidence of the primary outcome (cardiovascular death or worsening heart failure) and secondary outcomes according to sodium category (≤135 and >135 mmol/L). Additionally, we assessed: 1) whether baseline serum sodium modified the treatment effect of dapagliflozin; and 2) the effect of dapagliflozin on serum sodium. RESULTS Of 4,740 participants with a baseline measurement, 398 (8.4%) had sodium ≤135 mmol/L. Participants with hyponatremia were more likely to have diabetes, be treated with diuretics, and have lower systolic blood pressure, left ventricular ejection fraction, and estimated glomerular filtration rate. Hyponatremia was associated with worse outcomes even after adjustment for predictive variables (adjusted HRs for the primary outcome 1.50 [95% CI: 1.23-1.84] and all-cause death 1.59 [95% CI: 1.26-2.01]). The benefits of dapagliflozin were similar in patients with and without hyponatremia (HR for primary endpoint: 0.83 [95% CI: 0.57-1.19] and 0.73 [95% CI: 0.63-0.84], respectively, P for interaction = 0.54; HR for all-cause death: 0.85 [95% CI: 0.56-1.29] and 0.83 [95% CI: 0.70-0.98], respectively, P for interaction = 0.96). Between baseline and day 14, more patients on dapagliflozin developed hyponatremia (11.3% vs 9.4%; P = 0.04); thereafter, this pattern reversed and at 12 months fewer patients on dapagliflozin had hyponatremia (4.6% vs 6.7%; P = 0.003). CONCLUSIONS Baseline serum sodium concentration was prognostically important, but did not modify the benefits of dapagliflozin on morbidity and mortality in heart failure with reduced ejection fraction. (Study to Evaluate the Effect of Dapagliflozin on the Incidence of Worsening Heart Failure or Cardiovascular Death in Patients With Chronic Heart Failure [DAPA-HF]: NCT03036124).
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Affiliation(s)
- Su Ern Yeoh
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Kieran F Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City, Missouri, USA; and The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | | - Piotr Ponikowski
- Center for Heart Diseases, University Hospital, Wroclaw Medical University, Poland
| | - Marc S Sabatine
- TIMI Study Group, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Olof Bengtsson
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - David W Boulton
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - Peter J Greasley
- Early Research and Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anna Maria Langkilde
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Mikaela Sjöstrand
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
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17
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Scholtes RA, Muskiet MH, van Baar MJ, Hesp AC, Greasley PJ, Hammarstedt A, Karlsson C, Hallow KM, Danser AJ, Heerspink HJ, van Raalte DH. The adaptive renal response for volume homeostasis during two weeks of dapagliflozin treatment in people with type 2 diabetes and preserved renal function on a sodium-controlled diet. Kidney Int Rep 2022; 7:1084-1092. [PMID: 35570989 PMCID: PMC9091605 DOI: 10.1016/j.ekir.2022.02.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 12/20/2022] Open
Abstract
Introduction Proximal tubule sodium uptake is diminished following sodium glucose cotransporter 2 (SGLT2) inhibition. We previously showed that during SGLT2 inhibition, the kidneys adapt by increasing sodium uptake at distal tubular segments, thereby maintaining body sodium balance. Despite continuous glycosuria, we detected no increased urine volumes. We therefore assessed the adaptive renal responses to prevent excessive fluid loss. Methods We conducted a mechanistic open-label study in people with type 2 diabetes mellitus with preserved kidney function, who received a standardized sodium intake (150 mmol/d) to evaluate the effects of dapagliflozin on renin-angiotensin-aldosterone system (RAAS) hormones, volume-related biomarkers, urinary albumin-to-creatinine ratio (UACR), and estimated glomerular filtration rate (eGFR), at start of treatment (day 4), end of treatment (day 14), and follow-up (day 18). Results A total of 14 people were enrolled. Plasma renin and angiotensin II and urinary aldosterone and angiotensinogen were acutely and persistently increased during treatment with dapagliflozin. Plasma copeptin level was numerically increased after 4 days (21%). Similarly, fractional urea excretion was significantly decreased at start of treatment (−17%). Free water clearance was significantly decreased after 4 days (−74%) and 14 days (−41%). All changes reversed after dapagliflozin discontinuation. Conclusion Dapagliflozin-induced osmotic diuresis triggers kidney adaptive mechanisms to maintain volume and sodium balance in people with type 2 diabetes and preserved kidney function. ClinicalTrials.gov (identification: NCT03152084).
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18
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Fitzpatrick JK, Yang J, Ambrosy AP, Cabrera C, Stefansson BV, Greasley PJ, Patel J, Tan TC, Go AS. Loop and thiazide diuretic use and risk of chronic kidney disease progression: a multicentre observational cohort study. BMJ Open 2022; 12:e048755. [PMID: 35105612 PMCID: PMC8808372 DOI: 10.1136/bmjopen-2021-048755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To evaluate the association between diuretic use by class with chronic kidney disease (CKD) progression and onset of end-stage renal disease (ESRD). DESIGN Retrospective cohort study. SETTING Large integrated healthcare delivery system in Northern California. PARTICIPANTS Adults with an estimated glomerular filtration rate (eGFR) 15-59 min/1.73 m2 by the CKD-Epidemiology Collaboration equation with no prior diuretic use. MAIN OUTCOME MEASURES ESRD and a renal composite outcome including eGFR <15 mL/min/1.73 m2, 50% reduction in eGFR and/or ESRD. RESULTS Among 47 666 eligible adults with eGFR 15-59 min/1.73 m2 and no previous receipt of loop or thiazide diuretics, mean age was 71 years, 49% were women and 26% were persons of colour. Overall, the rate (per 100 person-years) of the renal composite outcome was 1.35 (95% CI: 1.30 to 1.41) and 0.42 (95% CI: 0.39 to 0.45) for ESRD. Crude rates (per 100 person-years) of the composite renal outcome were higher in patients who initiated loop diuretics (12.85 (95% CI: 11.81 to 13.98) vs 1.06 (95% CI: 1.02 to 1.12)) and thiazide diuretics (2.68 (95% CI: 2.33 to 3.08) vs 1.29 (95% CI: 1.24 to 1.35)) compared with those who did not. Crude rates (per 100-person years) of ESRD where higher in patients who initiated loop diuretics (4.92 (95% CI: 4.34 to 5.59) vs 0.30 (95% CI: 0.28 to 0.33)), but not in those who initiated thiazide diuretics (0.30 (95% CI: 0.20 to 0.46) vs 0.43 (95% CI: 0.40 to 0.46)). However, neither initiation of diuretics or type of diuretic were significantly associated with CKD progression or ESRD after accounting for receipt of other medications and time-dependent confounders using causal inference methods. CONCLUSIONS The use of thiazide and loop diuretics was not independently associated with an increased risk of CKD progression and/or ESRD in adults with stage 3/4 CKD.
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Affiliation(s)
- Jesse K Fitzpatrick
- Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Jingrong Yang
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Andrew P Ambrosy
- Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | | | | | | | - Jignesh Patel
- Nephrology, Kaiser Permanente Roseville Medical Center, Roseville, California, USA
| | - Thida C Tan
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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Yu H, Basu S, Tang W, Penland RC, Greasley PJ, Oscarsson J, Boulton DW, Hallow KM. Predicted Cardiac Functional Responses to Renal Actions of SGLT2i in the DAPACARD Trial Population: A Mathematical Modeling Analysis. J Clin Pharmacol 2021; 62:541-554. [PMID: 34657303 DOI: 10.1002/jcph.1987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/11/2021] [Indexed: 11/07/2022]
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2is) have been shown to reduce the risk of worsening heart failure (HF) in subjects with HF and a reduced ejection fraction (HFrEF) in multiple clinical trials. The DAPACARD clinical trial was conducted to examine the effects of DAPAgliflozin on CARDiac substrate uptake, myocardial efficiency, and myocardial contractile work in type 2 diabetes mellitus (T2DM) subjects. As a complement to the clinical study, a mechanistic mathematical model of cardiorenal physiology was used to quantify the influence of established natriuretic/diuretic effects of SGLT2i on cardiac function (myocardial efficiency and global longitudinal strain). Virtual participants reflecting the participant-level characteristics in the DAPACARD trial were produced by varying model parameters over physiologically plausible ranges. A second virtual population was generated by inducing a state of HFrEF in the DAPACARD T2DM virtual participants (DAPACARD-HFrEF virtual participants) for comparison. Cardiac responses to placebo and SGLT2i were simulated over 42 days. Cardiac hemodynamic improvements were predicted in DAPACARD-HFrEF virtual participants but not in DAPACARD virtual participants. In particular, the natriuresis/diuresis induced by SGLT2i improved the global longitudinal strain and myocardial efficiency in DAPACARD-HFrEF virtual participants within the first 14 days (change from baseline: global longitudinal strain: -0.95% and myocardial efficiency: 0.34%), whereas the global longitudinal strain and myocardial efficiency in DAPACARD virtual participants were slightly worse (change from baseline: global longitudinal strain: 0.35% and myocardial efficiency: -0.01%). The results of the DAPACARD virtual participants modeling were in line with the clinical data but do not preclude additional effects from other mechanisms of SGLT2i. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Hongtao Yu
- School of Chemical, Materials, and Biomedical Engineering, University of Georgia, Athens, Georgia, USA
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - Sanchita Basu
- School of Chemical, Materials, and Biomedical Engineering, University of Georgia, Athens, Georgia, USA
| | - Weifeng Tang
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - Robert C Penland
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Boston, Massachusetts, USA
| | - Peter J Greasley
- Early Clinical Development, Research, and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceutical R&D, AstraZeneca, Gothenburg, Sweden
| | - Jan Oscarsson
- Late Clinical Development, Cardiovascular, Renal and Metabolism, BioPharmaceutical R&D, AstraZeneca, Gothenburg, Sweden
| | - David W Boulton
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - K Melissa Hallow
- School of Chemical, Materials, and Biomedical Engineering, University of Georgia, Athens, Georgia, USA
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, Georgia, USA
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20
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Edwards NC, Price AM, Mehta S, Hiemstra TF, Kaur A, Greasley PJ, Webb DJ, Dhaun N, MacIntyre IM, Farrah T, Melville V, Herrey AS, Slinn G, Wale R, Ives N, Wheeler DC, Wilkinson I, Steeds RP, Ferro CJ, Townend JN. Effects of Spironolactone and Chlorthalidone on Cardiovascular Structure and Function in Chronic Kidney Disease: A Randomized, Open-Label Trial. Clin J Am Soc Nephrol 2021; 16:1491-1501. [PMID: 34462286 PMCID: PMC8499017 DOI: 10.2215/cjn.01930221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/16/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES In a randomized double-blind, placebo-controlled trial, treatment with spironolactone in early-stage CKD reduced left ventricular mass and arterial stiffness compared with placebo. It is not known if these effects were due to BP reduction or specific vascular and myocardial effects of spironolactone. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A prospective, randomized, open-label, blinded end point study conducted in four UK centers (Birmingham, Cambridge, Edinburgh, and London) comparing spironolactone 25 mg to chlorthalidone 25 mg once daily for 40 weeks in 154 participants with nondiabetic stage 2 and 3 CKD (eGFR 30-89 ml/min per 1.73 m2). The primary end point was change in left ventricular mass on cardiac magnetic resonance imaging. Participants were on treatment with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker and had controlled BP (target ≤130/80 mm Hg). RESULTS There was no significant difference in left ventricular mass regression; at week 40, the adjusted mean difference for spironolactone compared with chlorthalidone was -3.8 g (95% confidence interval, -8.1 to 0.5 g, P=0.08). Office and 24-hour ambulatory BPs fell in response to both drugs with no significant differences between treatment. Pulse wave velocity was not significantly different between groups; at week 40, the adjusted mean difference for spironolactone compared with chlorthalidone was 0.04 m/s (-0.4 m/s, 0.5 m/s, P=0.90). Hyperkalemia (defined ≥5.4 mEq/L) occurred more frequently with spironolactone (12 versus two participants, adjusted relative risk was 5.5, 95% confidence interval, 1.4 to 22.1, P=0.02), but there were no patients with severe hyperkalemia (defined ≥6.5 mEq/L). A decline in eGFR >30% occurred in eight participants treated with chlorthalidone compared with two participants with spironolactone (adjusted relative risk was 0.2, 95% confidence interval, 0.05 to 1.1, P=0.07). CONCLUSIONS Spironolactone was not superior to chlorthalidone in reducing left ventricular mass, BP, or arterial stiffness in nondiabetic CKD.
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Affiliation(s)
- Nicola C. Edwards
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom,Department of Cardiology, Green Lane Cardiovascular Unit, Auckland, New Zealand
| | - Anna M. Price
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom,Department of Nephrology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Samir Mehta
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Thomas F. Hiemstra
- Cambridge Clinical Trials Unit, Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom,GlaxoSmithKline, England, United Kingdom
| | - Amreen Kaur
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | - Peter J. Greasley
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - David J. Webb
- Center for Cardiovascular Science and Clinical Research Center, University of Edinburgh, United Kingdom
| | - Neeraj Dhaun
- Center for Cardiovascular Science and Clinical Research Center, University of Edinburgh, United Kingdom,Department of Nephrology, National Health Services Lothian, Edinburgh, United Kingdom
| | - Iain M. MacIntyre
- Center for Cardiovascular Science and Clinical Research Center, University of Edinburgh, United Kingdom,Department of Nephrology, National Health Services Lothian, Edinburgh, United Kingdom
| | - Tariq Farrah
- Center for Cardiovascular Science and Clinical Research Center, University of Edinburgh, United Kingdom,Department of Nephrology, National Health Services Lothian, Edinburgh, United Kingdom
| | - Vanessa Melville
- Center for Cardiovascular Science and Clinical Research Center, University of Edinburgh, United Kingdom
| | - Anna S. Herrey
- UCL Institute of Cardiovascular Science and Department of Cardiology, Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom
| | - Gemma Slinn
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Rebekah Wale
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Natalie Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - David C. Wheeler
- Department of Renal Medicine, University College London, United Kingdom,George Institute for Global Health, Sydney, Australia
| | - Ian Wilkinson
- Cambridge Clinical Trials Unit, Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom,GlaxoSmithKline, England, United Kingdom
| | - Richard P. Steeds
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom,Department of Cardiology, Queen Elizabeth Hospital Birmingham, United Kingdom
| | - Charles J. Ferro
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom,Department of Nephrology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Jonathan N. Townend
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom,Department of Cardiology, Queen Elizabeth Hospital Birmingham, United Kingdom
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21
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Althage M, Heinrich TM, Miliotis T, Bogstedt A, Ma L, Gautreaux MD, Hicks PJ, Palmer ND, MacPhee I, Hartleib-Geschwindner J, Greasley PJ, Freedman BI. Urine APOL1 Isoforms Reflect Plasma-Derived Liver-Synthesized Proteins. J Am Soc Nephrol 2021; 32:2442-2444. [PMID: 34162735 PMCID: PMC8722785 DOI: 10.1681/asn.2021030411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/04/2021] [Accepted: 06/17/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
- Magnus Althage
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Timothy M. Heinrich
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Tasso Miliotis
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anna Bogstedt
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Lijun Ma
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael D. Gautreaux
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Pamela J. Hicks
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nicholette D. Palmer
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Iain MacPhee
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Judith Hartleib-Geschwindner
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Peter J. Greasley
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Barry I. Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina
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22
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van der Aart‐van der Beek AB, Cherney D, Laverman GD, Stefansson B, van Raalte DH, Hoogenberg K, Reyner D, Li Q, Di Tanna GL, Greasley PJ, Heerspink HJL. Renal haemodynamic response to sodium-glucose cotransporter-2 inhibition does not depend on protein intake: An analysis of three randomized controlled trials. Diabetes Obes Metab 2021; 23:1961-1967. [PMID: 33908683 PMCID: PMC8360160 DOI: 10.1111/dom.14411] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/14/2021] [Accepted: 04/26/2021] [Indexed: 12/17/2022]
Abstract
High protein intake may increase intraglomerular pressure through dilation of the afferent arteriole. Sodium-glucose cotransporter-2 (SGLT2) inhibitors may reduce intraglomerular pressure through activation of tubuloglomerular feedback. Given these opposing effects, we assessed whether the effect of dapagliflozin on glomerular filtration rate (GFR) and urinary albumin-to-creatinine ratio (UACR) was modified by estimated dietary protein intake using data from three separate randomized controlled trials (DELIGHT, IMPROVE and DIAMOND). The median protein intake was 58.4, 63.6 and 90.0 g/d, respectively. In the DELIGHT trial (n = 233), dapagliflozin compared to placebo caused an acute and reversible dip in GFR of 2.1 and 2.2 mL/min/1.73 m2 , and reduced UACR by 20.5% and 28.4% in participants with high and low protein intake, respectively. Similarly, in IMPROVE (n = 30) and DIAMOND (n = 53), the effect of dapagliflozin on GFR and UACR was comparable in participants with high and low protein intake (all P for interaction > 0.40). This post hoc, exploratory analysis of three clinical trials suggests that dietary protein intake does not modify the individual response of clinical kidney variables to dapagliflozin.
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Affiliation(s)
| | - David Cherney
- Division of Nephrology, Department of MedicineUniversity Health Network and University of TorontoTorontoOntarioCanada
| | | | - Bergur Stefansson
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Daniel H. van Raalte
- Diabetes Centre, Department of Internal MedicineAmsterdam University Medical Centers, Location VUMCAmsterdamThe Netherlands
| | - Klaas Hoogenberg
- Internal MedicineUniversity of GroningenGroningenThe Netherlands
| | - Daniel Reyner
- R&D Bio Pharmaceuticals, Late CVRMAstraZenecaGaithersburgMarylandUSA
| | - Qiang Li
- George Institute for Global HealthUniversity of New South Wales SydneySydneyNew South WalesAustralia
| | - Gian Luca Di Tanna
- George Institute for Global HealthUniversity of New South Wales SydneySydneyNew South WalesAustralia
| | - Peter J. Greasley
- Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Hiddo J. L. Heerspink
- Clinical Pharmacy and PharmacologyUniversity of GroningenGroningenThe Netherlands
- George Institute for Global HealthUniversity of New South Wales SydneySydneyNew South WalesAustralia
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23
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Stefánsson BV, Heerspink HJL, Wheeler DC, Sjöström CD, Greasley PJ, Sartipy P, Cain V, Correa-Rotter R. Data from a pooled post hoc analysis of 14 placebo-controlled, dapagliflozin treatment studies in patients with type 2 diabetes with and without anemia at baseline. Data Brief 2021; 37:107237. [PMID: 34258337 PMCID: PMC8255174 DOI: 10.1016/j.dib.2021.107237] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 06/03/2021] [Accepted: 06/18/2021] [Indexed: 11/26/2022] Open
Abstract
Dapagliflozin is a highly selective sodium-glucose cotransporter 2 inhibitor associated with stabilization of estimated glomerular filtration rate (eGFR); reductions in glycated hemoglobin (HbA1c), systolic blood pressure, body weight, and albuminuria; and a small and consistent increase in hematocrit [1], [2], [3], [4]. This data set is based on the associated article [5] analyzing data from 5325 patients with type 2 diabetes from 14 placebo-controlled, phase 3 (one phase 2/3), double-blind dapagliflozin treatment studies of 24-104 weeks' duration. Data on dapagliflozin's effects (vs. placebo) on hemoglobin (Hb), hematocrit, serum albumin, serum total protein concentrations, urine albumin/creatinine ratio, eGFR, heart rate, blood pressure, body weight, and safety in patients with type 2 diabetes with and without anemia were pooled and analyzed. Patients were divided into two groups according to baseline Hb levels: anemia (Hb <13 g/dL in men and <12 g/dL in women) and no anemia. Some biomarkers associated with erythropoiesis and the presence of anemia, such as iron, transferrin, ferritin, reticulocytes, and hepcidin, were not included in the original studies and therefore data for these biomarkers were not available. Descriptive statistics were used for baseline characteristics and safety data and a longitudinal repeated-measures mixed model for efficacy data. Changes in Hb concentrations were evaluated, and the proportion of patients with baseline anemia who were no longer anemic at week 24 was determined, as was the occurrence of polycythemia (Hb >16.5 g/dL in men and >16.0 g/dL in women). Because anemia commonly occurs in patients with diabetes and chronic kidney disease [6], the data can be of value to further analyze trends in relevant physiological and pathophysiological parameters.
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Affiliation(s)
- Bergur V Stefánsson
- Late-stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Hiddo J L Heerspink
- Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands.,George Institute for Global Health, Sydney, Australia
| | - David C Wheeler
- George Institute for Global Health, Sydney, Australia.,Department of Renal Medicine, University College London, London, United Kingdom
| | - C David Sjöström
- Late-stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Peter J Greasley
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Peter Sartipy
- Late-stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden.,Systems Biology Research Center, School of Bioscience, University of Skövde, Skövde, Sweden
| | - Valerie Cain
- Bogier Clinical and IT Solutions, Raleigh, North Carolina, United States
| | - Ricardo Correa-Rotter
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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24
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Levin A, Reznichenko A, Witasp A, Liu P, Greasley PJ, Sorrentino A, Blondal T, Zambrano S, Nordström J, Bruchfeld A, Barany P, Ebefors K, Erlandsson F, Patrakka J, Stenvinkel P, Nyström J, Wernerson A. Novel insights into the disease transcriptome of human diabetic glomeruli and tubulointerstitium. Nephrol Dial Transplant 2021; 35:2059-2072. [PMID: 32853351 PMCID: PMC7716805 DOI: 10.1093/ndt/gfaa121] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 03/19/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Diabetic nephropathy (DN) is the most common cause of end-stage renal disease, affecting ∼30% of the rapidly growing diabetic population, and strongly associated with cardiovascular risk. Despite this, the molecular mechanisms of disease remain unknown. METHODS RNA sequencing (RNAseq) was performed on paired, micro-dissected glomerular and tubulointerstitial tissue from patients diagnosed with DN [n = 19, 15 males, median (range) age: 61 (30-85) years, chronic kidney disease stages 1-4] and living kidney donors [n = 20, 12 males, median (range) age: 56 (30-70) years]. RESULTS Principal component analysis showed a clear separation between glomeruli and tubulointerstitium transcriptomes. Differential expression analysis identified 1550 and 4530 differentially expressed genes, respectively (adjusted P < 0.01). Gene ontology and Kyoto Encyclopedia of Genes and Genomes enrichment analyses highlighted activation of inflammation and extracellular matrix (ECM) organization pathways in glomeruli, and immune and apoptosis pathways in tubulointerstitium of DN patients. Specific gene modules were associated with renal function in weighted gene co-expression network analysis. Increased messengerRNA (mRNA) expression of renal damage markers lipocalin 2 (LCN) and hepatitis A virus cellular receptor1 (HAVCR1) in the tubulointerstitial fraction was observed alongside higher urinary concentrations of the corresponding proteins neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1 (KIM-1) in DN patients. CONCLUSIONS Here we present the first RNAseq experiment performed on paired glomerular and tubulointerstitial samples from DN patients. We show that prominent disease-specific changes occur in both compartments, including relevant cellular processes such as reorganization of ECM and inflammation (glomeruli) as well as apoptosis (tubulointerstitium). The results emphasize the potential of utilizing high-throughput transcriptomics to decipher disease pathways and treatment targets in this high-risk patient population.
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Affiliation(s)
- Anna Levin
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anna Reznichenko
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anna Witasp
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Peidi Liu
- Department of Physiology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter J Greasley
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | | | - Sonia Zambrano
- KI/AZ Integrated Cardio Metabolic Center, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Johan Nordström
- Division of Transplantation, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Annette Bruchfeld
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Peter Barany
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Kerstin Ebefors
- Department of Physiology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Fredrik Erlandsson
- Late-Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Jaakko Patrakka
- KI/AZ Integrated Cardio Metabolic Center, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Peter Stenvinkel
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jenny Nyström
- Department of Physiology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Annika Wernerson
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden
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25
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van der Aart-van der Beek AB, Koomen JV, Dekkers CCJ, Barbour SJ, Boulton DW, Gansevoort RT, Greasley PJ, Abdul Gafor AH, Laverman GD, Li Q, Lim SK, Stevens J, Vervloet MG, Singh S, Cattran DC, Reich HN, Cherney DZI, Heerspink HJL. Evaluation of the Pharmacokinetics and Exposure-Response Relationship of Dapagliflozin in Patients without Diabetes and with Chronic Kidney Disease. Clin Pharmacokinet 2021; 60:517-525. [PMID: 33587286 PMCID: PMC8016788 DOI: 10.1007/s40262-020-00956-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVE Dapagliflozin, a sodium-glucose co-transporter inhibitor, was originally developed as an oral glucose-lowering drug for the treatment of type 2 diabetes mellitus. Emerging data suggest that cardiovascular and kidney benefits extend to patients without diabetes. Limited pharmacological data are, however, available in patients without diabetes. We aimed to characterise the pharmacokinetic profile of dapagliflozin in patients with chronic kidney disease without type 2 diabetes. METHODS Plasma samples were collected in a randomised, placebo-controlled, double-blind, cross-over trial (DIAMOND, NCT03190694, n = 53) that assessed the effects of 10 mg of dapagliflozin in patients with a glomerular filtration rate ≥ 25 mL/min/1.73 m2 and proteinuria > 500 mg/day. Mixed-effects models were used to develop a pharmacokinetic model and to evaluate the association between plasma exposure and response. RESULTS Plasma concentrations (n = 430 observations) from 48 patients (mean age 50.8 years, mean glomerular filtration rate 57.9 mL/min/1.73 m2, median proteinuria 1115 mg/24 h) were best described using a two-compartment model with first-order elimination. Apparent clearance and volume of distribution were 11.7 (95% confidence interval 10.7-12.7) L/h and 44.9 (95% confidence interval 39.0-50.9) L, respectively. Median dapagliflozin plasma exposure was 740.9 ng h/mL (2.5th-97.5th percentiles: 434.0-1615.3). Plasma exposure increased with decreasing kidney function. Every 100-ng h/mL increment in dapagliflozin plasma exposure was associated with a decrease in the urinary albumin:creatinine ratio (β = - 2.8%, p = 0.01), glomerular filtration rate (β = - 0.5 mL/min/1.73 m2, p < 0.01) and systolic blood pressure (β = - 0.4 mmHg, p = 0.03). CONCLUSIONS The dapagliflozin plasma concentration-time profile in patients with non-diabetic kidney disease appears similar to the profile of patients with diabetic kidney disease described in the literature. Furthermore, the plasma exposure was associated with changes in risk markers for kidney disease.
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Affiliation(s)
- Annemarie B van der Aart-van der Beek
- Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, PO Box 30 001, 9700 RB, Groningen, The Netherlands.,Clinical Pharmacy, Martini Hospital, Groningen, The Netherlands
| | - Jeroen V Koomen
- Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, PO Box 30 001, 9700 RB, Groningen, The Netherlands
| | - Claire C J Dekkers
- Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, PO Box 30 001, 9700 RB, Groningen, The Netherlands
| | - Sean J Barbour
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - David W Boulton
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Ron T Gansevoort
- Department of Nephrology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Peter J Greasley
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Abdul Halim Abdul Gafor
- Department of Medicine, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Gozewijn D Laverman
- Department of Internal Medicine, ZGT Hospital, Almelo and Hengelo, The Netherlands
| | - Qiang Li
- The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
| | - Soo Kun Lim
- Division of Nephrology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jasper Stevens
- Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, PO Box 30 001, 9700 RB, Groningen, The Netherlands
| | - Marc G Vervloet
- Department of Nephrology and Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Sunita Singh
- Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Daniel C Cattran
- Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Heather N Reich
- Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Hiddo J L Heerspink
- Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, PO Box 30 001, 9700 RB, Groningen, The Netherlands.
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26
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Scholtes RA, Muskiet MHA, van Baar MJB, Hesp AC, Greasley PJ, Karlsson C, Hammarstedt A, Arya N, van Raalte DH, Heerspink HJL. Natriuretic Effect of Two Weeks of Dapagliflozin Treatment in Patients With Type 2 Diabetes and Preserved Kidney Function During Standardized Sodium Intake: Results of the DAPASALT Trial. Diabetes Care 2021; 44:440-447. [PMID: 33318125 PMCID: PMC7818331 DOI: 10.2337/dc20-2604] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 11/08/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk for heart failure hospitalization potentially by inducing sodium excretion, osmotic diuresis, and plasma volume contraction. Few studies have investigated this hypothesis, but none have assessed cumulative sodium excretion with SGLT2 inhibition during standardized sodium intake in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS The DAPASALT trial was a mechanistic, nonrandomized, open-label study in patients with type 2 diabetes with preserved kidney function on a controlled standardized sodium diet (150 mmol/day). It evaluated the effects of dapagliflozin on sodium excretion, 24-h blood pressure, and extracellular, intracellular, and plasma volumes at the start of treatment (ST) (days 2-4), end of treatment (ET) (days 12-14), and follow-up (FU) (days 15-18). RESULTS Fourteen patients were included in the efficacy analysis. Mean (SD) baseline sodium excretion (150 [32] mmol/24-h) did not significantly change during treatment (change at ST: -7.0 mmol/24-h [95% CI -22.4, 8.4]; change at ET: 2.1 mmol/24-h [-28.8, 33.0]). Mean baseline 24-h systolic blood pressure was 128 (10) mmHg and significantly reduced at ST (-6.1 mmHg [-9.1, -3.1]; P < 0.001) and ET (-7.2 mmHg [-10.0, -4.3]; P < 0.001). Dapagliflozin did not significantly alter plasma volume or intracellular volume, while extracellular volume changed at ST (-0.7 L [-1.3, -0.1]; P = 0.02). As expected, 24-h urinary glucose excretion significantly increased during dapagliflozin treatment and reversed during FU. CONCLUSIONS During standardized sodium intake, dapagliflozin reduced blood pressure without clear changes in urinary sodium excretion, suggesting that factors other than natriuresis and volume changes may contribute to the blood pressure-lowering effects.
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Affiliation(s)
- Rosalie A Scholtes
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Marcel H A Muskiet
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Michiel J B van Baar
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Anne C Hesp
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | | | | | | | - Niki Arya
- BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD
| | - Daniël H van Raalte
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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27
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Stefánsson BV, Heerspink HJL, Wheeler DC, Sjöström CD, Greasley PJ, Sartipy P, Cain V, Correa-Rotter R. Correction of anemia by dapagliflozin in patients with type 2 diabetes. J Diabetes Complications 2020; 34:107729. [PMID: 32948397 DOI: 10.1016/j.jdiacomp.2020.107729] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/26/2020] [Accepted: 08/27/2020] [Indexed: 12/22/2022]
Abstract
AIMS Anemia is common in type 2 diabetes (T2D), particularly in patients with kidney impairment, and often goes unrecognized. Dapagliflozin treatment increases hemoglobin and serum erythropoietin levels. We investigated the effect of dapagliflozin 10-mg/day on hemoglobin in T2D patients with and without anemia. METHODS Data from 5325 patients from 14 placebo-controlled, dapagliflozin-treatment studies of at least 24-weeks duration were pooled. Dapagliflozin's effects (vs. placebo) on hemoglobin, serum albumin, estimated glomerular filtration rate (eGFR), systolic blood pressure, body weight, and safety in patients with and without anemia were evaluated. RESULTS At baseline, 13% of all T2D patients and 28% of those with chronic kidney disease (eGFR <60 mL/min/1.73 m2) had anemia. Hemoglobin increased continuously to at least week 8 and was sustained throughout 24-weeks follow-up in dapagliflozin-treated patients. Serum albumin increased in dapagliflozin-treated patients at week 4 and remained stable thereafter. Dapagliflozin was well tolerated and corrected anemia in 52% of patients with anemia at baseline (placebo: 26%). Incidences of new-onset anemia were lower in dapagliflozin-treated (2.3%) versus placebo-treated (6.5%) patients. CONCLUSIONS Treatment with dapagliflozin can correct and prevent anemia in T2D patients. A gradual increase in hemoglobin beyond week 4 may indicate an erythropoiesis-stimulating effect of sodium-glucose cotransporter 2 inhibition.
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Affiliation(s)
- Bergur V Stefánsson
- Late-stage Development Cardiovascular Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Hiddo J L Heerspink
- Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, the Netherlands; George Institute for Global Health, Sydney, Australia
| | - David C Wheeler
- George Institute for Global Health, Sydney, Australia; Department of Renal Medicine, University College London, London, United Kingdom
| | - C David Sjöström
- Late-stage Development Cardiovascular Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Peter J Greasley
- Research and Early Development, Cardiovascular Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Peter Sartipy
- Late-stage Development Cardiovascular Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden; Systems Biology Research Center, School of Bioscience, University of Skövde, Skövde, Sweden
| | - Valerie Cain
- Bogier Clinical and IT Solutions, Raleigh, NC, United States
| | - Ricardo Correa-Rotter
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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Forster BM, Nee R, Little DJ, Greasley PJ, Hughes JB, Gordon SM, Olson SW. Focal Segmental Glomerulosclerosis, Risk Factors for End Stage Kidney Disease, and Response to Immunosuppression. Kidney360 2020; 2:105-113. [PMID: 35368810 PMCID: PMC8785735 DOI: 10.34067/kid.0006172020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/30/2020] [Indexed: 02/04/2023]
Abstract
Background FSGS is a heterogeneic glomerular disease. Risk factors for kidney disease ESKD and the effect of immunosuppression treatment (IST) has varied in previously published cohorts. These cohorts were limited by relatively small case numbers, short follow-up, lack of racial/ethnic diversity, a mix of adult and pediatric patients, lack of renin-angiotensin-aldosterone system (RAAS) inhibition, or lack of subgroup analysis of IST. Methods We compared demographics, clinical characteristics, histopathology, and IST to long-term renal survival in a large, ethnically diverse, adult cohort of 338 patients with biopsy-proven FSGS with long-term follow-up in the era of RAAS inhibition using data from the US Department of Defense health care network. Results Multivariate analysis showed that nephrotic-range proteinuria (NRP), eGFR <60 ml/min per 1.73 m2, hypoalbuminemia, interstitial fibrosis and tubular atrophy, and interstitial inflammation at diagnosis and the absence of remission were all associated with worse long-term renal survival. IgM, C3, and a combination of IgM/C3 immunofluorescence staining were not associated with reduced renal survival. IST was not associated with improved renal survival in the whole cohort, or in a subgroup with NRP. However, IST was associated with better renal survival in a subgroup of patients with FSGS with both NRP and hypoalbuminemia and hypoalbuminemia alone. Conclusions Our study suggests that IST should be reserved for patients with FSGS and nephrotic syndrome. It also introduces interstitial inflammation as a potential risk factor for ESKD and does not support the proposed pathogenicity of IgM and complement activation.
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Affiliation(s)
- Benjamin M. Forster
- Walter Reed National Military Medical Center, Nephrology Department, Bethesda, Maryland
| | - Robert Nee
- Walter Reed National Military Medical Center, Nephrology Department, Bethesda, Maryland
| | - Dustin J. Little
- Walter Reed National Military Medical Center, Nephrology Department and Late Development, Cardiovascular, Renal and Metabolism BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland
| | - Peter J. Greasley
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - James B. Hughes
- Walter Reed National Military Medical Center, Nephrology Department, Bethesda, Maryland
| | - Sarah M. Gordon
- Tripler Army Medical Center, Nephrology Department, Honolulu, Hawaii
| | - Stephen W. Olson
- Walter Reed National Military Medical Center, Nephrology Department, Bethesda, Maryland
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29
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Karlsson C, Wallenius K, Walentinsson A, Greasley PJ, Miliotis T, Hammar M, Iaconelli A, Tapani S, Raffaelli M, Mingrone G, Carlsson B. Identification of Proteins Associated with the Early Restoration of Insulin Sensitivity After Biliopancreatic Diversion. J Clin Endocrinol Metab 2020; 105:5896394. [PMID: 32830851 PMCID: PMC7518464 DOI: 10.1210/clinem/dgaa558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 08/18/2020] [Indexed: 01/15/2023]
Abstract
CONTEXT Insulin resistance (IR) is a risk factor for type 2 diabetes, diabetic kidney disease, cardiovascular disease and nonalcoholic steatohepatitis. Biliopancreatic diversion (BPD) is the most effective form of bariatric surgery for improving insulin sensitivity. OBJECTIVE To identify plasma proteins correlating with the early restoration of insulin sensitivity after BPD. DESIGN Prospective single-center study including 20 insulin-resistant men with morbid obesity scheduled for BPD. Patient characteristics and blood samples were repeatedly collected from baseline up to 4 weeks postsurgery. IR was assessed by homeostatic model assessment for insulin resistance (HOMA-IR), Matsuda Index, and by studying metabolic profiles during meal tolerance tests. Unbiased proteomic analysis was performed to identify plasma proteins altered by BPD. Detailed plasma profiles were made on a selected set of proteins by targeted multiple reaction monitoring mass spectrometry (MRM/MS). Changes in plasma proteome were evaluated in relation to metabolic and inflammatory changes. RESULTS BPD resulted in improved insulin sensitivity and reduced body weight. Proteomic analysis identified 29 proteins that changed following BPD. Changes in plasma levels of afamin, apolipoprotein A-IV (ApoA4), and apolipoprotein A-II (ApoA2) correlated significantly with changes in IR. CONCLUSION Circulating levels of afamin, ApoA4, and ApoA2 were associated with and may contribute to the rapid improvement in insulin sensitivity after BPD.
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Affiliation(s)
- Cecilia Karlsson
- Late-stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Mölndal, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Correspondence and Reprint Requests: Cecilia Karlsson, MD, PhD, Assoc Prof, Late-stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden, Pepparedsleden 1, SE-431 83 Mölndal, Sweden. E-mail:
| | - Kristina Wallenius
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Mölndal, Sweden
| | - Anna Walentinsson
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Mölndal, Sweden
| | - Peter J Greasley
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Mölndal, Sweden
| | - Tasso Miliotis
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Mölndal, Sweden
| | - Mårten Hammar
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Mölndal, Sweden
| | | | - Sofia Tapani
- Early Biometrics and Statistical Innovation, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Mölndal, Sweden
| | - Marco Raffaelli
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Geltrude Mingrone
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Diabetes, King’s College London, London, United Kingdom
| | - Björn Carlsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Mölndal, Sweden
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30
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Yu H, Tang W, Greasley PJ, Penland RC, Boulton DW, Hallow KM. Predicted Cardiac Hemodynamic Consequences of the Renal Actions of SGLT2i in the DAPA-HF Study Population: A Mathematical Modeling Analysis. J Clin Pharmacol 2020; 61:636-648. [PMID: 33091173 DOI: 10.1002/jcph.1769] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/02/2020] [Indexed: 12/12/2022]
Abstract
The Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) study demonstrated that dapagliflozin, a sodium-glucose cotransporter-2 inhibitor (SGLT2i), reduced heart failure hospitalization and cardiovascular death in patients with heart failure with reduced ejection fraction (HF-rEF), with and without type 2 diabetes mellitus. Multiple potential mechanisms have been proposed to explain this benefit, which may be multifactorial. This study aimed to quantify the contribution of the known natriuretic/diuretic effects of SGLT2is to changes in cardiac hemodynamics, remodeling, and fluid homeostasis in the setting of HF-rEF. An integrated cardiorenal mathematical model was used to simulate inhibition of SGLT2 and its consequences on cardiac hemodynamics in a virtual population of HF-rEF patients generated by varying model parameters over physiologically plausible ranges and matching to baseline characteristics of individual DAPA-HF trial patients. Cardiovascular responses to placebo and SGLT2i over time were then simulated. The baseline characteristics of the HF-rEF virtual population and DAPA-HF were in good agreement. SGLT2i-induced diuresis and natriuresis that reduced blood volume and interstitial fluid volume, relative to placebo within 14 days. This resulted in decreased left ventricular end-diastolic volume and pressure, indicating reduced cardiac preload. Thereafter, blood volume and interstitial fluid volume again began to accumulate, but pressures and volumes remained shifted lower relative to placebo. After 1 year, left ventricle mass was lower and ejection fraction was higher than placebo. These simulations considered only hemodynamic consequences of the natriuretic/diuretic effects of SGLT2i, as other mechanisms may contribute additional benefits besides those predictions.
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Affiliation(s)
- Hongtao Yu
- School of Chemical, Materials, and Biomedical Engineering, University of Georgia, Athens, Georgia, USA
| | - Weifeng Tang
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - Peter J Greasley
- Early Clinical Development, Research, and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Robert C Penland
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, R&D, AstraZeneca, Boston, Massachusetts, USA
| | - David W Boulton
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - K Melissa Hallow
- School of Chemical, Materials, and Biomedical Engineering, University of Georgia, Athens, Georgia, USA
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, Georgia, USA
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31
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Cabrera CS, Lee AS, Olsson M, Schnecke V, Westman K, Lind M, Greasley PJ, Skrtic S. Impact of CKD Progression on Cardiovascular Disease Risk in a Contemporary UK Cohort of Individuals With Diabetes. Kidney Int Rep 2020; 5:1651-1660. [PMID: 33102957 PMCID: PMC7569691 DOI: 10.1016/j.ekir.2020.07.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 06/29/2020] [Accepted: 07/28/2020] [Indexed: 01/12/2023] Open
Abstract
Introduction It remains unclear whether an increased progression rate of chronic kidney disease (CKD) adds predictive information regarding cardiovascular disease (CVD) risk. The aim of this study was to evaluate the association between CKD progression, based on estimated glomerular filtration rate (eGFR) slope estimates and the risk for CVD. Methods We compared the updated eGFR slope calculated over multiple overlapping 2-year periods and the updated mean eGFR. Incident CKD subjects were selected from a prevalent population with diabetes (T2DM). Subjects from the UK Clinical Practice Research Data Link GOLD (CPRD) were followed from CKD diagnosis (n = 30,222) until heart failure (HF), myocardial infarction (MI), ischemic stroke (IS), or a composite end point including all 3 event types (MACE plus), mortality, database dropout, or end of study follow-up. Results Both the updated eGFR slope and updated mean eGFR were associated with MACE plus and HF. Updated eGFR slope decline of > –3 ml/min/1.73 m2 increased the risk for MACE plus (adjusted hazard ratio [HR] = 1.45; 95% confidence interval [CI], 1.26–1.67), HF (HR = 1.50; 95% CI, 1.27–1.76), and MI (HR = 1.39; 95% CI, 1.01–1.91). Conclusions This study strongly supports current evidence that CKD is an independent risk factor for CVD. From a clinical perspective, both rate of progression and cumulative status of CKD describe distinct aspects of the cardiorenal risk among persons with diabetes. This evidence is essential to enable more timely and improved use of treatments in this population.
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Affiliation(s)
- Claudia S Cabrera
- Real World Science and Digital, BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Alison S Lee
- Commonwealth Informatics, Inc., Waltham, Massachusetts, USA
| | - Marita Olsson
- AstraZeneca, Gothenburg, Sweden.,Department of Mathematical Sciences, Chalmers University of Technology, Gothenburg, Sweden
| | | | - Klara Westman
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Marcus Lind
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Medicine, NU-Hospital Group, Uddevalla Hospital, Uddevalla, Sweden
| | - Peter J Greasley
- AstraZeneca, Gothenburg, Sweden.,Early Clinical Development, Research and Early Development, Cardiovascular, Renal, and Metabolism (CVRM) BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Stanko Skrtic
- Innovation Strategies and External Liaison, Pharmaceutical Technology and Development, AstraZeneca Gothenburg, Gothenburg, Sweden.,Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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32
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Hallow KM, Boulton DW, Penland RC, Helmlinger G, Nieves EH, van Raalte DH, Heerspink HL, Greasley PJ. Renal Effects of Dapagliflozin in People with and without Diabetes with Moderate or Severe Renal Dysfunction: Prospective Modeling of an Ongoing Clinical Trial. J Pharmacol Exp Ther 2020; 375:76-91. [PMID: 32764153 DOI: 10.1124/jpet.120.000040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/09/2020] [Indexed: 12/25/2022] Open
Abstract
Sodium glucose cotransporter 2 inhibitors (SGLT2i) reduce cardiovascular events and onset and progression of renal disease by mechanisms that remain incompletely understood but may include clearance of interstitial congestion and reduced glomerular hydrostatic pressure. The ongoing DAPASALT mechanistic clinical study will evaluate natriuretic, diuretic, plasma/extracellular volume, and blood pressure responses to dapagliflozin in people with type 2 diabetes with normal or impaired renal function (D-PRF and D-IRF, respectively) and in normoglycemic individuals with renal impairment (N-IRF). In this study, a mathematical model of renal physiology, pathophysiology, and pharmacology was used to prospectively predict changes in sodium excretion, blood and interstitial fluid volume (IFV), blood pressure, glomerular filtration rate, and albuminuria in DAPASALT. After validating the model with previous diabetic nephropathy trials, virtual patients were matched to DAPASALT inclusion/exclusion criteria, and the DAPASALT protocol was simulated. Predicted changes in glycosuria, blood pressure, glomerular filtration rate, and albuminuria were consistent with other recent studies in similar populations. Predicted albuminuria reductions were 46% in D-PRF, 34.8% in D-IRF, and 14.2% in N-IRF. The model predicts a similarly large IFV reduction between D-PRF and D-IRF and less, but still substantial, IFV reduction in N-IRF, even though glycosuria is attenuated in groups with impaired renal function. When DAPASALT results become available, comparison with these simulations will provide a basis for evaluating how well we understand the cardiorenal mechanism(s) of SGLT2i. Meanwhile, these simulations link dapagliflozin's renal mechanisms to changes in IFV and renal biomarkers, suggesting that these benefits may extend to those with impaired renal function and individuals without diabetes. SIGNIFICANCE STATEMENT: Mechanisms of SGLT2 inhibitors' cardiorenal benefits remain incompletely understood. We used a mathematical model of renal physiology/pharmacology to prospectively predict responses to dapagliflozin in the ongoing DAPASALT study. Key predictions include similarly large interstitial fluid volume (IFV) reductions between subjects with normal and impaired renal function and less, but still substantial, IFV reduction in those without diabetes, even though glycosuria is attenuated in these groups. Comparing prospective simulations and study results will assess how well we understand the cardiorenal mechanism(s) of SGLT2 inhibitors.
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Affiliation(s)
- K Melissa Hallow
- Department of Chemical, Materials, and Biomedical Engineering, University of Georgia, Athens, Georgia (K.M.W., E.N.); Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland (D.W.B.); Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Waltham, Massachusetts (R.C.P., G.H.); Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centers, location VUMC, Amsterdam, The Netherlands (D.H.v.R.); Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands (H.L.H.); The George Institute for Global Health, Sydney, Australia (H.L.H.); and Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM) BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (P.J.G.)
| | - David W Boulton
- Department of Chemical, Materials, and Biomedical Engineering, University of Georgia, Athens, Georgia (K.M.W., E.N.); Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland (D.W.B.); Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Waltham, Massachusetts (R.C.P., G.H.); Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centers, location VUMC, Amsterdam, The Netherlands (D.H.v.R.); Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands (H.L.H.); The George Institute for Global Health, Sydney, Australia (H.L.H.); and Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM) BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (P.J.G.)
| | - Robert C Penland
- Department of Chemical, Materials, and Biomedical Engineering, University of Georgia, Athens, Georgia (K.M.W., E.N.); Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland (D.W.B.); Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Waltham, Massachusetts (R.C.P., G.H.); Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centers, location VUMC, Amsterdam, The Netherlands (D.H.v.R.); Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands (H.L.H.); The George Institute for Global Health, Sydney, Australia (H.L.H.); and Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM) BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (P.J.G.)
| | - Gabriel Helmlinger
- Department of Chemical, Materials, and Biomedical Engineering, University of Georgia, Athens, Georgia (K.M.W., E.N.); Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland (D.W.B.); Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Waltham, Massachusetts (R.C.P., G.H.); Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centers, location VUMC, Amsterdam, The Netherlands (D.H.v.R.); Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands (H.L.H.); The George Institute for Global Health, Sydney, Australia (H.L.H.); and Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM) BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (P.J.G.)
| | - Emily H Nieves
- Department of Chemical, Materials, and Biomedical Engineering, University of Georgia, Athens, Georgia (K.M.W., E.N.); Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland (D.W.B.); Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Waltham, Massachusetts (R.C.P., G.H.); Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centers, location VUMC, Amsterdam, The Netherlands (D.H.v.R.); Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands (H.L.H.); The George Institute for Global Health, Sydney, Australia (H.L.H.); and Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM) BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (P.J.G.)
| | - Daniël H van Raalte
- Department of Chemical, Materials, and Biomedical Engineering, University of Georgia, Athens, Georgia (K.M.W., E.N.); Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland (D.W.B.); Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Waltham, Massachusetts (R.C.P., G.H.); Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centers, location VUMC, Amsterdam, The Netherlands (D.H.v.R.); Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands (H.L.H.); The George Institute for Global Health, Sydney, Australia (H.L.H.); and Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM) BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (P.J.G.)
| | - Hiddo L Heerspink
- Department of Chemical, Materials, and Biomedical Engineering, University of Georgia, Athens, Georgia (K.M.W., E.N.); Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland (D.W.B.); Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Waltham, Massachusetts (R.C.P., G.H.); Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centers, location VUMC, Amsterdam, The Netherlands (D.H.v.R.); Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands (H.L.H.); The George Institute for Global Health, Sydney, Australia (H.L.H.); and Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM) BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (P.J.G.)
| | - Peter J Greasley
- Department of Chemical, Materials, and Biomedical Engineering, University of Georgia, Athens, Georgia (K.M.W., E.N.); Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gaithersburg, Maryland (D.W.B.); Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Waltham, Massachusetts (R.C.P., G.H.); Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centers, location VUMC, Amsterdam, The Netherlands (D.H.v.R.); Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands (H.L.H.); The George Institute for Global Health, Sydney, Australia (H.L.H.); and Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM) BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (P.J.G.)
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Jackson AM, Dewan P, Anand IS, Bělohlávek J, Bengtsson O, de Boer RA, Böhm M, Boulton DW, Chopra VK, DeMets DL, Docherty KF, Dukát A, Greasley PJ, Howlett JG, Inzucchi SE, Katova T, Køber L, Kosiborod MN, Langkilde AM, Lindholm D, Ljungman CE, Martinez FA, O’Meara E, Sabatine MS, Sjöstrand M, Solomon SD, Tereshchenko S, Verma S, Jhund PS, McMurray JJ. Dapagliflozin and Diuretic Use in Patients With Heart Failure and Reduced Ejection Fraction in DAPA-HF. Circulation 2020; 142:1040-1054. [PMID: 32673497 PMCID: PMC7664959 DOI: 10.1161/circulationaha.120.047077] [Citation(s) in RCA: 120] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Supplemental Digital Content is available in the text. In the DAPA-HF trial (Dapagliflozin and Prevention of Adverse-Outcomes in Heart Failure), the sodium-glucose cotransporter 2 inhibitor dapagliflozin reduced the risk of worsening heart failure and death in patients with heart failure and reduced ejection fraction. We examined the efficacy and tolerability of dapagliflozin in relation to background diuretic treatment and change in diuretic therapy after randomization to dapagliflozin or placebo.
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Affiliation(s)
- Alice M. Jackson
- BHF Cardiovascular Research Centre, University of Glasgow, UK (A.M.J., P.D., K.F.D., P.S.J., J.J.V.M.)
| | - Pooja Dewan
- BHF Cardiovascular Research Centre, University of Glasgow, UK (A.M.J., P.D., K.F.D., P.S.J., J.J.V.M.)
| | - Inder S. Anand
- Department of Cardiology, University of Minnesota, Minneapolis (I.S.A.)
| | - Jan Bělohlávek
- 2nd Department of Internal Medicine, Cardiovascular Medicine, General Teaching Hospital and 1st Faculty of Medicine, Charles University, Prague, Czech Republic (J.B.)
| | - Olof Bengtsson
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D (O.B., A.M.L., D.L., M.S.), AstraZeneca, Gothenburg, Sweden
| | - Rudolf A. de Boer
- Department of Cardiology, University Medical Center and University of Groningen, The Netherlands (R.A.d.B.)
| | - Michael Böhm
- Department of Medicine, Saarland University Hospital, Homburg–Saar, Germany (M.B.)
| | - David W. Boulton
- Quantitative Clinical Pharmacology, IMED Biotech Unit, Astra-Zeneca, Gaithersburg, MD (D.W.B.)
| | | | - David L. DeMets
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison (D.L.D.)
| | - Kieran F. Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, UK (A.M.J., P.D., K.F.D., P.S.J., J.J.V.M.)
| | - Andrej Dukát
- 5th Department of Internal Medicine, Comenius University in Bratislava, Slovakia (A.D.)
| | - Peter J. Greasley
- Cardiovascular, Renal and Metabolism Translational Medicines Unit, Early Clinical Development, IMED Biotech Unit (P.J.G.), AstraZeneca, Gothenburg, Sweden
| | - Jonathan G. Howlett
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, AB, Canada (J.G.W.)
| | - Silvio E. Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT (S.E.I.)
| | - Tzvetana Katova
- Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.)
| | - Lars Køber
- Rigshospitalet Copenhagen University Hospital, Denmark (L.K.)
| | - Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute, University of Missouri, Kansas City (M.N.K.)
| | - Anna Maria Langkilde
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D (O.B., A.M.L., D.L., M.S.), AstraZeneca, Gothenburg, Sweden
| | - Daniel Lindholm
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D (O.B., A.M.L., D.L., M.S.), AstraZeneca, Gothenburg, Sweden
| | - Charlotta E.A. Ljungman
- Department of Molecular and Clinical Medicine and Cardiology, Sahlgrenska Academy, Gothenburg, Sweden (C.E.A.L.)
| | | | - Eileen O’Meara
- Department of Cardiology, Montreal Heart Institute, QC, Canada (E.O.)
| | - Marc S. Sabatine
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (M.S.S., S.D.S.)
| | - Mikaela Sjöstrand
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D (O.B., A.M.L., D.L., M.S.), AstraZeneca, Gothenburg, Sweden
| | - Scott D. Solomon
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (M.S.S., S.D.S.)
| | - Sergey Tereshchenko
- Department of Myocardial Disease and Heart Failure, National Medical Research Center of Cardiology, Moscow, Russia (S.T.)
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael’s Hospital, University of Toronto, ON, Canada (S.V.)
| | - Pardeep S. Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, UK (A.M.J., P.D., K.F.D., P.S.J., J.J.V.M.)
| | - John J.V. McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, UK (A.M.J., P.D., K.F.D., P.S.J., J.J.V.M.)
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Cherney DZI, Dekkers CCJ, Barbour SJ, Cattran D, Abdul Gafor AH, Greasley PJ, Laverman GD, Lim SK, Di Tanna GL, Reich HN, Vervloet MG, Wong MG, Gansevoort RT, Heerspink HJL. Effects of the SGLT2 inhibitor dapagliflozin on proteinuria in non-diabetic patients with chronic kidney disease (DIAMOND): a randomised, double-blind, crossover trial. Lancet Diabetes Endocrinol 2020; 8:582-593. [PMID: 32559474 DOI: 10.1016/s2213-8587(20)30162-5] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/19/2020] [Accepted: 04/22/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND SGLT2 inhibition decreases albuminuria and reduces the risk of kidney disease progression in patients with type 2 diabetes. These benefits are unlikely to be mediated by improvements in glycaemic control alone. Therefore, we aimed to examine the kidney effects of the SGLT2 inhibitor dapagliflozin in patients with proteinuric kidney disease without diabetes. METHODS DIAMOND was a randomised, double-blind, placebo-controlled crossover trial done at six hospitals in Canada, Malaysia, and the Netherlands. Eligible participants were adult patients (aged 18-75 years) with chronic kidney disease, without a diagnosis of diabetes, with a 24-h urinary protein excretion greater than 500 mg and less than or equal to 3500 mg and an estimated glomerular filtration rate (eGFR) of at least 25 mL/min per 1·73 m2, and who were on stable renin-angiotensin system blockade. Participants were randomly assigned (1:1) to receive placebo and then dapagliflozin 10 mg per day or vice versa. Each treatment period lasted 6 weeks with a 6-week washout period in between. Participants, investigators, and study personnel were masked to assignment throughout the trial and analysis. The primary outcome was percentage change from baseline in 24-h proteinuria during dapagliflozin treatment relative to placebo. Secondary outcomes were changes in measured GFR (mGFR; via iohexol clearance), bodyweight, blood pressure, and concentrations of neurohormonal biomarkers. Analyses were done in accordance with the intention-to-treat principle. This study is registered with ClinicalTrials.gov, NCT03190694. FINDINGS Between Nov 22, 2017, and April 5, 2019, 58 patients were screened, of whom 53 (mean age 51 years [SD 13]; 32% women) were randomly assigned (27 received dapagliflozin then placebo and 26 received placebo then dapagliflozin). One patient discontinued during the first treatment period. All patients were included in the analysis. Mean baseline mGFR was 58·3 mL/min per 1·73 m2 (SD 23), median proteinuria was 1110 mg per 24 h (IQR 730-1560), and mean HbA1c was 5·6% (SD 0·4). The difference in mean proteinuria change from baseline between dapagliflozin and placebo was 0·9% (95% CI -16·6 to 22·1; p=0·93). Compared with placebo, mGFR was changed with dapagliflozin treatment by -6·6 mL/min per 1·73 m2 (-9·0 to -4·2; p<0·0001) at week 6. This reduction was fully reversible within 6 weeks after dapagliflozin discontinuation. Compared with placebo, bodyweight was reduced by 1·5 kg (0·03-3·0; p=0·046) with dapagliflozin; changes in systolic and diastolic blood pressure and concentrations of neurohormonal biomarkers did not differ significantly between dapagliflozin and placebo treatment. The numbers of patients who had one or more adverse events during dapagliflozin treatment (17 [32%] of 53) and during placebo treatment (13 [25%] of 52) were similar. No hypoglycaemic events were reported and no deaths occurred. INTERPRETATION 6-week treatment with dapagliflozin did not affect proteinuria in patients with chronic kidney disease without diabetes, but did induce an acute and reversible decline in mGFR and a reduction in bodyweight. Long-term clinical trials are underway to determine whether SGLT2 inhibitors can safely reduce the rate of major clinical kidney outcomes in patients with chronic kidney disease with and without diabetes. FUNDING AstraZeneca.
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Affiliation(s)
- David Z I Cherney
- Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Claire C J Dekkers
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Sean J Barbour
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Daniel Cattran
- Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Abdul Halim Abdul Gafor
- Department of Medicine, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Peter J Greasley
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Gozewijn D Laverman
- Department of Internal Medicine, ZGT Hospital, Almelo and Hengelo, Netherlands
| | - Soo Kun Lim
- Division of Nephrology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Gian Luca Di Tanna
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Heather N Reich
- Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Marc G Vervloet
- Department of Nephrology and Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Muh Geot Wong
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Ron T Gansevoort
- Department of Nephrology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands.
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Mulder S, Hammarstedt A, Nagaraj SB, Nair V, Ju W, Hedberg J, Greasley PJ, Eriksson JW, Oscarsson J, Heerspink HJL. A metabolomics-based molecular pathway analysis of how the sodium-glucose co-transporter-2 inhibitor dapagliflozin may slow kidney function decline in patients with diabetes. Diabetes Obes Metab 2020; 22:1157-1166. [PMID: 32115853 PMCID: PMC7317707 DOI: 10.1111/dom.14018] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/21/2020] [Accepted: 02/26/2020] [Indexed: 12/18/2022]
Abstract
AIM To investigate which metabolic pathways are targeted by the sodium-glucose co-transporter-2 inhibitor dapagliflozin to explore the molecular processes involved in its renal protective effects. METHODS An unbiased mass spectrometry plasma metabolomics assay was performed on baseline and follow-up (week 12) samples from the EFFECT II trial in patients with type 2 diabetes with non-alcoholic fatty liver disease receiving dapagliflozin 10 mg/day (n = 19) or placebo (n = 6). Transcriptomic signatures from tubular compartments were identified from kidney biopsies collected from patients with diabetic kidney disease (DKD) (n = 17) and healthy controls (n = 30) from the European Renal cDNA Biobank. Serum metabolites that significantly changed after 12 weeks of dapagliflozin were mapped to a metabolite-protein interaction network. These proteins were then linked with intra-renal transcripts that were associated with DKD or estimated glomerular filtration rate (eGFR). The impacted metabolites and their protein-coding transcripts were analysed for enriched pathways. RESULTS Of all measured (n = 812) metabolites, 108 changed (P < 0.05) during dapagliflozin treatment and 74 could be linked to 367 unique proteins/genes. Intra-renal mRNA expression analysis of the genes encoding the metabolite-associated proteins using kidney biopsies resulted in 105 genes that were significantly associated with eGFR in patients with DKD, and 135 genes that were differentially expressed between patients with DKD and controls. The combination of metabolites and transcripts identified four enriched pathways that were affected by dapagliflozin and associated with eGFR: glycine degradation (mitochondrial function), TCA cycle II (energy metabolism), L-carnitine biosynthesis (energy metabolism) and superpathway of citrulline metabolism (nitric oxide synthase and endothelial function). CONCLUSION The observed molecular pathways targeted by dapagliflozin and associated with DKD suggest that modifying molecular processes related to energy metabolism, mitochondrial function and endothelial function may contribute to its renal protective effect.
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Affiliation(s)
- Skander Mulder
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands
| | | | - Sunil B. Nagaraj
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands
| | - Viji Nair
- Michigan UniversityAnn ArborMichiganUSA
| | - Wenjun Ju
- Michigan UniversityAnn ArborMichiganUSA
| | | | | | - Jan W. Eriksson
- Department of Medical SciencesUppsala UniversityUppsalaSweden
| | | | - Hiddo J. L. Heerspink
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Center GroningenGroningenthe Netherlands
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Petrie MC, Verma S, Docherty KF, Inzucchi SE, Anand I, Bělohlávek J, Böhm M, Chiang CE, Chopra VK, de Boer RA, Desai AS, Diez M, Drozdz J, Dukát A, Ge J, Howlett J, Katova T, Kitakaze M, Ljungman CEA, Merkely B, Nicolau JC, O'Meara E, Vinh PN, Schou M, Tereshchenko S, Køber L, Kosiborod MN, Langkilde AM, Martinez FA, Ponikowski P, Sabatine MS, Sjöstrand M, Solomon SD, Johanson P, Greasley PJ, Boulton D, Bengtsson O, Jhund PS, McMurray JJV. Effect of Dapagliflozin on Worsening Heart Failure and Cardiovascular Death in Patients With Heart Failure With and Without Diabetes. JAMA 2020; 323:1353-1368. [PMID: 32219386 PMCID: PMC7157181 DOI: 10.1001/jama.2020.1906] [Citation(s) in RCA: 301] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Additional treatments are needed for heart failure with reduced ejection fraction (HFrEF). Sodium-glucose cotransporter 2 (SGLT2) inhibitors may be an effective treatment for patients with HFrEF, even those without diabetes. OBJECTIVE To evaluate the effects of dapagliflozin in patients with HFrEF with and without diabetes. DESIGN, SETTING, AND PARTICIPANTS Exploratory analysis of a phase 3 randomized trial conducted at 410 sites in 20 countries. Patients with New York Heart Association classification II to IV with an ejection fraction less than or equal to 40% and elevated plasma N-terminal pro B-type natriuretic peptide were enrolled between February 15, 2017, and August 17, 2018, with final follow-up on June 6, 2019. INTERVENTIONS Addition of once-daily 10 mg of dapagliflozin or placebo to recommended therapy. MAIN OUTCOMES AND MEASURES The primary outcome was the composite of an episode of worsening heart failure or cardiovascular death. This outcome was analyzed by baseline diabetes status and, in patients without diabetes, by glycated hemoglobin level less than 5.7% vs greater than or equal to 5.7%. RESULTS Among 4744 patients randomized (mean age, 66 years; 1109 [23%] women; 2605 [55%] without diabetes), 4742 completed the trial. Among participants without diabetes, the primary outcome occurred in 171 of 1298 (13.2%) in the dapagliflozin group and 231 of 1307 (17.7%) in the placebo group (hazard ratio, 0.73 [95% CI, 0.60-0.88]). In patients with diabetes, the primary outcome occurred in 215 of 1075 (20.0%) in the dapagliflozin group and 271 of 1064 (25.5%) in the placebo group (hazard ratio, 0.75 [95% CI, 0.63-0.90]) (P value for interaction = .80). Among patients without diabetes and a glycated hemoglobin level less than 5.7%, the primary outcome occurred in 53 of 438 patients (12.1%) in the dapagliflozin group and 71 of 419 (16.9%) in the placebo group (hazard ratio, 0.67 [95% CI, 0.47-0.96]). In patients with a glycated hemoglobin of at least 5.7%, the primary outcome occurred in 118 of 860 patients (13.7%) in the dapagliflozin group and 160 of 888 (18.0%) in the placebo group (hazard ratio, 0.74 [95% CI, 0.59-0.94]) (P value for interaction = .72). Volume depletion was reported as an adverse event in 7.3% of patients in the dapagliflozin group and 6.1% in the placebo group among patients without diabetes and in 7.8% of patients in the dapagliflozin group and 7.8% in the placebo group among patients with diabetes. A kidney adverse event was reported in 4.8% of patients in the dapagliflozin group and 6.0% in the placebo group among patients without diabetes and in 8.5% of patients in the dapagliflozin group and 8.7% in the placebo group among patients with diabetes. CONCLUSIONS AND RELEVANCE In this exploratory analysis of a randomized trial of patients with HFrEF, dapagliflozin compared with placebo, when added to recommended therapy, significantly reduced the risk of worsening heart failure or cardiovascular death independently of diabetes status. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03036124.
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Affiliation(s)
- Mark C. Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Subodh Verma
- Division of Cardiac Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kieran F. Docherty
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Silvio E. Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Inder Anand
- Department of Cardiology, University of Minnesota, Minneapolis
| | - Jan Bělohlávek
- Second Department of Internal Medicine, Cardiovascular Medicine, General Teaching Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Michael Böhm
- Department of Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Chern-En Chiang
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang-Ming University, Taipei, Taiwan
| | | | - Rudolf A. de Boer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Akshay S. Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mirta Diez
- Division of Cardiology, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - Jaroslaw Drozdz
- Department Cardiology, Medical University of Lodz, Lodz, Poland
| | - Andre Dukát
- Fifth Department of Internal Medicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Junbo Ge
- Shanghai Institute of Cardiovascular Disease, Department of Cardiology, Zhongshan Hospital Fudan University, Shanghai, China
| | - Jonathan Howlett
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tzvetana Katova
- Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria
| | - Masafumi Kitakaze
- Cardiovascular Division of Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Charlotta E. A. Ljungman
- Institute of Medicine, Department of Molecular and Clinical Medicine/Cardiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Jose C. Nicolau
- Instituto do Coracao (InCor), Hospital das Clínicas Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Eileen O'Meara
- Department of Cardiology, Montreal Heart Institute, Montreal, Ontario, Canada
| | - Pham Nguyen Vinh
- Department of Internal Medicine, Tan Tao University, Tan Duc, Vietnam
| | - Morten Schou
- Department of Cardiology, Gentofte University Hospital Copenhagen, Copenhagen, Denmark
| | - Sergey Tereshchenko
- Department of Myocardial Disease and Heart Failure, National Medical Research Center of Cardiology, Moscow, Russia
| | - Lars Køber
- Department of Cardiology Copenhagen University Hospital, Copenhagen, Denmark
| | - Mikhail N. Kosiborod
- St Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City
| | - Anna Maria Langkilde
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | - Piotr Ponikowski
- Center for Heart Diseases, University Hospital, Wroclaw Medical University, Wroclaw, Poland
| | - Marc S. Sabatine
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mikaela Sjöstrand
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Per Johanson
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Peter J. Greasley
- Early Discovery and Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - David Boulton
- Clinical Pharmacology and Safety Sciences, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland
| | - Olof Bengtsson
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Pardeep S. Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - John J. V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
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Sokolov V, Yakovleva T, Chu L, Tang W, Greasley PJ, Johansson S, Peskov K, Helmlinger G, Boulton DW, Penland RC. Differentiating the Sodium-Glucose Cotransporter 1 Inhibition Capacity of Canagliflozin vs. Dapagliflozin and Empagliflozin Using Quantitative Systems Pharmacology Modeling. CPT Pharmacometrics Syst Pharmacol 2020; 9:222-229. [PMID: 32064793 PMCID: PMC7180004 DOI: 10.1002/psp4.12498] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 01/03/2020] [Indexed: 01/10/2023]
Abstract
The aim of this research was to differentiate dapagliflozin, empagliflozin, and canagliflozin based on their capacity to inhibit sodium‐glucose cotransporter (SGLT) 1 and 2 in patients with type 2 diabetes using a previously developed quantitative systems pharmacology model of renal glucose filtration, reabsorption, and excretion. The analysis was based on pooled, mean study‐level data on 24‐hour urinary glucose excretion, average daily plasma glucose, and estimated glomerular filtration rate collected from phase I and II clinical trials of SGLT2 inhibitors. Variations in filtered glucose across clinical studies were shown to drive the apparent differences in the glucosuria dose–response relationships among the gliflozins. A normalized dose–response analysis demonstrated similarity of dapagliflozin and empagliflozin, but not canagliflozin. At approved doses, SGLT1 inhibition by canagliflozin but not dapagliflozin or empagliflozin contributed to ~ 10% of daily urinary glucose excretion.
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Affiliation(s)
| | | | - Lulu Chu
- Clinical Pharmacology & Safety Sciences, R&D, Astrazeneca, Boston, Massachusetts, USA
| | - Weifeng Tang
- Clinical Pharmacology & Safety Sciences, R&D, Astrazeneca, Gaithersburg, USA
| | - Peter J Greasley
- Early Cardiovascular, Renal & Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Susanne Johansson
- Clinical Pharmacology & Safety Sciences, R&D, Astrazeneca, Gothenburg, Sweden
| | - Kirill Peskov
- M&S Decisions, Moscow, Russian Federation.,I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Gabriel Helmlinger
- Clinical Pharmacology & Safety Sciences, R&D, Astrazeneca, Boston, Massachusetts, USA
| | - David W Boulton
- Clinical Pharmacology & Safety Sciences, R&D, Astrazeneca, Gaithersburg, USA
| | - Robert C Penland
- Clinical Pharmacology & Safety Sciences, R&D, Astrazeneca, Boston, Massachusetts, USA
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Block GA, Rosenbaum DP, Yan A, Greasley PJ, Chertow GM, Wolf M. The effects of tenapanor on serum fibroblast growth factor 23 in patients receiving hemodialysis with hyperphosphatemia. Nephrol Dial Transplant 2020; 34:339-346. [PMID: 29617976 PMCID: PMC6365767 DOI: 10.1093/ndt/gfy061] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 02/20/2018] [Indexed: 01/12/2023] Open
Abstract
Background Elevated serum fibroblast growth factor 23 (FGF23) is strongly associated with cardiovascular risk and mortality. Tenapanor, an inhibitor of gastrointestinal sodium/hydrogen exchanger isoform 3, decreased serum phosphate in a randomized, double-blind, placebo-controlled Phase 2 trial (ClinicalTrials.gov identifier NCT02081534) of patients receiving hemodialysis with hyperphosphatemia. Here, we report a secondary analysis of effects on serum FGF23 during that study. Methods After 1–3 weeks of washout of phosphate binders, 162 patients were randomized to receive 4 weeks of treatment with placebo or one of six tenapanor regimens (3 or 30 mg once daily, or 1, 3, 10 or 30 mg twice daily). Intact FGF23 concentrations were determined from serum samples collected at screening, post-washout and end of treatment, assayed in duplicate in a single batch at the end of the study. Results After phosphate-binder washout, serum FGF23 concentrations increased in all groups [range of geometric means: 1430–2605 pg/mL before, to 2601–6294 pg/mL after washout (P < 0.001 for all patients analyzed as a single group)]. Serum FGF23 concentrations subsequently decreased in tenapanor-treated patients (2030–3563 pg/mL), whereas they increased further in placebo-treated patients (6930 pg/mL). In an analysis of covariance, FGF23 decreased by 9.1–27.9% in tenapanor-treated patients and increased by 21.9% in placebo-treated patients (P ≤ 0.001–0.04). Conclusions Following a marked increase in serum FGF23 in response to withdrawal of phosphate binders, tenapanor significantly decreased serum FGF23 in patients receiving hemodialysis with hyperphosphatemia. Further studies are required to explore the long-term effects of controlling FGF23 with tenapanor.
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Affiliation(s)
| | | | | | | | | | - Myles Wolf
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC, USA
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Yakovleva T, Sokolov V, Chu L, Tang W, Greasley PJ, Peilot Sjögren H, Johansson S, Peskov K, Helmlinger G, Boulton DW, Penland RC. Comparison of the urinary glucose excretion contributions of SGLT2 and SGLT1: A quantitative systems pharmacology analysis in healthy individuals and patients with type 2 diabetes treated with SGLT2 inhibitors. Diabetes Obes Metab 2019; 21:2684-2693. [PMID: 31423699 DOI: 10.1111/dom.13858] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/31/2019] [Accepted: 08/11/2019] [Indexed: 01/21/2023]
Abstract
AIM To develop a quantitative drug-disease systems model to investigate the paradox that sodium-glucose co-transporter (SGLT)2 is responsible for >80% of proximal tubule glucose reabsorption, yet SGLT2 inhibitor treatment results in only 30% to 50% less reabsorption in patients with type 2 diabetes mellitus (T2DM). MATERIALS AND METHODS A physiologically based four-compartment model of renal glucose filtration, reabsorption and excretion via SGLT1 and SGLT2 was developed as a system of ordinary differential equations using R/IQRtools. SGLT2 inhibitor pharmacokinetics and pharmacodynamics were estimated from published concentration-time profiles in plasma and urine and from urinary glucose excretion (UGE) in healthy people and people with T2DM. RESULTS The final model showed that higher renal glucose reabsorption in people with T2DM versus healthy people was associated with 54% and 28% greater transporter capacity for SGLT1 and SGLT2, respectively. Additionally, the analysis showed that UGE is highly dependent on mean plasma glucose and estimated glomerular filtration rate (eGFR) and that their consideration is critical for interpreting clinical UGE findings. CONCLUSIONS Quantitative drug-disease system modelling revealed mechanistic differences in renal glucose reabsorption and UGE between healthy people and those with T2DM, and clearly showed that SGLT2 inhibition significantly increased glucose available to SGLT1 downstream in the tubule. Importantly, we found that the findings of lower than expected UGE with SGLT2 inhibition are explained by the shift to SGLT1, which recovered additional glucose (~30% of total).
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Affiliation(s)
| | | | - Lulu Chu
- Clinical Pharmacology & Safety Sciences, R&D BioPharmaceuticals, AstraZeneca, Waltham, Massachusetts
| | - Weifeng Tang
- Clinical Pharmacology & Safety Sciences, R&D BioPharmaceuticals, AstraZeneca, Gaithersburg, Maryland
| | | | - Helena Peilot Sjögren
- Discovery Biology, Discovery Sciences, R&D BioPharmaceuticals, AstraZeneca, Gothenburg, Sweden
| | - Susanne Johansson
- Clinical Pharmacology & Safety Sciences, R&D BioPharmaceuticals, AstraZeneca, Gothenburg, Sweden
| | - Kirill Peskov
- M&S Decisions, Moscow, Russian Federation
- I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Gabriel Helmlinger
- Clinical Pharmacology & Safety Sciences, R&D BioPharmaceuticals, AstraZeneca, Waltham, Massachusetts
| | - David W Boulton
- Clinical Pharmacology & Safety Sciences, R&D BioPharmaceuticals, AstraZeneca, Gaithersburg, Maryland
| | - Robert C Penland
- Clinical Pharmacology & Safety Sciences, R&D BioPharmaceuticals, AstraZeneca, Waltham, Massachusetts
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Dekkers CCJ, Sjöström CD, Greasley PJ, Cain V, Boulton DW, Heerspink HJL. Effects of the sodium-glucose co-transporter-2 inhibitor dapagliflozin on estimated plasma volume in patients with type 2 diabetes. Diabetes Obes Metab 2019; 21:2667-2673. [PMID: 31407856 PMCID: PMC6899523 DOI: 10.1111/dom.13855] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 01/04/2023]
Abstract
AIMS To compare the effects of the sodium-glucose co-transporter-2 (SGLT2) inhibitor dapagliflozin on estimated (ePV) and measured plasma volume (mPV) and to characterize the effects of dapagliflozin on ePV in a broad population of patients with type 2 diabetes. MATERIALS AND METHODS The Strauss formula was used to calculate changes in ePV. Change in plasma volume measured with 125 I-human serum albumin (mPV) was compared with change in ePV in 10 patients with type 2 diabetes randomized to dapagliflozin 10 mg/d or placebo. Subsequently, changes in ePV were measured in a pooled database of 13 phase 2b/3 placebo-controlled clinical trials involving 4533 patients with type 2 diabetes who were randomized to dapagliflozin 10 mg daily or matched placebo. RESULTS The median change in ePV was similar to the median change in mPV (-9.4% and -9.0%) during dapagliflozin treatment. In the pooled analysis of clinical trials, dapagliflozin decreased ePV by 9.6% (95% confidence interval 9.0 to 10.2) compared to placebo after 24 weeks. This effect was consistent in various patient subgroups, including subgroups with or without diuretic use or established cardiovascular disease. CONCLUSIONS ePV may be used as a proxy to assess changes in plasma volume during dapagliflozin treatment. Dapagliflozin consistently decreased ePV compared to placebo in a broad population of patients with type 2 diabetes.
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Affiliation(s)
- Claire C. J. Dekkers
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
| | - C. David Sjöström
- Late‐stage Development, CardiovascularRenal and Metabolic, BioPharmaceuticals R&DAstra ZenecaGothenburgSweden
| | - Peter J. Greasley
- Cardiovascular, Renal and Metabolism Translational Medicines Unit, Early Clinical Development, IMED Biotech Unit, AstraZenecaGothenburgSweden
| | - Valerie Cain
- Bogier Clinical and IT SolutionsRaleighNorth Carolina
| | - David W. Boulton
- Quantitative Clinical Pharmacology, IMED Biotech Unit, AstraZenecaGaithersburgMaryland
| | - Hiddo J. L. Heerspink
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
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Whittaker A, Kragh ÅM, Hartleib-Geschwindner J, Albayaty M, Backlund A, Greasley PJ, Heijer M, Kjaer M, Forte P, Unwin R, Wernevik L, Ericsson H. Safety, Tolerability, and Pharmacokinetics of the Mineralocorticoid Receptor Modulator AZD9977 in Healthy Men: A Phase I Multiple Ascending Dose Study. Clin Transl Sci 2019; 13:275-283. [PMID: 31584739 PMCID: PMC7070793 DOI: 10.1111/cts.12705] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 09/13/2019] [Indexed: 12/22/2022] Open
Abstract
Excessive activation of the mineralocorticoid receptor (MR) underlies the pathophysiology of heart failure and chronic kidney disease. Hyperkalemia risk limits the therapeutic use of conventional MR antagonists. AZD9977 is a nonsteroidal, selective MR modulator that may protect nonepithelial tissues without disturbing electrolyte balance. This phase I study investigated the safety, tolerability, pharmacokinetics, and pharmacodynamics of multiple oral doses of AZD9977 in healthy volunteers. Twenty‐seven male participants aged 23–45 years were randomized 3:1 to receive oral AZD9977 or placebo for 8 days (with twice‐daily dosing on days 2–7), in dose cohorts of 50, 150, and 300 mg (AZD9977, n = 6 per cohort; placebo, n = 3 per cohort). Adverse events occurred in 4 of 18 participants receiving AZD9977 (22.2%) and 6 of 9 receiving placebo (66.7%), all of mild or moderate severity; none were serious or led to withdrawal. AZD9977 was rapidly absorbed, with median time of maximum concentration of 0.50–0.84 hours across dose groups. Area under the curve and maximum concentration were approximately dose proportional but elimination and accumulation terminal half‐life increased with dose. Steady‐state was reached after 3–4 days, with dose‐dependent accumulation of 1.2–1.7‐fold. Renal clearance was 5.9–6.5 L/hour and 24–37% of AZD9977 was excreted in the urine. Serum aldosterone levels increased dose dependently from days −1 to 7 in participants receiving AZD9977, but serum potassium levels and urinary electrolyte excretion were unchanged. AZD9977 was generally well‐tolerated with no safety concerns. Exploratory outcomes suggested reduced hyperkalemia risk compared with MR antagonists. These findings support further clinical development of AZD9977.
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Affiliation(s)
- Andrew Whittaker
- Research and Early Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Åsa M Kragh
- Clinical Pharmacology, ADME and AI, Clinical Pharmacology & Safety Sciences, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Judith Hartleib-Geschwindner
- Research and Early Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | - Anna Backlund
- Research and Early Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Peter J Greasley
- Research and Early Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Maria Heijer
- Clinical Pharmacology Biologics and Bioanalysis, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Magnus Kjaer
- Early Biometrics and Statistical Innovation, Data Science and AI, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Pablo Forte
- Early Phase Clinical Unit, PAREXEL, Harrow, UK
| | - Robert Unwin
- Research and Early Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Linda Wernevik
- Research and Early Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Hans Ericsson
- Clinical Pharmacology, ADME and AI, Clinical Pharmacology & Safety Sciences, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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King AJ, Siegel M, He Y, Nie B, Wang J, Koo-McCoy S, Minassian NA, Jafri Q, Pan D, Kohler J, Kumaraswamy P, Kozuka K, Lewis JG, Dragoli D, Rosenbaum DP, O'Neill D, Plain A, Greasley PJ, Jönsson-Rylander AC, Karlsson D, Behrendt M, Strömstedt M, Ryden-Bergsten T, Knöpfel T, Pastor Arroyo EM, Hernando N, Marks J, Donowitz M, Wagner CA, Alexander RT, Caldwell JS. Inhibition of sodium/hydrogen exchanger 3 in the gastrointestinal tract by tenapanor reduces paracellular phosphate permeability. Sci Transl Med 2019; 10:10/456/eaam6474. [PMID: 30158152 DOI: 10.1126/scitranslmed.aam6474] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 10/31/2017] [Accepted: 03/06/2018] [Indexed: 12/16/2022]
Abstract
Hyperphosphatemia is common in patients with chronic kidney disease and is increasingly associated with poor clinical outcomes. Current management of hyperphosphatemia with dietary restriction and oral phosphate binders often proves inadequate. Tenapanor, a minimally absorbed, small-molecule inhibitor of the sodium/hydrogen exchanger isoform 3 (NHE3), acts locally in the gastrointestinal tract to inhibit sodium absorption. Because tenapanor also reduces intestinal phosphate absorption, it may have potential as a therapy for hyperphosphatemia. We investigated the mechanism by which tenapanor reduces gastrointestinal phosphate uptake, using in vivo studies in rodents and translational experiments on human small intestinal stem cell-derived enteroid monolayers to model ion transport physiology. We found that tenapanor produces its effect by modulating tight junctions, which increases transepithelial electrical resistance (TEER) and reduces permeability to phosphate, reducing paracellular phosphate absorption. NHE3-deficient monolayers mimicked the phosphate phenotype of tenapanor treatment, and tenapanor did not affect TEER or phosphate flux in the absence of NHE3. Tenapanor also prevents active transcellular phosphate absorption compensation by decreasing the expression of NaPi2b, the major active intestinal phosphate transporter. In healthy human volunteers, tenapanor (15 mg, given twice daily for 4 days) increased stool phosphorus and decreased urinary phosphorus excretion. We determined that tenapanor reduces intestinal phosphate absorption predominantly through reduction of passive paracellular phosphate flux, an effect mediated exclusively via on-target NHE3 inhibition.
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Affiliation(s)
| | | | - Ying He
- Ardelyx Inc., Fremont, CA 94555, USA
| | | | - Ji Wang
- Ardelyx Inc., Fremont, CA 94555, USA
| | | | | | | | - Deng Pan
- Ardelyx Inc., Fremont, CA 94555, USA
| | | | | | | | | | | | | | - Debbie O'Neill
- University of Alberta, Edmonton, Alberta T6G 1C9, Canada
| | - Allein Plain
- University of Alberta, Edmonton, Alberta T6G 1C9, Canada
| | - Peter J Greasley
- Cardiovascular and Metabolic Disease (CVMD) Translational Medicine Unit, Early Clinical Development, Innovative Medicines and Early Development (IMED) Biotech Unit, AstraZeneca Gothenburg, 431 50 Mölndal, Sweden
| | | | - Daniel Karlsson
- Bioscience, CVMD, IMED Biotech Unit, AstraZeneca Gothenburg, 431 50 Mölndal, Sweden
| | - Margareta Behrendt
- Bioscience, CVMD, IMED Biotech Unit, AstraZeneca Gothenburg, 431 50 Mölndal, Sweden
| | - Maria Strömstedt
- Bioscience, CVMD, IMED Biotech Unit, AstraZeneca Gothenburg, 431 50 Mölndal, Sweden
| | | | - Thomas Knöpfel
- Institute of Physiology, University of Zurich and National Center of Competence in Research Kidney Control of Homeostasis, CH-8057 Zurich, Switzerland
| | - Eva M Pastor Arroyo
- Institute of Physiology, University of Zurich and National Center of Competence in Research Kidney Control of Homeostasis, CH-8057 Zurich, Switzerland
| | - Nati Hernando
- Institute of Physiology, University of Zurich and National Center of Competence in Research Kidney Control of Homeostasis, CH-8057 Zurich, Switzerland
| | - Joanne Marks
- Department of Neuroscience, Physiology and Pharmacology, University College London, Royal Free Campus, London NW3 2PF, UK
| | - Mark Donowitz
- Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Carsten A Wagner
- Institute of Physiology, University of Zurich and National Center of Competence in Research Kidney Control of Homeostasis, CH-8057 Zurich, Switzerland
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Karlsson C, Greasley PJ, Gustafsson D, Wåhlander K. Development of Human Target Validation Classification that Predicts Future Clinical Efficacy. J Pharmacol Exp Ther 2018; 368:255-261. [PMID: 30482795 DOI: 10.1124/jpet.118.250894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 11/13/2018] [Indexed: 11/22/2022] Open
Abstract
Fewer new medicines have become available to patients during the last decades. Clinical efficacy failures in late-phase development have been identified as a common cause of this decline. Improved ways to ensure early selection of the right drug targets when it comes to efficacy is therefore a highly desirable goal. The aim of this work was to develop a strategy to facilitate selection of novel targets already in the discovery phase that later on in clinical development would demonstrate efficacy. A cross-functional team at AstraZeneca with extensive experience in drug discovery and development participated in several workshops to identify the critical elements that contribute to building human target validation [(HTV); the relevance of the target from a human perspective]. The elements were consolidated into a 10-point HTV classification system that was ranked from lowest to highest in terms of perceived impact on future clinical efficacy. Using 50 years of legacy research and development data, the ability of the 10-point HTV classification to predict future clinical efficacy was evaluated. Drug targets were classified as having low, medium, or high HTV at the time of candidate drug selection. Comparing this HTV classification with later clinical development efficacy data showed that HTV classification was highly predictive of future clinical efficacy success. This new strategy for HTV assessment provides a novel approach to early prediction of clinical efficacy and a better understanding of portfolio risk.
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Affiliation(s)
- Cecilia Karlsson
- Cardiovascular, Renal and Metabolism Translational Medicine Unit, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Gothenburg, Sweden (C.K., P.J.G.); Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (C.K.); Emeriti Pharma, AZ Bioventure Hub, Gothenburg, Sweden (D.G.); and KW Translational Medicine AB, Västra Frölunda, Sweden (K.W.)
| | - Peter J Greasley
- Cardiovascular, Renal and Metabolism Translational Medicine Unit, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Gothenburg, Sweden (C.K., P.J.G.); Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (C.K.); Emeriti Pharma, AZ Bioventure Hub, Gothenburg, Sweden (D.G.); and KW Translational Medicine AB, Västra Frölunda, Sweden (K.W.)
| | - David Gustafsson
- Cardiovascular, Renal and Metabolism Translational Medicine Unit, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Gothenburg, Sweden (C.K., P.J.G.); Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (C.K.); Emeriti Pharma, AZ Bioventure Hub, Gothenburg, Sweden (D.G.); and KW Translational Medicine AB, Västra Frölunda, Sweden (K.W.)
| | - Karin Wåhlander
- Cardiovascular, Renal and Metabolism Translational Medicine Unit, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Gothenburg, Sweden (C.K., P.J.G.); Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (C.K.); Emeriti Pharma, AZ Bioventure Hub, Gothenburg, Sweden (D.G.); and KW Translational Medicine AB, Västra Frölunda, Sweden (K.W.)
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44
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Hallow KM, Greasley PJ, Helmlinger G, Chu L, Heerspink HJ, Boulton DW. Evaluation of renal and cardiovascular protection mechanisms of SGLT2 inhibitors: model-based analysis of clinical data. Am J Physiol Renal Physiol 2018; 315:F1295-F1306. [PMID: 30019930 DOI: 10.1152/ajprenal.00202.2018] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [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: 01/12/2023] Open
Abstract
The mechanisms of cardiovascular and renal protection observed in clinical trials of sodium-glucose cotransporter 2 (SGLT2) inhibitors (SGLT2i) are incompletely understood and likely multifactorial, including natriuretic, diuretic, and antihypertensive effects, glomerular pressure reduction, and lowering of plasma and interstitial fluid volume. To quantitatively evaluate the contribution of proposed SGLT2i mechanisms of action on changes in renal hemodynamics and volume status, we coupled a mathematical model of renal function and volume homeostasis with clinical data in healthy subjects administered 10 mg of dapagliflozin once daily. The minimum set of mechanisms necessary to reproduce observed clinical responses (urinary sodium and water excretion, serum creatinine and sodium) was determined, and important unobserved physiological variables (glomerular pressure, blood and interstitial fluid volume) were then simulated. We further simulated the response to SGLT2i in diabetic virtual patients with and without renal impairment. Multiple mechanisms were required to explain the observed response: 1) direct inhibition of sodium and glucose reabsorption through SGLT2, 2) SGLT2-driven inhibition of Na+/H+ exchanger 3 sodium reabsorption, and 3) osmotic diuresis coupled with peripheral sodium storage. The model also showed that the consequences of these mechanisms include lowering of glomerular pressure, reduction of blood and interstitial fluid volume, and mild blood pressure reduction, in agreement with clinical observations. The simulations suggest that these effects are more significant in diabetic patients than healthy subjects and that while glucose excretion may diminish with renal impairment, improvements in glomerular pressure and blood volume are not diminished at lower glomerular filtration rate, suggesting that cardiorenal benefits of SGLT2i may be sustained in renally impaired patients.
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Affiliation(s)
- K Melissa Hallow
- School of Chemical, Materials, and Biomedical Engineering, University of Georgia , Athens, Georgia.,Department of Epidemiology and Biostatistics, University of Georgia , Athens, Georgia
| | - Peter J Greasley
- Early Clinical Development, Innovative Medicines, AstraZeneca, Gothenburg , Sweden
| | - Gabriel Helmlinger
- Quantitative Clinical Pharmacology, Early Clinical Development, Innovative Medicines, AstraZeneca, Waltham, Massachusetts
| | - Lulu Chu
- Quantitative Clinical Pharmacology, Early Clinical Development, Innovative Medicines, AstraZeneca, Waltham, Massachusetts
| | - Hiddo J Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - David W Boulton
- Quantitative Clinical Pharmacology, Early Clinical Development, Innovative Medicines, AstraZeneca, Gaithersburg, Maryland
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45
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Go AS, Yang J, Tan TC, Cabrera CS, Stefansson BV, Greasley PJ, Ordonez JD. Contemporary rates and predictors of fast progression of chronic kidney disease in adults with and without diabetes mellitus. BMC Nephrol 2018; 19:146. [PMID: 29929484 PMCID: PMC6014002 DOI: 10.1186/s12882-018-0942-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 06/07/2018] [Indexed: 11/26/2022] Open
Abstract
Background Chronic kidney disease (CKD) is highly prevalent but identification of patients at high risk for fast CKD progression before reaching end-stage renal disease in the short-term has been challenging. Whether factors associated with fast progression vary by diabetes status is also not well understood. We examined a large community-based cohort of adults with CKD to identify predictors of fast progression during the first 2 years of follow-up in the presence or absence of diabetes mellitus. Methods Within a large integrated healthcare delivery system in northern California, we identified adults with estimated glomerular filtration rate (eGFR) 30–59 ml/min/1.73 m2 by CKD-EPI equation between 2008 and 2010 who had no previous dialysis or renal transplant, who had outpatient serum creatinine values spaced 10–14 months apart and who did not initiate renal replacement therapy, die or disenroll during the first 2 years of follow-up. Through 2012, we calculated the annual rate of change in eGFR and classified patients as fast progressors if they lost > 4 ml/min/1.73 m2 per year. We used multivariable logistic regression to identify patient characteristics that were independently associated with fast CKD progression stratified by diabetes status. Results We identified 36,195 eligible adults with eGFR 30–59 ml/min/1.73 m2 and mean age 73 years, 55% women, 11% black, 12% Asian/Pacific Islander and 36% with diabetes mellitus. During 24-month follow-up, fast progression of CKD occurred in 23.0% of patients with diabetes vs. 15.3% of patients without diabetes. Multivariable predictors of fast CKD progression that were similar by diabetes status included proteinuria, age ≥ 80 years, heart failure, anemia and higher systolic blood pressure. Age 70–79 years, prior ischemic stroke, current or former smoking and lower HDL cholesterol level were also predictive in patients without diabetes, while age 18–49 years was additionally predictive in those with diabetes. Conclusions In a large, contemporary population of adults with eGFR 30–59 ml/min/1.73 m2, accelerated progression of kidney dysfunction within 2 years affected ~ 1 in 4 patients with diabetes and ~ 1 in 7 without diabetes. Regardless of diabetes status, the strongest independent predictors of fast CKD progression included proteinuria, elevated systolic blood pressure, heart failure and anemia.
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Affiliation(s)
- Alan S Go
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, USA. .,Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, CA, USA. .,Department of Health Research and Policy, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Jingrong Yang
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, USA
| | - Thida C Tan
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, USA
| | | | | | | | - Juan D Ordonez
- Division of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
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Hallow KM, Helmlinger G, Greasley PJ, McMurray JJV, Boulton DW. Why do SGLT2 inhibitors reduce heart failure hospitalization? A differential volume regulation hypothesis. Diabetes Obes Metab 2018; 20:479-487. [PMID: 29024278 DOI: 10.1111/dom.13126] [Citation(s) in RCA: 305] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/21/2017] [Accepted: 10/09/2017] [Indexed: 12/25/2022]
Abstract
The effect of a sodium glucose cotransporter 2 inhibitor (SGLT2i) in reducing heart failure hospitalization in the EMPA-REG OUTCOMES trial has raised the possibility of using these agents to treat established heart failure. We hypothesize that osmotic diuresis induced by SGLT2 inhibition, a distinctly different diuretic mechanism than that of other diuretic classes, results in greater electrolyte-free water clearance and, ultimately, in greater fluid clearance from the interstitial fluid (IF) space than from the circulation, potentially resulting in congestion relief with minimal impact on blood volume, arterial filling and organ perfusion. We utilize a mathematical model to illustrate that electrolyte-free water clearance results in a greater reduction in IF volume compared to blood volume, and that this difference may be mediated by peripheral sequestration of osmotically inactive sodium. By coupling the model with data on plasma and urinary sodium and water in healthy subjects who received either the SGLT2i dapagliflozin or loop diuretic bumetanide, we predict that dapagliflozin produces a 2-fold greater reduction in IF volume compared to blood volume, while the reduction in IF volume with bumetanide is only 78% of the reduction in blood volume. Heart failure is characterized by excess fluid accumulation, in both the vascular compartment and interstitial space, yet many heart failure patients have arterial underfilling because of low cardiac output, which may be aggravated by conventional diuretic treatment. Thus, we hypothesize that, by reducing IF volume to a greater extent than blood volume, SGLT2 inhibitors might provide better control of congestion without reducing arterial filling and perfusion.
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Affiliation(s)
- Karen M Hallow
- School of Chemical, Materials, and Biomedical Engineering, University of Georgia, Athens, Georgia
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, Georgia
| | - Gabriel Helmlinger
- Quantitative Clinical Pharmacology, Early Clinical Development, Innovative Medicines, AstraZeneca, Waltham, Massachusetts
| | - Peter J Greasley
- Early Clinical Development, Innovative Medicines, AstraZeneca, Gothenburg, Sweden
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - David W Boulton
- Quantitative Clinical Pharmacology, Early Clinical Development, Innovative Medicines, AstraZeneca, Gaithersburg, Maryland
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Yin J, Tse CM, Cha B, Sarker R, Zhu XC, Walentinsson A, Greasley PJ, Donowitz M. A common NHE3 single-nucleotide polymorphism has normal function and sensitivity to regulatory ligands. Am J Physiol Gastrointest Liver Physiol 2017; 313:G129-G137. [PMID: 28495802 PMCID: PMC5582881 DOI: 10.1152/ajpgi.00044.2017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 05/01/2017] [Accepted: 05/05/2017] [Indexed: 01/31/2023]
Abstract
Na+/H+ exchanger NHE3 mediates the majority of intestinal and renal electroneutral sodium absorption. Dysfunction of NHE3 is associated with a variety of diarrheal diseases. We previously reported that the NHE3 gene (SLC9A3) has more than 400 single-nucleotide polymorphisms (SNPs) but few nonsynonymous polymorphisms. Among the latter, one polymorphism (rs2247114-G>A), which causes a substitution from arginine to cysteine at amino acid position 799 (p.R799C), is common in Asian populations. To improve our understanding of the population distribution and potential clinical significance of the NHE3-799C variant, we investigated the frequency of this polymorphism in different ethnic groups using bioinformatics analyses and in a cohort of Japanese patients with cardiovascular or renal disease. We also characterized the function of human NHE3-799C and its sensitivity to regulatory ligands in an in vitro model. NHE3-799C had an allele frequency of 29.5-57.6% in Asian populations, 11.1-23.6% in European populations, and 10.2-22.7% in African populations. PS120/FLAG-NHERF2 fibroblasts stably expressing NHE3-799C had lower total protein expression but a higher percentage of surface expression than those expressing NHE3-799R. NHE3-799C had similar basal activity to NHE3-799R and was similarly stimulated or inhibited, by serum or forskolin, respectively. Tenapanor, a small-molecule NHE3 inhibitor, dose-dependently inhibited NHE3-799R and NHE3-799C activities. The IC50 values of tenapanor for NHE3-799C and NHE3-799R were significantly different, but both were in the nanomolar range. These results suggest that NHE3-799C is a common variant enriched in Asian populations, is not associated with compromised function or abnormal regulation, and is unlikely to contribute to clinical disease.NEW & NOTEWORTHY This study reports results on the functional significance of human NHE3-799C under basal conditions and in response to regulatory ligands, including a novel NHE3 inhibitor called tenapanor. We demonstrate that NHE3-799C is a common variant of NHE3 that is enriched in Asian populations; however, in contrast to our previous studies using rabbit NHE3, its presence seems to have limited clinical significance in humans and is not associated with compromised function or abnormal transport regulation.
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Affiliation(s)
- Jianyi Yin
- 1Department of Medicine, Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, Maryland;
| | - Chung-Ming Tse
- 1Department of Medicine, Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, Maryland;
| | - Boyoung Cha
- 1Department of Medicine, Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, Maryland;
| | - Rafiquel Sarker
- 1Department of Medicine, Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, Maryland;
| | - Xinjun C. Zhu
- 2Department of Medicine, Division of Gastroenterology and Hepatology, Albany Medical College, Albany, New York; and
| | | | | | - Mark Donowitz
- Department of Medicine, Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, Maryland;
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Petrykiv S, Sjöström CD, Greasley PJ, Xu J, Persson F, Heerspink HJ. Differential Effects of Dapagliflozin on Cardiovascular Risk Factors at Varying Degrees of Renal Function. Clin J Am Soc Nephrol 2017; 12:751-759. [PMID: 28302903 PMCID: PMC5477216 DOI: 10.2215/cjn.10180916] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 02/13/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Sodium glucose cotransporter 2 inhibition with dapagliflozin decreases hemoglobin A1c (HbA1c), body weight, BP, and albuminuria (urinary albumin-to-creatinine ratio). Dapagliflozin also modestly increases hematocrit, likely related to osmotic diuresis/natriuresis. Prior studies suggest that the HbA1c-lowering effects of dapagliflozin attenuate at lower eGFR. However, effects on other cardiovascular risk factors at different eGFR levels are incompletely understood. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This pooled analysis of 11 phase 3 clinical trials assessed changes in HbA1c, body weight, BP, hematocrit, and urinary albumin-to-creatinine ratio with placebo (n=2178) or dapagliflozin 10 mg (n=2226) over 24 weeks in patients with type 2 diabetes according to baseline eGFR (eGFR≥45 to <60 ml/min per 1.73 m2, eGFR≥60 to <90 ml/min per 1.73 m2, and eGFR≥90 ml/min per 1.73 m2). RESULTS Compared with placebo, reductions in HbA1c with dapagliflozin were 0.6%, 0.5%, and 0.3%, respectively, for each consecutive lower eGFR subgroup (P value interaction <0.001). Effects of dapagliflozin on hematocrit, body weight, and BP were similar regardless of baseline eGFR, suggesting that effects potentially related to volume and natriuresis are eGFR independent. Moreover, among individuals with baseline urinary albumin-to-creatinine ratio ≥30 mg/g, placebo-adjusted reductions in urinary albumin-to-creatinine ratio were larger in the lowest eGFR subgroup (P value interaction <0.001). Adverse events occurred more frequently in the lowest eGFR subgroup; this was true for both dapagliflozin- and placebo-treated patients. CONCLUSIONS The HbA1c-lowering effects of dapagliflozin decrease as renal function declines. However, dapagliflozin consistently decreases body weight, BP, and urinary albumin-to-creatinine ratio regardless of eGFR. These effects in conjunction with the finding of similar effects on hematocrit, a proxy for volume contraction, suggest that the effects of dapagliflozin are partly mediated via nonglucosuric-dependent mechanisms.
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Affiliation(s)
- Sergei Petrykiv
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | - John Xu
- AstraZeneca, Gaithersburg, Maryland; and
| | | | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Bjursell M, Ryberg E, Wu T, Greasley PJ, Bohlooly-Y M, Hjorth S. Deletion of Gpr55 Results in Subtle Effects on Energy Metabolism, Motor Activity and Thermal Pain Sensation. PLoS One 2016; 11:e0167965. [PMID: 27941994 PMCID: PMC5152857 DOI: 10.1371/journal.pone.0167965] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 11/25/2016] [Indexed: 02/06/2023] Open
Abstract
The G-protein coupled receptor 55 (GPR55) is activated by cannabinoids and non-cannabinoid molecules and has been speculated to play a modulatory role in a large variety of physiological and pathological processes, including in metabolically perturbed states. We therefore generated male mice deficient in the gene coding for the cannabinoid/lysophosphatidylinositol (LPI) receptor Gpr55 and characterized them under normal dietary conditions as well as during high energy dense diet feeding followed by challenge with the CB1 receptor antagonist/GPR55 agonist rimonabant. Gpr55 deficient male mice (Gpr55 KO) were phenotypically indistinguishable from their wild type (WT) siblings for the most part. However, Gpr55 KO animals displayed an intriguing nocturnal pattern of motor activity and energy expenditure (EE). During the initial 6 hours of the night, motor activity was significantly elevated without any significant effect observed in EE. Interestingly, during the last 6 hours of the night motor activity was similar but EE was significantly decreased in the Gpr55 KO mice. No significant difference in motor activity was detected during daytime, but EE was lower in the Gpr55 KO compared to WT mice. The aforementioned patterns were not associated with alterations in energy intake, daytime core body temperature, body weight (BW) or composition, although a non-significant tendency to increased adiposity was seen in Gpr55 KO compared to WT mice. Detailed analyses of daytime activity in the Open Field paradigm unveiled lower horizontal activity and rearing time for the Gpr55 KO mice. Moreover, the Gpr55 KO mice displayed significantly faster reaction time in the tail flick test, indicative of thermal hyperalgesia. The BW-decreasing effect of rimonabant in mice on long-term cafeteria diet did not differ between Gpr55 KO and WT mice. In conclusion, Gpr55 deficiency is associated with subtle effects on diurnal/nocturnal EE and motor activity behaviours but does not appear per se critically required for overall metabolism or behaviours.
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Affiliation(s)
- Mikael Bjursell
- Discovery Sciences Transgenics, AstraZeneca R&D, Mölndal, Sweden
| | - Erik Ryberg
- Cardiovascular and Metabolic diseases (CVMD) Innovative Medicines and early Development Biotech Unit, AstraZeneca R&D, Mölndal, Sweden
| | - Tingting Wu
- Discovery Sciences Transgenics, AstraZeneca R&D, Mölndal, Sweden
| | - Peter J. Greasley
- CVMD Translational Medicine Unit, Early Clinical Development AstraZeneca R&D, Mölndal, Sweden
| | | | - Stephan Hjorth
- Dept. of Molecular & Clinical Medicine, Inst. of Medicine, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
- * E-mail:
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Block GA, Rosenbaum DP, Leonsson-Zachrisson M, Stefansson BV, Rydén-Bergsten T, Greasley PJ, Johansson SA, Knutsson M, Carlsson BC. Effect of Tenapanor on Interdialytic Weight Gain in Patients on Hemodialysis. Clin J Am Soc Nephrol 2016; 11:1597-1605. [PMID: 27340281 PMCID: PMC5012484 DOI: 10.2215/cjn.09050815] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 05/02/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Interdialytic weight gain in patients on hemodialysis is associated with adverse cardiovascular outcomes and increased mortality. The degree of interdialytic weight gain is influenced by sodium intake. We evaluated the effects of tenapanor (AZD1722 and RDX5791), a minimally systemically available inhibitor of the sodium/hydrogen exchanger isoform 3, on interdialytic weight gain in patients with CKD stage 5D treated with hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This phase 2, randomized, double-blind study (NCT01764854; conducted January to September of 2013) enrolled adults on maintenance hemodialysis with interdialytic weight gain ≥3.0% of postdialysis weight and ≥2 kg. Patients were randomly assigned (1:1) to receive tenapanor or placebo. The primary end point was change in mean interdialytic weight gain (percentage of baseline postdialysis weight) from baseline (mean across a 2-week run-in period) to week 4. In a subgroup of inpatients, 24-hour stool sodium and stool weight were assessed for 1 week. RESULTS Sixteen patients received 1 week of inpatient treatment (tenapanor, eight; placebo, eight), and 72 patients received 4 weeks of treatment in an outpatient setting (tenapanor, 37; placebo, 35; completers: tenapanor, 31; placebo, 33). In the outpatient cohort, no significant effect on interdialytic weight gain was detected; least squares mean changes in relative interdialytic weight gain from baseline to week 4 were tenapanor, -0.26% (95% confidence interval, -0.57% to 0.06%) and placebo, -0.23% (95% confidence interval, -0.54% to 0.07%; P=0.46). During week 1 (inpatient cohort only), compared with placebo, tenapanor treatment resulted in higher stool sodium content (mean [±SD]: tenapanor, 36.6 [±21.8] mmol/d; placebo, 2.8 [±2.7] mmol/d; P<0.001) and higher stool weight (tenapanor, 172.5 [±68.1] g/d; placebo, 86.3 [±30.0] g/d; P<0.01). A similar safety profile was observed across treatment groups with the exception of diarrhea, which occurred more frequently with tenapanor treatment. CONCLUSIONS Tenapanor treatment increased stool sodium and weight over placebo in patients undergoing hemodialysis. However, over 4 weeks of treatment, there was no difference in interdialytic weight gain between patients treated with tenapanor and those receiving placebo.
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