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Cheng Y, Liu Y, Lin L, Li D, Peng L, Zheng K, Tao J, Li M. The effects of Tripterygium wilfordii Hook F on renal outcomes in type 2 diabetic kidney disease patients with severe proteinuria: a single-center cohort study. Ren Fail 2024; 46:2295425. [PMID: 38178377 PMCID: PMC10773657 DOI: 10.1080/0886022x.2023.2295425] [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] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 12/11/2023] [Indexed: 01/06/2024] Open
Abstract
AIM Tripterygium wilfordii Hook F (TwHF) has been shown to substantially reduce proteinuria in patients with diabetic kidney disease (DKD); however, the effect of TwHF on renal outcomes in DKD remains unknown. Accordingly, we aimed to establish the effects of TwHF on renal outcomes in patients with DKD. METHODS Overall, 124 patients with DKD, induced by type 2 diabetes mellitus, with 24-h proteinuria > 2 g, and an estimated glomerular filtration rate > 30 mL/min/1.73 m2 were retrospectively investigated. The renal outcomes were defined as doubling serum creatinine levels or end-stage kidney disease. Kaplan-Meier curves and Cox regression analyses were performed to analyze prognostic factors for renal outcomes. RESULTS By the end of the follow-up, renal outcomes were observed in 23 and 11 patients in the non-TwHF and TwHF groups, respectively (p = 0.006). TwHF significantly reduced the risk of renal outcomes (adjusted hazard ratio [HR] 0.271, 95% confidence interval [CI] 0.111-0.660, p = 0.004) in patients with chronic kidney disease (CKD) G3 (adjusted HR 0.274, 95%CI 0.081-0.932, p = 0.039). Based on the Kaplan-Meier analysis, 1- and 3-year proportions of patients without renal outcomes were significantly lower in the non-TwHF group than those in the TwHF group (92.8% vs. 95.5% and 47.2% vs. 76.8%, respectively; p = 0.0018). CONCLUSION In DKD patients with severe proteinuria, TwHF could prevent DKD progression, especially in patients with CKD G3. A randomized clinical trial is needed to elucidate the benefits of TwHF on renal outcomes in patients with DKD.
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Affiliation(s)
- Yaqi Cheng
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuhao Liu
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Liling Lin
- Department of Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Danni Li
- Department of Emergency, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Liying Peng
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ke Zheng
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jianling Tao
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Mingxi Li
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Iijima H, Gouda M, Hida H, Mori-Anai K, Takahashi A, Minai R, Ninomiya H, Saito Y, Miyawaki A, Wada J. Renal outcomes with sodium-glucose cotransporter 2 inhibitors in Japanese people with grade 3 chronic kidney disease and type 2 diabetes: Analysis of medical administrative databases. Diabetes Obes Metab 2024; 26:1615-1623. [PMID: 38413384 DOI: 10.1111/dom.15461] [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: 09/21/2023] [Revised: 12/25/2023] [Accepted: 01/04/2024] [Indexed: 02/29/2024]
Abstract
AIM To evaluate whether sodium-glucose cotransporter 2 inhibitor (SGLT2i) therapy is associated with a reduction of renal events compared with other glucose-lowering drugs (oGLDs) among Japanese people with type 2 diabetes (T2D) and grade 3 (G3) chronic kidney disease (CKD) in a real-world clinical practice setting. MATERIALS AND METHODS People with T2D who were newly prescribed an SGLT2i or an oGLD from April 2014 to November 2021 (without prior use of index drugs for ≥ 1 year prior to index date) and G3 CKD (estimated glomerular filtration rate [eGFR] ≥ 30 to < 60 mL/min/1.73 m2) were selected from the Medical Data Vision database (MDV-DB) and the Real-World Data database (RWD-DB). SGLT2i and oGLD users were matched (1:1) using propensity score on patient background characteristics. The primary endpoint was a composite of the development of end-stage kidney disease or a sustained decline in eGFR of 50% or more. Hazard ratios (HRs) were estimated using the Cox proportional hazards model. RESULTS Overall, 3190 (1595 per group) patients in the MDV-DB and 2572 (1286 per group) patients in the RWD-DB were included in the analyses. The composite outcome was significantly lower in the SGLT2i group than in the oGLD group in the MDV-DB (HR 0.49, 95% confidence interval [CI] 0.33 to 0.74, P < 0.001) and in the RWD-DB (HR 0.57, 95% CI 0.37 to 0.88, P = 0.011). CONCLUSIONS Japanese people with T2D and G3 CKD initiating an SGLT2i had a lower risk of renal events than people initiating an oGLD.
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Affiliation(s)
- Hiroaki Iijima
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan
| | - Maki Gouda
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan
| | - Hideaki Hida
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan
| | - Kazumi Mori-Anai
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan
| | - Akiko Takahashi
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan
| | | | | | | | - Atsushi Miyawaki
- Datack, Inc., Tokyo, Japan
- Department of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
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McCullar KS, Abbaspour S, Wang W, Aguirre AD, Westover MB, Klerman EB. Timing of diuretic administration effects on urine volume in hospitalized patients. Front Physiol 2024; 14:1208324. [PMID: 38321985 PMCID: PMC10844419 DOI: 10.3389/fphys.2023.1208324] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 12/27/2023] [Indexed: 02/08/2024] Open
Abstract
Importance: Some medications have effects that depend on the time of day they are given. Current knowledge of the time-of-day effects of specific medications in hospitalized patients with cardiovascular disease is very limited. In hospitalized patients, increased medication efficiency might reduce dose (and associated side effects) and/or the length of time in the Intensive Care Unit (ICU) or hospital-potentially improving patient outcomes and patient and family quality of life and reducing financial costs. We studied whether the time of day or night patients in Cardiac or Intensive Care Units receive a diuretic affects urine volume. Methods: In this observational study, data were collected from 7,685 patients (63% male, 18 to 98 years old) admitted to one hospital's Acute Care Cardiac units, Cardiac ICUs, Cardiac Surgery ICUs, and/or Non-cardiac ICUs who received intravenous furosemide (a diuretic), had measurements of urine volume, were hospitalized for ≥3 days between January 2016 to July 2021 and were older than 18 years. The outcomes of interest were urine volume normalized by the most recent (not older than 24 h) weight or body mass index (BMI), (i) in the hour after the time of diuretic administration, and (ii) when no diuretics were administered for the previous 3 h. Results: We identified diuretic medication administration time 23:00-04:59 as a predictor of higher urine volume response. For patients without recent diuretic medication, higher urine volume was predicted 11:00-16:59 and 17:00-22:59. Other factors that affected urine volume response to the diuretic were sex, age, medication dose, creatinine concentration, diagnoses, and hospital unit. Discussion: Time-of-day of medication administration may be a factor associated with increased medication efficiency. Randomized controlled trials should be conducted to quantify the relative effect of modifiable factors, such as time of medication administration, that may affect short- and longer-term outcomes.
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Affiliation(s)
- Katie S. McCullar
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, United States
| | - Sara Abbaspour
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, United States
| | - Wei Wang
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, United States
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, United States
| | - Aaron D. Aguirre
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - M. Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Elizabeth B. Klerman
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, United States
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, United States
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4
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Sohn M, Frias JP, Lim S. Cardiovascular efficacy and safety of antidiabetic agents: A network meta-analysis of randomized controlled trials. Diabetes Obes Metab 2023; 25:3560-3577. [PMID: 37649320 DOI: 10.1111/dom.15251] [Citation(s) in RCA: 2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/18/2023] [Accepted: 08/03/2023] [Indexed: 09/01/2023]
Abstract
AIM An important characteristic of glucose-lowering therapies (GLTs) is their ability to prevent cardiovascular complications. We aimed to investigate the cardiorenal efficacy and general safety of GLTs. MATERIALS AND METHODS Multicentre, randomized, clinical trials that included over 100 participants comparing antidiabetic agents with a placebo or a different antidiabetic agent and reporting major adverse cardiovascular events (MACEs), or primarily reporting heart failure, were searched in the PubMed, Embase and Cochrane databases. Data were extracted independently for random-effects network meta-analyses to calculate the hazard ratio estimates. RESULTS Forty-three trials that compared nine types of GLTs were included in the present analysis. The risk of three-point MACE was reduced in the presence of glucagon-like peptide-1 receptor agonists (GLP-1 RAs), sodium-glucose cotransporter-2 inhibitors (SGLT-2is) and thiazolidinedione therapy compared with the placebo, dipeptidyl peptidase-4 inhibitors, or insulin therapy. GLP-1 RAs were favourable for cardiovascular and renal outcomes. SGLT-2is reduced renal outcomes by ~40%, which was superior to other GLTs. Thiazolidinedione therapy increased the risks of hospitalization for heart failure and had no benefits on mortality. Adverse events leading to drug discontinuation were higher with GLP-1 RAs and thiazolidinediones than placebo. CONCLUSIONS GLP-1 RAs, SGLT-2is and thiazolidinediones reduced three-point MACE compared with other GLTs. Each drug class had unique advantages and disadvantages.
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Affiliation(s)
- Minji Sohn
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Juan P Frias
- National Research Institute, Metro Medical Mall, Los Angeles, California, USA
| | - Soo Lim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
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Olanrewaju OA, Sheeba F, Kumar A, Ahmad S, Blank N, Kumari R, Kumari K, Salame T, Khalid A, Yousef N, Varrassi G, Khatri M, Kumar S, Mohamad T. Novel Therapies in Diabetes: A Comprehensive Narrative Review of GLP-1 Receptor Agonists, SGLT2 Inhibitors, and Beyond. Cureus 2023; 15:e51151. [PMID: 38283440 PMCID: PMC10811430 DOI: 10.7759/cureus.51151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 01/30/2024] Open
Abstract
Diabetes mellitus, a widespread metabolic illness with increasing global occurrence, continues to have a significant impact on public health. Diabetes is a condition marked by long-term high blood sugar levels. It is caused by a combination of genetic, environmental, and lifestyle factors, which lead to problems with insulin production and insulin resistance. This dysfunctional state disturbs the delicate balance of glucose regulation, promoting the emergence of problems in both large and small blood vessels that have a substantial impact on illness and death rates. Traditional therapy methods have traditionally given more importance to managing blood sugar levels by using insulin sensitizers, secretagogues, and other medications that lower glucose levels. Advancements in our understanding of the underlying mechanisms of diabetes have led to a significant change in approach, focusing on comprehensive therapies that target not only high blood sugar levels but also the accompanying dangers to the heart and kidneys. This study examines the evolving field of diabetes therapies, explicitly highlighting the significance of GLP-1 receptor agonists and SGLT2 inhibitors. These two types of drugs have become essential components in modern diabetes management. GLP-1 receptor agonists replicate the effects of natural glucagon-like peptide-1, leading to insulin production that is reliant on glucose levels, reducing the release of glucagon, and providing cardiovascular advantages that go beyond controlling blood sugar levels. SGLT2 inhibitors, however, act on the process of renal glucose reabsorption, leading to increased excretion of glucose in the urine and showing significant benefits for cardiovascular and renal protection. This extensive investigation seeks to contribute to the ongoing discourse on diabetes therapies by synthesizing existing research. This review aims to provide clinicians, researchers, and policymakers with a comprehensive understanding of the disease background and the specific pharmacological details of GLP-1 receptor agonists, SGLT2 inhibitors, and other related treatments. The goal is to assist them in developing more effective and personalized strategies to tackle the complex challenges presented by diabetes.
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Affiliation(s)
- Olusegun A Olanrewaju
- Pure and Applied Biology, Ladoke Akintola University of Technology, Ogbomoso, NGA
- General Medicine, Stavropol State Medical University, Stavropol, RUS
| | - Fnu Sheeba
- Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Avinash Kumar
- Medicine, Bahria University Medical and Dental College, Karachi, PAK
| | - Saad Ahmad
- Medicine, Shalamar Medical and Dental College, Lahore, PAK
| | - Narendar Blank
- Internal Medicine, Liaquat University of Medical and Health Sciences, Hyderabad, PAK
| | - Reema Kumari
- Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Komal Kumari
- Medicine, New Medical Centre Royal Family Medical Centre, Abu Dhabi, ARE
| | - Tamara Salame
- Biological Sciences, Wayne State University, Detroit, USA
| | - Ayesha Khalid
- Medicine, Fatima Memorial College of Medicine and Dentistry, Lahore, PAK
| | - Nazdar Yousef
- Medicine, University of Kalamoon, Deir Atiyah An-Nabek, SYR
| | | | - Mahima Khatri
- Internal Medicine/Cardiology, Dow University of Health Sciences, Civil Hospital Karachi, Karachi, PAK
| | - Satish Kumar
- Medicine, Shaheed Mohtarma Benazir Bhutto Medical College, Karachi, PAK
| | - Tamam Mohamad
- Cardiovascular Medicine, Wayne State University, Detroit, USA
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Abstract
BACKGROUND Fibroblast growth factor 21 (FGF21) is deemed to play an important role in kidney outcomes, while the association between FGF21 and various kidney diseases remains largely unclear and inconsistent. Therefore, we conducted this meta-analysis to find out the role of FGF21 in various renal diseases. METHODS The outcome indicator of our study was assessed by the pooled standard mean difference (SMD) with 95% confidence intervals (CIs) which were calculated by random-effect model analysis. The risk of bias was assessed by Non-Randomized Studies of Interventions (ROBINS-I) tool. Funnel plot combined with Egger's and Begg's tests was performed to estimate the publication bias that existed in the study. RESULTS A total of 28 eligible studies with 19348 participants were included in our research. The agreement between authors reached a kappa-value of 0.88. Overall, the serum FGF21 level was strongly higher in CKD patients (SMD = 0.97 (ng/L); 95% CI, 0.70-1.24 (ng/L)) and the renal outcomes in T2DM patients (SMD = 0.54 (ng/L); 95% CI, 0.39-0.70 (ng/L)) compared with the control group. Consistent with this, the incidence of CKD (OR = 2.56; 95% CI, 1.72-3.81) and the incidence of renal outcomes (OR = 1.63; 95% CI, 1.31-2.01) in T2DM patients was significantly higher in the patients with high FGF21 concentration, indicating that high serum FGF21 level may predict the incidence of CKD and the renal outcomes in T2DM patients. CONCLUSION Serum FGF21 may be one of the strong predictors for various kidney diseases including the progression of CKD and the hard renal outcomes in type 2 diabetes patients, but more large-scale clinical research are needed to confirm this finding.
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Affiliation(s)
- Guo Yong
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Changsha, China
- Department of Organ Procurement Organization, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Ling Li
- Department of Urinary Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Shanbiao Hu
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Changsha, China
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7
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Wang J, Zhu M, Jiao C, Xu X, Xu F, Liang D, Liu Z, Chen Y, Zhang H. Association of regulatory T cells with renal outcomes in patients with proliferative lupus nephritis. Lupus 2023; 32:1237-1244. [PMID: 37695664 DOI: 10.1177/09612033231201619] [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] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
BACKGROUND Despite progress in the diagnosis and treatment of proliferative lupus nephritis (PLN), the prognosis remains unfavorable. Previous investigations have suggested that the deficiency of regulatory T cells (Tregs) is involved in the pathogenesis of systemic lupus erythematosus (SLE) and lupus nephritis (LN). But the prognostic value of Tregs in PLN remains controversial. This study aimed to investigate the association of Tregs with renal outcomes in patients with PLN. METHODS The baseline and follow-up data of patients with biopsy-proven PLN were collected in this study. All patients were divided into two groups according to whether the renal endpoint event occurred. Clinicopathologic features and therapeutic responses were compared between the two groups. Cox regression analyses curve fitting and threshold effect analysis were implemented to investigate the relationship between Tregs level and the long-term renal outcomes. The renal endpoint was defined as end-stage kidney disease (ESKD) or doubling the SCr value. RESULTS A total of 405 PLN patients were included. After a follow-up of 71.53 (53.13-97.47) months, 42 (10.4%) patients reached the renal endpoint. The Treg cell counts (16/μL) in the renal endpoint group were significantly decreased than that in the non-renal endpoint group (p < 0.001). Univariate and multivariate Cox regression analyses showed that the high level of Tregs was an independent protective factor for the long-term renal prognosis of PLN. Smooth curve fitting of the generalized additive mixed model analysis indicated that the risk of renal endpoint first decreased with Tregs and then slightly increased along with Treg cell levels. The segmented linear model revealed that when Treg cell counts <46/μL, the risk of renal endpoint decreased by 6.8% for every 1 μL increase in Treg levels (p = 0.0029). CONCLUSION Treg cell counts are closely related to the long-term renal outcomes of patients with PLN, and increasing Treg cell levels may play an important role in improving the prognosis of the kidney, but there may be a turning point (i.e., threshold effect) at the Treg cell counts that leads to directional changes in the renal outcomes.
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Affiliation(s)
- Jingjing Wang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Mengyue Zhu
- Department of Nephrology, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Chenfeng Jiao
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiaodong Xu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Feng Xu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Dandan Liang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhengzhao Liu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yinghua Chen
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Haitao Zhang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Rojas-Rivera JE, García-Carro C, Ávila AI, Espino M, Espinosa M, Fernández-Juárez G, Fulladosa X, Goicoechea M, Macía M, Morales E, Quintana LF, Praga M. Diagnosis and treatment of lupus nephritis: a summary of the Consensus Document of the Spanish Group for the Study of Glomerular Diseases (GLOSEN). Clin Kidney J 2023; 16:1384-1402. [PMID: 37664575 PMCID: PMC10468759 DOI: 10.1093/ckj/sfad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Indexed: 09/05/2023] Open
Abstract
Lupus nephritis (LN) is the most frequent serious manifestation of patients with systemic lupus erythematosus (SLE). Up to 60% of SLE patients develop LN, which has a significant impact on their quality of life and prognosis. Recent advances have improved the diagnostic approach to LN, and new drugs that block specific pathways and kidney damage progression have been developed. Several randomized and well-powered clinical trials have confirmed the efficacy of these agents in terms of proteinuria remission and preservation of kidney function in the medium and long term, with an acceptable safety profile and good tolerance. The combination of different therapies allows for reduction of the dose and duration of corticosteroids and other potentially toxic therapies and leads to an increase in the number of patients achieving complete remission of the disease. This consensus document carried out by the Spanish Group for the Study of Glomerular Diseases (GLOSEN) provides practical and updated recommendations, based on the best available evidence and clinical expertise of participating nephrologists.
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Affiliation(s)
- Jorge E Rojas-Rivera
- Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
- Departament of Medicine, Universidad Autónoma de Madrid
| | | | | | - Mar Espino
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | - Xavier Fulladosa
- Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Manuel Macía
- Hospital Universitario Nuestra Señora de la Candelaria, Tenerife, Spain
| | - Enrique Morales
- Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Hospital Universitario 12 de Octubre, Madrid, Spain
- Departament of Medicine, Universidad Complutense, Madrid, Spain
| | - Luis F Quintana
- Hospital Clínic de Barcelona, Barcelona, Spain
- Departament of Medicine, Universidad de Barcelona, IDIBAPS, Barcelona, Spain
| | - Manuel Praga
- Instituto de Investigación Hospital Universitario 12 de Octubre, Madrid, Spain
- Departament of Medicine, Universidad Complutense, Madrid, Spain
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Alshahrani AA, Qahtani SSA, Qahtani ASA, Mashhour SM, Alkhtani ZS, Alragea YM. Metabolic and renal outcomes of empagliflozin in patients with type 2 diabetes mellitus attending Armed Forces Hospital in Saudi Arabia: Retrospective cohort study. Saudi Med J 2023; 44:674-678. [PMID: 37463703 PMCID: PMC10370372 DOI: 10.15537/smj.2023.44.7.20230094] [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] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/07/2023] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES To explore the effects of empagliflozin (25 mg) on metabolic and renal parameters in patients with type 2 diabetes mellitus (T2DM). METHODS This retrospective observational comparative study was conducted at a military hospital in southern Saudi Arabia. All adults (aged >18 years) with T2DM who attended diabetic clinics between October 2021 to March 2022 (6 months), with or without insulin treatment, were eligible for inclusion in the study. RESULTS Following the initiation of empagliflozin treatment, statistically significant reductions in patient weight (kg) were observed at 1, 3-5, and 6 months. In addition, low-density lipoprotein levels significantly decreased 3-5 months post-treatment initiation (p=0.011). However, serum creatinine level decreased gradually with time during the treatment with empagliflozin, from 87.45±31.78 (0.105) to 78.39±27.43 (0.033). Furthermore, after empagliflozin treatment, the urinary albumin-to-creatinine ratio significantly decreased at 3-5 and 6 months. Moreover, HbA1c levels exhibited statistically significant decreases at 3-5 months (p<0.001) and at 6 months (p<0.001) following the initiation of empagliflozin treatment. Notably, systolic and diastolic blood pressure significantly reduced 6 months after empagliflozin treatment. CONCLUSION In the current study, empagliflozin has demonstrated efficacy in controlling blood pressure and body weight, and improving renal function, short-term dyslipidemia, and glycemic control in patients with T2DM.
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Affiliation(s)
- Ali A. Alshahrani
- From the Department of Family Medicine, Armed Forces Hospital, Khamis Mushait, Kingdom of Saudi Arabia.
| | - Saad S. Al Qahtani
- From the Department of Family Medicine, Armed Forces Hospital, Khamis Mushait, Kingdom of Saudi Arabia.
| | - Abrar S. Al Qahtani
- From the Department of Family Medicine, Armed Forces Hospital, Khamis Mushait, Kingdom of Saudi Arabia.
| | - Saeed M. Mashhour
- From the Department of Family Medicine, Armed Forces Hospital, Khamis Mushait, Kingdom of Saudi Arabia.
| | - Zayed S. Alkhtani
- From the Department of Family Medicine, Armed Forces Hospital, Khamis Mushait, Kingdom of Saudi Arabia.
| | - Yahya M. Alragea
- From the Department of Family Medicine, Armed Forces Hospital, Khamis Mushait, Kingdom of Saudi Arabia.
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10
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Brønden A, Christensen MB, Glintborg D, Snorgaard O, Kofoed-Enevoldsen A, Madsen GK, Toft K, Kristensen JK, Højlund K, Hansen TK, Søndergaard E, Hansen KB. Effects of DPP-4 inhibitors, GLP-1 receptor agonists, SGLT-2 inhibitors, and sulfonylureas on mortality, cardiovascular and renal outcomes in type 2 diabetes: a network meta-analyses-driven approach. Diabet Med 2023:e15157. [PMID: 37249579 DOI: 10.1111/dme.15157] [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] [Received: 12/22/2022] [Revised: 05/10/2023] [Accepted: 05/25/2023] [Indexed: 05/31/2023]
Abstract
AIMS The aim of our meta-analyses was to compare the effects of glucose-lowering drugs on mortality, cardiovascular and renal endpoints for a range of type 2 diabetes (T2D) subgroups defined by their specific cardiovascular risk profile. METHODS Meta-analyses comparing drugs within the classes of GLP-1RAs and SGLT-2 inhibitors were performed and compared to sulphonylureas and DPP-4 inhibitors with available cardiovascular outcome trials. The comparison between the different classes of glucose-lowering drugs included analyses of T2D populations with low risk and high risk for cardiovascular disease including populations with established cardiovascular disease and/or kidney disease. Outcomes included mortality, major cardiovascular adverse events (MACE), hospitalisation for heart failure (HHF) and a composite renal endpoint as applied in the underlying clinical trials. RESULTS SGLT-2 inhibitors and GLP-1RAs showed beneficial effects on mortality and MACE compared to the classes of DPP-4 inhibitors and sulphonylureas. SGLT-2 inhibitors were shown to be the most effective treatment in terms of HHF and kidney disease. Metformin was used as background therapy for the vast majority of participants in all included studies. Overall, the absolute effects of SGLT-2 inhibitors and GLP-1RAs on these important outcomes were evident for patients with established or at high risk for cardiovascular disease but limited for the low-risk subgroup. CONCLUSIONS The findings from our analyses substantiate the relevance of treatment with SGLT-2 inhibitors or GLP-1RAs as add-on to metformin in patients with T2D and a high risk for cardiovascular disease, and furthermore, support the recommendation for SGLT-2 inhibitor treatment in patients with T2D and heart failure or established kidney disease.
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Affiliation(s)
- Andreas Brønden
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen (2400, Copenhagen, NV), Denmark
| | - Mikkel Bring Christensen
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen (2400, Copenhagen, NV), Denmark
| | - Dorte Glintborg
- Danish Medicines Council, Copenhagen (2100, Copenhagen Ø), Denmark
| | - Ole Snorgaard
- Department of Endocrinology, Amager and Hvidovre Hospital, Copenhagen (2650, Hvidovre), Denmark
| | - Allan Kofoed-Enevoldsen
- Steno Diabetes Center Zealand, Nykøbing Falster Hospital, Nykøbing Falster (4800 Nykøbing Falster), Denmark
| | | | - Katja Toft
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen (2400, Copenhagen, NV), Denmark
| | | | - Kurt Højlund
- Steno Diabetes Center Odense, Odense University Hospital, Odense (5000 Odense), Denmark
| | - Troels Krarup Hansen
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus (8200 Aarhus N), Denmark
| | - Esben Søndergaard
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus (8200 Aarhus N), Denmark
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Tang H, Chen W, Bian J, O'Neal LJ, Lackland DT, Schatz DA, Guo J. Ethnic Variations in Cardiovascular and Renal Outcomes From Newer Glucose-Lowering Drugs: A Meta-Analysis of Randomized Outcome Trials. J Am Heart Assoc 2023; 12:e026791. [PMID: 37158069 DOI: 10.1161/jaha.122.026791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Background Hispanic populations are more likely to develop diabetes and its related diseases than non-Hispanic White populations. Little evidence exists to support whether the cardiovascular and renal benefits of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists are generalizable to the Hispanic populations. Methods and Results We included the cardiovascular and renal outcome trials (up to March 2021) that reported the major adverse cardiovascular events (MACEs), cardiovascular death/hospitalization for heart failure, and composite renal outcomes by ethnicity in individuals with type 2 diabetes (T2D), calculated pooled hazard ratios (HRs) with 95% CIs using fixed-effects models, and tested the differences between Hispanic and non-Hispanic populations (P for interaction [Pinteraction]). In 3 sodium-glucose cotransporter 2 inhibitor trials, there was a statistically significant difference between Hispanic (HR, 0.70 [95% CI, 0.54-0.91]) and non-Hispanic (HR, 0.96 [95% CI, 0.86-1.07]) groups in treatment effects on MACE risk (Pinteraction=0.03), except for risks of cardiovascular death/hospitalization for heart failure (Pinteraction=0.46) and composite renal outcome (Pinteraction=0.31). In 5 glucagon-like peptide-1 receptor agonist trials, there was no statistically significant difference in treatment effect on MACE risk between Hispanic (HR, 0.82 [95% CI, 0.70-0.96]) and non-Hispanic (HR, 0.92 [95% CI, 0.84-1.00]) populations (Pinteraction=0.22). In 3 dipeptidyl peptidase-4 inhibitor trials, the HR for MACE risk appeared greater in Hispanic (HR, 1.15 [95% CI, 0.98-1.35]) than non-Hispanic (HR, 0.96 [95% CI, 0.88-1.04]) populations (Pinteraction=0.045). Conclusions Compared with non-Hispanic individuals, Hispanic individuals with T2D appeared to obtain a greater benefit of lowered MACE risk with sodium-glucose cotransporter 2 inhibitors.
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Affiliation(s)
- Huilin Tang
- Department of Pharmaceutical Outcomes and Policy University of Florida College of Pharmacy Gainesville FL USA
| | - Weihan Chen
- Department of Pharmaceutical Outcomes and Policy University of Florida College of Pharmacy Gainesville FL USA
| | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics College of Medicine, University of Florida Gainesville FL USA
| | - LaToya J O'Neal
- Department of Family, Youth and Community Sciences Institute of Food and Agricultural Sciences, University of Florida Gainesville FL USA
| | - Daniel T Lackland
- Department of Neurology Medical University of South Carolina Charleston SC USA
| | - Desmond A Schatz
- Division of Endocrinology Department of Pediatrics University of Florida College of Medicine Gainesville FL USA
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes and Policy University of Florida College of Pharmacy Gainesville FL USA
- Center for Drug Evaluation and Safety University of Florida Gainesville FL USA
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12
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Boparai S, Lakra R, Dhaliwal L, Hansra RS, Bhuiyan MAN, Conrad SA, Krishnan P. Therapeutic Plasma Exchange in Severe Rhabdomyolysis: A Case-Control Study. Cureus 2023; 15:e39748. [PMID: 37398832 PMCID: PMC10310893 DOI: 10.7759/cureus.39748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 07/04/2023] Open
Abstract
INTRODUCTION Rhabdomyolysis is a serious condition that can cause acute kidney injury (AKI), compartment syndrome, severe metabolic and electrolyte derangement leading to arrhythmias, and even death. Total plasma exchange (TPE) has been used as a treatment modality to clear myoglobin, but the evidence is limited. In this study, we aim to investigate the use of TPE in critically ill rhabdomyolysis patients. METHODS We retrospectively chart reviewed adult patients admitted to the intensive care unit (ICU) with a diagnosis of rhabdomyolysis between 2012 and 2021. We dichotomized patients into two groups based on whether TPE was used or not in addition to standard care. PRISMA machines with TPE2000 filters and either 5% albumin or fresh frozen plasma were used in the TPE group. RESULTS The patients' age ranged from 23 years to 87 years (mean 49.4, SD 18.1), and 51% were male. Initial creatinine ranged from 0.6 to 16mg/dL (mean 3.4, SD 2.7), creatinine phosphokinase (CPK) from 403-93,232 U/L, and myoglobin from 934 to >20,000. The Sequential Organ Failure Assessment (SOFA)scores on admission ranged from 6 to 17 (mean 7.23, SD 3.40). Overall, 28.78% (N=19) of the patients received therapeutic plasma exchange. The overall mortality in our study was 31.9%, with the length of ICU stay ranging from 1-25 days (mean 7.10, SD 5.91) among survivors. Older age and the presence of shock were predictive of mortality in univariate and multivariate analyses. There was no statistically significant association in mortality between the TPE and non-TPE groups (36.84% in TPE vs. 36.17% in the non-TPE group, OR 0.7209, p=0.959). Only two patients in the non-TPE group developed CKD/ESRD on long-term follow-up. CONCLUSION Our study showed that TPE administration in critically ill patients with rhabdomyolysis did not improve mortality or length of ICU stay. Further studies are required to elucidate its indication and effect on long-term renal outcomes.
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Affiliation(s)
- Sukhmani Boparai
- Internal Medicine, Louisiana State University (LSU) Health Shreveport, Shreveport, USA
| | - Rachaita Lakra
- Internal Medicine, Louisiana State University (LSU) Health Shreveport, Shreveport, USA
| | - Lovekirat Dhaliwal
- Internal Medicine, Louisiana State University (LSU) Health Shreveport, Shreveport, USA
| | - Rajkamal S Hansra
- Pulmonary and Critical Care Medicine, Louisiana State University (LSU) Health Shreveport, Shreveport, USA
| | | | - Steven A Conrad
- Pulmonary and Critical Care Medicine, Louisiana State University (LSU) Health Shreveport, Shreveport, USA
| | - Prathik Krishnan
- Pulmonary and Critical Care Medicine, Louisiana State University (LSU) Health Shreveport, Shreveport, USA
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13
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Chung CP, Karakoc G, Dickson A, Liu G, Gamboa JL, Mosley JD, Cox NJ, Kawai VK. APOL1 and the risk of adverse renal outcomes in patients of African ancestry with systemic lupus erythematosus. Lupus 2023; 32:763-770. [PMID: 37105192 DOI: 10.1177/09612033231172660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) disproportionately affects individuals of African ancestry (AA) compared to European ancestry (EA). In the general population, high risk (HR) variants in the apolipoprotein L1 (APOL1) gene increase the risk of renal and hypertensive disorders in individuals of AA. Since SLE is characterized by an interferon signature and APOL1 expression is driven by interferon, we examined the hypothesis that APOL1 HR genotypes predominantly drive higher rates of renal and hypertensive-related comorbidities observed in SLE patients of AA versus those of EA. METHODS We performed a retrospective cohort study in patients with SLE of EA and AA using a genetic biobank linked to de-identified electronic health records. APOL1 HR genotypes were defined as G1/G1, G2/G2, or G1/G2 and low risk (LR) genotypes as 1 or 0 copies of the G1 and G2 alleles. To identify renal and hypertensive-related disorders that differed in prevalence by ancestry, we used a phenome-wide association approach. We then used logistic regression to compare the prevalence of renal and hypertensive-related disorders in EA and AA patients, both including and excluding patients with the APOL1 HR genotype. In a sensitivity analysis, we examined the association of end stage renal disease secondary to lupus nephritis (LN-related ESRD) with ancestry and the APOL1 genotype. RESULTS We studied 784 patients with SLE; 195 (24.9%) were of AA, of whom 27 (13.8%) had APOL1 HR genotypes. Eighteen renal and hypertensive-related phenotypes were more common in AA than EA patients (p-value ≤ 1.4E-4). All phenotypes remained significantly different after exclusion of patients with APOL1 HR genotypes, and most point odds ratios (ORs) decreased only slightly. Even among ORs with the greatest decrease, risk for AA patients without the APOL1 HR genotype remained significantly elevated compared to EA patients. In the sensitivity analysis, LN-related ESRD was more prevalent in SLE patients of AA versus EA and AA patients with the APOL1 HR genotype versus LR (p-value < .05 for both). CONCLUSION The higher prevalence of renal and hypertensive disorders in SLE patients of AA compared to those of EA is not fully explained by the presence of APOL1 high risk variants.
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Affiliation(s)
- Cecilia P Chung
- Division of Rheumatology and Immunology, Department of Medicine Vanderbilt University Medical Center, Nashville, TN, USA
- Tennessee Valley Healthcare System - Nashville Campus, Nashville, TN, USA
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Rheumatology, University of Miami, Miami, FL, USA
- Miami VA Healthcare System, Miami, FL, USA
| | - Gul Karakoc
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alyson Dickson
- Division of Rheumatology and Immunology, Department of Medicine Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ge Liu
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jorge L Gamboa
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan D Mosley
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Nancy J Cox
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Vivian K Kawai
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, USA
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Rastogi A, Januzzi JL. Pleiotropic Effects of Sodium-Glucose Cotransporter-2 Inhibitors in Cardiovascular Disease and Chronic Kidney Disease. J Clin Med 2023; 12:2824. [PMID: 37109162 PMCID: PMC10143176 DOI: 10.3390/jcm12082824] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/20/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2is) have been shown to improve cardiovascular and renal outcomes in patients with established cardiovascular disease, chronic kidney disease (CKD), and heart failure (HF) with reduced or preserved ejection fraction. Clinical benefit has been substantiated in patients with and without type 2 diabetes (T2D). Consequently, SGLT2is have an increasingly important role in HF and CKD management that extends beyond T2D treatment. Their pleiotropic pharmacological effects underlying their cardiovascular and renal benefits are not completely understood but include significant effects beyond blood glucose reduction. SGLT2is inhibit the reabsorption of glucose and sodium in the proximal tubule which, in addition to lowering blood glucose, activates tubuloglomerular feedback, leading to reduced glomerular hydrostatic pressure and the mitigation of glomerular filtration rate loss. SGLT2is have diuretic and natriuretic effects, leading to decreased blood pressure, preload, and left ventricular (LV) filling pressure, and improvements in other surrogates of afterload. In HF, SGLT2is mitigate the risks of hyperkalemia and ventricular arrhythmia and improve LV dysfunction. SGLT2is also reduce sympathetic tone and uric acid levels, increase hemoglobin levels, and are postulated to have anti-inflammatory properties. This narrative review discusses the multifactorial and interrelated pharmacological mechanisms underlying the cardiovascular and renal benefits of SGLT2is.
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Affiliation(s)
- Anjay Rastogi
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - James L. Januzzi
- Massachusetts General Hospital, Boston, MA 02114, USA;
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
- Baim Institute for Clinical Research, Boston, MA 02215, USA
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15
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Lin HYH, Chang LY, Niu SW, Kuo IC, Yen CH, Shen FC, Chen PL, Chang JM, Hung CC. High risk of renal outcome of metabolic syndrome independent of diabetes in patients with CKD stage 1-4: The ICKD database. Diabetes Metab Res Rev 2023; 39:e3618. [PMID: 36731513 DOI: 10.1002/dmrr.3618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 12/02/2022] [Indexed: 02/04/2023]
Abstract
AIMS To investigate whether metabolic syndrome (MetS) could predict renal outcome in patients with established chronic kidney disease (CKD). MATERIALS AND METHODS We enroled 2500 patients with CKD stage 1-4 from the Integrated CKD care programme, Kaohsiung for delaying Dialysis (ICKD) prospective observational study. 66.9% and 49.2% patients had MetS and diabetes (DM), respectively. We accessed three clinical outcomes, including all-cause mortality, RRT, and 50% decline in estimated glomerular filtration rate events. RESULTS The MetS score was positively associated with proteinuria, inflammation, and nutrition markers. In fully adjusted Cox regression, the hazard ratio (HR) (95% confidence interval) of MetS for composite renal outcome (renal replacement therapy, and 50% decline of renal function) in the DM and non-DM subgroups was 1.56 (1.15-2.12) and 1.31 (1.02-1.70), respectively, while that for all-cause mortality was 1.00 (0.71-1.40) and 1.27 (0.92-1.74). Blood pressure is the most important component of MetS for renal outcomes. In the 2 by 2 matrix, compared with the non-DM/non-MetS group, the DM/MetS group (HR: 1.62 (1.31-2.02)) and the non-DM/MetS group (HR: 1.33 (1.05-1.69)) had higher risks for composite renal outcome, whereas the DM/MetS group had higher risk for all-cause mortality (HR: 1.43 (1.09-1.88)). CONCLUSIONS MetS could predict renal outcome in patients with CKD stage 1-4 independent of DM.
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Affiliation(s)
- Hugo Y-H Lin
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Yun Chang
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Sheng-Wen Niu
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - I-Ching Kuo
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chia-Hung Yen
- National Natural Product Libraries and High-Throughput Screening Core Facility, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Natural Products, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Feng-Ching Shen
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Phang-Lang Chen
- Department of Biological Chemistry, University of California, Irvine, California, USA
| | - Jer-Ming Chang
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chi-Chih Hung
- Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Ghosal S, Sinha B. Finerenone in type 2 diabetes and renal outcomes: A random-effects model meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1114894. [PMID: 36742404 PMCID: PMC9895809 DOI: 10.3389/fendo.2023.1114894] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/09/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The nonsteroidal mineralocorticoid antagonist finerenone is a new addition to the list of agents (angiotensin converting enzyme inhibitors and sodium glucose cotransporter 2 inhibitors) conferring renal protection to patients with diabetic kidney disease. Two recent meta-analyses using the fixed effect model in patients with chronic kidney disease (both diabetic and nondiabetic populations) came to a conflicting conclusion on the effect of finerenone on eGFR decline. This meta-analysis was undertaken exclusively in the type 2 diabetes (T2D) population to explore the robustness and heterogeneity of the effect size by conducting a random effects model meta-analysis along with draft plots and prediction intervals. MATERIALS AND METHODS A database search was conducted using the Cochrane library, PubMed, and Embase to identify relevant citations. Analysis was conducted on the 14th of September 2022, using RevMan 5.4.1 and RStudio (2022.07.1, Build 554). The hazard ratio was used as the effect size for the renal composite, while the standardized mean difference (SMD) was used to estimate the effect size of eGFR decline and reduction in the urine albumin creatinine ratio (UACR). The Cochrane risk-of-bias was used to assess the quality of the studies. The primary outcome assessed was the renal composite defined as kidney failure, a sustained decrease of at least 40% in the eGFR from baseline, or death from renal causes. RESULTS A pooled population of 13,943 patients from four citations was included for analysis. The Cochrane risk of bias was used to assess the quality of the studies. There was a significant 16% reduction in the renal composite (kidney failure, a sustained decrease of at least 40% in the eGFR from baseline, or death from renal causes) [HR: 0.84, 95% CI 0.77-0.92, 2: 0, I2: 0%). Finerenone was also associated with reduction in UACR (SMD: -0.49, 95% CI -0.53 to -0.46, τ2: < 0.0001, I2: 0%, prediction interval: -0.57 to -0.41) and prevention of decline in eGFR (SMD: -0.32, 95% CI -0.37 to -0.27, τ2: < 0.0001, I2: 0%, prediction interval: -0.43 to -0.21) without any evidence for significant heterogeneity. Except for an increase in hyperkalaemia (RR: 2.22, 95% CI 1.93-2.24), adverse events were observed with fineronone compared to placebo (RR: 1.00, 95% CI 0.98-1.01). CONCLUSION There are significant benefits in renal outcomes associated with finerenone treatment in T2D patients with established chronic kidney disease with a side effect profile comparable to placebo.
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Affiliation(s)
- Samit Ghosal
- Nightingale Hospital, Kolkata, India
- *Correspondence: Samit Ghosal,
| | - Binayak Sinha
- Advanced Medical Research Institute (AMRI) Hospital, Kolkata, India
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Tian L, Ai S, zheng H, Yang H, Zhou M, Tang J, Liu W, Zhao W, Wang Y. Cardiovascular and renal outcomes with sodium glucose co-transporter 2 inhibitors in patients with type 2 diabetes mellitus: A system review and network meta-analysis. Front Pharmacol 2022; 13:986186. [PMID: 36506550 PMCID: PMC9731650 DOI: 10.3389/fphar.2022.986186] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/02/2022] [Indexed: 11/25/2022] Open
Abstract
Cardiovascular and renal impairment are the most common complications of type 2 diabetes mellitus (T2DM). As an emerging class of glucose-lowing agents sodium glucose co-transporter 2 (SGLT2), possesses beneficial effects on cardiovascular and renal outcomes in patients with T2DM. The aim of this study is to assess the efficacy of different SGLT2 inhibitors for cardiovascular and renal outcomes for patients with T2DM when compared with placebo. We performed a systematic search of PubMed, Embase, and the Cochrane library from inception through November 2021. Randomized clinical trials enrolling participants with T2DM were included, in which SGLT2 inhibitors were compared with each other or placebo. The primary outcomes including all-caused mortality, Cardiovascular outcomes (cardiovascular mortality, hospitalization for heart failure), and the renal composite outcomes (worsening persistent microalbuminuria or macroalbuminuria, new or worsening chronic kidney disease, doubling of serum creatinine, end-stage renal disease, renal transplant, or renal death). The data for the outcomes were pooled and recorded as Hazard rations (HRs) with 95% confidence intervals (CLs). Two researcher independently screened the trials and drawn the data. Ten trials enrolling 68,723 patients were included. Compared with placebo groups, Canagliflozin [HR, 0.85 (95%CI, 0.75-0.98)], ertugliflozin [HR, 0.93 (95%CI, 0.78-1.11)], and sotagliflozin [HR, 0.94 (95%CI, 0.79-1.12)] were associated with a reduction in all-cause mortality. Canagliflozin [HR, 0.84 (95%CI, 0.72-0.97)], dapagliflozin [HR, 0.88 (95%CI, 0.79-0.99)], empagliflozin [HR, 0.62 (95%CI, 0.49-0.78)], ertugliflozin [HR, 0.92 (95%CI, 0.77-1.10)], and sotagliflozin [HR, 0.88 (95%CI, 0.73-1.06)] were associated with a reduction in cardiovascular mortality; Canagliflozin [HR, 0.64 (95%CI, 0.53-0.77)], dapagliflozin [HR, 0.71 (95%CI, 0.63-0.81)], empagliflozin [HR, 0.65 (95%CI, 0.50-0.85)], ertugliflozin [HR, 0.70 (95%CI, 0.54-0.90)], and sotagliflozin [HR, 0.66 (95%CI, 0.56-0.77)] were associated with a reduction in hospitalization for heart failure. Dapagliflozin [HR, 0.55 (95%CI, 0.47-0.63)], Empagliflozin [HR, 0.54 (95%CI, 0.39-0.74)], canagliflozin [HR, 0.64 (95%CI, 0.54-0.75)], sotagliflozin [HR, 0.71 (95%CI, 0.46-1.09)], and ertugliflozin [HR, 0.81 (95%CI, 0.63-1.04)] were associated with a reduction in the renal composite outcome. All SGLT2 inhibitors showed a reduction in cardiovascular mortality, hospitalization for heart failure, renal composite outcomes and all-cause mortality. Canagliflozin and empagliflozin seemed to have the same efficacy in reducing hospitalization for heart failure, but empagliflozin had advantage in reducing cardiovascular mortality, whereas dapagliflozin most likely showed the best renal composite outcomes.
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Affiliation(s)
- Lei Tian
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Sinan Ai
- Renal Research Institution of Beijing University of Chinese Medicine, Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Huijuan zheng
- Renal Research Institution of Beijing University of Chinese Medicine, Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Hanwen Yang
- China-Japan Friendship Hospital, Beijing, China
| | - Mengqi Zhou
- Renal Research Institution of Beijing University of Chinese Medicine, Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Jingyi Tang
- Renal Research Institution of Beijing University of Chinese Medicine, Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Weijing Liu
- Renal Research Institution of Beijing University of Chinese Medicine, Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China,*Correspondence: Weijing Liu, ; Wenjing Zhao, ; Yaoxian Wang,
| | - Wenjing Zhao
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China,*Correspondence: Weijing Liu, ; Wenjing Zhao, ; Yaoxian Wang,
| | - Yaoxian Wang
- Renal Research Institution of Beijing University of Chinese Medicine, Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China,*Correspondence: Weijing Liu, ; Wenjing Zhao, ; Yaoxian Wang,
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Clements JN. Diabetes: how to manage chronic kidney disease. Drugs Context 2022; 11:dic-2021-9-10. [PMID: 35775073 PMCID: PMC9205574 DOI: 10.7573/dic.2021-9-10] [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: 09/27/2021] [Accepted: 01/17/2022] [Indexed: 11/22/2022] Open
Abstract
Background Chronic kidney disease (CKD) is a prevalent and progressive condition worldwide, and diabetes is a leading risk factor of this renal disorder. People with diabetes and CKD are at high risk of complications such as cardiovascular events and death. CKD is often unrecognized and undiagnosed amongst people with diabetes. To manage CKD, multiple existing and newer agents have been studied in trials and recommended in clinical practice guidelines. Methods A narrative review of primary and/or secondary renal outcomes from randomized, controlled trials is summarized in this article. The main objective was to provide the most up-to-date information regarding existing and new pharmacotherapy for the management of CKD amongst people with diabetes, specifically type 2 diabetes (T2D). Discussion Traditional agents, such as angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, have been used for 20 years to preserve kidney function. Other existing agents have received approval by the FDA for the management of CKD such as dapagliflozin, with a role in reducing intraglomerular pressure. Evidence with sodium–glucose cotransporter 2 inhibitors show a potential class effect on improving renal outcomes, independent on their effect on glycaemic parameters. Recently, finerenone was approved for people with T2D and CKD based on clinical evidence as a non-steroidal mineralocorticoid receptor antagonist. Overall, primary and secondary prevention trials have influenced changes in clinical practice guidelines regarding the use of existing and new pharmacotherapy for CKD. Additional considerations include lifestyle modifications, blood pressure management and achievement of glycaemic targets for people with diabetes and CKD, following adequate screening of glomerular filtration rate and/or severity of albuminuria. Conclusion Due to more robust evidence, clinical practice guidelines have been modified to reflect high-level recommendations for the management of CKD in people with diabetes, specifically T2D. Additional evidence is needed amongst people with lower glomerular filtration rates and in comparison with the standard of care.
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Affiliation(s)
- Jennifer N Clements
- Department of Nursing Administration, Spartanburg Regional Healthcare System, Spartanburg, SC, USA
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19
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Shen Y, Xiao T, Yu Z, Huang Y, He T, Li H, Zhang J, Xiong J, Zhao J. Arteriolar hyalinosis and renal outcomes in patients with immunoglobulin A nephropathy. Ren Fail 2022; 44:994-1003. [PMID: 35658824 PMCID: PMC9176706 DOI: 10.1080/0886022x.2022.2083974] [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] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The relationship between arteriolar hyalinosis and renal progression in immunoglobulin A nephropathy (IgAN) is not fully understood. We aimed to investigate the clinicopathological features and outcomes of IgAN with or without arteriolar hyalinosis. METHODS A total of 762 diagnosed with IgAN patients were retrospectively analyzed. We classified IgAN patients into two groups with or without arteriolar hyalinosis. Then, the clinicopathological characteristics of the two groups were compared. We used Kaplan-Meier survival analysis to compare the composite kidney outcome of the two groups and applied multivariate Cox regression analyses to test the association between arteriolar hyalinosis and composite kidney outcome. RESULTS Overall, 412 (54.1%) patients had arteriolar hyalinosis, including 173 patients diagnosed with hypertension. IgAN patients with arteriolar hyalinosis were older and had higher proteinuria, urea, uric acid, and blood pressure, while lower eGFR than those without arteriolar hyalinosis. Subgroup analysis showed similar results in IgAN patients with hypertension. Kaplan-Meier survival analysis showed that IgAN patients with arteriolar hyalinosis had worse composite kidney outcome than those without arteriolar hyalinosis. In addition, subgroup analysis revealed that patients with hypertension have worse composite kidney outcome than those without hypertension. Multivariate Cox regression analyses confirm that arteriolar hyalinosis (HR 2.57; 95% CI 1.41-4.69; p = 0.002) is an independent risk factor for renal prognosis in IgAN patients. CONCLUSIONS Our study demonstrated that arteriolar hyalinosis is a common vascular lesion in IgAN patients. Arteriolar hyalinosis connects closely with hypertension, and arteriolar hyalinosis is an independent risk factor for renal prognosis in patients with IgAN.
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Affiliation(s)
- Yunzhu Shen
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, P.R. China
| | - Tangli Xiao
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, P.R. China
| | - ZhiKai Yu
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, P.R. China
| | - Yinghui Huang
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, P.R. China
| | - Ting He
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, P.R. China
| | - Haiyang Li
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, P.R. China
| | - Jun Zhang
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, P.R. China
| | - Jiachuan Xiong
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, P.R. China
| | - Jinghong Zhao
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, P.R. China
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20
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Chang LH, Chu CH, Huang CC, Lin LY. Fibroblast Growth Factor 21 Levels Exhibit the Association With Renal Outcomes in Subjects With Type 2 Diabetes Mellitus. Front Endocrinol (Lausanne) 2022; 13:846018. [PMID: 35528011 PMCID: PMC9069677 DOI: 10.3389/fendo.2022.846018] [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] [Received: 12/30/2021] [Accepted: 02/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background Whether microalbuminuria predicts renal outcomes in patients with type 2 diabetes mellitus (T2DM) is argued. Fibroblast growth factor 21 (FGF-21) levels were elevated by the pathogenic process of diabetic kidney disease. The purpose of the study was to evaluate the associations of FGF-21 and renal outcomes in subjects with T2DM. Methods Chinese patients with T2DM were enrolled and then observed prospectively, and FGF-21 levels at baseline were measured. The associations of FGF-21 levels and renal composite events, defined by a drop > 30% of eGFR or worsening category of albuminuria, were evaluated using Cox analysis. The appropriate cut-off value of FGF-21 was mapped by the receiver operating characteristic (ROC) curve. Results Among 312 subjects, higher FGF-21 levels were associated with higher risks of renal events in Cox analysis. The area under the curve of FGF-21 levels in the ROC curve was optimal (0.67, p < 0.001), and the cut-off value of 1.40 pg/dl exhibited the best sensitivity (76.2%) and specificity (53.5%). The frequency of renal composite events was higher in subjects with FGF-21 ≥ 1.40 pg/dl than in others (30% vs. 10%, p<0.001 by the log-rank test). The worse renal outcomes predicted by FGF-21 ≥ 1.40 pg/dl were confirmed using the adjustments of Cox sequential models (hazard ratio 2.28, 95% confidence interval 1.23-4.24, p=0.009) and consistent across subjects with different status of baseline characteristics and renal risks. Conclusion FGF-21 levels were proportional to the risks of renal events in broad- spectrum Chinese T2DM subjects, making it a potential biomarker to predict the renal outcomes of T2DM.
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Affiliation(s)
- Li-Hsin Chang
- Division of Endocrinology and Metabolism, Department of Medicine, Yeezen General Hospital, Taoyuan, Taiwan
- Department of Medical Laboratory Science and Biotechnology, Yuanpei University of Medical Technology, Hsinchu, Taiwan
| | - Chia-Huei Chu
- Department of Otorhinolaryngology-Head and Neck Surgery, Mackay Memorial Hospital, Taipei, Taiwan
- Department of Audiology and Speech Language Pathology, Mackay Medical College, New Taipei City, Taiwan
| | - Chin-Chou Huang
- Division of Cardiology, Department of Medicine, Taipei, Taiwan
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Liang-Yu Lin
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei, Taiwan
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21
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Sim R, Chong CW, Loganadan NK, Fong AYY, Navaravong L, Hussein Z, Khunti K, Lee SWH. Comparative effectiveness of cardiovascular, renal and safety outcomes of second-line antidiabetic drugs use in people with type 2 diabetes: A systematic review and network meta-analysis of randomised controlled trials. Diabet Med 2022; 39:e14780. [PMID: 34962662 DOI: 10.1111/dme.14780] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 02/25/2021] [Accepted: 12/27/2021] [Indexed: 02/07/2023]
Abstract
AIMS To compare the cardiovascular, renal and safety outcomes of second-line glucose-lowering agents used in the management of people with type 2 diabetes. METHODS MEDLINE, EMBASE and CENTRAL were searched from inception to 13 July 2021 for randomised controlled trials comparing second-line glucose lowering therapies with placebo, standard care or one another. Primary outcomes included cardiovascular and renal outcomes. Secondary outcomes were non-cardiovascular adverse events. Risk ratios (RRs) and corresponding confidence intervals (CI) or credible intervals (CrI) were reported within pairwise and network meta-analysis. The quality of evidence was evaluated using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) criteria. Number needed to treat (NNT) and number needed (NNH) to harm were calculated at 5 years using incidence rates and RRs. PROSPERO (CRD42020168322). RESULTS We included 38 trials from seven classes of glucose-lowering therapies. Both sodium-glucose co-transporter-2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP1RA) showed moderate to high certainty in reducing risk of 3-point major adverse cardiovascular events, 3P-MACE (network estimates: SGLT2i [RR 0.90; 95% CrI 0.84-0.96; NNT, 59], GLP1RA [RR 0.88; 95% CrI 0.83-0.93; NNT, 50]), cardiovascular death, all-cause mortality, renal composite outcome and macroalbuminuria. SGLT2i also showed high certainty in reducing risk of hospitalization for heart failure (hHF), ESRD, acute kidney injury, doubling in serum creatinine and decline in eGFR. GLP1RA were associated with lower risk of stroke (high certainty) while glitazone use was associated with an increased risk of hHF (very low certainty). The risk of developing ESRD was lower with the use of sulphonylureas (low certainty). For adverse events, sulphonylureas and insulin were associated with increased hypoglycaemic events (very low to low certainty), while GLP1RA increased the risk of gastrointestinal side effects leading to treatment discontinuation (low certainty). DPP-4i increased risk of acute pancreatitis (low certainty). SGLT2i were associated with increased risk of genital infection, volume depletion (high certainty), amputation and ketoacidosis (moderate certainty). Risk of fracture was increased with the use of glitazones (moderate certainty). CONCLUSIONS SGLT2i and GLP1RA were associated with lower risk for different cardiorenal end points, when used as an adjunct to metformin in people with type 2 diabetes. Additionally, SGLT2i demonstrated benefits in reducing risk for surrogate end points in kidney disease progression. Safety outcomes differ among the available pharmacotherapies.
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Affiliation(s)
- Ruth Sim
- School of Pharmacy, Monash University Malaysia, Subang Jaya, Selangor, Malaysia
| | - Chun Wie Chong
- School of Pharmacy, Monash University Malaysia, Subang Jaya, Selangor, Malaysia
| | | | - Alan Y Y Fong
- Department of Cardiology, and Clinical Research Centre, Sarawak General Hospital, Sarawak, Malaysia
| | - Leenhapong Navaravong
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, School of Medicine, Salt Lake City, Utah, USA
| | | | - Kamlesh Khunti
- Leicester Diabetes Centre, University of Leicester, Leicester, UK
| | - Shaun Wen Huey Lee
- School of Pharmacy, Monash University Malaysia, Subang Jaya, Selangor, Malaysia
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Selangor, Malaysia
- Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
- Center for Global Health, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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22
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Shi H, Su X, Yan B, Li C, Wang L. Effects of oral alkali drug therapy on clinical outcomes in pre-dialysis chronic kidney disease patients: a systematic review and meta-analysis. Ren Fail 2022; 44:106-115. [PMID: 35176947 PMCID: PMC8865123 DOI: 10.1080/0886022x.2021.2023023] [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] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Metabolic acidosis accelerates the progression of chronic kidney disease (CKD) and increases the mortality rate. Whether oral alkali drug therapy benefits pre-dialysis CKD patients is controversial. We performed a meta-analysis of the effects of oral alkali drug therapy on major clinical outcomes in pre-dialysis CKD patients. METHODS We systematically searched MEDLINE using the Ovid, EMBASE, and Cochrane Library databases without language restriction. We included all eligible clinical studies that involved pre-dialysis CKD adults and compared those who received oral alkali drug therapy with controls. RESULTS A total of 18 eligible studies, including 14 randomized controlled trials and 4 cohort studies reported in 19 publications with 3695 participants, were included. Oral alkali drug therapy led to a 55% reduction in renal failure events (relative risk [RR]: 0.45; 95% confidence interval [CI]: 0.25-0.82), a rate of decline in the estimated glomerular filtration rate (eGFR) of 2.59 mL/min/1.73 m2 per year (95% CI, 0.88-4.31). There was no significant effect on decline in eGFR events (RR: 0.34; 95% CI: 0.09-1.23), proteinuria (standardized mean difference: -0.32; 95% CI: -1.08 to 0.43), all-cause mortality events (RR: 0.90; 95% CI: 0.40-2.02) and cardiovascular (CV) events (RR: 1.03; 95% CI: 0.32-3.37) compared with the control groups. CONCLUSION Based on the available and low-to-moderate certainty evidence, oral alkali drug therapy might potentially reduce the risk of kidney failure events, but no benefit in reducing all-cause mortality events, CV events, decline in eGFR and porteninuria.
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Affiliation(s)
- Honghong Shi
- Division of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Xiaole Su
- Division of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Bingjuan Yan
- Division of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Chunfang Li
- Division of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, China.,Division of Nephrology, Shanxi Cardiovascular Hospital, Taiyuan, China
| | - Lihua Wang
- Division of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, China
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23
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Liu X, Zhou H, Li G, Li F, Dong L, Wang S, Jiang Z, Tan J, Qin A, Tang Y, Qin W. Nocturnal heart rate rising is a risk factor for poor renal outcomes in patients with chronic kidney disease and hypertension. J Clin Hypertens (Greenwich) 2022; 24:292-299. [PMID: 35130369 PMCID: PMC8925008 DOI: 10.1111/jch.14428] [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: 11/13/2021] [Revised: 12/11/2021] [Accepted: 12/22/2021] [Indexed: 02/05/2023]
Abstract
The association of heart rate (HR) dipping pattern with renal outcomes in chronic kidney disease (CKD) patients with hypertension has never been investigated. In order to demonstrate if HR dipping pattern is a risk factor for renal outcomes, cardiovascular (CV) diseases, and mortality in hypertensive patients with CKD, we conducted the prospective longitudinal observational study. Patients were divided into three groups according to their nocturnal HR: HR dippers (night-day HR ratio ≤ 0.9), HR non-dippers (0.9 < night-day HR ratio ≤ 1.0), and HR risers (night-day HR ratio > 1.0). The primary outcome was renal endpoint, a composite outcome of progression to end-stage renal disease (ESRD) or estimated glomerular filtration rate (eGFR) decline ≥ 50%; the secondary outcomes included poor renal outcomes, CV events, and death. A total of 34 (11.3%) patients reached renal endpoint after a follow-up of 34 ± 17 months. Both HR non-dippers and HR risers were predictive to renal endpoint (hazard ratio 2.58, 95% confidence interval (CI) 1.04- 6.4, P = .04; hazard ratio 3.95, 95% CI 1.33- 11.79, P = .01, respectively), while only HR risers was shown to be correlated with a decline in eGFR≥ 50% (hazard ratio 5.28, 95% CI 1.45-19.16, P < .05), and decline in eGFR (β -0.17, 95% CI -0.33- -0.01, P = .04). No predictive value was found for HR dipping pattern to mortality and CV events. In conclusion, our study provided the first evidence that HR non-dippers, especially risers were a risk factor for poor renal outcomes in hypertensive patients with CKD.
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Affiliation(s)
- Xiang Liu
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,West China school of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Huan Zhou
- West China school of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Gen Li
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fangming Li
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Division of Nephrology, Department of Medicine, Chengdu 7th People's Hospital, Chengdu, Sichuan, China
| | - Lingqiu Dong
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,West China school of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Siqing Wang
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,West China school of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Zheng Jiang
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,West China school of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Jiaxing Tan
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,West China school of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Aiya Qin
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,West China school of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Yi Tang
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wei Qin
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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24
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Flippo B, Stone B, Stahr S, Khalil M, Davis R, Kamel M, Singh M. Short-Term and Long-Term Renal Outcomes in Patients With Obesity After Minimally Invasive Versus Open Partial Nephrectomy for the Treatment of Renal Cancer: Retrospective Study. JMIR Form Res 2022; 6:e19750. [PMID: 35006078 PMCID: PMC8787657 DOI: 10.2196/19750] [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: 04/30/2020] [Revised: 03/01/2021] [Accepted: 08/01/2021] [Indexed: 11/18/2022] Open
Abstract
Background Obesity is significantly associated with renal cell carcinoma. Surgery is the preferred treatment for demarcated lesions of renal cell carcinoma; however, obesity increases the complexity of surgical outcomes. Minimally invasive surgical techniques are preferred over open partial nephrectomy (OPN), but controversy remains regarding the most efficacious technique in patients with obesity. Objective This study aims to determine whether minimally invasive partial nephrectomy (MIPN) or OPN better preserves renal function and investigate short- and long-term renal outcomes in patients with obesity undergoing a partial nephrectomy. Methods We conducted a retrospective chart review of 242 adult patients aged ≥18 years who underwent MIPN or OPN between January 1, 2005, and December 31, 2016, at the University of Arkansas for Medical Sciences. Using creatinine as a measure of kidney function, patients’ preoperative levels were compared with their postoperative levels in 2-time frames: short (3-6 months postsurgery) or long (>6 months). The primary outcome was the change in creatinine values from preoperative to >6 months postoperatively in patients with obesity. Secondary outcomes included the change in creatinine values from preoperative to 3 to 6 months postoperatively in patients with obesity who underwent MIPN versus OPN. We also analyzed the creatinine values of nonobese patients (BMI <30) who underwent partial nephrectomy using the same time frames. Unconditional logistic regression was used to estimate crude and multivariable-adjusted odds ratios (ORs) and 95% CI to observe associations between surgery type and changes in creatinine values from while stratifying for obesity. Results A total of 140 patients were included in the study, of whom 75 were obese and 65 were nonobese. At >6 months after MIPN (n=20), the odds of patients with obesity having a decrease or no change in creatinine values was 1.24 times higher than those who had OPN (n=13; OR 1.24, 95% CI 0.299-6.729; P=.80). At 3 to 6 months after MIPN (n=27), the odds were 0.62 times lower than those after OPN (n=17; OR 0.62, 95% CI 0.140-2.753; P=.56). In the nonobese group, at 3 to 6 months after undergoing minimally invasive surgery (n=18), the odds of having a decrease or no change in creatinine values was 4.86 times higher than those who had open surgery (n=21; OR 4.86, 95% CI 1.085-21.809; P=.04). At more than 6 months after MIPN (n=14), the odds were 4.13 times higher than those after OPN (n=11; OR 4.13, 95% CI 0.579-29.485; P=.16). Conclusions We observed a nonstatistically significant preservation of renal function in patients with obesity who underwent OPN at 3 to 6 months postoperatively. Conversely, after 6 months, the same was true for MIPN, indicating the long-term benefit of MIPN. In the nonobese group, MIPN was favored over OPN.
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Affiliation(s)
- Brittany Flippo
- University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Bradley Stone
- University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Shelbie Stahr
- University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Mahmoud Khalil
- University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Rodney Davis
- University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Mohamed Kamel
- University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Manisha Singh
- University of Arkansas for Medical Sciences, Little Rock, AR, United States
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25
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Xiao X, Zhang J, Ji S, Qin C, Wu Y, Zou Y, Yang J, Zhao Y, Yang Q, Liu F. Lower bile acids as an independent risk factor for renal outcomes in patients with type 2 diabetes mellitus and biopsy-proven diabetic kidney disease. Front Endocrinol (Lausanne) 2022; 13:1026995. [PMID: 36277729 PMCID: PMC9585231 DOI: 10.3389/fendo.2022.1026995] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/22/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS Abnormalities of glucolipid metabolism are critical mechanisms involved in the progression of diabetic kidney disease (DKD). Bile acids have an essential role in regulating glucolipid metabolism. This study investigated the clinicopathological characteristics of DKD patients with different bile acid levels and explored the relationship between bile acids and renal outcomes of DKD patients. METHODS We retrospectively reviewed and evaluated the histopathological features and clinical features of our cohort of 184 patients with type 2 diabetes mellitus and biopsy-proven DKD. Patients were divided into the lower bile acids group (≤2.8 mmol/L) and higher bile acids group (>2.8 mmol/L) based on the cutoff value of bile acids obtained using the time-dependent receiver-operating characteristic curve. Renal outcomes were defined as end-stage renal disease (ESRD). The influence of bile acids on renal outcomes and correlations between bile acids and clinicopathological indicators were evaluated. RESULTS Bile acids were positively correlated with age (r = 0.152; P = 0.040) and serum albumin (r = 0.148; P = 0.045) and negatively correlated with total cholesterol (r = -0.151; P = 0.041) and glomerular class (r = -0.164; P =0.027). During follow-up, 64 of 184 patients (34.78%) experienced progression to ESRD. Lower levels of proteinuria, serum albumin, and bile acids were independently associated with an increased risk of ESRD (hazard ratio, R=5.319; 95% confidence interval, 1.208-23.425). CONCLUSIONS Bile acids are an independent risk factor for adverse renal outcomes of DKD patients. The serum level of bile acids should be maintained at more than 2.8 mmol/L in DKD patients. Bile acid analogs or their downstream signaling pathway agonists may offer a promising strategy for treating DKD.
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Affiliation(s)
- Xiang Xiao
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
- Department of Nephrology, The first affiliated hospital of Chengdu Medical college, Chengdu, China
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Junlin Zhang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Shuming Ji
- Department of Project Design and Statistics, West China Hospital, Sichuan University, Chengdu, China
| | - Chunmei Qin
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Yucheng Wu
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Yutong Zou
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Jia Yang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Yuancheng Zhao
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Qin Yang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Fang Liu
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
- *Correspondence: Fang Liu,
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Liu J, Tio MC, Verma A, Schmidt IM, Ilori TO, Knauf F, Mc Causland FR, Waikar SS. Determinants and Outcomes Associated With Urinary Calcium Excretion in Chronic Kidney Disease. J Clin Endocrinol Metab 2022; 107:e281-e292. [PMID: 34390334 PMCID: PMC8684460 DOI: 10.1210/clinem/dgab574] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 04/30/2021] [Indexed: 02/08/2023]
Abstract
CONTEXT Abnormalities in calcium metabolism are common in chronic kidney disease (CKD). Diminished urinary calcium excretion may promote vascular calcification and increased urinary calcium excretion may lead to nephrolithiasis and nephrocalcinosis, conditions associated with CKD. OBJECTIVE To study predictors of urinary calcium excretion and its association with adverse clinical outcomes in CKD. DESIGN, SETTING AND PATIENTS This study assessed 3768 nondialysis participants in the Chronic Renal Insufficiency Cohort study from April 2003 to September 2008. Participants were followed up to October 2018. EXPOSURE Clinically plausible predictors of urinary calcium excretion and 24-h urinary calcium excretion at baseline. MAIN OUTCOME MEASURES Urinary calcium excretion; incident end stage kidney disease (ESKD), CKD progression [50% estimated glomerular filtration rate (eGFR) decline or incident ESKD], all-cause mortality, and atherosclerotic cardiovascular disease events. RESULTS eGFR was positive correlated with 24-h urinary calcium excretion. The variables most strongly associated with 24-h urinary calcium excretion in males and females were 24-h urinary sodium (β = 0.19 and 0.28, respectively), serum parathyroid hormone (β = -0.22 and -0.20, respectively), loop diuretics (β = 0.36 and 0.26, respectively), thiazide diuretics (β = -0.49 and -0.53, respectively), and self-identified black race (β = -0.23 and -0.27, respectively). Lower urinary calcium excretion was associated with greater risks of adverse outcomes, but these associations were greatly attenuated or nullified after adjustment for baseline eGFR. CONCLUSION Urinary calcium excretion is markedly lower in individuals with CKD compared to the general population. Determinants of urinary calcium excretion differed between sexes and levels of CKD. Associations between urinary calcium excretion and adverse clinical events were substantially confounded by eGFR.
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Affiliation(s)
- Jing Liu
- Renal Division, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China
- Section of Nephrology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Maria Clarissa Tio
- Renal Division, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ashish Verma
- Renal Division, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Insa M Schmidt
- Section of Nephrology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Renal Division, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Titilayo O Ilori
- Section of Nephrology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Felix Knauf
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Correspondence: Sushrut S. Waikar, MD, MPH, Boston Medical Center, Renal Section, Evans Biomedical Research Center, 650 Albany Street, X504, Boston, MA 02118, USA.
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Elbert A, Castellaro C, Litwak L, Inserra F, Wassermann A, Sinay I. [Renal effects of GLP-1 agonists in type 2 diabetes]. Medicina (B Aires) 2022; 82:576-590. [PMID: 35904915] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023] Open
Abstract
The prevalence of type 2 diabetes mellitus (DM2) is increasing, generating a great impact both at individual and public health level. Nearly half of the patients with DM2 develop impaired renal function, so nephron-protection is highly important. The robust body of evidence that shifted the therapeutic focus from glycemic to cardio-renal metabolic therapy in DM2 led to the inclusion of new therapies with cardiovascular and renal benefits in international guidelines. Type 1 glucagon (GLP-1) receptor agonists have showed favorable effects on renal function and their potential protective actions are multifactorial, beyond glycemic control. These benefits have been demonstrated in efficacy and safety clinical studies, as well as in cardiovascular outcomes and real-life studies. This comprehensive review describes the direct and indirect effects of these molecules, as well as evidence obtained from pivotal clinical (LEADER, SUSTAIN 6 and REWIND) and real-life studies demonstrating their beneficial effects on renal function, and also introduces expectations of future results from ongoing studies with renal endpoints.
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Affiliation(s)
- Alicia Elbert
- Centro de Enfermedades Renales e Hipertensión Arterial, Avellaneda, Argentina. E-mail:
| | - Carlos Castellaro
- Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno (CEMIC), Buenos Aires, Argentina
| | - Leon Litwak
- Servicio de Endocrinología, Metabolismo y Medicina Nuclear, Hospital Italiano de Buenos Aires, Argentina
| | - Felipe Inserra
- Maestría de Mecánica Vascular e Hipertensión Arterial, Universidad Austral, Pilar, Argentina
| | - Alfredo Wassermann
- Fundación para el Estudio, la Prevención y el Tratamiento de la Enfermedad Vascular Aterosclerótica, Buenos Aires, Argentina
| | - Isaac Sinay
- Instituto Cardiovascular de Buenos Aires, Argentina
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Xu Y, Chen Y, Zhao JW, Li C, Wang AY. Effect of Angiotensin-Neprilysin Versus Renin-Angiotensin System Inhibition on Renal Outcomes: A Systematic Review and Meta-Analysis. Front Pharmacol 2021; 12:604017. [PMID: 34867310 PMCID: PMC8640344 DOI: 10.3389/fphar.2021.604017] [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: 05/30/2021] [Accepted: 10/21/2021] [Indexed: 11/23/2022] Open
Abstract
Aims: We aim to perform a systematic review and meta-analysis examining randomized controlled trials assessing the efficacy and safety of sacubitril/valsartan in patients on renal outcomes, in comparison with the renin–angiotensin–aldosterone system inhibitor (RAASi). Methods: Eligible studies were retrieved on MEDLINE, EMBASE, and Cochrane until September 2021. The primary outcome was the incidence of renal impairment, which was defined as the composite of increases in serum creatinine by >0.3 mg/dl and/or a reduction in eGFR ≥25%, development of ESRD, or renal death. We pooled relative risks (RRs) with 95% confidence intervals (CIs) or the mean difference with 95% CIs for the variables. Results: Our search yielded 10 randomized controlled trials with a total of 18,362 patients. Compared with RAASi treatment, patients treated with sacubitril/valsartan had lower incidence of composite renal impairment (10 studies, 18,362 patients, RR 0.84; 95% CI 0.72–0.96, p = 0.01; I2 = 22%), ESRD development (3 studies, 13,609 patients, RR 0.53; 95% CI 0.30–0.96, p = 0.03; I2 = 0%), drug discontinuation due to renal events (4 studies, 9,995 patients, RR 0.58; 95% CI 0.40–0.83, p = 0.003; I2 = 47%), severe hyperkalemia (6 studies, 16,653 patients, RR 0.80; 95% CI 0.68–0.93, p = 0.01; I2 = 25%) and a slower eGFR decline (4 studies, 13,608 patients, WMD 0.56; 95% CI 0.36–0.76, p < 0.00001; I2 = 65%). Subgroup analysis demonstrated that sacubitril/valsartan was associated with a lower incidence of renal impairment in patients with heart failure and preserved ejection fraction (HFpEF), but not in those with heart failure and reduced ejection fraction (HFrEF). The superior renal function preservation of sacubitril/valsartan treatment was not associated with different baseline eGFR levels and follow-up duration. There was a smaller increase in the change in the urine albumin-to-creatinine ratio (UACR) (3 studies, 9,114 patients, SMD 0.06; 95% CI 0.02–0.10, p = 0.003; I2 = 14%) with sacubitril/valsartan treatment. However, patients with heart failure appeared to have increased microalbuminuria, not patients without HF (p = 0.80 for interaction). Conclusion: Sacubitril/valsartan was associated with a lower incidence of composite renal impairment especially in patients with HFpEF, but higher microalbuminuria in patients with heart failure (both HFrEF and HFpEF) compared with RAASi. The lower incidence of severe hyperkalemia and drug discontinuation due to renal events in patients with sacubitril/valsartan treatment demonstrated its superior safety compared with RAASi.
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Affiliation(s)
- Ying Xu
- The Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,The Renal and Metabolic Division, The George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia.,The Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China.,National Key Clinical Department of Kidney Diseases, Institute of Nephrology, Zhejiang University, Hangzhou, China
| | - Yang Chen
- The Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,The Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou, China.,Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China.,National Key Clinical Department of Kidney Diseases, Institute of Nephrology, Zhejiang University, Hangzhou, China
| | - Jia Wei Zhao
- The Faculty of Medicine, Bond University, Gold Coast, QLD, Australia
| | - Chao Li
- The Renal and Metabolic Division, The George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia.,Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Amanda Y Wang
- The Renal and Metabolic Division, The George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia.,The Department of Renal Medicine, Concord Repatriation General Hospital, Concord, NSW, Australia.,Concord Clinical School, The University of Sydney, Sydney, NSW, Australia
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Zhang Y, Li JJ, Wang AJ, Wang B, Hu SL, Zhang H, Li T, Tuo YH. Effects of intensive blood pressure control on mortality and cardiorenal function in chronic kidney disease patients. Ren Fail 2021; 43:811-820. [PMID: 33966601 PMCID: PMC8118417 DOI: 10.1080/0886022x.2021.1920427] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Blood pressure (BP) variability is highly correlated with cardiovascular and kidney outcomes in patients with chronic kidney disease (CKD). However, appropriate BP targets in patients with CKD remain uncertain. METHODS We searched PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) of CKD patients who underwent intensive BP management. Kappa score was used to assess inter-rater agreement. A good agreement between the authors was observed to inter-rater reliability of RCTs selection (kappa = 0.77; P = 0.005). RESULTS Ten relevant studies involving 20 059 patients were included in the meta-analysis. Overall, intensive BP management may reduce the incidence of cardiovascular disease mortality (RR: 0.69, 95% CI: 0.53 to 0.90, P: 0.01), all-cause mortality (RR: 0.77, 95% CI: 0.67 to 0.88, P < 0.01) and composite cardiovascular events (RR: 0.84 95% CI: 0.75 to 0.95, P < 0.01) in patients with CKD. However, reducing BP has no significant effect on the incidence of doubling of serum creatinine level or 50% reduction in GFR (RR: 1.26, 95% CI: 0.66 to 2.40, P = 0.48), composite renal events (RR 1.07, 95% CI: 0.81 to 1.41, P = 0.64) or SAEs (RR: 0.97, 95% CI: 0.90 to 1.05, P = 0.48). CONCLUSION In patients with CKD, enhanced BP management is associated with reduced all-cause mortality, cardiovascular mortality, and incidence of composite cardiovascular events.
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Affiliation(s)
- Yong Zhang
- Department of Nephrology, Jianli People's Hospital, Jingzhou, China
| | - Jing-Jing Li
- Department of Ultrasonic Imaging, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - An-Jun Wang
- Department of Nephrology, Jianli People's Hospital, Jingzhou, China
| | - Bo Wang
- Department of Ultrasound, The First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Shou-Liang Hu
- Department of Nephrology, The First Affiliated Hospital of Yangtze University, Jingzhou, China
| | - Heng Zhang
- Department of Histology and Embryology, Xiang Ya School of Medicine, Central South University, Changsha, China
| | - Tian Li
- School of Basic Medicine, Fourth Military Medical University, Xi'an, China
| | - Yan-Hong Tuo
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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30
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Du J, Li Y, Sun Q, Wang Z, Wang F, Chen F, Wang H, Liu Y, Zhou H, Shang G, Chen X, Ding S, Li C, Wu D, Zhang W, Zhong M. Urinary exosomal CD26 is associated with recovery from acute kidney injury in intensive care units: a prospective cohort study. Clin Chem Lab Med 2021; 59:1535-1546. [PMID: 33882205 DOI: 10.1515/cclm-2021-0040] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 03/30/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Currently there is no validated method to predict renal reversal and recovery after acute kidney injury (AKI). As exosomes have the potential for AKI prognosis and CD26 is involved in the mechanisms in AKI, this study aims to investigate whether urinary exosomal CD26 is associated with renal-related outcomes and explore its prospect as a novel prognosis biomarker. METHODS This was a single-center, prospective cohort study. A total of 133 AKI patients and 68 non-AKI patients admitted to ICU in Qilu Hospital Shandong University from January 2017 to January 2018. Urine samples were collected at enrollment and the relative expression of CD26 (CD26 percentage) in urinary exosomes was examined, that was then categorized into a low-CD26 level and a high-CD26 level. RESULTS CD26 percentage was significantly lower in the AKI cohort than in the control cohort. Within the AKI cohort, a high-CD26 level was associated with lower incidence of major adverse kidney events within 90 days, but higher incidence of reversal within 28 days. In AKI survivors, a high-CD26 level had a 4.67-, 3.50- and 4.66-fold higher odds than a low-CD26 level for early reversal, recovery and reversal, respectively, after adjustment for clinical factors. Prediction performance was moderate for AKI survivors but improved for non-septic AKI survivors. CONCLUSIONS Urinary exosomal CD26 is associated with renal reversal and recovery from AKI and is thus a promising prognosis biomarker.
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Affiliation(s)
- Juan Du
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China.,Department of Critical Care Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Yihui Li
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China.,Department of Critical Care Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Qiang Sun
- Department of Vascular Surgery, Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Zhihao Wang
- Department of Geriatric Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Key Laboratory of Cardiovascular Proteomics of Shandong Province, Jinan, Shandong, P.R. China
| | - Feng Wang
- Department of Critical Care Medicine, Shandong Provincial Hospital, Jinan, Shandong, P.R. China
| | - Fangfang Chen
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Hao Wang
- Department of Critical Care Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Yirui Liu
- People's Hospital of Lingcheng District, Dezhou, Shandong, P.R. China
| | - Huimin Zhou
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Guokai Shang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Xiaomei Chen
- Department of Critical Care Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Shifang Ding
- Department of Critical Care Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Chen Li
- Department of Critical Care Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Dawei Wu
- Department of Critical Care Medicine, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, P.R. China
| | - Wei Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Ming Zhong
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
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Abstract
Type 2 diabetes is among the most prevalent chronic diseases worldwide and the prevention of associated cardiovascular complications is an important treatment goal. Sodium–glucose co-transporter 2 (SGLT2) inhibitors, glucagon-like peptide 1 (GLP-1) receptor agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors are second-line options after metformin, while cardiovascular outcome trials have been conducted to establish the cardiovascular safety of these antidiabetic drug classes. SGLT2 inhibitors have been shown to have the best overall mortality, renal and cardiovascular outcomes. Reduction in hospitalisation for heart failure is particularly consistent. GLP-1 receptor agonists have also showed some benefits, especially in stroke prevention. DPP-4 inhibitors showed neutral effects on cardiovascular outcomes, but may increase the incidence of heart failure. Favourable outcomes observed in trials of SGLT2 inhibitors mean that these should be the preferred second-line option. DPP-4 inhibitors are useful for patients with diabetes at low cardiovascular risk.
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Affiliation(s)
- Chris Wai Hang Lo
- Division of Clinical Pharmacology and Therapeutics, Department of Medicine, The University of Hong Kong Pokfulam, Hong Kong, China
| | - Yue Fei
- Division of Clinical Pharmacology and Therapeutics, Department of Medicine, The University of Hong Kong Pokfulam, Hong Kong, China
| | - Bernard Man Yung Cheung
- Division of Clinical Pharmacology and Therapeutics, Department of Medicine, The University of Hong Kong Pokfulam, Hong Kong, China.,State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong Pokfulam, Hong Kong, China.,Institute of Cardiovascular Science and Medicine, The University of Hong Kong Pokfulam, Hong Kong, China
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Sitticharoenchai P, Takkavatakarn K, Boonyaratavej S, Praditpornsilpa K, Eiam-Ong S, Susantitaphong P. Non-Vitamin K Antagonist Oral Anticoagulants Provide Less Adverse Renal Outcomes Than Warfarin In Non-Valvular Atrial Fibrillation: A Systematic Review and MetaAnalysis. J Am Heart Assoc 2021; 10:e019609. [PMID: 33728927 PMCID: PMC8174352 DOI: 10.1161/jaha.120.019609] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Non‐vitamin K antagonist oral anticoagulants (NOACs) have better pharmacologic properties than warfarin and are recommended in preference to warfarin in most patients with non‐valvular atrial fibrillation. Besides lower bleeding complications, other advantages of NOACs over warfarin particularly renal outcomes remain inconclusive. Methods and Results Electronic searches were conducted through Medline, Scopus, Cochrane Library databases, and ClinicalTrial.gov. Randomized controlled trials and observational cohort studies reporting incidence rates and hazard ratio (HR) of renal outcomes (including acute kidney injury, worsening renal function, doubling serum creatinine, and end‐stage renal disease) were selected. The random‐effects model was used to calculate pooled incidence and HR with 95% CI. Eighteen studies were included. A total of 285 201 patients were enrolled, 118 863 patients with warfarin and 166 338 patients with NOACs. The NOACs group yielded lower incidence rates of all renal outcomes when compared with the warfarin group. Patients treated with NOACs showed significantly lower HR of risk of acute kidney injury (HR, 0.70, 95% CI, 0.64–0.76; P<0.001), worsening renal function (HR, 0.83; 95% CI, 0.73–0.95; P=0.006), doubling serum creatinine (HR, 0.58; 95% CI, 0.41–0.82; P=0.002), and end‐stage renal disease (HR, 0.82; 95% CI, 0.78–0.86; P<0.001). Conclusions In non‐valvular atrial fibrillation, patients treated with NOACs have a lower risk of both acute kidney injury and end‐stage renal disease when compared with warfarin.
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Affiliation(s)
- Patita Sitticharoenchai
- Division of Cardiology Department of Medicine Faculty of Medicine King Chulalongkorn Memorial HospitalChulalongkorn University Bangkok Thailand
| | - Kullaya Takkavatakarn
- Division of Nephrology Department of Medicine Faculty of Medicine King Chulalongkorn Memorial HospitalChulalongkorn University Bangkok Thailand
| | - Smonporn Boonyaratavej
- Division of Cardiology Department of Medicine Faculty of Medicine King Chulalongkorn Memorial HospitalChulalongkorn University Bangkok Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology Department of Medicine Faculty of Medicine King Chulalongkorn Memorial HospitalChulalongkorn University Bangkok Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology Department of Medicine Faculty of Medicine King Chulalongkorn Memorial HospitalChulalongkorn University Bangkok Thailand
| | - Paweena Susantitaphong
- Division of Nephrology Department of Medicine Faculty of Medicine King Chulalongkorn Memorial HospitalChulalongkorn University Bangkok Thailand.,Research Unit for Metabolic Bone Disease in CKD patients Faculty of Medicine Chulalongkorn University Bangkok Thailand
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Abstract
Background: The relationship between hematuria, a typical presentation of immunoglobulin A nephropathy (IgAN), and long-term adverse prognosis of these patients is still controversial. This meta-analysis aims to clarify the effect of hematuria on renal outcomes in IgAN. Methods: Observational cohort studies reporting associations between various forms of hematuria and renal outcomes among IgAN patients were identified from the PubMed and Embase databases. The pooled adjusted risk ratios (RRs) were computed with random effects models. Results: Thirteen studies encompassing 5660 patients with IgAN were included. Patients with initial hematuria did not have a significantly increased risk of developing end-stage renal disease (ESRD) compared with those without hematuria (RR, 1.32; 95% CI, 0.87–2.00; p = .19). However, initial microscopic hematuria was associated with an 87% increase in the risk of ESRD (RR, 1.87; 95% CI, 1.40–2.50; p < .001), while macroscopic hematuria was associated with a 32% decrease in the risk of ESRD (RR, 0.68; 95% CI, 0.58–0.79; p < .001). Additionally, persistent hematuria might be an independent risk factor for ESRD or a 50% decline in eGFR. Conclusions: Among IgAN patients, hematuria, including initial microscopic hematuria and even persistent hematuria, was possibly associated with renal progression and ESRD. However, independent of other classical predictors, initial macroscopic hematuria might be a protective factor for IgAN.
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Affiliation(s)
- Peng He
- Department of Nephrology, State Key Laboratory of Cancer Biology & Institute of Digestive Diseases, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Hanmin Wang
- Department of Nephrology, State Key Laboratory of Cancer Biology & Institute of Digestive Diseases, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Chen Huang
- Department of Nephrology, State Key Laboratory of Cancer Biology & Institute of Digestive Diseases, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Lijie He
- Department of Nephrology, State Key Laboratory of Cancer Biology & Institute of Digestive Diseases, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
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Abstract
BACKGROUND Patients with chronic kidney disease (CKD) often have structural abnormalities of the heart due to pressure and volume overload. The aim of this study was to evaluate associations between echocardiographic parameters and renal outcomes (estimated glomerular filtration rate [eGFR] slope and progression to dialysis) in patients with stage 3-5 CKD. METHODS This longitudinal study enrolled 419 patients. Changes in renal function were assessed using the eGFR slope. Rapid renal progression was defined as an eGFR slope < -3 mL/min/1.73 m2/year, and the renal endpoint was defined as commencing dialysis. RESULTS Increased left atrial diameter (LAD), ratio of left ventricular mass to body surface area (LVM/BSA), ratio of LVM to height2.7 (LVM/ht2.7), and ratio of observed to predicted LVM (o/p LVM) were associated with eGFR slope in an adjusted model, but left ventricular ejection fraction (LVEF) was not. Furthermore, LAD ≥ 4.7 cm, LVM/BSA > 115 g/m2 in males and > 95 g/m2 in females, and LVM/ht2.7 > 48 g/ht2.7 in males and > 44 g/ht2.7 in females were correlated with progression to dialysis, but o/p LVM and LVEF were not. The maximum change in χ2 change to predict renal outcomes was observed for LAD, followed by LVM/BSA and LVM/ht2.7. CONCLUSIONS A large LAD and increased LVM, regardless of how it was measured (LVM/BSA, LVM/ht2.7 and o/p LVM), were correlated with adverse renal outcomes in patients with CKD stage 3-5. LAD had superior prognostic value to LVM and LVEF.
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Affiliation(s)
- Tzu-Heng Huang
- Department of General Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Hsuan Chiu
- Department of General Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Pei-Yu Wu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jiun-Chi Huang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Yen Lin
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Szu-Chia Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jer-Ming Chang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Yu B, Dong C, Hu Z, Liu B. Effects of sodium-glucose co-transporter 2 (SGLT2) inhibitors on renal outcomes in patients with type 2 diabetes mellitus and chronic kidney disease: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e24655. [PMID: 33663074 PMCID: PMC7909223 DOI: 10.1097/md.0000000000024655] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 11/29/2020] [Accepted: 01/08/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Many studies have shown the effects of SGLT2 inhibitors on type 2 diabetes, but the effects in patients with type 2 diabetes with chronic kidney disease remains unclear. This study aims to evaluate the effects of SGLT2 inhibitors on renal outcomes in patients with type 2 diabetes mellitus with chronic kidney disease. METHODS We conducted systematic searches of PubMed, Embase, and Cochrane Central Register of Controlled Trials up to April 30, 2020 and included randomized controlled trials of SGLT2 inhibitors in adult type 2 diabetes mellitus (T2DM) patients with chronic kidney disease (CKD) reporting estimated glomerular filtration rate (eGFR) and/or urine albumin/creatinine ratio (UACR) changes and/or acute kidney injury or failure (AKI). Random effects models were adopted to measure the pooled outcomes. RESULTS Nine studies with 8826 participants were included. SGLT2 inhibitors were not associated with a significant change in eGFR (mean difference (MD), -0.75 ml/minutes per 1.73 m2, 95% CI -1.61 to 0.10, P = .09) in type 2 diabetic patients with CKD. UACR reduction after SGLT2 inhibitors was significant in type 2 diabetic patients with CKD (MD -24.27 mg/g, 95% CI -44.46 to -4.09, P = .02). SGLT2 inhibitors associated with AKI in the patients were significant (OR 0.80, 95% CI [0.66 to 0.98], P = .03). CONCLUSION SGLT2 inhibitors had no significant effect on kidney function (eGFR measured) in the pooled analysis. And SGLT2 inhibitors effectively reduced UACR in T2DM with CKD. Besides, SGLT2 inhibitors could reduce the incidence of AKI.
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Rouabhi M, Durieux J, Al-Kindi S, Cohen JB, Townsend RR, Rahman M. Orthostatic Hypertension and Hypotension and Outcomes in CKD: The CRIC (Chronic Renal Insufficiency Cohort) Study. Kidney Med 2021; 3:206-215.e1. [PMID: 33851116 PMCID: PMC8039407 DOI: 10.1016/j.xkme.2020.10.012] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Rationale & Objective There are limited data about the prevalence and prognostic significance of orthostatic hypo- and hypertension in patients with chronic kidney disease. The objective of this study is to determine the prevalence of orthostatic hypo- and hypertension in a cohort of patients with chronic kidney disease and examine their association with clinical outcomes. Study Design Prospective cohort study: Chronic Renal Insufficiency Cohort (CRIC) Study. Setting & Population 7 clinical centers, participants with chronic kidney disease. Exposures Orthostatic hypotension (decline in systolic blood pressure [BP] > 20 mm Hg) and orthostatic hypertension (increase in systolic BP > 20 mm Hg) from seated to standing position. Outcomes Cardiovascular and kidney outcomes and mortality. Analytical Approach Logistic regression was used to determine factors associated with orthostatic hypo- and hypertension; Cox regression was used to examine associations with clinical outcomes. Results Mean age of study population (n = 3,873) was 58.1 ± 11.0 years. There was a wide distribution of change in systolic BP from seated to standing (from −73.3 to +60.0 mm Hg); 180 participants (4.6%) had orthostatic hypotension and 81 (2.1%) had orthostatic hypertension. Diabetes, reduced body mass index, and β-blocker use were independently associated with orthostatic hypotension. Black race and higher body mass index were independently associated with orthostatic hypertension. After a median follow-up of 7.9 years, orthostatic hypotension was independently associated with high risk for cardiovascular (HR, 1.12; 95% CI, 1.03-1.21) but not kidney outcomes or mortality. Orthostatic hypertension was independently associated with high risk for kidney (HR, 1.51; 96% CI, 1.14-1.97) but not cardiovascular outcomes or mortality. Limitations Orthostatic change in BP was ascertained at a single visit. Conclusions Orthostatic hypotension was independently associated with higher risk for cardiovascular outcomes, whereas orthostatic hypertension was associated with higher risk for kidney outcomes. These findings highlight the importance of orthostatic BP measurement in practice and the need for future investigation to understand the mechanisms and potential interventions to minimize the risk associated with orthostatic changes in BP.
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Affiliation(s)
- Mohamed Rouabhi
- School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Jared Durieux
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Sadeer Al-Kindi
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Raymond R Townsend
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mahboob Rahman
- School of Medicine, Case Western Reserve University, Cleveland, OH.,Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center and Louis Stokes Cleveland VA Medical Center, Cleveland, OH
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de Bhailís ÁM, Azmi S, Kalra PA. Diabetic kidney disease: update on clinical management and non-glycaemic effects of newer medications for type 2 diabetes. Ther Adv Endocrinol Metab 2021; 12:20420188211020664. [PMID: 34104399 PMCID: PMC8165820 DOI: 10.1177/20420188211020664] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 05/03/2021] [Indexed: 12/15/2022] Open
Abstract
Type 2 diabetes is a leading cause of chronic kidney disease worldwide and continues to increase in prevalence. This in turn has significant implications for healthcare provision and the economy. In recent years there have been multiple advances in the glucose-lowering agents available for the treatment of diabetes, which not only modify the disease itself but also have important benefits in terms of the associated cardiovascular outcomes. The cardiovascular outcome trials of agents such as glucagon-like peptide-1 receptor agonists (GLP-RAs) and sodium glucose cotransporter 2 inhibitors (SGLT-2) have demonstrated significant benefits in reducing major adverse cardiovascular events, admissions for heart failure and in some cases mortality. Secondary analysis of these trials has also indicated significant renoprotective benefit. Canagliflozin and Renal Outcomes in Type 2 Diabetes Mellitus and Nephropathy (CREDENCE) a renal-specific trial, has shown major benefits with canagliflozin for renal outcomes in diabetic kidney disease, and similar trials with other SGLT-2 inhibitors are either underway or awaiting analysis. In this article we review current goals of treatment of diabetes and the implications of advancing renal impairment on choice of treatments. Areas discussed include the diagnosis of diabetic kidney disease and current treatment strategies for diabetic kidney disease ranging from lifestyle modifications to glycaemic control. This review focuses on the role of GLP-RAs and SGLT-2 inhibitors in treating those with diabetes and chronic kidney disease with some illustrative cases. It is clear that these agents should now be considered first choice in combination with metformin in those with diabetes and increased cardiovascular risk and/or reduced renal function, and in preference to other classes such as dipeptidyl peptidase-4 (DPP-4) inhibitors or sulphonylureas.
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Affiliation(s)
| | - Shazli Azmi
- Department of Diabetes and Endocrinology, Manchester Royal Infirmary Hospital, Manchester Foundation Trust, Manchester, UK
| | - Philip A. Kalra
- Department of Nephrology, Salford Royal NHS Foundation Trust, Salford, UK
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Riello RJ, Pitt B. ARNI and MRA Combination in PARAGON-HF: Odd Couple or Dynamic Duo? JACC Heart Fail 2020; 9:25-27. [PMID: 33309576 DOI: 10.1016/j.jchf.2020.10.005] [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] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Ralph J Riello
- Department of Pharmacy Services, Yale-New Haven Hospital, New Haven, Connecticut, USA.
| | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, Michigan, USA
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Elnaem MH, Mansour NO, Nahas AF, Baraka MA, Elkalmi R, Cheema E. Renal Outcomes Associated with the Use of Non-Insulin Antidiabetic Pharmacotherapy: A Review of Current Evidence and Recommendations. Int J Gen Med 2020; 13:1395-1409. [PMID: 33324086 PMCID: PMC7733337 DOI: 10.2147/ijgm.s285191] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 10/04/2020] [Accepted: 10/12/2020] [Indexed: 01/17/2023] Open
Abstract
Background This study aims to discuss, summarize and compare the renal outcomes associated with non-insulin antidiabetic (AD) pharmacotherapy prescribed for patients with type 2 diabetes mellitus (T2DM). Methods A systematic search using predefined search terms in three scholarly databases, ScienceDirect, Google Scholar, and PubMed, was conducted. Original research articles published in the English language between 2012 and 2020 that reported renal outcomes associated with the use of non-insulin AD pharmacotherapy were eligible for inclusion. Review articles, meta-analysis studies, and conference proceedings were excluded. A study-specific data extraction form was designed to extract the author’s name, country, publication year, study design, study population, objectives, key findings, and conclusions. A narrative review of the key findings that focused on renal outcomes and renal safety issues was conducted. Results Of the 18,872 results identified through the initial search, a total of 32 articles were included in this review. Of these, 18 of the included articles reported the renal outcomes of newer antidiabetic medications, eg, SGLT2 inhibitors and GLP-1 agonists. Eight studies focussed on the well-established antidiabetic medications, eg, metformin and sulphonylureas. The review reported three main types of the clinical impact of the prescribed AD on the renal outcomes: “renoprotective effects”, “no additional risk” and “associated with a decline in renal parameters”. Seventeen studies reported the renoprotective effects of AD, including SGLT2i studies (n=8), GLP1 studies (n=6), and DPP4i studies (n=3). The reported renoprotective effects included slowing down the GFR decline, improving albuminuria, and reducing renal adverse events. The “no additional risk” impact was reported in eight studies, including DPP4i studies (n=3), two SGLT2i studies (n=2), metformin studies (n=2), and one study involving pioglitazone. Furthermore, seven studies highlighted the “associated with a decline in renal parameters” effect. Of these, three involved SGLT2i, two with metformin, and one for each DPP4i and sulphonylurea. Conclusion More than half of the studies included in this review supported the renoprotective effects associated with the use of AD medications, particularly GLP-1A, SGLT2i, and some of the DPP4i. Further studies involving patients with various stages of chronic kidney disease (CKD) are required to compare AD medications’ renal effects, particularly the newer agents.
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Affiliation(s)
- Mohamed Hassan Elnaem
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang.,Quality Use of Medicines Research Group, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang
| | - Noha O Mansour
- Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Cairo, Egypt
| | - Abdulrahman Fata Nahas
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang.,Quality Use of Medicines Research Group, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang
| | - Mohamed A Baraka
- Department of Clinical Pharmacy, College of Pharmacy, Al Ain University, Al Ain, United Arab Emirates.,Department of Clinical Pharmacy, College of Pharmacy, Al-Azhar University, Cairo, Egypt
| | - Ramadan Elkalmi
- Department of Clinical Pharmacy and Pharmacotherapeutics, Dubai Pharmacy College, Dubai, United Arab Emirates.,Department of Pharmacology, Faculty of Medicine, Sebha University, Sabha, Libya
| | - Ejaz Cheema
- School of Pharmacy, University of Birmingham, Birmingham B15 2TT, UK
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Abstract
INTRODUCTION A growing number of antidiabetic agents have demonstrated cardiovascular and renal benefits in cardiovascular outcome trials (CVOTs), despite such trials being principally required to rule out excess cardiovascular risk. AREAS COVERED This article addresses the Evaluation of Ertugliflozin Efficacy and Safety Cardiovascular Outcomes (VERTIS-CV) trial, its background, design, results, and implications. In patients at least 40 years of age with atherosclerotic cardiovascular disease (ASCVD), the VERTIS-CV trial demonstrated ertugliflozin was non-inferior to placebo for major adverse cardiovascular events, though not superior. Ertugliflozin significantly reduced hospitalization for heart failure compared to placebo. The composite renal outcome was not significantly different between groups. Ertugliflozin was generally well tolerated with a safety profile commensurate with other sodium-glucose co-transporter-2 inhibitors (SGLT-2) inhibitors. EXPERT OPINION In patients with type 2 diabetes and ASCVD, ertugliflozin appears safe with a noted non-significant trend toward improved renal outcomes. Approximately 23.7% of patients in the VERTIS-CV trial had heart failure, the highest among SGLT-2 inhibitor CVOTs. The VERTIS-CV trial reaffirms the reduction in heart failure hospitalizations as a likely class effect of SGLT-2 inhibitors. While the trial supports the use of ertugliflozin beyond glycemic control, agents with confirmed superiority for improved cardiovascular outcomes and mortality may be preferred.
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Affiliation(s)
- Kevin Cowart
- Department of Pharmacotherapeutics & Clinical Research, Taneja College of Pharmacy , Tampa, FL, USA.,Department of Internal Medicine, Morsani College of Medicine, University of South Florida , Tampa, FL, USA
| | - Nicholas W Carris
- Department of Pharmacotherapeutics & Clinical Research, Taneja College of Pharmacy , Tampa, FL, USA.,Department of Family Medicine, Morsani College of Medicine, University of South Florida , Tampa, FL, USA
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Zhang J, Pan S, Li D, Li Z, Jin L, Zhou Z, Pan M. A nomogram for the prediction of renal outcomes among patients with idiopathic membranous nephropathy. Exp Ther Med 2020; 20:3130-3137. [PMID: 32855681 PMCID: PMC7444415 DOI: 10.3892/etm.2020.9063] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/01/2020] [Indexed: 11/06/2022] Open
Abstract
The early prediction of renal outcomes in patients with idiopathic membranous nephropathy (iMN) remains challenging. The present retrospective study evaluated patients with iMN confirmed by renal biopsy. An optimized Cox regression model and a nomogram were constructed for the early prediction of renal outcomes. A total of 141 patients who met the inclusion criteria were evaluated in the present study. In total 18 (12.8%) patients eventually progressed to the endpoint, 6 of whom developed end-stage renal disease, and one patient died during follow-up. The optimized model demonstrated that 24-h proteinuria [hazard ratio (HR) 1.24; 95% CI, 1.10-1.40; P-value <0.001] and chronic tubulointerstitial injury [referred to as grade 0, grade 1 (HR), 5.12; 95% CI, 1.33-19.75; P-value=0.02] or grade 2 (HR, 6.43; 95% CI, 1.35-30.59; P-value=0.02) were independent risk factors for a poor renal outcome. Patients with an estimated three-year renal survival rate (ETR) less than 0.87 had a high risk of a poor renal outcome. In addition, patients with an ETR of 0.87 to 0.98 more quickly developed a decreased estimated glomerular filtration rate after two years of follow-up. In the present study a nomogram for the early prediction of renal outcomes in patients with iMN was developed. This nonogram suggested that patients with an ETR of 0.87-0.98 should receive greater attention during follow-up.
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Affiliation(s)
- Ji Zhang
- Department of Nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Shufang Pan
- Department of Nephrology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Duo Li
- Department of Nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Zhanyuan Li
- Department of Nephrology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Lingwei Jin
- Department of Nephrology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Zhihong Zhou
- Department of Nephrology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Min Pan
- Department of Nephrology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
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Zhang X, Zhong Z, Li Y, Li W. Long-term renal outcomes associated with sodium glucose cotransporter 2 inhibitors in patients with type 2 diabetes mellitus: A systematic review and meta-analysis. Diabetes Metab Res Rev 2020; 36:e3303. [PMID: 32134558 DOI: 10.1002/dmrr.3303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 03/18/2019] [Revised: 10/08/2019] [Accepted: 02/18/2020] [Indexed: 12/13/2022]
Abstract
AIMS The long-term impact of sodium glucose cotransporter 2 (SGLT2) inhibitors on renal functions remains undefined. This study was undertaken to investigate the renal outcomes associated with SGLT2 inhibitors in patients with type 2 diabetes (T2DM) in the long term. METHODS A systematic literature search of PubMed and ClinicalTrials.gov was conducted. Randomized controlled trials which reported renal outcomes at the study endpoint in patients with T2DM receiving treatments of SGLT2 inhibitors were included. Renal adverse events were determined using prespecified lists from the Medical Dictionary for Regulatory Activities or laboratory values. Odds ratio with 95% confidence interval (CI) was used for assessment of dichotomous data. The mean difference or standardized mean difference with 95% CI was used for assessment of continuous data. Random effects models were adopted to measure the pooled outcomes. RESULTS Thirty-nine studies involving 35 trials were identified. Compared with placebo or other anti-diabetic medications, SGLT2 inhibitors were associated with significant lower incidence of composite renal outcome and acute renal failure or injury in patients with T2DM. The risk of progression of albuminuria also appeared to be decreased. No significant changes of estimated glomerular filtration rate levels or urine albumin-creatinine ratios were found in patients receiving SGLT2 inhibitors. CONCLUSIONS Overall renal safety and beneficial effects are indicated for SGLT2 inhibitors. Further confirmative data from large trials and real-world studies are needed.
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Affiliation(s)
- Xiaodan Zhang
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhen Zhong
- Department of Endocrinology, The First People's Hospital of Nankang District, Ganzhou, China
| | - Yanli Li
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wangen Li
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Zhang J, Zhang J, Zhang R, Wang Y, Liang Y, Yang Z, Wang T, Xu X, Liu F. Implications of immunoglobulin G deposit in glomeruli in Chinese patients with diabetic nephropathy. J Diabetes 2020; 12:521-531. [PMID: 32031751 DOI: 10.1111/1753-0407.13024] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 12/15/2019] [Accepted: 01/30/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND In the current study, we explored the associations of glomerular immunoglobulin G (IgG) deposit and further investigated the pattern of IgG subclass deposition in the renal biopsy specimens from patients with diabetic nephropathy (DN). METHODS A total of 170 inpatients with type 2 diabetes mellitus and biopsy-proven DN who were followed up for at least 1 year were retrospectively recruited. Renal outcomes were defined by DN progression (end-stage renal disease [ESRD] or ≥ 50% reduction in estimated glomerular filtration rate [eGFR] from baseline). Additionally, 38 renal biopsy specimens of patients with renal IgG deposit underwent the immunofluorescence IgG1-4 staining. RESULTS The median follow-up period was 22 months. During follow-up, 38.23% (65) of patients progressed to ESRD, and 6.47% (11) of patients had an eGFR decline ≥50%. The multivariate Cox analysis demonstrated that the glomerular IgG deposit (hazard ratio, 1.835; 95% CI, 1.013-3.324, P = .045) was still significantly associated with DN progression when adjusted for the important clinical variables and pathological findings. In addition, a logistic regression showed that the glomerular IgG deposit was independently associated with glomerular basement membrane (GBM) thickness (odds ratio [OR], 1.276; 95% CI, 1.046-1.558; P = .016), Kimmelstiel-Wilson nodules formation (OR, 3.822; 95% CI, 1.052-13.881; P = .042), and C3 deposit in the glomeruli (OR, 124.883; 95% CI, 20.754-751.472; P < .001). The IgG subclass staining showed that IgG1 deposit along the GBM tended to be dominant (28/38) in IgG (+) patients with DN. CONCLUSIONS The glomerular IgG deposit affected glomerular structure and emerged as an independent risk factor for the renal clinical outcomes. In addition, IgG1 predominantly deposited along the GBM among the DN patients with IgG (+), which might be involved in the renal injury and progression of DN.
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Affiliation(s)
- Junlin Zhang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Jie Zhang
- Key Laboratory of Transplant Engineering and Immunology, Ministry of Health, Regenerative Medicine Research Center, Chengdu, China
| | - Rui Zhang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Yiting Wang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Yan Liang
- Core Facility of West China Hospital of Sichuan University, Chengdu, China
| | - Zhen Yang
- Core Facility of West China Hospital of Sichuan University, Chengdu, China
| | - Tingli Wang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Xuan Xu
- Division of Pathology, West China Hospital of Sichuan University, Chengdu, China
| | - Fang Liu
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
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Neves JS, Correa S, Baeta Baptista R, Bigotte Vieira M, Waikar SS, Mc Causland FR. Association of Prediabetes With CKD Progression and Adverse Cardiovascular Outcomes: An Analysis of the CRIC Study. J Clin Endocrinol Metab 2020; 105:dgaa017. [PMID: 31943096 PMCID: PMC7069215 DOI: 10.1210/clinem/dgaa017] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 11/02/2019] [Accepted: 01/14/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Despite our understanding of diabetes as an established risk factor for progressive kidney disease and cardiac complications, the prognostic significance of prediabetes in patients with chronic kidney disease (CKD) remains largely unknown. METHODS Participants of the Chronic Renal Insufficiency Cohort (CRIC) were categorized as having normoglycemia, prediabetes, or diabetes according to fasting plasma glucose, glycated hemoglobin A1c (HbA1c), and treatment with antidiabetic drugs at baseline. Unadjusted and adjusted proportional hazards models were fit to estimate the association of prediabetes and diabetes (versus normoglycemia) with: (1) composite renal outcome (end-stage renal disease, 50% decline in estimated glomerular filtration rate to ≤ 15 mL/min/1.73 m2, or doubling of urine protein-to-creatinine ratio to ≥ 0.22 g/g creatinine); (2) composite cardiovascular (CV) outcome (congestive heart failure, myocardial infarction or stroke); and (3) all-cause mortality. RESULTS Of the 3701 individuals analyzed, 945 were normoglycemic, 847 had prediabetes and 1909 had diabetes. The median follow-up was 7.5 years. Prediabetes was not associated with the composite renal outcome (adjusted hazard ratio [aHR] 1.13; 95% confidence interval [CI], 0.96-1.32; P = 0.14), but was associated with proteinuria progression (aHR 1.23; 95% CI, 1.03-1.47; P = 0.02). Prediabetes was associated with a higher risk of the composite CV outcome (aHR 1.38; 95% CI, 1.05-1.82; P = 0.02) and a trend towards all-cause mortality (aHR 1.28; 95% CI, 0.99-1.66; P = 0.07). Participants with diabetes had an increased risk of the composite renal outcome, the composite CV outcome, and all-cause mortality. CONCLUSIONS In individuals with CKD, prediabetes was not associated with composite renal outcome, but was associated with an increased risk of proteinuria progression and adverse CV outcomes.
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Affiliation(s)
- João Sérgio Neves
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Simon Correa
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Rute Baeta Baptista
- Pediatrics Department, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Portugal
- Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Miguel Bigotte Vieira
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - Sushrut S Waikar
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Sarafidis P, Loutradis C, Ortiz A, Ruilope LM. Blood pressure targets in patients with chronic kidney disease: MDRD and AASK now confirming SPRINT. Clin Kidney J 2020; 13:287-290. [PMID: 32699614 PMCID: PMC7367111 DOI: 10.1093/ckj/sfaa015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 01/07/2020] [Accepted: 01/13/2020] [Indexed: 01/06/2023] Open
Abstract
Recent American and European hypertension guidelines are not in agreement regarding blood pressure (BP) targets for persons with chronic kidney disease (CKD). Previous analyses from the African American Study on Kidney Disease (AASK) and Modification of Diet in Renal Disease (MDRD) trials suggested that strict BP control confers nephroprotection for patients with proteinuria, but a mortality benefit was not apparent. In contrast, an analysis of the Systolic Blood Pressure Intervention Trial (SPRINT) subpopulation of CKD patients showed a mortality benefit with the systolic blood pressure (SBP) <120 mmHg versus the SBP <140 target. A recent analysis of the combined MDRD and AASK cohorts supports previous evidence on nephroprotection but also findings from the SPRINT trial on all-cause mortality benefits of intensive versus usual BP control in individuals with CKD.
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Affiliation(s)
- Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University, Thessaloniki, Greece
| | - Charalampos Loutradis
- Department of Nephrology, Hippokration Hospital, Aristotle University, Thessaloniki, Greece
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz, School of Medicine, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain
| | - Luis M Ruilope
- Institute of Research i+12, Hospital Universitario 12 de Octubre, Madrid, Spain.,School of Doctoral Studies and Research, Universidad Europea de Madrid, Madrid, Spain
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46
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Quattrocchi E, Goldberg T, Marzella N. Management of type 2 diabetes: consensus of diabetes organizations. Drugs Context 2020; 9:212607. [PMID: 32158490 PMCID: PMC7048113 DOI: 10.7573/dic.212607] [Citation(s) in RCA: 14] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/23/2019] [Accepted: 11/27/2019] [Indexed: 12/13/2022] Open
Abstract
Despite the advances in diabetes management, people with diabetes are not reaching their target glycemic goals. Healthcare professionals often fail to initiate, escalate, or de-intensify therapy when indicated. There are several organizations that provide guidance on the management of diabetes to assist the practitioner in achieving improved glycemic control, and this can cause confusion to the practitioner on which organizations' guidance to follow. Diabetes mellitus is associated with an elevated risk of cardiovascular disease, and there have been studies that suggest some antidiabetic medications increase cardiovascular risk and some reduce cardiovascular risk. Diabetes organizations recommend the individualization of treatment goals and choices of drug therapy that will be safe and effective. Healthcare professionals should be knowledgeable and equipped to decide on the best treatment regimen for each of their patients with type 2 diabetes (T2D) and be familiar with how to utilize the different organizations' philosophies in treating their patients.
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Affiliation(s)
- Elaena Quattrocchi
- Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Pharmacy
| | - Tamara Goldberg
- Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Pharmacy
| | - Nino Marzella
- Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Pharmacy
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Alsaadoun S, Rustom F, Hassan HA, Alkhurais H, Aloufi M, Alzahrani S, Bakhsh S, Dalbhi SA. Aminophylline for improving acute kidney injury in pediatric patients: A systematic review and meta-analysis. Int J Health Sci (Qassim) 2020; 14:44-51. [PMID: 33192231 PMCID: PMC7644458] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Acute kidney injury (AKI) is a major cause of morbidity and mortality. Whether aminophylline administration can prevent or treat AKI among pediatric patients are not clear. This meta-analysis aimed to assess the efficacy and effectiveness of aminophylline for pediatric AKI. METHODS We carried out a systematic search of six databases: PubMed, EMBASE/Excerpta Medica, Scopus, Cochrane library, and Google Scholar from January 1995 up till May 2019. Summary measures of risk ratios and standard mean difference were calculated using the random effects model. RESULTS We identified seven papers containing data on aminophylline use in children with AKI. Meta-analysis of single-arm studies indicated no statistically significant difference in mean rate of serum creatinine clearance (-0.39 [-0.80-1.58], P = 0.52), mean urine output (1.99 [-1.43-5.42]; P = 0.25), or mean blood urea nitrogen levels (0.83 [-1.86-3.03], P = 0.54) before and after aminophylline administration. However, among double-arm studies, aminophylline administration in the intervention arm significantly reduced the serum creatinine level as compared to control arm (mean diff = -34 [-55.18--12.83]; P = 0.002). Mean urine output (-112.68 [-27.43-48.9], P = 0.17), incidence of AKI (RR = 1.05 [0.80-1.37], P = 0.72), and mortality rates (RR = 0.79 [0.42-1.47], P = 0.45) were found to be statistically insignificant. CONCLUSIONS Aminophylline administration in children with AKI reduces serum creatinine level without significant adverse effects or effect on the incidence of AKI, urine output, or mortality. Further, large-scale well-planned randomized controlled trials are needed to evaluate its use and its potential long-term effects.
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Affiliation(s)
- Saad Alsaadoun
- Department of Pediatric, Division of Pediatric Nephrology, Security Forces Hospital, Riyadh 13225, Saudi Arabia
| | - Faisal Rustom
- College of Medicine, AlFaisal University, Riyadh 11421, Saudi Arabia
| | - Hanan Abu Hassan
- Department of Pediatric Intensive Care, Prince Sultan Cardiac Center, PSMMC, Riyadh 11159, Saudi Arabia
| | - Hassan Alkhurais
- Department of Pediatrics, Security Forces Hospital, Riyadh 11481, Saudia Arabia
| | - Majed Aloufi
- Department of Pediatric Nephrology, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Saeed Alzahrani
- Department of Pediatric Nephrology, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Shireen Bakhsh
- Department of Pediatric Nephrology, Security Forces Hospital, Riyadh 13314, Saudi Arabia
| | - Sultan Al Dalbhi
- Department of Adult Nephrology, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia,
Address for correspondence: Sultan Al Dalbhi, Department of Adult Nephrology, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia. E-mail:
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48
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Li J, Woodward M, Perkovic V, Figtree GA, Heerspink HJL, Mahaffey KW, de Zeeuw D, Vercruysse F, Shaw W, Matthews DR, Neal B. Mediators of the Effects of Canagliflozin on Heart Failure in Patients With Type 2 Diabetes. JACC Heart Fail 2019; 8:57-66. [PMID: 31676303 DOI: 10.1016/j.jchf.2019.08.004] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/24/2019] [Accepted: 08/06/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The purpose of this study was to explore potential mediators of the effects of canagliflozin on heart failure in the CANVAS Program (CANagliflozin cardioVascular Assessment Study; NCT01032629 and CANagliflozin cardioVascular Assessment Study-Renal; NCT01989754). BACKGROUND Canagliflozin reduced the risk of heart failure among patients with type 2 diabetes in the CANVAS Program. The mechanism of protection is uncertain. METHODS The percentages of mediating effects of 19 biomarkers were determined by comparing the hazard ratios for the effect of randomized treatment from an unadjusted model and from a model adjusting for the biomarker of interest. Multivariable analyses were used to assess the joint effects of biomarkers that mediated most strongly in univariable analyses. RESULTS Early changes after randomization in levels of 3 biomarkers (urinary albumin:creatinine ratio, serum bicarbonate, and serum urate) were identified as mediating the effect of canagliflozin on heart failure. Average post-randomization levels of 14 biomarkers (systolic blood pressure, low-density lipoprotein and high-density lipoprotein cholesterol, total cholesterol, urinary albumin:creatinine ratio, weight, body mass index, gamma glutamyltransferase, hematocrit, hemoglobin concentration, serum albumin, erythrocyte concentration, serum bicarbonate, and serum urate) were identified as significant mediators. Individually, the 3 biomarkers with the largest mediating effect were erythrocyte concentration (45%), hemoglobin concentration (43%), and serum urate (40%). In a parsimonious multivariable model, erythrocyte concentration, serum urate, and urinary albumin:creatinine ratio were the 3 biomarkers that maximized cumulative mediation (102%). CONCLUSIONS A diverse set of potential mediators of the effect of canagliflozin on heart failure were identified. Some mediating effects were anticipated, whereas others were not. The mediators that were identified support existing and novel hypothesized mechanisms for the prevention of heart failure with sodium glucose cotransporter 2 inhibitors.
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Affiliation(s)
- JingWei Li
- Department of Cardiology, People's Liberation Army General Hospital, Beijing, China; Department of Cardiology, Xinqiao Hospital, Army Military Medical University, Chongqing, China; George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Mark Woodward
- George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; University of Oxford, Oxford, United Kingdom; Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Vlado Perkovic
- George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Gemma A Figtree
- Kolling Institute, Royal North Shore Hospital, Sydney, New South Wales, Australia; Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Hiddo J L Heerspink
- George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford Center for Clinical Research, Stanford University School of Medicine, Stanford, California
| | - Dick de Zeeuw
- University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Wayne Shaw
- Janssen Research & Development, Raritan, New Jersey
| | - David R Matthews
- Oxford Centre for Diabetes, Endocrinology and Metabolism and Harris Manchester College, University of Oxford, United Kingdom
| | - Bruce Neal
- George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia; Imperial College London, London, United Kingdom.
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McIsaac M, Kaban G, Clay A, Berry W, Prasad B. Long-Term Impact of Bariatric Surgery on Renal Outcomes at a Community-Based Publicly Funded Bariatric Program: The Regina Bariatric Study. Can J Kidney Health Dis 2019; 6:2054358119884903. [PMID: 31695923 PMCID: PMC6820179 DOI: 10.1177/2054358119884903] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 03/29/2019] [Accepted: 09/18/2019] [Indexed: 12/22/2022] Open
Abstract
Background: Obesity is recognized as an independent risk factor for chronic kidney disease through multiple direct and indirect biological pathways. Bariatric surgery is a proven, effective method for sustained weight loss. However, there is a relative paucity of data on the impact of bariatric surgery on renal outcomes. Objective: The primary objective was to evaluate the change in urine albumin/creatinine ratio (ACR) in patients undergoing bariatric surgery, at 12 months after the procedure. Secondary objectives were to determine the changes in ACR at (6 and 24 months), estimated glomerular filtration rate (eGFR; 6, 12, and 24 months), and hemoglobin A1c (HbA1c); 12 and 24 months) after the procedure. Design: This observational retrospective cohort study included consecutive obese patients who underwent bariatric surgery. Setting: Provincial Bariatric Surgery Clinic at the Regina General Hospital, Saskatchewan. Patients: This study includes 471 consecutive obese adult patients who underwent bariatric surgery between 2008 and 2015. Measurements: We studied the impact of bariatric surgery on body mass index (BMI), renal outcomes (urine ACR and eGFR) and metabolic outcomes (fasting glucose, total cholesterol, low-density lipoprotein, triglycerides, and HbA1c) in 471 patients. Methods: Patients were followed for 2 years postsurgery in the bariatric clinic. Mixed linear models that accounted for the repeated nature of the data were used to access changes in outcomes over time. Results: Patients were predominantly female (81%) with a mean age (±SD) of 46 ± 10 years. Most patients (87%) had a BMI > 40 kg/m2 and 81% of the patients underwent Roux-en-Y gastric bypass. The mean BMI decreased from 47.7 ± 7.8 kg/m2 at baseline to 37.1 ± 7.9 kg/m2 at 6 months and 34.8 ± 8.8 kg/m2 at 12 months. In a subcohort of patients with microalbuminuria, ACR showed an improvement from a median [interquartile] value of 5.1 [3.7-7.5] mg/mmol at baseline to 2.3 [1.2-3.6] mg/mmol at 6 months (P = .007), to 1.4 [0.9-3.7] mg/mmol at 2-year follow-up (P < .001). Similarly, eGFR increased in patients with microalbuminuria from 109 ± 10 mL/min/1.73 m2 at baseline to 120 ± 36 mL/min/1.73 m2 at 2-year follow-up (P = .013). There were statistically significant reductions in triglycerides, fasting glucose, and HbA1c. Limitations: This was a retrospective chart review, with the lack of a control group. Patients with eGFR less than 60 mL/min/1.73 m2 were not considered for surgery, and we had to measure renal outcomes predominantly on the presence of proteinuria. Conclusions: Our results suggest bariatric surgery significantly decreased weight and consequently improved renal and metabolic outcomes (eGFR, ACR, fasting glucose, cholesterol, and triglycerides) in patients with elevated BMI.
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Affiliation(s)
- Mark McIsaac
- University of Saskatchewan College of Medicine, Saskatoon, Canada
| | | | - Adam Clay
- Saskatchewan Health Authority, Regina, Canada
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Waheed A, Djurdjev O, Dong J, Gill J, Barbour S. Validation of Self-Reported Race in a Canadian Provincial Renal Administrative Database. Can J Kidney Health Dis 2019; 6:2054358119859528. [PMID: 31308951 PMCID: PMC6604118 DOI: 10.1177/2054358119859528] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 05/20/2019] [Indexed: 11/18/2022] Open
Abstract
Background: Administrative data are commonly used to study clinical outcomes in renal
disease. Race is an important determinant of renal health delivery and
outcomes in Canada but is not validated in most administrative data, and the
correlation with census-based definitions of race is unknown. Objectives: Validation of self-reported race (SRR) in a Canadian provincial renal
administrative database (Patient Records and Outcome Management Information
System [PROMIS]) and comparison with the Canadian census categories of
race. Design: Prospective patient survey study to validate SRR in PROMIS. Setting: British Columbia, Canada. Patients: Adult patients registered in PROMIS. Measurements: Survey SRR was used as gold standard to validate SRR in PROMIS. Self-reported
race in PROMIS was compared with census race categories. Methods: This is a cross-sectional telephone survey of a random sample of all adults
in PROMIS conducted between February 2016 and November 2016. Responders
selected a race category from PROMIS and from the Canadian census.
Sensitivity (Sn) and specificity (Sp) were calculated with 95% confidence
intervals (CIs). Results: A total of 21 039 patients met inclusion criteria, 1677 were selected for the
survey and 637 participated (38% response rate). There were no differences
between the PROMIS, sampled, and responder populations. PROMIS SRR had an
accuracy of 95.3% (95% CI: 94.2%-97.0%) when validated against the survey
SRR with Sn and Sp ≥90% in all race groups except in Aboriginals (Sn 87.5%).
The positive and negative predictive values were ≥95%, except in very low
and high–prevalence groups, respectively. The Canadian census had an
accuracy of 95.7% (95% CI: 94.4%-97.6%) when validated against PROMIS SRR
with Sn and Sp ≥90%. The results did not differ in subgroups based on age,
sex, birth outside Canada, or renal group (glomerulonephritis, chronic
kidney disease, hemodialysis, peritoneal dialysis, transplant recipients, or
live donors). Limitations: Analysis of minority groups and lower prevalence groups is limited by sample
size. Results may not be generalizable to other administrative
databases. Conclusions: We have shown high accuracy of PROMIS SRR that validates its use in the
secondary analysis of administrative data for research. There is high
correlation between PROMIS and census race categories which allows linkage
with other data sources that use census-based definitions of race.
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Affiliation(s)
- Aiza Waheed
- The University of British Columbia, Vancouver, Canada
| | | | | | - Jagbir Gill
- The University of British Columbia, Vancouver, Canada.,BC Provincial Renal Agency, Vancouver, Canada
| | - Sean Barbour
- The University of British Columbia, Vancouver, Canada.,BC Provincial Renal Agency, Vancouver, Canada
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