Effect of preceding drug therapy on the renal and cardiovascular outcomes of combined sodium-glucose cotransporter-2 inhibitor and glucagon-like peptide-1 receptor agonist treatment in patients with type 2 diabetes and chronic kidney disease

AIM

To conduct a post hoc subgroup analysis of patients with type 2 diabetes (T2D) from the RECAP study, who were treated with sodium-glucose cotransporter-2 (SGLT2) inhibitor and glucagon-like peptide 1 receptor agonist (GLP-1RA) combination therapy, focusing only on those patients who had chronic kidney disease (CKD), to examine whether the composite renal outcome differed between those who received SGLT2 inhibitor treatment first and those who received a GLP-1RA first.

METHODS

We included 438 patients with CKD (GLP-1RA-first group, n = 223; SGLT2 inhibitor-first group, n = 215) from the 643 T2D patients in the RECAP study. The incidence of the composite renal outcome, defined as progression to macroalbuminuria and/or a ≥50% decrease in estimated glomerular filtration rate (eGFR), was analysed using a propensity score (PS)-matched model. Furthermore, we calculated the win ratio for these composite renal outcomes, which were weighted in the following order: (1) both a ≥50% decrease in eGFR and progression to macroalbuminuria; (2) a decrease in eGFR of ≥50% only; and (3) progression to macroalbuminuria only.

RESULTS

Using the PS-matched model, 132 patients from each group were paired. The incidence of renal composite outcomes did not differ between the two groups (GLP-1RA-first group, 10%; SGLT2 inhibitor-first group, 17%; odds ratio 1.80; 95% confidence interval [CI] 0.85 to 4.26; p = 0.12). The win ratio of the GLP-1RA-first group versus the SGLT2 inhibitor-first group was 1.83 (95% CI 1.71 to 1.95; p < 0.001).

CONCLUSION

Although the renal composite outcome did not differ between the two groups, the win ratio of the GLP-1RA-first group versus the SGLT2 inhibitor-first group was significant. These results suggest that, in GLP-1RA and SGLT2 inhibitor combination therapy, the addition of an SGLT2 inhibitor to baseline GLP-1RA treatment may lead to more favourable renal outcomes.

Influence of the combination of SGLT2 inhibitors and GLP-1 receptor agonists on eGFR decline in type 2 diabetes: post-hoc analysis of RECAP study

Accumulating evidence has demonstrated that both SGLT2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP1Ra) have protective effects in patients with diabetic kidney disease. Combination therapy with SGLT2i and GLP1Ra is commonly used in patients with type 2 diabetes (T2D). We previously reported that in combination therapy of SGLT2i and GLP1Ra, the effect on the renal composite outcome did not differ according to the preceding drug. However, it remains unclear how the initiation of combination therapy is associated with the renal function depending on the preceding drug. In this post hoc analysis, we analyzed a total of 643 T2D patients (GLP1Ra-preceding group, n = 331; SGLT2i-preceding group, n = 312) and investigated the differences in annual eGFR decline. Multiple imputation and propensity score matching were performed to compare the annual eGFR decline. The reduction in annual eGFR decline in the SGLT2i-preceding group (pre: -3.5 ± 9.4 mL/min/1.73 m2/year, post: -0.4 ± 6.3 mL/min/1.73 m2/year, p < 0.001), was significantly smaller after the initiation of GLP1Ra, whereas the GLP1Ra-preceding group tended to slow the eGFR decline but not to a statistically significant extent (pre: -2.0 ± 10.9 mL/min/1.73 m2/year, post: -1.8 ± 5.4 mL/min/1.73 m2/year, p = 0.83) after the initiation of SGLT2i. After the addition of GLP1Ra to SGLT2i-treated patients, slower annual eGFR decline was observed. Our data raise the possibility that the renal benefits-especially annual eGFR decline-of combination therapy with SGLT2i and GLP1Ra may be affected by the preceding drug.

Renoprotective effects of combination treatment with sodium-glucose cotransporter inhibitors and GLP-1 receptor agonists in patients with type 2 diabetes mellitus according to preceding medication

AIMS

Combination therapy with sodium-glucose cotransporter inhibitors (SGLT2is) and GLP-1 receptor agonists (GLP1Ras) is now of interest in clinical practice. The present study evaluated the effects of the preceding drug type on the renal outcome in clinical practice.

METHODS

We retrospectively extracted type 2 diabetes mellitus patients who had received both SGLT2i and GLP1Ra treatment for at least 1 year. A total of 331 patients in the GLP1Ra-preceding group and 312 patients in the SGLT2i-preceding group were ultimately analyzed. Either progression of the albuminuria status and/or a ≥30% decrease in the eGFR was set as the primary renal composite outcome. The analysis using propensity score with inverse probability weighting was performed for the outcome.

RESULTS

The incidences of the renal composite outcome in the SGLT2i- and GLP1Ra-preceding groups were 28% and 25%, respectively, with an odds ratio [95% confidence interval] of 1.14 [0.75, 1.73] (p = .54). A logistic regression analysis showed that the mean arterial pressure (MAP) at baseline, the logarithmic value of the urine albumin-to-creatinine ratio at baseline, and the change in MAP were independent factors influencing the renal composite outcome.

CONCLUSION

With combination therapy of SGLT2i and GLP1Ra, the preceding drug did not affect the renal outcome.

Combined treatment by burosumab and a calcimimetic can ameliorate hypophosphatemia due to excessive actions of FGF23 and PTH in adult XLH with tertiary hyperparathyroidism: A case report

INTRODUCTION

X-linked hypophosphatemia (XLH) is the most prevalent type of heritable fibroblast growth factor 23 (FGF23)-related hypophosphatemic rickets. Recently, anti-FGF23 antibody, burosumab, has become clinically available. We herein report a patient with adult XLH and tertiary hyperparathyroidism.

CASE PRESENTATION

The serum phosphate level and tubular maximum reabsorption of phosphate per glomerular filtration rate (TmP/GFR) remained low, despite burosumab treatment. While the influence of the relationship between FGF23 and parathyroid hormone (PTH) on the phosphaturic effect is unclear, it was considered that a high level of PTH due to tertiary hyperparathyroidism remains to suppress renal phosphate reabsorption. A calcimimetic, evocalcet, increased the serum phosphate level and TmP/GFR.

DISCUSSION AND CONCLUSION

Therefore, it is important to evaluate the presence of secondary-tertiary hyperparathyroidism in patients whose serum phosphate level does not increase with burosumab treatment.

Mineralocorticoid Receptor Antagonists in Diabetic Kidney Disease

Diabetic kidney disease (DKD) is a major cause of end-stage kidney disease (ESKD) worldwide. Mineralocorticoid receptor (MR) plays an important role in the development of DKD. A series of preclinical studies revealed that MR is overactivated under diabetic conditions, resulting in promoting inflammatory and fibrotic process in the kidney. Clinical studies demonstrated the usefulness of MR antagonists (MRAs), such as spironolactone and eplerenone, on DKD. However, concerns regarding their selectivity for MR and hyperkalemia have remained for these steroidal MRAs. Recently, nonsteroidal MRAs, including finerenone, have been developed. These agents are highly selective and have potent anti-inflammatory and anti-fibrotic properties with a low risk of hyperkalemia. We herein review the current knowledge and future perspectives of MRAs in DKD treatment.

High-mobility group box 2 protein is essential for the early phase of adipogenesis

Understanding of the mechanism of adipogenesis is essential for the control of obesity, which predisposes toward numerous health problems. High-mobility group box protein 2 (HMGB2) is a non-histone chromosomal protein that facilitates DNA replication, transcription, recombination, and repair. Here, we studied the role of HMGB2 in adipogenic differentiation. The expression of HMGB2 was measured at the mRNA and protein levels in cultured 3T3-L1 pre-adipocyte cells and during the process of adipogenic differentiation induced bya cocktail of insulin, 3-isobutyl-1-methylxanthine, and dexamethasone. This increased in the early phase and decreased in the late phase of differentiation. However, 3T3-L1 pre-adipocyte cells did not differentiate into adipocytes after the knockdown of HMGB2 expression by small interfering RNA (siRNA). Similarly, mesenchymal stem cells (MSCs) isolated from Hmgb2^-/- mice did not express peroxisome proliferator-activated receptor gamma (PPARγ) in response to the adipocyte differentiation cocktail and did not differentiate. Wnt/β-catenin signaling is a negative regulator of adipogenic differentiation. We found that β-catenin expression was downregulated during 3T3-L1 adipogenic differentiation, as expected, but not when endogenous HMBG2 expression was knocked down using siRNA. These results indicate that HMGB2 plays an essential role in the early phase of the differentiation of pre-adipocytes and MSCs, and probably interacts with other regulators, such as PPARγ and Wnt/β-catenin signaling.

SUN-026 Selective Androgen Receptor Modulator S42 Has Anabolic and Anti-Catabolic Effects on Cultured Myotubes

Introduction: In an effort to develop a selective androgen receptor modulator (SARM) with beneficial activity in energy homeostasis, we previously screened 119 steroid analogs for the ability to induce uncoupling protein-1 (UCP-1) mRNA without increasing prostate-specific antigen promoter activity in human prostate cancer cell line, LNCap. As a result, we identified a novel SARM, S42, which is structural analog of testosterone. S42 dose not stimulate prostate growth but has a beneficial effect on lipid metabolism and also increased muscle weight of lavator ani in orchiectomized Sprague-Dawley rats. These findings prompted us to investigate whether S42 has a direct effect on cultured C2C12 myotubes. Method: Mouse myoblast C2C12 were seeded into 6well-plates at 2×10⁵cells/well and maintained in Dulbecco's modified Eagle's medium (DMEM) supplemented with 10% fetal bovine serum (FBS). When the cultured cells became 80-90% confluent, the medium was changed to DMEM supplemented with 2% horse serum (HS) and cells were further cultured for 4 days to induce differentiation into myotubes. Next, the medium was changed to DMEM containing 2% dextran-coated-stripped HS from one day before treatment with various drugs: S42, 5α-dihydrotestosterone (DHT), insulin and rapamycin were tested. Protein and mRNA expression levels were detected by Western blotting and Real time RT-PCR, respectively. Results: Muscle atrophy is mainly controlled by two specific genes encoding muscle ubiquitin ligase, atrogin1 and Muscle RING-Finger Protein1 (MuRF1). S42 significantly lowered expression levels of atrogin1 and MuRF1 in C2C12 myotubes, as determined by Real time RT-PCR. Phosphorylation of p70 S6 kinase (p70S6K), an essential factor for promoting protein synthesis in skeletal muscle, was significantly increased by S42 to almost the same extent as by insulin, but this was prevented by treatment with rapamycin, an inhibitor of mechanistic target of rapamycin complex 1 (mTORC1). However, phosphorylation of Akt upstream regulator mTORC1, was not changed by S42. S42 did not increase insulin-like growth factor 1 (IGF1) mRNA levels in C2C12 myotubes. Conclusion: These results suggest that S42 may have an anabolic effect through activation of mTORC1-p70S6K signaling, independent of IGF1-Akt signaling and may exert an anti-catabolic effect through inhibition of the degradation pathway in cultured C2C12 myotubes.

Selective androgen receptor modulator, S42 has anabolic and anti-catabolic effects on cultured myotubes

We previously identified a novel selective androgen receptor modulator, S42, that does not stimulate prostate growth but has a beneficial effect on lipid metabolism. S42 also increased muscle weight of the levator ani in orchiectomized Sprague–Dawley rats. These findings prompted us to investigate whether S42 has a direct effect on cultured C2C12 myotubes. S42 significantly lowered expression levels of the skeletal muscle ubiquitin ligase (muscle atrophy-related gene), atrogin1 and Muscle RING-Finger Protein 1(MuRF1) in C2C12 myotubes, as determined by real time PCR. Phosphorylation of p70 S6 kinase (p70S6K), an essential factor for promoting protein synthesis in skeletal muscle, was significantly increased by S42 to almost the same extent as by insulin, but this was significantly prevented by treatment with rapamycin, an inhibitor of mechanistic target of rapamycin complex 1 (mTORC1). However, phosphorylation of Akt, upstream regulator of mTORC1, was not changed by S42. S42 did not increase insulin-like growth factor 1 (Igf1) mRNA levels in C2C12 myotubes. These results suggest that S42 may have an anabolic effect through activation of mTORC1–p70S6K signaling, independent of IGF-1-Akt signaling and may exert an anti-catabolic effect through inhibition of the degradation pathway in cultured C2C12 myotubes.

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A SARM, S42 lowered expression levels of atrogin1 and MuRF1 mRNA in C2C12 myotubes.

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S42 increased phosphorylation of p70S6K through activation of mTORC1 in C2C12 myotubes.

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S42 may have anti-catabolic and anabolic effect in vitro.

[Characteristics and progress of treatment for gastric cancers detected by mass screening]

We devised an X-ray examination to detect early gastric cancer, especially small gastric cancer, during the period between 1996 and 1997. As a result, the rate of gastric cancer detection by mass screening was 0.50%; and the rate of early gastric cancer detection was 79%. 1. Characteristics of gastric cancer detected by mass screening: Characteristics of gastric cancer were depressive-type undifferentiated cancer less than 4.0 cm diameter in work-place screening and depressive-type differentiated cancer less than 4.0 cm in area screening; 2. gastric cancer less than 2.0 cm in diameter was 75 (68%) of the 110 cases (total detected gastric cancer). 2) We have to consider that gastric cancer differs by sex and age. 3) EMR accounted for 39 (35%) of the 110 cases in treatment. This method resulted in a higher gastric cancer detection rate and served to maintain QOL.

Structure and activity of mouse S-adenosylmethionine decarboxylase gene promoters and properties of the encoded proteins

The promoter regions of two S-adenosylmethionine decarboxylase genes (AMD genes) were isolated from a mouse genomic library. One promoter was that of the bona fide mouse AMD gene (AMD1) whereas the other was that of the intronless AMD gene (AMD2). There was no sequence identity between the two promoters. The sequence of the AMD1 promoter was highly homologous to the human AMD1 and rat Amd1B promoters. After transient transfection in various cell lines, the AMD1 promoter was one to two orders of magnitude stronger than the AMD2 promoter. Similar results were obtained by using stably transfected mouse FM3A cells. In S-adenosylmethionine decarboxylase (AdoMetDC)-overproducing SAM-1 cells, the AMD1 gene was amplified over 5-fold. AdoMetDC encoded by the intronless AMD2 gene had two amino acid replacements (Met to Ile at codon 70 and Ala to Val at codon 139), compared with the protein encoded by the AMD1 gene, and exhibited decreased catalytic activity (<50%) and decreased processing activity when expressed in AdoMetDC-deficient Escherichia coli cells. When Ile-70 of the protein encoded by AMD2 was converted into Met, both the catalytic and processing activities recovered markedly, indicating that Met-70 adjacent to the proenzyme-processing site is important for both activities. The third AMD locus (AMD3) in FM3A cells contains a pseudogene, in which deletion of two bases generates a premature termination codon at position 57. Since the AMD2 promoter had only 1-10% of the strength of the bona fide AMD1 gene and AMD2 protein possessed lower specific activity, the relative contribution of the AMD2-encoded enzyme to total AdoMetDC activity is small. Thus AdoMetDC activity in murine cells is thought to be due mainly to the product of the AMD1 gene.

Pharmacological and pharmacokinetic studies of the newly synthesized thiazolidinedione derivative 5-(4-(1-phenyl-1-cyclopropanecarbonylamino)benzyl)-thiazolidine-2 ,4-dio ne

DN-108 (5-(4-(1-phenyl-1-cyclopropanecarbonylamino)benzyl)thiazolidine-2, 4-dione, CAS 195604-21-8) is a newly synthesized thiazolidinedione derivative. Pharmacological and pharmacokinetic studies of DN-108 were done. In diabetic animal models KKAy and db/db mice, DN-108, orally given at doses of 3-30 mg/kg for 10 consecutive days, improved hyperglycemia, hypertriglyceridemia or hyperinsulinemia from day 1 or day 4 and the effects were almost maintained through the experiment. In KKAy mice, DN-108, orally given at doses of 3-30 mg/kg for 4 consecutive days, potently decreased serum glucose level as compared with troglitazone (CAS 97322-87-7) and the ED25 values of DN-108 and troglitazone were 7 and 283 mg/kg/day, respectively. DN-108 increased 2-deoxyglucose uptake in L6 muscle cell line to the same extent as troglitazone. Moreover, DN-108 inhibited aldose reductase activity in vitro as potently as troglitazone did. Pharmacokinetic parameters, Cmax and AUC of DN-108 after oral administration in rats were higher than those of troglitazone. These results suggest that DN-108 has antidiabetic effect with tissue sensitization for glucose uptake and high absorption after oral administration. It is expected that DN-108 will be a promising oral antidiabetic agent.

Valproate therapy does not deplete carnitine levels in otherwise healthy children

OBJECTIVE

To determine whether children with epilepsy undergoing valproate (VPA) antiepileptic therapy and who are otherwise healthy have a lower serum level of carnitine (CAR) and a higher plasma level of plasma ammonia than do normal children.

METHODOLOGY

A total of 45 children with epilepsy, 6.3 to 21.7 years of age, who were treated solely with VPA and were free of abnormal neurologic findings or nutritional problems were randomly selected (VPA-treated group). An age-matched control group (n = 45) was selected from subjects without epilepsy (control group). Total (T) and free (F) serum CAR, serum VPA concentration, and the plasma ammonia level were measured and analyzed.

RESULTS

Serum VPA concentration exhibited a weak negative correlation with both T- (r = -0.34) and F-CAR (r = -0.41). The T-CAR levels were 55.7 +/- 12.4 and 57.6 +/- 12.1 mM, and the F-CAR levels 42.7 +/- 9.9 and 44.4 +/- 9.9 mM in the VPA-treated and control groups, respectively. Thus, there was no significant difference in T- or F-CAR levels between the VPA-treated and control groups. Plasma ammonia levels were the same in the two groups: 26 +/- 9.2 and 29.4 +/- 11.8 mM in the VPA-treated and control groups, respectively. There was no significant correlation between blood ammonia and either T- (r = +0.024) or F-CAR (r = -0. 026).

CONCLUSION

Children on a regular diet ingest a sufficient amount of CAR that more than meets their daily CAR requirement. The level of neither T- nor F-CAR in patients with epilepsy and without severe neurologic or nutritional problems being treated with VPA appeared to be affected by VPA therapy. Because the blood CAR level depends on nutritional condition rather than on blood VPA concentration, CAR deficiency caused by VPA is not likely to occur in this population. The usefulness of supplementation of CAR for this type of patient with epilepsy, therefore, must be reevaluated carefully.

[A case of hereditary sensory and autonomic neuropathy type IV diagnosed following the development of acute encephalopathy due to heat stroke]

A fourteen-month-old girl, who had shown remittent fever frequently from the neonatal period, hypohidrosis, frequent change of face color and self-mutilation of the 1st and 2nd fingers of both hands and tongue in the first months of her life, developed an acute encephalopathy with generalized tonic convulsion outdoors on a sunny hot day. Generalized tonic convulsion subsided within two days, but doll's eye phenomenon, loss of pupillary reaction to light, palpebral myoclonus, and ballismus of arms and legs followed L-dopa showed some effect on the ballismus 1 month after the attack. During the hospital stay, biopsy of sural nerve was performed. Morphometric and ultrastructural studies of the sural nerve demonstrated decreased numbers of unmyelinated and small myelinated fibers. Skin biopsy of the leg revealed sweat glands with no nerve terminals, axons and Schwann cells around them. She was diagnosed as having hereditary sensory and autonomic neuropathy type IV based on the histological and clinical findings. After discharge, bone fracture was found three times without any evidence of trauma. Acute encephalopathy, probably produced in relation to the underlying neuropathy, was considered to be due to heat stroke.

[Idiopathic acquired generalized anhidrosis with normal numbers of eccrine gland nerve terminals and unmyelinated axons. A case report]

A 37-year-old man with acquired generalized anhidrosis but without other autonomic or somatic abnormalities (idiopathic acquired generalized anhidrosis) is described with special reference to histologic and morphometric findings of the eccrine gland and its nerve terminals and unmyelinated axons. The patient was admitted to our hospital in August 1989 with complaints of heat intolerance and anhidrosis of the face, trunk, and both limbs. General physical and neurological examinations revealed no abnormalities except generalized anhidrosis. Sweating tests revealed anhidrosis of most surfaces of the body except the axillae, mammary areolae, forearms, hands, popliteal fossae, and plantar surfaces. Sympathetic skin responses were absent in the axillae, and were decreased on the palms. Iontophoretically applied pilocarpine revealed a complete absence of active eccrine glands on the dorsal surface of the right foot. No other abnormalities were revealed by autonomic function tests. Light and electron microscopic studies of the eccrine glands of the distal and lateral aspects of the left leg were performed in this patient and six control subjects. Infiltration of mononuclear inflammatory cells around the duct and secretory coil of a limited number of eccrine glands on multiple sections was found only in this patient. Electron microscopic morphometric evaluation of the eccrine glands, associated nerve terminals and unmyelinated axons of this patient revealed no definite alterations when compared with those of the six control subjects. Therefore, we concluded that the nerves innervating the eccrine glands were not affected in this patient and suspect that either the cholinergic receptors or the function of secretory cells of the eccrine glands were involved.(ABSTRACT TRUNCATED AT 250 WORDS)

[Sensory ataxia in peripheral neuropathies--etiological and pathological analysis of four cases]

Among 85 neuropathy patients admitted and studied in the Department of Neurology, University of Occupational and Environmental Health, Japan, from 1979 to 1990, four patients suffering from sensory ataxia are reported with special reference to their etiological and pathological conditions. All of them were classified as having immune-mediated neuropathy. The first patient, a 56-year-old woman, was diagnosed as having chronic progressive ataxic sensory neuropathy. Her symptoms became progressively worse over a nine-year period after onset, but no evidence of cancer has been revealed. The positive rheumatoid factor was the only other feature noted. The second patient, a 63-year-old woman, after extensive laboratory studies, including the biopsy of the lymph node at the bifurcation of the bronchus in search of the cancer, was diagnosed as having subacute sensory neuropathy with small cell carcinoma of the lung. Chemotherapy was completed without subsequent obvious clinical benefits. The clinical diagnosis was confirmed on autopsy 29 months after the onset. The symptoms of the first patient were indistinguishable from those of the second patient, especially in the early clinical stage. In both patients, the proprioceptive sensations were severely affected and the disturbance of the proprioceptive sensations seemed to be almost parallel with the ataxia signs. The main site of the lesion seemed to be the neuron in the dorsal root ganglion in the first patient, as well as in the second patient who showed a marked loss of neurons in the dorsal root ganglion considered to be the primary lesion on autopsy.(ABSTRACT TRUNCATED AT 250 WORDS)

[The effect of ageing on the active sweat gland density in the dorsum of foot]

Focal sweating in the dorsum of foot induced by iontophoresis of 1% pilocarpine was quantitatively evaluated using silastic impression mold technique in 111 control subjects (71 men & 40 women), aged 14 to 89 years, to reveal the effect of aging on the density of active sweat glands. The subjects were divided into four groups (group I: aged 14 to 29 years, group II: aged 30 to 49 years, group III: aged 50 to 69 years, group IV: aged 70 to 89 years), and the difference of the density of active sweat glands was evaluated among the groups with Wilcoxon's rank sum test. It was statistically significant (p less than 0.001) between group II and III, and between group III and IV, but not significant between group I and II. Therefore, it was concluded that the density of active sweat glands decreases prominently after 50 years of age. The density of active sweat glands was not significantly different between man and woman in each group. In the regression analysis of the density of active sweat glands on age, the relationship (Density = -0.0178.Age2 + 232.6 (R2 = 0.54), p less than 0.0001) was obtained. Based on such relationship, the predicted density and the upper and lower limits of 95% confidence interval of the predicted density for each age were obtained. These results indicate that decrease of the density of active sweat glands due to ageing should be taken into consideration in the evaluation of the density of active sweat glands in the dorsum of foot among the patients with various neurological diseases.(ABSTRACT TRUNCATED AT 250 WORDS)