Effect of sodium-glucose cotransporter 2 inhibitors on cardiovascular and kidney outcomes-Systematic review and meta-analysis of randomized placebo-controlled trials

Association between sodium-glucose co-transporter 2 inhibitors and risk of bullous pemphigoid in patients with type 2 diabetes: A nationwide population-based cohort study

BACKGROUND

Certain anti-diabetic agents have been linked to the development of bullous pemphigoid (BP). However, the relationship between BP and sodium-glucose co-transporter 2 inhibitors (SGLT2is) remains inconclusive.

OBJECTIVE

To investigate the association between SGLT2i usage and BP.

METHODS

Participants were recruited from the Taiwan National Health Insurance Database between 2007 and 2018. A total of 149,060 patients with diabetes receiving SGLT2i were matched 1:2 with diabetic patients without SGLT2i usage. Factors such as age, sex, duration of diabetes condition, DPP4i usage, insulin usage, and selected comorbidities were included in the multivariate analysis.

RESULTS

Compared with the control, the 2-year-cumulative incidence was significantly low in patients using SGLT2i after adjustment for competing mortality. Patients with diabetes receiving SGLT2i had a low risk (adjusted hazard ratio [HR] 0·56, 95% confidence interval [CI], 0·33-0·96) for BP after adjustment for potential confounders. Age (HR, 1·06), renal disease (HR, 1·79), cerebrovascular disease (HR, 3·23), epilepsy (HR, 3·07), DPP4i users (HR: 2·55), and insulin users (HR: 2·56) were significant risk factors for BP.

CONCLUSIONS

The risk of BP did not increase in patients receiving SGLT2i. Thus, SGLT2i could be a safe choice for patients with diabetes having additional risk factors or a history of BP.

Sodium-Glucose Cotransporter 2 Inhibitors and Cardiac Remodeling

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have evident cardiovascular benefits in patients with type 2 diabetes with or at high risk for atherosclerotic cardiovascular disease, heart failure with reduced ejection fraction, heart failure with preserved ejection fraction (only empagliflozin and dapagliflozin have been investigated in this group so far), and chronic kidney disease. Prevention and reversal of adverse cardiac remodeling is one of the mechanisms by which SGLT2 inhibitors may exert cardiovascular benefits, especially heart failure-related outcomes. Cardiac remodeling encompasses molecular, cellular, and interstitial changes that result in favorable changes in the mass, geometry, size, and function of the heart. The pathophysiological mechanisms of adverse cardiac remodeling are related to increased apoptosis and necrosis, decreased autophagy, impairments of myocardial oxygen supply and demand, and altered energy metabolism. Herein, the accumulating evidence from animal and human studies is reviewed investigating the effects of SGLT2 inhibitors on these mechanisms of cardiac remodeling.

Hypoxia and chronic kidney disease

Hypoxia is an inherent pathophysiological characteristic of chronic kidney disease (CKD), which is closely associated with the development of renal inflammation and fibrosis, as well as CKD-related complications such as anaemia, cardiovascular events, and sarcopenia. This review outlined the characteristics of oxygen supply in the kidney, changes in oxygen metabolism and factors leading to hypoxia in CKD. Mechanistically, we discussed how hypoxia contributes to renal injury as well as complications associated with CKD. Furthermore, we also discussed the potential therapeutic approaches that target chronic hypoxia, as well as the challenges in the study of oxygen homeostasis imbalance in CKD.

Efficacy and safety of sodium-glucose cotransporter 2 inhibitors initiation in patients with acute heart failure, with and without type 2 diabetes: a systematic review and meta-analysis

BACKGROUND

There is uncertainty and limited data regarding initiation of sodium-glucose cotransporter 2 (SGLT2) inhibitors among patients hospitalized with acute heart failure (AHF). This systematic review and meta-analysis aim to establish the efficacy and safety of SGLT2 inhibitors initiated in patients hospitalized for AHF.

METHODS

PubMed/Medline, Embase, and Cochrane library were searched using the following terms: ("sglt2" and "acute heart failure") and ("sglt2" and "worsening heart failure") from inception till November 15th, 2021 for randomized controlled trials (RCTs) comparing the efficacy and safety of initiating an SGLT2 inhibitor compared with placebo in patients with AHF. Major cardiovascular and diabetes scientific meetings in 2021 were also searched for relevant studies. Prespecified efficacy outcomes were all-cause mortality, rehospitalization for heart failure, and improvement in Kansas City Cardiomyopathy Questionnaire (KCCQ) scale score. Prespecified safety outcomes were acute kidney injury (AKI), hypotension, and hypoglycemia. Random effects odds ratio (OR) and mean difference with 95% confidence intervals (CIs) were calculated.

RESULTS

Three RCTs with a total of 1831 patients were included. Initiation of SGLT2 inhibitors in patients with AHF reduced the risk of rehospitalization for heart failure (OR 0.52; 95% CI [0.42, 0.65]) and improved Kansas City Cardiomyopathy Questionnaire scores (mean difference 4.12; 95% CI [0.1.89, 6.53]). There was no statistically significant effect for initiation of SGLT2 inhibitors in patients with AHF on all-cause mortality (OR 0.70; 95% CI [0.46, 1.08]). Initiation of SGLT2 inhibitors in patients with AHF did not increase the acute kidney injury (OR 0.76; 95% CI [0.50, 1.16]), hypotension (OR 1.17; 95% CI [0.80, 1.71]), or hypoglycemia (OR 1.51; 95% CI [0.86, 2.65]).

CONCLUSION

Initiation of SGLT2 inhibitors in patients hospitalized for AHF during hospitalization or early post-discharge (within 3 days) reduces the risk of rehospitalization for heart failure and improves patient-reported outcomes with no excess risk of adverse effects.

Risk of Heart Failure in Patients With Nonalcoholic Fatty Liver Disease: JACC Review Topic of the Week

Heart failure (HF) and nonalcoholic fatty liver disease (NAFLD) are 2 conditions that have become important global public health problems. Emerging evidence supports a strong and independent association between NAFLD and the risk of new-onset HF, and there are multiple potential pathophysiological mechanisms by which NAFLD may increase risk of new-onset HF. The magnitude of this risk parallels the underlying severity of NAFLD, especially the level of liver fibrosis. Patients with NAFLD develop accelerated coronary atherosclerosis, myocardial alterations (mainly cardiac remodeling and hypertrophy), and certain arrhythmias (mainly atrial fibrillation), which may precede and promote the development of new-onset HF. This brief narrative review aims to provide an overview of the association between NAFLD and increased risk of new-onset HF, discuss the underlying mechanisms that link these 2 diseases, and summarize targeted pharmacological treatments for NAFLD that might also reduce the risk of HF.

Prognosis for patients with heart failure and reduced ejection fraction with and without diabetes: A 7 year nationwide veteran administration analysis

OBJECTIVE

Evidence suggests diabetes mellitus is an independent risk factor for adverse cardiovascular events in patients with heart failure. As a result, we sought to compare mortality in patients with heart failure with reduced ejection fraction (HFrEF) with and without diabetes.

RESEARCH DESIGN AND METHODS

The Veteran Affairs Hospitals' databases were queried to identify all veterans diagnosed with HFrEF from 2007 to 2015. From the overall sample of 165,159 veterans, 41,120 patients with diabetes were matched by their propensity scores (without replacement) 1:1 to non-diabetic patients. To estimate the association between diabetes (Type 1 and 2) and overall mortality of HFrEF patients, a Cox proportional hazard model was used on the matched sample and controlled for patient characteristics for a mean follow up of 3.6 years (standard deviation ±2.3).

RESULTS

In a matched sample of 41,120 veterans with HFrEF with and without diabetes, those with diabetes and HFrEF were more often on guideline-directed medical therapy than those without diabetes. In the matched cohort, the mortality risk for patients with concurrent HFrEF and diabetes was 17.7% at 1 year and 74.3% at 5 years, whereas the mortality risk for those without diabetes was 15.3% at 1 year and 69.2% at 5 years. After controlling for patient characteristics such as age, sex, body mass index, heart rate, medical therapies, comorbidities, medications, low-density lipoproteins, high-density lipoproteins, we found that patients with diabetes compared to those without had a significantly increased risk of mortality (HR: 1.85, 95% CI: 1.77-1.92, p < 0.001).

CONCLUSIONS

Diabetic HFrEF patients have a higher risk of mortality than non-diabetic HFrEF patients despite controlling for medical therapies and comorbidities.

A novel hypothesis linking low-grade ketonaemia to cardio-renal benefits with sodium-glucose cotransporter-2 inhibitors

The cardio-renal benefits of sodium-glucose cotransporter-2 (SGLT2) inhibitors are well established. In 2016, we postulated that these benefits are attributable, in part, to the occurrence of chronic low-grade ketonaemia and a shift in myocardial and renal fuel metabolism away from fat oxidation, which is energy inefficient, towards ketone oxidation, which is more energy efficient. This shift improves myocardial and renal function and can potentially translate into lower rates of progression to heart failure and end-stage kidney disease in patients with and without diabetes. There is now evidence that, in addition to being an efficient fuel substrate, ketones also have antiinflammatory and antioxidative benefits on the heart and the kidney. In addition, ketones have positive effects on mitochondrial biogenesis and function, and on erythropoiesis, and thereby are potentially able to further ameliorate the proinflammatory and hypoxic milieu in those with heart and kidney failure, independent of hyperglycaemia. In the present review, we propose a novel hypothesis to link the pleiotropic effects of low-grade ketonaemia to the cardio-renal benefits seen with SGLT2 inhibitors.

FcER1: A Novel Molecule Implicated in the Progression of Human Diabetic Kidney Disease

Diabetic kidney disease (DKD) is a key microvascular complication of diabetes, with few therapies for targeting renal disease pathogenesis and progression. We performed transcriptional and protein studies on 103 unique blood and kidney tissue samples from patients with and without diabetes to understand the pathophysiology of DKD injury and its progression. The study was based on the use of 3 unique patient cohorts: peripheral blood mononuclear cell (PBMC) transcriptional studies were conducted on 30 patients with DKD with advancing kidney injury; Gene Expression Omnibus (GEO) data was downloaded, containing transcriptional measures from 51 microdissected glomerulous from patients with DKD. Additionally, 12 independent kidney tissue sections from patients with or without DKD were used for validation of target genes in diabetic kidney injury by kidney tissue immunohistochemistry and immunofluorescence. PBMC DKD transcriptional analysis, identified 853 genes (p < 0.05) with increasing expression with progression of albuminuria and kidney injury in patients with diabetes. GEO data was downloaded, normalized, and analyzed for significantly changed genes. Of the 325 significantly up regulated genes in DKD glomerulous (p < 0.05), 28 overlapped in PBMC and diabetic kidney, with perturbed FcER1 signaling as a significantly enriched canonical pathway. FcER1 was validated to be significantly increased in advanced DKD, where it was also seen to be specifically co-expressed in the kidney biopsy with tissue mast cells. In conclusion, we demonstrate how leveraging public and private human transcriptional datasets can discover and validate innate immunity and inflammation as key mechanistic pathways in DKD progression, and uncover FcER1 as a putative new DKD target for rational drug design.

SGLT-2 inhibitors and cardiorenal outcomes in patients with or without type 2 diabetes: a meta-analysis of 11 CVOTs

BACKGROUND

It has been suggested that sodium-glucose cotransporter 2 (SGLT-2) inhibitors reduce the cardiorenal risk in patients with type 2 diabetes (T2D). The purpose of this study is to provide an update of all large cardiovascular outcome trials (CVOTs) with SGLT-2 inhibitors to assess their cardiorenal efficacy in patients with and without T2D.

METHODS

An electronic search up to 30 September 2021 was conducted in PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov. to determine eligible trials. We included CVOTs comparing any SGLT-2 inhibitor with placebo, reporting desired cardiovascular or renal outcomes and with a follow-up duration of at least 6 months.

RESULTS

Eleven CVOTs, with data from five SGLT-2 inhibitors (empagliflozin, canagliflozin, dapagliflozin, ertugliflozin and sotagliflozin) and 77,541 participants, were included. In the overall analysis, the risk of the composite CV mortality or hospitalization for heart failure (HF) was reduced by 23% (HR = 0.77, 95% CI 0.73-0.82, P < 0.001) compared with placebo, with not significant heterogeneity (I² = 26%, P = 0.20), and irrespective of the presence of T2D (P for interaction = 0.81) and age (> 65 vs ≤ 65 years, P for interaction = 0.78). The risk of CV mortality, total mortality and hospitalization for HF was significantly reduced by 16%, 13%, and 32%, respectively; similarly, the risk of the composite renal outcome was reduced by 35% (HR = 0.65, 95% CI 0.56-0.75), with moderate heterogeneity (I² = 32%). In the analysis of 6 CVOTs reporting the data, the risk of major cardiovascular events (MACE) was reduced by 12%, with low heterogeneity (I² = 21.2%, P = 0.19) and irrespective of the presence of established CV disease at baseline (P for interaction = 0.46).

CONCLUSIONS

Therapy with SGLT-2 inhibitors in patients with cardiometabolic and renal diseases results in a sustained to moderate reduction of the composite CV death or hospitalization for HF, robust reduction of HF and renal outcomes, moderate reduction of CV mortality, total mortality and MACE.

Outcome trial data on sodium glucose cotransporter-2 inhibitors: Putting clinical benefits and risks in perspective

BACKGROUND

Sodium glucose cotransporter-2 (SGLT2) inhibitors have significant heart failure and renoprotective benefits with a wide spectrum of unfamiliar and potentially serious adverse effects. Limited understanding of the risk-benefit profile of SGLT2 inhibitor treatment may result in under utilisation by prescribers and patients.

METHODS

Data from recent seminal randomized, placebo-controlled, outcome trials for multiple SGLT2 inhibitors were incorporated. Trial populations were sub-classified into high cardiovascular risk T2DM, HFrEF, and CKD. Efficacy outcomes of heart failure hospitalisation (HFH), cardiovascular (CV) mortality, total mortality, and prevention of renal deterioration were examined. Safety outcomes included were major hypoglycaemia, diabetic ketoacidosis (DKA), urinary tract infections (UTI), mycotic genital infections (MGI), hypotension, amputations and fractures. Absolute risk reduction/increase were used to calculate number needed to treat/harm.

RESULTS

Trial data comprised 71,545 patients, of which 53,144 were high risk T2DM, 9696 HFrEF and 8705 CKD. For HFrEF, NNT for HFH was 18, CV mortality 93, total mortality 76, prevention of renal deterioration 143 and prevention of DKA 6224. NNH for UTI was 557, MGI 356, hypotension 120, hypoglycaemia 574, amputations 707 and fractures 858. For CKD, NNT for HFH was 116, CV mortality 245, total mortality 138, and prevention of renal deterioration was 63. NNH for DKA was 1458, UTI 309, MGI 291, hypotension 165, hypoglycaemia 374, amputations 4450 and fractures 696. In the T2DM cohort, NNT for HFH was 139, CV mortality 851, total mortality 601 and prevention of renal deterioration 558. NNH DKA was 1525, UTI 239, MGI 69, hypotension 325, hypoglycaemia 472, amputations 1578 and fractures 9569.

CONCLUSIONS AND RELEVANCE

The cardiovascular and renal protective benefits of SGLT2 inhibitors far outweigh the risks. This paper puts into perspective the benefits and risks of treatment with SGLT2 inhibitors for clinicians and patients.

In-Hospital Initiation of Sodium-Glucose Cotransporter-2 Inhibitors for Heart Failure With Reduced Ejection Fraction

Sodium-glucose cotransporter-2 inhibitor therapy is well suited for initiation during the heart failure hospitalization, owing to clinical benefits that accrue rapidly within days to weeks, a strong safety and tolerability profile, minimal to no effects on blood pressure, and no excess risk of adverse kidney events. There is no evidence to suggest that deferring initiation to the outpatient setting accomplishes anything beneficial. Instead, there is compelling evidence that deferring in-hospital initiation exposes patients to excess risk of early postdischarge clinical worsening and death. Lessons from other heart failure with reduced ejection fraction therapies highlight that deferring initiation of guideline-recommended medications to the U.S. outpatient setting carries a >75% chance they will not be initiated within the next year. Recognizing that 1 in 4 patients hospitalized for worsening heart failure die or are readmitted within 30 days, clinicians should embrace the in-hospital period as an optimal time to initiate sodium-glucose cotransporter-2 inhibitor therapy and treat this population with the urgency it deserves.

Relationship of Nonalcoholic Fatty Liver Disease and Heart Failure With Preserved Ejection Fraction

Although there is an established bidirectional relationship between heart failure with reduced ejection fraction and liver disease, the association between heart failure with preserved ejection fraction (HFpEF) and liver diseases, such as nonalcoholic fatty liver disease (NAFLD), has not been well explored. In this paper, the authors provide an in-depth review of the relationship between HFpEF and NAFLD and propose 3 NAFLD-related HFpEF phenotypes (obstructive HFpEF, metabolic HFpEF, and advanced liver fibrosis HFpEF). The authors also discuss diagnostic challenges related to the concurrent presence of NAFLD and HFpEF and offer several treatment options for NAFLD-related HFpEF phenotypes. The authors propose that NAFLD-related HFpEF should be recognized as a distinct HFpEF phenotype.

The role of sodium-glucose co-transporter 2 protein inhibitors in heart failure: more than an antidiabetic drug?

INTRODUCTION

Heart failure (HF) places a great burden on both the patient and on medical facilities worldwide, with admission due to worsening HF being one of the leading causes of hospitalization. Optimizing HF in the community remains a challenge, but with appropriate medications, specialist review, and community support, the number of hospital admissions could be reduced. Sodium glucose co-transporter protein 2 (SGLT2) inhibitors have been shown to play a role in patients with heart failure and reduce adverse cardiovascular outcomes. This article seeks to investigate the existing medical literature to understand the role of SGLT2 inhibitors in patients with heart failure with reduced ejection fraction (HFrEF).

AREAS COVERED

An electronic search was undertaken looking at recent literature studying the outcomes of SGLT2 inhibitors on patients with heart failure. No limits were placed on the timing of the publications or the type of article. Keywords and MeSH terms were used, and the results were summarized in the relevant section.

EXPERT OPINION

This study shows that SGLT2 inhibitors are a safe and effective medication in the setting of HFrEF and has been shown to reduce symptoms of heart failure thus improving quality of life and reducing admissions due to heart failure and cardiovascular mortality.

GLP-1 receptor agonists vs. SGLT-2 inhibitors: the gap seems to be leveling off

Cardiovascular disease (CVD) remains the leading cause of death in patients with type 2 diabetes (T2D). Older age, prior heart failure (HF) and CV events, peripheral artery disease, and kidney complications can identify a subgroup of patients with T2D at high risk of mortality who are likely to achieve the greatest benefit from newer glucose-lowering agents. Both glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter-2 (SGLT-2) inhibitors can reduce CV risk in patients with T2D, and both are recommended by the American Diabetes Association to reduce the risk of major cardiovascular events (MACE). The magnitude of the benefits of GLP-1RA and SGLT-2 inhibitors on MACE are similar, ranging from 12 to 14% reduction of risk, but only GLP-1RA may reduce the risk of stroke. The most striking difference between the two classes of drugs relates to the amelioration on hospitalization for HF, as the benefit of SGLT-2 inhibitors surpass by threefold that obtained with GLP-1RA. Despite this, GLP-1RA also exert a significant benefit on HF which suggest their use when SGLT-2 inhibitors are contraindicated or not tolerated. The difference between the two classes is less impressive for the kidney outcome. Overall, the results of CVOTs published so far seems to suggest that the gap between the cardiorenal benefits of SGLT-2 and GLP-1RA is narrowing.

Regional variation of effects of new antidiabetic medications in cardiovascular outcome trials

BACKGROUND

In international trials, glucagon-like protein-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2Is) were effective in improving cardiovascular (CV) outcomes.

METHODS

We assessed the effect of GLP-1RAs and SGLT2Is treatment effect on CV endpoints by geographical region in multiple international trials using random effects weighted least squares meta-regressions.

RESULTS

The estimated effects of both SGLT2Is and GLP-1RAs on major adverse CV events (MACE) in North America (SGLT2Is n = 12,399, HR 0.90, 95% CI 0.81-1.01; GLP-1RAs n = 12,515, HR 0.95, 95% CI 0.83- 1.09) and in Europe (SGLT2Is n = 19,435, HR 0.93, 95% CI 0.85-1.02; GLP-1RAs n = 22,812, HR 0.88, 95% CI 0.79-0.99) were numerically lower but not statistically different to the rest of the world (ROW) (SGLT2Is n = 15,127, HR 0.83, 95% CI 0.75-0.92, p-value for interaction 0.26; GLP-1RAs n = 17,494, HR 0.82, 95% CI 0.73-0.92, p-value for interaction 0.28). Effects of SGLT2Is on heart failure readmission or CV death varied significantly by region (P = 0.0094). The effect of SGLT2Is was significantly smaller in Europe (n = 18,653, HR 0.86, 95% CI 0.78-0.95) than in the ROW (n = 12,463, HR 0.68, 95% CI 0.61-0.76, P = 0.0024). The smaller effect in North America (n = 9776, HR 0.76, 95% CI 0.66-0.87) did not differ significantly from that in the ROW (P = 0.2370).

CONCLUSION

The effects of SGLT2Is on HF events are larger in the ROW. Further analyses and studies are needed to better elucidate the differential effects of SGLTIs and GLP-1RAs by geographical regions.

Sodium-glucose co-transporter 2 inhibitors in nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is considered the most prevalent chronic hepatic disease, as it has been estimated that one of four individuals in the general population has been affected by NAFLD. The evolution of the referred entity, which includes nonalcoholic steatohepatitis (NASH) and hepatic fibrosis, may have crucial and even fatal consequences, leading to cirrhosis and hepatocellular carcinoma. Although NAFLD has also been linked with cardiovascular and renal diseases, and all-cause mortality increment, pharmacological therapy is as yet an unfulfilled demand. Since NAFLD is closely associated with type 2 diabetes mellitus (T2DM), a variety of anti-diabetic drugs have been investigated for their effectiveness towards NAFLD. Sodium-glucose co-transporter 2 inhibitors (SGLT-2i) improve blood glucose levels through increasing renal glucose excretion and they are recommended as one of standard therapeutic categories for T2DM patients. Based on preclinical animal studies, SGLT-2i have shown a beneficial effect on NAFLD, inducing histologically proven amelioration of hepatic steatosis, inflammation and fibrosis. Promising data have been also derived by clinical trials, which have indicated a potentially beneficial effect of SGLT-2i on NAFLD, at least in terms of liver function tests and imaging. Thus, it is not strange that there are many ongoing trials on the effect of various SGLT-2i in NAFLD. In conclusion, current evidence concerning the effect of SGLT-2i on NAFLD is encouraging; however, data from ongoing clinical trials with histological endpoints are awaited.

Projection of the health and economic impacts of Chronic kidney disease in the Chilean population

BACKGROUND

Chronic Kidney Disease (CKD) is a leading public health problem, with substantial burden and economic implications for healthcare systems, mainly due to renal replacement treatment (RRT) for end-stage kidney disease (ESKD). The aim of this study is to develop a multistate predictive model to estimate the future burden of CKD in Chile, given the high and rising RRT rates, population ageing, and prevalence of comorbidities contributing to CKD.

METHODS

A dynamic stock and flow model was developed to simulate CKD progression in the Chilean population aged 40 years and older, up to the year 2041, adopting the perspective of the Chilean public healthcare system. The model included six states replicating progression of CKD, which was assumed in 1-year cycles and was categorised as slow, medium or fast progression, based on the underlying conditions. We simulated two different treatment scenarios. Only direct costs of treatment were included, and a 3% per year discount rate was applied after the first year. We calibrated the model based on international evidence; the exploration of uncertainty (95% credibility intervals) was undertaken with probabilistic sensitivity analysis.

RESULTS

By the year 2041, there is an expected increase in cases of CKD stages 3a to ESKD, ceteris paribus, from 442,265 (95% UI 441,808-442,722) in 2021 to 735,513 (734,455-736,570) individuals. Direct costs of CKD stages 3a to ESKD would rise from 322.4M GBP (321.7-323.1) in 2021 to 1,038.6M GBP (1,035.5-1,041.8) in 2041. A reduction in the progression rates of the disease by the inclusion of SGLT2 inhibitors and pre-dialysis treatment would decrease the number of individuals worsening to stages 5 and ESKD, thus reducing the total costs of CKD by 214.6M GBP in 2041 to 824.0M GBP (822.7-825.3).

CONCLUSIONS

This model can be a useful tool for healthcare planning, with development of preventive or treatment plans to reduce and delay the progression of the disease and thus the anticipated increase in the healthcare costs of CKD.

2021 Consensus Pathway of the Taiwan Society of Cardiology on Novel Therapy for Type 2 Diabetes

Type 2 diabetes is a major threat to human health in the 21st century. More than half a billion people may suffer from this pandemic disease in 2030, leading to a huge burden of cardiovascular complications. Recently, 2 novel antidiabetic agents, glucagon-like peptide 1 receptor agonists and sodium-glucose cotransporter 2 inhibitors, reduced cardiovascular complications in a number of randomized control trials. To integrate new information and to achieve a streamlined process for better patient care, a working group was appointed by the Taiwan Society of Cardiology to formulate a stepwise consensus pathway for these therapies to reduce cardiovascular events in patients with type 2 diabetes. This consensus pathway is complementary to clinical guidelines, acting as a reference to improve patient care.

Intersection Between Chronic Kidney Disease and Cardiovascular Disease

PURPOSE OF REVIEW

The incidence of chronic kidney disease is increasing worldwide, and the previously decreasing incidence of cardiovascular disease has now plateaued. Understanding the intersection of both heart and kidney disease is crucial.

RECENT FINDINGS

Chronic kidney disease and cardiovascular disease share common risk factors and specific pathogenic mechanisms and impact a significant segment of the population. Patients with chronic kidney disease are more likely to have cardiovascular disease than progress to end-stage kidney disease requiring renal replacement therapy. We discuss shared risk factors and mechanisms for cardiovascular and chronic kidney disease. The following also addresses contemporary cardiovascular treatment considerations in patients with chronic kidney disease with a focus on atherosclerotic cardiovascular disease and heart failure.

Mineralocorticoid Receptor Antagonists in Diabetic Kidney Disease

Diabetes mellitus is a global health issue and main cause of chronic kidney disease. Both diseases are also linked through high cardiovascular morbidity and mortality. Diabetic kidney disease (DKD) is present in up to 40% of diabetic patients; therefore, prevention and treatment of DKD are of utmost importance. Much research has been dedicated to the optimization of DKD treatment. In the last few years, mineralocorticoid receptor antagonists (MRA) have experienced a renaissance in this field with the development of non-steroidal MRA. Steroidal MRA have known cardiorenal benefits, but their use is limited by side effects, especially hyperkalemia. Non-steroidal MRA still block the damaging effects of mineralocorticoid receptor overactivation (extracellular fluid volume expansion, inflammation, fibrosis), but with fewer side effects (hormonal, hyperkalemia) than steroidal MRA. This review article summarizes the current knowledge and newer research conducted on MRA in DKD.

Factors affecting the efficacy of SGLT2is on heart failure events: a meta-analysis based on cardiovascular outcome trials

Background

The efficacy of sodium-glucose transporter 2 inhibitors (SGLT2is) on heart failure outcomes is unestablished in various subgroups defined by clinically important factors. We intended to evaluate the effects of six important factors on the efficacy of SGLT2is on heart failure outcomes.

Methods

We included cardiovascular outcome trials (CVOTs) concerning SGLT2is. We assessed the heart failure composite outcome of cardiovascular death (CVD) or hospitalization for heart failure (HHF). Meta-analysis was conducted stratified by the following 6 factors: type of underlying diseases, type of SGLT2is, left ventricular ejection fraction (LVEF) level, New York Heart Association (NYHA) class, region, and race.

Results

Ten CVOTs were included. Compared with placebo, SGLT2is reduced heart failure composite outcome by 25% [hazard ratio (HR) 0.75, 95% confidence interval (CI), 0.72-0.78] independent of type of underlying diseases, type of SGLT2is, LVEF level, and region (P_subgroup: 0.673, 0.244, 0.429, and 0.127, respectively). SGLT2is led to greater reduction in the composite outcome in patients with NYHA class II (HR 0.66, 95% CI, 0.59-0.74) than in patients with NYHA class III or IV (HR 0.86, 95% CI, 0.75-0.99; P_subgroup=0.004), and in Black (HR 0.63, 95% CI, 0.49-0.82) and Asian (HR 0.64, 95% CI, 0.53-0.77) patients than in White patients (HR 0.81, 95% CI, 0.76-0.86; P_subgroup=0.016).

Conclusions

SGLT2is reduce heart failure composite outcome by 25% independent of type of underlying diseases, type of SGLT2is, LVEF level, and region. SGLT2is lead to greater reduction in the composite outcome in patients with NYHA class II than in patients with NYHA class III or IV, and in Black and Asian patients than in White patients.

Keywords

Sodium-glucose transporter 2 inhibitors (SGLT2is); heart failure; chronic kidney disease (CKD); type 2 diabetes.

Recent advances in new-onset diabetes mellitus after kidney transplantation

A common challenge in managing kidney transplant recipients (KTR) is post-transplant diabetes mellitus (PTDM) or diabetes mellitus (DM) newly diagnosed after transplantation, in addition to known pre-existing DM. PTDM is an important risk factor for post-transplant cardiovascular (CV) disease, which adversely affects patient survival and quality of life. CV disease in KTR may manifest as ischemic heart disease, heart failure, and/or left ventricular hypertrophy. Available therapies for PTDM include most agents currently used to treat type 2 diabetes. More recently, the use of sodium glucose co-transporter 2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1 RA), and dipeptidyl peptidase 4 inhibitors (DPP4i) has cautiously extended to KTR with PTDM, even though KTR are typically excluded from large general population clinical trials. Initial evidence from observational studies seems to indicate that SGLT2i, GLP-1 RA, and DPP4i may be safe and effective for glycemic control in KTR, but their benefit in reducing CV events in this otherwise high-risk population remains unproven. These newer drugs must still be used with care due to the increased propensity of KTR for intravascular volume depletion and acute kidney injury due to diarrhea and their single-kidney status, pre-existing burden of peripheral vascular disease, urinary tract infections due to immunosuppression and a surgically altered urinary tract, erythrocytosis from calcineurin inhibitors, and reduced kidney function from acute or chronic rejection.

Reversing endothelial dysfunction with empagliflozin to improve cardiomyocyte function in cardiorenal syndrome

Sodium-glucose cotransporter 2 inhibitors offer cardiovascular and renal benefits in patients with chronic kidney disease through not yet clearly defined mechanisms. Juni et al. showed that sodium-glucose cotransporter 2 inhibitor empagliflozin exposure in vitro can restore cardiomyocyte function by counteracting harmful effects of uremic serum on the endothelium-cardiomyocyte crosstalk between endothelial cells and cardiomyocytes. The author's findings improved our understanding of cardiovascular impairment in chronic kidney disease and provided new perspectives for the beneficial effects of sodium-glucose cotransporter 2 inhibitor therapy.

Prevention of heart failure events with sodium-glucose co-transporter 2 inhibitors across a spectrum of cardio-renal-metabolic risk

AIMS

Trials have tested the safety and efficacy of sodium-glucose co-transporter 2 inhibitors (SGLT2i) across various disease states. We performed a meta-analysis of randomized controlled trials (RCTs) to estimate the relative and absolute effects of SGLT2i in the prevention of heart failure (HF) events across different risk groups.

METHODS AND RESULTS

We conducted a systematic review and meta-analysis of large, placebo-controlled RCTs with >1000 participants evaluating HF hospitalization and the composite of cardiovascular (CV) death or HF hospitalization. Due to varying durations of therapeutic exposure and follow-up, absolute risk reductions and number needed to treat were calculated based on incidence rates (per 100 patient-years). Across 71 553 patients enrolled in 10 late-phase RCTs, SGLT2i reduced the risk of HF hospitalization by 31% [hazard ratio (HR) 0.69, 95% confidence interval (CI) 0.64-0.74; I²  = 0%] and the composite outcome of CV death or HF hospitalization by 24% (HR 0.76, 95% CI 0.72-0.80; I²  = 1.4%) compared with placebo. The number of patient-years of treatment exposure needed to prevent one CV death or HF hospitalization ranged from 19-26 (established HF) to 72-125 (chronic kidney disease) to 96-400 (high-risk type 2 diabetes). In mixed-effects meta-regression analyses, the benefits of SGLT2i on HF hospitalizations or the composite outcome (CV death or HF hospitalization) were not influenced by age, sex, or change in intermediate markers (glycated haemoglobin, systolic blood pressure, and body weight) (all P ≥ 0.10).

CONCLUSION

Despite wide variation in baseline risks and disease states evaluated, SGLT2i demonstrated comparable relative risk reductions in preventing HF events. Patients at highest baseline risk derived the greatest absolute benefits in preventing HF events. These composite estimates may help guide targeted implementation of SGLT2i for the prevention of HF events in type 2 diabetes and chronic kidney disease and in the treatment of HF.

Use of sodium-glucose co-transporter 2 inhibitors in patients with heart failure and type 2 diabetes mellitus: data from the Swedish Heart Failure Registry

AIMS

Use of sodium-glucose co-transporter 2 inhibitors (SGLT2i) in real-world heart failure (HF) is poorly characterised. In contemporary patients with HF and type 2 diabetes mellitus (T2DM) we assessed over time SGLT2i use, clinical characteristics and outcomes associated with SGLT2i use.

METHODS AND RESULTS

Type 2 diabetes patients enrolled in the Swedish HF Registry between 2016-2018 were considered. We performed multivariable logistic regression models to assess the independent predictors of SGLT2i use and Cox regression models in a 1:3 propensity score-matched cohort and relevant subgroups to investigate the association between SGLT2i use and outcomes. Of 6805 eligible HF patients with T2DM, 376 (5.5%) received SGLT2i, whose use increased over time with 12% of patients on treatment at the end of 2018. Independent predictors of SGLT2i use were younger age, HF specialty care, ischaemic heart disease, preserved kidney function, and absence of anaemia. Over a median follow-up of 256 days, SGLT2i use was associated with a 30% lower risk of cardiovascular (CV) death/first HF hospitalisation (hazard ratio 0.70, 95% confidence interval 0.52-0.95), which was consistent regardless of ejection fraction, background metformin treatment and kidney function. SGLT2i use was also associated with a lower risk of all-cause and CV death, HF and CV hospitalisation, and CV death/myocardial infarction/stroke.

CONCLUSION

In a contemporary HF cohort with T2DM, SGLT2i use increased over time, was more common with specialist care, younger age, ischaemic heart disease, and preserved renal function, and was associated with lower mortality and morbidity.

Effects of sodium-glucose cotransporter 1 and 2 inhibitors on cardiovascular and kidney outcomes in type 2 diabetes: A meta-analysis update

In this report, we aim to provide an updated meta-analysis of the sodium-glucose cotransporter 2 (SGLT2) inhibitors trial data with the new trial data on sotagliflozin, a first-in-class dual SGLT1 and SGLT2 inhibitor. We searched Medline, Cochrane library, and Embase databases for randomized clinical trials comparing cardiovascular and kidney outcomes between SGLT2 and dual SGLT1/2 inhibitors and placebo. Nine randomized clinical trials with a total of 60,914 patients with type 2 diabetes were included. In patients with type 2 diabetes, the use of SGLT2 and dual SGLT1/2 inhibitors improves the cardiovascular and kidney outcome.

Risk for recurrent cardiovascular disease events among patients with diabetes and chronic kidney disease

Background

Adults who have experienced multiple cardiovascular disease (CVD) events have a very high risk for additional events. Diabetes and chronic kidney disease (CKD) are each associated with an increased risk for recurrent CVD events following a myocardial infarction (MI).

Methods

We compared the risk for recurrent CVD events among US adults with health insurance who were hospitalized for an MI between 2014 and 2017 and had (1) CVD prior to their MI but were free from diabetes or CKD (prior CVD), and those without CVD prior to their MI who had (2) diabetes only, (3) CKD only and (4) both diabetes and CKD. We followed patients from hospital discharge through December 31, 2018 for recurrent CVD events including coronary, stroke, and peripheral artery events.

Results

Among 162,730 patients, 55.2% had prior CVD, and 28.3%, 8.3%, and 8.2% had diabetes only, CKD only, and both diabetes and CKD, respectively. The rate for recurrent CVD events per 1000 person-years was 135 among patients with prior CVD and 110, 124 and 171 among those with diabetes only, CKD only and both diabetes and CKD, respectively. Compared to patients with prior CVD, the multivariable-adjusted hazard ratio for recurrent CVD events was 0.92 (95%CI 0.90–0.95), 0.89 (95%CI: 0.85–0.93), and 1.18 (95%CI: 1.14–1.22) among those with diabetes only, CKD only, and both diabetes and CKD, respectively.

Conclusion

Following MI, adults with both diabetes and CKD had a higher risk for recurrent CVD events compared to those with prior CVD without diabetes or CKD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-021-01247-0.

Efficacy and safety of SGLT2 inhibitors in heart failure: systematic review and meta-analysis

AIMS

We sought to conduct a meta-analysis regarding the safety and efficacy of sodium-glucose co-transporter 2 (SGLT2) inhibitors in patients with heart failure (HF).

METHODS AND RESULTS

MEDLINE, Scopus, Cochrane CENTRAL, and ClinicalTrials.gov were searched from their inception to November 2020 for placebo-controlled randomized controlled trials of SGLT2 inhibitors. Randomized controlled trials were selected if they reported at least one of the prespecified outcomes in patients with HF. Hazard ratios (HRs) or risk ratios and their corresponding 95% confidence intervals were pooled using a random-effects model. A total of seven trials including 16 820 HF patients (N = 8884 in the SGLT2 inhibitor arms; N = 7936 in the placebo arms) were included. In the overall HF cohort, SGLT2 inhibitors compared with placebo significantly reduced the risk of the composite endpoint of first HF hospitalization or cardiovascular death [HR: 0.77 (0.72-0.83); P < 0.001; I2 = 0%], time to first HF hospitalization [HR: 0.71 (0.64-0.78); P < 0.001; I2 = 0], cardiovascular mortality [HR: 0.87 (0.79-0.96); P = 0.005; I2 = 0%], and all-cause mortality [HR: 0.89 (0.82-0.96); P = 0.004; I2 = 0%]. Results remained consistent across HF-specific trials and according to diabetes mellitus status. A trend towards benefit was observed in patients with HF with preserved ejection fraction for the composite of HF hospitalization and cardiovascular death [HR: 0.80 (0.63-1.00); P = 0.05; I2 = 29%]. No increased risk of hypovolaemia, hyperkalaemia, and hypotension was seen with SGLT2 inhibitors compared with placebo.

CONCLUSIONS

SGLT2 inhibitors significantly improve cardiovascular outcomes including cardiovascular and all-cause mortality in patients with HF without an increased risk of serious adverse events. A trend towards benefit was observed in patients with HF with preserved ejection fraction.